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. It is a story whose authors have long since left us, although their names and likenesses can still be seen in museums, on plaques, in textbooks that guide today’s medical students on their journey to becoming practicing physicians. And while the authors of this story were indeed men, that’s not the problem with it. The problem is, the story is not true.

Everyone has a master, after all, and the fault lies less with the individual men than with the system in which they lived and labored. 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.

This past is a presence in every doctor’s office and every research institution; in medical exam rooms, anatomy cadaver labs, hospital hallways, and operating rooms. It haunts our footsteps as we navigate the medical maze of women’s health that was built by men whose ideas about women, while sometimes well-intentioned, were limited at best, paranoid, misogynist, and abusive at worst.

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.

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.

History is also watching us. When the remains of today’s medical system are scrutinized by students centuries down the line, what will they understand about how we cared for women? Will we be curled up with our spoils, recognized for our strength, valued warriors in the fight against suffering and illness? Or will we be buried in the ruins of a broken system out of which we never found the strength to dig?

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.

If soldiers whose faces had been torn away by bursting shell on the battlefield could come back into an almost normal life with new faces created by the wizardry of the new science of plastic surgery, why couldn’t women whose faces had been ravaged by nothing more explosive than the hand of the years find again the firm clear contours of youth? —Max Thorek, MD, plastic surgeon, 1943

This is insane

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. And so perhaps it was inevitable that the plastic surgeon’s gaze, and scalpel, would eventually be aimed below the neck.

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.”

“We do not see things as they are, we see them as we are.”

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.

Hello???

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.

Even as our society fetishizes youth, or the appearance of youthfulness, to acknowledge this too openly—to let it show on your face in the form of having had obvious work done—is still, somehow, a bridge too far. 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 only constant was a forgone conclusion: that women’s bones revealed them to be primitive and frail, underdeveloped and inferior, and above all, in need of watchful protection by male stewards. After all, they had to be. The alternative—that women might be equal, or, God forbid, more evolved—was too horrifying to entertain.

And yet, women of the time surely noticed that a “healthy” posture was also one that put their bodies on display.

In addition to the idea that being immobilized was no big thing for women, patients suffering from frozen shoulder also appear to have been up against another form of prejudice that is by now familiar to any student of medical history: the notion that any problem mainly afflicting women must have a psychosomatic component.

Being so slender that your clavicles pop remains a mark not just of beauty but status; you can never be too thin or too rich, but if you’re one, you’re probably the other.

And on this front, they were in agreement: the worst thing about bicycles was that women could, and would, use them to masturbate.

“No woman should ride a bicycle without first consulting her medical man,” announced Harper’s Weekly in 1896.

At the center of the debate surrounding female athletes was an impossible, and preposterous, question: How athletic could a woman be before she didn’t count as a woman anymore?

And complicit in this humiliation of female athletes were doctors, who advised that a woman’s eligibility for competition be determined via roughly the same methods that farmers use for sexing livestock.

We want to prepare girls for their role of being the mothers of strong, healthy men. —Tenley Albright, MD, 1964

This is 1964

By the 1960s, the question of whether exercise itself was medically recommended was no longer in dispute; doctors agreed that physical activity was beneficial to everyone, regardless of sex. But for women, this advice had acquired an aesthetic, and decidedly unscientific, gloss: the exercises recommended for women were meant to make the body not stronger, and not healthier, but smaller.

male announcer cheerfully quips that having helped win the war effort at home, women must now wage war on their own bodies: “The battle of the bulges is still on!”

“The muscle-building type of exercise, such as weight lifting, does not suggest itself to any of us as suitable for girls, partly because a woman would not look attractive performing and partly because she would have to look unattractive to us if she had the muscles she’d need to perform well,” she wrote. “While this kind of exercise would not cripple a woman or decrease her ability to keep house well, it certainly would not add to her feminine image.”

In 1967, runner Kathrine Switzer became the first woman to complete the Boston Marathon. It almost didn’t happen: a few miles into the race, she was physically assaulted by a race manager named Jock Semple who tried to forcibly remove her from the competition.

In others, we are still beholden to all the same foolish fears: That a woman with a strong and capable body cannot also be a good mother. That the time and energy a woman spends exercising is time and energy wasted. That a woman’s strength is unsightly, unseemly, and unfeminine. That the most important thing a woman’s body can be is small.

Iyengar says, “To this day, almost every single weight loss intervention in women is geared towards body weight loss and achieving that skinny ideal. And we’re learning that that is not always the best approach, especially with some of the new fad diets like fasting, for example. You lose fat, but you’ll lose muscle as well.”

For too long, a woman could be in the best shape of her life, but this wouldn’t be seen as a positive thing—even by her physician—unless that shape was also exceptionally small.

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.)

In matters of the heart, women were routinely and systematically excluded: from diagnosis, from treatment, from research, and from the medical consciousness at large.

Today, fully one-third of women will develop heart disease at some point in their lives; for one woman in five, it will be the thing that kills her. That’s not just more than breast cancer; it’s more than all cancers, of every type, combined. A hundred years after William Osler declared that women’s heart failure is all in their heads, it is their leading cause of death: all too real, and all too often overlooked until it’s too late.

“A woman’s arrhythmic risk varies according to her menstrual cycle,” Khan explains. “When your estrogen peaks during ovulation, it’s not only body temperature that goes up; the heart rate goes up, too, by about two to four beats. Meanwhile, we’re at the lowest level of estrogen and progesterone right before the period starts, and that’s the time that women are more likely to have arrhythmias.”

A woman’s menstrual cycle is inextricably linked with her risk of fatal arrhythmia: patients with long QT syndrome, a disorder that can cause fast, chaotic heartbeats, are at greatest risk of death during pregnancy or just before menstruation.

When she published a 1992 landmark paper in the New England Journal of Medicine that summarized how much cardiac disease in women remained underresearched and unexplored, coronary heart disease was not only the number one killer of women but an underdiagnosed, undertreated condition whose dangers the general public remained grossly unaware of. It wasn’t until 2001, and the publication of a report from the Institute of Medicine titled Exploring the Biological Contributions to Human Health: Does Sex Matter?, that female mortality due to cardiovascular issues began to decline—and then it did so sharply.

Surrounded as they were by such rapturous depictions of tuberculous women, perhaps it’s no surprise that doctors romanticized the disease, too. An 1833 article in The London Medical and Surgical Journal actually praises tuberculosis for being so wonderfully photogenic: “Some diseases are borne in silence and concealment, because their phenomena are calculated to excite disgust; to others, the result of vicious courses, the stigma of disgrace is attached; unsightly ravages of the human frame, or the wreck of the mental faculties, inspire us with horror rather than with sympathy; but consumption, neither effacing the lines of personal beauty, nor damaging the intellectual functions, tends to exalt the moral habits, and develop the amiable qualities of the patient.”

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.

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.

As a result, women’s respiratory ailments frequently go undiagnosed, sometimes with the worst kind of results. Rates of lung cancer, for which the imagined “standard” patient is a male smoker in late middle age, have risen 84 percent in women since the late 1980s, even as they drop in men. Women are more likely to suffer from lung cancer despite never having smoked, as well as remain at greater risk even after quitting smoking.

We don’t talk enough, generally, about the way that women’s daily lives bring them into contact with things that may compromise their respiratory health. Cleaning chemicals. Salon products. Cooking fumes.

In 1994, Australian sociologist Deborah Luton found that the gendering of foods had changed very little since the Victorian era: participants in her study identified feminine foods as “light, sweet, milky, soft-textured, refined and delicate,” and specifically mentioned those tiny, crustless teatime sandwiches as a prime example of the type. The archetypal masculine food, meanwhile, was red meat.

If the notion of diet as gendered began as something of a meme, it soon took on the sheen of medical legitimacy. The foods most appropriate for one sex were contraindicated for the other, always with scientific-seeming justifications. Women were warned that stimulating foods, especially salty, spicy, or acidic dishes, would overtax their sensitive nervous systems—or worse, increase their sexual appetites.

In short, a woman with a dainty figure was, in her slimness, a portrait of self-restraint—which in turn advertised her as a person of culture, sensitivity, and elevated social class.

Today we find a similar entanglement of health status with wealth status, of medical wisdom with pseudoscientific quackery and fad dieting, and of a struggle for control over women’s lives that begins with controlling their appetites.

According to Kellogg, allowing women to enjoy spicy or even just flavorful foods was fraught with dangers both medical and moral: “Candies, spices, cinnamon, cloves, peppermint, and all strong essences, powerfully excite the genital organs and lead to the same result,” he wrote in the 1880s. The ominous “result,” of course, was masturbation, an act with which Kellogg was particularly obsessed.

His marriage was reportedly never consummated, and while he did raise forty-two children—all adopted—he and his wife slept in separate bedrooms all their lives.

this is insane

Thanks to the influence of Kellogg and his contemporaries, including Sylvester Graham, the earliest versions of what we now understand as “diet foods” entered the mainstream beginning in the early twentieth century. Kellogg’s bran flakes were among them; so was Graham’s eponymous cracker.