Growing Into Medicine (21 page)

Much of my professional life had been dominated by my lack of knowledge and by my anxiety that I would make mistakes. The opportunity to concentrate on the patient instead of myself was a new experience and a great relief. For the first time, I was encouraged to think not ‘was that right or wrong?’ but ‘what does that mean in terms of the patient?’ In addition, we were listening to stories of the sexual lives of our patients. It was particularly important that our personal lives were not exposed to the group in any way that we might regret later. Our professional selves were being studied, not our whole persons, allowing a more open and honest critique of our work.

The second tenet of the IPM, the study of what became known as the psychosomatic genital examination, emerged during Tom’s early work with family planning doctors. They noticed that before, during or after that vulnerable moment when people take their clothes off, they might get in touch with feelings they had not been aware of or had not connected with their symptoms. For most of us, when we lie on the couch, we are concerned to detach ourselves from the embarrassment of the exposure, to act unconcerned and sensible. The idea of further exposure, of feelings as well as flesh, is threatening. I was once asked if I obtained the patient’s permission to do such an examination – as if it was some invasive procedure, like an X-ray. It is nothing of the kind, merely an attempt to provide a listening and observing space where feelings can be allowed to emerge if they are pressing to do so. The most one could do to facilitate such exposure would be to comment on tension, sadness or fury evident in the face or body of the patient, or just present in the room.

As I became more confident I began to lecture on various courses. I will never forget being seized by the arm as I stood on an escalator leading to the underground in Stockholm. A young gynaecologist looked earnestly into my face as he asked, ‘Just how exactly do you do this psychosomatic examination?’ With the crowds surging round us, I was silenced by the impossibility of condensing several years of study and experience into a one-minute soundbite.

The next stage in the development of consultation skills was to learn how to step outside my feelings and interpret them to the patient in a meaningful way. Tom suggested that one cannot feel and think at the same time. The activity must be one of going close to feel with empathy, then pulling away to think, the movement one of rapid oscillation. I continued to struggle to develop this art for the rest of my professional life.

Because the feelings in the consultation were to some extent a product of our own internal worlds, our remarks had to be tentative and patient centred. Not ‘You are making me feel sad’ but ‘I wonder
if you are feeling sad’. Or even ‘There seems to be a lot of sadness (anger, fear) around.’ One colleague found herself almost asleep as the patient droned on. Instead of processing the feeling she said, ‘I’m feeling very sleepy.’ The patient replied, ‘Yes, I have that effect on everyone.’ The doctor was immediately interested and fully awake. I cannot decide if her remark was foolhardy or courageous. I would not have been so direct, but in this particular instance the remark freed the patient to let out something real.

Tom Main called the study and use of the doctor–patient relationship the
golden road to understanding
. He departed from Balint by believing that doctors who were not analysts could learn to lead training seminars. I became a leader and attended the leaders’ seminars. Although we learnt much about groups, the most striking aspect of these meetings was the way Tom always took the discussion back to the patient. As with the basic training, we were taught no theory, for Tom believed passionately that one learnt by doing, his favourite quotation being from Izaak Walton,
That art was not to be taught by words, but practice
.

I am concerned by a further memory. Tom frequently asked, ‘Is this patient suitable for a brief psychosexual approach?’ I don’t remember asking this in the groups I led and I wonder if I had enough experience of more disturbed people to make that judgement myself. I did refer some patients on for further psychological help so at least I was not trying to cure the world. Tom thought we could help those with a problem in a focused area of their personality. This is not the same as focusing on the sexual problem – that was always secondary to the doctor–patient relationship.

The skills of psychosexual medicine cross the boundaries between the body and the mind. Along with others, I often felt ignorant and ill equipped to help.

‘This work is really difficult,’ I complained to Tom one day.

‘What do you expect? Anything worth doing is difficult. Stick with it.’

That obligation to stay with the here and now of the consultation,
to remain in ignorance with the patient, required more courage than I realised at the time.

I have never felt myself to be courageous. Childhood and adolescence were full of frightening things. To my shame, when a gaggle of hissing geese approached, it was my younger sister who intervened to protect me. Since becoming an adult I had been able to avoid doing anything alarming. I only realised how easy it had been to run away from anxious situations when Ralph and I moved our cabin cruiser south from Yorkshire where it had been built. Bringing it by road would have been impossibly expensive, so we found a route via the canals and the tidal Trent. As soon as we passed through the lock into the rushing tide our engine failed. We were pulled back into the calm of the canal and had to wait a whole day while the engine was fixed and the tide reached the required height again.

There was no escape from the wild waters that waited for us. Glad of the pre-exam experience of controlling my nerves, I immersed myself in a novel, walked the dog along the towpath until exhausted, even tried to pray. Ralph read his book of knots, only looking at the engine manual when he thought I would not notice. I was glad he ignored me; we both knew that no words could relieve our anxiety.

When the time came to exit the lock for the second time all went smoothly. I clutched a handrail for support against the movement of our home, now a fragile matchbox in substantial waves. In the late afternoon we passed into the Fossdyke navigation via another lock. Once through to the other side, the scene was transformed. Boats were moored by the bank, motionless in the placid water where moorhens puttered about. Sitting in the still evening sunshine, protected from the fury of a nine-knot tide, made us realise that we knew nothing of the reality of nautical life.

The memory lingers as one of those moments of peace, so often provided for me by a river or canal. Some people long for the sea from which our antecedents, those minuscule creatures, dragged themselves onto the land. Perhaps the expanse of ocean signifies a
greater reality into which our beginning and end can merge. For me, the journey is more important than the arrival. From those days on the river Thames with my parents, via our canoe, various punts and then our canal boat, the inland waterways have coursed through my being. Upland brooks still call to me, even though I can no longer walk up the hills to reach them. Rivulets join to form small rivers that coalesce and become waterways, on which we humans can journey, becoming a part of the whole. During those years when I was struggling to learn how to consider the body and mind as one entity, these watery experiences shared with Ralph not only continued to hold our marriage together but fed what, in the absence of a better word, I have to call my soul.

14

Body Fantasies

As I write about psychosexual medicine my voice takes on the tone of the lecturer I became, originally as an occasional speaker on family planning courses, then to various other groups of health care professionals. Telling people about the work, or about my life, appears to negate the idea that listening is important. Perhaps the tension between these two opposites can provide ways to approach the truth. Neville Symington, in his book
The Analytical Experience
, says ‘Truth. . . is a reality that exists between two people seeking it. . . truth can be seen or glimpsed, not possessed.’

The truth of someone’s mental picture of his or her own body is certainly difficult to grasp. The word ‘fantasy’ often describes a pleasurable journey into an imagined world. It has also come to be used for the more florid misconceptions held about the body. These distorted images may underlie the problem of non-consummation.

The inability to have full, penetrative sex is a fascinating example of the interaction of the body and the mind at different levels. There can be no doubt that social attitudes are very important. Good sex education, a more open approach to the body and relationships and the more enlightened upbringing of children must have reduced the incidence, although accurate figures are impossible to obtain. The difficulty is often revealed during a family planning consultation. A woman might feel she needs a cervical smear but is unable to relax enough to allow it to be taken. The matter is intensely private and may only be forced into the open by the desire for children.

One of the first studies into the problem was published as a book
edited by Leonard Friedman under the title
Virgin Wives
, a report of the work of one of Michael Balint’s seminars. The group identified different character traits. To quote from Prue Tunnadine’s groundbreaking book
Contraception and Sexual Life
, these included the maternally enjoined ‘sleeping beauty’, the defensive-aggressive destructive ‘Brunhild’, and the ‘queen bee’ wishing for virgin motherhood. As Prue points out, these types are often blurred.

I did not use these concepts or talk about them with colleagues. I am left wondering why I shied away from exploring ideas that could have been useful. Perhaps my personal discomfort with the world of myth was partly to blame. I have only recently begun to appreciate the usefulness of story and the part that metaphor can play in the search for truth. On the other hand, in terms of the doctor–patient relationship, the avoidance could have been due to something coming from the patient, encouraging me to think in more concrete terms.

The satisfaction of helping a woman and couple to consummate their relationship is so great that it is tempting to overestimate the success of treatment, whatever method is used. Simple behavioural methods, ‘retraining’ with graded exercises, may be helpful, although I find the approach uncomfortably authoritarian. I listened once to the description of a woman who had been encouraged to put her finger in a saucer of strawberry jam because the feel was like that of the moist vagina. Not, I thought, very similar at all, and for me an unpleasant image of stickiness and grainy seeds.

The didactic methods employed by many ‘sex therapists’ fill me with horror. At one meeting I heard such a therapist holding forth about her methods which included a five-page questionnaire. ‘You must know the background fully,’ she said. I was reminded of the time-wasting nature of questions. In a careful study of 159 cases treated by members of the IPM (Bramley et al., 1983), all of whom had been trained not to ask questions, 60% consummated within six months. Over 80% of these patients had consulted other agencies before coming to us for help and the mean duration of symptoms was 4.2 years.

I don’t remember the first patient I saw, or the total number. The successes stay in my mind while the failures drift away like dandelion seeds in a summer breeze. The simile feels inappropriate when the difficulty is such a burden for the sufferer. But the image floated up when I tried to recall my failures – a defensive snapshot, as if the pain of not being able to cure has been converted into something that can be brushed away – although dandelion seeds do have a tendency to cling to one’s clothes.

The main thing we discovered by listening to patients before, during or after an attempted examination was the prevalence and variety of body fantasies. These beliefs had usually never been voiced before and were often unconscious. The range and multiplicity of these misunderstandings surprises me to this day. Nothing in the following paragraphs will be new to those who work to uncover hidden fears. I hope they may be of interest to the general reader. However, if you are squeamish I suggest you skip the next section of this chapter for it contains, as the TV warnings say, ‘scenes of a disturbing nature’.

The fear that there is a ‘block’ at the entrance to the vagina is so common that I used the word in the title of my book
Blocks and Freedoms in Sexual Life
, published in 1997. I was writing for the medical and allied professions but I find myself re-reading it now as I address a wider audience. After being away from the work for more than ten years I have to remind myself of the understanding that I was groping for at that time.

Vaginismus, a reflex spasm of the muscles, is often the cause of the apparent block. Occasionally there can be a physical abnormality. The hymen can be unusually thick and tight, as I found in one patient. I warned her that I thought she might need a small operation but she wanted to try and stretch it with her own finger. Within two weeks she had managed to have enjoyable sex – but then, she did not have irrational fears to hold her back. Other very rare conditions include double vagina and the presence of a hymen that extends across the whole entrance, causing abdominal pain in adolescence when the menstrual blood cannot escape.

The hymen and the whole question of virginity have been subjects of interest for thousands of years. One of the medical museums in Vienna has ninety-two hymens displayed in glass jars. Some of these are torn or scarred, some have bands across the opening, some have inelegant skin tags and some are thick with a tiny hole. I went round the exhibition as a medical student, after falling off a horse that had kicked me on the head. I was a bit dazed before the tour started. By the end I was in a whirl, but at least I realised how very difficult it can be, impossible in many cases, especially today when girls use tampons from an early age, to say if someone is a virgin. Yet this diagnosis still remains a matter of legal and emotional importance, especially in some Asian and Muslim cultures. I was amazed to find how many on-line questions were devoted to the subject. Most of the answers depended on the opinion of an examining doctor, which I suggest may be open to doubt. For Catholics the importance lies in the fact that the Pope can annul a marriage that has not been consummated.