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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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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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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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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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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This causes real grieving on occasions and certainly most of us feel unhappy or depressed, at least temporarily.

It is a vital part of growing up and maturing psychosexually that we do not marry our first love object after puberty – it would usually be disastrous if we were to do so. This then implies that we have to be able to accept the loss of a loved one and live to fight another day. This, of course, applies not only to love-sex objects but also to the loss of relatives, parents, or even pets. Throughout life people’s love-objects are withdrawn from them (by death or divorce for example) and most grieve their loss. At this time the affected person says to him- or herself, ‘I’ll never have another husband/dog daughter/ mother like that again’, and of course they are right because each person and animal is unique. However, Nature heals this wound over some years – depending on the individual’s personality and the nature of the relationship involved – and they are soon on the way to investing their love in someone else.

In a sense the original love for the love-object is displaced on to the new one, because, as we have seen, we all need to love and be loved. This primitive, instinctual drive leads many people to rush into the search for a new love-object after the loss of their original one and such people often choose someone very similar to the last one. In this way the lost love-object never dies (or disappears, in the case of divorce) – they live on in the remaining person’s memory, yet may be related to through the ‘new’ love-object.

Those who have invested an enormous amount of love in a person who subsequently dies or leaves often tell how they never really get over the loss but simply put on a brave face for the world and even to a new partner. Such a reaction can become troublesome to some people because they hanker after one perfect love-object (even if during the object’s time with them things were far from perfect), idealise the past and they cannot step into the future because they fear that no one will ever match up to the lost love-object.

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Once the operation and its immediate after-effects are over, worries about sex and sexuality often dominate a woman’s emotions about mastectomy. Many women say that they feel less of a woman and the natural reaction in the early days is to feel unsexy and undesirable. Some women even feel strongly enough to say that they would rather have kept their breast and lived a few years less.

The one key factor to emerge from the large amount of research into this subject is that the role of the woman’s partner is absolutely crucial. This is true of women of all personalities and of all levels of intelligence and education. Ideally, the woman’s husband should be actively involved through the whole process right from the time when the lump is discovered. In this way the woman feels she has the support she needs and so fares much better.

There is no reason why sexual intercourse should not be resumed the day the woman gets home. There is no such thing as too much sex after a mastectomy and as long as the wound area is not hurt there are no problems. It is a matter of trial and error to find a position that is comfortable for the woman and then to use it until healing is complete.

Some women are afraid that their partners will leave them – the underlying fear being that a woman with one breast is not able to attract and keep a man. The facts are that men are no more likely to leave their partner after a mastectomy than otherwise and that most worry a lot about how to be supportive and helpful. Although most women try to hide their chests from their partners (especially in the early days), most men are not as upset by the loss of the breast as their women think they will be.

Some couples approach mastectomy with considerable existing psychosexual and relationship problems and for them the mastectomy may be the last straw. That this is unusual can be seen from one study which found that two-thirds of post-mastectomy women judged their emotional state to be excellent or very good. Women who fared best had been married longer, had found their partners (and doctors) more supportive and were pleased with the response from their children and the hospital staff.

Strange though it may seem, most women say that the worst time emotionally is immediately after the lump is discovered. Only one in seven women in one study found the immediate

post-operative period the most difficult. Although most women have thoughts about mutilation, loss of femininity and death, several studies have found that the good news outweighs the bad. One study, for example, found that 71 per cent of women rated their husband’s reaction to the mastectomy as extremely or very understanding; 76 per cent felt that the loss of the breast made no difference or had a positive effect on their sexual satisfaction or their ability to be orgasmic; and 60 per cent rated their overall post-mastectomy adjustment as ‘very good’.

Many women have married after a mastectomy. If you are still having periods, you may find you will get the same sort of discomfort on your mastectomy side as you previously had at this time of the month.

Remember that talking about it with your husband, family and friends is bound to help. Slowly they will all come to terms with your new condition.

Stages of breast self-examination:

1) Stand in front of a mirror with your breasts bare. Look carefully to see if there is any change from your normal appearance.

2) Raise your arms and see how your breasts move. Are there any dimples or bulges that change their outline? Does each nipple point in the same axis as its breast? Is there any puckering of the skin?

3) Gently squeeze the nipples. If more than a drop of colourless fluid emerges, see your doctor.

4) Lie down on your back with a small pillow or towel under the shoulder of the breast you are feeling and work slowly round the breast, section by section, feeling with the tips of your fingers for lumps.

5) Don’t forget to feel at the very edge of the breast tissue which can extend high up on the chest and

6) Under the arm

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• It is sinful, immoral and promotes fornication. It may lead to divorce.

• It degrades and misuses women solely to satisfy male lusts.

• It is an exploitation of the weaknesses of men by women and would not occur if women did

not offer the temptation.

• It tends to be associated with crime and criminals.

• It affects certain areas of cities reducing property values and making life miserable for non-

prostitute residents. (The Sexual Offences Act 1985 aimed at preventing curb crawling has

done something to help in this respect.)

• Due to ignorance or lack of care, the prostitute may harm the performance especially of young

men by, for example, hurrying them and so conditioning them to become premature

ejaculators.

• It spreads disease. This does not appear to be particularly true, at least for London prostitutes, and similar reassuring reports have been published from Copenhagen.

In the main, London prostitutes now insist that new clients wear a condom. The main concern there is the tendency for condoms to burst. Fifty prostitutes examined in 1985 were all clear of HIV. Women working in the San Francisco sex industry are no more likely to be HIV-positive than other sexually active women there. Elsewhere, especially in Africa and Haiti, prostitutes are a source of HIV. However, there are grounds for concern. One in five London prostitutes allows regular customers to have unprotected intercourse and nearly all fail to use condoms with their boyfriends and pimps. A more recent survey found 3 HIV-infected London prostitutes in a group of 150 but two were also drug abusers. Furthermore, several had infections with gonorrhoea and chlamydia probably caught from boyfriends. Although customer sex with London prostitutes is fairly safe they could become a source of spread of HIV in the future.

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About a month after having sex with an infected person (often a homosexual man) the contact gets a chancre (pronounced shanker) at the site of the infection. This can be on the penis, vagina, nipple, finger tip, or lip. A woman may not know that she has it because it could be deep inside her vagina. The sore goes away after a few weeks. This stage is called primary syphilis.

The second stage starts with a copper-coloured skin rash produced as the germs spread through the body in the blood-stream. There is also a fever, sore throat, swollen glands and loss of hair. These symptoms go away too.

The third stage is a hidden one that can last for years. There are no symptoms but the germs are working their way into almost every organ of the body.

The fourth stage of syphilis which affects about a third of all cases is the one described in historical records with such horror. This stage damages the nervous system, along with most of the other organs of the body, and the person can be paralysed, go blind, go mad and eventually die.

A woman who is pregnant and has syphilis can pass the disease on to her baby who will be born dead or diseased. This disease can be detected easily by taking a swab from the sore and blood tests can help too. Treatment with antibiotics is effective, especially in the early stages. Any long-term changes that have occurred in various organs cannot, of course, be reversed.

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