Representative image. Photo: Marcelo Leal/Unsplash
- An essay prompt in a final-year paper for Bachelor of Ayurvedic and Medicine Surgery students in Karnataka was: “Women as an aphrodisiac medicine/syrup”.
- Sexism in medicine is not a new phenomenon. Several elements of it have existed in medical textbooks and syllabi, and both within and beyond Ayurveda.
- Medical students are not equipped to deal with the consequences of discrimination faced by women, tribal people and people from socio-economically marginalised groups.
- The National Health Policy 2017 drew attention to gender inequities and included a comprehensive response to gender-based violence as one of its priority areas.
Sexism is blatant and prevalent in medical education. This is a well-documented phenomenon that received a needless reminder recently in the form of an essay prompt in a final-year paper for Bachelor of Ayurvedic and Medicine Surgery (BAMS) students in Karnataka.
The prompt was: “Women as an aphrodisiac medicine/syrup”.
The Rajiv Gandhi University of Health Sciences (RGUHS), which conducted the examination in which this prompt appeared, stood its ground saying that the prompt was in accordance with the prescribed syllabus and that the university lacked the authority to add or delete content prescribed by the Central Council of Indian Medicine.
In fact, the specific textbook used by the students of the Ayurveda course, according to some of its critics, teaches the objectification of women as sources of pleasure or as instruments of reproduction.
The essay prompt in the exam does not come as a surprise because sexism in medicine is not a new phenomenon. Several elements of it have existed in medical textbooks and syllabi. It is also not limited to Ayurveda: all streams of medical education and textbooks are peppered with instances in which women are labelled in objectifying ways and/or are stereotyped.
We know that women who have approached the healthcare system in cases of rape should expect to undergo examinations to ascertain if they are “habituated to sexual activity”. Students in classrooms are taught to document the status of the hymen of women who have experienced sexual assault, signs of resistance and presence of injuries, the woman’s build, among other attributes. One forensic and toxicology textbook claims, “A well-built female cannot be raped by a single adult male”.
Such compulsive documentation practices stem from a mistrust of women that is endemic in our society – including among medical personnel. The contents of textbooks are reflected in the perceptions and practices of medical educators, who pass them on to their students.
For example, a 2015 study by the Centre for Enquiry into Health and Allied Themes (CEHAT)1 among medical educators in seven medical colleges in Maharashtra revealed perceptions of women displaying “hysterical symptoms” – especially “housewives” experiencing “intentional hysterical episodes” – even though ‘hysteria’ is no longer a psychiatrically recognised classification. While speaking of survivors of sexual violence, the educators also said that in many cases the rape was the result of “personal vengeance”.
We need to urgently review and rewrite textbooks of all streams of medicine to remove sexist language and attitudes.
Revamping MBBS curriculum
The National Health Policy 2017 drew attention to gender inequities and included a comprehensive response to gender-based violence as one of its priority areas. The policy also emphasised gender-mainstreaming in the undergraduate curriculum for medical students, to reduce inequities in healthcare.
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 needs to be gender-sensitive and compassionate towards patients.
Coming this far has taken many efforts by civil society organisations, women’s rights groups and other entities – but at the same time the new curriculum still has many lacunae. The syllabus still carries unscientific terms like “defloration”, “virginity testing” and “types of hymens”. Their use perpetuates the glorification of virginity and in turn objectifies women’s bodies.
In addition, while at one end of the spectrum is the use of archaic and unscientific terms that perpetuates biases against women, the other end is populated with a complete gender-blindness vis-à-vis health issues and issues of access to health care. For example, in spite of the acceptance worldwide that domestic violence is a public health issue, with considerable statistical evidence of its adverse impact on women’s health, it does not find mention in the CBME curriculum.
The curriculum also neglects to address the health issues of sexual minorities, doesn’t throw any light on the stigma and discrimination that they face in society and within healthcare facilities, and which inhibits them from entering the health system altogether.
As a result of these oversights, medical students are not equipped to deal with the consequences of discrimination faced by women, members of the LGBTQIA+ community, tribal populations and people from socio-economically marginalised communities. Many of them have been known to avoid seeking care because their care-providers are insensitive to their lived experiences and judge them harshly.
It is also notable that the competencies that CBME introduces are not sufficient. It must also include supporting modules and teaching material so that educators are able to teach their contents appropriately.
In an effort to integrate gender in medical education, CEHAT – in collaboration with Maharashtra University of Health Sciences (MUHS) – created gender-integrated modules for five disciplines of undergraduate curriculum. These modules are evidence-based and backed by tests that indicated their appropriateness for inclusion in MBBS teaching courses.
The feasibility study also indicated that gender cannot be taught in a one-time, standalone lecture but needs to be integrated across disciplines and semesters, to effect meaningful changes in gender-related knowledge, attitude and skills.
While there is great scope to enact changes in the revised CBME curriculum, the revision itself is a move towards positive transformation, a ray of hope that in the coming years we can expect medical education to be free of well-known biases and unscientific knowledge and practices. Recently, MUHS set an example by removing content based on “virginity testing” and “two-finger testing” from its syllabus.
The chapters on sexual assault and role of healthcare providers have been modified based on these changes in the latest editions of A Textbook of Medical Jurisprudence and Toxicology.
Maharashtra is the first state with an institute to have taken this step, and we hope that other states will soon follow its lead.
The authors would like to acknowledge review comments by Padmini Swaminathan and Padma Deosthali.
Sangeeta Rege is coordinator and Amruta Bavadekar is research officer – both at CEHAT (https://www.cehat.org/).
The authors work for this organisation and Amruta Bavadekar is one of the study’s coauthors.↩