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The Gynecologist’s Role in Marriage Counseling
The Gynecologist's Role in Marriage Counseling RALPH W. GAUSE, M.D.* ROBERT W. LAIDLAW, M.D.**
A'ITITUDE
THE gynecologist has too often been unwilling to fulfill a natural role of counselor to the patient. There are many reasons for this reticence and a frank discussion of these is important. Whether it be the major deterrent or not, certainly a better attitude toward marriage counseling is most essential. The tendency of the gynceologist to look down on marriage problems as affairs to be handled by the inept or elderly physician is deplorable. This attitude is perhaps more prevalent in the highly trained young men who have completed their residencies during the present decade. Should these important and difficult problems be brought into proper perspective, gynecological training might put more emphasis in this area and perhaps less on radical surgery. Few problems can be more important to the patient, and certainly the gynecologist has an unusual opportunity to help the patient understand and solve her personal problems. Why is the gynecologist negligent in seizing the opportunity to serve as counselor? It has been mentioned that his attitude is not sound. This is even more true when the problem is discussed among confreres. In the consultation room the doctor would like very much to help the patient, but alas, is lacking in adequate information and knowledge of approach. He excuses himself by virtue of being too busy. This type of negative counseling adds to the patient's fears and the problem is enlarged thereby. As in so many facets of life, the skill to do comes of doing. This is most true of marriage counseling. Counseling for the most part consists of holding a mirror up so the patient can see herself. What she sees must then be correctly interpreted. Action will depend upon the conviction
* Associate Clinical Professor of Obstetrics and Gynecology, CorneU University Medical College; Attending Obstetrician and Gynecologist, New York Hospital, New York, N.Y. ** Chief of Psychiatric Service, The Roosevelt Hospital, New York, N. Y.; Past President, American Association of Marriage Counselors. 545
Ralph W. Gause, Robert W. Laidlaw at hand. Thus, for the gynecologist, the willingness to accept the role of counselor requires an honest attitude plus some dedication of time. The patient, too, is frequently at fault: a quick cure is expected and often with complete exoneration of self. Sexual "adjustment" means different things to different persons. Some women consider their sex life happiest when they are able to refuse intercourse entirely. A casual question to such an individual elicits a completely misleading answer. Complete cures are not available for all. Some people will need to be satisfied with a crutch-if the defect is too great. Of importance, too, is the fact that financial indebtedness for these services come as a surprise to the patient. The average patient is willing to pay more for a momentary speculum examination than for an hour of patient listening. Who errs? Both doctor and patient can stand a change of attitudes. PREMARITAL
Premarital examinations and advice have become a standard 15 minute affair in the average doctor's office. The doctor and the patient can both be blamed, but the former is the more responsible. A busy wedding schedule leaves too little time for adequate premarital counseling. As a beginning point for discussion, the doctor may mention the three most important factors of a successful marriage: 1. The choice of a mate. This has already been done long before the gynecologist is consulted. 2. Attitude toward marriage. This important facet of history taking and self-analysis should be enlarged upon. The child of a broken marriage will need to prepare against such an eventuality. The presence of unmarried siblings and barren marriages in the family history can all be of value in considering family planning. A good attitude toward marriage can well be discussed in the light of past family experiences. This type of diecussion needs a third person approach to the most important contribution which the gynecologist has to offer, namely: 3. Technical information. In the hurried visit, the handling of problems of sex experience and interpretations can be clumsy. The chief information desired by the patient is how to prevent pregnancy. Even this is difficult to teach in one visit, and the least one can do is to offer a second visit, at which time the male marriage partner should also be invited. If it becomes possible to discuss problems of sex technique at a first visit, they can certainly be further discussed at a second visit. Pamphlets should be at hand and given for reading before a second visit. Not even an average counselor would settle for less than two premarital visits, and it behooves the gynecologist, less expert in these techniques, to do the same. Several basic concepts of normal sexual experience should be verbal-
The Gynecologist's Role in Marriage Counseling
547
ized. (a) There is a variability in sex drive in individuals. Completion of the sexual act by the female is the common denominator of good adjustment. (b) Achievement of orgasm by the wife is an absolute must; if perfect sexual harmony is to be present. This may not be possible in the early days of marriage and certainly is unlikely to occur at each coitus. (c) Anything which is necessary to bring this about is normal for this particular marriage. For the female to be a good sexual partner she must be, perhaps, a bit more of a hussy than the delicate, cultured darling that American society would have her be. This is quite a metamorphosis and cannot always be accomplished overnight. There is no place for false modesty when normal sexual responses are being developed. It is well that the reason for rapid sexual excitability by the male and slower psychosexual response by the female be understood. When these facts are accepted they can be dealt with intelligently. Should previous sexual experiences be related to the new partner in the way of "telling all"? This will need to be individualized. Many marriages may be more successful if past experiences are untold. When a matter may be important in the future health of either partner, it should not be withheld. In all matters concerning the bride-to-be, in physical examinations as well as discussion, the following rule is most important. Never take it for granted that she knows anything about the anatomy, physiology or even personal hygiene of the pelvic organs. This is a great source of error. Simple details and explanations are in order and are almost never unwelcomed. The patient has some responsibility, too, in asking questions and she should be invited to make a li~t for that second visit. POSTMARITAL
Problems of sexual adjustment are prone to increase in the years after marriage. They may become profound before help is sought. The gynecologist or obstetrician is often the first to be consulted. It behooves him to help in every way possible. Listening becomes the most prominent part of good counseling. It takes a good deal of listening before the average gynecologist will know whether this is a problem for him or not. Can all gynecologists counsel? Even though experience may be the greatest aid to successful counseling, there are a few doctors who had best leave the field to others. A patronizing attitude will get nowhere. The doctor will first need to understand his own self before help can be given to others. Aloofness is an error, just as is back-slapping cordiality. The rapport between counselor and patient must be favorable. It is because of this fact that the gynecologist should be in a prime position to provide assistance. It should go without saying that, even though the doctor and patient need complete privacy for the interview, an attendant or associate should be within calling distance. A neurotic woman may contend that the doctor has made improper advances. This type of accusation can be very
548
Ralph W. Gause, Robert W. Laidlaw
detrimental unless a witness is available to give facts. Many minor problems, which constitute the majority, can be resolved by listening and questioning until the patient perceives her own mistakes. Don't look for a complicated answer when a simple one will do. Many a patient would like to be told that her husband is wrong, and it may be that this is true but seldom can any benefit be obtained by agreeing. It is likewise true that the husband is almost never solely to blame. He will best realize his mistakes if his wife (the patient) sees her own faults and makes progress in correcting them. Don't take sides. If any side is to be favored, consider favoring the absent partner. This "overcorrection" will prevent too much sympathy or agreement with the patient. The art of interviewing and reorientation comes with time and painstaking effort. The situation is comparable to that of a woman wanting to propose to a man. She dare not propose, but she can put the man in the situation of wanting to do so himself. If she fails in this, she may actually make the proposal, but the results are not so satisfactory. So it is with counseling: take as little responsibility as possible in telling the patient what to do or not to do. The patient does not want to give up her habits or attitl!des, hence the trouble. What causes most sexual maladjustment is not politics, religion or housekeeping; rather, it is the attitude toward sex itself. Sex, recreation and housekeeping are three areas of friction in almost any unhappy marriage. Sex is such a fundamental part of marriage that it becomes the logical point to begin discussion with the patient. After lengthy questioning by the gynecologist, an examination should be made to rule out a physical cause for the maladjustment. It is the belief and hope of many patients that a physical cause can be found. Alas! one is almost never present. Is the problem a result of ignorance? Stating norms and relating a few sexual and cultural facts may be of some help in such cases. The teaching of sex techniques has been suggested as the most practical approach to marriage counseling, and this may be true insofar as the gynecologist is concerned. He should be versed on worthwhile books and pamphlets-even have them at hand for distribution. Many simple disturbances are prone to become manifest in the early months postpartum. Fatigue, fear of pregnancy and fear of pain are all prevalent. The obstetrician should point out this possibility to the patient in way of preparation. The Catholic patient will need extra reassurance regarding the employment of rhythm and abstinence. Selfishness, on the part of either partner, can play an irritating role in marital problems. Here again the gynecologist is concerned with his contact, namely the patient, and must look for this characteristic in her rather than the husband. The gynecologist is in a good position to diagnose and possibly aid in reorientation regarding this failing. The dominant individual is more likely to be the guilty partner. Altogether too
The Gynecologist's Role in Marriage Counseling many counselors are prone to exonerate the female partner. It behooves the gynecologist to put more burden on the patient and impress her with her responsibility in these problems. The culture of today, with almost complete emancipation of women from her traditional role, is of the greatest importance in creating marital problems. Noone wants women to spend their entire life in the home and kitchen; still the chances of marital bliss are greater when a dependent role is practiced and enjoyed. It is merely to be emphasized that the responsibility for aberrations from the considered normal must be accepted when a woman departs from her cultural role. This type of counseling can be entertained by the gynecologist. Should he err in pushing it too far, no permanent damage is likely to occur. True emotional problems which require long-term counseling are not within the province of the average gynecologist. His efforts are likely to be wasted and there is even a possibility that he may do damage. These cases require numerous visits with both the husband and wife, and careful evaluation of both personalities must be made before decisions can be rendered. A patient was once seen at the request of her internist to rule out gynecological disease. She was 28 years of age, had been married ten years and had three children. Her husband was a successful businessman of approximately the same age. She was bored with life, decided to leave all, go West and begin life over again. This was obviously a problem to be handled by a counselor of great experience. The gynecologist should do most or all of his postmarital counseling with the wife. These cases may and should be handled as if the wife were largely and completely responsible for the difficulties. He questions and listens when the patient is willing to talk, and should be positive about his ability to help or obtain help. Referral should be made in difficult cases. When this attitude is confidently maintained, these problems will work themselves into routine gynecological visits. Magical solutions are not to be expected by either doctor or patient. Sometimes the effects of treatments are not necessarily permanent. As in the case of diseases, these problems may recur and need further treatment. COMMENT BY DR. LAIDLAW
In the foregoing remarks Dr. Gause has made a real contribution to the field of preventive psychiatry. All too often we psychiatrists are forced to play the roles of mere repairmen-attempting to repair damage which need never have occurred in the first place. Surely it can be said that in this field of premarital and marital counseling an ounce of prevention is worth a pound of cure. Only rarely does the psychiatrist himself have an opportunity of seeing and working with a patient in what might be called this "preventive phase." Women entering upon marriage or encountering initial difficulties in marriage do not consider themselves candidates for psychotherapy
550
Ralph W. Gause, Robert W. Laidlaw
and only rarely consult a psychiatrist. It is therefore his nonpsychiatric colleagues to whom the psychiatrist must turn and upon whom he must rely in this most important aspect of preventive psychiatry. It cannot be overemphasized that most difficulties in the psychosexual sphere, which ultimately assume psychiatric proportions, are preventable. The optimum time for such preventive effort in the gynecologist's office is that of the premarital examination. At this time the gynecologist can do one of two things-he can carry out a routine pelvic examination, advise as to contraceptive measures, answer any questions which the patient may ask, and conclude the whole matter in the space of 15 minutes. Or he can do the thing right. This means giving a lot more time. It means, in addition to the above procedures, a careful drawing out of the patient, eliciting from her, by means of active questioning, her entire psychosexual history. The gynecologist must seek out material bearing upon sex play in childhood; masturbation; "crushes" on other girls, women teachers, etc.; petting experiences of varying degrees and intensities with boys; experiences involving premarital intercourse; traumatic experiences, where sex in some way has been forced upon the patient; attitudes toward sex which the patient has encountered in the home, church, school, etc. It is only rarely that the patient will offer this material spontaneously. It must be gently probed for. The examiner's approach must be objective and completely nonjudgmental. He must help the patient to come to feel that her experiences, whatever they may have been, are by no meanR as unusual or as "awful" as she may have thought them to be. For the whole purpose behind eliciting this factual information in regard to the patient's past experiences is to determine what reactions in the form of attitudes, past and present, the patient has had to them. If these attitudes are unhealthy, if the patient feels that sex is "bad," that she has sinned, that she has jeopardized her future marriage by the things which she has done, these things must be talked through with her by the gynecologist. To a clinical psychiatrist accustomed to working with involved longterm psychoneurotic or psychotic problems, it is both remarkable and gratifying to find how rapidly changes may be effected in essentially normal young women seeking premarital advice. Oftentimes only a few sessions will make all the difference between a woman ignorantly and fearfully entering upon marriage and a woman whom one feels is adequately equipped to make a satisfactory marital adjustment. The gynecologist who takes the time and trouble to bring such a transformation to pass may justly feel that this is a richly rewarding experience. As Dr. Gause has pointed out, postmarital problems are of a wide range of severity and complexity. Many of them stem from personality problems existing in one or both partners to the marriage which antedated the marriage itself, and where the problem of marital maladjust-
The Gynecologist's Role in Marriage Counseling
551
ment is simply a reflection of this more deep-seated condition. Such problems rightfully belong within the province of the clinical psychiatrist. There are, however, many marital difficulties brought by the married woman to the gynecologist where the marital relationship itself is the core of the matter. In this realm of psychosexual adjustment the gynecologist again is in a position to render vital service, as usually it is with her gynecologist alone that the patient will discuss intimate matters of her personal life. And even with her gynecologist the definition of such a problem may come out only after his gentle and skilled probing. Up until a few years ago I felt as does Dr. Gause that orgasm for the woman constitutes a "must" if a harmonious sexual adjustment is to be reached between the two partners. Further clinical experience of my own, however, coupled with the findings in Kinsey's "Sexual Behavior in the Human Female," has led me to feel that there is now a small but definite group of women to whom sex is an intensely enjoyable and meaningful experience, yet who fail to achieve anything comparable to our concept of a physiological orgasm. Instead of a tumultuous climax there is a gradual diminution in erotic feeling which subsides ultimately to the point of leaving the woman relaxed, satisfied and grateful to her husband. There is none of the ensuing tension, irritability and feeling of "being strung up on wires" which most women report on failing to achieve orgasm. With this small group, therefore, failure to achieve physiological orgasm should, I think, be looked upon as the consequence of a physiological variant, and, from a marriage counseling point of view, it would be a mistake to urge such a happily adjusted woman to strive for a reaction which is beyond her own innate sexual capacity. Reassurance on this point will also help the husband to feel that he is not at fault in failing to bring his wife to orgasm. The late Dr. Robert L. Dickinson, a past president of the American Gynecological Association and the foremost pioneer in America in the field of marriage counseling, once told me that he routinely instructed his secretary to schedule any case of premarital or postmarital counseling as his last appointment of the day. Thus, even though he had a very crowded gynecological practice, he was always able to give such cases the time that they deserved, albeit he was frequently very late for dinner. Perhaps some such arrangement would be of help to gynecologists of the present day in effecting the compromise between the pressure of time and the rendering of full service in the field of marriage counseling. 449 E. Sixty-eighth Street New York 21, N. Y. (Dr. Gause)
A'ITITUDE
THE gynecologist has too often been unwilling to fulfill a natural role of counselor to the patient. There are many reasons for this reticence and a frank discussion of these is important. Whether it be the major deterrent or not, certainly a better attitude toward marriage counseling is most essential. The tendency of the gynceologist to look down on marriage problems as affairs to be handled by the inept or elderly physician is deplorable. This attitude is perhaps more prevalent in the highly trained young men who have completed their residencies during the present decade. Should these important and difficult problems be brought into proper perspective, gynecological training might put more emphasis in this area and perhaps less on radical surgery. Few problems can be more important to the patient, and certainly the gynecologist has an unusual opportunity to help the patient understand and solve her personal problems. Why is the gynecologist negligent in seizing the opportunity to serve as counselor? It has been mentioned that his attitude is not sound. This is even more true when the problem is discussed among confreres. In the consultation room the doctor would like very much to help the patient, but alas, is lacking in adequate information and knowledge of approach. He excuses himself by virtue of being too busy. This type of negative counseling adds to the patient's fears and the problem is enlarged thereby. As in so many facets of life, the skill to do comes of doing. This is most true of marriage counseling. Counseling for the most part consists of holding a mirror up so the patient can see herself. What she sees must then be correctly interpreted. Action will depend upon the conviction
* Associate Clinical Professor of Obstetrics and Gynecology, CorneU University Medical College; Attending Obstetrician and Gynecologist, New York Hospital, New York, N.Y. ** Chief of Psychiatric Service, The Roosevelt Hospital, New York, N. Y.; Past President, American Association of Marriage Counselors. 545
Ralph W. Gause, Robert W. Laidlaw at hand. Thus, for the gynecologist, the willingness to accept the role of counselor requires an honest attitude plus some dedication of time. The patient, too, is frequently at fault: a quick cure is expected and often with complete exoneration of self. Sexual "adjustment" means different things to different persons. Some women consider their sex life happiest when they are able to refuse intercourse entirely. A casual question to such an individual elicits a completely misleading answer. Complete cures are not available for all. Some people will need to be satisfied with a crutch-if the defect is too great. Of importance, too, is the fact that financial indebtedness for these services come as a surprise to the patient. The average patient is willing to pay more for a momentary speculum examination than for an hour of patient listening. Who errs? Both doctor and patient can stand a change of attitudes. PREMARITAL
Premarital examinations and advice have become a standard 15 minute affair in the average doctor's office. The doctor and the patient can both be blamed, but the former is the more responsible. A busy wedding schedule leaves too little time for adequate premarital counseling. As a beginning point for discussion, the doctor may mention the three most important factors of a successful marriage: 1. The choice of a mate. This has already been done long before the gynecologist is consulted. 2. Attitude toward marriage. This important facet of history taking and self-analysis should be enlarged upon. The child of a broken marriage will need to prepare against such an eventuality. The presence of unmarried siblings and barren marriages in the family history can all be of value in considering family planning. A good attitude toward marriage can well be discussed in the light of past family experiences. This type of diecussion needs a third person approach to the most important contribution which the gynecologist has to offer, namely: 3. Technical information. In the hurried visit, the handling of problems of sex experience and interpretations can be clumsy. The chief information desired by the patient is how to prevent pregnancy. Even this is difficult to teach in one visit, and the least one can do is to offer a second visit, at which time the male marriage partner should also be invited. If it becomes possible to discuss problems of sex technique at a first visit, they can certainly be further discussed at a second visit. Pamphlets should be at hand and given for reading before a second visit. Not even an average counselor would settle for less than two premarital visits, and it behooves the gynecologist, less expert in these techniques, to do the same. Several basic concepts of normal sexual experience should be verbal-
The Gynecologist's Role in Marriage Counseling
547
ized. (a) There is a variability in sex drive in individuals. Completion of the sexual act by the female is the common denominator of good adjustment. (b) Achievement of orgasm by the wife is an absolute must; if perfect sexual harmony is to be present. This may not be possible in the early days of marriage and certainly is unlikely to occur at each coitus. (c) Anything which is necessary to bring this about is normal for this particular marriage. For the female to be a good sexual partner she must be, perhaps, a bit more of a hussy than the delicate, cultured darling that American society would have her be. This is quite a metamorphosis and cannot always be accomplished overnight. There is no place for false modesty when normal sexual responses are being developed. It is well that the reason for rapid sexual excitability by the male and slower psychosexual response by the female be understood. When these facts are accepted they can be dealt with intelligently. Should previous sexual experiences be related to the new partner in the way of "telling all"? This will need to be individualized. Many marriages may be more successful if past experiences are untold. When a matter may be important in the future health of either partner, it should not be withheld. In all matters concerning the bride-to-be, in physical examinations as well as discussion, the following rule is most important. Never take it for granted that she knows anything about the anatomy, physiology or even personal hygiene of the pelvic organs. This is a great source of error. Simple details and explanations are in order and are almost never unwelcomed. The patient has some responsibility, too, in asking questions and she should be invited to make a li~t for that second visit. POSTMARITAL
Problems of sexual adjustment are prone to increase in the years after marriage. They may become profound before help is sought. The gynecologist or obstetrician is often the first to be consulted. It behooves him to help in every way possible. Listening becomes the most prominent part of good counseling. It takes a good deal of listening before the average gynecologist will know whether this is a problem for him or not. Can all gynecologists counsel? Even though experience may be the greatest aid to successful counseling, there are a few doctors who had best leave the field to others. A patronizing attitude will get nowhere. The doctor will first need to understand his own self before help can be given to others. Aloofness is an error, just as is back-slapping cordiality. The rapport between counselor and patient must be favorable. It is because of this fact that the gynecologist should be in a prime position to provide assistance. It should go without saying that, even though the doctor and patient need complete privacy for the interview, an attendant or associate should be within calling distance. A neurotic woman may contend that the doctor has made improper advances. This type of accusation can be very
548
Ralph W. Gause, Robert W. Laidlaw
detrimental unless a witness is available to give facts. Many minor problems, which constitute the majority, can be resolved by listening and questioning until the patient perceives her own mistakes. Don't look for a complicated answer when a simple one will do. Many a patient would like to be told that her husband is wrong, and it may be that this is true but seldom can any benefit be obtained by agreeing. It is likewise true that the husband is almost never solely to blame. He will best realize his mistakes if his wife (the patient) sees her own faults and makes progress in correcting them. Don't take sides. If any side is to be favored, consider favoring the absent partner. This "overcorrection" will prevent too much sympathy or agreement with the patient. The art of interviewing and reorientation comes with time and painstaking effort. The situation is comparable to that of a woman wanting to propose to a man. She dare not propose, but she can put the man in the situation of wanting to do so himself. If she fails in this, she may actually make the proposal, but the results are not so satisfactory. So it is with counseling: take as little responsibility as possible in telling the patient what to do or not to do. The patient does not want to give up her habits or attitl!des, hence the trouble. What causes most sexual maladjustment is not politics, religion or housekeeping; rather, it is the attitude toward sex itself. Sex, recreation and housekeeping are three areas of friction in almost any unhappy marriage. Sex is such a fundamental part of marriage that it becomes the logical point to begin discussion with the patient. After lengthy questioning by the gynecologist, an examination should be made to rule out a physical cause for the maladjustment. It is the belief and hope of many patients that a physical cause can be found. Alas! one is almost never present. Is the problem a result of ignorance? Stating norms and relating a few sexual and cultural facts may be of some help in such cases. The teaching of sex techniques has been suggested as the most practical approach to marriage counseling, and this may be true insofar as the gynecologist is concerned. He should be versed on worthwhile books and pamphlets-even have them at hand for distribution. Many simple disturbances are prone to become manifest in the early months postpartum. Fatigue, fear of pregnancy and fear of pain are all prevalent. The obstetrician should point out this possibility to the patient in way of preparation. The Catholic patient will need extra reassurance regarding the employment of rhythm and abstinence. Selfishness, on the part of either partner, can play an irritating role in marital problems. Here again the gynecologist is concerned with his contact, namely the patient, and must look for this characteristic in her rather than the husband. The gynecologist is in a good position to diagnose and possibly aid in reorientation regarding this failing. The dominant individual is more likely to be the guilty partner. Altogether too
The Gynecologist's Role in Marriage Counseling many counselors are prone to exonerate the female partner. It behooves the gynecologist to put more burden on the patient and impress her with her responsibility in these problems. The culture of today, with almost complete emancipation of women from her traditional role, is of the greatest importance in creating marital problems. Noone wants women to spend their entire life in the home and kitchen; still the chances of marital bliss are greater when a dependent role is practiced and enjoyed. It is merely to be emphasized that the responsibility for aberrations from the considered normal must be accepted when a woman departs from her cultural role. This type of counseling can be entertained by the gynecologist. Should he err in pushing it too far, no permanent damage is likely to occur. True emotional problems which require long-term counseling are not within the province of the average gynecologist. His efforts are likely to be wasted and there is even a possibility that he may do damage. These cases require numerous visits with both the husband and wife, and careful evaluation of both personalities must be made before decisions can be rendered. A patient was once seen at the request of her internist to rule out gynecological disease. She was 28 years of age, had been married ten years and had three children. Her husband was a successful businessman of approximately the same age. She was bored with life, decided to leave all, go West and begin life over again. This was obviously a problem to be handled by a counselor of great experience. The gynecologist should do most or all of his postmarital counseling with the wife. These cases may and should be handled as if the wife were largely and completely responsible for the difficulties. He questions and listens when the patient is willing to talk, and should be positive about his ability to help or obtain help. Referral should be made in difficult cases. When this attitude is confidently maintained, these problems will work themselves into routine gynecological visits. Magical solutions are not to be expected by either doctor or patient. Sometimes the effects of treatments are not necessarily permanent. As in the case of diseases, these problems may recur and need further treatment. COMMENT BY DR. LAIDLAW
In the foregoing remarks Dr. Gause has made a real contribution to the field of preventive psychiatry. All too often we psychiatrists are forced to play the roles of mere repairmen-attempting to repair damage which need never have occurred in the first place. Surely it can be said that in this field of premarital and marital counseling an ounce of prevention is worth a pound of cure. Only rarely does the psychiatrist himself have an opportunity of seeing and working with a patient in what might be called this "preventive phase." Women entering upon marriage or encountering initial difficulties in marriage do not consider themselves candidates for psychotherapy
550
Ralph W. Gause, Robert W. Laidlaw
and only rarely consult a psychiatrist. It is therefore his nonpsychiatric colleagues to whom the psychiatrist must turn and upon whom he must rely in this most important aspect of preventive psychiatry. It cannot be overemphasized that most difficulties in the psychosexual sphere, which ultimately assume psychiatric proportions, are preventable. The optimum time for such preventive effort in the gynecologist's office is that of the premarital examination. At this time the gynecologist can do one of two things-he can carry out a routine pelvic examination, advise as to contraceptive measures, answer any questions which the patient may ask, and conclude the whole matter in the space of 15 minutes. Or he can do the thing right. This means giving a lot more time. It means, in addition to the above procedures, a careful drawing out of the patient, eliciting from her, by means of active questioning, her entire psychosexual history. The gynecologist must seek out material bearing upon sex play in childhood; masturbation; "crushes" on other girls, women teachers, etc.; petting experiences of varying degrees and intensities with boys; experiences involving premarital intercourse; traumatic experiences, where sex in some way has been forced upon the patient; attitudes toward sex which the patient has encountered in the home, church, school, etc. It is only rarely that the patient will offer this material spontaneously. It must be gently probed for. The examiner's approach must be objective and completely nonjudgmental. He must help the patient to come to feel that her experiences, whatever they may have been, are by no meanR as unusual or as "awful" as she may have thought them to be. For the whole purpose behind eliciting this factual information in regard to the patient's past experiences is to determine what reactions in the form of attitudes, past and present, the patient has had to them. If these attitudes are unhealthy, if the patient feels that sex is "bad," that she has sinned, that she has jeopardized her future marriage by the things which she has done, these things must be talked through with her by the gynecologist. To a clinical psychiatrist accustomed to working with involved longterm psychoneurotic or psychotic problems, it is both remarkable and gratifying to find how rapidly changes may be effected in essentially normal young women seeking premarital advice. Oftentimes only a few sessions will make all the difference between a woman ignorantly and fearfully entering upon marriage and a woman whom one feels is adequately equipped to make a satisfactory marital adjustment. The gynecologist who takes the time and trouble to bring such a transformation to pass may justly feel that this is a richly rewarding experience. As Dr. Gause has pointed out, postmarital problems are of a wide range of severity and complexity. Many of them stem from personality problems existing in one or both partners to the marriage which antedated the marriage itself, and where the problem of marital maladjust-
The Gynecologist's Role in Marriage Counseling
551
ment is simply a reflection of this more deep-seated condition. Such problems rightfully belong within the province of the clinical psychiatrist. There are, however, many marital difficulties brought by the married woman to the gynecologist where the marital relationship itself is the core of the matter. In this realm of psychosexual adjustment the gynecologist again is in a position to render vital service, as usually it is with her gynecologist alone that the patient will discuss intimate matters of her personal life. And even with her gynecologist the definition of such a problem may come out only after his gentle and skilled probing. Up until a few years ago I felt as does Dr. Gause that orgasm for the woman constitutes a "must" if a harmonious sexual adjustment is to be reached between the two partners. Further clinical experience of my own, however, coupled with the findings in Kinsey's "Sexual Behavior in the Human Female," has led me to feel that there is now a small but definite group of women to whom sex is an intensely enjoyable and meaningful experience, yet who fail to achieve anything comparable to our concept of a physiological orgasm. Instead of a tumultuous climax there is a gradual diminution in erotic feeling which subsides ultimately to the point of leaving the woman relaxed, satisfied and grateful to her husband. There is none of the ensuing tension, irritability and feeling of "being strung up on wires" which most women report on failing to achieve orgasm. With this small group, therefore, failure to achieve physiological orgasm should, I think, be looked upon as the consequence of a physiological variant, and, from a marriage counseling point of view, it would be a mistake to urge such a happily adjusted woman to strive for a reaction which is beyond her own innate sexual capacity. Reassurance on this point will also help the husband to feel that he is not at fault in failing to bring his wife to orgasm. The late Dr. Robert L. Dickinson, a past president of the American Gynecological Association and the foremost pioneer in America in the field of marriage counseling, once told me that he routinely instructed his secretary to schedule any case of premarital or postmarital counseling as his last appointment of the day. Thus, even though he had a very crowded gynecological practice, he was always able to give such cases the time that they deserved, albeit he was frequently very late for dinner. Perhaps some such arrangement would be of help to gynecologists of the present day in effecting the compromise between the pressure of time and the rendering of full service in the field of marriage counseling. 449 E. Sixty-eighth Street New York 21, N. Y. (Dr. Gause)