In 1603, William Shakespeare wrote: “Frailty, thy name is woman,” which aptly summed up attitudes about women in the 17th Century, and why their health wasn’t taken seriously by men. Four hundred years later, things are better, said breast cancer surgeon Elizabeth Comen, who quotes the Bard and other condescending men across history in her new book, All in Her Head: The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today (Harper Wave, 2024)—“but old ways linger.”
As an oncologist at Memorial Sloan Kettering Cancer Center, Comen knows a great deal about what’s lingering and what’s not today in women’s health. She also studied the history of medicine as an undergraduate at Harvard, giving her a deep knowledge of medicine past and present. This provides her book with a richly textured and often tortured history of women’s health alongside sharp observations and stories from the present about the continuing struggle to shift medicine from (white) male domination to a recognition that female bodies are not, as she says, “flawed inversions of the male ideal.” It also helps Comen provide wonderful and sometimes shocking context into why and how women’s bodies were treated for most of history as “objects to be practiced on: examined and ignored, idealized and sexualized, shamed, subjugated, mutilated, and dismissed.”
Comen deftly blends past attitudes and anecdotes from her own experience as a physician treating mostly women, and a wealth of studies and interviews to tell us a story that explains what many women feel when they step into an exam room or interact with the healthcare system. She divided the book up into eleven organ systems—skin, muscle, blood and circulatory, sex and reproductive, and more—that still frame medical education in the U.S. Each section tells stories of progress and lack of progress, and what she describes as a system where women too often remain voiceless in telling their own healthcare stories.
Cure interviewed Comen about her new book and about historic and present-day attitudes towards women in healthcare, and her experiences as a female physician, surgeon, academic leader, and mother. This conversation has been edited for length and clarity.
Cure: In your book you write: "When women come to me for treatment, one of the most important questions I ask is this, 'What brings you joy?'" Why is this important to you as a physician?
Comen: I have always been fascinated by the experience of illness, how women can have the same diagnosis when you look under a microscope and when you catalog the pathology of their disease, but how we experience disease is completely unique to who we are as individuals. Asking the question of 'what brings you joy ’ really homes in on the importance of not just surviving but thriving.
When I ask patients what brings them joy, it helps me understand the things that help them feel alive. I think that's what we are all hoping for is not just to plod through our days, but to have these moments that access the things that we love to do. Whether it's to dance, whether it's to read, whether it's to play sports, whether it's to be with our family, whatever it may be, those are the things that define us as individuals and help bring out what it means to really thrive in the world.
Asking some of your very sick patients about joy must be tough sometimes given how sick some of them are.
I do have a hard job of talking about some very scary things all the time, day in and day out, that zero in on death and anxiety around death and suffering. I think even in moments of suffering, we can still find joy. For me to be able with patients to talk about these moments of light also brings a levity and a joy to my practice that helps me continue and fuels me in my work.
I also get some sad answers when patients say, ‘It's been a long time’ since they experienced joy; or ‘I'm busy raising kids,’ or ‘I've been so busy with work, I used to like to do this.’ It's amazing to me how many women say, ‘I used to like to,’ fill in the blank. Why is it that we table so much of our joy? Why is it that we forego so much of what makes us happy to plod through the next moment into the next day?
What is it like to be a female patient today?
I think it's a better time to be a patient now than it probably ever has been. Obviously, in researching my book, there are just so many egregious, horrible things in the history of medicine related to women that made it nearly impossible for women to get the kind of care they deserve. I do think unpacking that legacy and how that shows up in the doctor's office today is incredibly important.
I think there's still a lot of insidious incuriosity about why women feel the way that they feel. What are we missing? Why does it take so long to diagnose different conditions? Some things that we don't even have names for because they haven't been valued enough to study in women. I still think there are lots of women that leave the doctor's office being told, ‘It's all in your head. You're fine. Calm down. Take this antidepressant.’ There's still a role and a need for women to advocate for themselves and also for the larger ecosystem of our healthcare world to start paying attention to what women are saying and feeling and experiencing.
How do today’s attitudes compare with what it was like in the past? I’m thinking of one issue you and others have written about—the fact that most drugs until recently were mainly tested on middle-aged men.
It was not until 1993 that the NIH was even required to include women and minorities in NIH-funded clinical studies. It wasn't until very recently that you had to report the gender or the sex of the mice that you were using that in turn were the basis of preclinical studies for many of the drugs and techniques and methodologies and imaging that we use in our medical system. Until very, very recently, clinical trials were mostly based on testing a 70-kilogram white male. We know that women are not small men, that head to toe we are fundamentally and biologically different.
It's not just our breasts and our uterus that make us different, but the way that we present with disease, the types of diseases that we present with. There are diseases that are specific to women entirely, and there's a long legacy of just transposing what we see in men and assuming that it would be the same in women. That still plays out in our healthcare system today. But there are now lots of initiatives, whether it's from the White House or academia or the lay public that are saying: ‘Enough is enough. We need to treat women differently and make sure that we're being sensitive to their needs.’
I heard from one researcher as recently as 2020 that one of the teams developing a vaccine for COVID was told by her male colleagues that they only wanted to test the vaccine in male mice to avoid what they called “complications” in female mice.
This is the idea that we can't study things in mice, or we can't study things in women because we're just so hormonal that we're impossible to understand. There was one example with COVID and the vaccine where its effects on menstruation was not an endpoint in the large studies that were done during the trials. So when women started reporting anecdotally that they were having delays in their period or menstrual abnormalities, many of them were told that's not true and were getting all this assurance it would not affect their fertility.
Of course, it didn't affect their fertility, but the idea that we couldn't reassure women and explain to them that this is common with vaccines and it would not be harmful to them was not something that we could provide because there was no data, and no one thought to include menstruation when a lot of women take that as a very serious endpoint for a reflection of their health. So that's a good example, or a bad example, of how not having the appropriate endpoints in clinical trials should have sparked real concern when they rolled out the vaccine.
You talk, too, about the idea of shame and apologizing. In your book there was a story of a very ill patient that was apologizing to you for being sick and not responding to the therapy. Can you tell us where that came from historically?
One of the reasons why I wrote this book and I'm so fascinated by the history of medicine is because I believe that science, just like everything else, doesn't happen in a vacuum. Understanding our bodies is inextricably linked to culture and society and religion and the environment in which we live. In this instance, when you talk about apologizing and shaming and blaming, we see this in our broad societal culture with respect to women. We are more apt to apologize. We're more apt to want to please people and not to want to ruffle feathers and to make sure that we're not making anybody else uncomfortable.
When we’re sick, this is the extreme of that. Many women don't want to look sick, understandably, but they also apologize for their pain and don't want to bother their doctor. It mirrors a lot of what we see from a societal standpoint. The types of things that women have apologized to me for are just preposterous—normal bodily function; not shaving; for being in pain; for calling when they had a question. You name it. For having a scar that they thought was ugly that I wouldn't want to look at. I think this is really sad and reflects a lot of how women have felt more holistically in our society.
Is that situation improving? How are you seeing that play out right now?
I think there are lots of reasons to have hope. We're having this conversation. These are the types of conversations that we're not having more publicly. You really see a ground swell of women talking more openly about their bodies head to toe, certainly from the menopausal women and aging women, they’re out there much more vocally, including many celebrities that say enough is enough, and we deserve good healthcare. So I do think that there are lots of bright spots.
Can you describe how women have been treated by healthcare providers throughout history?
If you go all the way back and look at the Greeks and Romans and some of the early founding fathers of our medical system, there are varying forms of women being the inverted, imperfect, lesser versions of the male. Whether you're talking about Charles Darwin or Hippocrates or Galen, a famous physician during the Roman era, throughout history there isn’t any narrative that exalted women's health or power or bodies as equivalent to men in any capacity, whether it was intelligence or strength or the ability to live a certain way.
The other thread that you see is women's sexual function, behavior and desire is woven throughout medical history as something that needs to be controlled, blamed and shamed, and is seen as the cause of everything bad. Whether it was hysteria, or too much or too little sex, which in some cases was a cure for certain things, but only when men dictated it as such.
I’m fascinated by the structure of the book, the chapters that focus on certain organs and systems in the body. Why did you use that format?
One reason is that I wanted to walk through women's bodies, not only through history, but by the same organ systems that were created during the early days of American medicine in the 19th century. I wanted to show that number one, women's health is not just bikini medicine about our breasts and our uterus. The other reason is because it is archaic to teach medical students about the human body as if it is neatly divided into different organs. We are wholly integrated beings, yet medicine became specialized in the early days of modern medical science. These fields are relatively new, and I wanted to show what happened to women's bodies when we fragmented them as such. In my field, for instance, we rarely speak to cardiologists or gastroenterologists. This siloing of the body has led to good things for both men and women in terms of focused research and experts, but the fragmentation also has led to a lack of integration and understanding of us as whole beings.
What is it like to be a woman in medicine?
I will tell you that I certainly had experiences, especially during my surgical rotation in medical school, that definitely wouldn't pass any human resources test. I experienced some very inappropriate behavior, including groping and name-calling and all sorts of things that I wouldn't wish on anybody, and it very much affected my ability to find my professional voice as a woman in medicine. I have been scrutinized for how I wear my hair, whether it's in a ponytail, what types of dress I wear and the tone of my voice. There is the assumption that women are more empathic and listen longer. The idea that you're the touchy-feely, warm, fuzzy doctor is great, but also maybe it’s less valued as someone who is going to discover a genetic mutation.
Is it changing as more women are going to medical school and becoming doctors?
It's wonderful that there are more women going into medicine right now. There's lots of data to show that women spend longer time with patients, and that women who see women physicians have better outcomes on average. But I don't think that that's what the future of medicine should look like, that we should just flood the system with women. We ought to be thinking about what are the traits that we value in women, or should be valued, that really help us take better care of patients? How do we value those traits in men as well? And not just make this gendered approach to medicine of who gets promoted and for what, but also value these more subtle immeasurable qualities that really are essential to healing.
As women get more in leadership positions, are they changing the system?
I don't think it's about your genitalia when it comes to becoming a leader. If we're having women rise in positions of leadership because they're trying to follow what's historically a masculine or male model of leadership, I don't think that does us any good. This is about a diversity of spirits, a diversity not just about whether you're born with a vagina or a penis, but what are the perspectives that you bring to the table? What are the traits that we value from a diverse set of people and backgrounds that represent the people that we care for?
Where do you see all this heading in the future?
I can't predict the future, although looking at the past I definitely would've been burned at the stake as a witch at certain times in history. But now I think there are lots of reasons to have hope in my specialty. There are newer, better treatments emerging for cancer that are not only allowing women to live longer, but also to live better. And it's not just about more aggressive therapy, but in some instances its deescalating the type of therapy because some harsh therapies from the past were not necessary.
More holistically with respect to women's health, there are lots of reasons to be optimistic that we're moving in the right direction. I think I'm an eternal optimist, and I think that people's intentions are in general good, especially those who go into medicine. If we get back to the core reasons of why we're doing it and why we're there and don't succumb to all these external pressures—and we really bang on the drum loud enough—I think we'll move the needle to an even better place.