The doctor’s agenda may be either relevant or irrelevant to the patient. Clearly the doctor may have personal problems which get in the way; there may be preconceived ideas about a particular patient or about certain types of patient (sometimes triggered by appearance or dress). The doctor may have a stereotype of the patient’s partner which is unhelpful: assumptions may be made about age, numbers of partners, sexual orientation or acceptable sexual activities. The doctor may find it difficult to view a patient he known from birth as a sexual adult and so tend to dominate the consultation in an authoritarian style.
If the doctor’s beliefs and values intrude into the consultation, concern and empathy may suffer. If the doctor does not believe in abortion, then referral should be organized to a colleague when a termination is requested. If the doctor is uncomfortable talking about how to put on condoms, different positions for lovemaking, masturbation, or does not believe sex should be fun, then the patient will sense this and not feel encouraged to continue talking about the problem.
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It is common to encounter young girls who are very uncertain about choosing a method of contraception. They attend and request advice on methods, but are disinclined to choose one; nothing seems quite right. Suggestions that they should postpone sexual activity may be met with verbal agreement, often apparent relief, only for the doctor to discover later that intercourse is still continuing. They are encouraged to use a reliable method by their advisers but seem unable to comprehend the need to use it sensibly, often missing their contraceptive pills, or complaining that it does not suit them or that the condom or diaphragm makes them sore. It is as though by not using contraception they are saying, ‘I am not really active sexually, you see, I’m not even managing to use contraception. This sexual activity is not my responsibility; the onus is on my partner to make the running.’ They often seem surprised if a pregnancy occurs as though their sexual activity is divorced from real life.
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Some women approaching their 40s suddenly find themselves very fearful of becoming pregnant. Through their late 20s and 30s, although not wanting any more children and having what they believe to be adequate contraception, an unwanted pregnancy would not be such a disaster, but in their 40s the fear of it can suddenly become overwhelming. They may present with fears that their contraception will let them down. Again, reassurance and explanation about their chosen method, or a suggestion to change to something safer could be sufficient, but acknowledgement of their fears and an attempt to understand the reasons behind the fears is crucial if the most satisfactory method of contraception is to be found for each individual couple. Other factors in their lives may precipitate such worries. One such factor is that of becoming a grandparent. The arrival of a grandchild brings home to the woman or couple the fact that they now do not have the stamina, physically or emotionally to cope with a baby. Another trigger is when patients approach the age at which their mother, a close relative or someone known to them had an unplanned and unwelcome pregnancy. Often they have not made the connection until they have the chance to talk freely to a professional person, when they may be surprised at what they find themselves saying.
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The concept of health advocates goes beyond translation in a professional sense. The advocates are trained in specific areas of health-related issues as well as interpretation so that they can amplify the clinician’s information and make it culturally more relevant where appropriate.
Most of the time we find ourselves using limited English and a mixture of sign language and suggestive mannerisms to bridge the gap. This is expedient and can serve well enough for straightforward transactions. The danger is that practitioners become too accustomed to working in this way, and they withhold better services from their patients. It requires a conscious effort to halt a consultation in order to set it up again with more language resources, and one also needs to explain and negotiate with patients so as to get their agreement. The imprisoning and prejudicial effect of the lack of verbal communication is illustrated by the astonishing change that can take place when a translator is brought in. As a patient is transformed from a silent marginal character into an animated participant talking at length, the doctor may find him- or herself behaving towards her in a truly dignified way for the first time. If one is consistently using a substandard method of communication with one’s patients, it is likely that one will develop a patronising attitude towards them. Doctors need to work to gain the ability to use a range of methods with flexibility, keeping alert for the moment when it is necessary to acknowledge that there are difficulties and a need to arrange for help.
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Emotional needs usually have more relevance to people with physical disabilities who are very aware and sensitive about their sexuality. People with mental handicap may be less sensitive to other people’s approval or disapproval, although of course the situation is even more complicated when physical and mental handicap coexist in the same patient.
One area of difficulty for the doctor may be that of inappropriate behaviour, which tends to occur in people with mental handicap who are disinhibited, or in people who have suffered head injury, stroke or neurological disease. The question of what is inappropriate behaviour needs exploring, as does the question of ‘inappropriate for whom’? While there are some activities we would all consider inappropriate, such as masturbating or having intercourse in public, other activities are a matter of opinion. A nonjudgemental exploration of the problem is necessary, as well as practical advice tailored to the specific situation. If the person has not been educated into what is acceptable social or sexual behaviour, it is very difficult for him to behave appropriately. The unease for both patient and doctor is made worse by society’s attitude that sex is for the young, beautiful and athletic, in whom, for instance, considerable public petting is acceptable. But people with disabilities, mental or physical, do not fit that image, and both they and others may feel more self-conscious. These attitudes can also affect the doctor/patient relationship.
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