Sexual health

Objective: To describe the epidemiology of infectious syphilis among Aboriginal and Torres Strait Islander (Indigenous) people in Australia.Design and setting: We assessed trends in national infectious syphilis notification rates from 2005 to 2009 using Poisson regression, with a focus on geographic and demographic differences by Indigenous status. We compared Indigenous and non-Indigenous rate ratios over the study period and summarised the annual changes (summary rate ratio).Main outcome measures: Crude notification rates and summary rate ratios by Indigenous status, jurisdiction, sex, age group and area of residence.Results: From 2005 to 2009, in the Indigenous population, there was a substantial decline in the notification rate for infectious syphilis nationally; as well as in the following subgroups: females, 15–29 year olds, and people living in outer regional and remote areas in the Northern Territory and Queensland. In contrast, there was a significant (P < 0.001) upward trend in the notification rate in the non-Indigenous population nationally; as well as in males, in people aged 20 years and over, and in residents of metropolitan and regional areas, New South Wales, Queensland, South Australia, Victoria and Western Australia. The highest summary rate ratios were seen in remote/very remote areas (86.33; 95% CI, 57.45–129.74), in 15–19 year olds (64.65; 95% CI, 51.12–81.78), in females (24.59; 95% CI, 19.73–30.65), and in Western Australia (23.89; 95% CI, 19.82–28.82).Conclusion: These data demonstrate that Australia has two distinct patterns of infectious syphilis: a substantially declining occurrence in Indigenous remote communities and an increasing incidence in males residing in urban and regional areas. Given the decline in notification rates in Indigenous remote communities, now might be the right time to move toward eliminating infectious syphilis from Indigenous communities.

James S Ward BA · Rebecca J Guy BAppSc, MAppEpid, PhD · Snehal P Akre MB BS, MPH · Melanie G Middleton BMedSc, MPH · Carolien M Giele RN, BSc(Hons), MPH · Jiunn Y Su MB, MPH · Craig A Davis MAE, MAppSc, BA · Handan Wand MA, MSc, PhD · Janet B Knox MB BS, MMed(STI/HIV), DTM · Patricia S Fagan MB BS, MPH, FAFPHM · Basil Donovan MD, MB BS · John M Kaldor PhD · Darren B Russell MB BS, FRACGP, DipVen

Objectives: To examine the experience of fear, the fear response, and factors affecting fear in adolescents undergoing school-based human papillomavirus (HPV) vaccination.Design, participants and setting: A purposive sampling strategy and qualitative methods, including observation and face-to-face interviews. Focus groups comprised adolescent girls who were involved in HPV vaccination in 2007 at schools in Sydney, New South Wales. Individual interviews were conducted with parents, teachers and vaccination nurses.Results: Data from observing vaccination days at three schools and from interviewing 130 adolescents in 20 focus groups, 38 parents, 10 teachers and seven nurses were included in the analysis. All participants discussed the issue of fear and distress experienced by adolescent girls in relation to HPV vaccination. Observations corroborated the focus group and interview data. Our results indicated that fear was promoted by witnessing the fear reactions of peers; perceived judgement by peers; lack of information or misinformation; and being vaccinated later in the day. Fear was moderated by procedural factors, the support of peers, appropriate knowledge, and nurses’ distraction techniques or approach. Fear also affected acceptance of HPV vaccination.Conclusions: Fear of HPV vaccination was a near universal experience among adolescents in the school setting and was often associated with significant distress that had an adverse impact on the vaccination process. School vaccination could be improved by proactively managing fear and distress.

Diana M Bernard MPH · Spring C Cooper Robbins PhD · Kirsten J McCaffery PhD · Caroline M Scott MHlthSc(Nurs) · S Rachel Skinner PhD, FRACP

Objective: To describe the proportion of 16–29-year-olds tested for chlamydia by Australian general practitioners in a 12-month period.Design and setting: Between October 2007 and September 2008, the national chlamydia testing rate in 16–29-year-olds was calculated by dividing the number of Medicare-reimbursed chlamydia tests by two denominators: (i) Medicare-reimbursed GP consultations; and (ii) estimated resident populations adjusted for the proportion who were sexually active.Main outcome measures: GP chlamydia testing rates in 16–29-year-olds per 100 patients attending a GP consultation and per 100 sexually active population, by patient age and sex, state/territory of residence, and remoteness area.Results: Among the estimated Australian population of 16–29-year-olds, 85.6% of females and 64.4% of males had at least one GP consultation in the 12-month period. The national GP chlamydia testing rate per 100 patients was 8.9% (95% CI, 8.88%–8.94%). The national GP chlamydia testing rate per 100 sexually active population was 8.0% (95% CI, 7.92%–7.98%). The rate per 100 sexually active population was higher in females (12.5%) compared with males (3.7%) (P < 0.01); higher in 20–24-year-olds (9.0%) compared with 16–19-year-olds (8.7%) and 25–29-year-olds (6.6%) (P < 0.01); higher in those living in non-metropolitan areas (11.0%) compared with metropolitan areas (8.4%) (P < 0.01); and highest in those living in the Northern Territory (21.4%) compared with other jurisdictions (P < 0.01).Conclusions: Despite clinical guidelines recommending annual chlamydia testing for sexually active 15–29-year-olds, our analysis showed that a high proportion of young people aged 16–29 years attend a GP each year, but few of the sexually active population in this age group were tested for chlamydia in general practice. Strategies are needed to support GPs to enhance chlamydia testing in young people.

Fabian Y S Kong BPharm, MEpi · Rebecca J Guy BAppSc, MAppEpid, PhD · Jane S Hocking MPH, MHthSc(PHP), PhD · Tony Merritt MB BS, MPH · Marie Pirotta MB BS, FRACGP, PhD · Clare Heal MB ChB, FRACGP, PhD · Isabel Bergeri PharmD, MSc, DTMPH · Basil Donovan MD, FRCPI, FAChSHM · Margaret E Hellard MB BS, FRACP, PhD

An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a "surgical vaccine" against future sexually transmitted HIV has attracted strong criticism from many of our readers (MJA 2011; 194: 97-101) To the Editor: In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy.1 In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.2 While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission,3 this is not so in low-prevalence environments where homosexual transmission is more important.4 Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited.5 Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase.6 There is minimal protection against homosexual acquisition of HIV.4 The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted.7 The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks.2 The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks. To the Editor: In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia.1 However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals. Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision2 and heterosexually transmitted HIV infection.3 Circumcision removes the most sensitive tissue of the penis4 and serious complications include death (about 0.9 deaths per 10 000 circumcisions).5 If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications. Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic,6 which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost-effectiveness.7 In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision.8 In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medicolegal issues. New 2010 Royal Australasian College of Physicians guidelines9 continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group.10 Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys.11 To the Editor: We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission.1 The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact.2 However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV.3 Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections.4 In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM. With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM. The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P = 0.90). As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than large-scale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse. To the Editor: In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV.1 There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy. There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results.2 The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence.2-4 There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection. Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost-effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodologic limitations and data insufficiencies”.2 Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices. In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue. To the Editor: In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV.1 However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%.2 Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission. Common law recognises the right of bodily integrity.3 International human rights law enshrines the right to security of the person.3 The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic.3 As male circumcision amputates healthy, functional, protective, erogenous tissue,3 imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault.3 Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%).4,5 HIV infection in Australia occurs mostly among homosexual men.6 It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant,7 so male circumcision would be of little value in reducing future Australian HIV infection rates. Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm8 on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault.3 To the Editor: Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection.1 They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine. The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques),2,3 the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection. This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent.4 We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised. As others point out,5 moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians6) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously. To the Editor: I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy.1 The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function. Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary,2-4 and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis3 — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction.4,5 It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need. To the Editor: I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission.1 Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission. In reply: In our editorial we, just as other academic experts in various countries,1-4 likened infant male circumcision to a “surgical vaccine”. Both vaccination and male circumcision effectively, safely and inexpensively afford lifelong protection against a wide array of adverse, sometimes fatal, medical conditions. Both are most effective if provided early in life. Both are criticised vigorously and relentlessly by opponents. There is now an impressive and growing number of high-quality research publications attesting to the wide-ranging benefits of male circumcision.2,4 The letters to the Journal in response to our editorial rely largely on opinions, and often cite superseded and spurious references. Forbes ignores the high prevalence in Australia of sexually transmitted infections (STIs), which male circumcision protects against, including oncogenic human papillomaviruses. Moreover, male circumcision provides similar protection against heterosexual HIV infections in men in low-prevalence settings as those in high-prevalence settings.1-5 In the United States, infant male circumcision is cost-saving for HIV prevention.6 In claiming that male circumcision increases HIV risk to women, Forbes, Boyle and Hill cite an outlier study, ignoring a meta-analysis and new data which show that male circumcision reduces the risk of male-to-female transmission.7,8 There is no reason to expect that male circumcision would protect a man who engages in receptive anal intercourse, the primary mode of HIV transmission in Australia and the US. Australian data show, however, greater than 90% protection against HIV and syphilis in the smaller proportion of homosexual men who are insertive only.9 While there are few Australian studies of other STIs and male circumcision in heterosexual people, research in the US and elsewhere, including randomised controlled trials (RCTs), shows strong protection.2,4 Paix argues that circumcision is a “highly mutilating operation which seriously impairs penile function”, while Travis and colleagues assert that circumcision “removes the most sensitive part of the penis”. However, there is now strong research evidence, including RCTs, showing not only no loss of function, satisfaction, sensitivity or sensation,2 but, in one large RCT, that sexual experience is enhanced by male circumcision.10 In rejecting male circumcision for HIV prevention, Travis et al and Boyle and Hill present arguments against circumcision repudiated previously by 48 international academic experts.11 Moreover, in response to Darby, it is well established that condoms are often not in place during sex, whereas male circumcision always is. Also, population-level condom use does not correlate with reduced HIV transmission.12 Parents have a duty to help prevent renal damage, physical, inflammatory and hygiene problems, STIs and cancers in their sons and their sons’ future sexual partners. They can do this by arranging for their son to be circumcised. The level of risk and severity of such adverse medical conditions in Australia is sufficiently high to support infant male circumcision. Not to do so may have legal ramifications.13 Chin argues that male circumcision should be delayed until the boy can make up his own mind. He fails to recognise that, as for vaccination, infancy is by far the safest, quickest, cheapest and most convenient time for male circumcision; when performed in infancy, circumcision confers immediate benefits with very limited short- and long-term risks.1-4 While our warning of a future HIV epidemic in Australia unless infant male circumcision is increased is based on a rise in the proportion of new infections attributable to heterosexual sex (from 841 in 2000–2004 [20% of total diagnoses] to 1185 [23%] in 2005–2008),14 there are currently epidemics of other STIs, many of which could have been prevented by male circumcision. The very low risk and considerable benefits of male circumcision attest to the wisdom of performing the procedure in infancy to maximise individual and public health gains.

David A Forbes · John W Travis · Sarah J Buckley · Paul Mason · Ken McGrath · Robert S Van Howe · George Williams · Anthony N Lyons · Marian Pitts · Anthony Smith · Jeffrey Grierson · Niall Conroy · Gregory J Boyle · George Hill · Robert J L Darby · Bruce R Paix · Jeremy J Chin · David A Cooper · Alex D Wodak · Brian J Morris

Sex, lies and pharmaceuticals. How drug companies are bankrolling the next big condition for women . Ray Moynihan. Sydney: Allen & Unwin, 2010 (256 pp). ISBN 9781742370187. SEX SELLS, as does the implication of a good scandal, so the title alone should generate some sales of Australian investigative journalist Ray Moynihan’s latest exposé of Big Pharma’s marketing machine. Building on the success of his earlier work, Selling sickness, Moynihan here teams up with Dr Barbara Mintzes (Assistant Professor in the Department of Anesthesiology, Pharmacology and Therapeutics at the University of British Columbia in Canada) to disassemble the story behind “female sexual dysfunction” or FSD. The story of FSD is traced through an investigative journalist’s eyes, from the revolution in sexual medicine in the late 1980s, through the launch of the now infamous phosphodiesterase type 5 inhibitors, to today. Along the way, with the benefit of hindsight, the authors assemble the jigsaw pieces of pharmaceutical company influences on researchers and clinicians to paint a picture of a series of disorders being created by the very industry which then fortuitously provides the panacea. Moynihan and Mintzes are no strangers to highlighting the effects of pharmaceutical company promotion and largesse. While it could be argued that this work is part of a sustained attack on the industry, Moynihan takes great care to emphasise the usefulness of pharmaceuticals for some women who have a sexual disorder. The main theme is that these women form a small minority — not 43% or similar figures quoted by proponents of such medical treatment — and that many non-drug therapies are as effective as drugs, if not more so. Sex, lies and pharmaceuticals is very readable, and its target audience is consumers, not health professionals. Its main aim is to encourage consumers (or patients) to ask questions of their doctors to gain an understanding of the diagnosis with which they are being labelled, and for which they are subsequently treated. It is $30 well spent to see what your patients may be reading and to question “Where did those useful diagnostic tools really come from?”.

Greg Kyle

Herbert Gibson, well known in Victoria for his dedicated work on HIV/AIDS, bloodborne viruses, and drugs and alcohol, died suddenly on 5 June 2010 at the age of 64. Born on 19 August 1945 in Bendigo, Victoria, Herbert studied medicine at Monash University, graduating in 1970. He did his residency at Bendigo Base Hospital and the Lakeside Psychiatric Hospital, Ballarat. In 1973, he helped found the Middle Park Clinic in Melbourne, where he was at the centre of medical care and studies to combat HIV/AIDS. His work included lecturing on sexually transmitted diseases and bloodborne viruses for Monash University, the Victorian Health Promotion Commission, the Royal Australian College of General Practitioners and the Alfred Hospital, where he was also Honorary Clinical Assistant at the Special Microbiology Unit (HIV/AIDS). In addition, he undertook honorary palliative care work for a number of Melbourne’s medical facilities. In 1994, Herbert moved back to his home town of Bendigo to care for his elderly mother. He became Senior Psychiatric Medical Officer with the Bendigo Health Care Group, and also worked for the Rural Health General Practice division of Monash University in Bendigo. He was an Outreach Rural Mental Health visiting consultant and Crisis Assessment Team clinician throughout the extensive Loddon/Campaspe region of Victoria. The stress of long hours and distance travel eventually took its toll, and family-inherited bipolar disorder and diabetes began to wear him down. In 2007, he retired from practice and moved to Sydney, where his health greatly improved. Apart from his dedication to medical care for the underprivileged and marginalised, Herbert’s passions in life were reading European history and tracking down rare stamps for his collection, especially stamps of Imperial Russia and the early Soviet Union. He also enjoyed painting with watercolours and relaxing with his music collection of Wagner, Mozart and Shostakovich. A suspected minor stroke/brain haemorrhage in 2010 saw him admitted to St Vincent’s Hospital, Sydney. He was transferred to the nearby Sacred Heart Hospice, where he died within a few days. A month later, a celebration of Herbert’s life was held in Melbourne, where some 70 former patients, staff, colleagues and friends gathered to remember a convivial, compassionate medic, a brilliant diagnostician and generous associate who enjoyed both solitude and good company.

Edward Underwood

Clinical records Patient 1 A 59-year-old man infected with HIV presented to hospital with sudden onset of tinnitus, vertigo and hearing loss in his right ear. An audiogram showed moderate bilateral sensorineural hearing loss, which was worse on the right. A magnetic resonance imaging scan of his brain showed no abnormalities. He was diagnosed with Meniere’s disease and managed symptomatically. Symptoms worsened over the following months, and he was reviewed in the neurology and ear, nose and throat (ENT) clinics of another tertiary hospital. Both clinics agreed with the diagnosis of Meniere’s disease. Serological tests for syphilis were performed 12 months after symptom onset. The rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) test results were reactive, with the RPR test showing a titre of 1:128. Cerebrospinal fluid (CSF) examination showed a mild lymphocytic pleocytosis and a reactive TPPA test result but a negative RPR test result (Box 1). A diagnosis of otosyphilis was made and the patient was treated with intravenous benzylpenicillin 2.4 million units 4 hourly and oral probenecid 2 g daily for 2 weeks, followed by three doses of weekly benzathine penicillin 2.4 million units intramuscularly. His symptoms stabilised but did not improve. Patient 2 A 30-year-old man infected with HIV presented to an HIV clinic having had tinnitus, hearing loss and imbalance for 3 months. He was referred to ENT clinics in two tertiary hospitals, both of which diagnosed Meniere’s disease. Audiological tests showed mild right sensorineural hearing loss. Serum RPR and TPPA test results were reactive, with an RPR titre of 1:516. CSF examination showed a mildly elevated protein level, but no other abnormalities (Box 1). A diagnosis of otosyphilis was made, and the patient was treated for 2 weeks with benzylpenicillin 2.4 million units 4 hourly. His symptoms resolved completely, and an audiogram performed 6 months after treatment showed that his hearing had returned to normal. The recent increase in early syphilis infections in Australia has been accompanied by the re-emergence of disease manifestations unfamiliar to modern clinicians. Otosyphilis is a rare cause of sensorineural hearing loss and dizziness, and is important for clinicians to consider because the hearing loss is potentially reversible with early diagnosis and treatment. We report two cases of otosyphilis occurring in patients infected with HIV. In both cases, the diagnosis of otosyphilis was initially missed, despite review by several specialist medical units. Cochleovestibular dysfunction is a well described complication of congenital and acquired syphilis. In acquired syphilis, it can occur at any stage of infection. In the pre-penicillin era, hearing loss was reported in 17% of patients with early latent infection and in 80% with symptomatic neurosyphilis.1 Cochleovestibular symptoms of neurosyphilis can occur via two main mechanisms. First, the eighth cranial nerve may be affected, for example in acute syphilitic meningitis. In these situations, hearing loss is usually accompanied by other neurological deficits, and findings on cerebrospinal fluid (CSF) examination will usually be abnormal. Second, and more commonly, hearing loss and vestibular symptoms present without features of coexisting neurosyphilis. These symptoms may occur at any stage of syphilis and are thought to result from direct damage to the vestibulocochlear apparatus. During dissemination, spirochaetes invade the inner ear perilymph, leading to inflammation of the labyrinthine structures and otic capsule. CSF parameters are usually found to be normal but, histologically, fibrosis and ischaemic necrosis of labyrinthine structures are seen2 and endolymphatic hydrops is common. These pathological findings are identical to those of Meniere’s disease, explaining the similar clinical features. Symptoms may be sudden or insidious in onset, and include bilateral (but often asymmetrical) sensorineural hearing loss, tinnitus and vestibular symptoms ranging from dizziness to severe vertigo. These symptoms closely resemble those of Meniere’s disease. Audiological testing shows sensorineural hearing loss, classically affecting low or high frequencies while sparing middle frequencies, and speech discrimination is poor. Without treatment, otosyphilis will progress to profound deafness over months to years. Symptoms can fluctuate markedly over time, but the overall course is one of deterioration.3 There is no established case definition for otosyphilis, but the diagnosis should be made on the basis of a typical clinical presentation and positive serological test results for syphilis. This approach is purposely “over inclusive”, as otosyphilis is a potentially reversible cause of hearing loss. The optimal treatment for otosyphilis is not established. The published literature is limited, consisting of case reports and small case series, but indicates that intravenous therapy is required. Intramuscular penicillin penetrates the perilymph poorly, and there are numerous reports of treatment failure when patients with otosyphilis are treated with penicillin regimens for latent syphilis. In one report, spirochaetes were recovered directly from a patient’s perilymph after treatment.4 Intravenous penicillin G at a dose of 18–24 million units per day, administered as 3–4 million units every 4 hours for 14 days, is the regimen recommended by the United States Centers for Disease Control and Prevention for treatment of otosyphilis. Probenecid is sometimes added, as are subsequent courses of intramuscular or intravenous penicillin.5 There is no high-level evidence to support any of these approaches. Steroids are commonly coadministered, although there are few supporting clinical data. The rationale is that inflammation of the endolymphatic duct appears crucial to the pathogenesis of otosyphilis. A typical steroid treatment regimen is prednisolone at a dose of 0.5–1.0 mg/kg tapered over 1–2 months. Regardless of the penicillin regimen used or whether steroids are employed, treatment outcomes are uniformly poor. Studies consistently show that auditory symptoms abate for only 30% of patients, while 7%–15% have improved results in audiological or speech discrimination tests. Tinnitus and dizziness have better outcomes, with 70%–80% of patients reporting improvement. Factors associated with better outcomes include duration of symptoms less than 5 years, age less than 60 years and fluctuating hearing loss.6 Both of these patients had HIV infection. Rates of syphilis are known to be substantially higher in the HIV-positive population.7 Otosyphilis has previously been described in patients infected with HIV, but relevant published literature is sparse. Patients co-infected with HIV and syphilis appear no different to HIV-negative patients in their clinical features, severity of disease or likelihood of developing this manifestation of syphilis. In both of the cases we report, the diagnosis of otosyphilis was missed despite review by several specialist medical units. In the past few years, rates of early syphilis have risen markedly in Australia, predominantly among homosexual men.8 Relevant practitioners should be aware of this diagnosis in patients presenting with the symptoms described here, especially those at risk of syphilis, such as sexually active homosexual men, including those with HIV infection. Current guidelines recommend syphilis screening in sexually active homosexual men at least annually (up to every 3 months in those at higher risk) and at regular intervals in individuals infected with HIV.9 1 Cerebrospinal fluid and serological test results for two patients with HIV and otosyphilis Patient 1 Patient 2 Cerebrospinal fluid Appearance Clear, colourless Clear, colourless White cell count (× 106/L) 1 polymorph 8 lymphocytes 0 polymorphs 1 lymphocyte Red cell count (× 106/L) 0 0 Protein (g/L) (reference range, 0.15–0.45 g/L) 0.52 0.7 Glucose (mmol/L) (reference range, 2.5–5 mmol/L) 2.7 2.7 Microbiological culture and sensitivity Nil Nil Treponema pallidum DNA polymerase chain reaction test Not detected Not detected Serum Rapid plasma reagin (titre) Reactive (1:128) Reactive (1:516) T. pallidum particle agglutination Reactive Reactive Lessons from practice Consider the possibility of otosyphilis in any patient (especially those with HIV infection or at risk of syphilis and/or HIV infection) presenting with auditory symptoms, particularly sensorineural hearing loss with tinnitus and vestibular dysfunction. Positive serological test results for syphilis will establish the diagnosis. All sexually active men who have sex with men should be screened for syphilis at regular intervals. Otosyphilis must be treated with intravenous penicillin regardless of findings of cerebrospinal fluid testing.

Janet M Pasricha MB BS(Hons) · Tim R Read MB BS, FAChSHM · Alan C Street MB BS, FRACP

The wisdom of whores. Bureaucrats, brothels, and the business of AIDS. Elizabeth Pisani. Sydney: Granta, 2008 (xvii + 372 pp). ISBN 978 1 84708 024 0. Given the provocative cover, I approached this book with reservations. And irritatingly, the author scatters the terms “AIDS mafia” and “AIDS industry” throughout the book. She never defines the terms, but she would probably class me as a member of both! Yet after two careful readings, I am totally disarmed. While I disagree on some points, Elizabeth Pisani tells the truth about AIDS clearly and unequivocally. Only global warming is more topical than HIV/AIDS. Any thinking person, lay or professional, must have serious questions. Why is the epidemic in sub-Saharan Africa so different from everywhere else? Why has the long-awaited Grim Reaper scenario (spreading throughout the general community) never eventuated? Why, with a virus which is “not actually all that infectious” but which has nonetheless caused 70 million infections world-wide, are we no nearer to controlling the epidemic? Pisani answers these questions with devastating clarity. She is eminently qualified to do so, with a PhD in epidemiology and more than 10 years’ field experience. She retains, too, the sharpness and ruthlessness of the investigative journalist she once was. There are ribald stories and humour here, but throughout runs a barely repressed strain of anger. Bucket-loads of money are being wasted, good science is often ignored, truth has been replaced by lies and, as the author reminds us, prevention “programs based on lies don’t work”. There is a softer side to this author. She is a friend of harlots and sinners. It is people considered the dregs of society who are most at risk. She says, “Getting HIV prevention services for people who needed them most has begun to seem like a debt I owe”. By her forthright analysis and outline of what needs to be done, she has gone some way towards paying her debt.

David L Bradford

Results are promising but long-term safety remains uncertain Hypoactive sexual desire disorder (HSDD; loss of desire that causes personal distress)1 is common, with proposed prevalences ranging between 8% and 50% (wide variation is due to differences among populations surveyed and questionnaires used).2,3 Women with HSDD have been observed to experience poor sexual self-image, feelings of unattractiveness, fear of disappointing their partners, depression, anxiety and diminished quality of life.4,5 The effect of HSDD on quality of life has been reported as similar in magnitude to the effect of other common chronic conditions, such as diabetes and back pain.5 Furthermore, both men and women reporting a discrepancy between their own and their partner’s sexual desire have lower relationship satisfaction,6 and individuals in sexually inactive marriages report less marital happiness.7 Thus, HSDD merits recognition and intervention. In many cases, counselling and general sex education are helpful. However, the proportion of postmenopausal women who continue to experience HSDD despite good clinical care are left with few options, as there are no approved therapies presently available for this condition. APHRODITE is the most recent of a series of randomised controlled trials (RCTs) evaluating the efficacy and safety of transdermal testosterone patch therapy in postmenopausal women with HSDD.8 This large, multinational study, involving women with either natural or surgical menopause, differed from preceding studies in that participants were not receiving concurrent oestrogen therapy. The study was conducted and financed by Procter and Gamble Pharmaceuticals. However, it was instigated by the investigators, who were concerned that women may resort to off-label use of the testosterone patch Intrinsa (Procter and Gamble), when it becomes available, in the wake of the findings of the Women’s Health Initiative Studies (these findings initially raised concerns about the safety of postmenopausal oestrogen therapy). As effects of testosterone use without concurrent treatment with systemic oestrogen are unknown, the investigators believed this study would provide much-needed data. In this 52-week trial, 814 women with HSDD were randomly assigned to receive a patch delivering 150 μg or 300 μg of testosterone per day, or placebo. The primary end point was the number of self-reported sexually satisfactory events per month. The findings were interesting on several fronts. At baseline, women reported engaging in sexual activity on average 5 times per month, with half these events reported as unsatisfying. Participants had low sexual desire and a high level of personal distress measured by validated scales. By 24 weeks, women treated with the testosterone 300 μg patch reported a mean of 4.5 satisfactory events per month compared with 3.2 satisfactory events per month for women in the placebo group. Sexual desire increased and distress diminished substantially for both groups of women receiving active therapy. These findings have been interpreted by some as representing very little gain.9 However, women treated with the 300 μg testosterone patch reported enjoying nearly all of their sexual encounters, whereas those who received the placebo experienced pleasure 65% of the time. It is worth noting that women treated with testosterone did not report a significant increase in total sexual activity; this may be an effect of strongly established relationship patterns, including interest and availability of partners. In line with previous studies of transdermal testosterone therapy in postmenopausal and premenopausal women, efficacy did not manifest until after 8 weeks of therapy.10,11 Although women who received testosterone were more likely to report increased hair growth (20% of women receiving testosterone 300 μg v 10.5% of those receiving placebo), withdrawal from the study due to androgenic effects did not differ between the groups, and women treated with placebo were more likely to withdraw (19% of women receiving placebo v 14% of those receiving testosterone 300 μg). No significant adverse metabolic or endometrial effects were detected. The main concern arising from this study was the finding of breast cancer in four women treated with testosterone and none in the placebo group; the ratio of participants receiving testosterone to those receiving placebo was 2:1. The relationship between these findings and testosterone use is unclear, with two of the cancers likely to have been pre-existing (one diagnosed within 4 months of randomisation and another in a woman who recalled symptoms before randomisation when diagnosed after 7 months of treatment). A third woman diagnosed with breast cancer had previously been treated with hormone replacement therapy for 25 years and had a sister with breast cancer. The fourth was diagnosed after completion of 24 months of the study. The literature regarding the breast cancer risk of exogenous testosterone does not illuminate this issue. No other RCTs have been large enough or long enough to provide meaningful data. Observational data for oral methyltestosterone suggesting an increase in breast cancer risk12 have major limitations — the data are from the 1990s when testosterone was commonly prescribed for mastalgia in postmenopausal women receiving oestrogen therapy and the comparator group comprised non-hormone users, such that any apparent risk may have been the risk of oestrogen or oestrogen plus progestin use. A subsequent study in fact suggests the latter may well be the case.13 Two independent observational Australian studies have not found an increase in breast cancer risk with therapeutic testosterone use.14,15 Available data indicate transdermal testosterone can be useful for the treatment of HSDD in postmenopausal women. Short-term use appears to be safe, yet the effects of long-term use remain uncertain. Ideally, long-term safety should be evaluated in large longitudinal studies; however, as 70% of women who elect to use testosterone for HSDD do so for less than 3 years,15 retention of women in such studies will be a challenge.

Susan R Davis MB BS, FRACP, PhD

To the Editor: Australia’s world-leading government-funded National Human Papillomavirus (HPV) Vaccination Program for women aged 12–26 years is made up of two components: an ongoing school-based program and a time-limited catch-up program delivered through schools, general practices and community vaccination services. The catch-up program started in April 2007 and was due to finish by July 2009, but has been extended to 31 December 2009 to allow women to complete the three-dose schedule. Assessing the coverage achieved by the National HPV Vaccination Program will be an important measure of the Program’s success, particularly in terms of ensuring equity in vaccine uptake — so that the current gap in cervical cancer incidence and mortality between Indigenous and non-Indigenous women is reduced, not widened.1 Vaccination coverage data are also needed to monitor vaccine effectiveness in preventing cervical lesions and cancer. Accordingly, an integral part of the Program was the establishment, enabled by legislation passed in August 2007, of Australia’s first national adult vaccine register — the National HPV Vaccination Program Register. The Register began collecting data in mid 2008 and is currently uploading notifications of the 5 million doses of HPV vaccine distributed in Australia to date. Initial coverage estimates from the Register will be published by the end of the year, with all notifications from the catch-up program due to be submitted to the Register by March 2010. General practitioner incentive payments of $6 per notification will be available until that time. Interim coverage data provided by various jurisdictions are encouraging; school-based program data for 2007 from New South Wales and Victoria estimate one-dose coverage of more than 80% and three-dose coverage of approximately 70%.2 Unfortunately, there are no routine systems in place to provisionally estimate coverage in women vaccinated outside of schools. In a small population-based telephone survey that was conducted by the Cancer Council Victoria 3 months after the Program commenced, 35 of 90 women aged 18–26 years (39%) had received HPV vaccine. Australian women are taking advantage of Australia’s most expensive vaccination program to date. We encourage vaccination providers to notify the Register3 of doses administered to ensure that this facet of Australian women’s health can be followed into the future. Although we anticipate complete notification of vaccinations given at schools, the accuracy and completeness of total coverage data will depend on GPs notifying the Register.

Julia M L Brotherton · Robyn M Mullins

One of the dilemmas in delaying sex-assignment surgery is the increased risk of gonadal malignancy Few areas of medicine are as controversial as the management of disorders of sex development (DSD). The use of the term DSD to describe patients born with ambiguous genitalia has undergone major change from older terms with negative connotations, such as “intersex”, “testicular feminisation” and “hermaphroditism”.1 Meanwhile, international debate continues about the ethics of performing genital surgery on affected infants and children. In fact, the debate has been raging for more than a decade between the medical profession and patient advocacy groups in Western countries, and has been documented by anthropologist Katrina Karkazis in a recent book.2 A long-term outcome study of 50 patients aged 18–32 years who had been treated in Melbourne when they were children showed that mental and physical health outcomes were as good for most of the DSD patients as for those in two control groups; however, there was a small minority of patients whose gender identity as adults was a source of such profound discomfort that they felt compelled to undergo treatment to change it.3 Clearly, this is unsatisfactory, and management practices have been reviewed internationally by clinicians looking for ways of minimising the risk of making such mistakes about gender assignment. The main problem relates to feminising genitoplasty (Box), which involves the removal of phallic erectile tissues and skin that cannot be replaced. This type of operation is considered appropriate for 46,XX girls with congenital adrenal hyperplasia (Box), who rarely identify as male when they are adults if they are treated with appropriate hormones to maintain androgen suppression from soon after birth and throughout childhood.4 However, feminising genitoplasty is much more of a problem in patients with a Y chromosome. For example, in one study of 14 adult patients with genetically confirmed partial androgen insensitivity who were treated at Johns Hopkins University in the United States as children, 25% experienced gender dysphoria (Box) as adults, and a small number wanted to undergo sex change surgery.5 Although policy changes are still being discussed, it seems likely that fewer and fewer XY patients with frankly ambiguous genitalia due to DSD will have feminising genitoplasty and be raised female. The option to assign a gender but postpone surgery until the child is able to give consent has been strongly advocated in some quarters,6 but has not gained much traction because of concerns that children might suffer psychological harm if left with ambiguous genitalia. In 2008, clinicians from Melbourne’s Royal Children’s Hospital, recognised for their expertise in the management of DSD, were required to meet representatives of the Victorian state Justice Department. They were asked to respond to a proposal — advanced by an advisory committee representing the interests of the gay, lesbian, bisexual, transsexual and intersex communities — that doctors wanting to perform surgery to treat ambiguous genitalia in children too young to consent on their own behalf should have to seek approval from the Family Court of Australia on a case-by-case basis. Also in 2008, the Australian Human Rights Commission decided to initiate a public inquiry into the same question, and circulated a draft discussion paper called Genital surgery for babies born intersex to health professionals for comment. Thus, in Australia as elsewhere, the arm wrestle between medical professionals and patient advocacy groups continues. What has largely been missing from the debate is recognition of the fact that surgery forms a necessary part of the risk management strategy for preventing gonadal malignancy. In any DSD associated with a Y chromosome, there is an increased risk of germ cell cancer,7 especially when the testes are intra-abdominal (the risk of seminoma in partial androgen insensitivity is 50% for an intra-abdominal testis) or when there is gonadal dysgenesis. In this issue of the Journal, a salutary case report by Parker and colleagues8 reminds us of the need to be mindful of this risk, and also to take a long-term view of risk. If the intra-abdominal gonad in the patient described had been removed at the initial surgery, he would never have needed to fear this tumour. It had not been removed because, by today’s standards, he had been inadequately investigated in the past, and therefore the intersex condition was not recognised. The trend for surgeons to recommend male-sex rearing for greater numbers of children with DSD could also mean greater reluctance to remove testes that pose a significant risk of cancer on the grounds that physiologically useful hormone secretion might be retained. It is therefore imperative that a risk management strategy be prepared for each patient. This would mandate: educating parents and patients about risk; removing all intra-abdominal gonads that cannot be brought down into the scrotum; regular clinical and ultrasound surveillance of scrotal gonads with removal of any that contain suspicious lumps; biopsy of testes after the onset of puberty, looking for early signs of malignant change; and effective communication between paediatric and adult care-providers at the time of transition. It is also important for all children identified as having DSD to be referred to a centre of excellence where they will be seen by paediatric endocrinologists, surgeons and other health care professionals with expertise in the field and who recognise the importance of a multidisciplinary team approach.9 Case conferences about patients diagnosed as having a DSD in adult life would be enhanced if paediatric specialists in DSD were asked to comment. Of equally great importance is the need for an accurate aetiological diagnosis wherever possible. At the moment, about 40% of patients with 46,XY forms of DSD are left without a precise diagnosis.10 The application of microarray (gene chip) technology,11 which is available in Australia, is an exciting and promising step forward in identifying genetic mutations. In this technique, samples of very large numbers of genes are arranged in a regular pattern on a solid surface or membrane, which is then incubated with DNA from a patient. Alterations in known (and even unknown) genes are rapidly detected by studying patterns of matches and mismatches. The current challenge for researchers is to develop new tools, such as microarray technology, that will lead to gene discovery and to better methods of screening patients for mutations in all the known genes. Glossary of terms relating to disorders of sex development DSD: Disorders of sex development, previously known as intersex. Congenital conditions in which development of the chromosomal, gonadal or anatomical sex is atypical. Feminising genitoplasty: Surgery carried out to give genitalia that were originally ambiguous a more female appearance. Usually involves clitoral reduction (removal of erectile tissue) and surgery to create a vaginal opening separate from the urethra. Congenital adrenal hyperplasia: A genetic disorder caused by a deficiency of the enzyme 21-hydroxylase in the adrenal cortex, and the commonest adrenal disorder of childhood. Cause of virilisation in an affected female fetus. Partial androgen insensitivity: An X-linked genetic disorder causing ambiguous genitalia in 46,XY individuals. Caused by a lack of androgen receptors in androgen target tissues, such as genital skin. Gender dysphoria: Mental distress caused by unhappiness with one’s own sex and the desire to be identified as the opposite sex.

Garry L Warne MB BS, FRACP · Jacqueline K Hewitt MB BS

Fixing sex. Intersex, medical authority, and lived experience. Katrina Karkazis. New York: Duke University Press, 2008 (xiii + 364 pp). ISBN 978 0 8223 4318 9. Currently, there is an intense ethical debate about genital surgery for infants born with ambiguous genitalia. The controversy rose to a new level of intensity in Australia in 2008 with the involvement of the Australian Human Rights Commission and the Victorian Government Department of Justice. Doctors in Europe and North America are facing the same dilemmas. This new book, possibly the best contribution to the debate yet published, is very welcome, not only because it is timely but because it is deeply thoughtful, thoroughly researched and very respectful of all points of view. The author, Katrina Karkazis, PhD, MPH, is a Senior Research Scholar with the Center for Biomedical Ethics at Stanford University in the United States. In addressing the historical basis for current understanding of sex and gender, Karkazis discusses the contribution to the understanding of sex development made by John Money (a psychologist at Johns Hopkins University) in depth, in a way that is refreshingly generous. She traces the development of what became the traditional treatment model, the scepticism that emerged, and the origins of Internet-based patient advocacy groups in the mid 1990s. Her exploration of what is posted on discussion boards is balanced by her careful study of what scientific long-term outcome studies have, and have not, delivered. She has also conducted hundreds of interviews with doctors, parents and adult patients. Her book concludes with the following:

Garry L Warne

To the Editor: Kaposi’s varicelliform eruption (KVE) is a disseminated cutaneous infection caused by herpes simplex virus (HSV) in patients with predisposing factors such as atopic dermatitis, widespread skin injury and sun exposure.1-5 I report a patient with KVE but no apparent predisposing factors. A 54-year-old man presented with a 3-day history of a rapidly progressing vesiculopustular rash on his trunk, legs, arms and hands (Box). He reported a burning skin sensation and had a temperature of 38.2°C. He had no labial or oral erosions, and no history of skin disease, HSV infection or any systemic disease. He was not taking any medication and reported no excessive sun exposure before symptom onset. Haematological, biochemical and immunological parameters, including levels of C-reactive protein, immunoglobulins, complement components, lymphocyte blastogenesis and natural killer cell cytolytic activity were normal. An HIV test was negative. Skin swabs from the lesion were positive for HSV-1 by polymerase chain reaction (PCR) testing; HSV-1 was also isolated on culture. Cultures were negative for bacterial, fungal and mycobacterial pathogens. A diagnosis of KVE was thus established. Based on past experience treating KVE with a combination of oral valaciclovir and vidarabine ointment, which accelerated resolution of symptoms,6 I treated the patient with oral valaciclovir (1 g three times per day) and vidarabine ointment (three times per day). The lesions were completely healed after 7 days of treatment. HSV-1 antibody titres on Days 1 and 7, respectively, were: IgM, 3.1 and 5.2 (reference range, < 0.8); and IgG, < 2.0 and 4.7 (reference range, < 2.0). HSV-2 IgM and IgG antibody titres on Days 1 and 7 were within reference ranges (< 0.8 and < 2.0, respectively). This case is unusual as it occurred in an otherwise healthy patient. KVE is usually associated with healing second-degree burns, peribuccal dermabrasion and laser skin resurfacing,2-4 and sun exposure in patients with recurrent HSV infection.5 The origin of the patient’s HSV-1 infection was not identified: there was no outbreak of HSV infection in his city of residence; his wife and two children were healthy and had no systemic or skin diseases; PCR testing of their saliva for HSV-1 and HSV-2 DNA 3 days after the patient’s presentation gave negative results; and the patient had no apparent contact with HSV-infected patients before onset of symptoms. KVE has been successfully treated with intravenous aciclovir (three times per day) or oral aciclovir (five times per day).2,5 However, intravenous aciclovir requires hospital admission, and compliance with the dosage regimen of oral aciclovir is troublesome. In contrast, oral valaciclovir (three times per day) and vidarabine ointment do not require hospital admission and are easier for patients.1,3,6 Oral valaciclovir is also very effective for preventing herpes infection.7 This case highlights that KVE should be considered in otherwise healthy patients with a sudden, rapidly progressing vesiculopustular rash. Vesiculopustular lesions in a patient with Kaposi’s varicelliform eruption

Hajime Kimata

Objective: To assess the impact of a long-term comprehensive control program for sexually transmitted infections (STIs) in remote Aboriginal communities in Central Australia, and to investigate a recent rise in gonorrhoea prevalence.Design: STI prevalence was determined from annual, cross-sectional, population-wide, age-based screening, 1996–2006. During 2006, gonococcal isolates were obtained by on-site culture and tested for antimicrobial susceptibility.Setting: Six remote clinics on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands, South Australia, which are served by Nganampa Health Council, an Aboriginal community-controlled health service.Participants: All resident Aboriginal people aged 14–40 years at the commencement date of each annual population-wide screen.Main outcome measures: Multivariable logistic regression models were used to compare prevalence of chlamydial infection, gonorrhoea and syphilis measured during each annual population-wide screen; antimicrobial susceptibility of gonococcal isolates obtained in 2006.Results: Between 1996 and 2003, there was a significant reduction in prevalence of gonorrhoea and chlamydial infection, by 67% and 58%, respectively. Subsequently, chlamydia prevalence rate plateaued, but there was a rapid rise in prevalence of gonorrhoea. Syphilis prevalence decreased linearly over the study period (odds ratio, 0.81; P < 0.001). During the first 6 months of 2006, 89 gonococcal isolates were obtained, 39 through on-site culture during the 6-week screening period, and all were sensitive to penicillin (in the less-sensitive category).Conclusions: The decrease in STI prevalence asssociated with the program was maintained until 2006 for chlamydial infection and syphilis, but not for gonorrhoea, which rose in prevalence after 2003. There was no change in antimicrobial resistance to explain this rise, and gonorrhoea transmission dynamics and travel of core transmitters to regions without STI control programs might be responsible.

Rae-Lin Huang MB BS(Hons), MPH, FRACGP · Paul J Torzillo MB BS, FRACP, FJFICM · Vivien A Hammond RN, RM, GradDipNursing · Stephanie T Coulter BLabMed · Adrienne C Kirby BSc(Hons), MSc

To the Editor: In the preceding article, we report on a substantial rise in prevalence rates of gonorrhoea in a population in remote Central Australia.1 This rise occurred in the context of a sustained major reduction in sexually transmitted infections (STIs) in the region, achieved by a comprehensive program of STI control, described in the article1 and previously.2 We found that the gonorrhoea outbreak was not due to penicillin resistance of the causative organism, and we hypothesise that it was due to the introduction and dominance of a more infectious clone.3,4 This rise in gonorrhoea in a region widely acknowledged to have the most successful STI control program in the country prompted several commentators to argue that both this program, and screening as a measure for STI control in remote Indigenous communities, had failed, and to advocate a range of other approaches.5 We recently completed the analysis of the 2008 annual population-wide STI screen, which achieved a 78% participation rate among eligible participants. These data strongly suggest that the gonorrhoea outbreak seen over the previous 4 years has been controlled (Box). Furthermore, the current prevalence rates are among the lowest seen in the past decade. These findings suggest that a comprehensive STI control program, such as that delivered by the Nganampa Health Council, can not only reduce STI rates, but also control outbreaks, provided the program is sustained. During most of the past decade, the prevalence of syphilis remained below 1%, of chlamydial infection below 6%, and of screening test-positive gonorrhoea below 8%, as measured during the annual population-wide screens. This program should be replicable in other regions, if appropriate resources and expertise are applied, thus providing an opportunity to improve an important area of Indigenous health using current public health knowledge. Age-adjusted prevalence rates of chlamydial infection, gonorrhoea and syphilis among 14–40-year-olds on the APY Lands, 1996–2008 APY = Anangu Pitjantjatjara Yankunytjatjara.

Rae-Lin Huang · Paul J Torzillo · Adrienne C Kirby

Objective: To identify the prevalence and correlates of three types of pelvic pain (dysmenorrhoea, dyspareunia, and other chronic pelvic pain [CPP]) in a nationally representative sample of Australian women.Design and setting: The CPP survey was part of a broader national study of health and relationships. Computer-assisted telephone interviews were administered to a random sample of 8656 Australian households; 4366 women aged between 16 and 64 years were interviewed in 2004 and 2005. Eighteen of the more than 200 potential survey questions related to pelvic pain.Main outcome measures: Self-reports of dysmenorrhoea, dyspareunia, and any other CPP not associated with sexual intercourse or menstruation.Results: Data on 1983 women aged 16–49 years who were still menstruating and sexually active were analysed. Prevalences were 71.7% for dysmenorrhoea, 14.1% for dyspareunia and 21.5% for other CPP; 23.3% of women reported no pelvic pain of any kind. Severe pain was reported by 15.0% (95% CI, 13.0%–17.1%) of women with dysmenorrhoea, 7.8% (95% CI, 5.0%–11.9%) of women with dyspareunia and 20.0% (95% CI, 16.1%–24.6%) of women with other CPP. Just over a third (34.2%) of women who reported any pain had sought advice from a health professional. Women reporting CPP were also likely to report other health conditions, most notably depression and anxiety. There were clear associations between CPP and sexual difficulties, pregnancy and pregnancy outcomes.Conclusions: Rates of pelvic pain in Australian women are high. General practitioners need to be ready to discuss these issues with patients, particularly in relation to underlying anxiety and depression.

Marian K Pitts BA(Hons), PhD, MAPS · Jason A Ferris BPsych(Hons), MBiostat, GStat · Anthony M A Smith BSc(Hons), PhD · Julia M Shelley BA(Hons), MPH, PhD · Juliet Richters BA, MPH, PhD

Premature ejaculation (PE) is ejaculation occurring without control, on or shortly after vaginal penetration and before the subject wishes it, causing marked distress or interpersonal difficulties. PE is the most common male sexual complaint. Primary (lifelong) PE has a physiological basis. Therapy should involve the man and his partner. The primary aims of therapy are for the man to regain a sense of control over his ejaculation time and for him and his partner to feel satisfaction with sexual intercourse. The most effective therapies for primary PE are certain selective serotonin reuptake inhibitors, given on a daily basis or “on demand” before sexual activity. Topical anaesthetics have also been shown to be effective. The most common cause of secondary PE is declining erectile function. The approach to treating secondary PE is to treat the underlying condition.

Neil R Palmer MB BS DObstRCOG · Bronwyn G A Stuckey BA, MB BS, FRACP

To the Editor: In Victoria from 2000 to 2006, infectious syphilis notifications (primary, secondary and early latent infections) increased about 25-fold from 0.2 cases per 100 000 population in 2000 to 4.7 cases per 100 000 population in 2006.1 The number of new diagnoses of HIV has also increased since 2004.1 After observing a few patients presenting with both syphilis and a concurrent new HIV diagnosis, we investigated the association of the two diseases using retrospective laboratory data. As the Victorian Infectious Diseases Reference Laboratory (VIDRL) incorporates the state HIV reference laboratory and also acts as the reference laboratory for syphilis serological testing, it was possible to identify the HIV status and/or time of HIV diagnosis of 85% of patients identified with infectious syphilis, based on syphilis serological findings and polymerase chain reaction testing as previously described.2 Three hundred and forty-seven male patients fulfilled the criteria for infectious syphilis in the period 1 January 2000 to 30 December 2006. This represents 68% of all patients with infectious syphilis notified to the Victorian Department of Human Services over the period. Within the group of 347 patients, there were 310 with a single episode of Treponema pallidum infection, of whom 44.5% were HIV-positive. Thirty-seven patients were reinfected with syphilis, including 21 with their first episode recorded since 2000, and 11 with a serological pattern consistent with old treated syphilis recorded before reinfection during the study period. Of the 37 patients, 33 (of whom 23 were HIV-positive) had a second recorded episode and four (of whom three were HIV-positive) had a third recorded episode within the study period. Overall, 70.3% of patients with multiple episodes of syphilis were infected with HIV. Twenty patients presented with a concurrent diagnosis of infectious syphilis and previously un-diagnosed HIV infection. The trend over time is shown in the Box. Several international studies have highlighted the disproportionate incidence of syphilis in patients infected with HIV in recent years. There is now good evidence that syphilis and HIV act synergistically with regard to both transmission and progression of both diseases.3-5 The above data clearly demonstrate the strong association between HIV infection and infectious syphilis in Victoria, and this trend continued in the first half of 2007. Given the more frequent syphilis reinfections observed in the HIV-infected group, it indicates persons with HIV form a potential reservoir for syphilis infection in this state. We would strongly recommend that any patient presenting with possible syphilis or HIV infection in Victoria or elsewhere in Australia should be tested for both diseases. Episodes of infectious syphilis in Victoria by year of infection and HIV status * Patients with evidence of prior syphilis infection at an unknown time.

David E Leslie · Nasra Higgins · Christopher K Fairley

To the Editor: The proposal by Bowden and Fethers1 to abandon “screen, treat and contact trace” methods of managing endemic sexually transmissible infections (STIs) in remote Indigenous communities and replace them with mass treatment programs in groups with defined threshold prevalence levels is flawed. Primacy must go to the question of why some STIs are so prevalent. Why deal only with the consequences rather than the causes of STIs? Without resolving these questions, the problems will persist. Bowden and Fethers’ approach has serious shortcomings. A major one is sweeping aside the concepts of one-on-one advice, counselling, opportunities to cooperate with health staff, avoidance of hazardous behaviours, and maintenance of effective follow-up. These cornerstones of public health strategies to control STIs depend on the ability of health professionals to establish meaningful relationships with Indigenous people. Transient populations move frequently between towns and remote communities. Therefore, the authors’ strategy neglects the serious risk to remote communities from inadequately controlled reservoirs of STIs that allow the diseases to be repeatedly reintroduced from rural or remote towns. The authors say, ironically, “Let’s not talk about sex”, but an essential part of the public health response to STIs must be to talk about sex. It is our observation that many Indigenous people are more comfortable talking about this subject than other Australians. Another risk in the authors’ approach is to overlook detection of HIV infection. Their proposal could also be interpreted by many Indigenous people as suggesting that they no longer need worry about STIs because the new blanket approach from their health carers will protect them from all such infections. Our long experience working in remote northern Western Australia suggests to us that a mass treatment approach would not resolve the problem of STIs. Control of many of the main chronic diseases of Indigenous people living in remote areas can be significantly enhanced by increased Indigenous community involvement, decision making, and trusting collaboration with health professionals.2 Crucially, additional government commitment is urgently needed to provide enough locally stable and adequately trained staff, facilities, and related resources to control these persisting problems in remote Australia.

Michael S Gracey · Randolph M Spargo

To the Editor: It was pleasing to see Bowden and Fethers raising the issue of public health approaches to sexually transmissible infection (STI) control in remote Indigenous communities.1 However, their suggestion that mass treatment programs would be more effective than screening programs is flawed. They note that screening programs have had some success in reducing the prevalence of STIs, but that an unacceptable prevalence persists. Rather than rejecting screening as an appropriate strategy, it would be more useful to investigate the reasons why screening programs have had limited success. It is likely that the main drawback has been inadequate coverage, and one of the main reasons for this is that there are hard-to-reach groups who are not being included in screening programs. In particular, this would include people with alcohol problems or other addictions, whose lifestyle makes them more at risk for STIs. People in this group, who often live a transient or homeless lifestyle in regional centres, have problems of access to health care and health programs. A mass STI treatment program would not overcome this difficulty and would be just as likely as current screening programs to miss this crucial target group. What is needed is better support for comprehensive primary health care programs, to allow an extension of current health programs to reach out to these groups. Bowden and Fethers suggest that screening programs are inadequate because of problems with current levels of staffing and health infrastructure. This is what needs to be addressed. Greater support for community-controlled comprehensive primary health care, to ensure adequate levels of staffing and infrastructure for STI screening (including outreach programs for hard-to-reach populations), would produce better results from STI screening and would also allow better control programs for other health problems. Furthermore, it would help reduce the problem of increasing antibiotic resistance that is likely to result from mass treatment programs.

David J Scrimgeour

To the Editor: With their radical population-based approach, Bowden and Fethers1 bring a refreshing perspective to the management of sexually transmissible infections (STIs) in Indigenous communities — normally a taboo subject with those at risk and their families. I recently participated in the federal government’s Northern Territory Emergency Response, and was told, both centrally and locally, that looking for STIs was off limits, as it might destroy the trust of Aboriginal communities. This meant that I could neither enquire about nor examine children or adolescents below the umbilicus. I noted that most teenage girls had contraceptive implants (a good public health measure), but no STI prophylaxis. I think this is a failure of the Response.

Bryan G Walpole

In reply: Although the title of our article was intentionally provocative, our suggested rethink of current approaches to control of sexually transmissible infections (STIs) in remote communities emphasises the role of individual autonomy and consent, education, health promotion and community involvement. We do not dismiss one-on-one advice, counselling, follow-up, the need for meaningful relationships with Indigenous people, or the risk of an HIV epidemic. However, we do suggest that there should be a separation of the strictly medical components of the strategy from the community development components. Furthermore, in the presence of endemic disease, we propose that presumptive treatment should be based on an assessment of risk made at a community level rather than at the individual level, and that removing the otherwise unavoidable delays between screening and treatment may be a more effective first step in reducing the burden of STIs in remote populations. A “screen, recall, treat and contact trace” approach works to some degree in the mainstream population, in which the prevalence of STIs is much lower than in remote communities, but what is considered “best practice” in suburban Australia does not automatically translate into best practice in the bush. We acknowledge the logistic difficulties of offering any type of broadly based community program in remote areas and we specifically address the problem of treating hard-to-reach groups in communities. We recognise the risk of giving a false sense of security to the target audience, but current approaches provide people in remote areas little protection from STIs. The recent roll-out of the human papilloma virus vaccination in young women could be similarly criticised, but it is possible to implement a biomedical intervention and still continue with education and health promotion. The question of antibiotic resistance is an important one. The aim of increasing the intensity of treatment over a defined time period is to reduce the total amount of antibiotics prescribed in the longer term. An increase in the level of resistance is the price that is paid for a reduction in the prevalence of disease in any population receiving antibiotics. Nevertheless, we indicated the need for monitoring of resistance patterns in any trials that are undertaken. The eradication of the eye disease trachoma is dependent on the availability of clean water and better housing, but while this crucial infrastructure is being built we have to continue to treat the condition where it occurs and apply “traditional” public health approaches to population-level control. We think it is reasonable to consider doing the same for STIs.

Francis J Bowden · Katherine Fethers

Cervical cancer prevention relies on two different age-specific technologies, and consumers should not be misled about the role of HPV vaccines The introduction of human papillomavirus (HPV) vaccines to clinical practice is the end result of a remarkable distillation of basic science, new technology, epidemiological understanding, clinical research and commercial development. It has brought together stakeholders from a variety of backgrounds to consider these developments, and Australia is now the first country to implement a population-based mass vaccination program against HPV. The Australian HPV vaccination program was commenced after cost-effectiveness of the quadrivalent vaccine was demonstrated,1 anticipating that the expected reduction in the cost of treating HPV-related disease in Australian women would compensate for the cost of the vaccine. This program, an Australian Government initiative,2 appears to have been very successful in terms of coverage, and offers young Australian women the opportunity to be among the first national cohort to be vaccinated against the virus types that cause most cervical cancers and a variety of other HPV-related diseases. The natural history of HPV infection and the consequent risk of developing cervical cancer are well documented. HPV infection, replication and particle maturation occurs in the stratified squamous epithelia of skin and mucous membranes, with virus spread occurring by skin-to-skin contact. Most people encounter genital HPV soon after the onset of sexual activity,3 with the highest risk of contracting the infection in the first 5–10 years after commencing sexual activity. The clinical consequences of infection will vary according to the type of HPV encountered, and most infections resolve spontaneously, presumably relying on the host’s immune system to clear the infection. For whatever reason, some individuals do not clear their infections, and if these infections are caused by some oncogenic or high-risk varieties of HPV, this persistence will lead to activation of oncogenic viral proteins, the loss of cellular control mechanisms and the potential for malignant transformation. Screening programs based on cytology have had significant impacts on the incidence and mortality of cervical cancer by detecting these potential cancer precursors, but HPV vaccines allow the opportunity to enlist the vaccinee’s own immune system to develop neutralising antibodies before exposure, and to primarily prevent the infection. The two currently available vaccines (a quadrivalent vaccine against HPV types 6, 11, 16 and 18, and a bivalent vaccine against types 16 and 18) have both been developed by recombinant genetic technology that allows expression of the major structural protein of HPV, the L1 protein, that spontaneously assembles into virus-like particles (VLPs) which are both type-specific and highly immunogenic. Both available vaccines contain VLPs, but the products differ in the types of HPV L1 proteins included as antigens, substrates used for production, adjuvant properties and in the final formulation. Antibodies raised to the VLPs provide protection against HPV infection, probably by transudation of IgG from serum to local mucosal/epithelial areas, especially at sites of trauma where HPV can otherwise gain access to basal epithelial cells.4 Published efficacy studies suggest subtle but probably insignificant differences between the two vaccines in preventing type-specific HPV infections and disease.5,6 It seems unlikely that cell-mediated immunity is involved as a direct effector mechanism of vaccine protection.7 Clearly, this mode of action highlights that the current vaccines will only be effective if administered before exposure. These vaccines have shown no therapeutic efficacy for pre-existing infections.8 Trials of both commercially available vaccines, while demonstrating very high efficacy (approaching 100%) in HPV-naïve populations, have shown diminished efficacy in populations with high rates of previous exposure.4,5 The results so far have indicated that women already infected with one of HPV types 16 or 18 can be protected against development of cervical intraepithelial neoplasia grade 2/3 or cervical adenocarcinoma in situ associated with the other type by vaccination. Both trials were conducted in young populations (generally in women aged between 16 and 25 years). Preliminary results indicating significant efficacy (greater than 90%) of the quadrivalent vaccine in an older population aged between 24 and 45 years have been presented, and these data form the basis of the vaccine sponsor’s application to regulatory authorities in both Australia and the United States for expansion of their age indication for this formulation.9 Doctors are used to being exposed to marketing from drug companies, and are susceptible to commercial persuasion with competing claims of superiority and product distinction. The quadrivalent vaccine, Gardasil (Merck), is available at no cost to Australian girls and women between the ages of 12 and 26 as part of the National Immunisation Program. The bivalent vaccine, Cervarix (GlaxoSmithKline), has to date not been included in the program, having initially been rejected by the Pharmaceutical Benefits Advisory Committee (PBAC) on the basis of uncertain cost-effectiveness,10 but subsequently recommended for inclusion.11 This recommendation has not yet been endorsed by the Australian Government. The sponsoring company appears to have decided to promote Cervarix specifically to older women,12 despite the absence of efficacy data and the uncertain population benefits in this age group. Indeed, the decision by the Australian Therapeutic Goods Administration (TGA) to register Cervarix for use in this population, in which no efficacy has been shown, is not easily understood. Under the Therapeutic Goods Act 1989 (Cwlth), the TGA is responsible for evaluating the quality, safety and efficacy of medicines.13 The World Health Organization has issued guidelines for the evaluation of HPV vaccines, indicating that studies that use immunogenicity data to bridge efficacy from younger to older women are not appropriate.14 In Australia, these guidelines have not been adhered to, and Cervarix has been licensed for use in women up to 45 years of age, despite lack of demonstrated efficacy in women over 26 years. To suggest that the vaccine will offer patients some theoretical potential benefit if they are prepared to pay for it does not reflect sound evidence-based, equitable health care provision. The promotion and media coverage of HPV vaccines in Australia have been extensive, and with this has come an increased awareness of HPV, its relation to cervical cancer, and the national HPV vaccination program. The promise of a cancer vaccine is alluring to women who perceive a risk of cervical cancer. Principles of consumer protection, however, demand that expectations should not be raised unduly, and that the available vaccine does not promise to deliver beyond its capacity. Excessive promotion in the older age group, when the vaccine is likely to be of substantially reduced efficacy because of either previous exposure or reduced risk of future exposure, potentially diverts attention and compliance with established methods of cervical cancer prevention based on cervical cytology. HPV vaccines are about preventing future infections. Cervical cytology detects cytological abnormalities from previous infections. It is important that the benefits of these two approaches to cervical cancer prevention are not confused, and that all women receive the best and most appropriate combination of two effective technologies.

Gerard V Wain FRANZCOG, CGO

Transsexual and other disorders of gender identity: a practical guide to management. James Barrett, editor. Oxford: Radcliffe Publishing, 2007 (298 pp). ISBN 978 185775 719 4. This is an outstanding book, fulfilling a marked need. Barrett, principal author and editor, is a consultant psychiatrist and lead clinician at the Charing Cross Hospital Gender Identity Clinic in London. He draws on 20 years’ clinical experience; his writing and presentation are clear and most helpful. The book concentrates on the major aspects of the health care of transgender men and women, including the role of the psychiatrist and the contributions made by other medical specialists, speech therapists, and surgeons. That the general practitioner’s role in patient care was not given emphasis surprised me. GPs are often in the best position to provide continuity of patient care and coordination of the various specialist consultations. For the male-to-female transsexual, a masculine voice may be the major obstacle to the person being accepted in the desired sex role. Two chapters describe what can be achieved by speech training and laryngeal surgery. Feminisation of the male body or masculinisation of the female body is one of the most urgent requests that transgender patients have at their first consultation. Once their diagnosis of transsexualisation has been established, they will require lifelong hormone therapy. The chapter on this subject is essential reading. It is a masterly dissertation on all of the principles of hormonal treatment and the various regimes and modes of administration. Side effects of such therapy and their management are also discussed. Discussions of surgical treatments deal with breast augmentation or reduction, removal of penis and testicles, vaginoplasty, vulvoplasty, and phalloplasty. All are excellent chapters, but that on phalloplasty deserves special mention because it deals with a difficult and complex subject in an enlightening manner. In all of these chapters, postoperative care and complications are adequately discussed, along with limitations of the various surgical procedures. The legal issues of gender change are included in a chapter that addresses marriage, the family, employment, pensions and privacy. Even transsexuals in the military services, various religious traditions and their teachings about gender change, and fertility issues affecting transsexuals are considered in the concluding chapters of the book. The editor and authors have definitely produced a practical text on gender identity disorders for everyday clinical use. I strongly recommend it to all health care professionals involved in the care and management of patients with issues of gender identity. Educators in medicine and the health sciences should consider recommending this book for their undergraduate students. It can truly be said that this book is a clinical gem.

William A W Walters

Gender is more than just a variable to be controlled for in statistical analyses Does ageing affect men and women equally? If not, how might differences affect research — and subsequently clinical practice? To answer this and related questions, the Mars and Venus: Does Gender Matter in Ageing? conference was convened by the University of Newcastle’s Research Centre for Gender, Health and Ageing, in association with the Australian Association of Gerontology and the Healthy Ageing Theme of the Australian Research Council/National Health and Medical Research Council (NHMRC) Research Network in Ageing Well.1 The 2-day conference, held in Newcastle in July 2007, featured longitudinal studies of ageing that have given specific attention to the health of men or the health of women, and introduced an NHMRC-funded initiative to link two of these studies. The conference also included a 1-day research workshop, sponsored by the Ageing Well Network, which involved researchers from longitudinal studies of ageing being conducted in Australia, and considered how such studies might take greater account of gender in their design and analysis. The conference attracted 85 participants from across Australia and overseas, who came together to consider ways in which the effects of ageing are unequal between men and women, and how these differences might be further exaggerated through interactions with socieconomic status and background. Conference overview: seeking balanced debateThe theme of the conference was set by Cherry Russell (School of Behavioural and Community Health Sciences, University of Sydney), who gave a keynote address, Ageing and the gender agenda: a critical reflection, which outlined gender differences in life expectancy, health, income, care needs, and level of social isolation, along with a discussion of gender biases in policy and service provision. Compared with men, women have more chronic illness and greater health service use at older ages; but they also live longer. Men have more fatal illness at younger ages.2 For instance, men have coronary artery disease earlier and have a higher death rate. Lung cancer is more common among men, who have had higher rates of smoking than women. Women have a higher incidence of musculoskeletal problems and a higher prevalence of incontinence, although these problems are also important for men. Although hip fracture also affects older men, the incidence increases at a later age and fewer men survive to the age of high risk. Women, therefore, dominate the clinical picture. Some health differences are related to biological sex; however, many differences are strongly linked to social influences of gender. These less obvious differences include environmental, occupational and behavioural risks, behaviour, and different adaptive techniques. There are also considerable differences in social roles and access to financial and social resources — which significantly affect the experience of ageing. Cherry Russell noted that there has been little balanced debate as to what the unequal effects of ageing for men and women mean and where they stem from. Debates about gender and ageing have focused on loss of men’s work roles, older women’s double disadvantage from age and gender inequality, and on a “paradigm of competitive suffering”. In contrast, this conference aimed for greater balance in considering how gender influences the health and wellbeing of men and women as they age. This theme was reflected in the proffered papers and workshops. Papers explored age and gender issues such as living arrangements; health and engagement for older men; gender bias in health service programs; retirement issues; and current research on gender differences, including results from the Household, Income and Labour Dynamics in Australia (HILDA) study and Melbourne Longitudinal Studies of Healthy Ageing (MELSHA). Workshop topics explored the needs of homosexual and transgender people, gender issues in dementia and sexuality in residential aged care, and the practicalities of conducting a large longitudinal study: the Australian Longitudinal Study on Women’s Health. Longitudinal studies: a focus on genderKeynote addresses throughout the conference featured longitudinal studies of older men and women. The Concord Health and Ageing in Men Project (CHAMP), presented by Bob Cumming (Centre for Research and Education on Ageing, School of Public Health, University of Sydney), involves 1705 men aged 70 years and over. Early findings from this study show a sharp increase in multiple falls, and declines in continence, cognitive function, and activities of daily living starting after the age of 80.3 The Florey Adelaide Male Ageing Study (FAMAS), presented by Gary Wittert (School of Medicine, University of Adelaide), focuses on chronic physical and psychological disease and reproductive and sexual health.4 Measures of testosterone show an age-associated increase in sex-hormone-binding globulin and a decrease in free testosterone, a change that may be adaptive rather than pathological. The Health in Men Study (HIMS), presented by Leon Flicker (Graduate Research School, University of Western Australia), involves 4262 men, and focuses on physical and psychosocial morbidity (including depression), health risks, weight and body mass index, cognition and mortality. One finding from this study has been the importance of health and lifestyle factors in determining cognitive function, even in advanced old age.5 Emily Banks (National Centre for Epidemiology and Population Health, Australian National University) provided an overview of the United Kingdom’s Million Women Study (MWS), which has shown increased risks of breast cancer,6 endometrial cancer,7 and ovarian cancer with use of hormone replacement therapy,8 and a protective effect on fracture.9 Annette Dobson (Division of Epidemiology and Social Medicine, University of Queensland) represented the Australian Longitudinal Study on Women’s Health (ALSWH), which has been running since 1996, and has investigated many factors affecting women’s health and ageing, particularly the influence of social context on health and health care use.10 Recent reports from this study emphasise the burden of illness associated with non-fatal conditions such as arthritis, the preventable burden of obesity, and safe levels of alcohol intake for older women.11 Leon Flicker, Annette Dobson and Julie Byles (Research Centre for Gender, Health and Ageing, University of Newcastle) also gave an overview of the recently funded Men, Women and Ageing Study, linking HIMS and ALSWH to generate cross-gender analyses. Additionally, Gita Mishra (University College, London) showed how gender interacts with effects of childhood socioeconomic status in determining early mortality in the 1946 British Birth Cohort. For example, a father’s occupation had a strong effect in women, but no significant effect in men. Studies of men and studies of womenWhat are the similarities and the differences?A workshop involving investigators from longitudinal studies and other researchers compared and contrasted issues, approaches and findings of longitudinal studies of men and women. Identified commonalities and differences between studies of men and women are shown in the Box. The main differences were conditions that could not be experienced by the opposite sex, such as hysterectomy for women and prostate disease for men. However, studies of men had a focus on testosterone and sexual function that was not mirrored by female equivalents. Studies of women measured oestrogen levels and sexual problems in relation to menopausal changes, not in relation to health in later life. Other differences were more subtle. For instance, while prostatism is a male issue, lower urinary tract symptoms are also experienced by women. It was agreed that more emphasis on these symptoms may be appropriate for studies involving women. As a general observation, studies involving men applied a biological framework, whereas studies of women applied a social model. For instance, caring has been emphasised in women’s studies but caring may be an equally important, although different, issue for men. Health after the death of a spouse has also been given greater emphasis in studies of women. Men are more likely to repartner, but this comparison is confounded by the construction of relationships, with men preferring to cohabit and women preferring to live apart from a new partner. Transport and mobility were also identified as major issues for women. This need may be experienced differently by men, for whom loss of a drivers licence may present more than a practical problem of “how to get around”, as it may also lead to depression and general decline. Cross-gender analyses: what are the opportunities?The workshops also explored how longitudinal studies of ageing can be analysed from a gendered perspective. It seems that almost any question on the ageing research agenda can be subjected to a gendered analysis. For instance, comparing genders: Which differences exist at a biological level, and which are socially determined? Does socioeconomic disadvantage have a differential effect on health? Does caring by men and women involve different activities and dimensions? What is the effect of ageing on sexual function, sensuality and spirituality? Is there a differential change in the importance of these outcomes with age? How do men and women engage with the health care system? Does health care need to become more gender-sensitive? Are there differences in diet and nutrition? Does nutrition have a differential effect on health outcomes according to gender? Are the predictors of survival and longevity different among women and men? For example, does comorbidity have a stronger effect in men? Do men and women have different health goals? If health is seen not as an end, but as a means to achieving life goals, then health will have different effects in men and women if their life goals are not the same. Gendered comparisons: simple or complex?However, gendered comparisons may not be as simple as stratifying variables by age and sex. Men and women may exhibit different levels of accuracy and reliability in reporting exposures and outcomes, and many measures have a strong gender bias. For instance, caring appears to have very different meanings and manifestations for men and women. Physical activity has a different nature, context, and inherent value. Even when the same measures can be used, different categorisations may be needed, especially if underlying distributions and associations vary by gender. Further, influences of gender may interact strongly with cognitive status, marital status and other socioeconomic factors. Cohort effects are also likely to be important, with changes in the social meaning of gender over time (for instance, disparities in education, employment, occupation, and assets have changed over the past century). The power that can be achieved by combining data from existing longitudinal studies, as will occur in the Men, Women and Ageing Study referred to above and in the Dynamic Analyses to Optimize Ageing (DYNOPTA) project led by Kaarin Anstey of the Australian National University, will allow robust statistical analysis of gender interactions and, in the case of DYNOPTA, the use of nested cohorts to control for cohort and geographical effects. Closing remarksJulie Byles and Hal Kendig (Faculty of Health Sciences, University of Sydney) noted that the discussion from the conference and the longitudinal studies workshop provided valuable insights into basic gender differences and will inform research for years to come. Sex and gender differences matter not only to the experience of ageing, but are also manifested in the design of the research projects which, to date, have shown a clear gender-specific focus. Participants agreed that gender is more than just a variable to be controlled for in statistical analyses — it needs to be understood within a social context and be included in all future analyses. In this way, we may achieve not only greater understanding but also greater benefits in future clinical practice. Commonalities and differences between studies of men and women identified at the workshop Commonalities Medication Obesity and weight Cardiovascular outcomes (heart attack, stroke) Health risks: smoking and alcohol Diabetes and the metabolic syndrome Falls Fracture and osteoporosis Hearing and vision Anxiety and depression Sleep Other medical history Quality of life Mobility and dependence Housing and neighbourhood Social support Health service availability, access and use Living arrangements and marital status Differences Men (Mars) Women (Venus) Testosterone levels Effects of hormone replacement therapy Hysterectomy Dementia and Alzheimer’s disease Sarcopenia (age-related muscle loss) Incontinence: urine flow Incontinence: leaking urine Lower urinary tract symptoms Dysuria Widowhood Caring Transport Prostate cancer Breast cancer Endometrial cancer Ovarian cancer Erectile dysfunction

Julie E Byles BMed, PhD · Matthew Carroll BA(Hons), PhD · and the Mars and Venus Writing Team