The pretty, quiet-mannered doctor came over to the little table in the corner and sat down. Her pen poised over the clean case sheet, she looked up at her new patient. She paused, laid down the pen and with an almost physical effort of concentration, excluded for both of them the large room with its screened cubicles, steaming sterilizer and busy nurses. "Why are you so embarrassed?" A pause. "Well, it is embarrassing, isn't it?" The patient made a little frustrated gesture - all that her anxiety would permit - to signify the indefinability of her emotion. It comprehended the clinic, its staff, the other patients, and the effort of will that had brought her to it. In the back of her mind she felt the presence of her neighbours, her home with its memories of her mother and grandmother, the inquiring eyes of her teenage children, and the husband for whose sake primarily, but without whose support, she had come.
This was one of my earliest observations in a family planning clinic. During the next three years in many waiting and clinic rooms I was to learn to recognize the symptoms of that undefined ill-ease.
INGRAINED GUILT
There were the women who felt that to prepare for lovemaking was like soliciting, or who felt rejected if their preparations were unwanted; the young bride whose marriage fantasies were troubled by the prospect of examination and cap-fitting; the older woman ashamed against her will that others should know that despite a grown-up family she and her husband were still intimate; those whose swaggering assurance betrayed an inner doubt; those who felt guilty despite good cause for postponing family building, and had to explain their reasons in propitiatory detail; and those who would so gladly - and sometimes did - find an excuse to run away. Beneath so much of it lay the ingrained guilt and shame of Adam and more particularly of Eve, and the awful persisting conspiracy of silence.
These patients sought to comply with one of the most urgent demands of our time, without which, even in this country, the expectations of our children will be in some measure threatened. Whatever their class, creed or country, whether teenage or 50, it was their tenseness on arrival, belying their confidence in the propriety of what they did, which commanded my attention.
The picture should not be overdrawn, but workers in family planning clinics over the past 30 years have recognized - and been disturbed to recognize - that many emotional problems underlie the approach to birth control. In addition to the practical help the clinics give, they provide for many patients their first experience of open and unreserved approval, and of acceptance of their embarrassment.
MEASURING MASCULINTY
What of those I met outside the clinics, among them representatives of that 25-30 per cent who use no methods at all, and of those others who use them so inefficiently as partly to defeat their aims?
There were men who still measure their masculinity by their wives' child-bearing, or who feel it threatened if they take part in measures for control. "If she wants to, let her do it herself"; the woman who feels sex is somehow dirty and could not "touch herself", or that the use of a condom ranks her with a prostitute; the "inefficient" women who can in childbearing satisfy a craving for achievement and those whose fear of failure prevents them trying; the men who will not trust their wives with a method under their own control; the women who want their men to be cave-men whatever the consequences, and men and women entering into extra-marital relations almost as a social ritual, yet regarding contraception as culpable premeditation.
The frequent failure to use birth control or to use it effectively in extra-marital relations presents the nation with an ever increasing number of illegitimate children, or children of post-conception marriages whose instability is all too frequently demonstrated by desertion and divorce.
It has been accepted all too easily that, given the means, individual motivation to birth control will be found built-in. And built-in it somehow requires to be, for a law forbidding conception is as unenforceable as that of Connecticut forbidding the use of contraceptives. What we do find built-in are much disinclination and conditioned opposition. We have made little study of the internal and external pressures on individual good intent and without this it is difficult to influence attitudes and motivations.
Of what order are these pressures? In time the principles of population control may be communicated to the primitive man within us and produce a lessening of the basic urge to procreate - but not yet! Furthermore, the complexities and anxieties of sophisticated communities, with their emphasis on satisfying relationships, or the miseries and frustrations of the underprivileged, place just those strains on the individual which call for the comfort, reassurance or distraction of physical union.
NEED OF UNIFORMITY
Pressures from state and religion intended to stimulate or control that primary urge, have filtered down to the individual in unending variation and contradiction, begetting conflicts and determining actions, many of which, their origin obscured, pass into common and unquestioned usage. The greater the conflict, the less certain does the propriety of family planning appear.
Local and central government organs vacillate under minority pressures, and only recently have most religions sanctioned and to some extent encouraged responsible family planning. But there is still no consensus on method. Instead of the confusing display of their residual differences, the churches need urgently to obtain uniformity of advice right down the line of pastoral care, or they will have little success in checking the backlog of their earlier teachings, for the authority of each now bears many faces, varying even from parish to parish.
The medical profession, save in relation to maternal health, largely sidesteps the whole problem in training and in clinical practice or public health provision. In medical deliberations it rarely finds a place, or is the subject of conflict or indifference often arising from personal rather than scientific or even humanitarian attitudes.
As instruments for promoting responsible, effective, and individually satisfying family planning, our schools and universities have proved a two-edged sword. While they have increased awareness of the surrounding conflicts in the field of personal relationships and have encouraged in general the questioning of unsubstantiated dogma, they have by their silence on birth control acquiesced in and lent authority to both dogma and conflict. They have done little to dispel ignorance of even the physiological components of reproduction, let alone the emotional ones. Rather, by the very rarity of their discussion of these problems they divest them of their urgency. Indeed, like doctors, educators are not trained in this task, and studies and evaluated experiments have not yet shown how such knowledge and a sense of individual responsibility can effectively be imparted at the various levels of educational and individual development.
CRIPPLING TABOOS
The scope for individual ignorance, discouragement, misinterpretation, apathy, and the perpetuation of crippling taboos is immense. Confusion offers poor competition to primary urges, and provides a background of conflict and guilt which helps to disturb marriage relationships, upon which so much else depends, and perhaps thereby increases the resort to extra-marital relationships and operates against the use of birth control in this context also.
It is not, therefore, surprising that despite our increasingly articulate and rational era the attitude of those who rightly seek medical advice is so often tense, anxious, embarrassed, guilt-ridden, antagonistic, or furtive, instead of confident and happy in the practice of an acknowledged social good.
We need urgently to assess what determines the use or avoidance of birth-control in or out of marriage, and to learn how to match methods of communication to changing attitudes and changing choice and availability of method, so that we can reach the rising generations and those individuals and sections of society who, despite availability of means, cannot or do not take heed for their children.
.lcThe Sixties was the decade of the sexual revolution, but contraception was still a taboo subject for many women. This article tries to dispel any embarrassment women might feel about going to a Family Planning Clinic for birth control.
