Indian women are making sex positive choices. Can doctors keep up?

Stigma and judgement from gynaecologists can lead to compromised care and lasting fear. The need for sensitivity and empathy are urgent

This article addresses instances of bodily pain and stigma. Reader discretion is advised.

For the modern Indian woman and queer individual, the quest to find a good gynaecologist is often marked by trepidation and doubt. Are online forums that list doctors’ qualifications and reviews deserving of trust, or is it better to look up crowd-sourced lists that circulate on social media? At 30, when she lived by herself in Delhi, Shreya (name changed on request) chose a more traditional approach—asking a friend for recommendations.

Shreya sought out the recommended doctor because of recurring sexually transmitted infections (STIs); when an initial round of tests and treatments were not able to resolve the problem, the gynaecologist recommended an in-hospital procedure to rule out cancerous growths. This required the presence of a blood relative. As she found herself dealing with both an emotionally draining breakup and a stubborn STI, Shreya preferred if her younger sister or a friend could accompany her. But the gynaecologist was insistent: “It’s best to call your parents.”

When she learnt that the test results were negative, Shreya was relieved—but she did not see what was coming next. As she was strapped to a hospital bed, in anticipation, the gynaecologist revealed details about her sexual history to her parents, without her consent. “It was embarrassing and humiliating. She decided it was okay to act as relatives do—recommending that I get married—when all I wanted was a good doctor,” says Shreya.

Shreya’s experience is symptomatic of a more pressing issue within women’s health—of women’s sexual choices, particularly those of unmarried women, being perceived with judgement and bias by a number of gynaecologists in India.

Anecdotal experience from across the country paints a picture of sexual and reproductive health that is focused primarily on marriage, motherhood, and infertility. A shift towards a more sex positive outlook and the decision to have more than one partner, in particular, have elicited several negative reactions from care providers. This raises questions about whether conservative attitudes lead to damaging experiences for patients and inadequate medical care.

Instilling unnecessary fear 

When she noticed spotting for the first time at 25, Urvashi visited a major hospital in Gurgaon, where a doctor asked her to get an ultrasound done to rule out ovarian cysts or cancer. In the wing where these tests are conducted, she was quizzed about her marital status multiple times. Urvashi then realised that she was the sole unmarried, unaccompanied woman; all the other patients were heterosexual couples, or pregnant women.

The very last person to ask if she was married was the ultrasound technician. “When I responded no, she finally asked if I was sexually active. When I responded in the affirmative, the technician vaginally penetrated me with a wand without any explanation or warning. It remains one of the most physically painful experiences of my life… I believe I was given inferior, more callous care because I was alone and unmarried,” says Urvashi.

The incident radically changed how Urvashi viewed both pain and medical care. It’s not uncommon for women and queer individuals to walk away from stigmatising experiences with hesitation to visit a gynaecologist in the future, for fear of being mistreated again. This can lead to an escalation of health issues. “A simple issue can become complex just because timely treatment is not initiated. For example, if a woman has an untreated STI, she could become infertile due to pelvic inflammatory disease where a simple antibiotic course initiated early on could have cured the infection completely,” says Sukriti Malpani, Vice President, Product & Business at Proactive For Her, a digital health platform for women. Meanwhile, Srinidhi Raghavan, a sexuality educator and researcher with feminist organisations, crucially points out that delayed care in cases such as abortions can be more intensive, more expensive, and harder to access.

Past judgement, or the fear of judgement, can hamper the taking of patient histories, which, in turn, affects the accuracy of tests and treatments that are prescribed. Individuals may shy away from providing details about past choices, like taking morning-after pills, says Ankita Gharge, a gynaecologist and expert on polycystic ovarian syndrome (PCOS). “ I may offer some form of contraception, but because of the fear of judgement, they may not accept it… They may also not articulate what exactly they need from the gynaecologist,” she says. Gharge adds that in Tier-2 and Tier-3 cities, where judgement-free care can be harder to access, individuals are also wary of doctor-patient confidentiality being compromised.

Perhaps the most damaging consequence is risk-taking behaviours, spurred on because individuals are scared to approach an expert, or underestimate the severity of their illness. “Women often depend on the internet for DIY solutions which are often medically unsafe, leading to minor or major complications,” explains Malpani. Gharge points out that such risks include buying over-the-counter medicines without prescriptions. “Complications and side-effects—ones that are life-threatening—can emerge from such situations,” she warns.

Compromising on health

The prospect of an intrauterine device being inserted without administering painkillers or anaesthesia, upon the recommendation of a doctor in the Netherlands—where she lives—prompted Nitya (name changed on request) to seek a second opinion in Mumbai. Then 23, she found that taking her mother along to these appointments was non-negotiable because the doctors insisted that an adult be present. 

“All three appointments turned out to be absolutely nightmarish. There was slut shaming, and my mother was rebuked for ‘allowing’ me to have sex before marriage. I was advised to get married, have a child, and then seek out an IUD,” recalls Nitya.

The strong association of gynaecological care with motherhood and related issues, and the shame that comes with routine check-ups, has prevented many women in urban and rural India from getting timely cervical screenings to detect cancer and Human Papillomavirus (HPV). Relatedly, a woman’s marital status can also be a hurdle when it comes to transvaginal ultrasounds: individuals find that radiology clinics and departments reject their demands for the test, or ask that the consent of a male relative be sought beforehand. Gharge explains that this is rooted in social norms of virginity and intact hymens, and not medicine itself. “Transvaginal ultrasounds give us more clarity about the issues we are treating. If patients are prevented from opting for this test for certain reasons, it is not beneficial,” she says. 

Doctors’ questions about marital status and pregnancy, however, must be viewed within India’s complicated social context. Ruma Satwik, a senior gynaecologist and obstetrician at New Delhi’s Sir Ganga Ram Hospital, points to figures from the National Family Health Survey 5, where only 3.1 per cent of 25,505 ‘never-married’ women replied in the affirmative about having had a sexual encounter—a response that reflects the conservative nature of society.

“Often, women are still accompanied by an older female relative during their visits to the doctor. Sometimes, it is not always possible to ask direct questions about being sexually active. A gynaecologist may ask if the patient is married, because marriage is a societally and familially acceptable context within which to have sex,” explains Satwik.

She adds that examinations and further questions have to be done in a sensitive environment where the patient can express herself, because they concern the most intimate details of their lives. “Gynaecological care isn’t merely about physical diagnoses and prescribing medicines. It includes understanding the woman’s perspective on what is leading to her condition as well,” adds Satwik. Thus, language can be a facilitator (or barrier) in taking a patient’s sexual history.

The need to establish trust

Across conversations with Satwik and Gharge, and female respondents, what emerged was the question of trust and how central it is to deliver quality care. A deficit of trust limits the gynaecological fraternity, says Gharge. “If someone is unable to seek out solutions to their concerns or speak freely about their health because of the judgement they may face, it is a gap and failure on the part of doctors,” she says.

Crowd-sourced lists of trusted gynaecologists first emerged nearly a decade ago, and had great utility for people who needed abortions; those who migrated across cities and didn’t know where to look; and those who felt let down by past experiences. Startups like Proactive For Her are a crucial next step to access judgement-free care, by introducing due diligence and feedback mechanisms. Malpani says the organisation goes out of its way to only onboard doctors whose values align with the startup’s mission and vision statements.

“The doctor team we have today really believes that women need to have safe spaces to share problems, and this ingrained belief shows when they are treating patients. When looking for new doctors to join us, along with looking at their clinical experience, we screen for value alignment and soft skills like bedside manners,” she explains.

To be able to reach underserved populations—who may not have an urban, privileged woman’s access to the Internet and financial independence—a larger drive to sensitise care providers is the next step. Satwik says that the importance of privacy and confidentiality have been central to medical education for many years, and now, gynaecological forums are also discussing sensitivity around gender and sexual choices. She also highlights progressive legislation, like the Medical Termination of Pregnancy (Amendment) Act 2021, under which the name and personal details of women cannot be revealed.

Gharge says that it is critical to see how doctors are products of the society that they are part of.

Speaking from her experiences involving medical students enrolled in short-term courses on affirming sexual health care, Raghavan says working with care providers is extremely important—and this goes beyond doctors. It must include radiologists, nurses, and care providers at different stages. “In these situations, it is important for us to make room for the diverse experiences one may encounter and work towards unpacking our information and pre-existing learning about what is ‘right’ and ‘wrong’,” she explains, drawing attention to medical curricula which does not emphasise the agency of women within such scenarios.

“It also furthers a singular experience of women getting married and then getting pregnant. Everything else is discarded or assumed to be ‘wrong’. The same goes for doctors' understanding of disabled women accessing reproductive care. There is a baseline assumption that needs to shift,” says Raghavan.

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