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Fears of damage to the fetus by either partner may result in sexual withdrawal. There may be an enforced period of abstinence due to threatened miscarriage or risk of dislodging a long-awaited pregnancy. Sexual dysfunction in the male such as impotence or premature ejaculation may result and may be further exacerbated after delivery when contraception is needed and sheaths are considered the method of choice. Alternatively, fear of damage to the fetus may be given as an acceptable excuse by the man who lacks sexual desire for his wife’s burgeoning and, to him, unattractive body.

The male fantasy of a mother’s purity and sexual innocence is not confined to those whose cultural and religious upbringing has held the Virgin Mother as an object of worship, but is an acknowledged phase of early childhood development. The first awareness by the man of his partner’s becoming a mother can reawaken this fantasy and be an unconscious reason for sexual withdrawal.

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Who controls the Pill? There is no doubt that it is in the woman’s hands, but men appear to have just as many worries about the health risks as women. However, these worries are often not expressed very loudly, but may be heard as asides: ‘How can you tell if she is taking it?’ Or reported by their partners: ‘Those clever doctors may let you down again.’ ‘They don’t tell you about all the side-effects.’ ‘Have you ever read the pack insert?’ There is rarely an opportunity to answer such questions adequately and they ask for a considerable degree of trust from the man. A psychosexual doctor may be prompted to ask why he feels he has to answer questions. Are they really questions or a request that the man should not be asked to put so much trust in something unnatural and a drug? One caring husband said, T wish I could take it instead of her.’ Again, asking men to rank effectiveness, the Pill came below condoms in their perception.

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During the contraceptive consultation it is difficult to remember that some of the women or couples will be consulting their doctor at a later date because of an infertility problem. Society is geared to the assumption that Marie Stopes made all those years ago, that every couple will bring forth a child when they want one; in other words, our society is constructed for the fertile.

Money is channelled into family planning and abortion services, and the maternity and child health services, but little is spent on the infertile. Such an arrangement adds to the suspicions of subfertile couples that their needs are not being listened to.

It is actually not an insignificant problem when it is remembered that for one in six couples, at some time in their lives, the wanted baby will not materialize without some medical intervention. These couples include those trying for their first baby as well as those who are having trouble conceiving their second or subsequent baby. Such couples suffer constant emotional pain, and can feel very isolated in society for, like all of us, their expectations of becoming normal adults and parents had been taken for granted, and it is only when a pregnancy does not ensue that they begin to realize that they may not be ‘normal’.

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Older women who choose to come to a young person’s clinic can be viewed as slow developers who are completing the tasks of adolescence late. Often they are only now developing a mature sexual identity, and may be on the brink of making what they hope will be a satisfying heterosexual relationship. They present a different challenge to the doctor. Though adult attitudes prevail during the consultation and history-taking, a larger proportion will conceal psychosexual problems, which may come to light at the genital examination.

Miss C, a 30-year-old patient who was on the Pill, attended the clinic for routine repeat of supplies. She was an attractive woman of eastern origin, who was due for a repeat smear. When the speculum touched the introitus the woman’s legs clamped together and her hand came down to push the speculum away. ‘I can’t,’ she said. ‘It hurts too much.’ The doctor wondered how the previous smear had been managed. ‘Oh, I just screwed myself up and let the doctor get on with it, but it was awful and I’ve put off having another one.’ Patient and doctor decided to postpone the smear and talk about the pain. Miss C. seemed happy to stay on the couch and told about her decision not to have sex when her friends first took the plunge. She chose to wait for a special man. When she finally lost her virginity (her words) she was 26 and her first sexual encounter was ‘very funny’.

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It is by no means only young people who have difficulty in reconciling the consequences of sexual intercourse with the strong passions and fantasies surrounding the act itself. Sex can be exciting, rebellious, experimental, a rite of passage into a new world. Condoms are perceived as sordid, evidence of prior planning and thus detracting from the romance, a butt of jokes. No amount of worthy sex education can bridge this gap, unless feelings like these are understood. Also, some women hold themselves in such low esteem, consider their sexual selves so worthless, that the only way they can impress or please is to agree to or encourage sexual intercourse. In young women in particular, pregnancy is often the result, leading to repeated requests for terminations.

She was 16, and making her third request for termination. The first time, she said, her doctor had arranged a termination at the local hospital, the second time, reluctantly, he had tried, but had had to send her up to London. Now, he had said he could no longer help. She sat there, passively, agitated only by the thought that her mother, who had paid for the second termination, would ‘kill her’. Had she tried contraception? A tiny shrug. Sometimes, well, not really, she didn’t really get on with it. What a problem, thought the doctor, and dumped in my lap! Both the nurse and the doctor felt angry at the girl, wanting to lecture her on her irresponsibility. The extreme passivity of the girl was striking. The only emotion so far had been directed at the mother. Was all this, thought the doctor, an attempt to rival or get back at the mother? ‘And Dad?’ asked the doctor. The girl froze. ‘Which Dad?” she said, and began to cry. Out came a sad story. Her real father had sexually abused her. Her mother had found out and left him, taking her daughter: ‘But, I missed my Dad!’ she wept. Now, her mother had a new boyfriend. The girl, angry, powerless, and feeling excluded and rejected, sought attention – in the only way she knew best.

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