The soap opera need

Medicine fulfils three basic needs in the physician: the puzzle need, the fix-it need and the soap opera need. The puzzle need is our desire to figure things out, unravel the mystery of differential diagnosis and apply our knowledge of physiology and “illness scripts” to the cases in front of us. However, if we only had a puzzle need, we would be bench researchers. The fix-it need is our desire to get in there, improve things, make stuff happen and cure. Then there is the soap opera need, the curiosity about other people’s lives. This is our need to understand our patients and who they are, how they think and live. I happen to have a huge soap opera need. Being a family doctor is like having a small but important role in everybody’s movie. People often feel comfortable asking questions they can’t talk to others about. Very often, what they want to talk about is sex, which is I have always been interested in other people’s love lives. Perhaps it is a little voyeuristic, but I think it comes from a genuine desire to help: I realize that most people don’t have access to trusted information about what is happening to them sexually. This might have started with my first lover, who earnestly manipulated my cervix with his fingers, assuming that it was my clitoris. Maybe it is because I came of age in the heady days of second-wave feminism when Masters and Johnson published their seminal research on female sexuality. Before I went to medical school, in the late 1970s, I worked at a “hippie clinic” called the Ste. Famille Street Youth Clinic. I started doing secretarial work and ended up as a peer counsellor and chaperone. One day I was hanging out in the lab when one of the moonlighting residents who staffed the clinic came in, opened the door of the linen closet and buried his face in the towels. Then he burst out laughing. Recovering his composure, he asked me to come into the room and translate for him. He gently and carefully explained to the naïve young couple in the exam room that the reason they had not yet had a child after two years of marriage was that babies were not conceived through the belly button. Using a picture and a mirror, he explained where the vagina was, what the clitoris was and gave the blushing young man a quick course on how to give his wife pleasure. “Oh my,” said the woman, “I never did really enjoy sex, but that was what my mother said would happen.” I thought this interaction was so significant and revealing that it was one of the pivotal experiences that drew me to medicine as a career. My sister Sandy says the real divide in people’s sexual lives is not who they have sex with but whether love is central to their sexual relationship. The real divide in people’s sexual lives is not who they have sex with but whether their sexual relationships are orgasm-based or relationship-based. Perhaps this is related to whether their preferred brain candy is dopamine or oxytocin. As someone who has been in a monogamous relationship for over 40 years, it was always interesting for me to talk to people for whom the thrill of the chase and the novelty of new partners is the real meaning of sex. I remember a married upper-middle-class couple brought to me by one of my residents years ago. They also were trying to have a child. On questioning, I found out that they only had sex one day a month and on the wrong day of the cycle. On further investigation, they revealed that theirs was a marriage designed to hide who they were from their very conservative parents. They did love each other but were not sexually attracted to each other. They liked to go out to bars, pick up a man, and have sex with him together. “Who would want to fuck a man more than two weeks, so boring!” A gay man, the husband was almost literally holding his nose to have vaginal sex with his wife so that they could have a baby together. We then had a little discussion about basal body temperatures and cervical mucous checking (hey, it was the 90s). “You guys are using condoms, right?” I asked, worried at the risks they were taking. This was at the peak of the AIDS epidemic, and people were dying all around us. “Well, we do now,” said the wife. “Obviously, we want my husband to be the father of the baby, but usually no, never.” I blanched. Around the same era, I began ordering sperm from sperm banks for my lesbian patients. In those days, infertility clinics in Montreal refused to help lesbians to conceive, and sperm banks would only deliver to doctors. The head of infertility explained, “These patients do not have an infertility problem; they have a penis problem.” So my office partner and I started ordering those giant tanks of liquid nitrogen packed sperm. We would inseminate our patients either in the office or we showed them how to do it at home. We encouraged home inseminations because we thought babies should be conceived in the context of an act of love. Sometimes, I have been the privileged recipient of happy stories, stories of how couples have learnt over time to become better lovers, responsive to each other’s needs and desires. This is most exciting for me when they are from generally conservative cultures where there is little premarital experience, and talking about sex is often taboo. “I love, I love it!” said my young patient three months into her arranged marriage. “The touching, the cuddling, the feelings, I am so in love!” I have had some of the frankest, most inspiring and fun conversations with my orthodox Jewish and religious Muslim or Sikh patients. I have made it my business to acquire some helpful knowledge in my pursuit of good sex for my patients. Most recently, I saw a pregnant woman just moved from Toronto. She was treated by my resident for a yeast infection because she was complaining of vulvar burning and itching, but when I saw her, it was evident to me that this was beyond simple yeast vulvitis. In fact, she had been suffering from intense burning and itching for years and had never had sex without pain. Her doctor in Toronto had explored trauma and suggested that she see a psychologist. When I looked at her vulva, she had the distinctive “keyhole” atrophic changes of lichen sclerosus. A little clobetasol later and this patient and her husband were having pain-free intercourse for the first time in their married lives. They were so happy, and I thought, this is so much fun! So almost five years ago, I developed breast cancer. It was a low-risk mammogram-discovered tumour, treatable only by surgery, radiation and hormone blockers. The sexual side effects were the worst. They really impacted my quality of life. Nobody asked me. I wish my doctors had been a bit more curious and a little bit sleazier. Because, of course, I have needs too. Dr. Perle Feldman is a family doctor practising in Montreal.

The soap opera need

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