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Premarital Counseling
Premarital Counseling JANET E. TOWNE, M.D. Clinical Professor of Obstetrics and Gynecology, Stritch School of Medicine of Loyola University; Chairman of the Department of Obstetrics and Gynecology, Mercy Hospital and Lewis Memorial Maternity Hospital, Chicago, Illinois
IN our complicated world, any simplification of the events around us is welcome and, in fact, almost necessary. CompUlsions to plan our lives, to take into account all possible adversities and to guard against them are problems familiar to all of us. It is not surprising, then, that women seeking happiness and sexual satisfaction attempt before marriage to prepare for avoidance of sexual anxieties and frustrations. PANORAMA OF SEX EDUCATION
Undoubtedly the need for sexual understanding has been recognized, as evidenced by the current marriage curriculums offered by high schools, colleges, Pre-Cana Conferences and marriage counsel clinics. Attendance at these classes would indicate that today's men and women view sex as a normal, wholesome, to-be-enjoyed-for-itself symbol of married life. This is one of the important reasons why prenuptial couples are so eager for sexual education and medical counseling. However, despite the tremendous contributions of liberal sex education to the improvement of our modern marriages, there are, as yet, a multitude of women who need guidance in such affairs. Inaccurate concepts based on sordid literature, gossip and superstitions are potential threats to marriage. Obviously, to dispel fixed ideas of romance derived from movies, fiction and other erroneous sources of sexual knowledge may be difficult. Sexual education today represents an attempt to correct some of the misconceptions and add to knowledge of sexual behavior that may prevent future insecurities and frustrations. Counseling, therefore, is a challenge that is geared to help young couples face real situations with poise and confidence. Against such educational backgrounds let us review some of the various phases of premarital counseling which may promote a natural progress into matrimony.
53
J ANET E.
54
TOWNE
APPROACH TO THE PATIENT
The participation of the physician in premarital counseling is needed to make sex something that a couple can understand. By assisting, the physician is capable of enlarging the scope of training by a personal approach that is not obtained in classrooms or literature. Fortunately, some physicians recognize the seriousness of this type of education and are prepared for it, while others have a limited knowledge obtained only from their own experiences. Bringing sexual problems into a discussion involves a reserve and a decorum that reflects respect, understanding, and the seriousness of the patient-physician relationship. Furthermore, the use of vulgar terms, fumbling attempts at jocularity, and embarrassment on the part of the medical advisor will destroy the dignity that must accompany marital education. One cannot stress too strongly the need for the establishment of a sympathetic rapport in the physician-patient relationship. Women are almost universally modest and anxious about their sexuality but are reluctant to discuss this fear even with their medical advisors. A busy physician performing a hurried examination along with the necessary serologic tests is more than likely to be unconscious of the emotional needs of the patient. If the physician will recognize the problem and adopt a sympathetic attitude, he can evaluate and treat problems which might otherwise be overlooked. The amount of time spent in premarital counseling is entirely dependent upon the needs of the patient. In some instances a few simple explanations suffice to prevent future misunderstandings but others may require several sessions to prepare for marital adjustment. The approach to, and the care of, the patient must be adjusted to her personality traits, previous environment and present needs. Once an appropriate background has been established, the physician must be thorough and wise in the execution of diagnostic and therapeutic counseling. The physician's instructions should be patterned in terms that express the importance of sexual problems upon general health and upon the marriage relationship itself. Moral Obligations
Marriage should be portrayed as a vocation dependent upon love and mutual respect which requires the assistance of God's grace to maintain its sanctity and happiness. Any effort directed toward cementing a solid marital union must be built upon the fundamental knowledge that marriage is not just an affair of human relationship. Although the physician may impart a rich store of biological information, this contribution may have little value in achieving marital happiness unless the moral obligations are fully realized. One should therefore recognize the necessity of encouraging the couple to seek guidance from the clergymen of their faith.
Premarital Counseling
55 HISTORY TAKING
The success or failure of premarital counseling may be determined by the initial interview. An adequate medical, personal and familial history should be obtained before a physical examination is made. By winning the confidence of the individual, and guaranteeing the secrecy of the records, information on significant conflicts relative to masturbation, prenuptial intercourse, promiscuous contacts, etc., may be obtained. The past indiscretions are often associated with feelings of guilt, shame and embarrassment and are significant in developing a picture of maturity or ignorance. Correlation of the accumulated evidence derived from the patient's background creates an insight into the individual needs of the patient. Any constitutional illness should be investigated thoroughly, not waiting until after the marriage. Chronic debilitating diseases, cardiac disease, thyroid and endocrine dysfunctions, obesity, nervous disorders and anemias are conditions which may affect sexual responses. State laws usually require serologic studies to rule out the presence of venereal disease before a marriage license is granted. This requirement presents the opportunity not only to initiate premarital counseling but to advise and carry out additional laboratory studies including urinalysis, hematocrit, hemoglobin, blood count and chest x-ray. A carefully taken gynecologic history will often reveal definite psychiatric problems related to such factors as (1) the menarche, (2) dysmenorrhea, (3) parental conflicts, (4) adolescent conflicts, (5) previous sexual experiences or (6) sexual orientation. In these cases psychiatric referral should be suggested before marriage is undertaken. THE PELVIC EXAMINATION
Most women, whether they be married or single, dislike and resent internal examinations. Deep-rooted fears of pain and instrumentation, and embarrassment over genital exposure are considerations that must be borne in mind before a pelvic investigation is begun. Privacy, dignity and gentleness are necessary. Each procedure should be preceded by a few words of explanation to gain the confidence of the patient. Assurance to the bride and her family that her virginity will not be molested is often necessary before an examination is permitted. Bimanual examinations may prevent many marital maladjustments. Developmental defects, immature genital organs or abnormalities of the bony pelvis which might affect the sex act or reproductive function may be uncovered. Irritating vaginal discharges as caused by Trichomonas, Monilia or cervicitis may aggravate coital distress and such disorders must be discovered and corrected.
56
JANET
K
TOWNl~
The Hymen Many young women are concerned about the structure and condition of the hymen but have little or no idea of its location in the pelvis. Moreover, deep-seated fear exists that it will be the source of bleeding and pain when sexual relations are begun. It is the responsibility of the examiner to ascertain the texture, capacity, elasticity, and any malformations of the hymen which might interfere with consummation of the marriage. Dyspareunia, often considered as psychosomatic in origin, can also be anatomical as a result of a rigid or imperforate hymen. It can also be caused by synechiae, vaginal atrophy or absence, septate vagina, condylomata, and numerous other physical and pathological conditions. There is no doubt that dyspareunia creates a serious emotional state that can lead to actual frigidity or neuroses with resulting sexual maladjustment. In order to avoid such frustrations, the hymen, when exhibiting evidence of being an impediment to marriage, should have corrective therapy. A fearful virgin must first be taught to cooperate and to relax. The patency of the hymen can then be determined by the insertion of a cotton applicator or a well lubricated examining finger. Any manipulation provoking pain and withdrawal should be stopped until the woman's confidence has been restored. When dilatation or stretching of the hymen is deemed necessary, the situation must be discussed with the couple before any procedure is carried out. In some instances, fortunately very few, the husband-to-be has insisted upon intercourse to ascertain the virginity of his bride. Furthermore, certain religious groups prohibit any interference until actual dysfunction is proved. Cooperative patients in need of hymenal stretching may be instructed to use the atraumatic technique described by Kavinsky.3 This method consists of first teaching the patient, in the office, to insert into the vagina anestheticaUy lubricated vaginal or rectal dilators, and to repeat these insertions once or twice daily at home. Occasionally, such self-applied methods are distasteful and must be carried out by the doctor at subsequent office visits, in which case graduated speculums may be employed. In other instances, to achieve a satisfactory adjustment, dilation under anesthesia, or such operative procedures m; hymenectomy or hymenotomy may be necessary. Success of any operative intervention demands perfect healing before sexual relations are attempted, for even moderate pain may initiate vaginismus or lead to fixed frigidity. Any training period must be maintained until a normal reaction has been established. Muscular Control
Attention may now, under appropriate circumstances, be directed toward teaching the impol'talH'e of muscular control. If the patient
57
Premarital Counseling
requests such information, or if her general attitude, reactions and questions indicate her ability to handle this sort of teaching objectively and naturally, the physician may undertake discussion of the functions of the pubococcygeus muscles, as described by Kega1. 4 Proper relaxation and contraction of the vaginal sphineter and the pubococcygeus muscles encourage a normal sexual rhythm and response which may relieve passive attitudes and contribute to mutual satisfaction during the sexual act. On the other hand, ignorance of the role of muscles can result in vaginismus. When such a condition arises, the powerful spasms of the levators, sphincters and pubococcygeus muscles produce frigidity which may make sexual union impossible. Although sometimes difficult to teach, the patient may initially learn to control muscular activity by constricting and relaxing the rectal sphincters. This type of activity creates an awareness of similar involuntary muscular movements within the vagina. If the patient is anxious for information and is having difficulty in effecting voluntary influence on the muscles, the physician might try to stimulate a vaginal response by introducing a dilator or examining finger into the vaginal vault. Obviously, such exercises call for caution if the physician is a male. A third person must be present in the room. If the physician has mistaken his patient and her response is erotic, the exercises must be terminated forthwith. PREMARITAL TOPICS
Upon completion of his examination the physician will have obtained an estimate of the patient's emotional maturity and sexual insight. At this time illustrations or pelvic models may be shown to the patient to supplement previous references to pelvic anatomy. Leading questions will help to establish the effectiveness of the discussions and the understanding obtained from the session. The amount of time necessary to devote to the patient in the postexamination counseling period depends entirely upon the skill of the counsel or and the maturity o(the patient. Since there are many possible threats to the success of a marriage, additional information is always needed. The following is suggested as an outline of premarital topics. Differences in Sexual Attitudes
As previously intimated, the anatomical principle is the same for sexual responses in the male and the female; however, both sexes vary considerably in their sexual attitudes. It would seem that many interrelated factors are responsible for the differences in sexual appetites. The average male creates a sexual energy from external stimuli or anticipation of sexual relationship; moreover, each coital act normally • terminates with an orgasm within a short span of time. On the other
58
JANET E. TOWNE
hand, the normal female is not so easily aroused and may only on occasion achieve a climax. This deficit in female libido is often responsible for much unhappiness. Women should be taught to create healthy sexual appetites by occasionally initiating coitus, refusing to participate only with valid reasons, and not to passively await the aggressive male approach. By attempting to instill an instinctive desire for sexual enjoyment, some of the destructive aspects of sexual activity may be abolished. 1. PRELIMINARY STIMULATION. The physician must sanction caresses by the husband of all the erogenous zones and emphasize that sexual response may depend upon the nature of the stimulus. The need for preliminary stimulation to develop sensory perception in the clitoris is biologically essential in the female. The effectiveness of the techniques depends primarily upon the male's knowledge and his utilization of this knowledge. For mutual satisfaction, the groom must be instructed to exercise tenderness, patience and affection through caresses and not to develop a mechanical approach. 2. ORGASM. Mutual responses in a sociosexual relationship provide the ultimate satisfaction and pleasure which contribute to the solidarity of a marriage. Yet, there are many misconceptions which must be corrected to avoid frustrations and disappointments. Most couples believe that normal sexual function and subsequent conception are dependent entirely upon a simultaneous orgastic response. However, studies in marital relations reveal that the average male may achieve an orgasm within three to five minutes while the woman, being more passive, requires a much longer time before a climax is reached. Whether the origin of the orgasm is clitoridal or vaginal has been the subject of much controversy. Nevertheless, because of its homologous relation to the penis anatomically and embryologically the clitoris may well play the major role in the mechanism of the female orgasm. Methods of stimulation, genital manipulations, coital movements and vaginal muscular exercises may be instrumental factors in achieving the ultimate goal. However, the couple must be warned that several months of manual stimulation or participation in sexual activity may elapse before a satisfactory orgastic response occurs in the female. 3. COITAL RESPONSE OF THE FEMALE. Failure of the female to be aroused or reach an orgasm must not connote an unwillingness to function sexually. Women should be taught that enthusiastic cooperation in changes of coital position may supply additional physical stimulation. It is not surprising to find that most young women have a limited understanding of the importance of a good sexual response. Many entertain fixed notions that passiveness, immobility, or mere acquiescence are the requirements of female marital activity. One must therefore encourage active participation in coitus which may contribute to the satisfactory response of both individuals. Technical literature may of course be
Premarital Counseling
59
constructive but teaching motivation can and will create healthier sexual appetites and responses. Furthermore, realization that sexual love grows and is enriched by marital experience is encouraging for most young couples to know. While explanations directed toward the duties of the partners are important, the giving of self in marriage should be depicted as a normal consequence of mutual love. Self-surrender and self-sacrifice are encouraged lest the marriage be buried in selfish interests. 4. CHILD-BEARING ABILITY. The knowledge that her genital organs can function sexually is important to the woman but equally so is assurance that her physique is one that can readily bear children. The procreation and education of children constitute the primary end of marriage. The other purposes of marriage-mutual love and harmonyare certainly important, but they are subordinate to the primary end. There are of course limits in determining the possibility of future pregnancies. Assurance that a normal pelvis indicates future child-bearing presupposes a knowledge of future medical problems. Requests for such assurance are reasonable but it is not right to give a positive answer. All conditions indicating favorable possibilities for future gestations should be carefully explained, whereas doubts must be prudently evaluated. In dealing with this situation, the equal responsibilities of both the husband and the wife must be stressed. Accordingly, it is important to give a brief description of the male and female reproductive organs and their functions and to outline the conditions required for conception. The woman is then advised that an adjustment period of sexual activity for one year after marriage may be needed to determine the fertility of the couple. Failure to conceive after this period would then necessitate a complete fertility study which should be explained as too time-consuming to be feasible before a marriage trial. 5. AVOIDING CONCEPTION. Since, in accordance with my religious convictions, I do not condone the use of "artificial" methods of preventing conception, I will confine this discussion to "natural" birth control, namely, the use of the rhythm method, which involves periodic continence and, perhaps, the use of "Tes-Tape." This method may be used by couples who have valid reasons for avoiding conception. For such, information is given on methods of determining the occurrence of ovulation by temperature charts, menstrual patterns, or Tes-Tape, and the couple is advised to refrain from intercourse during this fertile period. This information is helpful also to the couple wanting to know the optimum time for exercising their conjugal rights in order to achieve pregnancy. Frequency of Intercourse
Practices in this sphere vary greatly. Actually, marriage problems do not necessarily arise over whether sexual intercourse takes place two or three times a week but rather whether it is mutually satisfying. The
60
.J ANET E.
TOWNE
matter of partner consideration is of far more importance in a successful marriage than the frequency of coitus. Strenuous events preceding the wedding, emotional tensions, and exhaustion are not conducive to a good start in sexual adjustment. Initiation into sexual relationship under such circumstances can also affect future attempts and the couple should be forewarned. Patience and tolerance are needed during the period of adjustment which is gradual over the ensuing months of marriage. Consequently, a pattern as to the frequeney of coitus develops that is dependent upon personal enjoyment, physical needs and mutual love. Sexual Techniques
Coital positions must often be suggested to the timid or ignorant couple to dispel any ideas of abnormalcy. Sampling the various positions that may be assumed during intereourse should be emphasized as normal experimentation in the early months of adjustment. It should further be suggested that the position resulting in the utmost mutual satisfaction is the ultimate goal. The various coital positions may be stated as follows: (1) female supine facing the male, (2) male supine facing the female, (3) side to side, (4) female face down, with hips elevated, male above. Other positions, including sitting or standing, are sometimes employed by way of experiment. It is doubtful that anyone position has an advantage over another but variations are employed in an attempt to create individual patterns. Personal Hygiene
The intimacy of married life should not destroy the personal privacy enjoyed in the single status. Nothing hastens to destroy the esthetic values in marriage quicker than slovenly habits in personal matters. One must advise with delicacy on such matters as menstruation, the use and disposal of tampons or sanitary pads, personal cleanliness, modesty, and douching. Douching ranks high among traditional patterns yet women need never take a douche unless medically advised to do so. Obviously, under the influence of maternal guidance or personal beliefs many women insist that intercourse necessitates the use of the douche bag. Should such insistence prevail, insLructions should be given for plain water, weak vinegar, or saline solutions. Such preparations are not harmful but the strong caustic remedies so often recommended are destructive not only to the vaginal mucosa but to the normal flora as well. The subject of menstruation is also replete with superstition and ritualistic beliefs that prohibit intercourse during the menstrual flow. Contrary to the passages of Leviticus,7 medical opinion 1 today maintains no objection to sexual intercourse during menstruation unless the flow is excessive. Undoubtedly the prevailing belief that the period of the
Premarital Counseling
61
menstrual flow is one of uncleanliness will be hard to dispel. I do not advocate that the basic rights of a woman to remain chaste at this time, if she so chooses, be denied. Helpful Literature
Because of the diversity of situations encountered in premarital counseling, further effort must at times be expended to enlighted or reorientate some individuals. Intelligent patients ask questions which help the physician to evaluate their specific needs for further counseling. Others require several sessions to clarify sex physiology and techniques and dispel prejudices and fears. Most needed of all seems to be help in reaching emotional maturity. To supplement the information already given and aid in its interpretation the following books or pamphlets are suggested: Facts of Life and Lovn .... ........ Evelyn Duvall Marriage and Sexual Harmony. . .. Oliver Butterfield · .... Abraham Stone Marriage Manual. ........... . Modern Pattern for Ivlarriage .. . · .... Waiter Stokes Family Living ................ . · .... Evelyn Duvall Beginning Your Marriage ........ . · .... Cana Conference of Chicago COMMENT
The importance of premarital teaching and the advisory role of the physician have been discussed. Unfortunately, this instruction has been directed primarily toward the female from the viewpoint of the gynecologist. Of course, men as well as women may be sexually immature or inadequate in function and, when they contemplate marriage, should be willing to undergo an evaluation of their physical state and sexual knowledge. Most men are familiar with their sexual functions and are calmly sure of their own superiority and ability to consummate the sexual union. Others become annoyed, and occasionally absolutely furious, at all this "nonsense," basing their knowledge entirely OIl previous sexual experiences. Adequate preparation of men is a necessity, for sexual promiscuity is not a background conducive to understanding the baffling responses which may ()(~eur in their virginal brides. Premarital counseling is an attempt to overcome some of the difficulties and frustrations which affect the patterns of sexual adjustment. Furthermore, it is in part a concept of liberal education to make the couple more understanding of each other's needs. The couple invested with such knowledge can often cope with, or avoid, dangerous emotional problems which could terminate in dissolution of the marriage. Unfortunately, as life goes, the prohlem may not become really apparent until after the marriage in spite of adequate preparation. One cannot
62
JANET
E.
TOWNE
assume that additional assistance will not be needed. Education is instructing, experience is the teacher. Some parents are bewildered by our modern ideas on counseling that would attempt to solve premarital problems of ignorance. In their day, I would suspect it was considered intellectual to disregard the emotional or physical aspects of a marriage. Ignorance, however, is not bliss. It is the most expensive and dangerous thing in the world. The Bible gives you the answer, "And ye shall know the truth, and the truth shall make you free." REFERENCES 1. Chalmers, L. W.: Woman's Personal Hygiene. New York, Pioneer Publications, 1946. 2. Griffith, E. F.: Medical Aspects of Marriage Guidance. Lancet 1: 165, 1947. 3. Kavinsky, N. R.: Premarital Examination, J.A.M.A. 156: 692-695, 1954. 4. Kegel, A. H.: Sexual Functions of the Pubococcygeous Muscle. West. J. Surg. 60: 521-524, 1952. 5. Knight, R. P.: Functional Disturbances in the Sexual Life of Women. Bull. Menninger Clin. 7: 25, 1943. 6. Kroger, W. S.: Psychosomatic Aspects of Frigidity. J.A.M.A. 143: 526,1950. 7. Leviticus 15: 19-23, 18: 19, 20: 18. 8. Muller, P. F.: Group Premarital Counseling. Am. J. Obst. & Gynec. 73: 941,1957 9. Offen, J. A.: J. Obst. & Gynaec. Brit. Emp. 13: 302,1959. 10. Pierson, R. N.: Experiences in Premarital Counselling. J. Michigan M. Soc. 54: 2050, 1954. 11. Sinclair, D. A.: Marriage and Its Sexual Problems. Urol. & Cutan. Rev. 42: 378, 1954. 12. Stokes, W. R. and Harper, R. A.: The Doctor as Marriage Counsellor. M. Ann. District of Columbia 23: 670, 1954. 55 E. Washington Street Chicago 2, Illinois
IN our complicated world, any simplification of the events around us is welcome and, in fact, almost necessary. CompUlsions to plan our lives, to take into account all possible adversities and to guard against them are problems familiar to all of us. It is not surprising, then, that women seeking happiness and sexual satisfaction attempt before marriage to prepare for avoidance of sexual anxieties and frustrations. PANORAMA OF SEX EDUCATION
Undoubtedly the need for sexual understanding has been recognized, as evidenced by the current marriage curriculums offered by high schools, colleges, Pre-Cana Conferences and marriage counsel clinics. Attendance at these classes would indicate that today's men and women view sex as a normal, wholesome, to-be-enjoyed-for-itself symbol of married life. This is one of the important reasons why prenuptial couples are so eager for sexual education and medical counseling. However, despite the tremendous contributions of liberal sex education to the improvement of our modern marriages, there are, as yet, a multitude of women who need guidance in such affairs. Inaccurate concepts based on sordid literature, gossip and superstitions are potential threats to marriage. Obviously, to dispel fixed ideas of romance derived from movies, fiction and other erroneous sources of sexual knowledge may be difficult. Sexual education today represents an attempt to correct some of the misconceptions and add to knowledge of sexual behavior that may prevent future insecurities and frustrations. Counseling, therefore, is a challenge that is geared to help young couples face real situations with poise and confidence. Against such educational backgrounds let us review some of the various phases of premarital counseling which may promote a natural progress into matrimony.
53
J ANET E.
54
TOWNE
APPROACH TO THE PATIENT
The participation of the physician in premarital counseling is needed to make sex something that a couple can understand. By assisting, the physician is capable of enlarging the scope of training by a personal approach that is not obtained in classrooms or literature. Fortunately, some physicians recognize the seriousness of this type of education and are prepared for it, while others have a limited knowledge obtained only from their own experiences. Bringing sexual problems into a discussion involves a reserve and a decorum that reflects respect, understanding, and the seriousness of the patient-physician relationship. Furthermore, the use of vulgar terms, fumbling attempts at jocularity, and embarrassment on the part of the medical advisor will destroy the dignity that must accompany marital education. One cannot stress too strongly the need for the establishment of a sympathetic rapport in the physician-patient relationship. Women are almost universally modest and anxious about their sexuality but are reluctant to discuss this fear even with their medical advisors. A busy physician performing a hurried examination along with the necessary serologic tests is more than likely to be unconscious of the emotional needs of the patient. If the physician will recognize the problem and adopt a sympathetic attitude, he can evaluate and treat problems which might otherwise be overlooked. The amount of time spent in premarital counseling is entirely dependent upon the needs of the patient. In some instances a few simple explanations suffice to prevent future misunderstandings but others may require several sessions to prepare for marital adjustment. The approach to, and the care of, the patient must be adjusted to her personality traits, previous environment and present needs. Once an appropriate background has been established, the physician must be thorough and wise in the execution of diagnostic and therapeutic counseling. The physician's instructions should be patterned in terms that express the importance of sexual problems upon general health and upon the marriage relationship itself. Moral Obligations
Marriage should be portrayed as a vocation dependent upon love and mutual respect which requires the assistance of God's grace to maintain its sanctity and happiness. Any effort directed toward cementing a solid marital union must be built upon the fundamental knowledge that marriage is not just an affair of human relationship. Although the physician may impart a rich store of biological information, this contribution may have little value in achieving marital happiness unless the moral obligations are fully realized. One should therefore recognize the necessity of encouraging the couple to seek guidance from the clergymen of their faith.
Premarital Counseling
55 HISTORY TAKING
The success or failure of premarital counseling may be determined by the initial interview. An adequate medical, personal and familial history should be obtained before a physical examination is made. By winning the confidence of the individual, and guaranteeing the secrecy of the records, information on significant conflicts relative to masturbation, prenuptial intercourse, promiscuous contacts, etc., may be obtained. The past indiscretions are often associated with feelings of guilt, shame and embarrassment and are significant in developing a picture of maturity or ignorance. Correlation of the accumulated evidence derived from the patient's background creates an insight into the individual needs of the patient. Any constitutional illness should be investigated thoroughly, not waiting until after the marriage. Chronic debilitating diseases, cardiac disease, thyroid and endocrine dysfunctions, obesity, nervous disorders and anemias are conditions which may affect sexual responses. State laws usually require serologic studies to rule out the presence of venereal disease before a marriage license is granted. This requirement presents the opportunity not only to initiate premarital counseling but to advise and carry out additional laboratory studies including urinalysis, hematocrit, hemoglobin, blood count and chest x-ray. A carefully taken gynecologic history will often reveal definite psychiatric problems related to such factors as (1) the menarche, (2) dysmenorrhea, (3) parental conflicts, (4) adolescent conflicts, (5) previous sexual experiences or (6) sexual orientation. In these cases psychiatric referral should be suggested before marriage is undertaken. THE PELVIC EXAMINATION
Most women, whether they be married or single, dislike and resent internal examinations. Deep-rooted fears of pain and instrumentation, and embarrassment over genital exposure are considerations that must be borne in mind before a pelvic investigation is begun. Privacy, dignity and gentleness are necessary. Each procedure should be preceded by a few words of explanation to gain the confidence of the patient. Assurance to the bride and her family that her virginity will not be molested is often necessary before an examination is permitted. Bimanual examinations may prevent many marital maladjustments. Developmental defects, immature genital organs or abnormalities of the bony pelvis which might affect the sex act or reproductive function may be uncovered. Irritating vaginal discharges as caused by Trichomonas, Monilia or cervicitis may aggravate coital distress and such disorders must be discovered and corrected.
56
JANET
K
TOWNl~
The Hymen Many young women are concerned about the structure and condition of the hymen but have little or no idea of its location in the pelvis. Moreover, deep-seated fear exists that it will be the source of bleeding and pain when sexual relations are begun. It is the responsibility of the examiner to ascertain the texture, capacity, elasticity, and any malformations of the hymen which might interfere with consummation of the marriage. Dyspareunia, often considered as psychosomatic in origin, can also be anatomical as a result of a rigid or imperforate hymen. It can also be caused by synechiae, vaginal atrophy or absence, septate vagina, condylomata, and numerous other physical and pathological conditions. There is no doubt that dyspareunia creates a serious emotional state that can lead to actual frigidity or neuroses with resulting sexual maladjustment. In order to avoid such frustrations, the hymen, when exhibiting evidence of being an impediment to marriage, should have corrective therapy. A fearful virgin must first be taught to cooperate and to relax. The patency of the hymen can then be determined by the insertion of a cotton applicator or a well lubricated examining finger. Any manipulation provoking pain and withdrawal should be stopped until the woman's confidence has been restored. When dilatation or stretching of the hymen is deemed necessary, the situation must be discussed with the couple before any procedure is carried out. In some instances, fortunately very few, the husband-to-be has insisted upon intercourse to ascertain the virginity of his bride. Furthermore, certain religious groups prohibit any interference until actual dysfunction is proved. Cooperative patients in need of hymenal stretching may be instructed to use the atraumatic technique described by Kavinsky.3 This method consists of first teaching the patient, in the office, to insert into the vagina anestheticaUy lubricated vaginal or rectal dilators, and to repeat these insertions once or twice daily at home. Occasionally, such self-applied methods are distasteful and must be carried out by the doctor at subsequent office visits, in which case graduated speculums may be employed. In other instances, to achieve a satisfactory adjustment, dilation under anesthesia, or such operative procedures m; hymenectomy or hymenotomy may be necessary. Success of any operative intervention demands perfect healing before sexual relations are attempted, for even moderate pain may initiate vaginismus or lead to fixed frigidity. Any training period must be maintained until a normal reaction has been established. Muscular Control
Attention may now, under appropriate circumstances, be directed toward teaching the impol'talH'e of muscular control. If the patient
57
Premarital Counseling
requests such information, or if her general attitude, reactions and questions indicate her ability to handle this sort of teaching objectively and naturally, the physician may undertake discussion of the functions of the pubococcygeus muscles, as described by Kega1. 4 Proper relaxation and contraction of the vaginal sphineter and the pubococcygeus muscles encourage a normal sexual rhythm and response which may relieve passive attitudes and contribute to mutual satisfaction during the sexual act. On the other hand, ignorance of the role of muscles can result in vaginismus. When such a condition arises, the powerful spasms of the levators, sphincters and pubococcygeus muscles produce frigidity which may make sexual union impossible. Although sometimes difficult to teach, the patient may initially learn to control muscular activity by constricting and relaxing the rectal sphincters. This type of activity creates an awareness of similar involuntary muscular movements within the vagina. If the patient is anxious for information and is having difficulty in effecting voluntary influence on the muscles, the physician might try to stimulate a vaginal response by introducing a dilator or examining finger into the vaginal vault. Obviously, such exercises call for caution if the physician is a male. A third person must be present in the room. If the physician has mistaken his patient and her response is erotic, the exercises must be terminated forthwith. PREMARITAL TOPICS
Upon completion of his examination the physician will have obtained an estimate of the patient's emotional maturity and sexual insight. At this time illustrations or pelvic models may be shown to the patient to supplement previous references to pelvic anatomy. Leading questions will help to establish the effectiveness of the discussions and the understanding obtained from the session. The amount of time necessary to devote to the patient in the postexamination counseling period depends entirely upon the skill of the counsel or and the maturity o(the patient. Since there are many possible threats to the success of a marriage, additional information is always needed. The following is suggested as an outline of premarital topics. Differences in Sexual Attitudes
As previously intimated, the anatomical principle is the same for sexual responses in the male and the female; however, both sexes vary considerably in their sexual attitudes. It would seem that many interrelated factors are responsible for the differences in sexual appetites. The average male creates a sexual energy from external stimuli or anticipation of sexual relationship; moreover, each coital act normally • terminates with an orgasm within a short span of time. On the other
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JANET E. TOWNE
hand, the normal female is not so easily aroused and may only on occasion achieve a climax. This deficit in female libido is often responsible for much unhappiness. Women should be taught to create healthy sexual appetites by occasionally initiating coitus, refusing to participate only with valid reasons, and not to passively await the aggressive male approach. By attempting to instill an instinctive desire for sexual enjoyment, some of the destructive aspects of sexual activity may be abolished. 1. PRELIMINARY STIMULATION. The physician must sanction caresses by the husband of all the erogenous zones and emphasize that sexual response may depend upon the nature of the stimulus. The need for preliminary stimulation to develop sensory perception in the clitoris is biologically essential in the female. The effectiveness of the techniques depends primarily upon the male's knowledge and his utilization of this knowledge. For mutual satisfaction, the groom must be instructed to exercise tenderness, patience and affection through caresses and not to develop a mechanical approach. 2. ORGASM. Mutual responses in a sociosexual relationship provide the ultimate satisfaction and pleasure which contribute to the solidarity of a marriage. Yet, there are many misconceptions which must be corrected to avoid frustrations and disappointments. Most couples believe that normal sexual function and subsequent conception are dependent entirely upon a simultaneous orgastic response. However, studies in marital relations reveal that the average male may achieve an orgasm within three to five minutes while the woman, being more passive, requires a much longer time before a climax is reached. Whether the origin of the orgasm is clitoridal or vaginal has been the subject of much controversy. Nevertheless, because of its homologous relation to the penis anatomically and embryologically the clitoris may well play the major role in the mechanism of the female orgasm. Methods of stimulation, genital manipulations, coital movements and vaginal muscular exercises may be instrumental factors in achieving the ultimate goal. However, the couple must be warned that several months of manual stimulation or participation in sexual activity may elapse before a satisfactory orgastic response occurs in the female. 3. COITAL RESPONSE OF THE FEMALE. Failure of the female to be aroused or reach an orgasm must not connote an unwillingness to function sexually. Women should be taught that enthusiastic cooperation in changes of coital position may supply additional physical stimulation. It is not surprising to find that most young women have a limited understanding of the importance of a good sexual response. Many entertain fixed notions that passiveness, immobility, or mere acquiescence are the requirements of female marital activity. One must therefore encourage active participation in coitus which may contribute to the satisfactory response of both individuals. Technical literature may of course be
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constructive but teaching motivation can and will create healthier sexual appetites and responses. Furthermore, realization that sexual love grows and is enriched by marital experience is encouraging for most young couples to know. While explanations directed toward the duties of the partners are important, the giving of self in marriage should be depicted as a normal consequence of mutual love. Self-surrender and self-sacrifice are encouraged lest the marriage be buried in selfish interests. 4. CHILD-BEARING ABILITY. The knowledge that her genital organs can function sexually is important to the woman but equally so is assurance that her physique is one that can readily bear children. The procreation and education of children constitute the primary end of marriage. The other purposes of marriage-mutual love and harmonyare certainly important, but they are subordinate to the primary end. There are of course limits in determining the possibility of future pregnancies. Assurance that a normal pelvis indicates future child-bearing presupposes a knowledge of future medical problems. Requests for such assurance are reasonable but it is not right to give a positive answer. All conditions indicating favorable possibilities for future gestations should be carefully explained, whereas doubts must be prudently evaluated. In dealing with this situation, the equal responsibilities of both the husband and the wife must be stressed. Accordingly, it is important to give a brief description of the male and female reproductive organs and their functions and to outline the conditions required for conception. The woman is then advised that an adjustment period of sexual activity for one year after marriage may be needed to determine the fertility of the couple. Failure to conceive after this period would then necessitate a complete fertility study which should be explained as too time-consuming to be feasible before a marriage trial. 5. AVOIDING CONCEPTION. Since, in accordance with my religious convictions, I do not condone the use of "artificial" methods of preventing conception, I will confine this discussion to "natural" birth control, namely, the use of the rhythm method, which involves periodic continence and, perhaps, the use of "Tes-Tape." This method may be used by couples who have valid reasons for avoiding conception. For such, information is given on methods of determining the occurrence of ovulation by temperature charts, menstrual patterns, or Tes-Tape, and the couple is advised to refrain from intercourse during this fertile period. This information is helpful also to the couple wanting to know the optimum time for exercising their conjugal rights in order to achieve pregnancy. Frequency of Intercourse
Practices in this sphere vary greatly. Actually, marriage problems do not necessarily arise over whether sexual intercourse takes place two or three times a week but rather whether it is mutually satisfying. The
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matter of partner consideration is of far more importance in a successful marriage than the frequency of coitus. Strenuous events preceding the wedding, emotional tensions, and exhaustion are not conducive to a good start in sexual adjustment. Initiation into sexual relationship under such circumstances can also affect future attempts and the couple should be forewarned. Patience and tolerance are needed during the period of adjustment which is gradual over the ensuing months of marriage. Consequently, a pattern as to the frequeney of coitus develops that is dependent upon personal enjoyment, physical needs and mutual love. Sexual Techniques
Coital positions must often be suggested to the timid or ignorant couple to dispel any ideas of abnormalcy. Sampling the various positions that may be assumed during intereourse should be emphasized as normal experimentation in the early months of adjustment. It should further be suggested that the position resulting in the utmost mutual satisfaction is the ultimate goal. The various coital positions may be stated as follows: (1) female supine facing the male, (2) male supine facing the female, (3) side to side, (4) female face down, with hips elevated, male above. Other positions, including sitting or standing, are sometimes employed by way of experiment. It is doubtful that anyone position has an advantage over another but variations are employed in an attempt to create individual patterns. Personal Hygiene
The intimacy of married life should not destroy the personal privacy enjoyed in the single status. Nothing hastens to destroy the esthetic values in marriage quicker than slovenly habits in personal matters. One must advise with delicacy on such matters as menstruation, the use and disposal of tampons or sanitary pads, personal cleanliness, modesty, and douching. Douching ranks high among traditional patterns yet women need never take a douche unless medically advised to do so. Obviously, under the influence of maternal guidance or personal beliefs many women insist that intercourse necessitates the use of the douche bag. Should such insistence prevail, insLructions should be given for plain water, weak vinegar, or saline solutions. Such preparations are not harmful but the strong caustic remedies so often recommended are destructive not only to the vaginal mucosa but to the normal flora as well. The subject of menstruation is also replete with superstition and ritualistic beliefs that prohibit intercourse during the menstrual flow. Contrary to the passages of Leviticus,7 medical opinion 1 today maintains no objection to sexual intercourse during menstruation unless the flow is excessive. Undoubtedly the prevailing belief that the period of the
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menstrual flow is one of uncleanliness will be hard to dispel. I do not advocate that the basic rights of a woman to remain chaste at this time, if she so chooses, be denied. Helpful Literature
Because of the diversity of situations encountered in premarital counseling, further effort must at times be expended to enlighted or reorientate some individuals. Intelligent patients ask questions which help the physician to evaluate their specific needs for further counseling. Others require several sessions to clarify sex physiology and techniques and dispel prejudices and fears. Most needed of all seems to be help in reaching emotional maturity. To supplement the information already given and aid in its interpretation the following books or pamphlets are suggested: Facts of Life and Lovn .... ........ Evelyn Duvall Marriage and Sexual Harmony. . .. Oliver Butterfield · .... Abraham Stone Marriage Manual. ........... . Modern Pattern for Ivlarriage .. . · .... Waiter Stokes Family Living ................ . · .... Evelyn Duvall Beginning Your Marriage ........ . · .... Cana Conference of Chicago COMMENT
The importance of premarital teaching and the advisory role of the physician have been discussed. Unfortunately, this instruction has been directed primarily toward the female from the viewpoint of the gynecologist. Of course, men as well as women may be sexually immature or inadequate in function and, when they contemplate marriage, should be willing to undergo an evaluation of their physical state and sexual knowledge. Most men are familiar with their sexual functions and are calmly sure of their own superiority and ability to consummate the sexual union. Others become annoyed, and occasionally absolutely furious, at all this "nonsense," basing their knowledge entirely OIl previous sexual experiences. Adequate preparation of men is a necessity, for sexual promiscuity is not a background conducive to understanding the baffling responses which may ()(~eur in their virginal brides. Premarital counseling is an attempt to overcome some of the difficulties and frustrations which affect the patterns of sexual adjustment. Furthermore, it is in part a concept of liberal education to make the couple more understanding of each other's needs. The couple invested with such knowledge can often cope with, or avoid, dangerous emotional problems which could terminate in dissolution of the marriage. Unfortunately, as life goes, the prohlem may not become really apparent until after the marriage in spite of adequate preparation. One cannot
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assume that additional assistance will not be needed. Education is instructing, experience is the teacher. Some parents are bewildered by our modern ideas on counseling that would attempt to solve premarital problems of ignorance. In their day, I would suspect it was considered intellectual to disregard the emotional or physical aspects of a marriage. Ignorance, however, is not bliss. It is the most expensive and dangerous thing in the world. The Bible gives you the answer, "And ye shall know the truth, and the truth shall make you free." REFERENCES 1. Chalmers, L. W.: Woman's Personal Hygiene. New York, Pioneer Publications, 1946. 2. Griffith, E. F.: Medical Aspects of Marriage Guidance. Lancet 1: 165, 1947. 3. Kavinsky, N. R.: Premarital Examination, J.A.M.A. 156: 692-695, 1954. 4. Kegel, A. H.: Sexual Functions of the Pubococcygeous Muscle. West. J. Surg. 60: 521-524, 1952. 5. Knight, R. P.: Functional Disturbances in the Sexual Life of Women. Bull. Menninger Clin. 7: 25, 1943. 6. Kroger, W. S.: Psychosomatic Aspects of Frigidity. J.A.M.A. 143: 526,1950. 7. Leviticus 15: 19-23, 18: 19, 20: 18. 8. Muller, P. F.: Group Premarital Counseling. Am. J. Obst. & Gynec. 73: 941,1957 9. Offen, J. A.: J. Obst. & Gynaec. Brit. Emp. 13: 302,1959. 10. Pierson, R. N.: Experiences in Premarital Counselling. J. Michigan M. Soc. 54: 2050, 1954. 11. Sinclair, D. A.: Marriage and Its Sexual Problems. Urol. & Cutan. Rev. 42: 378, 1954. 12. Stokes, W. R. and Harper, R. A.: The Doctor as Marriage Counsellor. M. Ann. District of Columbia 23: 670, 1954. 55 E. Washington Street Chicago 2, Illinois