Gender Bias and the Legacy of Medicine


John Henry Fuseli, The Nightmare (Wikimedia)


My family loves books. We have a lot of them around, and we pass them from generation to generation. That is how I ran into a book called Current Medical Diagnosis & Treatment, which was once in my physician grandfather’s collection. It was first published in 1962, and copyrighted every year thereafter until the edition I discovered, published in 1979. As of 1979, it had been translated into six languages with three more translations on the way. It’s over 1100 pages and touts itself as a “useful desk reference”, meaning doctors could reach for it when they wanted to look something up in a hurry. They were supposed to literally keep it on their desks. I’m going to refer to it as “the book”. (The book, by the way, is still in print, updated annually.)

The 1979 edition of the book grabbed my attention because it is a fascinating window on a not too distant moment in medical research and thinking. It reveals that the state of medical knowledge and treatment have progressed a great deal, as prognoses for certain diseases have improved a lot. We can give thanks for that.

What’s also interesting about the book is its gendered landscape. It starts in the table of contents: there are literally ten times as many male authors as female authors. This piqued my curiosity, so I dug a bit deeper in an effort to learn whether medicine forty years ago was plagued by sexism and gender bias. (Cue rueful laughter by women of a certain age, women like me.) I poked around, looking up a bunch of topics. It didn’t take long to hit pay dirt.

Premenstrual syndrome (PMS) is one of those health conditions that has a presence both in the medical literature and the popular imagination. When I was in college – at exactly the time the book was published – college boys would refer to us girls as being “on the rag”, meaning we were unpleasant to be around when we were menstruating. The book claims that about 50% of women have PMS, mainly when we are in our 20s and 30s. These women fit a specific profile: they are mainly in their 30s and “emotional, unmarried, or nulliparous [meaning they haven’t given birth].” What an amazing social script for young women – that they may well fall ill if they reach their 30s without getting married and having a baby. I thought that kind of thinking had died out by the 1970s, but I guess not.

The question arises: why are these women suffering in this way? The book has a ready answer: “Dread of an impending period and concern regarding pregnancy, elimination, and femininity often are basic problems. The woman experiences ego depreciation and often blames her mother for her menstrual difficulties.” Really? But that’s not all: “Depression and self-pity may color the woman’s affect, or she may be contentious and aggressive.” What about the treatment for PMS? If patients are “responsive” and “cooperative” in regard to the treatment offered by the doctor or psychiatrist, they might get better.

There’s another health condition, which could affect both males and females, but it appears only in the gynecology and obstetrics section of the book. It’s about itching in the nether regions. One of the treatments is Valium three times a day, so the woman is just plain sedated.

The book also explores the problem of “psychogenic” pelvic pain in women, meaning pain for which an “organic” cause hasn’t been identified. The woman suffering from this pain becomes a psych case, so to speak. Here’s a description of her: “she is egotistical and vain, dependent, demanding and self-indulgent, shallow, dramatic, emotionally labile and inconsistent, and coquettish but relatively frigid.” Wow. That’s a lot to pack into one woman. I wonder how the (probably male) doctor figures out that she’s coquettish AND frigid at the same time? The woman is said to have a “bleak” future, as she is choosing “invalidism as a chronic way of life.”

To try for a bit of … journalistic balance… I searched the book for conditions related to male genito-urinary health conditions. I wanted to know what the analogues are for men and their health. A lot of things were missing from the book’s index. There are four listings related to the vagina but none for the penis. There is a short section on erectile dysfunction, and causes are divided into psychologic and physiologic.

Given the book’s perspective about women’s health, can you guess what it says about erectile dysfunction? Instead of a counter-portrait of what’s up with men psychologically, there’s a litany of physiologic causes of erectile dysfunction. It’s a long list, ranging from diabetes to medication side effects, from back problems to organ system issues, and from surgical complications to urologic problems. The psychological hypothesis is short and to the point: the condition is caused by interpersonal or intrapsychic problems. There is only one interpersonal problem listed: marital disharmony. And only one intrapsychic problem, probably believed to be caused by the marital disharmony – depression. (Do any unmarried males have erection problems? Apparently not.) Isn’t it amazing that women get blamed for their own medical problems AND those of men, too?

Fortunately, medical thinking has progressed a great deal since the 1979 edition of the book was published. But I have little pockets of doubt, because gender bias dies hard. I had an appointment with a dentist recently and, after he heard me relate that a different dentist had recently done something mouth-altering to me without asking (in other words, without informed consent), he suggested that I was “anxious”. He quickly recommended that I choose to be unconscious for a procedure he would perform on the problem tooth. I hadn’t asked one thing about sedation, though I knew it was available upon request. The dentist seemed to want me to have it, perhaps so I wouldn’t be awake to observe him working on me. I wish I didn’t have my little pocket of doubt about how a subset of male practitioners view female patients, but there it is.

How did biased medical thinking about women’s bodies get started? It dates so far back sources can’t even agree on the beginning. Some sources say that 4,000 years ago, in Egypt, the human uterus was first hypothesized to roam around the female body, causing women to be “hysterical”. The term “hysteria” – found on an ancient papyrus – was always associated with a mental disorder. Symptoms described in 1600 BCE included tonic-clonic seizures, a sense of being suffocated, and death. Treatments included getting the uterus to move down by placing vile-smelling substances near the woman’s nostrils. If the uterus was thought to be too low, then the vile substance would be placed near her vagina. The Greeks, including Hippocrates, had their own take on hysteria; they linked it to lack of sex and procreation. And on it went through the Romans, medieval Europe, and the Salem witch trials. By the turn of the 20th century, Sigmund Freud was firmly implanting the concept in the popular imagination. Returning to the book – the physician’s desk reference published in 1979 – hysteria is described as a personality type that is “dependent, immature, seductive, histrionic, egocentric, vain, emotionally labile.” The very organ that permits women to bring new life into the world is the organ that damns us.

Though medical thinking has transcended a great deal of gender bias, there is more work to be done. I am confident that no medical desk reference published in the U.S. can describe women’s health the way the book did in 1979, so we have a lot to be grateful for. I also want to point out that women are by no means the only ones on the receiving end of gender-biased treatment by medical practitioners. Men, children and, especially, people identifying as LGBTQIA+, have plenty to say on the subject as well.

I hold the view that bias against one group hurts all groups, whether it’s sexism, ageism, classism, racism, or any other systemic social ill.Calling each of these biases out, in part by talking about the historical legacies that gave rise to them, is an essential part of the work we need to do to create permanent change, justice, and equity.We have to know where we came from in order to create the future we desire and we deserve.May the book that has yet to be written treat us all with equal respect.

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