In order to recognize illness, you have to know what health looks like — what’s normal, and what’s not. Until recently, medical research generally calibrated “normal” on a trim white male. Such a patient, arriving in an emergency room clutching his chest as they do in the movies — and in the textbooks — would be immediately evaluated for a heart attack. But heart disease in women, inconveniently, doesn’t always come with chest pain. A woman reporting dizziness, nausea and heart-pounding breathlessness in that same E.R. might be sent home with instructions to relax, her distress dismissed as emotional rather than cardiac.
Heart disease has clear markers and proven diagnostic tools. When a woman’s symptoms are less legible or quantifiable — fatigue, vertigo, chronic pain — the tendency to be dismissive grows. In “Unwell Women,” the British scholar Elinor Cleghorn makes the insidious impact of gender bias on women’s health starkly and appallingly explicit: “Medicine has insisted on pathologizing ‘femaleness,’ and by extension womanhood.”
Cleghorn, framing her argument in terms of Western medicine, starts with Hippocrates, the Greek physician of antiquity who refocused medical science on the imbalances of the body rather than the will of the gods. Hippocrates understood that women’s bodies were different from those of men, but in his view, and for millenniums to come, those differences could be reduced to a single organ: the uterus. A woman’s purpose was to procreate; if she wasn’t well, it was probably her womb that was to blame. One Roman writer described the uterus as “an animal within an animal,” with its own appetites and the capacity to wander through the body in search of satisfaction. Most female afflictions could be reduced to “hysteria,” from the Greek word for womb. “The theory that out-of-work wombs made women mad and sad was as old as medicine itself,” Cleghorn notes. The standard cure was marriage and motherhood. As Hippocratic medicine was refracted through the lens of Christianity, the female anatomy was additionally burdened with the weight of original sin.
Moving steadily through the centuries, Cleghorn lays out the vicious circles of women’s health. Taught that their anatomy was a source of shame, women remained in ignorance of their own bodies, unable to identify or articulate their symptoms and therefore powerless to contradict a male medical establishment that wasn’t listening anyway. Menstruation and menopause were — and often still are — understood as illness rather than aspects of health; a woman’s constitution, thus compromised, could hardly sustain the effort required for scholarship or professional life. A woman with the means and the talents to contemplate such ambitions soon bumped up against the rigid shell of the domestic sphere. Her frustration and despair could cause physical symptoms, which her doctor would then chalk up to her unnatural aspirations. Conversely, a perfectly healthy woman who agitated for radical change — a suffragist, say — was clearly suffering from “hysteric morbidity.”
Though hormones eventually replaced wandering wombs as central to understanding women’s health, “old ideas about women’s bodies being naturally defective and deficient still pulsed through endocrinological theories,” Cleghorn writes. The marketing for early forms of hormone replacement therapy to relieve the discomforts of menopause was often directed at men. One horrifying magazine ad showed a radiant older woman laughing alongside male companions, with the tagline “Help Keep Her This Way.” Was hormone replacement therapy a way of liberating women from their reproductive biology, or keeping them cheerful for their husbands? And, as questions grew about estrogen and cancer, at what cost?
The intersection of class and race complicates things further. As early as 1847, the Scottish physician James Young Simpson argued in favor of anesthesia during labor and delivery, contradicting the age-old belief that the pain of birth was part of God’s judgment. (To this day, women who opt for an epidural instead of “natural childbirth” can feel a nagging sense of failure.) But even liberal-minded men like Simpson believed that what he called the “civilized female” needed his revolutionary innovation more than her less privileged sisters. Black women were thought to be less sensitive to pain and working-class women were considered hardier in general; certainly no one worried about whether these women could work while menstruating.
Each scientific advance came with its own shadow. Margaret Sanger may have campaigned for contraception “as a way for women to reclaim their bodies and lives from medical and social control” — but for women of color, birth control was presented more as a duty than a right, a weapon against overpopulation and poverty requiring the policing of women. The postwar advent of the National Health Service in Britain heralded a new era of comprehensive prenatal care for pregnant women, but the N.H.S. “also inherited the legacy that women were child-bearers, first and foremost, so their health care needs pivoted around their reproductive functions.” Women saw their doctors when they got pregnant, but illnesses unrelated to reproductive health might go undiagnosed and unchecked.
Especially illnesses with ambiguous symptoms. “The age-old question of what to do with women’s pain, now that diagnoses could be made by biomedical evidence rather than speculations and assumptions, was raising its rather inconvenient head,” Cleghorn writes. When women of an earlier era might have been subjected to clitoridectomies or ovariectomies to address their mysterious symptoms, 20th-century patients sometimes faced a lobotomy “when the extent of their pain exceeded their physicians’ patience.” Cleghorn is unsparing in her examples of women suffering unimaginable and unnecessary horror at the hands of doctors who were unwilling either to listen closely or to admit when they were stumped.
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It’s impossible to read “Unwell Women” without grief, frustration and a growing sense of righteous anger. Cleghorn’s prose is lively, and she has marshaled an enormous amount of material. But her decision to organize it chronologically rather than thematically can slow her momentum, forcing her to circle back to certain topics repeatedly. There are occasional detours — into the eugenic implications of abortion and birth control, for example — that aren’t strictly relevant to the thesis of a “culture of mystification” that compromises women’s health. And Cleghorn’s definition of that culture of mystification is tricky. She is rightfully advocating for a better understanding of diseases that disproportionately affect women and a re-examination of clinical norms centered on men. But in this era of ever-increasing medical specialization, byzantine insurance regulations and rushed office visits, women are not the only victims of mystification.
Cleghorn saves for her conclusion her most powerful illustration: her own experience. It started with leg pain and swelling. Her doctor suggested gout, or maybe she was pregnant? “I can see nothing wrong with you,” he said. “It’s probably just your hormones.” Doubting the significance of her own concerns, she endured seven years of pain and tachycardia, finally landing in the emergency room. Even then, her diagnosis was linked to the baby she had just delivered: “toxic postpartum heart disease.” An observant rheumatologist at last identified her disease as lupus.
“The lives of unwell women depend on medicine learning to listen,” Cleghorn concludes. And also on women claiming their right, as Cleghorn has, to speak.