The gender pain gap
For much of medical history women’s health has been interpreted through the lens of misogyny and myths about “female nature”. But, Elinor Cleghorn argues, women have long been determined to reclaim their bodies
In 1405 Christine de Pizan, a historian, poet and author – the only woman in France earning her living as a professional writer – composed The Book of the City of Ladies. It was a utopian dreamscape where female artistry, inventiveness, courage, creativity and thought were revered and celebrated. Behind the walls of her allegorical city, women and their accomplishments – both contemporary and historical – were protected from the rampant misogyny that permeated literature of the Middle Ages. Early in the book, Christine, the narrator, is visited by three virtues in the guise of ladies who guide the creation of her city. With Lady Reason, Christine discusses the “vile and disgusting things” that certain male authors had claimed about women’s bodies.
One anonymous offender wrote a popular treatise around the late 13th or early 14th century titled Secrets of Women (“De Secretis Mulierium”). Ostensibly, Secrets of Women aimed to enlighten celibate monks and churchmen as to “the nature of women” and the female body’s mystifying processes. The author covered topics including how embryos are generated, aids and impediments to conception, and diseases of the reproductive organs. But this was no midwifery manual or humane guide to healing. Secrets of Women was a punishingly sexist pseudo-medical diatribe. Christine asks Lady Reason what she makes of this “little book in Latin… which states that the female body is inherently flawed and defective in many of its functions”. Lady Reason denounces the book as “utter rubbish”. “You shouldn’t need any other evidence than your own body,” she tells Christine, “to realise that this book is a complete fabrication and stuffed with lies.”
Secrets of Women, as de Pizan wrote, was “outrageous nonsense”. According to the author, women’s “infirmities” – his euphemistic term for menstruation – could turn their already weak and defective bodies and minds poisonous and monstrous. A menstruating woman, he asserted, could become so deceitful and vindictive that she would conspire to mortally wound men’s penises. Women’s imaginations were so impressionable that they could induce deformities in their unborn children if evil images came into their minds during sex.
It’s easy today to laugh off the ridiculous beliefs of an unnamed medieval misogynist. But the essential beliefs about female biology that he promoted were not particularly unusual or sensational at a time when intense religious superstition and oppressive gender ideologies permeated medical ideas about women’s bodies and minds.
Since its beginnings in ancient Greece, medical discourse reflected and validated the patriarchal social order. Women’s existence was primarily defined by their ability to bear and raise children, so theories about their health and healing centred on their reproductive organs, especially their wombs. The authors of Diseases of Women – the foundational texts in the Hippocratic Corpus on the care and treatment of women’s illnesses, written in the fifth and fourth centuries BC – described an array of disorders of the womb that could be remedied with marital sex and pregnancy. The healthiest state for women was achieved when obeying their biological destiny and performing their social duty.
The evils of female flesh
By the time the author of Secrets of Women gave his ludicrous accounts of the evils of female blood and flesh, theories about the pathological influence of the womb on women’s health had been transmitted and translated over centuries. New learning, influenced by religious myths that women’s bodies were potentially corrupting and corruptible, was layered upon old. The Hippocratic premise that the female body
was governed by the biological and social imperative of procreation was reinterpreted according to the pernicious myth of women’s destructive and depraved biological nature.
As de Pizan pointed out, these myths flourished because men claimed ultimate authority over medical knowledge about the female body. While women themselves were excluded from medical discourse and practice, and silenced when it came to their own body experiences, harmful and degrading stereotypes like those in Secrets of Women spread, unchecked and unchallenged.
Christine de Pizan was one of the first women to publicly call out medical sexism and challenge the way that biological myths and falsehoods were exploited to control women’s lives. Today, more than 600 years later, women are still struggling in a medical system that often fails to take them seriously as reliable narrators of what is happening in their own bodies.
The public reckoning with institutional and systemic sexism and misogyny over the past five years has inspired many women to speak out about their experiences of gender discrimination in health and medical care. This follows the landmark 2001 study “The
Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain”, which explored how women’s accounts of their pain and other illness symptoms are routinely minimised and misdiagnosed, and led to the coining of a telling phrase: “gender pain gap”.
Women are the primary sufferers of chronic diseases that cause pain – including endometriosis and autoimmune conditions such as lupus and rheumatoid arthritis – which remain poorly understood, woefully underfunded, difficult to diagnose and
complicated to treat. Recent studies have shown that healthcare providers are more likely to perceive women’s expressions of pain and other symptoms as exaggerations. Women are also statistically more likely to have their pain dismissed as emotional or psychological than to be referred for further diagnostic investigations.
For black, Asian and ethnically diverse women, whose care and treatment is impeded by diminishing gender stereotypes and racist misbeliefs, these disparities are far greater. The dehumanising assumption that black women were less sensitive to pain than white women was enfolded into medical discourse in the early 19th century. Research shows that such assumptions have persisted as unconscious racial biases which still impact some health professionals’ perceptions.
Demanding to be heard
The treatment of unwell women is influenced by a centuries-long legacy of sexist and misogynistic attitudes and assumptions about who women are, what they should feel and how they could live. Throughout history, women have challenged social ideas upheld and enforced by male-dominated medical
A menstruating woman could be so vindictive that she would conspire to mortally wound men’s penises
culture, and fought against its complicity in silencing, oppressing and punishing women. From the Middle Ages to the 20th century, women campaigned to be allowed to study and practise medicine; they debunked myths about female physical inferiority and biological precarity; and they defended their rights to think, work and live independently, following the trail blazed by Christine de Pizan.
One such was May Edward Chinn, who fought against gender and racial prejudice to become the only practising black female physician in New York’s poverty-stricken Harlem district in the 1920s. While caring for marginalised communities, she witnessed the misery of untreated cancer, especially in women, and became determined to improve early detection and diagnostic procedures. Her work during the 1940s and 1950s contributed to the development of the “Pap” smear test that saves the lives of thousands of women every year.
Some of the most important critiques of medical sexism occurred at points in history when questions of women’s equality and liberty were brought to the fore. In the late 18th century, the English philosopher and women’s rights advocate Mary Wollstonecraft challenged the prevailing social and medical belief that women were emotionally and temperamentally unfit for anything other than domestic confinement and dependence on men. In A Vindication of the Rights of Woman, published in 1792, Wollstonecraft criticised theories established over the previous century, which decreed that all women were vulnerable to the dysfunctions of their feeble nerves and spirits. Women’s nervous illnesses, she countered, were not caused by some inherent physiological deficiency, but by the stifling conditions of marriage – which medicine posited as the cure, not the cause.
“Weak minds fall a prey to imaginary distress,” Wollstonecraft wrote elsewhere, “to banish which they are obliged to take as a remedy what produced the disease.” Having seen her sister suffer terribly from post-partum depression that was only relieved when she escaped her difficult marriage, Wollstonecraft spoke from bitter experience.
Phantom of hysteria
Into the 19th century, ideas about female nervous weakness prevailed. The spectre of hysteria was stealthily obscuring objective understanding of women’s diseases, and undermining women’s expressions of pain and other symptoms of illness, both physical and mental. The notion that women’s fragile nerves and unruly emotions had profound effects on their physical health led some physicians to assume that even a disease as devastating as breast cancer could be exacerbated by feelings and fears.
By the end of the century, hysteria had become a catch-all diagnosis for many pathologies of women’s bodies and minds – particularly when the cause was mysterious, or the illness evaded a doctor’s understanding. Silas Weir Mitchell, the American