EP. 139 — How Modern Medicine Has Failed Women with Elinor Cleghorn

Speaker 1 [00:00:00] Hello and welcome to Factually, I’m Adam Conover. Thank you so much for joining me again on the show. It’s such a pleasure to do this show. It’s the best part of my week every single week, and I thank you for being here as I talked to another amazing expert and have my mind blown. Hopefully your mind will be blown too. We’re going to have a great time together. Let’s talk about this week’s episode. I don’t know if you’ve noticed, but Western culture (or at least the version of Western culture I’ve grown up with here in the United States of America) is built around the idea that men are the default human. You got man as in mankind, the name we used for the entire species, and then you got a woman; which is like a man with something else added to it, right? Like a man, plus some weird ‘wuh’ kind of thing. The ‘wuh, ‘that’s what makes a woman. The man is the default. A woman is a man plus ‘wuh.’ It’s even embedded in our origin myths. In the Judeo-Christian Bible, the first woman Eve, was created from the rib of the first man Adam. Adam, of course, was created directly by God. But then God was like, ‘Oh, I already got the default human here, but I kind of want a different one. So let me just grab part of this one’s rib and I’ll make a weirdo different kind of human. Call it a woman.’ Now, of course, both of these ideas are bullshit, but they’re deeply, deeply embedded in our culture. This idea that women are different from men and somehow other: some weird thing that you have to work to understand. Nowhere is this fucked up idea more obvious than in the history of medicine. For literally thousands of years; as much as it has advanced, medicine has also fixated on the supposedly natural state of women as mothers and wives. Assumed that they’re inferior to men, that their pain is not to be taken seriously and that even their horniness is something to fear, control and manage, along with everything else that happens to their bodies. Male doctors and male scientists have treated women as some sort of strange creature driven by emotions and forces beyond male kin, with disastrous results for women’s health. It goes without saying that women even more marginalized in society, such as poor and nonwhite women, have had it even worse every step along the way. Now, if you’re a woman hearing this, you might not be surprised. If you’re a man, you might be. But look, either way, unpacking these ideas and resolving these myths is a critical piece of making sure that everyone in our society is cared for equally in the way that they need to be. So where do these ideas come from and how do they persist over the centuries? Who are the folks who were fighting against them all along the way? To answer, our guest today is Eleanor Cleghorn. She’s the author of ‘Unwell Women: Misdiagnosis and Myth in a Manmade World.’ Please welcome Eleanor Cleghorn. Eleanor, thank you ever so much for being here.

Speaker 2 [00:03:15] Thank you so much, Adam, for having me.

Speaker 1 [00:03:18] OK, let’s let’s start with the basics here. If if two people, if a man and a woman, go to the hospital today, how will they be treated differently or how have they been treated differently, historically?

Speaker 2 [00:03:29] Well, if they went to the doctors today, a man and a woman, then studies show us that they are very likely to be treated quite differently. Especially if they were turning up to the doctor’s office reporting some form of pain or another kind of subjective symptom that wasn’t maybe immediately diagnosable. The reasons for this are deeply historically rooted. We talk a lot about gender biases in society, and a major place in which gender bias is enacted and affects people’s lives are within the medical system and within the health care system, which has really embedded some of these biases over its really long history, centuries long history. So today, a man and a women walk into a doctor’s office, both reporting chronic pain. It’s been bothering them for a couple of weeks. They don’t know what’s causing it. According to studies, the man is more likely to describe his pain really straightforwardly. ‘I’ve got a pain in my arm. It’s hurt for two weeks.’

Speaker 1 [00:04:44] Mm hmm.

Speaker 2 [00:04:45] A woman is more likely to explain her pain in the context of her life or in the context of more social factors. Like, ‘I’m in pain, I can’t get up in the morning. I can’t look after my children properly. I’m worried about the impact on my relationship,’ et cetera. These are the masculine and feminine ways that we tend (not all of us, of course) to relate to our pain. Studies show, really recent studies, that the way women express their pain or sensations in their bodies; because they narrativize and because they tend to speak in more social, personal and emotional terms, that means that often they are perceived as being less reliable when they report that pain. Or because men tend to be more straightforward, more objective, less emotional in their articulation of something like pain, they are believed. This is a gender bias, this isn’t specific to medicine. We notice it across society in different ways. We see the ways in which women tend to be disbelieved when they tell stories about their bodies, right? But it’s really magnified in a medical setting because there’s a time pressurized situation. You’ve got a few minutes with that doctor (or health care provider) to translate what is happening in your body. It’s very personal, very subjective and then hope to get some answers or some explanations. So when explanations and answers aren’t immediately on hand, what tends to happen is that gender biases a fallen back on. So we’ll assume, for example, that women are more emotional, that their pain is probably psychological in origin and that men are more straightforward and their pain is physical in origin. So yeah, that’s the basis really of the gender biases that persist in medicine today and that have been really ingrained in medical attitudes across its long history.

Speaker 1 [00:07:01] Yeah, I want to ask about – The way you have been framing it so far is that men and women tend to present it differently, and so we have these deep biases. But the biases you’re describing are largely societal. They’re very widely distributed across our society, but we’re talking specifically about doctors who are supposed to know better. Like, I trust my doctor as much as the next person. That they’re extremely highly trained and that they’ve seen hundreds of thousands of people and they’re up to date on all the journal articles and et cetera. So we expect them to bring a certain scientific rigor to the situation. And so just saying, ‘OK, well, they have the biases that everyone else doe,’ we expect to hold them to a higher standard. But you’re also evoking that these biases are built into medical training, or medical practice to a certain extent, tell me more about that.

Speaker 2 [00:08:01] So to start with, I don’t believe that the majority of doctors are in any way out to get women or out to harm them. I believe that these issues that have really come to the fore in the last couple of years around gender disparity in healthcare are systemic. They sit above the level of individual prejudice. These biases tend to be unconscious. The issue that I explore in my book is where these biases come from and why they’re so persistent even today, when, as you say, you would expect that our scientifically based medical system would know better. So I’m not blaming individual doctors at all, and it’s not a misogynistic conspiracy on the part of health care professionals. But the issues that we come up against, that are really illuminated when women (especially) are trying to get answers about less immediately identifiable health issues is that a lack of knowledge can mean that these kind of gender biases raise their ugly heads because we do fall back on biases when we don’t know the answer. From the very beginning of medical history – I put that at the beginning of Western medical history, in the time of ancient Greece, with physicians such as Hippocrates, who hopefully listeners would have heard of. Because from Hippocrates, we get the Hippocratic Oath. That is the very basis of doing no harm. The medical ethical principle was formed in ancient Greece. But ancient Greece was also a deeply patriarchal society with very different ideas about how society was structured, in relation to the roles of men and women in that society. The Greeks also didn’t have x rays. They didn’t have blood tests. They weren’t able to monitor circulation. They weren’t able to see what was happening in a person’s immune system. They had to figure out what was happening in human bodies based on the knowledge that existed around them, and they applied that to the art of healing. So it made sense for the ancient Greeks to extrapolate that men and women were constitutionally different. Women existed, principally, to bear and raise children and  be reproductive creatures. Men, on the other hand, existed to work, to labor, to fight, to build. So the understanding of bodies, in terms of sex difference, was very distinct in the time of ancient Greece. Women would naturally seen as the weaker, more physically inferior sex because they didn’t do the kind of physical activities that help them stave off diseases of the body and mind. They were also very much at the mercy of their bodies because they were primarily seen as being reproductive: the reproductive cycle governed a women’s life in ancient Greece.

Speaker 1 [00:11:26] Mm hmm.

Speaker 2 [00:11:27] It was the purpose of her existence, shaped her existence, and it defined what her body was for in society. So we get this foundational idea from ancient Greece, that women’s bodies are really destined for purpose (childbearing) and they don’t have rational control over this purpose. Women are not able to decide for themselves what is done with their bodies because they’re predestined to reproduce.

Speaker 1 [00:11:55] Hmm. Yeah.

Speaker 2 [00:11:57] So it’s really important, I think, to remember that although a lot of the misogynistic fairy tales about the body are rooted in ancient Greece, that actually, when you look at ancient Grecian Greek society was like, this begins to make a little bit more sense.

Speaker 1 [00:12:17] Yeah, I mean, I’ve read I read some Plato in my time. I was a philosophy major. I read Plato. There’s some weird stuff about ancient Greeks society. We don’t need to get into it, but there’s some odd detail. You read like, ‘Oh, this is, how you guys are structuring things? Holy shit.’ So, yeah, that’s wild. I know the Hippocratic Oath. I know he’s the guy who wound the snake around the stick or whatever. This is also someone who took the first steps towards rationalizing the understanding of medicine and treating it more scientifically. So were there specific recommendations that he made that showed this, in your view?

Speaker 2 [00:13:09] Yes, there were. And you’re right, there are a lot of nuts things going on in ancient Greek society, especially where human bodies were concerned. Hippocrates, indeed, was the guy who rationalized medicine. He really moved medicine from being a practice based in myth and legend and religion, into being a pragmatic practice in which diseases and illnesses were diagnosed by looking at symptoms and thinking about what a body was going through. Rather than assuming, ‘Oh, you know, this dude’s ulcer, he’s obviously been punished by some gods.’ So he moves medicine into this really rational space that mirrors what we know medicine to be today; a kind of bedside art, if you will. So, yeah, sounds good. So so far, so good, right? So far so rational. One of the stranger things that the ancient Greeks believed, that to them was perfectly rational, was that women were defined by their wombs, their uteruses. So, the central organ of childbearing. Because women existed to bear children, their uteruses hungered to perform this duty. They had this sort of impulse. The organ wanted what the organ wanted. Because of that, he believed that women’s uteruses, if they were not in the act of conception or being weighed down with a fetus, would sort of shrivel and become hungry.

Speaker 1 [00:14:58] OK, this sounds like an A24 horror movie, is what this sounds like to me; a hungry uterus that demands to be fed.

Speaker 2 [00:15:10] ‘The Revenge of the Hungry Uterus.’ Yeah. Anyway, so Hippocrates believed that the uterus needed to be pregnant, needed to carry children in order to be healthful. So he endowed it with an almost animate impulse, an almost sentient human ability to go forth and get what it wanted. So he believed that when it wasn’t performing this ordained sacred duty of being involved in the processes of reproduction that it would shrivel, that it would become hungry and start roaming around a woman’s body in search of moisture. Who

Speaker 1 [00:15:52] What?! Wait. So how literally did he mean roving around? Like, ‘Oh, it’s going to take a trip into the right arm to see if I can find any moisture?’

Speaker 2 [00:16:03] Yeah, ‘I’m just going to slip into a crevice in the brain and start controlling the movement.’ No, he believed that it could almost float up towards the liver in the heart and that once it got there, that it would start compressing against those organs and it could cause all manner of really strange symptoms: suffocation, pain, fainting, even psychological symptoms like hallucinations and convulsions. So he really believed that this organ had these kind of appetites and that it had a really profound influence on women’s health. You can imagine it, in a sense, as the kind of engine running the whole show.

Speaker 1 [00:16:49] Wow, just almost like a second brain of some sort, that needs to be grappled with. That needs to be pleased and sated, or else the uterus will will hop up and start driving you around like a robot body.

Speaker 2 [00:17:04] Pretty much. Yeah.

Speaker 1 [00:17:09] This is a silly question. But was this la pseudoscientific belief on his part? Or did he actually have some – Was this poor dude in ancient Greece doing his best? Where did this idea come from? I guess, is my question.

Speaker 2 [00:17:27] Well, because the ancient Greeks didn’t practice human dissections. So they didn’t actually know. They didn’t know that the uterus was tethered in place. They didn’t understand. They just looked at symptoms and thought, ‘Hmm, this woman here is convulsing hallucinating. She’s got a raging fever. She’s muttering about something. Oh. Let’s have a look. OK, so it’s probably the uterus, and it is probably compressing that against the heart. And they have really different understandings about human organs, they endowed them with different characteristics. It made sense to them. So to our ears and minds, it just sounds like a fiction or horror movie or zombie thing. But to them, this was rational and this made sense. This was a pathway to making women healthier, by treating the symptoms of a wondering womb. Some of the possible cures for wandering womb – I mean, the main one you can imagine is sexual intercourse and conception. Number one, ideal treatment. If that’s not possible or doesn’t work, they often used fumigation of different smells because they believe that the uterus was attracted to certain fragrances and that it would smell a charred candlewick

Speaker 1 [00:19:03] ‘How to seduce a uterus back to its natural position? You can start with a lovely fragrance, they love the smell of rose hips.’ Bizarre! It’s easy to laugh at, and as a comedian. It’s almost hack to  make fun of what people thought of medical knowledge back in the day. But people were subjected to this. Real people’s lives were affected by this. And as much as you say that it was rational for them to believe it (to a certain degree based on what they knew), it was also based on this non-rational, more spiritual belief about what women were for, right? That’s one of the premises of that belief of the idea of an angry, hungry uterus; because you, a priori, believe that women are designed for procreation. Or was there any other basis?

Speaker 2 [00:19:58] No, absolutely. That was completely right, because women’s bodies were destined for reproduction, were put on Earth for reproductive purposes. It was a melding of a medical idea with a mechanism of social control, if you will. A way of endorsing or a way of justifying this social law that destined women for this reproductive role in society.

Speaker 1 [00:20:30] Yeah. Again, as much as it’s easy to make fun of people a couple thousand years ago, the basic thing that we’re talking about: using the rational abilities they had at the time, the limited knowledge but they’re doing their best jobs of trying to puzzle out the world. They still were basing their beliefs on these deep rooted assumptions, which is the same thing that we’re doing today. It’s what you described at the beginning of the show; our beliefs about women characterizing things more socially and that being more unreliable. That’s strikes me as an  unexamined belief that underlies an underlying a conclusion that we think of as rational. Or am I am I extrapolating too much?

Speaker 2 [00:21:20] No, you’re completely right. You’re absolutely on the money. It seems really odd to suggest that because Hippocrates espouses that women’s wombs were hungry and wondering and mischievous. That’s the basis of women being ignored, distrusted, doubted in the doctor’s surgery today. OK, so that seems odd. But in a sense it’s very true, because from the minute we begin to have the foundations of medical knowledge in ancient Greece, the physicians of ancient Greece were suggesting that women’s bodies were not really their own. So therefore, they were not the authorities over their bodies. They couldn’t speak to what was happening in their bodies, not only because they were not the authorities, socially speaking, (on anything, any form of knowledge) but also because how can you have any fidelity to something that isn’t under your control? So from the get-go, women are overly associated with bawdiness, but it’s not a bawdiness that women own. They don’t have rational control over it. So that kernel of thinking is what set in motion the circumstances that we grapple with today, by which women are not regarded as reliable narrators of their bodies when they speak about them. Of course, many centuries between ancient Greece and Hippocrates’ time and today have occurred and lots of medical knowledge has evolved and progressed. But some very foundational ideas about women’s bodies being not their own, being out of control, being unruly and needing to be tamed really persist. These myths of had real sticking power over the centuries, and they’ve almost been baked into medical knowledge even as it progressed into the science that we know it to be today.

Speaker 1 [00:23:26] One of the things that really fascinates me, before we move on because I want to talk more about different periods of history, but something that really fascinates me is this idea of rather than controlling your body, your body controls you. Your body is unruly and mysterious to you. I think there’s a lot of truth to that. When you’re describing that to me, it’s stirring something in me of that feeling true. That the body is, to a lot of us, still unexplored territory and you feel a way and you don’t know why. So there’s a lot of truth to that. But I don’t think that’s gendered, or I don’t think that sex specific. I think that’s true of anyone. And to a certain extent, to the extent that women are subjected to that, it’s also a way of thinking about your body that women are granted more access to in a way. Does that make sense? I’m like, ‘That seems like a way of thinking about the body that could also be potentially valuable in some contexts. And it’s odd that it’s gender specific that way.’ I don’t know what the hell’s going on with me half the time. I have a mysterious pain. I have diarrhea today. I don’t know what’s going on, but I’m not normally thinking of my body in this way.

Speaker 2 [00:24:49] Yeah, I think that’s so true and it’s definitely universal. We often don’t think about our bodies until something’s not quite right with them. Until we feel pain, until we get that mysterious twinge, until we get that stomach upset, until we get that fever and then this mysterious system that lurks beneath our skin; pulsing away and doing its thing, suddenly makes itself present to us and is asking us to act upon it in some way. It’s asking for something. Otherwise, I think the body often goes ignored. We go about our lives. We take for granted what our bodies are doing unless they start to malfunction.

Speaker 1 [00:25:40] It’s this deep, this deep confusion about what it is to be human, because on the one hand I’m a materialist right. I believe that like we are our bodies, fundamentally, what the body is shapes the mind and the spirit and all that. It’s this deep thing that we are, at the same time we are meat, but half of it is inaccessible to us. That we’re like, ‘Oh, something is happening, but I don’t know why.’ Or ‘Something happened, but I didn’t notice it until it was going on for a little while.’ That’s a very interesting thing about ourselves. I’m sorry, continue. Continue with your point, though.

Speaker 2 [00:26:21] So I think this is absolutely true. I think in our intimate relationships to our bodies, these issues around gender disparity don’t play out. I don’t feel like they play out. I feel like you and I would have a very similar sense of living in our bodies, on that kind of intimate level and that personal, unspoken level. When you think about what your body is and what it’s doing, it’s often really hard to articulate what it’s like to live in a body. But when we go to the doctor’s office because something isn’t right, that’s when we have to articulate what it’s like to live in our bodies. That’s when we have to try and put words around that really inarticulable experience of existing in a body. It is then that the problem starts, it’s then that the biases kick in because it’s about how the articulation of life within a body is perceived.

Speaker 1 [00:27:22] Yeah. You just made the process of going to the doctor seem so philosophically fraught; when you go to the doctor, you have to articulate what it’s like to be a consciousness housed in a biological framework that you don’t understand. That feelings appear that are maybe connected to what’s happening in your biology, but maybe not in this ineluctable way. And how could you possibly express it? It’s really stressing me out. Next time I have a cough, how will I represent this? How will I bridge the gap between consciousness? But there’s a truth to that. It is a very mysterious thing.

Speaker 2 [00:28:05] I’m sorry for stressing you out.

Speaker 1 [00:28:07] No, no, no, not at all!

Speaker 2 [00:28:08] It’s actually stressing me out a bit now, too. But I think the thing about pain, especially pain, is that it’s a universal human sensation. We all experience pain, but our relationship to pain is so subjective and so personal. What is pain to a person is never the same to another, and there is no language that adequately expresses the universal condition of pain. This is what a lot of the problem is in the communication of that pain, is how do you accurately communicate something that’s so personal, so subjective, so diverse? Yet it’s something that makes us human: the experience of pain. But getting good care at a doctor’s, for example, from a health care professional it really depends on that moment of communication. It depends on communication. Depends on listening. It really hinges on that.

Speaker 1 [00:29:07] Yeah and it’s so fraught. People talk about the pain scale where they say rate your pain from 1 to 10. That should be very clear and simple, right? OK, we’re trying to communicate very clearly. We’re trying to take a difficult thing and put a framework on it. But then I’ve heard people say, ‘Oh, you just got to say 9. Just say 9. No matter what it is, because 10 they won’t believe you and anything less than 9, they won’t listen. So just say 9.’ I’m sure nurses who are hearing this have the same sort of like, ‘Oh, this guy came in, he said 10. Fuck him.’ Or whatever. It quickly becomes this negotiation over care rather than a real communication. It’s a very difficult thing to do.

Speaker 2 [00:29:55] Very difficult. On the 1 to 10 pain scale, I think that a lot of women, when asked to rate your pain on a scale of 1 to 10, would fear going too high because they think, ‘Is this health care professional going to go “9? Are you hysterical? 9?”‘  So you kind of go, ‘6 probably seems reasonable.’ And then you think, ‘Am I pitching it too low?’ So again, something as simple as a 1 to 10 system then becomes fraught with a bunch of judgments and assumptions. This anxiety about how you’re going to be perceived, am I going to be seen as a fuss bonnet and then ignored? Am I going to be seen as exaggerating? Am I going to underplay it and not get the camera actually need? So again, it’s so fraught.

Speaker 1 [00:30:45] Yeah. OK, well, we have a lot more to get into, but we had to take a really quick break. We’ll be right back with more Eleanor Cleghorn. OK, we’re back with Eleanor Cleghorn, I want to learn more about the later history of medicine and its relationship with women, but I do want to ask one thing first; which is that people who have a uterus or that have ovaries, all these things, you do have different biology than someone with a dick and balls. There are different hormones going on. There’s different monthly cycles. There is different biology. How much has the history of this neglect caused women’s actual issues to be neglected? Again, you were talking about how the Greeks thought of women as being ruled by their bodies, et cetera, et cetera, and being fundamentally different. But there are fundamental biological differences. But it strikes me that probably the Greeks way of understanding it did not lead them to understand what those actual issues were and fix them. How does that piece of it come in?

Speaker 2 [00:32:11] Different forces then act upon that knowledge as it moves through history. So we get the ancient Greeks, the foundational medics saying, ‘OK, women are all about their wombs. Wombs move around if they’re not having a great time and raising a kid.’ Then you throw different religious, social, political ideologies, and forces into the mix upon that knowledge. So once we get Christian theology in the Middle Ages, the extant knowledge from ancient Greece is still there; it’s being translated and transmitted. The texts that survived the fall of Rome are being translated and transmitted into this new era of human history. But of course, they’re being respun according to new foundational beliefs about human bodies, about the difference between men and women. So the idea that a women’s womb is unruly then quickly evolves into the belief that a woman’s womb is dangerous. That it can lead her to do despicable, awful things. That because she has this womb that hungers for intercourse, she is depraved. She’s corrupt. She’s poisonous. And of course, that comes from the foundational biblical myth about the fall of Eve. Women’s corruptible bodies are responsible for all the sin in the world. So this is how these ideas evolve. It’s almost as if new learning is layered upon old, so you get the residue of those old mythologies. They stick there. A guy like Hippocrates was a very authoritative figure, and his ideas resonated across the centuries. So you get this kind of collage of ideas. The central truth is there, and it’s kind of impressed with the new thinking. You get this up until about the 19th century, really, until the dawn of biomedical health care and scientific medicine. Because medicine remains a very mythological (and often quite speculative) form of knowledge.

Speaker 1 [00:34:27] Yeah. You had people who were rediscovering the work of the Greeks. But then also they suddenly had the Garden of Eden story, and they had all these other things and they were mixing them together. I think the the 19th century period must be so fascinating because there was so much discovery all at once. What was the situation with women’s health at that time, or at least our understanding of it?

Speaker 2 [00:35:00] By the time we get to the 19th century, we see the disciplines of women’s health, of female health: obstetrics and gynecology, start to become of professional interest to male physicians. Throughout much of history, professional physicians were not largely interested, necessarily, in female biology. A lot of reproductive care was conducted by women. It was a very feminine space. And of course, male physicians did write extensively about the uterus, extensively about women’s reproductive bodies. But it didn’t mean they were necessarily wanting to hang their hat on that as their own discipline. It would come up in their general books about health and illness. So by the time we get to 19th century, we get gynecologists and obstetricians in the UK and the US. Our medical histories are very aligned around this time, they are venturing into a brave new world, as it were, and really establishing themselves as obstetricians and gynecologists with the capital letters. Forming professional societies, making a living from specializing in what was often called the diseases of women. This included everything that you just mentioned within that biological sphere of a female: the ovaries, the vagina, the vulva, the clitoris, the uterus. This whole space. The diseases of women encompass this whole biological space. The 19th century, as you said, was a period of really intense medical progress and evolution. We’re moving from this realm of theory and speculation to surgical interventions, to new understandings of where disease might come from, to new conceptions of chronic disease and acute disease. By the end of the century, germ theory emerges. So we move so fast and so rapid, but over that period of time is really when women’s bodies became the objects of medical attention in the sense we know them to be today. Doctors, physicians, gynecologists were specializing in trying to figure out those mysteries and mystifications that lurked within the female pelvis.

Speaker 1 [00:37:28] Yeah, this is maybe an improvement of perspective, but it’s moving from men Hippocrates being like, ‘Oh, the mysterious woman who’s ruled by her emotions and by her body and who can know what her problems are?’ And then a couple of thousand years later, they’re like, ‘Well, now we shall study the woman and we shall understand her mysteries and plumb her depths.’ But there’s still an othering there. There’s a treating it as like, ‘OK, this is a dark continent that we’re exploring. There’s a simplification and a paternalism there, certainly.

Speaker 2 [00:38:11] So much, and you see this paternalism really come to the fore around certain new innovations that become popular in the care of the diseases of women at the time. So, for example, in the early mid-19th century, the vaginal speculum became much more popular in gynecological practice. The speculum has existed for centuries. There was a speculum discovered in the ruins of Pompeii. These were used by different people throughout human history, but it was only really in the early mid-19th century that professional gynecologists started using them to, as you say, explore this hitherto unknown dark continent of the vagina and cervix. But the use of the speculum provoked insane debates because we’re still in the 19th century. We’re still being governed by the beginning of Victorian social mores, and this idea that an upstanding man, an upstanding, dignified male physician, would glance into a vagina was very improper. Forget treating her illnesses and diseases. Forget figuring out what’s really going on in her body. You’re risking your professional reputation. Furthermore, to this, the physicians who believe that the speculum was just this abhorrent indecent tool that had no place in an upstanding medicine also believed that women would become erotically excited by being examined with a speculum and it would unleash –

Speaker 1 [00:39:50] Everyone’s dream.

Speaker 2 [00:39:51] Everyone’s. They would say things like, ‘You can’t! If you go around examining women with speculums, all they’re going to do is go to erotically insane and they’re going to develop an insane sexual hysteria. And then their ovaries will shrivel up and no one will want to marry them. Don’t do it.’

Speaker 1 [00:40:09] Bizarre. But I mean, the speculum is a tool for peering inside, right? For getting an internal view. I read a couple of years ago, a history of the stethoscope as being a huge – I forget what year the stethoscope came into use, but the stethoscope as being a huge advance in medicine because suddenly you could get an internal view without having to cut somebody open. That was a big first, that was a watershed moment. But for the same thing, rather than for the heart, for the downstairs area to be treated as a horror or an object for debate. It goes to show you the difference in how these organs were treated by medicine at the time, that it wouldn’t be seen as as an incredible advance.

Speaker 2 [00:41:04] Some doctors did. Some physicians really understood that being able to properly look inside a woman’s body to see what was going on would enable diagnosis, would enable treatments. A few of the more progressive doctors did say, ‘This will help us move beyond the ignorance and superstition of the past, actually being able to get this objective view of what’s going on inside the body.’ But the majority view was really pivoted around these strange sexual politics, where medicine is completely dominated by men and men are completely governed by the social mores of the time: that are still very much, like, ‘Women’s bodies are shameful. As a man, you do not go near that part of a women’s body.’ These social superstitions, social beliefs, really trumped the need to create objective knowledge and create ways of healing and caring for women. The shame is always imbued in it, it’s imbued in those practices are even as they were developing. That’s then what impedes the progress from being objective and being straightforward, is that it’s always absorbing the social dynamics between men and women at whatever particular part in history that these advances were taking place.

Speaker 1 [00:42:43] This is almost a recurring theme for the show. We’ve talked about how, when you’re trying to do this, do these things, (the progress of science in the abstract, rational way) you always end up importing the biases of your time. I believe our episode with Ruhollah Benjamin, we’re talking about race and technology and about how there’s no such thing as technology that doesn’t have a racial dimension to it because it’s created by people. There’s a racial dimension to social life and some and it gets in there in ways that you don’t expect if you’re not cognizant of it. So this strikes me as sort of a similar process. You’re talking about the background social relationships with men and women of whatever time (Hippocrates on to the 19th century and today) just getting sucked up into medical practice, because why wouldn’t they? It’s another sphere of human activity

Speaker 2 [00:43:37] Very, very much. It’s not just that dynamic, that sort of sexual dynamic (if you were) between men and women, that does get really baked in to medical advances, medical progress, medical culture. It’s also the perceptions of women’s bodies that are a real hangover from ancient Greece. This idea of the unruliness, the untamable nature of a women’s body, but also women’s mind. So the idea that women are governed, principally, by their bodies and that they also have a very strong emotional connection to their bodies. They’re not associated with the mind in the way that men have been, historically. They’re not associated with the sphere of rational thought. They’re very embedded in their bodies, very embedded in their emotions. That attitude also clouded the understanding of diseases. We see it when certain chronic diseases are named, such as multiple sclerosis, for example, which now we know today is a disease (possibly) of autoimmune origin that affects more women than men. But when it was first being documented, when women were presenting with the symptoms that we know are a characteristic of this disease, they were assumed to be hysteric because that was the precedent when you had almost any symptom affecting a woman’s body. This was the context in which these symptoms were read. So the hysterical precedent being something that really solidified this really emotional relationship between a woman’s body and mind, in which we tend to think of women’s  physical symptoms as being somehow emotionally generated. So it’s the hysteric precedent that really did that. Today, calling a woman hysterical is a slur. It’s a gendered slur, but that had its origin in a medical idea about this sympathetic connection between the delicate, fragile and irrational female mind and the untamable, unruly and depraved center of her body.

Speaker 1 [00:45:56] Tell me a little bit more about that word because I almost wish we had gotten to it earlier, because I think it’s a central part of this story. As an amateur linguist, I can’t help but notice that you’ve got hysterical (as in ‘You’re being hysterical). Then you’ve got hysteria, the pseudoscientific disease that women were said to suffer from. And then you have what we still call a hysterectomy, which is the removal of the uterus. There’s a period when all these words are being used simultaneously with these three different meanings. One very medical, one pseudo medical and one just purely emotional. Where does that idea come from and how do those come together?

Speaker 2 [00:46:45] So one of the ancient Greek words for uterus (for womb) is hystera. So when the Greeks were talking about these movements of the womb, they were not talking about hysteria in the sense that we understand it today. In the sense of this very 19th century delirious fainting couch, too tight corsets situation of hysteria. They use that word because it meant uterus. So the symptoms of the uterus were hysteric symptoms. Fast forward to about the 17th century and hysteria as a – It wasn’t ever a disease, it was a diagnostic category invented by male physicians to explain the inexplicable symptoms that affected women. Hysteria could be anything a dude wanted it to be,

Speaker 1 [00:47:39] it meant ‘I don’t know what it is.’ It meant ‘This woman is suffering from something that I don’t understand. And hey, it’s not a rash. It’s not a heart attack. It’s something else. It’s hysteria.’ That’s the bucket for ‘I don’t know.’

Speaker 2 [00:47:51] Absolutely. It was an umbrella diagnosis. There was a wagon with every conceivable twitch, faint, convulsion, and mental symptom just piled on it. But it’s served male physicians really well because it essentially diminished women to their reproductive organs to their crazy minds, you know, reduced to women. All the complexities of the body that we were talking about earlier and all that incredible, inexplicable stuff going on underneath the skin. Hysteria reduced women to a gendered assumption that whenever they’re unwell, whenever they’re afflicted by mental or physical illness, it’s purely because of the nature of being female. That there is something inherently unwell, something inherently defective going on in this channel between mind and reproductive system. Hysteria was punitive, it could be a really punishing diagnosis. It could result in a stay in an asylum if that’s what one’s husband thought was the best. But it also masked the true nature of a lot of diseases and illnesses and clouded the understanding of others, too. By the time we get to the end of the 19th century, many physicians working in the field of women’s health are like, ‘OK, the jig’s up. Hysteria is load nonsense. It’s the will of the wisp, it’s a specter. It’s a star floating in the sky.’ They were very keen to debunk this because it was so dominant and it was time to move away from these narratives. That’s when hysteria was really taken up by the psychoanalytical community. Many listeners might associate the word hysteria with someone like Sigmund Freud saying, ‘The hysteric has these unbidden sexual impulses and she faints and screams and goes crazy because of them. And that’s hysteria.’ It loses its power as a medical diagnosis around the end of the 19th century, but it regains this psychological currency, and it remained in use as a diagnostic category at least until the 50’s and up until about 1980’s in some contexts. So it hovered around and it never had a real origin. It’s not something like cancer, that has changed its meaning and has changed its context over the centuries. But it’s always meant something that really existed in the body. That tumor, that growth, something that was really going on. Hysteria is a category applied to women, it’s a form of discriminatory knowledge imposed upon them. That is where we get this slur, calling women hysterical. You are diminishing her, her rational, her control, her intellect. That’s how it seeps into our cultural conversation in that way.

Speaker 1 [00:50:56] Wild. Well, you mentioned the 70’s, 80s, et cetera. And what that makes me think is, again, it’s so easy for us to make fun of ‘Here’s what people thought medically in the past.’ But as we’ve been talking about, our social beliefs today must leak into our medical knowledge in the same way. So bringing us up today, what are the ways in which we’re enacting this pattern today? You said at the beginning, women go in and they say, ‘I’m feeling pain.’ Their pain is not taken seriously. But let’s dig deeper than that. What are the assumptions that the medical profession is still carrying out that or that we as civilians are carrying around with us? And what are the effects on women of those, medically?

Speaker 2 [00:51:48] I think these old mythologies, these old ideas, impact our health (as both men and women) in really particular ways. And the most measurable ones are, as I talked about at the top of the program, the attitudes that tend to emerge when women and men express pain. And of course, the very real effects of these assumptions; of downgrading, belittling, diminishing female pain is that complex diseases often go misdiagnosed or undiagnosed. So we look at a disease, for example, like endometriosis. It takes between 10 and 12 years to be conclusively diagnosed with endometriosis. It affects a staggering number of people with uteruses across the globe. It was first named in 1927, but its symptoms have existed in medical history since before Hippocrates. Yet we still cannot diagnose this disease in a timely way and it’s still shrouded in mythology. The reason for this, is that those gendered misbeliefs, which were very germane to the pre-war period (the pre-Second World War period) have really stuck. They’ve impeded clear, objective understanding of what the disease is, how to diagnose it, how to treat it. We see a similar pattern in diseases like lupus, which is a disease I have. It affects 90 percent more women than men, or 90 percent of sufferers are born form female.

Speaker 1 [00:53:27] Really? I didn’t know that.

Speaker 2 [00:53:28] Yeah. There are different forms of lupus, but on the whole, 90 percent of sufferers are female and it takes between 6 and 8 years to be diagnosed, depending where you are in the UK or the US. And again, because a disease like lupus starts with nonspecific symptoms: I go to a doctor’s office and I say, ‘I’m tired, I’m exhausted all the time. I’m aching. I’m might have mental health issues as a result of that.’ With these symptoms, that’s when those biases and prejudices kick in and where the lack of knowledge exists. Why does the lack of knowledge exist? Because we have not prioritized diseases that disproportionately affect women because history has tended to fall back on gender biases and gender beliefs very reflective of the era in which they emerge. So now, really, is the time to disentangle that sort of antiquated gendered stuff from medicine as a science and an art form. It’s a time to face that and have a reckoning with it.

Speaker 1 [00:54:32] Yeah, endometriosis is one that I’ve recently been reading about, and by the way, could you tell us what endometriosis is? For those who don’t know.

Speaker 2 [00:54:41] Endometriosis is a multi symptomatic systemic disease; meaning that it can affect all the organs in the body. That affects people who have uteruses, and it also affects some men. Very small numbers of male people have it too, but it’s where tissue that is similar (not the same as but similar) to the tissue that grows inside the uterus grows in other parts of the body, and it can affect the person’s fertility. It can affect the functioning of all the different organs. So the tissue can appear in the lungs, it can appear outside the uterus. It’s a very poorly understood, multi symptomatic systemic disease that historically has always been associated with menstruation, with heavy menstrual bleeding, with fertility, and for this reason has either been stigmatized as something that women should just kind of deal with. ‘Oh, heavy periods, whatever.’Or it’s been overwhelmingly associated with fertility and reproduction, so it remains very poorly understood.

Speaker 1 [00:55:50] Yeah. My understanding of endometriosis, I’ve read a little bit about it, is as this poorly understood disease. It seems like there’s a circular thing to what you’re talking about, where there’s this belief or assumption of women as ruled by their bodies; the mysterious female body. Then the conditions themselves are poorly understood themselves, which lends to the feeling that the female body is a mysterious terra incognita. So it sort of goes around and around like that, when if proper attention were simply paid to the disease and we understood it fully, we might have less of that assumption about it.

Speaker 2 [00:56:36] Totally. When you get caught in this wheels within wheels, cyclical paradoxes and contrary ideas because a woman is (or for a long time through our history was overwhelmingly associated with) a body. Her body was seen to be mysterious and inexplicable, but yet her body was also very socially available and very discussed as a kind of social entity. People were always talking about women’s bodies, what women should do with their bodies. But yet the objective understanding that might result in care and well-being and understanding is lacking because it seems to me that the social notion of what women exist for, what women should do with their bodies, is always perceived to be more important than really carefully understanding what is happening in all that biological stuff that’s labeled female. So we’ve inherited such a lack of knowledge. This woeful gaps in knowledge that, previously in our history, have been filled in with old myths. Endo’s fascinating because when it was studied in the 1940’s by an American physician called Joseph Meeks, he assumed that it was becoming more diagnosed because women at that time were putting off having children until a little bit later in life. The reason this was happening is because we’re just coming out of the depression and more women are entering the workforce. The stable industries are the ones that can employ women. He’s saying, ‘OK, endometriosis is essentially a punishment for women who decide to keep on menstruating because they’d much rather go work than they would pop out a bunch of kids.’ That is very of it’s time. That’s completely rooted in the time in which he was espousing this nonsense.

Speaker 1 [00:58:35] That is wild to me. I want to bring in also, speaking about the discrimination that people of color face medically. The layered experiences that women of color have in medical settings. Can you talk a little bit about that?

Speaker 2 [00:58:57] Of course. Women, of course, are not a monolith. I as a white women risk being called hysterical when I speak about my pain. But for black or ethnically diverse women, they also face the double prejudice of racism and sexism. Medical racism spun quite a different narrative about the pain and illnesses of women of color. So if we go back briefly to the 19th century, we see racist ideas from anthropology being absorbed into dominant medical thinking and a lot of these racist anthropological ideas were trying to classify a biological difference between the races; which of course we know now to be complete falsehood. But then, it was trying to make these value judgments that were essentially all boiled down to being an apology for chattel slavery. It was these white dudes trying to justify the abhorrent and inhumane practices of chattel slavery. But what we get in medical thinking, is this a dire mass belief that white women who have access to leisurely colonial treats and exist in the colonial world are very refined and they’re capable of feeling this pain. That doesn’t mean they’re being cared for better because they’re seen as exaggerating, but they’re perceived as being capable of feeling. They’re refined and civilized enough to feel. Black women, on the other hand, and other women of color; the force that was perpetuated was that they were invulnerable to pain. Mm-Hmm. This is very rooted in the perception of humanity. The humanizing (or dehumanizing as it were) of people who are enslaved, people who are colonized, people who are racialized. These ideas that people of color did not feel pain were also married to other racist ideas: that people of color have thicker skin, fewer nerve endings, smaller brains. I mean, the list goes on. Racist biology is an awful, awful – It has a horrible history. But it had real ramifications as medical history progressed, for the understanding of the way that diseases and illnesses affected women of color. A good example is something like uterine fibroids. So fibroids that grow in the uterus. These were studied in white women back in the early 19th century and surgical interventions and medical interventions were developed for them. But in black women, uterine fibroids were overly associated with sexually transmitted diseases because of the prejudiced beliefs about black women’s sexuality. So that’s just one small example in which the racism that’s also embedded in medicine has impeded the care of Black women, and of women of color. We see it as well in the woeful rates of maternal mortality in both the US and the UK, where often women of color are disavowed their pain. They express pain and because of these persistent racist misbeliefs that people of color experience less pain, there might be some assumptions of exaggerating or just the idea that a health care professional might undervalue or underplay that pain and not necessarily notice what is happening with that particular person. So we have an entirely different sort of strand of neglect, of devaluing, of harm that’s been done because we have not adequately faced up to the legacy of medical racism that does persist today.

Speaker 1 [01:02:54] Yeah. Do you feel that any of these issues are getting better at all? In the 19th century, I assume there are very few female doctors. That’s changing now. Medical racism is something that we’re at least having a conversation about in the medical community. I just did a segment of the show that I’m making that’s going to come out on Netflix next year where we talked to folks at the NIH and we talked about these issues. These are issues that they’re working at the government’s National Institutes of Health. There are important people taking these issues seriously. So do you feel that progress is being made?

Speaker 2 [01:03:43] I do feel that progress is being made. The more we delve into this history and the more we see that it’s roots are still with us and that it still continues to affect people, it’s easy to feel really hopeless and easy to feel like it’s such an uphill battle. But I look at the way the conversations around structural racism, structural sexism, the systemic neglect that happens within systems of power like medicine. The way that we’re discussing them now, the way that these issues are being discussed in the press and on podcasts like this and in the media is (I feel) revolutionary. The more that people discuss these issues, the more that individuals face up to history but also share their personal experiences. It’s very meaningful because it creates conversation, and history has shown us that speaking out, finding community, building together, vocalizing experiences, talking about histories has made legitimate and really significant progress. So I do feel really hopeful. I think the conversations that are being had across the whole spectrum of healthcare are incredible at grassroots levels. Even at big government levels in the NIH, as you say, over here with the NHS. I really do feel like we’re reckoning with this stuff. I do, and it really makes me feel hopeful the more we can talk about it and the more we can face those histories and understand where some of these issues have come from, the less likely we are to repeat the mistakes of the past.

Speaker 1 [01:05:25] Do you have any thoughts for women who are in this situation? I haven’t wanted to tell anybody else’s story on this podcast, but so many things that you’ve said have resonated for me with women in my life. Where where I think, ‘Oh, someone I love has had an experience that resembles what you’re talking about.’ Where there’s a medical issue, where they go and they do not get resolution or comfort from the medical community or from the experience they’ve had. So do you have any words of wisdom for women, next time they’re sitting on the piece of paper on the weird bench with the weird medical smock on and the doctor comes in? Is there something that can be done, in that moment, to make that go a little bit more smoothly?

Speaker 2 [01:06:21] I think first and foremost, remember your body is your own. This is your body, only you know what it’s like to exist inside it. You can be in that situation, where you are either struggling to be diagnosed or struggling to communicate what’s happening in your body and feeling frustrated and feeling that you’re not being treated well. It can really help to take someone with you because when you’re unwell, it’s really emotionally taxing. It can be really traumatizing. It can help to take someone with you, not to speak for you, but someone who knows you, someone who can testify to what you’ve been going through. It can also really help (if you’re up to it and you feel like doing it) to keep a list or a little diary of symptoms because you can almost cut out the emotion and just read from your diary and say, ‘Look, I’ve been in pain for four months.’ It can help, little things like that can help. But above all, I would say that it’s your body and we’re very conditioned, I think, to listen to doctors and accept what they’re saying. And if we don’t get the answers we want, we internalize that as something that’s wrong with us.

Speaker 1 [01:07:32] I love that. First of all, knowing that what you’re experiencing in your body is real, but also bring along a friend or a loved one who can boost you up a little bit. Like, ‘No you listen here, motherfucker. She’s in pain. I got to sit here and watch this shit. So you do something.’ Just make it a little bit of a team effort.

Speaker 2 [01:07:57] Yeah, for sure. Because it’s so hard. When we talk a lot about how to advocate for yourself in life, how do you push? How do you demand more? And it sounds great. It sounds great to say to stand there and say ‘I’m not going to take this, I need a second opinion. Get that other doctor in here.’ That isn’t an experience that’s available to many of us. Even when we do have choice in our healthcare providers; you feeling unwell, you’re in pain, you’re up against a complex system. You’re not going to start getting your power pose on and go ‘I’m not gonna take this.’ So having some advocacy can happen in different ways. It can happen in ways that are much more accessible for us. Bringing someone with you who knows what you’ve been through, who can just be there for you, it can mean such a lot. I do think it helps cut through that almost antagonistic one on one dynamic that can happen, where you can feel like you’re being judged, you’re having to perform. How bad is this ache? How terrible is this knee pain? If you’ve got someone with you, it sort of cuts through that. It undermines that “them against you” feeling that can sometimes come up when you’re trying to seek treatment or seek diagnosis. So I think it’s something really simple, advocacy can be that. It can just be not being alone. As you say, making a bit of a team effort of it.

Speaker 1 [01:09:31] That is wonderful advice. I’m also really hopeful things are getting better in this regard. I can’t thank you enough for coming on the show to talk to us about it. Eleanor, it’s been really wonderful.

Speaker 2 [01:09:43] Thank you so much for having me. I’ve really enjoyed our conversation.

Speaker 1 [01:09:52] Well, thank you once again to Eleanor Cleghorn for coming on the show. If you enjoyed that, once again, check out her book at factuallypod.com/books. That’s factuallypod.com/books. I want to thank our producers, Sam Roudman and Chelsea Jacobson. Our engineer, Ryan Connor and Andrew W.K. for our theme song. The fine folks at Falcon Northwest, for building me the incredible custom gaming PC that I’m recording this very episode for you on. You can find me online at adamconover.net or @AdamConover wherever you get your social media. Thank you so much for listening, and we’ll see you next time on Factually.