One can picture a man entering his sexual life and making decisions about contraception. He is prepared by his early sexual and family experiences, and is under a yoke of expectation from both himself and others. He may be able to accept and assimilate such forces, or he may not be able to cope, using such defences as denial, splitting or internalized depression.
In our everyday work with patients, doctors will discover that the aggressive, pleasure-seeking stud is a rare beast, but if they can listen to the hidden feelings, doctors will find a more complex human being. Although he may have times of uncontrolled pleasure, they will be interspersed with upsurges of longing for safety and loving, and the problems brought by the need to be in control.
When in a stable pair bond, decisions about limiting his family will seldom be based on his personal needs alone. He will worry about his partner, and such concern is to be welcomed, but at other times it may be necessary to help him to pay more attention to his own needs. Such necessary concern for the emotional life of both partners may lead to a move from one contraceptive method to another until one is found that feels right.
Noticing the way in which couples interact together in the clinic or surgery can give an insight into how they interact together at home, and so play an important part in the help that can be offered to them. This type of counselling can be carried out by experienced clinicians at the same time as discussions about the advantages and disadvantages of investigations and treatments. Couples need the opportunity to weigh up their chances of a pregnancy so that they can make an informed choice about the direction to take. Sometimes this involves the painful realization of lost hopes and dreams.
On occasions the two individuals appear to have coalesced into one, in such a way that the wanted baby has become an amalgamation of their mutual desires. Their own individual personalities appear to have been lost many months or even years before. Although they must both have their own emotions and feelings about being childless, it can be very difficult for these to be respected by each other, let alone the doctor.
The particular woman’s circumstances, her support network and her own coping mechanisms and ethical framework will influence her decision as to how to proceed with any particular pregnancy.
For some women the factors can be equally balanced, making a decision very difficult.
Mrs C. is a married woman in her late 30s. Her existing children are growing up a little, she enjoys her independence and plans further education for herself. Although she has always liked the idea of another child, this pregnancy was unplanned (she has an IUCD). She loves babies but also values her newly found independence.
Whatever this woman decides will involve loss, either of a baby or of independence and education. Her age means she feels that another opportunity for a baby or for college may not come along. So this to her is a once-and-for-all decision. In the clinic she was initially very angry and critical of the staff. When this was pointed out to her she could see that she was angry at being pregnant and being placed in this position, and critical of herself for even considering abortion when she had a husband and a home.
Marie was brought, kindly but firmly, to the clinic by her health visitor. She was accompanied by four tiny, smiling and scrupulously clean children. Marie lived in a travellers’ encampment, in a small van with her five children, her husband and his elderly mother. Her last pregnancy (a baby left with mother) had been difficult, and she had been advised not to have any more, for a while anyway. And there the problems started. She would not take the Pill, would not even think of the cap and was horrified at the coil. Her husband considered the sheath unmanly, and she agreed with him. Marie was shy, modest and adamant. The doctor began to probe gently, listening to her, rather than educating or teaching. The Pill was bad for the body, everyone knew that. The cap seemed dirty, and rules in the van were strict about cleanliness, even when getting water was difficult. The coil gave heavy menstruation. Marie looked embarrassed but explained there were strict rules about periods and sex, and this would make things difficult. At the moment her husband was, well, not doing anything, but this was not right. He needed to love her, and she him. Hesitantly, the doctor suggested an injectable contraceptive, explained the problems but expected a refusal. Marie was delighted; one injection and then nothing for three months! But how natural! No amount of talk about side-effects could dent her pleasure.
There may be a discrepancy between the strength of the patient’s demand for contraception and her reliability in using it. Some women and couples do not use contraception at all, although they could benefit from doing so. They fail to attend either the general practitioner or family planning clinic for advice, but are nevertheless frequent attenders at the surgery for various physical ailments of themselves or their children. Such women or their children are often involved with the social services, and may have children on the non-accidental injury or sexual abuse register. They tend to be labelled as feckless and inadequate, or as ‘poorly motivated’. They form the bulk of the work of a domiciliary family planning service, and some of the insights gained in working with them will be discussed later in this chapter.