What happens should not stay hidden in the examination room.
–Racist, homophobic, transphobic, and moralistic gynecological traumas exist
The gynecological examination can create an environment in which one can feel vulnerable, fragile, and helpless and it can become a traumatic experience when it intersects with the immigration experience. Gynecological violence becomes visible when we listen to the experiences that break the silence around it. We need to listen to what they (Women, LGBTQI+) have to say. In this piece, I try to let each person have their say as much as possible, and hope that gathering and listening to their stories will contribute to our healing.
“Oh, are you really a virgin? Why are you still a virgin?”
Senem describes their first gynecological examination in Germany as very emotional and disturbing. They were very surprised, Senem said, when they were questioned about their sexuality instead of getting some medical information about the urinary infection they had. Senem is a 31-year-old non-binary person who came to Germany in 2013. They consider theirself part of the new immigration wave created by the economic and political environment in Turkey as well as the increasing restrictions against LGBTQI+ in recent years. It took them a long time to realize that what they experienced in the gynecologist’s room was gynecological violence.
Gynecological violence includes inappropriate and intrusive comments, all kinds of acts without consent, sexist, homophobic, and transphobic behaviors, preconceptions about motherhood, fertility, sexual and gender identity assignments, insufficient information, and wrong treatments. One of the reasons that make it difficult to identify gynecological violence is due to the lack of descriptive data on it. An important reason for this is that it is not prioritized by mainstream studies (Eurocentric and gender-binary scientific research). The European Union Agency for Fundamental Rights Report (2019) defined gynecological violence as: “Obstetrical and gynecological violence is a form of violence that has long been hidden and is still too often ignored.” The report refers to a study (which excludes LGBTQI+ experiences due to its gender binary structure), conducted by the World Health Organization, and says that nearly 42% of the women surveyed stated that they had experienced physical or verbal violence or discrimination during obstetrical and gynecological examinations. Even though it is not an inclusive study, the number is so high that we should still pay attention.
When Women, LGBTQI+ individuals who have a migration background, are targeted by gynecological violence, discriminatory and racist acts also become a part of it. However, this is rarely defined and reported as abuse. Those who are exposed to it are not always aware that their experiences can be considered gynecological violence. Shame and embarrassment, which are feelings imposed by society, make it very difficult to report it.
Unsafety, vulnerability, and oppression…
“They never explain, never look you in the eye, but we got used to it somehow. They should say, something will enter you right now, it may hurt a little, it may be cold, something metal or gel, etc. Normally, the doctor should say this first and do it later. But again the permissions for physical interventions were missing.”
Bahar, a cis-woman, is a Ph.D. student who came to Germany in 2014. She describes the real, life situations she has experienced more than once during the gynecological examinations. Since the gynecological examination differs in method, some steps are required in the physical intervention. Dr. Irmak Saraç, a gynecologist from Turkey, who researches gynecological violence, explains as follows: “Not only talking about your privacy and sexuality can make you feel vulnerable but also the gynecological chair puts the person in an unguarded position.”
Gökçe, who has been living in Berlin for ten years, was found to have a decrease in her egg reserve as a result of the hormone tests. She shared that she still recalls her doctor’s hurtful comment:
“There is a hierarchy between the doctor and the patient and this hierarchy was very strong with her. She sits higher than you, you sit lower. She said my egg reserves were very low. The way she said it, I felt crushed by the information she gave me: ‘If you had a partner, I would say go and try to get pregnant right away. But I can’t say that because you have no one in your life. So maybe something better will be to do, like adopt a child, save a child’s life.’ Well, not everybody has to have children. She carved out a role for herself about a very sensitive issue in my life.”
Dr. Irmak Saraç says that the examination requires consent for all steps and any procedure without the consent of the patient is harassment. During every intervention (especially operations being under anesthesia), it may not be possible to get approval. Doctors have to make spontaneous decisions about the patient’s health in emergency cases. However, if there are communication and approach deficiencies before or after the procedure from the healthcare providers’ side, this can create a negative impact on the patient
Menekşe, who is now 60 years old and came to Germany in the first wave, had a very traumatic experience also due to the lack of information given to her by doctors and inefficient consultations. At the age of 35, it was decided that her uterus should be removed because of existing infections. Before the operation, she agreed that only the uterus should be removed. However, she explained that after the operation she was confronted with the following situation:
“My ovaries were also removed along with my uterus, and they said ‘we considered it necessary at the time of surgery and took them out.’ But later, I learned that there could be different alternatives to that decision. I went through early menopause. No one consulted me. You are an immigrant, you have no knowledge, and you have no information. An organ has been taken out of your body, you can’t put it back in its place.”
Dr. Saraç says that being subjected to severe rights violations like operations without consent or not giving information by the doctor about an action personally can leave patients in a position of anxiety and fear of going to the gynecologist in the future. Menekşe’s experience reflects this:
“I had early menopause and then another doctor told me that I didn’t need to have my ovaries removed, but I will never know. No one has given me any information at any stage. I have to take pills for a lifetime, but no one explained why. I came out of the operating room as a different person, as if my body had aged. I didn’t want to go to the gynecologist again, but I had to. I experience the same thing over and over again, a feeling like the pain of surgery is always there.”
Another violation that takes away a person’s autonomy and limits a person’s choices and control over their body is conditional access to abortion in Germany, which means it is only tolerated when you get a confirmation letter from abortion counseling centers (under the law §218). These centers, instead of recognizing the personal reasons for the decision and creating support mechanisms, can cause traumatic experiences. Leyla says:
“The place I went for counseling was also a place that offered gynecologist examination. He (the doctor) asked questions that have nothing to do with the subject ‘Why do you want to have an abortion?’ Actually, I read on the internet that they don’t have the right to ask that. You are not legally required to say such a thing. He spoke in a humiliating manner to me as if I were doing something bad. He gave me no information about what my options were.”
With this relative legality of abortion, some doctors seem to use this service (abortion) more as an additional source of profit under the disguise of “counseling.” If counseling is meant to be a support mechanism for people in situations of unwanted pregnancies, its functionality in Berlin is very questionable. Everyone has the right to safe, legal, and accessible abortion in all circumstances, but this relative inaccessibility results in limitations and even loss of rights.
Normalization of Discrimination: “Where are you from?”
The gynecological experience becomes more complex with immigration, which itself represents an individual reality that is psycho-socially stressful and fragile enough. The question “Where are you from?” is a routine part of daily life for many immigrants. How can someone react to this common question in the gynecological examination room?
Leyla, a cis-woman who is a graphic designer living in Berlin for more than 10 years, wanted to talk about her options after having her second miscarriage, but there was a misunderstanding between her and the doctor. She said, almost apologetically, that her German is not very good. The doctor then asked where she was from. When the doctor found out that she is from Turkey, she bluntly said “Turks here can speak German…” Leyla describes her feelings as follows:
“Being an immigrant, being a woman, and in a situation where you already feel emotionally helpless, she actually did the opposite of what she was supposed to do, insulting you without showing any empathy.”
One of the founders of Puduhepa, a migrant women’s association that supports Turkish-speaking women, children, and LGBTQI+ individuals, Sociologist Tuğba Kıratlı Spriewald explains why it is important to examine the health needs of immigrants from Turkish backgrounds as:
“Immigration from Turkey to Germany has a history of 60 years. People who were born and raised here have built a lot of things with their own hands. Yet they can still face racism and discrimination. At the same time, newcomers have their own concerns. Therefore, more data should be produced on this subject.”
To understand these concerns, Puduhepa and Rosa-Luxemburg Foundation prepared “The Need Analysis (Bedarfsanalyse) Report” in 2018. The report is based on interviews with immigrants from Turkey about their needs in different areas of life. Kıratlı Spriewald explained the results of the health section of the study as:
“The greatest challenges in the health care system in Germany for Turkish migrants are their lack of access to information in the German health system and expensive insurance fees. And of course, the language barrier was the biggest and main source of all the problems experienced.”
Kıratlı Spriewald stated that with the increase of health professionals and doctors among second-generation immigrants over time, there are more Turkish-speaking doctors and health workers, especially in big cities like Berlin. However, it is difficult to get an appointment from them because the infrastructure cannot meet the high demand. There is still no effort to provide translators by the government institutions, especially in hospitals and in emergencies. This situation has caused various fears in the people I met. More than one of my interviewees mentioned their anxiety as “How will I explain my problem“ or “I wonder how we will not be able to understand each other again now.” However, we see a possible source that may lie at the root of this fear in Bahar’s experience:
“What I fear is not the language, but the fear of having the person in front of me being racist. Because this means that they don’t talk to you even though they can. This fear is there, it’s always there. That’s why I prefer doctors that speak Turkish.”
There is not enough research and data yet to discuss whether this is a structural problem or systematic racism, but Leyla and Bahar’s experiences reveal a shared concern. I also witnessed that many of the interviewees created their own alternatives like going to Turkey for gynecological examination, as well as for other treatments, and bringing medicine from Turkey. As a matter of fact, some end up not going to the doctor unless there is an emergency.
One way of understanding gender and sexuality
Another important aspect of discrimination experiences in gynecological examinations are presuppositions about heteronormativity. Assuming some individuals as heterosexual in these medical settings, rather than just perceiving them as patients is one of the very common forms of discrimination. According to the study by Schwulen Beratung Berlin, which is based on a survey of 500 queer people who live in Berlin, people can get questions including sexual assumptions like whether “intercourse with a man has taken place” at LGBTQI+ counseling centers and at the doctors’ offices. They are often asked if they use contraception pills, which is described by the informants as an insistent suggestion to use without the person’s request for any information or help about it. And when the pill request is rejected, they said, they get “shocked” or “strangely disparaging” looks from the doctor.
One of my interviewees, Deniz who is a lesbian queer person also complained about attitudes similar to those in the report:
“There is a fear that homophobia comes up or sexism comes up. I’m assumed to be hetero from the beginning and the doctor is trying to prescribe me a contraceptive. Or they say that you are already a lesbian, and you do not need to have certain tests (STI), but this is not true. It is a ridiculous statement, especially coming from medical personnel.”
As Deniz stated, people who are Woman/Trans/Non-Binary/Lesbian/Asexual are often assumed to not need STI (sexually transmitted infections) testing. These tests are also not paid by the statutory health insurance unless you have symptoms or a positive partner. However, many sexually transmitted infections – such as gonorrhea, chlamydia, trichomonads, and HPV (human papillomavirus) – often run their course without symptoms. These infections can happen to anyone. They may be transmitted through oral sex or contact through infected objects, e.g. when genitals are rubbed together or when sperm or vaginal secretions come into contact with the other person’s genital area. That’s why it is so important that tests are accessible and free for everyone.
Of course, discrimination also takes different shapes and forms depending on the discriminated individual. For example, trans/non-binary people also experience additional levels of discrimination. Under the term trans/non-binary people, I include all those who do not or only partially identify with the gender they were assigned at birth. 82.3% of trans and non-binary people in the survey reported having experienced discrimination in health care. Discriminatory acts are, for example, violations of personal integrity, physical integrity, the right to equal treatment or data protection. For example, trans and non-binary people often face additional discrimination because their insurance cards are inaccurate and include their gender at birth and their dead name. In the survey, they stated that at almost every visit to the doctor, the doctor addressed them with their dead name and wrong pronouns. They explain to the staff that they would like to be called by their dead first and last names, but the staff does not show the necessary care. They have to educate medical professionals very often, costing them energy and time.
Last but not least, as an intersection point when a migrant identity overlaps with the LGBTQI+ identity, the risk of discrimination increases. Tülin Duman, a queer activist and a former health consultant who specializes in migration and LGBTQI+ rights worked with Robert Koch and the Federal Health Administration explains this situation as follows:
“Even though the system sees immigrant and LGBTQI+ identities as victims, and despite the efforts and achievements of immigrant and LGBTQI+ organizations working on this issue for many years, we see that the system does not have the support for them to access sufficient information that will protect them positively in health care environments.”
As Duman said, many forms of discrimination against LGBTQI+ are often not visible. Either these discriminations are so internalized in the system that they are no longer perceived as such, or they are not direct hostilities but there are sayings, comments, or remarks that are more subtle but more frequently experienced. For this reason, most people I talked with are looking for support in their immediate social environment. However, this requires a social network and strength. Not all people are able to do this.
What could be a mechanism for combatting gynecological violence?
Last winter, experiences of harassment during gynecological examinations were circulated on Twitter under the hashtag #frauenbeimarzt (women at the gynecologist). Austrian Twitter user @Joanalistin started the hashtag #frauenbeimarzt to expose women’s sexualized or degrading experiences during gynecological examinations. The response has been overwhelming and many have described unpleasant experiences. These include offensive or inappropriate comments, not being taken seriously, and violence against women in pregnancy, especially during childbirth. And that’s not all: some patients reported sexual assault and even violence.
People who are confronted with hurtful and humiliating situations (up to physical and psychological violence) at doctors’ offices are often left speechless with shame or anger, and instead of reporting them, they avoid going to the doctor and many people are deprived of basic health services. This can result in existing diseases going unnoticed, being discovered late, and perhaps leading to late treatment. So, this is an existential emergency, and therefore it is very important that it is shared and reported. This hashtag not only started a general discussion about gynecological violence but can also be understood as a form of data collection. Therefore, it appears to be a very valuable resource, as more data is needed to identify adequate measures to not only combat gynecological violence but also racism and discrimination during gynecological examinations. As I mentioned, people who have been discriminated against or who observe discrimination need to have support mechanisms that they can resort to without barriers like language, race, sexuality etc.
After all, we should not only discuss the stories of negative experiences in the examination room – but also all the individual, collective, and political strategies developed to combat gynecological violence in migrant, women, and LGBTQI+ communities. As Tülin Duman said, many immigrant, women, and LGBTQI+ solidarity mechanisms that are available today in Germany were created by first-wave immigrants as a result of their quest for such support mechanisms, between the 60s and the 80s. The situation at present is, of course, significantly improved compared to the past. The number of refugee organizations offering support in different languages has increased and feminist organizations such as KuB (Kontakt- und Beratungsstelle für Flüchtlinge und Migrant_innen e. V.), TBB (Türkischer Bund in Berlin), DaMigra (Dachverbend der Migrantinnenorganisation) and LesMigraS (Lesbian Counselling Centre Berlin), also offer counseling services in Turkish. Many people I interviewed said that they go to doctors by taking recommendations from their friends. In the same way, some of the people stated that they get information from a website created by a queer feminist activist group, which has information about doctors and health centers based on positive references of patients. At the end of the day, what makes migrants, women, and LGBTQI+ feel strong and safe are not the support mechanisms offered by the official care systems, on the contrary, its regulations and structures create extra obstacles and burdens.
This article was an attempt to illustrate this distorted system and give voice to people who endured discrimination in it. Gynecological violence exists and it is not enough to simply define it or acknowledge its existence. People’s experiences are what will make it truly visible, but we also need to keep in mind that a person can remain silent because their experiences are unexpressed, unrecognized, and cannot be perceived by others. Such a condition brings out a feeling of great powerlessness, where the victims can’t raise their voices against the problem and the perpetrators don’t face any consequences. Hopefully, the experiences shared here can help readers understand this injustice and help others feel empowered by the mechanisms that people have built to feel strong and safe. Thus, let these experiences contribute to the visibility of the situation for everyone.
Last but not least, it is not self-evident that all these stories can simply be brought to the table or brought by everyone. It is therefore very important that the interviewer, as a listener, respects people’s space, understands the boundaries they want to share, and does not go beyond them. This article does not contain the experiences of any trans person, which is a very crucial missing aspect. There are many reasons why trans individuals may not want to share their experiences. Trusting someone you don’t know about women and LGBTQI+ sexuality, which is such a private, taboo topic, and even more so, sharing it with the world, even anonymously, is a challenging experience. I felt that maybe not everything could be said in these conversations, and not all stories can be told unless a safer place is established. Stories are still out there and just because we don’t hear them doesn’t mean that they do not exist.
* Names have been changed.
**The interviews in this article were conducted between June 2021 to October 2021.
*** Illustration by Nesil Kalenderoğlu
Bibliography
1. The European Union Agency for Fundamental Rights Report (2019)
2. BirGün – Dr. Irmak Saraç – İğneyi Kendimize Batırabilmek.
3. KAOSGL- Dr. Irmak Saraç – Jinekoloji Muayenesinde Ne olur Ne olmaz
4. Schwullen Beratung Berlin – Diskriminierung von LSBTIQ* im Gesundheitssystem in Berlin Survey
5. Bianet Jinekolog Hikayeleri Tekrar Jinekoloğa Nasıl Gideceğim?
6. Feminist Bellek – Selen Göbelez – Doğum Siddeti ve Obstetrik Şiddet.
7. KAOSGL – Aslı Alpar- Cinsel Sağlık Heteroseksüel Kadına Göre Anlatılıyor
8. The Washington Post – Kimberly Seals Allers – Obstetric Violence is a Real Problem9. Nd Journalismus von Links – Julia Trippo – Reihenweise Sexuelle Übergriffe beim Arzt
