Low and colleagues present a very important paper. They should be given
the opportunity to remove my doubts about the validity of their findings:
They used a cross sectional design to determine incidence; however,
unless the average duration of conditions is known longitudinal studies
are required to determine this. The presented study assessed
disease status of self-selected participants over a period of...
Low and colleagues present a very important paper. They should be given
the opportunity to remove my doubts about the validity of their findings:
They used a cross sectional design to determine incidence; however,
unless the average duration of conditions is known longitudinal studies
are required to determine this. The presented study assessed
disease status of self-selected participants over a period of 2 years. For
most of the participants the disease status at the beginning of the 2-year
study period was unknown. This allows the calculation of the period
prevalence, “which represents the proportion of cases that exist within a
population at any point during a specified period of time. The numerator
thus includes cases tat were present at the start of the period plus new
cases that developed during this time”.[1]
For conditions with a long duration (such as asymptomatic infection in
women) the incidence may be considerably lower than the period prevalence.
The key message of the paper is that rates of gonorrhoea and chlamydia diagnosis differ between different black ethnic groups. As the
authors mention in their discussion “differential sexual heath service use
by the ethnic groups may account for some of the observed disparity”.
Knowledge, attitudes, individual and group norms, resources and ease of
access determine care seeking. Ease of access should be similar for
members of different ethnic groups living is the same ward. Maybe Low and
colleagues would like to present the data controlling for confounding by
ward of residence.
References
(1) Hennekens CH, Burning JE. Measures of disease frequency in Epidemiology
in Medicine. Ed, Mayrent SL. Boston 1987:54-100.
Although our study population was homogeneous and Baltimore is known
to have high sexually transmitted disease (STD) rates, we believe
sufficient evidence exists to support our recommendation of twice yearly
chlamydia screening of sexually active females less than 25 years of age.
Chlamydia screening in most adolescent female populations yields
prevalence rates greater than 10%, except in areas wit...
Although our study population was homogeneous and Baltimore is known
to have high sexually transmitted disease (STD) rates, we believe
sufficient evidence exists to support our recommendation of twice yearly
chlamydia screening of sexually active females less than 25 years of age.
Chlamydia screening in most adolescent female populations yields
prevalence rates greater than 10%, except in areas with long-standing
chlamydia control programs, such as in the United States Pacific
Northwest.[1-5] In a large private sector managed care organization serving
a diverse adolescent population, including members residing in wealthy
suburban communities, we found chlamydia prevalence rates well above 10%
in adolescents chlamydia tested and a median time to reinfection of six
months among those with repeat tests.[1]
Drs. Pittrof and Kegg claim that our recommendation of twice yearly
chlamydia screening “apply only to … self selected women who attend sexual
health clinics.” In our study, the females with the highest rates of
infection were screened at school-based health centers providing
comprehensive primary care health services.[6]
Drs. Pittrof and Kegg advocate for screening practices to be dictated
by disease prevalence in specific populations. We agree in concept.
However, the chlamydia burden in private sector populations has not been
well described, and most health services do not have the resources or
technology to generate population-based incidence or prevalence data. In
addition, many chlamydia prevalence rates are determined with less
sensitive tests than were used in our study and may underestimate the true
disease burden.[2]
Chlamydia is mostly an asymptomatic infection with serious
consequences. We were unable to predict risk of infection among adolescent
females based on prior STDs, clinical presentation, or risk behaviors.
Since the risk of pelvic inflammatory disease and its sequelae increase
with the duration of untreated infection, we feel it is cavalier to assume
without supporting evidence that chlamydia is not a hidden problem in any
given adolescent population. Therefore, we recommend screening all
sexually active adolescent females for chlamydia infection twice yearly
until evidence to the contrary is generated.
Gale R Burstein, MD, MPH
Jonathan M Zenilman, MD
Johns Hopkins University
Baltimore, MD
Thomas C Quinn, MD
Johns Hopkins University
Baltimore
National Institute of Health
Bethesda, MD
(1) Burstein GR, Snyder MH, Conley D, Boekeloo B, Quinn TC, Zenilman
JM. Sexually transmitted disease screening practices and diagnosed
infections in a large managed care organization. Sex Transm Dis In Press
(2) Schacter J. Chlamydia trachomatis: the more you look, the more you
find – how much is there? Sex Transm Dis 1998;25:229-231.
(3) Winter L, Goldy AS, Baer C. Prevalence and epidemiologic
correlates of Chlamydia trachomatis in rural and urban populations. Sex
Transm Dis 1990;17:30-36.
(4) Fisher M, Swenson PD, Risucci D, Kaplan MH. Chlamydia trachomatis
in suburban adolescents. J Pediatr 1987;111:617-20.
(5) Cohen DA. Nsuami M. Etame RB. Tropez-Sims S. Abdalian S. Farley
TA. Martin DH. A school-based Chlamydia control program using DNA
amplification technology. Pediatr 1998 101:E1
(6) Burstein GR, Zenilman JM, Gaydos CA, Diener-West M, Howell MR,
Brathwaite W, Quinn TC. Risks of incident Chlamydia trachomatis infections
diagnosed by DNA amplification testing among inner city females with
repeat clinic visits. Sex Transm Infect 2001;77:26-32.
Bailis does not support his claim that male circumcision provides significant protection against disease with recent data. He uses antique data that are highly suspect.1
The Diseker study uses data from inner city STD clinics.2 This introduces significant population bias due to the significantly uneven distribut...
Bailis does not support his claim that male circumcision provides significant protection against disease with recent data. He uses antique data that are highly suspect.1
The Diseker study uses data from inner city STD clinics.2 This introduces significant population bias due to the significantly uneven distribution of ethnic groups within the United States between urban and suburban areas. Moreover, Diseker et al. later reports a 15.6% clinician error in determination of circumcision status.3 Therefore, such data cannot be considered to be reliable. Van Howe's survey of the literature found only a slight reduction in genital ulcer disease (GUD) in circumcised men that was counterbalanced by an increase in urethritis.4 Van Howe reports that the rate of STDs in the United States has increased as the rate of circumcision has increased.4
Laumann et al. report that the United States adult male population is 77% circumcised.5 If circumcision reduced STIs, then one would expect to find the United States to be nearly free of STIs. Such is not the case. Tanne reports an epidemic of STDs in the United States.6
Circumcision is an injurious surgical procedure. There is a high rate of complications.7 Circumcision amputates significant amount of erogenous tissue and leaves a lifetime irreversible injury.8 Adverse sexual and psychological effects are documented.9 The current state of medical science contraindicates the prophylactic use of male circumcision.
George Hill
Executive Secretary
Doctors Opposing Circumcision
2442 NW Market Street, Suite 42
Seattle, Washington 98107
USA
Web: http://faculty.washington.edu/gcd/DOC/
References:
Bailis SA. Letter. Sex Transm Infect 2001;77(6):462-3.
We were interested in the case report, "Perianal Crohns Disease
masquerading as perianal warts"[1] (August)
In which the authors highlight the diagnostic difficulty with other
anogenital conditions such as perianal warts.
Plus the initial lack of obvious bowel symptoms considered to be the
hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged
43 wh...
We were interested in the case report, "Perianal Crohns Disease
masquerading as perianal warts"[1] (August)
In which the authors highlight the diagnostic difficulty with other
anogenital conditions such as perianal warts.
Plus the initial lack of obvious bowel symptoms considered to be the
hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged
43 who presented with a vulvitis of several months duration, the main
symptoms being pruritis vulvae and superficial dyspareunia. There was
absolutely no gastrointestinal symptoms or systemic upset and past general
health was good.
Initial clinical examination revealed diffuse erythema and swelling
of the Labia Majora, and some perineal fissuring was also noted.
All routine STI screening tests were negative, and a provisional diagnosis
of Vulval Dermatitis was made.
With agreement of the patient a therapeutic trial of Hydrocortisone 1 % was
tried but with no effect.
A vulval biopsy was therefore carried out which revealed histological
features consistent with Crohns disease,i.e. non-caseating granuloma,giant
cells and chronic inflammatory infiltrate.
A colonoscopy was reported as normal and the patient remains asymptomatic.
This case, in common with the reported case[1], reminds us that Crohns
disease can present initially as a common clinical condition to GU
Clinics, such as warts or vulvitis.
The diagnosis rests primarily on biopsy of the lesion,this is especially
so in cases of "metastatic disease"[2] either preceeding bowel involvement
by years,[3] or exclusive involvement of genital tract only.[2]
Is it possible that Crohns disease of the genital tract is an
underdiagnosed condition?
Benjamin Goorney
References
(1) Garg M, Kawsar M, Forster GE, and Medows NJ. Perianal Crohn’s disease masquerading as perianal warts. Sex Transm Infect 2002;78:302-303.
(2) Urbanek M, Neill SM, Mckee PH. Vulval Crohns disease: difficulties in diagnosis. Clinical and Experimental Dermatology 1996;21:211-214.
(3) Bruce L, Donaldson, MD. Crohns disease: its gynecologic aspect. Am J Obstet Gynecol 1978;131:196-202
This has been an interesting study of releasing information about the
reason for encouraging partner notification. I wonder whether it is
possible to have some information about what happened in practice.
Presumably, there were some male patients, who had non-gonococcal
urethritis diagnosed on their first visit, and, at that time, it was not
known whether Chlamydia trachomatis was the cause....
This has been an interesting study of releasing information about the
reason for encouraging partner notification. I wonder whether it is
possible to have some information about what happened in practice.
Presumably, there were some male patients, who had non-gonococcal
urethritis diagnosed on their first visit, and, at that time, it was not
known whether Chlamydia trachomatis was the cause. Was partner
notification encouraged and were contact slips issued then and, if so,
what information did they carry about the patient's diagnosis? If such
patients re-attended when the C. trachomatis result was known to be
positive, were revised contact slips issued?
I read Ison and Hay’s paper concerning validation of grading of
vaginal smears with great interest but am concerned there was no mention
of earlier work which closely resembles their new grading system.[1]
The
examination of stained specimens of vaginal secretions for diagnosis,
research and classification of vaginal pathology has a long and sometimes
confusing history. Medline searches date from...
I read Ison and Hay’s paper concerning validation of grading of
vaginal smears with great interest but am concerned there was no mention
of earlier work which closely resembles their new grading system.[1]
The
examination of stained specimens of vaginal secretions for diagnosis,
research and classification of vaginal pathology has a long and sometimes
confusing history. Medline searches date from 1966 and authors can easily
overlook archived papers, many of which may remain relevant today. In 1914
Curtis described the vaginal flora in health and disease publishing
photomicrographs of stained vaginal specimens from healthy women and from
those with leucorrhoea. He noted that “the more patients deviate from the
absolute normal, with only Döderlein bacilli, i.e, the greater the
tendency to discharge formation and the more purulent its nature , the
more nearly do the bacteriological findings resemble in character the
picture presented by pathological cases.” [2,3] Curtis also cited even
earlier work by Döderlein (1882), Menge & Krönig (1897) and Wegelius
(1909) all of whom contributed to our understanding of the vaginal
bacterial flora.[2] In 1921 Schröder classified the vaginal flora into
three grades of cleanliness, (Reinheitsgrade).
Grade 1: Döderleins bacillionly,
Grade II Döderleins bacilli and other organisms, Grade III organisms
other than Döderleins bacilli, cited by Rakoff, Feo and Goldstein, 1944.[4,5]
In 1939 Liston and Liston, though not referencing Schröder’s earlier
work, introduced a modification of his classification as follows. “Type I,
a pure Döderlein flora’, Type II, Döderlein bacilli with an admixture of
Gram positive bacilli of diptheroid type,with perhaps one or two Gram-negative organisms only. Type III, many different kinds of organisms,
chiefly Gram-negative , generally small cocco-bacilli but including a few
Gram positive bacilli and cocci, comma bacilli (probably an early
reference to Mobiluncus species) leptothrix and spirochaetes.” [6]
Several
later publications concerning vaginal bacteriology also either adopt
and/or refer to Schröder’s original classification. These include Hite,
Hesseltine and Goldstein (1947), Weaver , Scott and Williams( 1950) , Lang
(1955) , Hunter and Long (1958), Burch ,Rees and Kayhoe (1958) and
Davidson and Layton (1968).[7-12] It is interesting that several early publications
note the relationship between increasing vaginal pH and increasing grade
of vaginal flora leading the way to Amsel’s diagnostic criteria for non-
specific vaginitis in 1983.[5,9,13,14]
It is of particular interest that in 1942 Hesseltine, Wolters and
Campbell classified the bacterial flora of the vagina as follows: “type I
reveals only vaginal bacilli present; type II, a mixture of vaginal
bacilli and other bacteria; type III, other bacteria without vaginal
bacilli; and type IV, a single type of some abnormal bacteria.” 15 This
is very similar to Hay and Ison’s new criteria “grade 0 epithelial cells
with no bacteria seen; grade I(normal flora), lactobacillus morphotype
only; grade II (intermediate flora), reduced lactobacillus morphotype with
mixed bacterial morphotypes; gradeIII (BV), mixed bacterial morphotypes
with few or absent lactobacillus morphotypes; grade IV epithelial cells
covered with Gram positive cocci only”.[1] The absence of any bacteria (Hay/Ison grade 0) can be considered normal if a woman has recently used
oral or topical (vaginal) antibacterial agents whilst the presence of
epithelial cells covered with Gram positive cocci (Hay/Ison grade IV)
begs the question of how one should classify a Gram stain in which
planktonic Gram positive bacteria only are observed.
How also should we grade the microscopic findings of gonococcal vaginitis, which, although
more common in prepubertal females, may also occur in adult women? [16]
Hesseltine and colleagues’ grading system (which was in practice a
modification of Schröder’s ) may therefore have distinct advantages. My
personal preference for describing the microbiology of the vagina by Gram
stain is to use Schröder’s original grading for bacteria with a fourth
category, “Other-specify” or, better still, “None of the above-specify”.
The fourth category should describe simply what is seen e.g. “no
bacteria”, “scanty/un-evaluable slide”, “Gram negative diplococci with
polymorphonuclear leucocytes”, “spores/mycelia” etc, etc. The majority of
specimens will reveal a vaginal flora that can be readily ascribed to one
of Schröder’s grades but the fourth category permits a pragmatic solution
for describing smears which cannot be so designated.
Finally, having read many old papers on vaginal infection gleaned by
laboriously hand searching the archival section of the library at St
Thomas’s hospital, London, in the 1970s and 80s, I find it difficult to
admit to having ever had a truly original thought on the subject. I feel
therefore that we should give due credit to Schröder’s work when naming
any “new” classification system of vaginal bacteriology, I wish also to
apologise to any now long dead researcher whose work I have overlooked.
References
(1) Ison CA, Hay PE. Validation of a simplified grading of Gram
stained vaginal smears for use in genitourinary medicine clinics. Sex
Transm Infect 2002; 78,6:413-16
(2) Curtis AH. Etiology and Bacteriology of Leucorrhoea. Surg Gynecol
Obstet 1914;18:299-306.
(3) Döderlein A. Uber Scheidensekrete und Scheidenkeime.
Verhandl.deutsch. Gesellsch. Gynak 1892 ;4:35
(4) Schröder R. Zur Pathogenese und Klinik des vaginalen Fluors .
Zentralbl. Gynak 1921;45:1350
(5) Rakoff AE, Feo LG, Goldstein L. The biological characteristics of
the normal vagina. Am J Obstet Gynecol 1944; 47:467-94.
(6) Liston WG, Liston WA. A study of Trichomonas Vaginitis in
Hospital Practice in Edinburgh. J Obstet Gynecol 1939; 22:474-94.
(7) Hite KE, Hesseltine HC, Goldstein L. A study of the bacterial
flora of the normal and pathologic vagina and uterus. Am J Obstet Gynecol
1947;53:233-40
(8) Weaver JD, Scott S, Williams OB. The bacterial flora found in non-
specific vaginal discharge. Am J Obstet & Gynecol 1950;60:880-84.
(9) Lang WR. Vaginal Acidity and pH. A Review. Obstet and Gynecol
Surv 1955;10:546-60.
(10) Hunter A, Long KR. A study of the microbiological flora of the
vagina. Am J Obstet Gynecol 1958; 75:865-71.
(11) Burch TA, Rees CW, Kayhoe DE. Laboratory and clinical studies on
vaginal trichomoniasis. Am J Obstet Gynecol 1958;76: 658-65.
(12) Davidson AJL, Layton KB. Vaginitis and Haemophilus vaginalis .
Med J Aust 1968;1:757-60.
(13) Cruickshank R,Sharman H. The biology of the vagina in the human
subject. Part II The Bacterial flora and secretion of the vagina in
relation to glycogen in the vaginal epithelium. J Obstet & Gynaec Brit
Emp 1934;41:208-226.
(14) Amsel R, Totten PA, Spiegel CA, et al. Non-specific Vaginitis.
Diagnostic Criteria and Microbial and Epidemiologic Associations. Am J Med
1983;74: 14-22.
(15) Hesseltine HC, Wolters SL,Campbell A. Experimental Human Vaginal
Trichomoniasis. J Infect Dis 1942;71:127-30 .
(16) Blackwell A L . Penicillinase producing Neisseria gonorrhoeae
associated with severe vulvo-vaginitis in a post menopausal woman. Genito-
Urin Med 1993; 69:482-83.
Despite the long-standing recommendation to vaccinate men who have sex with men (MSM) attending genitourinary medicine (GUM) clinics,[1] coverage of vaccination in this group has been difficult to achieve.[2,3] In a study of GUM attendees, post infection immunity (anti-HBs prevalence) was found to be 31% in homosexual men and vaccine coverage to be 40% in London and only 24% outside London.[4] Yee and Rhodes...
Despite the long-standing recommendation to vaccinate men who have sex with men (MSM) attending genitourinary medicine (GUM) clinics,[1] coverage of vaccination in this group has been difficult to achieve.[2,3] In a study of GUM attendees, post infection immunity (anti-HBs prevalence) was found to be 31% in homosexual men and vaccine coverage to be 40% in London and only 24% outside London.[4] Yee and Rhodes highlight the need for cheap and available hepatitis B vaccine as one way to increase immunisation rates among homo/bisexual men.[5]
In England, the Department of Health (DH) has introduced specific vaccination standards for MSM as part of their strategy for sexual health.[6] All MSM who are attending GUM clinics for the first time should be offered vaccination against hepatitis B. To help facilitate this, the DH has distributed extra doses of vaccine to all GUM clinics in England.
As Yee and Rhodes point out, vaccination uptake rates need to be monitored to determine whether this strategy will be effective. To help achieve this, a simple surveillance system called HepB3, was introduced to all GUM clinics across England in December 2002. The survey is being coordinated by the Communicable Disease Surveillance Centre (CDSC) on behalf of the DH. In an attempt to avoid adding to the already substantial workload of clinics,[7,8] the breadth of data requested has been kept to a minimum. None-the-less, it will enable first dose and complete courses of vaccine among new MSM attendees to be monitored, along with reasons for non-vaccination. While in essence the study is merely an audit, this is the first step towards enhanced surveillance of hepatitis B vaccination. It is proposed that the HepB3 survey will eventually be assimilated into the Programme of Enhanced Surveillance of Sexually Transmitted Infections, currently operating in GUM clinics in London and parts of South East England and which is planned for roll out nationwide over the next few years. This will enable immunisation data to be linked with anonymised, patient-based, demographic data such as ethnicity, previous infection and some behavioural information. Over the next few years, it will be possible to determine whether the DH’s strategy for increasing hepatitis B vaccination rates in MSM has been effective, and our understanding of factors influencing vaccination coverage in this group should be substantially improved.
(2) MacKellar DA, Valleroy LA, et al. Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men. American Journal of Public Health 2001;91(6): 965-971.
(3) Rhodes SD, DiClemente RJ, et al. Correlates of hepatitis B vaccination in a high-risk population: An internet sample. American Journal of Medicine 2001;110: 628-632.
(4) Department of Health. Prevalence of HIV and hepatitis infections in the United Kingdom 2000. Annual report of the UA prevalence monitoring programme 2001: 32-36.
(5) Yee LJ, Rhodes SD. Understanding correlates of hepatitis B virus vaccination in men who have sex with men: what have we learned? Sex Transm Infect 2002;78: 374-377.
(7) Djuretic T, Catchpole M, et al. Genitourinary medicine services in the United Kingdom are failing to meet current demands. Int J STD & AIDS 2001;12:571-572.
(8) Foley E, Patel R, et al. Access to Genitourinary medicine clinics in the United Kingdom. Sex Trans Infect 2001;77(1):12-14.
Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sex...
Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sexual health.
Problems in sexual functioning such as erectile dysfunction (ED),premature ejaculation, low sexual desire in women and vulvadynia affect a third of men and well over a third of women in the UK [2]. Fifty per cent of patients so effected would want treatment for their problem [2]. Management of ED significantly improves both the quality of life and its
concomitant mental illness [3][4]. Although the absolute cost of ED treatments has risen three fold between 1997 and 2000 in the UK, the cost per patient fell significantly [5]. Much of the cost effectiveness in the treatment of ED is related to very effective pharmaceutical agents such as
sildenafil [4]. However, female sexual dysfunction (FSD), which is largely managed at present by sex therapy and cognitive behaviour therapy, appears to be similarly cost effective [6].
It is my impression that a decade ago most GU medicine clinics did not offer treatment for SD. A study in 1997 [7] and again in 2000 [8] suggested that over 80% of GU clinics supported the notion of treatment of SD and that over 40% actually carried out SD management.
Treating SD, apart from its direct effects on restoring sexual functioning, quality of life and reversing depression, may indeed have positive spin offs in decreasing STI acquisition in men ( e.g. condom use
is only effective on an erect penis) and women with low sexual desire [9].
SD management in GU medicine clinics in the UK, I believe, is still treated as a Cinderella subject by central government and local purchasers, in spite of the surrogate and indirect evidence of its success over the past 10 years. Furthermore, there is no specific funding for it.
Its mention in the National Strategy for Sexual Health document might be perceived as mere lip service to placate the few champions who voice their opinions on behalf of the literally vast numbers of patients with SD
who suffer in embarrassed silence.
I believe central government should look carefully at this neglected success story and encourage it to continue by means of adequate education of medical students and junior doctors in the SD field as well as proper financial support.
References
(1) Department of Health. The National Strategy for Sexual Health and HIV. DoH, London, 2001.
(2) Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of the
prevalence and need for health care in the general population. Fam Pract
1998;15:519-524
(3) Guest JF, Das Gupta R. Health related quality of life in a UK based poulation of men with erectile dysfunction. Pharmacoeconomics2002;20): 109-117
(4) Guiliano F, Pena BM, Mishra A, Smith MD.
Efficacy results and quality of life measures in men receiving sildenafil citrate for the treatment of erectile dysfunction. Qual Life Res2002;(11)359-369
(5) Wilson EC, McKeen ES, Scuffham PA et al. The cost to the United Kingdom Health Service of managing erectile dysfunction: the impact of sildenafil and prescribing restrictions. Pharmacoeconomics, 2002;(20):879-889
(6) Goldmeier D, Malik F, Green J, Phillips R. Cost effectiveness of sexual dysfunction – the female picture, Int J Impotence Res,in press.
(7) Keane FE, Carter P, Goldmeier D, Harris JR The provision of psychosexual services by genitourinary medicine physicians in the United Kingdom, Int J STD AIDS, 1997;(8):402-404
(8) Kell P, The provision of sexual dysfunction services by
genitourinary medicine physicians in the UK 1999, Int J STD AIDS, 2001;(12):395-397
I am sure it is not pure co-incidence that the
editorial 'Sexual Health-Health of the Nation' appears
in the same issue as a paper emphasising the missed
opportunity of treating sexually transmitted
infections in primary care and like Michael Adler, I
feel melancholic about the future of the sexual health of
our nation. As a GP/Hospital Practitioner in GU
Medicine for thirty years, I fail to comprehe...
I am sure it is not pure co-incidence that the
editorial 'Sexual Health-Health of the Nation' appears
in the same issue as a paper emphasising the missed
opportunity of treating sexually transmitted
infections in primary care and like Michael Adler, I
feel melancholic about the future of the sexual health of
our nation. As a GP/Hospital Practitioner in GU
Medicine for thirty years, I fail to comprehend the
apparent shambolic lack of co-ordination of the
various programmes for better STI care.
We are encouraged to develop strategies for universal
Chlamydia screening, which has been placed before
successive governments and warm political words of
encouragement have been received in the same breaths
as the apparent hollow promises of strong finance to
follow. Do they think us stupid? Actually, we must be,
for we believe them every time! Despite the many
hundreds of hours put in by hundreds of dedicated HCWs
into strategies to improve the health of this nation,
based on strong clinical evidence, it would seem that
these opinions are for nothing.
The current Sexual Health policy encourages GPs,
amongst others, to participate in the control of
sexual diseases and the programmes for training are
being enthusiastically attended and enjoyed. I may not
be the brightest cookie in the tin but I can smell
staleness when the 'sale by dates' of policies are
passed. Recently, all GPs have received a tome called
their new contract. This was defined in conjunction
with a review body and, in draft form, seemed
encouragingly thorough and well-intentioned and we all
thought a bright new sensible future was dawning. Once
again, how stupid we are; I can find no written words
in the whole document relating to the Sexual Health
Strategy. Contraception, maternity care, termination
and cervical smears are given a cursory and
traditional style mention but nowhere can I find any
encouragement for GPs to take the sexual health
strategy seriously. However, we are told that we will
be rewarded for collecting data on the investigation
and treatment of heart disease, diabetes and chest
ailments, but sexual health is no longer politically
important. Why has no one incorporated the sexual
health strategy into the GP contract? What a golden
opportunity of timing has been missed. Is the reason
for this omission a genuine oversight, poor
intelligence (an expression used by American
politicians to cover stupidity), or, is it a
deliberate fudge in order to disguise the lack of
money for any excellent and intelligent new strategy?
I suspect it is the latter.
Twelve months ago, I was flattered to be asked to sit
as a GP representative on the DoH Sexual Health
Services Data Group in order to produce a 'Recommended
Minimum data-set for sexual health services providing
levels 1-3 elements of care in England'. Many of the
esteemed and experienced committee members had already
been dealing with this weighty tome for many months
before, but the constant hammering in my mind about
this essential tool was the threat that there had to
date been no mention of finance behind the strategy.
Sadly, my nightmares seem to be coming true. It would
appear that there has never been any intention to co-
ordinate GP time and to offer financial incentive into
this paper, or sexual health would be up there with the
other major threats in the new contract, and, unless it
is mentioned alongside items of service payment, no GP
in the land is going to bother to put his or her
gloves on for this 'below the belt' topic. Yet again,
the politicians have sold us a dummy.
Perhaps it is time that all those altruistic HCWs who
spend hundreds of unpaid hours of their lives
dedicating time to the services of Whitehall should
stop wasting it and return to the three to six week
queues of patients clamouring in the waiting rooms of
their clinics.
In 1997, Professor Adler’s stark assessment of the deterioration of
sexual health of the UK [1] laid the blame for it on presumably highly
influential (though unnamed) groups attempting "to withhold information on
the basis of a particular agenda of family values and morality.[2] At least
his 2003 editorial,[2] charting more recent decline on every parameter
examined, does not repeat this former unre...
In 1997, Professor Adler’s stark assessment of the deterioration of
sexual health of the UK [1] laid the blame for it on presumably highly
influential (though unnamed) groups attempting "to withhold information on
the basis of a particular agenda of family values and morality.[2] At least
his 2003 editorial,[2] charting more recent decline on every parameter
examined, does not repeat this former unreferenced and, in my view
unsupportable, scape-goating. This time, he appears to blame the
government for not making sexual health "an NHS or political priority".
Whilst I agree they have not and the currently allocated financial
resources are totally inadequate, it is the political correctness of
sexual-health policy-makers that is the main barrier to improving the
sexual health of the nation. It is widely accepted that up to 80% of
unplanned pregnancies are due to contraceptive (mainly condom) failure,[3] yet condoms still continue to be promoted as a "the solution" the
very problem they contribute so heavily towards.[4,5]
Condoms, when used consistently and correctly, do provide reasonable
protection against HIV and gonorrhoea.[6] However, they are rarely
consistently and correctly used [7] and even when they are, there is no
evidence that any protection they may provide against the majority of
sexually transmissible agents is anywhere near as good at that for HIV;[6,8] in the case of HPV it is possibly none at all. [6,9]
Adler indicates that reversing adverse trends in sexual behaviour is
a key priority in controlling STI escalation. Increased condom use alone
is "not enough to offset the increase in sexual partners". He also
suggests the increase in sexual intercourse among under-17s as a major
contributor to poor sexual health. If delaying the age of first coitus is
therefore so important, why is there seemingly complete denial in the
Department of Health about the effectiveness of abstinence education?[10]
Both unplanned pregnancy and STI rates have been reduced in appropriate
abstinence-based programmes, not only in the USA [11,12] but also in
Zambia [13] and Uganda.[14]
In spite of such evidence for their effectiveness, abstinence
programmes are labelled in the UK as being unworkable.[15] Instead we
continue to base our programmes for reducing unplanned pregnancy on
condoms, the failure of which is implicated in 80% of them. More recently
the emphasis has switched to the emergency pill, but the unrestricted use
of this from pharmacies will only further the increase in STIs.[16] Until
such short-sighted policies change, we will indeed sadly "witness failure
upon further failure" in sexual health in the UK. However, Professor Adler has not told us the real reasons why.
References
(1) Adler M. Sexual health- a Health of the Nation failure. BMJ 1997;314:1743-1747.
(2) Adler M Sexual health – health of the nation. Sex Trans Infec 2003;79:85-7.
(3) Pearson VAH, Owen MR, Phillips DR, Pereira Gray DJ, Marshall MN.
Pregnant teenagers’ knowledge and use of emergency contraception. BMJ
1995; 310:1644
(4) Richens J, Imrie J, Copas A Condoms and seat belts: the parallels
and the lessons Lancet 2000 355 400-3
(5) Doughty S Charity to hand out free condoms to 11-yr olds Daily
Mail 28.3.2003 http://www.likeitis.org.uk/welcome_to_like_it_is.html
(7) de Visser RO Smith AM When always isn’t enough; implications of
the late application of condoms for the validity and reliability of self-
reported condom use. AIDS Care 200012:221-4.
(8) Mann J, Stine C, Vessey J The role of disease-specific
infectivity and number of disease exposures on long-term effectiveness of
the latex condom. Sex Trans Dis 2002;29:344-9.
(9) Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection,
external genital warts or cervical neoplasia? A meta-analysis. Sex Trans
Dis 2002;29:725-35.
(11) Doniger AS, Adams E, Riley JS, Utter CA, Impact evaluation of the
"Not Me, Not Now”' abstinence-oriented, adolescent pregnancy prevention
communications program, Monroe County, New York. J Health Communication 2001;6:45-60. http:// www.notmenotnow.org/research/NMNNimpactevaluation.pdf
(12) Mohn JK, Tingle LR, Finger R An analysis of the causes of the
decline in non-marital birth and pregnancy rates for teens from 1991 to
1995. Adolesc and Fam Health 2003;3:39-47.
(13) Martin K Zambia’s HEART programme evaluation shows youth respond
positively to AIDS prevention plan promoting abstinence. John Hopkins
University Centre for Communications Programmes 2002. http://www.jhuccp.org/pressroom/2002/07-11.shtml
(14) Hogle J, Green EC, Nantulya R, Stoneburner J et al. Whatever
Happened in Uganda? Declining HIV prevalence, behaviours change and the
national response USAID-Washington and The Synergy Project TvT Associates
Washington D.C. 2002 http://www.usaid.gov/pop_health/aids/Countries/africa/uganda_report.pd
(15) Swann C, Bowe K, McCormick G, Kosmin M Teenage pregnancy and
parenthood; a review of reviews. Health Development Agency 2003.
(16) Stammers T. Emergency contraception from pharmacists misses
opportunity. BMJ 2001;322:1245.
Low and colleagues present a very important paper. They should be given the opportunity to remove my doubts about the validity of their findings: They used a cross sectional design to determine incidence; however, unless the average duration of conditions is known longitudinal studies are required to determine this. The presented study assessed disease status of self-selected participants over a period of...
Dear Editor,
Although our study population was homogeneous and Baltimore is known to have high sexually transmitted disease (STD) rates, we believe sufficient evidence exists to support our recommendation of twice yearly chlamydia screening of sexually active females less than 25 years of age. Chlamydia screening in most adolescent female populations yields prevalence rates greater than 10%, except in areas wit...
Dear Editor
We were interested in the case report, "Perianal Crohns Disease masquerading as perianal warts"[1] (August) In which the authors highlight the diagnostic difficulty with other anogenital conditions such as perianal warts. Plus the initial lack of obvious bowel symptoms considered to be the hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged 43 wh...
Dear Editor
This has been an interesting study of releasing information about the reason for encouraging partner notification. I wonder whether it is possible to have some information about what happened in practice. Presumably, there were some male patients, who had non-gonococcal urethritis diagnosed on their first visit, and, at that time, it was not known whether Chlamydia trachomatis was the cause....
Dear Editor
I read Ison and Hay’s paper concerning validation of grading of vaginal smears with great interest but am concerned there was no mention of earlier work which closely resembles their new grading system.[1]
The examination of stained specimens of vaginal secretions for diagnosis, research and classification of vaginal pathology has a long and sometimes confusing history. Medline searches date from...
Dear Editor
Despite the long-standing recommendation to vaccinate men who have sex with men (MSM) attending genitourinary medicine (GUM) clinics,[1] coverage of vaccination in this group has been difficult to achieve.[2,3] In a study of GUM attendees, post infection immunity (anti-HBs prevalence) was found to be 31% in homosexual men and vaccine coverage to be 40% in London and only 24% outside London.[4] Yee and Rhodes...
Michael Adler’s editorial on sexual health - health of the nation - makes pessimistic reading. While it is apparent that the rate of STIs and unwanted pregnancy has increased in the UK over the last 10 years, he fails to mention what has happened to sexual dysfunction (SD) over that period of time. The National Strategy for Sexual Health and HIV document mentions SD a number of times [1]. SD is indeed part of sex...
Dear Editor
I am sure it is not pure co-incidence that the editorial 'Sexual Health-Health of the Nation' appears in the same issue as a paper emphasising the missed opportunity of treating sexually transmitted infections in primary care and like Michael Adler, I feel melancholic about the future of the sexual health of our nation. As a GP/Hospital Practitioner in GU Medicine for thirty years, I fail to comprehe...
Dear Editor
In 1997, Professor Adler’s stark assessment of the deterioration of sexual health of the UK [1] laid the blame for it on presumably highly influential (though unnamed) groups attempting "to withhold information on the basis of a particular agenda of family values and morality.[2] At least his 2003 editorial,[2] charting more recent decline on every parameter examined, does not repeat this former unre...
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