Weight loss and diet plan for a healthy lifestyle.

Again, this phase is one from Neighbour’s model (1987), although he calls it ‘safety-netting’, an expression which may not be immediately clear to everyone. This phase involves agreeing an outline of further management and the timing of the next appointment. Equally, it is important to make clear how to gain access to the doctor or nurse in the event of any difficulty, the symptoms which a patient should report immediately and the possibility of changing contraceptive method if the proposed method does not suit.

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Complaints that the method of contraception is affecting sexual performance or desire, especially if frequently presented, can indicate a problem within the relationship which the patient does not wish to face. The anxieties are focused on the method of contraception; the fantasy is that, if only this could be made all right, so would the relationship. Doctors are often aware that underlying relationship problems may be behind the request for sterilization or vasectomy (or to stop contraception to have a baby to ‘mend’ the marriage), but sometimes forget that such difficulties may be behind an otherwise reasonable-sounding request.

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Some women of any age find it hard to ask for help which is essentially help to be sexual. The older woman may find it harder because of a perception within herself that sex is for the young, or because of a feeling that the doctor will disapprove of sexuality in someone of her age. The widowed and the divorced may have an added sense of disloyalty, especially if the previous partner was known to the doctor. For women with an extramarital partner, especially if the husband has had a vasectomy, the problem is even greater.

A request for postcoital contraception may also be difficult. It may be forgivable for the young to make mistakes or get carried away in a moment of passion, but there is a feeling that at over 40 society expects you to know better. Or perhaps it is a feeling that society does not expect you to have strong, that is sexual, feelings at such an age. Yet women in this situation have to approach an authoritative member of society for help. It must not be forgotten that doctors are still seen as authority figures. In this context it may be particularly difficult to approach the general practitioner, however good and sympathetic he may be. Indeed, this very goodness and concern for the patient can be a barrier. Most people want their regular doctor to see them as a sensible and competent, and it can be particularly difficult to expose the silly side of oneself to the person who will be providing continuing medical care. An alternative source of help, where the patient need never return unless she wants, is vital.

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Saeeda Nessa had lived in the UK since 1983. Five children had been born between 1975 and 1983, and any space between pregnancies had arisen because of her husband’s visits to the UK. Since living with her husband in London, she had had a baby every October, all boys. She had a past history of pulmonary tuberculosis, leaving her with partial bronchiectasis and recurrent bronchitis. Her husband, who always accompanied her to the surgery, was rather demanding and overbearing with reception staff, and frequently referred to the Race Relations Act if they did not accede to his peremptory requests. The GP’s attempt to discuss contraception during the gestations of the 1987 and 1988 babies were repudiated by him with the rules of Islam. The religious laws were never confronted directly by the GP, but longer experience of this man revealed that his bark was worse than his bite and that the family was not in such awe of him as might at first appear. The message about contraception was respectfully but relentlessly put. Saeeda finally came without her husband, but with his tacit consent, for her first discussion about contraception. It is now four years since her last child was born and her husband smiles wryly whenever the doctor checks with Saeeda about her contraception.

Conversely, a physical symptom or other problem may be presented as the reason for not getting on with a method, in order to avoid discussing cultural issues. A consciousness that one’s culture’s general opinions about coils or Pills are held to be ridiculous by a sophisticated westerner may also incline one to pull down the cultural shutter.

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Feelings of diffidence in the doctor may come from within, but are often a reflection of the patient’s diffidence. There can be a strong feeling of the need for approval on the patient’s part, and from the doctor’s viewpoint there seems to be a need to be the permission giver. When people have disabilities there is a sense in which their body no longer belongs to them, for other people take it over and do things to it. It is difficult for the patient to obtain or accept responsibility for his own choices and actions. Such a handing over of responsibility is particularly common when there is a mental handicap, where the expectation of compliance is an everyday experience, the person being expected to do as he is told and to have decisions made for him.

Encouragement by the doctor to explore choices and to make decisions, to try, and to see the act of trying as a success, is the greatest help. The person may need to return again and again for the continued reassurance that ‘it is OK’. There is a hint of seeking parental approval, but with encouragement a growth of confidence and the acceptance of a sexual role can develop, as well as an ability to make worthwhile relationships.

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