Examining medical and cultural bias against female pain in accordance with gendered stereotypes
On a recent episode of The Michelle Obama podcast, the former first lady sat for a forty-minute interview with her close friend Dr. Sharon Malone, a multi-decade practicing OBGYN. In their discussion, the pair talked about puberty, menopause, their shared insistence on passing accurate sexual health information to their respective children, and the different expectations men and women experience in regards to pain.
“How many men,” Obama asked, “do you think could deal with the severest form of cramps – which, literally feels like a knife being stabbed and turned. And then released. And then turned. And then released — and then you gotta do this and that, you gotta get up and keep going. Go to work, go to school, go play on the basketball court…I don’t know any man who can conceive of what that feels like.”
in her 2017 HBO standup special Nice Lady, comedienne Michelle Wolf also poked at the different expectations polite society has for men and women in expressing their physical experiences. When discussing the way women are culturally encouraged to keep quiet about menstruation, Wolf quipped, “that is the only time a human is bleeding and that’s not what the conversation is about.”
Wolf went on to describe how a setup to one joke, in which she compared her period to a man having his arm ripped off, drew criticism from some of her male friends. One suggested she swap a nosebleed for amputation. They accused her of exaggerating, embellishing. Of being hysterical.
“You think it’s like a nosebleed?” she asked, her tone dripping with sarcasm, her face contorting through a compendium of exasperated expressions.
She didn’t need to say the rest out loud though. The question was, after all, rhetorical. Everybody laughed anyway, because they already knew the answer.
A Classical? History of Hysteria
Male clinicians have a very long history of minimizing – and misunderstanding — pain in their female patients.
The ostensible reason for this is a basic historical lack of data. Medical research has, for the better part of history, been conducted by male physicians on male subjects, as most physicians believed that all adult bodies were more or less identical in terms of form and function. This dearth in understanding has crippled medical research into female biology. According to the NIH’s Office of Research on Women’s Health, it wasn’t until 1993, when Congress passed the NIH Revitalization Act — which featured an inclusion rider — that studies were required to test both male and female subjects. As recently as 1977, the FDA recommended that women of childbearing age be excluded from early phases of clinical drug trials, citing the challenges of managing a woman’s shifting hormones in experimental procedures, as well as the potential for female participants to give birth to babies with medical deformities.
While we now have reams of research illustrating how male and female health are treated differently today, academic study also finds that the discrepancy goes quite far back. Exactly how far back depends on who’s telling, or translating, the story.
A lack of biological knowledge, coupled with clinicians previously conceived notions of male and female physicality and emotional state, lead to a catchall for any manner of female complaints: Hysteria.
Cultural lore has held that Hippocrates, the revered father of medicine and originator of the Hippocratic Oath, established hysteria as a standard diagnosis for women. British scholar Helen King has long assailed the idea that our conception of hysteria originated in antiquity, even going so far as – when working as a Women’s Studies editor and advisor for the Oxford English Dictionary – writing an entry on ‘hysteria’ that contradicted the earlier cultural history of the word.
In her 1993 paper, “Hysteria from Hippocrates”, part of an anthology titled Hysteria Beyond Freud (University of California Press), King expanded her scholarship on the misconceptions around the origins of hysteria. She re-examined the common textual translation of Hippocrates work, and the cultural touchstones we’ve taken from those translations, and found them riddled with misrepresentations, rather than faithful renderings. King’s research traced both the textual and cultural mistranslations of Hippocrates work to the translations of Emile Littré, a nineteenth–century French philosopher, lexicographer and philologist. After thorough study, King concluded that Littre had misread the text, leading to centuries of misconception. She attributed this misreading to two distinct factors.
The first was purely textual. King examined Littré’s translations, finding that his Greek verb conjugation was incorrect. The form ‘Hysterikos’ (meaning “from the womb”, “connected with the womb” or ‘liable to disorders of the womb’) is textually present, as is its plural conjugation ‘hysterika’ (meaning hysterics when related to the womb’). ‘Hystera’, the Greek noun for womb, (and the root of the hysterectomy procedure label, in which a woman’s reproductive organs are surgically removed) is also present. What is not present, however, is a single identification of ‘hysteria’. Along with this mistranslation, King also points to Littré’s independent decision, when interpreting the text, to group several chapters under the single section ‘hystérie’, and to add additional chapter headings not in the original Greek.
“Littré,” she writes, “read the Hippocratic corpus in the context of the mid-nineteenth century, in which hysteria was a recognized condition of debated etiology; he expected to find hysteria in the text, duly found it, and drew it out in the headings he wrote for various sections.”
In challenging Littré’s translations, King shifted our textual understanding of hysteria, correcting the popular assertion that what Hippocrates described was a specific diagnosis with a corresponding set of symptoms. Instead, she determined that what the text actually described was simply a general medical classification, when discussing various diseases of the womb.
While hysteria itself doesn’t have classical origins as a medical diagnosis, female bodies and pain do have a classical history of seeming mysterious, troublesome, and dangerous to men. Physicians of Ancient Greece believed that a woman’s womb, when suffering from irregular menstrual cycles, exhaustion, hunger, or sexual abstinence/lack of sufficient lubrication, was prone to wandering about the body. Other ancient cultures had their own theories. For example, Galen, a Roman physician from the second century A.D., believed that rather than roving around the body, women’s wombs were instead prone to becoming infected with rotting female seed.
Treatment for these conditions varied, from prompting women into sneezing fits in an effort to coax the womb back into place, to encouraging sexual intercourse in an effort to clear the womb of a toxic buildup. Still, no woman of ancient times was ever sent home with a prescription to cure hysteria.
Hysteria as We Know It
When you think of a hysterical person today, a few different things probably come to mind: A toddler having a tantrum. Someone in the throes of a serious panic attack or crying jag. Various Karen’s who’ve filled up our newsfeeds with videos of incoherent shouting at passersby. In all these cases, we picture a person, usually a woman or child, who has lost all control over their mental faculties. A cursory search for synonyms of ‘hysteria’ turns up the following synonyms, in no particular order: agitation, frenzy, madness, excitement, delirium. All adjectives of heightened emotion, not a collection of similar medical conditions.
Whether physical or psychological, scholarship traces the decline of hysteria’s value as a diagnostic label to the mid-twentieth century. By that time, researchers had found that many patients diagnosed with hysteria had been proven to instead suffer from different underlying physical conditions. This lead nineteenth-century neurologist C.D Marsden to determine that “there can be little doubt that the term ‘hysterical’ is often applied as a diagnosis to something that the physician does not understand.”
Prior to this conclusion, however, nineteenth-century physicians had seen a shift of hysteria from a physical diagnosis to a psychological one. This was due to cases of recorded hysteria having no recognizable physical cause that physicians could determine—they therefore determined that the problem was psychological. Most people credit this more familiar conception of hysteria with Freud and his 1896 Treatise “Studies on Hysteria.” In the text, Freud and collaborator Joseph Breuer surmised that supposed physical symptoms of hysteria were actually the result of buried emotional trauma in women, and could be treated with hypnosis. Freud later went on to retract this theory.
King viewed Freud’s connection with hysteria quite differently, positing that Freud had an altogether small part in furthering the research on the condition, and was just better at utilizing resources to publicize his work than other nineteenth-century physicians who also studied the diagnosis. Instead, King draws the connection between this psychological understanding of hysteria back to assertions about the work of Hippocrates. This, according to King, is the second crucial way Littré affected our conception of hysteria. In addition to amending the original writing with his own textual conflations, Littré declared that Hippocratic physicians made distinctions between “real” and “imaginary” movements of the womb, drawing a link between physical symptoms and psychological diagnoses. King unequivocally refuted this argument, positing that while Hippocratic physicians did record movements of the womb, they were regarded as having entirely physical organic causes, rather than psychological or ‘imaginary’ ones.
Hysteria and Biases in Pain Management
The physical sensation of pain, which is acknowledged to have both physical and psychological components, is a warning to take stock of our surroundings. Pain, by design, is a warning label, a nudge from your body to check for physical or psychological threats. “Pain protects us” writes Elizabeth Barnes, a professor of philosophy at the University of Virginia, “but it’s better understood as a warning sign that your body believes itself to be in danger, rather than a direct perception of physiological damage.”
In an ideal society, the idea that pain registers as a confluence of the physical and the psychological in both male and female patients would be weighed equally. However, extensive research has illustrated a gap in the way men and women’s pain is triaged and treated, and how it relates to the way men and women communicate in regards to pain.
Chronic pain is pervasive in much of modern western society, but as a whole, we’re not set up to deal with pain, or pain management, particularly well. As stated above, pain is an alarm system, a way for your brain to let your body know it has a perceived problem, whether physical, psychological, or both. Problems cause delay. They require fixing, which is usually expensive, both financially (either to the injured party, their employer, or their health insurance company) and in terms of productive work hours lost in recuperation.
Instead of designing a system in which health care is efficient and easy to access, we have instead developed methods, both cultural and pharmacological, that almost demand the sublimation and transformation of pain.
The way that these messages are socially communicated to men and women vary in compliance with western gender norms. For men, the “strong and silent” type is a venerated trope in popular culture. This expectation, reinforced by lucrative advertising apparatuses, athletic franchises, various familial and financial stressors, and cultural epithets such as “real men don’t cry,” “suck it up and be a man”, “play through the pain,” etc., instill in men a simple, brutal message: pain endurance is synonymous with strength, and strength is the be all end all of masculinity. As such, men are much less prepared from young ages to communicate and express any negative emotions, including pain.
Dr. William Pollack, Director of the Centers for Men and Young Men at McLean Hospital and Assistant Clinical Professor in the Department of Psychiatry at Harvard Medical School, points specifically to the shame and guilt boys are taught to associate with feelings of weakness and vulnerability. “The problem for those of us who want to help”, Dr. Pollack writes in his 1998 book, Real Boys: Rescuing Our Sons from the Myths of Boyhood (Random House), “is that, on the outside, the boy who is having problems may seem cheerful and resilient while keeping inside the feelings that don’t fit the male model–being troubled, lonely, afraid, desperate.”
The stigma against any and all “weak” emotions can push male patients to deny the severity of their pain to researchers or medical professionals. In their 2001 paper, The Girl Who Cried Paid: A Bias Against Women in the Treatment of Pain, Professors Diane E. Hoffmann and Anita J. Tarzian cited studies indicating that men were less likely to report pain in front of a female researcher than a male one. These findings strengthened the assertion that men, even in a medical context, are culturally taught to prioritize the appearance of masculinity over pain management.
Studies do show, however, that when men do communicate pain, that very expression is taken as a sign of severity, and pain medication is administered quickly and frequently.
Female patients, meanwhile, are subjected to a very different set of standards when it comes to discussing and seeking treatment for internal (invisible) pain, as Obama, Wolf, and countless other women have discussed at length. While men are culturally taught to deny, harness, or suffer through their pain, women — emotional women, hysterical women — are taught that they are faulty arbiters of their own physical experience.
In describing the conflation of female pain and hysteria, Barnes cites the credibility deficit. A phenomenon coined by City University of New York philosopher Miranda Fricker, it describes how women are automatically treated as less credible sources of information, due to the enduring cultural stereotypes of women as irrational and overly emotional.
In a 2015 essay for The Atlantic, writer Joe Fassler recounted a harrowing night spent inside a Brooklyn hospital with his wife. Describing the acute fear and alarm he felt as he rushed her to the ER — for what would turn out to be an extremely painful condition called ovarian torsion, in which an ovarian cyst, left undetected, grows so large that it twists the fallopian tube, cutting off blood flow to the ovary and requiring emergency surgery– Fassler renders the pervasive apathy of the medical staff, who met his wife’s pain and panic with dismissal, condescension and frustration. They told her to “stop crying”, that it was “just a little pain, honey”, that they would get to her when they could. Rather than soothing her, they reprimanded her, insisting that she had to sit still for blood tests and CT scans. They thought her overdramatic and high-maintenance when she claimed to be in too much pain to manage it.
It wasn’t until fourteen and a half hours later — much longer than the nationwide average patient wait of 28 minutes — when doctors actually took the time to thoroughly examine her body and scans, that they were made aware of the severity of the problem. She hadn’t been hysterical after all. They had all been wrong.
This dismissive reaction to intense female pain in the medical community, the idea that women are usually exaggerating or embellishing their pain, is incredibly common. Hoffman and Tarzian’s earlier paper supports this, citing a prospective study showing that women complaining of chest pain were less likely to be admitted to the hospital than male patients with similar symptoms. They were also less likely to be sent in for laboratory tests. Physicians, when confronted with female pain, were more likely to draw a connection to psychosocial causes, such as stress or relationship issues, and to give diagnoses of psychological issues, such as depression and anxiety. A 2014 study found that, out of 2,400 U.S women, nearly half was told the pain was in their head.
What Fassler and his wife were battling has been identified in the academic community as ‘Yentl syndrome’. According to a 1996 study, researchers found that women were more likely to be treated less aggressively in their initial encounters with the health-care system. In medical settings, the burden of proof falls on female patients to prove the severity of their pain. Only once they’ve succeeded, once they’ve gotten sick enough, are their complaints acknowledged and honored. Only once Fassler had annoyed medical staff enough to do a more thorough examination of his wife, was she able to get the treatment, and pain relief, she desperately needed.
Looking at the discrepancy in which male and female pain is believed, it would be accurate to assume a corresponding imbalance in the way women are medicated. Men are likely to be given pain medication more quickly than women (a 2008 study found that women waited an average of sixteen minutes longer than men to receive painkillers when complaining of stomach pain, if they received them at all) and women were more frequently prescribed sedatives, rather than analgesics, to treat their pain.
In findings that will shock no one, the research highlights further disparities in regards to pain management between white women and women of color. Pain in women of color is often significantly under-treated, as compared to their white peers. A 2012 study found that African American patients reported less-effective pain treatment from doctors. Diane Talbert, an African-American woman from Virginia, sought treatment for shoulder pain and hand swelling, but multiple doctors dismissed her symptoms. Some physicians said she was overreacting, or going through early menopause. It wasn’t until Talbert, dissatisfied with these diagnoses, found a doctor to take her pain seriously that she was subsequently diagnosed with psoriatic arthritis, a rare and painful autoimmune condition, and prescribed meds to manage the pain. Here again, the burden of proof laid on the patient to prove the veracity of their pain.
Reasons for this discrepancy mirror previously stated problems in the demographics of medical researchers. Just as there’s been a lack of research on female pain due to a lack of female clinicians and subjects, a similar gap exists in terms of how physicians view patients not in their in-groups—in other words, in patients that don’t look like them. In a 2016 study of white medical professionals (nationwide, 72% of doctors are white), half of the hundreds of participants reported believing a disproven myth in how people of color respond to pain — such as the idea that African Americans have nerve endings that are less sensitive to pain – and were therefore less likely to treat adequately with medication.
While we may have moved past medical diagnoses of hysteria, the legacy it has left on cultural gender expectations for women can still be felt. While there is more awareness of the discrepancy in male and female pain treatment today, there is scant evidence of real movement. “Awareness alone will not solve the problem, and neither will one-off empathy training sessions” said Salimah H. Meghani, an associate professor at the University of Pennsylvania School of Nursing. “A lot of things need to change simultaneously for this deeply ingrained culture to change.”
Much of this still stems, all these centuries later, from the same basic lack of understanding of the female body. According to Amy M. Miller, President and CEO of the Society for Women’s Health Research, female patients are still liable to hear — particularly when complaining of pelvic or menstrual pain (i.e. “womb” related pain) — that it’s simply “part of being a woman.”