Growing Into Medicine

by Ruth Skrine

  One of the first studies into the problem was published as a book edited by Leonard Friedman under the title Virgin Wives, a report of the work of one of Michael Balint’s seminars. The group identified different character traits. To quote from Prue Tunnadine’s groundbreaking book Contraception and Sexual Life, these included the maternally enjoined ‘sleeping beauty’, the defensive-aggressive destructive ‘Brunhild’, and the ‘queen bee’ wishing for virgin motherhood. As Prue points out, these types are often blurred.

  I did not use these concepts or talk about them with colleagues. I am left wondering why I shied away from exploring ideas that could have been useful. Perhaps my personal discomfort with the world of myth was partly to blame. I have only recently begun to appreciate the usefulness of story and the part that metaphor can play in the search for truth. On the other hand, in terms of the doctor–patient relationship, the avoidance could have been due to something coming from the patient, encouraging me to think in more concrete terms.

  The satisfaction of helping a woman and couple to consummate their relationship is so great that it is tempting to overestimate the success of treatment, whatever method is used. Simple behavioural methods, ‘retraining’ with graded exercises, may be helpful, although I find the approach uncomfortably authoritarian. I listened once to the description of a woman who had been encouraged to put her finger in a saucer of strawberry jam because the feel was like that of the moist vagina. Not, I thought, very similar at all, and for me an unpleasant image of stickiness and grainy seeds.

  The didactic methods employed by many ‘sex therapists’ fill me with horror. At one meeting I heard such a therapist holding forth about her methods which included a five-page questionnaire. ‘You must know the background fully,’ she said. I was reminded of the time-wasting nature of questions. In a careful study of 159 cases treated by members of the IPM (Bramley et al., 1983), all of whom had been trained not to ask questions, 60% consummated within six months. Over 80% of these patients had consulted other agencies before coming to us for help and the mean duration of symptoms was 4.2 years.

  I don’t remember the first patient I saw, or the total number. The successes stay in my mind while the failures drift away like dandelion seeds in a summer breeze. The simile feels inappropriate when the difficulty is such a burden for the sufferer. But the image floated up when I tried to recall my failures – a defensive snapshot, as if the pain of not being able to cure has been converted into something that can be brushed away – although dandelion seeds do have a tendency to cling to one’s clothes.

  The main thing we discovered by listening to patients before, during or after an attempted examination was the prevalence and variety of body fantasies. These beliefs had usually never been voiced before and were often unconscious. The range and multiplicity of these misunderstandings surprises me to this day. Nothing in the following paragraphs will be new to those who work to uncover hidden fears. I hope they may be of interest to the general reader. However, if you are squeamish I suggest you skip the next section of this chapter for it contains, as the TV warnings say, ‘scenes of a disturbing nature’.

  The fear that there is a ‘block’ at the entrance to the vagina is so common that I used the word in the title of my book Blocks and Freedoms in Sexual Life, published in 1997. I was writing for the medical and allied professions but I find myself re-reading it now as I address a wider audience. After being away from the work for more than ten years I have to remind myself of the understanding that I was groping for at that time.

  Vaginismus, a reflex spasm of the muscles, is often the cause of the apparent block. Occasionally there can be a physical abnormality. The hymen can be unusually thick and tight, as I found in one patient. I warned her that I thought she might need a small operation but she wanted to try and stretch it with her own finger. Within two weeks she had managed to have enjoyable sex – but then, she did not have irrational fears to hold her back. Other very rare conditions include double vagina and the presence of a hymen that extends across the whole entrance, causing abdominal pain in adolescence when the menstrual blood cannot escape.

  The hymen and the whole question of virginity have been subjects of interest for thousands of years. One of the medical museums in Vienna has ninety-two hymens displayed in glass jars. Some of these are torn or scarred, some have bands across the opening, some have inelegant skin tags and some are thick with a tiny hole. I went round the exhibition as a medical student, after falling off a horse that had kicked me on the head. I was a bit dazed before the tour started. By the end I was in a whirl, but at least I realised how very difficult it can be, impossible in many cases, especially today when girls use tampons from an early age, to say if someone is a virgin. Yet this diagnosis still remains a matter of legal and emotional importance, especially in some Asian and Muslim cultures. I was amazed to find how many on-line questions were devoted to the subject. Most of the answers depended on the opinion of an examining doctor, which I suggest may be open to doubt. For Catholics the importance lies in the fact that the Pope can annul a marriage that has not been consummated.

  Old myths persist. Phrases like ‘she hasn’t been broken in’, and the need for blood on the sheets to prove virginity, add fuel to the fire of unrecognised fears. One patient told me she knew the solid flesh had to be torn through the whole length to make a passage. With her muscles clenched she could not believe a well-lined space already existed. She showed immense courage in her efforts to feel for herself, her terror making her blood pressure fall so she felt faint, visit after visit. Stretching the entrance under anaesthetic, a practice that is still carried out, seldom helps these fears.

  When working with such patients I was often the first to use the word hymen and sometimes found it difficult to do so, as if the very word was a sort of rape. The hymen may be considered as one of the guardians of the entrance, not only to the vagina but also to the very self. As I parted the lips of one woman, prior to inserting a finger, she said, ‘There is an outer and inner part of me, the curtains have to be drawn.’

  The relief, and sometimes the disappointment, when the tip of the doctor’s finger is eased inside, can be intense. Even when a patient can insert one or more of her own fingers, she cannot always give up the fantasy of a block. It is as if the hymen retreats up the vagina until it is still lying intact, covering the cervix. Here the image may get muddled with ideas about the need to ‘break through into the womb’.

  Several of my patients had a fear that the penis would go into the wrong place, usually into the bladder. Many living creatures have a cloaca, an internal space into which the urinary system, digestive tract and sometimes the reproductive organs open. The muddle may be due to the emphasis on animals in the biology syllabus, especially in the past when human biology was hardly mentioned. But I suspect serious misunderstandings arise much earlier in life, when the baby girl is exploring her own body. If so, then it is unlikely that even good sex education will be able to remove those fears that are not available to conscious awareness.

  Once through the barrier, or ‘gate’ as one patient described it to me, a whole range of different phobias may lie waiting, acting like hidden parasites draining the strength of their hosts. Beyond the muscles, the upper part of the vagina can be imagined as a limitless void, a hole with no end. One woman was afraid that if her finger slipped through she would touch her liver. Having never seen a human liver she had no idea how far away it lay, snuggling smooth and glistening under the ribs. Her vision was of a raw, bloody slice in the butcher’s window.

  If the hole has no walls, things could get lost inside. If tampons went in, how would they get out? This ties in with male fantasies of castration. The most precious and sensitive part of a man’s body could be lost inside, broken off or stuck. Even damaged by hidden teeth. One of my patients said he thought the inside was like ‘rice pudding’. His facial expression showed how much he disliked that food.

  Because men keep their sexual organs on th
e outside, fantasies about their own bodies are less common than those of women. However, I did meet one young man, a well-built country lad who was brought to the clinic by his girlfriend. Whenever he tried to penetrate he got a sore at the base of his frenulum (the fold that joins the foreskin to the tip of the penis on the underside). He had been given cream, which helped, but the problem recurred whenever he tried to have sex. I examined him and found a small ulcer. Despite my reassurance that everything else looked fine, he made no effort to get up from the couch but continued to lie looking up at the ceiling.

  ‘You still look worried?’

  ‘It doesn’t go back.’

  ‘How do you mean, go back?’ I had checked that the foreskin retracted fully and easily.

  ‘You know, properly back.’ He was touching the base of his penis.

  ‘I wonder why you think it has to go back there?’

  ‘Well, it does in horses.’

  Light dawned on us both at the same time. ‘You mean, it all goes inside?’ he asked.

  I nodded. No wonder he kept traumatising himself.

  Such simple misunderstandings will be less common now the teaching of human anatomy and sex education has improved, but the remaining problems are likely to be more difficult. The depths and type of fantasy, often more than one, are personal to each individual. Any attempt to guess at the picture in the patient’s mind will hinder her efforts to get in touch with the unconscious images that are acting as a block.

  I have led a relatively sheltered professional life, for I have never seen a woman who has suffered genital mutilation, or been asked to comment on the results of very early sexual abuse. Such trauma to the body, before it has been softened by the oestrogen surge of puberty, can lead to terrible scarring which is particularly difficult to assess in a traumatised child. Such work is for the experts, as indeed is help for recent victims. In psychosexual work we do hear of childhood sexual abuse, and in an audit of my clinic published in 1991, 11% of patients gave such a history. I found that the degree of psychological damage was very varied. Many were helped as quickly as those patients without such a history. However in one study, of the five patients I referred for longer and more extensive psychotherapy, three had suffered abuse. The most important lesson I learned was the care needed in asking about such a history. More than one patient became angry at the assumption that she must have been abused. In some instances this could be a conscious or unconscious denial of the past, but for this reason it was important to let such memories emerge when they were ready to do so. Asking questions only invites denial and may encourage false memories. The doctor often has to accept that the literal truth of what is being revealed may be impossible to prove. What matters are the feelings that have been evoked.

  Body fantasies can also emerge later in sexual life, for instance after childbirth. When I had my own baby I was lucky that the delivery was straightforward and that I was in an environment that felt totally safe. My few stitches were inserted with the greatest care and did not cause me any problems. It took time for me to learn that, in those who had not been so lucky, their experiences could trigger a variety of new fantasies, and in particular to appreciate the symbolic importance the body image could hold for one or both partners.

  More than one patient has described her vagina as being left huge and gaping, like a ‘Wellington boot’. The muscles may be a bit loose but can be improved with exercises and physiotherapy. If the image represents the feeling of being so huge in her role as a mother that she cannot also be the firm, excited and exciting lover of previous times, physical methods alone are unlikely to be helpful.

  For some women a tender scar may be drawn forward by muscles tense with fear, so that it is rubbed during intercourse. But again, if the woman believes the stitches have been put in too tightly and that she is now too small, not big enough to be both a mother and a lover, reassurance alone will be useless. One patient had been unable to make love since the birth of her baby three years earlier. With me she managed to insert three of her fingers easily but still looked worried. Only later in the consultation did she say thoughtfully, ‘If I had been stitched up as I imagined, after six babies there would be no hole left.’ As she spoke she was making a movement with her hand as if she was cobbling up a hole in a stocking. In reality, the stitches only restore the integrity of the wall and entrance and do not reduce it in size.

  One of the traumatic memories of childbirth that can become fixed on the body is that of being out of control. Some people need to feel in control of every aspect of their lives. One particular couple came together to ask for an operation to remove the scar on her perineum. As they described it I imagined some grotesque deformity. When I plucked up enough courage to examine her I found a perfectly healed scar, a thin white line, almost invisible. Any operation could only have made it worse. As they talked I began to realise how distressing the birth experience had been. They were a professional, well-organised couple, used to being in full command of themselves and the world around them. Their own doctor had been called away while she was in labour so she was delivered by a stranger. In addition, the person stitching her up was told by a superior that she had not done it properly. The stitches had to be taken out and redone, leaving the couple feeling vulnerable and at the mercy of incompetent people over whom they had no control. The sense of having been damaged by incompetence had become fixed on the scar.

  The majority of young people, even twenty years ago, had picked up enough information about the way their body worked for them to use it for love making with few problems. For those who were in trouble, looking at the doctor–patient relationship could be helpful. With many of my patients who could not allow full intercourse I found myself becoming more instructive than usual, asking them to draw pictures of their bodies, encouraging self-examination, even buying and lending a set of expensive trainers, dildos in graduated sizes. All these strategies could be helpful: but not to everyone. I seldom noticed that I was being so bossy, or if I did, I felt uneasy and defensive about it. My sense of being pulled between a parental role and a more adult interaction can be seen as a reflection of the conflict inside the patient where the child was afraid to grow up, indeed a sleeping beauty.

  Sometimes the patient’s need to be in control, her inability relax and let go of her self and her muscles, could be observed in the doctor–patient relationship. I had been seeing one patient regularly for some time. One day I found myself driving her home. Only when I realised there had been no good reason for me to do so, did I notice that this was the same patient about whom I wrote in my diary, ‘Don’t be late’. This rather pathetic looking waif of a girl was in fact extremely powerful, controlling all those around her, including me.

  The fear underlying the need to control is, I believe, much more than the fear of pain. In my book I explored the idea that sharing that part of the body with another person could pose a threat to the integrity of the whole self. One patient, who had been married for five years with no full sex, said that she had been alone so long that she could not imagine being ‘with’ him. Another woman, who suffered from severe eczema and had endured many years of painful dressings by others, felt that the inside was the only part of her body that belonged to her.

  The idea that every woman needs to ‘own’ her own vagina, take control of it from her mother, is well established. One of my most vivid memories of Prue Tunnadine is her description of a successful outcome for a couple who have not been able to make love. Hopefully they will want to inform the doctor of their success but then get rid of her. ‘Thank you and good bye,’ accompanied perhaps by a symbolic gift of chocolates or flowers. The doctor needs to be firmly shut out of the bedroom so that the couple can regain their privacy.

  I am not sure if I ever made full use of the doctor–patient interaction in these cases. How much better if I could have stopped and thought, even asked the patient, ‘I wonder why you need me to explain to you – why it is so difficult for you to find out these thin
gs for yourself?’ Perhaps only from the distance of retirement can I see more clearly that my own particularly strong need to help, to cure, to make better, chimed with the need of these patients to be cured and cared for. I never confessed my bossiness in a group when Tom Main was present, for he would have disapproved, chastised me for regressing, without thought, to a more traditional sort of doctoring. At least, that is what I imagined. Perhaps he would have helped me to interpret what was going on. The most important lesson I learned from him reverberates in my head to this day. ‘Fantasies must be fully explored and truly valued before they can be buried with full military honours.’

  Despite the ubiquitous way that sex is displayed in our culture it remains, for many individuals, a delicate, personal matter, so the choice to talk about it to a doctor in privacy is not surprising. For me, the openness of my parents in their bathroom did not remove an inborn shyness about my own bodily functions. In the first few years of my professional life I would not have believed anyone who suggested my career would culminate in working and lecturing in the sexual field. I had chosen family planning because the hours fitted my domestic arrangements. The pressing misery of patients then drove me to listen to the stories of their sexual despair. However, the discipline of listening, and discussions within the IPM, have given me a superficial ease about such matters. When my grandchildren were small I was discussing the possible sex of the fish in my small pond, thinking that I was being usefully zoological. Helen burst out, ‘Oh Mum, can’t you think of anything but sex?’ It was difficult for my family to tolerate the work I did. My mother in particular, despite her own emancipation, did not like to use the word ‘sex’ to her elderly friends. I too would hesitate and talk about medical gynaecology, unsatisfactory when an increasing number of patients were men.