If the Journal Editor can bear yet another letter on this subject in addition to those that have already appeared in print in this Journal,1,–,4 would it help for all concerned to step back, take a calm look at the situation and consider what else may be involved?

Dr Hutt feels that he may be “living in a different world” from Dr Devonald, the reason for that may be that the two doctors (or rather their patients) are indeed in different worlds; Dr Hutt's practice where 80% of intrauterine device (IUD) insertions are in nullips is surely very exceptional. Patient-centred medicine may demand very different practice (although the same attitudes) in different circumstances, depending not only on parity but on the woman's total experience.

I have injectable anaesthetic available, and I agree that it can make a huge difference for those women who need it, but they are by no means the majority. (Incidentally, my dentist also asks if I want local anaesthetic; no automatic injections from him either.) However, there are other ways to minimise the stress and anxiety that can lead to pain, and these are also very serious ethical issues.

One is easy access to IUDs. I have fitted one for a distressed woman who had travelled across London in search of a post-coital IUD, having been turned away by two services that were fully booked or too busy to see her.

Another is long waiting times due to staff shortages, the young woman with two screaming children and a crying baby who turns up in a Monday walk-in clinic for a post-coital IUD probably needs little analgesia, but only if she can be seen quickly before her children are totally distressed and she becomes tense and exhausted (although without causing a riot in the waiting room and accusations of ‘queue jumping’!). A difficult issue in times when funding is being reduced.

Finally, has anyone else found that there is a link between fainting and new NHS buildings where air conditioning has been banned (on environmental grounds) but no other system has been set up to ensure that rooms stay cool in the summer? Truly, this issue is more complex than it appears at first sight.