Suicide missions, abuse, physical threats: International Legion fighters speak out against leadership’s misconduct

Added on Dec. 1, 2022: In November, the Kyiv Independent ran a follow-up to this investigation. This second story looks into other alleged misconduct of the leadership of the International Legion, including light weapons misappropriation and physical threats toward soldiers. Read it here.

Disclaimer: The Kyiv Independent is publishing this investigation to shed light on the alleged abuse of power in the leadership of one wing of the International Legion – a legion created for foreign fighters dedicated to defending Ukraine. The members of the Legion’s unit say that they reported their commanders’ misconduct to Ukrainian law enforcement, the parliament, and President Volodymyr Zelensky’s Office, but saw no proper reaction and thus turned to journalists as a last resort. Soldiers who pointed at the problems within this unit of the Legion claim they received threats for speaking up. For their safety, we do not disclose their identities.

Top findings:

In early May, a fighter from Brazil arrived in Ukraine to join the International Legion following President Volodymyr Zelensky’s call to “citizens of the world” to come and help defend Ukraine.

He thought his vast experience in the Brazilian army had prepared him for pretty much any task.

Yet he was neither ready to carry out suicide missions by order of his command, nor to tolerate orders to loot and steal.

As a platoon commander of the International Legion, he was ordered to do just that.

The Brazilian officer recalls his subordinates saying, before resigning from the legion: “We came here to help these people to fight for this country, against this invasion. We didn’t come here to do exactly what f*cking Russian people do when they’re on Ukrainian soil.”

The Kyiv Independent’s investigation reveals endemic problems in one of the International Legion’s wings that is overseen by Ukraine’s intelligence.

Some of the unit’s commanders are implicated in arms and goods theft, sexual harassment, assault, and sending unprepared soldiers on reckless missions, according to multiple sources.

The allegations in this story are based on interviews with legionnaires, written testimonies of over a dozen former and current members of the legion, and a 78-page report they’ve put together about problems within this particular unit of the International Legion.

For about four months, foreign fighters have been knocking on the doors of high offices asking for help. The report was filed to the parliament, and written testimonies were sent to Zelensky’s office. Alyona Verbytska, the president’s commissioner for soldiers’ rights, confirmed she had received legionnaires’ complaints and passed them on to law enforcement.

But authorities, soldiers say, are reluctant to solve the issue.

Failed leadership?

 The International Legion, soldiers say, consists of two wings. Ukraine’s Ground Forces oversee one. The Defense Ministry’s Directorate for Intelligence, known under its Ukrainian acronym GUR, coordinates the other.

The allegations in this report concern the GUR-run wing of the Legion. At its strongest, this unit had up to 500 people, and comprised about one-third of the International Legion, according to the Kyiv Independent’s sources among the soldiers.

GUR did not respond to the Kyiv Independent’s request for comment by publication time.

According to members of the intelligence-run wing of the Legion, their commanders report directly to the head of GUR, Kyrylo Budanov, who Zelensky also appointed to head the intelligence committee in the president’s office in late July.

Officially, the GUR wing of the Legion is run by major Vadym Popyk. However, he is not running the unit on his own.

The power is in the hands of a few people: Popyk’s right hand, major Taras Vashuk (referred to by soldiers as “young Taras”), an intelligence officer in his late 20s or early 30s, according to the foreign fighters; Vashuk’s uncle, also Taras (referred to as “old” Taras) and also an intelligence officer; and 60-year old Sasha Kuchynsky.

“They are like best buds,” an American legionnaire told the Kyiv Independent of the three men.

Young Taras, old Taras, and Sasha run the operations of the unit. They send soldiers on missions and coordinate the intelligence wing of the Legion’s work. Sasha is also in charge of logistics and supplies.

The legionnaires accuse the trio of various wrongdoings. For the two Tarases, the major complaints concern them sending soldiers on suicide missions.

An American soldier interviewed by the Kyiv Independent described a couple of missions that took place near the southern city of Mykolaiv, one of the war’s hot spots.

Russian troops discovered their squad’s position and started to shell it heavily. The rest of the troops retreated from the secondary position behind them, leaving the squad to hold the front line alone, with no backup.

“We were literally left (behind) and they didn’t want to evacuate us,” the soldier said. His fellow soldier, Scott Sibley, was killed, while three others were severely injured on that mission.

Shortly after the squad escaped the shelling, another group from the same unit was ordered to take the same position.

“We told the commander those positions were discovered by Russians… If we go back there, we are all dead,” the American soldier told the Kyiv Independent.

The older Taras did not listen and sent another group to the very same place, the soldier said. The story repeated itself, but this time with four killed, multiple injured, and one taken captive. The captive soldier, Andrew Hill, now faces a fake “trial” and possible execution in Russian-occupied Donetsk on accusations of being a mercenary.

Sasha Kuchynsky’s actions, however, stand out in their breadth of alleged wrongdoing.

Apart from sending fighters to die, legionnaires said, Kuchynsky forced them to help him loot stores. Fighters told the Kyiv Independent that he is also a heavy drinker who abuses his subordinates.

Another soldier, an American Jew, told the Kyiv Independent that Jewish soldiers experienced antisemitism from Kuchynsky.  He emphasized that he did not encounter it from anyone else in the Ukrainian military.

The soldier also says Kuchynsky demanded to have a share of the gear and equipment that the soldier bought for his close peers from the legion. When the soldier refused to give it away, Kuchynsky pointed a gun at him.

“And then Sasha (Kuchynsky) just started yelling, screaming,” the soldier recalled. “He said, ‘I know there’s stuff here. Give me your stuff’.”

“And in front of the translator, he raises his weapon at me. And I was like: ‘You’re gonna shoot me? You’re gonna shoot me.’ And then there’s like this kind of look of, honestly, remorse, but like ‘Oh, f*ck’ and he put down his gun,” the soldier went on.

He said that he once met a legionnaire at whom Kuchynsky had also raised a gun.

According to another American legionnaire, Kuchynsky also harassed female medics in their unit, using sexually suggestive language with them. According to the American soldier, the legion’s medics complained, but nobody did anything about it. The foreign medic he knew that was harassed by Kuchynsky is no longer with the Legion and has since left Ukraine, he said.

When in trouble, legionnaires say, Kuchynsky would turn to Taras Vashuk for a cover-up.

“Sasha would call Taras and get confirmation that he can do whatever he wants to do. And Taras would constantly back him up,” a Scandinavian soldier told the Kyiv Independent.

However, to date, Kuchynsky remains in his de-facto commanding position in the Legion despite his subordinates’ complaints and despite the fact that, according to Ukrainian law, he can’t as a foreigner hold executive roles in the army.

When confronted with legionnaires’ accusations, Kuchynsky refused to address them.

“It’s up to the Military Prosecutor’s Office to address these questions,” he told the Kyiv Independent over the phone. “No comments. I’m busy.”

He then hung up.

An investigation by the Military Prosecutor’s Office wouldn’t be the first time Kuchynsky has had trouble with the law.

‘Sasha Kuchynsky’

 According to the Kyiv Independent’s sources inside the legion, Sasha Kuchynsky is not the man’s real name. He is allegedly Piotr Kapuscinski, a former member of a criminal organization from Poland, who fled to Ukraine after several run-ins with the law.

Upon request from the Kyiv Independent, our colleagues from the Bellingcat investigative journalism group ran an image comparison of the photos of Sasha Kuchynsky, provided by the legionnaires, and photos of Piotr Kapuściński from Polish media. The results support the conclusion that the photos are of the same person.

An image comparison of the photos of Sasha Kuchynsky, provided by the legionnaires, and photos of Piotr Kapuściński from Polish media, support the conclusion that the photos are of the same person. (Courtesy of The Bellingcat)

An image comparison of the photos of Sasha Kuchynsky, provided by the legionnaires, and photos of Piotr Kapuściński from Polish media, support the conclusion that the photos are of the same person. (Courtesy of The Bellingcat)

In Poland, Kapuscinski is wanted for fraud and faces up to eight years in prison. According to Polish Gazeta Wyborcza, he has previously served time.

He fled Poland in 2014, and resurfaced in Ukraine two years later. He was investigated in Ukraine for aggravated robbery and sexual assault in October 2016 but was only charged with robbery. In November 2016, he was detained and spent over a year behind bars.

Warsaw asked Kyiv to extradite Kapuscinski in 2017, but Ukrainian authorities said they would first try him themselves.

He resurfaced again in May 2021, when law enforcement searched his vehicle where they found a semi-automatic pistol and bullets and proceeded to search a building that he used, finding explosives. He faced up to seven years in prison for possession of illegal weapons but was almost immediately released on bail of nearly $2,500.

After the all-out Russian war broke out in February, Kapuscinski joined the military, at which point the courts suspended his case and then paid back his bail in May 2022.

His criminal past did not prevent Kapuscinski from getting into the Legion and obtaining an executive role there. The legislation says all foreign recruits must go through background checks before joining the Ukrainian army. It’s not clear whether a criminal record counts as a deal breaker.

In Ukraine, citizens can serve in the military if they have ongoing criminal proceedings or a spent conviction. The law, however, doesn’t refer to foreigners. So when a Ukrainian court suspended Kapuscinski’s case and paid back his bail, it was applying the same norm that applies to Ukrainians.

Piotr Kapuscinski, known in the International Legion as Sasha Kuchynsky, is seen standing at the railway station wearing a Ukrainian military uniform and a colonel’s epaulet. (Courtesy of the Legion’s fighters)

In the Legion, Kuchynsky (Kapuscinski) calls himself a colonel and wears a colonel’s epaulet, according to the soldiers’ testimonies and the photographs of Kuchynsky the legionnaires provided to the Kyiv Independent. In fact, foreigners are only allowed to serve in Ukraine’s Armed Forces in the lower ranks, as privates, sergeants, and petty officers.

Since the start of the year, the man who calls himself Sasha Kuchynsky has allegedly gone from a criminal suspect on bail to a free man and de-facto commander in a high-profile Ukrainian military unit.

Polish past: Broda, the gangster 

According to reports in Polish media, in Poland, Piotr Kapuscinski is known as “Broda” (Beard), an influential former member of the Pruszków gang, once the largest mafia in the country.

He was the right-hand man of the group’s inner leadership, “Wanka” and “Malizna,” and laundered money for them, according to Mariusz Kaminski, a vice president of the Law and Justice party and currently Interior Minister of Poland and a coordinator of Poland’s secret services.

Polish media reported that he allegedly avoided at least 71 charges, including kidnapping for ransom, by cooperating with law enforcement as a “crown witness” in 2009 in the case focusing on the Pruszkow gang.

Piotr Kapuscinski, part of the criminal gang in Poland, poses for a photograph holding a rifle. (crime.com.pl)

Some time around 2010-2011, Kapuscinski testified against the murderers of Marek Papala, the Polish police chief, assassinated in 1998. Kapuscinski reportedly confessed that he had assisted the two killers, a Russian and a Belarusian, by helping them to rent an apartment in Poland.

Following his testimonies in “various cases against organized crime,” at least 20 people, including the bosses and other members of the Pruszkow gang, were charged with participation in organized crime. Nine were sentenced while the cases against Kapuscinski were suspended, according to Polish media reviewed by the Kyiv Independent.

In February 2020, he was stripped of the “crown witness” status, in part, for failing to appear in court and when called upon to appear at the prosecutor’s office.

For his alleged wrongdoings in the International Legion, Kuchynsky has already been questioned multiple times.

First, by the Security Service of Ukraine (SBU) after threatening one of the American soldiers with a gun. According to the soldier, Kuchynsky didn’t face any consequences.

Then, by the Military Prosecution Office following other legionnaires’ complaints against him, according to the Kyiv Independent’s law enforcement sources. The complaints alleged abuse of power, fraud, and assault. Kuchynsky denied the accusations and kept his job. The investigation, however, is ongoing.

Sent to die

The probe into Sasha Kuchynsky, among other episodes, concerns him sending soldiers on what they call a suicide mission in Sievierodonetsk, a key city in Luhansk Oblast that Russian troops seized in late June.

According to the Brazilian fighter who spoke to the Kyiv Independent, Kuchynsky’s orders were inconsistent.

At first, the Brazilian’s unit spent two weeks preparing for a demining mission in Zaporizhzhia Oblast, a southern region.

In early June, a few days into the mission, they were suddenly moved to another location. Kuchynsky ordered them to go to Sievierodonetsk in the eastern Luhansk Oblast and hold a position close to enemy lines.

Going into one of the war’s main hotspots was very different from a demining mission. That wouldn’t have been a problem if they were prepared for it, the Brazilian officer said, but they weren’t.

“We’ve been two weeks preparing these guys with all the type of training and metal detectors and anti mines…and now you’re going to send us to the industrial zone to the urban type of combat. Sasha, this is crazy,” the legionnaire recalls telling his commander.

“I understand. I am with you there, but that’s the order,” Kuchynsky reportedly replied.

Fighters of the International Legion accuse some of their commanders of sending them on so-called suicide missions unprepared and with no information about the location of the friendly and enemy troops. (Illustration: Karolina Gulshani)

The Brazilian fighter started planning the operation in Sievierodonetsk, but neither Kuchynsky nor Taras Vashuk, the other commander, gave him any information – which he said they were supposed to – about the situation on the ground. By then, Sievierodonetsk was a center of heavy fighting. Ukrainian troops would retreat from the city a couple of weeks later.

“A lot of questions asked were not answered, like where friendly troops were,” the Brazilian officer said.

Only later did he learn that the previous group sent on this very mission came under friendly fire by Ukrainian soldiers. Another Brazilian legionnaire was killed and they had to retreat.

“We got into the field without knowing what was going on,” the officer said.

“I realized those motherf*ckers won’t let us plan,” he said of Sasha and Taras. “They would just bring us into the middle of the place, dump us there to fight, dump us there to die.”

Upon arrival, a Ukrainian special forces serviceman filled them in. He told the Brazilian that Ukrainian troops are inside the buildings along their way, but they have no established communication with them so they shoot at everyone who breaks through.

“What the f*ck? How are we gonna pass? These (Ukrainian) guys are gonna shoot at us?” the Brazilian said he asked.

“Yeah, that’s right. We need to hide,” the Ukrainian soldier reportedly told him.

They spent four days there instead of the planned two. They ran out of food and water and asked for rotation, but Kuchynsky, who sent them there, wouldn’t reply.

“Nobody slept, everybody’s super tired. Some of my guys are dehydrated, and one injured guy. And we stood there. That’s when Sasha (Kuchynsky) went off the radar,” he said.

Soon someone they didn’t know got in touch via radio saying a new group was on their way. The soldiers arrived but then left in the middle of the night without saying anything. The next day, another squad came in to replace them.

The Brazilian believes that Kuchynsky had no plan for their extraction.

“A bunch of wannabes, playing with people’s lives,” he said of the unit’s leadership. His account of suicide missions is confirmed by other soldiers – both in their conversations with the Kyiv Independent and in their official testimonies they filed to the President’s Office.

The Brazilian platoon leader and a couple of his soldiers got injured but survived. After finally getting evacuated from Sievierodonetsk, most of the squad fighters decided to quit the Legion.

“We’re not f*cking staying. We’re leaving,” the fighter recalled them saying.

The team of the Brazilian fighter is not the only one that left the Legion, disappointed.

Foreigners quitting the International Legion due to poor organization, lack of equipment, and indefinite contracts have already made headlines across international media.

Shopping mall plunder

Around the time of the Battle of Sievierodonetsk in early June, the legionnaires received a controversial task from Kuchynsky: to drive from their base to a local shopping mall in the front-line city of Lysychansk in Luhansk Oblast and take merchandise from the shops.

“I directly heard Sasha Kuchynsky’s order to the soldiers of my unit to break into the shopping center, collect the furniture and electronics as soon as possible and collect all possible valuables along the way,” a Canadian fighter wrote in his statement following the incident.

Fighters of the International Legion accuse some commanders of giving them orders to loot a shopping mall. (Illustration: Karolina Gulshani)

According to the soldiers’ official testimonies obtained by the Kyiv Independent, “Sasha” also told subordinates to take whatever they liked: shoes, women’s clothes, jewelry, watches, and electronics.

Many soldiers obeyed as they come from professional military backgrounds where they don’t question superiors’ commands.

“(Normally) you should say ‘yes, sir’ and get it done. Because you believe that your commander knows what he’s asking you to do…You just assume that this action is legal, and you’re going to go for it. You’re not supposed to question it,” the Brazilian legionnaire told the Kyiv Independent.

“Locals saw how we loaded the furniture which made me very uncomfortable. It felt like we were robbing them. I didn’t come to Ukraine for this,” a testimony of a Columbian soldier reads.

“There were local residents near the shopping mall, one of whom, seeing this, shouted insults, and the others looked at us with reproach and condemnation. I don’t know whether it was legal or not but I felt ashamed to carry out the order of Sasha Kuchynsky and take away furniture and valuables from stores during hostilities and in front of local residents who suffered from the war,” a French legionnaire wrote in his statement.

Some soldiers refused to follow the order.

In a video obtained by the Kyiv Independent, some foreigners can be heard in the shopping mall questioning the legality of “Sasha’s” orders.

“We will not be implicated by any means as looters. We will not stand for this,” an English-speaking soldier is heard saying.

He then tells the crowd that he will not stay in front of the stolen goods and is going downstairs to wait until the car picks him up and drives back to the base. “Sasha” becomes angry at the soldiers’ refusal to carry out his orders.

“Listen, (do not set) conditions for me. This is an order, to stay here and wait for the commander. This is an order. You get it? An order. This is the army,” the Polish commander says in broken Russian.

“I do not find that order lawful. We do not see this as reasonable,” the soldier replies.

The video ends with the soldier saying to his peers: “Let’s go downstairs, guys. We are not playing these games.”

According to the legionnaires, Kuchynsky ordered similar lootings on multiple occasions and Ukrainian soldiers were ordered to participate as well.

The legionnaires don’t know where the items were sent to. In a video obtained by the Kyiv Independent, one soldier is heard saying in Russian that the furniture and electronics taken from the mall were for their unit’s headquarters in Kyiv.

Theft allegations

According to the legionnaires, they regularly witnessed what they believe were suspicious arms movements.

“The car is coming, the cars going, the boxes of weapons coming, the boxes of weapons going,” one of the American soldiers said.

Despite the legion’s armory rooms being loaded with all sorts of heavy weaponry and ammunition, the soldiers say they often didn’t end up in their hands.

“During my stay in Sievierodonetsk, a civilian vehicle painted in camouflage containing thermal imagers arrived,” a Columbian soldier wrote in his testimony. “They were not distributed among the soldiers due to their alleged absence. Meanwhile, Sasha Kuchynsky proposed to the military personnel of the International Legion to buy these thermal imagers for $300.”

“I think, Sasha Kuchynsky artificially created the impression of a shortage of some ammunition to illegally enrich himself by providing it to fighters (for money) as if from himself,“ another fighter from Columbia wrote in his testimony.

According to him, two of his fellow soldiers damaged their hearing due to the lack of headphones that he knew were in their armory, under Kuchynsky’s control.

Soldiers say Kuchynsky would take away part of the ammunition they would independently receive from volunteers and donors. They called it the “Sasha tax.”

“So you have to give Sasha what he wants. And then you can give (the rest) of this stuff to your guys,” one of the American soldiers said. “Everything just seems like a cover-up. It’s very strange. It feels like an (organized) business.”

The same happened to another American soldier. His shipment arrived at the base while he was on a mission. When he returned, some parcels were gone.

“It was labeled for our team. So basically, simple as that, half of the stuff wasn’t there.”

Waiting for solution

The foreign soldiers say they did not want to publicize the crisis in the International Legion and tried to solve the issue behind the scenes.

They first complained to their commanders, then lawmakers, and finally went as far as the President’s Office. Since the Legion was created upon Zelensky’s order, foreign fighters counted on his administration’s support, but did not get much help from there, they said.

Alyona Verbytska, the president’s commissioner for soldiers’ rights, told the Kyiv Independent she had informed her superiors about the legionnaires’ complaints. She did not elaborate on who exactly she reported to.

In the President’s Office, two people oversee the Legion for Zelensky, according to the Kyiv Independent’s sources close to the Office. They are Vitaliy Martyniuk, a national security expert, and Roman Mashovets, deputy head of the Office and former employee of the GUR intelligence agency.

The President’s Office did not reply to the Kyiv Independent’s request for comment before publication.

Complaining to the President’s Office didn’t work out. Things even got worse, the soldiers said, as those who sounded an alarm about the Legion’s leadership started to feel under pressure and receive threats.

Meanwhile, many professional members left the unit due to alleged mismanagement and problems with paperwork. The Legion failed to provide some of them with official contracts.

“There were really good special (forces) guys. I mean, not from the regular military. A lot of special (forces) guys literally just said: ‘No, thank you. We can’t work like that anymore’,” an American soldier said.

Those who stayed in the unit want it to keep helping Ukraine to stand against Russia. To do it effectively, they believe, the Legion must be reformed under new leadership.

“I have a very, very, very pleasant experience with everybody in the Ukrainian military outside of Sasha and Tarases,” one of the American soldiers said.

“I’ve always just kind of kept my mouth shut. Just because people like Sasha really discredit all of this,” he said.

Note from the authors:

Hi, it’s Anna and Alexander here. We worked hard to piece the evidence together and break this story. We believe it is crucial to shed light on mismanagement in the army, especially in times of war. We wanted to help bring change to the International Legion so it continues to assist Ukraine in defending itself against Russian aggression. Now, however, many legionnaires are resigning due to the commanders’ misconduct.

Woman’s body, man’s medicine

Our starting point is an androcentric medicine that has investigated manifestations in men and extrapolated the results to women.

It was thought that reproductive health was the only differentiating characteristic, but the symptoms, treatments and recovery for the same disease might not be the same.The biological differences, which are often invisibilised, explain only part of the health inequalities, which are also conditioned by gender roles.

The following are some of the specific characteristics of women’s health

1. Mental health: From mixed bag to overmedication

More cases of depression and anxiety
Worse living and working conditions for women, double working days (particularly for less qualified workers), domestic and care work, guilt and perfectionism can all have an impact on women’s health. Women are more likely to experience mental health problems such as anxiety and depression, which affect almost twice as many women (13.7%) as men (7.4%). Moreover, one in three women says they feel emotional distress, while in men this figure is one in five.

“It’s a mixed bag. Anything that happens to a woman is attributed to her being anxious or overstressed, without taking into account her working or care conditions. A pill isn’t the solution. We have to change living and working conditions.”

Carme Valls, Endocrinologist and author of Mujeres Invisibles Para La Medicina 

More anxiolytics
Women are more likely to be sent away with a diagnosis of mental illness at an initial visit than men; in the latter, an organic cause is immediately suspected and additional tests are requested. This gender bias leads to overmedication in women: 85% of psychotropic medications are administered to women. This overdiagnosis can also render invisible physical diseases that are hidden behind an incorrect diagnosis of mental illness or psychosomatic symptoms because they might not fit the “normal pattern,” i.e. the male model.

The taboo of motherhood
Another area ignored by science is mental health and motherhood. One in four women experience some kind of mental health problem, some more severe than others, during pregnancy or in the postpartum period, and most of them are not treated. This is not helped by the fact that the postpartum and nurturing period is a lonely time for many women. Traumatic childbirth, a difficult pregnancy, childhood trauma or stressful situations can trigger postpartum depression and the most common symptoms are sadness, hopelessness, emotional changes, insomnia or difficulty bonding with the infant.

2. Cardiovascular disease: Heart attacks are mistaken for anxiety

Leading cause of death
Cardiovascular disease is the leading cause of death in women in Spain, ahead of breast cancer. While men experience more heart attacks and women more strokes and heart failure, women are twice as likely to die in the event of a heart attack. The mortality rate of myocardial infarction is 9% in men and 18% in women. There are various reasons for this. It takes women longer to go to the hospital and their symptoms are often mistaken for anxiety.

“Cardiovascular diseases are very well differentiated in men, but in women, the diagnosis is much less specific and less cautious than in men. Fewer tests are carried out, assuming ‘the chest pain must be anxiety’. No. At the very least an electrocardiogram, imaging study or stress test must be performed to rule out an organic cause.”

Antonia Sambola, Cardiologist at Vall D’Hebron Hospital and expert in women’s cardiovascular health

Delayed diagnosis
Women seek care later, downplaying their symptoms or putting the care of others before their own, and this leads to delayed diagnosis. The symptoms are also confusing at times. Chest pain is a symptom in 90% of women, but they also have other additional symptoms, which are more intense than in men, including nausea, vomiting, dizziness and headache. “They also have chest pain and shortness of breath, like men, but by the time women go to the doctor the chest pain has already passed because they are already in heart failure,” adds Sambola.

More research
Practitioners are calling for more emphasis on cardiovascular disease prevention as there are risk factors in women that are largely left unaddressed and that are closely related to pregnancy and childbirth, such as preeclampsia, gestational diabetes and premature birth. “Menopause also increases cardiovascular risk. Has that been explained? There isn’t enough information. We’re completely lost,” acknowledges Elisa Llurba, Head of the Gynaecology Department at Sant Pau Hospital. Practitioners also call for campaigns to promote self-care.

3. Breasts: Between aesthetics and pathology

Aesthetic pressure
Breasts have been used to sell everything from cars to perfumes, but we have rarely studied what they look like on the inside. The breast has not been studied from an anatomical or physiological perspective. “It has become trivialised as something which is aesthetic rather than functional, and we have gone from not knowing anything about breasts to knowing only their pathology, breast cancer,” says surgeon Maria Jesús Pla. Furthermore, the depiction of a perfect breast has failed to take into account the fact that they come in all shapes and sizes. “The mammary gland is neither seen nor explained. We don’t know how it works, but they do teach us how the liver and kidneys work. Most women don’t know what the raised bumps on the areola of the nipple are called,” adds breastfeeding expert Alba Padró.

Breastfeeding
Over 90% of women who give birth breastfeed their children in the first few days, a percentage that decreases as time passes. There are multiple reasons for this, ranging from insufficient leave from work to a lack of breastfeeding support.

“Healthcare professionals do not receive specific training on breastfeeding and the training they do receive is not enough. Much emphasis has been placed on the benefits, a chapter that has since been closed, but not on the solution to the problems. You would expect paediatricians to be trained in breastfeeding but they’re not, and this is the first reality check: breasts are essentially no one’s territory.”

Alba Padró, Cofounder of LactApp and IBCLC breastfeeding expert

Breast cancer
Approximately one in every eight women will develop breast cancer in their lifetime. It is the most common tumour in women worldwide and in Catalonia, it accounts for about 30% of the tumours affecting women. Most cases are diagnosed between the ages of 35 and 80, with the highest number of cases between the ages of 45 and 65. The disease also has an emotional impact that other cancers might not have, as it is a more visible organ and has sexual and aesthetic implications. The challenge for these patients is to return to their work and sexual life.

“Surgeons must be sensitive to the aesthetics of the breast because tumours here have special implications. Conservative surgery rates are very high, at over 75%, and when this isn’t possible, immediate reconstruction is performed. You shouldn’t end up with a line. But it’s also important to remember that a woman is more than just two breasts.”

Maria Jesús Pla, Breast surgeon at Bellvitge Hospital

Controversial mammograms
Survival rates have increased with the improvement in treatments, as this is a tumour that is subject to a lot of research and early detection through population screening. In Catalonia, mammograms are recommended between the ages of 50 and 69 every two years, not annually. Routine mammograms are not recommended in women under the age of 50 with no risk factors. The effectiveness of screening in women between the ages of 40 and 49 is a controversial debate. “The disease is less prevalent and mammograms are less effective. If population screening were to be extended, it has been said that it would be better to do so amongst women between the ages of 70 and 75,” explains Maria Jesús Pla.

4. Respiratory Disease: Conditions on the rise among women

Lung diseases
Respiratory diseases that were considered to be predominantly male conditions have risen among women due to the increase in smoking. This is the case for chronic obstructive pulmonary disease (COPD), which, according to a study by the Hospital del Mar, shows more symptoms in women: increased breathlessness, increased muscle involvement and more lesions than in men with equally severe disease. COPD is a disease that is underdiagnosed in women. According to Carme Valls, there is a tendency to diagnose women with asthma when in actual fact it is COPD. Practitioners believe it progresses differently not only because of the biological characteristics of sex but also because of the sociocultural characteristics of gender. Women with this disease have a worse quality of life.

Lung cancer
Lung cancer, which is the leading cause of cancer death, is also on the rise among women due to the increase in smoking. It has gone from being the fourth most common tumour among women in 2015 to the third, and it is expected to continue increasing in the coming years, overtaking breast cancer. Meanwhile, it is expected to become less common among men due to the decline in smoking.

“Lung cancer used to be considered a male disease and this has likely led women to be less cautious with smoking. Perhaps there should be gender-specific public health campaigns aimed at women and young girls.”

Enriqueta Felip, Head of the thoracic, head and neck cancer unit within the oncology department at Vall D’Hebron Hospital

Long COVID
There are people, mostly women, who have already had an acute coronavirus infection but continue to have symptoms six months later. These are generally young women, between the ages of 35 and 50, who have a wide range of fluctuating symptoms including headaches, extreme fatigue, tachycardia, muscle and joint pain, breathing difficulty and memory loss. This even occurs after having had a mild form of COVID. The symptoms are similar to those of chronic fatigue, a condition with which they also share preconceptions and a lack of understanding. Long COVID is thought to affect between 10% and 20% of patients. There has been a lack of information on this condition for months, which has led to underdetection and those affected have at times felt questioned by the healthcare system.

5. Reproductive system and sexuality: Invisbilised diseases and the medicalisation of physiological processes

Silenced disease
There are diseases that only affect women, such as endometriosis, for which there is a lack of investment and research because, as scientist Maria Montoya from the Spanish National Research Council (CSIC) ironically puts it, “they only affect 50% of the population.” Endometriosis is the gynaecological disease with the highest incidence: it affects at least 10% of women of reproductive age, but this figure could be higher as the condition is underdiagnosed. It is a chronic disease, and its best-known symptoms are pain during menstruation, pelvic pain and infertility. However, the pain has become socially normalised among women to the point that a diagnosis can take up to eight years.

Obstetric violence
The healthcare system has medicalised normal physiological processes in women, such as pregnancy, childbirth and menopause, by imposing a paternalistic approach: seven out of ten women say they have felt belittled during pregnancy or childbirth. However, women are becoming increasingly informed and empowered and are pushing for a change in the care model, demanding more humanised and less medicalised care. “Depending on how we deal with childbirth, we can leave a young, healthy woman with a chronic condition, and the healthcare system and practitioners must be held accountable for this,” says Maria Llavoré, a midwife at Sant Pau Hospital.

“We are being self-critical. There is an element of unconscious structural violence, and the sooner we accept this, the sooner we can fix it. There’s no point in becoming bogged down in whether or not to call it obstetric violence. We can and must do better.”

Elena Carreras, Head of obstetrics at Vall D’Hebron Hospital

The caesarean section rate in Catalonia (27.4%) is still double the WHO’s recommended rate (15%) and is, together with inductions, an indicator of obstetric quality. Episiotomies, the Kristeller manoeuvre and overmedication are just some of the practices that have been criticised. But infantilising a woman or disregarding her consent is also considered to be obstetric violence. This respect applies not only to childbirth but also to miscarriages, abortions and infertility or assisted reproduction procedures. The Ministry of Equality, like the Catalan law on gender-based violence before it, plans to include obstetric violence as a form of violence against women in the reform of the abortion law. The Catalan Society of Obstetrics and Gynaecology and the four Catalan medical associations have recently acknowledged that obstetric violence exists and are calling for a debate, even though they have admitted that the term makes them uncomfortable.

Sexuality
Female sexuality has been invisibilised or is full of taboos and stereotypes, and pleasure and the female body have long been an unknown reality, even to women themselves. We have not received sex education, and the education we have received has perpetuated sexist models. However, more and more women are reclaiming their pleasure while making sexual and gender diversity visible beyond binarism. Beyond this, consultations related to sexuality are increasing because issues such as pain during sex and anorgasmia are no longer normalised.

“The level of ignorance about women’s bodies is appalling, even among some practitioners. The clitoris hasn’t been studied, it’s unknown, it’s not drawn and it doesn’t appear in photos. If we don’t talk about it, it doesn’t exist. If women don’t know where it is, they don’t know where to stimulate it.”

Maria Llavoré, Midwife at Sant Pau Hospital

Pelvic floor
Almost half of women (46%) have one or more pelvic floor disorders, such as urinary or bowel incontinence or pelvic organ prolapse. This has a major impact on their quality of life. Pregnancy and childbirth are key factors, but there are also other causes such as high-impact sport, constipation, ageing and menopause. Until recently, it was considered that, since no one died, it was simply accepted, but practitioners are calling for check-ups and treatment of the pelvic floor to be routine practice in the healthcare system and for there to be a prevention strategy: the pelvic floor should be discussed from an early age, and training should be provided in schools. Teaching how to do Kegel exercises should be like teaching them how to brush their teeth.

Gynaecological cancers
These cancers begin in the female reproductive system. They can affect the cervix (the neck of the uterus), ovaries, uterus, vagina and vulva. The risk increases with age and some gynaecological cancers are caused by the human papillomavirus (HPV). Girls and women between the ages of 9 and 26 can be vaccinated against HPV, and vaccination is recommended before becoming sexually active. If the vaccine were less expensive, practitioners believe that it would also be advisable to administer it to boys.

6. Joints: Women’s pain: an unresolved issue

Chronic pain
One in three women reports having pain or discomfort, while in men this figure is one in five. Women are more likely to experience chronic pain as most diseases that cause muscle or joint pain are more common in women. “Chronic pain is one of medicine’s unresolved issues,” says endocrinologist Carme Valls. Experts are calling for it to be addressed as a public health problem.

“It is important for healthcare professionals to consider not only the disease but also what comes before it: the living conditions that may have led to these disorders. Including the gender perspective is an improvement in care. You can’t take care of people’s health without taking into account their living conditions, which are very different for men and women.”

Lucía Artazcoz, Director of the Public Health Observatory of the Barcelona Public Health Agency

Physical and mental overload
Rheumatic and musculoskeletal diseases such as arthritis, osteoarthritis, back pain, osteoporosis and fibromyalgia are common causes for consultation in primary care. It is estimated that these conditions take up around 30% of primary care physicians’ time. Valls states in her text that the pain of many women is often silenced or rendered invisible with psychotropic medications and that studies do not take into account the physical and mental overload experienced by women in their lives and workplaces.

Fibromyalgia
Fibromyalgia is characterised by chronic pain throughout the body, particularly in the muscles and joints of the back and limbs, and hypersensitivity to pain, noise, smells and light. It can also be accompanied by cognitive and sleep disorders, gastrointestinal disorders and fatigue. It is a disease that occurs more frequently among women (4.2% of women and 0.2% of men in Spain), its origin is unknown and, in many cases, it is debilitating. Those affected can spend years going from one consultation to the next until eventually reaching the diagnosis of a highly stigmatised disease.

“The prevalence among women is huge. There are no doubt hormonal and pain perception factors involved, but we’re not really sure about this. What we do know is that the pain exists and that they’re not making it up. There are some very hard-hitting cases. What is the cause? That is up for debate, but the pain is real.”

Josep Blanch, Head of the Rheumatology Department at Hospital Del Mar

It is not without controversy. Carme Valls wrote in her text that “all kinds of muscle pain for which no explanation could be found have been attributed to this disease, with no objective evidence.” She questions the fact that it is treated with psychotropic medications and believes that more research studies are needed for women diagnosed with fibromyalgia.

7. Autoimmune Diseases: Complex diseases that affect women the most

Attacked by our own defences
Autoimmune diseases are those in which the immune system attacks the body’s own organs. It is estimated that one in ten people in Catalonia has an autoimmune disease. Some only attack specific organs, such as autoimmune thyroiditis, the most common form, which affects the thyroid gland, while other systemic forms involve a generalised attack. Sjögren’s syndrome is the most prevalent of these, but lupus is the most paradigmatic.

More women affected
Two-thirds of those affected are women and in some specific conditions this proportion is even larger: for every man with lupus there are nine women, and for every man with Sjögren’s syndrome there are six women. There are multiple reasons for this, but female sex hormones are a major factor, and “periods in which they are more active, from puberty until menopause” is when the most disease onsets and the most flare-ups occur.

“In the case of lupus, treating the kidney or nervous system is just as important as treating reproductive issues or skin lesions on the face, something that perhaps would not be as important for a man.”

Ricard Cervera, Head of Autoimmune Diseases at Clinic Hospital

Pregnancy
It also affects women of childbearing age, which has special implications. Forty years ago it was said that women with lupus would not be able to have children as they would miscarry and the disease would flare-up. Nowadays, they have similar fertility to the general population and pregnancies are more closely monitored.

The other bias
In this case, it is men who may experience a delay in diagnosis because, in theory, doctors find it hard to believe that a man might have lupus, for example. But when they do have it, it is more severe.

8. Research and Drugs: The effect of excluding women from clinical trials

Clinical trials
For decades there has been gender bias in clinical research. Due to hormonal changes and for safety reasons, women are often not included in clinical trials and this exclusion has led to gaps in knowledge. This is also the case for studies with non-human animals, in which two-thirds are male. When women have been included in trials, the results have not been segregated, meaning that the results are applied equally to both men and women, even though the participation of women is lower. “When you don’t segregate by sex, you don’t know the situation for either men or women, or the specific characteristics of each of them, and that’s bad science,” notes Lucía Artazcoz. But this is changing, partly thanks to COVID.

“Men and women react differently to the coronavirus and this must be taken into account. The disease is teaching us not to treat patients as a homogeneous entity and we can all benefit from this, as it enables us to adjust treatments or medication doses.”

Maria Montoya, Head of the viral immunology group at the Margarita Salas Centre for Biological research of the Spanish National Research Council (CSIC)

Adverse reactions
Excluding women from clinical trials means that adverse drug reactions are either unknown or take years to be noticed and for measures to be taken. Eight out of ten drugs withdrawn from the market in the USA between 1997 and 2000 had greater health risks for women than for men. As an example, statins, a widely used drug, have been shown to have more adverse effects on women.

The way in which the drug is metabolised or how we benefit from the drug is different due to metabolic and genetic history as well as hormonal issues. Again, there is little information available, or incomplete information, regarding the adverse effects of drugs on pregnant and breastfeeding women, and the coronavirus vaccine is an example of this. The information on COVID in pregnant women has been contradictory since the start of the pandemic.

“In oncology, chemotherapy is administered according to body surface area and this does not take into account the differences in body composition between the sexes. The patient’s sex also affects the absorption, distribution, metabolisation and excretion of drugs.”

Dorothea Wagner, Head of the Gastrointestinal Cancer Unit at Lausanne University Hospital

Dosage
It has been assumed that if a dose is appropriate for a man, it is also appropriate for a woman, but men and women are different in many respects, one of which is body mass. For example, men have 80% fat-free body mass and women have 65%, and this affects the way in which we metabolise a drug.

In oncology, “the same drug may be less effective or ineffective in one sex compared to the other, and we might have to use different drugs depending on whether the patient is a man or a woman,” Wagner adds. But this also poses a challenge because sex is not the only factor involved in the variability of responses to a drug. To this end, practitioners are calling for more clinical trials and the inclusion of non-binary genders, too.

Contraceptive pills
To downplay the risks of thrombosis of the AstraZeneca vaccine, they were compared to those of contraceptive pills, which are more common, and no one was surprised. Without criminalising contraceptives, which were a liberation for women, women are demanding that they be provided with full information about side effects. The risk of thrombosis is estimated to be 1 to 10 in every 10,000 women, making it a rare adverse effect, but we must be aware of the factors that may favour it, such as family history, being over 35, smoking, excess weight and hypertension. The other most common side effects include mood disorders, reduced libido, migraines, nausea and fluid retention. They are also prescribed for other conditions such as polycystic ovaries and endometriosis, and this may lead to other possible solutions not being investigated.

“Over time, instead of investigating any small changes in the regularity of the menstrual cycle or in the intensity of menstruation to diagnose the causes, they have been initially treated with normal contraceptives.”

Carme Valls, Endocrinologist and author of Mujeres Invisibles Para la Medicina 

The pills are said to “regulate the cycle,” but in actual fact they inhibit it. With contraceptives, there is no real bleeding because there is no ovulation. It is fictitious bleeding because during the break there is a sudden hormonal change. This is meant to mimic the female cycle because it is a way of reassuring women, but it is not really menstruation, although many women do not know this. “Why the male contraceptive pill has never been marketed is a matter for further reflection,” writes Valls. As for the relationship between contraceptives and breast cancer, there is much controversy and there are no conclusive studies, although Pla assures that “it has not been proven to be a risk factor.”

Menopause
On the other hand, hormone replacement therapy (HRT) with oestrogens and progestin, which is used to alleviate some of the effects of the menopause, such as vaginal dryness and hot flushes, has been linked to an increased risk of breast cancer and women are advised against receiving it for over five years. According to a 2004 study, 43% of women who were prescribed this were unaware of the risks involved in its use.

“Menopause research is needed. I have found very few studies on this and every practitioner has different answers. Natural or artificial methods? There is no clear evidence. We’re in limbo. Have women been asked what concerns they have about this stage? Because the needs of women nowadays are not the same as 25 years ago.”

Elisa Llurba, Director of the Gynaecology and Obstetrics Department at Sant Pau Hospital

9. Conclusion
No more, no less.
Just different

The paradox when we talk about gender and health is that women live longer but have a poorer quality of life. “They have diseases that don’t kill them, but they don’t let them live,” according to public health specialist Lucía Artazcoz. Socialisation and gender roles condition our health. Primary care practitioners see this on a daily basis. “When you ask women what makes them suffer, you see that we all have a shared experience that has an impact on our health,” explains Meritxell Sánchez-Amat, a general practitioner at Besòs Primary Care Centre, who is calling for more time per patient and more home visits to allow for a psychosocial approach, as “drugs are the quick and easy answer”. She believes that introducing the gender variable would help avoid medicalisation and overdiagnosis.

“But it’s difficult. It means going against the tide. As practitioners, we are part of this patriarchal society, and as a healthcare institution we are not self-critical.”

Meritxell Sánchez-Amat, General Practitioner and President of the Catalan Forum for Primary Care (FOCAP)

Gender-sensitive medicine and research are also closely related to the fact that there are more women in leadership and decision-making positions. “It is essential to change the way we look at things,” says cardiologist Antonia Sambola. Gynaecologist Elisa Llurba, who is calling for the Catalan public broadcaster to dedicate an edition of its annual TV3 telethon exclusively to women’s health, admits that she was previously unaware of this gender bias. “I didn’t see it until now, because I considered many practices to be normal and I hadn’t understood them from that perspective.” According to fellow gynaecologist Elena Carreras, “gender bias in medicine exists, and as soon as you become aware of it, it’s no longer an option to do nothing.” This benefits men as well as women, “because this outlook makes us question whether we are doing it right.” While women are overdiagnosed with mental health problems, men are underdiagnosed with depression, fibromyalgia and osteoporosis, which are more common in women. This approach should also be taken on at universities and in the continuing education of healthcare professionals.

Including sex is not enough
To break this bias, it is not enough to include the sex variable alone. We must also include that of gender. “We just assume that a patient is male or female, but there are individuals who are intersex. We also assume that patients are cisgender – when gender identity matches the sex assigned at birth – but we must move away from assuming and start asking. We need to be more empathetic with gender identities because this strengthens the science,” said Ewelina Biskup, Professor at the Shanghai University of Medicine and Science, at a conference on gender-sensitive medicine held at Vall d’Hebron Hospital. This is the first hospital to have created a health and gender committee, and the Department of Health plans to extend this to all centres to incorporate this approach into healthcare practice. As Artazcoz says, “we are still a long way from gender-sensitive medicine”, and the first step is to stop using men as a benchmark. “Women’s health is no more and no less than men’s health. It’s just different.”