Steer clear of the Botox cowboys

On Friday, the Department of Health will be issuing new guidelines on the use of Botox and fillers. But what they are going to propose has left many of the more conscientious within the industry feeling that the DoH has bottled out of imposing any regulations at all. The guidelines will ask the industry to take the lead on improving safety and regulate itself. It is understood they will be proposing a voluntary system whereby clinics join a register run by the Independent Healthcare Advisory Services. No legislation, and no penalties for bad practice.
The British Association of Aesthetic and Plastic Surgeons (BAAPS) is not at all happy with this, saying it will not protect the public from cowboy clinics. They want a system of fines or the register to be compulsory. Currently Botox can be carried out anywhere by anyone with training in giving injections. Podiatrists, physiotherapists and veterinary surgeons have all enquired about injecting the toxin for cosmetic reasons and in fact anyone could set up shop offering Botox jabs. The temptation to do so must be huge, with the anti-wrinkle treatment becoming increasingly popular, especially in London. Over 100,000 Britons a year use Botox and take up has gone up 2,500% in three years, making it the fastest-growing treatment in the cosmetics industry. It’s big business.
The medical profession is usually pretty strict about what can and cant be done by people with various levels of qualification, but Botox and fillers seem to have been overlooked. They are invasive procedures and Botox is a prescription-only medicine. Patient safety should be paramount. When things go wrong, and they do, (think Leslie Ash) patients can be left physically or psychologically scarred for life.
Botox blocks the nerve signals to muscle in the area it is injected, so that the muscles relax, smoothing and softening wrinkled areas. Its effect wears off after four to six months. It is generally safe and well tolerated but it isn’t always harmless. Cliff Richard and Lynne Franks both suffered drooping brows after treatment, and other users have had headaches, double vision or sagging facial muscles. In rare cases, it can cause an allergic reaction that can kill.
It is also sold to patients in some very unethical and irresponsible ways. Alcohol fuelled Botox parties. Two for One, time limited offers and non-refundable deposits all put pressure on patients to undergo procedures they may well later regret. This is immoral in any branch of medicine. The GMC states that the patient must have a two-week cooling off period to think it over before deciding to have work done.
In France and Denmark there are laws that limit who can do what, to whom and where, and the same is likely to happen in Mexico and Spain, yet still the British government is avoiding improving regulation to safeguard patients. I’m not at all sure why.
If you are considering any sort of cosmetic procedures I would urge you to check your surgeon's qualifications first. They should be on the Specialist Register of the GMC, and preferably registered with BAAPS, but remember that the UK government insanely refuses to recognize cosmetic surgery as a specialty. If a surgeon is not listed on the Specialist Register, they have not received a full surgical training in the UK.
The cosmetic surgery industry was born in the 80s but the law has failed to keep pace with regulation and training. But as many will argue self-regulation is better than no regulation at all, as is currently the case.

The perils of heels

The years of ignored warnings have finally become a reality for Victoria Beckham as she caves in to pain, discomfort and deformity and elects to have surgery to correct her impressively large bunions. Wearing six-inch heels constantly, even to do daily activities, has predictably taken its toll. At only 34 one would think that Posh is really rather young to be having this sort of surgery, but the allure of heels now means that orthopaedic surgeons are busier than ever correcting the damage that tottering around on spikes causes.
I have seen some truly horrific injuries to the ankles of teenage or twenty-something year old girls that occurred due to a combination of alcohol and unsuitable footwear. Ankle fractures sustained by ‘going over’ on a heel can be extremely messy, with no single clean break, and often require complex pinning operations that never fully restore normal use of the ankle, and inevitably cause osteoarthritis of the joint in later life.
The body comes with a wide array of early warning and damage protection mechanisms, pain being the most obvious one. If something hurts, then it is probably causing damage and should be stopped. This is common sense. Yet surveys have shown that 42% of women will happily endure pain in order to wear a pair of killer heels.
What I found more worrying were the images of 3-year-old Suri Cruise being proudly showed off by her mother whilst wearing high heels. If you want to cripple a child before she reaches her teens then stick her in heels.
Heels cause many stresses on the foot: in addition to restricting, they also massively increasing the weight pressing down on the restricted areas, pushing the toes with enormous force into a small wedge shape. The best-known foot problem is probably the bunion, known medically as hallux valgus. It occurs because the big toe becomes excessively angled towards the second toe – and a bunion is a symptom of this deformity. Once the big toe starts leaning like this then the problem tends to get progressively worse. The jury is still out on whether high heels actually cause bunions; we know there is a genetic component involved, but heels certainly exacerbate them. Bunions do occur in societies that don’t wear heels at all however.
Whilst I fully appreciate that telling women not to wear heels will be about as effective as telling kids not to eat sweets I thought I would give you my top tips on how to minimise the damage as much as possible.

1. Make sure your heels are properly fitted. Most are not. If your feet slide to the front, leaving a gap behind your heel then they don’t fit. Look for narrow heels with a snug but not tight fit.

2. Try to avoid very thin, heels and opt for a thicker one, to increase stability. They should give you better balance and may help relieve some pressure by distributing the weight on your foot more evenly.

3. Invest in some silicone metatarsal pads, which act as excellent shock absorbers and help reduce pain and damage to the ball of your foot.

4. Avoid heels with a straight drop down from the heel to the toe. These can be very hard on your arches: go for a gentler slope.

5. Wear open-toe high heels to relieve pressure on corns and calluses. Closed-toe heels cramp and deform the toe joints more.

6. Try these exercises to strengthen the muscles and tendons around your big toe: put your feet side by side, and try to move your big toes towards each other. Do this three or four times a day, 10 reps each time.

Carbon Monoxide leaks are a hazard in the home

Towards the end of last year I saw a young girl in clinic with rather strange and non-specific symptoms. As well as dizziness, nausea and shortness of breath, which would have hinted at some sort of respiratory infection, she had one very worrying sign: she was pale, but had bright cherry red lips. She had been staying with her mother in a rather swish houseboat moored on the Thames at Chelsea.
Because of certain suspicions I sent her to the nearest hospital to have her blood gas composition analysed and it showed carbon monoxide levels in her blood of 22%. Normal levels are around 0.1 to 2%.
She was given oxygen therapy under pressure and thankfully made a full recovery. Investigation revealed a faulty exhaust system on the boat that had causes levels of gasses to build up at the end of the boat where the girl slept.
Carbon monoxide is a colourless and odourless gas that accumulates rapidly in the lungs and blood. It can bind to haemoglobin and does so about 240 times more tightly than oxygen, forming a compound called carboxyhaemoglobin. This means that if both carbon monoxide and oxygen are inhaled, carbon monoxide will preferentially bind to haemoglobin. This reduces the amount of haemoglobin available to bind to oxygen, so the body and tissues become starved of oxygen. Carboxyhaemoglobin also has direct effects on the blood vessels of the body - causing them to become 'leaky'. This is seen especially in the brain, causing the brain to swell, leading to unconsciousness and neurological damage.
Symptoms of toxicity are rather non-specific including headache, nausea, dizziness, confusion, vomiting, and lethargy and are often misdiagnosed. Long-term neurological complications of CO toxicity occur in 14% to 40% of patients and include cerebral oedema, cardiac ischemia, rhabdomyolysis, and thrombosis.

I hate to admit it but I suspect that in private practice CO poisoning is rarely ever considered as a possible diagnosis for a simple reason: we usually think of those at risk of CO poisoning as staying in crummy bed sits and run down hostels: not the type likely to be accessing private healthcare, and certainly not well-heeled Chelsea types. But doctors should never make assumptions about class and background in this way, for obvious reasons: if we misjudge, it could kill.
As if on cue a new national campaign called Carbon Monoxide – Be Alarmed! has just been launched to try to reduce the number of deaths and injuries caused by carbon monoxide poisoning. It’s also lobbying for legislative change to make putting alarms in new builds and rented properties law. According to their research this subject is particularly relevant to us Londoners. We are half as likely as the national average to have an audible carbon monoxide alarm in their home and significantly less likely to understand the risks and characteristics of carbon monoxide.
I had never really thought this much of an issue before. But this recent case of mine was an eye opener. 93% of homes have smoke alarms, but only 15% have carbon monoxide alarms. And as it is the most common cause of fatal poisoning in Britain today, again a fact that I did not know and would never have guessed, this is clearly something we all need to address.

It’s not just politics - families do need fathers

The role of the father is one that has been more stereotyped than any other. We have two main characters: the bumbling, useless, out-of-his-depth father and the househusband, the super-dad who does it all — and there's very little in between.
But set against these clichés, new research has identified two fresh trends in fatherhood today: men who spend more time with their children than ever before and fathers who are completely absent.
Two hundred years ago, the father was the focal point of the family — the paterfamilias — and acted as moral mentor and teacher. But the Industrial Revolution took many men away from home to work, leaving mothers to raise the children single-handedly.
Now, as more mothers return to the workforce, the set-up is similar to that of a couple of centuries ago, with the domestic workload, including the raising of the children, more evenly distributed between both parents. When surveyed, 75 per cent of fathers said they would trade career advancement for more time with their children, and the number of dads present at their children's births has risen from 27 per cent in 1974 to nearly 90 per cent today.
Inevitably, fatherhood has now become a political issue too. The Tories have called for fathers to be more involved with their children and have attacked “deadbeat dads” who abandon their responsibilities, while Labour wants to counter criticism that it has been too focused on mothers' rights by putting fatherhood at the centre of its social policy.
Health minister Andy Burnham will announce tomorrow that prospective fathers will receive lessons on breastfeeding and supporting their partner through childbirth. Meanwhile, a families green paper will propose measures to get fathers more involved in their child's upbringing from before birth and beyond, including forcing single mothers to name the biological father on the birth certificate and encouraging hospitals to allow fathers to stay overnight after the birth of a child.
But it's not all just a desperate vote-winning strategy. Research has, to an extent, confirmed the importance of dads: children benefit greatly from having increased interaction with their fathers and show better cognitive abilities when their fathers are highly involved during their development. Fathers offer greater tactile stimulation and are more likely to physically interact when they play, whereas mothers are more verbal and toy-mediated in their interaction.
Studies have shown that the young rely more on their fathers for factual information and look to their mothers for day-to-day care and emotional support: children are twice as likely to receive As in school when their fathers are involved in their education. And the benefits start early; babies are twice as likely to be breastfed if their fathers have received instruction about the benefits before birth, and further studies reveal that fathers who are around at the birth are far less likely to flee.
So while these initiatives certainly won't guarantee Labour safely through the next election, they may well help improve family life for future generations.

I am exploding the myths about health and winter

How is it that I can travel to a tiny Austrian village in the Alps to ski each year with minimal hassle yet can't go five stops on the Bakerloo line in winter to get to my Harley Street clinic?It seems we Londoners are out of touch with our seasons and how to cope with them. But in a way you can't blame us because so much nonsense is written about health and winter. The best-known myth is that going out in cold weather increases your chances of catching a cold. There is no evidence that you can get a cold from exposure to cold or wet weather: viruses cause colds. There are more colds at this time of year simply because people are cooped up indoors in sustained contact with others who might be contagious. However, cold weather may make the lining of your nose drier and more vulnerable to viral infection.
Another popular myth is that we lose most of our body heat through our heads: again, untrue. Head heat loss is usually less than 20-30 per cent of total heat loss. As one scientist who researched this put it: “If we lost 45 per cent of body heat through our heads, going out without a hat would feel like going out with no trousers.”
The complementary medicine brigade is responsible for more rubbish: echinacea, a herbal supplement which people use to treat colds, has been shown not to help prevent colds in adults and is useless in the treatment of children aged two to 11. In a similar vein, many swear that vitamin C wards off colds. But large-scale, controlled studies have produced no conclusive data as to its effectiveness. It's big money for manufacturers, however.
What is true is that a 5C drop in temperature has been associated with a 12 per cent increase in admissions for heart attacks and that 53 per cent more heart attacks take place in the winter than summer. The cold can cause arteries to constrict, reducing blood flow and therefore oxygen supply to the heart, leading to a heart attack. Research has also shown that very cold weather may increase the risk of blood clots via its effect on platelets in the blood. So we do need to be better prepared for our winters and if you're starting a new fitness regime, take the cold weather into account.
Always start gently — it won't then be such a shock to your system. Your cardiovascular system can adapt to slow, progressive changes but it has more difficulty adapting to sudden ones. You'll feel less sick and dizzy at the end of your workout and may actually keep it up beyond January.
Look on this month as a warm-up, a time for getting into the habit of exercise and healthy eating, rather than expecting unrealistic results. And whatever you do, try to do it indoors and avoid sudden exertion outside — it's this that can precipitate heart attacks and strokes.

Help for those who aren't waving but drowning

January is traditionally grim. The come-down after Christmas and New Year's celebrations hits us, we still haven't begun our tax returns, and the threat of an unbroken year of work stretches before us. So it's not surprising that January is when doctors are overrun with patients seeking advice for anxiety and depression.
Depression, stress and anxiety are certainly increasing: as life becomes more complex and demanding, we as a species have yet to evolve coping techniques and so are suffering as a result. The phrase “not waving but drowning” comes to mind.
Traditionally the medical profession has stuck those unable to cope on antidepressants. But the times they are a-changin'. It's now known that a combination of talk therapies and drugs works best. Research has shown that cognitive-based therapy, when conducted well, works as quickly and thoroughly as the drugs. When a person continues using the skills they learn with CBT, relapses are prevented — something the drugs don't do.
This is all great news but there is a problem: accessibility is limited.
As more people are diagnosed with depressive-type disorders, the national charity the Mental Health Foundation is quite rightly calling for more talk-based therapies to be made available, including meditation and yoga in the form of Mindfulness Based Cognitive Therapy. The National Institute for Clinical Excellence has approved MBCT, a treatment based on meditation techniques, as a suitable treatment which can cut relapse rates for depression by half.
The report claims that Mindfulness meditation can affect the workings of the brain and even its structure, and that people undertaking Mindfulness training showed increased activity in the pre-frontal cortex — the area of the brain which is less active in people who are depressed.
A large majority of GPs think this treatment would help their patients but only one in five has access to the therapy. What is most concerning is that three-quarters of GPs have prescribed medication to people with long-term depression, believing another form of treatment would actually have been better for them. That really goes against all the training and ethical guidelines that we medics should follow.
And here lies the problem. The best treatments may well be the talk therapies but they are simply not available to most.
I have another slight reservation: MBCT usually consists of an eight-week course in Mindfulness meditation, with elements of CBT and yoga, which sounds wonderfully holistic but I feel this is a wildly impractical aim in an already overburdened NHS. Also, every doctor knows that it's hard enough to get patients to finish a course of antibiotics, so I'm certainly not convinced a depressed, demotivated patient will bother attending meditation and yoga classes.
We clearly need to find a middle ground that provides good patient care with long-term lasting results which is accessible to all who need it. But then, isn't that the great challenge in all areas of the NHS, and one that may now be an impossible pipe dream without a radical overhaul of the way our health service is run and funded?

Christmas means coping with the hangover from hell

Nagging about diet and exercise is all well and good but I do sometimes feel we doctors could give a little more useful advice from time to time. At this time of year an obvious theme jumps out at me: how to avoid hangovers.I hear so many myths circulating on this subject and most are complete nonsense. So whilst I cannot possibly condone heavy drinking, even to celebrate so auspicious an event as the arrival of the baby Jesus, I can at least advise you on how to get through your Christmas parties with the minimal of damage and pain afterwards.The first mistakes people make occur before they have even left the house. Number one error is not eating before a night on the booze. Drinking on an empty stomach can lead to a rate of absorption of alcohol that is similar to being given it via an IV drip. This leads to disaster very quickly, and while the liver is in overdrive dealing with the booze it is not able to metabolise glucose very well. This causes blood sugar levels to drop, causing shakes and sweats. The heart pumps harder as well, causing blood pressure to rise, thought to be the reason why some drinkers suffer heart attacks the next morning. Wolfing down a dodgy kebab on your way home is too little too late, and will probably only make your hangover nausea worse. The reason some people get completely sloshed very quickly and others take much longer is partly to do with food, but it’s also partly due to genetics. The quantity of stomach enzymes that break alcohol down differs: women get drunk more quickly than men because they have more fat, less muscle and fewer enzymes. The good news for women is that as they get older women almost catch up with men. Brains shrink a little with age too, making them less prone to headaches the morning after.Whilst out, be aware of the need to avoid dehydration. The kidneys will produce more urine than normal, in response to the diuretic properties of alcohol, and this will dehydrate and deplete the blood's levels of sodium, potassium, calcium and magnesium. Although your brain may seem to tell you otherwise the next morning, alcohol doesn’t actually dehydrate the brain; it causes it to swell, creating pressures on the surrounding membranes and causing the infamous headache. Avoid this by alternating one alcoholic drink with one soft drink, to keep up your hydration levels, and the advice of drinking a pint of water before you go to bed is sound, provided you are not so pissed that you pee yourself in the night.
Despite what you have heard, all alcohol is the same, whether you are drinking the finest champagne or the roughest of alcopops. All drinks contain ethanol which your liver and brain deal with it in exactly the same way whatever the source. It's a myth that mixing your drinks makes a hangover worse. Beer before wine, or wine before beer, both will make you feel rough if you drink enough of them. What does make a big difference is what is mixed with the alcohol. Different drinks will affect you in different ways, and at different times, so choosing what you drink will help you the next day. Generally speaking the browner the drink, the worse the hangover it causes. Rum, whiskey, brandy and port can all be cruel. Vodka is least likely to give you a hangover as it is repeatedly filtered to remove as many impurities as possible. Beer is probably the least dangerous to drink but it's the most calorie rich - one pint contains between 170 and 200 calories.Lastly, I should warn you that knocking back painkillers can be dangerous. Aspirin is popular but can irritate the stomach, and even causing bleeding with alcohol. Paracetamol, too, is not ideal as it can promote further liver damage when combined with alcohol –this makes it a popular although slow acting suicide choice. Taking some before you go to sleep will not help –their effects will have worn off in about 4 hours and probably long before you wake up.And for our herbal and ‘complementary’ friends researchers have reviewed all the available studies on hangover pills, such as yeast and artichoke extract and concluded that there is no compelling evidence of any effective treatment. The only proven cure is time, and getting it right the night before.

Warnings about iPods may fall on deaf ears

I come from a relatively small family but still find choosing Christmas presents one of the great headaches of the year.
Some small short-circuit occurs in my brain that prevents any form of sensible thought occurring any time I plan who should get what.
I thought I had it cracked this year, however. MP3 players are, according to consumer research, top of the list of most popular Christmas gifts. For Londoners, they provide some much-needed escape from the stress of Christmas shopping and the commute to work each day, so I thought I had my solution: iPods all round.
I'm sure even my mother would find some use for one, downloading Intermediate Spanish to practise on the bus, or listening to Eileen Atkins reading the latest Alan Bennett. But I've had to backtrack.
Increasingly shrill warnings are being issued by the various hearing protection organisations about how these gadgets, played at excessive volume, are setting us up for a future of hearing problems and deafness. Perhaps not the best present for a doctor to give after all —back to the drawing board.
Actually, come to think of it, I can't think of anything more irritating than sitting next to someone listening to their MP3 player too loudly. The tinny frenetic beat of their always utterly-unsuitable-for-the-time-of-day music is impossible to shut out.
It's the modern-day equivalent of the Chinese water torture. I have started asking people to turn theirs down.
But experts would say that I am doing these headbangers a favour. London commuters face the greatest risk of all as the noise on the Underground means that the devices have to be played at potentially damaging volume levels to be heard.
Hearing specialists are warning that for young people this is a huge problem and that prolonged listening could lead to permanent damage.
It's not an exaggeration. I have certainly seen an increase in young people coming to see me in clinic with ear problems, mainly tinnitus or dullness to their hearing, and on questioning they nearly all use MP3 players and go to concerts regularly.
Tinnitus can be an early sign of hearing damage due to noise, and occurs when the sensory hair cells in the cochlea are damaged by loud sounds. Some ear, nose and throat specialists explain the damaging effect of the noise exposure on the inner ear as being similar to the effect of a storm on a field of corn, flattening and damaging the stalks.
Proposals have been made to limit the maximum volume of a player to 100dB. As a rough guide to decibels, if you are listening to sound at 70dB it's possible to hold a conversation at normal volume; at 90dB one needs to talk loudly; at 100dB loud shouting is necessary, and from 105dB upwards it is no longer possible to hear speech at all.
Most MP3 players have a maximum volume of 125dB (equivalent to the sound of an aeroplane engine a few metres away, and more than 40dB more than generally permitted noise levels for a working environment), and according to a British study, 39 per cent of 18-24-year-olds listen to music for at least an hour a day at close to this upper volume limit.
This creates a serious danger of becoming deaf within about five years — and herein lies the problem. The damage can take a long time to show up and therefore is of no real concern to young people now.
One audiologist has even predicted that at current rates one third of young people using MP3 players today will need a hearing aid by the time they hit 50.

Sex and booze and the festive"spirit"

An advantage of the Virgin Birth was that it neatly bypassed the risk of catching STIs. Before you accuse me of blasphemy there were significant numbers of STIs around, even in Jesus’ day. Indeed his persecutor Herod was thought to have died of syphilis, a common disease of the time, his death following internal pains and burning sensations, swelling of the feet, convulsions, an ulcerated colon, putrefied and worm-eaten genitals, and very, very bad breath. Many biblical stories and particularly the list of rules offered in parts of the Old Testament merely give practical medical advice on how to stay fit and healthy during those times. Most is utterly outdated today of course but it’s interesting to read how circumcision, mandatory in biblical times, has now been shown to reduce infection rates of herpes, HPV and to a lesser extent HIV. As the world turns full circle and another Christmas approaches the threat of syphilis and other STIs remains ever present, but unfortunately for our STI and teen pregnancy stats virgin births seem few and far between. The NHS is launching a campaign warning Londoners about ‘Christmas Chlamydia’ as the party season approaches. This is inspired by research showing that a quarter of under 25 year olds admitted having unprotected sex during last year’s festive season, of which 60% were left unsure whether they had caught the sexually transmitted infection or not. The main culprit, of course, is alcohol. Sex and alcohol is a powerful combination that frequently leaves you with more than you bargained for. Alcohol based stats show that more than one in ten 18 – 34 year olds in London have had sex with someone they just met due to the influence of alcohol at a party over the festive season, more than one third admitted to having sex under the influence of alcohol that they wouldn’t have had if sober, nearly two in five have had sex that they regretted the morning after it happened and the majority have drunk to the point where they would describe themselves as ‘out of it’. Women are also more at risk of an unplanned pregnancy during Christmas and New Year than at any other time. Marie Stopes International is so aware of the problem that they have advised women to stock up on emergency contraception to cover this season. They have also put together festive family planning pack (containing two condoms, two luminous spikeys [to stop people spiking your drink], the Emergency Contraception pill Levonelle 1500, a pocket sized Christmas sexual health guide and even a festive chocolate) priced at £15 in an effort to reduce the incidence of unwanted pregnancies and infections. The excess of alcohol and the general over-excited atmosphere of the dreaded office party lead to fewer inhibitions and more casual hook ups, again upheld by the stats which reveal that almost one third of those surveyed claimed to have had sex with a colleague either during or after an office party. This then makes less surprising the news that in January and February of 2007, more women than ever before in MSI’s thirty year history, attended its nine UK centers for abortion services and official statistics show that the first quarter of every year always produces the highest numbers of women having abortions.But there is a darker side. Along with the increased alcohol and reduced inhibitions comes increased vulnerability. Sexual consent can be a confusing subject at the best of times. Add in buckets of alcohol and the pent up frustration of the past year spent flirting at the photocopier and things can get badly out of hand. But to the police there are no grey areas with regards to sex without consent: if there is doubt, it’s treated as rape.
If you have had unprotected sex over the festive period, a test for sexually transmitted infections is advisable, even if you don’t have symptoms, and if you are a woman and don’t want to be pregnant, visit your local pharmacy, doctor’s surgery or sexual health clinic for emergency contraception as soon after the unprotected sex as possible. All this can be avoided, however, by making sure you carry condoms with you; in AD2009 this is no longer seen as meretricious.

Doctors must stop refusing to confront Aids

Yesterday was World Aids Day. It's a hugely important event given that there are more than 33 million people living with HIV worldwide and it is the number one killer of women aged 15-44. It matters.
New research offers some hope that the number of new Aids cases is decreasing but fear and misunderstanding of HIV are still, even in 2009, hindering the introduction and implementation of more improvements.
HIV prevention programmes are having an impact but as in so many areas of sexual medicine shame, embarrassment and ignorance are our greatest opponents. And then comes stigma and taboo, which are still rampant.
As long as discrimination exists, people will be much less willing to get tested. My faith in human nature is sorely tested when I hear, even today, people stating that HIV and Aids is revenge from God for promiscuity.
Continental Europe is streets ahead of us, promoting greater openness and understanding in dealing with sexuality, including teen sexuality.
This has created wider and easier access to sexual health information and services for people of all ages.
Most important for me is that in Europe political and religious interest groups have little influence on public health policy.
This means that the stigma of sexually transmitted infections (STIs) is just not there - going for a check-up is seen as being cool and responsible.
How have they achieved all this? For a start, doctors make STI screening and HIV testing part of normal GP practice.
Ours, in many cases, do not. Ignorance and stigma apply not just to the public's attitude but also, I'm ashamed to say, to my colleagues too.
Many UK doctors still view HIV/Aids as a specialist subject and one that they do not feel confident or willing to get involved with.
HIV is now so prevalent, especially in a large city such as London, that it must now been seen as part of normal, everyday general medicine.
While I agree that the management of HIV-positive patients does indeed require expert care, basic advice and, in particular testing, does not. Any doctor should be able to do it.
There are still far too many GPs who refuse to do HIV tests and send their patients to GUM (genito-urinary medicine) clinics instead.
This sort of insensitive handling only adds to the stigma, and decreases the public's willingness to be tested.
It can take a lot of courage for some people to seek help and one callous comment - even if unintentional - from a stressed doctor can do untold damage.
GPs do an incredible job (for little thanks and many complaints) and are probably in the best possible position to make a difference.
All too often many of us allow personal prejudice, religious beliefs or even academic ambitions to affect the way we practice.
This must stop if doctors are ever going to improve medicine and come crawling from the 20th century into the 21st.
We alienate ourselves at the expense of our patient's health and I am sorry to say that I suspect we may compound the problem of worsening STI and HIV figures in many cases, instead of helping to lower them.