Psychosexual skills are not a watered down form of psychotherapy, although psychodynamic ideas are used in the training and practice. The doctor develops a focused way of working in an important area of the patient’s emotional life. Those in training will probably want to arrange times when they can give their patients a few longer appointments, but they are not encouraged to engage in extended therapy. Indeed, the doctor/patient relationship where the doctor becomes over-involved with the patient is worthy of study, and may be revealing a particular problem of dependency for that patient. The aim of training is not to suggest that doctors should provide time-consuming long-term support, which may be more appropriately provided by others, but that they should learn to use specific skills within the practice of their normal work. The general practice and clinic settings, and particularly the family planning consultation, provide patients with repeated opportunities to visit doctors about routine matters, and they can choose the moment that is appropriate for them to discuss their inner pains.

*374/197/1*

It has been shown that positioning chairs in the consulting room so that the doctor and patient face each other across the corner of the desk encourages more verbal interaction than when doctor and patient are on opposite sides of the desk (Pietroni, 1976). Also, it has been estimated that two-thirds of the communication which goes on in a two-person conversation is nonverbal and only one-third verbal.

The beginning of the consultation has proved to be of great interest and of vital importance. Clearly, to get off on the wrong footing may ruin the whole consultation. Neighbour (1987) has analysed this phase in considerable detail. ‘Curtain raisers’ are little throw-away lines such as, ‘You’ll be getting fed up with me’ which may be missed as the patient enters. The consultation has begun at this stage and interventions from now on can disturb the flow of the consultation. Lines such as ‘You are busy today, doctor’ (really meaning ‘you have kept me waiting 40 minutes’) may even provoke some anger in the doctor if pressure of work that day is beyond his or her control.

*336/197/1*

This patient had not needed any ‘therapy’; she had the answers within herself but needed a skilful listener to enable her to make the transition from ‘obedient nonsexual child’ to ‘independent sexual adult’. By recognizing that the doctor/patient relationship started as teacher/pupil and by refusing to instruct her, the doctor helped Miss A. to take a more adult role, accept the problem as her own, understand the difficulties and see that she could solve it herself. The skill here lies not in what the doctor did but what she restrained herself from doing in response to the initial doctor/patient interaction.Doctors and nurses unskilled in picking up clues about hidden problems may find some contraceptive consultations baffling and frustrating. The patients who can never find a satisfactory method; this Pill made them sick, that one gave them headaches, the coil made them bleed, they had cystitis with the diaphragm, and there is no chance the partner will use a condom. These patients manage to outmanoeuvre and defeat their advisers. Only by understanding that ‘nothing is right with contraception’ may be a synonym for ‘nothing is right with my sexual life’ can this be untangled (Rogers, 1989). Sometimes specific complaints with contraception can turn out to have quite different causes.

*297/197/1*

For many couples with a disability, as for able-bodied couples, the question of the timing of a sterilization is paramount. Often, if the doctor can help them to find a method for the next year or two, the situation can then be reviewed. Not only will the couple then be older, but other practical and emotional changes may have taken place which can profoundly effect their decision.

The care of individuals with mental disability has changed a great deal in recent years, and there is now a greater understanding of their needs and less fear of their condition (Greengross, 1976). However, instances are still seen where control of fertility was considered a priority which tended to over-ride other emotional needs of the patient.

*259/197/1*

After a time practitioners may feel comfortable with their attitudes in theory, but maintaining them in practice is not so easy. It would be simpler if consultations were clearly confined to one subject such as contraception, but this is rarely so. The social concerns of recent immigrants overlap with their medical needs. The doctor/patient relationship is often conducted in the context of the doctor/family relationships. Doctors may be distracted by the need to look for opportunistic surveillance of young children who attend with their parents, as well as trying to support the families’ social needs, especially housing. The problems of overcrowding will lead naturally to a discussion of contraceptive needs, but it is important not to let one’s anxiety about uncontrolled fertility undermine the relationship of trust by appearing to blame the patient for her fertility. Dealing with so many issues and patients in one consultation can be very wearing, and it would be surprising if the practitioner never felt under strain, with a sense of burning out, when dealing with such needy families. Poor coping mechanisms lead to doctors using the issue of culture as a reason for not being effective, and lowering their standards. The support of colleagues is essential both emotionally and as a context for looking at ways of making practical changes that can help.

*221/197/1*