‘Why? Why? Why?’ Ukraine’s Mariupol descends into despair

MARIUPOL, Ukraine (AP) — The bodies of the children all lie here, dumped into this narrow trench hastily dug into the frozen earth of Mariupol to the constant drumbeat of shelling.

There’s 18-month-old Kirill, whose shrapnel wound to the head proved too much for his little toddler’s body. There’s 16-year-old Iliya, whose legs were blown up in an explosion during a soccer game at a school field. There’s the girl no older than 6 who wore the pajamas with cartoon unicorns, among the first of Mariupol’s children to die from a Russian shell. 

They are stacked together with dozens of others in this mass grave on the outskirts of the city. A man covered in a bright blue tarp, weighed down by stones at the crumbling curb. A woman wrapped in a red and gold bedsheet, her legs neatly bound at the ankles with a scrap of white fabric. Workers toss the bodies in as fast as they can, because the less time they spend in the open, the better their own chances of survival.

“The only thing (I want) is for this to be finished,” raged worker Volodymyr Bykovskyi, pulling crinkling black body bags from a truck. “Damn them all, those people who started this!”

The children of medical workers warm themselves in a blanket as they wait for their relatives in a hospital in Mariupol, Ukraine, March 4, 2022. (AP Photo/Evgeniy Maloletka)

An apartment building explodes after a Russian army tank fires in Mariupol, Ukraine, Friday, March 11, 2022. (AP Photo/Evgeniy Maloletka)

A body lies covered by a tarp in the street in Mariupol, Ukraine, March 7, 2022. (AP Photo/Evgeniy Maloletka)

More bodies will come, from streets where they are everywhere and from the hospital basement where adults and children are laid out awaiting someone to pick them up. The youngest still has an umbilical stump attached.

Each airstrike and shell that relentlessly pounds Mariupol — about one a minute at times — drives home the curse of a geography that has put the city squarely in the path of Russia’s domination of Ukraine. This southern seaport of 430,000 has become a symbol of Russian President Vladimir Putin’s drive to crush democratic Ukraine — but also of a fierce resistance on the ground.

In the nearly three weeks since Russia’s war began, two Associated Press journalists have been the only international media present in Mariupol, chronicling its fall into chaos and despair. The city is now encircled by Russian soldiers, who are slowly squeezing the life out of it, one blast at a time.

Several appeals for humanitarian corridors to evacuate civilians went unheeded, until Ukrainian officials said Wednesday that about 30,000 people had fled in convoys of cars. Airstrikes and shells have hit the maternity hospital, the fire department, homes, a church, a field outside a school. For the estimated hundreds of thousands who remain, there is quite simply nowhere to go.

The surrounding roads are mined and the port blocked. Food is running out, and the Russians have stopped humanitarian attempts to bring it in. Electricity is mostly gone and water is sparse, with residents melting snow to drink. Some parents have even left their newborns at the hospital, perhaps hoping to give them a chance at life in the one place with decent electricity and water.

People burn scraps of furniture in makeshift grills to warm their hands in the freezing cold and cook what little food there still is. The grills themselves are built with the one thing in plentiful supply: bricks and shards of metal scattered in the streets from destroyed buildings.

Death is everywhere. Local officials have tallied more than 2,500 deaths in the siege, but many bodies can’t be counted because of the endless shelling. They have told families to leave their dead outside in the streets because it’s too dangerous to hold funerals.

Many of the deaths documented by the AP were of children and mothers, despite Russia’s claims that civilians haven’t been attacked.

“They have a clear order to hold Mariupol hostage, to mock it, to constantly bomb and shell it,” Ukrainian President Volodymyr Zelenskyy said on March 10.

Just weeks ago, Mariupol’s future seemed much brighter.

If geography drives a city’s destiny, Mariupol was on the path to success, with its thriving iron and steel plants, a deep-water port and high global demand for both. Even the dark weeks of 2014, when the city nearly fell to Russia-backed separatists in vicious street battles, were fading into memory.

And so the first few days of the invasion had a perverse familiarity for many residents. About 100,000 people left at that time while they still could, according to Serhiy Orlov, the deputy mayor. But most stayed put, figuring they could wait out whatever came next or eventually make their way west like so many others.

“I felt more fear in 2014, I don’t feel the same panic now,” Anna Efimova said as she shopped for supplies at a market on Feb. 24. “There is no panic. There’s nowhere to run, where can we run?”

That same day, a Ukrainian military radar and airfield were among the first targets of Russian artillery. Shelling and airstrikes could and did come at any moment, and people spent most of their time in shelters. Life was hardly normal, but it was livable.

By Feb. 27, that started to change, as an ambulance raced into a city hospital carrying a small motionless girl, not yet 6. Her brown hair was pulled back off her pale face with a rubber band, and her pajama pants were bloodied by Russian shelling.

Her wounded father came with her, his head bandaged. Her mother stood outside the ambulance, weeping.

As the doctors and nurses huddled around her, one gave her an injection. Another shocked her with a defibrillator. A doctor in blue scrubs, pumping oxygen into her, looked straight into the camera of an AP journalist allowed inside and cursed.

“Show this to Putin,” he stormed with expletive-laced fury. “The eyes of this child and crying doctors.”

They couldn’t save her. Doctors covered the tiny body with her pink striped jacket and gently closed her eyes. She now rests in the mass grave.

Oleksandr Konovalov, an ambulance paramedic, performs CPR on a girl injured by shelling in a residential area as her dad sits, left, after arriving at the city hospital of Mariupol, eastern Ukraine, Sunday, Feb. 27, 2022. The girl did not survive. (AP Photo/Evgeniy Maloletka)

The lifeless body of a girl killed during shelling at a residential area lies on a medical cart at the city hospital of Mariupol, eastern Ukraine, Sunday, Feb. 27, 2022. (AP Photo/Evgeniy Maloletka)

The same geography that for so long worked in Mariupol’s favor had turned against it. The city stands squarely between regions controlled by the Russia-backed separatists — about 10 kilometers (six miles) to the east at the closest point — and the Crimean Peninsula annexed by Russia in 2014. The capture of Mariupol would give the Russians a clear land corridor all the way through, controlling the Sea of Azov.

As February ended, the siege began. Ignoring the danger, or restless, or perhaps just feeling invincible as teenagers do, a group of boys met up a few days later, on March 2, to play soccer on a pitch outside a school.

A bomb exploded. The blast tore through Iliya’s legs.

The odds were against him, and increasingly against the city. The electricity went out yet again, as did most mobile networks. Without communications, medics had to guess which hospitals could still handle the wounded and which roads could still be navigated to reach them.

Iliya couldn’t be saved. His father, Serhii, dropped down, hugged his dead boy’s head and wailed out his grief.

Serhii, father of teenager Iliya, cries on his son’s lifeless body lying on a stretcher at a maternity hospital converted into a medical ward in Mariupol, Ukraine, March 2, 2022. (AP Photo/Evgeniy Maloletka)

Marina Yatsko, left, runs behind her boyfriend Fedor carrying her 18 month-old son Kirill who was fatally wounded in shelling, as they arrive at a hospital in Mariupol, Ukraine, Friday, March 4, 2022. (AP Photo/Evgeniy Maloletka)

Medical workers unsuccessfully try to save the life of Marina Yatsko’s 18 month-old son Kirill, who was fatally wounded by shelling, at a hospital in Mariupol, Ukraine, March 4, 2022. (AP Photo/Evgeniy Maloletka)

Marina Yatsko and her boyfriend Fedor comfort each other after her 18-month-old son Kirill was killed in shelling in a hospital in Mariupol, Ukraine, March 4, 2022. (AP Photo/Evgeniy Maloletka)

On March 4, it was yet another child in the emergency room — Kirill, the toddler struck in the head by shrapnel. His mother and stepfather bundled him in a blanket. They hoped for the best, and then endured the worst.

“Why? Why? Why?” his sobbing mother, Marina Yatsko, asked in the hospital hallway, as medical workers looked on helplessly. She tenderly unwrapped the blanket around her lifeless child to kiss him and inhale his scent one last time, her dark hair falling over him.

That was the day the darkness settled in for good — a blackout in both power and knowledge. Ukrainian television and radio were cut, and car stereos became the only link to the outside world. They played Russian news, describing a world that couldn’t be further from the reality in Mariupol.

As it sunk in that there was truly no escape, the mood of the city changed. It didn’t take long for grocery store shelves to empty. Mariupol’s residents cowered by night in underground shelters and emerged by day to grab what they could before scurrying underground again.

Serhiy Kralya, 41, looks at the camera after surgery at a hospital in Mariupol, eastern Ukraine on March 11, 2022. Kralya was injured during shelling by Russian forces. (AP Photo/Evgeniy Maloletka)

Medical workers treat a man wounded by shelling in a hospital in Mariupol, Ukraine, March 4, 2022. (AP Photo/Evgeniy Maloletka)

On March 6, in the way of desperate people everywhere, they turned on each other. On one street lined with darkened stores, people smashed windows, pried open metal shutters, grabbed what they could.

A man who had broken into a store found himself face to face with the furious shopkeeper, caught red-handed with a child’s rubber ball.

“You bastard, you stole that ball now. Put the ball back. Why did you even come here?” she demanded. Shame written on his face, he tossed the ball into a corner and fled.

Nearby, a soldier emerged from another looted store, on the verge of tears.

“People, please be united. … This is your home. Why are you smashing windows, why are you stealing from your shops?” he pleaded, his voice breaking.

Yet another attempt to negotiate an evacuation failed. A crowd formed at one of the roads leading away from the city, but a police officer blocked their path.

“Everything is mined, the ways out of town are being shelled,” he told them. “Trust me, I have family at home, and I am also worried about them. Unfortunately, the maximum security for all of us is to be inside the city, underground and in the shelters.”

People lie on the floor of a hospital during shelling by Russian forces in Mariupol, Ukraine, March 4, 2022. (AP Photo/Evgeniy Maloletka)

A Ukrainian serviceman guards his position in Mariupol, Ukraine, March 12, 2022.(AP Photo/Mstyslav Chernov)

And that’s where Goma Janna could be found that night, weeping beside an oil lamp that threw light but not enough heat to take the chill off the basement room. She wore a scarf and a cheery turquoise snowflake sweater as she roughly rubbed the tears from her face, one side at a time. Behind her, beyond the small halo of light, a small group of women and children crouched in the darkness, trembling at the explosions above.

“I want my home, I want my job. I’m so sad about people and about the city, the children,” she sobbed.

This agony fits in with Putin’s goals. The siege is a military tactic popularized in medieval times and designed to crush a population through starvation and violence, allowing an attacking force to spare its own soldiers the cost of entering a hostile city. Instead, civilians are the ones left to die, slowly and painfully.

Putin has refined the tactic during his years in power, first in the Chechen city of Grozny in 2000 and then in the Syrian city of Aleppo in 2016. He reduced both to ruins.

“It epitomizes Russian warfare, what we see now in terms of the siege,” said  Mathieu Boulegue, a researcher for Chatham House’s Russia program.

People settle in a bomb shelter in Mariupol, Ukraine, March 6, 2022. (AP Photo/Evgeniy Maloletka)

A woman holds a baby in a bomb shelter in Mariupol, Ukraine, March 8, 2022. (AP Photo/Evgeniy Maloletka

People queue to receive hot food in a improvised bomb shelter in Mariupol, Ukraine, Monday, March 7, 2022. (AP Photo/Evgeniy Maloletka)

A man plays with a baby in a bomb shelter in Mariupol, Ukraine, March 6, 2022. (AP Photo/Evgeniy Maloletka

By March 9, the sound of Russian fighter jets in Mariupol was enough to send people screaming for cover — anything to avoid the airstrikes they knew would follow, even if they didn’t know where.

The jets rumbled across the sky, this time decimating the maternity hospital. They left a crater two stories deep in the courtyard.

Rescuers rushed a pregnant woman through the rubble and light snow as she stroked her bloodied belly, face blanched and head lolling listlessly to the side. Her baby was dying inside her, and she knew it, medics said.

“Kill me now!” she screamed, as they struggled to save her life at another hospital even closer to the front line.

The baby was born dead. A half-hour later, the mother died too. The doctors had no time to learn either of their names.

Ukrainian emergency employees and volunteers carry an injured pregnant woman from a maternity hospital damaged by shelling in Mariupol, Ukraine, Wednesday, March 9, 2022. The baby was born dead. Half an hour later, the mother died too. (AP Photo/Evgeniy Maloletka)

Mariana Vishegirskaya walks down stairs in a maternity hospital damaged by shelling in Mariupol, Ukraine, March 9, 2022. (AP Photo/Evgeniy Maloletka

Mariana Vishegirskaya lies in a hospital bed after giving birth to her daughter Veronika, in Mariupol, Ukraine, March 11, 2022. (AP Photo/Evgeniy Maloletka)

Another pregnant woman, Mariana Vishegirskaya, was waiting to give birth at the maternity hospital when the strike hit. Her brow and cheek bloodied, she clutched her belongings in a plastic bag and navigated the debris-strewn stairs in polka-dot pajamas. Outside the ruined hospital, she stared motionless with wide blue eyes at the crackling flames.

Vishegirskaya delivered her child the next day to the sound of shellfire. Baby Veronika drew her first breath on March 10.

The two women — one dead and one a mother — have since become the symbol of their blackened, burning hometown. Facing worldwide condemnation, Russian officials claimed that the maternity hospital had been taken over by far-right Ukrainian forces to use as a base and emptied of patients and nurses.

In two tweets, the Russian Embassy in London posted side-by-side images of AP photos with the word “FAKE” over them in red text. They claimed that the maternity hospital had long been out of operation, and that Vishegirskaya was an actress playing a role. Twitter has since removed the tweets, saying they violated its rules.

The AP reporters in Mariupol who documented the attack in video and photos saw nothing to indicate the hospital was used as anything other than a hospital. There is also nothing to suggest Vishegirskaya, a Ukrainian beauty blogger from Mariupol, was anything but a patient. Veronika’s birth attests to the pregnancy that her mother carefully documented on Instagram, including one post in which she is wearing the polka-dot pajamas.

Two days after Veronika was born, four Russian tanks emblazoned with the letter Z took up position near the hospital where she and her mother were recovering. An AP journalist was among a group of medical workers who came under sniper fire, with one hit in the hip.

The windows rattled, and the hallways were lined with people with nowhere else to go. Anastasia Erashova wept and trembled as she held a sleeping child. Shelling had just killed her other child as well as her brother’s child, and Erashova’s scalp was encrusted with blood.

“I don’t know where to run to,” she cried out, her anguish growing with every sob. “Who will bring back our children? Who?”

By early this week, Russian forces had seized control of the building entirely, trapping medics and patients inside and using it as a base, according to a doctor there and local officials.

Orlov, the deputy mayor, predicted worse is soon to come. Most of the city remains trapped.

“Our defenders will defend to the last bullet,” he said. “But people are dying without water and food, and I think in the next several days we will count hundreds and thousands of deaths.”

Anastasia Erashova cries as she hugs her child in a corridor of a hospital in Mariupol, Ukraine, March 11, 2022. (AP Photo/Evgeniy Maloletka)

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.”