General practitioners are familiar with the idea that illnesses are seldom due to purely physical or purely emotional causes. The input of each side has to be weighed at every consultation. Seminar training can foster the skill of keeping an open mind, and promote the study of the interaction between the body and the mind, which is especially important in the sexual area of the patient’s life.

Doctors learn to look for and think about direct clinical evidence in the ‘here and now’ of the consultation. Such evidence can provide powerful hints about the patient’s predicament. If and when the patient chooses to talk about past relationships and memories, these will have been remembered because they have special meaning for the patient in the present. They are then far more relevant to the current problem than answers provided in reply to questions about the past history.

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Establishing rapport is to do with making the patient feel at ease. Ascertaining the name the patient likes to be called is useful; it may well be different from the names given at registration. ‘Matching’ is a technique which may be needed early on to get in touch with the patient; for example, adopting the patient’s tone of voice or posture can be a powerful signal that one is adjusting to their wavelength. A patient’s diffidence is reduced by these means and worries are thus less likely to be held back.

Does it matter what sort of clothes the doctor wears? Instinctively, one would say that ordinary dress would be more welcoming than white coats. The fact is that GPs tend to wear ordinary clothes in their surgeries and clinic and hospital doctors white coats, and the public are used to this. In one study about clothes in family planning consultations (Stewart and Woodhouse, 1987), the majority of patients in a community clinic setting thought that the doctors should wear white coats. This view extended throughout all age groups, although the majority was not quite so large among the under-20s.

Once rapport has been established, the consultation can proceed more effectively because the doctor/patient relationship is in harmony (Freeling and Harris, 1984). When doctor and patient get to know and trust each other, the first phase of the consultation may become redundant. However, as with all relationships, rapport may have its ups and downs and work may be needed to rebuild rapport from time to time.

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Miss P. attended a clinic asking for non-allergenic condoms. The nurse enquired why and was told that the patient was allergic to ordinary sheaths. Undetered by the patient’s defensive manner, the nurse enquired further and was told that the patient was sore after intercourse. She explained that this might be due to many causes other than allergy and put the patient through to see the doctor. Initially the patient appeared quite angry: ‘What was this all about? All I want was the condoms.’ The doctor resisted the impulse to give a lecture on the causes of soreness, merely saying that allergy to condoms was really rather rare, and could Miss P. tell her some more about what was wrong? Miss P. then told or how she had started to be sore after intercourse using condoms with her partner about two years previously. She knew it was the condoms because it was all right without, but they usually used condoms because he did not want her to get pregnant. She hastened to explain in some detail that he already had two children by his wife from whom he was separated. The doctor wondered silently why this decision not to get pregnant needed such anxious defence and asked, ‘Had you thought about changing to a different method of contraception?’ There was a long confused explanation – all about Pills upsetting her and him wanting to look after her and make sure she would not get pregnant – and the doctor did not clearly understand what Miss P. meant. She said, ‘It seems to me that you are saying that he needs to be sure that you are not going to get pregnant?’ There was a long silence. The doctor looked at Miss P.’s bowed head and eventually reached out and touched her hand saying, ‘You have some strong feelings about this?’ Miss P. looked away and said in a muffled voice, ‘I’m 28 now. I want to get married and leave home and have a family of my own, but he won’t get a divorce in case he can’t see his children again.’ There was another long silence.

‘What happened two years ago?‘ the doctor asked, remembering the length of the history. ‘He went back to his wife then but couldn’t stand it and left again.’ Miss P. compressed her lips and then burst out, ‘It isn’t fair, I know he would be happy with me but he won’t risk getting married again. If only we had a baby, I know it would be all right. He would love a baby, he loves children, he can’t bear to be away from his children. If I had his baby it would be all right, he would marry me then,’ and she wept, hot, angry, body-jerking tears. When she had sobbed herself to a standstill, work could continue on the real reason for her ‘soreness’ when condoms were used.

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A sad woman in her mid-30s was referred to hospital asking for her sterilization to be reversed. She came with her husband. They were living a completely independent life in their own home. The woman had attended a school for children with learning difficulties. She was an only child and her mother had been deeply distressed when she became pregnant at the age of 18. At her mother’s insistence the baby was placed for adoption, and to prevent any further illegitimate pregnancies a sterilization was undertaken. The woman had been acquiescent over her situtation until she had married, and then both she and her husband wanted a child. She had felt no anger at the time of the sterilization, clearly being completely unaware of the likely consequences.

This situation is unlikely to occur today, but the consequences of past eugenic policies can still be seen. Today it is recognized that the children of handicapped parents tend to revert towards the average intelligence of the population. This new knowledge has helped to change the attitude towards childbearing by women with a mental handicap.

In 1987 arguments were heard in British legal courts concerning the possibility of authorizing the sterilization for a severely mentally handicapped girl aged 17. The case was heard in the lower courts and eventually reached the House of Lords. The arguments on both sides were complex, but the underlying principle agreed by both sides was that if the operation took place it would be for the ultimate benefit and protection of the girl rather than the community (Lee and Morgan, 1989).

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Doctors, nurses or other health care workers who are new to an area that includes significant numbers of patients from a different cultural group may find themselves faced with a barrage of folk-lore from older hands. This is not always dispassionately given; those that have been in the field a long time may have become discouraged and unreliable witnesses, passing on hearsay rather than first-hand experience. Generalizations tend to fuel anxieties rather than enlarge one’s views, and most health care professionals have to learn on the job. This may involve re-learning and adjusting preconceived ideas.

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