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5' council of the Royal Collbge of General Proc- uuoners and the General Medical Services Committee (Wales). Ih overall terms our deputation feared'that the general principles of tbereferral isystem wereeom- promised, access to specialist psychiatric services was ill defined, and the declared'role of the meotal health team in primary tsre could Ithd only to fragmentation and confusion,, Furthermore, the contractualiobligations of the general practitioner were totallyy bypastedl The deputation'received a sympathetic hearing, and it was with,great d'tsappouttment that we read the final paper, Menral Hral1A' Sersiaa, a Saarejy for Wakr, issued in June 1989: Littk has changed from that set out in the cottsultation document, and we are conviitced'that if the recommendations of this paper are implemented the task of treating' psychiatric disorder in Waits is likely' to be muddled and expensive. C,ekna. u. PowysNPS1AP Ud.e<.iry ora,le. cme~.fMi;cloe, cadarGF44XN R C HUMPHREYS N C H STOTT I Shephsrd M'. Prwrry oR uf pntents.ith meotddoatd8r m tk'e communuty: BrMdJ 1919;299:666-9. (9Septmber.) Rape and subsequent seroconversion to' HIV SIR,-The paper by Dr S Murphy and colleagues highlights the potential risks and worries for women who have been sexually assaulted during the current phase of the HIV epidemic.' If we assume that such assailanu are hettsosexual men the overall risk of transmission is likely to be small in view of the present low carriage rate for the virus atttottg:this group in Britain,! In addition, vaginal ~ intercoursse is possibly a less likely mode of trans- mission than anal intercourse.! The situation for male victims of sexual assault may, however, be different. Male "rape 'a5 altgal term dUGSs not.ellst in the United Kingdom, as rape specifies forcible vaginal peaetration: Furthermore, taale sexual'assattlt is nor recogni szi as s distinct entity within the 1976 :? z+ It Offeny: _~ ('.lmendment) Act.' Thismay well' itavrwnsequences for thenumber of cases reported and for public awareness of such events.' Docu- mented cases of sexual assault of men by women have been reported,' but it is generally thought that men att more commonly assaulted by other men. In the United States it has been estimated that only J 0+20°/d of all sexual assaults are ever reported.' In addition, there is some evidence to suggest that male victims are more reluctant to come forward than'their female counterparts, possibly related to the fear of being labelled as bomosexual' or to society's concept that a'"real man" c,nnot be npeA.' Pat t! y Ls a.:ont<q ttence of its legal non-ezistence there a, v ao reliable figures of the frequentv'and natura of male sexual assault in Britain. The onlyy orgaw irinn providing care for victims of male sexull ?vanlbiu Btitainanpresentis'"Survivors; a servic>, no by ^luntc?rs to which various govern- ment vnd +:iiariitblr agencies refer their clients.. The service piovides a telephone belb line (currently ans-wering just over 100 inquiries a month),t ,gether :vith counselling and support. No studies tu date have assessed'the risk of sexually acquirni'.infection in malt victims ofassault; but of 5 12 v ic t Gns known to Survivors in 1'988, 24 of 73' who sought medical advice were diagnosed as naving a sexually transmitted: disease presumed' be consequent on their assault, Data on HIV seroconversion are not available, but 148 of the 512' victims reported skin or mucosal bleeding, and 278: expressed concern about the possibiliry of'ttans- mission of HIV. In 92 of the cases the assailann deliberately threatened the victim with the possi; billrv ofcontracting HIV infection as a consequence of the assault L It has been suggested that between 50%" and 82%' of assailants of male victims are either homosexual or biscxual. The assailants are there- fore in relatively higher risk groups for HIV infection than heterosexual assailants of women. Futhermore„anal penetration, blood'v non-genitall violence, , and mulUple: assailants are more likely when the victim is male.' Rape treatment centres have been set up pri- marily for female victims and'amy lack the skills to deal with men, We believe that an increased level of awareness of male sexual assault is needed among the general'public and especially by health care professionals to encourage victims to come forward. Only when tbis happens can the scale of the problem be fully grasped and appropriate treatment provided. RICHARDHILLMANt>rtViD TAYLOR-ROBINSON Dtmm o(SccuaBy Tummltred Dt.o.n,. Glinia4 Rewrch Cmuc, H,.eo., Mddlesc sunw,,. to.doo WCI NIGF1 O'AMRA I MwmbyS, Kncbm V,.Hartu JRC", Fonur SM.. Rape lod wbietiucni lavconvenqo toH1V: BrMd J1949199:718:. (16 Sepmm6er.) 2 PHLSCammuntobk Due.e SurreiWoce Ceaue. Huwoutmuoode6cxocTy..vus (HIV-1) anobodj..,teporu: United', Fnedom; :.ak's a4U5-89[39. Gwm+o.nrui4Orunv R pmo. 1989;40:3. 3. P.dii.n NS. Hetero.e.ual trm.nuuton of.tcquired immuno de6LK0[}•', f)RIQtCme: Nif(IYtlotlil, PCRPCCUVC{ltlld ; ytqpV peoronans. Res.1 nlmDu. 1987;9;94 i40. 4 M~ 'G'„RutaM. Thceffecesof.esuuLUSaWt on tnen.: a uurq.of 22'vtct+nu. PMrhuf Med 19a9;19:205-9. 5M-y G, Kivts M. Male vxtum of saual awWt. Me! Sn Lem 1987;27:122-4.. 6Scbiff AF. Fsam¢nt,uoo .nd ttntmeut ~of'tbe mJk upe vwtlm. Sa.th'M.dJ 1980773:1498'.502 7Gene FR. SesuaOy rshted tnuma. E-rr Md Cla. NwU Aw. 196a:6:439b6.. t Raufman ~ A, . Div.no P, Jacksaa R, Voorbees. D, Ctinsty. J: Mak r.pe ncums: nooinsutuawoali}ed auWt. A. J PryrAury 1980;t37:221-3. 9Glircr JB, Hammenchla8 MR, Mcfarmack WM. Epidemw lop: of'.exuallytrwsmmeddnrsus m upe v+cums. Rml•Jat Du 19a9;1 t:246-54. I0GraA AN,.Bursess AW:.M.k npe:.onenders andv,ctimt. Aw. j Prydnany 1980i137:806-10. F E r t c V t t a f t I . , relative risk for active smokers compared with Passive smoking and lifelong non-smokers is 5,85. This would be 3 incompatible with rrtes of'denial greater than 5%. cardiorespiratory lhealth, in Therefore, the largest relative risk to be expected Scotland among p.ssive smokers due to this form of biu " " avhen the true risk is unity is 1 F20. A relative risk StR,-Mr Peter N Lee' implies that our obser- of 2•41 was foundin our study: , ~ vation of increased risk for four respiratory Again, the same approach applied to iachaemic symptoms and two cardiovascular symptoms, heart disease assttming a"•rrtte" relative risk of 3 for mortality ftom lung cancer,, mortality from acuve smokers and 1 for passive smokers and a raee i ( ischaemic beart disease, all causes of death related of denial of smoking of 5% produces an obaerved to smoking, and mortality from all causes in reiative risk of 1•05 for passive smokers and 2•42 passive smokers compared witli controls' can be for active smokers. Thus if the relative risk for explained by bias-that of smokers declaring active smokers is considerably Jess than 20, as in all i themselves to be lifelong non-smokers. He cites the conditions we considered other than lung (presumably) lung cancer, for which ifs as he C3nCer, the effecrofmicnlo«ifv.nuan is to produce supposes, no increased risk is usociated' with only'small biases in the relative risk for passive exposure to environmental tobacco smoke and the strookers. Our risks for each of the respitatay "true" risk is increased 20 times in active smokers, sympooms, urdiovascttlar, symptnms, and orr v r L-. TASCS l-Differeniial msrzl6ssificasan canted by 2'A.of rndex'rabjectr denvmg swto4ing rejardleu of cnAabuee'r swrokiwg Aab'its ~ c Eepo.u+c Obxrved "True" Flfeets of Pmt.enuar who ara+p' distntiution} dlsvibuum denultuvcsmoked' V.1 t F ~ Canvola 9'~17. a81 t36~ 3-9' li" r Pzu,.e>moken 1538 1461 .77 5-0 ~ lA ~ Su>sle unoken t751. 1797 -36 . rTi r Doubk .moken 3791 3868 -77 W ' h •As dt6zted by Hole n d.' tDau fromn ubl! I of Hote a n!.•' L li- 1 2%' of smokers denying smoking would'result in observed relative risks of 1 74 for passive smokers and 6•90 ifor active smokers. This is illustrated in his table, using the distribution of subjects in the smoking groups defined in our study. But why does he use only men and ignore women when our analysis and results were based on both sexes and' women comprised 84 2% of our passive smokers?, If' he had included women 5-0% of passive smokers and 3:996 of'controls would have smoked''(table I)'-quitediffetent from the figures of 15-6% and''6•8% respectively presented in his tablt. Our figures in turn produce an observed relative risk of 1'•12 for passive smoking (sub- stantiall'y less than the ]f74'be quotes by sdecting only men) and considerably less' than our study finding of 2-41 for lung cancer among passive smokers. Ckeariy; misclas.ifinrion owing to the 2% rate of denial of smadcing he suggests does not aplain our finding. in addH]Onl higher r7te.s of dlnial of smoking do aot produce sufficient bias to crpl*in our risk for „htng cancer. Table II presents the effect on the basis of a'"true" relative risk of 20 for active smoking and I for passive smoking and of rates of denial varying from J% to 1,0%. Two facts emerge: firstly, the bias in the relative risk for passive smokers does not increase linearly' as the rate of denial increases, it flattens considenbly; secondly; the observed relative risk for active smokers diminis}ies lapidlV as the rate of denial increases. TABLE tt-Relattrae risks forpatsine aad art'roe tmoking fortwrying rates of rmokirtg Obrerrcd rdluvc risk Rate.of denW (%). Pasv.•e smoken . Acuw smokers 1 1•07 13-95~ 2~ 1.12 10-67. 3. 1.15 B•61 4 1•IB 7•17 5. 1•19 6- 14 6~ 1-2Q~ 5•35~ 7~ 1.21 473 a 142 443 9~. 1•23'. 3•82~ 10~. 123. 3•47. This is important, as by comparing the observed relative risk for active smokers from abe table with the relative risk found in the study'an upper bound nn: be defined for the rate of denial The study 1100 BMJ VOLUME 299' 28'oc-rosER 1989 1

It in ,kers :din Ithe why I our ' cies ;5]v. ,, ures • his -ved sub- tin8 udy sive the not do for the uve s of rge: sive = of 1Jy, :crs ses. Sories of mortality quoted are well in excas of that produced by the form of biu suggested. Also, as oontr+ol subjects expertena some level of ta.iron- mental tobacco smoke" otu esumates of risk could be caatervativo. Mr Lee misunderstands our use of urinary cotinine concentrations in passive smokers. We were using published data to establish whether our~ study had sufhcient statistical power to detect the size of risk that might be expected among passive smokers. If Mr Lee is correct and urinary rotinine concentntions are equivalent i to a lower, dose than assumed then our decision not to rely solely on statistical sigaificancc as evidence of a genuine effect was definitely coetxt, Ours was a cohort study of a general population and was not subjecti to the biases associated with a case-control design: , In addition, subjects reported their own smoking histories, and' environmental exposure was based I on record linkage of cobabitees, thereby avoiding, the need to rely on self reporting of passive exposure. Our observations on lung cancer may be based on only nine deaths but arr consistent with the aeatlit of a metaynatyas' combining 13 sep.nte soldies, which concluded that breathing other peoplc's tobaeoo ®oke auses lung cancer. The smporunce of our study lles in the estimates of t•isk for ischaemic heart disease (based on 84 deaths), all causes of death related to smoking (175 deaths), mortaliry from all causes (263 deaths), respiratory, symptoms (292 ases), and cardiovascular .symptoms (117 oses): The consistent increae in riaks for such a wide variety of health otttoomes trom an unbiased prospective cohort study together with a dose-reesponse relauon in passive smokers atrongly, ssuggests that there is now a cse to be answered agttinst pssive smoking that estends beyond the causation of liing cancer. DAViDfHOLE QiARLFS R GILLIS Wen of ScoUMd C.ecv. Sm.eill.e¢ Unir, RWChiB Hospral, G Waw G2a 9NB' CA1tOL CHOPRA VICTOR M HAw7HORNE ~ed ith nd idy tth be 96. ed' ias. Isk Rg' Deprtuu:au d Epdemwloay; UL-ry dMra4pm, Mrch,aan, Umred Sous I I.x PN. Pasove mokint. .od ordiansyuuory lellh, m. Sttoelurod.. Br Med.J 1919;299:742: (16 SepemEer, ). 2Hols DJ.• GiBrsCR, mopn C, Hhtlaw vM~ Pauac®akma. and ordqrespra,ory Aala6 u.aeonl popul+owo m tAe of smtl.m. Be Mrd Ja 9t9;299:Q3-7. (12 Autuw:) . 3w.1d NJ, N4u:haWK, TDomp- SCG,.Cuckk.HS. Don bruNima aNer people'r.oCrco moMe ouu luna oocv?Br. M1dJ 1996;793:1217-22:. Referrals from general practice to hospitaD outpatient departments SIR,-One aspect highlighted in the report by Drs John Emmanuel and Nigel !Walker' is treatment of skin disorders in general practice. Proposals in the white paper are likely to encourage more minor surgery to be undertaken by general practitioners. This may be more cost effective (although our own experience indicates that this tmy not necessarily be so), but skin surgery should be undertaken in general'pnctiee only if the diagnosis is certain- otherwise referrals may be innvsed rather than decreased as intended. We report two problems that resulted from inappropriate skin surgery in general practice. A 49 year old woman had a pigmented lesion removed by curettage and cautery from her lower leg by her general practitioner. Histology, showed ttnlignant melanoma, but~ it was iafpossible to ascertain the depth of the tunwur on the basis of, the inadequately thin cunettage specimen. The patient then had a wide excision and graft, but!it is possible that she would not have required an extensive operation because narrow excision margins can sometimes be adequate for very thin i melanomas. In another patient, a 46 year old woman, a slightl}, raised nodule on the leg was treated by curettage and'autery by her general'practiuoner. Histology showed invasive squamous cell ar- cinoma and the patient was referred for further advice. Because it was diffieult to know the ade- quacy of the initial i treatment the patient was committed to prolonged follow up to exclude recurrence of'tlie lesion. Dep.rtmrni of tleemnoioay, Bnuvqo, Hocp, W ':.. Lnar,n IA1,2JF Dep~i of P.ceolotl, lanarrtt Mnor }io:prud, Luas,a lAl 3RJ i PHILIP HARRISON ROBERT BLEB°ITT 1 t.mm.nuel'~. J, waher N. Refanlf from amer.l P..ctier m tmsfxud oucp.um. dep.otmepn:. stntet\-lor ®peo.®ent.. BrMrd,j 19t9;299:722y(. (16September.) Provision of services SIR,-It seems to be the custom that when a specialist advisory committee pronounces on how sen•ices should be provided this is accepted; but there arc occasions when someone needs to stand up and say "You are wrong." The North West Thames eu, nose, and throat regional advisorv subcommittee says that inpatiem ear, nose„and throat services should be provided only in subregional specialisrcentres and nat,in the smaller district gcnernl'hospitalt. I have been the anaesthetist for three to four nr, nose, and throat lists per week fonover 20'years and knoww that most of these operations are everyday bread and butter surgery, and that over half are on children. Indeed the commonest pudiatric open. uons are ear, nose, and throat-tonsils, glue ean„ etc. These services have ahvavs been available at the local hospital and to say they should all go to subregional eentres is tantamount to saying all hernias and ingrowing toenails should go to specialised units. Not only does this deprive patients of what I would call a core service but it has , profound knock on, effects on most other services in the district general hospital through the possible loss of recognition of anaesthetic jobs. Before someone brings out the old chestnut of "Make rotations"'I will!answer "Just you try to," We are facing this situation in North'i West Hertfordshire District„where the loss of inpauentt ear, nose, and'throat services will disadvantage our patients and could cause havoc with the hospital servtces9s a wliole• Iiam afiaid'that this may be only the beginning of specialist groups building their own little empires without regard to the patients and hospitals from whom they withdraw their services. Sr AItuns OtpHonp-l, 5r At6.ns AL3 9XX MARGARET E PICKERING-PICK Psychiatric illness among the homeless StR,-Dr Max Marshall describes a high pro- poruon of residents of Oxford hostels for the homeless as being ••long term psychiatric patients" and implies that. they are deinstitutionalised long stay patients.' Our findings, however, suggest that hostel l residents with psychiatnc disabilities may have had numerous yet relatively brief hospitall admissions and'inciude those sometimes referred to as "revolving door" patients. We are currently evaluating a psychiatric liiison service to residents of a direct access hostel for homeless women in central London. Of 33 women seen to date„26 are known to have had at least one previous psychtatric admission, but only four have spent periods of more than one year continuously as inpauents: We believe the current emphasis on deinstituuonalised'dong stay patients is mispiaced: it is the needs of those with ~ chronic, severe psychiatric disabilities in the communin• and' the revolving door patients that are not bemgg addressed. Deferring the closure of psychiatric hospitals~ will have little impact on this large group of people. The Department of Hbalth has stated that the forthcroming white paper on cotnmunin are will contain plans to prevent the unplanned discharge of long staypanents into the communin. Thesc safeguards will be of no value to mosl severeh• disabled psyehiatnc patients in the commurlirv: Dr Marshall's findings and our own data both sliow,high levels of unmet need and are in keeping with most surveys of people witli psychiatnc disorders in the commtlniry. These findings clearly indicate inadequate provision of cars, but they should not be used as evidence of the inef7ectiveness of deinstituuonalisation pro- grammes or properly planned'and funded cont- mututy services. The few controlled studies: of selected patients discharged within arefullyv planned community programmes' sliou that long term psychiatric patients (whether or not they have had long stay psychiatric admissions) can be maintained outside hospital without the deterioration in symptoms, poor psychosocial functioning, and readiltissions that are al1 too commonly found in the surveys. Perhaps more importantly, the controlled studies in whicti patients : wishes and satisfaction have been recorded clearli,• show that they prefer to be trnted'in the community. KRLETI¢J.tC R PUGH Depnmrn, dPryduwl , , Mrddksa Ho.pW, Laodoo W I N~~ tAA' I. Marsli.B M, . Golknd;.nd netkcud: - Odordbuqeb for Uu• 6ourku 511mt up~p ab dnfbkd pycEutnr poema? B. Mkd J.19r9;299! 7D6A: (16Sep®bcr. ), 2welYec BGA,.C'6[ke MP9, Coker E„Mahome.d S. C-a au CUnstmu 19a6. Lakrr 14E7 u:553-~:. 3Bnun P: Kocb.nsky" G, Shapvu R, nof. O-: demsuru- uauirarwo of I ps.chmrK p.urn,s... mcual. m•r- doutco®r audin: Aw ) Pryrfmrry19a I:138:736-" . Safety of Picolax in inflammatory bowel disease StR,-In view of the suggestion of Dr A J G McDonagh and colleagues that further evaluation of Picolax is merited' we would like to report our own experience with this preparation in a large cohort of' ehildien undergoing fibreoptic colonoscopy at St Bartholomew's Hospital. Between 1982 and'1988 we performed 534 colono- scopies on 412 children attending this hospital and, with few exceptions, Picolax was used routinely to prepare the colon before endoscopy. This in- cluded the 287 procedures performed on children with chronic inflammatory bowel disease (163 with Crohn's disease, 101 with ulcerstlve colitis, 23 with indeterminate colitis) that was either known to preKxist or suspected and confirmed'at the time of endoscopy: We found the preparation to be successful forcleansing the bowel and free of major complications. Based on our experience we have developed the following regimen for preparing the colon before endoscopy, in children. The child is given only 8uids for 24 hours before the procedure and is given two doses of Picolax, one about 15 hours before endoscopy and the other three hours before. The dose is age dependent: children oven6 years :9 BMJ voLUME 299 28 OCTOBER 1989 1101