When our past is also our?present

The origins of women’s medicine, and why healthcare today is anything but modern.

Lexi—my best friend from college—has been living with chronic pain for years. Her cramps were always bad, and it was always chalked up to period pain. Doctors cycled her through different birth control medications but nothing ever worked. She tried homeopathy, putting aside her skepticism but still finding no relief.

As we graduated and grew into adulthood Lexi was first to marry. Then she had a kid. Then another. Then another. Maybe the pain was worse now than it was before, or maybe it was the same. But it definitely was chronic. 

Eventually, with some gentle nudges from her friends and family, Lexi saw a specialist. Then another. Then Lexi found a specialist who was a woman. In one session Lexi got the answer that had been eluding her for nearly two decades: endometriosis. 

What stunned her, and me, was the specialist’s casual quip, “Oh yeah, endometriosis is under-diagnosed, or often misdiagnosed by male doctors. But usually, they miss it.”

Wait, what? 

Lexi’s experience isn’t only a critique of women’s healthcare today, but is a painful reminder of the origins of women’s medicine—and just how far we haven’t come. 

Innovation for some, obsolescence for the rest 

There is no shortage of technological breakthroughs in healthcare. Surgical robots help surgeons treat and heal us faster. 3D printed medication now makes personalized medicine possible and affordable. Digital tattoos are poised to replace EMRs. 

So why is it that when medical innovation does come for women it must be paid for out of their own pocket*— and not through a change in how medicine is practiced? 

Fertility testing for the low price of $159

At-home, DIY ultrasounds starting at $2,000

An (out of pocket) annual membership for women’s only primary care

When funding for health tech has blown past $7B, why is funding for Femtech* only 11% of that—$820MM? Why has the design of the speculum not changed in over a century? When the rest of medicine has come so far—why is women’s health so far behind?

Racist, exploitative origins

(Trigger warning)

The speculum in 1845 and today

This origin story can’t be told without talking about a man named James Marion Sims — considered the father of modern gynecology. Sims borrowed, bought, and enslaved women for the explicit purpose of conducting medical experiments. While anesthesia was widely available he chose not to use it, operating repeatedly, in one woman’s case up to 40 times.

What Sims learned from human experimentation he put into practice at a Women’s Hospital he founded in New York. There, he treated only white women for fistulas, but continued to opt-out of anesthesia because surgery was “not painful enough to justify the trouble and risk attending their administration.”* Today, treatment of fistulas is performed with either local or general anesthetic. 

Sims’ inhumane experimentations also gave us that device whose design hasn’t changed in over a century—the speculum. His contributions to modern medicine are the result of the torture and exploitation of Black women. His legacy is a cruel, racist one. But Sims was no outlier, he was part of a medical tradition that shrouds women’s medicine in a stigma that persists today.

The sexualizing and shaming of women’s health

James Marion Sims, father of Gynecology

Sims was not alone in his revulsion for women’s bodies. Plenty of his contemporaries (all of whom would go on to shape modern gynecology) shared his disdain. The invention of the speculum sparked great controversy not because of the pain it inflicted on patients, but because physicians worried that women would derive sexual pleasure out of these medical examinations.* 

Robert Brudenell Carter, a widely published and highly regarded British surgeon, wrote that he’d “seen young unmarried women, of the middle class of society, reduced by constant use of the speculum to the mental and moral condition of prostitutes; seeking to give themselves the same indulgence by the practice of solitary vice; and asking every medical practitioner … to institute an examination of the sexual organs.”

The medical textbooks students learned from normalized this fear and ignorance. Instructional illustrations for conducting a pelvic exam advised doctors to reach up underneath a women’s skirt and fumble around. They were taught to “reassure a female patient that he was not looking at her private parts by doing one of two things: gazing off into the distance or maintaining eye contact with her the entire time.”* 

It’s not surprising that today’s medicine perpetuates the shame and violence that pockmarked its founding.

Vestigial shame: how the past shows up today

Statue of James Marion Sims being removed from Central Park in April 2018

Cow tongues. Pig anuses. Car washing sponges. These are the tools medical schools use to train students in the 21st century. They’re considered economical, best in class, and good enough for learning how to repair vaginal lacerations caused by childbirth. Anatomically correct training models are virtually non-existent—for women. 

For those who become pregnant at 35 or older, the medical code to describe the care provided is “supervision of elderly trimester*”.

In 42 out of 50 states it is legal to perform pelvic exams on unconscious women without their consent.* Often, those exams are done for the benefit of training a medical student. This practice so eerily resembles Sims’ that informed consent advocate Robin Fretwell Wilson declared, “We know we shouldn’t treat women’s bodies like they’re somebody’s property, and that extends to medicine.”

Innovation after innovation has come for the speculum and yet it remains largely unchanged. Why? Because despite the many—and better—redesigns, the medical community doesn’t see a need to change.* It’s not news that pelvic exams today are uncomfortable, traumatic, or embarrassing. It is outrageous that they still are, and that it’s a choice someone else has made.

Women’s medicine today is not the arc of progress it ought to be, nor is it a departure from its origins.

It’s time for a refounding of women’s medicine

For women’s medicine to have a better and more equitable future, it needs a reset—and a conscious break from the past. We must part ways with a racist and misogynistic legacy. We must no longer settle for “good enough” in the tools and training of women’s medicine. We must eschew the stigma that surrounds women’s bodies and talking about women’s health. We must not allow for differences in health outcomes because of the color of a woman’s skin. 

It’s time for a refounding. Time for a new origin story for women’s medicine. 

Let’s create a future that embraces womanhood in all its dignity and diversity. 

Let’s make consent the start of every medical conversation. 

Let’s revolutionize—and modernize—the tools and training of the trade. 

Let’s find what works locally and scale it globally.

Together, we can define and uphold a new standard of care for women’s medicine. One that reflects all of these things (and more) and leaps the entire field forward. One that benefits all of us, from physicians, to providers, to educators, to leaders—and most importantly—for women. 

About the authors

Arthur Julio Nelson is a startup advisor and founder of Crazy Studios, a strategy and design studio. 

Christine Goudie is co-founder and CEO of Granville Biomedical, which makes anatomically accurate training models for women’s healthcare providers.

Factual and editorial footnotes:

1. The consumerization of healthcare is a good thing. The consumerization of healthcare as a stop-gap for public health crises is a very bad thing.

2. Health tech funding surpassed $7.4B USD in 2019 per Deloitte. “Femtech” is the name venture capitalists (who are predominantly white men) give to all startups and innovations that address women’s health. The term is deeply problematic, as it genders technology while also only gendering technology when it serves women. There is no “Masc-tech”. Sex and gender are independent axes, it misuses a gender term when what they mean is sex. 

3. Wikipedia article about J. Marion Sims

4. “According to women’s health expert Margarete Sandelowski, after Sims popularized one of the first speculum models, it caused a debate within the medical community on the ethics of viewing a woman’s reproductive organs. In 1850, physicians from the Medicine and Chirurgical Society of London in London, United Kingdom, attended a meeting to debate arguments for and against the use of the speculum in gynecology, with some worrying that female patients would mistake examinations for a sexual experience.” (source)

5. Why No One Can Design a Better Speculum, The Atlantic, November 2014

6. The medical code for treatment of pregnant women 35 or older is ICD-10-CM CODE O09.529, supervision of elderly trimester.

7. She didn’t want a pelvic exam. She received one anyway, The New York Times, February 2020

8. Why no one can design a better speculum, The Atlantic, November 2014