they lead; words like emotional and irrational are used when they object. Men are exhorted to be more aggressive in the workplace, but not so with women. What’s interesting is that SSRIs reduce aggression, poor impulse control, and irritability while increasing cooperation and affiliative behaviors. Primate research shows that SSRIs augment social dominance behaviors, elevating an animal’s status in the hierarchy. So they may well help women get along, and even get ahead, in the workplace, but at what cost?
I notice in my female patients a certain self-consciousness about being assertive. “I think, maybe” is the way a woman begins her sentence even when she knows damn well that she’s right. We hem and haw to seem as if we’re unsure, even though we should trust our gut and speak firmly and bravely. Growing up, I was taught, directly and indirectly, how to couch my ideas so they’d be taken as suggestions or opinions and not as statements of facts. I will not teach my daughter to tone down her self-confidence when she speaks. Little girls need every ounce of self-esteem they can get. It’s much easier to soften the edges later in life than it is to build up a foundation of self-worth. And girls who hold on to their assertiveness and self-esteem are less likely to grow up to be depressed women.
The H Word
In the nineteenth century, hysteria was a uniquely female diagnosis that became a catchall for many women’s complaints that couldn’t be immediately remedied. Nearly all physicians were men in the 1800s, and they lumped a number of physical and emotional symptoms reported by women under one heading, derived from the Greek word for uterus, hystera. Criteria for hysteria included malaise, headaches, irritability, nervousness, insomnia, fatigue, low libido, high libido, water retention, and, eventually, any behavior undesirable to society, such as organizing the right for women to vote. One treatment for hysteria involved bringing the patient to orgasm, while another, clitoridectomy, involved surgical removal of the clitoris, and was performed throughout the 1880s and into the 1920s.
These days, hysteria has a more specific meaning: excessive expression of emotion, especially vulnerabilities such as despair or panic. If a woman behaves in a way that a man finds uncontrollable or inconvenient, she will be accused of being hysterical, basically being told she doesn’t have a right to feel or act that way because it isn’t in line with how a man would feel or act. Keep in mind, many a boy grows up at the mercy of his mother’s emotions, and so men fear the emotionality of women. This may be one reason that some male doctors are quick to squelch any expression of emotion in their female patients, most easily by reaching for a prescription pad.
While the term hysteria is no longer officially used in medicine, there is the increasingly common diagnosis of the “women’s disease” fibromyalgia. Symptoms include mysterious muscle aches, joint pain, and exhaustion. Coincidentally, the current treatment for fibromyalgia is antidepressants. Epidemiological studies show a female-to-male preponderance of three-to-one for chronic pain diagnoses like fibromyalgia. Men are less apt to receive a diagnosis of fibromyalgia than women, even if they have the same symptoms.
In my office, I often hear stories of misdiagnosis from my female patients. They offer lists of physical complaints to their male doctors, who are quick to dismiss them as hysterical, though they never utter that word if they’re smart. “You’re just stressed” is a popular conclusion offered instead, or else they’re saddled with the diagnosis of fibromyalgia and treated, conveniently, with the same medicine they’d get if they were “just stressed”—antidepressants. Over the years, I’ve had multiple patients misdiagnosed with fibromyalgia when in fact they had Lyme disease, lupus, hypothyroidism, rheumatoid arthritis, or, in one case, ovarian cancer.
Women’s sensitivities extend to the physical; our bodies feel more pain than men’s do. There is overwhelming laboratory evidence that women have lower thresholds for pain, experience greater pain intensity, and have a lower tolerance for experimentally induced pain. Women are also more apt to notice aches and pains in their bodies, due to their neurologic underpinnings, particularly their more active insulae. We have more serotonin receptors to process pain, and our hormones estrogen and progesterone affect endorphin transmission and opiate receptors, leading to higher perceptions of pain.
It is important to note that where we are in our menstrual cycle also affects our pain sensitivity. We are more sensitive not just to social slights before our periods but to physical pain as well. Add to this the fact that many of us do somaticize, that is, focus on how our body feels and convey that to others. Again, this may be the insula in action. Some of our awareness and discussion of our physical pain may be caused by our experiencing, but not giving a voice to, the psychic pain of feeling put-upon or burdened. Our psyches are silently screaming for attention and relief, but we translate that psychic pain into bodily pain, which is easier to attempt to eradicate with medications and the attention of (often male) physicians.
The study of pain specific to women is in its infancy. In the journal Pain, nearly 80 percent of the studies included male subjects only, with only 8 percent studying females only. Medicine is not keeping pace with the pain so many women suffer. Men presenting with the same symptoms as women are taken more seriously and given a more thorough diagnostic workup. You see this in reports of chest pain, in lung cancer, and in general complaints and diagnostic workups. Without a doubt, you see it the most in psychiatric complaints.
Women are still, very simply, second-class citizens in the world of medicine. Until recently, surgeons knew much less about female pelvic anatomy and nerve-sparing surgery for women than for men. This ignor-ance has translated into thousands of hysterectomies (the US performs this operation more than any other country) with avoidable complications, like diminished or absent orgasms or urinary incontinence.
Nearly all medical research, and in particular drug research, is still performed on male subjects, whether animal or human. Later, when the drugs come to market, problems specific to women may surface only after the drug has been in use for many years. Eight of ten drugs withdrawn from the market between 1997 and 2001 posed greater health risks for women than for men. After twenty years on the market, the sleeping pill zolpidem finally has a separate recommended dose for women, half the strength of the usual dose, because it turns out that women metabolize the drug differently, having higher levels in their blood from the same dose. People are finally talking about the fact that women are unrepresented in clinical studies, but until the medical community better recognizes the complexity of the female brain and body—and how they differ from men’s—we will be at a disadvantage.
We are not men. We are women. We feel more deeply, express our emotions more frequently, and get moody monthly. It’s normal. It’s nature’s way. And we don’t necessarily have to medicate away the essence of who we are to make others more comfortable. In fact, once we better understand our bodies and our own moods, we will realize that as women we have many
