Women in the UK are suffering injuries and other health problems as a result of the growing popularity of anal sex among straight couples, two NHS surgeons have warned.
The consequences include incontinence and sexually transmitted infections (STIs) as well as pain and bleeding because they have experienced bodily trauma while engaging in the practice, the doctors write in an article in the British Medical Journal.
Tabitha Gana and Lesley Hunt also argued that doctors’ reluctance to discuss the risks associated with anal sex was leading to women being harmed by the practice and letting down a generation of women who are not aware of the potential problems.
In the journal, they said “anal intercourse is considered a risky sexual behaviour because of its association with alcohol, drug use and multiple sex partners”.
However, “within popular culture it has moved from the world of pornography to mainstream media” and TV shows including Sex and the City and Fleabag may have contributed to the trend by making it seem “racy and daring”.
However, women who engage in anal sex are at greater risk from it than men. “Increased rates of faecal incontinence and anal sphincter injury have been reported in women who have anal intercourse,” the report said.
“Women are at a higher risk of incontinence than men because of their different anatomy and the effects of hormones, pregnancy and childbirth on the pelvic floor.
“Women have less robust anal sphincters and lower anal canal pressures than men, and damage caused by anal penetration is therefore more consequential.
“The pain and bleeding women report after anal sex is indicative of trauma, and risks may be increased if anal sex is coerced,” they said.
National Survey of Sexual Attitudes research undertaken in Britain has found that the proportion of 16- to 24-year-olds engaging in heterosexual anal intercourse has risen from 12.5% to 28.5% over recent decades. Similarly, in the US 30% to 45% of both sexes have experienced it.
“It is no longer considered an extreme behaviour but increasingly portrayed as a prized and pleasurable experience,” wrote Hunt, a surgeon in Sheffield, and Gana, a trainee colorectal surgeon in Yorkshire.
Many doctors, though, especially GPs and hospital doctors, are reluctant to talk to women about the risks involved, partly because they do not want to seem judgmental or homophobic, they add.
“However, with such a high proportion of young women now having anal sex, failure to discuss it when they present with anorectal symptoms exposes women to missed diagnoses, futile treatments and further harm arising from a lack of medical advice,” the surgeons said.
NHS patient information about the risks of anal sex is incomplete because it only cites STIs, and makes “no mention of anal trauma, incontinence or the psychological aftermath of the coercion young women report in relation to this activity”.
Health professionals’ disinclination to discuss the practice openly with patients “may be failing a generation of young women, who are unaware of the risks”.
Claudia Estcourt, a professor of sexual health and HIV and member of the British Association for Sexual Health and HIV (BASHH), backed the surgeons’ call for doctors to talk openly about anal sex.
“BASHH strongly supports the call for careful, non-judgmental inquiry about anal sex in the context of women with anal symptoms,” she said.
“Within sexual health services, women are routinely asked about the types of sex they have so that comprehensive assessment of likely cause of symptoms, investigations needed and management can be made.
“We find that by explaining why we are asking these questions, asking them in sensitive, non-judgmental ways and giving patients time to answer, are all key to providing the best care.
“We are highly skilled in assessment of women with possible sexually caused anal trauma, whether through consensual or non-consensual sex, and would encourage women with concerns to contact their local sexual health clinic or sexual assault service as appropriate.”
Providers of sex education in schools are teaching children that prostitution is a “rewarding job” and failed to advise a 14-year-old girl having sex with a 16-year-old boy that it was illegal.
Outside organisations teaching children about sex also promote “kinks” such as being locked in a cage, flogged, caned, beaten and slapped in the face, The Times has found.
One organisation encouraged pupils to demonstrate where they like to touch themselves sexually, in a practise criticised as “sex abuse” by campaigners.
Another provider, an LGBT+ youth charity called the Proud Trust, produces resources asking children aged seven to 11 whether they are “planet boy, planet girl, planet non-binary”.
Last night campaigners said that “inclusiveness is overriding child safeguarding” and that the materials were “bordering on illegal”.
This week Rachel de Souza, the children’s commissioner, revealed that she would review sex education being taught in schools after Miriam Cates, an MP, was contacted by a parent whose nine-year-old child came home “shaking” and “white as a sheet because they’d been taught in detail about rape”.
Relationship and sex education (RSE) became compulsory in English secondary schools in 2020, with many contracting out the teaching. Since then an industry has sprung up of providers who produce resources and go into schools to teach sex education and gender issues.
Staff do not need education or child development qualifications and there is no professional register or regulation of their curriculum.
One organisation, Bish, is an online guide to sex and relationships for children aged over 14. It is written by Justin Hancock, who teaches sex education in schools and provides teacher training on sex education.
The website features a question from a 14-year-old girl having a sexual relationship with a 16-year-old male. She states that she is worried about becoming pregnant because they are not using contraception and are using the “withdrawal” method. In his response Hancock, who describes himself as a freelance sex and relationships educator, said that “your risks of pregnancy are very, very low”, a statement described as “dangerously reckless” by campaigners. He also failed to mention that the relationship was illegal and advised using lubricant during anal sex.
In another post on the site, a reader wrote to say that she felt “dirty” after being coerced into having sex for money. Hancock replied: “There are many many people doing sex work who do enjoy what they do — even if they don’t necessarily enjoy the sex. It can be a really difficult job but many people find it rewarding — just like other jobs.
“This is especially true if sex workers mainly have good clients, which I don’t think you do. If you did want to continue, maybe you could get better clients?”
In a post about “kink”, Bish links to a blog that provides a list of sexual activities including using manacles and irons, whips, swinging and beating.
In a post about masturbation, parents are told: “If your kid is having trouble understanding this, or you want to explain how to touch themselves, you could get hold of some Play-Doh or plasticine and make a model of what someone’s genitals might look like. They could practice touching the models gently in a similar way to how they may touch their own.”
The Safe Schools Alliance said: “Telling children to practise masturbating on a plasticine model is child sexual abuse.”
Bish claims that more than 100,000 young people a month learn about sex from its website. The site was funded by Durex but the condom brand withdrew its sponsorship. It is not clear why. The website is now funded by donations from the public and schools pay Hancock for resource packs that he provides. Hancock says on his website that he has taught “a broad variety of RSE topics in state and independent schools”.
A full day of teaching costs £500 a day for local authority schools, £550 for academy schools and £600 for fee-paying schools.
Hancock says that his website “is not designed for classroom RSE teaching”, and that teachers should visit his training site for resources, which can be bought on his online shop.
In 2019 the government announced that schools would be given access to a £6 million RSE training and support package so that teachers in England could provide new classes on issues such as healthy relationships, safe sex and consent. Last month the website Vice reported that only £3.2 million had been taken up by schools.
A survey by the Sex Education Forum of children aged 16 and 17 last year found that 35 per cent rated the quality of their school’s RSE provision as “good” or “very good” — down six percentage points from the previous year. This was attributed to many of the basics not being covered.
The Proud Trust produced a range of resources called Alien Nation that asked primary schoolchildren aged seven to 11 whether they felt closest to “planet boy, planet girl, planet non-binary”.
It also asks: “Which planet were you sent to as a baby” and “What would your ideal planet be like?”. Its website states that the resource was funded by Cheshire West and Chester council. The charity Educate & Celebrate, founded by Elly Barnes, a teacher, promoted a book called Can I Tell You About Gender Diversity?, which tells the story of Kit, a 12-year-old girl who is being medically transitioned to live as a boy.
Resources on their website include lesson plans for children aged seven to 11 that suggest pupils “create a gender neutral character” that they can share with the rest of the class.
Teachers should encourage them to “refrain from saying he or she” and “introduce gender neutral pronouns and language, eg They, Zie and Mx”. The group says that its methods have been adopted by “hundreds of schools”.
Last month Lord Macdonald of River Glaven, a former director of public prosecutions, said that providers were preventing parents from viewing teaching resources, citing commercial confidentiality.
Tanya Carter, spokeswoman for Safe Schools Alliance and an early years practitioner, said: “We are very much in favour of sex education but it should be for the benefit of children — learning about rights, how to protect themselves, and how to get help if someone is abusing them. It should not be about promoting prostitution and abuse to already vulnerable children.
“We don’t think Bish or Justin Hancock should be anywhere near children because he clearly doesn’t understand child protection. It’s completely indefensible what he’s been promoting to children and some of it is verging on a criminal offence.”
Hancock declined to comment. The other providers did not respond to a request for comment.
A spokeswoman for Cheshire West and Chester council said: “The Alien Nation book aimed to support teachers and schools to explain gender identity and gender variance. Lesson plans were created by the Proud Trust to accompany the book, which could be used by schools if they wished.
“The council will always take on board comments and will share these with the Proud Trust in relation to the Alien Nation book. The support pack is not available on the council’s website.”
A mother was reported to social services after she objected to the way her children were being taught about sex and gender at school (Charlotte Wace writes).
The woman said that she wanted her six daughters, four of whom are foster children, “to know they have [a] right to safe spaces based on biological sex and equality in sport”. She wrote to the school after being told that two of the girls, aged 12 and 13, were due to have lessons on sex and gender, and asked to see material used in the lessons in advance.
It amounted to “indoctrination”, she claimed in her letter, and she asked the school to add “some scientific balance”.
She was summoned to a meeting with social workers, an educational adviser and the member of school staff who had alerted the authorities. It was decided that a social worker would speak to the mother. The social worker summarised that they, along with other social workers, held “no concerns” relating to the mother’s care of the children and that no further action was required.
The woman has started legal action against the teacher who made the complaint and is suing for defamation.
The school has declined to comment.
Most parents approach children’s questions about sex with careful thought. We know that our period chat, puberty Q&A, our bleakly vital guidance on sexting and porn won’t just affect their present happiness and bodily ease, but future relationships too. We entrust schools to make up for our shortfalls or embarrassment, to further our conversations with sensitivity and fact.
We’d expect RSHE (relationships, sex and health education) lessons to be conducted by trained teachers, schooled in biology, alert to pornified and misleading internet content. We’d hope our kids learn not just where babies come from but that sexuality is diverse, that sex isn’t just about problems, like STIs and abortion, but a source of joy.
Instead your child may be taught by the School of Sexuality Education which asked kids to Google then draw masturbating animals. Or the Proud Trust, whose dice game asks 13-year-olds to speculate how various body parts and objects will pleasure their anus. Or Diversity Role Models, which promoted the message beloved of paedophiles: “Love has no age limit.”
Because any organisation can now teach RSHE, including activist groups with political agendas. Staff don’t need education or child development qualifications. There is no professional register or regulation of their curriculum. The Department for Education (DfE) says it is a school’s responsibility to oversee lesson content but many don’t have time, often entrusting outside speakers to address classes with no teacher present. And if parents demand to see teaching resources, groups often cite copyright law and refuse.
RSHE teaching, as Miriam Cates, a Tory MP and former biology teacher, noted in her Westminster Hall debate on Thursday, is “a wild west”. Indeed it is a deregulated, privatised, quintessentially Conservative mess.
The government’s response to criticism about inadequate sex education was to make it mandatory from September 2020 for both primary and secondary pupils. The DfE advocates a “programme tailored to the age and the physical and emotional maturity of the pupils”. But instead of providing funds to recruit or train RSHE specialists, it left schools often to outsource lessons to groups, some newly formed to win these lucrative contracts. Since then many parents have voiced concerns. First at the inappropriately sexualised content of lessons for young children: 11-year-olds asked to work out from a list if they are straight, gay or bisexual; ten-year-olds told to discuss masturbation in pairs. Compelling pre-pubescent children to talk about explicit material with adults transgresses their natural shyness and is a safeguarding red flag.
Many groups brand themselves “sex positive”, a confusing term which doesn’t mean “relationships are great” but that no sexual practice is off-limits and the sex industry, specifically pornography, is wholly liberating. BISH Training’s website entry on “rough sex” dismisses the notion that online porn is responsible for a rise in choking, hair-pulling and spitting as “annoying”. Although 60 British women have died of strangulation during sex, BISH simply tells young people to go slow “at first”.
Reading RSHE groups’ online material, and most is hidden from public scrutiny, none addresses the fact that boys and girls are fed different sexual scripts from increasingly violent mainstream porn. Those being choked, violently penetrated in multiple orifices are rarely male. Yet there is no feminist critique or much focus on female pleasure.
Such teaching is supposed to uphold the 2010 Equality Act in which sex is a protected characteristic, yet much of it blurs biology. The Sex Education Forum divides us into “menstruaters” and “non-menstruaters”. Just Like Us states that sex can be changed. Amaze suggests boys who wear nail varnish and girls who like weightlifting could be trans.
Researching my report on the Tavistock child gender service, I spoke with parents of girls on the autistic spectrum who’d always felt like misfits but after listening to outside speakers at school assemblies or RSHE classes now believed they were boys. Gender ideology, with no basis in science or fact, is being pushed in schools, as Cates says, “with religious fervour”.
In its carelessness and cheap-skatery, the government has enabled teaching that is well out of step with public opinion. More In Common polling of 5,000 people found that while 64 per cent of us are happy for schools to teach that some children have two dads or mums, only 31 per cent believe primary schools should teach about trans identity. Parents know it is confusing, unscientific and predicated upon gender stereotypes.
The government’s present hands-off policy also leaves schools vulnerable when challenged by homophobic religious groups, as in Birmingham when extreme Islamists stirred up parents to oppose teaching about gay parents. Head teachers then said they’d have welcomed more prescriptive government guidance so parents could hold elected politicians, not individual schools, to account.
At Thursday’s debate, the chastened schools minister Robin Walker noted that parents should have ready access to all RSHE teaching materials and said the equality and human rights commission is working out guidance on how gender identity should be taught in schools. Such lessons must include evidence of social contagion, the harms of puberty blockers, warning about irreversible treatment and the experience of a growing number of “detransitioners”.
But the government needs to go further, with a register of outside groups and close monitoring of misleading materials. It should also teach critical thinking, so children can evaluate the porn-suffused culture in which they live. There’s no point parents putting such care into how we teach children about sex if the government gives none at all.
While some girls feel they are expected to look and behave like porn stars, with hairless, glistening bodies, a few boys are turning to plastic surgery because they worry their penises aren’t large enough. A friend who is a north London GP and mother of two boys says, “I’m getting requests from teenage boys for penis enlargement. That’s surely a result of too much porn.”
Almost every expert, parent, teacher and teenager I talk to feels that it’s the rise of online porn that underlies the current problems – for boys and girls. Only 25 per cent of parents think their 16-year-old sons have watched porn. Yet a survey by the NSPCC showed that two thirds of 15 to 16-year-olds have seen pornography online, and nearly a third of 11 to 12-year-olds, with the majority being violent and non-consensual.
“Pornography is everywhere,” says Mohammed, now in the sixth form of an all-boys school in Yorkshire and a champion debater. “You can’t avoid it. It’s just a click away while you are doing your homework and it makes you feel inadequate. That’s why my generation needs alcohol or drugs to do this kind of stuff. I envy my friends who’ve been in a steady relationship since they were young, and my parents, who had an arranged marriage.”
Our children have become subject to the whims of a vast $97 billion profit-seeking industry that has no concern whatsoever for their emotional or sexual health, according to Simon Bailey, the National Police Chiefs’ Council lead on child protection. He has been demanding a national debate about the potentially devastating impact of online porn ever since I first interviewed him a decade ago. The sense of young male entitlement, he says, “sometimes feels medieval. Boys get some of their sex education from porn, which once might have been a picture of a naked woman spread across a page,” but now involves images of gagging, rape, anal sex and domination. “More and more children are watching hardcore porn and it soon becomes normalised,” says Bailey, who is heading the police service response to investigating the Everyone’s Invited allegations. “You can’t rely on families or schools alone to tackle this. The tech industry needs to take responsibility. No one under 18 should be able to see this stuff.”
Dr Caroline Douglas-Pennant, a counselling psychologist working in west London, who has four daughters, believes boys need new boundaries. “Boys think about sex a lot of the time, but it’s vital they understand that their sexual needs are not more important than women’s and what may even have been tacitly acceptable in their parents’ generation is unacceptable now,” she says. Children receive sex education classes at school. “But a lot of boys and girls feel that adults and teachers are still letting them down. They are being tokenistic and just ticking the boxes with their relationship and consent classes without helping them address the real problems. It’s the competitive, pressurised, misogynist culture we need to tackle.”
Porn, she agrees, has exacerbated the situation. “It gives the message women are constantly available and enjoy aggressive sex. Boys at 17 are driven by testosterone. They need to be shown how to control it. Dads are extremely important role models for loving and respectful relationships for their boys and we need to encourage them to think about their position in the conversation and be curious about why they may feel defensive or attacked.”
When Britney Spears lost it in 2007, shaving her head and waving a baseball bat at anyone who approached her, I confess that my initial reaction was “get in! Now THAT’s what I call a protest!” A decade before the eruption of #metoo, there was a woman truly raging, in an industry that tends to reduce female anger to getting a bit feisty about your ex while wearing a push-up bra. The head shaving felt satisfyingly symbolic – see how swiftly the feminine mystique can be dispensed with! I loved her for that. It reminded me of Donita Sparks throwing her sanitary protection into an unappreciative Reading crowd, uttering the immortal line “eat my used tampon, fuckers!” Only that was L7, so you kind of expected it. This, though, was Britney!
After that I fully expected Spears to re-emerge, Alanis Morrisette-like, with a ton of songs dissing everyone in the music industry who’d ever exploited her. Instead, she shrank, with her father Jamie being assigned the role of her conservator, managing her wealth and personal decisions, in 2008. She grew her hair back, re-embraced the art of femininity and got back to business, gyrating and thrusting as before. Like many, I found it strange for her to be working so hard and so publicly if she was too ill to be in control of her own life. This week, after 12 years, Spears filed to have her father permanently removed from his role (though others may assume some control).
What gets me is the optics of the thing – the clipping of wings, the silencing of protest, the return to paternal authority. It’s like something out of Showalter’s The Female Malady, or one of those works of feminist fiction – Wide Sargasso Sea, The Yellow Wallpaper – in which a husband drives his wife insane by defining and treating her as such. It’s reminiscent of twentieth-century stories of fathers seeking to “manage” their socially embarrassing daughters by having them institutionalised or even lobotomised (the most famous example being John F Kennedy’s sister Rosemary). It’s a million stories, as Showalter documents, of psychiatric diagnoses being used as “punishment for intellectual ambition, domestic defiance, and sexual autonomy”. It looks like a woman being punished – and driven to the edge – for stepping out of line.
What I’m suggesting might sound anachronistic. Mental illness diagnoses may once have been weaponised, but there’s a general feeling that this died a death with deinstitutionalisation in the late twentieth century. We are clever now, psychiatry is clever, and when individuals have control of their own lives taken from them, it is only because they are truly ill. The trouble is, I bet that’s what fathers of lobotomised daughters and husbands of neurasthenic wives told themselves, too. How do you check the purity of your own motivations when judging the depths of another’s delusions?
However much outside observers speculate on Spears’ state of mind – she looked a bit weird in that video, her pupils are all funny, was that Instagram message a secret sign? etc. – you don’t have to decide she looks well to suspect there is something wrong in how she is being treated. Sick or healthy, it’s very hard to see how she might ever get out of it. There are few things that are harder to prove than sanity once you’re deemed to have fallen on the wrong side of it (see the Rosenhan experiment, which, for all its possible flaws, still rings true). And then there’s that feedback loop between treating someone as though they are “abnormal” and them behaving “abnormally”.
This process is captured beautifully in Wide Sargasso Sea. Jean Rhys’ 1966 novel reimagines the life of the first Mrs Rochester (aka Bertha Mason, the “madwoman in the attic” from Charlotte Brontë’s Jane Eyre). In Rhys’s telling, Rochester is a weak, frightened man, unable to cope with the different culture of his Caribbean wife and easily swayed by rumours about her “insane” family background. Antoinette – Bertha’s name before he takes it from her – finds she cannot please him, resorting to increasingly desperate measures. One night she asks him if he hates her:
‘“I do not hate you, I am most distressed about you, I am distraught,” I said. But this was untrue, I was not distraught, it was the first time I had felt calm or self-possessed for many a long day.’
If you’ve ever been in a similar situation, lines like this can hit you full in the gut, because they are so familiar. That moment when you know you’ve been outmanoeuvred by a man’s performance of sadness at your supposed insanity:
“We won’t talk about it now,” I said. “Rest tonight.”
“But we must talk about it.” Her voice was high and shrill.
“Only if you promise to be reasonable.”
You read it, and you want to scream in his face (only you’d end up in the attic, too). Reasonable, my arse.
I first read Wide Sargasso Sea as an A level set text in 1992. It was four years since I’d completed an eight-month stay in what was euphemistically called an adolescent unit. This was ostensibly for anorexia, but anything you did in that place could be construed as mad and usually was. I could write reams about that place – don’t worry, I’ll try not to – but one particularly delightful part of the daily routine was the handover, when night staff handed over to day staff, and vice versa. For reasons I will never grasp, this had to be done with everyone, patients and staff, gathered together in a room so that everyone could hear what was being reported about everyone else.
“Victoria spent a long part of Tuesday evening staring at the TV room curtains … On Wednesday afternoon, Victoria seemed very fixated on Madge in Neighbours … On Thursday morning, Victoria insisted on eating her cereal with a soup spoon despite an availability of dessert spoons … We are increasingly concerned about Victoria’s fixation on Madge and would like to alert staff in case this should extend to Scott and Charlene.”
This is literally how it would go. The curtain thing in particular has stuck in my mind (hey, maybe I am fixated?). I wanted to complain that I wasn’t staring at the curtains, only that would have constituted denial. In order to demonstrate a healthy grasp of reality, you had to accept that anything anyone else said about you was true.
It’s incredibly hard to convey what this does to you, knowing your every move is being over-analysed and noted down in order to be broadcast to everyone around you (a bit like being famous, I guess, which makes Spears’ situation all the more agonising). It makes you desperate to “act normal” but telling yourself to act normal is like telling yourself not to think of an elephant. It makes you do the opposite. It’s like Catch 22 (another cultural artefact I’ve neither seen nor read, but nonetheless have opinions about).
This is why Wide Sargasso Sea affected me so much and remains one of my favourite books. Antoinette made me think of me. And now she makes me think of Britney. And the worst of it is, it never goes away.
As Charlotte Perkins Gillman illustrates so terrifyingly in The Yellow Wallpaper, patriarchy doesn’t just tell women they’re mad, but can make them so. It deprives them of bodily autonomy, intellectual stimulation, community, a basic feeling of safety. I still have a “contract” I had to sign, aged 12, listing the privileges I had to “earn back” as part of my treatment for anorexia. I’m glad I still have it, otherwise I’d think I’d imagined denying girls books – books! – was still a thing in 1987. It becomes impossible to distinguish between symptoms of an illness and responses to its treatment. I am doubtful, for instance, as to whether I would have made meals last four hours had I been granted anything else to do other than stare at walls. Yet timing meals is something that stayed with me for years.
In Why Women Are Blamed For Everything, Dr Jessica Taylor draws parallels between the diagnostic criteria for borderline personality disorder and those formerly used for hysteria:
“They are essentially the same diagnosis. They are both targeting women and girls. They are both built around gender role stereotypes. They both oppress traumatised and abused women. Where hysteria (or ‘wandering womb syndrome’) was said to be caused by women’s hormones and biology, BPD is said to be a disordered personality. Both are innate, internal causes which need to be medicated, treated and dealt with.”
I increasingly see the mention of BPD in reports on anorexia and bulimia, with the implication that this makes sufferers less manageable during treatment. It makes me feel little progress has been made in recognising trauma. As Judith Herman writes, trauma survivors “often tell their stories in a highly emotional, contradictory and fragmented manner which undermines their credibility”. They don’t sell themselves well. They starve, binge, shave their heads, wave baseball bats. Meanwhile, self-styled guardians, calm as Rochester, maintain “[their] prerogative to name and define reality”. They get their conservatorships.
By the time I was aged thirty, I had a PhD and a full-time job, had been with my partner for five years and was thinking of starting a family. This didn’t stop a male family member from turning up unannounced at my partner’s place of work to berate him about how unstable I “really” was, even though I was “good at hiding it”. I had tried to persuade him not to, but that had been construed as me not being in touch with reality. This impasse was only resolved months later, at which point it was agreed that I wasn’t particularly ill, but that this meant I’d been making people think I was ill, which was in itself a mad thing to do. I’ve never really challenged this. There reaches a point where you have to go along with other people’s narratives – “yeah, soz for pretending to be mad, don’t know what got into me” – because you can’t be arsed to bring any more accusations your way by protesting. You try to speak and hear every word going through the “madness” filter before it reaches anyone else (“her voice was high and shrill”, as Rochester puts it. Isn’t it always? That’s how people talk when they’re scared).
So what can you do? Say what they want you to say. Grow your hair. Do your dance. The whole thing is profoundly patriarchal, when you think about it. Therefore you try not to think about it too much, otherwise you’d prove them right by genuinely losing your mind.
We can all identify someone having a stroke, can’t we? A sudden loss of function on one side of the body, drooping face, slurred speech, numbness. Sure we can — but that someone will most probably be a man.
With women, stroke symptoms are very different. They may present as a migraine-like headache, light-headedness, possibly a drop in co-ordination. Transient ischaemic attacks, or mini strokes, are often described by women as, “I felt funny for five minutes, but now I’m fine” or, “I had total brain fog for an hour, but I’m OK.”
The critical thing, says Dr Alyson McGregor, an emergency medicine consultant, is that these unique female symptoms are only now being pinned down. Many doctors, let alone the public, don’t recognise them, meaning women’s strokes are often misdiagnosed or undiagnosed.
Unsurprisingly, although men are more likely to suffer strokes, more women die of them; twice as many, in fact, as die from breast cancer. Strokes are the third leading female cause of death, but their symptoms are often brushed off as urinary tract infections, migraine or anxiety. This means proper treatment is frequently delayed, anticoagulants are prescribed at a lower, less effective dose than they are for men, and outcomes are poorer.
McGregor is one of America’s experts in the male-centric bias in the medical profession, which for years has nurtured doctors with the false belief that apart from the sex organs, men and women are biologically identical. While everything from textbooks and medical tenets to drug research and dissection mannequins treat male bodies as the human norm, she says women’s bodies react differently from their DNA up. (In fairness, a leading US medical school puts a wig on a mannequin to flag it as female.)
The unconscious sex bias in medical knowledge, which first came to my attention in Caroline Criado Perez’s book Invisible Women last year, is fairly jaw-dropping stuff. Heart attacks, for instance: men often get the classic symptoms of pain down the left arm, chest pressure, nausea, cold sweats, while women may present with only mild pain and discomfort, fatigue, possible shortness of breath and a strong feeling “something isn’t right”. They’re often told they’ve got a panic attack and anxiety, and sent home.
One study of cardiac misdiagnosis in 100,000 people showed that women under 55 who went to A&E with significant heart-attack symptoms are seven times more likely to be sent home than men, doubling their risk of death. Overall, women are three times more likely than men, in the US at least, to die after a serious heart attack.
Women’s hearts fail differently. After cardiac arrest, unlike men, their hearts have pulseless electrical activity — they flatline and they’re not shockable. Any TV hospital drama featuring doctors waving electric paddles on a woman is cobblers. (Apparently the only tools are CPR and adrenaline.) Plus, while men gather big clots of plaque in their blood vessels, women’s vessels absorb it, weakening and stiffening. This microvascular dysfunction stresses the heart, but — guess what? — angiograms aren’t designed to detect it. And, poignantly, women are the primary victims of Takotsubo cardiomyopathy — broken heart syndrome — thought to be caused by a massive surge of fight or flight hormones after a stressful event, such as a family death. Suddenly the left ventricle of the heart balloons and cannot beat properly.
Women are less likely to be treated for sepsis, arrhythmia and chronic pain conditions such as fibromyalgia. They’re less likely to be referred for tests for irritable bowel syndrome (IBS), and autoimmune and various neurological disorders. In other words they’re undertreated and underbelieved.
Women metabolise prescription drugs differently from men 40 per cent of the time, but most drugs are still tested almost exclusively on men. It’s cheaper and easier. The catastrophe of thalidomide tightened regulations to protect women of child-bearing age and many researchers then chose to exclude them completely. Big Pharma’s testing protocols are developed to identify male-pattern symptoms.
Take statins. A prominent female cardiologist, quoted in the book, says they have little benefit for the millions of women who take them — and there is zero evidence that they lower the risk of heart attack or stroke for women. Or aspirin: the anti-blood-clotting benefits of aspirin have been observed only in men; with women, they don’t outweigh the risks. Another study shows naltrexone, an anti-addiction drug, reduced the use of alcohol and drugs in men, but increased it in women.
Most roads in women’s health, though, lead back to a male idea of female anxiety. Women are more likely to receive a psychiatric diagnosis — always remembering “hysteria” is derived from the Greek word for uterus, “hystera” — and there is “a pervasive unconscious belief in medical culture that women are prone to illogical and unreasonable outbursts”. In other words, they’re attention-seekers and their complaints less believed. McGregor sees this implicit bias everywhere in medicine.
In one study of IBS, men were more likely to be offered x-rays, women anti-anxiety medicine and lifestyle advice. Another study showed severely injured women were less likely even to be brought to A&E (49 per cent women, 62 per cent men). The researchers ruled out all other factors and found subconscious gender bias.
In the same way, the emphasis on anxiety as the go-to female condition means women themselves discount their inner wisdom and apologise for their feelings instead of trusting them. They “talk themselves down”. McGregor has seen women with heart-attack symptoms leave emergency waiting rooms because they or their husband persuaded them it was just anxiety. On similar lines, the Yentl syndrome describes the vicious circle whereby the more women try to explain their pain, the more doctors tune out. She is convinced women that process pain differently — but because the physiology is not understood, their pain isn’t properly tackled by existing drugs.
A pint of semi-skimmed, 20 Bensons, a scratchcard and, er, a porn pass . . . The odds on this becoming a regular corner-shop scenario crashed this week as Jeremy Wright, the culture secretary, announced that age verification checks for accessing online pornography would be delayed yet again, this time because the government forgot to inform the European Commission. No wonder it’s been called Sexit.
Age verification began as a thoughtful response by the coalition government to alarming NSPCC research that 65 per cent of 15 to 16-year-olds and almost a third of 12-year-olds access porn. That porn sites should be age-verified, as gambling domains already are, has a 67 per cent approval rating. The problem is that it’s technologically impossible to enforce.
From July 15, clicking on a porn site was supposed to generate a page where a user must provide proof via a credit card, passport or driving licence that they are over 18. Unfortunately Britain stands nobly alone in this endeavour against a global porn industry. And any fool can easily install a VPN (virtual private network): a bit of software which conceals your geographical location. British kids use them already to dodge rights issues, particularly to access US Netflix with its superior range of films.
A VPN would allow a porn user to swerve the UK age-blocker. And which punter wouldn’t do that rather than give personal details to the state-approved verification firm AgeID (which, unbelievably, has the same owner as Pornhub)? No amount of blah about safe encrypted data will reassure anyone that their name and mugshot won’t one day pop up alongside their taste for “watersports” and MILFs.
The alternative would be to go into a shop and, after showing an age ID, buy a £4.99 porn pass. While oldsters might find this no more embarrassing than the time they bumped into their mate’s mum while buying a copy of Razzle, young people have grown up under the total anonymity of the web. Besides, they would simply access porn on platforms such as WhatsApp, Reddit or Snapchat. And a VPN can make the internet an even more dangerous landscape, opening up blocked extremist, paedophile and drug sites on the dark web.
Yet whether age-verification is feasible should not distract from the bigger, more pressing question: does allowing the porn industry to pipe its product unrestricted into every home have toxic consequences? Ireland is reeling from the murder of Ana Kriegel, 14, found naked with extensive injuries and a ligature around her neck, killed by two 13-year-old boys. One of the boys was found to have phones containing thousands of pornographic images, many involving children and animals. The Irish prime minister has said he will be viewing Britain’s age-verification plans closely.
This, of course, is the most extreme scenario. Experts speculated in 1993 whether James Bulger’s killers were inspired by “video nasties” or were just disturbed children who’d have killed in any era. But there is no question that having immediate access to images once obtained only by writing to obscure PO box addresses has changed society. Police now investigate 1,000 cases of offenders viewing child abuse images each month: our jails could not accommodate them all so most are dismissed with a caution on a first offence. Many such men say that viewing “barely legal” porn involving teenagers on legal sites drew them to younger children.
There has also been a spate of deaths of women at the hands of partners who claimed they were engaged in consensual “sex games”. These include Anna Reed, 22, from Harrogate who was suffocated in a Swiss hotel room; Charlotte Teeling, 33, from Birmingham, who was strangled, as was Hannah Dorans, 21, from Edinburgh. Natalie Connolly, 26, was penetrated with a bottle of carpet cleaner and left for dead at the bottom of the stairs. All the men concerned argued that “rough sex” or “Fifty Shades of Grey games” had gone wrong, that these women had, in effect, consented to their own deaths.
These are scenes choreographed by violent pornography, which is not some rare category but just a click away. Researchers studying aggressive porn that involves slaps, hair-pulling and choking found that in 95 per cent of cases the actresses responded with expressions of pleasure, suggesting to the viewer that violence is desired.
Is it any coincidence that the first generation of children exposed to hardcore pornography before their first kiss have epidemic levels of mental illness? The extreme aesthetics of porn fuel body-hatred in young women, while psychologists are concerned that a growing cohort of young men are so desensitised by porn that they suffer erectile dysfunction and emotional disconnection from real women. Moreover, when sex is learnt through porn — a misogynist industry focused solely on male desire — girls prioritise their performance above their own pleasure.
This is now normalised in the mainstream: Teen Vogue ran a feature on anal sex, which most women find uncomfortable, even painful, but is demanded by some men because it’s a major porn trope. Teen Vogue’s anatomical diagram did not even include the clitoris.
Yet young women are not allowed to balk at porn. In the US high school comedy Booksmart, two girls watch porn on their phone in horror. One tries to tell herself she must enjoy it because “I’m a sex-positive feminist”. Not to love porn marks a girl out as uncool, conservative and “unwoke”. Age-verifying technology is, alas, a distraction from the real conversation we need with young people about porn. That it is not feminist nor is it positive sex.
Jayne Ozanne is right that conversion therapy is almost exclusively carried out by faith groups (‘It takes a lifetime to recover’, G2, 8 August). However, psychotherapists and counsellors should not be complacent. There are things we need to own and attend to.
First, there is a history of homophobic non-acceptance of same-sex love on the part, in particular, of psychoanalysis. Much has been done within that modality to make necessary revisions to theory and practice.
Second, the psychotherapy professional groups need to make it crystal clear that the answer to this problem of continuing – but non-professional – conversion therapy is not to take the entire profession under some kind of statutory regulation. The drawbacks of that are well-established by now. The Professional Standards Authority’s scheme of accredited voluntary registers is working.
Finally, we need to make it absolutely clear that if you come to psychotherapy wishing to explore issues of sex and sexuality, you will still be able to do so. There is no way in which the condemnation of conversion therapy should impose a cordon sanitaire on one of the main reasons people come to psychotherapists.
When I was chair of the UK Council for Psychotherapy in 2009-12, at the time when the memorandum of understanding banning conversion therapy was conceived, we wanted to reassure potential patients that sexuality was still something we expected our clients and patients to engage with. However, this reassurance slipped off the agenda because it was – wrongly – deemed too complex a matter.
Clarity on this issue is really important, because ‘conversion therapy’, the attempt to alter a person’s sexuality, is being conflated with any approach to gender dysphoria or gender identity confusion that isn’t ‘affirmative’, that is, agreeing that the person is in the ‘wrong body’.
There is an example of this in the Guardian very recently, the examples in the article and the films described are all gay conversion, but the journalist describes ‘conversion therapy’ as “any treatment aiming to change a person’s sexual orientation or suppress their gender identity”.
This matters, because, as Jesse Singal reports: “All else being equal, this research suggests that the most likely outcome for a child with gender dysphoria is that they will grow up to be cisgender and gay or bisexual. Researchers don’t know why that is, but it appears that in some kids, nascent homo- or bisexuality manifests itself as gender dysphoria. In others, gender dysphoria can arise as a result of some sort of trauma or other unresolved psychological issue, and goes away either with time or counselling. And in still others, of course, it is a sign that the child will identify as transgender for their whole adult life. While the actual percentages vary from study to study, overall, it appears that about 80 percent of kids with gender dysphoria end up feeling okay, in the long run, with the bodies they were born into.”
There has been no systematic research into the ‘gender affirmative’ approach; but claims of 100% ‘success’ rates from ‘gender affirming’ doctors (ie, of all the children treated with ‘gender affirmation’, none of them desisted).
The UK Council for Psychotherapy has launched a new Memorandum of Understanding on Conversion Therapy to include ‘gender identity,’ leaving therapists, counsellors, GPs and clinical professionals in a position where they may be afraid to do anything but agree with a patient’s self-diagnosis as ‘transgender.’ Anything other than ‘affirmation’ could lay a professional open to the charge of conversion or reparative therapy.
‘Affirmation’ is an untested approach to children with gender dysphoria, a result of demands by political activists rather than an approach developed on the basis of research and evidence.
Of course, we support the original Memorandum of Understanding on Conversion Therapy which outlaws attempts to change a person’s sexual orientation. But ‘gender identity’ should not be conflated with sexual orientation as if the two things are essentially the same issue. For gender dysphoria, the choice of approach is between ‘affirmation’ and ‘watchful waiting’ but its inclusion in the Memorandum suggests that the watchful waiting approach could be considered to be conversion therapy if a child subsequently desists.
What it means is that for a health practitioner to offer any therapeutic support or exploration of underlying factors, motives or reasons for a cross-sex identity in childhood they are now taking a professional risk. Instead, a practitioner must confirm and therefore reinforce a child’s belief that they really are the opposite sex. If a boy thinks he’s a girl, he’s a girl. If a girl believes herself to be a boy, she’s a boy, no questions allowed.
No concession is given to children and young people whose identities are in development and highly susceptible to influence from parents, peers and professionals as well as an increasingly powerful transgender lobby. ‘Affirmation’ is not a neutral approach, it is a strong statement of belief that a girl can be born in a boy’s body and vice versa. No practitioner should be imposing false and non-scientific beliefs on a child or young person or knowingly mislead them about reality.
Ironically, the new MOU asserts that practitioners should be “free from any agenda that favours one gender identity […] as preferable over other gender […] diversities” and yet ‘affirmation’ explicitly favours one identity over another and is wholly dependent upon the agenda of trans activists who have fought to impose this approach.
The statement “no gender identity is inherently preferable to any other” hides the fact that this ideology says that one kind of sexed body is preferable to the other and that the only treatment pathway is medical change of the body to ‘match’ the identity. Under the guise of ‘support’, the assertion “your identity is right” is a cover-up for the underlying message “your body is wrong.”
Professionals are warned that ‘conversion therapy’ constitutes any attempt to ‘bring about a change in someone’s gender identity.’ In other words, even if a child’s belief does not match reality, it must be affirmed as the truth. In no other area of health care is a practitioner compelled to confirm a patient’s false belief. Protection of a child’s belief about which sex they are, by definition takes away all normal protections for a child’s body and fertility. Afraid to do anything which may lead to a change in identity, therapists are compelled to facilitate treatment to bring about medical change of the body.
With no trace of irony, righteous condemnation of ‘conversion therapy’ is used to justify the most extreme medical ‘conversion’ of the physical body into cosmetic imitation of the opposite sexed body. Why, uniquely in this case, are children and young people’s bodies not protected from unnecessary and invasive treatment with some effects irreversible and others unknown, while their beliefs are considered worthy of our greatest efforts at preservation?