Prasansa Acharya* was 19 when she went to Norvic Hospital to get checked for a vaginal infection. The gynecologist conducting the pelvic examination looked up and asked loudly, “Where is your hymen?” shaming Acharya, it seemed, for being sexually active. [Contrary to popular belief, there is no connection between the presence or state of the hymen and sexual intercourse.]
“I was mortified,” Acharya, who is now 23, told me. The experience left her so distraught that she didn’t seek further medical care despite having persistent symptoms for three months after her initial visit. “I haven’t gone to the gynecologist since.”
Ria Adhikari*, 26, in her appointment with a gynecologist, was not offered a gown or a towel. During the examination, she was asked what her husband did for a living, the assumption being that since she was sexually active she must be married. Adhikari is not married.
“I picked up my test results but I didn’t go back to the doctor to discuss them with her.”
21 year old Minu Rai* wanted to be prescribed birth control pills for menstrual irregularities. Her gynecologist at Grande Hospital became really judgemental as soon as she heard that Rai was unmarried and sexually active.
“She asked me if I was having sex frequently enough to require pills, even though this wasn’t the reason I wanted a prescription in the first place.”
Acharya, Adhikari, and Rai are among the many unmarried women across Kathmandu who go to the gynecologist’s office to seek medical care, but are instead subjected to moral judgements about their sex lives and marital status, and made to feel so much anxiety, embarrassment, shame and discomfort that they are hesitant to ever go back again.
Women have negative experiences with the medical system around the world, not just in Nepal. Women are seven times more likely than men to be misdiagnosed and discharged while in the middle of having a heart attack, women in pain are much more likely than men to be prescribed sedatives, rather than pain medication. Women’s bodies, and conditions that primarily affect them, are less likely to have been studied in clinical trials.
In South Asia, systemic problems with how biomedicine understands and treats women’s bodies are compounded by the fact that certain kinds of medical care are shrouded in stigma. In a 2016 paper about the use of reproductive health services by unmarried women in India, Mohammadi, Kohan et al. outline four main factors that can make unmarried women’s experiences with gynecology negative: stereotypical thinking patterns in society, the fear of being judged and labeled by others, discrimination, and feeling ashamed of seeking reproductive health services.
Many – though certainly not all – gynecologists hold traditional views about sex being reserved for heterosexual married couples. When they meet patients, these views about how women should behave often translate into condescension, if not outright hostility.
These factors appear to apply to Nepal as well, and many unmarried women in Kathmandu say that gynecologists’ conservative thinking about female sexuality is a big source of stigma that makes them hesitant to go to the doctor even when they know that something is wrong. Many – though certainly not all – gynecologists hold traditional views about sex being reserved for heterosexual married couples. When they meet patients, these views about how women should behave often translate into condescension, if not outright hostility.
Dr. Swastika Garg* is a gynecologist with a two decade old private practice. When asked about whether she gets unmarried patients or not, she told me that she did, and that it made her deeply uncomfortable.
“I talk to them politely, but I always think, why are they doing this and that when they should be studying? They bring infections, they get abortions. Aile gali garne jamana ta chaina, but I always tell them that they shouldn’t be engaging in these things before they are married.”
Garg says her views about premarital sex don’t impact the care she is able to provide to her patients. This may be true, but many women visiting gynecologists can feel the judgement, and it makes them hesitant to be forthcoming with concerns about their bodies.
While individual doctors are a big part of the problem in women’s negative experiences with gynecologists, a generalized anxiety about how they will be perceived and discomfort with their own bodies also makes women unable to ask for and receive the medical care they need.
Dr. Roshan Thapa Rayamajhi, a gynecologist at Himal Hospital, told me that about 10-15 percent of her patients are unmarried women who come to her with problems related to sexual intercourse. While many from urban, liberal backgrounds share their problems with her openly, some women will not give her all the information she needs to treat them properly.
“Sometimes, from a patient’s symptoms, it seems possible that she may have an STI. But when I ask about sexual activity, she’ll say that she hasn’t had contact. In these cases I can’t force them to have an examination.”
Dr. Jageshwor Gautam, a gynecologist and the director of Paropakar Maternity & Women’s Hospital believes that doctors at Paropakar are non-judgemental, and do not discriminate between people who are “married, unmarried, or engaged” [‘engaged’ is the hospital’s euphemism of choice for sexually active]. But unmarried women, particularly those who come to get abortions at the hospital, are afraid of being seen at the hospital and do not use all the aftercare services that are available.
Internationally-funded public health organizations, including Marie Stopes, Family Planning Association, and the Nick Simons Institute, also say that their focus is on providing care across Nepal to women regardless of their marital status. But when asked specifically about gynecological services for unmarried women, they say that this is a “sensitive subject.” Data that is about usage of gynecological services by unmarried women is hard to come by, and when it is mentioned, it is brushed under the rug with the statement “unmarried sexual activity is rarely reported in Nepal.”
Dr. Swaraj Rajbhandari, a gynecologist at Nidan Hospital and a public health professional who practiced in Accham and Dadeldhura, believes that sexual activity among unmarried women is much more common than government surveys and NGO reports state, both within Kathmandu and outside.
“Legally, gynecological care and abortion is supposed to be free in government hospitals,” Rajbhandari said. “But it is definitely true that many doctors and health professionals are biased against unmarried women and will refuse to administer IUDs and contraceptive pills. Women are getting married later now. Health professionals need to come to terms with the fact that this means that a lot of people are having sex outside of marriage, and this shouldn’t interfere with the care they give patients.”
Body and choice
One could argue that experiences with gynecologists would be better if women ignored the stigmatizing comments and focused on getting healthcare from medical providers, but the taboo surrounding women’s sexuality is so entrenched in society that many women have deeply internalized shame about their bodies, leading to delaying or avoiding much-needed visits to the doctor.
Anandi Sharma,* 30, spent many years when she was younger self-medicating and taking emergency contraceptive pills as birth control.
“Nobody teaches you these things!” Sharma said with frustration. “It took a long time for me to understand my body. At this stage in my life, I am very comfortable explaining my medical history to gynecologists. I know how big my ovarian cyst was, I can explain what medications have worked for me when I have had yeast infections. Even for someone like me, who is quite knowledgeable about these things now, going to the gynecologist is an uncomfortable experience. They can be so cold and dismissive. I can’t imagine what it’s like for people who have no idea what is going on!”
Despite being confident in her life choices and her body, Sharma has found it easier to lie about her marital status at the doctor’s office than to tell the truth and risk being ostracized.
“I’ve been married for two and a half years for the last five years,” Sharma told me with a laugh. “I’ve also gone to 10 different gynecologists. I’m always afraid that if I show up with a different sexual partner when I go to the same gynecologist again, they will really judge me.”
“When I told my gynecologist that I didn’t want a child, she was completely shocked.”
While pretending to be married solves some problems, it also creates new ones. Sharma went to a gynecologist a couple of years ago when she had a pregnancy scare. The doctor told her, with some disappointment, that she wasn’t pregnant, and chastised her for not being open to the idea of having children.“You’ve been married for two-and-a-half years, it’s time for you to be a mum now!”, she was told.
Shanu Gurung*, 40, who doesn’t want children, recounted facing similar pressures.
“When I told my gynecologist that I didn’t want a child, she was completely shocked. She asked me if ‘I was at least going to adopt’ and by that point, I was so ready to get out of that room that I responded with ‘yes, I’m probably going to adopt.’”
Women’s health at risk
There is ample research that shows that doctors have biases, as all people do. Many doctors, whether subconsciously or not, provide differential care based on class, race, weight, and of course, gender. The fact that many Nepali gynecologists believe premarital sex to be morally reprehensible and women’s duty to be mothers unquestionable is perhaps not surprising.
But whatever views doctors may hold personally, the Nepal Medical Council code of ethics dictates that doctors should always consider the health of their patient first and “not allow consideration of age, sex, religion, nationality, ethnicity, politics, or social standing” to interfere with their medical responsibilities. For many gynecologists, it appears as though marital status is not part of this list.
Visits to the gynecologist are not optional. They are recommended for any woman with issues relating to menstruation, cancers of the reproductive tract and breasts, fertility, pregnancy, pregnancy-related tumors, menopause, contraception, sterilization, pregnancy termination, among a host of concerns. But a devastating combination of moralizing by doctors, a general culture of shame around women’s bodies, and a lack of sensitivity on the part of doctors leads to many women choosing not to go to the gynaecologist when they should be.
Noticing how many women in Kathmandu have the shared experience of being stigmatized by their gynecologists, Shubha Kayastha, a sexual health advocate affiliated with the organization Body & Data, started a crowdsourced list of gynecologists in Kathmandu who are disabled people-friendly, LGBTI people-friendly, and youth-friendly.
“A friend told me that there was a crowdsourced list in India, and I had heard so many horror stories with gynecologists here, that I thought it would be a good idea to start one,” Kayastha told me.
Visiting a doctor from the crowdsourced list may be a start, but a broader cultural shift is urgent and necessary. Until gynecologists start respecting women’s bodily autonomy and their sexual choices, and the shame around bodies and sexuality is abated, many women in Kathmandu will continue to have deeply unpleasant encounters with doctors, or avoid going altogether.
“The first time I went to the gynecologist, laying there with my legs up while getting examined, was such a vulnerable experience,” Sakshi Karn*, 22, recounted. “I was lucky to have a gynecologist who asked for my consent before examining me, and really listened to what I was saying. If I hadn’t had that experience I don’t know if I would want to go back.”
**Correction: A previous version of this article contained the sentence “Some products used primarily by women, such as the oral contraceptive pill, are based on research studying male hormones,” citing a BBC article that states that “Even medical products used only by women – like the oral contraceptive pill – are based on male bodies (in the case of the pill, male hormones).” This sentence is inaccurate and has since been deleted. You can read about the history of the oral contraceptive pill here.