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

by Elizabeth Comen

But the emotion I encounter most in the examination room, more potent and insidious than fear, is shame.

The women who apologize to me for being sick are part of a medical legacy, passed down over hundreds of years and still visible today. From that legacy, a story has emerged. It’s a story about what a woman’s body should look like and how it should feel, in work, in play, in learning and thought, in sex, in motherhood, in sickness and in health—and yes, even on her deathbed.

Western medical storytelling has largely eschewed the discussion of women’s bodies, let alone elevated them as powerful, capable, or of equal worth to men’s. 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.

In the late fifteenth century, Catholic clergymen authored a remarkable document titled Malleus Maleficarum, or The Hammer of the Witches. Over the next several centuries, this document was used to hunt down and systematically murder tens of thousands of women who were accused of practicing witchcraft.

Generations of healers, mainly women trained in practical methods like botany, midwifery, and herbal therapies, were subject to torture and death. The Hammer of Witches was particularly explicit as to the threat presented by female healers who attended to reproductive care, pregnancy, and childbirth: “Witches who are Midwives in Various Ways Kill the Child Conceived in the Womb, and Procure an Abortion; or if they do not this, Offer New-born Children to the Devil.”

While medical and scientific advances progressed for the next several centuries (and both faith-based healing and burning women at the stake fell out of style), the field of medicine would continue to be haunted by the misogyny and superstition that fueled the witch hunts of the 1600s.

By the turn of the twentieth century, women had been systematically shut out, including from the fields in which they had once been traditional knowledge bearers. It wasn’t just germ theory, laboratory medicine, and science; the field of midwifery, subsumed into the new specialization of gynecology, was now the exclusive purview of men.

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.

The role of women was proscribed in medicine as in society, bolstered by the stereotype of the female nurturer: Doctors cured. Nurses cared.

Women remain underrepresented and overlooked in medical research, even though many treatments interact differently in a female body than in a male one.

The bias in medicine extends to female physicians as well as patients. Like so many women, my path into the medical profession has been littered with obstacles specific to my sex; I have been undermined, underestimated, and held to standards that my male colleagues are not.

One recent study revealed that women operated on by men have significantly worse outcomes, including death, than when operated on by women. (As for the men, their outcomes were the same whether a man or woman operated on them.)

Rather, it is to ask for a medical world that is more human, more holistic, more capable of seeing the patient as a whole person and not just a series of broken parts. *

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.

Unlike other chapters in this book, this is not a history of women’s health issues going overlooked, ignored, or misdiagnosed for lack of interest. Indeed, it’s a physician’s preoccupation with women’s bodies, women’s beauty, that has driven many of the advancements in the field—and sometimes without much concern for what the women themselves think about it.

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.

As the field evolved, surgeons began to divide into two camps: those who did reconstructive surgeries on damaged faces and bodies, and those who performed cosmetic procedures on otherwise healthy people. And here, the line between medical and moral authority began to blur. Doctors, long valued for their expertise in matters of health and healing, were now the arbiters of aesthetics, too. Beauty, as always, was in the eye of the beholder—but now, the beholder was holding a scalpel.

Reconstruction was mainly the purview of men with facial disfigurements, and treated as a medical necessity even when the reason for the surgery was, in fact, social in nature: looking like a monster made a man unemployable, even if he was functionally capable of living and working normally.

But the cosmetic surgeons, who mainly treated women, were seen as lacking legitimacy by the larger medical establishment: the reconstructive surgeons were doctors practicing medicine, while the aesthetic ones were quacks hawking shoddy and unnecessary procedures to ugly, gullible ladies.

But for women, whose access to society was even more closely tied not just to looking normal but to being sexually desirable, cosmetic surgery promised to make the difference between a lonely, unhappy life on the fringes and a full, productive one as a wife and a mother. Men could have surgery and get a job; women could do the same and get a man.

To his mind, the connection between ugliness and criminality is obvious, even organic: when a woman so clearly looked like a bad person, how could she help but become one? And if an ugly face begat ugly character, then surely redemption could be found in beauty—and so, too, could the legitimacy of Crum himself as a practitioner of medicine.

And yet, Crum was also onto something when it came to the pathological nature of ugliness and its impact on women’s lives, a topic he remarked on in the 1930s in language that feels eerily (and maybe depressingly) contemporary: despite the “present world-wide emancipation of woman . . . a beautiful face is still reckoned as one of woman’s most valuable assets.”

The idea of a medical link between health, well-being, and beauty—a broken heart on the inside, a busted face to match—soon became central to the practice of elective cosmetic interventions on otherwise healthy women.

Suddenly, ugliness was no longer an aesthetic matter but a pathological one, a disease whose symptoms manifested as the psychological condition known as an inferiority complex. Unattractive features (or the effects of age) were increasingly reimagined as “deformities” that rendered the patient functionally incapable of living a normal life.

The effort to lend scientific legitimacy to cosmetic surgeries resulted in some truly remarkable, and often racist, lines of reasoning: at one point, the criteria for diagnosing deformity was rife with racial stereotypes about the undesirability of “ethnic” features, as plastic surgeons claimed that remaking patients to look more generic (read: white) would save them from persecution, discrimination, and other psychological harms.

Of course, it was always women who were seen to be at the greatest disadvantage for having been overlooked when nature was handing out pulchritude. 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.

This doctor-patient dynamic is not just unique but frequently gendered: most plastic surgery patients are women, and the majority of these receive treatment from male doctors. Other areas of medicine have seen great advancements in gender parity; this one, despite some incremental change, remains largely dominated by men.

importantly, it’s a story about men with the power to make women beautiful, and the authority to decide what “beautiful” looked like.

This is true of not just cosmetic procedures, but reconstructive ones—where the patient has been ravaged by something much more brutal than the simple passing of time. As late as the mid-1970s, many doctors believed that reconstructing the breasts of post-mastectomy cancer patients was a frivolous, unnecessary endeavor. The notion that women who had undergone radical mastectomy might be traumatized by the permanent disfigurement of their bodies was scoffed at, including by some of the most respected physicians at the time. T.A. Watson, a leading radiation oncologist treating breast cancer patients, wrote in 1966 that suggestible women were only professing to be devastated by the loss of their breasts because doctors insisted on asking about it: “We are frequently amazed at the therapeutic passions aroused by what is . . . an affliction of a superficial easily disposable utilitarian appendage.”

Watson’s attitude toward reconstruction, and to the women who wanted it, speaks not only to a serious dearth of compassion (“easily disposable utilitarian appendage”!!!) but a one-track mindset bent on aggressively eradicating disease, no matter the cost. Doctors were there to keep women from dying, not to ensure their quality of life thereafter—indeed, the reluctance to reconstruct a breast post-mastectomy stemmed in part from a fear among physicians that doing so would cause them to miss the recurrence of more cancer—and so their patients were simply expected to make peace with their breastless bodies; after all, per Watson, they hadn’t lost anything of value.

Arguably, Gerow’s silicone implants did play a big role in reconstructive surgeries for women who’d lost their breasts to cancer. But Gerow himself never conceived of implants in such an altruistic capacity; he was just a guy who liked breasts, and especially liked the idea of making breasts bigger. The population he had in mind for his surgery wasn’t cancer patients but rather women whose bosoms sagged after childbirth.

If the notion that small breasts were a deformity in need of surgical correction seems absurd, it did not register as such within the field of plastic surgery. Doctors re-christened the condition of small-breastedness with the scary-sounding medical term “micromastia,” which quickly became ubiquitous in medical reference books and textbooks.

the American Society of Plastic and Reconstructive Surgeons petitioned the FDA to deregulate silicone implants as a matter of medical necessity, describing small breasts as not just a deformity but a disease: “There is a substantial and enlarging body of medical information and opinion, however, to the effect that these deformities are really a disease which in most patients result in feelings of inadequacy, lack of self-confidence, distortion of body image and a total lack of wellbeing due to a lack of self-perceived femininity. The enlargement of the female breast, is, therefore, often very necessary to insure an improved quality of life for the patient.”

And so, while doctors like T.A. Watson were still decrying the selfish narcissism of women who grieved the loss of their “superficial, easily disposable utilitarian appendages”—even as he saved their lives—Frank Gerow not only pioneered the practice of breast augmentation but also instilled in the public consciousness the idea that it was a vital, even medically necessary procedure. He didn’t just enhance women’s breasts. He gave them permission to care about how their breasts looked, to believe that they were not easily disposable appendages but a valuable and vital asset to their womanhood, their health, their happiness.

There’s a Talmudic proverb that was once popularized by Anaïs Nin, the world-famous French diarist and bon vivant: “We do not see things as they are, we see them as we are.” But when Nin looked in the mirror, she saw something else: physical imperfections that were already holding her back, and would only further decrease her value to society as she got older.

Long before casually nipping and tucking oneself came into vogue, Nin had the same intuitive understanding as Crum did as to the location of her social value: not in her heart or her pen, but on the surface of her skin. Also crucial to Nin’s understanding was that beauty was hers to pursue but not define—because beauty was not only about beauty, but desirability. And who decided what was desirable? Men, of course.

On the one hand, we imagine that women are empowered by the ability to change the way they look—except that this “empowerment” takes the form of complete and utter submission, the woman lying unconscious on a table while a person she barely knows with a blade slices into her pliant flesh. And what are we to make of the competing notions that beauty is the most superficial and shallow of pursuits, while at the same time being the greatest asset a woman can have?

Plastic surgery is far more regulated today than it was when Dr. Gerow installed untested implants in Timmie Jean Lindsey’s chest in 1962. But the legacy of those early days is still with us—including in the process whereby a woman’s normal, healthy body is pathologized as a deformity in need of a surgical fix, and where the “ideal” is based as much as on what men desire as what women want.

The opinion of a straight male doctor becomes a proxy for the desires of men at large; the plastic surgeon’s expertise is not just in medical technique, but in being able to tell his patients how they should look if they want to be wanted by men.

In some cases, the new beauty standards are female-driven and arguably positive, corresponding with an increased diversity in the range of looks and body types that are considered desirable, as well as the increased accessibility and affordability of cosmetic procedures. We’ve come a long way from the days when doctors believed that looking too “ethnic” was a psychologically distressing deformity that required surgical correction.

But in many cases, the desires of men, their particular preferences, are still the elephant in the operating room. What breast implants were to the 1960s, the Brazilian butt lift is today—not only in terms of reshaping women’s bodies into a caricature of sexual desirability but also in the unregulated, Wild West–like atmosphere surrounding the procedure.

The shift from breasts to butts in beauty culture has also inverted an existing surgical pipeline: where surgeons once augmented women’s breasts using fat grafts from their buttocks, the Brazilian butt lift reshapes the buttocks using excess fat from the upper body.

And then there’s labiaplasty, for which one of the most popular search terms is “Barbie vagina.”

problem: women who find their genitals visually displeasing, usually owing to asymmetrical or undesirably long labia minora. Recent years have seen a 40 percent increase in women having labiaplasties; even ten years ago, it was practically unheard-of.

the vast majority of women cite aesthetic reasons for wanting the surgery—raising the question of whose aesthetics, exactly, should dictate the appearance of a body part that is rarely in a position to be seen by anyone, including the woman herself.

All told, the average graduate of a medical school is entering an industry in which female genital cosmetic surgery is on an unprecedented upswing—but with no concept whatsoever of how normal anatomy might vary from woman to woman, no basis for being able to reassure a patient on the fence about having surgery that there’s nothing medically wrong with her. What they have instead, based on some combination of personal experience and pornography consumption, is a highly personalized and probably misinformed notion of what labia are “supposed to” look like.

And indeed, we can’t talk about labiaplasty, or about its predominance in the field of plastic surgery, without talking about porn. Here, once again, we see how surgical standards come to be influenced not by what is healthy but by what is considered attractive: the average labiaplasty has very little to do with medical necessity and a great deal to do with what men like to look at.

Modern medicine hasn’t done much better: in 1975, Professor Sir Norman Jeffcoate, a physician and former president of the Royal College of Obstetricians and Gynaecologists, compared elongated labia minora to a dog’s ears and concluded, erroneously, that women were causing the condition by masturbating too much. Almost fifty years later, the notion persists that longer labia are a reflection of depravity or sexual promiscuity, particularly among religious conservatives still fighting the purity wars.

Oddly enough, the cultural breakout moment for the concept of the “designer vagina”—which arguably heralded the popularity of labiaplasties—came in 2008, amid a sex scandal that resulted in the resignation of New York governor Eliot Spitzer. The escort with whom Spitzer had been involved, Ashley Dupré, was reportedly the possessor of “the most beautiful vagina in New York,” leading to much speculation about just what a beautiful vagina might look like.

“The labia minora have a function,” she says—a fact that patients don’t always seem to recognize. If too much tissue is removed, the patient can experience chronic vaginal discharge, irritation, chafing, and debilitating pain. And worst of all, this is a problem with no easy solution; one of plastic surgery’s foundation principles is that it’s relatively easy to remove tissue from a body but extremely hard to add it back in. For this reason, when Preminger performs labiaplasties, she steers patients away from the “Barbie vagina” aesthetic that might create a medical issue where none previously existed.