291
available. Washing in streams is routine practice when moving from one village to the next but, by the time the next village is reached, profuse sweating has restored the status quo. The second delight is the availability of electricity from a small diesel generator, which allows unhindered reading after nightfall without the need to jostle around a single Tilley pressure lamp. The third pleasure is sleeping on a comfortable bed secure in the knowledge that neither rats nor fleas nor bed-bugs will be unwelcome companions. The research in progress had its own amusing moments. We were carrying out a series of motor and cognitive tasks on young men and women. When calling out the names of those to be tested, the men were not shy in coming forward, but the women were far more reticent. That they were there was confirmed by the giggling among the crowd. Thinking this shyness arose from me being a male, I called to the only woman in our party, a young medical student, and asked her to collect the next subject for testing. My concern that the sex difference might be the cause of the reticence was ill founded, but one young man in the crowd volunteered the information that the reluctance of the young women to come forward arose not because I was a male but because I was white. When the next testing slot became vacant I called to my 15-year-old tall, fair-skinned, and eminently eligible son to collect the subject. Within a few moments a queue of young girls had formed, all eager to join in the testing
statements were recently supported by a poll about psychosomatic illnesses: people in the east have far more physical complaints of that kind than people in the west. According to Maaz there were two principal ways in which the psyche responded to this pressure. The oppressed character was dependent on receiving orders and obeying them, anxious to avoid mistakes. Maaz thinks that many of the informants of the security police, the Stasi, could be characterised in this way. For others, discipline, order, and security were the most important principles in life. The system gave special privileges to those with ambitious pursuits. Successful sportsmen and party activists were good examples of this type of personality. But probably most provocative is what Maaz writes about the people who started the peaceful resistance and the demonstrations. That the Berlin wall fell eventually, he says, was mainly due not to the fight of this opposition but to the combined political effects of events such as the massive stream of people leaving the country and perestroika. Because the opposition in East Germany had also been damaged psychologically and loathed any form of hierarchy, they had not been able to form a functioning political
which could propose a realistic alternative reunification with West Germany. structure
to
the
Annette Tuffs
procedure. Never has the definition of an epidemiologist-someone who is broken down by age and sex-been made explicit with such stark candour! However, every cloud has its silver lining-I was also made aware of how little skin colour really matters when anything important is at stake.
P. O. D. Pharoah
Germany: A "psychological revolution"? Are all former East Germans psychologically deformed? recent book by the East German psychotherapist Dr Hans-Joachim Maaz from Halle has caused quite a stir in the east. Naturally, the people there object to this unflattering assessment, and many of Maaz’ colleagues disagree with his provocative statements. Maaz has lectured on this theme all over the country, with obvious successhis book was sold out by the beginning of the year. The book is called Der Gefiihlsstau, which might be translated as ’Blocked Emotions’. And this title already stands for his theory that the whole of the former East Germany is suffering from the effects of suppression of natural aggressive feelings during 40 years of tyrannical rule. During the so-called "peaceful revolution" in the autumn of 1989 no violence occurred-for Maaz not necessarily a fact to be proud of, but a rather worrying sign. Only recently, more than a year after the revolution, have sporadic outbreaks of hooliganism and street fighting occurred in the east. Maaz calls for a "psychological revolution"-the people, he says, need to go through a phase of pain and to admit their failings in the past, if possible with psychotherapeutic support, before they start to build a new life in a free society. Maaz gives a detailed and unsettling description of the psychological mechanisms in an undemocratic socialist system, where neither the state nor the family allowed the free development of individuality. There was chronic stress and frustration affecting body and soul, he writes. His
A
Medicine and the Law Benzodiazepines and sexual assault, Canada The potential for certain types of benzodiazepine to induce sexual fantasies in women has only recently been recognised.12 In 1990 two British dentists using benzodiazepines for sedation were prosecuted for sexual assault; one was convicted on some counts but acquitted on others, and the second man was acquitted on all charges.3 Often in such cases there are no independent witnesses and English law has always been cautious of accepting uncorroborated claims of sexual assault.4 Sometimes, however, even if there are no witnesses, there may be forensic evidence and other suspicious circumstances that support the allegations. In Canada, a complaint against a 35-year-old hospital doctor resulted in legal proceedings stretching over more than 4 years. A criminal charge of sexual assault was dismissed on the grounds that the incident could have been a drug-induced fantasy, and the acquittal was upheld on appeal. However, the College of Physicians and Surgeons of Ontario subsequently charged the doctor with sexual impropriety with a patient. The doctor failed to have the charges quashed on the grounds that they would expose him to double jeopardy, and he was found guilty.s The different verdicts on the same evidence can be explained by the fact that in the disciplinary proceedings the burden of proof was civil (the balance of probability) not criminal (beyond reasonable doubt). None the less, in Canada a finding of professional misconduct does require "clear and cogent evidence". There was corroborating evidence of a largely forensic nature before the disciplinary committee and the doctor’s licence to practise was revoked; pending an appeal, this penalty was suspended. The Ontario Divisional Court upheld the finding of guilt but found the penalty too harsh, and substituted a reprimand and 9 months’ suspension.
292 A 21-year-old university student had been admitted to hospital with chest pains and hyperventilation. She was given 10 mg diazepam intravenously. She awoke in a recovery room, with the lights turned down, and claimed that she heard conversations in the nearby emergency room, which she recalled accurately and which were confirmed. The doctor who had attended her earlier came into the room and then, she alleged, placed his penis in her hand and masturbated. He then wiped himself with a tissue, which he dropped into a bin, and washed her hand with a wet flannel. The patient did not cry out because she did not know where she was and felt vulnerable. Soon after the doctor had left the room, a nurse came in and found the patient crying. The patient’s mother, on being told what had happened, announced that her daughter was accusing the doctor of exposing himself. The doctor immediately tried to demonstrate the twofinger test, which he said must have been wrongly interpreted by the patient who was confused by the drugs given to sedate her. However, subsequent forensic tests revealed semen on the doctor’s underpants. The doctor claimed that when he had been roused from sleep to deal with the emergency he found he had nocturnal emission. The tissue with which he had wiped himself had later been dropped in the bin in the recovery room. However, nocturnal emissions in a 35-year-old married man would be very unusual. At the disciplinary proceedings, the view was taken that the patient’s description of events was much more detailed than would be likely if the allegations had been prompted by a drug-induced illusion. The College’s disciplinary committee revoked the doctor’s licence because he had consistently denied his conduct and in not facing up to his problem was thus a continuing risk to the public. They said he needed psychiatric care. The Divisional Court, on the other hand, said there was no evidence of the need for psychiatric treatment and that the committee’s argument that the most severe penalty was warranted, in part at least because the doctor did not acknowledge his guilt, was not acceptable. RosenbergY (Farley and Coo JJ concurring) said that a person is entitled to defend himself "without in any way jeopardising his position when it comes to sentence in the sense that his sentence should be more harsh because he does not plead guilty". This issue is also raised in College of Physicians and Surgeons of Ontario vs Boodoosingh, which is pending appeal. (In that case a psychiatrist treated a 30-year-old woman who was depressed and vulnerable, in part because of sexual assaults. By the third session, the doctor told her he found her body attractive and petting eventually led to a mutual agreement to a single act of intercourse. The doctor did not admit guilt or remorse, and this failure to admit guilt was deemed to make it unlikely that he could ever be rehabilitated.) Although the law provided for a doctor to be tried by his peers, and the court would interfere only in the most unusual of circumstances, here the disciplinary tribunal’s reasoning was not in accordance with the law. The penalty was too harsh. Since the assault 4 years earlier the doctor had been practising with restrictions, and the court decided to impose its own, lesser penalty rather than delaying matters further by referring the case back to the disciplinary tribunal. The College has now moved to appeal against the reduction in penalty, and the doctor seeks to cross-appeal against confirmation of the finding.
College of Physicians and Surgeons of Ontariov Gillen. Ontario Court of Justice (General Division) (Divisional Court), Rosenberg, Farley, and Coo ,7. Nov 28, 1990.
Diana Brahams
JW. Do fantasies occur with intravenous benzodiazepines. SAAD Dig 1986; 6: 72-76; Further data on sexual fantasies during benzodiazeine sedation. SAAD Dig 1989; 7: 171-72. Dundee JW. Fantasies during sedation with intravenous midazolam or diazepam. Med-Leg J 1990; 58: 1-29. Brahams D. Benzodiazepine sex fantasies: acquittal of dentist. Lancet 1990; 355: 403. Brahams D. Benzodiazepine sedation and allegations of sexual assault. Lancet 1989; i: 1339. Brahams D. Benzodiazepine and sexual fantasies. Lancet 1990; 335: 157.
1. Dundee
2. 3. 4. 5.
Noticeboard Breast
cancer
screening
The National Health Service Breast Screening Programme (NHSBSP), set up in the UK five years ago in response to the Forrest report, costs about £ 25 million a year. As a basis for the planning of quality improvement and service development of the programme the Department of Health’s advisory committee has reviewed’ data collected since the Forrest report. The three main issues that the committee examined were whether breast screening is efficacious, whether the results obtained in trials can be reproduced in national screening programmes, and whether the benefits of screening outweigh the adverse effects. Since November, 1986, new evidence on breast cancer screening has emerged from seven trials in the UK and abroad, all taking mortality from breast cancer as an end point. The Committee’s assessment is that screening does reduce mortality from breast cancer. When uptake is 70%, a 25% overall reduction in mortality can be expected; the reduction is 40% among those who are screened. From those figures, 1250 deaths from breast cancer would have been prevented in the UK by the end of this decade, and a woman whose life is thus saved will be given on average an extra 20 years of life. The new data also lend support to the decision to exclude women under 50 from population screening. The costbenefits of annual screening compared with those of three-yearly screening are being compared in a trial organised by the UK Coordinating Committee on Cancer Research (UKCCCR). Experience with the NHSBSP indicates that adequate levels of quality are being achieved. A survey of the first 25 screening units showed that a 70% uptake was being attained and that pre-set standards are being met-for instance, 7-6% women were recalled for further investigations (recommended minimum standard less than 10%), 1’ 1 % underwent a biopsy (minimum standard less than 1-5%), and cancer was detected in 6-6 per 1000 women screened (minimum standard more than 5 per 1000). Some units are having difficulties meeting the costs of investigations and treatment, and these problems are being analysed. Nevertheless, the committee concludes that, provided consultant surgeon time is available (and this needs to be monitored), sufficient resources are being provided for treating cancers detected by screening. The risk of radiation-induced cancer is double that predicted by the Forrest report because the radiation dose has been increased to improve accuracy; the risk of such cancer is now one extra breast cancer per million women screened per year after a latent interval of 10 years. However, other anxiety-provoking effects have been less than predicted-for instance, the proportion of women referred for further investigations. Some unnecessary treatment through overdiagnosis is inevitable but can be minimised by adequate quality control, says the committee. The main focus of attention concerning overdiagnosis and unnecessary treatment is ductal carcinoma-in-situ. There is no consensus on its management or on its probability of becoming invasive, so a trial has been set up by the UKCCCR to study the effects of local excision with or without adjuvant therapy. The committee’s conclusion is that breast cancer screening is effective and that the costs are in line with many other effective health service activities. It doubts the validity of the QALYs approach to quantify benefits against adverse effects and says that it is up to the individual to make this assessment herself. To maximise quality, the NHSBSP has been run with greater central control than is customary in health service development. There is concern that with the NHS reform, some districts may want to opt out of the present arrangements, a move that could threaten quality during the consolidation phase of the programme. Hence the committee recommends that the present management arrangements should be continued for another three years.
1. Breast Cancer Screening 1991. Evidence and Experience since the Forrest Report A report of the Department of Health Advisory Committee (chairman Prof Martin Vessey). 1991 Pp 40. Sheffield: NHSBSP Publications. Available from Julietta Patnick National Coordinator NHSBSP, Trent Regional Health Authority, Fulwood House, Old Fulwood Road, Sheffield S10 3TH
available. Washing in streams is routine practice when moving from one village to the next but, by the time the next village is reached, profuse sweating has restored the status quo. The second delight is the availability of electricity from a small diesel generator, which allows unhindered reading after nightfall without the need to jostle around a single Tilley pressure lamp. The third pleasure is sleeping on a comfortable bed secure in the knowledge that neither rats nor fleas nor bed-bugs will be unwelcome companions. The research in progress had its own amusing moments. We were carrying out a series of motor and cognitive tasks on young men and women. When calling out the names of those to be tested, the men were not shy in coming forward, but the women were far more reticent. That they were there was confirmed by the giggling among the crowd. Thinking this shyness arose from me being a male, I called to the only woman in our party, a young medical student, and asked her to collect the next subject for testing. My concern that the sex difference might be the cause of the reticence was ill founded, but one young man in the crowd volunteered the information that the reluctance of the young women to come forward arose not because I was a male but because I was white. When the next testing slot became vacant I called to my 15-year-old tall, fair-skinned, and eminently eligible son to collect the subject. Within a few moments a queue of young girls had formed, all eager to join in the testing
statements were recently supported by a poll about psychosomatic illnesses: people in the east have far more physical complaints of that kind than people in the west. According to Maaz there were two principal ways in which the psyche responded to this pressure. The oppressed character was dependent on receiving orders and obeying them, anxious to avoid mistakes. Maaz thinks that many of the informants of the security police, the Stasi, could be characterised in this way. For others, discipline, order, and security were the most important principles in life. The system gave special privileges to those with ambitious pursuits. Successful sportsmen and party activists were good examples of this type of personality. But probably most provocative is what Maaz writes about the people who started the peaceful resistance and the demonstrations. That the Berlin wall fell eventually, he says, was mainly due not to the fight of this opposition but to the combined political effects of events such as the massive stream of people leaving the country and perestroika. Because the opposition in East Germany had also been damaged psychologically and loathed any form of hierarchy, they had not been able to form a functioning political
which could propose a realistic alternative reunification with West Germany. structure
to
the
Annette Tuffs
procedure. Never has the definition of an epidemiologist-someone who is broken down by age and sex-been made explicit with such stark candour! However, every cloud has its silver lining-I was also made aware of how little skin colour really matters when anything important is at stake.
P. O. D. Pharoah
Germany: A "psychological revolution"? Are all former East Germans psychologically deformed? recent book by the East German psychotherapist Dr Hans-Joachim Maaz from Halle has caused quite a stir in the east. Naturally, the people there object to this unflattering assessment, and many of Maaz’ colleagues disagree with his provocative statements. Maaz has lectured on this theme all over the country, with obvious successhis book was sold out by the beginning of the year. The book is called Der Gefiihlsstau, which might be translated as ’Blocked Emotions’. And this title already stands for his theory that the whole of the former East Germany is suffering from the effects of suppression of natural aggressive feelings during 40 years of tyrannical rule. During the so-called "peaceful revolution" in the autumn of 1989 no violence occurred-for Maaz not necessarily a fact to be proud of, but a rather worrying sign. Only recently, more than a year after the revolution, have sporadic outbreaks of hooliganism and street fighting occurred in the east. Maaz calls for a "psychological revolution"-the people, he says, need to go through a phase of pain and to admit their failings in the past, if possible with psychotherapeutic support, before they start to build a new life in a free society. Maaz gives a detailed and unsettling description of the psychological mechanisms in an undemocratic socialist system, where neither the state nor the family allowed the free development of individuality. There was chronic stress and frustration affecting body and soul, he writes. His
A
Medicine and the Law Benzodiazepines and sexual assault, Canada The potential for certain types of benzodiazepine to induce sexual fantasies in women has only recently been recognised.12 In 1990 two British dentists using benzodiazepines for sedation were prosecuted for sexual assault; one was convicted on some counts but acquitted on others, and the second man was acquitted on all charges.3 Often in such cases there are no independent witnesses and English law has always been cautious of accepting uncorroborated claims of sexual assault.4 Sometimes, however, even if there are no witnesses, there may be forensic evidence and other suspicious circumstances that support the allegations. In Canada, a complaint against a 35-year-old hospital doctor resulted in legal proceedings stretching over more than 4 years. A criminal charge of sexual assault was dismissed on the grounds that the incident could have been a drug-induced fantasy, and the acquittal was upheld on appeal. However, the College of Physicians and Surgeons of Ontario subsequently charged the doctor with sexual impropriety with a patient. The doctor failed to have the charges quashed on the grounds that they would expose him to double jeopardy, and he was found guilty.s The different verdicts on the same evidence can be explained by the fact that in the disciplinary proceedings the burden of proof was civil (the balance of probability) not criminal (beyond reasonable doubt). None the less, in Canada a finding of professional misconduct does require "clear and cogent evidence". There was corroborating evidence of a largely forensic nature before the disciplinary committee and the doctor’s licence to practise was revoked; pending an appeal, this penalty was suspended. The Ontario Divisional Court upheld the finding of guilt but found the penalty too harsh, and substituted a reprimand and 9 months’ suspension.
292 A 21-year-old university student had been admitted to hospital with chest pains and hyperventilation. She was given 10 mg diazepam intravenously. She awoke in a recovery room, with the lights turned down, and claimed that she heard conversations in the nearby emergency room, which she recalled accurately and which were confirmed. The doctor who had attended her earlier came into the room and then, she alleged, placed his penis in her hand and masturbated. He then wiped himself with a tissue, which he dropped into a bin, and washed her hand with a wet flannel. The patient did not cry out because she did not know where she was and felt vulnerable. Soon after the doctor had left the room, a nurse came in and found the patient crying. The patient’s mother, on being told what had happened, announced that her daughter was accusing the doctor of exposing himself. The doctor immediately tried to demonstrate the twofinger test, which he said must have been wrongly interpreted by the patient who was confused by the drugs given to sedate her. However, subsequent forensic tests revealed semen on the doctor’s underpants. The doctor claimed that when he had been roused from sleep to deal with the emergency he found he had nocturnal emission. The tissue with which he had wiped himself had later been dropped in the bin in the recovery room. However, nocturnal emissions in a 35-year-old married man would be very unusual. At the disciplinary proceedings, the view was taken that the patient’s description of events was much more detailed than would be likely if the allegations had been prompted by a drug-induced illusion. The College’s disciplinary committee revoked the doctor’s licence because he had consistently denied his conduct and in not facing up to his problem was thus a continuing risk to the public. They said he needed psychiatric care. The Divisional Court, on the other hand, said there was no evidence of the need for psychiatric treatment and that the committee’s argument that the most severe penalty was warranted, in part at least because the doctor did not acknowledge his guilt, was not acceptable. RosenbergY (Farley and Coo JJ concurring) said that a person is entitled to defend himself "without in any way jeopardising his position when it comes to sentence in the sense that his sentence should be more harsh because he does not plead guilty". This issue is also raised in College of Physicians and Surgeons of Ontario vs Boodoosingh, which is pending appeal. (In that case a psychiatrist treated a 30-year-old woman who was depressed and vulnerable, in part because of sexual assaults. By the third session, the doctor told her he found her body attractive and petting eventually led to a mutual agreement to a single act of intercourse. The doctor did not admit guilt or remorse, and this failure to admit guilt was deemed to make it unlikely that he could ever be rehabilitated.) Although the law provided for a doctor to be tried by his peers, and the court would interfere only in the most unusual of circumstances, here the disciplinary tribunal’s reasoning was not in accordance with the law. The penalty was too harsh. Since the assault 4 years earlier the doctor had been practising with restrictions, and the court decided to impose its own, lesser penalty rather than delaying matters further by referring the case back to the disciplinary tribunal. The College has now moved to appeal against the reduction in penalty, and the doctor seeks to cross-appeal against confirmation of the finding.
College of Physicians and Surgeons of Ontariov Gillen. Ontario Court of Justice (General Division) (Divisional Court), Rosenberg, Farley, and Coo ,7. Nov 28, 1990.
Diana Brahams
JW. Do fantasies occur with intravenous benzodiazepines. SAAD Dig 1986; 6: 72-76; Further data on sexual fantasies during benzodiazeine sedation. SAAD Dig 1989; 7: 171-72. Dundee JW. Fantasies during sedation with intravenous midazolam or diazepam. Med-Leg J 1990; 58: 1-29. Brahams D. Benzodiazepine sex fantasies: acquittal of dentist. Lancet 1990; 355: 403. Brahams D. Benzodiazepine sedation and allegations of sexual assault. Lancet 1989; i: 1339. Brahams D. Benzodiazepine and sexual fantasies. Lancet 1990; 335: 157.
1. Dundee
2. 3. 4. 5.
Noticeboard Breast
cancer
screening
The National Health Service Breast Screening Programme (NHSBSP), set up in the UK five years ago in response to the Forrest report, costs about £ 25 million a year. As a basis for the planning of quality improvement and service development of the programme the Department of Health’s advisory committee has reviewed’ data collected since the Forrest report. The three main issues that the committee examined were whether breast screening is efficacious, whether the results obtained in trials can be reproduced in national screening programmes, and whether the benefits of screening outweigh the adverse effects. Since November, 1986, new evidence on breast cancer screening has emerged from seven trials in the UK and abroad, all taking mortality from breast cancer as an end point. The Committee’s assessment is that screening does reduce mortality from breast cancer. When uptake is 70%, a 25% overall reduction in mortality can be expected; the reduction is 40% among those who are screened. From those figures, 1250 deaths from breast cancer would have been prevented in the UK by the end of this decade, and a woman whose life is thus saved will be given on average an extra 20 years of life. The new data also lend support to the decision to exclude women under 50 from population screening. The costbenefits of annual screening compared with those of three-yearly screening are being compared in a trial organised by the UK Coordinating Committee on Cancer Research (UKCCCR). Experience with the NHSBSP indicates that adequate levels of quality are being achieved. A survey of the first 25 screening units showed that a 70% uptake was being attained and that pre-set standards are being met-for instance, 7-6% women were recalled for further investigations (recommended minimum standard less than 10%), 1’ 1 % underwent a biopsy (minimum standard less than 1-5%), and cancer was detected in 6-6 per 1000 women screened (minimum standard more than 5 per 1000). Some units are having difficulties meeting the costs of investigations and treatment, and these problems are being analysed. Nevertheless, the committee concludes that, provided consultant surgeon time is available (and this needs to be monitored), sufficient resources are being provided for treating cancers detected by screening. The risk of radiation-induced cancer is double that predicted by the Forrest report because the radiation dose has been increased to improve accuracy; the risk of such cancer is now one extra breast cancer per million women screened per year after a latent interval of 10 years. However, other anxiety-provoking effects have been less than predicted-for instance, the proportion of women referred for further investigations. Some unnecessary treatment through overdiagnosis is inevitable but can be minimised by adequate quality control, says the committee. The main focus of attention concerning overdiagnosis and unnecessary treatment is ductal carcinoma-in-situ. There is no consensus on its management or on its probability of becoming invasive, so a trial has been set up by the UKCCCR to study the effects of local excision with or without adjuvant therapy. The committee’s conclusion is that breast cancer screening is effective and that the costs are in line with many other effective health service activities. It doubts the validity of the QALYs approach to quantify benefits against adverse effects and says that it is up to the individual to make this assessment herself. To maximise quality, the NHSBSP has been run with greater central control than is customary in health service development. There is concern that with the NHS reform, some districts may want to opt out of the present arrangements, a move that could threaten quality during the consolidation phase of the programme. Hence the committee recommends that the present management arrangements should be continued for another three years.
1. Breast Cancer Screening 1991. Evidence and Experience since the Forrest Report A report of the Department of Health Advisory Committee (chairman Prof Martin Vessey). 1991 Pp 40. Sheffield: NHSBSP Publications. Available from Julietta Patnick National Coordinator NHSBSP, Trent Regional Health Authority, Fulwood House, Old Fulwood Road, Sheffield S10 3TH
