It is suggested that sterilization requires grieving. All sterilization involves a loss – a loss of fertility. Though it may be by vasectomy or tubal ligation or naturally, as at the menopause, it is not necessarily welcomed. Mr G. was left numb and empty after the procedure. It was not acceptable for him to be angry with his wife for pushing him to do it. Although there was some camaraderie and group support in ‘joining the club’, he needed help to see why he went off sex and is only now enjoying it again two years later.
What features of the grief reaction should be expected. Emptiness, denial, anger and later readjustment to a world that will never be the same. This is not a time to hand over control on the spur of the moment. Doctors are sometimes asked by a partner to arrange vasectomy for the spouse. It is essential to determine how the request has come about; perhaps interviewing the man alone. Doctors may be asked for advice when a choice for a vasectomy or tubal ligation seems even handed. An important parameter to consider is to identify who would grieve least from losing their fertility.
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Nowadays, with a national cervical screening programme in place, someone like Mrs H. may not manage to avoid a smear for so long, but she would certainly have managed to find some effective way of keeping both doctors and her husband away from her emotional fears surrounding intercourse until she wanted a baby: if not away from the actual physical examination, as had happened here. The patient has to want some changes to be made before treatment can begin to be effective, but Mrs H. could not acknowledge her own desire to have intercourse and all that it might mean for her. However, now it was for a baby she felt that it was a suitably acceptable reason to approach her doctor about such an uncomfortable topic.
It took Mr and Mrs H. almost a year to achieve intercourse and there followed 18 months of infertility before the psychosexual doctor met them again, this time in the infertility clinic. Mrs H. had changed into a confident woman compared with the little girl that had appeared originally. A simple ovulation induction regime proved successful and they now have a healthy young son.
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These terms are often used interchangeably. Unplanned may also mean unwanted. For some women, an unplanned pregnancy may be a very unwelcome intrusion into her life. For others, unplanned pregnancies may not necessarily be unwanted. It is estimated that up to one third of pregnancies may be unplanned (Fleissig, 1991). Some women may go on to term because of moral objections to abortion, but some of these unplanned pregnancies do become very much wanted. Efficient contraception is meant to lead to ‘family planning’ but we all know plenty of women who look lovingly at their bulging abdomen and say, ‘It wasn’t planned’ Efficient contraception means being able to take responsibility for deciding when to have a baby. To some this means waiting for the right situation in terms of marriage, accommodation, money and career. It also means being able to say to the world that they are now mature enough to become a parent and responsible enough to care for another individual. Some women can allow themselves to have a baby in less than ideal circumstances only by allowing it to be unplanned.
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It is common for the coil (intrauterine contraceptive device, or IUCD) to be chosen by the woman after all other methods have been discussed and rejected, for whatever reason. All doctors are familiar with the lady who, sitting back in her chair, looks with a marked lack of enthusiasm at the tiny curl of plastic and copper, and says, dubiously, ‘Well, I could give it a go.’ By this time, the doctor, for medico-legal reasons, has gone into gruesome detail about possible, horrific sounding side-effects, so it is surprising that women choose it at all. The next, inevitable question is ‘Will it hurt?’ In other words, the woman is accepting that here she is placing herself directly in thedoctor’shands, and is prepared to suffer the pain, vulnerability and humiliation of having a foreign body inserted into her precious womb. What can this method mean?
It is sometimes considered that this is a passive response by the woman, placing the responsibility onto the doctor. It has to be said that, as far as this doctor is concerned, such a feeling is rare. This author is usually more aware of admiration for the sheer courage of a woman prepared to undergo this experience. Why should she choose this method?
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Thus to use contraception requires at some level a grieving for all the possible loved babies that could be born. We are all too aware of the terrible irony of couples assiduously and conscientiously using contraception for years, only to discover that one or other or both of them are infertile. An awareness of these often unspoken feelings may explain some of the enormous fear of the reliable methods of contraception that can underlie some contraceptive difficulties. Such methods are too powerful and will damage fertility. There is a fear of retribution, the woman will be unable to have children, and hence some will play contraceptive roulette in order to ‘placate the gods’.
The reality, of course, has been that human beings from earliest historical times have tried to control their fertility when it was inconvenient to have a child. The sin of Onan in the Old Testament exemplifies this. Onan should under Hebraic law have impregnated his dead brother’s wife. Instead he ‘cast his seed upon the ground’ angering God. This story has been used as evidence that all forms of non-reproductive sex and the use of contraception are against God’s will. The ancient Egyptians used a vaginal pessary made of crocodile dung to prevent conception, and instruments to procure abortion were used in Roman times. Hippocrates, the father of medicine, advocated violent exercises. Thus powerful opposing forces are present in our psyches, both the urge to reproduce but also the urge to abort. All this may seem a far cry from the ordinary contraceptive consultation but every now and then these forces will be evident.
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