I saw Jennifer in my surgery during a routine evening appointment. She was 24 years old, wearing drab, unfashionable clothing. I had seen her before a few years ago when she had come for the oral contraceptive pill. She worked as a book-keeper.
Once in the consulting room she stared at the floor. I asked her what I could do for her. She told me how she had had a vaginal discharge for ages that would not go. I looked at her notes. Three swabs had been taken, all were clear. She had even been sent to the local clinic for sexually transmitted diseases and been given a clean bill of health. Finally, my partner had referred her to a gynaecologist. She had seen the gynaecologist and was on the waiting list for cryosurgery to her cervix. In the meantime she still had this “awful” discharge, please could I help her. I was puzzled as she had seen the specialist and was due at the hospital soon.
“I had better examine you then,” I said.
She looked horrified but went behind the curtain. I followed to find that she had taken her things off but was lying on the couch with the blanket right up to her neck.
“This must be a horrible job for you doctor,” she said.
“I’m interested that you feel that about it,” I said.
As I went to examine her I could see the disgust on her face. There was no vaginismus and I easily passed a speculum. There was no more than the minimum of physiological discharge. There was a very small ectropion.
“Everything down there looks clean and healthy to me,” I said.
She looked sad and ashamed.
“You don’t seem to like this part of yourself,” I said.
There was no answer. “It must make sex difficult if you feel like this about your body.”
“You are right doctor, I can’t have sex at all. I think my fianc will leave me soon.”
At that point she burst into tears and, still sobbing, sat up clutching the couch blanket around her lower body. I perched on the edge of the couch still wearing my examination gloves. I did not want to lose this moment.
“When did this start?” I asked.
She calmed down and told me her story. “Peter was my first proper boyfriend. We’re planning to get married. I love him a lot and, although I thought it was wrong at first, we started to have sex together. It was great and we felt so close. I felt safe as I am on the pill. We were both virgins and we did not think that we would need to use condoms. My father would вЂњkill meвЂќ if I got pregnant. My parents are very religious. When I came for a pill check-up, your nurse did a smear.”
Her lip started to tremble as she told me how the result had come back showing no abnormality apart from some candida on the slide. “The letter that the nurse wrote to me said that I had an infection and that if I still had a discharge I must get it treated. I came to see another doctor who gave me a pessary but it did no good and I still had the discharge.”
I said, “I am confused that an infection such as thrush can make you seem so disgusted with your body.”
Her demeanour changed and she looked angry. “I want to know where I got it from,” she spat out. I must have got it from Peter as I have been with no-one else. He swears that he has not been unfaithful. I feel dirty and used. I can’t let him near me. He refused to go to the clinic for a check-up as he said it wasn’t his fault, and now I have got to have this operation.”
“You don’t catch thrush from anyone,” I said quietly.
She sat bolt upright and looked me in the eye. “What do you mean, you don’t catch thrush from anyone?”
I explained to her the nature of the disease and she looked very thoughtful. “How can I have been so ignorant?” she said.
She quickly put her things on and made to leave. There was a much lighter atmosphere in the room. I asked her to make another appointment to talk about the cryosurgery and she quickly left. The appointment had lasted about 15 minutes.
She came to see me again about 2 weeks later. She had changed her hairstyle and looked more grown up. I asked her how she was and she answered that she was much better. Sex was fine and she did not want to talk about it. She apologized for having been so stupid. She said she should have asked the other doctors about the transmission of thrush but felt too ashamed and embarrassed. She still had some discharge but agreed that she could live with it and asked me to cancel the surgery. I suggested that she did it by ringing the consultant’s secretary. I did not suggest another appointment.
What had happened in this consultation?
- I had stuck to the here and now, concentrating on the atmosphere in the room.
- I had reflected back to her the disgust with her body that she was emanating.
- The vaginal examination acted as a moment of truth when her defences were down and her real fears were addressed.
- I allowed her to regain control by cancelling her own appointment.
- Details of her newly improved sex life were not to be shared with the doctor as there was no longer a medical problem.
- She knows where I am if there are any future difficulties.