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Do you give Viagra to man with known abusive past?

Case history

Fred is a 58-year-old widower with two daughters. Ten years ago Anne, 37, disclosed serious sexual abuse by her father. Her family were unaware and she was helped by counselling.

It seemed that, at the time, Fred was a heavy drinker and is now 'a different character' ­ teetotal and religious.

Anne is now a happily married mother and has a good relationship with her father. Fred is unaware that you are aware about the abuse.

Three years ago Fred had radical surgery for prostatic carcinoma and was rendered impotent. Shortly afterwards his wife died suddenly, leaving him alone with daughter Jane, then aged 13.

Anne was confident that Jane was safe and that she would confide in her if anything happened.

Six months later Fred requested Viagra, which was denied when it was apparent he was not in a relationship. He has brought the subject up a few times stating he knows he could buy it but would not do so without your approval.

Jane, now 16, is still living at home and becoming more withdrawn. She denies being abused.

Fred has presented even more demands of treatment 'just in case' he meets that 'someone special'.

Dr Patrick Wills

'Even if not abused, Jane has some problems'

This reads like a plot for a soap opera, although as all GPs know, real life is stranger than fiction.

The arbitrary rules that govern the prescription of Viagra say Fred is entitled to it free, if it is medically appropriate.

If truth be told I suppose I will be looking for the let-out clause ­ perhaps

he is on nitrates which it would be impossible to withdraw, or has terrible hypertension.

Reasonable probes for information from Jane and Anne suggest that in fact Jane is not being sexually abused. I'm not sure that anything else can be done to assess this in the absence of any evidence or even any allegation. Jane, however, sounds like she has problems, even if she is not being sexually abused. She needs help one way or another. She has lost her mother in her early teens and has a father who has been a heavy drinker, has allegedly abused her elder sister, has cancer, has then found God, but is now on the lookout for casual sex.

Confused? I'm sure she is. She may be depressed or have other psychological illness that needs addressing.

We have to make a lot of assumptions and judgments in this case, as is the situation in real life. We have incomplete information, and can only do our best to do the right thing. The bottom line is I wouldn't really want to give Fred Viagra, but would want to encourage Jane to seek help.

Dr Rupal Shah

'He might be abusing her even without Viagra'

Of more immediate concern than Fred's sexual difficulties is Jane's safety. If Fred is reverting to his old ways, he might be abusing Jane even without the Viagra. I think I would prevaricate about the prescription, perhaps by using a pretext of concern about its safety.

I would try to explore whether Fred had started drinking again and emphasise the dangers of casual sex. I might take the opportunity during the consultation to inquire about Jane and try to broach the subject of the change I have noticed in her.

In the meantime, I would attempt to contact Jane again and ask her to come in to the surgery. I would try to elucidate the reasons for her recent withdrawn mood ­ it may of course be normal teenage behaviour or there may be some other explanation for her manner.

If I felt there might indeed be cause for concern, I would strongly encourage her to engage with the local adolescent psychiatric services and offer to contact social services for her. Of course, Jane is technically an adult and this cannot be forced upon her.

If she didn't want further action, I would hope at the least she might feel comfortable enough with me to be able to come back in the future, and I would also suggest she speaks to Anne. It would be important, of course, to keep my partners fully informed.

Dr Harry Brown

'The crux here seems to be if Jane is at risk of sexual abuse'

There are lots of issues here and it may take more than one consultation to cover them, especially when there is more than one person involved. The gaps between the consultations allows time for reflection on what I would do next. Equally, it would allow me time to discuss this with colleagues.

Interestingly, Fred was denied Viagra for the reason he was not in a relationship. I wonder if this reason to decline a prescription is truly legitimate? It is also interesting to notice that he wants his GP's approval for the prescription and, though he claims he can obtain the drug illegally, he prefers to come to the GP.

The crux of this issue seems to be if Jane is at risk of sexual abuse, so it is important to review the facts. There is obviously some medical contact with Jane because she denies abuse, but she is noted to be withdrawn. Equally, her sister is confident she is not at risk and believes her father to be a changed person.

Importantly, the older sister is confident she would be made aware of any problems. So we can deduce that Jane is at low risk from sexual abuse. On that basis, if Fred indeed wanted Viagra and there was no medical contraindication, then I would be happy to prescribe Viagra on an NHS prescription.

But I would want to explore the need for Viagra in the assumed absence of a partner, and why there are regular requests and demands. There has to be a reason and I would challenge him by asking, if I refused, why would he not go elsewhere to obtain the Viagra?

It is also important to follow up Jane and discover why she is becoming withdrawn. It may be sensible to see Jane both alone and with her sister but in the absence of her father. In particular I would be looking for a possible depressive illness and an abnormal bereavement reaction in Jane ­ after all, she was a young girl when her mother died, which was only three years ago.

The complex relationship between the three people in this story requires regular follow-up of all concerned, a cool head from the doctor, a logical analysis of the facts and making a risk assessment of the situation. Finally, it is important to respect confidentiality of all parties in this complicated situation.

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