Caroline Handel

In Michael Che’s Netflix stand-up special Shame the Devil, the comedian discloses to the audience that he’d only recently discovered that periods cause women pain.  As the audience chuckles along in good-natured disbelief, Che jovially defends himself, explaining that nobody had ever presented him with the information. None of the women in his life—not his mother, or his sisters, or even his ex-girlfriend—would verbally express their discomfort to him, referring to periods only as “my time of the month.”

“And 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.”

Unconsciously, Che highlighted a key difference between men and women when it comes to communicating and managing discomfort—men externalize, women internalize. 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 in regarding to expressions of 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

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

Cultural lore has held that Hippocrates coined hysteria as a standard diagnosis for any and all internal issues that women experienced in his care. However, British scholar Helen King has debated that hysteria has ancient origins. In the essay “Hysteria from Hippocrates”, part of an anthology titled Hysteria Beyond Freud (University of California Press, 1993), King re-examined the common textual translation of Hippocrates’ work and found them riddled with misrepresentations. 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 mistranslated the text, leading to centuries of misconception.

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, 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 toxic buildup. Even so, no ancient women were ever sent home with a prescription to cure hysteria.

Hysteria as We Know It

When we think of hysteria today, we picture a person — usually a woman or child — who has lost control of themselves. A cursory search of ‘hysteria’ on Thesaurus.com turns up the following synonyms, in no particular order: agitation, 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 led 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 to a psychological diagnosis. This was due to cases of recorded hysteria having no recognizable physical cause that physicians could determine—they therefore determined that the problem was a mental one.

 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 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 physical sensation of 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.”

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 modern western society, but as a whole, our world isn’t set up to deal with pain, or pain management, particularly well. As stated above, pain functions as an alarm system. Rather than designing a healthcare system that can efficiently respond to that alarm, the United States has instead developed methods, both cultural and pharmacological, that sublimate and distract from pain rather than treat it directly.

The way that these messages are socially communicated to men and women vary in compliance with 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 tangible 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 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 book Real Boys: Rescuing Our Sons from the Myths of Boyhood (Random House, 1998), “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 relief. 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. 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. Rather than kindness and empathy, his wife’s pain was met with cold dismissal and condescension. 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 —  much longer than the nationwide average patient wait of 28 minutes  — 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 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’. Researchers have found that women are likely to be treated less aggressively in their initial encounters with the health-care system. 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. Only once Fassler had annoyed medical staff enough to do a more thorough examination of his wife was she able get the diagnosis and pain relief she desperately needed.

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 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 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. “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.”