Undress, the doctors will see you now

Blast from the past for two dirty old men from Milan, Italy. In 2013, the gynaecologists Paolo Vercellini and Luigi Fedele published a “case-control study” which is so vile in every respect that a criminal police investigation would be in order. In brief, the two doctors racially-profiled almost 500 female patients in order to judge their sexual attractiveness, for a pet evolutionary-psychology project. The preselected young and white-only candidates were misinformed to about the nature of the “research”, made to sign an fraudulent “informed consent”, disclose their sexual lives, and then, after having seen “everything”, measured breasts, and stuck all they needed into their victims’ patients’ vaginas, the two doctors (and some their female assistants) judged the subjects’ sexual attractiveness on the scale of 1 to 5. The study’s only limitation according to authors: they didn’t get enough blondes, that being Italy.

This is the paper, flagged previously on Twitter and PubPeer, which appeared in the American Society for Reproductive Medicine journal Fertility and Sterility 6 years ago:

Paolo Vercellini, Laura Buggio, Edgardo Somigliana, Giussy Barbara, Paola Viganò, Luigi Fedele

Attractiveness of women with rectovaginal endometriosis: a case-control study

Fertility and Sterility (2013) doi: 10.1016/j.fertnstert.2012.08.039 

The research team was led by Paolo Vercellini, born 1955, past president of the World Endometriosis Society, and Luigi Fedele, born 1947, both professors of Obstetrics and Gynaecology at the Università degli Studi in Milan, and both directors of gynaecology departments at “Luigi Mangiagalli” clinic, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico in Milan. The two dirty old buggers and their willing collaborators discovered this, after extensive leering at female breasts and into vaginas and even anuses:

“Women with rectovaginal endometriosis appeared more attractive to external observers than those with peritoneal and/or ovarian endometriosis, as well as those without endometriosis. Moreover, compared with controls, women with rectovaginal endometriosis had a leaner silhouette, larger breasts, and an earlier coitarche [sexual intercourse]”.

Apparently that was meant as good news for young women suffering from severe pain and even infertility due to rectovaginal endometriosis: their gynaecologists will find them sexually attractive. This from the study’s methods section, highlights mine:

“Women undergoing surgery for benign gynecological conditions at the “Luigi Mangiagalli” Department of Obstetrics and Gynecology, University of Milan, Italy, from January 2006 to March 2011, were consecutively evaluated for inclusion in the study. […] The local institutional review board approved the research protocol and all participants signed an informed consent.

Participants were informed that the study focused on several phenotypic variables and they knew that, in general, the overall physical appearance would be assessed. All the practical aspects relative to the planned evaluations were described in detail. However, in order to limit potential unintentional seductive behaviors that might have swayed the raters’ judgment, information on the specific hypothesis of different degrees of attractiveness in the three study groups was not given in advance of the physical evaluation. Women were aware that the study focused also on patterns of sexual behavior associated with various benign gynecological conditions. All patients admitted for surgery to our unit routinely undergo a standardized diagnostic interview and examination, which include collection of general and gynecological data, physical examination, and transvaginal ultrasonography.

After completion of the baseline screening, women were considered for recruitment in the study. Inclusion criteria were age between 20 and 40 years, nulliparity, Caucasian origin, no previous pelvic procedures before the index surgery, and a regular menstrual cycle. Exclusion criteria were malignancy, ongoing pregnancy, congenital anomalies, acquired physical defects (e.g., following an accident of any type or a medical/surgical disease with physical consequences), previous esthetic and plastic surgery procedures, presence of visible tattoos or piercing, fixed orthodontic appliances, colored contact lenses, and completely dyed hair.

Before surgery, eligible subjects were asked to complete a standardized questionnaire. The women were left alone in a quiet room for as long as they needed. If a companion was present, he or she was requested to leave the room. Trained physicians were available to clarify any aspect of the questionnaire. Initially investigated items included general demographic and anthropometric variables, personal habits, and obstetric and gynecological information. The second part aimed at investigating sexual history and sexual habits. Most items were evaluated using a 5-point rating scale. Thereafter, women underwent a physical examination by the two trained physicians, including weight and height assessment, measurement of hip, waist, breast and under-breast circumferences. Once this overall evaluation was completed, other four different physicians (two females and two males), blinded to the women’s preoperative diagnosis but not to the study hypothesis, independently gave a judgment, based on direct evaluation, on patient attractiveness on a 5-point rating scale (5 = very attractive; 4 = rather attractive; 3 = averagely attractive; 2 = little attractive; 1 = not at all attractive). The mean of the scores expressed by the four independent evaluators defined three separate categories (>3.5 = very attractive or rather attractive; 2.5–3.5 = averagely attractive; <2.5 = little or not at all attractive) that were used for data analysis. Two male and one female evaluator remained the same throughout the study period, whereas the fourth female evaluator changed twice.

No price to guessing who the two male evaluators were. The study received ethics approval and was even publicly funded:

“Supported by a research grant from the University of Milan School of Medicine (FIRST number 12-01-5068118-00067 )”

@schneiderleonid I think it's important to read the paper. 6 authors (3M, 3F based on names). Evaluators 4M, 4F. What this paper in effect addresses is (modern) notions of beauty, which are unhealthy. #Ethics oversight was not mentioned (poor). Forget salacious headlines.

— Michael J Wise (@some_wise) August 15, 2019

It seems, some patients saw through what their doctors planned:

“Four hundred eighty-eight women were deemed eligible for the study, but 62 refused to participate (unwilling to compile the sexual part of the questionnaire, n = 29; unwilling to undergo physical assessment, n = 21; personal or other reasons, n = 12)”

Now it gets even worse:

“We cannot confirm previous findings on specific pigmentary traits in women with endometriosis (6, 9, 10). Indeed, the Mediterranean origin of the women enrolled implies an overwhelming prevalence of dark hair and eye color. Nonetheless, the proportion of subjects with green or blue eyes was 11% in the rectovaginal endometriosis group and 3% in the nonendometriosis group.”

The good doctors prefer natural blondes, obviously. They then lamented about “lack of a “hard” main outcome”, what with being elderly gentlemen unhappy about their erectile performance despite so many attractive nude women in front of them, waiting to be judged. So we get some rather unpleasant evolutionary psychology as mechanistic insights instead:

“In fact, esthetic perception is influenced by sexual hormones (29). Women with higher estrogen levels have more feminine, attractive, and healthy looking faces than those with lower levels (24, 29). Because female attractiveness could be the expression of higher estrogen levels (24, 28, 33), it cannot be excluded that a stimulating endocrine environment might favor the development of aggressive and infiltrating endometriotic lesions, particularly in the most feminine subjects. Unfortunately, we did not measure serum estradiol levels in our study subjects. […]

According to the principles of phenomics, phenotypic information could be used in conjunction with genetic and environmental data to help uncover the pathogenesis of several disorders (1, 2, 3). In this regard, we not only confirmed previous findings on the association between some phenotypic characteristics and endometriosis (4, 5, 7, 8, 11, 12) but also observed that physical attractiveness is higher in women with the most severe disease form. Genetic and endocrine factors may underlie the expression of a particularly feminine phenotype and predisposition to the development of deep endometriosis”.

Obviously all of that is so pathetically lame and stupid, a drunk incel living with his mum would have invented a better pseudoscientific mantle for such a “study”.

the endo community responded at the time of publication and the authors issued this reply: https://t.co/VvZNgT5999

— CtrForEndometriosis (@CtrForEndoCare) August 15, 2019

The study has been criticized already back in 2013. To that, the authors issued a statement , where they argued:

“It has been suggested that Marilyn Monroe had endometriosis”

Update 18.08.2019. I am really not sure what to do with this expert opinion from the member of Committee on Publication Ethics (COPE) and research integrity specialist, Michael Wise, to which a patient then had to explain medical ethics:

Physicians are not social scientists. A patient who receives care from you does not have the same ability to refuse to participate in your study as a participant who just signed up for a psych study at a research lab. This study reflects very poorly on the medical profession.

— C Σ R V I X (@C3RV1X) August 18, 2019

Also Vercellini, Fedele and coauthors provided on 17 August 2019 a lengthy statement on PubPeer:, here an excerpt:

“We do not understand also the accuse of racism. Is this because only women of Caucasian ethnicity were recruited? Ethnicity is fundamental when investigating the hypothetical genetic basis of diseases, and the preplanned inclusion of women of exclusively Caucasian origin was decided to prevent an obvious genetic bias that would have confounded the findings.

Finally, except for the assessment of facial attractiveness, there was no deviation from our standard clinical management. Nothing different was done with respect to our routine practice. Exclusively women with an already discussed and agreed surgical indication were considered. Reading that we performed surgery after the outpatient clinic evaluation to verify whether women had endometriosis or not is extremely offensive and defamatory.”

Now I am confused. Wherever did they read that accusation? Do they even understand the criticisms of their paper? Sylvie Coyaud tried to make sense of that “Miss Endometriosi della Mangiagalli” contest here. But what on Earth is this offer of help from Vercellini et al supposed to mean?

“How could we even imagine to disrespect the women we are trying to help to the maximum of our possibilities?”

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Update 5.08.2020.

The paper is retracted now. Seven and a half years after a retraction was requested by ASRM committee.

The original letter from the EC committee is included below:

February 2, 2013
Craig Niederberger, MD
Antonio Pellicer, MD
Co-Editors Fertility and Sterility

Drs. Niederberger & Pellicer,

The Executive Committee of the Mental Health Professional Group of ASRM would like to 3/

— Angela Lawson, PhD (@DrAngelaLawson) August 4, 2020