A body of its own. Women against medical androcentrism - Gatopardo

What would happen if suddenly, by magic, men menstruate and women don't? Gloria Steinem—journalist, activist and one of the icons of the American feminist movement—started from this question to write a satirical essay that Ms. magazine published in 1978. The text humorously illuminated the way in which a dominant social group uses its attributes to justify their superior status. If men did menstruate, in a world controlled by them, she wrote, “menstruation would become an enviable, petulant, masculine event. They would flaunt the length and amount of bleeding, and the boys would speak of it as the longed-for beginning of manhood. Gifts, religious ceremonies, dinners and bachelor parties would mark the day. To avoid job losses every month among the powerful, Congress would found the National Institute of Dysmenorrhea [menstrual pain]. Doctors would do less research on heart attacks, because men would be protected by hormones, and they would know all about colic."

What happens in real life is, of course, the opposite of what Steinem wrote in "If Men Could Menstruate." Despite being a daily reality for women of childbearing age and a biological function closely related to reproduction, it has been considered an embarrassing issue that should not be discussed in public. In many ancient societies, menstruating women were segregated based on superstition; Today, even medical science downplays the pain associated with this biological function. The experts agree that even in the 21st century there is little research on the menstrual cycle and disorders such as endometriosis or polycystic ovary. To date, there is no specific drug to relieve pain that, according to the American Family Physician magazine, is severe in two out of 10 women.

Elizabeth Rosales is in that group. Since she began menstruating, at the age of 11, she not only had to deal with the presence of intense and recurrent pain in her life, but also with defending the veracity of the suffering, which paralyzed her month after month, before her family and health professionals. . As it happens to most women with endometriosis before they know they have it, Elizabeth undertook a long pilgrimage in search of scientific answers and had to listen to dozens of doctors and doctors alike dismiss again and again the symptoms of her. . Finally, she received a diagnosis at the age of 24 and this led her to found, some time later, Endometriosis Mexico, the first and only association of patients with this condition in the country.

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She was still a girl in the last grade of elementary school when she had her first bleeding, profuse and very painful. She shares her memory of her from those days at school: “I stained everything because the flow was too much. Then the teacher would send me to the office so the children wouldn't see me. They would talk to my mom and she would bring me clothes so she could change me.” In sixth grade she was already aware that one day “a few drops” of blood would come out from between her legs and that this could make her feel “a little bad”, but she never imagined what would come. The first few times she experienced that fierce, relentless pressure in her womb she wondered if her whole life was going to be like this. “It was a colic that made me sweat almost all day, that didn't go away. There was no rest time; she wore it fixed, fixed, during the eight days that my cycle lasted, ”she recounts in an interview. "It's normal," she recalls that her mother consoled her, "every woman is different and some suffer more than others." Her older sister was one of the first to doubt: "Could it be that you exaggerate?" Her adolescence in Monterrey, in the north of Mexico, passed with those pains that returned punctually, but each time stronger and prolonged. "It's normal," assured two, three, nine more gynecologists; "The pain will stop when you grow up and have sexual activity or get pregnant," they told her, as if giving birth wasn't also a painful experience and as if reproduction was written in her future. When regular painkillers wore off for her, she replaced them with sublinguals, and when those stopped working, too, painkillers injected in emergency rooms followed. "It's normal," repeated nurses and residents a couple of years later, "your pain is normal." And she began to believe it. “Many times I thought that maybe I was exaggerating and that I had to get used to living like this. It is a very difficult situation, because the pain is felt, but the doctors themselves say that you have to put up with it. This is why many women with endometriosis lose all self-confidence,” she says.

New symptoms were added to the violent colic: diarrhea, vomiting, inflammation of the abdomen and lack of control of blood sugar levels. The latter led her to visit an endocrinologist, who requested a more thorough review. With an ultrasound, they detected two tumors in one ovary, 11 centimeters each: evidence, finally, that this pain was not normal. When they were removed and biopsied, she finally learned the name of her complaint: endometriosis, a word she was hearing for the first time.

***

The endometrium is the tissue that lines the inside of the uterus, the surface layer of which is shed and discarded at the end of each menstrual cycle, causing bleeding. Endometriosis is a disorder that occurs when there is endometrium in other places besides the uterus: in the ovaries, in the fallopian tubes or in the tissues of the pelvis, more commonly -although it can also grow in other vital organs-, where it forms cysts, adhesions and tumors. The causes of this pathology are unknown, and it can affect fertility and has no cure, but it is usually controlled with hormonal treatment.

According to Endometriosis Mexico, one in 10 women of childbearing age lives with this condition —around 180 million in the world—, although the vast majority do not know it. In Western countries, the diagnosis usually comes between seven and nine years after its presentation, in part because the symptoms can easily be confused with common dysmenorrhea, but also because of gender stereotypes about the menstrual cycle. It is quite common for gynecologists to refer their patients with endometriosis to a psychiatrist. In a clinical guide to care for patients with this condition, published in 2017 by the National Institute for Health and Care Excellence in England, the main recommendation for health professionals is to believe women.

Claudia Lacorti lives with endometriosis and is a volunteer for Endometriosis Mexico. She coordinates the organization's activities, such as holding events, patient care, fundraising, and relationships with specialists.

Gender bias in medical care for this disease is so widespread that figures such as actress and screenwriter Lena Dunham, creator of the Girls series, have publicly denounced it: "If your appendix is ​​bursting, your kidney is failing or a valve is your heart needs replacement, the doctors pay attention. I was saying 'this organ is failing [the uterus], I need your help!' I felt that pain for 13 years before I heard the word 'endometriosis' from a doctor”, she recounts in a testimony for Cosmopolitan. "Diseases of the female genitalia are things we generally don't want to talk about," she says later. “In addition, there is the idea that we are hysterical, more susceptible to pain or more likely to invent. There is a whole sexist ideology in doctors, although they do not understand that they have internalized it”. Dunham decided to have a hysterectomy at age 31, giving up her desire to have biological children in exchange for her well-being.

Rosales, recently diagnosed, was recommended by several doctors to prioritize getting pregnant before starting treatment – ​​which consisted of taking the contraceptive pill throughout her fertile life – arguing that it would be more difficult after her. “She was neither prepared nor had she thought about having children nor did she have a partner and had other plans for my life,” recalls the electronics engineer, now 43 years old. She has not had a hysterectomy, but she decided not to become a mother because of the risks involved in her case. "It was a difficult decision, because not every man accepts it." Some of her colleagues in Endometriosis Mexico have managed to get pregnant, but for those who can't and want to, this is usually a severe factor of depression.

The members of the association, all of them patients, have created physical and virtual spaces for 10 years to provide support and spread information. During the pandemic they have organized online events such as conferences with specialists and talks among themselves. On many occasions they have approached medical schools to share their experiences with future doctors and thus help others to be diagnosed quickly, but only the National Autonomous University of Mexico (UNAM) has been receptive and gave them a space exhibitor at its annual fair; other universities, Rosales accuses, did not even respond.

Jennifer Mier is a nutritionist and researcher at the National Institute of Perinatology. She began studying endometriosis in 2004, with an epidemiological approach, to understand how this condition occurs in women in Mexico.

The lack of research on endometriosis is a problem that transcends borders. The French journalist Élise Thiébaut, diagnosed after living with pain for 30 years, wrote about it in her book This is my blood, where she states that the fact that menstruation remains a taboo prevents this disorder from being fully understood. Like Gloria Steinem, she also wonders, in a Huffington Post article, what the scenario would be if for some reason this condition affected the opposite sex: “Sometimes I try to imagine what would have happened if a painful and invasive disease had mysteriously installed itself in the men's prostate for centuries, causing suffering comparable to a cardiac crisis and causing infertility in half of them. Something tells me that they would not have been burned in public places accused of witchcraft —as was done with the women because of the belief that they were possessed by the devil—, and that a treatment would have been found a long time ago”.

***

José Botella, a gynecologist and researcher who became rector of the Complutense University of Madrid, affirmed in his books and articles that women were physiologically frigid, that they were incapable of feeling any type of pleasure in the sexual act and that the exaltation of female libido was due to a "masculinoid" character. Bottle's texts were circulating in Spanish medical schools when Carme Valls was studying at the University of Barcelona. The Catalan endocrinologist, researcher, teacher and former deputy, now 75 years old, is one of the pioneers in approaching health with a gender perspective and she herself tells the anecdote of that professor in one of her books, Invisible Women for Medicine (2020). There she explores the multiple ways in which a science originally "done by and for men" affects women's health, an issue that has permeated her scientific and activism work and for which she was recognized with the Medal of the University of Valencia in 2019. Currently, in addition to writing, teaching and offering private consultations —because in the public health system of his country you cannot exercise after 65—, he directs the Women, Health and Quality of Life program of the Center for Health Analysis and Programs (caps) of Catalonia, a non-governmental scientific organization of which she is also vice president.

Valls acknowledges that, when she was a student, she was not yet aware of gender bias in her field of study; That's why she didn't find it strange that, in anatomy classes, her pictures always showed male bodies. Now he remembers, between laughs, his teachers justifying themselves: "They said that it eroticized, that if they put the image of a naked woman, oh!, the young boys would get it up... Well, but they were pure muscles!", he says smiling, while gesturing with his hands when speaking in a video call that takes place at night in Barcelona in January 2021.

In her book, she explains that medical science, from its birth, considered the male body as the standard and assumed that, except for the reproductive aspect, it was the same as studying that of women. Today science can verify that there are differences between the two in how they get sick of the heart, the endocrine glands, the skeletal muscle and in the experience of pain, among others, but the teaching materials have not changed much. A study published in 2008 in Science Daily analyzed 16,000 images from books recommended by the most prestigious medical schools and found that the figure of man as a universal model was present three times more than that of women.

The British journalist and activist Caroline Criado Pérez mentions this research in The invisible woman, which earned her the Royal Society award for the best science book of 2019, where she analyzes how contemporary women are affected, in various fields, by existing in a world made to the measure of men. She says that, in 2017, as part of her research, she set out to check it out by going through the huge medical section of a London bookstore: “The covers of human anatomy books were still adorned with muscular men. In the illustrations of the traits common to both sexes there continued to be unwarranted penises. I saw posters that read: 'Otorhinolaryngology', 'The nervous system', 'The muscular system' and 'The vascular system and viscera' and on all of them there was a large-scale drawing of a man”.

The differences in the health of men and women interested Valls after graduating from university in 1968, and as a primary care physician she began to make observations: “I realized that women primarily came to health care and that in the emergency room we saw more men. That was my first realization of a difference. But I thought, and still think, that men don't care so much about their bodies and arrive at the hospital when they are already very bad, while women ask for help earlier. Her choice to specialize in endocrinology, after three years of practice, arose from a personal motivation: “I had a special interest in the menstrual cycle, because I saw that in college they had not taught me anything about the cycle and menstruation had hurt me a lot. . 'If they only explain it to you in an hour of class, it's not important', I thought all my life. But the patients I saw told me they had very painful periods. I realized that it was an almost unknown topic.”

Ana Hop's photo.

Valls began to collaborate with CAPS and in this organization she found an ally to develop her work. From there she coordinated, in 1990, the first international congress on women's health, where she also presented her thesis on differential morbidity. In it, she maintains that the health sciences lack —and need— an orderly and systematized study of the differences by sex and by gender between women and men; that is, they need to consider the different ways women get sick and die, caused both by having a body with specific characteristics (sex) and by the social meaning of these biological differences (gender). The endocrinologist believes that, if such knowledge were part of the training of health professionals, it would be easier to eradicate gender bias, which has historically caused female pathologies to be misdiagnosed, women to be excluded from trials clinical conditions or unnecessarily medicalize processes such as pregnancy, childbirth or menopause.

Valls shares a common example. During adolescence, when menstrual bleeding is heaviest, iron loss can lead to anemia. The doctor recalls that when she studied the phenomenon, it was very difficult to find girls between the ages of 13 and 20 who had adequate levels of iron. “With that they are already tired, they lose memory, ability to concentrate, their nails break, their hair falls out. But when I explain this to the doctors they tell me: 'Oh yes, all women are very deficient in iron. It is normal'. And I tell them, 'but what are you going to do? Don't you give it to them? If you lacked iron, what would you do?' Just because an event is frequent does not mean that we have to normalize it. It is frequent and we have to change it. Doctors have to learn that what they have been told is normal, sometimes it is not.

***

Writer and feminist Charlotte Perkins Gilman wrote her most famous short story, "The Yellow Tapestry," in 1892 after suffering from severe postpartum depression. She, there, clearly illustrated the possibilities of a woman from the end of the 19th century—in this case, from the upper class—in the face of the discomforts of her body and mind. In a fragment, the narrator suspects that the reason why she cannot feel well is, paradoxically, her husband's medical profession: “She doesn't think she is sick! And what can one do? If a prestigious doctor, who is also your husband, assures friends and relatives that what is happening to his wife is not really anything serious, just a minor transient nervous depression (perhaps a slight propensity to hysteria), what? what can be done? My brother, who is also a prestigious doctor, maintains the same. I mean, I take I don't know if it's phosphates or tonics and I travel and breathe fresh air and exercise and I'm strictly forbidden to 'work' until I feel well again. Personally, I disagree with his ideas. Personally, I think a nice and interesting job would suit me. But what can one do?

It was also Perkins Gilman who popularized the term "androcentrism" to refer to a worldview that takes the male experience as universal. In her 1911 essay, The World Made to Measure for Man or Our Androcentric Culture, the author analyzes the negative effects that single-sex domination had hitherto had on different areas of social life, such as the arts, education, religion, sports or politics; a trend that could be traced back to the beginning of writing in ancient Egypt. “In this period we have almost universally had what I call here an androcentric culture. History, as we know it, was made and written by men. The mental, mechanical and social development was almost entirely theirs. Until now we have lived, suffered and died in a world made by men,” she wrote.

A century later, Perkins Gilman's term continues to serve those who seek to explain inequities rooted in medicine. Carme Valls speaks of "an androcentric culture that has considered women's health problems inferior or less important." She also points out the reproductive reductionism in which they are still pigeonholed and by which policies related to women's health focus on pregnancy, contraception and family planning, but dismiss other frequent problems of women's health. Valls says that, when she was a legislator in the Catalan Congress, between 1999 and 2006, she launched an initiative that, although it seems small, she remembers as a great achievement. In Catalonia there was a network of public clinics called Women's Care Centers, which were actually dedicated to reproductive health. Valls demanded to call things by her name and argued in a parliamentary session: "But if the woman is something more than a uterus with legs!"; now these clinics are called Sexual and Reproductive Health Care Units.

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Help needed please. Does anyone know how to actually contact @hermes the parcel people. I have a dispute with them… https://t.co/G72artsak1

— Hibiscus Ceremonies Sun Nov 11 13:03:50 +0000 2018

Yentl, a fictional character created by Nobel laureate Isaac Bashevis Singer, is a young Jewish woman from the early 20th century who is so interested in studying the Talmud that she decides to cut her hair and act like a man in order to gain access to an education that, in its time, it was banned for women. The New York cardiologist Bernadine Healy —the first woman to lead her country's National Institutes of Health (NIH)— was based on it when she coined the term "Yentl syndrome" in 1991, denouncing in The New England Journal of Medicine that there were gender biases in primary care for cardiovascular diseases. He wrote that if a man and a woman came to the emergency room with symptoms of a heart attack, she was less likely to receive an effective diagnosis and therefore timely treatment, and that this was due to to the fact that the symptoms of a heart attack in women are not always those that the books classify as typical; that is, the most frequent that men suffer, such as the crushing pain in the center of the chest that radiates to the left arm. Atypical symptoms are common in the female body: a state of nausea or indigestion, shortness of breath, anguish, as well as upper abdominal pain that rises to the neck and jaws. Healy denounced the false but widespread belief that women get less heart disease due to the protection provided by their hormones, which was explained by decades of clinical trials carried out only with men, which, in turn, caused their symptoms to increase. will be taken as the norm. Another cardiologist, Nanette Wenger, believes that the origin of the myth lies in the fact that men have heart attacks younger, when they are "at the peak of their careers and more visible," she told CNN, while women do. most commonly after the age of 65, relegated to their homes and condemned to invisibility.

One of the emblematic cases of malpractice due to gender bias in the care of heart attacks is that of Paula Upshaw, a 34-year-old woman from Maryland, United States, who arrived at the emergency room with the typical symptoms of a heart attack . She knew them well because she was a health professional and worked as a respiratory therapist. Probably because of her sex and age, those who reviewed her never considered that it was actually a heart attack, despite the fact that she had an electrocardiogram performed at the patient's insistence. They probably didn't look at it. In the end, she was told that her symptoms were the result of indigestion and was sent home with a prescription for antacids and anti-ulcer medication. But the pain did not stop and she insisted on two more visits to the hospital in a span of almost two weeks. After the third EKG, and a third misdiagnosis, Ella Upshaw refused to leave until admitted. The next day, an on-call cardiologist, reviewing EKGs from the day before, asked, “Who is the 34-year-old with a massive heart attack?” That same day, she had emergency surgery, coronary artery bypass surgery to redirect her blood flow.

Because of irreparable damage to her heart muscles due to her early neglect, Upshaw lived out the rest of her days—until age 58—with limited heart capacity. “I always tell women to ask to see their test results,” she told the LA Times in 2003. “Even if you don't know what they mean, act like you do, because that will force the doctor to explain and they'll have to look. the study. That's the guilt I live with on a daily basis: that I wasn't a good lawyer for myself."

***

Gabriela Borrayo was born in Tetitlán, Nayarit, in 1968. She is the sixth of eight children in a family that she describes as traditional and is the daughter of a sugar cane farmer and a housewife. In her memories, education was always egalitarian. "I never saw differences in the treatment between women and men, neither as a girl nor as a young man nor as a student, until I came to the cardiology specialty," he says in an interview in March 2021, before entering a meeting with some of his medical colleagues. She is dressed in a wine-colored jacket and a flower scarf around her neck. She wears a KN95 mask, her dark hair is loose. “Everything was fine while I was a resident, but when they started giving me positions of greater responsibility, the problems started,” she says via Zoom.

In October 2020, the National Association of Cardiologists of Mexico (ANCAM) appointed her president, the first in her 37 years, and Borrayo took the reins despite the resistance he encountered, such as sabotage attempts by the dominant group in one of the unions with the highest rate of masculinization (80% men and 20% women). A year before, she received the National Health Award for Excellence in Cardiology and, between 2015 and 2016, she directed the public hospital Centro Médico Nacional Siglo XXI. From her management at ANCAM she hopes to increase the number of cardiologists, as well as raise awareness among the female population about cardiovascular diseases.

In addition to holding leadership positions in public and private health institutions, she is a researcher, author of scientific articles, and mother of two college-age children. The subject that she has studied the most is infarction, which is the death or damage of the heart muscle —the myocardium— due to the obstruction of one of the coronary arteries that nourish the heart. She became an expert on the subject during the master's and doctoral programs in Medical Sciences, which she finished with honors at UNAM. Her analysis of a database of more than 50,000 patients from the National Social Security Institute (IMSS) with heart attacks was the starting point for what would become the Infarction Code program. The doctor calls it “my pride program”: She worked on the protocol for three months, in an eight-square-foot cubicle, before presenting it to the director of the nation's largest public health organization.

Heart Attack Code is a protocol designed to guarantee the timely diagnosis and treatment of patients in the emergency room, through the training of doctors, male and female nurses, as well as stretcher bearers, guards, medical assistants and heads of service, so that their coordinated actions shorten the time of attention and sudden deaths can be avoided. In the IMSS Digital application you can find the medical units that follow the protocol and locate the closest one. According to Borrayo, the time in which the electrocardiogram is performed, when a patient arrives at the emergency room, has been reduced from 15 to seven minutes. According to figures from the IMSS itself, since the strategy was launched in 2015, deaths from this cause have been reduced by 58%.

Despite advances in eradicating the belief that heart disease only affects men, efforts are still needed. “This comes from the lack of information, because the same specialists have not been able to transmit it. We have not been very clear in communicating that women die more from the heart”, reflects Borrayo. The story has been different in the case of breast cancer, a disease whose prevention has been very successful, but which affects far fewer women. In 2019, 7,527 deaths from breast cancer were recorded in Mexico, while 72,768 women died from heart disease; on average, 200 a day, according to INEGI. Although, in absolute numbers, more men die from heart failure (83,258), when analyzing deaths from heart attacks in hospitals, a higher mortality is observed in them. The causes are related to gender bias in medical care and self-perceived gender role. Borrayo explains: “Women take longer to get to the emergency room, between 30 and 60 minutes, because in many cases they have the [previous] experience of labor pain and the heart attack pain is not as strong. In addition, her symptoms are atypical and, due to a cultural situation, the woman says 'I must be fine, I'm going to put up with it'. When a woman with a heart attack finally arrives at the emergency room with symptoms that are not standard, someone who is not well trained can tell her 'you have stress or psychiatric problems'”. For this reason, during the training for Heart Attack Code professionals, emphasis is also placed on the need to believe women. The phenomenon is not exclusive to Mexico. In the United States, the American Heart Association launched the Go Red for Women initiative, a platform to raise awareness of heart health in women.

To all this we must add that women have more accumulated risk factors, due to a greater proportion of suffering from arterial hypertension (in Mexico, 45% against 33% of men of the same age, according to INEGI), diabetes (25% against 20 %) and overweight or obesity (31% vs. 22%). Other risks exclusive to them are having had menstruation or menopause at an early age, the use of contraceptives, suffering from polycystic ovary syndrome or preeclampsia during pregnancy.

Borrayo knows that it is very important that women be recognized as a high-risk group for heart disease. That is why he joined with other colleagues in the creation of the Women's Heart Initiative, which was recently formalized as a chapter of ANCAM. The professionals that make it up have organized medical congresses and talks aimed at the population, live and now also through a YouTube channel. One of its first actions, in 2015, was a campaign on public roads, outside the World Trade Center, in Mexico City, where a group of nurses evaluated 500 women, aged 40 to 45, who were going through that place. The cardiologist remembers her findings by heart: “They had a body mass index of 27 or 28 [the normal index is between 18.5 and 24.9], more than 90 centimeters of abdominal perimeter, 56% hypertensive and diabetic, who did not know it. , eleven%. We also measured cholesterol and 70% had an alteration. That's when we realized that Mexican women walk down the street with a time light bulb."

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When Luz María Moreno studied Medicine at UNAM, between 1969 and 1975, 70% of the students enrolled were men and 30% were women. Today the proportion has been reversed with about 65% female students. However, according to the founder and coordinator of the Program for Gender Studies in Health of the UNAM Department of Public Health, the increase has not put an end to sexist discrimination by teachers nor has it eradicated the androcentric discourse that is part of of medical socialization in college. “Medicine is a very androcentric and hierarchical field, where women occupy a position of inferiority,” she says of the implicit male discourse that permeates medical research and education.

Luz María Moreno is coordinator of the Gender and Health Studies Program of the UNAM Department of Public Health. She is also a professor of the subject "Medical practice with a gender perspective" and one of the coordinators of the collective book The gender perspective in health (UNAM, 2016).

At UNAM, the formal curriculum only includes an optional subject to analyze medical practice from a gender perspective. It is taught by Moreno, a 72-year-old woman who was responsible for introducing this approach to the faculty almost two decades ago. The seed was sown in her a few years ago, thanks to her participation in a seminar given by Graciela Hierro, one of the forerunners of feminism in Mexico and the founder of the University Program for Gender Studies. “I entered out of curiosity, without knowing exactly what it was about, but then I realized that I had always been a feminist, even though I hadn't identified it as such,” she says at a leisurely pace and via videoconference from her home in Mexico City.

Most of her students are women —first and second year students— and the professor has observed that, at each beginning of the course, they arrive with greater interest and sensitivity, even identifying themselves as feminists. "This is good news, although for me the ideal would be to be able to reach those who have no sensitivity, in whom you can really create gender awareness." She knows the difficulties this represents; When she began to disseminate among colleagues about the relationship between gender and health, she received many harsh jokes and disqualifications: “I have always said that we have to be stubborn and let it slip; You have to have a lot of resistance to frustration.” In 2008, the Program for Gender Studies in Health was formalized, which she still directs and through which seminars, forums and other academic activities are organized. Since then, she Moreno and some of her classmates have made efforts to include her study topics in some compulsory subject, but they have only received refusals: “Many teachers think that these topics are not important. They say that the students already take too many subjects. I have even proposed to them to hold reflection workshops in which we bring together various groups, but there is a lot of opposition”.

Moreno was born in Tlaxcala, in the center of the country. Her parents were elementary school teachers. When she was about to choose a medical career, her father suggested that she consider becoming a teacher and her sister-in-law thought that it would be very difficult for her to find a husband if she pursued such a long career. But she continued with her plans and moved to another city. From her years as a student, she does not remember having suffered any episode of gender discrimination. “Since I have an indigenous profile, she perceived ethnic discrimination more than gender discrimination, but I must have experienced it. I think she was very well socialized,” she says. Contrary to her sister-in-law's predictions, at college she met her husband, today an oncologist, with whom she had two daughters and a son. They have been married 46 years.

Luz Maria Moreno.

The professor adopted her current line of research several years later, after raising her children and her encounter with feminism. In 1995, she enrolled for a master's degree in teaching and submitted a thesis on the relationship between cervical cancer and gender stereotypes. “I wondered why Mexican women didn't go for a Pap test, when it is relatively simple and prevents cervical cancer. The test solved the problem in developed countries, but in Mexico less than 50% of women regularly go for checkups. There are many who never do it, ”she explains.

In the study, she looked at two groups of patients diagnosed with cancer. The first was made up of women who had only been tested once and thus discovered that they were in an advanced stage of the disease. In the second group, the women had come for regular check-ups, so they discovered an early and curable cancer.

"I found that there were differences in terms of gender construction in one group and another," says the academic. The women in the first group had had violent relationships and had assumed the role of submission; they had had more children, since they were younger —which implies a greater risk for this type of cancer—; they had a lower level of schooling; the relationship with his parents was distant; and sexuality remained a taboo subject. The women in the other group, on the other hand, showed greater openness to talk about sexuality; they deviated more from the traditional gender role; they were more aware of their right to a life free of violence, which is why they had broken off relationships of this type; and they had had more partners. Moreno concludes that a more conservative and stereotyped construction of gender, the result of training in patriarchy, is associated with less access to sexual and reproductive health. And that gender inequality costs lives.

***

Cervical cancer is known to be caused by the evolution of certain types of the Human Papillomavirus (HPV). But it is less known —and Luz María Moreno was surprised to find out one day, through her students— that among doctors there is talk, laughing, of another syndrome with a similar sound: PVH, the acronym for “Fucking Old Hysterics” . The derogatory term refers to a real tendency to go to health centers with ailments and complaints that doctors alike minimize or do not diagnose. The phenomenon is known as “hyperfrequency of services”, it is more common in women and some mental health experts have studied it from a gender perspective. Among them, Shoshana Berenzon, professor-researcher at the Ramón de la Fuente Muñiz National Institute of Psychiatry and winner of the 2018 National Psychiatry Award, who coordinated a qualitative study with users of primary care centers in Mexico City, low-income women from between 17 and 70 years old.

Shoshana Berenzon Gorn is director of the Epidemiological and Psychosocial Research Department of the Ramón de la Fuente Muñiz National Institute of Psychiatry. She has published scientific articles on the psychology of women with high-risk pregnancies and other topics related to mental health and addictions.

In the interviews, the patients reported feeling bad, restless, irritable or desperate and some presented complaints such as body aches, tiredness, headaches, hot flashes, memory failures, insomnia, hand tremors and high blood pressure. This was associated with having problems at home, lack of economic resources and living in an environment of violence, among other factors. But they also recognized that they do not talk about the above with the doctors: neither do they ask or give it importance, nor is there enough time for them to express their concerns in consultation. In her course, Moreno emphasizes that her students take into account gender conditions in patients: "What we see is that these women probably suffer violence and that makes them go to health services as a refuge ; Each case should be studied carefully before cataloging them in a derogatory manner”.

Medical androcentrism can be expressed as a bad joke, but in practice it can destroy lives. There is the case of obstetric violence, that suffered by women during pregnancy, childbirth or postpartum - violations of their human and reproductive rights by health personnel, disguised as ridicule, scolding, irony or humiliation, but which entail manipulation of information, invasive practices such as unjustified caesarean section, postponement of urgent care or forced sterilization—. Of 8.7 million Mexican women who had at least one birth between 2011 and 2016, a third of them (33%) reported having suffered some type of abuse (ENDIREH, 2016).

Shoshana Berenzon Gorn.

Mariana Campos made public on her social networks, last 8M, that she was a victim of obstetric violence. The coordinator of the Public Expenditure and Accountability Program of the organization México Evalúa decided to tell her story to make this type of aggression against women visible. She narrated that nine years ago she lost her newborn daughter due to the negligence of her doctors (a man and a woman), whom she denounced in a case that reached the Supreme Court of Justice of the Nation. (SCJN). The economist explains that her doctors prescribed a contraindicated medication in the 38th week of pregnancy, which damaged the circulation of the fetus. When Campos began to feel changes in her daughter's usual movement, she immediately called one of the doctors, who did not give importance to the fact and prescribed rest. She insisted on speaking to her doctor on the phone, but he "was at a New Year's celebration that I imagine he didn't want to interrupt" and given the lack of response, she went to the hospital. “Upon arrival, a nurse and a doctor on duty performed fetal monitoring on me; From the beginning, it showed that my daughter was seriously ill, that it was a life or death situation. But I didn't have an emergency C-section because the doctor on call wanted me to have it done by my attending physician. He said that he wanted to wait for him. They decide for us." The doctor arrived several hours later, indicated to administer dextrose serum and left again. “He left the hospital, he abandoned us while my daughter was so seriously ill, still in my womb. She continued to waste time, denying me the right to timely care for the emergency of pregnancy, which is considered in the standard of care for pregnancy. My daughter was dying little by little. The doctor reappeared when Campos demanded her presence in the operating room by phone, but it was too late. “My daughter was born very serious and she died an hour later. One of my biggest pains is that I never saw her open eyes. When I left the recovery room I received the news of her death and when I picked her up, she was already dead and with her little eyes closed”.

Mariana Campos is coordinator of the Public Expenditure and Accountability Program of México Evalúa. On March 8, she shared on her social media that she was a victim of obstetric violence and she lost her newborn daughter as a result of medical negligence. Her case reached the Supreme Court of Justice of the Nation (SCJN).

Her legal battle lasted nine years and ended with an injunction granted to the doctors by the SCJN. “The lack of professionalism and even the possible corruption that occurred in the attention of my matter by the First Chamber of the SCJN is a violation of my human rights and those of my daughter: her right to life, our right to health and my right to justice”, he wrote at the end of a testimony that received more than 3,800 reactions on Twitter. Some women shared their own stories in the comments. Campos responded to one of them: "All cases have a common denominator: they don't listen to the patient, they ignore how you feel, they minimize you."

Since Bernadine Healy wrote Yentl's Syndrome 30 years ago to appeal to the medical community, significant advances have been made that can give rise to optimism. Journals such as The Lancet demand research in which men and women are studied proportionally and articles that present their results disaggregated by sex. Some 20 US universities have adopted a multidisciplinary women's health program for resident interns, The Women's Health Track. As Carme Valls states, “medical science is androcentric but that has to change; We have to turn it around."