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| UNWELL WOMEN | 《不健康的女人》(Unwell Women) |
| Misdiagnosis and Myth in a Man-Made World | 男性主导的世界中的误诊和谬论 |
| By Elinor Cleghorn | 作者：埃莉诺·克莱格霍恩(Elinor Cleghorn) |
| In order to recognize illness, you have to know what health looks like — what’s normal, and what’s not. Until recently, medical research generally calibrated “normal” on a trim white male. Such a patient, arriving in an emergency room clutching his chest as they do in the movies — and in the textbooks — would be immediately evaluated for a heart attack. But heart disease in women, inconveniently, doesn’t always come with chest pain. A woman reporting dizziness, nausea and heart-pounding breathlessness in that same E.R. might be sent home with instructions to relax, her distress dismissed as emotional rather than cardiac. | 为了识别疾病，你必须知道健康是什么样子——什么是正常的，什么是不正常的。直到最近，医学研究还普遍将“正常”偏向以白人男性作为校准。这样的病人，像电影里那样——也是像教科书里那样——捂着胸口来到急诊室，医生会立即评估是否是心脏病发。但是，女性患心脏疾病并不总是直观地伴随着胸痛。一名在同一个急诊室自述头晕、恶心和心跳加速的呼吸困难的女性可能会被送回家，并被告知要放松，她的痛苦被认为是情绪导致的，不是心脏的问题。 |
| Heart disease has clear markers and proven diagnostic tools. When a woman’s symptoms are less legible or quantifiable — fatigue, vertigo, chronic pain — the tendency to be dismissive grows. In “Unwell Women,” the British scholar Elinor Cleghorn makes the insidious impact of gender bias on women’s health starkly and appallingly explicit: “Medicine has insisted on pathologizing ‘femaleness,’ and by extension womanhood.” | 心脏病有明确的指征和经验证有效的诊断工具。当女性的症状不太清晰或难以量化时——疲劳、眩晕、慢性疼痛——排除心脏病的倾向就会增加。在《不健康的女人》中，英国学者埃莉诺·克莱格霍恩(Elinor Cleghorn)直言不讳地指出了性别偏见对女性健康的潜在影响：“医学一直坚持将‘女性特点’——以及广义来讲所有成年女性——病态化。” |
| Cleghorn, framing her argument in terms of Western medicine, starts with Hippocrates, the Greek physician of antiquity who refocused medical science on the imbalances of the body rather than the will of the gods. Hippocrates understood that women’s bodies were different from those of men, but in his view, and for millenniums to come, those differences could be reduced to a single organ: the uterus. A woman’s purpose was to procreate; if she wasn’t well, it was probably her womb that was to blame. One Roman writer described the uterus as “an animal within an animal,” with its own appetites and the capacity to wander through the body in search of satisfaction. Most female afflictions could be reduced to “hysteria,” from the Greek word for womb. “The theory that out-of-work wombs made women mad and sad was as old as medicine itself,” Cleghorn notes. The standard cure was marriage and motherhood. As Hippocratic medicine was refracted through the lens of Christianity, the female anatomy was additionally burdened with the weight of original sin. | 克莱格霍恩从西方医学的角度阐述了她的论点，从古希腊医生希波克拉底(Hippocrates)开始，他将医学重新聚焦在身体的失衡上，而不是神的意志上。希波克拉底明白女性的身体与男性的身体不同，但在他看来，以及后来的几千年里，这些差异可以归结为一个器官：子宫。女人的作用是生育；如果她不舒服，那可能是她的子宫惹的祸。一位罗马作家将子宫描述为“动物体内的动物”，它有自己的胃口和在身体中游荡以寻求满足的能力。大多数女性的痛苦都可以归结为“歇斯底里”(hysteria)，该词源自希腊语中的子宫。克莱格霍恩指出：“未在使用中的子宫使女性发火和难过的理论与医学本身一样古老。”结婚和做母亲是标准的治疗方法。由于人们以基督教的眼光看待希波克拉底医学，女性的生理结构也额外背上了原罪的重担。 |
| Moving steadily through the centuries, Cleghorn lays out the vicious circles of women’s health. Taught that their anatomy was a source of shame, women remained in ignorance of their own bodies, unable to identify or articulate their symptoms and therefore powerless to contradict a male medical establishment that wasn’t listening anyway. Menstruation and menopause were — and often still are — understood as illness rather than aspects of health; a woman’s constitution, thus compromised, could hardly sustain the effort required for scholarship or professional life. A woman with the means and the talents to contemplate such ambitions soon bumped up against the rigid shell of the domestic sphere. Her frustration and despair could cause physical symptoms, which her doctor would then chalk up to her unnatural aspirations. Conversely, a perfectly healthy woman who agitated for radical change — a suffragist, say — was clearly suffering from “hysteric morbidity.” | 克莱格霍恩沿着历史的足迹描绘了几个世纪以来女性健康的恶性循环。由于被教导她们的生理结构是耻辱的来源，女性仍然对自己的身体一无所知，无法识别或阐明她们的症状，因此无力反驳一个反正也没有在倾听的男性主导的医疗机构。月经和更年期曾经——往往至今仍然——被理解为疾病，而不是从健康的某些方面；女性的身体构造因此是不完整的，几乎无法承受学术或职业生活所需要付出的努力。一个有能力和才能来考虑这种野心的女人，很快就受到了家庭领域的僵硬限制。她的沮丧和绝望可能会导致身体症状，然后她的医生会将其归咎于她不自然的愿望。相反，一个完全健康的女性如果要求社会改变——如一位女性参政支持者——显然是“歇斯底里的病态”发作。 |
| Though hormones eventually replaced wandering wombs as central to understanding women’s health, “old ideas about women’s bodies being naturally defective and deficient still pulsed through endocrinological theories,” Cleghorn writes. The marketing for early forms of hormone replacement therapy to relieve the discomforts of menopause was often directed at men. One horrifying magazine ad showed a radiant older woman laughing alongside male companions, with the tagline “Help Keep Her This Way.” Was hormone replacement therapy a way of liberating women from their reproductive biology, or keeping them cheerful for their husbands? And, as questions grew about estrogen and cancer, at what cost? | 尽管激素最终取代了闲置的子宫成为理解女性健康的核心，“关于女性身体天生有缺陷和不足的旧观念仍然通过内分泌学理论产生，”克莱格霍恩写道。用于缓解更年期不适的早期激素替代疗法的营销通常是给男性看的。一则令人生畏的杂志广告展示了一位容光焕发的老妇人与男性伴侣一起大笑，标语是“帮助她继续保持如此”。激素替代疗法是将女性从生殖生物学中解放出来，还是为了让她们为丈夫而保持愉悦？而且，随着关于雌激素和癌症的问题越来越多，这样做的代价是什么？ |
| The intersection of class and race complicates things further. As early as 1847, the Scottish physician James Young Simpson argued in favor of anesthesia during labor and delivery, contradicting the age-old belief that the pain of birth was part of God’s judgment. (To this day, women who opt for an epidural instead of “natural childbirth” can feel a nagging sense of failure.) But even liberal-minded men like Simpson believed that what he called the “civilized female” needed his revolutionary innovation more than her less privileged sisters. Black women were thought to be less sensitive to pain and working-class women were considered hardier in general; certainly no one worried about whether these women could work while menstruating. | 与阶级和种族的交点使事情进一步复杂化。早在1847年，苏格兰医生詹姆斯·扬·辛普森(James Young Simpson)就主张在分娩时使用麻醉剂，这与古老的信念相矛盾，即分娩的痛苦是上帝审判的一部分。（直到今天，选择无痛分娩而不是“自然分娩”的女性会感到一种挥之不去的失败感。）但即使是像辛普森这样思想开明的男性也认为，他所谓的“文明开化的女性”更需要他的革命性创新，而不是她那些没有特权的姐妹们。黑人女性被认为对疼痛不那么敏感，而工人阶级女性通常被认为更能忍耐；当然没有人担心这些女性在月经期间是否可以工作。 |
| Each scientific advance came with its own shadow. Margaret Sanger may have campaigned for contraception “as a way for women to reclaim their bodies and lives from medical and social control” — but for women of color, birth control was presented more as a duty than a right, a weapon against overpopulation and poverty requiring the policing of women. The postwar advent of the National Health Service in Britain heralded a new era of comprehensive prenatal care for pregnant women, but the N.H.S. “also inherited the legacy that women were child-bearers, first and foremost, so their health care needs pivoted around their reproductive functions.” Women saw their doctors when they got pregnant, but illnesses unrelated to reproductive health might go undiagnosed and unchecked. | 每一项科学进步都伴随着它的阴暗面。玛格丽特·桑格(Margaret Sanger)曾宣传避孕为“作为女性从医疗和社会控制中拿回身体和生活的一种方式”——但对于有色人种女性而言，节育更多地被视为一种义务而不是权利，一种对抗人口过剩和贫困的武器，因为需要对女性进行管控。战后英国国民保健服务(NHS)的出现预示着孕妇全面产前保健的新时代，但NHS“还继承了女性生育孩子的传统，因此她们的医疗保健需求围绕着她们的生殖功能”。妇女在怀孕时去看医生，但与生殖健康无关的疾病可能得不到诊断和检查。 |
| Especially illnesses with ambiguous symptoms. “The age-old question of what to do with women’s pain, now that diagnoses could be made by biomedical evidence rather than speculations and assumptions, was raising its rather inconvenient head,” Cleghorn writes. When women of an earlier era might have been subjected to clitoridectomies or ovariectomies to address their mysterious symptoms, 20th-century patients sometimes faced a lobotomy “when the extent of their pain exceeded their physicians’ patience.” Cleghorn is unsparing in her examples of women suffering unimaginable and unnecessary horror at the hands of doctors who were unwilling either to listen closely or to admit when they were stumped. | 尤其是症状不明确的疾病。“现在可以通过生物医学证据而不是推测和假设做出针对疼痛的诊断，如何处理女性疼痛这个由来已久的问题却招来了不便，”克莱格霍恩写道。早期的女性可能会接受阴蒂切除术或卵巢切除术以解决其神秘症状，而当20世纪的患者的“痛苦程度超出医生的耐心时”，她们有时会面临额叶切除术。克莱格霍恩在她的例子中毫不留情地描述了当医生既不愿意仔细倾听，也不愿意承认他们被难倒时，女性所遭受的难以想象和不必要的恐惧。 |
| It’s impossible to read “Unwell Women” without grief, frustration and a growing sense of righteous anger. Cleghorn’s prose is lively, and she has marshaled an enormous amount of material. But her decision to organize it chronologically rather than thematically can slow her momentum, forcing her to circle back to certain topics repeatedly. There are occasional detours — into the eugenic implications of abortion and birth control, for example — that aren’t strictly relevant to the thesis of a “culture of mystification” that compromises women’s health. And Cleghorn’s definition of that culture of mystification is tricky. She is rightfully advocating for a better understanding of diseases that disproportionately affect women and a re-examination of clinical norms centered on men. But in this era of ever-increasing medical specialization, byzantine insurance regulations and rushed office visits, women are not the only victims of mystification. | 阅读《不健康的女人》时，不可能不感到悲伤、沮丧和越加义愤填膺。克莱格霍恩的文笔生动活泼，而且她整理了海量材料。但她按历史顺序而不是按主题组织写作的决定会影响她的连续性，迫使她反复回到某些主题。偶尔会有一些弯路——例如优生运动带来的堕胎和节育的影响——与损害女性健康的“神秘化文化”的论点并不严格相关。克莱格霍恩对神秘化文化的定义是取巧的。她主张更好地了解严重影响女性的疾病，并重新审视以男性为中心的临床规范，这是理所当然的。但在这个医疗专业化程度不断提高、保险法规错综复杂和问诊匆忙的时代，女性并不是神秘化的唯一受害者。 |
| Cleghorn saves for her conclusion her most powerful illustration: her own experience. It started with leg pain and swelling. Her doctor suggested gout, or maybe she was pregnant? “I can see nothing wrong with you,” he said. “It’s probably just your hormones.” Doubting the significance of her own concerns, she endured seven years of pain and tachycardia, finally landing in the emergency room. Even then, her diagnosis was linked to the baby she had just delivered: “toxic postpartum heart disease.” An observant rheumatologist at last identified her disease as lupus. | 克莱格霍恩将她最有力的例证保留在她的结论中：她自己的经历。症状开始于腿部疼痛和肿胀。她的医生怀疑是痛风，或者也许她怀孕了？“我看不出你有什么问题，”他说。“这可能只是你的荷尔蒙作祟。”她也怀疑自己的担心是多余的，于是忍受了七年的疼痛和心率过快，最终进了急诊室。即便如此，她的诊断仍与她刚刚分娩的婴儿有关：“产后中毒性心脏病”。一位细心的风湿病学家最终将她的疾病确定为狼疮。 |
| “The lives of unwell women depend on medicine learning to listen,” Cleghorn concludes. And also on women claiming their right, as Cleghorn has, to speak. | “身体不适的女性的生命取决于医学是否能学会倾听，”克莱格霍恩总结道。而且，像克莱格霍恩那样，也取决于女性为自己发声的权利。 |
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