1The History of Hysteria
How did we get here? The treatment of women throughout history provides insight into why period problems, pelvic pain, and other gynecologic health issues are often minimized or overlooked today. From ancient Greek physicians to witch hunts to modern medicine, women’s reproductive functions, mental and emotional health, and perceived moral character have been inextricably linked. Even though these beliefs were often inaccurate, they were so commonly viewed as facts that the difference between truth and myth is still difficult to distinguish today. Indignities, injustices, and traumas that women have suffered throughout the centuries seep into modern views of female bodies and health.
Women’s bodies and medical concerns have been misunderstood, mismanaged, and outright dismissed since the beginning of recorded history. The fathers of Western medicine and philosophy, who were greatly respected for their pioneering work in some regards, put forth many theories about women’s health that sound absurd today but were accepted as gospel for generations. For example, if a woman exhibited symptoms that couldn’t be explained, she was said to be suffering from faulty sexual organs, sinister forces such as witchcraft, or the catchall explanation: hysteria. This word, hysteria, contains all the judgments and assumptions about female bodies that have existed for thousands of years. It suggests that women’s distressing physical symptoms stem from a combination of anxiety, mental or neurologic weakness, and broken uteri, rather than from not-yet-understood medical conditions.
Hysteria—an idea that originated in ancient Greece—was thought to be a combination of physical, emotional, and psychological distress somehow tied to the uterus or womanhood; it was considered an actual medical affliction for hundreds of years. In modern language, the word hysterical implies a person is out of control, overreacting, and imagining things, but the concept of hysteria originated as a physical malady. Through the centuries, hysteria shifted from a disease of the body to one of the mind, but the connection between the supposed flaws of women’s reproductive organs and their mental well-being remained.
History provides the philosophical framework of modern-day medical systems. Even if the terms are antiquated, some concepts persist as an undercurrent in how gynecologic health is perceived and managed today. Holding the fallacies and mistakes of the past up for scrutiny can illuminate the ways in which healthcare systems must change in the present.
THE WANDERING WOMB
One of the foundations of Western medicine is a body of work called the Hippocratic Corpus, a collection of theories and teachings by Greek physicians dating from the fifth century BCE. Many people have heard of the Hippocratic oath, the code of ethics recited by students upon entering medical school. But most people don’t know that Hippocrates theorized that many medical problems were caused by the uterus literally moving around the body—fleeing from unpleasant sensations such as feeling cold, or running toward desirable targets like sex and pregnancy. This concept, called the wandering womb, was thought to be caused by lack of sexual activity. Healers recommended treatments such as genital massage, intercourse, and pregnancy to appease the uterus and even held honey or other sweet foods near the genitals to trick the uterus into returning to its rightful place. The Greek philosopher Plato explained the wandering womb this way:
And in women again … whenever the matrix or womb as it is called—which is an indwelling creature desirous of child-bearing—remains without fruit long beyond the due season, it is vexed and takes it ill; and by straying all ways through the body and blocking up the passages of the breath and preventing respiration it casts the body into the uttermost distress, and causes, moreover, all kinds of maladies, until the desire and love of the two sexes unite them.
While no modern doctor believes that the uterus is literally zipping around the body, echoes of these ideas persist in today’s treatment of certain gynecologic problems. Patients with endometriosis are sometimes told to get pregnant to treat the condition, which is hardly a sustainable long-term plan, especially for patients who don’t want to be pregnant. The medical community and society in general too often presume that anyone with a working uterus must want to use it for pregnancy, even when people say that they don’t want to conceive or are done having children.
Many patients who seek tubal ligation or hysterectomy (surgery to remove the uterus), some who are well into their thirties or forties and who have children already, are told by doctors that they are too young to make such a decision and will someday regret it. Even in modern times, society still assumes women will always desire fertility—they just don’t realize it. It’s hard to imagine a non-gynecologic medical scenario where physicians would tell competent adult patients that they don’t actually know their goals and therefore can’t make decisions about their health. In this regard, the historical influences of the wandering womb remain.
FROM ANCIENT GREECE TO WITCH TRIALS
The term hysteria is derived from the ancient Greek word for uterus, hystera, and the condition was considered for centuries to be a physical malady caused by the uterus, an expansion of the concept of the wandering womb. Hysteria covered a wide range of symptoms, including fits, seizures, strange movements, hallucinations, anxiety, insanity, and pain.
Although disturbing behaviors and madness were thought to be signs of demonic possession or witchcraft in medieval and Renaissance Europe, some doctors were still attributing these symptoms to frustrated uteri. In 1602, an English physician, Edward Jorden, published a book titled A Briefe Discourse of a Disease Called the Suffocation of the Mother—mother being an old-fashioned term for the womb. In this book, Jorden explained that the physical symptoms attributed to witchcraft were actually from passio hysterica, or “womb suffocation.” Similar to the wandering womb, a suffocated uterus—one that was not fulfilling its natural needs for sex or pregnancy—could cause distressing signs in the rest of the body. Jorden argued that this was why virgins and widows were more susceptible to the fits that were interpreted as witchcraft. He gave testimony at trial on behalf of women accused of witchcraft, trying, unsuccessfully, to explain that they were not witches but simply the victims of a suffocated uterus. Jorden’s book is considered to be the earliest description of hysteria in the English language. In trying to present a scientific counterpoint to witchcraft and demonic possession, Jorden fell back on the equally misinformed idea that hysteria was to blame for these women’s symptoms.
Today, despite centuries of advances in other areas of medicine, many aspects of women’s health are still poorly researched and lack data to guide treatment. A surprising number of professional gynecologic recommendations over the years have been based on the opinions of leaders in the field rather than on objective facts or scientific studies. For this reason, the most cutting-edge medical theories and treatments of their time have later been deemed incorrect—in some cases, after causing suffering that exceeded the original problem being treated.
THE CLITORIS AND OVARIES IN THE NINETEENTH CENTURY
The heyday of hysteria was the 1800s, when doctors attempted to understand its origins and treatment through a formal medical lens. The uterus was no longer thought to be the source of the problem, and other female sexual organs were scrutinized as possible causes. At the same time, the field of gynecology began to develop as a specialty within Western medicine.
In the mid-1800s, gynecologists experimented with the surgical removal of the clitoris (known as a clitoridectomy) or the ovaries (an oophorectomy) to treat hysteria. Isaac Baker Brown was a well-known gynecologist in England and the president of the Medical Society of London. He recommended clitoridectomy as a treatment for insanity, epilepsy, and hysteria because he hypothesized these conditions were caused by masturbation. In the United States, Dr. Robert Battey, the president of the Georgia Medical Association, was one of the first physicians to surgically remove the ovaries; at the time, oophorectomies were known as Battey’s operations. Battey attributed various medical problems, including epilepsy and hysteria, to the ovaries and recommended removal of the ovaries for cases that didn’t respond to other treatments. Many thousands of oophorectomies were performed in the United States in the latter part of the nineteenth century because of these mistaken beliefs.
Fortunately, “therapeutic” clitoridectomies and the removal of normal ovaries fell out of favor relatively quickly due to their surgical risks, mortality rate, and lack of effectiveness, but not before scores of women suffered the unnecessary removal of their sexual organs.
Today, doctors no longer diagnose hysteria or perform clitoridectomies or oophorectomies to relieve it. Surgeries to remove the uterus and ovaries definitely have a role in modern medicine to treat certain conditions, such as fibroids and gender dysphoria, or to decrease cancer risks. The problem arises when people are told that they have no options except a hysterectomy or an oophorectomy, even when they want to preserve their fertility, or when they are not adequately counseled about potential risks or alternatives. I’ve had many patients who underwent a hysterectomy or an oophorectomy without knowing exactly why; they just say, “The doctor told me I needed it.”
HYSTERIA AND THE CENTRAL NERVOUS SYSTEM
In the late nineteenth century, neurologists took their turn at managing hysteria, treating it as a disorder of the nervous system. Dr. Silas Weir Mitchell is considered one of the founders of modern neurology. While caring for injured soldiers during the Civil War, he became an expert in nerve injuries and even coined the term phantom limb syndrome. He observed that nerve damage could cause hysterical symptoms and developed a famous rest cure for victims of neurologic trauma that involved a combination of social isolation, bed rest, limited physical and intellectual activity, a diet of rich foods, and electrotherapy to restore the nerves. After the war ended, he started a lucrative practice applying this rest cure to white middle- and upper-class women suffering from what was diagnosed as hysteria and nervous exhaustion. Some of the patients who underwent the rest cure were intellectuals, writers, and artists, among them Virginia Woolf, Edith Wharton, and Jane Addams. While resting and eating well sounds pleasant, the women subjected to this rest cure often faced extreme physical, social, and intellectual restrictions.
Charlotte Perkins Gilman was a patient of Mitchell’s, and she based her famous short story “The Yellow Wallpaper” on her experience of the rest cure. Intellectual and creative activities were thought to exhaust the nerves and sap energy from the body, so patients were isolated and kept idle. For Gilman, this caused even worse “mental agony” than the depression the cure was supposed to be treating. In “The Yellow Wallpaper,” a nameless protagonist is subjected to the rest cure by her physician husband; she’s kept in an infantilized state in a New England nursery and forbidden to work or write. She is driven to madness and imagines that a woman is trapped within the wallpaper. By the end of the story, she has become the woman in the wallpaper and frees herself by ripping the wallpaper off the walls.
While women are no longer literally trapped in rooms for modern gynecologic treatments, the pattern of paternalistic management of female patients lingers. Women continue to be treated as if they need to be protected from their own minds when it comes to reproductive decisions such as birth control, sterilization, and abortion. Similarly, treatments that can cause people to feel worse than their original problems do continue to be used. For example, hormonal birth control and antidepressants can be absolutely transformative for many patients, but for some, the mental and physical side effects are worse than the symptoms being treated. The problem isn’t that these options are offered but rather that some healthcare providers insist that patients continue to use them even when the treatments are causing significant distress and aren’t improving symptoms.
CHARCOT, FREUD, AND THE MIND
By the end of the nineteenth century, the perceived cause of hysteria had moved from the sexual organs to the nerves to, finally, the mind. Dr. Jean-Martin Charcot, a French physician, is considered one of the founders of modern neurology. He was the first to identify conditions such as multiple sclerosis, Charcot-Marie-Tooth disorder, and amyotrophic lateral sclerosis (ALS). He also gained fame for treating women diagnosed as hysterical with hypnosis; he held large public demonstrations wherein women would writhe, shriek, moan, and then alter their behavior under the influence of hypnosis. Photographs from these dramatic performances are still used as a visual representation of the concept of hysteria.
Dr. Sigmund Freud was a student of Charcot, and he also initially tried to cure hysteria with hypnosis. In the book Studies on Hysteria, he and his coauthor, Dr. Josef Breuer, theorized that hysteria was the physical manifestation of repressed memories. Freud developed these ideas further in his psychoanalytic theories, stating that repressed memories of childhood sexual trauma and sexual fantasies were the causes of hysteria and that getting the patient to identify the repressed memories and fantasies through talk therapy could cure physical symptoms. Charcot and Freud took the concept of hysteria from a disease of the body to one of the mind, leading to the modern perception that if a patient is suffering from disturbing symptoms but no physical cause for them can be identified, the problem must be psychological.
There is an entire category in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM), a reference used by mental health professionals, called somatic symptom disorders. Patients with somatic symptom disorders suffer from bodily complaints without an identifiable medical cause that are then thought to be a result of psychosocial stresses or trauma. The vast majority of patients diagnosed with somatic symptom disorders are women, with a ten-to-one female-to-male ratio. Given that many women with medical conditions such as endometriosis and autoimmune diseases are initially told that their symptoms are all in their heads, it’s likely that many people diagnosed with somatic symptom disorders actually suffer from an undiagnosed physical malady. Since gynecologic conditions such as endometriosis, pelvic floor dysfunction, and premenstrual dysphoric disorder can cause a wide range of symptoms but don’t show up on imaging studies or lab tests, patients will often be told by doctor after doctor that there is nothing wrong with them and that the problem must be emotional or mental. Sadly, this is our twenty-first-century version of hysteria.
BLACK WOMEN AND BODILY AUTONOMY
In the United States, historical records and research about women’s health have traditionally focused on the health of white, cisgender, heterosexual women. The experiences of people of color and those in the LGBTQIA+ community have largely been left out of the textbooks and research studies.
In recent years, we’ve seen clear evidence of serious racial disparities in health outcomes for Black women, most notably when it comes to maternal mortality rates compared with white women. Researchers are investigating why such major differences exist. While the causes are complex, the American College of Obstetricians and Gynecologists (ACOG) and other professional organizations within the field of OB-GYN acknowledged the role that racism has played in a joint statement issued in 2020:
Recognizing that race is a social construct, not biologically based, is important to understanding that racism, not race, impacts healthcare, health, and health outcomes. Systemic and institutional racism are pervasive in our country and in our country’s health care institutions, including the fields of obstetrics and gynecology. Many examples of foundational advances in the specialty of obstetrics and gynecology are rooted in racism and oppression.
Racial biases can be traced back to the earliest days of gynecology. The physician considered the father of gynecology, James Marion Sims, founded the first hospital for women in the United States and invented the modern version of the speculum used for examining the vagina by bending a pewter spoon. He pioneered surgical techniques for the repair of vaginal fistulas, which are injuries between the vagina and the bladder or rectum caused by obstructed childbirth. He was president of the American Medical Association, and he became one of the most famous physicians in the country, with numerous statues and memorials erected to honor him. Until recently, the medical community and the general public didn’t know that he had developed several of his surgical techniques by operating on unanesthetized, enslaved Black women. Sims’s records suggest there were perhaps a dozen women in total, but we know the names of only three of the women: Anarcha, Betsey, and Lucy. Anarcha alone endured thirty experimental surgical procedures. Sims conducted his experiments in the 1840s, when anesthesia for surgery was not yet widely utilized, and per Sims’s own notes, the women suffered terribly during these operations. In that time, it was widely believed that Black people were less sensitive than white people to pain, both in terms of the hardships endured in slavery and the pain from accidents and surgical procedures. While Sims might not have declared this belief outright, it is notable that he did not perform fistula repair surgeries on white women until several years later, when he had perfected his techniques and used anesthesia.
Several recent studies have demonstrated that unconscious biases still exist in the treatment of Black patients, particularly Black women. Black patients are consistently undertreated for pain; they receive less pain medication than white patients do for objectively painful conditions such as broken bones and appendicitis. Black patients are less likely to be offered minimally invasive surgery for the treatment of fibroids and they experience higher rates of complications from surgery. A 2016 study showed that half of the medical students and residents polled believed that Black people had less sensitive nerve endings, thicker skin, and lower perception of pain than white people, which has no basis in scientific fact.
Black women also endure markedly elevated rates of maternal mortality. In the United States, they are three times more likely than white women to die in pregnancy or childbirth, even after accounting for factors such as income, education level, insurance coverage, and prenatal care. This statistic goes up in the UK to four times more likely. A large study conducted by the National Bureau of Economic Research that looked at birth records from California over a ten-year period showed that the maternal mortality rate for the richest Black women (top quintile in income) was similar to that of the poorest white women (lowest quintile). Therefore, the differences in outcomes are not simply because of resources, nutrition, or access to quality healthcare. There is likely a complex combination of factors at play, including potential implicit biases that may lead healthcare providers to take complaints of pain or symptoms that suggest preeclampsia or blood clots less seriously. Some researchers suggest that the chronic stress of discrimination and being in a constant fight-or-flight state, which causes high cortisol and epinephrine levels, results in adverse effects or weathering of the body, worsening blood pressure, increasing the risk of heart disease, and even changing the DNA itself. The weathering hypothesis can potentially explain why people of all races who are subject to chronic social stress experience poorer health, but this phenomenon has been studied most often in the context of health disparities facing Black communities. Research has shown that Black people experience more social stressors, such as discrimination, than white people, even after adjusting for socioeconomic status, and there is a clear relationship between life stressors and poor health.
Systemic racial biases can also affect health in unexpected ways, even through something as seemingly innocuous as hairstyle. In a study by Duke University School of Business in which participants were given different photos of potential job candidates with identical qualifications, Black women with natural hair were given lower scores for professionalism and were recommended less often for interviews than Black women with straightened hair or white women with straight or curly hair. These biases put pressure on Black women to alter their hair to fit Eurocentric standards of beauty by using relaxers and hair straighteners. Unfortunately, some chemical relaxers have been shown to increase the risk of both fibroids and uterine cancer. This is one mechanism through which racism can cause serious health disparities.
RESEARCH AND REPRESENTATION
The modern medical system prides itself on being evidence-based and using well-conducted research studies and clinical trials to guide treatment, but bias and gender inequality even seep into scientific research methods. The National Institutes of Health (NIH) is one of the largest sources of funding for medical research in the world, and yet some of the biggest multicenter clinical trials funded by the NIH in the twentieth century excluded women altogether, and it wasn’t until 1993 that President Clinton signed an act mandating that NIH-funded human research projects must include women and racial minorities. That was the same year that the U.S. Food and Drug Administration (FDA) finally eliminated a policy from 1977 that actively excluded women of childbearing potential from early-phase drug trials because the medications might cause birth defects. That meant that all reproductive-age women were barred from participation in these studies, even if they were not sexually active, were using contraception, or were in same-sex partnerships. Due to these decades of excluding women from research trials, data about everything from heart disease to medication efficacy do not include information about the effects on women or potential gender differences in results.
Further, there has been very little funding for research on gynecologic conditions and diseases that disproportionately affect women. In the late 1980s, less than 15 percent of the NIH budget was allocated for the study of diseases “unique to or more prevalent or serious in women,” including breast and gynecologic cancers, osteoporosis, autoimmune diseases, and other common conditions. Research studies on non-gynecologic diseases that affect the same number of people, or even far fewer, receive significantly more funding than common gynecologic conditions. In 2022, the NIH allocated $37 million for research on smallpox, a disease that was completely eradicated from the United States in 1949. Compare this with the $27 million budgeted for endometriosis, which affects at least 10 percent of women, or the $15 million for fibroids, which affect 70 percent of white women and 80 percent of Black women.
Lack of adequate funding and research means that doctors don’t know the basic causes of many gynecologic conditions, much less have options for early diagnosis or effective treatment. For many non-gynecological chronic medical conditions, such as hypertension, diabetes, and asthma, there are multiple different treatment options that target biological causes. However, since the causes of many gynecological conditions, such as endometriosis, fibroids, and polycystic ovarian syndrome, aren’t actually known, treatments are limited to managing symptoms or surgically removing organs after the disease has developed. This leads to frustratingly persistent symptoms and repeated procedures and surgeries without a guarantee of lasting relief. In many parts of the world, people who suffer from a litany of gynecologic conditions are offered only birth control or a hysterectomy, without much discussion of alternatives, often because there are no other accessible options. And despite the widespread use of hormonal birth control, there are very few studies comparing different brands and formulations in terms of side effects, tolerability, and effectiveness. The choice of which birth control to use is usually determined by patient preference and trial and error, whereas the type of medications used to treat non-gynecologic conditions such as hypertension and diabetes is based on studies and research.
Copyright © 2024 by Karen Tang
