Textbooks, teachers and teaching methods prompt medical students to see the human body as impersonal, female sexuality as little more than childbearing, and rape victims as so much evidence in a medico-legal case. In the family welfare departments and maternity wards of hospitals, they learn to treat women as cattle
I joined medicine at a government-run medical college in Chennai. My first impression was of the anatomy dissection hall. Groups of us were allotted a cadaver each to dissect. We would compare what we saw with our textbooks to learn the minute details of human anatomy. In hindsight, this was the most impersonal way to start studying medicine -- from the beginning, the human body was transformed into something that could be explored at will in the name of science, something that was as dead as a log, something that was not seen as having once been a person with life, experiences and emotions.
Health problems begin in the community as much as in the body. This is one of the most important lessons health workers (and their instructors) have to learn. From this point of view, to start with anatomy is the kiss of death (Werner and Bower 1982).
On the other hand, faced with a situation of total lack of emotional support from the system when dealing with this sudden exposure to cadavers, such impersonalisation definitely helped us students cope. The cadavers sometimes were even given names -- this may seem irreverent but was probably a coping mechanism.
Each body part was studied separately, a few in each semester. The upper limb, the lower limb, head and neck, chest, abdomen -- each was dealt with separately. Our group was assigned a male cadaver. However, the sex of the cadaver did not really matter for the dissection till we reached the reproductive organs. The difference between ‘male’ and ‘female’ was reduced to the reproductive organs; everything else was essentially the ‘same’.
To understand the female anatomy we were assigned to a group that was working on a female cadaver. I found understanding the anatomy of the female external genital organs, especially the perineal musculature, very difficult. Although there were anatomical diagrams in dissection manuals to refer to, these seemed too complex. There was no guidance, one felt shy to ask, and no one talked about it openly. One never even thought of looking at oneself as a means of understanding women’s anatomy. It was always ‘the female anatomy’, something impersonal.
Handling the cadavers had its own connotations. The person assigned to the upkeep of the cadavers to be used for dissection was a dalit. None (except one) of the faculty of the department would touch the cadavers to help us with the dissection. It was up to the attendant to move the cadavers around, turn them during the course of our anatomy lessons. Thus the notion of the body as being impure was probably strengthened subconsciously.
The first year also included physiology lessons. The physiology of sex was a part of the curriculum. While this described the sexual act and the physiological process of erection, ejaculation and orgasm in detail, it did not in any way connect it with pleasure or with either men or women’s sexuality. The following excerpt from a physiology textbook highlights the totally impersonal way in which the physiology of the human body was presented and taught. It also highlights the patriarchal notion of equating female sexuality with childbearing.
The female orgasm. When local sexual stimulation reaches maximum intensity, and especially when the local sensations are supported by appropriate psychic conditioning signals from the cerebrum, reflexes are initiated that cause the female orgasm, also called the female climax. The female orgasm is analogous to emission and ejaculation in the male, and it perhaps helps promote fertilisation of the ovum. Indeed, the human female is known to be somewhat more fertile when inseminated by normal sexual intercourse rather than by artificial methods, thus indicating an important function of the female orgasm (Guyton 1991).
Another subject in which women’s bodies were dealt with in some detail and probably had a formative role in medical college students’ conceptualisation of the human body (and especially the woman’s body) was forensic medicine. I am referring here particularly to sections on the medico-legal aspects of rape and sexual assault. While the need for medical examination of a rape victim was part of the curriculum, the discussion about how to handle such a situation sensitively was never referred to. The practicalities of how one took the various samples required in a court of law were also never demonstrated. The textbooks, while mentioning some of these perfunctorily, very often spelt out only what the law said. The chapters on the law regarding rape and sexual assault are particularly revealing in their misogynist approach. In her review of a few textbooks on forensic medicine, Flavia Agnes brings these out thus:
An examination of the presumptions and comments made under the guise of neutrality reveals that, blatantly or subtly, what is being advocated in the name of caution and prudence is an anti-women bias. The message to the doctors that they should be wary of the woman who approaches them with an allegation of rape is loud and clear… While at one level there is an over-emphasis that a medical jurist has great responsibility, for very often he will find that he is the only reliable evidence on which depends the liberty or life of a fellow being (Cox p 55), at the other, the concern for a victim of sexual assault is singularly lacking. It is little wonder that young doctors, who pass out from medical colleges fed on this doctrine, make unwarranted comments about the conduct and character of a rape victim, based on the level of elasticity of her vagina. The woman’s chastity, morality and virginity is put in the dock (Agnes 2005).
The classes on rape and sexual assault were taught separately for men and women students -- it was felt by the faculty that details of sexual assault that had to be delved into during the classes would be titillating for the men and could result in both sexes feeling uncomfortable and the men ‘misbehaving’ with the women. Thus, even teaching modalities subtly reinforced gender stereotypes and construed sexual assault from a voyeuristic perspective rather than reinforce its criminal nature.
Forensic medicine also involved witnessing post-mortems done for medico-legal purposes. Here again, the bodies were handled and cut by dalit attendants with the medical officer in charge taking copious notes during the procedure, standing a fair distance from the table. These attendants used to be perennially under the influence of alcohol, presumably to cope with the stench and stigma of their work.
The out-patient area in the gynaecology department was arranged in assembly-line fashion. All the women who came to this clinic with any complaint had to go through a set of procedures. After someone took the person’s medical history and measured the blood pressure (BP), all patients, whatever their complaint, were shunted off to the ‘pelvic exam area’. This was an inner room covered by curtains from the rest of the clinic, with curtains again separating two different examination tables. A senior gynaecologist did pelvic exams on each of the patients, one after the other, alternating between one table and the other so there was no time lost waiting for patients to undress and dress. This pelvic exam was watched by a group of medical students and postgraduates standing around the examination table -- these students also read out the history of the patient for everyone, while watching the exam. The woman’s consent was never asked. If the woman raised a feeble protest, very often she was scolded and sent off without a pelvic exam. There was no attempt to understand the context that she came from and her concerns, or to help her undergo something as traumatic as a pelvic exam.
The other area that was significant in shaping the way we saw women and their bodies was the labour room. In the college that I studied at, there were about 10 labour cots arranged in a long hall. The medical team used to sit at one end of the hall. This position provided a vantage point to survey all the cots easily, without having to go close to the woman or touch her. On admission, the women, called ‘patients’ or ‘cases’, were subjected to a pelvic exam by a senior resident -- this pelvic exam would decide whether she was in labour or not, whatever her complaints, and thus would decide whether she would or would not be admitted to the labour room. This was followed by giving the ‘patient’ an enema and half-undressing her ‘to prepare her’ admission. Following this, she was made to lie on a cold hard metal labour cot with no family or friends around. There was no process of explaining to her what was happening, or when she was expected to deliver. The duty obstetrician, who was usually of an assistant professor rank, came in once every four to six hours and did a ‘PV round’ -- a pelvic exam was done on each of the women one after the other, whether indicated or not. After each of these rounds, she would decide whether any of them needed a caesarean section. Some obstetricians preferred to do all the caesareans waiting late at night while some preferred to do the surgeries early in the morning -- depending on the whims of the obstetrician, the woman laboured on for whatever duration it took.
Since there was no system of routine monitoring, there were many instances when, in this tertiary referral facility, the woman delivered the baby on her own on the labour cot while the doctors sat at their desks. There was almost routine episiotomy given to all women who came for their first delivery. When the woman delivered, very often postgraduate students put in an intra-uterine contraceptive device immediately after the delivery. A lot of times consent was never asked -- the woman was only informed of what had been done. This was based on the fact that immediately after delivery, and the pains she had gone through, the woman was ‘most receptive’ to contraceptive advice. Whether the woman in her totally fatigued state post-delivery even understood what had been said was never looked into.
Another area that comes to my mind is the family welfare department where women were treated like cattle. Hordes of women were posted for sterilisation with no counselling on its appropriateness, permanent nature, or its effects. Women who reached the hospital requesting an abortion were coerced into undergoing family planning surgeries; if they refused, the abortion service was refused to them. Unwed women who requested an abortion were abused verbally -- very often their sexuality was denigrated in terms of morality. A total lack of privacy and confidentiality faced them in the institution.
Another thing that I observed during the five-and-a-half years in government medical college was the frequent sexual harassment of women staff by some male doctors, especially senior members of the faculty. As women medical students, we were vulnerable, but paramedical staff like nurses were most vulnerable. This took on various forms, from verbal harassment using lewd language and sexual innuendo to physical abuse. This form of harassment within health facilities has been documented in a study of medical institutions in Kolkata (Chaudhuri 2006).
Thus, the whole period of undergraduate training in medical college reinforced certain notions regarding the human body and specifically women’s bodies:
• The human body was just that -- a ‘body’ -- something that could and even should be studied piecemeal for the betterment of science and humanity. Objectivity was paramount, and thus subjective issues like emotions, contexts were not important.
• The human body was impersonal, not something each of us lived and experienced with.
• The human body was also ‘dirty’ -- social norms that assigned ‘dirty’ jobs to dalits were adhered to.
• The difference between men and women was only to do with the anatomy and functioning of the reproductive organs.
• Emotions, pleasure, sexuality were essentialised into mere physiological processes.
• The woman’s body was titillating; it could induce men to be aggressive. Men in power could use this hierarchy to abuse women. The woman’s body was also something to be careful about.
• Women accessing healthcare were a set of diseases, abnormalities and physiological processes.
• The physiological process of labour was seen to be pathological and women undergoing labour became ‘patients’.
These notions were reiterated again and again, through textbooks, teachers, teaching methods and through the way teachers behaved and the system functioned. Thus, medical college taught us to view humans, and especially women, as bodies and not as persons who embodied that body. Women were the same as men, except with female reproductive organs. In retrospect, this also affected the way we socialised with our patients -- looking at and referring to them as ‘cases’, as separate body parts and diseases rather than living humans, taking care not to get too involved emotionally with them.
(Excerpted from ‘Women’s Bodies and the Medical Profession’, Economic & Political Weekly, April 24, 2010, Vol X1V, No 17)
(B Subha Sri is a Chennai-based gynaecologist and works on issues of reproductive health)
Agnes, F (2005). ‘To Whom Do Experts Testify? Ideological Challenges of Feminist Jurisprudence’, Economic & Political Weekly, Vol 40, No 18
Chaudhuri, P (2006). ‘Sexual Harassment in the Workplace: Experiences of Women in the Health Sector’, Health and Population Innovation Fellowship Programme, Working Paper No 1, Population Council, New Delhi
D’Oliviera AFPL, Diniz, S G and Schraiber, L B (2002). ‘Violence Against Women in Healthcare Institutions: An Emerging Problem’, The Lancet, Vol 359, pp 1,681-85
Guyton, A C (1991). Textbook of Medical Physiology, Eighth edition, W B Saunders Company, Harcourt Brace Jovanovich, Inc, Philadelphia, p 912
Sabala, Kranti (1995). Na Shariram Nadhi (My Body Is Mine), Mumbai
Werner, D and Bower, B (1982). ‘Helping Health Workers Learn: A Book of Methods, Aids, and Ideas for Instructors at the Village Level’, Hesperian Foundation, Palo Alto
Infochange News & Features, December 2012