Eighty six people have died so far this year in. Cornwall whose home address was not Cornish. That most of these were on holiday is suggested by the fact that ...
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Myocardial infarction on holiday Dr D F Levine wrote to draw attention to the large number of holidaymakers who end up on his ward at the West Cornwall Hospital, Penzance (20 August, p 562). They may be the tip of the iceberg; many others are admitted straight to the mortuary. Eighty six people have died so far this year in Cornwall whose home address was not Cornish. That most of these were on holiday is suggested by the fact that only seven deaths occurred up to the end of April, whereas 79 occurred from 1 May. to the present. Roughly the same number has died each year since 1980. During the summer months holidaymakers account for at least 15% of our postmortem workload. Necropsies were carried out on 68 of these people. Thirty nine died of ischaemic heart disease, 11 of other cardiovascular causes, 4 of acute asthmatic attacks, and 14 of other causes. Most of these deaths were not predictable. However, even from the few details supplied for a coroner's necropsy, it is evident that among those patients were some who had poorly controlled angina, poor left ventricular function, or severe asthma. A holiday may be a stressful period and there must be a case for suggesting that patients like those above are safer staying at home. R J MARSHALL J T WHATLEY
While this letter was being composed the number increased to 88. Royal Cornwall Hospital, Truro TRI 3LJ
Homosexuality Dr D E B Powell (20-27 August, p 555) confuses homosexuality and promiscuity when he warns of the dangers to health of a homosexual lifestyle. Promiscuous heterosexuals have suffered the consequences of their behaviour for centuries, but no one would then argue that living a heterosexual lifestyle is bad for health. It is unclear what the supposed benefit of a "contribution critical of homosexuality published in the journal" would be. Criticism of people's lifestyle is not part of a doctor's professional activity, and, although doctors have a duty to advise about the harm caused by a variety of behaviours, the mere possession of a homosexual orientation cannot itself be considered harmful to anyone. If the topic under discussion were alcoholism among doctors, our starting point would not be a criticism of doctors in general; rather we would examine the factors that specifically relate to the problem, with the aim of offering help, not criticism. 738
Perhaps with homosexuality it is more difficult than we imagine to "face the issue truthfully." Indeed, it is often unclear what the issue really is, as Dr Powell indicates when he redirects his attention from the harm that befalls some homosexuals to a consideration of what is "natural" behaviour. His final assertion that the penis and vagina have only one useful function seems as irrelevant as it is untrue. It is difficult to see how such arguments are of help to anyone, and I find it disturbing that the more humane responses in your correspondence columns came from non-medical writers. Doctors can help homosexuals to maintain their health but will not do so by attempting to deny them expression of their sexuality. R G PETHER
Maudsley Hospital, London SE5 8AZ
Mr A W Fowler's comment (20-27 August, p 554), "Dogs mount dogs simply because we deprive them of unspayed bitches," is simplistic. Homosexual contacts between all mammals have been found in almost every species studied. Even though heterosexual contacts outnumber homosexual ones, the balance seems to depend on a host of factors. Thus heterosexuality is facilitated by the greater aggression of males, which allows them to be able to mount a female, and the relative ease of vaginal as against anal penetration. Appropriate pheromones and hormone secretions may facilitate this behaviour.' In some pack animals mounting is also used to signal dominance or submission in the hierarchy, and in certain groups of monkeys only the dominant pair breed, while the rest live on the periphery and exhibit homosexual behaviours.2 A cow that is not in oestrus will often mount one that is so, and likewise bulls will mount bulls. There is no scientific basis for calling this sort of behaviour abnormal. Whitam studied homosexual men in different societies and found many similarities in their interests.3 Men who showed exclusively homosexual interest with minimal heterosexual proclivity, the Kinsey types 5 and 6, constituted about 5% of all the populations he studied. Lesbians occurred slightly less frequently. This would support the view that exclusive homosexuality has a biological basis. Just how such individuals fare depends on the particular society in which they find themselves. There is evidence of cognitive differences between homosexuals and heterosexuals, comparable to those between men and women,4 and it has been suggested that in evolutionary terms it cannot but advance a society to contain individuals who think differently and who have different interests from the majority. Like everything else, sex is a function of the brain: the more complex and intelligent a species is the more complex and varied
will be its behaviour patterns. Man has never been content with the status quo and will always seek variety. The current AIDS epidemic, devastating as it is, has nevertheless led to unprecedented international scientific research and debate and to a re-examination of our understanding of both sexual behaviour and morality. It would, however, be wrong to condemn as "unnatural" behaviour that we do not yet fully understand. RAYMOND E GOODMAN Hope Hospital, Salford M6 8HD 1 Kinsey AC, Pomeroy WB, Martin CE, Gebhard PH. Sexual behavior in the human female. Philadelphia: WB Saunders, 1953. 2 Goy RW, Goldfoot DA. Neuroendocrinology: animal models and problems of human sexuality. Arch Sex Behav 1975;4:405-20. 3 Whitam FL. Culturally invariable properties of male homosexuality: tentative conclusions from cross-cultural research. Arch SexBehav 1983, 12;3:207-26. 4 Sanders G, Ross-Field L. Neuropsychological development of cognitive abilities: a new research strategy and some preliminary evidence for a sexual orientation model. Int J Neurosci 1987;36: 1-16.
Mr A W Fowler and Dr D E B Powell (20-27 August, p 554, 555) use words like "honest doctors," "perversion," and "natural" in their criticisms of Dr Bancroft's editorial on homosexuality. These are precisely the attitudes held by some in the medical profession that he was warning us about, which prevent homosexual men from confiding in their doctors. Reports in this country and the United States show that fewer than one in two homosexual men are open about their sexuality with their doctor.'2 Recent surveys, which have included general practitioners, psychiatrists, and homosexual doctors, have shown, however, that more than 90% thought that homosexuality had not been covered adequately in their medical education (D Bhugra, annual conference of Royal College of Psychiatrists, Brighton, 1988). Despite this more than three quarters of general practitioners in London thought that homosexuals should be accorded the same legal rights and freedoms as heterosexuals.3 Patients are needlessly being deterred when it seems that most doctors take little cognisance of these distasteful minority views. MICHAEL KING DINESH BHUGRA Institute of Psychiatry, London SE5 8AF
I King MB. AIDS and the general practitioner: views of patients with HIV infection and AIDS. BrMedJ 1988;297:182-4.
2 Dardick L, Grady KE. Openness between gay persons and health professionals. Ann Intern Med 1980;93:115-9. 3 King MB. London generalproctitioners: management ofpsychosocial probkms of patients with HIV infection. London: Institute of Psychiatry, 1988. (Research report.)
BMJ
VOLUME 297
17 SEPTEMBER 1988
