Medical Misogyny and the Implications of Not Believing Women

• forensic
• women
• gender
• ethics
• medical

As forensic psychiatrists, we are trained to detect malingering in forensic evaluations, to maintain healthy skepticism when our evaluee has something to lose or win, and to search inwardly for any biases we may hold. Recent literature has examined the gender, cultural, and racial biases inherent in forensic psychiatry, as in society at large. For example, gender bias is contained in the legal construct of battered women syndrome.¹ Gender bias was also a theme of Dr. Susan Hatters Friedman’s presidential address and recent article, “Searching for the Whole Truth: Considering Culture and Gender in Forensic Psychiatric Practice.”² This awareness is encouraging and is especially important in light of recent public cases^3,4 in which women were not believed in the medical setting. It is also salient in the context of the Supreme Court and various state courts’ rulings that are affecting how the medical profession treats women’s reproductive health.⁵ Even with increased awareness on gender disparity (as well as racial and cultural disparities in medicine), the history of gender disparity in medicine and its impact on women’s health is long and entrenched, and it is often difficult to tease out, as it is still not widely understood or taught.

“Tell me what you don’t like about yourself” is the line in the beginning of almost every episode of Ryan Murphy’s 2003 to 2007 dark comedy and medical drama Nip/Tuck,⁶ where two extremely good-looking male plastic surgeons are asking the question of a new patient, usually a woman. In the 2024 book, All in Her Head,⁷ Elizabeth Comen, MD, a breast oncologist, discusses the history of misogyny in medicine, which includes the roots of the field of plastic surgery in efforts to cure not only disfigurement but esthetics and where the plastic surgeons were primarily men. Women were most often patients who believed that there was something wrong with them because they did not meet the standards of beauty that were considered ideal at the time. Comen discusses how women in her oncology practice apologize for getting sick, for having symptoms, for sweating, and for having side effects of chemotherapy. She discusses how the history of medicine includes the premise that something is wrong with female bodies.⁷

A study of women veterans showed that a third of the women experienced gender discrimination while obtaining care from the Veterans Affairs (VA) and that the perceived gender discrimination was associated with medical illness, psychiatric illness, and military sexual trauma. The perceived discrimination scores were higher among women with increased age, medical illness, or history of sexual trauma in the military, whereas lower scores were associated with obtaining care at the same VA over a long period of time.⁸

In The New York Times podcast, “The Retrievals,”⁹ a respected academic fertility clinic failed to believe numerous patients when they literally cried out in pain during and in the aftermath of the retrieval process. Some of the patients were treated as medication seeking, some as hysterical. It was later revealed that the fentanyl medication used for sedation and pain was being diverted by an opioid-addicted nurse. The women were revictimized when their pain and suffering was minimized or dismissed by the institution, even after the truth came to light.⁹

This subject of not believing women caught my attention during an especially memorable and difficult forensic psychiatric evaluation in which a woman alleged that she had been bound and raped on and off for a 24-hour period in an institution that was supposed to protect her and then was not believed when she reported it. She was again not believed by the male forensic psychiatrist retained by the defense. During my evaluation, she had an episode where she was detached from reality and reliving the event, crying, and calling out and where she was not able to respond to me calling her name for about 15 minutes. A similar episode was described in the defense psychiatrist’s report, but she was considered by him to be malingering or acting.

In the Netflix miniseries “Unbelievable,”^.10 based on a true story as reported in Propublica in 2015,¹¹ a young woman is not believed when she claims to have been raped because of her unusual response to the trauma. She ultimately retracts her story out of shame and is subsequently charged with perjury. Only years later was she vindicated, when two female detectives in another state find her driver’s license among the trophy collection of a serial rapist. According to the review of Unbelievable in The Journal, “There is no universal response to being sexually assaulted. Unbelievable deals with society’s unfounded beliefs of how a rape victim is supposed to act and the consequences of not believing a victim of trauma” (Ref. 12, p 139).

In medicine, there is a long history of male physicians not taking the symptoms of women seriously. Often women try to dismiss their own symptoms or apologize for having symptoms, as in Dr. Comen’s experience, or perhaps they do not complain as much as their male counterparts might. One notable and tragic example of someone being undiagnosed after her reported symptoms were not taken seriously was the beloved comedienne, Gilda Radner.¹³ Gilda Radner of Saturday Night Live suffered from multiple symptoms, including missed periods, excessive bleeding, exhaustion, fatigue, depression, and brain fog. She was diagnosed with multiple conditions during that time, including, but not limited to, Epstein Barr, depression, and feeling her ovulation. She lost weight all over her entire body, including her face. She was given an antidepressant. She had severe bone pain. When asked what she was afraid of, she told her psychiatrist she was afraid of cancer. When she was finally diagnosed with ovarian cancer, and after the initial response, she turned to her husband, Gene Wilder, and said, “Thank God, finally someone believes me!”¹³

In the field of cardiology, there has been bias in estimating women’s risk of cardiovascular disease.¹⁴ Studies have shown there is less research involving women and cardiovascular disease, including their risk for stroke and myocardial infarction (MI). There has been a lack of awareness regarding “nonfocal or nonspecific symptoms that are more commonly present in women with minor stroke/TIA or cerebral venous thrombosis” (Ref. 14, p 1868). The authors explain that atypical symptoms of stroke more often seen in women have been attributed to causes other than a stroke, such as migraine. In addition, there has been a lack of history taking regarding hormonal contraception, which could increase the risk for stroke in women.¹⁴ There have also been studies showing less aggressive care for women with cardiovascular problems in assisted living facilities.¹⁴

In psychiatry, there are many diagnoses that are missed in women, such as attention deficit hyperactivity disorder (ADHD).¹⁵ In my practice, I have seen many women whose ADHD was not diagnosed in childhood, as it was not recognized for what it was and was often mislabeled as anxiety, as many undiagnosed girls experience anxiety because of their difficulties with certain subjects in school.¹⁵ Young and colleagues also found that ADHD in girls and women often goes unidentified “due, at least in part, to lack of recognition and/or referral bias in females” (Ref. 15, p 1). They offered some guidelines to support health care practitioners in recognizing ADHD in girls and women and recommended taking a “lifespan perspective.”¹⁵ They also recommended training for the detection of ADHD in women in the criminal justice system, as women with ADHD in the criminal justice system are unlikely to have had a prior diagnosis of ADHD, as it had gone unrecognized.

Ally Greenhalgh, in her New York University post, “Medicine and Misogyny: The Misdiagnosis of Women,” agrees with Comen that the American health care system is “built upon patriarchal ideas,” similar to most other societal institutions.¹⁶ Ms. Greenhalgh explained that, even though there has been some improvement in including women in clinical trials, often the data are still compiled together and the biological differences between men and women are erased in the results. When women empower themselves by doing their own research into their health and symptoms, they are often not believed or are dismissed by their doctors. Greenhalgh wrote, “if female patients come across such patronizing attitudes, it can be deeply disheartening and cause them to be less likely to speak up for themselves again in the future. The emotional and psychological toll of being dismissed by an ‘expert’ deepens the insecurity that many women may already feel in such male-dominated spaces.”¹⁶

One of the most public examples of established institutions covering up for a successful male physician was the case of Dr. Larry Nassar. Shortly after the 2016 Summer Olympics, the story broke that Nassar had been sexually abusing his gymnast patients through unorthodox “treatments.” One of the first victims, Trinea Gonczar was 10 or 11 in 1990 or 1991 when she first began receiving vaginal massages two to three times weekly.¹⁷ She did not report it as she did not realize it was abuse until after Nassar was charged in 2016. But in 1997, two teens did tell a gymnastics coach about the treatments at Michigan State University. Similar complaints were made almost every year since 1997, but Nassar was not charged until 2016.¹⁷

In the case of the young woman who was allegedly raped and experienced a dissociative episode in my office, she was worried about speaking to me at first because she said she had felt dismissed and belittled by the expert psychiatrist for the defense, which had been retraumatizing for her. My experience of forensic psychiatrists not believing women is not limited to male colleagues. In a workplace harassment case, the psychiatrist for the defense not only rebutted the diagnosis of posttraumatic stress disorder (PTSD), but she opined that the distressed, black female plaintiff, with medical complications that necessitated her taking family medical leave, was misinterpreting or inventing the negative events at work that she reported that she experienced.

Sidhu and Candilis in 2018 discussed “a feminist perspective for forensic practice” in the wake of the #MeToo and #Time’sUp movement.¹⁸ The authors aptly pointed out that law and medicine are not immune from the gender-based discrimination and sexual harassment that have been highlighted in other areas of society and in society as a whole. They placed the importance of believing women in the forensic psychiatry setting in an ethics context. They concluded that “the application of feminist thought demonstrates that forensic cases cannot be easily resolved in favor of the lone nondominant individual, especially if professionals and institutions maintain traditional ethics affected by centuries of partiality” (Ref. 18, p 444-5).

In Delicate, the 13th season of American Horror Story,¹⁹ Ryan Murphy adapts Danielle Valentine’s novel, Delicate Condition,²⁰ and again illustrates the powerlessness that women have experienced over their own bodies, this time in the context of pregnancy and childbirth. Among some of the notable differences between the novel and the series is that Valentine’s Delicate Condition deals with racist ideas surrounding pregnancy and childbirth, such as the myth that women of color experience pain differently than white women do.^20,21

Ryan Murphy’s Delicate harkens to the critically acclaimed 1968 film, Rosemary’s Baby.²² In both Delicate and Rosemary’s Baby, the pregnant protagonists are made to feel that what they are experiencing is not real, that their symptoms are all in their head, and they are dissuaded against following their own instincts. Ryan Murphy intimates that the dynamic of society and the medical community deciding what is best for the pregnant woman has not changed that much in over 55 years. The new American Academy of Psychiatry and the Law (AAPL) Practice Resource for Reproductive Psychiatry/Women’s Health in Forensic Psychiatry Practice is a hopeful development.⁵

As forensic psychiatrists concerned with ethics, it is important that we remain aware of the entrenched gender discrimination that remains in society, specifically in the medical field, so that we can work to overcome our own biases and educate the courts when we detect this disparity in our individual cases.

• © American Academy of Psychiatry and the Law