Six years ago, Dr. Elizabeth Komen, a breast cancer specialist at Memorial Sloan Kettering Hospital in Manhattan, held the hand of a patient who was hours before death.
As Dr. Komen leaned in for a final goodbye, she pressed her cheek to her patient’s wet face. “Then he said it,” Dr. Komen recalled.
“”I’m so sorry to make you sweat.”
In her two decades as a doctor, Dr. Komen has found that women are constantly apologizing to her: for the sweating, for the follow-up questions, for failing to detect their cancer earlier.
“Women are apologizing for being sick or seeking care or advocating for themselves,” she said during an interview in her office: “I’m so sorry, but it hurts. I’m so sorry, this looks gross.”
Those experiences in the exam room are part of what led Dr. Komen to write “All in Her Head: The Truth and Lies Early Medicine Taught Us About Women’s Bodies and Why They Matter Today.” In it, she traces the roots of women’s tendency to apologize for their sick or unruly bodies to centuries of degradation by the medical establishment. It’s a legacy that continues to shape the lives of female patients, she argues.
Today, women are more likely to be misdiagnosed than men and take longer to be diagnosed with heart disease and some cancers. they may be less likely to be offered pain medication. Their symptoms are more likely to be written off as anxiety—or, as the book’s title suggests, as all in their head.
“The anxious female, the hysterical female, has been a specter that looms and weaves throughout medical history,” Dr. Komen said. “It’s a default diagnosis.”
Collectively, she argues in the book, these injustices help explain why many women report feeling invisible, frustrated or embarrassed in doctor’s offices. Shame may be the symptom, but Dr. Comen believes a deeply misogynistic medical system is the disease.
A story of exclusion
A mother of three in her 40s, Dr. Komen is quick with a camera-ready smile that has helped her become a regular in media coverage of breast cancer. She occasionally tears up when discussing her patients.
She once cried at her medical school job and a male resident responded by telling her to “pull yourself together.”
“I felt I had to justify my answer,” she said, sitting behind her desk. “And now I cry with patients all the time.”
Her approach has been shaped by decades of experience, as well as what she learned about the place of the female body in medicine while studying the history of science as an undergraduate at Harvard.
“The sense that women’s bodies were not just different but broken is evident not only in the way doctors talked about female anatomy but also in the medical vocabulary itself: women’s external genitalia were called ‘pudenda’, a Latin word meaning “things to be ashamed of,” he writes.
In “All in Her Head,” Dr. Komen offers a comprehensive look at the ways in which she says modern medicine ignores women. For centuries, she writes, early medical authorities believed that women were merely “little men” — albeit lacking external genitalia and comparable mental capacity, governed by noxious humors and hormones.
For too long, doctors dismissed “what might legitimately be physiological problems as irrelevant, as hormonal and therefore not important,” said Wendy Klein, a professor of the history of medicine at Purdue University.
And that was the case with white women in the media, Dr. Comen writes in the book. If you were a woman of color or were poor, you were viewed by medical authorities as having even less authority over your own body, and therefore less worthy of care and compassion.
“For black women, when we enter a clinical setting, we have to think about race and gender discrimination,” said Keisha Ray, an associate professor of humanities and bioethics at UTHealth Houston who studies the effects of institutional racism on Black health. “It tends to be more exaggerated, the lack of compassion and the lack of care you get.”
Take heart disease for example. In the late 19th century, Dr. William Osler, one of the founders of modern medicine, stated that women presenting with what we now know to be symptoms of heart attacks or arrhythmias—including shortness of breath and palpitations—almost certainly suffered from “ pseudo-angina” or pseudo-angina, “a collection of symptoms caused by neurosis masquerading as genuine disease,” writes Dr. Komen.
Only in the last 25 years have cardiac studies included women in significant numbers. Today, some heart attack symptoms more common in women, such as jaw and back pain, are still described as “atypical” simply because doctors don’t see them as often in men and are less likely to be taken seriously , even though 44 percent of women will develop heart disease at some point in their lives, and one in five women will die from it.
“We’ve used the male model for diagnosis, for treatment, as the gold standard,” said Dr. Jennifer Meares, a cardiologist at Northwell Health and co-author of “The Smarter Heart for Women.” This “has led to continued misinformation, misdiagnosis, and under-recognition of heart attack in women.”
How to advocate for yourself
In each chapter of “All in Her Head,” Dr. Comen interviews doctors who are working to improve the system, starting with taking female patients’ complaints seriously — not just reporting physical symptoms, from breast pain to fatigue and gastrointestinal distress, anxiety to ruling out all other causes, for example.
Dr. Comen also shares practical tools to better work with an imperfect system.
First, she writes, it is essential for all patients to trust their knowledge of their own bodies and advocate for themselves. Before an appointment, ask yourself: What is really bothering you about your body?
“Not what you think you need to worry about,” writes Dr. Komen. “Not what you think your doctor will be able to handle with more comfort and ease.”
Then, if you feel anxious about your health or that you are not when listening, enlist a friend or family member to accompany you on appointments. This person can serve as an advocate and an extra set of eyes and ears.
Finally, if you don’t like your doctor, find a new one. This may be easier said than done, he acknowledged, but a relationship of trust and respect with his health care provider is every patient’s right.
The sound is produced by Sarah Diamond.
