The Health Blog

Patients may have continuing problems of which the doctor is aware, and which may or may not be relevant to refer to in a particular consultation. An example would be a relationship difficulty which might itself need attention in its own right or because of its direct bearing on the presenting problem, for instance a request for a change of method of contraception.

Risk factors can be assessed, in particular noting any new ones since the last attendance. Opportunistic health promotion is the other item which comes from the Stott and Davis model (1979). This may be irrelevant on some occasions, for example, a request for emergency contraception. The term includes screening (cervical cytology, rubella immune status and blood pressure checks for those using non-hormonal methods) and positive health promotion (help with giving up smoking, dietary advice, suggestions for improving relationships with the patient’s partner and raising the question of safer sex and reducing risk of sexually transmitted diseases, including HIV infection).

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Others at this stage in their emotional development are still trying to assert their individuality and establish themselves as adults in the eyes of authority (parents and other parental figures such as teachers and social workers). The irony is that they do so in an irresponsible way, demonstrating to the parental figures that they cannot be relied upon to be sensible and adult. For this group, becoming pregnant is often a subconscious way of proving to the parent that they are old enough to be treated as an adult, so they forget their Pills and fail to turn up for their repeat appointments.

Peer group pressure may make some girls attend for contraception when they do not need any. Their regular attendance and acceptance of packets of Pills may hide a hidden desperation that they are not like other girls.

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New-found independence, which often comes when there has been a final acceptance that the child-bearing days are over, provides freedom to enjoy life as a couple again. In the same way a new job or entry into training for a new career makes the need to avoid pregnancy or prime importance, so couples may need to reconsider their contraceptive method.

At this stage in life a late period can be a cause of great alarm. Pregnancy must be excluded, for an assumption that the patient is menopausal is unhelpful and may give a sense of false security which is disastrously dispelled if a pregnancy is later confirmed. If the woman has been using the rhythm method or the safe period, with or without the intermittent use of a barrier method, explanation is necessary: now that she is peri-menopausal she cannot rely on the safe period as her menstrual cycle will be irregular. Women who have continued to use natural family planning or a combination of those methods with a barrier method may need a lot of education and support, as well as an examination of their fears if they are to be helped to use a safer method such as the IUCD or hormonal contraception. The fact that they have not chosen those methods before may tell doctors something about their feelings towards them.

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Certain clinical problems arise in contraceptive practice that are general to transcultural medicine. The clinician needs to be aware of symptoms and signs that indicate a disease more prevalent in such patients than in the ethnic majority. The problems of rickets, tuberculosis and diabetes in Asian patients, and hypertension in Afro-Caribbeans are widely discussed. More particular to patients in the child-bearing age group is the issue of preconception counselling and genetic disease. Recent immigrants from rural areas are less likely to have had rubella immunization. Higher rates of consanguinity in Asian couples, haemoglobinopathies and hepatitis  carriage in those from the Far East, are all problems that require the practitioner to be aware, or the record system to be arranged so as to prompt the doctor, to check for these risks.

Training for staff to use different naming systems is available in some areas where local courses are held. Birth dates may be unknown to patients from areas where birth registers are not used, and those given on passports should not always be considered reliable data.

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For the doctor, it can be an advantage to have an interest in the subject of disability because of the awareness, insight and expertise that can be provided, although comfort with questions of sexuality and counselling skills are without doubt the most important aspects of the care that can be provided. Doctors trained in psychosexual medicine develop individual styles, but there is a common pattern of a patient-centred and listening approach which gives a framework to their work, and the security of what is familiar. When trying to help a person with a disability some change in technique may be needed if the real person within is to be reached. For instance, speech difficulties due to neurological disease make it difficult for the patient if the doctor merely listens and encourages the patient to do all the talking. The physical exhaustion and strain of speaking, especially about stressful things, takes too high a toll. The doctor must therefore adapt his technique.

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