Journal of the Royal Society of Medicine Volume 83 June 1990
I would like to add to the responses to Roberts and Porter's paper (May 1989 JRSM, p 288). The main purpose of what is, admittedly, a brief interview (average 15 minutes) is to rejet candidates who would not fit into the individual medical school's ethos. A proportion of these applicants with high predicted 'A' level grades will be judged by theinterview panel as being unsuitable to undertake a medical course because their perception of doctoring or their motivation for studying medicine is poor. When the effects of the impending demographic time bomb are felt in the recruitment of young people to medicine, this feature of risk limitation by interview will surely become even more important. Sub-Dean, St Mary's Hopital S S TACHAKA Medical School, Horace Joules Hall, Central Middlesex Hospital, London NW10 7NS
Successful treatment of infertility using LIPSI with follicular puncture In their paper, Brincat et aL (June 1989 JRSM, p 370) describe their successful treatment of infertility using laparoscopic intraperitoneal sperm insemination (LIPSI) with follicular puncture as new method between DIPI and GiFT. We would like to take issue with the authors on the following points: (1) The stated advantage that follicular puncture takes place at the time of insemination. This, however, does not necessarily require laparoscopy. It is probably quicker to puncture the follicles under vaginal ultrasound guidance and certainly without the need for general anaesthetic. In addition, there is no explanation as to why follicular puncture took place 18 h and not 34 h after hCG injection almost certainly releasing immature oocytes. (2) Their stated present policy of puncturing follicles greater than 17 mm in diametr without retrieving the oocytes is dangerous. It will inevitably increase the risk of multiple pregnancies in view of the unlimited number of oocytes available for pick-up by the patent fallopian tube. This is neither medically desirable nor ethically acceptable. The ability to only puncture follicles .17 mm must also be at question. (3) The contention that increasing experience with the method might enable determination of the optimum size and number offollicles that should be punctured is not based on sound scientific' evidence. Multiple ovulations with or without development of ovarian hyperstimulation syndrome are real risks of ovarian stimulation protocols similar to the one used in this case. The implications of leaving excess oocytes in the pelvis are extremely dangerous and should be avoided at any cost. (4) This patient had AIH in addition to the LIPSI and it is possible that she could have conceived despite the later procedure. R W SHAW N AMso
Academic Department of Obstetrics & Gynaecology, The Royal Free Hospital, Pond Street, London NW3
Fragile X syndrome The discovery of the fragile site Xq27.3 and its association with the Martin Bell Syndrome is, arguably, one of the most important contributions to
our knowledge of psychobiology in recent years. In my opinion it thoroughly merits the prominence which it has been given through being the subject of an editorial in your journal (January 1990 JRSM, p 1). There remain, however, questions adumbrated by the authors but not directly answered. In the final paragraph, for instance, they stress the importance of antenatal diagnosis in affected families. However, the data which they present indicate that 20% of males and possibly 50% of females expressing the fragile site will not be mentally handicapped, and therefore will not have the Martin Bell Syndrome. Moreover, the authors review none of the treatments, whether biological or psychosocial, which may be of benefit to individuals with the Martin Bell Syndrome. Therefore, when the word 'effective' is used to describe antenatal diagnosis, it is entirely unclear what is meant. I should be most appreciative if the authors could clarify the ways in which antenatal diagnosi,s may be effective in the management of the Martin Bell Syndrome. Registrar in Mental Handicap, SIMON HALSAD St Lawrence's Hospital, Caterham, Surrey CR3 5YA
In response to Dr Halstead's comments on the editorial, we would just like to clarify that our point in stressing the value of antenatal diagnosis in affected families is to make experienced counselling available to such families at appropriate times so that enlightened decisions can be made by the family. H M GOODYEAR P M SONKSON
Queen Elizabeth Hospital for Children Hackney Road, London E2 8PS
Acceptability of day care surgery The interesting article by Senapati and Young raises a number of questions which the authors have not addresd (December 1989 JRSM, p 735). There are methodological problems in the survey which seem to make it unduly pesimisic. First, the investigation was carried out on inpatients. There is no ssessment of those with similar conditions on the waiting list. Thirteen patients lived too far from the hospital, so their inclusion in the 'unsuitables' is relative rather than absolute. In their discussion, the authors state that 'the disadvantages of day surgery are discomfort, inconvenience, anxiety and perhaps danger'. Discomfort should not be a problem if wounds are adequately infiltrated with bupivacaine, and patients given suitable oral analgesia subsequently. 'Inconvenience' covers a multitude of concepts. Is it inconvenient for a child to spend a night separated from its parents? What is incontrovertibly inconvenient is for an individual to linger unnecessarily on a waiting list. Anxiety, likewise, is dispelled by proper information, and is not alle'viated by longer stay. Danger occurs from inadequate performance of simple preoperative precautions. Have the authors screened their notes for pre-anaesthetic guideline information and tests? How many women of childbearing age had haemoglobin results available to the operating team, and how many of the patients over 65 had ECG traces before anaesthesia? These standards are regularly met in our recently opened unit where a single theatre serves adult general, gynaecological and urological surgery. In the first 6 months we achieved a rate of 2400 cases pa
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Journal of the Royal Society of Medicine Volume 83 June 1990
from our population (310 000). There were 30 admissions from the unit or within 24 h during that time, and no deaths. The exercise has also produced a 'self-clerking' outpatient pro forma which relieves the junior staff of much, and often all, drudgery. Its use has prevented 'same day' cancellation for medical reasons, and ensures accurate information and investigation of each patient before anaesthesia or sedation. In these circumstances, might it be possible that day-case anaesthesia is safer than traditional hospital care? Simpson1 calculates approximate savings of £0.5-1 million in each health district through the conversion of suitable activity to day care. Given that figure, it is hard to allow any district which fails to organize itself to hold up its head amongst its fellows. A W CLARK Consultant Surgeon 32 Westbourne Villas, Hove East Sussex BN3 4GF
Reference 1 Simpson JEP. In: Bradshw, Davenport, eds. Day care London: Edward Arnold, 1989
The author replies: We read with interest Mr Clark's comments on our paper. He is clearly an enthusiast for day-case surgery and this is probably to be welcomed. We have a daycase unit in this hospital substantially larger than that which Mr Clark describes in Brighton. It is fully and enthusiastically used and produces of course not overall financial savings for the hospital, but merely increased throughput of patients. Amidst a welter of well-meaning enthusiasm for day-case surgery we wished merely to look at the potential drawbacks for day-case surgery when seen from the patient's point of view. We hope Mr Clark has not forgotten that for all of us our primary intent should be to provide the care that is best for the patient. Day-care surgery may be cheaper, but it may be less satisfactory for the patient. That possibility needs continued exploration. The patients and their views should not be overlooked. A E YOUNG Director, Surgical Services St Thomas's Hospital, London SE1 7EH
The transsexual predicament Whilst the views and facts in my letter on the Ethics of Transsexuality (August 1989 JRSM, p 509) may appear a challenge to Snaith (February 1990 JRSM, p 125) I should be saddened if he regards these other than as complementary to his obviously dedicated work in this difficult field. Transsexualism is an affliction which appears inborn, remains throughout life and defies all 'cure', and I have always maintained that there is a proportion of applicants for gender change who are worthy of every assistance, having helped many on their way. These true transsexuals are rare, often asexual and, although popular, usually lonely sensitive souls, and it is these who primarily
deserve our pity and confidential time-consuming help. However, large numbers of homosexuals, anti-socials, exhibitionists and perverts have for some time been jumping onto the transsexual bandwagon, bringing the subject and the medical profession into disrepute. These are more aptly transhomo-sexuals, often having their partners at their side when having surgery, many afterwards becoming prostitutes. It is among this majority that the phases of homosexuality, transvestism, soul-searching and guilt do exist - and form part of the maturing transsexual process, catalysed by the administration of sex hormones. This could explain why, despite up to 100 cases a year receiving surgery at one London teaching hospital alone, waiting lists remain long. The five cases Snaith refers to hardly compare with the many analysed by myself', Benjamin2, Randell3, Green4'5 and Money4. Although commendably carefully selected, results are more heartening than wholly satisfactory. One year is also too soon for them to feel the full opprobrium of society, or to discover there is no escape from their true biological sex whenever their past, and present, become answerable medically, legally or socially. They remain mentally disturbed if only because they must believe their change is not the illusion it is. The fantasy world in which these sufferers live both before and after 'sexchange' surgery makes them unreal people in an unreal world. It is this predicament for which we have to have deep compassion. My book', its reviews6, and my contribution to a 'shock' television programme7 which first dared to discuss 'sex-change', show that I have always championed the transsexual cause within the bounds of respectability. Until transsexuals and the medical profession are seen to act more responsibly, however, the subject will remain the sick joke of soap operas and the media. Ultimately, it is up to those directly involved whether society condones or condemns. 59 Hill Brow GEORGINA SOMERSET (NEE TURTLE) Hove, East Susex BN3 6DD References 1 Turtle G. Over the sex border. London: Gollancz, 1963 2 Benjamin H. The transsexual phenomenon. New York: Julian Press, 1966 3 Randell J. Preoperative and postoperative status of male and female transsexuals. In: Green R, Money J, eds. Transsexualism and sex reassignment. Baltimore: Johns Hopkins Press, 1969 4 Green R, Money J, eds. Transsexualism, and sex reassignment. Baltimore: Johns Hopkins Press, 1969 5 Green R. Sexual identity conflict. London: Duckworth, 1974 6 Review. Transsexualism - finding a place. Medical News 26 July 1963:8. Swyer G. Change of sex. Nursing Mirror March 1964:187. Comfort A. Change that turns to despair. Sunday Telegraph 14 July 1963:16. Over the sex border, Lancet 1963:ii 7 Somerset G. Sex change. 'Horizon' BBC 2.17 November 1966
I would like to add to the responses to Roberts and Porter's paper (May 1989 JRSM, p 288). The main purpose of what is, admittedly, a brief interview (average 15 minutes) is to rejet candidates who would not fit into the individual medical school's ethos. A proportion of these applicants with high predicted 'A' level grades will be judged by theinterview panel as being unsuitable to undertake a medical course because their perception of doctoring or their motivation for studying medicine is poor. When the effects of the impending demographic time bomb are felt in the recruitment of young people to medicine, this feature of risk limitation by interview will surely become even more important. Sub-Dean, St Mary's Hopital S S TACHAKA Medical School, Horace Joules Hall, Central Middlesex Hospital, London NW10 7NS
Successful treatment of infertility using LIPSI with follicular puncture In their paper, Brincat et aL (June 1989 JRSM, p 370) describe their successful treatment of infertility using laparoscopic intraperitoneal sperm insemination (LIPSI) with follicular puncture as new method between DIPI and GiFT. We would like to take issue with the authors on the following points: (1) The stated advantage that follicular puncture takes place at the time of insemination. This, however, does not necessarily require laparoscopy. It is probably quicker to puncture the follicles under vaginal ultrasound guidance and certainly without the need for general anaesthetic. In addition, there is no explanation as to why follicular puncture took place 18 h and not 34 h after hCG injection almost certainly releasing immature oocytes. (2) Their stated present policy of puncturing follicles greater than 17 mm in diametr without retrieving the oocytes is dangerous. It will inevitably increase the risk of multiple pregnancies in view of the unlimited number of oocytes available for pick-up by the patent fallopian tube. This is neither medically desirable nor ethically acceptable. The ability to only puncture follicles .17 mm must also be at question. (3) The contention that increasing experience with the method might enable determination of the optimum size and number offollicles that should be punctured is not based on sound scientific' evidence. Multiple ovulations with or without development of ovarian hyperstimulation syndrome are real risks of ovarian stimulation protocols similar to the one used in this case. The implications of leaving excess oocytes in the pelvis are extremely dangerous and should be avoided at any cost. (4) This patient had AIH in addition to the LIPSI and it is possible that she could have conceived despite the later procedure. R W SHAW N AMso
Academic Department of Obstetrics & Gynaecology, The Royal Free Hospital, Pond Street, London NW3
Fragile X syndrome The discovery of the fragile site Xq27.3 and its association with the Martin Bell Syndrome is, arguably, one of the most important contributions to
our knowledge of psychobiology in recent years. In my opinion it thoroughly merits the prominence which it has been given through being the subject of an editorial in your journal (January 1990 JRSM, p 1). There remain, however, questions adumbrated by the authors but not directly answered. In the final paragraph, for instance, they stress the importance of antenatal diagnosis in affected families. However, the data which they present indicate that 20% of males and possibly 50% of females expressing the fragile site will not be mentally handicapped, and therefore will not have the Martin Bell Syndrome. Moreover, the authors review none of the treatments, whether biological or psychosocial, which may be of benefit to individuals with the Martin Bell Syndrome. Therefore, when the word 'effective' is used to describe antenatal diagnosis, it is entirely unclear what is meant. I should be most appreciative if the authors could clarify the ways in which antenatal diagnosi,s may be effective in the management of the Martin Bell Syndrome. Registrar in Mental Handicap, SIMON HALSAD St Lawrence's Hospital, Caterham, Surrey CR3 5YA
In response to Dr Halstead's comments on the editorial, we would just like to clarify that our point in stressing the value of antenatal diagnosis in affected families is to make experienced counselling available to such families at appropriate times so that enlightened decisions can be made by the family. H M GOODYEAR P M SONKSON
Queen Elizabeth Hospital for Children Hackney Road, London E2 8PS
Acceptability of day care surgery The interesting article by Senapati and Young raises a number of questions which the authors have not addresd (December 1989 JRSM, p 735). There are methodological problems in the survey which seem to make it unduly pesimisic. First, the investigation was carried out on inpatients. There is no ssessment of those with similar conditions on the waiting list. Thirteen patients lived too far from the hospital, so their inclusion in the 'unsuitables' is relative rather than absolute. In their discussion, the authors state that 'the disadvantages of day surgery are discomfort, inconvenience, anxiety and perhaps danger'. Discomfort should not be a problem if wounds are adequately infiltrated with bupivacaine, and patients given suitable oral analgesia subsequently. 'Inconvenience' covers a multitude of concepts. Is it inconvenient for a child to spend a night separated from its parents? What is incontrovertibly inconvenient is for an individual to linger unnecessarily on a waiting list. Anxiety, likewise, is dispelled by proper information, and is not alle'viated by longer stay. Danger occurs from inadequate performance of simple preoperative precautions. Have the authors screened their notes for pre-anaesthetic guideline information and tests? How many women of childbearing age had haemoglobin results available to the operating team, and how many of the patients over 65 had ECG traces before anaesthesia? These standards are regularly met in our recently opened unit where a single theatre serves adult general, gynaecological and urological surgery. In the first 6 months we achieved a rate of 2400 cases pa
415
416
Journal of the Royal Society of Medicine Volume 83 June 1990
from our population (310 000). There were 30 admissions from the unit or within 24 h during that time, and no deaths. The exercise has also produced a 'self-clerking' outpatient pro forma which relieves the junior staff of much, and often all, drudgery. Its use has prevented 'same day' cancellation for medical reasons, and ensures accurate information and investigation of each patient before anaesthesia or sedation. In these circumstances, might it be possible that day-case anaesthesia is safer than traditional hospital care? Simpson1 calculates approximate savings of £0.5-1 million in each health district through the conversion of suitable activity to day care. Given that figure, it is hard to allow any district which fails to organize itself to hold up its head amongst its fellows. A W CLARK Consultant Surgeon 32 Westbourne Villas, Hove East Sussex BN3 4GF
Reference 1 Simpson JEP. In: Bradshw, Davenport, eds. Day care London: Edward Arnold, 1989
The author replies: We read with interest Mr Clark's comments on our paper. He is clearly an enthusiast for day-case surgery and this is probably to be welcomed. We have a daycase unit in this hospital substantially larger than that which Mr Clark describes in Brighton. It is fully and enthusiastically used and produces of course not overall financial savings for the hospital, but merely increased throughput of patients. Amidst a welter of well-meaning enthusiasm for day-case surgery we wished merely to look at the potential drawbacks for day-case surgery when seen from the patient's point of view. We hope Mr Clark has not forgotten that for all of us our primary intent should be to provide the care that is best for the patient. Day-care surgery may be cheaper, but it may be less satisfactory for the patient. That possibility needs continued exploration. The patients and their views should not be overlooked. A E YOUNG Director, Surgical Services St Thomas's Hospital, London SE1 7EH
The transsexual predicament Whilst the views and facts in my letter on the Ethics of Transsexuality (August 1989 JRSM, p 509) may appear a challenge to Snaith (February 1990 JRSM, p 125) I should be saddened if he regards these other than as complementary to his obviously dedicated work in this difficult field. Transsexualism is an affliction which appears inborn, remains throughout life and defies all 'cure', and I have always maintained that there is a proportion of applicants for gender change who are worthy of every assistance, having helped many on their way. These true transsexuals are rare, often asexual and, although popular, usually lonely sensitive souls, and it is these who primarily
deserve our pity and confidential time-consuming help. However, large numbers of homosexuals, anti-socials, exhibitionists and perverts have for some time been jumping onto the transsexual bandwagon, bringing the subject and the medical profession into disrepute. These are more aptly transhomo-sexuals, often having their partners at their side when having surgery, many afterwards becoming prostitutes. It is among this majority that the phases of homosexuality, transvestism, soul-searching and guilt do exist - and form part of the maturing transsexual process, catalysed by the administration of sex hormones. This could explain why, despite up to 100 cases a year receiving surgery at one London teaching hospital alone, waiting lists remain long. The five cases Snaith refers to hardly compare with the many analysed by myself', Benjamin2, Randell3, Green4'5 and Money4. Although commendably carefully selected, results are more heartening than wholly satisfactory. One year is also too soon for them to feel the full opprobrium of society, or to discover there is no escape from their true biological sex whenever their past, and present, become answerable medically, legally or socially. They remain mentally disturbed if only because they must believe their change is not the illusion it is. The fantasy world in which these sufferers live both before and after 'sexchange' surgery makes them unreal people in an unreal world. It is this predicament for which we have to have deep compassion. My book', its reviews6, and my contribution to a 'shock' television programme7 which first dared to discuss 'sex-change', show that I have always championed the transsexual cause within the bounds of respectability. Until transsexuals and the medical profession are seen to act more responsibly, however, the subject will remain the sick joke of soap operas and the media. Ultimately, it is up to those directly involved whether society condones or condemns. 59 Hill Brow GEORGINA SOMERSET (NEE TURTLE) Hove, East Susex BN3 6DD References 1 Turtle G. Over the sex border. London: Gollancz, 1963 2 Benjamin H. The transsexual phenomenon. New York: Julian Press, 1966 3 Randell J. Preoperative and postoperative status of male and female transsexuals. In: Green R, Money J, eds. Transsexualism and sex reassignment. Baltimore: Johns Hopkins Press, 1969 4 Green R, Money J, eds. Transsexualism, and sex reassignment. Baltimore: Johns Hopkins Press, 1969 5 Green R. Sexual identity conflict. London: Duckworth, 1974 6 Review. Transsexualism - finding a place. Medical News 26 July 1963:8. Swyer G. Change of sex. Nursing Mirror March 1964:187. Comfort A. Change that turns to despair. Sunday Telegraph 14 July 1963:16. Over the sex border, Lancet 1963:ii 7 Somerset G. Sex change. 'Horizon' BBC 2.17 November 1966
