Hopefully, this chapter has shown how radically doctors’ consultations nowadays should differ from those of, say, 50 years ago. It seems that the fundamental elements are setting aside the illness/diagnosis model with its direct questions about bodily systems and adopting a patient-centred counselling style with its associated intuitive component. In this way doctors can not only elicit the real reasons why a patient is consulting them, but work out solutions together. By tackling problems at a deeper level doctors can learn from the relationships with their patients and help them to apply this understanding to other relationships. The doctor can then truly be said to be fulfilling his or her role as teacher, as the derivation of the word doctor implies.

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Other patients have difficulty seeing themselves as sexual once they become parents. They cannot imagine their own parents behaving sexually (although intellectually they know they must have done so), and have problems re-establishing sexual activity for pleasure after delivery. The emotional demands a new baby makes on the mother, and the intense bonding that occurs, the physical tiredness, the hormonal changes and even depression, all conspire to exclude the husband and diminish the wife’s desire for closeness with him. Some mothers may even say they do not need birth control, and not use it or refuse intercourse until they want to become pregnant again. For some, motherhood is the only role in which they feel fulfilled.

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It was clear that this patient had moved on and was beginning to look forward to being freer and to doing different things with her life. Hopefully her sexual life will return, too, when she can value it again for itself rather than as a means to a pregnancy.

For some women it is not so much the loss of future babies that is the underlying sadness, but a more general sense that the end of the ability to be a fertile woman is the end of a central part of herself, something which is in some way the essence of her being.

Listening to such accounts one can understand the power of myth and legend that is handed down from generation to generation. Perhaps this is where the art of medicine comes in, to demystify and clarify.

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In the second half of the twentieth century, sterilization has become a very popular method of contraception. Worldwide in excess of 60 million women have been sterilized (Elias, 1991), and it is reported from the USA that 640000 tubal sterilizations were undertaken there in 1987 alone (Schwartz, Wingo, Antarsh et al., 1991). In the UK in 1980, one in three couples chose this method of contraception, and in 1983 it is reported that 90000 women and equal numbers of men were sterilized, at least a fifth of the women being under 30 years old. It seems likely that the forecast made in 1974, that in time one in three couples would rely on sterilization by the age of 35, will come true (Wellings, 1986).

At present, sterilization is undertaken once a family is complete, although previously the procedure was used for eugenic reasons. Even now, it is a very potent method of population control and is used as such in some parts of the world. At first the number of female sterilizations rose more quickly than those for vasectomy because of the legal doubts over vasectomy, but the numbers of operations are now more equal. The UK government has given financial support to a policy of sterilization in suitable cases, and the success of this policy has obvious long-term implications for the provision of contraceptive services (Allen, 1981). The popularity of the programme is such that it may become necessary to move resources from GP and community provision of family planning to the provision of sterilization and vasectomy.

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Feelings were explored and some practical difficulties uncovered. Due to the loss of his leg he felt unbalanced and wobbly when they tried to make love, as they always used the missionary position. When the doctor asked him why he had to do it in that position he was amazed and said he had never thought of doing it any other way. This led to a discussion of other positions and options. It was necessary to consider how he would feel if he was in the underneath position as he already felt ‘flattened’. There had been no real communication with his wife about his doubts and fears. He felt she did not want to upset him, and she tended to say things like, ‘It’s all right, don’t worry about it.’ He felt ashamed of the sexual difficulty, and of the loss of his limb, hoping that when he limped people would think he had a touch of arthritis. There was a need to grieve for all the losses.

Following this meeting with the doctor, Alan was able to talk to his wife at length, and he felt they could now share the problem. He had a smile on his face as he said that they had experimented with new positions and that it was now fine and there were no problems.

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