CONTRACEPTION AFTER CHILDBIRTH – THE IMMEDIATE PUERPERIUM (ABNORMAL BABY)

When the delivery is known to have been traumatic in physical terms, when the baby is not thriving or has died, or when an abnormal baby has been born, a particularly sensitive approach to discussion of contraception will be needed. The woman’s pain and distress or anger at what has happened may be hard for the family planning adviser to bear, and it may be tempting to avoid counselling such a woman with the excuse that she needs help in coping with her misfortune rather than consideration of her sexual activity in the future. And yet, these are often the women who need the most help, for to treat them differently may only increase their feelings of isolation and abnormality. They may have considerable anxieties about when to embark on a pregnancy again, and even at the height of their grief they may be looking forward in their mind. Time needs to be spent in allowing the woman to share her grief, while acknowledging with her that her need for comfort and closeness with her partner could lead to sexual activity. She may need encouragement to allow herself to consider sexual pleasure, especially where there are feelings of guilt or blame. Time spent exploring her anxieties at this stage may allow natural healing to begin to take place.

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THE SECOND BABY – INSTANCE; CONCLUSION

Mrs P. was seen initially in a psychosexual clinic following the birth of her first child who suffered from osteogenesis imperfecta (brittle bone disease). Intercourse was extremely painful. She was unable to gain any insight into how angry she was with the doctors for not diagnosing the problem correctly so that some fractures occurred during the baby’s delivery, but she was also angry with her husband for possibly causing some fractures when he lay on her having intercourse.

The previous fun of lovemaking had led to a wanted pregnancy, but it had caused so much pain now for her and her baby. How could she possibly enjoy it again? She did not want any more children and therefore there was no need for intercourse. She decided not to attend for further help with the psychosexual problem because of lack of progress.

Three years later she appeared at the infertility clinic having decided herself, a year before, that the time was right for another baby. She looked surprised when the doctor asked if she was enjoying lovemaking again, as though that painful time had not existed.

The power of time to heal both pain and anger can sometimes be surprising, and doctors have to accept that they will often never know if the work they have done with a patient has played any part in the healing process.

*127/197/1*

COUNSELLING THE PATIENT WITH THE UNPLANNED PREGNANCY – THREE MAJOR COMPONENTS

Bearing in mind all the above difficulties, there are three major components to be considered in counselling a woman with an unplanned pregnancy, not necessarily in this order.

Giving accurate information about the options, procedures and relative risks so that the woman can make an informed decision. Despite the fact that abortion is a commonly carried out surgical procedure, it is often not openly discussed. A woman with an unplanned pregnancy may set out with very little accurate knowledge of her options. Much of the information available may be produced by radical pro- or anti-abortion groups carrying strongly emotional overtones. It is important that the woman receives accurate information before making a decision.

Allowing the woman the opportunity to explore her feelings about this pregnancy in particular and her fertility in general.

Helping the woman reach an understanding as to why she fell pregnant at this particular time. Sometimes this is related to a simple contraceptive failure or mistake (Hutchinson, 1992). She may need help in finding a suitable method of contraception and be given proper instructions as to how to use it. Sometimes the reason for the present pregnancy is more complex, to do with the woman’s emotional problems and attitudes to her sexuality. These may need to be understood before she can make use of any contraception offered. She may occasionally need further help from other agencies such as Social Services or psychotherapy.

*90/197/1*

CARE OF THE YOUNGER PATIENT – INSTANCE

An 18-year-old girl attended a clinic two hours away from her home. A new doctor expressed surprise at the distance she had travelled, noting that she had been attending for four years. ‘I like coming here,’ the girl said. ‘I know I could go to a nearer clinic, but I first came here in a state, needing the ‘morning-after’ pill.’

Her first experience was good, and she found the staff kind and friendly. At that time she had been worried on two counts, the risk of pregnancy and the risks of the Pill. Her mother had frightened her with myths about the Pill causing breast and cervical cancer. She felt that at the clinic her anxieties had been given credence and replaced by information. Four years on she is a happy Pill user who prefers to return for her contraceptive care to the clinic where her first experience, in a crisis, was good. This girl, only 14 years at the time of her first attendance, had achieved a considerable degree of emotional maturity, being able to take responsibility into her own hands and finding the first contraceptive consultation all that she had hoped for.

*53/197/1*

SEX OFFENDERS: METHODS AND TERMS

Since the scientific value of any piece of research is determined in large part by the methods employed it is incumbent on the scientist to describe them. Our interviewing techniques have been amply dealt with in prior publications, our sampling method is discussed in the next chapter, so here we shall deal with method solely in the sense of data processing and exposition, making explicit the assumptions underlying our methodology.

One of our basic assumptions is that our data are unsuited to elaborate statistical treatment, and that measures of statistical significance and expected variation are not ordinarily helpful, since our data are not derived from probability sampling. Our philosophy might be summed up thus: if an inference cannot be justified by simple statistical techniques, it should either be discarded or labeled as a speculation. In choosing simplicity of method we have not, however, tolerated crudity where it was avoidable. Simplicity of method is a form of honesty—a rejection of the omnipresent temptation to apply more complex statistical tortures to the body of data until it finally yields up certain preconceived results.

*1\161\2*

ENGAGEMENT AND PREMATURE MARRIAGE

Courtship is an intensely personal business but after a time, if the couple feel fairly sure that they are right for each other, they will want to start making long-term plans for being together. This will usually mean getting married. The bridge between courtship and marriage is engagement. Ideally this is a public declaration to the world that the two like each other greatly, are basically well adapted to one another, have done their ‘homework’ during courtship and are setting out to make a life together.

If at any time courtship fails and the relationship ends it is very sad. However, the partners should know much more about themselves and the opposite sex than they did before. They may even realise their choice was incorrect, learn the lesson and do better next time.

Of course, not every courtship, nor even every engagement, ends in marriage and it is helpful to know what the commonest reasons for ‘failure’ are, so that a couple can see these worrying signs in their relationship.

*31\164\2*

SELECTION AND COURTSHIP: COURTSHIP

Once a choice has been made this is hardly the end of the matter. The chosen partner should be explored and the potential for longterm happiness further assessed. At this stage the best advice, based on the evidence, is to avoid copulation. Anybody can be happy, for a spell at least, in bed. Women, particularly, seem to need a word of caution here. When asked how many occasions you should go out with a man you like and who seems to like you before allowing full sexual activity the majority of young women say at least three! There is some evidence that the threat of AIDS is making people slightly more cautious.

A woman first meeting a man who excites her will use him in her masturbation fantasies from the start. As we point out elsewhere, it seems natural for women to express their emotional feelings by close body contact and sex. All that is required is that she likes the man and that sufficient time has elapsed for her to feel a relationship exists and that she is not a whore. But is this approach wise?

In a relationship which is not intentionally casual the period between first meeting and first intercourse could be called courtship. If a long relationship is hoped for then slow progress needs to be the policy. This is where the scepticism mentioned earlier comes in. The idea can be expressed in a question to one’s self along the lines ‘Can I really believe my luck — after all this time can I really have met someone who understands me and yet still loves me and whom I understand and love more than ever?’ Courtship should be a time for exploration, testing and the establishment of genuine communication. If, at any stage, the relationship is seriously not right, and cannot be made right, it should be abandoned. This is not to say that at the first difficulty it should be given up but rather that the ability to overcome the difficulty should be tested.

At this stage progress is best made out of bed. The point is not that sex is off the menu but that it is taken slowly and gently, stage by stage. In itself it is one test of compatibility and ability to communicate and proceeds whilst the personalities and capacity for mutual interest and happiness are explored. Those who have been in many previous relationships may consider that courtship is unnecessary but it is more essential than ever if a real relationship with the real person is to be established and not just an image of one based on past experiences. Everyone, after all, is different and it is unfair to apply generalisations to others.

So, running in parallel with the social, emotional and psychological development of the relationship, the sexual relationship unfolds. It is part of the learning about each other which goes on in courtship. Progress may take weeks or months and first intercourse may be deferred until marriage but the stages fall into a pattern which recapitulates psychosexual development.

First there is kissing and cuddling. Some people find kissing very exciting but others are indifferent or even dislike it. Now is the time to find out about your partner’s preferences. Deep kissing early on in a relationship may, these days, give rise to anxieties due to the fear of AIDS. Many women love their necks being kissed and their ears nibbled. For others, of both sexes, kissing is a whole body activity and they like the bodies to be pushed together while kissing. Cuddling is probably an under-rated activity. Virtually all women say they love to be cuddled and that cuddling alone can make them feel happy and content. Many men too like cuddling but fear to ask for it or promote it in case they come across as being less than ‘manly’.

The next stage is stimulation over clothes, especially of the woman’s breasts, back, bottom and thighs. She may similarly stimulate the man. Now the special erogenous values of each area to the partner can begin to be learned. Since the relationship is deepening it is best to be open and unashamed about what is required from now on. If such revelations are unacceptable to the other, now is the time to find out. In the same way it is best to be open about your personality and not to try and conceal features which it might be feared are unacceptable. ‘Glasnost’ should be the policy followed. It is foolish to pretend to be something we are not.

The stage which follows is partial, and eventually perhaps total, nudity. No sensible person regards their body as perfect or expects anyone else to be so. Nevertheless women often seem all too keen to draw attention to the real or imagined imperfections of their bodies even before they have shown them to the man. This is a mistake. Those women who complain that men are interested only in their bodies for sex underestimate the extent to which Mother Nature has made men susceptible to the beauties of the female body. Tastes vary, as we said earlier, but men have an appreciation which most find hard to express in any adequate language, and which goes far beyond the genitals. Men too have their anxieties about their bodies which an understanding woman can do a lot to allay. One aspect of love is mutual admiration. At this stage further investigations of erogenous zones and how the partner most likes them to be stimulated is possible.

Some moralists may object to the next stage, which many people, even today, still avoid out of shame, and yet its benefits are enormous. It is the stage of mutual masturbation. It powerfully assists the growth of trust if this stage can be negotiated successfully. The young especially are, due to the influences of their upbringing still exerting a large effect, often very shy and secretive about this aspect of themselves and even more so where a member of the opposite sex is involved.

Ideally the couple should show each other how they like to be stimulated and teach one another to be expert with their genitals. All women masturbate differently so no matter how many previous partners the man has masturbated he knows nothing of the present one until he finds out. Having found out he now has a reliable way of producing an orgasm for her. This increases his confidence and decreases his performance anxiety thereby making penile failure in the future less likely. Eventually the skill can be used before, during and after intercourse to enhance the woman’s pleasure and make orgasm for her more likely. Many men worry about their ability to produce an orgasm for their lover.

Similarly, the woman learns to masturbate her man as well, or better, than he can himself. He becomes used to and confident about ejecting and ejaculating in front of her and, if she does not want or cannot have intercourse in the future, she can still relieve him. In effect she tells him that she accepts his masturbation. This is helpful because many men stop or reduce masturbation when they meet a woman who they know is going to be special. All this involves much more than simply inducing an orgasm, it has to do with learning to do it really well based on the needs of a particular partner.

Even more embarrassing for many, and in many ways even more important, is the uninhibited and honest communication of masturbation fantasies and special needs. This involves deep intimacy and considerable love. Secrets are shared now and used to the benefit of one another. Such revelations are liberating and the gratitude felt towards the partner for accepting and indulging the ‘shameful’ needs is often enduring and life-long. If this level of communication can be achieved nothing is likely to be more difficult in the future.

Finally, when the penis first penetrates the vagina it is not going to be copulatory contact with a stranger but true intercourse with someone loved and understood who loves and understands in return. Most importantly of all it makes the woman and the man real friends and powerful allies. Some people find this level of intimacy and sharing intimidating or even disgusting but in reality it is beautiful. To fail to go through the stage in full means that assumptions are made about the sexuality of the other and this diminishes real love.

Courtship can be a beautiful process too. The couple learn how to behave gracefully, politely and happily with each other, often to the vast relief of agonised parents who see an oaf of a son or a rebellious, moody daughter blossom into the attractive person they always hoped for. As the partners enthuse the other with their interests new horizons begin to open.

During courtship the emphasis should be more on reality than romance. Faults in the other should be perceived realistically and decisions taken as to whether these departures from notions of an ‘ideal’ partner can be overlooked or even turned to advantage. People can, within reason, be as loveable for their faults as their virtues. Courtship too is a time of confession but it is best not to be too detailed for fear of provoking later jealousy.

If at any time courtship fails and the relationship ends it is very sad. However, the partners should know much more about themselves and the opposite sex than they did before. They may even realise their choice was incorrect, learn the lesson and do better next time.

*30\164\2*

SELECTION AND COURTSHIP: WHAT INFLUENCES CHOICE?

Some say that opposites attract. Whilst this may be true, it is not often the basis for a good

long-term relationship. For example, a woman whose whole pleasure in life is centred around the home and her relationship with her husband will be unlikely to be happy for long with a man to whom achievement at work and advancement are the main pre-occupations in life. No two people are exactly similar in personality but gross fundamental dissimilarities are no prescription for a happy marriage.

However, some women who regard themselves as having some serious physical or psychological defect say they are attracted to men with the opposite characteristic and it sometimes crosses their mind that if they ever had a baby by him it would, with luck, inherit his and not her characteristics or at least cancel out her ‘defects’ in the child.

Another view is that many people seek to marry a replica of their mother or father. This hypothesis makes sense if the childhood relationship with the opposite sex partner has gone well and been happy or if it has been a failure. In the latter case the individual may unconsciously seek to return to childhood and’re-work, the relationship in the hopes of a happier outcome. Also the child receives half its genes from the opposite sex parent arid so is similar to him or her to some extent. Therefore choosing a partner who is similar in adulthood may involve choosing someone who is similar to our opposite sex partner.

Although it does not seem that there is any noteworthy tendency for people to marry partners who look the same as their opposite sex parent the effect could be more subtle. One’s defences, so to speak, may go down more readily when someone is encountered who, no matter how unconsciously, is seen to have a similar smile, gesture, manner of speaking and personality style of a much-loved and much wanted opposite sex parent. Such a person may be seen almost from the outset as particularly exciting sexually, desirable and loveable. The fact that the first deep relationship of many young men is with an older woman and of many young women with an older man suggests that such an effect exists but it must be stressed that it is not worked out in the conscious mind.

Similarly, for some individuals, a much-loved brother or sister seems to be the unconscious basis of choice and in such cases physical similarities can be important. Some such couples look as if they could be brother or sister. In fact it has been found that men with younger sisters who married women with older sisters were happier than in the reverse situation.

Age is another consideration. Most women marry men one to five years older than themselves. Since boys mature more slowly than do girls this makes sense since they are likely to be equally mature at marriage. However, in the longer term it would make more biological sense for women to marry men about seven years younger than themselves given the longer life-span of women. In fact the happiest marriages have been found to be between women with husbands four to ten years younger than themselves. However, this may be an unsafe guide in general since it is possible that such women are more maternal than average and such men more immature than most or they may have a special need for a mother-like woman.

Since relationships are between personalities and these are independent of age it follows that large age disparities are not necessarily fatal to a happy marriage. In fact if chronological age were disregarded and only the psychosexual (or mental, or emotional, or maturational) age of the partners considered then some couples with very discrepant chronological ages would be found to be the same age psychosexually. Even where the psychosexual ages are discrepant the relationship can still make sense. For example, a mature man with a weak male ego can have a happy relationship with a psychologically immature woman since she badly needs a daddy and to have an adoring and devoted woman boosts his ego. Of course, such a mutually beneficial relationship still needs similarities in the basic personalities if it is to prosper.

Social class also matters if only because attitudes and aspirations are partly governed by class. In consequence people tend to marry in the same social class but men tend to marry ‘down’ more often than do women.

What the available scientific evidence shows is that the more similar people are in background, rearing, attitudes, beliefs, education, intelligence, ambitions, prejudices and so on, the more likely are they to be happy together. Obviously such couples tend to understand each other easily and communication between them is relatively free. This state of affairs is called homogamy. Dealing with someone who has a different cultural or social background to ourselves can be very difficult when it comes to partner selection. Their backgrounds and values are sufficiently different to make it especially difficult, without considerable effort, to understand precisely the feelings their speech and behaviour are intended to convey. For this reason inter-racial marriages can be fraught unless the partners have been brought up in similar cultures. However, for some individuals, marriage to a foreigner is an advantage for reasons which may often ultimately spring from sexual guilt; that is to say, the foreign partner is very different from the opposite sex parent and in consequence unhampered sexual and emotional inter-action is possible with them even if they find it difficult to have sex with a partner of the same race.

*29\164\2*

MYTH: MEDICATIONS RARELY CAUSE IMPOTENCE

Fact: This is false. Many men fail to make the connection between medications and impotence, but there is a strong one—a fact that many physicians neglect to tell their patients (see chapter 3).

It’s important to realize, though, that individuals react differently. A drug that causes problems in Harry may have little or no effect on Paul. And although certain types of medications are well known as possible impotence-causers, knowledge in this area is changing and increasing so that in the future perhaps even more drugs will be identified as causing potency difficulties. In general, stopping the medication that’s causing the problem will clear it up. (Always consult your doctor first.)

But remember that drugs in combination with other drugs and everyday substances can have an effect far more powerful than the drug alone. A man who takes a pill for his cold, has a beer, puts drops in his eyes and smokes a cigarette is ingesting a large number of chemicals. Any one of them may work against his potency. Together, they can wreak havoc on his ability to get or maintain an erection.

*16\184\8*

SEX AND THE OPERATING TABLE: DON’T HURT YOUR PARTNER

Some people worry that they will hurt their partner. Telling them where and how to touch or moving their hand to avoid pain and find the most pleasurable spots will get around this anxiety. During and after cancer treatment it is common to feel weak and tired. If this is the case, it may help to ask your partner to take a more active role than usual in lovemaking.

No matter what kind of cancer treatment, the ability to feel pleasure from touching almost always remains. Some will need to learn new techniques or, in the case of gynecological surgery, may even need to relearn how to have orgasms. Keeping your options open means maintaining an open mind about ways to feel sexual pleasure. Many people have a narrow definition of ‘normal’ sexual activity. As an example, it is not uncommon for some people to think ‘sex equals penis-in-vagina intercourse in the missionary (what do you mean there’s more than one?) position.’ This restricted attitude stands in the way of sensual fulfillment.

Using fantasies of happy memories or special places will distract you from the fears and unpleasantness of the realities. Taking time to explore sensitive parts of your body or playing around with a vibrator will increase stimulation. Trying out different positions to avoid pain and using lubricating jelly to get around vaginal dryness will help to overcome some of the discomforts.

*141\17\9*

SEX AND SEXUAL PROBLEMS: DISINTEREST

In some cases sexual disinterest is a longterm prospect. Emotional factors are high on the list. Chronic depression or stress are frequently associated with loss of interest in sex. Alan became depressed after a series of business failures when he was in his thirties. ‘At the time I just wasn’t getting any sleep. I had so much on my plate that months would go by when I hardly thought about sex at all. It wasn’t until I saw the light at the end of the tunnel when things started to improve at work that I realized how little interest I had had in sex.’

How interested you are in sex depends heavily on the target of your affection. Sexual chemistry is a funny thing. ‘Chemistry’ implies a cocktail of ingredients — triggers — that set off another person’s sexual interest like a smile, a perfume, hair color, body movements. Romantic poets depend on it. No scientist has been able to explain it. It defies logical definition, yet it is such a vital element in any successful sexual relationship. Two people can be totally compatible as friends, enjoying each other’s company and sharing the same interests but if that intangible we call chemistry just isn’t there, then libido might be a bit evasive.

Being with the wrong partner can be the reason for a relatively lower interest in sex but consider the effect of partners being the wrong gender for you. The possibility that you are not interested in sex because you would actually prefer a partner of the same gender can be immensely confronting, particularly as it goes against the grain of a lifetime of conditioning. This rarely becomes an issue until strong sexual feelings are ignited by a person, an event, or a fantasy. And it can come as quite a shock, as it was for Kate.

‘I remember, as a teenager, having crushes on older girls at school but that wasn’t anything unusual amongst my friends. I started dating boys when I was about sixteen but I wasn’t really that keen on the whole process. When I met my husband we got on incredibly well together and I knew I was in love with him but I always had the feeling there was something missing. Although I didn’t avoid sex with him, I certainly didn’t initiate things very often. My girlfriends had always been very important to me but when I met Marie it was totally different. It sounds like a clich? but it was like I had been hit by a bolt of lightning. I remember being acutely aware of an intense sexual attraction between us and thinking, “I don’t want this to happen; it’s just too hard”, but it was impossible to stop the feelings. My libido felt like it was turbo-charged, and I realized this was what I really needed.

*121\17\9*

SEX AND PREGNANCY: MISCARRIAGES

One woman who has endured four miscarriages told me, ‘Anyone who thinks life doesn’t start at conception has never had a miscarriage. Actually, the first one wasn’t so bad. It didn’t really connect for me that it was a baby I had lost … more like a blood clot or something … and I explained to myself that there must have been something wrong with the baby. Nature’s way of getting rid of abnormal babies … you know what people say to try and make you feel better. After I had my first live baby, my attitude really changed. It was much more real then. I wanted a big family more than anything in the world but I had three miscarriages in two years. The first went to sixteen weeks and the next two only lasted twelve weeks. Each time I had a miscarriage it was as though I had lost a baby at full term. It’s impossible to describe the pain of the grief. Lying in the hospital ward with a drip in my arm before the curette, it was so lonely. The staff were trying to be really understanding, but to them miscarriages were so commonplace that they were just a routine. I thought if one more person says “Better luck next time” I will just scream! One strange thing that happened each time I got pregnant was that I became incredibly protective of myself and the baby as a unit. I wouldn’t let my husband anywhere near me. Sex was out of the question and my only priority was getting the pregnancy to term. I wouldn’t do anything that would disturb the baby. I would cringe even if he wanted to give me a cuddle because I’d think, “Oh no, he wants to do it!” I really felt like I was being attacked.’

The harder it has been to get pregnant or to take the pregnancy to full term, the stronger this siege mentality gets and it really is understandable. In fact women with a history of repeated miscarriages may well be advised to avoid intercourse for the first few months of the pregnancy as a precaution, although most will do so anyway as an instinct. This is one of those situations when it is important that the woman’s partner understands the reasons the advice has been given. That makes it a team effort for a common goal, rather than the man feeling totally shut out of the pregnancy. I’ve heard it said that the Freudian concept of ‘penis envy’ is just a decoy invented by men to take the attention away from their ‘womb envy’, an unfulfilled desire to experience pregnancy for themselves. The point here is that the more pregnancy is treated as a team effort the less likely you are to run into problems, and that means men being involved and informed as much as possible at every stage.

*100\17\9*

MAKING A COMMITMENT: WHEN YOUR PARTNER BECOMES SERIOUSLY ILL

Another case where a secondary relationship can develop is when one partner becomes seriously ill or permanently disabled to the point where a sexual relationship is no longer possible, as in the case of advanced AIDS-related illness. The other partner takes on the role of carer and may remain deeply committed but establishes a separate sexual relationship.

A secondary relationship may also reflect a person’s lack of self-confidence — asking themselves if they are still sexually attractive — but it can also be a sign of a relationship in trouble. If a person is considering leaving their partner, they may well be looking to establish another relationship before they finish it. You could call it the ‘Tarzan Tactic’. Imagine Tarzan swinging through the trees from vine to vine. He won’t let go of the last vine until he has a firm hold on the next.

There is no question that the disclosure of a secondary relationship can leave a partner feeling shocked, betrayed, jealous, angry and hurt. It is frequently the cited cause of relationships breaking up but does this necessarily need to be so? It can be a good time to reassess the whole relationship.

*80\17\9*

SEX AND SEXUALLY TRANSMITTED DISEASES: SAFE SEX. IS IT POSSIBLE?

It is often said that there is no such thing as totally safe sex (except masturbation on your own) and that the campaigns to increase condom usage fail to take into account that condoms can break in action. They even changed the expression ‘safe sex’ to the more accurate ‘safer sex’. It’s true that sex education is still in a process of evolution and we need to know where the misunderstandings are so that the information can be adjusted to account for them. Moreover, it is becoming more and more obvious that safer sex instructions need to be detailed enough so that there can be no room for error. It is not enough to say ‘use a condom’ without making it clear that putting it on at the last minute, just in time to catch the ejaculated semen, may be too late. Many people don’t realize that you needn’t actually ejaculate to pass on an infection. In particular syphilis, genital herpes and warts just need skin to skin contact, so for protection the condom needs to be put on before there is any genital contact at all.

It also helps to know things like how to put a condom on and take it off again correctly, that you need to keep squeezing the teat, at the end until the condom is rolled right down to the base of the penis, and that using a water-based lubricant helps to prevent the condom from breaking.

*60\17\9*