Dr. Elizabeth Comen is a medical oncologist specializing in treating breast cancer at Memorial Sloan Kettering Cancer Center and Assistant Professor of Medicine at Weill Cornell Medical College. She earned her BA in the History of Science from Harvard College and her MD from Harvard Medical School, then completed her residency in Internal Medicine at Mount Sinai Hospital and her fellowship in oncology at Memorial Sloan Kettering Cancer Center.
Below, Elizabeth shares five key insights from her new book, All in Her Head: The Truth and Lies Early Medicine Taught Us About Women’s Bodies and Why It Matters Today. Listen to the audio version—read by Elizabeth herself—in the Next Big Idea App.
1. You are not crazy.
Time and time again, I validate for patients that their medical concerns are real—their pain is real, their symptoms are real—and not as they may have heard “all in your head.”
Across the board, including today, there is boundless evidence and a rising public tidal wave finally acknowledging just how misunderstood, invalidated, and unheard many women feel in our health care system. A recent study showed that more than one in three women felt that a doctor either did not believe them, made incorrect assumptions, or blamed them for a health problem. In my world, in particular, these experiences can then lead to a serious delayed diagnosis or misdiagnosis.
Medicine has a long history of calling women crazy, especially hysterical. In fact, the specter of the hysterical woman has infiltrated nearly all aspects of women’s health—even to the present. Throughout medical history, the consensus was that simply having a uterus put any woman at a biological disadvantage, as this temperamental organ could not help but impact the workings of the brain.
Did you know that the word hysteria comes from the Greek word for “womb?” Reading famous texts from ancient Greek physicians, including Hippocrates, one would think that the uterus wandered around the body, sowing chaos, and was responsible for innumerable medical problems in women. Throughout history, a version of the hysteria diagnosis would shift to whatever was in vogue at the time, whether it be demonic possession during the medieval era or the anxious housewife in the 1970s. This meant extreme, often barbaric treatments for women.
For example, in the late 19th century, hysteria as a diagnosis really got a boost from one of the most famous founding fathers of the field of neurology, Dr. Jean Martin Charcot, who practiced in Paris. Now, we certainly have him to thank for laying the groundwork for our understanding of many diseases of the nervous system, such as multiple sclerosis. He termed the hysterical patient, and he had an entire ward—of largely women—that he would parade in a weekly demonstration (side note: Sigmund Freud was sometimes in the audience). During these demonstrations, he would hypnotize women to perform degrading acts and even recommended violent treatments.
In the 1940s, Dr. Walter Freeman advanced a procedure called the lobotomy—whereby he used an ice pick through the eye socket to sever certain ties in the brain. He claimed to be able to treat everything from insomnia to anxiety. Not surprisingly, some women died from the procedure, and many more had irreversible brain damage.
So next time you hear a woman called hysterical or crazy, particularly in a medical setting, think about where this word comes from and what it really implies.
2. As the science of medicine advanced, women were sidelined.
In the 1800s and prior, an ancient theory called humourism governed how doctors treated patients. They believed the body was a balance of four humors: blood, phlegm, yellow bile, and black bile. Medicine was not codified as a profession the way it is today, and many doctors may not have even gone to medical school as we know it today. However, that changed over the 19th century, and those changes particularly affected women.
For most of human history, the health of women was primarily a woman’s issue. Women were tended to by other women in the family and often midwives, who had generations’ worth of specialized knowledge about women’s bodies.
But as medicine underwent a scientific revolution and formalized in the mid 1800s with the rise of germ theory and increased scientific knowledge about the body, it spawned its own institutions, hierarchies, and specialized fields of research. Midwives were increasingly sidelined and scorned by the system as uneducated practitioners of folk medicine. Medical schools became a place for learning about medicine in the U.S. and women were primarily shut out of attending them. Women who had long been the primary custodians of knowledge about the medical issues that impact women specifically found themselves relegated to the fringes. Medicine began to fracture into the system of specialization that still exists today, as doctors began to conceive of patients less as whole people than as an amalgamation of systems and body parts.
“Midwives were increasingly sidelined and scorned by the system as uneducated practitioners of folk medicine.”
A consensus within the medical community was that women were much too fragile, nervous, and discombobulated to become doctors Within a single generation, a seismic shift had taken place: women were systematically shut out at the very moment that their field was beginning to advance by leaps and bounds. They were deprived of the opportunity not only to contribute their own knowledge but to share in the discovery of new science. Doctors in the mid-1800s took over the age-old duties of female midwives and became the primary stakeholders of this new field of “gynecology.”
One specific example of the consequence of this exclusion of women and the fracturing of the body into specialties: the medical community seemed to forget that women need to pee, too. For example, the American Urological Association (AUA) was founded in 1902, but when most people think about the field of urology, they think of male doctors and male patients. Urology is a specialty devoted to men’s genitalia, yet there are many urologic conditions predominant in women.
I recall seeing a sign in a public woman’s bathroom advertising for resources at an academic hospital. It read: “Your man spending too much time in the bathroom? Weak urinary flow can be an early warning sign for prostate cancer. Get him checked.” Now imagine the reverse campaign for women who have incontinence after childbirth. Can you even imagine a sign like this in a men’s bathroom? “Is your woman urinating on herself when she runs? She doesn’t have to. Get her help.”
Among the many areas of medicine that seem to forget women, is it really that surprising that countless women suffer from treatable urologic conditions, not knowing that there is an entire field of medicine dedicated to helping them, too?
3. Women’s health is not just bikini medicine.
The discussion around women’s health is often focused on our breasts and reproductive anatomy—bikini medicine, if you will—but that, of course, does not encompass the totality of our health. The insidious incuriosity about other aspects of women’s health and how they may differ from men has limited our understanding of many disease presentations, including those that are predominant in women.
For example, 80 percent of autoimmune diseases are in women, affecting over 50 million women in the U.S. alone—but we don’t consider this a “women’s health” issue. A woman’s risk of Alzheimer’s is almost two times greater than men, and yet our understanding of the disease and funding for research for the disease is woefully limited. Cardiovascular disease is the number one killer of women in the United States. When I was in medical school, I was taught that the way a woman presents with chest pain and a heart attack is often “atypical” when compared to a man. How are women atypical in their symptoms when we are greater than 50 percent of the population? In fact, only one-third of clinical trials for heart disease properly include women.
The heavy focus on bikini medicine has meant that women were often excluded from critical clinical trials. It’s only been since 1993 that women have been required to be included in clinical trials. Some of the landmark trials of aspirin and cholesterol drugs included thousands of men and not one woman.
“It’s only been since 1993 that women have been required to be included in clinical trials.”
When we did include women, including in recent history, sometimes we really missed the mark! For example, when the COVID-19 vaccine came out, many women anecdotally reported unexpected menstrual changes. But menstruation wasn’t included as an endpoint in any of the clinical trials for the COVID-19 vaccine, despite this being an important metric that women use as a marker of their health. It was only after a study spearheaded by female scientists—after they started questioning their own menstrual patterns after the vaccine—that a study validated the anecdotal experience in women after the vaccine. Seventy-one percent of women on birth control and sixty-six percent of post-menopausal women reported breakthrough bleeding within two weeks of getting vaccinated.
Ultimately, the incuriosity of medicine about diseases beyond bikini medicine means that we are still far from gender parity in medicine.
4. Women’s sexual desire, the fear and control of it, has underscored nearly every aspect of the history of women’s health.
When researching women’s medical history, I was astounded by just how often men either prescribed sex as a treatment for a woman’s medical problem (with only their husband of course) for everything from hysteria to a type of anemia during the Victorian era called Chlorosis. Alternatively, doctors blamed and claimed their female sexual desire and even masturbation was to blame for a remarkably litany of medical problems.
From scoliosis to incontinence to anemia, some element of female sexuality infiltrated all medical ailments. For example, at the turn of 19th century, Dr. Robert Tuttle Morris (a surgeon and one of the founders of endocrinology society) claimed that a women’s masturbatory habits could lead to laziness, which in turn would lead to curvature of the spine.
Another 19th century example was a truly horrific condition that women would apparently suffer from if they rode a bike. This was called bicycle face. Bicycle face was a diagnosis that doctors said women would have if they rode a bicycle wherein their faces would become frozen in a horrible grimace from the exertion of riding a bicycle, not to mention extreme distortion of their bodies, with bulky grotesque muscles. Now this “bogeywoman” patient actually never existed, but it didn’t stop physicians from weighing in that women should not ride a bicycle, as it would be bad for their health.
According to doctors of the time, the worst of the damage from bicycle, however, is hidden in their pants. The patient’s labia have hardened as a result of repeated bruising by the bicycle seat , pushing her reproductive organs into disarray. Furthermore, doctors claimed that women could and would use bicycles to masturbate. The sexually exciting nature of bicycle seats made for a remarkable example of the medical establishment reaching a conclusion before doing the research and writing off the woman who contradicted their assumptions as untrustworthy liars.
Dr. Robert Latou Dickinson, a famous gynecologist, wrote in 1895 that he could find no cases in which riding a bike turned a woman into a chronic masturbator, but this didn’t sway him from his belief that all possible steps should be taken to prevent it from happening: “It is perfectly conceivable that under certain conditions the bicycle saddle could both engender and propagate this horrible habit.”
“From scoliosis to incontinence to anemia, some element of female sexuality infiltrated all medical ailments.”
Are we really so surprised that when it came to actually addressing women’s sexual health and satisfaction throughout history, the medical establishment was largely silent? When you look at medical textbooks throughout medical history, men claim to have discovered, then ignored, lost, and rediscovered the clitoris. Somehow, it wasn’t until 2005 that a female urologist actually mapped the entirety of the clitoris. When women are polled today, over 40 percent of women have a sexual health concern. Is it not surprising, then, that in the field of oncology, oncologists are two times more likely to ask male patients about sexual side effects than women?
Sadly, throughout medical history, we’ve resoundingly told similar messages when it comes to women’s sexuality and desire: you’re damned if you do, damned if you don’t. That remains a damn shame.
5. It is possible to partner with an imperfect health care system.
I am a doctor, but I’m also a daughter, a mother, a friend, and a patient myself. At the end of writing this book, I ironically had an unexpected complication for a surgery and suffered longer than necessary because I struggled with advocating for myself. I minimized my pain. I apologized, and I didn’t want to bother anyone on my care team.
There are some real concrete ways to navigate what is at times a broken healthcare system. Try to include an ally in your health care team—a friend, a loved one, a family member. Someone who can take notes and be another set of eyes and ears in doctor’s appointments—especially if you have a new diagnosis or are particularly anxious. Come prepared with questions if you can. Establish the key players on your health care team. In today’s medicine, sometimes that includes a nurse and nurse practitioner.
Understanding who does what on the medical team can help optimize communication. Clarify how you want information communicated to you. The recent Cures Act means that you may receive medical results before even your doctor has seen them. Clarify with your doctor how you want to receive information, as medical data without professional context can be scary and misleading. If you don’t like your doctor or think they don’t like you, don’t stick it out. Move on. Remember, you deserve to feel healthy and good in your body. Your health care concerns matter. If you do like your doctor, trust them with what really matters to you and perhaps even what really scares you. Chances are they entered medicine with a deep desire to help, and trusting them with your concerns will lead to better care all around.
To listen to the audio version read by author Elizabeth Comen, download the Next Big Idea App today:
