Representative image. Photo: Marcelo Leal/Unsplash
- An essay prompt in a senior year paper for Ayurvedic surgery and medical students in Karnataka was: “Women as medicine/aphrodisiac syrup”.
- Sexism in medicine is not a new phenomenon. Several elements of it have existed in medical textbooks and curricula, and both within and beyond Ayurveda.
- Medical students are not equipped to deal with the consequences of discrimination experienced by women, tribal peoples and people from socio-economically marginalized groups.
- The 2017 National Health Policy drew attention to gender inequalities and included a comprehensive response to gender-based violence as one of its priority areas.
Sexism is blatant and widespread in medical education. This is a well-documented phenomenon that received an unnecessary reminder recently in the form of an essay prompt in a final year paper for Bachelor of Ayurvedic and Medical Surgery (BAMS) students in Karnataka.
The prompt was: “Women as medicine/aphrodisiac syrup”.
The Rajiv Gandhi University of Health Sciences (RGUHS), which conducted the review during which this prompt appeared, stood its ground saying that the prompt was in line with the prescribed curriculum and that the university had no no authority to add or remove content prescribed by the Central Council of Indian Medicine.
In fact, the specific manual used by the students of the Ayurveda course, according to some of its detractors, teaches the objectification of women as sources of pleasure or as instruments of reproduction.
The essay prompt on the exam comes as no surprise as sexism in medicine is not a new phenomenon. Several elements have existed in medical textbooks and programs. Nor is it limited to Ayurveda: all streams of medical education and school textbooks are littered with examples in which women are objectivizingly labeled and/or stereotyped.
We know that women who have come to the health care system in rape cases should expect to be tested to see if they are “used to sexual activity”. Students in classrooms learn to document the state of the hymen of women who have been sexually assaulted, signs of resistance and the presence of injuries, the build of the woman, among other attributes. A textbook of forensic medicine and toxicology states, “A well-built woman cannot be raped by a single grown man.”
These compulsive documentation practices stem from a distrust of women that is endemic in our society – including among medical personnel. The content of textbooks is reflected in the perceptions and practices of medical educators, who pass them on to their students.
For instance, a 2015 study by the Center for Inquiry into Health and Allied Themes (CEHAT)1 among professors of medicine at seven medical colleges in Maharashtra revealed perceptions of women exhibiting “hysterical symptoms” – particularly “housewives” experiencing ” intentional hysterical episodes” – although “hysteria” is no longer a recognized classification by psychiatry. While talking about survivors of sexual violence, educators also said that in many cases rape was the result of “personal revenge.”
We need to urgently review and rewrite the textbooks of all streams of medicine to remove sexist language and attitudes.
Redesign of the MBBS program
The National Health Policy 2017 drew attention to gender inequalities and included a comprehensive response to gender-based violence as one of its priority areas. The policy also emphasized gender mainstreaming in the undergraduate medical student curriculum, to reduce inequities in health care.
The most recent and welcome step taken to overhaul the MBBS curriculum was the National Medical Commission’s decision to introduce “Competency-Based Medical Education” (CBME) in 2019. According to CBME, an Indian medical graduate must be gender sensitive and compassionate towards patients.
Getting there has taken a lot of effort from civil society organizations, women’s rights groups and others – but at the same time, the new agenda still has many shortcomings. The program still includes non-scientific terms like “defloration”, “virginity test” and “types of hymens”. Their use perpetuates the glorification of virginity and in turn objectifies women’s bodies.
Moreover, while at one end of the spectrum is the use of archaic and unscientific terms that perpetuate prejudice against women, the other end is populated by complete gender blindness to gender issues. health and problems of access to health care. For example, despite worldwide acceptance that domestic violence is a public health issue, with considerable statistical evidence of its negative impact on women’s health, it is not mentioned in the CBME agenda.
The program also fails to address the health issues of sexual minorities, sheds no light on the stigma and discrimination they face in society and in health care settings, and which prevents them from entering the health system. health.
Because of these oversights, medical students are not equipped to deal with the consequences of discrimination experienced by women, members of the LGBTQIA+ community, tribal people, and people from socio-economically marginalized communities. Many of them are known to avoid seeking care because their caregivers are insensitive to their lived experiences and judge them harshly.
It should also be noted that the skills introduced by the CBME are not sufficient. It should also include support modules and teaching materials so that educators are able to teach their content appropriately.
In an effort to mainstream gender into medical education, CEHAT – in collaboration with Maharashtra University of Health Sciences (MUHS) – has created gender mainstreaming modules for five disciplines in the undergraduate curriculum. These modules are evidence-based and backed by tests that have indicated their suitability for inclusion in MBBS teaching courses.
The feasibility study also indicated that gender cannot be taught in a single, stand-alone course, but needs to be integrated across disciplines and semesters, to effect meaningful changes in related knowledge, attitudes and skills. to gender.
While there is plenty of room to adopt changes in CBME’s revised program, the revision itself is a step towards positive transformation, a beacon of hope that in the years to come we can expect medical education to be free from well-known biases and unscientific knowledge and practices. Recently, the MUHS set an example by removing content based on “virginity tests” and “two-finger tests” from its curriculum.
The chapters on sexual assault and the role of health care providers have been updated to reflect these changes in recent editions of A Handbook of Medical Jurisprudence and Toxicology.
Maharashtra is the first state with an institute to take this step, and we hope other states will soon follow suit.
The authors would like to thank Padmini Swaminathan and Padma Deosthali for their comments.
Sangeeta Rege is coordinator and Amruta Bavadekar is research fellow – both at CEHAT (https://www.cehat.org/).