Abstract
Previous research indicates the presence of deeply ingrained gender biases within the health system, resulting in instances of mistreatment and violence against women and sexual dissidents. This study aimed to explore the stories of people assigned female at birth about their experiences of gynecological violence in Chile. Twenty-one women were recruited as participants, and semistructured interviews were conducted. Thematic analysis of the transcribed dialogs was performed, and four themes were developed: legitimization of violence, objectivation and loss of autonomy, transgression of intimacy and fear of abuse, and consequences of violence over time. This article sheds light on the impact and aftermath of gynecological violence among those seeking gynecological services, highlighting the convergence of cultural, institutional, and interpersonal factors that perpetuate this issue.
Keywords
The term “gynecological violence” (GV) has been introduced in the literature to encompass instances of violence rooted in gender biases that occur within the realm of gynecological healthcare (Cárdenas & Salinero, 2021, 2023). While the concept of obstetric violence is gaining acceptance and there is a growing body of research in this field (McGarry et al., 2017), GV encompasses, precedes, and even anticipates obstetric violence (Cárdenas & Salinero, 2022), with the latter being an expression of the former. It is part of the continuum of violence experienced by women and individuals assigned female at birth, where various categories of oppression intersect. GV is a form of interpersonal violence, institutionally sustained, and rooted in gender biases. It also has a historical dimension that is necessary to consider in order to understand practices sustained over time and their connections to discipline as a construction of knowledge-power (Kapsalis, 2022). This type of violence is perpetrated by healthcare professionals, including doctors, midwives, nurses, and others. It encompasses practices that perpetuate a subordinate relationship between medical personnel and patients, as well as any forms of psychological or physical violence directed towards the bodies of women and individuals assigned female at birth, along with instances of abuse and sexual violence. Gynecological violence can result in immediate suffering and have long-term psychological and physical consequences.
The subordination within the doctor–patient relationship manifests through various specific practices (Cárdenas & Salinero, 2023), including hiding or denying information, making ironic comments, scolding or infantilizing patients, disregarding their preferences and wishes regarding medical treatment, and invalidating their symptoms. Additionally, we have encountered instances of inappropriate comments or actions directed at patients’ bodies, such as body or genital critiques. Excessive medicalization, often contrary to patients’ preferences, and intentionally painful procedures have also been identified as forms of violence, particularly directed towards patients perceived as “problematic” for questioning healthcare providers’ decisions or asking more questions than usual. Furthermore, abuse and sexual violence can be present (Salinero et al., 2023), as seen in cases where patients are obliged to undress unnecessarily, experience inappropriate touching of their bodies or genitals, or even encounter incidents of rape.
Gynecological examinations pose a vulnerable situation for women and individuals assigned female at birth (Cárdenas & Salinero, 2023; O’Laughlin et al., 2021). This vulnerability arises not only from the power imbalance between doctors and patients but also from the nature of the procedures themselves. These examinations are conducted while patients are undressed, with their genitals exposed on a gynecological stretcher, and their legs positioned apart. There is no equivalent experience for men that accompanies them routinely throughout their entire lifespan, and it becomes a mechanism exclusively aimed at exerting control over the bodies of individuals assigned female at birth.
Furthermore, the doctor–patient dynamic is often framed within a context of assistance and care, leading many instances of violence to be reinterpreted as acts of help by healthcare professionals. The harm inflicted by such violence becomes even more significant when it originates from individuals who are trusted to provide care, potentially resulting in profound consequences for the victims. These consequences may include distortions in self-perception and body image, the emergence of both short- and long-term physical and psychological issues, as well as substantial challenges in interpersonal relationships with partners, family members, and friends. The severity of these repercussions is heavily influenced by the ability and opportunity of women and individuals assigned female at birth to process their experiences, as well as the availability of resources to navigate such situations.
Routine gynecological examinations have, in many respects, become a new gender role obligation, whereby women and individuals assigned female at birth are expected to undergo regular check-ups (typically on an annual basis if asymptomatic). Failing to comply with these expectations is often met with guilt, making them feel irresponsible for their health. Such deviations from societal norms are reproached and, in many instances, punished by healthcare professionals. As a result, those assigned female at birth strive to attend these examinations regularly, even though evidence suggests that annual pelvic exams are unnecessary for asymptomatic women (American College of Obstetricians and Gynecologists Committee on Gynecologic Practice [ACOG], 2018; Qin et al., 2020). Moreover, these exams are often highly uncomfortable and humiliating experiences (Ehrenreich, 2018), associated with anxiety and fear (O’Laughlin et al., 2021).
Gynecological violence is a complex issue involving the intersection of cultural, institutional, and interpersonal factors. However, it often goes unrecognized due to the normalization of improper practices in the field of gynecology and the challenges associated with reporting and verifying such violence. Cultural factors encompass deeply ingrained values, norms, beliefs, and practices that subordinate women and sexual dissidence in our society (Sanday, 1981). These cultural factors significantly influence institutional structures, including health system policies, norms, and regulations, affecting decision-making processes, resource allocation, and institutional responses to discrimination, gender violence, and inequality (García-Moreno, 2002). Moreover, interpersonal factors refer to the dynamics and relationships within the health system, encompassing attitudes, behaviors, and communication styles. These factors can impact interactions, potentially hindering empathy, trust, respect, effective communication, and the establishment of healthy boundaries. In the context of gynecological violence, interpersonal factors may involve patterns of abusive behavior, control, coercion, and manipulation, all occurring within a framework of unequal power relations.
The potential for GV to inflict harm is substantial. Therefore, it is crucial to delve into the significance of these experiences for individuals seeking gynecological services, with the intention to eliminate such instances and address their consequences.
Methodology
Design and data collection
We conducted an exploratory qualitative study using a conversational approach for data collection, specifically, semistructured interviews. The thematic script employed allowed us to gain insights into individuals’ experiences of gynecological violence, explore their beliefs regarding its occurrence, and analyze its impact on the participants. The interviewees were contacted by members of our research team, and each interview lasted approximately 90 minutes. We recorded and professionally transcribed the interviews verbatim. The study received ethical approval from the Institutional Scientific Ethics Committee at Universidad de Talca.
Participants
A total of 21 individuals participated in the study, ranging in age from 24 to 67 years old, with an average age of 34. All participants had resided in Chile for at least 1 year. The convenience sample was selected using purposive sampling, with the following inclusion criteria: (a) assigned female at birth, (b) utilization of gynecological services in Chile, (c) age over 18, (d) residency in the country for at least 1 year, and (e) experience of gynecological violence. Among the participants, 15 identified as cisgender women, three as transgender individuals (trans masculine), and three as gender-fluid or nonbinary individuals. Regarding sexual orientation, the sample consisted of six lesbians, two bisexuals, and 13 heterosexuals. Two participants were migrants who had been residing in the country for several years, and two identified themselves as belonging to native ethnic groups (Mapuche and Aymara). The sample was composed of individuals from all socioeconomic levels, with a predominance of those belonging to middle-income levels. Participants were recruited from among the personal contacts of the research team members. Similar to previous studies where surveys were used, we encouraged participants to leave their contact information if they so wished, enabling them to take part in a qualitative study where they could elaborate on their experiences and engage in more in-depth conversations about them.
Data analysis procedure
Thematic analysis, as outlined by Braun and Clarke (2006), was employed to analyze the transcribed data. This method proved particularly valuable in identifying and describing patterns within the interviews. The transcripts were meticulously examined to discern both surface-level and underlying meanings. Concerning these transcriptions, we followed the recommended steps for a proper analysis. The first step involved becoming familiar with the data by carefully reading the interview transcripts before initial coding. The second step was the generation of codes. In this process, we coded data that were considered meaningful in addressing our research questions. Codes were developed to represent meaningful units within the data, and themes and subthemes were derived by identifying recurring patterns of meaning across the transcripts. Both researchers conducted the initial coding independently, and subsequently discussed and reviewed it with the research team during regular meetings. Discrepancies were resolved through consensus. Inductive coding was carried out and meanings were labeled using participants’ own language. Third, we moved toward constructing themes. The themes were constructed by categorizing similar codes in a more deductive manner. The next step involved reviewing the potential themes to look for relationships among categories. Once we had a solid conceptual map of categories, the fifth step entailed defining and naming themes. The last step was the production of reports as we wrote the draft of this manuscript.
Results
Reported events of violence and main themes
A wide range of events of violence was reported, spanning a continuum of behaviors from scolding to verbal abuse, teasing, derogatory comments, refusal to answer patients’ questions or attending to them based on their sexual orientation or identity, criticism regarding their bodies or sexual practices, dismissal of their symptoms or questioning of their pain, performing intentionally painful procedures, various forms of violence during childbirth, unnecessary or public undressing unrelated to the purpose of the consultation, denial of procedures due to gender bias (e.g., tubal ligation or uterus removal based on age and potential for pregnancy), mistreatment during abortion procedures, and inappropriate touching with evident sexual undertones.
Through the analysis, four main categories emerged: objectification and loss of autonomy, legitimization of violence, violation of intimacy and fear of abuse, and consequences of violence (physical, psychological, and interpersonal). Each category encompasses various forms of psychological, physical, or sexual violence, collectively reinforcing the power imbalance between the medical team and patients, thus enabling the control over the bodies of individuals assigned female at birth. These issues reveal an organizational structure within the field of gynecology that undermines the agency and care-seeking of women and individuals assigned female at birth while exerting control over their bodies and perpetuating dependency on the medical model (creating a captive clientele). Additionally, these actions contribute to reasserting societal power dynamics by “putting patiens in their place.” All of this is camouflaged under a rhetoric of care, suggesting that these actions are carried out in the interest of patients’ well-being.
Objectification and loss of autonomy
This theme emerged from a series of codes that highlight situations in which patients are treated in a dehumanizing manner, their questions go unanswered, or their decision-making capacity is restricted. It encompasses instances where patients’ autonomy is denied, either through a lack of necessary information for making decisions, lack of consultation regarding treatment preferences, or failure to ask for patients’ consent when interventions are performed on their bodies. Consequently, individuals assigned female at birth feel that healthcare personnel do not engage in dialogue, fail to consider their perspectives, and objectify them, reducing them to mere body parts or organs. The primary consequence of this dehumanized treatment is that patients experience subordination, diminished worth, or feelings of being nullified, as they are not fully considered and have limited power to freely make decisions regarding their body, sexuality, reproduction, pleasure, or contraception. GV is a social relationship where the other is denied, where intersubjective recognition is absent and individuals are treated merely as objects, focusing on a specific organ, which makes it impossible for healthcare providers to see the person in front of them in a holistic manner and thus recognize them as a person. My first experience was bad. The doctor was a very cold old man. He didn’t explain anything. He was very detached in general … and he talked about me like I was a picture in an anatomy manual. They don’t talk to you about your body. I never thought that I could demand something, like to receive an answer, or to be looked in the face … but, of course, I am in a position, on the stretcher … at that moment you find yourself in the same position of an object … that the health provider is looking at, analyzing it, revising it, taking notes of it and touching it.
The initial narratives illustrate the overwhelming sense of being objectified and the accompanying dehumanization experienced by individuals. In these instances, healthcare providers cease to perceive the person before them and instead view them as a collection of organs and symptoms. Additionally, the established relationship becomes hierarchical, resulting in the dismissal of patients’ knowledge about their bodies. The relationship is very hierarchical. I was never looked in the eyes, I was never called by my name. I was never informed that the proceeding was going to be painful, I was never reassured during the proceeding, nor told: “Don’t worry, sometimes this can be painful, or it can feel uncomfortable.” They look down on you. You know nothing and they know it all. They disregard popular wisdom, feminine intuition, and what one feels, just because they know it all. This worsens with poor or less educated people like me.
As a result, only the healthcare provider's inquiries are deemed significant, and patients are expected to provide precise answers. Conversely, when patients pose questions, they often receive unsatisfactory responses that fail to address their needs. Patients are not regarded as the focal point of attention, and any attempts on their part to reclaim that focus are disregarded through infantilization or outright dismissal. They asked me a lot of questions: “When was your last period? Are you regular? How often do you have your period? How many days does it last?” The truth is, I wasn’t very good at answering, because these things make me uncomfortable. And they ended up scolding me. And there starts the process of feeling like a little girl. From the moment you enter the room, whatever age you are, they infantilize you … and I have always felt like they were giving me only the pieces of information they wanted, not all of it. I didn’t feel much comfortable asking questions because the answers were always given in a very specific medical language. There were things that I was in my right of being ignorant about, but he had this great ability to make me feel stupid.
Furthermore, feelings of sadness are frequently expressed as seeking medical consultations entails significant personal effort and costs, yet the care provided fails to meet the patients’ expectations. The consult lasted exactly 5 minutes and I was out of it. I was worried because I had some zits in my intimate area and because I felt a strong pain in the uterus. When I told the guy, he laughed and told me that it was normal; that it could be hair that wasn’t growing well. But he didn’t take the time to visit me, he didn’t explain anything and just gave me a prescription for some pills. That was all. I went home with some pills, his opinion, his mockery, and the shame of having asked. When the doctor arrived, he started looking at his cell phone, he didn’t pay attention to me. I was just another patient. When I talked about my symptoms, he said that they were normal, how could I not know that? But for me they weren’t normal, since I hadn’t felt them during my other pregnancies. You aren’t allowed to listen to your body. They own your body … you can’t even ask or decide anything. You need to keep silent and that's all. They define the proceedings with no explanations. The informed consent is impossible to understand.
The issue of consent deserves particular attention, as many participants report experiencing intrusive procedures for which they were not adequately informed or prepared. The power imbalance in the doctor–patient relationship is such that some healthcare providers feel entitled to disregard protocols and even become upset when individuals set boundaries on their actions. When I entered the consultation, the doctor was with five students. Nobody asked. He didn’t even ask if I was ok with them touching me … and he gave them instructions about how and where to touch me…. When I entered, they told me to get on the stretcher, get undressed. Nobody asked me if I was ok with it, and nobody asked for my permission. Then I fell apart when I saw how they were touching me one after another. I didn’t exist and they were talking among themselves like I wasn’t even there. I headed home all choked up and when I arrived, I started crying. The doctor did a vaginal swab test and I was expecting to be told to get up, but instead, I was subjected to another test … a rectal swab. “You need to relax, otherwise the swab can’t get in,” but I wasn’t even told that the test was going to be done. I felt very uncomfortable at that moment … then I got dressed, I didn’t sit. I asked what the test was about. “It's part of the tests that are done.” Nothing else, just that. I should have been told and asked for permission.
The duty to provide information about procedures and their associated risks, as well as the right to give consent or refuse, holds great importance as it safeguards against arbitrary practices within healthcare. Nevertheless, the findings of this study indicate that participants have felt violated, disregarded, and infantilized, all stemming from hierarchical and asymmetrical relationships that fail to prioritize the well-being of the patient. By treating individuals as objects, invalidating their experiences, and dismissing their knowledge of their bodies, the stage is set for violent interventions. These interventions are not mere individual excesses but rather reflect deep-rooted issues within the medical model itself.
Legitimization of violence
This theme encompasses the various forms of symbolic or tangible violence inflicted upon women and individuals assigned female at birth, which are unjustly legitimized as part of medical practice. These acts of humiliation and abuse serve as small rituals to assert power dynamics in a relationship that is inherently asymmetrical and unequal. They include hurtful comments, ridicule, and mistreatment aimed at discrediting patients and enforcing their subordinate position, blaming them for the violence they endure (whether for refusing to comply with requests, attempting to assert their rights, or questioning healthcare decisions). Furthermore, we identify comments or actions that undermine patients’ perspectives, casting doubt on their symptoms, pain, and experiences. These actions demonstrate that knowledge is confined solely to one side of the doctor–patient relationship. The theme of the legitimization of violence aims to highlight that some actors perceive it as just, or at least inevitable, almost as an obligation to obey the medical authority system. Legitimacy involves this request for obedience, where healthcare personnel (and even many patients) assume the norms that constitute a certain social order as obligatory, as something that “must be” that way, as something to which they have an inherent right. Only when a situation of social of injustice is defined as such can new meanings be generated to challenge a particular social order. The one described here is a form of institutional violence, socially legitimized and sanctioned, so much so that violence can be exercised by any person who is part of the healthcare system, feeling immune to consequences. I started seeing a gynecologist at the beginning of my pregnancy. And it all started on the wrong foot because he would always scold me a lot … I felt physically very bad, I had lost a lot of weight and I felt weak. Moreover, I was vomiting a lot, and when I would tell him, he would say: “Since it's your first baby, you’re exaggerating, vomiting is normal.” He would minimize it; he wouldn’t listen and he would never look me in the eye. He was very detached, and I felt anguish because he wouldn’t answer my questions, I felt alone. For him, everything was normal, and I was thinking, “how can it be normal if I feel so sick?”
A relevant example highlighting this issue is the case of a participant whose discomfort and symptoms were questioned. She lost her baby when she was 5 months pregnant, and she strongly believes that there might be a connection between the dismissal of her discomfort and the symptoms she experienced leading to the loss of her baby. She holds the belief that if her concerns had been listened to and timely action had been taken, the outcome could have been prevented. In the middle of my pregnancy, I suffered a placental abruption. When the doctor arrived, he didn’t say hello and I remember him saying that he was having the time of his life on the beach and that I had ruined his trip. I was induced into dry labor because my baby had died, and it lasted the whole day. I remember fainting because of the pain, I fainted all over again. After 10 hours, they decided to do a curettage. I went to see the doctor with my husband a week later. He didn’t look at me. He just asked: “How is your pregnancy going?” I felt wounded and upset. I told him that less than a week earlier he had done a scraping on me, that I had lost my baby. I remember I got up and left. Being in the hospital is very humiliating. Whoever wants to can shout at you or attend to you like garbage. If they want to, they treat you, if they don’t want to, they don’t. Nobody really cares about you, if you’re feeling alright or not.
Furthermore, participants frequently reported instances of jokes and comments aimed at downplaying the seriousness of their ailments. The absence of respect for patients and their discomfort shifts the focus away from their well-being, and such comments are experienced as a form of violence. Denying the validity of patients’ experiences and minimizing their pain, especially without having personally experienced a similar situation, is perceived as a particularly hurtful form of aggression. When I would go to my checkups, they would start making cheap jokes while I had to undress: “Well, now you’ll have to do a striptease.” I would just laugh uncomfortably since I had to undress to be checked by at least three doctors for ovary cancer. And he said: “But it doesn’t hurt that much.” And I found that quite violent. I said: “How can you say that if you have never experienced ovary pain?” The doctor answered: “But pain can be graphically represented, therefore I know what I’m talking about. I’m a man of science.” And I said: “Nobody ever represented my pain graphically; how do you know? Maybe my graphic is different from the other women that you’ve seen” … I found that pain thing quite violent. To be feeling something that society doesn’t recognize.
An issue that particularly affects individuals belonging to diverse sexual orientations is the assumption of heterosexuality within gynecological care. This gender bias manifests in the automatic assumption and treatment of patients as heterosexual, without even inquiring about their sexual identity or orientation. Individuals belonging to diverse sexual orientations perceive gynecology as a discipline exclusively for cisgender women, as they believe that their interests and needs are not recognized by it, or that they may face discrimination if they reveal their sexual orientation. This also happens when they are denied certain procedures due to their sexual practices (e.g., refusal to perform a Pap smear) or when they feel they lack information about specifics care methods for women who have sex with individuals of the same gender (e.g., barrier methods such as dental dam). This type of situations often force sexual minorities to disclose their sexual orientation or identity during consultations, which can be threatening due to the prevalent prejudice towards them in Chilean cultural context. These biases highlight another characteristic of gynecological care (and the medical model as a whole), which is its inclination to medicalize various aspects of life. Many participants expressed frustration that regardless of the reason for their consultation, they consistently received a prescription for contraceptive pills, irrespective of whether it was relevant or necessary considering their sexual orientation or practices. I went to see a gynecologist that someone had recommended to me. It was horrible. When I entered the room, she didn’t even say hello and just went: “Ok, get in and undress.” And I thought, “is she even going to ask my name?” She didn’t let my partner in. I didn’t tell her about my sexual orientation because I didn’t feel I could trust her, and she scolded me by telling me that I had to use a contraceptive method to avoid pregnancy and prescribed me pills. It was very violent. The first time I went to see a gynecologist was when I was 17 or 18 years old. The first thing he did was to scold me for not going earlier. Doctors just assume a position of moral superiority. I went back 2 years later, and it was very unpleasant because this time he scolded me for not taking contraceptive pills. I told him I didn’t need them, that I had a monogamous, stable relationship with a woman. So, to be scolded because you don’t take contraceptives without even asking first about your sexual orientation, I think it's ridiculous … I became defensive because he was questioning a personal decision. After that, I stopped going. I was discouraged by prejudice and the lack of information they have about women who like women.
Additionally, there are numerous accounts of mockery and mistreatment by healthcare providers. Inflicting pain as a form of punishment for individuals’ sexual choices is an ongoing occurrence within a medical model which is plagued with biases and prejudices. The experience of humiliation is recurring. I went to the emergency room at the hospital because I had candidiasis. They let me in, and three midwives examined me. They let in a lot of people while I was there with my legs spread. They were teasing: “Look at this girl,” they said, “Look at that,” and they didn’t tell me what I had. I asked them to tell me what was wrong, but they left. Then the doctor came in. I was 21 and I felt upset, very vulnerable. I felt judged, they made me feel dirty. They laughed at me while I was there in that position, I couldn’t move, with my legs spread open, tied. I arrived at the hospital unconscious due to a hemorrhage. I was assigned a bed, without bandages, so I stained everything with blood … After a while, a woman came, a midwife, she put me in a wheelchair and put on top of my legs the tools they were going to use during the operation. It was a wooden box, opened, with that spoon they use to perform curettages, scissors, and bandages. And they brought me from one wing of the hospital to another. Time perception is subjective, but I felt I was being brought here and there more than necessary just so I was exposed. Then I was put on a gynecologic stretcher, with my legs up. They direct the lamps at me, and I started crying and shivering. I was in panic. I said: “please, can you wait for a second for the anesthesia to start working?” I also said I needed to go to the bathroom, but nobody listened to me … the doctors were talking about a trip, a picnic, and boiled eggs, while I was asking them to wait for the anesthesia to kick in. I pooped and peed myself … then they brought me back to the same bed stained with my blood where I was before. All the blood I had lost was still there. During that pelvic examination, a woman introduced some sort of tube and scissors. It was very cold, and she who did it was angry and grumpy … I don’t practice penetration, and she had to introduce all those things. The examination was very painful. I told her that I was in pain, but she continued being abrupt. I ended up being in pain for a while after the examination. It all was very violent. I went for a Pap test for the first time, and it was a horrible, traumatic experience. The woman who did it was rude. I told her it was the first time and asked if it was going to hurt. She said: “Just sit down” and “Open your legs.” It hurt a lot, very much. She didn’t explain anything. She said: “You’re a woman and you’re going to have a lot of painful experiences. So you need to put up with it.” I came out crying.
Violence during childbirth is a significant aspect of gynecological violence that merits discussion. While it has received more attention in research, its importance has been underestimated. Childbirth is a context where violent interventions often find greater acceptance, and the lack of explicit consent is particularly prevalent. Many interviewees shared that they did not recall signing consent forms, and if they did, it was likely during labor, when the minimum conditions for informed authorization of interventions on their bodies were not met. I remember the nurse getting on top of me. My ribs hurt, and the veins under my eyes burst. She kept saying: “Push and stop shouting! Push and stop shouting!” … I was cut open, then they put some stitches in. They did it wrong and created an ulcer that lasted for a long time, they said it was normal, but it generated a lot of problems in my sexual life. For 2 years I avoided seeing another gynecologist. I was 20 and in labor, but with no dilation. I was given a lot of intravenous medication, but nothing changed. The midwife tore the membrane with scissors. Then, she got on top of me and pushed with all her strength, she broke everything there was to break down there … I had a terrible tear and violent hemorrhage. The pain of the stitches was unbearable like a throbbing pain … 3 days later they sent me home. I was still in pain, and I started noticing that the cut smelled bad despite having done everything I was told: clean it with a syringe and other things. I couldn’t even sit. And all that while taking care of my newborn baby. I felt so alone, and I had a feeling that something wasn’t right, I could smell something that wasn’t healthy. I was septic. I had to be operated on again because they had left the placenta inside me and that was why I wasn’t getting better. It was rotting inside my body and that was the smell I felt. I ended up very hurt, and I needed quite some time for all that to become… let's say, touchable, again.
Transgression of intimacy, fear of abuse, and sexual abuse
The violation of bodily boundaries and privacy was experienced as a significant threat and transgression by the majority of participants. The exposure of their bodies and genitals to unfamiliar individuals left them in a vulnerable position and evoked fear of potential abuse. It also reawakened traumas related to past experiences of sexual abuse, exacerbating their feelings of vulnerability. This issue is of the utmost importance because sexual abuse within the medical consultation setting appears to be more prevalent than commonly acknowledged. Inappropriate touching, unnecessary undressing, and nonconsensual pelvic examinations are reported as forms of sexual abuse. Such acts are either carried out to punish perceived differences or to sexually exploit individuals, particularly minors. These acts represent severe forms of violence due to their explicit sexual nature, and are inflicted upon women who are exposed and often experience shame and fear. The trust of patients is violated, and the abuse is perpetuated through the exertion of power based on the perceived prestige of medical professionals, their social authority, and the lack of clear guidelines regarding appropriate conduct during consultations. Furthermore, reporting such events to authorities and providing evidence pose significant challenges for the victims. The transgression of boundaries has a dual meaning: on the one hand, it involves fear of physical boundaries being crossed and, on the other hand, concerns about privacy being violated or social boundaries being overstepped. The latter is illustrated by instances where questions or opinions are expressed about sexual practices, intruding into matters of intimate nature, or when an overly familiar tone is assumed, especially when the person is, as most of the times is the case, a stranger to the patient. Male gynecologists made comments about my body, and that was scary. This one had a lecherous look … he was looking all over me, and his eyes didn’t stop at my eyes, he was looking at my breasts. It's a vertical kind of look … I have always attended gynecological examinations with fear; to be told to spread open your legs, to relax knowing that they’re going to put something in, the exploration, the speculum. It's the worst.
Reports of inappropriate touching during gynecological consultations are distressingly common. The first time I went to the gynecologist alone I was 17 years old. I went to seek contraceptive pills because I wanted to start having a sexual life. The doctor didn’t let my boyfriend in. He asked me questions like it was an investigation. I was wearing my school uniform … The questions were about whom I was living with and if my family knew that I was there. He told me that was I was doing was bad and I shouldn’t be doing it. Then he made me remove my top and started touching my breasts. He described them with technical language. Later, I understood that there was no need for him to touch me. I only went for contraceptives pills. He wasn’t doing the examination well. He didn’t have to do a pelvic. I had never had penetration before, and he knew. He didn’t have to touch me. He didn’t perform a routine examination; he went directly to my vagina. I’m angry. Why didn’t I just get off and run? How could I be so stupid, how could I let him treat me like that? The thing is, I get off the stretcher wearing a gown and head to the room divider to get dressed, and suddenly he grabs my butt. He just grabs it, and I freeze, and start cold sweating. I look at the closed door and expect the worst. He kept grabbing me for a few seconds. It felt like an eternity. I told him that I wanted medicine stop breastfeeding. He told me to undress to examine me, and I said that I didn’t need that because I was asking for something very specific. He insisted that he had to check if there was a problem because I had told him that I had had mastitis. Yes, I had had it. A very long treatment that had already finished. I felt forced. Precisely because I had had mastitis, I knew what the breast examination was like, how they touch you, the kind of touch, and the kind of questions they ask you. He didn’t wear gloves and grabbed my nipple. He did it two times and said “Ok, you’ve got nothing.” I felt horrible, he just wanted to touch my breasts. I felt abused. The guy made me undress entirely. He touched me all over, more than once. First, he checked down there, and then he started touching both my vulva and my breasts. It was so uncomfortable, and I just wanted him to stop. When I got out, I was feeling horrible. I went out of there crying and called a friend. I said to her: “I feel I was abused.”
Consequences of gynecological violence
The stories shared by the participants shed light on the profound emotional and physical impact of gynecological violence. These experiences can leave deep psychological wounds and lasting physical permanent scars that may never fully heal. The consequences of the loss of autonomy, violence, and sexual abuse within the gynecological consultation space are far-reaching. They affect individuals’ self-image, self-esteem, and social relationships. Additionally, they can result in long-lasting bodily injuries such as fistulas, tears, and wounds. The psychological effects include persistent sadness, fear, guilt, and self-reproach, as well as feelings of insecurity and shame. In this fourth topic, we have grouped the references to this important and insufficiently studied aspect of gynecological violence. It is important to recognize that these consequences are not isolated or individual instances but are often interconnected with other experiences of vulnerability and humiliation faced by individuals assigned female at birth in patriarchal societies. I think that day really changed me because I thought I was a strong and capable woman, but that day affected my self-esteem … I tried not to let this sad feeling crush me, but every time I remembered it, I couldn’t avoid it. I was upset for months, and it also affected my relationship with my daughter because I didn’t feel capable of anything … For a long time I felt that what had happened that day was my fault, that I wasn’t capable, that my body was faulty. I blamed myself, my self-esteem went down and down.
The reports refer to bodily pain, physical injuries, scars, and tears that not only have altered the participants’ self-image and the relationship with their bodies but have also led to a deep sense of privatizing their pain. This privatization has caused a disconnection between them and their bodies. At that moment, I started disconnecting from my body, and I got sick. Many things happened; I lost a lot of weight … I experienced a strong disconnection from myself. What I did was to block the situation … I locked the pain in a box and put it away. And that's why I say that I didn’t deal with it, because I didn’t want more of it. One learns to chew anger, chew pain, and put it away.
The impact of the most severe physical violence can be detected in the context of relationships. Problems arise between partners due to the physical and psychological consequences suffered by the victim. Partners cannot understand why they are unable to have the same sexual experiences in terms of frequency and pleasure as they did before the traumatic event. Their parners often interprets this difficulties as a lack of affection. Similarly, the inability of partners, especially men, to provide emotional support is experienced as anger and pain. When sexual activity is resumed, it is often described as painful, worrisome, and accompanied by vigilance, as individuals anticipate the potential effects of the violence suffered in the past. My sexuality was affected because I was scared. I was scared despite wanting to be with my partner … many months passed, 6 or 7 before I could start feeling more comfortable. It brought problems with my husband because he thought that I didn’t … that I didn’t want to be with him. But it wasn’t that; the problem was that it wasn’t pleasurable. It really hurt. Imagine, you’ve got a wound, touching it is very painful. In the end, I just did it to fulfill my duty as a wife, so he could be satisfied, and that's it … He would humiliate me because he thought that I didn’t want to be with him, and I felt like I was a useless woman because I didn’t want to do it and I was young. I was 20. That wound brought so many problems. After the gynecological examination, I couldn’t have sexual intercourse for 3 months. There were many times when I was pressured [by her partner] and that was one situation of abuse and rape within the couple. My sexual life was terrible … I didn’t want to do it, and he was zero understanding. He didn’t force me, but he didn’t have much empathy about it. I lived with that fistula until I was 45 … I was always thinking about it. It was a problem for me, to wash, wash, wash myself all the time. It was an obsession. Check my underwear, check myself, the smell, the control. I was always thinking about it. It haunted me during my sexual life after the break of my marriage.
The impact of violence extends to relationships with family and friends, as it undermines the individual's ability to actively listen. The experience of violence diminishes the capacity to empathize with others and often leads to dismissive remarks that invalidate their pain. Moreover, gender differences become apparent in terms of the ability to listen and comprehend the gravity of the situation. I would talk about it a lot with my husband and with … yeah, also with my mum and my girlfriends, but I would always receive comments like “At least everything went well with your daughter” or “Maybe that's what had to happen.” After a while, I realized that it wasn’t something that had to happen at all. Gender difference leads to very different reactions. For example, when I tell my girlfriends, they generally understand. But when you tell men, at least that's what's happened with my dad and brothers, they don’t get it.
As a consequence of the violence suffered, a significant number of the individuals who shared their stories here have actively sought gynecological care from female healthcare providers or have refrained from seeking medical attention altogether, either temporarily or permanently. One fears the way they may treat you. In my case, I don’t get Pap tests regularly because of it, it was traumatic for me … but to decide not to go to a place because of fear, and feeling that you could be mistreated, that shouldn’t happen. You go to a place where they should take care of you, and instead, these things happen. Maybe the solution is to stop going consultation, but women want to take care of ourselves … Instead of scolding us because we don’t go to consultations, they should ask themselves why.
Discussion
We have delved into the experiences of gynecological violence of individuals assigned female at birth in Chile. Participants in our study shared a diverse array of experiences that shed light on the varying degrees of legitimacy associated with these violent practices. They highlighted the loss of autonomy resulting from such experiences, as well as the fear stemming from violations of privacy and the potential for sexual abuse. These themes are deeply interconnected and often coexist within the narratives we have collected. Furthermore, we have gained insight into the significant physical and emotional consequences endured by those affected.
Gynecological consultation has historically played a significant role in exerting control over the sexuality of individuals assigned female at birth (Shai et al., 2021). This control manifests symptomatically through the denial of decision-making power to patients in relation to various aspects of their sexual lives, ultimately impacting their ability to fully enjoy their sexual and reproductive rights. The imposition of decisions upon individuals assigned female at birth, regardless of their preferences and desires, exemplifies an unacceptable form of paternalism that assumes patients are incapable of making autonomous choices. This process of infantilization undermines women's autonomy over their bodies.
Currently, we have abundant empirical and theoretical evidence regarding experiences of obstetric violence (Tobasía-Hege et al., 2019). The concept we propose (gynecological violence) expands on the concept of obstetric violence. In this sense, it points to a form of violence, based on gender biases, that accompanies women and individuals attending gynecological services throughout their lives. It aims to include all those who are not in the reproductive stage or do not wish or cannot conceive. Hence, we consider the concept of obstetric violence as limited and incorporate it into the more general notion of gynecological violence. This broader concept encompasses situations where women may be exposed to violence that is not linked to reproduction (such as consultations for dysmenorrhea, dyspareunia, urinary infections, the presence of fibroids or cysts, etc.). As an illustrative example, consider that the second most prevalent surgical intervention in women after C-section is hysterectomy, affecting over 20% of women in Chile (González et al., 2021), and more than 600,000 each year in the United States (Vargas-Lejarza & Villagra-Blanco, 2016).
We propose that the doctor–patient relationship in the field of gynecology often perpetuates the legitimization of violence. This violence finds institutional support through various invasive practices that are, in some cases, unnecessary or ill-advised within gynecological and obstetric treatments. Consequently, several commonly performed procedures have come under scrutiny. Examples include pelvic examinations conducted without consent or under anesthesia as part of student training (Barnes, 2012; Coldicott et al., 2003; York-Best & Ecker, 2012), routine pelvic exams for asymptomatic women (ACOG, 2018), or the use of bimanual exams for ovarian cancer detection (Ebell et al., 2015). Such practices violate the autonomy of individuals assigned female at birth and objectify them, disregarding their wishes and failing to consider their concerns. In the realm of gynecological consultations, it is the patients who are absent.
Across our interviews, we found that the violation of privacy and the fear of abuse are particularly pronounced among young individuals, lesbians, and those with diverse sexual orientations. These experiences represent an extension of the threat of sexual violence faced by these individuals due to their deviation from societal norms of heterosexuality. Within the context of gynecological consultations, this threat is transferred, and individuals may feel pressured to disclose their sexual orientation, knowing that it may be met with societal sanctions. In previous studies, we have demonstrated how inappropriate touching can be an attempt to “correct” what is perceived as a deviation from normative sexuality (Cárdenas & Salinero, 2023).
Gynecological care is associated with self-care by women. Despite the often precarious conditions of care and the presence of violence, many women still seek gynecological care as a means to take responsibility for their health. However, violence is driving many women away from the healthcare they require and is undermining their trust in healthcare providers, which is essential for the healthcare experience to be emotionally satisfying.
In the same way, and despite gynecological violence being a common experience shared by women, it is evident that ascription to certain categories (belonging to a native ethnic group, identification as Afro-descendant, having a nonheterosexual sexual orientation, among others) significantly increases the probability of experiencing violence in the gynecological field. In our interviews, intersectionality is particularly evident in the case of immigrants or individuals of sexual dissidence. In other studies, in line with research on obstetric racism (Campbell, 2021; Davis, 2018), we have shown that Afro-descendant women are 3 times more likely to experience gynecological violence. Similarly, individuals from sexual dissident communities have twice the likelihood of experiencing gynecological violence compared to heterosexual women in Chile (Cárdenas & Salinero, 2023). These intersecting categories overlap and are socially relevant for organizing differences, contributing to maintaining and reinforcing power imbalances between social groups. Therefore, gynecological violence operates intersectionally (Crenshaw, 1991; Hill-Collins & Bilge, 2019). Evidence indicates that individuals from various disadvantaged groups experience worse health outcomes (Calabrese et al., 2015; Harnois, 2014; Szymanski & Owens, 2009).
Furthermore, our sample included individuals from various socioeconomic levels, indicating that gynecological violence is a common experience for individuals assigned female at birth, regardless of social position. However, it is undeniable that individuals with lower socioeconomic status may be more vulnerable, as they may not have the option to choose the services they attend due to the significant segmentation and hierarchization of the healthcare system in Chile. We believe that all individuals assigned female at birth are always exposed to this form of violence, but the expression of violence may vary depending on the type of service they seek for gynecological health (Cárdenas & Salinero, 2022) and the patients’ characteristics in terms of race/ethnicity, social class, or gender identity. As an example, private hospitals in Chile have a much higher C-section rate compared to public ones, reaching around 76%, and exceeding 90% in some clinics. We know that this procedure is often accompanied by unnecessary interventions. Therefore, the likelihood of a woman with high economic status undergoing unnecessary cesarean section is higher than that of a woman with low economic status.
The concept of gynecological violence includes significant aspects of the life cycle and medicalized physiological processes that are not visible in the concept of obstetric violence. We emphasize how the gynecological discipline, from its origins, introduces significant gender and race biases, having ingrained within it a foundational violence (Oakley, 1984). Each visit to the gynecologist would prepare, transmit, and reinforce an unequal form of relationship that subordinates those who use such services. We believe that the conditions for obstetric violence to occur could be set long before, when we consent to surrender power to doctors to decide on nonreproductive issues, when we consent to the medicalization of our lives and the disqualification of our knowledge over our own bodies and care. It is an epistemic rupture of enormous magnitude (Chadwick, 2021; Sesia, 2020), naming a long-standing, systemic, and structural problem that results in the expropriation of decision-making capacity and autonomy. This concept seeks to broaden the focus, starting from the reproductive aspect but including all gynecological care of individuals assigned female at birth, recognizing that focusing solely on obstetrics relegates many service users, who do not wish or cannot reproduce but still desire appropriate care, to the background.
The present results provide a compelling basis for evaluating the types of relationships and communications established between medical teams and patients. Recognizing the importance of patients’ knowledge, experiences, desires, and self-awareness as significant elements in decision-making and procedure management is essential. Such environments would help patients feel less exposed and vulnerable, ensure privacy, and foster interpersonal connection. This would include the opportunity to discuss expectations regarding the consultation, talk about relevant events in patients’ personal history that should be taken into consideration, and receive care that is not excessively rushed, as is often the case today. Emotional connection, a caring environment, and the reassurance that the medical team genuinely aims to provide assistance are fundamental aspects that can encourage many women and individuals assigned female at birth to seek gynecological healthcare. This includes those who have ceased attending or irregularly attend these services due to the fear of reliving experiences of violence they have previously endured. Treating patients as individuals with initiative, agency, their own knowledge, and the ability to make decisions guided by a medical team dedicated to their well-being can make the difference between receiving appropriate care, a right that all individuals deserve, and abandonment of healthcare by patients.
Furthermore, it is crucial to recognize that informed consent is not merely a formal document but an ongoing aspect of the doctor–patient relationship. Nothing should occur during a consultation without the explicit consent of patients. Every procedure and treatment should be explained in advance, providing different alternatives so that the decision-making power lie with the patients themselves. Failing to prioritize informed consent inevitably leads to arbitrariness and perpetuates violence. This aspect should be emphasized in the training of healthcare professionals and among those already involved in medical practice.
It is important to acknowledge the limitations of our study when interpreting the results. Firstly, our sample consisted of a relatively heterogeneous but small group of individuals assigned female at birth, primarily residing in urban areas of Chile, with only a few cases representing nonheterosexual, immigrant, Afro-descendant, or indigenous women. As we specifically recruited participants who had experienced gynecological violence, we cannot say from these data how prevalent GV is among people seeking gynecological care. Additionally, it is worth noting that many participants recounted their experiences years after the events took place, which could interfere with how the events were remembered. Nonetheless, this study does not pass judgment on what constitutes violence but rather focuses on its consequences, serving as a potential guide for future research on the subject. Therefore, future studies should include testimonies from a larger number of gynecological services users (particularly those who belong to more disadvantaged groups or who belong to various social categories marked by inequality). This would allow us to better understand the magnitude of the phenomenon and include a wider range of experiences. Similarly, we consider it important to study the relationship between the medical habitus and the violent practices exercised by many professionals working in gynecological services.
Footnotes
Acknowledgements
We thank those who participated in the larger study on which this paper is based for sharing their lived experiences. We are also grateful to the reviewers for their constructive feedback which informed the drafting of this paper. Special thanks to Silvia Falorni for her invaluable help with the translation of the text and its final revision.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received funding from the National Research and Development Agency of Chile (ANID) through the FONDECYT Project 1210102.
