Caroline Handel

In Michael Che’s Netflix special Shame the Devil, the comedian discloses to the audience that he’d only recently discovered that periods were painful. As the audience chuckles along in good-natured disbelief, Che explains that none of the women in his life—not his mother, or his sisters, or even his ex-girlfriend—would ever verbally express their discomfort to him, referring to periods only as “my time of the month.”

“That’s all they’d say about it,” he says. “They didn’t talk about it the way I would talk about it if I got a period. If I got a period, it’d be all I talked about.”

Former First Lady Michelle Obama also discussed this discrepancy on an episode of her limited audio series, The Michelle Obama Podcast. Speaking with close friend and OBGYN Dr. Sharon Malone, the pair discussed the different societal reactions men and women experience when they talk about 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 you’ve 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.”

A Classical History of Hysteria

Clinicians have a very long history of misunderstanding — and minimizing — female pain. For centuries, a lack of biological knowledge, along with clinician’s limited understanding of female emotions and physicality, led to a catchall diagnosis for any manner of womanly complaints: Hysteria.

British scholar Helen King has debated the popular theory of hysteria as a medical diagnosis bestowed by Hippocrates. In her essay “Hysteria from Hippocrates”, King re-examined the common textual translation of Hippocrates’ writings, eventually determining that what the text actually described was simply a general medical classification, discussing various diseases of the womb, rather than a specific ailment.  

While King dismantled the theory of hysteria as a medical diagnosis female bodies and pain do have a 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 and wreaking havoc.

Treatment for these conditions varied, from prompting women into sneezing fits to coax the womb back into place, to encouraging sexual intercourse to clear the womb of toxic buildup.

Hysteria as We Know It

Eventually, the common definition of hysteria shifted from physical to psychological. When we think of hysteria today, we picture a behavior — usually from a woman or child — who has lost control of themselves. A cursory search of ‘hysteria’ turns up the following synonyms: agitation, madness, excitement, delirium.

The decline of hysteria’s use as a diagnostic label came about during the nineteenth 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 led 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.”

Most people credit the psychological conception of hysteria with Freud and his 1896 Treatise “Studies on Hysteria.” In the text, Freud and collaborator Joseph Breuer surmised that supposedly physical symptoms of hysteria were actually the result of buried psychological trauma in women, and could be treated with hypnosis. Freud later retracted this theory.

Hysteria and Biases in Pain Management

The sensation of pain 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.”

Extensive research has illustrated a gap in the way men and women’s pain is triaged and treated, as well as in how men and women are perceived when they communicate their pain. Medical research has, for the better part of history, been conducted by male physicians on male subjects. According to the NIH’s Office of Research on Women’s Health, it wasn’t until 1993, when Congress passed the NIH Revitalization Act, that clinical 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.

Chronic pain is pervasive in much of the population, but as a whole, we’re not set up to deal with pain, or pain management. If pain functions as an alarm system, rather than designing a healthcare system that can efficiently respond to that alarm, America has instead developed methods, both cultural and pharmacological, that sublimate and distract from pain rather than treat it head on.

The way that these methods are socially communicated to men and women vary with gender norms. For men, the “strong and silent” type is a well known trope of 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 undeniable proof 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 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 book Real Boys: Rescuing Our Sons from the Myths of Boyhood, “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. These findings strengthened the assertion that men, even in a medical context, have been programmed to prioritize masculinity. 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 are subjected to a very different set of standards when it comes to discussing and seeking treatment for pain. While men are 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. Through this lens, 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 described a pervasive apathy from hospital staff towards his wife, who was suffering from an extremely painful, dangerous condition called ovarian torsion. Medical personnel thought her overdramatic and hysterical when she claimed to be in too much pain to sit still for tests. It took fourteen and a half hours of pain for doctors to discover the severity of the problem.

This 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 cites a prospective study showing that women complaining of chest pain were admitted to the hospital less often than male patients with similar symptoms. Physicians are more likely to draw a connection to psychosocial causes, such as stress or relationship issues, and to give psychological diagnoses, 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.

Researchers have found that women are likely to be treated less aggressively in their initial encounters with the health-care system, a phenomenon known as as ‘Yentl syndrome’. More often than not, the burden of proof falls on female patients to prove the severity of their pain. It’s only when they’ve been deemed truthful that their complaints are acknowledged.

Given the low rate in which male and female pain is believed, it’s not a surprise that there’s also a gap in the way female patients are medicated. Men are given pain medication more quickly than women (women waited an average of sixteen minutes longer than men to receive painkillers when complaining of stomach pain, according to a 2008 study), and women are more frequently prescribed sedatives, rather than analgesics, to treat their pain.

In findings that will shock no one, research highlights further disparities in regards to pain management between white women and women of color. 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 as an overreaction, or maybe early menopause. Some physicians said she was overreacting or going through early menopause. It wasn’t until Talbert independently found a doctor to take her seriously that she was subsequently diagnosed with psoriatic arthritis.  

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 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 and were therefore less likely to treat adequately with medication.

While we may have moved past medical diagnoses of hysteria, the legacy it for women is still brutally evident. 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, told The Washington Post. “A lot of things need to change simultaneously for this deeply ingrained culture to change.”

Much of this stems 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 that it’s simply “part of being a woman.”