ception are high among adolescents but that they lack the sense to assess personal risk.8`' These studies suggest that cognitive development plays an important part in adolescents' sexual behaviour. Hein mentioned four features of adolescent sexual behaviour: feelings of invulnerability, concrete versus abstract thinking, peer conformity, and denial." Adventure and gratification (short term and immediate) could also be included in this list. We need to teach adolescents skills and values in making decisions about their sexuality, including delayimg sexual intercourse. These interpersonal behavioural skills are more likely to be acquired in a supportive social and economical environment and a society that is comfortable when talking about both the positive and negative consequences of sexual relationships. JAYSHREE PILLAYE
Public Health Division, Health Education Authority, London WCiH 9TX I Smith R. Promoting sexual health. BAMJ 1992;305:70-1. (11
July.) 2 Secretary of State for Health. The health of the nation: a strategy for health in England. London: HMSO, 1992. (Cm 1986.) 3 Office of Population Censuses and Surveys. 1985 Birth statistics. London: HMSO, 1986. (Series FMI No 12.) 4 Office of Population Censuses and Surveys. 1990 Birth statistics. London: HMSO, 1992. (Series FMl No 19.) 5 Catchpole MA. Sexually transmitted diseases in England and Wales: 1981-1990. CDR Revzev 1992;No 1. 6 Cancer Research Campaign. Cancer of the cervix uteri. London: CRC, 1990. (Factsheet 12.2.) 7 Health Education Authority. Young adults' health and lii]estvle: sexual behaviour. London: Health Education Authority, 1990. 8 Balassone ML. Risk of contraceptive discontinuation among adolescents.J7 Adol Health Care 1989;1O:527-33. 9 Rickert VI, Jay MS, Gottlieb A, Bridges C. Adolescents and AIDS. Females' attitudes and behaviours toward condom
purchase and use.J Adolesc Health Care 1989;10:313-6. 10 Durant RH, Sanders JM. Sexual behaviour and contraceptive risk taking among sexually active adolescent females. j Adolesc Health Care 1989;10: 1-9. 11 Hein K. AIDS in adolescence. _7 Adolesc Health Care 1989;10:
10-35S.
EDITOR, -In his editorial Richard Smith writes of a meeting of social engineers of indeterminate status at Leeds Castle.' This faceless group's purpose is to change people's attitudes in some unspecified way that is supposed to promote sexual health-a term used without definition. The intended propaganda offensive seems to be but an intensified and more explicit version of the sort of thing in place now, replete with a jauntier but equally meretricious alternative slogan to "safe sex." The wish is to encourage "a more erotic, positive, and diverse kind of sexual behaviour" as a contribution to the struggle against HIV. In the front line as a general practitioner and a parent, I thought this approach wrong 30 years ago and feel sufficiently vindicated to prophesy that it will continue to be counterproductive: it has been accompanied by increasing promiscuity, abortions, venereal disease, and broken marriages. Ominously, Smith says that those at this meeting not only condemned opposition to their views from moralists but, with breathtaking hubris, determined that it was their "duty not to bend to these people." No doubt there are those in the group who have the power to manipulate opinion in the media, including the BM7, to suppress argument uncongenial to "amoralists" or "immoralists" (whatever the suitable word is for the opposite of people labelled moralist). I would hope that professional integrity would induce them to turn from such wickedness, but I am not the least bit confident of this now that they have proclaimed a higher duty. JOHN FINDLATER
Camforth, Lancashire LA5 OTT 1 Smith R. Promoting sexual health. BMJ 1992;305:70-1. (11 July.)
BMJ
VOLUME 305
8 AUGUST 1992
EDITOR,-In discussing the best way to tackle HIV infection Richard Smith mentions that people should be able to exercise choice in sexual relationships.' To make an informed choice, however, people need to know certain facts about use of condoms. A discussion of attempts at developing a condom made of plastic stated, "While a more expensive material than latex, plastic is more uniform with fewer pinholes or variations in thickness."2 In the same issue ofPopulation Reports a recent analysis for the World Health Organisation of data from nine published studies was quoted. It found that people using condoms faced a risk about two thirds that of non-users of developing gonorrhoea, trichomoniasis, or chlamydia infection; when data on transmission of HIV from 10 studies were combined the analysis found a relative risk of 0 4 for people using condoms (M Rosenberg et al, strategies for viricide research meeting, World Health Organisation, March 1990). A survey of people experienced in using condoms from a family planning clinic in Manchester reported that "52% of respondents had experienced condoms bursting or slipping off in the previous 3 months."3 The authors went on, "We were surprised to find how commonly our clients had experienced 'accidents,' even those who had apparently relied on condoms as their method of choice for contraception." The senior author of the above report also criticised the statement that "Most condom failure is due to incorrect usage" and added "We do the public no favours by promoting the idea among medical staff that it is all the fault of the user when things go wrong. "4 JOHN KELLY
within teenage relationships without the medical profession stoking the fire. A R MELLANBY F A PHELPS J H TRIPP
Department of Child Health, Postgraduate Medical School, Exeter EX2 5SQ I Smith R. Promoting sexual health. BMJ 1992;305:70-1. (I I July.) 2 Curtis H, Lawrence C, Tripp J. Teenage sexuality: implications for controlling AIDS. Arch Dis Child 1989;64:1240-5. 3 Ford N. The sexual and contraceptive lifestyles of young people: part 1. British Journal of Family Planning 1992;18:52-5. 4 Hall C. Nearly half of young people lose virginity before 16. Independent 1992 July 21:2. 5 Baric L. Social expectations vs personal preferences-two ways of influencing health behaviour. Journal of the Institute Of Health Education 1977;15:23-8. 6 Rundall TG, Bruvold WH. A meta-analIsis of school-based smoking and alcohol use prevention programs. Health Education Quarterls 1988;15:317-34.
EDITOR,-Richard Smith highlights the problems encountered at a recent conference at Leeds Castle in finding a way of changing sexual behaviour to reduce the chances of HIV infection and unwanted teenage pregnancy.' The present emphasis is on the need to find a clear and readily understandable message. Given the gravity of the risks, would it be wrong to suggest that this should be "No sex outside marriage"? Such an approach might ease the burden on some teenagers, who may perceive themselves to be under pressure from their peers and the establishment to embark on sexual activities for which they are not really ready. J W MYLES
Birmingham B15 21'H
Peterborough PE3 9PG
I Smith R. Promoting sexual health. BM.J 1992;305:70-1. (I I July.)
1 Smith R. Promoting sexual health. BMJ 1992;305:70-1. (11 July.)
2 New condoms in thc 1990s. Popul Rep[H] 1990;8:28-31. 3 Kirkman RJE, Morris J, W'ebb AMC. User experience: MN1ates' v Nuforms'. Brntish Journal of Familsv Planning 1990;15: 107-11. 4 Kirkman RJE. Condom use and failure. Lancet 1990;336:1009.
EDITOR,-Richard Smith's editorial on promoting sexual health addresses an important and sensitive public health issue.' His statement that "Roughly half of 16 year olds in Britain have had sexual intercourse" requires close examination, particularly because his article, rather than original data, is liable to be used by the mass media. National statistics are not available, but recent surveys have shown that most teenagers are not sexually active before their 16th birthday.2' Although half of teenagers are probably not virgins by their 17th birthday, so that Smith's statement is technically correct, we believe that his statement may mislead and be interpreted, particularly by the media, as suggesting that the rate of sexual activity is higher than it actually is for teenagers below the age of consent. For example, a recent headline in the Independent read "Nearly half of young people lose virginity before 16,"4 even though the original article quoted did not give this information.' An analysis of the given data (presuming that the age cohorts are equal) suggests a figure of roughly 34% -that is, a third rather than half, which is entirely consistent with other data.2 Society's view of what is normal has an important influence on individual behaviour.' "Everyone's doing it" is a common myth among teenagers. Those attempting to reduce risk taking by teenagers in other aspects of their lives have found it useful to expose similar myths.6 If teenagers are led, by both the medical and the general press, to believe that most of their peers are sexually active this will increase pressure on them in their relationships still further. Those under 16 who are virgins may be labelled as a minority group, with an implication of abnormality. Should we perhaps be more circumspect in our reporting of such figures? There is enough heat
EDITOR,-We endorse Richard Smith's view that the struggle against HIV needs reinvigorating and agree that the clarity of messages regarding health is important.' We are concerned that messages from some professional bodies are not only unclear but also damaging. For example, a statement from the Royal College of Surgeons of England earlier this year includes the recommendation: "If a patient is in a high risk category, he or she should be offered an HIV test, provided that facilities for counselling are available both before and after the test."2 This is with a view to an operating surgeon deciding what extra precautions should be taken to minimise transmission of HIV during treatment or surgery. No guidance is given regarding who should be included in such a category (it does not include known or suspected cases of HIV infection, for which there is a separate recommendation). Any assessment of high risk would require a detailed history, not just about injecting drug use and homosexual practice but also about heterosexual activity since the proportion of adults with AIDS reported to be heterosexual is 20%.' We doubt whether such a history is part of the routine preoperative assessment undertaken by surgeons. In our view, the term "high risk category" is inappropriate and stigmatising and, in the context of control of infection, leads to false reassurance with regard to patients who are not perceived as being at high risk. Indeed, the recommendation is contrary to that given by the World Health Organisation, which advocates universal precautions regarding blood and body fluid (that is, that all blood and certain body fluids are assumed to be infectious for hepatitis B virus and HIV and other bloodborne pathogens) as the cornerstone of preventing transmission of bloodborne infections.4 Terminology and messages are important: the continued use of the term high risk category suggests that there is still a widely held belief that HIV infection occurs only in specific well defined 363
groups of people who are somehow recognisable. Is it any wonder that, as Smith asserts, "heterosexuals have simply not adopted safe sex in large enough numbers to prevent HIV spreading through the heterosexual population"? CATHERINE QIJIGLEY
Department of Public Health MNtedicine, Trafford Health Authority, Urmston, Manchester MN31 3FP PAUL GARVEY
Department of Genitourinary Medicitte, T'rafford Health Authority I Smith R. IPromoting scxtual hcalth. BMt7 1992;305:70-1. (11 Jul.) 2 Royal College of Surgeons of England. .4 statement by the colle,geo n AIDS and HIT infectiotn. Iondon: RCS, 1992. 3 AIDS and HIVA- infection in the United Kitsgdom: mottthly report. Commutticable D)isease Retport 1992;2:115-6. 4 World Health Organisation. (ilobal programme on AII)S. HIN and HBV transmission in the health care setting. WMkl EpidemiolRec 1991;66:189-91.
EDITOR,-TO me the most important point in Richard Smith's editorial on promoting sexual health is that we are going to have to change a great many of the attitudes of people in Britain before we can possibly change their health habits.' So many are mealy mouthed when it comes to anything with a sexual content and squirm with horror at direct, honest language. As Smith says, "Use a condom" is a clear and simple message, but for far too many Britons it is made complicated by being put into words at all. Too many people in Britain believe that talking about sex is acceptable only if it's in the "dirty joke" mode, never if it's simple and direct. I should know. I have been bombarded with complaints from women who think it is disgusting that I mention on television the fact that women menstruate and have to use sanitary towels. The commonest reason for complaint has been that the advertisements in which I appear have been screened at times when children were watching. "And how can I possibly talk about such things to my children? I shouldn't have to listen to even the mention of periods in front of my teenagers." We're going to need all the help we can get in promoting honest talk about shared sexual experiences. Once we get that maybe we will be able to promote sexual health. CLAIRE RAYNER
Harrow on the Hill, Middlesex HAI 3BU I Smith R. Promoting sexuLal hcalth. BMJ 1992;305:70-1. I I July.)
Heterosexual transmission of HIV
and the Communicable Diseases (Scotland) Unit were classified, based on the information in the reports, into transmission within long term sexual partnerships (marriage, cohabitation, and relationships of six months or more) or short term partnerships (lasting less than six months). Cases were also classified according to characteristics of the partner into first generation (partner infected through injecting drugs, receiving contaminated blood, or homosexual intercourse) and second generation (partner infected heterosexually). Where the type of partnership was known, 18 of the 21 first generation cases (86%) and 13 of the 31 second generation cases (42'S() were presumed to have arisen in long term partnerships. There was a pronounced difference between the sexes, with 73% of the men having been infected in short term partnerships and 83% of the women in long term
partnerships (table). Heterosexual transmission of HIl' in United Kingdom: analysis of reported cases of AIDS by duration of partnership to December 1991 First generation transmission
Typc of partniership
Male
Female
Long tcrm Short term Not known
4 1 1
14 2 4
2 15 16
11 3 3
Total
6
20
33
17
This information was not collected in a systematic way, and its completeness may be biased. Because of the long incubation period cases of AIDS may not reflect the present pattern of transmission. Data on AIDS, however, are not subject to ascertainment bias as most patients will seek medical care, in contrast to patients with HIV infection. Further information is needed on the type and duration of partnership in which recent infections occurred and, for those infected by partners in a high risk group, whether they were aware of their partners' risk factors at the time of the partnership but still had unprotected sex or whether they were not aware. From the data available on cases of AIDS, however, heterosexual transmission of HIV in long term sexual relationships should not be ignored. L. C RODRIGUES London School of Hygiene and Fropical MNecdicinc, London VIC E 7HTI B EVANS KHOLOUD PETER Public Health Laboratorv Service AIDS Cenitre, Communicable lDisease Surveillance Ccntre, London NW9 5EQ 1 Smith R. P'romoting sexual hcalth. (11
EDITOR,-Richard Smith's editorial addresses the promotion of sexual health.' In Britain most mass health education regarding heterosexual transmission of HIV- 1 infection has presented sex with casual partners as the main risk. But if most heterosexual intercourse involving infected people took place in stable relationships long term partners would be the most at risk from unprotected sex.- In Sweden 53 heterosexual partners of people with HIV infection were infected: 32 by steady partners and 21 by casual partners.' In the United States, having a partner who used drugs, but not the number of partners, carried a significant risk of HIV infection.4 Of 35 women who acquired HIV heterosexually in Copenhagen, 10 were infected by a cohabiting partner; only one of the 25 women with partners in a high risk group was aware of the partner's risk activities when the relationship started.' All cases of AIDS resulting from heterosexual transmission within the United Kingdom reported to the Communicable Disease Surveillance Centre
364
Male Female
Second generation transmission
Julyt.)
be sent to general practitioners.' The society's reason was that the specific importance for general practitioners was not evident. Wilbers and colleagues quote a previous finding that six out of 29 responding general practitioners (from 75 contacted) had had erotic physical contact with a patient. Kardener et al's American study,' referred to in Thomas Fahy and Nigel Fisher's editorial,3 showed that half of 100 respondents thought it might be therapeutically beneficial to indulge in "non-erotic hugging, kissing and affectionate hugging" while a quarter thought that erotic contact may at some time be beneficial. Only 3%, however, admitted to having engaged in erotic practices.2 The media have given a lot of attention recently to claims about doctors making advances towards patients, and many doctors have experienced the reverse. General practitioners are particularly at risk because of more frequent contact and longer acquaintance with patients, the congeniality of surgeries and intimacy of home visits, and the greater likelihood of contact outside the professional relationship. Though a few doctors may enjoy erotic involvement with patients, many fear it. This may lead them to avoid taking any interest in a patient's sexuality, to the potential detriment of the patient's health. Sexual dysfunction is common, and many would seek help for it if encouraged to do so by their physician.4 The family doctor may be the professional of choice.' He or she needs to be comfortable with the subject. Nearly four fifths of gynaecologists in Wilbers and colleagues' study thought that more attention should be paid to sexuality during training.' Brief intensive exposure to sexual issues at undergraduate level has been shown to alter attitudes to sexuality favourably and encourage greater awareness.' Problems of sexual dysfunction can often be helped without a great deal of extra training and should be addressed by all practitioners during undergraduate and postgraduate training. M P MYRES
OsCrton on lDee, Wrcxham, Clwvd LL13 O)D
2
3 4
5 6
Wilbcrs D, Veenstra G, van dc Wiel HBAM, WeiImar Schulz WCM. Sexual conitact in the doctor-patient relationship in the Netherlanids. BMJ 1992;304:1531-4. (13 June.) Kardetter SH, Fuller M, Mensh IN. A survey of physicians' attitudes and practices regarding erotic and non-erotic contact with patients. Amj Psychilatr 1973;130:1077-81. Fahy f, Fisher N. Scxual cotttact between doctors and patients. BJIJ 1992;304:1519-2(0. (13 June.) Schein MNI, Zyganski SJ, Levine S, Medalie JH, Dickman RL, Alemagno SA. The frequency of sexual problems among family practice patients. Fam Pruct Resj 1988;7:122-34. Hanscn JP, Bobula J, Meyer D, Kushner K, Pridham K. TIreat or refer: patients' interest in "family physician" involvement in their psychosocial problems. ] Fam Pract 1987;24:499-503. Stanley E. An introduction to sexuality in the medical ctrriculum. led Educ 1978;12:441-5.
Bitt7 1992;305:70-1.
2 Rodrigues LC, (Garcia MN1orenio C. HI'V transmission to womcn in stable relationiships .N Fnggl Mcd 1991;325:966. 3 Gisecke J, Ramstedt K, Granath F, Ripaa 1, Rado Gi, Westrell M. Efficacy of partner notification for HIV infection. I.aticet 1991 ;338: 1096-100. 4 Marmor M, Krasinski K, Sanchez 1, Cohen H, Dubin N, W'eiss L, et al. Sex, drugs atsd HI' infection in a Ncw York city hospital otttpaticnt population. journal of the Acquired Immune
Deficiencv Ssndrome. 1990;3:307-17.
Mlathiesen LR. Heteroscxttally acqtlired human immtunodeficiencv virus infection in wtomcn in Copenhagen: sexual behaviour and other risk factors. Interttational journal of Sexuallv Transmitted Diseases andAII)S 1990;1:416-21.
5 Smith E, Kroon S, (ierstoft INIJ, Kvinesdal B,
Sexual contact in the doctorpatient relationship EDITOR,-I was interested to read in D Wilbers and colleagues' report of their study of sexual contact between doctors and patients that the Dutch National Society for General Practitioners had withheld its approval for the questionnaire to
Site of injection for vaccination EDITOR, -I agree with Mark Henley that BCG vaccination above the deltoid insertion should be avoided.' He is, however, incorrect in stating that the only vaccination for which a specific site on the upper arm is recommended is rabies. It is also recommended for hepatitis B vaccine. Both the Joint Committee on Vaccination and Immunisation in the United Kingdom and the Immunisation Practices Advisory Committee in the United States recommend that, although the anterolateral thigh is the preferred site for infants, hepatitis B vaccine should be given into the deltoid muscle in adults.2' In particular, the buttock must not be used: it is associated with a suboptimal response, probably because of injection into subcutaneous fat rather than into muscle.4 Injection into the thigh might prove unsatisfactory for the same reason, especially in overweight adults. Vaccination of health care workers against
BMJ
VOLUME 305
8 AUGUST 1992
Public Health Division, Health Education Authority, London WCiH 9TX I Smith R. Promoting sexual health. BAMJ 1992;305:70-1. (11
July.) 2 Secretary of State for Health. The health of the nation: a strategy for health in England. London: HMSO, 1992. (Cm 1986.) 3 Office of Population Censuses and Surveys. 1985 Birth statistics. London: HMSO, 1986. (Series FMI No 12.) 4 Office of Population Censuses and Surveys. 1990 Birth statistics. London: HMSO, 1992. (Series FMl No 19.) 5 Catchpole MA. Sexually transmitted diseases in England and Wales: 1981-1990. CDR Revzev 1992;No 1. 6 Cancer Research Campaign. Cancer of the cervix uteri. London: CRC, 1990. (Factsheet 12.2.) 7 Health Education Authority. Young adults' health and lii]estvle: sexual behaviour. London: Health Education Authority, 1990. 8 Balassone ML. Risk of contraceptive discontinuation among adolescents.J7 Adol Health Care 1989;1O:527-33. 9 Rickert VI, Jay MS, Gottlieb A, Bridges C. Adolescents and AIDS. Females' attitudes and behaviours toward condom
purchase and use.J Adolesc Health Care 1989;10:313-6. 10 Durant RH, Sanders JM. Sexual behaviour and contraceptive risk taking among sexually active adolescent females. j Adolesc Health Care 1989;10: 1-9. 11 Hein K. AIDS in adolescence. _7 Adolesc Health Care 1989;10:
10-35S.
EDITOR, -In his editorial Richard Smith writes of a meeting of social engineers of indeterminate status at Leeds Castle.' This faceless group's purpose is to change people's attitudes in some unspecified way that is supposed to promote sexual health-a term used without definition. The intended propaganda offensive seems to be but an intensified and more explicit version of the sort of thing in place now, replete with a jauntier but equally meretricious alternative slogan to "safe sex." The wish is to encourage "a more erotic, positive, and diverse kind of sexual behaviour" as a contribution to the struggle against HIV. In the front line as a general practitioner and a parent, I thought this approach wrong 30 years ago and feel sufficiently vindicated to prophesy that it will continue to be counterproductive: it has been accompanied by increasing promiscuity, abortions, venereal disease, and broken marriages. Ominously, Smith says that those at this meeting not only condemned opposition to their views from moralists but, with breathtaking hubris, determined that it was their "duty not to bend to these people." No doubt there are those in the group who have the power to manipulate opinion in the media, including the BM7, to suppress argument uncongenial to "amoralists" or "immoralists" (whatever the suitable word is for the opposite of people labelled moralist). I would hope that professional integrity would induce them to turn from such wickedness, but I am not the least bit confident of this now that they have proclaimed a higher duty. JOHN FINDLATER
Camforth, Lancashire LA5 OTT 1 Smith R. Promoting sexual health. BMJ 1992;305:70-1. (11 July.)
BMJ
VOLUME 305
8 AUGUST 1992
EDITOR,-In discussing the best way to tackle HIV infection Richard Smith mentions that people should be able to exercise choice in sexual relationships.' To make an informed choice, however, people need to know certain facts about use of condoms. A discussion of attempts at developing a condom made of plastic stated, "While a more expensive material than latex, plastic is more uniform with fewer pinholes or variations in thickness."2 In the same issue ofPopulation Reports a recent analysis for the World Health Organisation of data from nine published studies was quoted. It found that people using condoms faced a risk about two thirds that of non-users of developing gonorrhoea, trichomoniasis, or chlamydia infection; when data on transmission of HIV from 10 studies were combined the analysis found a relative risk of 0 4 for people using condoms (M Rosenberg et al, strategies for viricide research meeting, World Health Organisation, March 1990). A survey of people experienced in using condoms from a family planning clinic in Manchester reported that "52% of respondents had experienced condoms bursting or slipping off in the previous 3 months."3 The authors went on, "We were surprised to find how commonly our clients had experienced 'accidents,' even those who had apparently relied on condoms as their method of choice for contraception." The senior author of the above report also criticised the statement that "Most condom failure is due to incorrect usage" and added "We do the public no favours by promoting the idea among medical staff that it is all the fault of the user when things go wrong. "4 JOHN KELLY
within teenage relationships without the medical profession stoking the fire. A R MELLANBY F A PHELPS J H TRIPP
Department of Child Health, Postgraduate Medical School, Exeter EX2 5SQ I Smith R. Promoting sexual health. BMJ 1992;305:70-1. (I I July.) 2 Curtis H, Lawrence C, Tripp J. Teenage sexuality: implications for controlling AIDS. Arch Dis Child 1989;64:1240-5. 3 Ford N. The sexual and contraceptive lifestyles of young people: part 1. British Journal of Family Planning 1992;18:52-5. 4 Hall C. Nearly half of young people lose virginity before 16. Independent 1992 July 21:2. 5 Baric L. Social expectations vs personal preferences-two ways of influencing health behaviour. Journal of the Institute Of Health Education 1977;15:23-8. 6 Rundall TG, Bruvold WH. A meta-analIsis of school-based smoking and alcohol use prevention programs. Health Education Quarterls 1988;15:317-34.
EDITOR,-Richard Smith highlights the problems encountered at a recent conference at Leeds Castle in finding a way of changing sexual behaviour to reduce the chances of HIV infection and unwanted teenage pregnancy.' The present emphasis is on the need to find a clear and readily understandable message. Given the gravity of the risks, would it be wrong to suggest that this should be "No sex outside marriage"? Such an approach might ease the burden on some teenagers, who may perceive themselves to be under pressure from their peers and the establishment to embark on sexual activities for which they are not really ready. J W MYLES
Birmingham B15 21'H
Peterborough PE3 9PG
I Smith R. Promoting sexual health. BM.J 1992;305:70-1. (I I July.)
1 Smith R. Promoting sexual health. BMJ 1992;305:70-1. (11 July.)
2 New condoms in thc 1990s. Popul Rep[H] 1990;8:28-31. 3 Kirkman RJE, Morris J, W'ebb AMC. User experience: MN1ates' v Nuforms'. Brntish Journal of Familsv Planning 1990;15: 107-11. 4 Kirkman RJE. Condom use and failure. Lancet 1990;336:1009.
EDITOR,-Richard Smith's editorial on promoting sexual health addresses an important and sensitive public health issue.' His statement that "Roughly half of 16 year olds in Britain have had sexual intercourse" requires close examination, particularly because his article, rather than original data, is liable to be used by the mass media. National statistics are not available, but recent surveys have shown that most teenagers are not sexually active before their 16th birthday.2' Although half of teenagers are probably not virgins by their 17th birthday, so that Smith's statement is technically correct, we believe that his statement may mislead and be interpreted, particularly by the media, as suggesting that the rate of sexual activity is higher than it actually is for teenagers below the age of consent. For example, a recent headline in the Independent read "Nearly half of young people lose virginity before 16,"4 even though the original article quoted did not give this information.' An analysis of the given data (presuming that the age cohorts are equal) suggests a figure of roughly 34% -that is, a third rather than half, which is entirely consistent with other data.2 Society's view of what is normal has an important influence on individual behaviour.' "Everyone's doing it" is a common myth among teenagers. Those attempting to reduce risk taking by teenagers in other aspects of their lives have found it useful to expose similar myths.6 If teenagers are led, by both the medical and the general press, to believe that most of their peers are sexually active this will increase pressure on them in their relationships still further. Those under 16 who are virgins may be labelled as a minority group, with an implication of abnormality. Should we perhaps be more circumspect in our reporting of such figures? There is enough heat
EDITOR,-We endorse Richard Smith's view that the struggle against HIV needs reinvigorating and agree that the clarity of messages regarding health is important.' We are concerned that messages from some professional bodies are not only unclear but also damaging. For example, a statement from the Royal College of Surgeons of England earlier this year includes the recommendation: "If a patient is in a high risk category, he or she should be offered an HIV test, provided that facilities for counselling are available both before and after the test."2 This is with a view to an operating surgeon deciding what extra precautions should be taken to minimise transmission of HIV during treatment or surgery. No guidance is given regarding who should be included in such a category (it does not include known or suspected cases of HIV infection, for which there is a separate recommendation). Any assessment of high risk would require a detailed history, not just about injecting drug use and homosexual practice but also about heterosexual activity since the proportion of adults with AIDS reported to be heterosexual is 20%.' We doubt whether such a history is part of the routine preoperative assessment undertaken by surgeons. In our view, the term "high risk category" is inappropriate and stigmatising and, in the context of control of infection, leads to false reassurance with regard to patients who are not perceived as being at high risk. Indeed, the recommendation is contrary to that given by the World Health Organisation, which advocates universal precautions regarding blood and body fluid (that is, that all blood and certain body fluids are assumed to be infectious for hepatitis B virus and HIV and other bloodborne pathogens) as the cornerstone of preventing transmission of bloodborne infections.4 Terminology and messages are important: the continued use of the term high risk category suggests that there is still a widely held belief that HIV infection occurs only in specific well defined 363
groups of people who are somehow recognisable. Is it any wonder that, as Smith asserts, "heterosexuals have simply not adopted safe sex in large enough numbers to prevent HIV spreading through the heterosexual population"? CATHERINE QIJIGLEY
Department of Public Health MNtedicine, Trafford Health Authority, Urmston, Manchester MN31 3FP PAUL GARVEY
Department of Genitourinary Medicitte, T'rafford Health Authority I Smith R. IPromoting scxtual hcalth. BMt7 1992;305:70-1. (11 Jul.) 2 Royal College of Surgeons of England. .4 statement by the colle,geo n AIDS and HIT infectiotn. Iondon: RCS, 1992. 3 AIDS and HIVA- infection in the United Kitsgdom: mottthly report. Commutticable D)isease Retport 1992;2:115-6. 4 World Health Organisation. (ilobal programme on AII)S. HIN and HBV transmission in the health care setting. WMkl EpidemiolRec 1991;66:189-91.
EDITOR,-TO me the most important point in Richard Smith's editorial on promoting sexual health is that we are going to have to change a great many of the attitudes of people in Britain before we can possibly change their health habits.' So many are mealy mouthed when it comes to anything with a sexual content and squirm with horror at direct, honest language. As Smith says, "Use a condom" is a clear and simple message, but for far too many Britons it is made complicated by being put into words at all. Too many people in Britain believe that talking about sex is acceptable only if it's in the "dirty joke" mode, never if it's simple and direct. I should know. I have been bombarded with complaints from women who think it is disgusting that I mention on television the fact that women menstruate and have to use sanitary towels. The commonest reason for complaint has been that the advertisements in which I appear have been screened at times when children were watching. "And how can I possibly talk about such things to my children? I shouldn't have to listen to even the mention of periods in front of my teenagers." We're going to need all the help we can get in promoting honest talk about shared sexual experiences. Once we get that maybe we will be able to promote sexual health. CLAIRE RAYNER
Harrow on the Hill, Middlesex HAI 3BU I Smith R. Promoting sexuLal hcalth. BMJ 1992;305:70-1. I I July.)
Heterosexual transmission of HIV
and the Communicable Diseases (Scotland) Unit were classified, based on the information in the reports, into transmission within long term sexual partnerships (marriage, cohabitation, and relationships of six months or more) or short term partnerships (lasting less than six months). Cases were also classified according to characteristics of the partner into first generation (partner infected through injecting drugs, receiving contaminated blood, or homosexual intercourse) and second generation (partner infected heterosexually). Where the type of partnership was known, 18 of the 21 first generation cases (86%) and 13 of the 31 second generation cases (42'S() were presumed to have arisen in long term partnerships. There was a pronounced difference between the sexes, with 73% of the men having been infected in short term partnerships and 83% of the women in long term
partnerships (table). Heterosexual transmission of HIl' in United Kingdom: analysis of reported cases of AIDS by duration of partnership to December 1991 First generation transmission
Typc of partniership
Male
Female
Long tcrm Short term Not known
4 1 1
14 2 4
2 15 16
11 3 3
Total
6
20
33
17
This information was not collected in a systematic way, and its completeness may be biased. Because of the long incubation period cases of AIDS may not reflect the present pattern of transmission. Data on AIDS, however, are not subject to ascertainment bias as most patients will seek medical care, in contrast to patients with HIV infection. Further information is needed on the type and duration of partnership in which recent infections occurred and, for those infected by partners in a high risk group, whether they were aware of their partners' risk factors at the time of the partnership but still had unprotected sex or whether they were not aware. From the data available on cases of AIDS, however, heterosexual transmission of HIV in long term sexual relationships should not be ignored. L. C RODRIGUES London School of Hygiene and Fropical MNecdicinc, London VIC E 7HTI B EVANS KHOLOUD PETER Public Health Laboratorv Service AIDS Cenitre, Communicable lDisease Surveillance Ccntre, London NW9 5EQ 1 Smith R. P'romoting sexual hcalth. (11
EDITOR,-Richard Smith's editorial addresses the promotion of sexual health.' In Britain most mass health education regarding heterosexual transmission of HIV- 1 infection has presented sex with casual partners as the main risk. But if most heterosexual intercourse involving infected people took place in stable relationships long term partners would be the most at risk from unprotected sex.- In Sweden 53 heterosexual partners of people with HIV infection were infected: 32 by steady partners and 21 by casual partners.' In the United States, having a partner who used drugs, but not the number of partners, carried a significant risk of HIV infection.4 Of 35 women who acquired HIV heterosexually in Copenhagen, 10 were infected by a cohabiting partner; only one of the 25 women with partners in a high risk group was aware of the partner's risk activities when the relationship started.' All cases of AIDS resulting from heterosexual transmission within the United Kingdom reported to the Communicable Disease Surveillance Centre
364
Male Female
Second generation transmission
Julyt.)
be sent to general practitioners.' The society's reason was that the specific importance for general practitioners was not evident. Wilbers and colleagues quote a previous finding that six out of 29 responding general practitioners (from 75 contacted) had had erotic physical contact with a patient. Kardener et al's American study,' referred to in Thomas Fahy and Nigel Fisher's editorial,3 showed that half of 100 respondents thought it might be therapeutically beneficial to indulge in "non-erotic hugging, kissing and affectionate hugging" while a quarter thought that erotic contact may at some time be beneficial. Only 3%, however, admitted to having engaged in erotic practices.2 The media have given a lot of attention recently to claims about doctors making advances towards patients, and many doctors have experienced the reverse. General practitioners are particularly at risk because of more frequent contact and longer acquaintance with patients, the congeniality of surgeries and intimacy of home visits, and the greater likelihood of contact outside the professional relationship. Though a few doctors may enjoy erotic involvement with patients, many fear it. This may lead them to avoid taking any interest in a patient's sexuality, to the potential detriment of the patient's health. Sexual dysfunction is common, and many would seek help for it if encouraged to do so by their physician.4 The family doctor may be the professional of choice.' He or she needs to be comfortable with the subject. Nearly four fifths of gynaecologists in Wilbers and colleagues' study thought that more attention should be paid to sexuality during training.' Brief intensive exposure to sexual issues at undergraduate level has been shown to alter attitudes to sexuality favourably and encourage greater awareness.' Problems of sexual dysfunction can often be helped without a great deal of extra training and should be addressed by all practitioners during undergraduate and postgraduate training. M P MYRES
OsCrton on lDee, Wrcxham, Clwvd LL13 O)D
2
3 4
5 6
Wilbcrs D, Veenstra G, van dc Wiel HBAM, WeiImar Schulz WCM. Sexual conitact in the doctor-patient relationship in the Netherlanids. BMJ 1992;304:1531-4. (13 June.) Kardetter SH, Fuller M, Mensh IN. A survey of physicians' attitudes and practices regarding erotic and non-erotic contact with patients. Amj Psychilatr 1973;130:1077-81. Fahy f, Fisher N. Scxual cotttact between doctors and patients. BJIJ 1992;304:1519-2(0. (13 June.) Schein MNI, Zyganski SJ, Levine S, Medalie JH, Dickman RL, Alemagno SA. The frequency of sexual problems among family practice patients. Fam Pruct Resj 1988;7:122-34. Hanscn JP, Bobula J, Meyer D, Kushner K, Pridham K. TIreat or refer: patients' interest in "family physician" involvement in their psychosocial problems. ] Fam Pract 1987;24:499-503. Stanley E. An introduction to sexuality in the medical ctrriculum. led Educ 1978;12:441-5.
Bitt7 1992;305:70-1.
2 Rodrigues LC, (Garcia MN1orenio C. HI'V transmission to womcn in stable relationiships .N Fnggl Mcd 1991;325:966. 3 Gisecke J, Ramstedt K, Granath F, Ripaa 1, Rado Gi, Westrell M. Efficacy of partner notification for HIV infection. I.aticet 1991 ;338: 1096-100. 4 Marmor M, Krasinski K, Sanchez 1, Cohen H, Dubin N, W'eiss L, et al. Sex, drugs atsd HI' infection in a Ncw York city hospital otttpaticnt population. journal of the Acquired Immune
Deficiencv Ssndrome. 1990;3:307-17.
Mlathiesen LR. Heteroscxttally acqtlired human immtunodeficiencv virus infection in wtomcn in Copenhagen: sexual behaviour and other risk factors. Interttational journal of Sexuallv Transmitted Diseases andAII)S 1990;1:416-21.
5 Smith E, Kroon S, (ierstoft INIJ, Kvinesdal B,
Sexual contact in the doctorpatient relationship EDITOR,-I was interested to read in D Wilbers and colleagues' report of their study of sexual contact between doctors and patients that the Dutch National Society for General Practitioners had withheld its approval for the questionnaire to
Site of injection for vaccination EDITOR, -I agree with Mark Henley that BCG vaccination above the deltoid insertion should be avoided.' He is, however, incorrect in stating that the only vaccination for which a specific site on the upper arm is recommended is rabies. It is also recommended for hepatitis B vaccine. Both the Joint Committee on Vaccination and Immunisation in the United Kingdom and the Immunisation Practices Advisory Committee in the United States recommend that, although the anterolateral thigh is the preferred site for infants, hepatitis B vaccine should be given into the deltoid muscle in adults.2' In particular, the buttock must not be used: it is associated with a suboptimal response, probably because of injection into subcutaneous fat rather than into muscle.4 Injection into the thigh might prove unsatisfactory for the same reason, especially in overweight adults. Vaccination of health care workers against
BMJ
VOLUME 305
8 AUGUST 1992
