During a routine Pill check consultation the patient mentioned that she had experienced painful intercourse since the birth of her baby six years previously. She believed that she had been ‘ripped’, and that the stitches had come undone. She had already consulted two gynaecologists who were loathe to undertake any surgery as she appeared well healed. As the doctor looked at the healed but scarred perineum, noticing the scar tissue was a lighter and pinker colour than the slightly pigmented skin on either side of it, the patient said that she had looked at it in the mirror and there was no ‘space’ between the front and back passages. What she seemed to be saying was that the vagina and rectum felt to her to be joined, with no wall between them. It is interesting that she had also been complaining of a lot of wind which she felt was ‘getting in from below’. There was a sense that air was getting from the rectum to the vagina and thence ‘to the insides’.

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The consultation was first broken down into phases in work done in Manchester, where nearly 2000 audiotaped consultations were analysed (Byrne and Long, 1976). Six phases were defined which appeared frequently to follow each other in sequence, but the emphasis was still very much on the doctor .

Next the consultation was viewed from the angle of maximizing the potential of each consultation, and not just dealing with the presenting problem and getting the patient out through the door (Stott and Davis, 1979). This important work described how other key elements of care, such as the management of continuing problems and opportunistic health promotion, could be raised when appropriate. However, it did not help doctors to understand where they were in the progress through a consultation.

1. The doctor establishes a relationship with the patient.

2. The doctor either attempts to discover or actually discovers the reason for the patient’s attendance.

3. The doctor conducts a verbal or a physical examination or both.

4. The doctor, or the doctor and the patient, or the patient (in that order of probability) consider the condition.

5. The doctor, and occasionally the patient, details treatment or further investigation.

6. The consultation is terminated, usually by the doctor.

The Byrne and Long consultation model (1976).

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The patient with a physical ailment is a whole person with feelings about that disability or disease. Feeling less of a woman or man because of the development of illness may profoundly affect sexual responsiveness and desire. A woman who has had an operation which she regards as mutilating (removal of a breast, or an abdominal scar) may be fairly easy to identify; one whose feeling of damage is concealed (for example, after a cone biopsy or removal of an ovarian cyst) may be more difficult. Patients after any illness or surgery may grieve for their previous good health or completeness and find sexual responsiveness inhibited.

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For such women there is usually no conscious desire for a baby, and they need a reliable method of contraception, but one that can at the same time allow them to fantasize about the possibility of pregnancy. If such a method can be found their sexual responses are likely to remain intact.

Men can have fantasies and feelings about what the operation of sterilization does to the woman, and again these can be difficult to elicit.

A pale and withdrawn woman in her early 30s was referred for counselling as she was unable to allow intercourse. There was a long and sad history of personal tragedy culminating in hysterectomy at 28 years for uncontrolled menstrual bleeding. Following this, the woman had become more and more unhappy, had retreated into a fantasy life of romantic fiction, and when first seen, sat behind a veil of unkempt hair.

It became clear that her partner was angry and unsympathetic, and that he was engaged in a long and serious sexual affair with a colleague. It took many hours of listening before he was able to state that in his opinion, a sterilized woman was by definition a useless sexual partner, and he could see no way forward in his marriage. In fact, once both partners had identified the underlying anger on either side, there was an improvement in their situation and a marked gain of confidence in the wife, who managed to pick up the threads of her life again.

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The attitudes of professionals to different cultural customs change as the views of society change. A legacy of Christian moral imperialism that parallelled colonialism has been succeeded by an agnostic, generally liberal tendency towards non-interference. Lack of absolutism has, on the whole, got rid of the view that non-Christian cultures are heathen, but not replaced that certainty with very much to rely on when faced with a cultural dilemma. Modern western doctors may see themselves, and probably most of their patients, as culturally neutral, perceiving problems only with ethnic minorities and Roman Catholics. That we are not so bland is demonstrated by the intense national debate that takes place whenever events bring ethical decisions concerning reproduction to public notice. We have not yet become, in Britain, the culture of the pre-eminence of individuality. We need to be aware of the relativism of our culture when working in a transcultural setting.

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