Ever wonder why hysterectomy and hysteria sound similar?

• Hystera = uterus in Greek
• hysterectomy = removal of the uterus
• hysteria = emotional excess

What’s the connection? “Hysteria” was used by ancient doctors to describe emotional and physical symptoms caused by a “wandering womb.” (FYI: that’s not a thing.) The term was a catch-all diagnosis doctors used to blame physical symptoms on mental delusion—on people with pussies* being “hysterical” when they couldn’t figure out what was actually wrong with them—and it was used up until the 1950s. This isn’t a valid diagnosis today, but many feminine-presenting people (femmes) still get ignored and misunderstood by doctors because the stereotype of the “hysterical woman” still exists and is perpetuated by a medical system that’s ill-equipped to see and hear femmes’ symptoms. This is called gender-biased diagnosing.

Bias (prejudice against one thing, person, or group) is often unconscious—even cisgender women doctors can be biased against femme patients, because bias comes from the society you’re raised in, your educational background, and your past experiences. It’s not necessarily about being mean or misogynistic; you can be biased without even realizing it. Most of us are. Bias comes from the stories we tell ourselves to understand the world around us. We’ve all heard the stereotype of “the weaker sex”, and that’s one of the stories that we as a society have unfortunately been telling ourselves for millennia: that femmes are irrational, overly emotional, melodramatic, that they exaggerate or are somehow out of touch with the truth of what they’re feeling—in other words, that they’re hysterical. That’s the story doctors can often bring with them into the room when they see a femme patient—whether they consciously believe those things or not.

As a result, femmes can suffer the emotional, physical, and financial consequences of waiting years for proper diagnoses and treatment of common ailments. For example, it takes, on average, 7.5 years for cis women in the UK to receive a diagnosis for endometriosis (a disease which, by definition, only affects “female” reproductive systems), despite the fact that 1 in 10 cisgender women in the UK have it.1 In the U.S. this time is shorter but still really long, on average 4.4 years since the start of symptoms.2

Another example: through the 1970s medical textbooks incorrectly suggested that Black women would have lower risk of endometriosis because of stereotypes that endometriosis was largely a disease of older white women who delayed childbearing. These textbooks suggested that Black women were “more promiscuous” and would therefore be at lower risk of endometriosis, and today diagnosis of endometriosis is still lower among Black compared to White women.3

Endometriosis is incurable and gets progressively worse if it’s not treated, but quality of life for people with the condition can be improved significantly with treatment. One reason for the diagnostic delay is that it requires invasive surgery, a step which both doctors and patients understandably want to avoid.2 But because of gender bias, doctors could also be mistaking the symptoms for normal period pain exaggerating by a “hysterical” patient.

In the Victorian era, women were characterized as sickly and weak. “There was the societal  belief (in America and Europe) that women were more ladylike if they were pale and faint in appearance. In addition, retiring early to bed due to ‘sick headaches’ and ‘nerves’ was viewed as fashionable,” writes the sociologist Shari Munch. She says that the myth of female emotional frailty continued to seep into medical models, and doctors were quick to suspect a mental or emotional cause when they were unable to figure out the biological cause of femme’s physical symptoms.4

As recently as the 70s, respected medical texts encouraged doctors to jump to the conclusion that femmes’ symptoms were ‘all in their head’: “Dysmenorrhea [period pain] is generally a symptom of a personality disorder,” stated the 1971 textbook Office Gynecology. And a 1993 study found that cisgender women who had typical symptoms of bladder disease were frequently diagnosed with Somatic Symptom Disorder instead—a mental illness where the patient has unexplained physical pain.4

The Iranian-American writer Porochista Khakpour, author of the memoir Sick about her chronic Lyme disease, describes the emotional toll of being ignored by the medical institution in an interview: “It took a huge toll and continues to take a toll. I have so much trauma around this. I have many forms of PTSD… You go through years of this—I have literally been in tears begging and pleading with doctors for years and years. It destroys you to have to do this again and again and it bleeds—pun intended!—into other aspects of your life too.”5

Sometimes symptoms are not ignored, but misunderstood. This happens because medical researchers know much less about the health of feminine-presenting people in general. The reason for this isn’t mystical; cis women (and especially trans women) just haven’t been studied as much as cis men. For decades, the “standard” subjects in medical research were cis white men. As recently as 1977, the U.S. Food and Drug Administration recommended that drug companies exclude “women in their childbearing years” from clinical trials.6 Decades worth of medical studies based on male bodies formed the basis of health claims that were then applied to everybody. And doctors, of course, were educated based on this information. There’s a huge lack of research on the kinds of potential health-hazards femmes tend to have more exposure to, such as household work and cleaning products.4

Some of the most fundamental studies of human health are not balanced at all. The Baltimore Longitudinal Study, a huge study about aging which started in 1958, “included no women for its first 20 years because… the facility in which the study was conducted had only one toilet. The study’s 1984 report, entitled ‘Normal Human Aging’, contained no data on women.”7 (Women apparently don’t qualify as "normal humans.")

This didn’t start to change until very recently. The US Congress didn’t make it mandatory for drug companies to include “adequate” numbers of people with pussies* to understand the different ways that drugs affect different bodies until 1993.8 (“Adequate” is not totally consistent either: in 2015, the makers of “female Viagra” studied how their pill interacts with alcohol on 25 people, two of which were cis women.)9

Bodies with different weights and hormones process substances and react to malfunctions differently. Understanding those differences can help doctors efficiently and correctly diagnose their patients. But aiming for a balance of subjects in medical research shouldn’t be used as a means of overstating biological differences between cis men and cis women. There is a common distinction between sex and gender. Sex is biologic ( XX vs XY chromosomes) and gender is socially-constructed. But recent research has shown that biology is not black and white. The idea of male or female is oversimplified and ignores intersex, trans, and non-binary people.10

Our cultural ideas about gender influence health conditions because they affect so many aspects of people’s lives (like what kinds of exercise people do, environmental conditions they’re exposed to, and what they eat). Ideas about gender also influence how people perceive and express their own health conditions and how doctors interpret reported symptoms.11

Take heart attacks. Heart disease is the number one killer in the U.S.12 When you’re having a heart attack, the immediate care you receive in the hospital is critical in saving your life. But 14.6% of cis women die from heart attacks in hospitals, compared to only 10.3% of cis men.13

What’s going on here? Doctors learn in medical school that the hallmark symptom of a heart attack is chest pain.13 But in fact, heart attacks show up in different ways for different people: 33% of people having a heart attack actually won’t experience chest pain as one of their symptoms,14 and cis women are less likely to have chest pain than cis men.13 The data shows that as patients get older, this difference in the number of deaths evens out—because older cis women are, in fact, more likely to experience chest pain, and less likely to die of a heart attack in the hospital.

What this suggests is that it’s not the patient’s gender that’s preventing them from getting proper treatment, but the fact that they don’t report chest pain.14 If the doctor doesn’t suspect that you’re having a heart attack because you don’t have chest pain, they’re not likely to supply proper heart attack care. And since more cis women don’t have chest pain, this means that they’re disproportionately affected by the fact that doctors aren’t trained to look for their symptoms. The easy fix would be to study more deeply how heart attack symptoms are presented differently across genders and educate doctors so they know what to look for.

The medical community, from doctors to drug companies, needs to fully recognize its gender bias and strive to see people for all their complicated human-ness. Medical research should accurately represent the gender diversity of our world. Opportunities should be created and supported for more research studies to be authored by femmes, and especially trans women, which has been shown to increase the likelihood that the study will take gender differences into account.15 Until then, we have to be advocates for ourselves in the doctor’s office — even at the risk of seeming hysterical.

For personal stories of gender-biased diagnosing, here’s a suggested reading list:

• Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick — Maya Dusenbery
• Sick: A Memoir — Porochista Khakpour
• The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain — Diane E. Hoffmann & Anita J. Tarzian
• Ask Me About My Uterus: A Quest to Make Doctors Believe in Women's Pain — Abby Norman
• Invisible: How Young Women with Serious Health Issues Navigate Work, Relationships, and the Pressure to Seem Just Fine — Michele Lent Hirsch

Author's Dedication: To my mom—sorry not sorry for saying ‘pussy’ so many times.