The gender pain gap: perceptions of women’s health through history

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

Ilustration showing thorned brambles growing up the nervous system of a pink torso, the brambles at the bottom of the piece are growing in the shape of a uterus, and there are blackberries where the ovaries should be. A blue, gloved hand is coming in from the left to pluck at the ovary blackberry, and another gloved hand coming in from the right is using gardening secateurs to cut one of the branches. A metaphor for endometriosis, and in a broader sense, women's medical neglect and oppression

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.

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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.”

An illustration from Christine de Pizan’s The Book of the City of Ladies
An illustration from Christine de Pizan’s The Book of the City of Ladies (1405). In this work, de Pizan criticised medieval beliefs that women’s bodies were intrinsically flawed, branding them “utter rubbish”. (Photo by: Photo12/Universal Images Group via Getty Images)

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.

A menstruating woman could be so vindictive that she would conspire to mortally wound men’s penises

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”.

The physician Hippocrates (or possibly Asclepius, the god of medicine) treating a female patient
The physician Hippocrates (or possibly Asclepius, the god of medicine) treating a female patient. The Greeks believed the womb “wandered” around the body, causing sickness. (Photo By DEA / G. DAGLI ORTI/De Agostini via Getty Images)

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 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.

A patient diagnosed with hysteria, lying down
A patient diagnosed with hysteria at Salpêtrière, a hospital for mentally unwell women in Paris. (Photo by: Universal History Archive/Universal Images Group via Getty Images)

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 neurologist who devised the infamous Rest Cure for nervous disorders, proclaimed in 1875 that hysteria “were as well called mysteria for all its name teaches us of the host of morbid states which are crowded within its hazy boundaries”. But while he was questioning the legitimacy of hysteria, Mitchell was also using it as a diagnostic slur to invalidate and belittle unwell women.

A prescription of months of complete bed rest pushed one woman 'near the borderline of utter mental ruin'

After being subjected to the Rest Cure in 1887, the American feminist writer, lecturer and activist Charlotte Perkins Gilman wrote The Yellow Wallpaper, a short story that remains one of the most widely read texts on the invalidation and mistreatment of women’s pain. Gilman spent months following Mitchell’s prescription of complete bed rest with little intellectual or creative activity after she became desperate to cure her severe depression. But this punishing regimen pushed her “near the borderline of utter mental ruin”. The Yellow Wallpaper, about a woman whose mental health disintegrates after she is confined to bed by her physician husband for a “slight hysterical tendency”, was written partly to help women who might be vulnerable to these medical “therapies” and empower them to challenge the presumed authority of male physicians. “It was not intended to drive people crazy,” Gilman reflected, in 1913, “but to save people from being driven crazy. And it worked.”

A 19th-century woman playing chess
Perplexing cures were suggested for womb fury, such as chess (as shown in a c1860 photograph), no reading and winding a wheel for hours. (Photo by Sepia Times/Universal Images Group via Getty Images)

Gilman began to recover when she was treated by the pioneering and progressive American physician, scientist and teacher Mary Putnam Jacobi, who believed that symptoms labelled “hysteric” should be treated by stimulating a patient’s intellect, not diminishing it. Putnam Jacobi, who campaigned for equality in medical education, had disproved the myth that education and professional occupations were detrimental to women’s menstrual and reproductive health. By analysing physiological data gathered from hundreds of women in the 1870s, she showed that study and physical exercise had no impact on women’s menstrual health.

Fighting for rights

Arguments around women’s right to be educated to the same standard and level as men, and to be admitted to male-dominated professions including medicine, were rife in Britain and the US in the mid to late 19th century. Putnam Jacobi was one of several trailblazing physicians, health experts and social reformers who worked tirelessly from the late 19th through to the early 20th century to dispel accepted medical beliefs that female biology was far too delicate and susceptible to damage for women to pursue lives outside the “separate sphere” of marriage, homemaking and motherhood.

In this article I’ve highlighted just a few of the incredible physicians, activists, researchers, scientists, rebels, campaigners and patients who fought against the sexism perpetuated and promoted throughout medicine’s history. They all exposed and redressed ingrained mythologies about women’s bodies, minds and lives that became embedded in discourse on female illness and disease.

In today’s gender pain gap, we have inherited the legacy of female health concerns being invalidated, women’s pain being misdiagnosed, and women’s accounts of being unwell sidelined and distrusted. This gap was forged over centuries of women’s symptoms being interpreted through discriminatory beliefs and stereotypes about “female nature”. But we have also inherited a legacy of incredible women-led and feminist activism against the misogynistic medical attitudes that have insidiously controlled women’s lives. As Christine de Pizan knew more than 600 years ago, and as all those fighting to close the gender pain gap understand today, women need to be trusted as the most reliable narrators of what is happening in their own bodies.

Ailing ovaries and unruly uteruses

These four historical (and false) afflictions were believed to ravage women’s minds and bodies – and treatments ranged from the bizarre to the downright dangerous

1 Wandering womb

In ancient Greek discourse on female bodies and health, including the Hippocratic Corpus, many illnesses of the female body were attributed to the womb “wandering” from its rightful place and impacting other vital organs such as the heart and liver. Thought to be caused by the womb becoming dry and stifled from lack of moisture, women who were not having marital sex or bearing children were most vulnerable to afflictions of the “wandering womb”.

In the fourth century BC, Plato likened the womb to a creature that hungered for intercourse and conception, while around the second century AD, the physician Aretaeus described it as an “animal within an animal”. Although the belief that the womb could wander unbidden was dispelled, these classical physicians set the precedent for centuries of medical theories that placed the womb, and its almost animalistic imperative to procreate, at the centre of discourse about the diseases of women.

2 Ovaritis

Ovaritis was a term used by English gynaecologist Edward Tilt in the mid-19th century to describe a disorder of the ovaries that could lead to hysteria. Ovaritis was most common in middle- and upper-class young women who excited their ovaries with activities including horse-riding, reading, listening to music and too much physical exercise while menstruating. At the time, recent understandings of the role of the ovaries in menstruation, and theories about the sympathy between ovaries and the nervous system, meant attention had shifted away from the uterus as the epicentre of female hysteric illnesses.

The primacy of the ovaries in emerging theories about women’s physical and mental health led to the ovariotomy – surgical removal of the ovaries – becoming popular in both the UK and the US. Ovariotomy was a dangerous and controversial procedure with a high mortality rate. Some surgeons, including Thomas Spencer Wells, prioritised women’s safety and limited operations to those suffering life-threatening ovarian cysts and tumours. But others were not so scrupulous; ovariotomy was often performed when no evidence of ovarian disease existed. Needless – and dangerous – ovariotomies were endured by women deemed morally depraved or mentally defective, in public asylums in the UK and the US, in the late 19th century.

3 Hysteria

Derived from the ancient Greek word hystera, meaning womb, hysteria was a diagnostic term used from the 17th to the 20th century for collections of physical and psychological symptoms seen almost exclusively in women. Used to pathologise the influence of women’s excessive emotions on their already delicate constitutions – and vice versa – the apparent causes of hysteria were variously ascribed to the reproductive organs, the nervous system and the brain from the 17th to the early 20th centuries.

Diagnoses of hysteria also carried the implication that the patient was feigning, exaggerating or embellishing their pain and other symptoms. Moreover, physicians tended to label an illness “hysterical” when they were baffled by its courses and causes. Treatments for hysteria and its associated afflictions were as all-encompassing as its definitions, but many – including stays in asylums, the Rest Cure and gynaecological surgical interventions – were punishing and barbaric.

4 Womb fury

In the late 16th century, and possibly before, furor uterinus or “womb fury” – sexual obsession ascribed to uterine agitation – was thought to be caused by corrupt humours emanating from an unruly uterus when it wasn’t procreating. Treatments for furor uterinus ranged from the predictable – marital sex – to the bizarre, including vaginal fumigation, massages with salt-and-vinegar sprinkled linen, and loudly shouting the patient’s name in her ear.

In the 18th century, furor uterinus was linked to unmarried women’s unrequited desires. Remedies to curb a lascivious imagination – and, by extension, control female sexuality – included, alongside marriage and pregnancy, a morality-improving regimen of bland foods, baths, bloodletting and constant supervision.

When a new gynaecological tool called the vaginal speculum gained popularity in the mid-19th century, some physicians argued that being examined internally could induce sexually obsessive hysteria similar to furor uterinus. English ophthalmologist Robert Brudenell Carter believed the speculum would cause young women to become so fixated on their genitals that they would be morally ruined and unmarriageable. His suggestions for taming such illicit attentions – also thought to cause heavy menstrual bleeding and abdominal pain – included chess, astronomy, winding a wheel around for hours and no reading.

Elinor Cleghorn is the author of Unwell Women: A Journey Through Myth and Medicine in a Man-Made World (Weidenfeld & Nicolson, 2021). Her Twitter handle is @elinorcleghorn. Elinor appeared on the HistoryExtra podcast to discuss unwell women throughout history

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This content was first published in the August 2021 issue of BBC History Magazine