Miriam Al Adib: "I have practiced what the WHO defines as obstetric violence, now I would act differently"
Miriam Al Adib is a gynecologist and obstetrician, disseminator and lecturer. Sometimes singled out for speaking of obstetric violence, she is convinced that naming is necessary to end a set of practices that the World Health Organization itself, and many associations and activists, have been pointing out for some time. Al Adib is also the author of several books, such as' Let's talk about vaginas', 'Let's talk about ourselves. Reflections of a rebellious gynecologist 'or' Understanding endometriosis', titles with which she wants to bring to the general public notions and knowledge about cycles, bodies and women's health.
Why do you consider yourself a rebellious gynecologist?
That's what they tell me. Many times I go beyond what is established. I am very critical of scientism, the instrumentalization of science, and sometimes that means going against the established or at least pointing out many things that are considered normal. The patient must be in the center of care and the principle of autonomy must be respected. This treatment, which is not so vertical, in which there is respect for the decisions that each one makes with their body, is in a certain way rebellious because in gynecology there is still this idea that the medical professional is the authority, and I I rebel against that. We are nobody to practice a medicine in which we base our attention on authority, there is something that is inviolable which is the principle of autonomy.
What is scientism?
The problem today is that we have gone from pseudoscience to scientism. One thing is science and another is scientism, believing that science is synonymous with the only truth, that there is only what science shows, and instrumentalizing it: it ceases to be an end in itself to know and becomes an instrument to support other people's interests. to knowledge. These interests can be political, economic, professional ... Science is not absolute truth, it changes depending on new and better studies that say different things than the previous one.
Speaking of science, scores of women have reported changes in their menstrual cycles after getting the coronavirus vaccine. There are, in fact, several studies underway in this regard, has there been gender bias in the development of these vaccines?
The problem with medicine is that it has considered man the model of human being to be studied. The same has happened with vaccines. Either the studies are done with men and a small sample of women, or differences by sex are not taken into account, for example, if we metabolize differently and need more or less doses of something. Conclusions are drawn from men to women. How many women have come to the consultation because they have bled in a way that is not normal or because a lump has appeared in the breast after receiving the vaccine ... Even if the result of the investigations is that the disorders of the hormonal cycle or the exit of lumps in the breasts were minor consequences of the vaccine, they must be included. In the technical sheet of any medication you put from the mildest to the most serious, and if there is something that happens in the menstrual cycle it is something remarkable.
You are leading a study on this, did you do so because you started observing these cases yourself?
In my daily clinical practice I see these cases, women in menopause who start to bleed, women with normal cycles that are now ahead or behind them or who bleed abnormally ... but that is not scientific and that is why we thought about doing a study. We are doing a study with the same methodology as the one at the University of Illinois, through surveys. The objective is to know if the vaccine has implications in the female menstrual cycle and in other aspects related to our health, such as the breasts, axillary lymph nodes ... We have already carried out almost 20,000 surveys. From there we will draw conclusions.
One of the hot topics of the moment is obstetric violence. The Ministry of Equality wants to include the modification of the abortion law and many associations have been denouncing it for years, but the medical associations do not see this concept favorably. Is there obstetric violence?
I am not saying it, the World Health Organization says it, which defines it as a dehumanized treatment in which the patient loses her principle of autonomy, ends up feeling like an object to whom things are done without knowing what they are, nor why what or anything. The problem is that the majority of medical colleges and gynecology and obstetrics colleges do not want to accept it because they say that this expression makes gynecologists look like criminals and that violence is associated with intentionality. But it doesn't have to be: in every society there are types of violence that are normalized and internalized. Many stop looking normal when they are named.
Although it hurts us, we have to talk about this violence, it is not about persecuting gynecologists and saying that they are all very bad but about naming things. We are going to sit down and talk, we have to go to the fundamental questions, to ask ourselves what is happening so that so many women tell these stories and talk about traumatic births. Some will have been due to malpractice, others due to obstetric violence and others because the circumstances will have been traumatic although there has been neither one thing nor the other. That they tell you 'if you were not so fat this would not have happened to you' or that they do not give you an explanation of what they are doing to you, that a woman comes out of a caesarean section and does not know where she is, nor is she informed or the family, and separate her from her baby ... what is that?
What does it take to change those practices?
Shift work with a lot of care pressure is a factor that can lead to doing things that are not entirely correct. That would be an important thing to look at. On the other hand, you have to respect the patients, I think it is something that will be understood little by little. The fact of talking about this violence, even if there are those who deny it, is positive because professionals already have it in their minds and that perhaps makes certain practices already rethink. I was not happy to understand what obstetric violence was, in fact it was difficult for me to recognize that I have practiced obstetric violence, it is that I did not know that I was doing obstetric violence.
In what way did you exercise it?
For example, medicalizing a childbirth unnecessarily. It is a structural violence, you make yourself and learn in a system where you already internalize that and you believe that it is so. Now with the knowledge I have, I would act differently. There have been moments where maybe I have not been at the same level as the patient, I have not sat down with her to talk and explain to her, she was just another patient. When you are tired you don't realize it, you think 'what a nonsense they are calling me for', but for that person it is very important at that moment, even if you have already seen a hundred women that day. I have not always exercised that human treatment that I defend, I am also wrong. You have to name things.
Changing the subject, from time to time the delay of the maternity age appears in the public debate. Many women feel that they have not had, not only the opportunities, but the adequate information to decide about their motherhood. At the same time, there are also complaints about the pressure that some professionals sometimes exert in their consultations. How to combine accurate information on fertility without women feeling that they are saying that of 'you miss the rice?
If I see that a patient does not have a long way to go to become a mother, I have to tell her, but I tell her that it is not pressure at all, but information. We are going to give the information aseptic, without judgment and making it clear that it is for them to handle that information as they want, but the reality is that there is no unlimited time to be a mother. If they don't want to be mothers, let them forget it, but if the desire to be a mother is in your head, keep the information in mind to do whatever you want with your reproduction. And of course, do not talk to the patients as if they were little girls or tell them if they are going to pass the rice or go where no one calls us.
Do we lack information? Education?
If we had quality sex education, women would not be so sold in the consultation. But there is so much misinformation. Higher education, better health, they go hand in hand. And within sexuality, the same: the better sexual education, the better sexual health you will have. Sex education is not only to protect yourself and to avoid STIs or unwanted pregnancies, but it is usually understood in a very mechanistic way, very disconnected from the psycho-affective part, from the emotional part, from respect towards your body and towards other people. That sexual education is useless, curiosity is innate and any adolescent, if you don't talk about this, will look for information on the Internet.
We have grown up naturalizing that period hurts. But does the rule hurt?
The period can hurt but it is not normal that it hurts, if it hurts, something happens. If the pain is too intense and is accompanied by discomfort in relationships or when defecating or urinating, it must be ruled out that it is not endometriosis. Almost half of the women suffer from it and it takes an average of eight years to be diagnosed precisely because of this normalization of pain. It may also be that you do not have an organic pathology, but the pain means something, you can have, for example, an imbalance in the mediators of inflammation with a predominance of prostaglandins and we have to see why it happens. Generally, it is usually when there is an overexposure to certain environmental conditions, such as bad habits, and you have to go to the root, it is not worth giving the contraceptive as the only option. The easy thing in medicine is to treat the symptom and not go to the root, but improving lifestyle habits greatly improves pain. If a woman prefers the contraceptive, perfect, the case is to have options.
He mentions endometriosis, a disease that we are beginning to talk about more but about which there is still a lot of ignorance. How is it possible that the diagnosis is so complicated? Missing? Resources, training ...
When you start to investigate what is wrong, the dramatic thing is that what is wrong is that we do not listen to the patients. There is an important gender bias in the diagnosis of certain pathologies: if women complain of pain, fatigue, depressive symptoms ... things that cannot be measured, the most frequent thing is that we end up taking a psychoactive drug home instead of looking for it. before organic causes. It does not mean that in many cases it is not necessary but that we should first rule out other causes. On the symptoms that cannot be measured, many times a veil is drawn and we psychiatrize some autoimmune diseases. We treat only the tip of the iceberg.
