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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It is impossible to think of love without jealousy – a wholly negative emotional state in which the sufferer becomes anxious, suspicious and angry in response to real or imagined threats to the love-bond between him or her and another. Some degree of sexual jealousy is probably normal and it has been extensively studied and copiously represented in literature over the centuries. Such normal jealousy probably plays a part in holding couples (and their families) together and probably stops errant partners from indulging their sexual whims more than they otherwise would. It can, of course, work the other way and turn homes, in the words of one expert, ‘into hells of discord and hate’. Marital sexual jealousy can be very dangerous indeed and men are more dangerous than women because of their greater physical strength and aggressiveness. Sexual jealousy affects both homosexual and heterosexual couples and can drive people to commit crimes of violence and even murder.

Jealousy is a strange emotion because it has a large component of self-pity and selfishness to it. In jealousy there is often more self-love than love. Any situation that makes one of the partners feel at a disadvantage in the straggle to obtain or keep a mate predisposes the handicapped person to sexual jealousy. Impotence on the part of the husband and frigidity on the part of the wife and a marked disparity between the sexual appetites of the couple are often predisposing factors.

There are perfectly well-recognised psychological and medical causes for sexual jealousy too. For example, some forms of mental subnormality and certain sorts of brain damage are known to cause it. Drunkenness makes people jealous; as do cocaine and amphetamines. During pregnancy, in the post-natal period and around the menopause women often feel jealous even when there is no reason for them to do so. This could be hormonal in origin but is more likely to come about because at these times women feel disadvantaged in the sex market in comparison with other women.

Often jealousy is a sign of inferiority in the complaining (jealous) partner. He or she is threatened because of the possible loss of his or her spouse’s love. This often means he or she has no confidence and sees every man or woman as a threat to the relationship.

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There is some hard evidence that sex promotes health but it has to be admitted that some people seem to manage perfectly well and live healthy and happy lives without it. Possibly they find satisfaction in displacing, or sublimating as it is called, their sexual energies into other activities. Others are unable to do this and become miserable without a regular sex life.

Priapism-This is the medical name given to an erection which is painful and will not subside. It is rare and needs medical attention urgently. More common (but not commonplace) is the man who is repeatedly woken at night by a painful erection if he has already had intercourse or has masturbated. Repeated intercourse or masturbation does not seem to help. Time is the healer and no other cures are needed.

Phimosis-This is a condition in which the foreskin is very tight in an uncircumcised boy or man. It can be caused by parents forcibly retracting and tearing their baby’s foreskin, which then rejoins, with the formation of scar tissue, so tightening up the whole area. Infection behind such a foreskin can cause troublesome balanitis. Anything other than a moderate degree of phimosis needs treating (by circumcision) because intercourse can be painful.

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Unbelievable though it might seem to many people, there are individuals, lots of them, who believe that any form of sexual expression other than putting the penis into the vagina is a perversion, and for some women, to enjoy sex simply for the pleasure it gives them is near perverse.

Such notions still underlie our cultural heritage. Unconsciously, many people, including those who think of themselves as sexually liberated, believe that any indulgence in sexual pleasure is likely to bring punishment from God, perhaps in the form of mental illness or disease. Our laws and customs also reflect the view that sex is sinful and harmful.

Our sexualities work against this suppression imposed in childhood and adulthood. But the desires and instincts that are blocked may have to find an outlet in some closely related form and this, by definition, is a deviation. However, our sexualities are as various as our personalities, so some people all of the time and all of us some of the time are going to be attracted to activities, either as a prelude to intercourse or as a substitute for it, which do not conform to the basic cultural norms of copulation. Because there is often so much shame attached to the desire it may not be admitted to the individual’s partner. Even if it is, some partners cannot cope with the request for what to them is very odd behaviour and sometimes use a deviation like this as a reason for divorce.

Because the whole subject is so shrouded in secrecy the public’s knowledge of what ‘normal’ people do or would like to do sexually is poor and it is easy to denounce the sexual behavior of others as abnormal, deviant or perverse. Such condemnation used to be very prevalent, but many activities that used to be thought of as unusual or perverted are now known to be widespread and well within the range of acceptable and ‘normal’ behaviour. Oral sex (fellatio and cunnilingus) is an example and is dealt with in the chapter on foreplay.

Today the topic of oral sex has been so widely discussed that it has become a positive fashion. Most couples use it simply as a sexual enhancer before actual intercourse and so long as it remains a form of foreplay to arouse or an occasional change from vaginal intercourse it is acceptably normal but a person who can have only orgasms as a result of oral sex probably needs professional help.

Cunnilingus is probably increasing and the main explanation other than the fact that inhibited women can often succeed in having an orgasm only with oral sex, may be that the male population collectively is losing its self-confidence with regard to penile performance and is increasingly depending on the more reliable tongue, which does not lose its erection or come too quickly. In the end, though, we are mammals and mammals suckle their young. So our first physical pleasure in life is oral and this involves sucking another person. It would be surprising if orality were not important in our sexuality – it certainly is in some other mammals. Its practice in the past has been denounced as a perversion simply because it seemed to lead to: ‘pleasure sex’ rather than furthering copulation as a reproductive duty.

What we have said about oral sex can be used as a model to discuss almost any sexual activity other than basic and unadorned copulation. Nearly all the activities involved can be used as a part of foreplay (as a sexual enhancer), as an occasional alternative to penis-in-vagina sex, or as a more or less perpetual substitute for it.

In foreplay we tend to re-enact not only our psychosexual development but also the stages through which most young people progress from first sexually kissing a member of the opposite sex to first having intercourse. So foreplay usually contains elements of pre-genital behaviour (oral, anal and phallic) and to this extent could be (wrongly) regarded as perverse. Good foreplay also contains an element of courtship too. Everyone, or nearly everyone, unless they repress them into the unconscious, has sexual fantasies which they, or others, would think of as perverse. Foreplay can be the way in which couples, especially younger ones, both express and contain their perverse thoughts and fantasies. This explains why young couples tend to experiment more sexually and this is good because they should in this way slowly evolve a pattern of sexual behaviour which suits them both. In general, a sensible rule is that anything which helps one’s partner to greater arousal and better quality orgasms and satisfaction is not only permissible but welcome. So voyeuristic, exhibitionist, oral and even minor sadistic and masochistic acts as well as bondage could well be involved.

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Until the seventies the existence of this incurable condition was hardly known to the public. It is caused by a virus (the cold-sore virus) which produces painful, burning, fluid-filled genital blisters. There may also be burning pain on passing urine and painful lumps in the groin. The sores can become infected. About 30,per cent of sufferers have other symptoms such as tingling pain down the legs, back pain, a fever and swollen lymph nodes (glands). The blisters may recur several times a year and some people have as many as twelve bouts a year with stress and menstruation seeming to act as triggers.

Genital herpes is caused by the herpes simplex virus which is closely related to the virus that causes cold sores. Of babies infected during birth (as they come down their mother’s infected vagina), about half die or are severely retarded – so it is a serious disease for them. In women, recurrent attacks are thought to increase the risk of cervical cancer five- to eight-fold and sufferers are advised to have a smear done every six months.

Probably the most unpleasant thing about the disease is the terrible psychological and emotional effects it can have. These have been aggravated by exaggerated propaganda about the disease. However, the thought of having to declare that one has an incurable venereal disease before having intercourse with someone is a tremendous strain and carries an enormous responsibility. In the US so great is the problem that special self-help herpes groups have been formed. A new drug (Acyclovir) is available to help treat the disease but has to be given intravenously which means a short stay in hospital. Various other treatments including diets, locally applied yoghurt, whisky and ether have been tried but have proved ineffective.

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What are the commonest misconceptions children have about sex?

Children (like adults) have all kinds of strange ideas about sex, mainly because they feel it is a ‘no-go’ area, about which they cannot ask, or that if they do they will not get an honest answer.

Here are some of the most common misconceptions, so that you can work them out before they come up. (They are arranged approximately in order of the child’s age.)

A woman gets pregnant by swallowing a man’s seed.

Babies come out of eggs like chickens.

You can buy a baby at a shop.

Babies come out with urine from a woman’s body.

Babies are born from a woman’s anus.

Babies come out of the navel.

Even if a man and a woman only kiss they will have a baby.

Every time a man and a woman have sex they have a baby.

Girls used to have a penis but it was cut off for some reason.

Men have nipples so they must be able to breastfeed.

All fat women are pregnant.

Only women who are married can have a baby.

Only women who love their partner can have a baby.

The only time a man and a woman have sex is when they want a baby.

Masturbation will make you homosexual.

Masturbation will give you spots.

Girls can keep your penis in their vagina and even cut it off in there.

Girls who have just started having periods cannot have babies.

The only time a woman can have a baby is when she is ‘on heat’ (menstruating).

A girl cannot get pregnant unless she has an orgasm. You can only get VD from toilet seats. French kissing can get you pregnant. Orgasms can make you pregnant.

Being in love means you ought to have sex with someone.

Sex is the best way of proving you are in love.

Parents cannot possibly begin to understand what you are going through because they are too old-fashioned.

No mothers masturbate and they are too old for sex.

Aims for ideal sex education-Sex education should prepare the young for the conflicting and difficult emotions they are about to experience (or actually are experiencing) and should help them cope with them.

An ideal sex-education programme would undo previous harm, correct tendencies towards perversions, and detect children who need more personal education and care or perhaps even therapy. Through insight it would simultaneously maximise both the child’s potential and control. These, surely, are sound educational aims whatever subject is being taught.

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