Two fifths of women have no interest in Sex.

Well that sounds quite physiological to me .Its a well known and well researched fact that women always have a significantly lower interest in Sex(all the other categories of women exclusively not included as in women in the fashion industry,prostitutes etc)

More men report libido women reporters are significantl low.

I have heard of more men going behind women the converse also possible but probably is not as much the former group.

It has always been know that women dont explicitly indicate their interest or so to say never in proportions equivalent to that of men.That probably explains more sexual crimes from men to women not the converse again.

Also explaining the tendancy of homosexuality more amongs men groups not again amongst women groups.

Sex is I believe one of the primary drives for a humanbeing and just as the same as thirst/hunger for food and its again a well known fact that a woman probably can sustain their deprivations to a significantly larger extent than the men again the desire for Sexual drive highlighted in this context.

I havent again done a proper study but I am amalgamating a lot of issues I have read through so far.....a metaanalysis so to say of my own.

Well as a laywoman I wish to speak to any body who could probably throw some light in the following issues.So this is in reality not a true response in itself but just an added thought.The article by John Frank is however in its simplest form for anybody to comprehend and a good one.

Microwawe energy is one of the ubiquitiosly used appliances and its energy is ionising radiation and i wish to know how safe it is to use it for general use/the pregnant women/long term effects?Are there any studies done so far??

There are a lot of radiocontrasts being handled by porters/healthcareprofessionals/into the body of patient and excreted eventually...............So just a thought about how far are we polluting the environment?

Is it negligible in comparison to the huge benefits we actually get from their usage(both radiocontrast/ionising radiation)

Radioluminescent objects likethe traffic aprons worn/many articles of amusement,watchdials /toys etc ,are they emitting harmful ionising radiation?If so should a legislation be involved in prohibiting their general use???

I fully agree with the authors but in the diseases like asthma and allergy rising trends seen world-wide has one single reason i feel that is unlikely. In both developing and developed countries, environmental factors present during pregnancy and in the first 3 years of life are most relevant to the observed increase in asthma and allergy.

The study of Lynch and coworkers (cited in a review article by S. T. HOLGATE IN Q.J.Med. 1998; 91:171?184) has shown that from a public health standpoint, high levels of non-specific IgE may prove to protect rural dwellers who are exposed to parasites from allergy and asthma. thus putting ourselves on a crossroad that which path to follow

The union sounds like good news. I just don't want the sBMJ to change. I like it just the way it is with its nice blend of education, interviews and career advice.

It is the present treand among oversease gradutes to apply for what ever the jobs they see in BMJ.It doesnt matter if it intrests them or not.This has made people doing the intervews badly and obviously not gettin the jobs.

i think that Michael J fox is an inspiration to anyone who has the disease, and to those who are studying it. i am currently studying geneticdiseases, and i came across this site during my research, and i have to say the report is trully moving. it shows that anything is possible and that iracles do happen. eventhough michael j fox is an outstanding actor doesnt make him different or special from anyone else with the disease, it just shows that how precious life is, and how we take everything for granted. it just shows if one person can help make their life count, others can do it to.

The GMC and its understanding of the disabilities of the doctors is fraught with many limitations .

The appearance and dangers caused by the disabilities are more often covert for them to be recognised.The nature,intensity of the harm or lack of efficiency of the doctors/medical students with disabilities are often difficult to define,query in open as it is confidential for the person concerned solving the issue only taking the back seat.

The biggest concern is those of the mental disorders particularly those lacking insight like the cognitive disorders and can prove quite dangerous.I havent come across so far of many countries' medical councils having rules and legislations in respect of the same.

So the hierarchy of the medical students being monitred by the supervisors,SHOs by the Registrars and the Registrars by the Consultants but who is concerned or actually is supervising or when needed monitoring the Consultants.This is not to question the credibility of the consultants ,not to undermine the efforts and experience making them a consultant but in case of a need who is actually responsible remains to be known.Nobody can be perfect and nobody can all the time make no mistakes.

Dear stephen

I'm a fourth year student from Queens in Belfast. Read you article this evening and found it most interesting.

You mention that religion has no place in modern medicine. In one way i can see your point and in another way i cant.

I can because i firmly agree with you that no-one has the right to attempt to impose their religious beliefs on anyone else. It can be on many occassions arrogant and thoroughly inappropriate.

On the flip side of things, we are continually being hammered with (and i suspect you are to) the need to treat the whole individual, physically, emotionally and spiritually. Though wildly vague, it would appear from our teaching that "spiritual health" fits in somewhere.

Free speech and debate are excellent and essential things. I liked your article, though it belittled and dismissed the faith of many people. A question: you seem confident that religion is irrelevant/untrue; I am curious if, in our evidence-based world, you have examined the claims of the bible (and even independent history around 0bc) in the sort of analytical and critical way that you would approach a medical article? Probably sounds stupid, but an issue so important is definately worth a thorough look.

Best regards

James Nelson

ps - "If i were god i would make myself clearer" is an excellent 100 page book by john dixon that you may find interesting. You may rather use it to light the fire! I mention it encase you're bored, interested or fancy having some good ammo for slagging christians!

Dear stephen

Unlike Stephen Goldie¹, it would seem, I have yet to meet a pious doctor or nurse whos faith was detrimental to the treatment of their patients. Indeed, my own Christian faith directs me to love God and love others². If this compromises the care of my future patients, I'm sure Mr. Goldie will let me know.

I would also like to ask him WHY religious faith should have no place in medical practice, especially since a) I can love God and others within the bounds of evidence based medicine, and b) it was this very faith (and the subsequent 'love for others') that drove me to do medicine in the first place.

If Mr. Goldie doesn't want me to stuff a New Testament down his throat, I won't. But I will live my life, and perform medicine, to the best of my abilities by following the example of Jesus - loving God, and loving others.

1. Religion must not influence medical practice, student BMJ2003;11:435
2. Jesus Christ, quoted in Matthew's Gospel, chapter 22 v37-39

Personal view: Medical practice must not influence religion

Sir,

I read with interest Stephen Goldie's article in this month's studentBMJ regarding his disapproval of religious views in general and the role of religion in healthcare specifically. I write to express the alternative view that religion and medicine are, in fact, complementary and certainly not mutually exclusive as the article implies.

My first contention with Goldie's article is his assertion that religious faith necessarily prevents people from rising up against "poverty, oppression and disease". On the contrary, Jesus Christ teaches his followers throughout the four gospels of the New Testament to do precisely that (e.g. Matthew 5:23-24, 43-4, 43-48, 6:19-24, 7:1-6 etc.). Moreover, Jesus himself performed many miracles of healing (Matthew 8:14-17, 28-34, 9:1-8, 18-34 etc.). Rather than dismiss this religious teaching as "an ancient relic", we should acknowledge its relevance and strive towards obedience. It is interesting that the word religion derives from the Latin religare, meaning "to bind together": religions can hardly be accused of encouraging poverty, oppression or disease; they unite us.

Secondly, whilst "hectoring and pontificating" (an interesting choice of words) is certainly to be discouraged, why should those of us with a religious faith be embarrassed about it? Why should we not discuss our beliefs with our patients within a mutually comfortable patient-doctor relationship? Indeed, why dismiss our patients' beliefs as "illogical" just because we disagree with them? A doctor with respect for patient autonomy should be willing to discuss all the factors that are likely to affect treatment compliance and disease status, and should refer to specialists such as hospital chaplains as necessary.

On the subject of evidence-based medicine, Goldie might be interested in the findings of some recent research in the United States. 66% of the respondents in a Philadelphia study1 of patients' spiritual needs agreed or strongly agreed that they would like their doctors to ask whether they have "spiritual or religious beliefs that would influence their medical decisions" if they became "gravely ill"; 9% disagreed, 7% strongly disagreed, and 18% gave no opinion. Two thirds also agreed that a doctor's enquiry about spiritual or religious beliefs would "strengthen their trust in the doctor", whereas 10% disagreed and 7% strongly disagreed.

In times of crisis, such as life threatening illness, individuals may experience disharmony of mind, body and spirit2 and psychoneuroimmunology has established that emotions such as anxiety and hope can be factors in illness outcomes3. When patients feel that their spiritual needs are neglected in standard clinical environments, they may be driven away from effective medical treatment3. For these reasons, the doctor's duty of beneficence requires respect for patient spirituality and there have been many recently published research papers on the subject on spirituality in medicine.

In conclusion, I am in agreement with Goldie that we should practice evidence-based medicine with regard to religious beliefs, but the evidence seems to support the appropriate inclusion, not exclusion, of religious beliefs in the consulting room. If Goldie and those in a similar position find themselves unable to discuss issues of faith with patients, I would encourage them to refer on appropriately to colleagues, medical or otherwise, in order to meet with their patients' spiritual and medical needs most effectively.

1. Ehman, J.W. et al (1999) Do Patients Want Physicians to Inquire About Their Spiritual or Religious Beliefs If They Become Gravely Ill? Archives of Internal Medicine 159(15):1803-1806
2. Baldacchino, D. and Draper, P. (2001) Spiritual Coping Strategies: a Review of the Nursing Research Literature Journal of Advanced Nursing 34(6):833-841
3. Post, S.G. et al (2000) Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics Annals of Internal Medicine 132(7):578-583

Dear Stephen and all medical students around the world,

I'm Wisnu Trianggono, medical student at University of Indonesia.

It's very nice to read Stephen's article. Thank you Stephen, for making us aware to this issue...

I am one of the follower of Hollistic-Approach Paradigm in Medicine. We as a medical student (and doctor-to-be), have to see and to treat patient as a whole person. Tension-headache patient comes to us not only with her/his head. Hypertension patient comes to us not only with her/his vessels or blood. They all come to us with all of their body and mind.

Dont we understand the concept of somatoform disorder, either in Internal Medicine or Psychiatrics? Yes. Body and mind are unseparatable parts. The body can influence mind, and also in contrary.

What will we sugest for therapy of people with hypertension? Of course, one of them is stress management. We know that stress is risk factor for hypertension.

Then what can we suggest for people with hypertension so that they can manage their stress better? May be psychothetapy. But, for the people who have religion or faith, I think it's better for us to sugest them to have also a religious therapy. So, it's only for the people with religion or faith.

Is that wrong for us to suggest our patients so that they practice their religion/faith much more better, even we are atheist doctors? I think, not.

We have to practice all of our best and all the way we have to solve our patients' health problem. All ways, including religious ways.

And as we know, WHO has agreed that the definition of HEALTH covers the aspect of bio-psycho-socio-spiritual. Here we know that spirituality is unseparatable and integrated aspect of health.

We all want our patients to be healthy, dont we? So, please dont forget this fourth aspect: SPIRITUALITY, even we are atheist...

It's patient's right...

Thank you.

I am writing in response to the views expressed by Stephen J. Goldie in his article, "Religion Must Not Influence Medical Practice," in the November issue of the student BMJ.

I found his statement " The same standard of medical care must be provided equally by all doctors and must be based on evidence and not on personal beliefs," particularly interesting. Whilst I wholeheartedly share his views about evidence-based medicine, I'm sure the readers will have appreciated the delicious irony of the statement, given that it written in the section, " Personal View."

However, leaving semantics aside, I find myself completely unable to support his position that personal belief should be removed from medicine. Our beliefs are an integral part of who we are. They affect all of our thoughts, words and actions even if we are not always consciously aware of them.

Medicine, I believe, is first and foremost about treating people, not conditions. At the heart of virtually all faiths is the question of what humanity is. If our beliefs tell us that there is no God and that we are the result of pure chance evolution then we will see humans in one way. If we believe that we the creative work of an all-powerful God who loves us then we will see humanity in quite another way. The values that we prescribe to humanity will certainly influence our treatment.

My point is that beliefs represent a part of who we are. If I did not have my faith in Jesus Christ I question whether I would still be doing medicine. It was my beliefs that led me to take up medicine and it does not seem to be appropriate to divorce them now I have embarked upon career.

Of course I do not believe that doctors should be discriminating about how they treat different groups of people, but if we remove belief from medicine, what basis do we have to make any ethical decisions at all?

Religion in medical practice

I was saddened to read Stephen Goldie's view on religion and medicine1 in a recent issue of studentBMJ. While I agree that all patients should be treated with equality, respect and non-judgemental care, belief in God and adherence to most religious traditions is not at odds with this. Indeed, the implication that religious beliefs lead to inequities in care is ill at ease with the teachings of most faiths. Earlier in the same issue, Tej Pal Singh relates a story that admirably reflects this2 and explains how, as a Sikh, he is called to approach everyone in need with equality. Fiona Pathiraja describes how Buddhist principles of tolerance and respect for others have taught her to avoid prejudging patients3 and to ensure that her own beliefs do not affect their welfare. Similarly, Christians will be familiar with the parable of the Good Samaritan.

But such religious teachings do not only encourage equality. The role of God in healing has ensured that caring for the sick is regarded as an important part of many faiths, and has led to the provision of healthcare to vast numbers of people the world over, particularly in inaccessible places and during conflict. For example, in Papua New Guinea, almost half of the government's national health plan is delivered by church-derived health services. In conflict, the most prominent medical/humanitarian organisation works under the symbols of two of the great religions, the cross and the crescent, and espouses the principles of universality, charity, fraternity, equality and non-discrimination. As Jacques Meurant reminds us4, the driving force behind what is now the International Red Cross/ Red Crescent was Christian charity. It therefore seems that contrary to Marx (and Goldie), faith in an omnipotent being provokes and maintains the human fight against the evils of poverty, oppression and disease.

Stephen Goldie also writes about death and his belief that the only scientific conclusion to life is that we rejoin the nitrogen cycle. While some people share this conviction, many more believe in life after death and everyone approaches the event from a unique perspective. As doctors, we are primarily concerned with the physical and mental needs of our patients, but must recognise that there is a spiritual dimension to many people that is as important to them as their physical health. We need to acknowledge that ideas, concerns and expectations are not restricted to the body or constrained by mortality, particularly at the end of life and that we are uniquely positioned to help our patients prepare for death, if they want us to. An easy solution is to say that this is the work of hospital chaplains, not doctors. But how will Stephen Goldie react when a frail old lady takes his hand and confides in him that she's afraid to meet her maker? What will he say when a terminal patient asks him to pray for them, or a grieving parent asks whether he believes in heaven? These events happen every day and are an inescapable part of medicine. Our responses matter. Our empathy, compassion, and shared faith can do immeasurably more good than cold hard science or medical interventions.

Finally, Hippocratic medicine is cited by Stephen Goldie as a triumph of science over religion, because Hippocrates believed that disease has only natural causes. However, recognising that diseases are subject to the laws of nature does not mean that nature and humanity are not subject to God, and the Hippocratic Oath reflects this. Those professing the Oath are bound to it by, "Apollo the physician, and Aesculapius and Health and All-heal, and all the gods and goddesses . . ."

So, religious teachings compel us to work to the best of our ability, to demonstrate equity in practice and to be tolerant of others. Religious ideals have resulted in healthcare provision to poor and inaccessible populations throughout the world and have produced a leading humanitarian organisation. Faith allows us to see our patients as more than flesh and bones and to consider their spiritual needs with compassion as they approach death. For all these reasons, I believe there is a very important place for religion in the practice of medicine.

Brian T. Wilson
postdoctoral clinical student,
University of Newcastle upon Tyne.

1. Goldie, SJ. Religion must not influence medical practice. studentBMJ 2003;11:435.
2. Singh, TP. Resisting Zulum. studentBMJ 2003;11:427.
3. Pathiraja, F. Following the middle path. studentBMJ 2003;11:428.
4. Meurant, J. The 125th. anniversary of the International Review of the Red Cross - a faithful record. International Review of the Red Cross 1995;307:447-468.

I must thank the writer for sparking such an interesting debate. Living in a multi-racial, multi-religious society has taught me the importance of accepting different practices and views. Instead of striving for conformity, we ought to appreciate the beauty of adversity. Only when we have learnt to accept other people whom are different from us, we can move forward together. It is this lack of maturity that has impeded the progress of humankind, not religion.

Whilst I would certainly not describe myself as 'religious', I was nonetheless irritated by Stephen Goldie's piece in the November edition of the Student BMJ (1).

I don't believe that many doctors or nurses hold religious beliefs which interfere with their medical practice - indeed, from what I understand, most major religions promote caring for others, regardless of their religious beliefs; in short, treating others as you yourself would wish to be treated. Perhaps Mr. Goldie disagrees with me, but is that not what we should all be striving for?

And Mr. Goldie's assertion that 'religions are no more than social clubs' is quite simply, wrong. He needs only to look at some of the articles which have been published in the student BMJ over the past few months, about medical students and their faiths, to see that religion can be central to an individual's life an influence it in a positive way.

Whilst I don't attempt to deny that there are doctors who may have to struggle with their conscience over issues such as abortion and euthanasia, this is not in itself a problem, as long as they are able to prevent their personal beliefs from adversely affecting their patients' treatment.

Perhaps I'm hopelessly naïve, but I would think all doctors are professional enough to do so.

Yours Faithfully,

Laura McBrearty

1. Goldie, SJ. Religion must not influence medical practice, Student BMJ; 11:435

I have read with great interest the responses to Stephen Goldie's article 'Religion must not influence medical practice'. While I fully agree that we must not treat patients differently because of their beliefs, I believe that faith has an important place in medicine. However, instead of echoing points which have already been well made by Jamie Robertson and Robin Edwards, I'd like to refer to the GMC's position on a related issue:

The GMC Annual Report (1993) states that 'the profession of personal opinions or faith is not of itself improper', and concludes that 'it would not be right to try to prevent doctors from expressing their personal religious, political or other views to patients'.

While these statements refer more to doctors sharing their beliefs with patients, they show that the GMC sees a place for religion within modern medicine.

Finally, I was interested by Goldie's reference to Hippocrates as a man who could 'separate medicine from religion'. The opening to his famous oath includes the statement 'I take to witness all the gods, goddesses, to keep according to my ability...'. These don't sound like the words of a man who did not have beliefs in any kind of God or gods.

Marx was a patronising sort, wasn't he? He wrote off an entire aspect of human experience just because he didn't understand it. Like all ideologues, Goldie falls into the same trap. But let's not get personal: let's keep it rational. Goldie obliquely invokes the use of evidence in assessing the relative merits of religion and Marxism. Here are two pieces of historical evidence he might like to consider:

1. Between 1900 and 1987, Marxist governments were responsible for the deaths of approximately 200 million people.
2. Whither Marxism now? We can hardly look to China and North Korea as shining lights "when it comes to looking after people."

Perhaps Goldie should heed his hero's maxim: "We know only a single science, the science of history". History has shown that any kind of illiberal dogma is dead meat, and, to mix my metaphors, that Marx has blood on his hands.

Dear Editor

My attention was drawn to an article in last month's issue entitled "Religion must not influence medical practice", as I strongly agree with this statement. The same standard of care must be given to all.

I was disappointed, however, to read a judging and narrow-minded personal view from someone hoping to become a member of the medical profession. Patient care, as the main priority of any doctor, is ultimately dependent upon respect for the opinions of all other human beings, whether they are patients or colleagues.

I am religious and would strive to never let any personal opinion compromise the care I give to a patient. However, acknowledging that professionalism is essential to the practise of medicine, I would emphasise that a lack of emotion and personal belief is not. If I felt personal feelings could compromise the care I gave a patient, I would refer him to someone who could more effectively deal with his concern.

Everyone has an opinion on something, religious or otherwise, and everyone has a right to their own opinion. Many conflicts are seen to be caused by religion, but are in fact due to a lack of acceptance of this concept. As future doctors, we should be the first to embrace the need for understanding and acceptance of individual opinions and beliefs.

Christine Kelly,

Members of dominant social groups often fail to wholly appreciate that they fall into such a category; rather the fact remains a peripheral assumption that is embedded in their subconscience. Subsequently, this leads to a lack of understanding of one's own social standing and of other's. This is the reason why people who are in a majority social class take the liberties and advantages that are available to them for granted as they are not subject to the other hardships and metaphorical 'stumbling blocks' that members of minority social groups are exposed to.

A failiure to realise these hardships that face others leads to a naievety amongst our society as they only view the world from their own perspective as there seldom comes an instance whereby they have to out of necessity contemplate the world views of members of different social classes. Since the majority of Doctors com e from the majority social group, patients who are from minority social groups often tend to feel that the Doctor lacks respect or awareness for their particular culture or way of life. This may not necessarily be the case, but it is what is manifested in the eyes of the patient and it occurs due to a lack of understanding of the various social gropus of society.

I agree with the author to some extent but he did not given enough evidence to support his title.

If we see the medical practice in India most of the corporate sector (private) hospitals were run by the non-doctors. They spend huge amount of money to establish the Hospitals and charge high amount of fee from the patients. But at the end the doctors are getting the blame of all these charges.

I agree that the medical profession is under siege these days but this is not only in India. Most of the developing countries face this problem. So it is not appropriate to use 'especially in India' by the author in his letter.

Involvement of the professional bodies may help to some extent about falling standards of care among the doctors. But I would say that the students whoever are more of medical service oriented should choose the medical profession rather than who want to make money from this profession. Then only the charm and respect to the doctors will continue.

Having known what each of these modalities of investigations are it is quite essential that a medical student knows what his/her role of getting the relevant investigation done namely CT/MRI/USG/CXR(Computed Tomography,Magnetic Resonance Imaging,Ultrasonography,Chest X ray)

In the first place one needs to know why the investigation has been requested.

If a request has been made its quite essential that the patient knows why it is being ordered and its limitations .

Do not be surprised to see some patients assume that a scan to could get rid of all problems

The nursing staff need to be clearly informed by when you expect the scan be taken.Any special needs of the patient need to be addressed in which case this would be told during the ward rounds and a request form available needs to be filled completely and legibly with patients name/hospital number and area and type of scan clearly mentioned.Once the films arrive its quite important to discuss with a senior colleague and be well conversant with some of the commonly observed clinicoradiological changes

All these might appear very simple but yes if these simple steps are omitted at any point it can result in a loss of the precious time required to take vital clinical decisions

To state that ultrasound, as a mode of investigation is devoid of any adverse effects will be little early. There is no evidence of any remarkable adverse health effects, does not mean there are no adverse effects. In many studies, in vivo and in vitro cell structure changes have been noted. The changes are more severe with high intensity ultrasound and with long duration of exposure to the tissues. These microscopic changes are in form of altered cell membrane behavior and non-inheritable changes in DNA.(1) Changes are affecting both the soft tissues and bones but bones can absorb more amount of rays and therefore bone heating is more compared to soft tissue heating. One curious, and the only finding that has been proven statistically significant till date(2) was noted in a Norwegian study, where male children exposed to ultrasound were less likely to be right handed (dominant left hand or no dominant hand).(3) This shows that ultrasound plays some role in cell migration during embryonic stage. This issue, since it came to limelight, is still debated on various occasions.(4) Other notable effects include extravasation of blood cells in lungs exposed to high intensity ultrasound, suspected causal association of ultrasound with low birth weight, delayed learning and dyslexia and childhood malignancies.

As a note of caution, medical students can remember two things: as a doctor in future, avoid prescribing ultrasound investigation 'just to have a look' and as the operator of the machine to reduce the exposure to patient to as low as possible, especially so when the patient is pregnant, and at the same time not compromising with the quality of the imaging.

References:

1. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging(4th Ed.) 2001 Churchill Livingstone, London
2. Epidemiology of diagnostic ultrasound during pregnancy - EFSUMB safety tutorial. EFSUMB Newsletter, 2002.16(1): 15-18
3. Salvesen KA et al. Routine ultrasonography in utero and subsequent handedness and neurological development. Br Med J, 1993. 307:159-164
4. Salvesen KÅ. Ultrasound and left-handedness: a sinister association? Ultrasound Obstet Gynecol, 2002 19: 3, 217-221

Well I am not surprised that this article is well written and very practically applicable to the present times.................

I am happy to state that I have actually gone through all those phases of learning how to be successful in acquiring a job all by my own experience and its quite true that all my successful applications were applicable in places where I was considered and all my unsuccesful applications were deemed to be so.

Retrospectively when I think back some of my job applications where I was appropriately unsuccesssful mean so much to me ..........because eventually where I was accepted the job seemed to suit me more as much as myself fitting into the job quite as much.

The bottom line being the Panel members interviewing the job applicants mostly give the job after carefully scrutinising the application and truly giving the job the candidate deserves.

I am happy to state that I thoroughly enjoyed all the jobs as much as the employees in all the jobs I have done so far.

Hughes and Evans' editorial addressed a very important area of healthcare for a group whose needs may often be neglected by the medical profession.

I feel the title's reference to 'women who have sex with women' is misleading. This is a useful term for sexual health issues, but it is not as relevant for other healthcare issues affecting lesbians and bisexual women where specific sexual behaviour is not a useful way of defining health risks. Sex is just one aspect of being a lesbian/bisexual woman. It is important to acknowledge that a woman who considers herself to be a lesbian or bisexual may have never had sex, may have only had sex with men, may have had sex with both men and women, or may have had sex with only women. Regardless of her sexual activity, she could be at risk of all of the physical, mental and social health issues identified in the editorial. Sexual identity cannot be defined by sexual practice alone, and assumptions should be avoided when dealing with patients.

The editorial focuses upon sexual health risks, but lacks practical advice to give women who have sex with women about safer sex to minimise these risks. Some simple advice includes:

• Avoiding the transfer of vaginal fluid from one woman to the other on fingers etc.
• Avoid sharing sex toys. If sharing, ensure toys are washed well between uses or covered with a condom which should be changed for each woman.
• To make oral sex safer, use a dental dam (available from many sexual health clinics or may be made from a cut-up condom or non-porous cling film) to cover the vulva.
• Using a lubricant on sex toys helps prevent soreness/friction.
• Be aware that if blood is involved through menstruation or trauma, there is a risk of HIV.

In Glasgow there is a lesbian-specific health clinic. In an audit of use, over half of attendances were for reproductive and gynaecological issues (Carr et al). In a study I conducted in Glasgow, 69% of lesbians and bisexual women either had children or hoped to have children in the future. Reproduction is therefore one of the most common lesbian-specific health concerns. There are three options available for conception: sex with a man, self-insemination and clinic insemination. There are also the further options of adoption and fostering, both of which are open to lesbians and bisexual women. Doctors should be aware of all the options available and be prepared to offer accurate advice and appropriate referrals.

Many lesbians are not 'out' to their healthcare providers. This is a problem as it may compromise care and lead to irrelevant focus on issues such as birth control and reproduction while neglecting more relevant issues. For instance, in one study, 16% of lesbians had been pressurised by their GP into accepting a form of birth control (Lehmann et al). Doctors should provide a non-judgemental atmosphere and avoid assumptions about heterosexuality or sexual activities in order to make their patients feel comfortable about disclosing the information which may be very relevant to their care and allow a holistic approach to healthcare.

References

• Lehmann JB, Lehmann CU, Kelly PJ.Development and health care needs of lesbians. J Womens Health. 1998 Apr;7(3):379-87
• Carr SV, Scoular A, Elliott L, Ilett R, Meager M. A community based lesbian sexual health service - clinically justified or politically correct?
  Br J Fam Plann. 1999 Oct;25(3):93-5

Whilst I agree with the idea of communicating risk by relation to everyday events[1]; I believe it is imperative that those risks be correctly identified. The authors suggest a table which includes several references to the UK National Lottery in its definitions of risk - but these have been incorrectly calculated by a previous paper[2] and not corrected since. A patient told a one-in-ten wound infection rate after general surgery is the same as "three balls on the national lottery" is being misled by a factor of six.

Here are the correct figures:

• 3 numbers - 1 in 57
• 4 numbers - 1 in 1032
• 5 numbers without bonus - 1 in 55491
• 5 numbers with bonus - 1 in 2330636
• 6 numbers - 1 in 13983816

1. Sedgwick P, Hall A. Teaching medical students and doctors how to communicate risk. studentBMJ 2003;11:396-7 (November)
2. Adams A, Smith A. Risk perception and communication: recent developments and implications for anaesthesia. Anaesthesia 2001;56:745-55

The informative article by Clare Hughes and Amy Evans, highlighted many of the problems surrounding the under-researched and ill-understood group of women who identify as lesbian and bisexual.

I recently carried out a research project which attempted to discover how to improve the sexual health service for lesbian and bisexual women. It involved 161 women who identified as lesbian or bisexual in Edinburgh and one of my findings was that women who were 'out' to their GP had, on average, visited their GP within the last 5 months as compared to an average of 13 months for women not 'out' to their GP. My study supported another recent Scotland based study showing that only around 60% were 'out' to their GP (Coia et al).

Another finding was that respondants were significantly more likely to contact an openly 'gay-friendly' GP, if they were very worried about their sexual health, than they would be to contact a GP who was not openly 'gay-friendly'.

There are increased risks of various problems, including sexual health problems but particularly mental health problems, for example Coia et al.'s 2002 study found that of lesbian and bisexual women in their research, 25 years and under, 43% had been diagnosed with depression and 32% had attempted suicide.¹ Since this is the case it is even more important that this group feel able to visit their GP and that the care he/she offers is appropriate to the individual. My research shows that this is not always the case.

Only 57% of the sample who were 'out' to their GP were happy that the current health service met their needs (as compared to 48% of the sample who were not 'out' to their GP) so improving the health service for this group is not just an issue of encouraging them to 'come out' to their health care provider although this is an essential first step.

What I found particularly worrying was the variability between sub-groups in the answers I received. It was striking that of the small group of women (n=35) who filled in questionnaires anonymously in bars on the day of the Pride Scotia march but did not actually attend the march (as the main sample of respondants had), fewer were 'out' to their GP, more smoked, fewer had had cervical smears or undergone breast screening and they were less likely to attend any health service when worried about their sexual health. Assuming that for at least some of the sample the reason for non-attendance at the march was fear of being 'outed', it illustrates that those who are not 'out' to many people could be overlooked by research (due to the difficulty in identifying them as research candidates when a lot of research involves members of gay groups or political organisations), may be benefiting even less from the health service than those who are involved in research, and may well make up the majority of lesbians and bisexual women.

"Something to tell you" - A Health Needs Assessment of Young Gay, Lesbian and Bisexual People in Glasgow. Summary report 2002; Nicky Coia, Sue John, Fiona Dobbie, Shona Bruce, Margaret McGranachan and Lucy Simons.

Here are some more tips in addition

Children find aprons a bit strange.....so its better to avoid long doctors' aprons with things like dangling stethoscopes etc. After a silent introduction its best to keep the conversation to a minimum low pitched and all the time observing the child and enticing him/her with whatever he/she delights on.

Even the slightest distraction of attention of either the caretaker/doctor towards the child might be inviting the child's cry ....

I agree with the article in that teaching medical students and doctors about how to communicate risk(1) is an important issue. It is important that doctors of all grades be aware of the risks and benefits to a patient of any proceedure they may undertake in order to make the best clinical descions and then in turn to be able to accurately and profficiently translate this information to their patients to ensure true informed consent is gained.

Alanna Pentlow,
Final year medical student, Newcastle University

1. Sedgwick P, Hall A.Teaching medical students and doctors how to communicate risk.Student BMJ 2003;11:396-7 (November)

Statistics obtained from the national lottery website, www.national-lottery.co.uk

My fears about many young medics (including me minus two crucial years) confusing atheism and agnosticism is proved true by this article.As an agnostic i do not believe in god. i also do not deny his existence, unlike an atheist.

I want rational medicos not to accept or refuse the being of supremacy. If we do that, there ends our search - life's vital dynamism. Do not take sides. Stand erect; do not lean; And think.Be agnostic till the truth is made known to you through YOUR quest. COGITO; ergo sum .

I read Keith Amarakone's article (Science without Religion, sBMJ, Nov 2003) with great interest. It was refreshing to read an article which presented an honest, rational approach to medicine without reference to an external God or Gods. Since joining medical school I have encountered a large number of students with various religious and cultural beliefs who, widely-speaking, approach medicine and patients with care and with thought. Equally, as Keith Amarakone suggests, it is possible to approach medicine (and life) as an atheist. I also share Keith Amarakone's liberal scientific upbringing and beliefs. However, I have decided that it possible to combine my scientific, rational approach with an 'unscientific' approach to life based on a personal polytheism that I have fashioned myself, largely for convenience. It could be said that one should not adopt a religion for the sake of 'convenience', but I hold an anthropological view of religions; they grow and recede as hum! an societies and cultures change. For example, I've never met anyone who believes in Thor very much, but I'm sure there used to be a lot of Vikings who thought he was 'the big man' and believed in him as firmly as anybody now believes in a Christian God, or Allah or any of the deities of the other world religions.

It seems to me that religions exist and are perpetuated because they satisfy important human social and psychological needs. They provide a framework for society and a moral or ethical code and they encourage goodwill to others, especially if they share the same faith. Beyond imposing order, religions are able to offer hope, provide answers and go some way towards explaining what is otherwise mysterious. I've also found that the Christian union sometimes have free lunches. These are all things that should be applauded. And with this in mind I have fashioned my own religion.

I have embraced a form of polytheism. This is a fantastic approach to life as it helps to explain all the problems of everyday life. For example, just this very morning I burned the toast. Clearly this was no random kitchen accident based on my flatmate changing the dial on the toaster. It is obvious to me that I have angered the Kitchen Gods and they have punished me. I acknowledge that I failed to refill the salt grinder and I have now paid a fair price. Similarly I have, in the past, angered the Engine God in my E reg VW polo, by not feeding His (or Her) thirst for what we call petrol. I see this now. It has also become clear to me that it is no mere 'coincidence' that alcohol can be consumed as a 'spirit'. My Saturday morning hangover is clearly the retribution of the beer Gods, sulky because I forced them to socialise in my belly with some snooty wine Gods and something grouchy that lives in whisky.

Setting aside these aspects of my religion for a moment, as I mentioned before, I firmly believe in Darwin. Belief in Darwin might seem antithetical to any form of religious belief. However, that is not the case. I believe that Darwin lived and that he probably died too, he wrote an important (if slightly dull) book and I like to think that he probably had quite a nice beard. And, as such, I insist that all my followers have beards and believe that, one day, a bear might turn into a whale.

To return to another question I raised earlier. Some of you may be wondering what ever happened to Thor and his big hammer? Where do old God's go, and who is looking after them? One of my good friend's sagely observed that 'Tesco is the new Church'. Now I don't claim to know which God's patronise Tesco and which one's use Sainsbury's. I'm a Tesco man myself and I'm not ashamed to say so. Anyway, I'm absolutely sure (like all good religions, I only deal in absolutes) where Thor might be. I believe that he is hiding out in the quieter isles of B&Q, getting a buzz off the Sunday shoppers and eyeing the power tools. Whenever I shop there, I say a quiet prayer for him.

I believe wholeheartedly in all that I have said and hope that some of you will join me in this polytheism. There is an explanation for anything and everything; all you need do is choose to believe. All that my religion requires for membership is a pledge of £10 to the charity of your choice (I like cats myself, but don't let that sway you) and a promise to be a good doctor. Send me the receipt and I might even send you a badge. May you all sprout fins, kind regards

Tom Winter

It is certainly possible, as Amarkone suggests, to be scientific without being religious. However, it seems to me that science does require an act of faith. We cannot prove that nature is not capricious - that the laws of physics are the same in all places and at all times - or even that the universe is knowable at its deepest level. Yet science cannot proceed without these assumptions The scientific enterprise, like religion, has its own articles of faith.

Dear editor

In my experience medical students do appreciate the importance of cultural and social awareness in medicine. Any complacency in their attitude, i feel, is due to the way in which the issues have been taught.

My education in dealing with cultural and social issues in medicine has come largely from real life experience in my clinical years and not from the lectures in my pre-clinical years- I simply can't remember them.

Surely rather than listing the issues facing an asian diabetic, one should talk to such a patient in clinic and grasp the issues that may arise.

I am not saying we shouldn't have formal ethical teaching- just not so much, keep it non-repetitive and relevant.

Better time management in this area will lead to more effective learning for students and will hopefully improve their attitude to ethics- we all love it really!