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recently visited a friend whose Edinburgh street hosts a free library comprising two small shelves of books, protected by a wooden door, bolted to railings. Anyone can borrow or donate books, and I felt like browsing. Both shelves were crammed with paperbacks, and the previous donor had wedged their hardback into the cupboard, supported only by the closed door. When I opened it, An Illustrated Anthology of Erotica (Little, Brown and Co, 1992) fell into my arms.
On the cover, directly beneath a large-font ‘EROTICA’, was Heinrich Lossow’s painting of Leda and the Swan. Leda hadn’t gone to the riverbank to feed the ducks; that was clear. So too was the fact that I hadn’t heard the approaching footsteps of an elderly gentleman of military bearing. His look of disdain as I spun around — affording him the chance to register ‘EROTICA’ above the recumbent Leda in my trembling hands — was withering, and I scurried off, unwilling to wrestle the troublesome anthology back into place.
“Mmm,” was my wife’s unenthusiastic response to this true account, and ‘mmm’ is my unenthusiastic response to this anthology; the visual equivalent of a symphony played on one note. Having plunged in, as it were, to emerge with my eyes duly boggled, I turned to the foreword, which quotes the German art collector Eduard Fuchs (1870-1940), who claimed that “eroticism lies at the root of all human life”. Really? In that case, I can’t help feeling how dull I am.
When does eroticism become pornography? Possibly when subdued lighting yields to floodlit spectacle. And pornography is about more than sex, otherwise there wouldn’t be a demand, say, for a dominatrix in a jacuzzi full of custard.
But despite the absurdity of blank-eyed purveyors of customised — even ‘custardised’ — sex, pornography is no joke. For example, in Raymond Cleaveland’s Pornography and Priestly Vocations (www.catholicculture.org/culture/library/view.cfm?recnum=6182), his tale of porn-drenched priests includes the observation: “Like never before in the 2,000-year history of the Roman Catholic Church, the young men called to the priesthood today have been immersed in a pornographic world from the day of their birth.” Unsurprising perhaps, since as Shakespeare’s character Angelo demonstrates in Measure for Measure, nothing corrupts like virtue.
And if, as Fuchs notes above, eroticism does lie at the root of all human life, then there’s the risk of courting a sexually-transmitted disease, especially among those who cavort on computer screens. For instance, when Hill et al considered ‘Condom use and prevalence of sexually-transmitted infection (STI) among performers in the adult entertainment industry’, their results, published in the International Journal of Sexually Transmitted-Diseases and AIDS (2009, 20: 809–810), showed that men who had sex with men (MSM) reported higher rates of condom use “than either women or heterosexual men (25 per cent, versus 0 per cent, versus 7 per cent, respectively)”. There was a high prevalence of STIs among the study group, who had attended the STI clinic over 400 times. Thus, eight MSM had a total of 123 STIs, 14 heterosexual men had 135 STIs, and 15 heterosexual women had 22 STIs.
Given examples such as these, let us leave aside the question of the morality and ask whether pornography is a public health problem, as the US state of Utah declared in 2016. Perhaps the Utah state legislators had read Dr Mary S Calderone’s ‘Pornography as a public health problem’ in the American Journal of Public Health (March 1972, 374-376). Calderone complained that our capacity to judge when the expression of eroticism is appropriate “is so poorly developed in such a large proportion of individuals that the term ‘pornography’ begins to be applied with faulty judgment — one might almost say — promiscuously”.
But when it comes to determining what is eroticism and what is pornography, who, asks Calderone, “is to arbitrate and adjudicate the question, and on what basis?”
The answer appeared to be public health physicians. Dr Calderone, incidentally, was the Executive Director of the Sexuality Information and Education Council of the United States, which she founded in 1964.
Which dovetails into Prof Irving Zola’s essay Healthism and Disabling Medicalisation, where he cites Dr P Henderson’s 1971 address to the British School Health Service Group. Henderson called for school health workers’ involvement in a series of “health problems”. Zola cites 10, including maladjustment, juvenile delinquency, children in care and maladjustment. “One wonders,” asks Zola, “who or what is left out?” Pornography, I suggest.
My inclination is to favour the views expressed by David Boaz, writing in the Business Journal (22 July 2016), whose title asserts that “Porn is not a ‘public health crisis’”.
He warns that bureaucracies are notorious in their wish to expand: “So, true to form, the public health authorities have broadened their mandate and kept ongoing.” And it seems to me that the exclusion of a pornography subtype of hypersexual disorder from the DSM-5 was probably a close-run thing.
Erotica or pornography? Either way, it seems to me that sex is about a feeling… which a tastefully-illuminated dominatrix in a jacuzzi of custard will never evoke.
Everyone needs an editor”, observed London-born American writer Tim Foote (1926-2015), pointing out that Hitler’s original title for Mein Kampf (1925) was Four-and-a-Half Years of Struggle against Lies, Stupidity and Cowardice.
Leaving aside the thought that what Hitler needed more than an editor was an early demise, his rise to power and the collapse of the Weimar Republic enfeebled Germany’s hitherto vibrant medical press. For example, in his Racial Hygiene: Medicine Under the Nazis (1988: p70), Robert N Proctor notes how, in December 1933, Germany’s leading medical journal, the Deutsches Ärzteblatt, drooled over the benefits conferred by Nazism: “Never before has the German medical community stood before such important tasks as that which the national socialist ideal envisions for it.”
This “national socialist ideal” included human experimentation of appalling depravity. Decades later, the ethical backwash of those crimes stimulates contemporary debate in the biomedical community. For example, Dr Robert L Berger, in the New England Journal of Medicine (17 May 1990), considers ‘Nazi Science — The Dachau Hypothermia Experiments’, finding that some scientists insist on banning citations of these tainted data, while others advocate their dissemination, claiming that they might save lives.
Yet the assumption that the lessons of publishing and/or citing ethically-suspect experimental results might not have been lost on those who exercised medical editorial clout in the post-war era is mistaken. For example, published results acquired from the infamous 40-year Tuskegee Syphilis Study in Alabama evidently met editorial and ethical standards of scrutiny.
But in what other ways might patients’ lives be risked for the want of moral and editorial rigour? In a recent paper in the Journal of Medical Ethics, the philosopher Prof Thomas Ploug asks: ‘Should All Medical Research be Published? The Moral Responsibility of Medical Journal Editors’, contemplating the permissibility of conducting research but not publishing results. One example Ploug cites in support of his contention that publishing certain studies may harm patients is the analysis by Abramson et al in the BMJ (22 October 2013), titled ‘Should People at Low Risk of Cardiovascular Disease Take a Statin?”, where they note that “[t]he side-effects of statins… occur in about 20 per cent of people treated… ”
Ploug cites one study’s claim that “as many as 200,000 people in the UK have stopped taking statins” following media coverage, apparently increasing the likelihood of harmful effects to these people.
Ploug’s faith in editors’ ability to foresee “the potential harmful effects of publishing research” is evident because “[m]ost if not all editors have a background in research and therefore must be expected to be able to understand and critically engage with the content of research publications. And, very importantly, they are aided in these efforts by the reviewers, who may have a firmer grasp of specific areas within a particular field of medical research.”
So, did the editors/reviewers of the British Journal of Sports Medicine (online 21 January 2018) act irresponsibly in publishing ‘Statin Wars: Have we Been Misled About the Evidence? A Narrative Review’, a challenge to the efficacy of statins from Dr Maryanne Demasi, stating that “[d]octors and patients are being misled about the true benefits and harms of statins, and it is now a matter of urgency that the raw data from the clinical trials are released”?
Conversely, the notorious Naudé review raises questions about the extent to which certain editorial boards and reviewers are “able to understand and critically engage with the content of research publications”. In July 2014, the journal PLoS One published Naudé et al’s ‘Low Carbohydrate versus Isoenergetic Balanced Diets for Reducing Weight and Cardiovascular Risk: A Systematic Review and Meta-Analysis’. It reported that when the energy consumed by people following low-carbohydrate and balanced diets was similar, there was no difference in weight loss. This conclusion was crucial in Prof Tim Noakes — a leading promoter of low-carbohydrate, high-fat diets — being charged with “disgraceful conduct” by the Health Professions Council of South Africa two months later; a charge which he defeated… twice.
In ‘Lore of Nutrition: Challenging Conventional Dietary Beliefs’ (2017) by Noakes and Sboros, Noakes describes how his and UK researcher Dr Zoë Harcombe’s reanalysis of the review uncovered 15 material errors. Harcombe and Noakes corrected these errors, repeated the meta-analysis and found that the lower-carbohydrate diet “produced significantly greater weight loss than did the balanced diet”.
Harcombe and Noakes reported their findings in the South Africa Medical Journal (2016, 106: 1,179-1,182), asking whether the Naudé review was “mistake or mischief?”, with Noakes commenting in ‘Lore of Nutrition’ (p 128) that “the reluctance of the editors of PLoS One to properly investigate the nature of the material errors raises questions of who the journal is protecting, and why”. To date, the Naudé review remains unretracted. A correction that was issued on 2 July 2018 fails to address many remaining substantive issues raised by Harcombe and Noakes.
Scientific facts and human values are intertwined, entailing a moral responsibility on researchers and editorial boards to promote a spirit of genuine enquiry and constructive criticism based on ethically-acceptable content, but not unsubstantiated opinion nor authorial reputation.
Many years ago, we lived in London’s Braemar Avenue, where Ginger Baker of the super-group Cream had stayed in the 1960s. Despite my fondness for Ginger’s drumming, it was another resident — our local GP — who eclipsed Braemar Avenue’s rock god.
Impeccably clad, often in a Marengo dinner suit, white shirt, bow tie and cummerbund, this fine Asian gentleman received patients in his well-appointed consulting room.
The atmosphere evoked Edwardian Bloomsbury, not 1970s Neasden, and one felt less of a patient but rather a member of an establishment club. “So, how’s that cyst doing, hmm?” he might ask in his received-pronunciation English, reclining in a leather-upholstered chair and rolling an unlit cigar between manicured finger and thumb. We could have been dining in Belgravia, recalling an Old Etonian chum, now administering a distant outpost of Empire. The last thing our immaculately-tailored GP looked at was his watch. Consultation over, diagnosis made, treatment finalised, one emerged to find an orderly queue, its members drawn to his unhurried temperament and determination to treat patients, not diseases.
So how to respond to Cohen et al’s recent ‘An observational study of patients’ attitudes to tattoos and piercings on their physicians: The ART study’ in the Emergency Medical Journal (doi:10.1136/emermed-2017-206887)? This American study of over 900 emergency department patients concluded: “In the clinical setting, having exposed body art does not significantly change patients’ perception of the physician.”
Well, if I were admitted to an emergency department with a cardiac arrest or a smashed kneecap, I would uncomplainingly endure the ministrations of a medic as ‘inked’ as a tugboat captain and with ornamental ironmongery dangling from his — or her — ears like carabiners from a mountaineer’s hip. But faced with such an individual in the relatively relaxed surroundings of a consulting room, I might be less interested in what’s causing my gall bladder to swell like a wind-sock in a typhoon, and more interested in why, precisely, my doctor has tattooed on his — or her — forearm a shotgun-toting chipmunk.
In these ‘anything goes’ times, many would assert that it’s none of my business if a physician chooses to heal the sick with the Gettysburg Address tattooed down one side of his — or her — neck. Yet for all I know, beneath his impeccable Savile Row threads, Braemar Avenue’s star GP of the 1970s might have sported the Battle of Thermopylae all over his back; although my impression was that no tattooist’s ink had despoiled his skin. And one’s impressions help determine the success of a medical consultation. For example, writing in Clinical Paediatrics (2016, 55: 915-920), Johnson et al considered the ‘Adverse effects of tattoos and piercing on parent/patient confidence in health care providers’. In this American study, 314 voluntary participants were shown photographs of tattooed and non-tattooed practitioners, both with and without facial piercings. The participants “rated tattooed practitioners with lower confidence ratings when compared with non-tattooed practitioners and reported greater degrees of discomfort with greater degrees of facial piercing”.
And would you blame me if I were to hesitate before giving a surgeon — whose gamboge-hued bicep portrayed allegiance to ancient human-sacrificing Aztecs — the free run of my innards for a few hours of an afternoon? I only ask having been given cause to speculate that the psychological landscapes of some individuals who opt for tattoos might contain one or two darker contours than those who choose to remain unadorned. This was contemplated by Dr Viren Swami, whose ‘Written on the body? Individual differences between British adults who do and do not obtain a first tattoo’ appears in the Scandinavian Journal of Psychology (2012, 53: 407-412). His investigation of 136 British residents who visited a tattoo parlour found that “… compared to individuals who did not subsequently obtain a tattoo, individuals that did were significantly less conscientious, more extraverted [sic], more willing to engage in sexual relations in the absence of commitment and had higher scores on sensation-seeking”.
All in all, I prefer my physicians not to be inked… at least not so that I can see, but nor do I expect them to achieve the sartorial heights attained by Braemar Avenue’s star GP (although his ability to express himself clearly in plain English is a gift that has deserted many present-day practitioners and is one to be prized). However, I do recommend the findings of Dr Selena Au, who considered ‘Physician attire in the intensive care unit and patient family perceptions of physician professional characteristics” in JAMA Intern Med (2013, 173:465-467) and found that most respondents “indicated that it was important for physicians to be neatly groomed, be professionally dressed and wear visible name tags, but not necessarily a white coat”.
To many, I suspect, such strictures may represent a reluctance to change with the times and given the grave nature of these times, a tattooed medic is surely a trivial matter. Indeed, it is… which is my point. As Howard Jacobson once observed in the context of sexism: “To trivialise is also to dishonour.”
A tattooed medic dishonours the star GP of Braemar Avenue.
In his novel The Doctor (1812), Robert Southey warns: “Beware of those who are homeless by choice.” By way of context, Southey maintained that a man who cared no more for one place than another was someone “who loves nothing but himself”. Southey was long dead by the time George Price (1922-1975) came along to disprove his assertion. Price, an evolutionary biologist, was born in America, lived in England and far from loving nothing but himself, arguably loathed nothing but himself, finally taking a pair of nail scissors to his throat in a London squat.
Trained as a chemist, and with a Harvard doctorate, Price worked on equations first devised by William Hamilton, the founding father of sociobiology, who discovered a mathematical formula suggesting a genetic basis for human idealism. Price showed that while self-sacrificing behaviour exists among animals and humans, it is a behaviour shorn of nobility: Only altruism which spreads the genes that cause it can achieve long-term survival.
This insight plunged Price into a malignant sadness, and depression ensued. In 1972, in a letter to biologist John Maynard Smith, with whom he was preparing a paper for Nature, Price wrote: “I am now down to exactly 15p and my visitor’s permit for staying in the UK expires in less than a month.” Yet he remained optimistic, buoyed by the knowledge that there were baked beans in the fridge. Embracing the unconditional altruism embodied by The Good Samaritan, he cleaved without equivocation to the motto: “Sell all you have and give to the poor.” When Price helped tramps, alcoholics and assorted outcasts, they stole his money and he fled to a squalid Euston squat — where his hand found the nail scissors.
Many medical professionals press the tenets of evidence-based medicine into service as a means of uncovering scientific truth. But when it comes to health-related aspects of life as experienced by ‘the homeless’, George Price’s story contributes to an evidence base supporting the fact that ‘the homeless’ do not exist; at least they don’t exist as anything beyond a category. Categorisation can help in the search for scientific truth, but while the round hole of a ‘homeless’ category containing both George Price and the alcoholics who robbed him might bulge with data, to become meaningful, it needs a synthesis that acknowledges the square pegs of the individual lives that are rammed into it. Such a synthesis, I suggest, cannot occur without striving to accommodate at least a grain of critical truth. The challenge is to reconcile the fact that whereas the pursuit of scientific truth demands brains, the search for critical truth recruits the mind.
And it is here that the importance of the medical humanities asserts — or should assert — itself. Take, for example, the recent review by Gulati et al of the University of Limerick, published in the Irish Journal of Psychological Medicine (doi:10.1017/ipm.2018.15), which investigated ‘The Prevalence of Major Mental Illness, Substance Misuse and Homelessness in Irish prisoners: Systematic Review and Meta-analyses’. The prevalence of psychotic disorder was 3.6 per cent; affective disorder, 4.3 per cent; those homeless on committal, 17.4 per cent; alcohol use disorder, 28.3 per cent; and substance use disorder, 50.9 per cent. Noting that Ireland has the lowest per capita availability of secure psychiatric beds in developed countries, Gulati et al not only call for more beds within Irish mental health services, but also for “changes in attitudes towards mentally-disordered offenders” (my emphases).
In this context, it was encouraging to read an editorial in the journal Medical Humanities (2012, 38: 1) in which Dr Deborah Kirklin considers “the isolation, loneliness and helplessness of being homeless”, observing that she finds it “entirely plausible that changes in attitude and consequent realignment of priorities and outcomes can be effected by art”. While acknowledging that if such changes were to happen, they would be subtle, occur beneath the evidence-based radar and be unquantifiable, Kirklin states they would also be “to my mind at least, no less clinically significant”.
One can infer from the work of Gulati et al that raw data are essential to help define the problems associated with, say, homelessness and imprisonment. However, attitudinal change — perhaps including approaches advocated by, for example, Kirklin — might help to shape a refined response that addresses these problems.
On the other hand, it cannot be denied — and I write as someone who struggles to see modern art as anything more than talentless would-be celebrities daubing on canvas — that art isn’t all it’s cracked up to be. As John Carey reminds us in What Good are the Arts? (2005, p 140), Hitler excelled as a patron of the arts, informing Goebbels “at the height of the Stalingrad campaign… of his pleasure in Bruckner’s symphonies, and concluded by comparing the philosophies of Kant, Schopenhauer and Nietzsche”.
Yet despite this caveat, I suggest that one’s search for scientific truth can be much enhanced when it is tempered by an awareness of the need to also sharpen a humanities-derived, non-scientific gift which we all possess: Criticism.
Perhaps if he’d lived, George Price might have worked out an equation for it.
I waited for the trail to steepen before making my move. The lady in front – in her 60s – appeared to be struggling, and I offered a few words of encouragement as I passed. We were approaching the halfway mark of a 38-mile cross-country ultra-race. Thirty minutes later and faced with the first of the route’s three peaks I had slowed to a stuttering jog, slathered in sweat, my legs burning. Taking off my rucksack, I rummaged for a banana sandwich, cramming it into my mouth.
“Keep going,” said the same lady, overtaking me and easing up the tussocky hillside en route to the summit. Gorging on my food, I hoped she would interpret my “Hmphh rrggh” as “thank you”. I never saw her again, but in our brief exchanges we had shared the life-enhancing pleasure and pain of sport. We were competitors, and the better person had finished before me. To me, this was athletics at its best.
Athletics at its worst used to be associated with disgraceful doping behaviour by athletes. But even this has now been eclipsed by disgraceful dopey behaviour from athletics administrators. This is exemplified by the award-winning fracas, which the International Association of Athletics Federations (IAAF) has taken great pains to generate. And with a display of the same steely determination, which earned him a multitude of middle-distance medals and records, IAAF President Lord Sebastian Coe is bent on sustaining its mind-boggling folly.
It began when the South African athlete Caster Semenya won the 2009 African Junior Championships 800 metre women’s final in 1:56.72. By the time she won the World Championships in 1:55.45 later that year, questions over whether Semenya’s ‘masculine’ physique conferred an unfair advantage were being raised, not least by those she had beaten, with sixth-placed Elisa Piccione complaining “For me she is not a woman.” Meanwhile, as Jordan-Young et al (BMJ, 28 April 2014) note in “Sex, health, and athletes”, Semenya had undergone intensive medical and psychological examinations and justifiably commented that she had been “subjected to unwarranted and invasive scrutiny of the most intimate and private details of my being”.
By May 2011 the IAAF – endorsed the following month by the International Olympic Committee (IOC) – had introduced the “hyperandrogenism” rule that women participating in elite sport must have a serum testosterone concentration of less than 10nmol/L. According to the IAAF, “there is a difference in sporting performance between elite men and women, that is predominantly due to higher levels of androgenic hormones in men”. But this was contradicted by Ferguson-Smith and Bavington. Writing in Sports Medicine (2014, DOI 10.1007/s40279-014-0249-8), they acknowledged that although there is a relationship between exogenous testosterone and muscle mass and strength in men, “no such relationship between endogenous testosterone levels and muscle mass and strength has been established for women or, in particular, for female athletes”. Ferguson-Smith and Bavington further cite a study of hormone profiles in 693 post-competition elite athletes suggesting “serum testosterone is not related to athletic performance in women”, yet despite this, “the new regulations on female hyperandrogenism that now replace the rules for gender verification perpetuate the view that testosterone levels are the critical factor”.
As Prof Peter Sonksen notes (British Journal of Sports Medicine, 2018; 52: 219-229), the IAAF ruling led to several elite female athletes being banned from competition and at least four subjected to unnecessary medical and surgical intervention. Sonksen makes the point that “many eminent scientists felt that it was unfair, scientifically unsound and discriminatory”. Yet although the ruling was subsequently rescinded, the IAAF has now introduced draft revised “Hyperandrogenism Regulations”, that would be applicable to women’s track events between 400 metres and the mile and are currently under consideration by the Court of Arbitration for Sport in Lausanne, Switzerland.
This dogged attempt by the IAAF to introduce such blatant discriminatory regulations prompted the resignation of Prof Steve Cornelius from the IAAF’s disciplinary tribunal, telling Lord Coe in a stinging letter that he did not wish to be associated with an organisation that “insists on ostracising certain individuals, all of them female, for no other reason than being what they were born to be”.
In her response to the proposed ruling, Caster Semenya showed that while she might have raised serum concentrations of testosterone, she certainly has an abundance of intelligence: “I don’t talk about nonsense,” Semenya said.
At a time when there is much talk about gender identity, women’s rights and inclusivity, it is disappointing to read the comments of former marathon world champion Paula Radcliffe, who supports the proposal, observing that without a ruling “girls on the start line know they’re never going to get a medal in an 800m. That’s the bottom line”.
No, the bottom line is that we’re all different. For all I know the lady in her 60s who coasted past me may have been hyperandrogenic, although my guess is that she was a better runner who had trained harder. But if she had been hyperandrogenic, so what? That’s life, so let’s get on with it and stop whining.