The blog is about health and gives useful information on health and disease.

Mrs A. took the progestogen-only Pill while she was breast feeding her second child but was advised to change to the combined Pill when she began to wean him. She now had a girl and a boy and felt her family was complete. She was already working part-time. Before her first pregnancy she had taken the combined Pill and again between the children, but now it did not seem to suit her. She had been back to the doctor several times with minor complaints and tried different brands. This time she asked to be fitted with a cap. The doctor noticed that Mrs A. seemed very anxious and asked a lot of questions during cap fitting. She wondered whether Mrs A. was worried about choosing a less effective method, having said she wanted no more children, or whether perhaps she really did want more children and was hoping ‘to make a mistake’, but she kept these thoughts to herself and listened.

‘Can the cap do any damage? How long does it take the Pill to get out of your system? Should I have another cervical smear?’ Instead of offering reassurance, the doctor said, ‘You seem to be rather worried about yourself.’ ‘It’s only since my son was born. It’s all so silly really, but I feel I’ve got to keep myself healthy for them. I suppose it all goes back to when my little brother was born. My mother was a long time in hospital with him. I don’t really know what was wrong, but I know she nearly died. I was only four but I still remember it.’

Did Mrs A. think that what had happened to her own mother might happen to her, or was it the frightened child of four within her that the doctor was reassuring?

The doctor shared these thoughts with the patient, thoughts which had been provoked by the patient’s remarks and were therefore more relevant than her previous ideas about reliability, and after a moment or two Mrs A. said, ‘I think I’ll try just one more Pill. There’s no reason at all why I shouldn’t. I was perfectly happy on it before and I really don’t want to risk getting pregnant again.’ Two months later, having shared her anxieties with the doctor, Mrs A. had settled happily on the Pill and all was well.

In this case the experience of the birth of her son reawakened memories and feelings in Mrs A. from her early childhood. In some women the feelings may come from the deepest levels of the unconscious, and may be so traumatic that serious psychological upset can occur. However, in many women such as Mrs A. the memory can easily be dealt with once it is put it into words, and the doctor who can assist in that process has a great deal to offer.

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The cap lies in the vagina. It is a temporarily accommodated guest without eyes or ears. Provided it does its job, it is tolerated, and guests are fine to have around if you feel well. If you are not feeling so well, they are not so fine.

Most doctors are familiar with the issues that a cap brings to the fore for a woman, but the feelings it arouses in the man are less well studied. Men have been heard to use combative phrases to decribe it. T don’t fancy catching my weapon on that’, and ‘What if I knock it into the wrong position?’ For them it is not an unnoticed companion in their private place.

Mr E. is now separated from his wife. Things had been strained for some time. She had asked him to go back to condoms ‘because of the mess’. Later she announced, ‘You can leave them off if you want now.’ Mr E. said he could cope with the cap, but could not understand how hurt he felt when she told him she had been using it for several weeks before she told him. ‘I had hoped it meant we were getting closer’, he said, ‘but that thing [the cap] was worse because I couldn’t see it.’

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This may well be a happy event requiring no special support, but an unplanned pregnancy may occcur when a woman feels ill-prepared for parenthood and she may need extra emotional and social support. If she had considered abortion, she may harbour feelings of guilt, sometimes resulting in over-zealous protection of her child. The very factors making her consider abortion may still be present when the child arrives and the practical difficulties will need to be faced.

The patient with an unplanned pregnancy may present with many conflicting emotional needs, which require rapid assessment. The doctor with psychosexual training is in a particularly good position to help such women reach a satisfactory conclusion and make sense of her situation. A student once asked this author if she found the work depressing. Interesting, exhausting challenging, frustrating possibly, but helping women with unplanned pregnancy is not depressing. There are perhaps very few situations where one can be of such benefit to the patient so quickly.

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At the next visit Miss R. had stopped taking the Pill and then started it again, and had many complaints about feeling weak and tired, and having vague aches and pains. Again, she was not examined. During the next year she saw many different members of the clinic staff with complaints about sore breasts, fear of infection, pain in her leg (which could have been a deep vein thrombosis), and continuing anxieties about her parents finding out she was on the Pill, and about her marriage prospects. Finally, one day Dr A. noticed that the boyfriend was always in the waiting room, and was able to lead the patient to a discussion of the question of choice, and the patient’s right to say yes or no to sex. This led to further questions about virginity, and the state of her hymen, although again no genital examination.

Following this important consultation her visits to the clinic became less frequent, and later she was able to admit that she was not ready for sex when she started and that she should not have done it. However, there was no discussion of the feelings that led her to start.

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Mrs H.’s unpredictable behaviour resulted from her conflict between the wish for a stable life and motherhood and the desire for a good time. She had no model of a stable mother hence her distress and anger when her first social worker left. Hurt and rejected by her mother, she nevertheless envied her apparent freedom and gaiety. She loved her father but also despised him for being unable to control her mother. These feelings were later transferred to her husband. Without inner control she looked to others for control, but then found difficulty in accepting it. Her very inadequacy as a mother made her get pregnant in the hope that she could prove she was different from her mother. However, each time she found the demands of babies and small children too great.

In this case a measure of understanding about the unconscious forces underlying Mrs H.’s actions, and close co-operation between the doctor and social worker, allowed a consistent approach, and prevented the conflict about control being acted out between those who were trying to help.

Sustained support from the same workers over a considerable time is needed for such women until they can take the responsibility for contraception themselves. It is essential for the woman to be supported in her choice of method so that she can learn about her own limitations in using it. Eventually she may come to accept that outside control – in the form of sterilization – is the answer, but this can be done only when the woman herself wants it and should never be imposed.

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