3.1 Who are the GPs?
In line with reality – GP is rapidly becoming a women’s profession in the Netherlands– ten GPs are female. The majority is of native white Dutch origin, one is Jewish Dutch, one is from Aruba (Dutch Antilles), one is of white British origin and two GPs are of Turkish origin. Most of them are already GP for a very long period and are holding practice in the same ethnically mixed neighborhood. The average time they are holding practice is twenty-three years with one GP holding practice for two years, and on the other end two GPs practicing for thirty-nine years. Therefore, they sometimes have several generations of one family as patients. Their patients of migrant background initially were labor migrants, usually of Turkish or Moroccan background and colonial migrants like people from the Dutch Antilles and Surinam, and later also people with a refugee background. Six GPs have their practice in the big cities, as these are the places where the majority of people of migrant origin in the Netherlands live. Still, also in smaller towns we found GPs with patients of migrant background, because they were recruited for a nearby industry or a refugee center was established nearby. Thus, five participants hold practice in smaller towns.
3.2 The GPs experiences with troubling cases of gender and culture
Table 1
| General practitioner |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 |
| Forced Marriage | + | + | + | + | + | − | + | − | + | + | − | − | + | - |
Family violence not honor related | + | + | - | - | - | - | - | - | - | - | - | - | + | - |
Honor-related violence | + | + | + | + | + | + | + | + | + | + | − | − | - | - |
Honor-related repudiation after rape | + | + | − | − | + | − | + | − | + | - | - | - | - | + |
Virginity Certificate | + | + | + | + | + | − | − | - | + | + | + | − | + | + |
Hymen ‘repair’ | − | + | + | + | − | − | − | − | + | + | − | + | - | - |
Female Genital Cutting | − | + | + | + | + | + | + | + | + | + | − | − | + | + |
Forced Abortion/give up the child | − | − | + | − | − | + | − | − | − | − | + | + | + | + |
Non- acceptance of Homosexuality | - | + | - | - | - | - | - | - | - | - | - | - | + | + |
Overview of the main cases mentioned by the GPs. |
The troubling cases of gender and culture that were mentioned most often by the GPs are female genital cutting (11 GPs), requests for virginity certificates (10 GPs), honor related violence (10 GPs), and forced marriage (9 GPs).
When mentioning female genital cutting the GPs meant they had adult patients in their practice who had been cut in their youth. All forms of FGC are forbidden in the Netherlands and doctors are obliged to discuss the issue with women stemming from risk countries and when they suspect there is risk of FGC to take place, to report this to the authorities. Nevertheless, the GPs rarely had conversations with patients who are genitally cut, as the women were aware that FGC is forbidden by law and denied they had any intention to have their daughters genitally cut. Neither did the GPs discuss other issues known to be related to FGC, like physical and psychological complaints, with their patients. This probably means that women, who are genitally cut, find it difficult to discuss health issues related to this with their GP, as is confirmed by other research.
The distinction between arranged and forced marriage, and with that between voluntary and forced marriage, is always tenuous. Even in Dutch culture, where the romantic love marriage is the ideal, parents may try to influence their children’s partner choice. We have classified as ‘forced marriage’ all those cases in which the patient had explicitly indicated that she – all cases of forced marriage concerned women – did not want this marriage. One GP had several patients who were forced to marry the man who had raped them. The arranged marriages that ten GPs mentioned also involved considerable pressure from the family on the daughter, and in several cases the son, to comply. Usually they were marriages within the family (often cousin marriages, mentioned by eight GPs) and sometimes with a big age difference (five GPs mentioned this).
The background to honor related violence was that the victim was suspected of transgressing codes of proper female sexual conduct. The cases of honor related violence included threats of violence, but patients also came with injuries and two GPs had lost patients who had become the victim of an honor killing. Six GPs had had patients who were repudiated by their husband and families after they had ‘confessed’ that in the past they had been raped. Requests for virginity certificates were made by young women, often accompanied by their mother, because the daughter’s reputation was at stake. Five GPs had experienced that a young unmarried woman was forced to have an abortion and one that the woman was forced to give up her child for adoption. Hymen ‘repair’ refers to cases in which young women who had had premarital sex asked for surgery to (re)construct their hymen. Two GPs had had male patients, whom they suspected struggled with their homosexuality and one GP told about patients of hers, who had had an arranged marriage to, as she suspected, a homosexual man.
Beside the named practices in the table, a variety of other, unclassifiable, cases were put forward by the GPs. Several GPs had had female patients who were send back against their will to the country of origin. Many cases were expressions of unequal gender relations, like a wife who had caught a sexually transmitted disease (STD) from her husband but did not dare to confront him with that. Also, GPs referred to cases of young women who were expected to fully shoulder the informal care for relatives in need, which led to complaints of overburdening, but also meant that they could not continue their education or start a family of their own.
A preliminary conclusion we can draw is that the majority of cases is related in one way or the other to (the regulation of) sexuality.
In many cases the GP’s felt there was little they could do. Patients disappeared from their practice and only later they learned what had happened. When patients did mention their worries to them their usual course of action was to offer a listening ear and if they were open to it give some advice or organize help. Still, some GPs wanted to do more, and did more, but then crossed the boundaries of their professional ethics, whilst others were kept back, or restrained themselves, by their professional ethics, by their respect for their patients’ autonomy in particular, from acting. In the next two sections we’ll discuss these two issues.
3.3 In the name of patient well-being all is allowed?
The GPs were very committed to their patients and also in cases of gender and culture they found troubling wanted to help in whatever way they could. GP1 for instance told that in a case involving honor related violence she was asked by a young female patient to pick her up from the pharmacy. The young woman was expected at home hours before and now did not dare to go home because of the sanctions she feared. The family was familiar to the doctor with family violence. So, the doctor picked her up, brought her home and lied to the family that she was ill and had to go to bed with some painkiller. GP2 told she had a woman in her practice who asked for contraceptives without her husband knowing. When later the couple came to consult her, because the woman did not get pregnant, she avoided a straightforward answer by explaining that there can be many reasons why women do not become pregnant. Yet, their acting in the best interest of the patient was not without moral dilemmas. This became most clear in the issue that the GPs experience as the morally most trying, when they were asked to establish a patient’s virginity. Ten GPs had had requests for virginity testing, and six had complied. The context was usually that the family pressured the young woman to have her virginity confirmed because there were doubts about her chastity. There were threats of sanctions and the doubts could be an obstacle to get married. Some doctors had in some cases actually performed a vaginal examination, although they knew of course that technically there is no necessary relationship between the status of the hymen and virginity and hence it is impossible for doctors to establish whether a woman is still a virgin. More common however was that they sought to have a private conversation with the young woman to hear from her what was the matter and what she wanted, and then to write a virginity certificate or if the family settled for that, to verbally transmit the result of the ‘examination’. The other four GPs had refused, because they did not consider this as part of their job or believed that by complying they would strengthen the sexual morality they rejected or that it might pave the way to other undesirable things, like a marriage with a husband the young woman did not want (the man demanded proof of his bride’s virginity).
The World Health Organization (WHO) has declared in 2018 virginity testing a harmful practice. The interviews took place in 2017, yet none of the GPs referred to the testing as a harmful practice. What then bothered them? Was it that the requests for the testing were made under pressure and coercion from the families? Normally, an intervention needs the patient’s voluntary consent. Yet, if women are forced to ask for an intervention, this condition is not met. Yet, the GPs did not seem to notice the problem that the request cannot be considered an autonomous choice. Another reason for their moral distress might be that they were responding to a sociocultural instead of a biomedical problem. The notion that patients’ needs can be social in nature is well recognized by the first principle of the Constitution of the WHO: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ Yet, as Pablo De Lora pointed out, the idea of medical need is still a matter of controversy, as shows for instance from the battle between insurance companies and patients over what treatment is medically necessary. In the Netherlands the importance of experiencing social acceptance and positive self-worth for a patient’s well-being is accepted as justification for other non-medically indicated interventions, like surgery on children with flap ears, that is covered by in the optional package of many health insurances. On the other hand, while being circumcised is important for social acceptance in Jewish and Muslim communities, male circumcision for religious reasons is currently only part of the optional health care package of one insurance company. Writing out a virginity certificate undoubtedly promotes social acceptance, but less obviously so positive self-worth, and whether it prevents harm to the woman in question is questionable given the WHO’s statement. Yet, what bothered the GPs was not that they were acting on a social problem instead of a physical complaint. Their problem was that they were falsely diagnosing a condition. When they wrote that they could not establish that the young woman has lost her virginity, they were well aware these are ‘diplomatic certificates’ as Juth and Lynøe [14] name them, as the double negation makes that technically they are not lying, but that did not ease their discomfort. GP13 explained why, still, he complied with the request: ‘I take them under my protection by saying that I cannot see that the hymen is ruptured. … I go along in (it) because if I don’t, it is a big problem for them. …’ GP3, herself of Turkish origin, similarly stated: ‘You are a social worker. You try to be non-judgmental. Sometimes you have to trespass certain boundaries, or, you are not obliged to, but you do what is beneficial for the patient. To protect the patient, you do sometimes things you think of as bullshit.’ GP14 therefore called the certificate ‘the nonsense certificate’.
Hence, the GPs wanted to act in the best interest of the patient, but when this came down to engaging in deceit, they trespassed their private and professional moral boundaries. This is particularly so when it concerned virginity tests. While the GPs did not see it as a harmful practice, the WHO does. Doctors performing virginity tests would hence, according to WHO standards, violate their patients’ human rights and doctors suggesting they performed the test, would contribute to the continuation of a tradition that violates women’s human rights.
3.4 Non-intervention in the name of autonomy?
Autonomy has become a very central principle in biomedical ethics. The GPs also found it very important to respect the autonomy of the patient. Illustrative is their acting regarding unwanted marriages. Sometimes patients visited them because of health problems caused by the accompanying distress, sometimes they came with a direct request for help. The practice usually is that a young woman who is raised in the Netherlands comes to tell the doctor that she is going to marry a man from ‘the village’ – that is the village in the country of origin where the family stems from. They are not forced to marry these men, but as GP1 called it ‘are being massaged’ for years into marrying them. GP3 and GP4 had also men who had problems with their marriage being arranged. GP4 told about a male patient of hers: ‘In the years before his mother died – his father had already passed away – he had many stress-related complaints that I could not pin down. Later, he told me that these complaints were because he was so unhappy in his marriage, but that he had to go through with it for his mother. … He had never wanted this woman … And when the mother died, the man told his wife that he wanted to divorce.’ GP3, herself of Turkish origin, explained that generally the children are afraid to go against their parents’ will, because they fear they will lose all contact with them. Her experience, however, was that in most cases the parents later come to terms with it. That is what she always tells the young people together with the message that they have to decide for themselves and not consent to this marriage only because the parents want it. From what GP2 related about a woman of Turkish origin, it becomes clear that, contra to GP3’s experience, the family can react badly if a family member goes her own way. The young woman ran away from home with a Turkish boyfriend to show up only three weeks later. She married the young man, but it turned out that he maltreated her. GP2: ‘Father and brothers never wanted to see her again and that is still the case now, six years later … and the mother and her sister couldn’t bear to watch it. And they were very angry at me at that time, that I did not do anything, but I did not know what I should do. … They were desperate. And now … mother and sister secretly have contact with that girl and the father more or less knows this, but the brothers absolutely not, because they are still furious with her, because the honor is so tarnished by what she did…. The daughter [at home, xx/yy] is even more in a fix [than the parents], because she sees her parents suffering, whom she loves very much, and about whom she feels very clearly that they cannot act otherwise, and on the other hand she says “It is terrible what is happening, we have to help my sister”.’ The maltreated sister did not dare to divorce, because she had harmed her family already so much by her dishonorable behavior, that she could not on top of that divorce. The GP’s intervention was that she started conversations with the parents and the daughters, which is her normal practice, to offer a listening ear and give some advice. Apparently, the family expected her to do more, but she did not know what to do.
The Dutch Society of Medicine, KNMG, has a code on family violence, that includes FGC, honor related violence and forced marriage, that makes clear that in some cases the patient’s choices may be overruled. When an adult victim refuses to give permission to report the case, if this is because of the dependency relationship with the perpetrator, including fear for repercussions, this does not count as a free choice, and the code prescribes to report the case to stop further bodily or mental harm.
Nevertheless, the GPs were reticent to intervene. They felt it as an intrusion in other people’s lives that was only justified if patients explicitly consented with or requested the intervention. As GP1 explained: ‘It is a meddling in other people’s lives, about which you ask yourself ‘Is this my role?’ and ‘Do I know enough about it’ (their culture xx/yy). Her general viewpoint was: ‘It is not up to me to interfere in people’s lives. Except when they ask me to, then I might do it, but not of my own accord. It is up to people themselves to live their lives. And in my eyes young people are sometimes the victim of their parents’ culture, but it is also up to them to struggle out of that. And if they cannot do that, then they can’t, and if I do it (for them) then afterwards they are still not able to. So, my idea is that one has to have patience and believe that the next generation will do it differently.’ It may be that their duty of professional confidentiality restricted their room for intervention, as discussing the problem in the family or calling in professional help breaks confidentiality and requires the consent of the patient. Yet, none of the GPs mentioned this argument. They appeared driven primarily by the wish to respect the autonomy of their patients. This led them to expect their, mostly female, patients of migrant background to explicitly consent with or request for intervention before they would act. Yet, given the oppressive family circumstances of these patients this might be overdemanding, as is also suggested by the KNMG code on family violence. The outcome is non-intervention.
3.5 Comparison cases: labiaplasty and male circumcision
When it comes to Dutch patients, usually young women, who ask for labiaplasty, the GPs usually entered a conversation to discourage the patient, because after inspection almost always it turned out that it was for cosmetic reasons only. They felt little inhibition to speak their minds towards the patient. This contrasts sharply with their moral rule to refrain from judgment when it concerns patients of migrant background. GP1 said for instance about the perpetrators of honor related violence: ‘I have seen those boys when they were little, and when they grow up they start kicking their sister to pieces. That is so hard to accept, but this is how they are raised, this is what you have to do, how you are a good son and a good brother. So, to only despise them is too easy.’
If not medically indicated, male circumcision is not covered by the health insurance. Most families, therefore, go directly to specialized private clinics. Still, GPs could raise the issue with them, but they refrain from it. GP13, male, expressed what the other GPs too feel: ‘Male circumcision is of a different order than female circumcision, less mutilating and far-reaching than for a girl. And it feels like it is a hopeless task, I must say.’ With this he meant that it as a practice that is so commonly accepted by their Islamic and Jewish patients that a conversation has no use. Yet, the GPs also experienced it themselves as a non-controversial subject. GP1, herself Jewish, considered it is up to the Muslim or Jewish communities, not to the GP to make an issue out of it. Only GP3, herself of Turkish origin, was outspoken: ‘It is not in the Koran that boys must be circumcised. It is because once upon a time Mohammed has done it, it is a cultural thing, not a religious thing.’ Still, she also said: ‘It is so deeply rooted … it is not accepted … You can better have it done when they are a child then that they feel cast off or not accepted, because that subject is really holy, male circumcision, you may not touch that. The same with Jewish people. It is not open to discussion.’ And so, she too, refrained from raising the subject with her patients.