Balint (1964) emphasized that if doctors ask questions in the manner of medical history-taking, they will always get answers – but hardly anything more. The main skill in receiving the patient’s agenda is careful listening. This is not a passive activity – all sorts of ideas, paradoxes and questions may come into the doctor’s mind as well as being able to notice verbal cues such as what the patient omits to say or speech idiom and nonverbal cues such as facial expression or posture. Skilled doctors can ask questions which are relevant to what the patient is talking about which, although interruptions, may be facilitative and may maintain or even encourage the flow of the consultation,

One important cue which Neighbour (1987) describes and had entirely passed this author by is the ‘internal search’. While a patient is intent on remembering or imagining something important, the body becomes relatively still and the eyes defocused and fixed in position. While attention is directed inwards, thoughts and memories begin to associate in the imagination. Sometimes an internal search follows a question the doctor has asked and the patient may finish up with a new insight into the problem. It is important not to interrupt anyone during an internal search.

The quality of empathy is required of the doctor. Freeling and Harris (1984) define empathy as putting oneself imaginitively into someone else’s position and experiencing the feelings which doing so arouses. These feelings will be returned to under the heading of ‘Self-monitoring’ below.

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Problems tend to present because of specific triggering factors and often with changes in circumstances. Some patients seem to have difficulty in accepting that they can have enough control over their own lives to choose to use birth control. The woman who staggers from one crisis to another bewailing that ‘Everything happens to me’ often seems powerless to decide for herself what should happen.

This woman’s lack of awareness that she had any rights over her body, her acceptance of the authority of the boyfriend and the urgency in her need to comply with his instructions about contraception, all pointed to a deeper disturbance. The irritation felt by the doctor with this lack of self-determination had to be controlled in the search to make sense of it all. How much easier it would have been just to be authoritarian in turn and tell her what she must do!

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Sometimes the fact that children are now grown-up, becoming independent and often leaving home, can give the woman a sense of freedom, and she sees an opportunity to regain her sexuality. Her method of contraception may be a hindrance now that she and her husband have more time to themselves; the sheath or the cap, previously well tolerated, now become a bit of a chore. One sometimes picks up a kind of cheerfulness and a sense that sexuality is going to be even better now. If the doctor can accept such feelings while at the same time giving positive messages about the combined oral contraceptive, the progestogen-only Pill or the IUCD in a woman of this age it can be very helpful.

For many couples in their early 40s, sterilization can be the ideal method as they may have come naturally and comfortably to accept that their child-rearing days are over. In the later 40s it can be seen as rather an extreme step when the woman’s menopause is near and she is in any case at a less fertile stage of her life.

However, the sense of sexual freedom conferred by the end of childbearing can rebound on the couple, causing a change in the balance of the relationship, at a time when that relationship is in any case having to adapt to changing life situations. Some of the difficulties that may arise are explored in the next sections.

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Sultana Noor, recently registered, living with only her two daughters, asked for an abortion of her eight-week pregnancy. She had had an affair with the husband of her neighbour, and was overwhelmingly concerned that no-one in the Muslim community should find out. She wished to ensure that none of the nurses at the hospital would be Muslim. For herself there seemed to be little room for personal feelings.

If it is hard to gauge how much a spouse’s own feelings may reinterpret their partner’s words, it is almost impossible to estimate the interference of attitudes from an unofficial unrelated interpreter. They may be quite detached, or on the other hand, oppressive, haranguing and bullying the patient, taking their perception of the clinicians needs to extremes. By contrast, almost complete detachment is obtained with telephone interpreters. This must surely be the most cost-effective method of coping with translation. A team of interpreters in all the languages prevalent in the borough is provided by the local health authority and they are available by telephone from their office. They are fully trained to keep strictly to translation. If hands-off handsets are not available, they will lend doctors double-socket handsets. The disembodied voice is only briefly alarming, as they quickly introduced themselves and explain the confidentiality of their service. The clinician explains who they are and what the consultation is about in broad terms. Thereafter they translate back and forth and their physical absence goes some way to maintaining the semblance of a confidential doctor/patient relationship. For many doctors this suits their style of work. For other health workers such as domiciliary family planning nurses, home visits can be planned so as to be able to go jointly with an interpreter.

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Some patients will have no difficulty asking for help with their problems as they see such help as a right, and rightly expect their needs to be addressed. However, many find it difficult to ask because of feelings of unworthiness and poor self-esteem. They often perceive themselves in terms of the disability itself with a person attached, as opposed to a person who happens to have a disability. If the doctor also feels this way then the patient’s expectation that the doctor will be shocked by his request for sexual help is likely to be fulfilled. The patient’s need for recognition of his sexuality places a responsibility on the doctor, who needs to be able to see beyond the disability to the person. At the same time the doctor cannot ignore the disability, for to do so prevents an understanding of the whole person of whom the disability is a part.

The doctor may feel inhibited about making enquiries or offers of help lest the patient be shocked at the intrusion into such private areas. The doctor’s unease may be an echo of the patient’s unease, as both are wary of rejection. In practice most patients express relief if their sexual needs can be acknowledged.

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