Gynecological Maltreatment in Türkiye

1. Gynecological Maltreatment in Türkiye Elif is a 27-year-old sexually active heterosexual woman who has never visited a gynecologist because of fear and anxiety. She has heard, from friends, about disturbing practices/manners of certain ob/gyn experts, which has made her uncomfortable. Even though Elif wants to have routine checkups, hearing about such experiences has made her anxious. She also says that if she had some sort of medical condition that required her to see a doctor, she would ask many detailed questions before choosing the doctor. Unfortunately, this is not an uncommon feeling. Most people feel anxious before seeing a gynecologist in Turkey, now Türkiye. One study found that 47% of participants only go to the gynecologist when they have a medical emergency. Thus, they do not visit gynecologists for routine checkups. The same study asked the participants how they felt about the gynecological examination, ranging from 0 (comfortable) to 50 (anxious) and 100 (do not feel good). The results of the participants fell into the 44 range, meaning they mostly felt uncomfortable and nervous. Why do many people feel this way when accessing a basic healthcare service? Let’s look at people’s gynecological examination experiences in a deeper sense. Imposition of doctor’s moral perception and lifestyle For one, doctors often project their own moral perceptions and lifestyle choices onto patients and make unnecessary comments about their lives. In Türkiye, doctors often ask if the patient is married or not to get information on whether the patient is sexually active. This reflects the cultural mindset that you can only be sexually active if you are married and heterosexual. Even though patients need to be respected and treated without judgment, they feel judged when sharing information about their sexual lives. Many have experienced being shamed during gynecological examinations for not being a virgin. One woman says that when she first went to a gynecologist, the doctor said, ”The hymen prevents microbes, but now you are dirty and open to all kinds of sexual infection” (1). Also, some doctors refuse to do STI and smear tests on single women. Abortion care services and motherhood Besides the issues surrounding virginity, doctors often project their own moral perceptions onto the issues of abortion and motherhood too. Rooted in the heteronormative assumptions and pronatalist ideology, some doctors act like every woman should give birth. For instance, a doctor told a patient with polycystic ovary syndrome, “You should get married as soon as possible because you will not have any children soon,” showing the doctor’s personal opinions on marriage and childbirth. Another traumatic experience was when the patient went for

2. an abortion, the doctor made her listen to the fetus’s heartbeat and said, “It is a very healthy baby” (2). In a national study on contraception, it states, “Only 7.8% of state hospitals provide abortion services without regard to reason, which is provided for by the current law, while 78% provide abortions when there is a medical necessity” (3). Moreover, recent findings showed that the ratio of abortion services for medical necessities decreased to 14% in 2020. Hence, while abortion is not illegal in Türkiye, it is tough to access, and doctors make it even more difficult by imposing their opinions on the patients. This is a very personal decision, and doctors shouldn’t have anything to say other than provide necessary information about the process. Contraception use: the example of intrauterine devices (IUDs) An IUD is a small T-shaped plastic and copper device placed in the uterus to interrupt the process of insemination. Evrim is a bisexual woman who does not want to get pregnant, and after detailed research, she decided to get an IUD. However, when she went to the doctor, the doctor said that they do not recommend that unmarried women who are planning on giving birth get IUDs. Once again, this reflects the mentality that every woman should get married and have children. It is also a misconception that women who have never given birth cannot use an IUD. Although, it has been found that women who have never given birth have a slightly higher rate of expulsion. This means that the woman is no longer protected from pregnancy, but there is no harm to her (4). Moreover, IUDs are reversible. If the person changes her mind, it can easily be removed. After it is removed, fertility returns to normal very soon. Doctors should objectively inform their patients about the risks involved and let them decide independently. Heteronormativity and lack of information on LGBTI+ health LGBTI+s cannot access nondiscriminatory sexual and reproductive health because of the heteronormative and heterosexist approach of medical education, sexual health, and family planning. Heteronormativity is the presumption that heterosexuality is the default sexual orientation and everyone lives in this way. Thus, heterosexuality is taken as the norm and natural, depicting other identities as ”unnatural” and deviant. Patients in gynecological service are often assumed to be heterosexual and cisgender women. So, LGBTI+s are often invisible and sidelined, making their experiences even more challenging. When encountering an LGBTI+ patient, healthcare providers can be overly curious and ask unnecessary questions. Deniz is a nonbinary person with a vulva who’s in a sexual relationship with another person with a vulva. They reported that during a gynecological examination, they were asked ”how they engage in sexual intercourse” and ”how sexual intercourse can happen without a penis,” even though these questions have nothing to do with the examination. This shows doctors do not have the necessary knowledge on LGBTI+s sexual and reproductive health. Lesbian and bisexual women do not feel that providers understand their sexual habits and consequential health risks.

3. Lack of communication between healthcare providers and patients According to gynecologist Irmak Saraç, it is necessary to inform the patient at every step of the examination in order to create trust and a safe space. The doctor should ask for the patient’s consent before doing anything and say things like ”we can stop if you like, we are not in a hurry” and remind the patient to breathe. When following these steps and creating reliable communication, a gynecologic examination is not painful or traumatic. It is important to talk to the patient throughout the examination, and when the patient does not want to be touched, the doctor must stop. Otherwise, it would be an act of harassment and abuse (2). However, this is not really what usually goes on during examinations. As a person who has been traumatized by a lack of communication, I want to share my own experience. The first time I went to a gynecological examination, I was asked if I was married. I answered, ”No, but I am sexually active.” The doctor rolled her eyes and started the examination without giving me any information on what she was going to do. I specifically mentioned that it was my first time, and I was quite nervous, but she did not care at all and continued examining me in a hurry. She examined me with her fingers and did a smear test and vaginal ultrasound in just two minutes, which were all painful for me. I left the room feeling quite terrified and traumatized. This is, sadly, not an uncommon experience. Not being appropriately informed about the steps of the examination can create so much anxiety, that many never go to a gynecologist again. In contrast to those negative experiences, good examples show that gynecological examinations do not have to be stressful and traumatizing. After a careful search, Deniz said that they found a doctor who explains what she will do for each stage of the examination and asks for consent and how they feel. These doctors, unfortunately, are not within reach for everyone. They often work at private hospitals or have private clinics. Also, even in private centers, people can still encounter negative attitudes. State hospitals are often quite crowded, doctors are in a hurry, and their attitudes are problematic. Doctors should be nonjudgmental and comforting, making sure that patients’ physical and mental integrity is valued and promoted. It is highly important to teach healthcare professionals not to be judgmental, not to think within heteronormativity, and how to create a safe space for patients through healthy communication. I hope this piece will contribute to the current understanding of sexual and reproductive health and its deficiencies. As a person traumatized by a gynecologist, I am happy to reflect on some of the voices and show that these stories are not uncommon. This requires urgent action in order to shift us towards a human rights-based sexual and reproductive healthcare policy and planning. Note: you might be interested by blog “6 nurses share their advice for sexual and reproductive health”.