20 An Independent Patient Review

	In 1985 Dr David Axelrod, New York State Commissioner for Health said, 	"Doctors are not the healers they think they are. If you don't need a 	doctor, don't go to one and if you do, deal with them as aggressively as 	you would any salesman."
	The Diseases of Civilisation by Brian Inglis

Medicine - sexist and elitist

In Understanding Doctors Dr Gillian Rice writes that, "The wish to maintain his priviledged professional status may encourage a doctor to "look down" on, and explain little to, patients. Even those who have no such motives (at least consciously) may have been trained to adopt a paternalistic attitude to patients, and so may fail to discuss important issues with them."
Because of the complexity of their reproductive cycle, the medicalisation of their biology, and because they are usually lumbered with the job of caring for the sick, women tend to be more often at the receiving end of medical attention than men. The profession is generally condescending. As Ms Faulder notes, "the view that patients have rights has hardly gained an inch in this country inside the medical establishment" and Ms Scully found that the residents she studied preferred "happy", obedient, respectful and thankful patients. Analysing 27 medical textbooks Bart and Scully found "a persistent paternalistic and sometimes condescending attitude on the part of the doctor toward his female patient. Women were portrayed as most appropriately fitting into traditional sex roles: anatomically destined for motherhood, they were fulfilled as people only by reproducing, mothering and attending to their husbands..
We consistently found gynecologists defining what the female role should be in terms of their own values and then labelling as emotionally unstable those women who sought fulfillment in other roles."
Women are therefore even more likely to have their ailments and their wishes disregarded by the male dominated, paternalistic medical profession. They often find it extremely difficult to persuade doctors to take their complaints seriously and many female complaints have been, and frequently still are, assumed to have no "real" physical basis.
I have heard of 3 cases where women with breast cancer were told not to bother the doctor with their lumps. A girl with bone cancer was told to exercise. Women wanting investigation of pain get valium. At other times they will be patronised because of what doctor regards as foolish or misplaced fears - no doubt due to "old wives' tales".
In 1983 it was revealed that it was common practice for anaesthesised women patients in teaching hospitals to be examined vaginally, without their consent being sought. Faulder writes that, "The shadow cast by medical paternalism is pervasive and infectious. Junior doctors learn their manners from their seniors, ward sisters play up to the consultants, and the patients humbly surrender their bodies for treatment." If junior doctors are taught to assault unconscious female patients then it is no wonder that they have no regard for either women's feelings or legal rights.
On 21 January 1984 World Medicine recorded the opinion of a Dr Margaret Puxton that if informed consent was going to be necessary before assaulting patients then "it might be necessary for clinicians to consider whether to admit patients on such terms".***
In May 1995 there were further allegations of violations of unconscious women.
Of course private patients are not molested in this manner.
Ms Faulder noted that we seem to be moving backwards into a situation in which the price that NHS patients pay for getting "free" medicine is that they are deprived of a choice and a voice in their treatment unless they go as private patients. However the NHS is funded by taxes paid by its patients. It is the many millions of working class men and women who ultimately provide the money to build the hospitals and pay the consultants who ignore or abuse them.
Dr Dally points out that, "The NHS did not change power relationships or the bias of gender and class in medicine. In practice it reinforced it" while in Gathorne-Hardy's Doctors Dr Tudor Hart noticed that patients are socially intimidated by doctors and that, "There are feudal social relationships within the Health Service". Ms Faulder notes that, "Doctors are invariably middle class... whereas a large number of their patients will be working class. This puts the latter at a distinct disadvantage when it comes to voicing their preferences or doubts to someone who speaks with a different accent, almost in a different language and who is surrounded by the trappings of authority....
Worried that they may be wasting the doctor's time, intimidated by the hospital aura, and often conditioned to believe that doctor knows best, they may be quite genuinely frightened of saying anything which might upset the doctor."
In that bastion of capialism the US, where the poor are treated in state hospitals, the situation pictured by Prof Ryan in Blaming the Victim is even worse. He writes that "The obscenities of clinic practice and emergency room brutality are too well known to repeat in detail: the long waits, the cursory examinations, the impersonal cold world of nameless men and women in white - a cast of characters that seems to be exchanged almost daily, each set of replacements being more discourteous, prejudiced, and unsympathetic than the last. Instances of the dramatic stories are known to almost everyone - the patient bleeding to death unattended while the health professionals prolong their coffee break; the misdiagnoses; the grossly incompetent treatments; the constant, obsessive concern with paying the bill."
Terri Mizrahi noted that the low class patients she observed in an American hospital were often referred to as "GOMERs" (Get Out of My Emergency Room), "hits", "trainwrecks", "turkeys", "scumbags", "dirtbags", "crocks", garbage", "junk" and "SHPOs" (sub human pieces of shit), sometimes within hearing of the patient.
Not so much Chicago Hope as Chicago Hopeless.
Although poorer people have shorter lives, worse health and more disability they also get less medical attention. The Black Report noticed that middle class patients tend to have longer consultations than working class. They ask more questions, cover more problems and are more likely to be known personally by the doctor, or visited by him if hospitalised. Higher class patients are more likely to get a voluntary explanation from their doctor and are more likely, especially older women, to be referred to a specialist. Higher class men, with a lower risk of heart disease, had the highest rate of heart investigations and the professional classes, with no lack of private transport, also had the highest proportion of home visits. It was found that richer people had more spent on them in drugs and the better off had better health care facilities. In 1994 the situation was unchanged with doctors in wealthy areas given more money for patients by the government than GPs working in socially deprived, unhealthy inner cities. Those in least need get most. And as medicine is a middle class industry the middle classes play the system better. 
The Black report was "very concerned about the standard of GP service in some poor areas with high mortality. There are single-handed general practitioners who live at a considerable distance from the areas in which their patients reside, have little knowledge of or interest in local culture - which lead as them to prescribe or otherwise treat patients inappropriately - who rely for a disproportionately large part of the year, the week or the day on the deputising services, and take little or no interest in the possibilities of new health centres, group practice or other forms of collaboration among and between health service and social service professional personnel."
Dr Gould's account in Medical Mafia is rather more colourful, "A few of these lock-up surgery proprietors gave their patients a moderately competent service during working hours, undertaking day-time home visits, and at least spotting those who needed expert attention, and referring them to the right consultant. But others practised an appalling travesty of medicine, prescribing harmful or dangerous amounts of inappropriate drugs, missing the signs and symptoms of serious disease, delaying response to urgent calls until it was time for the deputizing service to take over and neglecting altogether those patients too old or too ill to make it to the surgery."
Only 10% of practices are now single handed. It makes much more sense to share out medical cover between a number of doctors than to have to organise it all on your own, and some are now attempting to offload all out of office hours sickness. Gathorne-Hardy noted that although deputizing services are supposed to be an occasional relief for GPs a good many of them use the services continually. Even when it is made by a relief service a GP gets paid for a night call, on which he pays tax but he can charge what he pays the relief service against tax. He also gets travel and telephone tax concessions.
Mr Gathorne-Hardy wrote of a GP, spending most of his time raking in money from the Edinburgh hotel trade, who restricted his NHS list to 1,000 patients to gain the maximum financial benefits. "Because you get the basic practice allowance [then ?7,000], 70% of two ancillary staff, the rent and rates of my surgery." To ensure minimum disruption of his private money spinning empire his 1,000 patients were carefully selected - "Healthy adult males and females, under fifty. If they have any children - out."
About ?1,700 million, 7.5% of the NHS budget, goes to 30,000 general practitioners. They get 4 types of fees and allowances: a fee for each patient, more for older ones and supposedly more for those in deprived areas; a practice allowance; extras such as treating temporary residents, maternity services, night visits, contraceptive services, health promotion, examination of new patients, clinics, child health monitoring and minor surgery; and target payments for smear tests and immunisations. Other payments include the rent and rates of premises, and staff costs, which used to be 70% of the cost of 2 full time staff for each doctor but is now determined by a new, cash limited scheme.
And doctors are encouraged to take up residence in health centres provided by the district health authority or practice-owned, custom built premises, for which highly advantageous loan arrangements are provided and where they can increase their income by providing services such as asthma and smear clinics, run by nurses.
Helton is a depressed district with one of the highest breast cancer death rates in the world, high infant mortality, high unemployment and an asthma blackspot. I looked up home addresses for GPs in the area. Of the 18 I found only 3 lived in richer areas of the town whose inhabitants provided their livelihood. Of the rest 10 lived in the posh districts of Flimflam and Queenly, 5 miles to the south. The district Health Index showed that my home estate was the second least healthy area, with the other estates on the unhealthy side of the index. Flimflam and Queenly were the second and third healthiest. Most middle class doctors do not want to live among or have more contact with their low class patients than that strictly medically necessary. Why should they? Who in their right mind would want to live in a depressed district? Even my nursing sister won't live in Helton.

In the US Diane Scully noted that charity patients were used as teaching material and treated as less than human. One doctor told Ms Scully that she would be shocked at some of what she would see and that "some residents were just cruel and cause all kinds of unnecessary pain and suffering." Pregnant teenagers were the most abused, being subjected to repeated, painful pelvic examinations, snapped at if they moaned and threatened with being deprived of painkillers if they did not suffer in silence.
Besides excessive numbers of pelvic examinations women were delivered by forceps because residents wanted practice at forceps deliveries. Caesarian hysterectomies were sometimes performed unnecessarily. Patients were talked into having more hazardous hysterectomies instead of simple sterilisation. Appendixes were sometimes removed for "teaching purposes". Even the type of operation was determined by the sort of surgery a resident wanted to practice. Ms Scully notes "another abused form of gynecological surgery was hysterectomy for small, benign, asymptomatic fibroids, which can disappear without surgical intervention or remain intact without symptom."
Ms Scully believes that many women are not pleased with their obstetrical and gynecological care, being insulted by paternalistic physicians who expect them to act like happy, obedient children.
In Adverse Effects Sari Tudiver writes that, "Most women, even the highly educated, have at times, felt patronized or demeaned by doctors, reduced to uncomfortable silence, and made to feel too ignorant to even know what to ask" and Ms Faulder recorded that "psychological studies and plenty of empirical evidence indicate that often it is the most compliant patients who are inwardly seething with hostility and feelings of resentment and suspicion. Unable to express themselves articulately or at least in language which they think doctors expect to hear, unable to frame the questions they want to put, fearful of retribution if they do voice objections, these same patients may nonetheless feel quite desperately that they are being pushed around and treated as objects."
And they are perfectly correct in thinking so.
However sexism in the medical profession is directed not only against female patients. Doctor-to-be Sarah Holdsworth noted that "medicine is sexist" towards female doctors as well. The American Feminist Majority Foundation is attempting to halt medical sexism by "Empowering Women in Medicine". They point out that medical research is sex-biased, being based on the white, 150 pound male, and doctors neglect women, as in kidney patients where women are less likely to receive a transplant than men, those between the ages of 46-60 having only half the chance of that of a male of the same age.1
Although fewer medical students are now men the percentage of males at top medical levels is not decreasing and a study of those who became faculty members in 1976 showed that 11 years later only 3% of the women, compared to 12% of the men, had become professors.
In 1989 only 15% of British consultants were women, and in the higher status specialities even fewer are female with only 3% of general surgeons being women. General practice is 24.8% female but 60% of low status public health medicine and community health doctors are women. And although they live longer than men fewer women become fellows of the medical societies.
Consultants meet in secret to award each other 7,223 bonuses ranging between ?10,235 and ?48,605 which hospitals are obliged to pay in full, even to part-time consultants with large private practices, as long as they work 21 hours or more a week with NHS patients. However while 37% of male consultants get a bonus only 20% of women do.
Although consultants are supposed to be assessed each year in fact, Gould claims, it is a matter of being in with "the right people who will champion your claim", resulting in most of the money going to the more glamorous specialities, in high profile places.
Bourne and Bruggen wrote in 1975 that the system "means that elderly men continue to elect their own successors in perpetuity, and the repetition of existing patterns, right or wrong, is an inevitable consequence".
Mrs Stokes also remarked on this "dead hand rule", the result of which is that many women today are still treated according to the patronising, male supremist, outlook of the medical society's male, Victorian founders.

Unhealthy Practices 

An inaugural lecture of 1840 at St George's Hospital began with the words "You are about to begin your medical studies. The sole objects of such studies are two: first to get a name; secondly to get money."
Richard Gordon, in The Alarming History of Medicine, often mentions the immense sums doctors frequently commanded from their patients and Dr Scheider repeatedly stresses the financial advantages of surgery for the surgeon. Gathorne-Hardy notes that in the past, "it is clear a good number of GPs were even better off than they are today." He records the income generated in the early days of medical practice by the dispensing of ineffective placebos as, "Out of a 2s 6d bottle we made 220,000 per cent profit."
Even today although medical people nearly always support each other against the patient, doctors can be very nasty to each other in their money making efforts, and some senior practice partners have been extremely exploitative. Gathorne-Hardy's Dr Abney spoke of "working your guts out... and getting a thirteenth of what he was... it did nark after a time. His attitude was you could either like it or leave it." And Dr Thriplow said that in the last couple of years the senior partner didn't really do any work at all, although he still took three quarters of the money.
This was also noted by Dr Rice, who wrote that, "Several doctors I spoke to also complained that they had been the victims of unscrupluous older partners who loaded a great deal of work on to their shoulders and paid them a pittance in return. I heard of several practices in which a senior partner, who handled virtually all the financial maters alone, had embezzled many thousands of pounds from practice funds, while naive junior partners remained oblivious to the trickery going on under their very noses."
Another medical racket was described by Gathorne-Hardy's Dr Colkirk - "we're beginning to hear of a lot of nasty arrangements among doctors. Like an established principal taking on an assistant with a view to partnership, and then never proceeding to the partnership. Leading the guy along the garden path for a couple of years and then when the guy says "Well, what about this  partnership?" "What partnership?" So the guy leaves after two years, and he gets another sucker for two years."
The introduction of GP training provided another opportunity for exploitation, noticed at an Exeter conference in 1981:-
"They all said they weren't being "trained" at all. No teaching, no seminars, just greedy lazy GPs eager to get an extra pair of hands to take surgeries, do night calls and weekends and pocket masses of cash as well."
And of course it wasn't only each other they robbed.
Some GPs claimed capitation fees for non-existent patients, one claiming for 43 persons supposed to be living in a 3 bedroom house and another claiming for 23 patients at the same address - a 1 bedroomed flat which the doctor owned. In one West London area the FHSA was paying for 800,000 patients, although the census found a population of only 600,000.
In 1982 an Australian Health Ministry report stated that 2,500 of the country's 27,000 doctors were suspected of cheating the national insurance scheme. And Dr Velling, speaking of a colleague, said "He spent all his time seeing private patients, but was using my NHS script pads. And leaving me to do all the NHS work. He was also cheating BUPA... He was a meticulous surgeon, but he was a crook."
Besides extra jobs in industry, media appearances and writing medical reports, books and articles the drug industry also provides money making opportunities. By prescribing new drugs to patients the doctor can claim gifts or financial rewards and it has been claimed that upto ?50,000 a year can be made this way.
Professor Inman of the Drug Safety Research Unit is reported in a What Doctors Don't Tell You special report as saying, "I blew the whistle on one product where a doctor had 230 patients in a study for rheumatoid arthritis when he had only 5 sufferers in his practice. He alone was responsible for 10 per cent of the entire market for that drug."
The professor was probably more annoyed by the perversion of scientific principles than the fraud perpetrated. The more usual situation is described by Gathorne-Hardy's Dr Wheatacre, "doctors stick together, as patients often say, and I said to a student, "You know, you're in this profession, you're safe for life." Well, if you go mad, perhaps. But you can take to the bottle, you can take to drugs. The chances are you will never be found out. Your colleagues will do nothing about it."
And many doctors do take to the bottle. As Dr Rice observed, "In 1981 it was estimated that there could be as many as 3,000 practicing GPs who are alcoholics, and another study concluded that GPs were nearly three times as likely to become alcohol dependent as other people of the same social class. Along with other doctors, GPs are roughly three times more likely to commit suicide than the general population and twice as likely to be admitted to a psychiatric ward."
Physician heal thyself!
In When To Say No To Surgery Dr Schneider notes that "There are only limited constraints on bad surgeons and bad surgery", and points out that, "Both pilot and surgeon are highly trained professionals in whose hands lie the responsibility for your life. But the pilot must pass semiannual examinations of his physical, mental, emotional and professional qualifications. Doctors with failing eyes and trembling hands do delicate surgery and there is no one to say nay. It is as rare as a blizzard in July for a doctor's hospital, colleagues, medical society or state licensing board to inquire into or remove a doctor's privileges for ailing physical health. But that blizzard in July is frequent compared to action against an M.D. for drug abuse, alcoholism, mental aberration or criminal or moral failings. With almost half a million doctors in the United States, only a meagre few lose their licenses each year."
However although flying is said to be the safest form of travel, air accidents are likely to be spectacular, result in the deaths of healthy people and are often held to be caused by the flight crew. Many more people die under medical attention but they are usually in ill health and their deaths are unspectatular single events. And although the medical profession is applauded when patients survive it is rarely accounted responsible for their demise. Since medics are rarely held responsible for deaths not only is their competence unmonitored but newly qualified doctors are expected to put in hours incompatible with efficient working practice. Could you imagine an airline pilot yawning his way to the cockpit, having had only 5 hours sleep in the last 48 hours?
A surprising thing is that although doctors will cover up for drunks and incompetants they will rarely gave real support to a doctor suffering from the sometimes considerable stresses of medical practice. Which may be one reason for their high suicide rate. One of Rice's doctors reported, "Generally, in medicine, doctors don't talk about emotional things. And when a colleague has a problem they don't want to know."
Another of Gathorne-Hardy's doctors spoke of the racial prejudice amongst GPs, "It's a hidden thing in general practice, you'll find quite a lot of white doctors, to my embarrassment, will be extremely rude about Indian, Pakistani and other foreign graduates."
In The Health Conspiracy Dr Collier notes that racism is "deeply rooted in the structure of the medical profession", revealing that as late as 1986 an applicant to St George's Hospital Medical School would be awarded 17 penalty points for being judged as being of "non-caucasian origin".

Dr Kildare - or Dr at Sea?

Most sickness is dealt with at home with occasional visits to the doctor. And 93% of all consulted illness is managed in general practice. Yet GPs are taught in hospitals where the diseases encountered in training are not those frequently found in general practice. Many illnesses such as childhood diseases, common infectious diseases and aches and pains are never seen in a hospital at all. And although it is doctors that usually have to tell people that they are seriously ill or dying, or that close relatives are dying or dead, they have little or no training to to do this job, which may be left to the youngest, and least experienced, of medics.
Gathorne-Hardy's Dr Uplees noticed, "That was the trouble, they didn't teach you anything except things you could learn from books anyway. They didn't teach you that people have feelings and adolescents don't know everything - they don't teach you about people and it's rotten for the patients." Dr Yetts noticed a similar lack of training in sex information, "We're not trained to sex counsel. I wasn't even trained in contraception at medical school. I picked it up purely by reading."2
In fact, Gould's opinion was that hospitals are "bad places in which to teach the art of medicine, and the present medical course is a disaster...
The schools do now pay lip service to the need for some tuition in the handling of sick people, as opposed to merely coping with disease... Most of their time, however, is spent at the feet of the hospital gurus, whose interests are narrow, even though their learning be profound, and none of whom will have had the least instruction in how to teach...
Thus bright and idealistic school leavers enter medical school at an immature age, and thenceforward are isolated from their fellows in other walks of life, to emerge, six or seven years later, their idealism weakened or killed by starvation, their brains made rubbery and set by overcooking, having been rigorously and vigorously "processed", but educated hardly at all."
Even worse than the lack of instruction in common complaints Gathorne-Hardy found that, "Studies at Edinburgh, Manchester and Aberdeen, reinforced by other work, suggest that quite a number of students not only have a number of qualities trained out of them, but had adverse attitudes trained in. For instance, a high proportion left Edinburgh with views that at the least indicated insensitivity towards, and at the worst a positive hatred of, people and patients. Elsewhere, students have shown insensitivity to mental illness, suicides and the old."
Finally Dr Miston said of the vast majority of GPs, "They really have retired intellectually. They are simply prescription and certificate pushers... The doctors are more interested in their own free time and making money than in the actual clinical care of patients."
Studies suggest that a doctor's diagnosis is right only half the time, their prescribing habits are similarly faulty and less than half their patients take their medicine as instructed. This implies that only one in 8 patients gets the right medicine at the right time.
In one experiment when patients with severe abdominal pain were diagnosed by a computer the machine's conclusion as to whether surgery was necessary was more reliable than their doctor's. J Hughes of the MacLean Center for Clinical Ethics, Chicago University, describes doctors as "dinosaurs in a high tech world" and declares that "even the crudest of our current computerized dignosis and treatment programs are more consistent and accurate than the decision-making of individual doctors". During the first 2 months use of its computerized drug system Abbott-NorthWestern Hospital in Minneapolis marked 1,500 drug orders as inappropriate while LDS Hospital in Salt Lake City found that the incidence of adverse reactions fell from 5 to 0.2% and the post-surgical infection rate fell from 1.8 to 0.4%.
It is, in fact, logically impossible for any person to really know all about all the drugs currently available. What is needed is a comprehensive database which when given a patients medical facts and diagnosis would provide one or more suggested drug treatments, along with information about side effects and counterindications. What is available is the British National Formulary.

You might think that at least whose licensed to cut people open would all be well qualified, especially in the US, but Dr Schneider tells us that, "At the 1981 annual meeting of the American College of Surgeons, the highest ranking body of surgeons in the country, Dr G Thomas Shires, president of the College, stated that, "Surgery is performed in many approved hospitals by untrained and unqualified individuals." He rated 20,000 of the 70,000 physicians doing surgery in the United States as substandard."
And among the specialities gynaecology has low esteem. In 1973 Tyson noted that gynaecology residents had low exam marks and high levels of foreigners and remarked that, "Obstetricians and gynecologists are looked upon by many members of other branches of medicine as substandard surgeons whose ability beyond caesarean section and simple hysterectomy are inadequate." In fact there was so little experience of surgery other than caesarian section and hysterectomy in their training that some hospitals restricted gynaecologists' operating privileges to simple gynaecological procedures, requesting them not to attempt repairs of any injuries they inflicted upon surrounding tissues.
Ms Laws thinks this low opinion is because, "In a sense, gynaecologists do the dirty work of the patriarchy, dealing in areas which are on the whole hidden from the male view. The speciality is not highly respected within the medical profession, perhaps exactly because it is only women over whom the gynaecologist can exercise medical power."
It came as something of a shock to find that what I thought must surely be a paranoid view of gynaecologists had been observed by others, such as Susan Quilliam and Dr Gould, who remarked that "Some gynaecologists seem, by their actions and attitudes, to actually dislike and despise the sex they have chosen to serve, so that you wonder why they ever went in for the trade. Could it be in order to assert a dominance over women they fear they may not naturally possess?"
An interesting thought.
In 1993 an American study reported that most residents prescribed the pill and tied tubes but 38% had never inserted an IUD, 47% had never performed an early abortion and 43% had never done a late abortion. It was concluded that IUDs were underused because of doctor misinformation and lack of training. The cap is apparently not even available in the US. A shortage of abortion doctors was noted, though considering that in their attempts to preserve unwanted womb parasites avid Pro-Lifers have taken to assassinating abortionists, this is hardly surprising.
With this lack of proficiency in the US, British women will not be reassured by the words of Dr Cavanagh of Tampa who writes that, "house staff education in Britain compares unfavourably with graduate education in obstetrics and gynecology in the US. In Britain there has been a failure to develop residency programs involving graduated responsibility, and the house staff are engaged in service rather than education. This has lead to the dumping of the "distasteful chore" of NHS abortion on the house staff, further increasing their service workload."
As the one thing gynaecologists do get lots of practice at is removing female organs you would think that at least they could get that right but Monaghan points out that removing a womb with a fibroid in its neck can be difficult, as surrounding tissues may be displaced. Although a little surgical know-how makes the operation "relatively simple and safe" he says that some surgeons have given up the attempt. The bleeding from such operations may be severe.
Damage to the urinary system is fairly common in gynaecology, with many cases involving routine hysterectomies with no complicating features.
As Monaghan points out when a surgeon tears and traumatizes tissues his patients have high complication rates and long recovery periods. Nikki Henrique's surgeon also noted this saying, "your GP should choose the surgeon carefully by referring you to a consultant whose wounds heal. It's like gardening. Good surgeons have perfected a technique which involves a minimum amount of tissue handling, which results in rapid recovery. There are some surgeons whose wounds heal and there are some who are very clever but who always get into complications - the wounds get infected, there is a discharge, they break down. It all lies in the way you handle the tissue."
Patients are, of course, never given any information on the complication rates or recovery times of a surgeon's patients.
In a dilation and curettage, labelled by one woman's magazine as "the unnecessary operation", Dr Schneider describes the curette used to scape out the womb as "an instrument as delicate as a potato peeler." Endometrial aspiration is a quicker, less dangerous way of getting a sample of the womb lining and, as Dr Angela Coulter points out, a D & C won't help your heavy periods. Yet the D & C remains the most common gynaecological procedure, with over 117,000 being performed in 1975 Britain, and Dr Schneider relates how a gynaecologist can "pocket over a thousand dollars for a couple of hours' work doing a procedure that took only a few hours to learn during his first month as a gynecology resident."
Some French doctors believe that adhesions (called synechia) which form inside the womb as a side effect of scraping it out may cause infertility problems, and do not like to use D & C for diagnostic purposes. At least one study of infertile women showed that many had these adhesions, and that nearly all them had previously had previously had a D & C, either for abortion or as a diagnostic procedure.
Dr Scheider's guide to hospitals is similarly depressing. "Privately owned hospitals are moneymaking machines. In many cases patients are exploited to the limit (of their insurance or their pocketbook) by overpriced and unnecessary services. The institution is run like a business, for that is what it is, with the profit motive coming first.
Municipal or county hospitals provide essentially free medical care to the unemployed or uninsured out of the begrudging tax dollars of the better-heeled citizens. They are often shabby, shoddy, ill-equipped and understaffed."
Scheider points out that even when profit is not a major consideration the interests of the patient are still a long way down the list.
"Nonprofit hospitals do not pay dividends to shareholders like privately owned hospitals, but there are beneficiaries nonetheless. The hospital provides a career home for the full-time physician who for one reason or another does nor care to brave the vissitudes of private practice. Good income, fringe benefits, security, power and prestige provide motivation for keeping good old Hometown Community Hospital afloat with a steady tide of paying patients.
Teaching and university hospitals house many physicians whose primary interest is research, second is teaching of new crops of doctors and a distant third is patient care. Despite the lip service of so-called informed consent, the house staff is practicing new or learning old procedures (many tricky or dangerous) on your body, procedures that you have been led to believe you need for your health care. Some of them sincerely and misguidedly think you need it too, having been conditioned by an interventionist-orientated medical philosophy. Meanwhile, the instructors of these medical students, interns and residents are including you in their clinical trials of new drugs to find out - on your biological system - if they work and what fascinating and unexpected toxicities develop. Humanitarian motives may be present, but the pressing desires of the academic physician are publication and promotion."
It is interesting that Terry Mizrahi records the academic Stella as saying, "I know I'd be frustrated and bored within six months if I were only able to treat patients with currently available treatments. It's fun to try new drugs".
I wonder if it's fun for the patients too.

Major Mutilation with Minimal Trauma

As it leaves only a few small scars and may take only days to recover from, keyhole surgey has become understandably popular with patients. However organs cannot be as clearly seen during keyhole surgery and it takes practice to use the remote control instruments. Because of these difficulties there have been deaths and complications caused by damage done to organs during surgery. The Panorama production Bad Medicine asked whether too few controls on doctors lead to patient deaths. Their expert, Professor Cuschieri, was certain that patients were at risk because of the lack of training in laparoscopic techniques.
There has been a surge of interest in keyhole surgery with many doctors wanting to play with the latest toys. And as Dr Schneider writes, "Before a pilot can fly a new plane, use new aircraft equipment or use airports with new electronic systems, he must study for and pass rigid qualifying tests. Surgeons need only dare to do a new procedure."
Most major complications occur during the first 10 performances of a procedure by a surgeon, so supervision during the learning period would seem to be a very good idea. However the College of Surgeons refused to accept any regulation or any effective control on keyhole surgery. The Royal Colleges issued surgery guidelines but no training was required before a surgeon operated on a human. Only recently, with publicity from laparoscopic deaths, have the colleges made an attempt to ensure that surgeons are at least minimally competent. This has come too late for the patients of Dr Siddle, a gynaecologist struck off the medical register after inflicting injuries on a series of women during keyhole surgery.
Also randomised tests have suggested that the benefits of keyhole surgery may be less than expected while the hazards can be considerable, as gallbladder removal seemed more likely to be followed by dangerous complications when done by the keyhole method.
When performed by an experienced operator keyhole surgery is no more dangerous than open surgery, leaves smaller scars and, if the operation is major, is usually followed by a quicker recovery. There is also no chance of your surgeon infecting you with disease through accidentally cutting himself and bleeding into your body cavity, as happened to at least 20 patients of a doctor carrying the hepatitis B virus. It does not seem to be indicated for more minor surgery like hernia and appendix operations, where open surgery appears to take no longer to recover from and is less expensive and time consuming.
I thought a journal article about the performance of 82 laparoscopically assisted vaginal hysterectomies at an American university hospital was illuminating. In all 29 different staff members had a go, 13 doing only 1 operation and only 4 doing 5 or more. And 4 doctors attempted their first procedure without guidance from an experienced surgeon. As 2 had done an animal laboratory course and the other 2 a medical education course in operative laparoscopy they considered themselves perfectly qualified to operate without any further training or supervision. None of the others attended any educational courses on laparoscopy before operating on women. Senior gynaecology residents were always involved and most of the time performed half of the surgery.
A Dr Malinak wrote that laparoscopic surgical methods had become popular without clinical trials to determine their efficacy and safety. He noted that the New York State Department of Health recommends supervision on 10 to 15 cases for credentialing. And a consensus panel of the National Institutes of Health recommended even more stringent criteria. He was not happy at surgeons performing new techniques with no supervision at all or the fact that medical apprentices did much of the surgery. And as early as 1973 Patrick Steptoe thought it was "appalling" that anyone "should think of attempting to train people in laparoscopy, particularly for sterilisation, in a course lasting a few days".
The overall impression given is that the patients were experimental fodder for the medical staff to practice surgical techniques upon. Guinea pigs who were also paying for their experimentation. Moreover at $12,800 the cost of laparoscopic assisted vaginal hysterectomy was significantly higher than either abdominal ($10,500) or vaginal ($9,300) hysterectomy. And as other medical centres had laparoscopic assisted hysterectomy costs of between $4,000 and $6,000 and abdominal hysterectomy bills about $6,000 the hospital was generally expensive.
In the following discussion Dr Dennis Lutz declared that his own vaginal hysterectomy rate was nearly 80%, with an average operating time of 34 minutes and a cost saving of $3,000 to $8,000 over laparoscopic assisted vaginal hysterectomy. Dr Pildes thought the operating time incredible as any competent vaginal surgeon could do a routine vaginal hysterectomy in less than an hour. He wanted to know why only 18% of their vaginally mutilated patients were also castrated and declared that residents were being trained by people who didn't know how to do vaginal hysterectomy properly. His own vaginal hysterectomy rate was 90%.
This article says that young women with no history of surgery, endometriosis or pelvic inflammatory disease will not usually require laparoscopy for a safe vaginal hysterectomy. But as Dr Goldfarb writes, "If a vaginal hysterectomy is not being performed for prolapse the chances are it doesn't have to be done at all." If a woman's organs can be so easily removed, there can be little wrong with them and scant justification for their removal.

The Pen is Mightier Than the Knife?

The American books that related the less pleasant facts about medical treatment, like Dr Mendelsohn's MALePRACTICE and Scheider's When To Say No To Surgery were not easy to obtain. Dr Cutler's book Hysterectomy: Before and After is the most detailed book on the effects of hysterectomy that I came across with references to nearly 1,000 journal articles. My local library could not find it anywhere in Britain - not even in the British Library. They eventually got a copy from a medical library in Limerick. Not only was there not even a single copy of Lynne Payer's book How to Avoid a Hysterectomy anywhere in the UK but as it was out of print they couldn't get a copy from its American publishers either. Yet superficial pap written by members of the medical establishment, glossing over the facts that there is little medical knowledge, or adequate medical treatment, of female complaints and that surgery may be hormonally devastating and fraught with complications is found is every library in the land.
In Fundamentals of Obstetrics and Gynaecology Vol 2 Gynaecology, published 1990, Dr Llewellyn-Jones writes that, "Total hysterectomy is indicated in cases of symptomless myomata if the uterus is larger than 14 weeks gestation and the patient is aged 40 or more (or is younger but has no desire for children).
The physician must explain that the removal of the uterus has no side-effects. Consequently the sexual urge is unaltered. Finally it must be stressed that coitus can take place normally after hysterectomy once the vaginal wound has healed as the length of the vagina is, if anything, increased."
Of course Dr Llewellyn-Jones does not say that hysterectomy does not upset your hormones, damage your love life and expose you to operative and infective risks - merely that the patient should be told that it is complication free.
And his statement about vaginal length is a complete contradiction of Given's actual measurements of vaginas.
As hysterectomy is prescribed for pelvic and sexual pain, and is supposed to improve women's health, you would expect an increase in sexual satisfaction afterwards but in another 1990 publication, The A - Z of Women's Health, Dr Llewellyn-Jones admits of the operation, "In a study of the sexual function of women after hysterectomy about one third of women were found to enjoy sex more, about one third enjoyed it less and in the remaining third there was little change." So overall there is no sexual benefit from being mutilated. However the doctor plays "blame the victim" and continues, "If the woman had a good and satisfying sex life before hysterectomy she was likely to have a good (or a better) sex life after the operation."
So if you do have problems afterwards it's not due to surgical damage, hormonal upsets or sensory deprivation it's down to your own bad attitude. But the doctor is consistent in his view of women and blames the neurotic little woman's bad attitude for painful sex, irritable bowels, irritable bladder, pelvic congestion, pelvic pain, "side effects" of the pill, itchy bum, and non consumation of sex, which is usually due not to him being unable to get it up but to her twitchy vagina (vaginismus) due, wouldn't you just know, to fear of penetration caused by gossiping with the girls. And negative feelings about menstruation come not from male dominated social pressures but from the bad attitudes of mummies and friends.
Considering that only 0.17% of women suffer from vaginismus while (according to Best magazine) 10% of men experience long term impotence Dr Jones' view of causes of sexual difficulties may be coloured by the facts that 1) he sees no male patients and 2) few males like to admit to having periods of impotence. Or perhaps it may be that sexual frustration for a female is socially regarded as matter of no importance while a frustrated male clearly needs his defective mate sorted out.
There is no separate entry for myomectomy, an operation Dr Jones clearly reserves for childless women, as shown by "If a woman desires children, the fibroids can be "shelled" out of the uterus, and the shape of the uterus restored to normal by an operation called a myomectomy", and one so rarely done as not to require any further mention.
It is depressing to think that Dr Llewellyn-Jones is one of the less sexist and patronising of medics.
The BMA's Complete Family Health Encyclopedia, yet another 1990 publication, does have an entry for myomectomy - 4 short lines. The entry for hysterectomy consists of a full column of text, an illustration and 3 diagrams. The BMA also notes that "until about the 1940's most surgery involved the cutting out of diseased, damaged or deformed tissues or structures... Today, many operations emphasise repair or replacement rather than excision..."
Benagiano might agree, writing that, "Increasing emphasis must be placed on the use of myomectomy rather than hysterectomy" and "as long as 90 years ago, some gynaecologists realized that "the guiding for the surgery of the 20th century" should be "the conserving of the function", rather than "extirpation" of the uterus."
But for the vast majority of practitioners the much preferred treatment for  female organs remains excision - and the more they can excise, and the more often they can excise it, the better they like it.

CINAHL is a Nursing and Allied Health database designed to meet the information needs of nurses and allied health professions - or so it says. Although about 30% of women will develop them, and 1 in 15 will be hysterectomized because of them, I found only 18 references to fibroids (4 of them hysterectomy articles and 1 concerning fibroids in the gullet) and the only reference to myomectomy concerned the problems of blood conservation when operating on a Jehovah's Witnesses. There were 149 references to hysterectomy. Obviously the nursing profession has no need for information about myomectomy since hysterectomy is nearly always "the procedure of choice."

The National Hysterectomy Service

Are the abuses noted by Dr Mendelsohn and Diana Scully not perpetrated in England or is it just that nobody has studied them? As British surgeons are not piece workers there is no obvious financial reason for them to perform unnecessary operations. And indeed the British hysterectomy rate is only half that of the US. But as in so many things the American experience, and the American attitude to women, childbirth, the womb and ovaries, is found in most of the rest of the world - a male dominated world. And though the underlying financial reason for escalating medical intervention may not apply in other countries the interventionist attitude is copied and the same contempt for female organs is globally evident.
Dr Cutler thinks that you should consult a doctor as soon as you become aware of a symptom and thinks that in an ideal world, your doctor would:

1)	be willing to take a conservative approach when appropriate;
2)	bring to your relationship reasonable amounts of time, patience, and goodwill;
3)	be capable of listening to you and reflecting about your problems and your overall health needs;
4)	have the proper training to deal with your problem;
5)	be frank about the limitations of his or her training or skills, and be willing to recommend another doctor when appropriate.

So how well does your NHS general practitioner fit the bill?
NHS patients have a right to have a GP but the GP can refuse to refer you to a specialist. You have no right to be referred to the specialist of your choice and no right as such to a second opinion. You have no right to choose who performs your operation and no right to choose the anaesthetist. You can object to students observing you but not a posse of doctors and nurses. You have no right to choose your own treatment. You can refuse any form of treatment proposed including drug treatment but if you refuse the consultant's choice he can dump you, no matter how ill you are, and many of them will do so. And of course they can malign you in your medical notes, or to each other, warning what a bolshie, awkward, ungrateful or even, in their professional opinion, neurotic, cow you are.
And you can't have any of their disparagements removed from your records.
Henriques and Dickson noticed that, "it is crucial to be referred to a surgeon who is competent", but "Patients on the NHS are very much restricted to the luck of the draw as to who happens to be a gynaecologist in their hospital catchment area. Therefore the GP's choice is vital to the successful outcome of the operation, as patients do not have access to revelant information." It is interesting that this implies that some surgeons are not competent. And patients are not allowed access to any of the scant information on surgical ability, since they might then refuse to be operated on by inferior surgeons, and what would expensively trained incompetents then do for a living?3
However as the local health services would have to pay for any non local treatment if the desired treatment was locally available they could refuse to pay anybody else. So unless your local hack cannot even attempt conservative treatment you may have to be operated on by the local medic, no matter how inexperienced or incompetent they are.
Unless of course you pay privately - when you can have whatever you can afford.
The average consultation time in general practice is about 6 minutes, scarcely long enough to give a diagnosis, never mind time to listen and reflect about your problems. One Helton practice leaflet informed patients that its emergency, same day, appointments were for problems that would take up less than 5 minutes of the doctor's time, so you'd better not have an obscure, acute ailment.
Pulse reported in July 1982 that a survey done of 15 countries found British doctors spent less time - less than European, American, Scandinavian, Israeli or Canadian doctors - consulting with patients. They spent 4 hours a day consulting while Canadians spent 7 hours. In hospitals the situation is often even worse. As Mizrahi noted, "So intent were the staff on doing everything to the patient, there appeared to be little time or awareness devoted to doing anything with or for the patient". Doctors are too busy being medical specialists to have time for patients.
Even if the doctor does listen to you, as Naomi Stokes says, "the only thing a male doctor knows about being a woman he knows by hearsay." And what he does not experience he may discount as unimportant or even imaginary. As Ann Oakley remarks "It is not accidental that the two main biological events placing women beyond men's understanding, namely menstruation and childbirth, have both generated psychiatric diagnoses in the form of PMT and post partum depression." Barely 25% of GPs are female and the medical machine has so imbued them with its sexism that most of them behave like honorary men.
Writing in Positive Smear Susan Quilliam found that among the women she interviewed, "There were many reports of questions going unanswered, and there were also many complaints about doctors being patronizing or "talking down" to their patients. When women tried to discuss treatment they were often met with an unwillingness to accept the possibility that they have any say in the matter." Many women also felt that doctors in general had a vested interest in appearing infallible.
In spite of the empty promises of the Patients Charter there is no absolute right to information on your treatment. Doctors cannot be bothered to tell you about the many sorts of operative and drug risks and unless you ask specifically and repeatedly for information about risks any damage you suffer will be legally regarded as your own bad luck.
Ms Faulder writes, "In effect the patient will be told only what the doctors think it is fit for her to know not what she might consider necessary to make an informed decision for herself. This outrageous paternalism has been endorsed in case after case in the English courts where judges have unfailingly maintained that the only standards which counts for asssessing the amount of information to be disclosed is the standard upheld by a substantial body of medical opinion."
And we all know what is the opinion of the medical profession when it comes to female organs. The Telegraph magazine relates that when it was noticed that one woman's migraines were related to her menstrual cycle her doctors decided she should have a hysterectomy. Afterwards she found "the attacks become more severe and frequent rather than less." Would any other organ be destroyed in such a cavalier fashion?
When the FDA insisted on package inserts for ERT carrying warnings about the risk of cancer the drug industry, the American Medical Association and the American College of Obstetricians and Gynecologists all objected to women getting this information. In September 1977 the Pharmaceutical Manufacturers Association and the ACOG claimed in the US District Court in Delaware that the FDA proposal "interferes with the practice of medicine by physicians according to their best judgement and by dictating the way in which they may practice their profession... The regulation will discourage patients from accepting estrogen therapy when prescribed by their doctors which will impair the reputation of estrogens and reduce the sale of the drug and others."
They all preferred to have ignorant, uninformed punters, blindly depending upon false reassurances from their medics and the drug industry. In Britain no such warnings about HRT were given to the women who are the ones taking these risks.
Even where there is an obligation provide informed consent the patient rarely gets it. After a patient was briefly told of possible complications Dr Harrison writes of the advice she was given was that, "It was all lies. She would be in agony after her surgery and it would be weeks, even months, before she had her strength back. And no one was telling her about the common changes in sexual functioning after hysterectomy, the decrease in vaginal lubrication, difficulty in reaching orgasm, difficulty with arousal."
Marcia Millman informs us that "New patient consent forms and requirements are actually more specifically designed to protect physicians against liability than to make sure that patients are well informed about the procedures they submit to" and that, "As patients demand more information and access to their medical records, the chart is more frequently constructed as a "case record" having more to do with protecting the doctor from lawsuit than anything else."
Patients in clinical trials fare no better. A FDA survey of compliance with informed consent requirements in 238 cinical studies found that in the majority of cases there was at least one major violation of informed consent regulations.
Institutional Review Boards are rarely inspected and of the 25 Boards inspected between 1971 and 1974, 17 failed to include people from one or more of the backgrounds required by FDA regulation, 13 had approved faulty consent forms, 8 did not review the study after approval, 5 kept no minutes of meetings, records or documents and 4 had incomplete or sketchy records.
Faulder states that, "If a doctor proposes an operation to a patient but omits to tell her that it is an operation of choice and is not the only possible treatment for her condition then the doctor is practising coercion by deceit." If doctors tell all fibroid females that their fibroids alone can be removed then I'm a sex goddess.
As far as wombs are concerned conservative approaches are restricted to breeding females under the age of 35, and any older female who doesn't like this will usually be ignored and steamrollered into accepting the proper, destructive treatment for female complaints. When you are referred to a specialist you will get whatever treatment that specialist's "firm" likes - not what you want. The firm will tell you that its chosen treatment is "best", that it is in your own interests, or that any other treatment is impossible. In short they will lie if you dont like their treatment choice and want treatment the boss can't do or doesn't approve of.

In 1989 the College of Health's check list advised that, "Patients should be encouraged to tape record their consultation and listen to it again in the more relaxed atmosphere of their own home."
Taping your medical consultations is also advised by Naomi Stokes, who also advises having nothing to do with any doctor who refuses to answer questions or has a holier-than-thou attitude. Considering how little a stressed out patient remembers, or even understands, of a consultation it would seem to be a very good idea to be able to go over the conversation and listen again to any information or explanations given. Henriques and Dickson write that the patient should be aware of the need for tact and diplomacy in dealing with the "doctor's paranoia". Personally I think that a patient should be concerned first and foremost with herself and her interests and should ask herself whether she really wants to be cut up, or dosed with toxins, by an unrestrained paranoid.
Patients are often advised to make written lists to help explain or get information on a problem. Unfortunately research at Leicester has found that although 71% of GPs agreed that lists helped to clarify problems, 67% said they were time consuming, 90% thought list makers were obsessional, 75% thought they were anxious and over 50% considered them neurotic.
I think it helps to be able to refer to any written records, though both poor handwriting and abbreviations may make them confusing. Until recently patients' records have been totally concealed from the patients themselves and even now doctors still have the legal option to hide records just by saying that they don't think it in the patient's "best interest", as defined by the doctor, to see them. And when a patient does insist on seeing their records they may find them lost, hidden, incomplete, inaccurate or illegible.
In fact the patients' official watchdog, the Association of Community Health Councils, has said that when trying to see their medical records patients find their rights whittled down by small print, high charges and doctors' decisions.
Mrs Stokes advises getting at least four more opinions, pointing out that many women get second or third opinions and still suffer unnecessary surgery. But does it help? Not according to Dr Schnieder:-
"Is there evidence that obtaining a second surgical opinion acts as a brake on bloated operating-room schedules? Quite the contrary, New York Blue Cross... found that second opinions increased the percentage of patients going to surgery, apparently by reinforcing the sense of "need" in reluctant patients..
Recently a surgeon friend confessed to me how touchy it is to render a contrary second opinion in a community hospital setting, taking into account personal relationships and hospital politics. In a burst of honest indignation, this physician exclaimed that we could go to the operating room any day of the week, examine the OR schedule, and find that 70% of the operations were unjustified. He cited with bitterness operations performed on elderly patients with multiple diseases and negligible life expectancy, for whom major surgery made no sense. And righteous though his indignation was, he was quick to ask me not to use his name."
If the female of 35+ does not go to one of the small band of gynaecologists who both respects a womb owner's opinion of her organs and is experienced in conservative surgery she will be told that because she is over the hill hysterectomy is "best" for her. It is therefore vital to be referred to the right person.
Surprisingly, conservative treatment is sometimes available even on the NHS. One such case was that of a 32 year old London singer who had menstrual pain, painful sex and constipation associated with dense adhesions, pelvic inflammation and endometriosis. She was given Provera, a progestogen, for 4 months but did not like it. It provided no pain relief and caused weight gain, loss of sex drive and depression. The weekly cost of Provera at 30 mg a day is about ?5.40.
She was then put on danazol for 6 months. She stopped taking this because of unpleasant side effects. Danazol at 600 mg a day costs about ?12.75 a week.
As hydronephrosis developed because of the endometriosis she was pressurised to accept man's favourite mutilation - coyly referred to as "pelvic surgery". But Miss Nightingale still had plans for her reproductive system. And the medical profession finally came up with an acceptable treatment. This was Zoladex which within 3 months made her feel much better. Oestrogen and progestogen were added to counteract the bone thinning Zoladex produces and after 12 months of treatment no adverse bone effects were detected and the singer felt fine. The weekly cost of Zoladex alone is ?31.50 and the addition of oestrogen and progestogen would further inflate the bill.
Few women will get the chance to try this option. The doctor who wrote up the case stressed the high cost and said that it was the lack of long term safety that limited its use for time being.
Not that safety considerations have ever before stopped the medical profession from dishing out dubious treatments to women.

The Prostate - A Suitable Case for Procrastination

The prostate is a walnut sized gland at the base of the male urethra.
As Chet Cunningham says in Your Prostate: What every man over 40 needs to know - Now, prostate problems are one of the leading ailments in men over 40. More than half of all men over 60 have some degree of BPH (prostate enlargement) and 80% of men in their 80's have BPH.
They may also get infectious and non-infective prostatitis. And for men prostate cancer is the second most common cancer. The American Cancer Society has estimated that 1 in 11 men will develop prostate cancer and consultant urologist Mark Speakman has said that at autopsy 30% of 50 year olds and 90% of 80 year olds were found to have it. Some 10% of all surgery done to relieve BPH results in finding early stages of cancer development.
In the chapter on Bebunking some lies, Myths and Old Wives' Tales4" Mr Cunningham states that in BPH surgery only 5% of patients suffer any impotency although half to two thirds are sterile due to retrograde ejaculation. Urinary problems result in up to 4% of cases and 1% suffer from bleeding.
Prostate surgery is 95% TURP, which involves no cut. There is no suggestion that prostate removal can disturb your hormones or increase your risk of brittle bones or heart disease.
Nevertheless Mr Cunningham writes, "A prostatectomy also can bring up a whole set of problems that the patient didn't have before." and says that "In the early stages of symptomatic BPH a patient is not a good candidate for surgery." 
He advises on how to reduce urinations from 3 times to once a night by reducing drinking, especially coffee and alcohol.
Medical therapies include drugs to relax the muscles about the prostate, an enzyme blocker called proscar and hytrin. Herbal remedies are usually based on amino acid preparations as combinations of glycine, alanine and glutamic acid seem to have BPH reducing properties.
Besides observation alone there are minor surgical treatments such as a balloon operation which can open up the urethra. And ultrasound, microwave and cryogenic techniques are being developed to remove overgrown prostate tissue with less trauma.
The 5% chance of disruption of the male orgasm is taken very seriously, even in very old men. As Mr Cunningham puts it, "For most men the sexual side of life is always a vital part of their existence. It's like watching a shiny new bus stop at your corner. It's nice to know the bus service is always there, even though you seldom use it any more." The medical profession will try hard to restore function, even to the extent of fitting an implant. And there is, of course, no suggestion that the old men with erection problems after surgery have brought their sexual difficulties upon themselves through their own bad attitudes.
The hysterectomised woman, on average nearly 30 years younger than the prostatectomy patient, is left with sexual difficulties in up to 30% of cases. The response of the medical profession is to deny that the mutilation can possibly affect the sex life or say, "Occasionally a patient complains that the loss of the cervix has affected her libido during coitus but an assurance that a possible cancer-bearing area has been removed should be enough to satisfy her".5 That is a woman's sex life is worth the removal of a small chance of endometrial or cervical cancer - which can be, and is, screened for.
Mrs Stokes view is that "Some male gynaecologists suffer from a male contempt of women as valid sexual beings, capable of feeling pleasure in their own right. And there are women gynaecologists who subscribe to the same view, having accepted the mistaken concepts about women passed down in medical schools for centuries. For a physician to assert that a woman's reproductive organs have nothing to do with her sex organs shows either abysmal ignorance or an incredible lack of concern for the woman involved."
An enlarged prostate gets larger. An operation will be easier when the prostate is smaller. Yet even with the certainty that the growth will only get worse men are not urged to be operated on. Mr Cunninham writes "The problems caused by BPH are a small inconvenience, they are something you can learn to live with. The alternative is not a happy thought... Many urologists have men on maintenance programs for 15 years before surgery is necessary." And in Prostate Problems Jeremy Hamond says "Confronted with any symptoms short of extreme urgency or acute retention many GPs will tell the patient to relax and come back if things get worse."
A woman with menstrual problems, on the other hand, has a time limit. Bleeding after the menopause is a very unusual event and fibroids stop growing and usually shrink. Yet a woman with symptomless fibroids larger than a 12-14 week pregnancy will be told to have major, mutilating surgery, which will leave her with risks of sexual dysfunction, depression, hormonal damage, heart disease, brittle bones and menopausal symptoms. This advice is given in all the gynaecology textbooks, who all agree that myomectomy must be reserved for breeding females only. 
Bleeding women are not only not urged to put up with the symptoms but frequently there is no attempt made to measure actual menstrual loss and, as Coulter et al found, there may be not even the slightest attempt made at medical control of their condition. This results in more than half of those mutilated for "heavy bleeding" not actually losing more than the normal range of blood, according to the medical profession's own criteria.
Despatching a woman for a routine hysterectomy is the easiest, quickest way for a doctor to deal with a patient. And provides the gynaecologist with the material to do what he likes doing best - amputate female organs.

Mr Cunningham says, "As the public learns more about the male prostate and BPH, more men will demand non-intrusive treatment whenever possible." And in the introduction to Mr Hamond's book Graham Watson, consultant and senior lecturer, writes, "There are many new treatments on the horizon, and many of these will find an established place for treating prostate problems, including prostatitis and possibly cancer.
My prediction is that routine prostatic surgery for urinary obstruction will still be with us in 1 or 2 decades time, but that it will be used for only the most refractory cases. The urologist will be relying primarily on tablets and a variety of high technological manipulations for treating 90% of prostate sufferers."
I wonder if many gynaecologists can envisage any future not totally dominated by the wholesale excision of female organs?
Although every effort is to be made to preserve the male system the executive vice president of the American Medical Association justified hysterectomy to prevent conception or later cancer on the grounds of it being beneficial to women with excessive anxiety. Dr Mendelsohn says of this that "hysterectomy for the relief of anxiety is indistinguishable from the archaic medical view of the uterus as the seat of hysteria. To put the sexism of this principle in perspective, you need only apply the same principle to a male patient who is experiencing anxiety because of a morbid fear that he may develop cancer of the penis. How many male surgeons would "cure" his anxiety by cutting it off?"

The Medical Attitude

The relative value accorded the different sexes is shown clearly in the medical treatment of two people. After years of tests Julie Searle was found to be infertile but was considered to be reproductively over the hill and the NHS refused to provide any treatment for her. After a court case the Law agreed that the NHS could legitimately refuse to treat an infertile, old crone of 36 - though she could certainly be treated privately if she had the money to pay for it, so there was no moral or legal bar to such treatment. In The Independent Robert Gretton relates how, at the grand old age of 56, he had surgery on the NHS to reverse his vasectomy. Twenty years older than Ms Searle he had his self-imposed sterility treated, while the unfortunate female must suffer her unwanted and unsought childlessness with no assistance whatever from our ever compassionate health service. She finally gave birth when her fertility treatment was paid for by an unnamed donor.
It is not only male reproductive organs that are accorded far more respect than the female reproductive system. During 1994 Ian Hudson took a trip down to the railway line and amputated his withered leg by having a train sever it for him. In spite of the shock suffered by those who found him he was unrepentant. After 6 years and 20 operations he had had enough of the pain. A painful womb would have been quickly scheduled for amputation with no attempt whatsoever at any conservative treatment. Yet biologically the reproductive system is a vital part of an animal while the limbs are classed as appendages and often given only a brief description in zoology texts. A leg can be replaced by an artificial limb, which may not be as attractive as flesh but which may function almost as well, while there is no replacement possible for a womb. And, as in the Asimov story, just as Eyes Do More Than See so the womb, in spite of allegations to the contrary, does more than bear children. But the medical profession is determined to view, and treat it, as less than an appendage; an unnecessary left-over like the appendix or spleen; in fact something rather unpleasant of which its owner should be cleansed.
The impression of medical care given by Scully and Harrison is one of callous manipulation of women by men. Harrison writes of, "the hospital, where the doctor's word is law, the patient's proper attitude is submission". Residency seems to be spent in squabbles over rotas, scoring points over procedures, sucking up to senior doctors and backbiting and scheming to get as much surgical practice as possible. Terri Mizrahi quoted private practitioner Noland, agreeing with the picture painted by the novel The House of God, as saying that "You're just providing a service, and you don't have any personal connection with the patient. They're slabs of meat that you're here to process."
The unfortunate patient is so much fodder to be consumed, or as Dr Harrison puts it, "Medicine, particularly as it is practiced in the hospital, is a service industry that systematically and impersonally processes sick and healthy people... If you are sick, or even if you are having a baby, you are presumed to be incapable of intelligent judgement, and therefore - quite properly - under the control of the experts." Moreover, "The physicians, too must fit the mold. Their ideas, their techniques, even their demeanor are processed by the system. It is by this same process that the system makes itself invulnerable - even to beneficial change."
For success in the medical field is very much determined by an individual's ability to ingratiate themselves with their superiors and conform to the system. Gould writes that, "as a student you have to toady to your betters in order to stand half a chance of obtaining a first job in a blue-ribbon hospital. Then for the next ten to fifteen years you must sustain the sycophancy as you now slowly climb towards the consultants bar. Having eventually climbed over that you must carry on soft-soaping, and wearing the right ties, and voicing "sound" opinions if you hope to climb any higher, and certainly if you aim to reach the top".
This hierarchy was described by Shem in his novel The House of God as "a pyramid - a lot at the bottom and one at the top. Given the mentality required to climb it, it was more like an ice-cream cone - you had to lick your way up. From constant application of tongue to next uppermost ass, those few towards the apex were all tongue."

The zoologist Desmond Morris pointed out the importance of status to humans. Basically the normal human likes to lord it and hates grovelling. So while flattering and toadying may accomplish your aim it builds up resentment, which needs to be taken out on something, or somebody. Is this one reason why patients are condescended to? Are medics getting back their status by controlling the patients they process? Even Dr Gould admits that "the more arrogant and less thoughtful" of doctors believe that their training and status gives them the right to dole out treatments "without let or hindrance from lesser beings outside the medical fold", including, of course, the patient.
Dr Harrison also suggests that the long hours worked in training help to brainwash fledgling doctors, ensuring that the medical survivors conform to the prides and prejudices engrained in the system. A system founded upon surgery as the proper, or even only, method of dealing with all female ailments; where women are hapless slabs medically processed out of their pregnancy, cleaned out of all parts of their reproductive system not required by men and the neutered remnant dosed with horse hormones to keep it happy.

Dr Rice believes that, "doctors must stop playing God and patients must allow them to relinquish that role. Medical decision-making can then become a dual responsibility, with both sides working to understand the medical problems and personal needs which must be attended to in treatment." I had no intention of having decisions made for me, yet it is clear that the hysterectomists I saw had made up their minds that I should be mutilated because I was too old to have my reproductive system taken seriously. No attempt was made to even consider conservative surgery and my feelings on the subject of mutilation were totally ignored. Mrs Languid and Miss Godly seemed not only perfectly happy retaining their celestial role but quite determined to do so.
Dr Rice acknowledges that, "Those who have practiced medicine for many years may be so entrenched in their view of patients and of disease that no amount of encouragement will persuade them to adopt a new, more equal partnership with those to whom they give medical care." Yet young Mrs Languid, a newly appointed consultant, had no qualms about trying to hustle me into mutilation. And it was the professor about to retire that was willing to allow me to choose to keep my organs. So expectations of divine privilege do not originate only in recalcitrant, stubborn old men. The freshly qualified are just as likely to have aspirations of godhood - or is that arrears of status that need to be recouped?
Finally Dr Rice states that, "The time has come for patients publicly to defend the personalised and humane medical care they value if they are to prevent it disappearing altogether from the public health centre." If, that is, they can find the personalised and humane medical care to which she is referring. During the 18 years that Craft-Tort was my GP he frequently wrote me down as Mrs Nomark and referred to me both as Miss and Mrs Nomark on the referral letter to "the Consultant Gynaecologist". And a radiographer at Helton hospital knew of my persistant virginal state 15 years before the GP did, as when he sent me for an X-ray (because of my asthmatic wheezing) he had again written me down as Mrs Nomark and I finally told her just why I couldn't possibly be pregnant.
Ms Faulder's view that "Doctors feel quite correctly that their power and prestige is under threat, and they react defensively to any suggestions that maybe Doctor does not always know best", is nearer the mark, though I would say that doctors more often react offensively than defensively to any suggestion that they are not all-knowing gurus.
Dr Collier acknowledges that "opinion surveys repeatedly describe doctors as aloof, overbearing, distant, disinterested, dismissive, frightening and engendering feelings of guilt in the patient" and that when patients "dare to show any intelligent interest in their own bodies, most doctors see them as a threat and adversary, rather than as an ally".
Yet, as Millman notes, "while most lay persons agree that physicians are often rude and insensitive and likely to cut off anything but the most 
minimal conversation with their patients, physicians themselves believe that they know their patients well enough to be able to determine what a patient wishes or wishes not to hear."
Dr Gould is sure that "Patients are in no position to challenge the professional advice offered by the doctors they consult". And doctors like to keep it that way. As Dr Collier notes most doctors "seem to prefer their patients to be quiet, passive and complaint - people who will do what they are told, take their medicines without question and reliably follow instructions". So doctors "have chosen to make patients feel passive and dependent. They have kept their methods secret, resisted telling patients the results of their diagnoses, and have failed to give the name of the medicines they prescribe." He concludes that "This level of domination may massage the ego of arrogant physicians, but it is wretched to discover patients who have got progressively iller - not from a disease, but from the side effects of medication - and yet who were too timid or intimidated to question their treatment and stop swallowing the tablets".
And it is not only the doctors who think they have the right to determine the treatment a patient is allowed. Dr Harrison tells of a woman who, with her husband, "wrote a four page letter to the hospital describing what they wanted by way of a birth experience: no drugs, no episiotomy, Jack's right to be with her at all times. When the letter arrived two weeks ago, staff were really angry, and one nurse even said, She'd better not come in when I'm on, because I'm not about to take care of her."
The message is clear. A woman cannot expect the treatment which is right for her; she is expected to feel grateful for whatever treatment doctors and the medical system chooses to dish out to her.

The Independent Patient

Hilda Scott in Working Your way to the Bottom: The Feminization of Poverty remarks on the fact that most of the work women do is unpaid or low paid. Women are crowded into low paid female work ghettos, and although they do two thirds of the world's work they receive only 10% of the money and own less than 1% of the land. The value of unpaid housework has been reported at 25-40% of the gross national product. This female drudgery put into households around the globe subsidises male dominated society as their unpaid work underpins the official world labour market.
It seems unlikely that increasing numbers of women in more priviledged jobs will make any real difference to the position of women since it is male society that determines the value of labour, and where more women enter a profession so its prestige - and income - falls. When teaching was the occupation of men only the pedagogue's position was respected but when increasing numbers of women entered teaching its status fell. Although doctors are globally respected in Russia, which has the highest numbers of women medics, the esteem of the medical profession is at its lowest. And where both men and women work in an occupation men take the highest paid positions. Thus all 7 teachers at my niece's primary school are female but the head teacher is a man and though only some 11% of British nurses are male they hog 23% of senior hospital nursing posts. Given time I should not be surprised to find the emergence of ordinary nursing jobs, filled by women, and the separate occupation of nursing officer, filled by men, who acquire the post after being trained as a junior nursing officer, without ever having to come within 20 yards of a bedpan.
Another depressing fact is that many women appear to succeed in "male" fields by becoming honorary men. Is it significant that the Spitting Image puppet of Margaret Thatcher visited the gents and obviously had a bigger member than her cabinet?
Woman is truly the "nigger of the world" for although racial minorities are discriminated against in other lands, in their country of origin at least the male Paki or Chink may be honoured fellow citizens. Woman has no such homeland and all countries discriminate against her socially and economically; in fact if not, theoretically, in law.
Even naming systems proclaim female inferiority for a clan or family carries a man's name. When she lives with a husband she bears his name. If she kept her maiden name it would be her father's name, not her mother's. And if she took her mother's name this would be her grandfather's name. No woman has her own name. Hence she may be named Watson or Thomson but not Maryson or Janesdaughter.
Woman's work is regarded as being of no real value, her habits are frivolous and her biology, especially her menstrual cycle, is disgusting. Small wonder then that the female reproductive system is so consistently treated by medics as something that the average female is better off without; and that many women are socially conditioned to accept this view of their organs.
For a nigger remains a nigger while they still think of themselves, and allow themselves to be treated, as inferior. Although blacks in America were declared legally "free" by Lincoln a century later they remained social, economic and educational serfs whose civil rights were established only at the cost of much effort and blood. Today although they are still discriminated against at least many are now proud to be black.
Until women are respected their work, and their persons, will not be respected. And until women value and respect themselves, including their reproductive system, men will not respect them.

On surgery the "medical heretic" Robert Mendelsohn advises:-

Don't assume that the operation is necessary.
Don't be deceived by a well-polished air of confidence.
Don't assume that all the treatment choices have been considered.
Don't assume that the surgery will make you feel better.
Don't assume that the surgeon cannot make mistakes.

Before deciding on hysterectomy a woman should be sure of what it is she is agreeing to. Hysterectomy means mutilation for sure. In most cases it means scarring, pain and possibly fever. It means a moderate risk of ovarian failure with increased risks of heart disease and brittle bones. And the possibility of ruining your sex life. It means taking a chance of being left with persistant urine leakage - uncommon but it happens. And of course the chance of dying as a result of surgery.
Is a little blood really worth taking these chances? If flow reduction is really necessary then mefanemic acid treatment often reduces blood loss by a half. Another possiblity is a intrauterine contraceptive device which releases a low dose of levorgestrel (20 ug daily), decreasing menstrual blood loss while providing contraception. Some women with heavy menstrual periods found their blood loss reduced by up to 75%. And endometrial resection reduces blood flow in more than 80% of cases with no cuts at all.
On the positive side of hysterectomy there is no possibility of developing later womb cancer, no further bleeding problems and no need to bother with sanitary protection again. As fibroids are so common there is the chance of developing more growths after myomectomy and 10% - 20% of patients have required further surgery. However it should be noted that few of these were older women who, with fewer menstrual years left, have a shorter time left for fibroid recurrence. Moreover even after hysterectomy about 4% of patients are re-hospitalised for further treatment.

Doctors expect women to be universally grateful for the mutilations presented to them as the best that the medical profession can do to cure their ailments. They trivialise both the intensity of symptoms that women experience and the trauma that female neutering can bring. To add insult to injury they also traumatise the natural process of childbirth. It is men who determine the treatment dished out to female organs. Men and male dominated institutions set up when women were regarded more as property than persons and still tainted by sexist thoughts and actions.
The response to almost every female complaint is "rip it out", yet these men would be very unhappy if the treatment for every malfunction of their reproductive organs was excision. Would men feel happy if the treatment of their diseased or damaged sex organs was determined by a gaggle of women? And if the preferred treatment for male systems, whatever the ailment, was mutilations and castrations galore, even when their gonads were healthy, what would men think of their medical advisors?


1 However as it is men who have the money this may be just an American financial discrimination.
2 I'm sure that was very reasssuring for the women he fitted with coils!
3 Teach probably
4 Wouldn't you know it was those old wives again, spreading unnecessary alarm among sensible men with foolish tittle-tattle!
5 The New Our Bodies, Ourselves.