All in Her Head: The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today

by Elizabeth Comen

In the medical history that defines women’s “normal” bodily functions—as well as their pain, pleasure, strength, and intellectual capacity—the voices of women themselves are notably absent.

From this moment, male doctors became unique, powerful shareholders and experts on women’s bodies—while women’s healing and knowledge were downgraded and dismissed as old wives’ tales. And in the coming years, the professional field of medicine would stratify along gendered lines into doctors on one side, nurses on the other: a world where male superstars performed miracles while female supporting actors mopped up the mess. The role of women was proscribed in medicine as in society, bolstered by the stereotype of the female nurturer: Doctors cured. Nurses cared.

We need to stop apologizing for our medical needs, and start asking the questions that lead to better knowledge, better health, and better lives. We need to ask how to cultivate a relationship with our bodies that is not just comfortable, but joyful; how to know when something isn’t right and to advocate, not apologize, for our needs; how to navigate a healthcare system that will never be perfect but could be better; how to be as assertive, as informed, and as confident in the care we deserve in a doctor’s office as we are in the rest of our lives. I

In the field’s infancy, male doctors found themselves empowered to act as both enablers and enforcers of women’s beauty, putting the stamp of medical legitimacy on the social pressure to be pretty. Today, the practice of cosmetic medicine is one that walks the line between empowering women to control their bodies and trapping them in a gilded cage of punishing beauty standards.

The equation of female ugliness with the type of life-altering disfigurement that left former soldiers requiring surgery just to live normally only works in a world where a woman’s social value is inextricably tied to her physical appearance—and not only that, but to her sex appeal.

As a result, the history of plastic surgery is primarily a story about male doctors operating on female patients. But perhaps more importantly, it’s a story about men with the power to make women beautiful, and the authority to decide what “beautiful” looked like. The development of new and improved plastic surgical techniques often finds advancements driven by the personal taste of a male doctor, not by what women wanted themselves, and female patients treated more like guinea pigs than consumers driving demand. For a given procedure to be developed, refined, and made ubiquitous has always depended on a man finding it interesting enough to pursue.

The single professional in her thirties who wondered how she would date again after a mastectomy, the mother who cried as she explained that her children were frightened by the way she looked without hair or eyelashes: these patients were experiencing a devastation to their sense of self that was just as debilitating as any other cancer symptom, only these symptoms, many doctors refused to take seriously.

Women, we are told, should age gracefully. And yet the notion of aging gracefully requires grace, in the form of a sort of passivity that is just as feminine-coded as full lips or perky breasts. The alternative to engaging with the medical establishment in this case is resignation. A choice not to fight back against the vagaries of time, of gravity, of too much laughing

The study of anatomy seems to have been permeated early on with a double standard: the depiction of men’s bones conveyed medical knowledge about the human body, while the depiction of women’s bones conveyed aesthetic, cultural, and social concerns. In these early texts, the adult female skeleton is often rendered as if it were a child’s: underdeveloped, frail, breakable. It’s worth noting that this view of women’s bones was not the exclusive purview of men: when the French scientist Marie-Geneviève-Charlotte Darlus Thiroux d’Arconville published her drawings of the female skeleton in 1759, she exaggerated the sexed differences to the point of caricature. The skull was vastly smaller, the pelvis much wider. Embedded in the depiction was a message: women, with their smaller skulls and larger hips, were clearly intended by nature itself to be mothers, not thinkers. It was a message that thoroughly permeated the medical thinking of the time. The French medical encyclopédie of 1765, rather than omitting the female skeleton, dwells heavily on the differences between the bones of men and women before drawing this final conclusion: “All of these factors prove that the destiny of women is to have children and to nourish them.” In 1796, German anatomist Samuel Thomas von Sömmerring famously—and inaccurately—illustrated the female skeleton with a disproportionately tiny head, an enormously broad pelvis, and an improbably narrow rib cage. The inaccuracies were so marked that some doct...

In 1868, Parisian anthropologist and surgeon Paul Broca determined that the study of women had become a specific and urgent necessity. The women’s rights movement was beginning to pick up steam in Europe and North America, which was a sinister development in Broca’s view: women reformers seemed set to interrupt the natural order of things, cause a “perturbance of the races,” perhaps even divert evolution entirely. But if doctors and anthropologists could point to scientific evidence of women’s natural inferiority—a destiny literally written into the curves of their skulls—surely these intemperate ladies would see reason, go home, and cease their silly agitating for things like voting rights, temperance, or an end to child labor.

A central tenet of craniology held that brain size—and hence skull size—indicated mental ability. To the medical men of the moment, all those illustrations of female skeletons with their wide pelvises and tiny skulls looked not just like the embodiment of delicate femininity but like divine Darwinian truth. (The issue of skull size did present a problem, briefly, as scientists realized that women’s skulls could sometimes be bigger in proportion to their bodies—but in these cases, they simply pivoted to argue that these large-skulled women resembled children, and hence were still clearly inferior. Heads I win, tails you lose.)

A world in which women’s athletics are valued and celebrated is a world in which we can begin making long-overdue inquiries into how sport interacts with women’s health, from brain function and memory to bone density, joint stability, hormone levels, and more.

The “shrink it and pink it” approach to creating gear for female athletes is increasingly out of style, in favor of designs that not only consider but center women’s anatomical differences.

The “humorism” that dominated medicine for more than two thousand years was particularly rife with sexist nonsense that stood in the way of science, to the point where the humors themselves were assigned a gendered valence. The common medical wisdom was that female bodies were “phlegmatic” (which is to say, full of and/or ruled by the humor phlegm) while male bodies were “sanguine” or “choleric,” ruled by blood and bile. Even as doctors understood that every human body contained all four substances, blood itself was seen, medically speaking, as more of a guy thing. A man with a preponderance of blood was virile, healthy, a magnificent specimen. A woman, on the other hand, needed her blood kept in check, or even drained on purpose, lest it render her dangerously unbalanced.

Over the course of the next few centuries, chlorosis would continue to afflict young women, and to confound physicians who found the condition at once mystifying and titillating, synonymous as it was with virginity, desirability, and sex. And while the idea of marital intercourse as a chlorosis panacea would eventually go out of style, the idea that chlorosis was a lifestyle disease that required the patient to surrender her autonomy to a male authority did not.

Unfortunately, this conflation of good health with good etiquette—and of feminine propriety with an absence of appetite—created a catch-22 for chlorosis patients: what would have helped them medically (that is, eating red meat to improve their iron levels) was contraindicated morally (that is, eating meat was seen as a hallmark of a depraved and entirely unladylike craving for flesh).

As was typical for the era, the medical understanding of chlorosis was haunted by the specter of uncontrolled female sexuality; the fact that iron deficiency was often accompanied by odd dietary cravings—for chalk, dirt, charcoal—only contributed to the idea that poor health in young women was fundamentally linked to a perverse and insatiable appetite.

But it is also thanks to Osler that cardiac medicine was designed with a male patient in mind, while women presenting with heart complaints were understood to be suffering from neurosis, anxiety, or hysteria. Heart attacks in particular were meant to be understood as linked not just to maleness but to masculinity, particularly tragic in their tendency to cruelly strike down a particular breed of virile, hardworking man in the prime of his adult life: “It is not the delicate neurotic person who is prone to angina,” Osler declared, “but the robust, the vigorous in mind and body, the keen and ambitious man, the indicator of whose engines is always at full speed ahead.” Nearly all the case studies in Osler’s 1897 text on heart disease are male, with the classic angina patient described specifically as “a well ‘set’ man from 45–55 years of age, with a military bearing, iron-gray hair, and a florid complexion.” Women, meanwhile, were said to be afflicted with what Osler termed “pseudo angina”—literally, false angina—which described a collection of neurosis-induced symptoms masquerading as genuine disease. (Ironically, anxiety or emotional stress were still described as serious risk factors for a heart attack—but only in men.)

And indeed, not only did physicians come to believe that heart attack in women was so vanishingly rare that it hardly needed consideration as a diagnosis, the study of cardiac medicine came to systematically exclude women as patients. In keeping with Osler’s assertions, conditions ranging from heart attack to rhythm abnormalities were broadly dismissed in female patients as a symptom of emotional unbalance, rather than organic circulatory disease.

In other words: heart attacks were for warriors; arrhythmia was for sissies. And as for women, they were simply left out of the discussion altogether. As far as the medical community was concerned, cardiac issues were the purview of men—and if a woman presented with complaints, the problem wasn’t with her heart but all in her head.

William Osler passed away in 1917 and left behind quite a mixed legacy: a model of medical training that still remains in use in 2022, and a latent incuriosity about heart disease in women that persisted for nearly as long. So convinced was the medical community that cardiac issues were almost universally the purview of men that the first American Heart Association conference for women wasn’t held until 1964—and even then, this conference was for women but about men. Titled “On Hearts and Husbands,” it instructed women in how to attend to (or manipulate) the men in their lives to live a heart-healthy lifestyle. (It was also, perhaps needless to say, a veritable buffet of classic midcentury sexism, replete with tips such as: “Your own daily housekeeping chores like sweeping, dusting, making beds and chasing toddlers, already place you way ahead of your husband in the exercise department; help him catch up.”) But as absurd as the Hearts and Husbands conference was, the entrenched attitudes it betrayed about women as cardiac patients were not just serious but deadly. In matters of the heart, women were routinely and systematically excluded: from diagnosis, from treatment, from research, and from the medical consciousness at large. When doctors conducted the first medical trial to establish a link between cholesterol and heart disease in 1982, their data set included 12,866 men—and no women. In 1995, the seminal study establishing that aspirin could reduce the risk of heart at...

In 1929, the year that Bertha Hunt sparked a mini revolution by lighting up at the Easter Day Parade, the notion that cigarettes represented liberation from the sexist days of yore was not entirely unfounded. Smoking was still considered an unseemly activity for women to engage in, a form of spiritual and moral corruption. In some places, including New York City, local governing bodies passed bills and ordinances that made it illegal for a woman to smoke in public—or even in the privacy of her own home if she had children. If this was bad news for women’s autonomy in the eyes of the law, it was also bad news for cigarette companies, who had an obvious, powerful financial incentive to smash the female smoking taboo. Enter Lucky Strike cigarettes and their main marketing strategist, a public relations pioneer named Edward Louis Bernays. “The president of the largest tobacco company called me in and told me they were losing half of their market, because men did not permit women to smoke either in public or even at home,” an elderly Bernays recalled, in an interview conducted shortly before his death in 1995. “‘What can we do about breaking down that taboo?’ he asked.” Bernays, who was Sigmund Freud’s nephew (small world!), naturally turned for advice to the nearest, respected disciple of his uncle, Abraham Arden Brill. What Brill said proved revelatory: shattering the cultural stigma around women smoking wasn’t just about getting women to enjoy cigarettes. It was about gettin...

The ad campaign resulting from Bernays’s conversation with Brill is an early, notable example of how doctors would lend their expertise—and sometimes even a medical stamp of approval—to marketing products that were the opposite of healthy. It also might be the first documented instance of the phenomenon known as “woke capitalism,” in which corporations sold products to women under the guise of helping to liberate them. The so-called protest, in which women smoked openly at the Easter parade, was actually a stunt staged by Bernays, based on the ideas articulated by Brill. Before the parade, Bernays strategically spread rumors that a group of suffragettes planned to demonstrate there by openly smoking cigarettes. He carefully selected the group of ten women who would light up alongside Bertha Hunt—herself an employee of Lucky Strike—noting that “while they should be good looking, they should not look too model-y,” lest ordinary women find the whole enterprise unrelatable. And before the parade, he enlisted the help of a committed feminist, Ruth Hale, whose invitation to her fellow activists to smoke at the parade could have doubled as ad copy: WOMEN! LIGHT ANOTHER TORCH OF FREEDOM! FIGHT ANOTHER SEX TABOO.

From the rah-rah feminist smoking ads of yesteryear to the rise of contemporary wellness culture, attending to the respiratory system has increasingly become coded as a matter of self-care for women, rather than healthcare. Women are inundated with pseudoscientific suggestions to meditate, to download a breath-counting app, to get more exercise. There’s even a magazine called Breathe (subtitle: “and make time for yourself.”) Granted, this began as more a cultural problem than a medical one, but as in eras past, the medical community now ends up taking its cues from the culture—in this case, one that says respiratory health is a woman’s problem to solve, rather than a doctor’s to diagnose. The same medical establishment that told women in 1929 that smoking was a path to freedom, now responds skeptically when women say they can’t breathe, despite their disproportionate exposure to environmental factors that can cause pulmonary disease.

Respiratory medicine is plagued by the same tendency as other fields to write off a woman’s symptoms as anxiety without searching more deeply for an organic cause. Lindsay Lief, an ICU/critical care/pulmonary specialist at NewYork-Presbyterian/Weill Cornell Medical Center, tells me she’s trying to change this, saying, “I’m constantly drilling into my residents: anxiety is a diagnosis of exclusion in the hospital. You must first prove that you have explored everything else. I don’t want to hear, ‘I think she’s just anxious,’ when a patient presents with shortness of breath.”

The Victorian conflation of good health and good character make it difficult to untangle the medical conventions of this era from the moral ones, particularly when it comes to gastroenterology. The most influential health experts of the time, even the ones with formal medical education, operated more like modern-day wellness influencers when it came to the guidelines and treatments they promoted, and the dietary advice aimed at women in particular was designed less to improve health than to make their bodies and behavior conform to cultural norms. Women were discouraged from eating meat, or eating too much, not out of concerns that doing so might lead to bad health outcomes, but because appetite was a vice—one they were already considered congenitally less capable of controlling, hence the need for strict rules to contain

Not long thereafter, in 1902, the field of urology sprang up as gynecology’s male counterpart—and if you’d asked one of these doctors at the time, he surely would have told you that they had everything covered. Boys have a penis, girls have a vagina, and each has a doctor, so what’s the problem? And that’s how the medical profession just sort of forgot that women need to pee, too.

These women, though, the ones whose bladder complaints have no clear cause, no obvious surgical solution? Nobody knows what to do with them, and the litany of familiar accusations begins to pile up. They’re hysterical, neurotic, masochistic. They’re imagining it or they’re making it up. They’re fabricating their symptoms: for attention, for sympathy, for the . . . erotic thrill of being catheterized? Sure, why not. Women could pee if they wanted to; or, they could hold it in if they just tried harder. Whatever it was, doctors agreed, women were probably doing it to themselves.

When a medical field goes underdiscussed and unexamined the way that women’s urology has, the resulting knowledge vacuum attracts all sorts of peculiar theories to fill it, and peculiar people to go with them: doctors who are less concerned with healing patients than in using them to support a pet hypothesis about, say, the physical manifestation of female masochism as urinary complaints. Berthold Schwarz, the psychiatrist who attended chronic cystitis patient Agnes in 1958, was one such person: he was convinced, along with his case study coauthor Bowers, that her condition was largely psychosomatic—that her bladder was discharging not only urine, but “unconscious hatreds” stemming from her abusive upbringing.

What Parran could do, and did, was institutionalize the mistrust of women within the public health system. Under his watch, a powerful and toxic idea wove its way into the fabric of government, of medicine, and of American society: when it came to the spread of disease, women were always to blame, and never to be trusted—not with their freedom, not with their healthcare, not even as authorities on what was happening in their own bodies.

Although the national security threat represented by STDs—and the women who were allegedly responsible for spreading it—faded out of consciousness after WWII, the notion of vaginas as a source of sickness and putrescence was by now medically ingrained and culturally ubiquitous, even without the fear of a specific disease attached. The cult of cleanliness that had long surrounded women’s domestic lives had also made its way into the boudoir, along with an entire cottage industry devoted to making them feel as bad about their unhygienic bodies as they did about their messy homes.

For all the impact of the sexual revolution, and all the work of feminists to eradicate the stigma from being a sexually active woman, the doctor’s office remains a holdout: one of the few places left where a woman can be shamed for having sex, for being unclean, and all under the guise of it being for her own good.

Here, too, the avoidance of research on female subjects stems from a belief that their fluctuating hormone levels make them too complicated to study, even though this same biological variability directly impacts the efficacy and effects of medicines in women’s bodies as compared to men’s. And often, the proposed solutions to women’s lack of inclusion in biomedical research are hardly better than the original problem: in one case, researchers suggested doing experiments on male mice first, and then testing female mice only as a point of comparison to the male “default.”

Women are 80 percent more likely to suffer from autoimmune disorders than men, for reasons that scientists have yet to understand. They account for 80–95 percent of patients with primary Sjögren’s syndrome, systemic lupus erythematosus (SLE), primary biliary cirrhosis, autoimmune thyroid disease, and systemic sclerosis; they make up 60 percent of arthritis and multiple sclerosis patients. In most cases, these gender disparities are acknowledged but never studied; doctors have long been prone to writing off the differences as hormonal without further inquiry. And when it comes to the patients themselves, women’s perspectives go underrepresented for all kinds of reasons: lack of curiosity. Lack of research. Lack of trust from their doctors—and lack of confidence in their own abilities to speak up, ask questions, and demand answers about their health.

In my own practice, I see women diagnosed with metastatic breast cancer who have been scolded that the most important thing they can do is maintain a positive outlook—as if survival is not a matter of medicine but proper mental hygiene. This toxic idea is pervasive across culture and class alike; I have seen women from religious communities told that they should pray their cancer away, while women from elite wellness circles try to manifest and visualize themselves into remission. It is enraging, and it is also history made manifest: when sickness spreads, even through her own body, a woman will be blamed.

The closest medical research can come to including women, even now, is to study them as if they were men.

The fourteenth-century specter of the foul woman with a womb full of deadly rot, which infected the imaginations of medical men at the time, has taken many other shapes over the years. She is Martin Luther’s syphilitic whore. She is the immigrant cook, garnishing your dinner with teeming microscopic disease. She is the early twentieth-century fashionista spreading flu with her naked ankles. She is the 1940s good-time girl who looked so sweet, so clean—or the 1950s housewife whose neglect of “proper feminine hygiene” makes her husband gag. She’s the cancer patient who couldn’t visualize her immune system back to health. She’s the derelict who let Covid into her house because she didn’t wipe down the groceries with Lysol. She’s the conspiracy theorist who wouldn’t stop talking about how the vaccine altered her period. She could be anyone. She could be you.

And the female body, so many of whose workings remain medically mysterious even in an otherwise enlightened age, and so revered for its ability to grow, nurture, protect, and eventually give forth new life, also remains a vessel into which we can place all manner of things: blame, ignorance, incuriosity, fear.

for our purposes, the nervous system is best understood not as one biological apparatus, but as a prism through which the medical community’s entire understanding of women is refracted.

Historically, the “bitches be crazy” theory of neurology can be observed as much in absence as in evidence: not once, in the entire human history of medicine, has anyone ever advanced a competing theory that women are the smarter, saner, more sensible of the sexes.

Here, a pattern begins to emerge. Women who were diagnosed with hysteria in fact suffered from a variety of illness, physiological and mental alike (except on the numerous occasions when there was nothing wrong with them at all). What they had in common was not a medical condition but something far more intractable: they were all frustrating to men. Hysterical women didn’t listen, didn’t cooperate, didn’t behave. Their symptoms often seemed rooted in defiance—of convention, of etiquette, of a husband’s or doctor’s demands, and of the inferior role that physicians had been so reliably assured was their evolutionary birthright. As such, it’s not a coincidence that the preferred treatments for hysteria often involved restricting women’s freedom, whether it was to pursue an education or even to get out of bed. But when these measures proved insufficient to curtail hysterical symptoms—which by this point had expanded to include anything from tonic-clonic seizures to being tired to reading too many novels—the medical establishment was all too happy to restrict these patients’ lives even further . . . all the way into a squalid cell with bars on the windows, guards at the door, and the wails of fellow imprisoned women echoing down the halls all night long.

Every human body, regardless of sex, is internally awash in hormones; every human being, regardless of sex, produces the sex hormones associated with both male and female bodies. And yet, despite both the ubiquity of hormones and the breadth of the functions they perform, somehow only women have ever been saddled with the suggestion that their hormones make them unpredictable, incompetent, and unfit for certain types of work—and only women are commonly dismissed as “hormonal” when their emotions or behavior become inconvenient.

An organ, at least, could be removed; the discovery of hormones, on the other hand, suggested that women were simply marinating at all times in a potent mix of chemicals that made them volatile, foolish, and emotionally unstable from the moment puberty hit.

Male hormones were exalted while female hormones were maligned. A man with high testosterone, it was understood, was virile, a warrior, a stud. A woman with too much estrogen, on the other hand, was just crazy.

And yet, this is what happens when the archetype of the hormonal woman becomes entrenched not just in the cultural consciousness but in the healthcare system: we end up downplaying, overlooking, and ignoring the vitally important and complex role that hormones play in a woman’s health. Doctors and patients alike write off a dysfunctional endocrine system as both a forgone conclusion and no big deal (“Oh, it’s just hormones.”). And women’s suffering from endocrine issues, whether it’s debilitating PMS or the symptoms of menopause, is shrugged off as natural and hence untreatable.

Despite being the main site of women’s sexual function and orgasm, and hence a vital part of the human anatomy, the clitoris was virtually ignored by the medical community for nearly two millennia. Mentions of the organ were rare, and those that did exist were generally not positive: between the first and fifteenth centuries BCE, one of the few documents to directly address the existence of the clitoris is the 1486 Malleus Maleficarum, which described it as the “devil’s teat” and advised that any woman who had one could be assumed to be a witch.

Indeed, this organ, inessential to reproduction and yet utterly crucial to a woman’s sexual function—and which doctors have largely treated as either insignificant or sinister when they weren’t congratulating themselves for discovering it—serves in many ways as an avatar for the uniquely difficult relationship that the medical system has, and has always had, with women’s sexual health. Despite the initial assessment of women’s anatomy as inherently inferior, inverted, and other, medicine was ultimately forced to recognize the importance of the parts of a woman that produce eggs and hormones, maintain a pregnancy, and facilitate the birth of a child—all of which have long been treated as a woman’s biological destiny, her sole reason for being. But the clitoris represents an anatomical wild card: its very existence suggests that women can enjoy sex on its own merits, not just as a means to motherhood. And this, as we’ll see in the coming pages, made certain people very uncomfortable.

At the same time, the idea that women should be shamed out of sexual pleasure or desire had begun to permeate not just gynecology but other areas of medicine, including the burgeoning field of psychoanalysis. Sigmund Freud led the charge here, with his theory of the so-called vaginal orgasm: “Whenever a woman is incapable of achieving an orgasm via coitus . . . and prefers clitoral stimulation to any other form of sexual activity, she can be regarded as suffering from frigidity and requires psychiatric assistance.” In Freud’s view, clitoral orgasms were the hallmark of an immature, unactualized woman who was repressed by childhood sexual fantasies; instead, he said, women should forgo clitoral stimulation and aspire only to vaginal orgasms, an anatomically illiterate concept that he had essentially invented out of a combination of wishful thinking and thin air.

What began with the belief that the female body is a broken, inverted riff on the male ideal has evolved today into a sustained sense that women’s bodies are mysterious and unknowable, which in turn leads to women being decentered in conversations about their own care.