By Zenisha Gonsalves
About a year and a half ago, Disha* became pregnant. Disha was 19. Wanting an abortion, she went to a clinic in Pune with her boyfriend, where they sat in a waiting room full of older, pregnant women who looked at them curiously. “Before the procedure, when I tried asking the doctor and the nurses questions, they were dismissive of my worries. They looked at me like I was unworthy of information, and the only thing that would have made me less anxious that week, would have been to know what was happening, and what would happen. I couldn’t tell my parents about the abortion, so I really needed the gynaec to answer my questions,” Disha says.
Within a larger culture of doctors underestimating a patient’s ability to understand medical information – and consequently not conversing with a patient about their own health – an already dangerous tendency of leaving patients out of the loop acquires a vicious quality when a gynaecologist’s moral judgements about a woman’s place in the world are thrown into the mix.
Apart from playing the moral police or refusing to provide treatment, withholding information is one of the cruellest things a gynaec can do when a woman is already extremely anxious. After the procedure, when Disha asked the doctor if it had been successful, the doctor only replied with a, “Wait for the report.” “I was in a lot of pain after the abortion, and I tried calling the doctor on her mobile. When she finally picked up, she yelled at me for disturbing her and hung up.” The report came a full, excruciating four days later.
In retrospect, Disha says, “The strangest thing was that the gynaec was so hesitant to look at me. She seemed as scared of nudity as an ENT would be! And she’s a gynaecologist!”
Most medical students we spoke to – from colleges in Belgaum, Goa, Mangalore, Hyderabad, and Manipal – say that they are taught to ask women whether they’re married or unmarried, but are taught not to ask whether they’re sexually active. In the same breath, they all say that they’re also taught not to distinguish between married and unmarried women, in their treatment. However, as many women were quick to observe, “Are you married?” is the Indian stand-in for, “Are you sexually active?”
Simran Sawhney, project associate at Sama: Resource Group for Women and Health, was talking to adolescents at a government school in Chhattisgarh (as a part of their initiative to enhance adolescents’ sexual and reproductive health and rights through health system engagement) when a 16-year-old girl opened up to her and said that she was sexually involved with someone. The girl also said that she hadn’t gotten her period for three months, and asked Sawhney if she would take her to a clinic. “At the clinic, they only gave her one of those pregnancy kits to determine whether she was pregnant, and I’m not even sure how accurate those are,” Sawhney says. “They didn’t do a urine test, or anything else, to confirm whether she was pregnant, and if I hadn’t specifically mentioned to the gynaecologist that the girl was sexually active, they would’ve assumed that she had missed her period because of other reasons – like not eating properly.”
Dr Chitra Ramamurthy, a senior consultant in the Obstetrics and Gynaecology department at Apollo Hospital, Bangalore says, “We cannot ask whether a woman is sexually active – we’re still in India, we live in a conservative society.” That all unmarried women are virgins then becomes the single assumption that gynaecologists must work with. Dr Vidya Desai, a gynaecologist at Manipal Hospital in Bangalore, says, “I don’t judge unmarried women who are sexually active, as long as they’re taking the necessary precautions, but I cannot ask a woman whether she is sexually active – that question is generally asked on a need-to-know basis.”
Current medical education in India does not account for women who are unmarried and sexually active – a gap which significantly affects the quality of medical care that young women are getting. For many women we spoke to, the answer to “Are you married?” became the point from which their gynaecologists approached them.
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A few months ago, Myna visited a gynaecologist at Chinmaya Mission Hospital in Bangalore, for what seemed like a urinary tract infection to her. The doctor, whom Myna says was either in her late 40s or early 50s, (though the age of the doctor is not a factor in how judgemental or non-judgemental s/he is) asked what the problem was, and Myna explained her symptoms. She then asked her whether she was married. Myna says, “I knew that she was asking the question as a proxy for, “Are you sexually active?” and I answered, “No – yes – I’m 25 and in the middle of a divorce.” She replied, “I don’t care – I want to know when you were last sexually active.” Myna says, “Despite my mounting panic – because I knew what was coming – I said, “So yes. Last night.””
According to Myna, the doctor then began a rant, which consisted of, “Why are you following all these Western habits? All this is not in our culture, having sex outside marriage.” When Myna asked what was wrong with having sex outside marriage, the gynaec replied, “You’ll get into trouble! Like this!” The truth is that UTIs hit men, women, children and the elderly. Women get UTIs more frequently than men because of their shorter urethra, which makes it easier for bacteria to get to the bladder. Newly sexually active women (with or without the benefit of the marriage certificate) get one variety of UTI so often that it is nicknamed honeymoon cystitis.
“To give the doctor credit,” Myna says, “When I emphasised that I was there for medical advice, she left it at that, though she was brusque for the rest of the appointment.” Not every patient is assertive enough or lucky enough to steer doctors from their morality side-tours, and a woman’s marital status is too often the qualifier or disqualifier for the medical attention she will receive from her gynaecologist.
Although married and unmarried women suffer the same health problems (and it is ridiculous that this even needs to be said), the latter are often denied treatment. For example, oral contraceptive pills lower the hormone levels in women who have polycystic ovary syndrome (PCOS), and help regulate their periods. But when Vijeta (who is 25 and unmarried) was diagnosed with PCOS, she asked her gynaec for birth control and was told, “To come back with my mother if I really wanted it.” (Aside: If Vijeta’s mother had asked for oral contraceptive pills to temporarily stop Vijeta’s periods so she could visit a temple or get married, the gynaec might very likely have said yes.)
In 2006, Kavita went to a public hospital in Pondicherry, to see a gynaecologist for what she thought might be a fungal infection. At the time, she was 23 years old. “The doctor first asked whether I was married, and when I told her that I wasn’t, she didn’t seem convinced,” Kavita says. “She then asked whether I was a virgin, and I told her that I was.” Unconvinced, for a second time the gynaec asked Kavita whether she was a virgin, “And when I said that I was, she lost it, and pointed to a table in the room, and delivered an unbelievable threat, “You know we have a table here – we can examine you if we want, and check.””
Kavita was surprised at how angry the doctor seemed to get, with each question that she asked her. She says, “Finally, she only asked me a couple more questions, and based on what I told her, prescribed medicine. She didn’t even examine me.” Later, when Kavita told a nurse friend of hers about everything that had happened, she replied, “Maybe she did that because girls usually lie about these things.”
Unfortunately, the question that needs to be asked is not, “Why would a younger, unmarried woman lie to her gynaec?” but “Why wouldn’t she?” What do younger, unmarried women have to gain from being honest with their gynaecologists? Several women we spoke to said they became hesitant to go to a gynaecologist only after the first visit, when they were either lectured or flat-out denied the medical help that they were seeking. Vijeta has never gone back to a gynaecologist after her last encounter with one; Myna says, “I will now definitely think twice about going to a gynaecologist, and I’m inclined to stereotype older gynaecs, which I don’t want to do!”
What is perhaps even more disturbing than a gynaecologist who has felt the call of the moral police from yonder, or a gynaecologist who is convinced that if she scares you enough you will tell her the ‘truth’, is a strange habit amongst med students and gynaecs to assess the seriousness of a problem based on the marital status of a woman.
When I asked Dr Anuradha S, a gynaecologist at Cloud Nine in Bangalore, why young unmarried women might be hesitant to approach a gynaecologist, she said, “They might have issues that they wouldn’t want to share.” Although she then emphasised that gynaecs need to make an effort to make young women more comfortable, she also went on to make a distinction between Serious Issues in older women, and Issues in younger women. When I asked her what these issues in younger women were, she responded, “Things like unprotected sex and infections.” What then, are serious issues in the case of older women, if not things like unprotected sex and infections? Unless she was referring to cancer, and although certain cancers only develop in older women – particularly around menopause – cancer can strike any of us and remain undiscovered. Particularly in the case of younger women, since we are more terrified of the gynaecologist than of disease.
Where doctors are unwilling to provide medical help to younger, unmarried women, or to take issues related to their sexual health seriously, they are willing and sometimes enthusiastic in their role as protectors of The Hymen. For instance, Dr Ramamurthy at Apollo Hospital, Bangalore says, “You cannot do a pelvic examination for a virgin. It could tear the hymen.”
Aishwarya, a student at Goa Medical College, says, “As a medical student, we don’t do it [transvaginal ultrasounds] for unmarried women because it’s a polite way of saying ‘virgin’, since that is almost always the case except when we get rape cases. If we manually check for cysts it ruptures the hymen and when they get married later they face domestic abuse over not being virgins.”
Transvaginal ultrasounds are done to check for cysts and fibroids, when there is unexplained vaginal bleeding, or pelvic pain, and a variety of other reasons. They can be uncomfortable for women who have never had sex and usually avoided in the case of ‘unmarried’ women, but using the term ‘unmarried’ for ‘virgin’ is more irresponsible than it is polite – gynaecologists shouldn’t assume that most unmarried women who come to see them are virgins or that they are heterosexual, if, (according to young women’s accounts) they neither ask them whether they are sexually active, nor actually do check-ups, instead relying on verbal information to prescribe treatment.
Within the walls of a gynaecologist’s practise, conversations that should be happening between doctor and patient, are instead happening between doctor, and the various people who are not present in the room – parents who care about hymens, future spouses who care about hymens, future mothers and fathers-in-law who care about hymens, and the stern face of Conservative Society. Before a young woman has the opportunity to talk about her sexual health, her gynaecologist has already conversed with the phantoms in the room. When a man goes to a doctor because he thinks he has a UTI, would a doctor think it unnecessary to examine him because one day he will be married?
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In India, especially post-Nirbhaya, there is some official protocol regarding women’s sexual health, but it pertains to cases of sexual violence. And in practice, as The Ladies Finger established in the story “The Two-Finger Test Doesn’t Work? No One Told The Medical Colleges,” issuing protocols does not mean that these protocols actually make their way into doctors’ offices.
“There is no protocol for younger, unmarried women’s sexual health in general,” Sawhney says. “This might be because gynaecologists assume that women who are unmarried only come in for irregular periods. There is a tendency to treat younger, unmarried women only as potential mothers – their sexual health beyond reproduction is not taken into account.”
*Some patients’ names have been changed at their request.
UPDATE (10/6/2015): As soon as our piece was posted, stories of unpleasant encounters with judgey gynaecs came streaming in on social media, and that oft-asked question: “Do you know a good gynaecologist?” began doing the rounds again. Fortunately for the world, @AmbaAzaad and others who had previously been discussing creating a list of trustworthy gynaecologists on Twitter decided to swing into action. @AmbaAzaad, @Hirishitalkies, @Pavithra420 and @jimanish created an amazing crowdsourced list of questions on what people are looking for from their gynaecologists, including concerns such as whether they will treat you as autonomous (and not demand permission from your parents or partner); whether they are queer friendly, and whether they will look for solutions to your illness without advocating marriage or pregnancy. And most wonderfully, they now have a superb crowdsourced list of gynaecologists spanning over 20 cities, and are planning to translate it into multiple languages. If you know a good gynaecologist who will privilege providing quality healthcare over their personal prejudices, do add to this list. And if you’re one of the many people looking for a gynaecologist, hopefully you’ll find a good one near you. Head over here.