This article was originally published on Thred Media. 

Women (defined here as both female-identifying people, and people with wombs) have always found it much harder than men to have their bodies defined in the medical sphere.

Given that histories are recorded and circumstances dictated by men, it’s not surprising that womanhood is "othered" in our self-definition as a species — pushed to the boundaries of experience — but this sense of alienation is particularly prevalent when it comes to our physiognomy.

The female body has long been admired and feared by artists, writers, theologians, and scientists alike. For all recorded history we’ve been seen as boundaryless, apocryphal, excessive, and sinful; capable of divine acts of immaculate conception as well as wild and untameable; connected to the moon and the tide, bleeding and overflowing and seductive.

Though women have been menstruating since before homo sapiens were fully evolved as a species, it wasn’t until the 19^th century that scientists linked periods to ovulation.

Ancient societies associated periods with witchcraft, postulating that the blood could stop hailstorms, kill crop yields, and cure leprosy, if they wrote about menstruation at all. As late as the 1920s, medical professionals believed periods regulated women’s emotions and tempers, and were disconnected from them physiologically.

Narratives like this place the female form on a pedestal where it can be admired, suspected for its mysterious qualities, and kept in the shadow of ignorance. Centuries on, and the liminal nature of the female body has become so ingrained that even now we do not have a scientific grasp on them.

Many female specific ailments, like endometriosis, polycystic ovary syndrome (PCOS), premenstrual dysphoric disorder (PMDD), and vaginismus are woefully under-researched, with their causes and treatments unknown. Women are constantly misdiagnosed and mistreated by both male and female physicians, and the lack of desire to curb this trend is yet another sign of the taboo around female bodies.

The gender health care gap is both a national and an international issue — while health care is administered locally, medical research is conducted globally. The problem is inherently one of discourse: as female issues continue to be swept under the rug, unconscious bias will continue to be part of medical training and practicing.

So, if talking and active consciousness is the cure, let’s discuss.

Girl, interrupted

In The Second Sex, Simone de Beauvoir lays out perhaps the best summary of the roots of sexism I’ve ever read: "Representation of the world, like the world itself, is the work of men; they describe it from their own point of view, which they confuse with absolute truth."

This is entirely true when it comes to medical science. To understand how the male body became the default human construction, we have to go back to the 15^th and 16^th centuries when biology was first meaningfully applied to humans.

Physicians used to employ graverobbers to excavate cadavers or steal them from the gallows for dissection. The corpses they brought back became the basis for the earliest understandings of how we move, bleed, digest food, think, and feel; and, as female hormonal fluctuations were considered too deviant to make consistent calculations, they were, of course, always male. Maleness became the model by which medications were developed, and their effects on people studied.

Centuries later, and that masculinity still seems to be the industry standard. Learning from male bodies is frequently the default in clinical trials today, where subjects are overwhelmingly men — even the standard laboratory mice are male. The Medical Research Council (MRC), which funds and helps coordinate medical research in the UK, has stated that they are yet to produce guidelines on study design relating to the sex or gender of participants.

This is incredibly restrictive to women hoping to access proper medical care, as the only options available to us are functionally potluck.

The range of remedies arbitrarily thrown at ill women throughout history reads like a Doctor Seuss advice column. They were told to swallow toads to ease heavy menstrual flow, had hemp and corn forced up their vaginas to induce labour, and told to marry and bear children early lest their womb (thought by the ancient Greeks to have a mind of its own) dislodge and glide freely about their body.

"Hysteria" was a common medical diagnosis for women who displayed all manner of symptoms, ranging from shortness of breath, to fainting, to insomnia, to fluid retention. It was as much a catch-all term for physicians as a form of social control: a bad case of hysteria was attributed to women who had sex outside of marriage, displayed an attraction to the same sex, or violated any of the myriad patriarchal social mores of the time.

Though "hysteria" is no longer a legitimate medical diagnosis, many centuries later there remains a worrying trend of mass invalidation when it comes to women and the health care system. 

Research has found that women are assumed to be both more emotionally volatile, and to have a higher pain threshold, than men. This means that they are far more likely to have their pain reported by doctors as "emotional", "psychogenic", and "not real" according to a seminal 2001 study.

Ohmygods look at the absolute state of this misogyny! 😆

Have constant internal bleeding from #endometriosis for 25y that no doctor, medication, or surgery can cure and then come back with "doing it wrong" when you've understood science facts, kiddo ⭐ https://t.co/JRlJuspDAF

— Miss Lucy 🦸🏻‍♀️ Ageless Wonder(Woman) (@TheCurlyLucy) September 1, 2020

Indeed, women’s bodies are inherently linked with pain — childbirth, PMS, menopause — and the nature of that pain has always been considered vague, shrugged off with the adage that "being a woman inherently hurts". The same 2001 study also revealed that when in pain, men are more likely to be given painkillers, while women are more likely to be given sedatives or antidepressants.

This lack of ability, or even desire, to take women at their word predictably leads to high rates of misdiagnosis and delayed care. A study funded by the British Heart Foundation revealed that women who suffer heart attacks are half as likely as men to receive the recommended medical treatment for cardiovascular issues — for instance, only 15% of female patients were fitted with a stent after a heart attack, compared to 34% of men.

This follows other recent research by the BHF which found that over 8,000 women in England and Wales had died of misdiagnosed or untreated heart attacks they’d tried to report over a 10-year period.

In fields as diverse as brain cancer, chronic pain, and dementia, women can take up to seven times longer than male patients to receive a diagnosis.

"The health gender gap is fed by perceptions of women as being over-emotional and exaggerating the extent of their pain and suffering," says women’s health specialist Dr. Larisa Corda. "In reality, many women under-report symptoms… If they’re not taken seriously when they do see a doctor, it propagates the notion that whatever they’re going through isn’t serious, which can have massive implications."

If women are losing the battle in the arena of general medicine, we’re even more hamstrung in the field of female-specific illnesses. Endometriosis, a painful, cancer-like disease which causes cells to grow haphazardly around the uterus and effects one in 10 women, is as much a mystery to doctors today as the day it was discovered.

Across the board, less than 2.5% of publicly funded research has been dedicated exclusively to female reproductive health despite the fact that one third of women will experience severe reproductive health issues in their lifetime, according to Public Health England.

There has been five times the amount of research into male erectile dysfunction, which afflicts 19% of men, than there has been into premenstrual syndrome, which effects 90% of women.

How gender bias in medicine and a lack of research in women’s health creates a dearth of knowledge on the part of the GP is the subject of the first ever report released by the All-Party Parliamentary Group on Women’s Health in the UK (Women’s Health APPG).

In a survey of over 2,600 women with endometriosis and fibroids, the APPG found that 42% of the women found their cases were not handled with dignity and respect whilst being treated; 62% were not satisfied with the information they received about treatment options; and nearly 50% weren’t told about the short or long-term side effects arising from these options.

Dig even deeper and you’ll find further imbalances: Black women in the UK are five times more likely than white women to die in childbirth; people who are LGBTQ+ are more likely to suffer physical and mental health issues than their hetero peers; and there is almost no working research currently being done on how medical treatments affect trans bodies.

All of this matters, and matters deeply. Doctors can’t help patients if they don’t have enough information, and without a proper diagnosis, patients can’t make informed decisions about their health. To return to Beauvoir and The Second Sex: "The body is not a thing, it is a situation: it is our grasp on the world and our sketch of our project."

Enmeshed in our corporeal selves, our bodies are how we interact with and experience the world phenomenologically; what’s more, we typically internalise our view of ourselves under the gaze of others. The project of feminism is to detach femininity and women’s physical selves from the dominant gaze of another, but this cannot be achieved if each time a female body breaks down it must be assessed and cured under the male purview.

Search for a cure

Neuroscientists have found that unconscious bias is ingrained in us from a very early age. And, like everything else, medical training is taught in a way that affirms pre-existing prejudices, regardless of the gender of the trainee.

As Dr. Natalie Ashburner, a psychiatry registrar and member of the Doctors’ Association UK, told Cosmopolitan: "There’s a lot to learn in medical school, so often we’re taught to recognise patterns; things that are common. I think this can lead to certain groups not being recognised when we’re looking at how to treat them."

Our brains tend to cluster people into groups for cognitive ease, so that we can process information faster. This is a useful evolutionary tool on the whole but can become a destructive force in something as nuanced as medicine.

If a patient’s symptoms don’t fall into the expected pattern — one built on data from already gender biased studies — then the chances of a health condition being recognised decrease. Combine this potential for oversimplification with typically overstretched health services, and academic minorities like women and people of colour can easily be swept into the wrong pot.

There are those who often hail medtech as the next frontier in patient treatment, and the answer to humanity’s prejudice problem. Theoretically, AI could relieve pressure on health care services, and create a more level playing field when it comes to diagnostics and treatment. And AI-integrated health care systems would be able to avoid many of the pitfalls of fallible, biased humanity.

But, unfortunately, one of 2019's best examples of a medical service extrapolating seemingly sound conclusions from biased data sets (ultimately leading to a biased and therefore wrong conclusion) came from an algorithm.

The health care app Babylon was discovered to be doling out vastly different medical advice regarding chest pain to men and women. The system had advised a 60-year-old male smoker reporting sudden chest pains and nausea to go to A&E with a suspected heart attack. However, a woman who input exactly the same information was told she was likely having a panic attack.

Women are 50% more likely to die from a heart attack than men.

Babylon made calculations based on male-centric studies, and the chances are it was built by group of men — after all, men account for 76% of people currently working in STEM fields. Hence, the AI ran into the same problem that all non-human intelligences inevitably must: it can only put out what we put in, and, if all we can put in is our bias, we’ll get bias back.

Not sacred, but profane

On the whole, doctors are compassionate people who entered their field due to a desire to help others. But even the most egalitarian health care practitioner is working from a field constructed around male bodies. Medicine is a rigid practice by design — you need to build a sturdy framework of rules and regulations when people’s lives are at stake — but the structure we’ve ended up with only shelters a certain group of people.

In 2020 we’ve come far in talking about social injustices, but health care is lagging behind.

"We’ve only really started to look at these gender differences over the past decade," says Dr. Sanne Peters, a research fellow in epidemiology at the University of Oxford’s George Institute, who is currently researching inconsistencies between male and female access to treatment for heart conditions.

"So there’s a problem in terms of awareness that they’re an issue, and also in terms of our knowledge of what’s causing them — whether they’re down to biological factors that put women at a higher risk, or gaps in treatment caused by bias," Peters adds.

We’re only at the start of the process of gathering the data needed for the situation to change on a systemic level. Femtech, a fast-growing sector including period tracker apps, is playing a part in collecting female-centric data, which is beginning to increase the health care industry’s understanding of women’s illnesses.

To change the unconscious biases often at work when we visit our GP or walk into an appointment with a specialist, however, more effort and awareness is needed at training level.

"Medical misogyny is more widely known about than ever before, but tackling it needs to be a priority from the start of doctors’ careers," says Peters. "It starts with listening to women, not assuming they’re hysterical."

Certainly, there are times when your doctor is right — it isjust stress. But even the allegedly high rates of stress and anxiety in women could be chalked up to centuries of forced confoundment with our own bodies.

Women have been taught to recognise themselves as vessels, at once too corporeal and too emotional, but never before as merely flesh and blood; earthly objects in need of tuning just like our male counterparts. Structurally, women must be re-embodied.