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Editor's Choice


BMJ 2010; 341 doi: (Published 19 August 2010) Cite this as: BMJ 2010;341:c4530
  1. Trish Groves, deputy editor, BMJ
  1. tgroves{at}

    Economist John Appleby observes that if the NHS were not protected from the UK government’s forthcoming spending cuts, it would have to reduce its budget by around 14% over the next few years (doi:10.1136/bmj.c4350). A 30% real pay cut for all staff, non-provision of drugs, sacking all consultants and general practitioners, or abolishing the NHS either in London or in Scotland and Wales—any of these could deliver such savings. But none, he admits wryly, would be very appealing, and even if less drastic cuts were made across the board these would be highly unpopular with the NHS-loving British public. Yet David Hunter, professor of health policy and management, argues against ring fencing the health budget (doi:10.1136/bmj.c4354): he believes that protecting the NHS at the expense of other public spending will hamper efforts to reduce social inequalities and prevent disease.

    Moving straight from drastic spending cuts to physical cuts may seem in poor taste, but this week’s journal has several articles on what many see as mutilating interventions. Sophie Arie discusses the American Academy of Pediatrics’ plan to revise its policy on neonatal circumcision of boys (doi:10.1136/bmj.c4266). In 1999, and again in 2005, the academy concluded that evidence of benefit was insufficient to recommend this procedure routinely. But will more recent evidence from Africa overturn this judgment? The Royal Dutch Medical Association is sceptical about the new studies’ conclusions. So much so, that in May the association deemed routine circumcision medically unnecessary and an abuse of the rights of the child akin to female genital cutting—a practice on which the American academy recently had to retract its controversial advice that a ritual “nick” might sometimes be an acceptable harm reduction strategy (BMJ 2010;340:c2922).

    Richard J Wassersug and Tucker Lieberman write passionately about the removal or chemical destruction of testes to treat prostate cancer (doi:10.1136/bmj.c4509). “The language of emasculation remains perjorative and shameful. Fearing such shame, many patients hide their medically modified morphology and deny that they feel any different. Thus they remain invisible and their condition is poorly understood.” Worse, the paucity of research leaves these men without evidence based support and treatment. Although medical emasculation may be as distressing for men as mastectomy is for women, when these authors searched PubMed for “castration” and “mastectomy” plus terms indicating psychological effects they found over 50% more articles about the experience of losing a breast.

    Having a uterus removed may be less distressing, overall, than these other physical losses. Or at least that’s what an individual patient meta-analysis by Lee J Middleton and colleagues suggests (doi:10.1136/bmj.c3929). Their systematic review of 30 randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and the levonorgestrel releasing intrauterine system (Mirena) in heavy menstrual bleeding—along with meta-analysis of the raw data from 2814 women in 17 trials—found low levels of reported dissatisfaction with all of these treatments after about a year. The women were, on average, in their early 40s. Does this mean that most saw their uteruses as redundant, and might that explain the low levels of distress?


    Cite this as: BMJ 2010;341:c4530


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