How Gender Bias in Medicine Has Shaped Women’s Health

In the mid-1990s, up to 40 percent of menopausal women in America were prescribed hormone replacement therapy (HRT), many of them indefinitely. Doctors urged even asymptomatic women to take HRT, telling them it would decrease their risk of cardiovascular disease and dementia, prevent osteoporosis, and improve their overall sense of well-being. Then, in 2002, the Women’s Health Initiative study showed that prolonged use of HRT increases women’s risk of heart disease, stroke, and breast cancer. Prescriptions for HRT plummeted. Though the study has widely been considered flawed, today under 5 percent of menopausal American women take HRT. Of those who do take it, most do so for less than five years, even if they feel it benefits them and wish to continue taking it.

The rise and fall of HRT might be viewed as a simple case of medical knowledge advancing — we did better when we knew better, to paraphrase Maya Angelou. But Elizabeth Comen, MD ’04, a breast oncologist at NYU Langone Health, sees a darker, parallel story in which sexism and misogyny have negatively affected the medical care women receive, the extent to which women’s autonomy regarding their own bodies is respected, and the quality of research on women’s health.

In All in Her Head: The Truth and Lies Early Medicine Taught Us About Women’s Bodies and Why It Matters Today, Comen exhaustively explores how male-dominated culture has informed women’s health care from Hippocrates to the present day. She’s especially interested in the ways women’s health concerns have so often been misunderstood, ignored, or dismissed as anxiety. Comen, who shares stories from her own life and medical practice in her book, acknowledges that she’s been on the receiving end of sexism in medicine as a patient and as a trainee and that at times she’s perpetuated it unintentionally as a doctor.

You were a history of science concentrator as an undergraduate at Harvard. Were the seeds of this book planted back then?

Medicine doesn’t exist in a vacuum. I have had a long-standing interest in how science is reflected in the humanities, back and forth, that porous membrane. When I was in college, I worked in a lab at Dana-Farber studying the estrogen receptor and wrote my undergraduate thesis in part on the history of breast cancer treatment and the estrogen receptor. But I never imagined, even if I went into the field of breast cancer, that I would be a women’s health advocate. The idea of women’s health was really just gynecology in my mind. I was a product of the reductionist thinking that I’m trying to fight against now — that we’re not just “our boobs and our tubes” but we’re head-to-toe different. Our biology and our presentation of disease are extraordinarily different from men’s.

The scope of this book is enormous. You cover every organ system and millennia of history. Clearly you were bringing your humanities background to this effort. How did you research and write it?

In bite-size pieces. I think there had to be some bravery to take on the history because I’m not a professor of the history of science. I thought that if I divided it up, like we do in medical school, with each chapter devoted to a single organ system or function, I could make the research more manageable.

I started with nineteenth-century Boston physician Horatio Storer. I’d read about how Storer treated a woman who was married to an older man and who presumably had a higher libido than her husband. Storer diagnosed the woman with nymphomania and recommended that she be committed to an asylum if his barbaric treatments didn’t work. Not surprisingly, he condemned his own wife to an asylum for “catamenial mania” (menstruation-induced insanity). Yet Storer believed himself to be an early and passionate advocate for women’s health and founded Boston’s first gynecological society.

There’s a long-standing idea that because we endure childbirth we’re meant to endure pain.

I thought this was a fascinating example of how the culture of the times intersected with the medical care of women. I collected more compelling historical stories, those of my own patients, as well as interviews with experts. I thought about which diseases or syndromes or conundrums — because some of them didn’t have names — women present with and asked who laid the groundwork and the blueprint for what we think today. Then the book really wrote itself.

You write that modern medicine has grown on the “twisted roots” that were established in the nineteenth and early twentieth centuries and that we’re still reaping the fruits of beliefs about women that we now think of as ridiculous, such as that menstrual blood is toxic. How are these roots manifested now?

A clear example is how we continue to dismiss women’s pain. You do a skin biopsy in a dermatologist’s office and they numb you up before. Yet many women get IUDs placed or have an endometrial biopsy without proper pain management. There’s a long-standing idea that because we endure childbirth we’re meant to endure pain. And this idea, by the way, pervades what women physicians are expected to do in academic settings. We’re the peacekeepers. We volunteer for things. We engage in unpaid labor in and out of the home. We endure.

You write in your book about the long-standing medical view of women as “not men,” of female bodies as defective or incomplete versions of male bodies, as “other.” Do you think this othering, this dehumanization, contributes to inadequate pain management as it does for people of color?

There has never been, in the history of Western medicine, a belief system that extolled women’s bodies, women’s intelligence, as being as powerful as men’s. This framework still infiltrates all of medicine.

The issue of control comes up over and over in your book. You write of women sent to asylums for reading novels and how women were more likely to receive lobotomies than men. You also describe many instances, including in the story of Horatio Storer, where a woman whose behavior is troubling or inconvenient to men is pathologized and then locked up or subjected to unnecessary and cruel procedures. Is one of your themes that the pathologizing of women has been a means of controlling them?

Absolutely. I think we see that even today in how women’s activity is limited. We aren’t encouraged to become strong and participate in sports the way men are. Doctors learn very little in medical school about strength training for women or the type of exercise that women should do — about what is actually critical for their mobility, their longevity, and their bone health. In the nineteenth century women were told they’d get an ugly “bicycle face” if they rode bicycles. We still hear about activities that don’t “look feminine,” such as weight lifting. The medical profession has long been involved in keeping women smaller, promoting the idea that we’re not strong enough or powerful enough to engage in all aspects of the world professionally and personally.

You write that when you were fourteen your injured knee wasn’t repaired because the surgeon you saw advised you to wait and see how active you would be.

Yes, and for me that was devastating. It had huge psychological consequences. I was a dancer, I played volleyball and tennis, and that instability in my knee limited me tremendously. And when I did finally have my knee reconstructed, I didn’t have rehabilitation specific to my body. My physical therapist specialized in treating male ice hockey players. I didn’t have the kind of physical therapy we would provide for a woman with an ACL injury today.

You write quite charitably about how some of these doctors in the nineteenth century and beyond were products of their times and some of them clearly meant well — though some clearly did not. But on the other hand, some of the theories and practices they espoused were so absurd it’s hard to understand how intelligent and educated men believed in them. How do you account for that?

I tried to lean in with compassion and empathy in the book. For all my advocacy, for all my desire to be an equitable, compassionate doctor, I know I’ve fallen prey to many of these stereotypes that are woven into my own behavior, that I’m still unpacking. Researching the history of women’s health, it’s enraging and saddening to read and imagine what women must have gone through physically and psychologically. My hope is that the anger translates into constructive change moving forward. I’m an oncologist and optimistic by nature. My compass is focused on the future.

Speaking of the future, despite the fact that there are now more women than men enrolled in medical school and more women than men doctors under thirty-five in the U.S., the culture of medicine remains “male.” How can we promote gender equity for both patients and health professionals going forward?

I think what you’re bringing up isn’t so much a gender war, it’s a spiritual war: not valuing what we traditionally call “feminine” attributes, these ineffable qualities that are so important to what it means to care for somebody, that both men and women can engage in, but that we have not historically valued in medicine — compassion, empathy, listening. We have data showing that women demonstrate these qualities better because we’ve been culturally ingrained to listen, to show compassion. But it is not always something that’s valued in our academic medical system or by payers. There aren’t more insurance dollars for holding a dying patient’s hand. There may be money for developing a new drug or a surgical procedure or an infusion, but if you listen longer, is that considered productive? You actually lose money for listening longer. What have we done to denigrate empathy from a productivity standpoint? And in the process the North Star of caring for the patient gets lost.

I’m an oncologist and optimistic by nature. My compass is focused on the future.

I think the problem we have today is that we have this objective, quantifiable system of medicine that has fragmented the patient. And so no matter how many women we have in medicine, it’s not really about that. It’s about having a diversity of approaches to medicine that equally and equitably have a place in leadership, which we don’t see today. We have many women entering medicine but just as many women leaving medicine because of burnout, because they don’t feel valued, or because they’re entering fields like primary care or palliative care or pediatrics, and those fields have trouble getting remunerated. Continuity of care fields that might be really attractive for certain types of personalities ultimately aren’t valued by the system of medicine.

Finally, as we speak, a woman is running for president. You point out that historically women were thought to be too “hormonal” to have such positions of leadership (as if, you point out, men don’t also have hormones). Do you see in these attacks echoes of sexism in the history of medicine?

Of course! If you look throughout history, what was valued and focused on in the health of women was predominantly the idea that we are vessels, that we are valued for our childbearing capacity, whether it was being excluded from NIH trials because you couldn’t have women of childbearing age, or you couldn’t run a marathon because your uterus would fall out, or whatever it may be as it related to your primary god-given function on earth to reproduce. And when you see the criticism of a potential female president, whether it be for her race or because she hasn’t given birth to children, it’s fascinating and at times tragic to see how a woman is valued (or devalued) by society. We have not escaped the caged limits of our past even when it comes to potentially electing a woman president.

The problem is that so many things women face are unique to their biology — we are not small men. For example, 80 percent of autoimmune disease cases occur in women. Those presentations were not as common in the men who were treating them. It’s human nature to be interested in that which could affect you or your peers. Look at frozen shoulder, which disproportionately affects women. The historic treatment for that was benign neglect. Imagine men not being able to use their arms to throw a ball or work on a farm. We would never have treated that with “there, there you’ll be fine, just suffer for two years and it will get better” when we know there are more targeted, direct, and humane treatments for that.

It’s human nature that when something is outside your own experience, we say it can’t be something that I don’t know or I haven’t figured out — it must be something wrong with you. When you’re faced with something you don’t know, it takes bravery to be curious. The insidious incuriosity about women’s health by a male-dominated medical profession is in part why we are where we are today. We need to remain curious, thoughtful, and empathetic to have a more equitable future.
 

Suzanne Koven is an associate professor of medicine and of global health and social medicine at HMS and writer-in-residence at Massachusetts General Hospital, where she also practiced internal medicine for more than 30 years. She is the inaugural recipient of the Valerie Winchester Family Endowed Chair in Primary Care Medicine at Mass General. Her memoir, The Mirror Box, will be published in 2026.

Image by Flynn Larsen