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Sexism in medicine? It’s not “it’s all in his head.”

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Six years ago, Dr. Elizabeth Comen, a breast cancer specialist at Memorial Sloan Kettering Hospital in Manhattan, held the hand of a patient who was hours away from death.

As Dr. Comen leaned down to say goodbye, she pressed her cheek against her patient’s damp face. “Then she said it,” Dr. Comen recalled.

“‘I’m so sorry for sweating on you.’”

During his two decades as a doctor, Dr. Comen found that women constantly made excuses to him: for sweating, for asking follow-up questions, for not detecting their own cancer sooner.

“Women apologize for being sick, for seeking care or for self-advocacy,” she said in an interview in her office: “’I’m really sorry, but I’m hurting. I’m so sorry, that looks disgusting.’”

These experiences in the exam room are part of what inspired Dr. Comen to write “All in Her Head: The Truth and Lies That Early Medicine Taught Us About Women’s Bodies and Why It Matters Today ‘today’. In it, she traces the roots of women’s tendency to apologize for their diseased or unruly bodies back to centuries of diminishment by the medical establishment. It’s a legacy that continues to shape patients’ lives, she says.

Today, women are more likely to be misdiagnosed than men and take longer to be diagnosed with heart disease and certain cancers; they may be less likely to be offered painkillers; their symptoms are more likely to be dismissed as anxiety – or, as the book’s title suggests, as being all in their heads.

“The anxious woman, the hysterical woman, is a looming ghost that runs through all of medical history,” Dr. Comen said. “It’s a default diagnosis.”

Collectively, she argues in the book, these injustices help explain why many women report feeling invisible, frustrated or ashamed in doctor’s offices. Shame may be the symptom, but Dr. Comen believes a deeply misogynistic medical system is the disease.

A mother of three in her 40s, Dr. Comen has a bright, camera-ready smile, which has helped make her a regular in media coverage of breast cancer. She sometimes cries when talking about her patients.

One day, she cried at work at medical school, and a resident responded by telling her to “get it together.”

“I felt like I had to excuse my response,” she said, sitting behind her desk. “And now I cry with patients all the time. »

Her approach was shaped by decades of experience, as well as what she learned about the place of the female body in medicine while majoring in the history of science while an undergraduate at Harvard.

“The sense that women’s bodies were not just different but broken is evident not only in the way doctors spoke about female anatomy but in medical vocabulary itself: the female external genitalia were called pudenda ”, a Latin word that means “things to be ashamed of,” she writes.

In “All in Her Mind,” Dr. Comen offers an in-depth look at how she believes modern medicine has neglected women. For centuries, she writes, early medical authorities believed that women were just “little men” – albeit ones lacking external genitalia and comparable mental abilities, governed by harmful moods and hormones.

For too long, doctors have dismissed “what might be legitimate physiological problems as irrelevant, hormonal and therefore unimportant,” said Wendy Kline, a professor of the history of medicine at Purdue University.

And that was the case for affluent white women, Dr. Comen writes in the book. If you were a woman of color or poor, medical authorities viewed you as even less of an 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, associate professor of humanities and bioethics at UTHealth Houston, who studies the effects of institutional racism on Black health. “The lack of compassion and the lack of care that you receive tends to be more exaggerated. »

Take heart disease, for example. In the late 19th century, Dr. William Osler, one of the founding fathers of modern medicine, said that women experiencing what we know today as symptoms of a heart attack or arrhythmia, including shortness of breath and palpitations, almost certainly suffered from “pseudo-angina” or false angina, “a set of neurosis-induced symptoms masquerading as a real illness,” writes Dr. Comen.

Only in the last 25 years have studies in cardiology included significant numbers of women. Today, some heart attack symptoms more common in women, like 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, however, 44 percent of women will develop heart disease at some point in their lives and one in five women will die from it.

“We used the male model for diagnosis and treatment as a reference,” said Dr. Jennifer Mieres, a cardiologist at Northwell Health and co-author of the book “Heart Smarter for Women.” This has “led to misreporting, misdiagnosis and under-recognition of heart attacks in women.”

In each chapter of “All in Her Mind,” Dr. Comen speaks with doctors who are working to improve the system, starting with taking patients’ complaints seriously — not just noting physical symptoms, from chest pain to fatigue to gastrointestinal discomfort. anxiety until all other causes are ruled out, for example.

Dr. Comen also shares practical tools for better collaborating with an imperfect system.

First, she writes, it is essential that all patients trust their knowledge of their own bodies and advocate for themselves. Before a date, ask yourself: What are you really worried about about your body?

“This is not what should worry you,” Dr. Comen writes. “It’s not what you think your doctor will be able to treat in the most comfortable and easiest way.”

Then, if you feel worried about your health or that you are not of course, ask a friend or family member to accompany you to your 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. It may be easier said than done, she acknowledged, but a relationship of trust and respect with your health care provider is every patient’s right.

Audio produced by Sarah Diamond.

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