Bias in women’s healthcare: From hysteria to the female Viagra

A woman pipetting at a laboratory bench.

A historial perspective on the “disease of womanhood”. Image credit: National Cancer Institute via Unsplash

To the woman, he said, ‘I will make your pains in childbearing very severe; with painful labour you will give birth to children. Your desire will be for your husband, and he will rule over you’. Genesis 3:16

Perhaps no other statement better reflects the sexism experienced by women throughout history: that their very purpose is sex and childbirth. Their lot in life is pain. Her role is subservient to that of man. These ideas have permeated all aspects of women’s lives—including healthcare. As a result, numerous diseases afflicting women were thought to arise from a failure to perform such duties.

This attitude existed as far back as ancient Greece when women’s health was tightly linked to sexuality. In Diseases of Women, Hippocrates wrote of the benefits of sex and procreation, which were seen as necessary to open the bodily canals and cleanse a woman’s body of her humours. He states clearly: ‘if women have intercourse, they are more healthy’.

For at least two millennia, physicians believed that the lack of sex would lead to the womb wandering around the body, causing disease. This notion gave rise to the term “hysteria”, from the Greek word for womb. Symptoms of hysteria included anxiety, tremors, convulsions, and paralysis. Unsurprisingly, sex and orgasm were frequently prescribed as treatments.

Hysteria persisted into the deeply religious Middle Ages in the form of demonic possession, especially in the early Medieval period. Many unexplainable symptoms, particularly those resembling that of epilepsy, were considered the work of the Devil. From Aristotle to Thomas Aquinas, women were long referred to as “a misbegotten male”, inferior to men, and thus predisposed to such demonological afflictions.

From Aristotle to Thomas Aquinas, women were long referred to as “a misbegotten male”, inferior to men, and thus predisposed to demonological afflictions.

In the 19th century, American physician Frederick Hollick proposed ’bad physical and moral education’ as a primary cause of hysteria. ‘Indolence’, ’weak constitution’, ’too great devotion to music’, and the ‘perusal of exciting novels’ were also listed as predisposing factors. Notably, these traits also characterised a morally unsavoury woman, reflecting the view that womanhood itself was the cause of disease. As Elinor Cleghorn puts in her book Unwell Women, ‘medicine has historically pathologized what it means to be a woman’.

The gender health gap today

Connotations of demonic possessions and moving organs are thankfully a thing of the past for modern women, but women’s health remains fraught with inequities. Increased disease prevalence, lack of access to health information and healthcare, and poorer health outcomes are examples of health inequalities experienced by many women, better described as the gender health gap.

As we shift our focus to contemporary medicine, we must also acknowledge that the gender health gap is part of a bigger picture of health inequality across the globe. Health outcomes are heavily influenced by non-medical factors including, but not limited to, socio-economic status, gender identity, and cultural norms. These broader determinants of health can intersect in numerous ways, which can privilege or disadvantage people. For instance, members of the LGBTQ+ community are more likely to experience mental health problems and have poorer primary care experiences. In particular, trans women and intersex people face a unique set of barriers to healthcare, whereas the standard of healthcare for cisgendered women rapidly improved in the 20th century. For this reason, this article will use the term “women” to primarily describe the experiences of cisgendered women.

Indeed, the experiences of women today are a far cry from the time of Hippocrates. After all, hysteria was struck off the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. However, the legacy of dismissing women’s physical symptoms as psychiatric or psychosomatic persists, as exemplified by patterns of misdiagnosis in multiple sclerosis (MS).

The legacy of dismissing women’s physical symptoms as psychiatric or psychosomatic persists.

MS is a severe neurodegenerative condition that can shorten a person’s lifespan by 5-10 years. Symptoms include fatigue, spasms, and depression, all of which overlap with numerous other conditions. MS is thus frequently misdiagnosed in both men and women—but not comparably. Women are disproportionately more likely than men to be misdiagnosed with functional or psychiatric disorders like anxiety, functional neurological disorder, and, until the 1980s, hysteria. On the other hand, misdiagnosed men are more frequently offered orthopaedic referrals, legitimising their physical symptoms. Perhaps due to this tendency to psychologise women’s symptoms, women were historically underrepresented in MS populations, leading to the belief that men were more likely to develop MS than women. Today, we understand that the opposite is true: women are, in fact, three times more likely to develop MS than men.

Beyond MS, the gender health gap manifests in numerous other ways. Women receive poorer dementia treatment, girls are frequently told that they have “emotional problems” when they have attention deficit hyperactivity disorder (ADHD), and over a third of menopausal women are wrongly prescribed antidepressants for hormone-related mood problems.

It’s all in your head

In no other area is this health gap more pronounced than in the treatment of pain. Women often report having their physical symptoms psychologised, being told “it’s all in your head”, or accused of malingering. A 2021 study found that women’s pain was consistently underestimated and that they were prescribed more psychotherapy, while men received more pain medication. When reporting pain, women are frequently trivialised and dismissed due to the perception that they have a lower pain threshold. This contributes to women receiving less analgesia in emergency departments despite similar pain scores as men. These inequalities are also informed by gender bias. In the same 2021 study, perceivers who estimated women to be in less pain also believed that women were more willing to report pain.

Women often report having their physical symptoms psychologised, being told “it’s all in your head”.

Endometriosis highlights that the barriers to receiving proper medical treatment for pain exist at every stage. Affecting 10% of menstruating women, endometriosis is a chronic condition where tissue resembling the lining of the uterus grows elsewhere. Besides infertility, endometriosis is also associated with severe menstrual pain and chronic pelvic pain. Despite its prevalence and severity, it takes a median of 1.5 years for women to seek medical help, with a median of 8.5 years of total diagnostic delay.

A qualitative study in 2006 investigated the reasons for this delay, with reasons spanning from childhood to the clinic. From a young age, girls are taught to accept and internalise menstrual pains, and cultural norms have long informed them that pain is a natural part of being a woman. These norms influence women’s understanding of the severity of their own pain. Women report believing that their heavy, painful periods are merely due to bad luck and preferring to accommodate rather than disclose their pain. If they decide to seek medical attention, many women recount feeling dismissed by their doctors and sensing disbelief about the intensity of their pain.

This perception of not being treated seriously is associated with a doubling of the duration between symptoms and diagnosis. Ultimately, 40% of women require over ten visits to their GP before finally being referred to a specialist, and a majority of women have to see three or more doctors before being diagnosed with endometriosis.

The veil of objectivity

Of course, it is not the conscious desire of physicians to belittle their patients or endorse stereotypes. Nonetheless, physicians are not exempt from implicit bias and the cultural norms that shape their perceptions of patients’ experiences. If doctors genuinely perceive women to be in less pain, they can only prescribe medication and treatment according to the perceived extent of that pain. ‘Medicine’s focus on objective factors and its cultural stereotypes of women combine insidiously’, wrote Diane Hoffman and Anita Tarzian in The Girl Who Cried Pain.

Certainly, numerous diagnostic tools like the International Classification of Diseases (ICD) and the DSM are part and parcel of how medicine has embraced objectivity as a key virtue of health practitioners. However, when gender bias hides behind the veil of objectivity, we must question the validity of medical research that informs the diagnostic lenses of health practitioners.

When gender bias hides behind the veil of objectivity, we must question the validity of medical research that informs the diagnostic lenses of health practitioners.

A 2018 paper identified ‘serious male biases’ in biomedical research, citing an analysis of research papers published in 2009. Of ten disciplines, eight had a greater ratio of articles including male-only versus female-only subjects. This bias was most pronounced in neuroscience, physiology, and pharmacology. Interestingly, sex was omitted in over 60% of immunology articles despite a greater prevalence of autoimmune diseases in women.

Studies in reproduction, on the other hand, exhibited a female bias. Cardiologist Nanette Wenger coined this the “bikini medicine” phenomenon, whereby women’s health research largely centres around the parts of her body covered by a bikini.

Another study that investigated ten withdrawn drugs between 1997 and 2001 found that eight posed greater risks to women, bringing into question why these conclusions weren’t drawn during trials. In another bizarre case, men represented all but two of the 25 participants recruited in a phase 1 study looking into the alcohol interactions of the female-specific drug flibanserin (also known as Addyi, a drug commonly touted as the “female Viagra”).

The reasons for excluding women from these studies and trials were variable but often involved hormonal differences and childbearing ability. In drug trials, it was feared that the drug would affect reproduction since women are born with all the eggs they will ever produce. In other fields like metabolism, female rats tend to be excluded from studies due to concerns that hormonal changes from their menstrual cycles would lead to uninterpretable results.

The irony in this reasoning brings the gender health gap into the territory of the frighteningly comical. Researchers exclude women because they respond differently, yet the conclusions drawn from male research participants are extrapolated to women.

It’s not all doom and gloom. Change is happening on all fronts, both inside and outside of clinical settings. In 1998, the FDA required new drug applications to present safety by sex, age, and race. Female doctors are now almost equally represented as male doctors in the UK. Female representation in the House of Commons is at an all-time high of 35%, putting policymaking in the hands of women.

The impact of having women in these positions of power is tangible—the number of gender-vocal articles published in the BMJ increased dramatically after Fiona Godlee took the position of editor-in-chief in 2005. Medical history is being rewritten by the greatest advocates for women’s health: women themselves, who time and time again exhibit the resilience and courage to speak out. Medicine need only listen.