and downright myths have shaped medicine's understanding of the female body.

While the modern era has seen progress, today's guest tells us those narratives about women and their bodies continue to shape the care provided to women today.

She's Dr. Elizabeth Comen this week on "Story in the Public Square".

(upbeat music) (upbeat music continues) Hello and welcome to the "Story in the Public Square" where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller, also with Salve's Pell Center.

- And our guest this week is Dr. Elizabeth Comen, MD an oncologist and professor at New York University.

She's also the first time author of a new book 'All in Her Head: The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today".

She joins us today from New York City.

Elizabeth, thank you so much for being with us.

- Thank you for having me.

- You know, the book is tremendous.

And I mentioned to you just before we started taping that I was intrigued by the fact that you had studied the history of science as an undergrad, because we get a lot of history about the myths and lies that were told when you were a student.

Did you know you wanted to be a physician?

- I always had a passion for medicine and science and understanding how the body worked and stories.

And so much of medicine is about the stories we tell ourselves about our bodies, what has been told about us, and the narrative behind that.

So when I was in college, what was really special about this major was that I didn't have to give up all my love of humanities, for literature, for history, for context.

And yet I also got to examine that within the love of science that I have for biology, for chemistry.

And as you know, science doesn't happen in a vacuum.

It's inextricably linked to who we are, the minds that create it and those that have a seat at the table.

So for me, it was a perfect marrying of an intellectual passion.

- Well, and you are a respected oncologist.

You are- - Hope so.

- You bring deep credentials to writing this book.

What inspired you to write it in the first place?

- Well, so I've dedicated my career to taking care of breast cancer patients.

And while there are some men that get breast cancer, the vast majority of my patients are women, women of all ages and all stages of life.

And in taking care of thousands of women over my career in these very private sacred settings, I have heard some of the most heartbreaking stories of how women choose to live and survive and how they wanna thrive.

And many of what they have talked to me about has, in some part, to do with their cancer, but more about the rest of their lives and what's held them back, including maybe other medical diagnoses times that they have felt shame, blame, dismissed, misunderstood.

And for me, I really wanted to tackle head-to-toe, women's healthcare and have a better understanding of all the ways that we could help women thrive better in their bodies.

- So you open the book with an account of one of your patients, Ellen, who is dying of metastatic breast cancer.

You lean in to hug her goodbye, and then she said, quote, "I'm so sorry for sweating on you" words, you have heard many, many times that this speaks to shame more potent and insidious than fear you write.

Talk about the shame women feel, why, and- - I think women have shame in all sorts of different places, but particularly about their bodies.

We talk about how women are in some settings, anxious about what they're wearing walking down the street.

Imagine what they may feel in a doctor's office when they have intimate and very personal questions.

But when you look at the history of medicine, so much of what women have been taught about their bodies is even the names of like pudenda, which is refers to female genitalia, comes from the Latin word for shame.

So much of what we have been taught about our bodies is to behave or that they're dirty or not worthy of the same types of pleasure or have simply just been misunderstood, whether it's diagnoses that were still struggling to tackle and understand better for women.

At every level of their bodies and their soul, I think women have inherited, many women have inherited stories about shame.

- This has deep historical roots, but it continues today as we know when you read the book.

Talk about today.

We're gonna get into the history a little bit later, but talk about today.

- Sure.

- How many times you've seen this?

I mean, you've, you've treated thousands of patients, I'm assuming.

- Every day.

- Every day.

- Every day.

I think if you ask the women in your life, have they ever felt shame about their bodies or anxious about it or dismissed or somehow inherited a sense of blame?

I think almost every woman I've ever met certainly has a story about that.

And I, and the reason why I incorporated the history is not to get us stuck in the past, but to really understand where does this legacy come from?

How does it relate to culture and what we, and religion, but also the society that we live in today, that perhaps could free women more of that shame, particularly in the doctor's office.

- So you mentioned blame and blame seems to go hand in hand with shame.

What do women blame themselves for that they shouldn't?

- I think we are, and not to stereotype women, but I think historically there's a lot of apologizing there.

So when you talk about blame, I think we feel shame and blame and apology for all sorts of things.

I've heard women blame themselves for not being able to make it to their mammogram on time when, you know, maybe they didn't get time off from work, or maybe they didn't have someone to watch their child, or they blame themselves for the stress in their lives and assume that that's why they got sick.

Or they apologize for everything, including their pain.

I've had countless women on any given clinic day apologize for the questions they have or the pain that they're in, or if you're seemingly bothering their doctor for questions and concerns.

It spans the spectrum of everything you could possibly imagine.

- So outside of the doctor's office in the hospital, this is also a theme in media, correct?

I mean, if, if you look at TV shows today in the past, is that also reinforcing or making that shame worse, the popular culture?

- I think so.

I mean, I don't think the doctor's office again exists in a vacuum.

I think it reflects who we are when we walk out that door or into that door.

And that's why understanding the web of societal's connection to the things we study in medicine, the things we devote money to, the ways we honor bodies in and outside of medicine, is so woven into the fabric of the experience of illness in this country.

- You know, Elizabeth, one of the things that struck me about the book was just the frankness with which you talked about issues that are every day and normal and natural, but it might not be something that I as a man, I'm sensitive to the fact that we're too men interviewing you about this topic, but maybe had not thought about.

What's the reaction been to, that you've received from people who have read this book?

- Well, first of all, this book is for women and men.

And if you read the book and you know me a little bit better, you'll know that this is definitely not about the war of the sexes.

I think men are capable of being extraordinary healthcare providers, extraordinary types of empathy and compassion.

And my hope is that we honor that everyone in our society, no matter who they are, can be great doctors and also feel empowered in their bodies.

And in terms of the authenticity of the language and the humor, I really wanted to make this book accessible to everybody and not some sort of, you know, wha wha (hosts laughing) of ivory tower academics, you know, but something that we could all really relate to.

This isn't meant to be a death by PowerPoint presentation about our healthcare system, but one that reflects the stories of the past, the stories of today in accessible language and sometimes provocative language.

I tend to be unfiltered in the way that I communicate.

And I think that sometimes that's the best way to just be honest, authentic, and use the language that we really crave to describe the problems that we have.

- Well, you know, so you mentioned empathy and one of the, that struck me at, in the mid-20th century when men principally were dominating healthcare and were were making pronouncements about women's health in particular, one doctor emerges who uses empathy.

He doesn't just describe the challenges that women face.

He actually listens to women.

And he was not exactly an angel.

He was selling something.

But can you talk to us about the role of empathy in healthcare, both historically and today?

- Absolutely.

I am fascinated by the concept of empathy.

I think there's a lot of misconception about it, that somehow women are better listeners, that we take more time, that we are more gentle.

I think that's been baked into the system of who we are and the assumptions about us.

But I think that's really reductionist.

There are incredible men, that if we value empathy in our healthcare system, I think you'd see more of it.

So much of partnering with our imperfect healthcare system today is a result of these crammed in 15 minute appointments with third party players, like insurance companies that know nothing about the patient, but yet we are dictated by the care that we can give our patients as a result of these external forces.

But when you break it down as a society and as an individual, I think we are all craving that sense to be heard, to be understood, to be validated, to be honored for the pain that we all may experience some point in our lives.

And that really requires empathy from the next person.

And I hope that this book encourage us to invigorate our healthcare system with a lot of the empathy that I think we all believe is missing.

- So Elizabeth, you organized the book into 11 chapters for the 11 systems of a woman's body.

And I'm gonna read what those are.

Skin, bones, muscle, blood, breath, guts, bladder, defense, nerves, hormones, and sex.

We don't have time to get into every single chapter.

We're gonna get into a couple at least.

Let's start with the chapter skin.

- Yes.

- Much of that is devoted to plastic surgery.

- Yes.

- Talk about that, 'cause that was a fascinating, and you know, just an incredible piece of writing.

- Thank you.

So, you know, the history of plastic surgery is pretty interesting because the history of plastic surgery really started in large part, you could go back further in time, but really, really gained traction once at the turn of the century when you had the ability to operate on seemingly healthy people for a cosmetic problem.

But it started on the battlefield when you had these wars where people are having terrible, horrific injuries and you could provide anesthesia, which was relatively new.

You helped correct these wartime injuries, but at the same time, you had the rise of the ability to operate on seemingly healthy people who had cosmetic concerns.

But that field really arose where it was male doctors operating on female patients.

So in that, you can imagine a real power dynamic of what does it mean to be operated on where what's dictated is really the male gaze, where maybe the pathology is not a broken limb, but more so an unattractive face.

It's really, really fascinating.

So when you look at the history of breast augmentation, you look at labia plasties, look at many of the cosmetic injuries that we do they're in large part related to what men think is beautiful about women.

- But are there some women who get some benefit from plastic surgery?

- There are many women.

I'm perfectly, maybe one day I'll have some.

I mean, I've got my forehead, I've got Botox in my forehead right now, proudly.

So I am happy to say that there's a lot that we can offer with plastic surgery and cosmetic procedures, including helping women feel empowered in their bodies.

But I think what the book really asks women to do is think, is to take a step back and to think about where did these visions of what beauty mean come from?

Who are the arbiters of that?

And are you doing it for yourself?

What does that mean?

Are you subscribing to some punishing beauty standards that are really just impossible?

Or are you feeling empowered in your body?

And I think when you understand these procedures a little bit better, where they came from, and think about who's putting pressure on you or not, to have them, it empowers you to make the best decisions for yourself.

- Wait, what gives the, you know, the subtitle of the book, right, is "The Truth and Lies of Early Medicine", "The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today", why do the lies continue to resonate in 2024 when we have science, when we have, we're supposedly so much more advanced than we were a century ago.

Why do these lies continue to have traction?

- I think the lies continue to have traction because we haven't fully unpacked them.

I think there's this tremendous movement in our society to move forward, to have better access, to care, to have women feel empowered in their bodies.

But I take care of women all day, every day.

And there was so much in this book that I had no clue about when it came to women's health.

I had no idea that 80% of autoimmune diseases were in women.

And I had to really think about, well, wow, I don't consider that a women's health disease.

Two thirds of Alzheimer's patients are women.

Women are two times more likely to suffer from Alzheimer's disease than men.

That we know that heart disease is the number one killer of women, and yet we miss it so very often in women and we present that women have atypical symptoms of chest pain when in fact they're typical for us.

So there's so much that I think that we need to retrain the medical system about who we are.

There's so many new questions that we need to be asking, and in part of doing that, we unpack the legacy that we've inherited to help have a more empowered future for us all.

- Well, and the title of the book itself, "All in Her Head", speaks to this idea that women are more hypochondriac.

I'm not sure if that's, if that's the way to express it, but you know, how do we square those two sides of it?

In the chapter about where you discuss women and their nerves, there's a lot of misogyny.

- Yes, I think if you look at the history of medicine, this idea of the hysterical woman in whatever way you refer to her as the anxious woman, the ghost of the hysterical woman, the woman in the 1970's who's told to call calm down and take an anti-anxiety medicine called Valium, or today where, you know, they present with some abdominal pain, we don't know what it is.

And well, maybe it's just all in her head.

The number of women that have been told throughout their lives about their bodies that they need to calm down or whatever they're feeling is all in their head is frankly ridiculous.

And a lot of it reflects what we don't understand about women's bodies.

And you know, unfortunately, I wish the title of the book didn't resonate with so many women, but it is, and I think my greatest hope moving forward is that the title will be One Day Obsolete.

And that my daughter will say, well, that's just kind of like a funny thing that we used to say to women, but not anymore.

- So in addition to the deep history that you get into, and we know where that came from, given what you majored in at Harvard, also, you imbue this book with many accounts of patients.

And I want to have you talk about a patient named Miriam.

It summarizes what you describe as quote, "The systemic disenfranchisement that women with neurological issues experience within the medical system."

Tell us about Miriam.

- Well, Miriam is my mother.

So my mom was hit by a bike in New York City.

She was admitted to an emergency room.

She hit her head both on a garbage can and on concrete.

And the focus when she got to the emergency room was her broken clavicle.

Very little attention was paid to the fact that she hit her head so hard.

She didn't have a bleed in her head, but she clearly was at risk for a concussion, which she horrifically had.

And despite my access to many resources, many doctors, and having, you know, real stature among the medical community, it took me well over a year to truly get her- - Wow.

- The right care and a proper diagnosis moving forward.

And I can't imagine, cannot imagine what it is like for the average patient or the under-resourced patient to find the kind of care that they need.

And it also speaks to the fact that women are often the primary care caregivers in society, the ones who make decisions about our healthcare system and the primary providers of healthcare to their families.

So as a daughter, I am often in a position of both taking care of my children and taking care of my extended family.

And that is something that, you know, we don't talk about enough in our country because it can't just be the, it can't just be the daughters that care for the parents.

- So mistrust of the medical system is another recurring theme in the book, mistrust by women.

Talk about that.

- Well, I think when there's been so much that's been misdiagnosed or misunderstood, or women feel that they're not heard or things that are all in their head, or it takes 10 years to have a diagnosis of endometriosis where it shouldn't be that long, it's not surprising that many women have distrust in our healthcare system.

And it's also worth mentioning that that distrust is compounded for minorities in this country who, as we know, have a very long history of being abused in our medical system and certainly being dismissed.

The, when you look at black women across all accounts of medical subspecialties, they often have worse care, worse access to care.

There are unfortunate cultural assumptions that are involved, that are imbued in our healthcare system, you know, for example, about pain and how that affects different members of society, which is just absolutely preposterous and leads to horrifically, horrific inequalities in our healthcare system.

- So the health consequences for these women can be dire.

Correct?

- Absolutely.

Black women are 40% more likely to die from breast cancer than any other ethnicity or race in this country.

And that is not because of underlying biology, but rather access to care and access to the right type of really academic resources and standard of care and screening for breast cancer.

That absolutely needs to change.

And those statistics are true in, across the board for other sorts of really serious diagnoses.

- Yeah, Elizabeth, just the, you know, thinking about the totality of the argument that you're making, how much of this is unique to Western and American healthcare in particular?

Do we see this in other countries, in other parts of the world?

- Well, I'm certainly not a global health expert, but in speaking with my friends who are, if you look at healthcare across the world and third world countries, it is worse for women.

And as I said, women are often the epicenter of caring for everybody else in society.

And that's true whether it's a rich country or a poor country.

And so my fear, although I have not examined these healthcare economics, is that in other countries as well, women suffer the burden of worse healthcare in every part of the world.

- You talked about the experience your mother had, another experience was your own, you became a patient.

Talk about that.

- Well, you know, I wrote this entire book about empowering women and all the things that I didn't know about medicine.

And at the end of writing it, it came time to write the conclusion and I happened to have had a small back surgery and a complication from that.

But it's a long, winding story, but the bottom line is I had a complication.

I knew immediately what was wrong with me, but when I mentioned it to another doctor, he told me I was absolutely bleeping ridiculous and insane.

And it led me down a rabbit hole of really second guessing myself, not communicating with my surgeon, not wanting to bother him, not wanting to really express the level of pain that I was in.

And I ultimately ended up with a very, much worse complication and being admitted to the hospital.

And when I got there, I was still apologizing for my pain, apologizing for not showering, even though I couldn't even pick my head up off, you know, the floor.

So everything that I had argued for women when it came time to myself, I couldn't do for myself.

And it really made me recognize just how hard it is as a woman, particularly in pain, to advocate for yourself.

And it's why I really say that when you have a problem, when you're anxious about a new diagnosis, you have to have somebody with you if you can, to come with their questions, to come help advocate for you to ask, well, what is the rationale to the doctor or provider of why you're thinking what you're thinking?

Because I don't care how smart you are or how empowered you are or how strong of a voice you are, if you're in pain, if you're suffering, if you're anxious, it's almost impossible to really bolster yourself enough to get the kind of care that you need and deserve in those settings.

- For someone who is in that same situation, you know, you're a respected oncologist, you've been educated at the best universities, you know what you're talking about.

How does a lay person walk into that environment and advocate for themselves with or without someone who's there to advocate for them?

- I think we have to keep training ourselves to trust our gut and our trust our gut means not saying, "Oh my gosh, I'm, I can Google how to fly a plane and then know how to fly a plane myself."

Or, you know, Google a medical diagnosis and then say, "Hey doctor, this is the medicine I need."

But really trust our gut about the relationships that we encounter in our medical system because we do have to have some level of trust to say, this person in front of me who has decades of experience and has worked so hard in this field is here because they care and they want to partner with me, and also I need them to listen to what I am worried about.

And there is that natural organic moment between a doctor and a patient where they feel heard and the doctor is trusted and that's really ideal.

So if you feel like you need a second opinion, if you don't trust the answers that you're getting, go with your gut.

Go with your gut, get a second opinion or ask that question.

Look, I just don't feel comfortable, can you explain this to me?

- So let's take the broad view here.

What can be done to improve the medical treatment of women in America?

- Thank you so much.

And I'm gonna answer that as a blue sky sort of answer.

If I could have everything I ever wanted, with a little bit of realistic framework.

I think we really have to start with the questions that we're asking in our healthcare system.

And that requires us thinking about the research that we're doing, because if we keep having the same people at the table asking the same questions, we're never gonna get anywhere.

So it starts with the preclinical models, it starts with the research.

It starts with saying, what are the problems that are existing in women's healthcare?

What are these gaps?

And then it involves really funding those research questions.

We have a new White House initiative from Joe Biden, the Women's Research Initiative that's extraordinary, which will funnel money into some of the most important questions that we need to answer in some of these unmet needs.

And from the research we need to make sure that we're including women in clinical trials, asking the right questions and then translating that into clinically meaningful treatments for women.

But it also requires in that doctor patient relationship, my hope is that with medical curriculum, that we continue to take a step back and ask really of these new doctors and existing doctors, what are the biases that we've inherited?

How do we dismantle them?

How do we really show up with an open mind and an open heart and empathy towards the issues that so many women face?

And I think there's a lot of reason to have hope and promise for why we can have more equitable care moving forward.

- So I was just gonna ask, do you have optimism that this can happen?

I mean, your book, I think is a, a major step in that, but you do have optimism that this can happen.

- Absolutely.

If you read my book, you'll see these bonkers, ridiculous, egregious stories from the past, which are absolutely insane.

We're in a far better place than we were a 100 years ago, I just think we could do even better.

And I have a lot of belief and trust in our system and the men and the women that are building it today.

I think there's lots of reason to be positive and optimistic about the future.

- Elizabeth, this was your first book?

- Yes.

- Yeah.

So what, did anything in the process of writing the book, did anything surprise you?

- Everything surprised me.

(hosts laughing) It was a surprise, but I'll say how much I didn't know, how much I have to learn about women's healthcare, how much women's sexuality and desire seemed to be a focus of doctors, whether controlling it or manipulating it in, I mean, let's be clear, masturbation is not a cause of scoliosis, but you can find a lot of doctors historically that said it.

So the focus on that was really just shocking to me.

And also just realizing how sad some of these cases of the past were and my sincere hope that we can do better moving forward.

- Well, Elizabeth Comen, Dr. Elizabeth Comen, the book is "All in Her Head" and it's remarkable.

Thank you for spending some time with us today.

That is all the time we have, but if you wanna know more about 'Story in the Public Square", you can find us on social media or visit pellcenter.org where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes asking you to join us again next time for more "Story in the Public Square".

(upbeat music) (upbeat music continues) (upbeat music continues) (upbeat music)