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A doctor’s account of gender and moral biases that are rife in the health care system.

A few years ago I was invited to a debate by a society of post graduate doctors. The topic? “Emergency Contraception is the cause of moral downfall of society”.
When the earnest young man who had called for the invitation informed me about the topic, I laughed on the phone, assuming that this was a no-brainer. But later it seemed that they had not been able to find anyone to speak against the motion. They couldn’t find a single doctor to argue that emergency contraception is necessary and not evil.
The debate took place in a packed auditorium in a big city. I am not getting into too many details that will identify me for reasons that will become apparent as you read on.
One male doctor did join my side of the debate but he seemed to just want to help the organizers even out the contest – not because he actually believed in emergency contraception (EC).
We began. I spoke about the importance of preventing unwanted pregnancies and the opposition countered saying this was the only fear that prevents young women from having sex before marriage. I spoke of the need that married women also have when husbands don’t use or let them use contraception. That was countered with saying that we need more counselling.  I asked, counselling where and by whom. Do we remotely have the human resources trained and capable and available in our communities?
My team lost the debate. By a vote of something like 5 to 300. That day in 2011, emergency contraception was voted by these young, highly educated big city doctors as the cause of the moral downfall of society. Apparently, mainly driven by sex crazed and irresponsible young women.
The audience of doctors had so much to say. About how the Pandavas would never have been born if Kunti had EC, about irresponsible young girls who will just have sex all the time with no fear of a pregnancy (alone without any men involved apparently) , about preserving Indian culture (no one saw any irony in making these arguments about ‘irresponsible girls’ given Kunti’s pre-marital birth, or that the birth of the Pandava dynasty itself was due to the pre-marital sex by Rishi Parashar who kind of forced himself on Matsyagandha who was ferrying him to the other side, with a promise to make her a virgin again by the time the boat reached the shore and then created a cloud around them so they had privacy… ye gods.)
After the debate one of the doctors followed me out and asked me why I was against nature and why I was promoting EC pills. I asked him why he vaccinates children ? He said ‘all this’ was against our culture. I asked him which culture? The one which wrote the Kamasutra or the one which promoted Sati? He just nodded at me sadly and then climbed into his so-natural and culturally authentic SUV and drove off.
That day left me feeling rather dazed and genuinely alarmed. It wasn’t the last time.
More recently I’ve heard a psychiatrist argue during a workshop that all gay people are in need of electro convulsive therapy, what regular people call shock therapy, to become ‘normal.’ When he was told that the World Psychiatry Association has recently apologized to all homosexuals for having labelled them abnormal and forced into treatment over the decades, he just dismissed that with a wave of his hand. This person is the only senior psychiatrist at a small town public hospital and I shudder to think of the power he has to damage people’s lives. The thing I have begun to ask is this, who taught him these values?
During a workshop on HIV prevention many years ago when the epidemic was at its peak in India, senior family physicians told me that if a gay man gets HIV ‘it is his punishment’. They saw no reason to advise him about using condoms for protection. Where did they learn this from?
Once you start noticing, it’s hard to stop.
Here is a frequent forward on doctors’ Whatsapp groups. A woman gets pregnant for the second time, too soon after having a baby, and goes to obtain a medical termination. The good old doctor says to her: why don’t we kill the baby you are holding instead? His oh-so-sensitive option is always greeted by claps and thumbs up and Namaste emojis from others on Whatsapp.
I’ve been in meetings to discuss issues with the sex ratio, where almost all doctors agree that the sex ratio must be improved. When asked why, many male doctors and some older women doctors were vocal in telling me: who will boys marry if there are less girls? And if these boys/men are left single then wink-wink-nudge-nudge they will indulge in ‘naughty behaviour’. What was this naughty behaviour? Do they mean men having sex with men ? Do they mean more clients for sex workers? I’ve asked but they never tell.
They are convinced that rape and violence against women will go up, if the sex ratio continues to be poor. When asked if the same will happen if the sex ratio was skewed the other way, if somehow boys are much less and girls are much more, then no one has any answers. So we must save the girl child basically for the boys. Meanwhile women are being abandoned, beaten with hockey sticks and set on fire for giving birth to girl children
A Delhi-based campaign Haiyya Organize is currently asking for signatures for a petition asking the The Federation of Obstetric and Gynaecological Societies of India (FOGSI) ‘to send a directive to all member doctors to protect sexual health rights of unmarried women’.  Why does it need a petition and why are gynaecologists not doing so already? Also, do we actually believe doctors are supporting the rights of married women?
In the increasingly difficult and often hostile interface between doctors and those they treat, there is a need to step back and reflect on how we got here and how we can change things moving forward.
Let’s go back to where it all starts. Medical college.
It takes 5 and a half years of MBBS and then 3 years of residency training to become a qualified forensic medicine specialist or a psychiatrist or a gynaecologist in India. During those 8 and half years no one mentions the word gender equality, patriarchy, misogyny or discrimination. Reproductive health accounts for 99% of the theory and skills training and sexuality is not even a topic in the curriculum.
Of course, our country has some sensitized and sensitive doctors who speak to women respectfully, who explain to them what is going on and why the treatment has to proceed in a certain way. Who don’t shout at them for coming in for another abortion, or force them to use long term contraceptives. But that is usually due to their own personal value systems or sensitivities and not much due to any positive inputs from the educational system or environment.
Let’s look at where a doctor could possibly learn to be sensitive.
Much of a doctor’s education is learnt during ward rounds and through the attitude and approach of seniors and the prevailing system. All doctors have seen our seniors, our teachers, sarcastically asking an unmarried, pregnant girl that if she opened her legs earlier to have sex, why was she so resistant to open her legs again on the operation table now that she’s getting an abortion. All this while 15 to 20 medical students are standing around listening, while the girl and maybe her mother weep silently. We have heard male doctors make rude comments about any woman lying naked and unconscious on the operation table. We doctors have heard our senior colleagues say openly that women just make false claims of rape all the time to get men into trouble. We know that doctors get enraged at women who come for repeat abortions and shout at them for being irresponsible. Maybe when they finally do perform the abortion it will be without anaesthesia, to ‘teach her a lesson’.
We know of stories from public hospitals where the family sometimes does not come to take the woman home post-delivery if she has had a girl child. We know that men refuse vasectomy which is a minor procedure under local anaesthesia while women are willing to undergo an internal abdominal surgery under spinal. The values of our seniors in medical college is not so different from those of some of our supposedly ignorant patients. We have heard of women resident medical officers being told by seniors not get pregnant so that they would not mess up the duty rota.  Male residents of course could carry on having children since obviously they would not be contributing to any child care or need any special considerations. But none of us doctors are taught to see if there are connections to be made in any of these stories.
Now, let’s talk about medical textbooks.
You may not believe this. I can barely believe myself that this is happening in 2017. Despite efforts by NGOs and women’s health activists, the second year MBBS students still have a textbook, Dr AC Mohanty's Legal Medicine by Dr Mahapatra and Dr Kulkarni with a lovely chart explaining the difference between the female external genitals of a virgin and a deflorate ( yes that is what they call a woman who has had sex). This amazing chart tells medical students that the labia majora is thick and firm in a virgin but thin, flat and soft in a deflorate girl/ woman. That the clitoris is small vs enlarged (compared to what?), breasts are hemispherical firm with small nipples while in the deflorate woman they are flabby, pendulous and larger nipples. Such is the nature of facts.
When students are being taught such medical ‘facts’ without any potential for dialogue/ debate let alone dissent, and in an environment where there is simply no conversation on gender, patriarchy, discrimination, sexuality or any of the social-cultural determinants of health, what really do we expect from them when they graduate and begin work as doctors ?
Doctors can also be victims of an indifferent and sometimes hostile system. The system rewards those who can work within it. This is why in the recent case of the encephalitis deaths, the doctor who ran from pillar to post to obtain more oxygen cylinders and used his own money to buy ore, is already being called a ‘good Samaritan’ in inverted commas and has been sacked. This is why the doctor who performed 83 tubal ligations in 3 hours during a sterilization camp in Chattisgarh was awarded by the State earlier for having fulfilled huge targets in earlier settings. 13 women died in that camp. Some of them were as young as 26 and had already had 3 children.
Then there is the question of recognizing that gender issues affect women doctors and the entire system too.
More young women are entering medical colleges now than ever before but is there genuine equality? For post graduate specialization, how many female doctors choose or are able to practise in fields which are seen as higher demand and also higher paying? According to an article in the Journal of American College of Cardiology “ Women seeking a career in cardiology face deterrents, including the “impairments to family planning, poor work-life balance, and perceived radiation risks, ” Even if they do, how many can continue on the same trajectory as their male colleagues? How many are in full time attachments vs on calls all the time? How many work part time after they have kids? How many take days off when the children are sick? As compared to not even a single guy who has taken a back seat and works part time because he has children who come home at 3 pm and he needs to be there for their homework and general child care? These are larger systemic issues which play out in individual lives. But this is what eventually results in a situation like this in India where 51% of the medical college admissions are girls but they eventually make up only 17% of the practising doctors!
We are never taught to see if there is any similarities in the way gender plays out in our lives and that of our patients.
It seems that things are improving somewhat. For instance in one teaching hospital in Mumbai at least, I hear, a department of medical humanities is being set up.  But, if we want sensitive doctors we need a more holistic approach to teaching the art of healing and not just the techniques of diagnosis and treatment, we need to invest in systems across the country in every medical college where such learning and dialogue can happen.
Dr Anamika Pradhan is a practising specialist in Mumbai who has studied at one of the medical colleges in the city and feels strongly about the need to produce more humane and thoughtful doctors who can be agents of change in society.
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