by Katherine Huang
This is the first post in our series about how scientific findings are communicated and the consequences thereof.
“Abortion bans are on the ballot this year, and they are going by the name Doug Mastriano.”
So began a get-out-the-vote advertisement that I, based in Philadelphia, saw multiple times on YouTube in the weeks before the 2022 midterm elections. Similar ads centered on the anti-abortion stances of other Republican candidates for office. Abortion rights loomed large on the ballot last November, following the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization barely five months earlier to overturn Roe v. Wade. The Roe decision had limited the ability of state governments to regulate abortion in the first two trimesters, interpreting the 14th Amendment of the Constitution as conferring a right to privacy in such cases. Now, the Dobbs decision declared that the Constitution does not protect the right to an abortion at all, and restricting abortion at any stage of pregnancy is up to the states.
Abortion is only one aspect of women’s healthcare, which, throughout history, has been as much of a social matter as a medical matter, if not more so due to social attitudes influencing all aspects of life. (I note here that while I use the term “women” and she/her pronouns for conciseness throughout this article, the issues I discuss are relevant to all individuals with anatomy that is traditionally assigned female at birth, regardless of gender.) Male-dominated as medicine was and still is, misogyny has contributed many deliberate and accidental misunderstandings about women’s bodies to both professional medical knowledge and that of the general public. Hiding this misogyny behind science has only exacerbated access to abortion and other reproductive healthcare measures.
Unsurprisingly, misconceptions about women’s health have largely been related to reproductive health, though some such connections have been subtler than others. Until 1993, research funded by the National Institutes of Health was not required by law to include women. In fact, the Food and Drug Administration recommended in 1977 that “premenopausal female[s] capable of becoming pregnant” should be excluded from Phase I and early Phase II drug trials. While the concern for fetal health was appropriate following the notorious thalidomide disaster, the assumption that women could not prevent pregnancy if they wanted to participate in early clinical trials essentially proclaimed that the potential to bear healthy children was paramount over any other health concern.
Besides the risk of reproductive problems, other reasons women have been underrepresented as medical research subjects include dismissive attitudes towards women’s pain and reluctance to study women because of their complex hormone fluctuations. This has led to a major lack of data on the effects of drugs in women, which often contrast greatly with those in men. It has also created knowledge gaps in the ways in which diseases like heart attack and stroke present differently in women versus men.
The notion that women are responsible above all else for childbearing has existed since ancient times, and its implications have hobbled women’s healthcare throughout history. Let’s take a brief look at how these kinds of perspectives have affected women’s healthcare in general, and then abortion specifically in the United States.
Historical Misconceptions About Women’s Bodies
People have made incorrect assumptions about women’s bodies for centuries. Those assumptions may seem absurd given what we know today. Yet, the fact that they were introduced by learned men, whose educational opportunities far exceeded those of women for a long time, lent authority and longevity to those errors. The Greek philosopher Aristotle, for example, thought women were deformed men whose bodies lacked enough “heat” to secrete semen, and so their discharge came out instead as menstrual blood, an impure version of semen. His ideas about women’s inferiority to men laid unfortunate groundwork for the subordination of women in Western civilization.
Even earlier, the Greek physician Hippocrates, known as the father of modern medicine (modern Western medicine, that is), famously postulated that the uterus wanders around the body, resulting in various illnesses and emotional instability in women. These ailments were collectively termed “hysteria,” after the Greek word for uterus. To cure hysteria, a woman had to have sexual intercourse and become pregnant to fix the uterus in place. While belief in the “wandering womb” largely disappeared by the 1500s, the uterus continued to be thought of as the entity responsible for women’s illnesses and “irrationality.” Treatments for “female hysteria,” widely diagnosed in the 18th and 19th centuries and by that time considered a more psychological than physical disorder, still centered on the uterus and other reproductive organs.
Later in Classical history, the Roman natural philosopher Pliny the Elder initiated a number of myths about menstruating women, including that a menstruating woman could scare away hailstorms and make bees abandon their hives. Pertinent to abortion, another Greek physician, Galen, who lived and worked in Rome in the 2nd century AD, believed that women who were rape victims could not become pregnant [1] because a woman could only release her “seed” to conceive if she had an orgasm. Orgasm, in turn, would only occur if she enjoyed the sexual experience, and therefore her sexual encounter could not have been rape. As recently as 2012, the late former US House Representative Todd Akin, R-Mo., drew upon this idea to defend his anti-abortion stance, stating his belief that a woman would rarely get pregnant from “legitimate rape.”
The Influence of Misconceptions on US Abortion Policies
In the US, as women gained educational and professional opportunities in the 19th and 20th centuries compared to earlier times, male physicians weaponized healthcare in an attempt to curtail those opportunities. For example, in 1902, American physician George Cook argued against allowing women to pursue advanced education. He wrote that a “thorough education for women” creates “a conflict for blood, of which there is not enough for both, between an overstimulated brain and an under-developed body,” which is suboptimal because “how can it be expected that [women] will be prolific and the mothers of a healthy progeny if they themselves are not vigorous?”[2]
In an odd way, that almost seems like a good argument for allowing women to participate in sports. Yet, in a variation of the wandering womb myth, women were discouraged and excluded from competitive sports because rigorous exercise was believed to displace the uterus and make women unable to bear healthy children.
Many such misconceptions boiled down to fear, and men’s fear of competition from women was palpable in medicine. Before the mid-19th century, women’s reproductive health and childbirth especially were considered the domain of midwives in both the US and around the world. In 1847, the American Medical Association (AMA) was established, and with that establishment, male physicians in the US became determined to modernize obstetrics and gynecology from the “old wives’ tales” of midwifery. Increasingly, they pushed out midwives to make room for themselves as the providers of female reproductive healthcare, especially in more urban areas, despite having far less training in such matters. Abortion, a powerful way for women to assert autonomy over their own bodies and another skill within the expertise of midwives, became a target for the AMA, which campaigned for abortion to be banned. Between the 1860s and 1880s, at least 40 anti-abortion state laws were passed, outlawing the practice in most states. By 1910, except in select physician-determined situations to save a patient’s life, abortion was illegal in every US state.
Abortion in US Politics and Popular Culture
Although the medical field initially had a heavy hand in restrictive abortion policies in the US, other factors have certainly always been involved, and came to figure more prominently in the battle over abortion rights since the 20th century.
Today, abortion seems to be a heavily partisan issue in the US, with the Democratic party favoring pro-choice policies and the Republican party adopting a more anti-abortion stance. However, it was not until the late 1980s that abortion really entered American politics. Following Roe v. Wade, which was decided in 1973, evangelical Christians united around resistance to abortion and aligned themselves with the Republican party, resulting in that party’s support for restricting abortion. In 2014, a Pew Research study of 35,000 Americans found that 63% of evangelical Christians believe abortion should be illegal in most or all cases, ahead of Catholics at 47%. As of 2021, white evangelical Christians make up only about 14% of the US population, but they hold a large sway over Republican political priorities, notably those related to abortion.
Curiously, while mass opposition to abortion among evangelical Christians did not begin due to any particular misconceptions about women’s health, the large political divide in abortion views is itself a bit of a misconception. According to a FiveThirtyEight poll conducted shortly before the Dobbs decision was released, 64% of Republicans (and 89% of Democrats) actually agree that abortion should be legal in cases of rape, incest, or to save the life of the mother. The same poll asked Democrats and Republicans to estimate those percentages for the opposing party. While Republicans estimated that 68% of Democrats would agree with the statement, Democrats estimated that only 30% of Republicans would do the same.
Beyond religion, secular portrayals of women’s reproductive health have also influenced public attitudes towards the topic. Specifically, they have presented distortions of reality that can interfere with pregnant people’s ability to make optimal healthcare decisions for themselves, including the decision to have an abortion. In entertainment, for example, Dr. Sarah Banet-Weiser, of the University of Pennsylvania (Penn)’s Annenberg School of Communication, notes that the proportion of fictional characters on US television experiencing an abortion-related “complication, intervention and/or negative health effect” was many times greater than the real-life proportion. As such, even if safe options were available to them, pregnant individuals may be dissuaded from obtaining abortions because of such depictions. Additionally, anti-abortion individuals and organizations can exploit these types of depictions to frighten people into agreeing with their perspective.
How Patients and Physicians Talk About Abortion
The future of abortion rights may not be something pregnant patients and their physicians can directly control. However, certain aspects of patient-physician conversations regarding healthcare decisions can help patients consider more options and make more informed decisions about their reproductive health. They can also help to clear up any misconceptions patients may have previously held on the topic.
I learned about some of these aspects last October when I attended the 2nd Annual Penn Medical Communication Research Institute Symposium, which focused on messaging related to women’s reproductive health. Among the speakers at the symposium were the faculty mentioned below, as well as Dr. Banet-Weiser from earlier in this discussion.
Dr. Lisa Harris, of the University of Michigan’s Departments of Obstetrics and Gynecology and Women’s and Gender Studies, emphasizes that doctors are caregivers, not political pundits whose purpose is to take a stance on abortion with strong language. As such, they should not only acknowledge but also lean into the moral complexity of abortion. This can help patients relax and have productive discussions with their healthcare providers without feeling that a particular option or opinion is being forced upon them.
In a related vein, Dr. Chioma Ndubisi, of Penn’s Perelman School of Medicine, notes the importance of unbiased, patient-centered counseling when discussing contraception. This includes asking a patient early during a visit if it is even helpful to discuss contraception that day. Patient-centered counseling contrasts with traditional, more provider-dominated counseling where a physician assumes that a patient is most interested in the birth control methods that are most effective at preventing pregnancy; a patient could be more interested in the side effects that occur while using a particular method, or the impact of the method on sexual enjoyment. Dr. Ndubisi mentions historical examples of how reproductive coercion in the US has harmed Black, Latinx, and Indigenous people, as well as people of lower socioeconomic status, implying that patient-centered counseling can be especially important for those groups. That is, being more attentive to the needs and wants of those patients, who may be aware of this coercion history, can actively give them more agency and autonomy in their reproductive health decisions. While Dr. Ndubisi did not say it explicitly, I believe similar points can be extended to discussions of abortion as well.
From a linguistic angle, Dr. Betsy Rymes, of Penn’s Graduate School of Education, discusses the indexicality of the term “abortion.” Indexicality refers to the same word being understood differently in different contexts. In a political/legal context, “abortion” refers to the elective procedure for pregnancy termination that conservative policies (are trying to) ban. In a medical context, any pregnancy that ends before 20 weeks is called an abortion, no matter how the termination occurred. This includes miscarriages, which are also called spontaneous abortions. Additionally, ectopic pregnancies count as abortions in the GxPxxxx code for summarizing a patient’s pregnancy history. When “abortion” as a neutral medical term gets conflated with “abortion” as a more charged political term, patients can become fearful of discussing abortion as necessary healthcare. Dr. Rymes suggests that better communication between these different contexts is needed, implying that physicians can help patients of varying personal views feel less anxious about abortion by making them aware of this indexicality.
Conclusion
Women’s health, and women’s reproductive health in particular, has suffered from misconceptions and paternalistic control since ancient times and continues to be a battleground today. This piece certainly does not cover everything in its focus on a subset of Western women’s health history. It also does not account for misconceptions surrounding reproductive health that have arisen from inadequate sex education and misinformation on the Internet. While there is much more to explore in this regard, the sure thing is that more nuanced, open conversations between patients, physicians, researchers, and the general public about women’s reproductive healthcare can help reduce misconceptions and increase understanding about women’s health.
Smith, Merril D. Encyclopedia of Rape, Greenwood Press, Westport, CT, 2004, p. 155.
Cook, George W. “Puberty in the Girl,” American Journal of Obstetrics and Diseases of Women and Children, United States, W.A. Townsend & Adams, 1902, p. 806-807.