PSYCHOSEXUAL PROBLEMS IN THE CONTRACEPTIVE CONSULTATION – EXAMINING THE WHOLE PATIENT (HIDDEN PROBLEMS)
Some patients will provide clues about hidden problems from their reaction to suggested physical examinations. Most women attending for contraceptive consultations expect a vaginal examination and doctors feel that it is appropriate to offer it. Some may welcome it (as above), most regard it as a necessary evil, but some positively avoid it. The patient who always attends with a period, or breakthrough bleeding, or has to dash off to another appointment, needs to have her anxieties about vaginal examination explored. One patient who avoided examination feared that the doctor would be able to tell that she had had a previous termination of pregnancy, which had been arranged without telling her GP. Another was having painful intercourse and feared that the examination would be painful, or reveal some sinister cause for the pain. When finally achieved, it was found to be due to vaginismus, which was be relieved by an understanding of the ‘fear-contraction of muscles-pain-fear’ cycle. Insisting that the patient must be examined without noticing the nonverbal signals of incipient panic can lead to disaster. One doctor related the story of a patient who had been told to undress in an examination cubical and await the arrival of the doctor to do a cervical smear. The doctor arrived to find the cubical locked against him and the unnoticing nurse had to spend many minutes persuading the patient that she could leave without being touched. The doctor had to refer the patient onto a colleague (she refused ever to attend him again) and the history of nonconsummation eventually emerged.
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