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.”

One in every five Polish vets has considered suicide: “I broke down on December 23rd when I had to put down nine animals in one day.”

A preliminary task: count the amount of people around you who have committed suicide in recent years.

Vets are conscientious, detail-oriented, and great at science. Calculations are a normal part of their work. 

Magda Jaszczak takes a moment to consider. One, two, three… Thirteen people, she counts. 

The first was a doctor who employed her in a clinic in northern England sixteen years ago. He was kind enough to give Magda two months to move out of a neighbouring town and organise her life in the new environment. When she moved there for good, he was already dead. Next, there were three female vets. In 2019, they passed away one by one, all within a span of three months. One of them used to be Magda’s mentor. She had just founded a thriving clinic. The second one was an internationally renowned academic teacher. She trained veterinary nurses. A few months ago, another acquaintance of Magda, a 50-year-old vet, passed away, also having committed suicide. In the Swedish town where she currently runs a clinic, a vet killed himself four years ago. Quite recently, at a hospital in a large city next door, it was a young female graduate, an intern. And so on.

Magda: “In this industry, everyone has a colleague who has died in this way, regardless of whether you work in Poland, England or Sweden.”

Natalia Strokowska, a vet working in Warsaw, says that for her, it’s three people. “Last year, it was a friend from university. She suffered from bipolar disorder. Earlier, a colleague who I helped find a job abroad. He was addicted to drugs. Oh, and a veterinary technician. He treated my guinea pig once. He had been stealing drugs, he was addicted to them. Nobody knew.”

Szymon Najdora, the owner of a veterinary clinic in Katowice, knows two people: “Four years ago, it was one of my employees. A great vet who was adored by her clients. A few hours before she had called me to ask about her vacation; she had wanted to extend it to meet a friend. At that time, we were taking care of a dog at the clinic who had had a strange accident. He was left at home with a group of children, and when the parents returned, his hind legs were paralysed. The owners left him with us. They did not want to contribute to the treatment. It was a tough experience for the entire team, but this girl was hit the hardest. She fought hard for that dog. We even got him a trolley so that he could move around. The dog is doing well now, the partner of our late colleague adopted him. 

I went to another funeral last November. She was a young, talented woman who had achieved a lot. Also around 30 years old. That’s why it hurts so much. Among my other colleagues, there have been five suicide attempts in the past few years.”

Paula Dziubińska-Bartylak is the owner of a clinic in Bydgoszcz and specializes in exotic animals, dogs and cats: “In 2020, my close friend committed suicide. A few years earlier, in the first year that I worked in Poznań, it was a female colleague who was on duty on New Year’s Eve. At another clinic, years ago, another female colleague. She tried to do it at the clinic. Our chief, who went out to consult on a horse, came back because she’d forgotten to take her equipment and medication with her. She arrived just in time. The girl was lying on the office floor, and they managed to resuscitate her. If I were to count the suicide attempts among my colleagues and close friends in the industry, I would run out of fingers.”

A few years ago in the UK, vets were asked, “If you couldn’t treat animals, what kind of profession would be an alternative for you?” Many of them filled in accounting. Magda: “Yes, it makes sense. Most of us are perfectionists, proficient in sciences. Maybe if we were dealing with figures and not animals, we wouldn’t lose so many people.”

The murderous training begins at university: veterinary medicine is one of the most difficult and demanding programs. Before the first major exam, students need to learn the anatomical systems of several species: from pigs and cows to horses, sheep, dogs and cats. You need to remember every bone name in both Polish and in Latin. And this is just the beginning. There is also mental conditioning, an aspect where students, especially female ones, learn that they are nobody.  

Natalia Strokowska is originally from Kraków. Seven years ago, she completed her course in veterinary medicine at Warsaw University of Life Sciences (SGGW). For the first three years of the program, she alternately studied, worked, and slept. She hardly had time for private life. She spent half of her time breathing formalin fumes in the dissecting room and the other half looking through a microscope. From the very beginning, lecturers told her she wouldn’t make it. Students took to sedatives. Every now and then, someone ‘disappeared.’ They dropped out of university, took a medical leave of absence, or ended up in a psychiatric hospital. It was whispered about in the university corridors. 

Natalia also ended up consulting a psychiatrist during the third year of her studies. She received a referral for publicly-financed therapy in her hometown Kraków. She could not afford a course of private therapy in Warsaw, so every Friday she would buy a cheap ticket for a TLK train to Kraków, attend a therapy session, gather strength among her relatives and friends, and then on Monday she would return to the capital for classes. Natalia is an attractive, tall blonde woman and over time she started to earn extra money by modeling. She also took part in the Miss SGGW competition. One professor asked her, “My dear, would you prefer to become a vet or walk down the runway?” Another lecturer, infamous for his ‘weakness’ for pretty girls, handed her a note after a class inviting her to his office. A few years later, he got dismissed on a disciplinary basis. There was also another professor who liked to lean against female students under the pretext of peering into the microscope from behind their backs. He flunked Natalia by a quarter-point, forcing her to resit exams in the September session. At the end, he commented, “I hope this time you can demonstrate your abilities.” He currently teaches at another university.

Today, Natalia is completing her PhD thesis and is a lecturer herself. She notes that some of her students are no longer capable of even hiding signs of self-harm. Natalia sees the suffering in their pale, tired, grey faces. She is able to guess their condition by looking at the pulled-down sleeves of their jerseys. And although the current authorities at her university are aware of the importance of the mental health of future vets, the measures taken are just a drop in the ocean of their needs.

Natalia: “The profile of a veterinary surgeon has changed during the last thirty years. Until the 1990s, the profession was dominated by men who treated farm animals. Today, there is a demand for the treatment of pets, and it’s mostly women who want to study veterinary medicine. They often have a strong sense of purpose, they love animals and want to save them. Then, once they’re at university, they bump into old-school lecturers who sometimes openly show their disrespect. There is an unwritten rule of ‘survival of the strongest.’ In my class, after the first two semesters, the drop-out rate was 40%. In the following years, we were joined by the so-called “parachutists,” those who ended up a class down to repeat a year. The record-holder in my class repeated his year three times, he was several years older than us.” 

Magda graduated from Warsaw University of Life Sciences 16 years ago. “After the third year, I had a mental breakdown and took a leave of absence. Mobbing was ubiquitous at the Faculty. Any pretext was good enough for the lecturers to flunk a student at the exam. One of the lecturers derided me for having red hair. I got a diploma with a mere Pass. When I did my specialisation course in England, I graduated with honours.”

In England, Magda became involved in the activities of Vetlife Charity, which runs a helpline for vets and veterinary students. “In England, they see changes similar to those occurring in Poland. There, the 50-year-old vets in checked shirts and dirty gloves are being replaced by the so-called “pony girls,” the daughters of wealthy parents who loved their ponies so much that they decided to study veterinary medicine. Then, when such a “ponygirl” is confronted with reality, she experiences shock. They are often perfectionists, slim, flawless women wearing well-fitting clothes who, unlike their older colleagues, do not take to drink but suffer from anorexia or torture their bodies in gyms. While I was working at the charity, we received about 20 emails a day from male and female vets. They wrote about self-harm, anorexia, depression, suicidal thoughts, and problems with their clients and bosses. Our task was to offer them support, which included referring them to an appropriate therapist.”

Paula: “The word ‘leisure’ was removed from my vocabulary when I was first started studying veterinary medicine. The amount of work you have to put in is shocking: the treadmill never stops, you have to give it 120% all the time. There were times when I would go to sleep in my day clothes which I came home from uni and then I would wear them the entire following day. I didn’t want to waste time changing my clothes, I would rather study. Studying veterinary medicine, I learned to reduce my own needs to zero.’

Szymon: “I don’t have bad memories from my studies in Katowice. But I did see the pressure that the female students faced. Derision from the lecturers and claims that there is no place for women in the profession was a daily occurrence. The women had to work a lot harder than the men to achieve the same results.”

If there existed a survival manual for vets, the first chapter would be about the university and might end with something like this: “So you have survived university and believe that it will get only better from now on, huh? You don’t even realize how wrong you are.” Szymon: “Maybe if someone told us right away in the first year that this job is not really about animals only, then we wouldn’t have to attend so many of our colleagues’ funerals.”  

Survival Manual, Chapter Two: “You will barely make ends meet and you’ll be considered a rip-off merchant.”

It’s 2014 and Natalia’s just started her first job at a clinic near Warsaw. The boss mentally abuses doctors and 17 employees pass through the clinic in three years. Natalia’s earnings: PLN 980 handed over in an envelope, no social security. Natalia models on the side so she can get by. When she receives her doctoral scholarship, she reaches 2,000 zlotys a month. For several months she passes through various veterinary clinics in Warsaw where she is employed illegally or part-time. In 2015, she registers as a freelancer and starts teaching Medical English. The doctoral scholarship is spent paying the social security contributions, a bookkeeping service provider and a room at a dormitory. She also gets her first contract for doing on-duty jobs at British clinics. After a few years, she finds jobs in Sweden. This is the first time she sees any savings in her account. 

Sedlak & Sedlak’s report shows that the average net salary of a veterinary surgeon in Poland is PLN 2,900. The research conducted by the company Natalia works for (Vetnolimits) in 2018 shows that more than a half of Polish veterinary surgeons have financial problems.

Natalia: “People often consider a vet to be a rip-off merchant basking in luxury. The reality couldn’t be more different. The wealthy ones are the clinic owners who have worked for their position over the years or the vets that take care of large-scale industrial herds. Single-vet surgeries or small clinics often barely get by. Clients require services at the level of human medicine, so vets go into debt buying very expensive equipment like ultrasound scanners, X-ray scanners and tomographs. Products that amount to hundreds of thousands or even millions of zlotys of credit. On top of that, there are the costs of specialisation courses and life-long training, which we pay for ourselves. And our clients are not always willing to pay for the service delivered. What if the animal does not wake up from anaesthesia after surgery or dies despite our attempts to save it? Has the service been delivered or not? Some think it hasn’t been and are prepared to fight to prove they’re right. I hear from other vets that uncollected bills for veterinary treatment may even exceed 50,000 zlotys.”

Szymon: “People buy a pet at a pet store for 50 zlotys and expect its medical treatment to cost more or less that amount. They are shocked when they learn that a surgical procedure will cost them several hundred zlotys. They raise hell, they insult us. Sometimes clients who cannot afford treatment leave their pet, for instance, a rabbit, with us and then we pass the animal on to charities. This is not a good thing because it teaches people that what is broken can be left behind. Several times a year, we also find animals in serious condition abandoned at the door of our clinic. That’s why I believe that having an animal should be a privilege. A luxury.”

Survival Manual, Chapter Three: “You have no idea what extreme despair or extreme rage truly mean.”

Natalia remembers a woman nine months pregnant who came in to have her old dog examined. An ultrasound examination showed that the animal had a giant, bleeding tumour on its spleen. The owner howled in shock and despair and fell to the floor. She lay with the dog for a dozen or so minutes and wept, holding her pregnant belly. Her mother was sitting next to her, also crying. Natalia sat down next to them and held their hands until they calmed down.

Paula: “When an animal dies during surgery, people can roll on the ground and shout, “It can’t be true! It is not possible!” On such occasions, I don’t know what to do. Go out? Lie down next to them and comfort them? I definitely cannot say, “Please pull yourself together and take a seat.” During our studies, no one prepared us for what it would be like to work with people. We never had psychology classes. At the beginning of my career, I didn’t feel equipped to inform clients about the death of their pets. I would dial the number and hang up because I was crying. Finally, there is also the question of the bill. I might forgo my own remuneration, but what about the cost of the procedure? The fee of the anaesthetist who will send me an invoice?” 

The despair of clients is sometimes paired with aggression. 

Five years ago, Szymon consulted a client about his dog. The animal weighed 10 kilos, half of its intended weight. The dog was vomiting violently, it had a tumour that covered almost half of its leg and a few airgun pellets in its body. The owner reluctantly agreed to euthanasia. Later on, he gave Szymon a single-star internet rating with a comment: “If I hadn’t chosen that particular vet, the dog would probably be alive today.” Szymon: “Not a week goes by without me being called a quack and a murderer. Over time, you’re supposed to become immune to such things, but when someone leaves crying out, “We’ll burn this shack of yours to the ground!”, your skin crawls. The worst part is that these aggressive owners often cause their pets’ fatal conditions themselves. We recently had a rabbit with an enormous tumour on its testicle, decayed teeth, a stone in the urethra, a broken leg, and a tangle of fur and dried faeces. The owner looked straight into my eyes and said, “He was fine yesterday.” He tried to pass on the responsibility for the pet’s condition to me.”

Paula feels like she has already heard everything out there. She was called a “heartless murderess,” and one client threatened to kill her child. There were also those who announced that they would destroy her or “fight her until she broke.” 

She also had cases like this one. A dog already has heavy dyspnoea but the client doesn’t agree to euthanasia because she wants the pet to die at home. It will be in agony for two days because “the owner loves it so much.” Paula questions this love. Because if the owner did love the dog, why didn’t she seek medical treatment for the dog six months earlier instead of waiting for the tumour to drag over the ground, decay and eventually rot? Paula sees multiple cases of such neglect every week: “Most of these animals could have been cured. As it is, instead of curing them, I have to euthanise them or watch their human take them home, thus condemning them to more torment. How am I supposed to recover from something like this?”

At the other extreme, there are clients who are not going to let go. Even now, Paula can remember an old cat with kidney failure whose owners kept dragging it from one specialist to another for a year. They spent thousands on its prolonged death: more pumps, more nasoesophageal probes, more nasopharyngeal tubes and drips. The cat was as good as dead. Paula recalls it spread on the examination table like a wet cloth, surrounded by cables and IV drops and tormented by suffering. Paula couldn’t do a thing. The owner can do what they like in this situation. If they want the animal to suffer at home unattended, no one can stop them. But if they are willing to spend tens of thousands on persistent therapy, the vet is equally helpless. The common denominator of both situations is suffering. The kind of death that Paula would not wish on any human being.

Paula: “Desperate people are capable of anything. Why did no one teach us at the university how to talk to them?”

Natalia: “We shepherd our clients through powerful crises even though we don’t have any psychological training to help us to do so. We do it intuitively, at the price of our own sanity. Over time, some cut themselves off from their own emotions in order to survive. It even has a name: “compassion fatigue.” Emotional exhaustion is caused by your own compassion. But if you’ve stopped feeling anything, it means it’s high time to consider changing your profession. 

In January 2019, the US CDC (Centre for Disease Control and Prevention) published the first large-scale study on mortality rates among American vets. The results were alarming: in male vets, the probability of suicide turned out to be more than twice as high as in the general population; for female vets, this factor is as much as 3.5 times. Research has also shown that vets specialising in the treatment of pets are at the highest risk of death by suicide.

Researchers try to explain these statistics by referring to the specific working conditions of vets: working overtime, poor work-life balance, the growing demands of clients, and the necessity of performing euthanasia – not only in old and sick animals but also in those neglected by their owners. 

But that’s not all. Research done in both the USA and the UK shows that veterinary medicine attracts people of a specific personality type: conscientious, empathetic perfectionists. These traits in themselves can contribute to the development of mental disorders resulting from high levels of stress, and when we add in extreme working conditions, this creates a perfect storm – a combination of circumstances in which tragedy comes easy. The issue of money is also important. Most veterinary medicine graduates leave university with massive debt that they have to pay back over the following years.

In Poland, no statistics similar to the American ones have been collected, but there are many signs that the problem is universal and exists in most European countries. The research of Natalia Strokowska shows that one in every five Polish vets has considered suicide, and 4% of vets have frequent suicidal thoughts. In addition, they suffer from addiction, mostly alcohol and drugs, from financial problems, working overtime, low levels of job satisfaction and disturbed family relationships.

Survival Manual, Chapter Four: “You will see more suffering than you can bear.”

Szymon: “There are happy moments, but in general this is a so-called disaster industry.”

Natalia: “I was devastated by a recent shift during which I put down a dog.”

And it was not so much this single death, but the endless loop: life, death, life, death. The euthanised dog’s owners wanted the presence of a tumour confirmed by post-mortem examination. Natalia carried the dog over to the examination table and opened its stomach. While her hands were inside its still-warm body, the receptionist burst into the room, “You need to hurry up, there’s a client coming with a kitten to be vaccinated.” Natalia put away the liver containing the tumour, took off her gloves, disinfected her hands, and stretched her mouth with a professional smile. It’s a joy to meet a new family member. You need to admire it, stroke it tenderly, and enjoy its arrival together with your client. But your thoughts are elsewhere. They’re next door, with the body of the dog that an hour ago was still very much alive. For which someone is mourning. The client with the kitten left, and Natalia came back to the other room to close the dog’s body. She could not swallow her lunch. Within minutes, she would be performing another planned euthanasia.

Magda: “In England, where I worked for 13 years, I once had to put down a pregnant bitch together with her entire, as-of-yet unborn litter. The client could not afford a caesarean. The bitch was in bad shape and she probably wouldn’t have survived the surgery; despite that, this euthanasia was one of the worst ones for me. In my own clinic, I could have let the client pay for the caesarean in instalments, but it was a veterinary corporation, so I didn’t have that option. The clinic owners only took care of the bottom line. The killing was on me.”

Paula describes her last working day. First, patient number one dies – a rabbit brought in by the owner two days too late. On Saturday, the man sent an email to the clinic, in which he said that the animal refused to eat. He was told to bring the rabbit in immediately. He wrote back that maybe he would find time on Sunday afternoon. He didn’t. He brought in the extremely dehydrated rabbit on Monday. The fight for its life began immediately because the animal no longer had the swallowing reflex. By Tuesday morning, the rabbit was dead. During the post-mortem examination, it turned out that the ulcers had perforated its stomach wall and all the undigested content had spilt into its belly. Patient number two: a guinea pig that suffered from pneumonia. Paula had been fighting for it for months, but on that day, despite resuscitation, the guinea pig died. Patient number three: a rabbit with gastric dilatation. It might survive. 

Paula: “Don’t forget to mention that this was, in theory,  my day off. I just drove over to the clinic to help the girls who just couldn’t handle so many emergency patients.”

Magda: “I broke down on the day on which I had to perform nine euthanasia procedures. It was on the 23rd of December, a date known to vets all over the world as the ‘holiday cleaning’ day.

Paula: “In Poland, we call it the “warehouse clearance.’”

Magda: “In England, we would put down the biggest amount of animals before Christmas Eve. They were mostly old dogs, often in poor condition. However, with a little push, they could live a little longer. But the thing is that an old, deaf dog with a smelly muzzle is hardly attractive to Christmas guests. Especially when a breeder is already waiting for a new puppy to be collected. Pre-Christmas euthanasia procedures are interspersed with vaccinations of puppies. It hits your psyche. The more so because neither in England nor in Sweden am I entitled to refuse to perform euthanasia. There, everything can qualify as persistent therapy and for that, I can be sued.’

Paula mentions that before Christmas Eve, the owners try everything to persuade her to perform euthanasia. “He’s definitely going to get worse during Christmas,” is one claim clients often make. In such situations, she says that her decision depends on the outcome of the clinical examination. If she finds the dog to be in very bad shape, she agrees. After all, this is a final act of mercy towards the dog. Since the owner had done nothing for the dog for ten years, they could just as well have taken it out to the forest and abandoned it there before Christmas. Instead, they brought the animal to her. If the dog is not in a desperate condition, Paula informs the client that it needs medical treatment. Some clients take offence and leave. Others change their mind. 

Paula: “I once had a client whom I told that her dog needed a blood test. She looked at me in shocked disbelief, “How’s that? A dog has blood?” I try not to get upset with such things. When I bought my first car, I had no idea that the engine oil needed to be changed at times. The mechanic looked at me with pity. Some people have a similar approach to buying a dog. Then I try and educate them and sometimes I see a change: suddenly they start taking good care of the animal, buy specialist food, and order the most expensive tests. Such miracles also happen.”

Magda took a medical leave after the ‘holiday cleaning.’ The family doctor she saw couldn’t understand what her problem was: Do you have debts? Family problems? Are you in danger of losing your job? Magda shook her head. No, the point was that within a single day she took nine lives. The doctor shrugged and gave her a referral to a psychologist. The therapist was young, a recent graduate. She couldn’t bear to listen to Magda’s story.

Magda: “That’s why we screened the psychologists we employed at the Vetlife Charity. Vets had repeatedly complained that the therapists in England didn’t view them as patients but rather saw them as professionals. Some of them went as far as taking out their phones mid-way of a therapeutic session to present pictures of their own dogs. Or they would ask, “Okay, so which anthelmintic is the most effective in your opinion?”’ 

Chapter Five: “There will always be someone to say you haven’t done enough.”

Natalia: “We often face painful dilemmas. For instance: the animal could be cured, but the owner cannot afford to pay for the treatment. I feel like crying when I read the criticism on the Internet that says that we should save such animals at our own expense because being a vet is a mission in and of itself. My reply would be: Do doctors adopt babies found in baby hatches? Do dentists take pity on the homeless who hang out in front of their offices and put tooth crowns in or give them root canal treatment for free? Because we, vets, constantly pick up injured birds, cat litters, tormented dogs or puppies stuck in boxes at our clinic doors. And we treat them, often for free, and find them new homes. But to many people, especially those who comment anonymously on the internet, this is still isn’t enough.”

Paula: “Not long ago, I had a client whose rabbit did not wake up from anaesthesia after surgery. It wasn’t anyone’s fault, I warned the owner beforehand about how this sometimes happens. Despite this, the woman could not believe it had happened. She sat down in my office and, in tears, demanded an explanation. Meanwhile, clinic employees were calling other owners to say that their pets’ surgeries would be delayed. “So what the hell are you doing there all day?” a client waiting for his rabbit to get castrated shouted. That day, we called it a day at one in the morning. It’s impossible to please everybody.”

Chapter Six: “Save yourself.”

Paula: “I’m not tired of my own compassion, I’m tired of death.”

For Paula, the need to keep jumping from mourning to joy and back is similar to bipolar disorder. In 2020, she felt that none of the versions of herself was real. Not one who comforts distraught clients, nor the one who expresses happiness about having cured a dog’s lymphoma. Arriving home from work, she would stare at the wall and feel nothing. She had the impression that she was made of cardboard: clean, without any feelings, perfectly indifferent. And this is where it gets dangerous. It doesn’t matter to a ‘cardboard person’ whether they live or die. When her close friend committed suicide, the thought crossed her mind that ‘just one step and we can be together again.’

Paula: ‘Our entire industry is steeped in dying. To us, death seems a simple and perfect solution. After all, we know everything about it. We are getting accustomed to it every day. This way of thinking is extremely dangerous.’

This year, Paula decided: “Enough is enough. I need help.” She started therapy and also attends classes with a coach to better cope with the management of the clinic. She does it both for herself and for her little daughter. The ‘new Paula’ tries to turn the phone off and reminds herself that she cannot help everyone. The ‘old Paula’ goes to the clinic even on vacation and sometimes doesn’t come back home for three days in a row, sleeping at the office. That’s how she is: someone else’s suffering torments her. As long as it’s possible for her to reduce it to a manageable level, she keeps working. She feels pity for both animals and people, even when the latter’s ignorance or neglect infuriates when. 

Magda has set up her own clinic in Sweden. She’s also become involved in creating the country’s first charity to support vets with mental health problems. For Swedes, who don’t like to speak out about uncomfortable problems or emotions, this is a novelty.

Szymon says that he has therapeutic support available at home because his partner is a psychologist. And when he notices that a client is unable to cope with a pet’s death, he discreetly hands over her business card.

Natalia Strokowska has founded her Vetnolimits company where she offers mentoring and professional support to vets. Not long ago, together with Halszka Witkowska, a suicidologist, she talked about the risk of suicide in her profession at a virtual Congress of Polish Psychiatrists. Several hundred psychiatrists listened to her speak. 

She talks a lot about mental health with her students. Natalia: “This is a generation that is different from mine. They are not ashamed to talk about what hurts them. For them, consulting a psychiatrist or a psychologist is not a reason to feel ashamed but a logical solution when the realities in their life become too difficult. They thank me every time I tell them about my own experiences because it makes them feel less alone. This does not mean, however, that the call for systemic changes should be stopped. First of all, the ways in which vets are trained has to be changed. In order to prevent tragedies, students should learn something about psychology, ethics, and mechanisms of coping with difficult situations during their university years. One thing will not change for sure: this profession will always attract people who are exceptionally sensitive and empathetic beyond compare. We must not let them be destroyed.”