Letters and emails

3 World Health Organization. WHO Recommendations for Induction of

Labour. Geneva: WHO; 2011 [http://whqlibdoc.who.int/publications/2011/
9789241501156_eng.pdf]

Chuks Nzewi

MRCOG

Princess Elizabeth Hospital, St Martins Guernsey

George Araklitis

MBBS

Kings College Hospital, London, UK

Nitish Narvekar

MD MRCOG

Kings College Hospital, London, UK

Re: Targeted encouragement of sexually active drugand alcohol-dependent women to use long-acting
reversible contraception is legitimate

Dear Sir
Eyo and Chenoy correctly draw our attention to an
important area of bioethical discussion: reproductive
autonomy of people with drug and alcohol dependency.1
Their arguments arrive at the correct conclusion that it is
permissible to use financial incentives, otherwise known as
contingency management or conditional cash transfer, as a
means to increase the uptake of long-acting reversible
contraceptive (LARC) methods. In line with NICE clinical
guidelines and after having discussed it at length with our
clinical ethics committee we have been doing this for the past
12 months.2 We were thus very surprised to read the
justification of Eyo and Chenoy for their recommendation.
Our main concern is that their paper suggests that people
with substance dependence problems have cognitive
dysfunction with devastating results: Therefore all
advanced planning decisions are hindered by the
pathological disregard for future goals, even when sober.
Eyo and Chenoy argue that people with drug and alcohol
dependency are not able to make autonomous decisions and
that using biased encouragement, can have the effect of
inducing compliance from those patients within the
target population.
This is an unusual argument in biomedical ethics. Most of
us will know people with drug and alcohol dependency who
function at a high level and the General Medical Council will
not automatically bar drug and alcohol dependent doctors
from working.
In our view, far more valid reasons to use contingency
management to encourage the people with drug and alcohol
dependence to use LARC methods are:
 Using low-level incentives, such as 25 supermarket
vouchers, is an effective method to achieve behaviour
change and is part of NICE guidance.2

2015 Royal College of Obstetricians and Gynaecologists

 Low level incentives do not constitute an irresistible bribe

and do not affect patient autonomy. They rather move
patients from contemplation to action.
 Where some pregnancies will be complicated and may
cause psychological difficulties for mother and child
following enforced separation, the use of low-level
incentives may prevent harm (beneficence).
 Incentives are not converted immediately into drugs and
even if they were, the harm that could be done with a 5
supermarket voucher is small (non-maleficence).
 The costs of children in care is very high, about
35,000/year, and hence low level incentives are a
justifiable use of public resources.
This line of argument does not require an assessment of
the patients ability to make a reasoned decision about the
future or the assumption that people with substance
dependence problems are unable to consider future goals.
The argument given by Eyo and Chenoy could be perceived
by many people with addictions and those working in the
field as too paternalistic, not patient-centered, and opposing
the general aims of drug rehabilitation and damaging for the
therapeutic relationship.

References
1 Eyo M, Chenoy R. Targeted encouragement of sexually active drugand alcohol-dependent women to use long-acting reversible
contraception is legitimate. The Obstetrician & Gynaecologist 2014;
16:26971.
2 National Institute for Health and Care Excellence. Drug Misuse Psychosocial
Interventions. London: NICE; 2007. [http://www.nice.org.uk/guidance/cg51/
resources/guidance-drug-misuse-psychosocial-interventions-pdf]

An Vanthuyne

MB ChB BSc(Hons) DRCOG MFSRH

Guys and St Thomas NHS Foundation Trust, London, UK

Rudiger Pittrof

MSc MRCOG MFSRH DipGUM DTM&H FHEA

Guys and St Thomas NHS Foundation Trust, London, UK

Alastair Boyd

MB ChB MSc

South London and Maudsley NHS Foundation Trust, London, UK

Franco Moscuzza

MB BS FRCA MA (Medical Ethics Law)

Chair of the Clinical Ethics Advisory Group. Guys and St Thomas NHS
Foundation Trust, London, UK

Authors reply

Dear Sir
Dr Vanthuyne et al. correctly highlight that the effects of
drug dependence need not be interpreted as absolute; indeed,

137

Letters and emails

as with many aspects of medicine the scale of the capacity for

autonomous decision making, which would be in line with
the true values (such as, moral and social) that one holds, is
expansive. Research suggests that the state of drug addiction
can provide an insurmountable barrier to the propagation of
these values with its ability to act as a coercive force against
decisions that one might make but for the addiction.1,2 Be
that as it may, this does not provide justification for
regressive paternalistic decision-making on the part of
clinicians and it was not our intention to suggest otherwise.
Dr Vanthuyne et al. have helpfully provided the platform
to clarify the distinction between the degrees of legitimate
clinical persuasion when identifying a patient who is suffering
drug addiction. What is paramount is creating an
environment where informed decision-making can occur,
which may require adaptations and aids to ensure
information is received appropriately. This method
provides respect for patient autonomy. In addition, one
might argue that where the patient has communicated their
values and yet struggles to identify what choices would best
achieve those values, the clinician is justified in placing
emphasis (biased3 was perhaps the incorrect word to
describe the presentation of information in a way that is
partial to the values that the patient has stated) upon those
clinical decisions that would best meet those very values, and
therefore the autonomy, that we seek to protect.
We would like to thank you for this platform to add
clarification to the previously printed article.

research experience with vulvodynia which extends over

some years. It concerns only the non-dermatological types of
vulvodynia. In 2004 we published a hypothesis on vulvodynia
being a referred pain from laxity in the uterosacral
ligaments.2 This followed an observed cure of vulvodynia
with a posterior sling in three patients who also had various
elements of the posterior fornix syndrome, urgency, nocturia,
dragging lower abdominal pain and abnormal bladder
emptying. This quadrain of symptoms have been attributed
to laxity in the uterosacral ligaments as part of the 2nd (1993)
exposition of the Integral Theory.
The hypothesis of the uterosacral origin of vulvodynia pain
was later tested by injecting 2 cc of 2% xylocaine into each
of the uterosacral ligaments into the posterior fornix
of the vagina in 10 consecutive patients diagnosed
with vulvodynia.3
The 10 patients were retested after 5 minutes. Eight patients
reported complete disappearance of introital sensitivity, by two
separate examiners. In the other two patients, direct testing
confirmed that the allodynia (exaggerated sensitivity) had
disappeared on one side, but remained on the other side.
Retesting the patients after 30 and 60 minutes showed that the
blocking effects disappeared after 30 minutes. We believe that
the short-term disappearance of introital pain especially on one
side is an important step in further substantiating our
hypothesis that vulvar vestibulitis (vulvodynia) may be a
referred pain originating from the inability of weakened
uterosacral ligaments to support the nerves running along
these ligaments.

References
1 Redish AD, Jensen S, Johnson A. A unied framework for addiction:
vulnerabilities in the decision process. Behav Brain Sci 2008;31:
415487.
2 Hayashi T, Ko JH, Strafella AP, Dagher A. Dorsolateral prefrontal and
orbitofrontal cortex interactions during self-control of cigarette craving.
Proc Natl Acad Sci USA 2013;110:44227.
3 Eyo M, Chenoy R. Targeted encouragement of sexually active drug- and
alcohol-dependent women to use long-acting reversible contraception is
legitimate. The Obstetrician & Gynaecologist 2014;16:26971.

Mary Eyo

MBBS BSc

Colchester Hospital, Colchester, Essex, UK

Rachna Chenoy

MA MBBS FRCOG

Newham General Hospital, Plaistow, UK

Re: Vulvodynia: integrating current knowledge into

clinical practice

Dear Sir
We read with interest the excellent review by Nagandla
et al.1 We write to inform TOG readers of our clinical and

138

Figure 1. Simple posterior fornix repair. A transverse incision is made

in the posterior fornix 34 cm below the cervix. A large No 1 needle is
inserted widely laterally below the vaginal skin and the loose
uterosacral ligaments (USL) are approximated (arrows) with a strong
vicryl or polypropylene sutures. CL=cardinal ligament; CX=cervix;
E=enterocele.

2015 Royal College of Obstetricians and Gynaecologists