All in Her Head

Elizabeth Comen, a breast oncologist at Memorial Sloan Kettering Cancer Center, opens with a scene from August 2018 in which she sits at the bedside of Ellen, a dying patient whose most memorable words to her doctor are an apology for sweating. Comen observes that women's responses to a cancer diagnosis almost invariably follow the same arc: fear of death, self-blame, and shame about bodily functions. She has never encountered comparable shame in a male patient. This discrepancy, she argues, is not innate but inherited, the product of a medical legacy authored overwhelmingly by men whose ideas about women ranged from well-intentioned but limited to misogynist and abusive. She traces this legacy from the fifteenth-century Malleus Maleficarum, a document used to persecute female healers as witches, through the rise of medical schools that barred women, to the present day, in which women remain underrepresented in research and female physicians are underpaid and steered toward caretaking roles. The book is organized around the eleven organ systems taught in physiology textbooks, examining each to reveal the myths and biases women have inherited through generations of male-dominated medicine.

The chapter on skin examines cosmetic medicine's history. Comen introduces Timmie Jean Lindsey, a factory worker and mother of six who came to a Houston hospital in 1962 to have tattoos removed and was persuaded by Dr. Frank Gerow and Dr. Thomas Cronin to receive the world's first silicone breast implants, despite her preference to have her ears pinned back. Comen traces plastic surgery from its origins in World War I battlefield medicine through the contemporary landscape of Brazilian butt lifts, labiaplasties (surgeries altering the labia), and social media influencers marketing procedures aligned with male desires, arguing that medical education provides virtually no instruction on the normal diversity of women's genitalia.

The chapter on bones traces how early anatomists illustrated only male skeletons labeled "HUMAN," while the few female depictions exaggerated differences to reinforce the idea that women were destined for motherhood, not intellectual achievement. Nineteenth-century pseudosciences like phrenology and craniology, which measured skulls to rank intelligence, provided further ammunition against women's equality. Comen connects these biases to contemporary problems, including the treatment of frozen shoulder by "benign neglect" for nearly sixty years because the overwhelmingly male specialists were not affected by it.

The muscular system chapter traces two centuries of discouraging women from exercise, from fabricated Victorian-era patients supposedly destroyed by bicycling through Olympic sex testing that subjected female athletes to humiliating genital examinations. The post-World War II era replaced exercise for strength with exercise for thinness. Comen presents a breast cancer patient who appears thin but whose body composition reveals dangerous visceral fat and osteoporosis, illustrating how equating health with thinness leaves women at elevated risk.

The chapter on blood argues that the conviction that heart disease was exclusively a male concern led to more than a century of women being excluded from cardiac research. Comen focuses on William Osler, widely regarded as the father of modern medicine, who dismissed female cardiac patients as neurotic and characterized their symptoms as "pseudo angina" that was never fatal. She presents Paula, a thirty-eight-year-old mother who died from peripartum cardiomyopathy, or heart failure related to pregnancy, in the emergency room where Comen was a twenty-six-year-old intern, and documents the systematic exclusion of women from landmark cardiac studies.

The respiratory chapter traces how the romanticization of tuberculosis in women, followed by the co-optation of smoking as feminist empowerment through campaigns like Lucky Strike's 1929 "Torches of Freedom," coded women's lung health as a self-care issue rather than a medical priority. Comen presents Sierra, a patient sent away by three doctors with incorrect diagnoses before her lung cancer was discovered, and examines how strangulation, one of the most dangerous forms of domestic violence, is chronically underrecognized in emergency rooms.

The digestive system chapter examines how women's gut health has been shaped by the entanglement of appetite with morality, from Catherine of Siena's fourteenth-century starvation, which earned her sainthood, through John Harvey Kellogg's dietary guidelines designed to prevent masturbation, to William Osler's 1912 characterization of irritable bowel syndrome patients as self-centered and neurotic. Comen argues that the contemporary wellness industry's gut-health messaging continues the same exploitative pipeline that nineteenth-century quack remedies established.

The urinary system chapter argues that women's bladder health has fallen into a gap between gynecology and urology, with neither field claiming responsibility. Comen examines James Marion Sims, who developed the surgical repair for vesicovaginal fistulas (perforations between the bladder and vagina causing incontinence) by performing repeated experimental operations on enslaved women without anesthesia in the 1840s and 1850s. Even after this breakthrough, the establishment dismissed women's urinary issues as psychosomatic, with a 1970 urology textbook suggesting that interstitial cystitis, a chronic and painful bladder condition, was caused by female masochism.

The immune system chapter argues that women have been scapegoated as disease spreaders throughout medical history, from medieval theories about poisonous vaginas through the case of Mary Mallon (Typhoid Mary), an Irish immigrant cook quarantined for twenty-six years as the only one of several hundred known asymptomatic typhoid carriers ever imprisoned. Comen examines the American Plan, a government program that from 1917 through the mid-twentieth century detained and forcibly treated women suspected of carrying sexually transmitted diseases. The chapter closes with the Covid-19 vaccine controversy, in which women who reported menstrual side effects were dismissed until research more than a year later confirmed the disruptions were real.

The nervous system chapter argues that hysteria, though removed from the diagnostic manual in 1980, persists in medicine as a reflex to attribute women's neurological complaints to anxiety. Comen traces the concept from ancient descriptions of a "wandering womb" through Jean-Martin Charcot's theatrical exhibitions of patients at the Pitié-Salpêtrière hospital in Paris, the rise of lobotomies disproportionately performed on women, and the sedative drugs marketed as solutions for the "occupational disease of the homemaker" (247). She presents the case of her own mother, Miriam, whose concussion after being knocked down by a cyclist went undiagnosed because doctors attributed her symptoms to anxiety or aging.

The endocrine chapter argues that the discovery of sex hormones entrenched a false binary in which estrogen was seen as uniquely harmful to women. Comen examines the development of the birth control pill, whose trials exploited incarcerated psychiatric patients and impoverished Puerto Rican women, and Robert Wilson's 1966 book Feminine Forever, which framed hormone replacement therapy (HRT) primarily as a means of making women more pleasant to their husbands. She discusses the Women's Health Initiative controversy that caused a panicked 70 percent drop in HRT prescriptions and presents Michelle, a young breast cancer survivor whose estrogen-suppressing medication caused such severe side effects that Michelle told Comen she would rather risk her cancer returning than continue treatment.

The final chapter on the reproductive system argues that the medical view of female anatomy as a deformed variation on the male ideal has left women's sexual and reproductive health chronically misunderstood. Comen traces this from Aristotle, who called the female body a deformity, through the centuries-long dismissal of the clitoris as useless or sinister, to Sigmund Freud's theory of the "vaginal orgasm," which pathologized clitoral stimulation as sexual immaturity. She presents Dana, who spent fifteen years being told her excruciating periods and painful sex were normal before being diagnosed with endometriosis, a condition in which tissue similar to the uterine lining grows outside the uterus, and one of the most common conditions affecting women.

In the conclusion, Comen recounts an episode from late 2022 in which a celebrated male plastic surgeon at a New Year's Eve party overrode her accurate self-diagnosis of a cerebrospinal fluid leak. Despite her medical training, she deferred to his incorrect diagnosis. Days later, when the leak was confirmed in the emergency room, her first words to the nurse were an apology for forgetting to wear deodorant, echoing Ellen's apology from the book's opening. Comen calls for a medical system that values empathy and patient relationships alongside scientific discovery, closing with Dr. Francis W. Peabody's 1925 address to Harvard students: "The secret of the care of the patient is in caring for the patient" (323).