Perspectives on Failures in the Science of Women's Health
Photo credit: National Cancer Institute
My freshman year of college I flipped over the handlebars of my bike and fractured my orbital bone.
In the emergency room, the nurse discovered I was a biology major. When I asked for a distraction from the throbbing pain in my eye socket, he bet me that I had never heard this before: on average, women wait 17 minutes longer in the emergency room for heart-attack treatment than men. He was right: both about the waiting discrepancy, which hasn’t changed by more than a minute since the 90’s, and that I had, in fact, never heard that before.
That night, as I was trying not to fall asleep due to my newly-diagnosed concussion, I fell down a seemingly-endless Google Scholar rabbit hole about discrepancies between women’s and men’s healthcare. What I discovered shocked me: Emergency room heart attack treatment was only the tip of the iceberg of women’s healthcare inequity, and this system of inequity has deep historical roots.
I was horrified at these findings because I am a woman, and felt my personal health to be at risk. But I was also horrified because I am a scientist in training, and medicine has its foundations in science. I believed science was objective and misinformation would only arise from experimental error and the limitations of instruments. In reality, scientists are human, and they make choices based on social biases.
Before that dazed, late-night internet browsing in the ER, I had never before been confronted with the reality of the damage done by scientific mistakes based on social biases. Good scientific processes acknowledge that these biases exist, and attempt to work around or mitigate them (for example, by advocating for scientists with diverse life experiences). But there is still a lot of work to be done in preventing the kind of damage caused by socially-biased science in the future. This work can’t be done without first acknowledging past mistakes. This includes acknowledging the harm done by medical science based on the assumed inferiority of sexes and races that were not male and white. Here, we examine the historical gaslighting and unnecessary procedures performed on women diagnosed with “hysteria.”
Hysteria: A Historical Case Study
Hysteria is a term with a long and storied history. Symptoms include selective amnesia, shallow or volatile emotions, and overdramatic or attention-seeking behavior. Importantly, these symptoms were disproportionately (but not always) identified in women. However the theorized causes of hysteria have varied. For example, in Ancient Greece, hysteria was thought to be caused by the uterus physically moving throughout a woman’s body — a “wandering womb.” In the 19th century, the medical consensus was that hysteria was caused by the overload of the nervous system by various reproductive functions.
Under this model, voluntary motion and judgment were believed to be functions of the central nervous system, while bodily functions like reproduction were thought to be regulated by a reflex nervous system (which we now know to be entirely false). It was thought that sexual excitement or reproductive disorders caused immense strain on the nerves and could prompt hysteria, or even outright insanity. Women, who possessed large and complicated reproductive systems and smaller brains, were considered far more susceptible than men to the predominance of reflexive action over rational thought.
According to early 1900’s medical researcher Dr. John Harvey Kellog (of cereal fame), penetration, masturbation, or even just sexual fantasies were thought to create a “nervous excitement” in the uterus, which in turn became the source of an “extravagant” moral and mental disorder.
Photo credit: Clay Banks
Physicians quickly became frustrated when they could not cure hysteria. This, along with structural inequalities that left women unable to advocate for their own healthcare, led to a series of brutal and chilling “treatment” attempts by physicians in the 19th century to cure women with hysteria. One physician, Dr. Brudenell Carter, spoke of the “mental warfare” required to treat hysteria. He employed “humiliation and shame” and “threats of exposure” to encourage reformation of the “pretended illness.”
Physicians also actively mutilated women in the name of hysteria treatment. Particularly popular was the application of acid to the external genitals in an effort to dissuade the patient from masturbating. To physician Dr. Baker Brown however, these were considered “half measures,” and he innovated the clitoridectomy, or surgical removal of the clitoris, as a “permanent cure.” Physicians marveled at the success of this procedure to treat even the "most severe" cases, claiming that the clitoridectomy was all but a guarantee in instances of nymphomania. One does not have to think very hard as to why.
Another surgical cure for hysteria which is rooted in its gendered conception is the ovariotomy. In this surgery, healthy ovaries are removed to induce an artificial, hysteria-curing menopause. Of course, some physicians were ethically opposed to this procedure, not because of the risks involved with removing healthy organs, or the risks to the skeleton due to premature menopause, but because to remove a woman’s ability to have children would make a physician, according to a John Hopkins gynecologist, “the destroyer of everything that makes a woman’s life worth living.”
Then and Now
Hysteria was a major diagnosis in Western societies during the 19th Century until World War II. After the World Wars, there was a marked decrease of hysteria diagnoses. Data of annual admissions for hysteria to psychiatric hospitals in England and Wales from 1949 to 1978 show that they are diminished by nearly two-thirds. This is in part because the symptoms associated with hysteria diagnosis started to be seen in men with “shell-shock,” now known as PTSD. Over two decades, the diagnosis of hysteria became progressively decoupled from gender, and was finally removed from the Diagnostic and Statistical Manual of Mental Disorders in 1980. The invalidation of the hysteria diagnosis was a step in the right direction, and a demonstration of how scientists can try to do better than their predecessors. But it’s not the end of the story.
Photo credit: Simone van der Koelen
Sexism still impacts science, as can be seen in the research gap between studies of male vs. female reproductive health. There have been 5 times more studies into erectile dysfunction, which affects 19% of men, than on premenstrual syndrome, which affects 90% of women (and of which the major causes still remain unknown). This research gap is in part because the American National Institutes of Health didn’t require research trials to include women until 1993.
While I have specifically discussed here how social conceptions of sex impact scientific conclusions, other social biases, like those involving race, are still also at play in science at large. For example, Black patients are significantly less likely than white patients to receive analgesics for extremity fractures in the emergency room (57% vs. 74%), despite having similar self-reports of pain. One 2016 study found that 50% of interviewed medical students believed at least one falsity about Black pain tolerance and physiology, including that their nerve endings were less sensitive, their blood coagulates more quickly, or their skin is thicker.
All this is to say scientists still struggle with social bias. We make individual mistakes — we’re human. But, more importantly, our scientific fields have deeply ingrained biases that often reflect social prejudices, and these are much tougher to identify and fight against than individual beliefs. The existence of the above studies demonstrates that we’re trying to understand the negative impact those biases have, and how they can be mitigated for. Isaac Newton said if science progresses, it is because it “stands on the shoulders of giants,” or builds upon past work. But it also progresses when we try to understand how our predecessors went wrong, and how we can do better.
-Katie
Photo credit: Irina Iriser