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Anibal Faúndes

Anibal Faúndes: The man who learned how to see women as people

Chilean physician who helped to transform women’s health care talks about sexuality, rape and terminating pregnancy

Entrevista_Anibal_04Léo RamosAt 85, Chilean physician Anibal Faúndes never seems to flag. A specialist in human reproduction and female sexuality, Faúndes helped to transform women’s health care in the late 1980s by demonstrating that programs focused exclusively on women were not benefitting them. He is still fully booked with commitments that take him abroad several times a month. Between April and May 2016, his agenda took him to seven countries on three continents. He traveled to India, Zambia, Switzerland, Cameroon, Denmark, Kyrgyzstan and Turkey,
always in a professional capacity.

Faúndes graduated from the University of Chile’s medical school in 1955. During his residency, the post-graduate period in which medical students live and work at the hospital, he was struck by the poor treatment of and stigma assigned to women who had abortions – the subject of his book The Drama of Abortion, published in 2007 and co-authored by his colleague José Barzelatto – and he began his work to reduce the number of illegal abortions, one of the main causes of maternal mortality. “There are two ways to reduce the number of abortions: sex education and information on effective means of birth control, in addition to access to both,” says Faúndes, who presides over a working group to prevent illegal abortion associated with the International Federation of Obstetrics and Gynecology (FIGO). “Women who have abortions are not in favor of them, but they see them as a solution,” he says.

In 1973, when General Augusto Pinochet took power in Chile, Dr. Faúndes had to flee the country. At the time, Director of the Faculty of Medicine at Unicamp José Aristodemo Pinotti, Faúndes’ former student, invited him to come to Campinas. In Brazil, Faúndes worked to pioneer women’s health programs and helped to create the Women’s Total Health Care Program (PAISM).

On the morning of May 30, two days after returning from Istanbul, Dr. Faúndes sat down for an interview with Pesquisa FAPESP at CEMICAMP, an NGO that conducts studies on health and sexual and reproductive rights in partnership with Unicamp. Tall, thin, with a low voice and an agile mind, Faúndes drew the conversation to a close after two and half hours and flew down four flights of stairs. In answer to the question, “Do you ever get tired?” he said: “When I was your age, I tired easily.”

How does society in Brazil and elsewhere in the world view women?
Unfortunately, women are still seen as being very dependent on men. They need to serve men so that the men feel comfortable. I think women themselves even feel this somewhat.

Why is this still the case today?
There’s that famous saying that behind every successful man is a woman whose importance derives from her having helped the man, not because she herself is important. This is how many people see things. Women are seen as someone who makes men’s lives better because they eat well and dress well. In my first marriage (to Argentine sociologist Ellen Hardy, who died in 2010), I was taught to appreciate the women’s perspective. It was an intensive learning experience.

What was that like?
I met Ellen after I had already become a doctor and she was still in high school – she was nine years younger than I. She was 17 when I met her, and we married in Chile two years later. I was already somewhat known and thought: “I will shape her in my image.” The exact opposite occurred. At the outset, she played the role of dutiful housewife, taking care of her husband and children, until we moved to the United States on a scholarship, where we lived from 1963 to 1964. She was a passionate reader – she devoured books. Every week she took out books from a mobile library. She read The Feminine Mystique, by the first well-known feminist, Betty Friedan, and found the answer to her unhappiness, even though she was playing the role that society had assigned her. Ellen was unhappy because she was not developing her own intellect, her productive capacity. She presented me with this dilemma, and I said: “I support you, and you can study whatever you want; when we return to Chile, we will find someone to take care of the children.”

Obstetrics and gynecology
Degree in medicine from the university of Chile (1955)
University of campinas (Unicamp), campinas center for research on reproductive health (Cemicamp)
Scientific production
Author of about 460 scientific articles, two books, and 83 chapters in books. Supervised 26 master’s theses and 26 doctoral dissertations

Where did you live in the United States and what were you studying there?
Near Boston. I went to the Worcester Foundation for Experimental Biology, where the birth control pill was developed. Gregory Pincus, one of the researchers who invented the pill, worked there. When we returned to Chile, Ellen decided to study sociology. We had two children, and she had graduated from high school eight years earlier. She graduated from the Catholic University of Chile, which was the most competitive, and years later, when we were already in Brazil, she was hired as a professor by Unicamp, where she had an important role in developing their graduate programs. At the School of Medicine, she introduced the idea of ethics in research and established the first committee to deal with it before the founding of CONEP, the National Commission for Ethics in Research.

How did she influence you?
When she told me why she was unhappy, she said: “Why can’t I be like you, just because I am a woman? I am a productive person, and I am only cleaning the house and taking care of the children. Why should my intellectual range be limited to this?” Gradually, she showed me that we had these different roles merely because she was a woman and I was a man. When we came to Unicamp, where my life was calmer, I began to share the responsibilities related to our three children and the household duties. She made a list of chores, and one of us did the dishes while the other cleaned the house. I began to appreciate the feminist sensibility and the need for equal rights. She showed me how society just accepted the fact that women had fewer rights than men, and every time I behaved in accordance with our upbringing, she corrected me. She learned to think differently, and I also recognized that men and women should have equal rights. She was the one who taught me that.

And you brought this knowledge to the office.
Of course. When we internalize something, we start to behave differently. At CEMICAMP, she conducted a study on sexual violence that included a question about whether the woman had ever had sex against her will. When I saw the results, I could not believe that 63% of women had had sex against their will at least once in their lives. The rate of rape was 7%, about 20% involved sex under threat, when the man imposes a condition like “if you don’t have sex with me, this will be the consequence.” A similar percentage of women said they felt obligated to have sex because they were women. Ellen said: “You never forced me to have sex?” I said no, and she said “Really? And that time when …” This is how she showed me that the idea that women and men do not enjoy equal rights got lost, since it is the outcome of a culture that teaches us that women have obligations and men do not. And that men have power over women. Men are actually happier when they accept that women have equal rights because the partnership is happier.

Does this view of women exist everywhere?
Very few countries have managed to change it. There is a lot of machismo in the United States. Europe is really behind. The Scandinavian countries and Switzerland may have a bit less machismo. Arab countries are the worst. But it exists everywhere: in socialist and capitalist countries and under dictatorships.

How does this culture of masculine superiority affect women’s health?
Awhile back I wrote a paper entitled, “Gender, power and sexual and reproductive rights.” In it, I analyzed the three types of delay that two American researchers, Sereen Thaddeus and Deborah Maine, associated with maternal mortality. The first delay is related to accepting that there is a problem and that help is needed. The second delay ensues once the decision is made and the woman must get to a health facility. And the third involves the delay in treating the problem once she has arrived at the clinic. The first delay happens because in many countries, women cannot decide to go to a hospital if her husband does not allow her to or if he does not accompany her. This is common practice in Africa. But if we take the case of Brazil today, how much autonomy does a woman have to consult a doctor without her husband’s knowledge?

Is this still happening today?
Yes, even today. In May, I was in Turkey speaking with some groups from Arab countries on the topic of women who don’t use birth control because their husbands don’t allow it even when they need it. It’s also like this in much of Brazil and Chile. Women cannot use birth control unless their husbands agree. About 15 or 20 years ago, Ellen directed a study we did on reversing tubal ligations, one of the sterilization methods for women. We interviewed women who came to us to reverse the procedure because they wanted to have children, and we discovered that in many cases, the ligations were performed when the husband directly requested them from the doctor without informing their wives.

Was this a common practice?
I don’t know, but the problem existed at a time when Brazilian doctors were performing the ligations at the same time as a cesarean section. The doctor would arrange with the woman to perform the C-section and leveraged the opportunity to do the ligation, at a separate charge, even though he performed his services within the public health system. Among the cases we looked at, there were a few in which the woman was sterilized very early and others where they did not even know they had been sterilized. There are other ways in which men intervene in women’s health care. In some cases, women do not seek prenatal care because their husbands aren’t willing to take time off work to stay with the child they already have. The power imbalance between genders means that women neglect their health to some degree. Men flirt with women and say they’ll use a condom. At the moment of truth, they don’t use one, and it’s left to the woman to take care of herself. In all of the surveys done, when you analyze who has the responsibility for preventing a pregnancy, it’s the woman. Men don’t take responsibility for their own sexuality. Doctors who take care of women need to do so carefully because of the huge power gap between the provider of health care and the recipient. This power differential is even greater if the doctor involved in her care is a man.

Faúndes and his first wife, Ellen Hardy, on their wedding day in January 1959

Personal collection Faúndes and his first wife, Ellen Hardy, on their wedding day in January 1959Personal collection

What are the main problems women face in the area of reproductive health?
With respect to sexual health, it’s maternal mortality, which in Brazil and elsewhere in Latin America has reached unacceptable levels. Here, the mortality rate should be about 50 deaths per 100,000 live births. I say about because there is no other health statistic which is more underreported. Women die during pregnancy, childbirth and in the post-partum period, and statistics don’t capture that. When you ask about the cause of death, the answer is hemorrhage, acute renal insufficiency or anemia.

The specific cause of death is recorded.
Yes. But the hemorrhage occurred during childbirth or because of an abortion. In places where abortion is a crime, deaths as a result of this procedure are hidden. In a study conducted by Dr. Mary Angela Parpinelli, who analyzed almost 1,000 deaths of women between the ages of 10 and 49 in Campinas in the early 1990s, the cause of maternal death most often underreported was abortion. The number of deaths appears in official statistics, which are those registered by the death certificates. But in a study of each of the deaths of women between the ages of 10 and 49, we discovered that a large number of maternal deaths were not included in the statistics. If I’m not mistaken, only 35% of deaths as a result of abortion were recorded. No one should die as a result of undergoing an abortion because the procedure we perform today is so simple that it should not involve any more risk than that involved in receiving a penicillin injection. I am not exaggerating: childbirth is much riskier than getting an abortion.

Are you in favor of abortion?
I am not, and I don’t know anyone who is. But I am absolutely opposed to the idea that a woman who has an abortion should be punished. These are very different phenomena. To wit: countries with the lowest number of abortions are often those with the least restrictive laws and greatest access to health care. Last year we published an article demonstrating that when abortion is legal, there is an initial increase in the number performed. We don’t know whether this ensues because more are actually recorded or if more are actually performed. Soon after, the rate starts to fall. The impact of legalizing abortion is that fewer abortions are performed.

What explains these data?
When abortion is considered a crime, if a middle class woman needs the procedure, she finds a good doctor and pays him or her to do it. The person who performs the abortion earns money. When a public health institution provides the procedure, the institution does not want the woman to return for another one. It provides information on how to prevent pregnancy, explains the risks and suggests or administers birth control. As a result, the number of repeat abortions, which constitute half or more of all cases of abortion, goes down. Keeping abortion secret is one way you keep the abortion rate high. It is idiotic for lawmakers to draft laws against the procedure and increase criminal penalties against those who perform it. We have enough evidence that outlawing abortion does not reduce the number of abortions. It increases maternal mortality and raises health care costs across the board.

It ends up being cheaper to teach people how to prevent pregnancy.
We need to determine why women seek abortion. There are two ways to reduce the abortion rate: first, provide sex education; second, provide birth control information. Sex education means making people available to schools who can answer questions about sexuality. Adolescents have a lot of questions about sex. And where do they get answers? From the Internet and magazines, which often distort the information. Studies conducted in Brazil show that when you teach young adults how to behave responsibly, rather than increasing the incidence of sexual intercourse and the number of sexual partners, it actually decreases the frequency. We must teach them that if they’re going to have sex, they need to use a condom to prevent the sexual transmission of disease and prevent a pregnancy that they’re not prepared to handle. We also need to give them information about birth control and access to it. Unfortunately, health professionals do the bare minimum. It’s much easier and quicker to prescribe the pill or a monthly or quarterly injection from the comfort of your desk than to get up, examine the patient and put an intrauterine device (IUD) in place.

How effective is the IUD?
It is much more effective. This is another issue. When we talk about effectiveness and birth control methods, it usually refers to the result when instructions included in the insert are followed exactly. This is effectiveness as defined in clinical trials, which are highly controlled. James Trussel, an economist and professor at Princeton University, compared the effectiveness observed in population studies by measuring how many women got pregnant one year after using the birth control pill, the vaginal ring or injection and termed this effectiveness with habitual use.

What were the results?
When instructions are followed exactly, three women out of every 1,000 are pregnant at the end of one year of pill use. In the case of habitual use, this number climbs to nine. This shows you how poor the information is on the effectiveness of birth control methods. In real life, it’s different. In some cases, when women run out of money, they delay their purchase of a new package of birth control pills and only go back to taking the pill after the ideal time period. If a woman delays even just two or three days, she can get pregnant. Some time ago, we conducted a study on the distribution of birth control pills by the Ministry of Health. We found that they reached the municipalities, but not even 30% of outpatient clinics had birth control available all the time. Often, women get pregnant because unless they have enough money or the appropriate knowledge, they may not have access to birth control.

This is the reality for most Brazilians.
That’s correct. In addition, people don’t know that the best form of birth control, freely available in Brazil, is the copper IUD, whose effectiveness when used exactly according to instructions or habitually is the same as that of tubal ligation. At the outpatient clinic at CEMICAMP, nurses insert the IUD. Campinas is the only place in Brazil because many years ago I brought a Chilean nurse midwife who was really skilled at inserting the device. In Chile, England and Scandinavia, nurses insert the IUD. It is still considered a medical procedure here. The Ministry of Health wants to encourage the use of the IUD because they have already purchased and distributed them. But doctors are not inserting them. I am working in Recife on a project for women who do not want to get pregnant in the region where Zika is present to increase access to birth control methods that are highly effective with habitual use, specifically the IUD and hormone implants. The project involves removing the barriers that impede access to birth control. This means we must have birth control available and doctors trained and willing to protect these women.

Is this project to be carried out only in Pernambuco?
We are also conducting it in Paraíba. We intend to show that it’s possible to do this so that the ministry and the state-level health secretariats take an interest in replicating the model. The goal is to determine how to ensure that women who live in the favela actually have access to birth control. We are going to measure the number of unplanned pregnancies. Globally, more than half of pregnancies are unintended.

A few moments ago, you said that you didn’t know anyone who was in favor of abortion. Even women in precarious situations?
A woman who has an abortion would rather not have gotten pregnant. She is not in favor of abortion; she sees abortion as her only option. It’s not accurate to say that a woman will have emotional problems if she has the procedure. She will have emotional problems because she is pregnant and she didn’t want to have a child. Abortion provides relief to women. Being in favor or against abortion is not the real dilemma. Condemning women for having abortions only makes it more difficult to solve the problem. The answer is to provide universal access to sex education from childhood on, including accurate information and highly effective birth control methods in accordance with the woman’s preferences. Every woman has the right to decide if she wants to use the pill or an IUD. If she does not take care of herself, it will always be more likely that a pregnancy results.

Isn’t this the woman’s right to control her own body?
Of course. Former President Bill Clinton once said that abortion should be safe, legal and rare. I completely agree. A feminist friend said that every woman has the right to control her own body, including the right not to use birth control and to elect to have an abortion. I do not agree because I believe that most women don’t agree with this. I do not accept the idea that women have the right not to use birth control because they can elect to have abortions. This is how people sound when they are speaking on behalf of other people.

You must pay a high price for opinions like these.
A priest in Goiás put a picture of me on the internet that was covered in blood which he said was from the babies whose deaths I was guilty of causing. What a ridiculous idea. Recently, when Chile’s Chamber of Deputies was debating a bill to decriminalize abortion, which hadn’t yet been approved, a few deputies who voted against it and lost said that whoever voted for it would be responsible for the large number of abortions that would result in Chile. They say this as if there weren’t already between 80,000 and 150,000 abortions a year there. Since abortion is hidden and illegal, the deputies don’t think it exists. Uruguay legalized abortion in December 2012 and, in two months, they made the procedure available to all women. In 2015, the rate of abortion there was 12 for every 1,000 women, one of the lowest in the world. In Brazil, it is 30 to 40 per 1,000.

Let’s move on to another subject. When did you arrive in Brazil?
On July 4, 1976. I had some trouble getting a contract with Unicamp because the Brazilian government, which was under military control at the time, consulted the Chilean government, which was also run by the military, and they said that I had left Chile because I was a dangerous doctor. I was director of women’s health programs under the government of Salvador Allende, who was overthrown by the military. I separated women’s health care from infant care because women don’t exist only as mothers. A woman is a woman before and after she becomes a mother, and she has health care needs that do not have anything to do with motherhood. The women’s health care program in Brazil is a carbon copy of the program we started in Chile in the 1970s.

Where did the idea come from?
At some point I realized that the women’s health care programs that were out there were programs that used women but weren’t designed for women. Prenatal health care aims to ensure that newborns are healthy. Breast feeding programs exist so that infants are well nourished and grow steadily. Family planning programs were designed to decrease population growth. The goal of antiretroviral treatment offered to HIV-positive women was to prevent the transmission of the virus to the fetus. Women’s health programs were used as a means to attain these objectives, all of which are very worthy. But what was missing was a women’s health program just for women.

Were you a pioneer with this proposal?
I was in Chile and Brazil. In Chile, I was an advisor in the area of maternal and infant health under the administration of Jorge Alessandri, who was on the right, and Eduardo Frei Montalva, who was Christian, and when Allende was elected from the left, the government invited me to become director of the program. I spent a little over a year running the program because they began to demand that I join a political party. I am too independent to deal with the nuances of party politics. I went back to my regular job at the national health service. Fortunately, because had I still been the director, I would have been arrested soon after the coup. One week later I had left to attend a research meeting in Miami and, the next day, my name appeared on a list of doctors who were dismissed from the hospital. My wife confirmed that I was on the list of dangerous doctors assembled by the Medical College of Chile. I was put on the list because I was the head of the physicians on duty at the only hospital in Santiago that did not join the national strike. We were working in a very poor neighborhood. If we had gone on strike, who would have taken care of those women? All of the doctors who were arrested were sent to an island in the south of the Magellan Strait. Except for me, since I was not in Chile and I did not return.

What did you do?
We had already sent our three children to Buenos Aires, where my mother-in-law lived. That was in June, and the coup took place in September. I flew to Buenos Aires from Miami, and my wife met me there. We left everything behind in Chile. My wife was very beautiful, blond with green eyes, and she spoke English. The military couldn’t conceive of her as a leftist revolutionary, so she was not prevented from leaving. Along with a friend, I was already involved with a sexual and reproductive health training program at the World Health Organization. There was a meeting in Buenos Aires the week following my arrival, and they proposed that I move to Geneva, to WHO’s headquarters. At the time, there was a lot of talk about the brain drain from Latin America to work in the developed world. My wife and I didn’t want to be a part of that so we decided to stay in Latin America. I was already known and was offered a position in the Dominican Republic, where I lived for two and a half years before moving to Brazil.

Internship in Uruguay, 1961: (circled), Faúndes standing and Caldeyro, seated

Personal collection Internship in Uruguay, 1961: (circled), Faúndes standing and Caldeyro, seatedPersonal collection

What did you do there?
I was an advisor to a family planning program. I worked at the Ministry of Health and also started a program to prevent uterine cancer in addition to putting together a program to promote breast feeding for women.

Could you tell us how you were invited to come to Brazil?
José Aristodemo Pinotti, who had been my student in Chile and who was director of the Department of Obstetrics and Gynecology at Unicamp, was the first person who called us after the coup and to invite me to come here. Bussâmara Neme, who had established the department at Unicamp, sent Pinotti to study with me and we became very good friends. In that call, Pinotti said that when I was ready to leave the Dominican Republic, I should let him know. At the time, I was starting to receive offers from different places. We did not want to go to developed countries so we decided to come here.

What did you find when you arrived here, since the medical program was just beginning at Unicamp?
We stayed at the Santa Casa de Misericórdia, in the downtown area of Campinas. When I arrived, I discovered that it was routine for people to enter the delivery room dressed in their street clothes when the medical personnel there were already in appropriate medical gowns. Once there was a breech birth, and we called the resident. He entered the room in street clothes and put on an apron. I said: “You do not enter this room to assist in childbirth dressed like that. I will handle it.” I decided that from then on no one would enter the delivery room without the appropriate medical attire. I imposed discipline. I was a professor in the delivery room and on the ward. Each student had two patients, and I challenged them to get to know each of them better, because I knew them all. I never allowed them not to know their patient by name, or to come in to perform an exam without saying hello and asking permission to do so. It’s because of this respect that patients really like this maternity hospital.

Was there any resistance to your hiring at Unicamp?
Zeferino Vaz was the chancellor, and she was very close to Roberto Caldeyro and Barcia, my precept in Uruguay. After Caldeyro told her that I would be a really good hire, Zeferino told the Brazilian government that she would take responsibility for me. I arrived on July 4, and ten days later was invited by the Ministry of Health to discuss challenges to maternal-infant health. At the meeting, I said that we needed to establish maternal mortality committees, and that worked for a while. I still believe that one of Brazil’s problems is the lack of these committees, which consist of highly qualified people who meet to discuss each maternal death in a given region. The goal is to understand why the death occurred, since most of them can be avoided, and to take steps to correct the problem.

Isn’t this punitive?
Punishing does not work. In Campinas there was a functioning municipal committee until recently. I always said that these committees needed to be staffed by professionals and could not function with volunteers. It is difficult to investigate this type of death if there is no system to collect data and deliver them to the committee chair. This costs money and requires expert professionals. We organized the first seminar on maternal mortality in Campinas. We discussed the topic and wrote a book, Morte materna, uma tragédia evitável [Maternal Death, An Avoidable Tragedy]. It can be avoided, but it hasn’t been.

Has women’s health care improved since you arrived in Brazil?
It has in some places, and in others, it’s worse. The problem in Brazil is cesarean sections, which are very risky. The procedure leaves a scar on the uterus, and when the woman wants to have another child, the risk of placenta previa, placenta accreta or premature rupture of the membranes is greater. We are creating a generation of women with a high risk of complications. Many doctors still believe that C-sections are safer for newborns and that there is no risk for the mother. Global evidence demonstrates that this is not true. The risk is actually higher for the baby and the mother. The evidence also shows that future obstetrical outcomes for a woman who has had a C-section will be problematic for the rest of her life. There are many more cases of placenta previa than before because with the next pregnancy, the placenta anchors on the scar tissue. We have more cases of placenta accreta, where the placenta penetrates the myometrium and cannot be removed, which means the uterus has to be removed, leading to hemorrhage and high rates of maternal mortality. The more C-sections a woman has, the higher her risk.

You said that maternal mortality can be prevented in every country. Where are the most effective prevention programs in our region?
Uruguay has lower rates of maternal mortality today than the United States. In the Americas, only Canada has a lower rate of maternal mortality than Uruguay. The countries with the lowest rates of maternal mortality in Latin America are Uruguay, Chile, Cuba and Costa Rica.

In the 1980s you submitted a proposal to the federal government to create the Women’s Total Health Care Program (PAISM), seen as a means to offer birth control. How was the program supposed to work?
Take the case of a woman who goes to a health clinic because she has diabetes. No one thinks about her getting pregnant. Not least because if she gets pregnant, her diabetes will get worse and her pregnancy will be at risk. The focus is on the diabetes, not the woman. We have to think of the woman, that we need to offer her an appropriate method of contraception and then monitor. The idea is simple. I always said to my students: “You are not taking care of a uterus. You are taking care of a woman, who goes on with her life after she can no longer be a mother. You need to concern yourselves with all of her needs, not just childbirth.” We doctors focused only on the physical health, and a group of feminists at the Ministry started to consider their social and psychological needs as well. We have to consider the woman as a whole person, not focus only on the reason she came into the clinic. This program was not fully implemented, but women’s health care improved a lot.

You did a study on violence against women. What did you learn?
My first wife, Ellen, did research on non-consensual sexual intercourse, which I already referenced. And once again, this led to the issue of abortion, which is legal in Brazil in cases of rape and sexual violence. So I brought the two phenomena together here. On the one hand, there is rape, and on the other, I began to see evidence that no women were able to terminate their pregnancies in cases of rape. At Unicamp, we had one or two cases a year because of an agreement with an NGO, SOS Mulher [SOS Woman]. When a pregnancy occurred as a result of rape, we received those patients at our maternity clinic, and the head of gynecology, who was an evangelical Baptist and very humane, terminated the pregnancy. After I arrived, there were two of us. No one else was willing to do it. Sometime later, Fernando Magalhães Maternity Hospital began to perform abortions in Rio de Janeiro as did the Municipal Hospital of Jabaquara in São Paulo. Only three maternity hospitals in Brazil complied with the law. So we decided to investigate how women managed to find out about these services and obtain an abortion. We also researched the procedures followed at these hospitals. Then we did a population-based study, inspired by an article in the American Journal of Obstetrics and Gynecology, which correlated changes in the menstrual cycle with a history of sexual violence. We examined women who had been raped, who had been coerced into having sex and those who had undergone neither, and we cross referenced the data with gynecological and obstetrical pathologies, basically changes in menstrual cycles and sexual problems, such as a lack of libido or inability to achieve orgasm.

What were the results?
We found the same thing as what had been described in the United States. Rape victims have more disturbances in their menstrual cycles. The more serious the rape, the more frequent the disturbance. Women who had been raped had more problems with their menstrual cycles than women who had been coerced into having sex. And those who were coerced had more problems than those who had sex out of a sense of obligation. These phenomena occurred in sequence. The same thing was seen in the sexual arena. No libido, difficulty reaching orgasm, both are related to having a history of rape.

Is there a culture of rape in our society?
The culture says that women have to accept whatever men decide. And then there is the myth that even when a woman says no, she wants to have sex, and afterwards she’s glad she did. Anyone in an abusive situation does not like it. Rape is the worst form of violence. In the case of the 16-year-old girl who was gang raped in Rio in May 2016, I read on the Internet that she said it wasn’t her uterus that hurt, it was her soul. In 1976, we held the first seminar on sexual violence, and from that there emerged the notion of emergency care for women who are victims of sexual violence. The first thing we do is offer psychological support, because what is most painful is the damage to the soul. After that, we provide protection against sexually transmitted diseases and contraception. And of course, long-term follow up.

Is this care widely available?
It is one of the success stories that came from our initiative. We have a program called Superando Barreiras [Overcoming Obstacles]. There is still resistance to the termination of pregnancy. But today in Brazil there are more than 1,000 hospitals that offer emergency health care for women who have experienced sexual violence.

What should a woman do first, go to the police or to the hospital?
She should go to the public hospital. Here in Campinas, where the services are better organized and there is municipal support, there were more reports filed with the police initially than treatment at the hospital. Now, there is much more treatment provided by the health care system than reports filed with the police.