293 factors influence this and that the four factors have complex interactions. First, in the same issue of the BJGP, Salisbury et al found that age is associated with disease prevalence and also with consultation rates with GPs in England. Therefore, GPs working in affluent areas may have an equally high workload as those in deprived areas if they have a large proportion of older patients. In Monifieth, Scotland, we not only have a large proportion of older patients but also a large proportion of patients living in care homes. The care homes we look after include a home for those with high care needs, such as survivors of head injuries. In the past these very sick patients would have been looked after in secondary care. Today, they require us to make more house visits than the average. Second, people in affluent areas are likely to have higher social mobility. This results in families being more geographically widespread and less able to help one another. This may lead to increased dependence on health professionals such as GPs. Third, distance from the GP and poor transport links may increase the number of house visits required of GPs in leafy affluent areas compared to their colleagues in more tightly-knit urban deprived areas. Additionally, in rural or semi-rural areas it can take well over an hour to do just one visit, and visits in a single day may be spread out over a large geographical area. These factors may interact. For example, professional people often retire to northeast Fife to an idyllic rural location. They may have few friends and family in the area and rely on their car for transport. As they age they may become ill and require home visits due to lack of family support and poor transport links. Finally, GPs are widely acknowledged to have an important ‘gatekeeper’ role. We suggest that educated, professional patients are more likely to be informed about their health and about potential treatments for illness. Retired professionals or affluent groups have often also been used to having private health care attached to their work that The World Health Organization further classifies female genital mutilation into four major types. Type 2 excision includes ‘partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora’ — does this not accurately describe labial reduction? At a time when there is such a big international drive to stamp out female genital mutilation because it is viewed as a violation of human rights, is it right that in western countries female genital cosmetic surgery is actually on the increase? May we be seen as hypocritical in condemning countries that practice female genital mutilation if we willingly refer girls for female genital cosmetic surgery?