Letters

"Saving sex for sexual health: readers’ responses"

Anisa Nasir’s article about abstinence in March’s Student BMJ sparked a lively discussion on student.bmj.com, with 17 responses from 14 authors in about half a dozen countries (2008;16:98-9; http://student.bmj.com/issues/08/03/life/098.php). Although a couple of respondents agree with the concept of abstinence on religious grounds only, some take issue with other respondents, or the perceived ideological or moral basis of the authors’ reasoning. Most responses, however, reflect the complexity of the matter as presented in the article itself and perhaps raise questions or prompt discussion rather than take sides.

One correspondent argues that abstinence is not a medical question but a social one; several others do see it as medical, and one even says that as such its efficacy should be studied in real life conditions, rather than ideal trial conditions. Ghana and Uganda are named as two examples where an abstinence policy has reduced rates of sexually transmitted infections. But another correspondent argues that an abstinence only programme is inadvisable because it doesn’t teach adolescents about other forms of contraception. Several correspondents say that teaching protected sex is probably still the safest option because the need to “demystify” sex would not be met by portraying it merely as an activity that gives people sexually transmitted infections.

In life as in trials, compliance will always be a problem, especially given the young age of those most at risk—physically and emotionally—from unprotected sexual encounters. The latter point is tackled by two correspondents. They recommend counselling before youngsters become sexually active to ensure that by the time they become teenagers they might be able to accept abstinence as a possible way of life, without feeling manipulated into it.

Several are in agreement that it would make sense to add abstinence to the list of possible medical interventions to prevent pregnancy and sexually transmitted infections, especially as the established methods are not effective enough in preventing these. As one of these possible methods, abstinence would then not be used in the sense of directive counselling—which would contravene guidelines set by the UK General Medical Council, for example.

Rather than regarding sex advice from doctors as patronising or out of turn, several correspondents think that doctors generally have their patients’ best interests at heart, and that, therefore, in the context of sexual health counselling, abstinence should be included as one of several options available.

"Depression is stigmatised"

Healthcare professionals have raised awareness about depression, and the comprehensive guidelines from the National Institute for Health and Clinical Excellence make treatment more structured.¹ However, could the real problem be the less easily treated stigma associated with a mental illness? Many patients do not seek advice or treatment for fear of the stigma associated with both depression and mental illness in general.² People’s opinions are deeply rooted and so are difficult to change. The government has set out a five year plan to combat this stigmatism and negative stereotyping, but how effective can it really be?³ Also, as our population ages, mental illnesses, including depression, will inevitably increase in incidence. Are we prepared to deal with this burden and the problems associated with stigma?

1. Slack R, Chaplin R. Tackling depression. Student BMJ 2008;16:116-7. (March.)
2. Barney L, Griffiths K, Jorm A, Christensen H. Stigma about depression and its impact on help-seeking intentions. Aust N Z J Psych 2006;40:51-4.
3. Gould M. Government moves to end stigma of mental illness. BMJ 2004;328:1456.

"Depressed patients need counselling"

In addition to the points raised in the article about tackling depression, in the March issue of the Student BMJ, lack of adequate provision of counselling and cognitive behaviour therapy in parts of the United Kingdom have made doctors hesitant when managing depressed patients.¹ I don’t blame them. For many patients antidepressants combined with cognitive behavioural therapy is the most effective form of treatment.

There may be a shortage of NHS counsellors for depressed patients

My general practitioner-tutor has the agonising task of explaining to his patients, some of whom are in desperate need of care, that there will be a nine month wait to see an NHS counsellor. This in itself can be a deterrent for doctors at all levels to diagnosing a patient as having moderate depression. The media have labelled doctors “pill pushers,” but how are we to move away from this image without the resources to provide holistic care for our patients?

1. Slack R, Chaplin R. Tackling depression. Student BMJ 2008;16:116-7. (March.)

"Sadness is not depression"

Depressive disorder exists and can be a devastating condition that needs medical attention, but Slack and Chaplin’s article in March’s Student BMJ was symptomatic of a fallacy that exists in the psychiatric profession, which has failed to understand normal human sadness.¹ The system of diagnosis that psychiatrists have proposed, the classification in the Diagnostic and Statistical Manual of Mental Disorder (DSM), fails to take into account any understanding of normal sadness and its difference to a depressive disorder.

The “universal symptoms of depression,” as stated in DSM-IV are more precisely Western ways of expressing distress that have been medicalised through a number of expert theories that build on various aspects of our language based folk model of depression. To provide all doctors and medical students simply with lists of symptoms and to state that effective remedies exist, such as pharmacotherapy or cognitive behaviour therapy, is of little use to either the healthcare professional or the patient.

Better systems need to be put in place to understand depression and its multiple external causes. The prevalence of depression, on which the authors base their argument, is symptomatic of an overly broad description that has led to the misidentification of people’s emotions and moods. After all, the answer to how many people have depression depends on how it is diagnosed. The persistence of some of the symptoms listed by the authors tells us nothing because the markers are arbitrary.

Without a knowledge of the situation in which the symptoms are grounded, which Slack and Chaplin ignore in their proposed screening of two questions, the natural reaction to a diagnosis of cancer, desertion of a spouse, or loss of work will be misinterpreted as pathology. Alongside the reductionist claims made, it is widely held that depression is not “an internationally recognised disease.” A large body of evidence, stemming from linguistics and anthropology as well as psychiatry, indicates that because the assumption of universal prototypes of emotion is incorrect so must be the assumption that emotions and emotional expression are universal categories.

The notion of depression has many unstable polythetic categorisations, and the multiple causes are often diffuse and socially embedded. It is these intricacies that get overlooked and ignored with the responses and management plans recommended by Slack and Chaplin in their reductionist approach.^{2 3 4}

1. Slack R, Chaplin R. Tackling depression. Student BMJ 2008;16:116-7. (March.)
2. Horwitz A. The loss of sadness: how pyschiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press, 2007.
3. Jadhav S, Littlewood R. Attitudes towards depression: some medical antropological queries. Pysch Bull 1994;18:572-3.
4. Kleinman A, Good B, eds. Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder. Berkely: California University Pre ss, 1985.

"Peer led training has flaws"

I worked on setting up an expanded version of the peer led training described by Saidi and coauthors.¹ I think the programme is only as good as the information delivered. I have since been marking the students that attend this teaching, and they seem to have been instructed incorrectly, causing them to perform at best average compared with their peers, and in contrast to what is said in the article. In theory peer led training works. But in practice it needs to be continually updated with the curriculum components and evidence based practice, which is currently lacking.

1. Saidi S, Lievesley A, Lee M, Gent L, Lin R, Jones L. Peer led training in communication skills. Student BMJ 2008;16:114. (March.)

"Doctorates don’t make a doctor"

As a potential applicant to medical school I was intrigued to read the article about a former pornographic actor who switched careers to become a “doctor.”¹ I am interested because my past is a little different to the typical applicant, but not quite so provocative: I have the back of my hands tattooed and large obvious facial piercings. Given that medicine is a conservative profession, I don’t think US admissions committees will have much interest in me if I walk in with them in full view, so I will have to hide them surgically.

After the research I have done about how medical schools might respond to my visible body modifications and the extreme competition for places, I find it incredibly difficult to believe that a former porn star would be admitted. I looked this actor up, and both the article and Wikipedia state that she has a doctoral degree; however, she is not a medical doctor. Current colloquial use of the term “doctor” is reserved for practitioners of medicine—general practitioners, physicians, surgeons, or other specialists. Simply because you have a doctorate and use the title Dr in front of your name does not mean that you are a doctor. Please let us try to avoid such confusions.

1. Richards L. Sex, clinics, and videotape. Student BMJ 2008;16:100-1. (March.)

"An inspiring doctor"

Having recently attended a lecture by Professor Harold Ellis titled “60 years in the NHS: an old surgeon looks back,” it was a pleasure to read the article by Peter Cross in April’s Student BMJ.¹ As a fourth year student I am fast approaching the end of the undergraduate medical curriculum, and it seems an appropriate time to reflect on the characters that I’ve met along the way and how they have affected my personal development.

When I started I expected to be encouraged and motivated by doctors who were enthusiastic about medicine, with a fire for their specialty. But what I found was rather different. Doctors were exhausted by policy and red tape and were unable to recall why they chose medicine. Some doctors were keen to put students off medicine and scoffed at eagerness and idealistic views of the health service.

These views are understandable given the current climate in the National Health Service and medical education but don’t serve to motivate future professionals. This was not true of all the doctors I have met, but it was the over-riding theme. Professor Ellis’s talk was a breath of fresh air, however—a real inspiration. It was refreshing to see a doctor with a fervour for medicine and teaching, and I encourage any students looking for inspiration to attend one of his talks.

1. Cross P. A surgical superstar (Harold Ellis). Student BMJ 2008;16:159-60. (April.)

"Going back to Nigeria?"

I am a British medical student, originally from Nigeria, and I am often asked whether I will go back to Nigeria to practise. I don’t know, but it is something I think about often. I have experienced the public healthcare system in Nigeria, and the situation Ejibe described in March’s Student BMJ is as I have observed.¹

Imagine having to work long hours with substandard or non-existent equipment, for insubstantial earnings. Turning patients back from hospitals is not unusual, and many doctors watch their patients die without being able to do anything. Even patients that can be helped can end up dying because they can’t afford the prescribed drug.

In Nigeria doctors work either for the government in public hospitals or privately if they have the capital. There is no free health care even in public hospitals. And if you work privately you end up helping only rich people. The people who really need your help can’t afford to pay.

Medical professionals in the United Kingdom should be given the opportunity to experience medicine in poor countries so that they value the opportunities they have. Such experience could also equip them to work with limited resources. Understanding these circumstances also helps to explain the medical “brain drain.” Most doctors who move to rich countries to practise are not driven by greed—not everyone can deal with the challenges of working in a poor setting every day.

1. Ejibe D. Making do in Nigeria. Student BMJ 2008;16:130. (March.)

   

 Printable version     Download PDF    E-mail this to a friend    Respond to this article