Hysterical

PART ONE

That Day

One day in our early lives as women, everything changes. we start bleeding. The beginning of our menstrual cycle, our fecundity, renders us different. In an instant we’re no longer children. I was on a crazy golf course overlooking Cromer Pier when I experienced period pain for the first time. It was the summer holidays, and I’d started my period while away with my dad, brother, and sister just before my fourteenth birthday. I’d taken to wearing my hair all scraped back, and my abundant forehead was absorbing the North Norfolk sun with vigor. As I stared between a pair of wooden clown lips to putt my ball between, my lower body rippled with new sensation. It was a pain that didn’t fit inside my body. My pelvis hung suspended, like a bowling ball, threatening to burst from between my legs. That classic British coastal breeze perfume, thick with sun-roasted kelp and old deep-fat-fryer oil, took the nausea that seemed to come with these sharp churns to another level. I had to sit down on the grass. I thought, This is crazy.

Girls talked about period pain at school. Some fainted in class or on the benches next to the netball courts because of it. One girl vomited all over her desk in a math class and started crying before being led to the nurse’s office, the teacher’s hand gently holding the small of her back. These girls gained noble status. Their syncopes were crowns of maturity. To myself and others who hadn’t yet “started,” they were kind of a different species because their bodies knew things ours didn’t. We used to ask each other how bad it could be, us nonstarters, because we all knew what a stomachache felt like. But for a stomachache to have girls falling on their backs and puking into their pencil cases seemed wild.

Until I felt it.

This new pain burned through my thighs. My legs were like pipe cleaners as a teenager. That holiday they were so tanned they looked wood-stained. The blonde hairs on them caught in the light like fiberglass, and sitting on the grass, I wondered if I should start shaving above the knee (Mum had always said not to) as others did at school rather than stopping at the cap. My thighs carried on burning. I explained to Dad that I didn’t feel well. He nodded and told me just to “sit quietly.” I was aware of the shift in his gaze toward me in a way that I absolutely did not have the language for. Only feeling.

Something set me apart from my younger sister. A vague sense of shame swam about me. A few days earlier, we’d been in a four-man tent in Southwold, and I’d been sat by the zipper feeling a peculiar nostalgia or longing that I couldn’t place. I told myself I was homesick, even though home wasn’t a particularly great place to be then. When we got to Cromer, I went to the toilet and found maturity in my knickers. An initial rush of excitement—I could go back to school and be part of the in crowd! The swooning girls!—gave way to a funny sadness. I had to leave the house immediately after telling Dad. It wasn’t quite embarrassment that made me leg it—he did his best to make it a nonthing, a mini-celebration, even—but in my core I felt uncomfortable. That whole holiday was one of heavy, wordless feelings.

I recall that afternoon on the golf course so clearly, I think, because the overwriting of what my body once knew as pain felt so significant at the time. The letters of the word, p, a, i, n, are symbols. Abstract. But there was a physiological process happening in my body and brain as they learned to accept this new state and its corresponding language. I began to embody the word differently. I had known pain before, of course—broken fingers, headaches, tonsillitis, bruises, scratches, and bite marks from fighting with my siblings. This was different; it had texture. Emotion. I looked down at the grass and thought, for a split second, that it would never stop. That the pain was time itself.

Dad gave me the keys to go back to the house and take some ibuprofen. I made catlike sobbing noises the whole way. Back at the house, I lay on the sofa waiting for them to kick in. No one had mobile phones yet, so I couldn’t relay my woes to any friends on WhatsApp. Anguished emojis were years and years away. It was so quiet in that moment, apart from the pitiful cawing of seagulls (why do they always sound so desperate?) overhead. Strangely, though, it wasn’t lonely. The pain spoke to me. It told me my human fabric had changed. As evidence of the encoding that happened that day, now, on most occasions that I hear seagulls, I will have flash visions of lying on that sofa holding my young, tortured belly.

I’m in my thirties now, and ever since my first period, they’ve always been a slog. I’ve had my own swooning and vomiting episodes as cramps ripped through my body—not ever at school, but often in shopping centers. I learned to deal with what always used to seem to me like an excessive amount of blood, which came in a variety of colors and consistencies. As a teenager, when I was on (why did we say that? Upon what did we stand and then step off again?), I’d be forever looking backward at myself in mirrors to check I hadn’t leaked through my clothes: a steadfast paranoia that, although lessened, still lingers today.

I have spent quite some time now trying to gain autonomy over the way my hormones seem to make my mind and body behave each month. At some point in the last five years, as part of my ongoing quest for peace of mind after a confidence-obliterating breakdown of sorts forced me finally to seek help for the anxiety that I had done my very best to conceal from everyone around me, including myself, for well over a decade, I started thinking about my menstrual health as part of my mental health. It was after a particularly bad period buildup one month, which felt like a week of crying from nowhere, overeating, and spending too many evenings lying on my front in an existential torpor, that I went to my GP. I asked her if this could really just be premenstrual syndrome (PMS).

Before the appointment I had somehow had the common sense to start making a monthly diary (read: a series of symbols Sharpied on the Cliff Richard calendar my best friend bought me) and realized that this way of being and feeling crept up on me every couple of weeks for a few days at a time. Notably, after my period, I’d have a week of feeling almost fantastic: productive, calm, resilient, porous to all the smell and color of life. I say almost because in the back of my mind, I’d be worrying about feeling hijacked again. So I asked the doctor what I could do about feeling as though my soul was fermenting every single month in a way I could not control. Since then I have tried all sorts of interventions in my quest for emotional stability. More medications after several conversations with (almost exclusively male) gynecologists, who have made me feel either (a) madder or (b) ever so slightly less mad for a short amount of time. Acupuncture. Vitamin supplements. Diet changes. Broadly speaking, this precise, reliable emotional state I sought was, is, elusive at best and impossible at most realistic. I will revisit my hormonal quest in much more detail later on, but for now let’s just say that few of the interventions brought me relief. But in time, through addressing all the above with a new psychologist, and in the research I did for this book, I began to see things slightly differently and asked myself, “What am I seeking relief from?” Even if I could control certain symptoms of my premenstrual distress—low mood, for example—and a type of drug would be the answer, on a much deeper level, I wanted to know, “What is the question?”

One thing that became very clear on this journey was what I knew, didn’t know, or had forgotten about when it came to what was going on inside my body; my baby-making machinery as yet had made no babies but for the love of god wouldn’t stop preparing for them each month. I wanted to explore what happens at each stage during the menstrual cycle in more detail because, through conversations I’ve had with many women, it seems that having greater awareness of what’s going on can be helpful in managing our moods but also in conceptualizing what a mood actually is: a state of being that is, by its nature, temporary. Whether that awareness comes from using a period-tracking app, starting a diary, doing online research, or reading books, the hope is that a greater level of acceptance of our fluctuations in mood and emotion can develop.

Some women out there seem able to embrace their premenstrual selves without much shame because there are lots of different ways of being a woman. As I am typing this, I am thinking of a brilliant line from an episode in season two of The Good Fight. Lawyer Diane Lockhart, actress Christine Baranski’s multilayered lead and also my hero, is accused by a young woman at the helm of a #MeToo-esque website called Assholes to Avoid of failing feminism for being part of the site’s takedown. “Women aren’t just one thing,” she snaps, “and you don’t get to determine what they are.”

No woman gets to determine what another woman is, wants, or desires.

In all the appointments I’ve had with GPs and gynecologists, I’ve been through a kind of reeducation of what my body does and why. I have realized how little I remembered from my school education and felt quite ashamed by it. There’s a flash vision I often have of sitting in a hall at secondary school with the rest of my year, watching a TV that was showing a cartoon woman inserting a tampon. Any anatomical accuracy was dispensed with in favor of a vague, hairless triangle that only flashed into view for a second. She appeared to take her trousers down, unwrap the tampon’s packaging, position her body, and push the thing up herself in one dainty movement. All with a big shit-eating grin on her face. She was absolutely delighted about it all, our animated protagonist. Everyone giggled because, you know: vaginas. Obviously, we learned more about sex hormones, puberty, and reproduction in biology lessons (I even took it as an A-level subject with a view of going to medical school). But until a few years ago, when I had a sharp awakening regarding my fertility, I had forgotten a lot of it or taken its function for granted.

In 2014, during an operation I was having to free up bands of scar tissue that were adhering my small bowel and womb to one another—part of the legacy of my burst appendix and all its gangrenous, bits-of-bowel-being-removed glory—the surgeon had received my consent to do a fertility test “while they were there,” like a bike mechanic might check your chain while repairing your brake cables. To do this they injected an iodine-containing dye into my womb to see if it came out the ends of both fallopian tubes. If it didn’t, I may never be able to conceive without medical intervention. In recovery, as I was gingerly eating digestive biscuits and doing my best to pay attention through an opiate haze, the surgeon told me my fallopian tubes were damaged by scar tissue. I’d have to consider IVF if I wanted to become pregnant—or egg and/or embryo freezing. As the morphine flowered in my blood, I promptly vomited into one of those cardboard top hat things before the surgeon had finished talking.

After a year on the waiting list at my local NHS hospital, I embarked on the process of embryo freezing. With donor sperm bought from a bank in New York (I am a woman who sleeps with women; sperm is a little low on the ground around here), I ended up with five embryos ready to spend some time on ice. I often think about them sitting in the freezer at my local teaching hospital. During this grueling process, I learned more from the doctors and nurses about what actually happens during the menstrual cycle and how my ovaries and hormones work than I think I ever had in my life. How bizarre that it took having fertility treatment to learn about myself, an adult woman who had been menstruating for nearly twenty years. Or was this awakening, of sorts, so unusual?

Through frank discussions I have had with other women—family, friends, colleagues, research participants, sources for my journalistic work, strangers on social media—I have realized I am far from the only woman to have lived in a kind of disconnect with her body. We are everywhere. So at what point should we, like a London cabbie acquiring the “knowledge” of London’s back alleys and one-way systems, have acquired the “knowledge” of our bodies? How could I have fallen so out of sync with what makes me me?

It feels as if a movement is happening right now regarding women’s health. Menstrual cycle–tracking apps like Clue are becoming increasingly popular. Female entrepreneurs are creating new sanitary product businesses left, right, and center. More and more magazine articles are being written about previously icky subjects like vaginal health, our menstrual cycles, and the realities of menopause. We’re talking more about the tyranny of ideals around birth control, conception, pregnancy, and women’s experiences of giving birth. We’re talking about how the medical establishment doesn’t always listen to our specific needs as women and how, when we’re failed by health care, the effect on our sense of self can be catastrophic. When I wrote an article for the website the Pool about how PMS was often poorly understood and routinely dismissed in modern health care, I received more messages from readers than I have about any article I’ve ever written. So many women shared the article with variations on “thank god someone is saying it” and with details of how their experiences had been diminished or stigmatized. In my day-to-day life, I have noticed that in the last couple of years, the women I know increasingly want to talk about aspects of their health they may have previously felt shy about. It is as though a thick, collective cork is being slowly winched out of us. Yet beneath the tentative conversations of liberation, the bottle is still full of mystery, ignorance, and stigma regarding our bodies. It warrants our examination.

We must ask ourselves why, for example, cervical smear testing rates among young women have plummeted when rates of cervical cancer are increasing. When asked why they are reluctant to have a smear test, many young women speak about “being judged.” The fear around having a smear test is not just about whether it will hurt when the speculum is put inside us; it is about how we feel our bodies will be perceived, whether our genitals look or smell right, for example. This gaze we cast on ourselves is an internalized male gaze—the product of not just the shiny, hair-free expectations of porn but centuries of patriarchal oppression over our bodies in general. We are ashamed of what makes us women because deep down we believe that, in someone’s eyes, it will never be quite right, that it will be too much.

The relationship we have with our bodies and what goes on inside them is deeply complex. Our reproductive systems are designed to grow babies and constantly prepare for them—even if we don’t want them—and the hormonal fluctuations behind our reproductive processes mean that the workings of our inner world are often in collision with the outer world and all the expectations we perceive it to have of us. How society’s continued perceptions of women affect our perceptions of ourselves is what I am most interested in. My personal experience of seeking treatment for PMS and the sadness, heightened sensitivity, and anxiety I can feel during my cycle and reaching the point of effectively running out of treatment options made me realize how entrenched my analysis of my own thoughts and behavior was with more general ideas of how I should or shouldn’t be as a person. A woman.

This book is underpinned by my journey of becoming more knowledgeable about myself and accepting the emotional changes I feel over the course of my cycle rather than seeing the changes as a pathology, forever scrutinizing and labeling. It also became clear to me, while researching the history of how society has understood, treated, and talked about women’s physical and mental health, that from the Hippocratic beginnings of medicine to the present day, our collective knowledge and attitudes have been shaped by the hubris of powerful men. We know a lot more about what’s going on inside us than we did in 460 BC, but we’ve never quite lost the air of being mysterious creatures prone to physical and emotional excesses that ultimately need containing. When it comes to our bodies, in so many areas, our voice and our autonomy continue to be the weakest currencies. Medicine has an inherent bias against women. Women presenting at hospitals with pain are not only given fewer painkillers than men are but are often offered sedatives instead (because we’re easier when we’re quieter). Treatment for women with coronary heart disease is delayed compared with men. All these facts are corroborated by robust data. When a woman says how she feels, what she wants, or what she needs, someone—usually a man or a system founded by a man—always knows better.

I believe we can link women’s biology as a source of oppression throughout history, and pejorative terms like hysterical, to the modern-day experience of women in so many ways. The massive societal reckoning that is happening in the wake of the #MeToo movement, for example, has led us to examine why so many women’s horrific experiences of abuse have been disbelieved or minimized and why so many women have felt powerless to speak out about something so painful. To me, the very concept of pain is the skeleton key to unlocking why believing women is not a given and to understanding our continued oppression. The reality is that, as women, our pain is not often taken at face value, and we know it.

Physical or emotional, the meaning of our pain has always been up for grabs, swallowed, or dismissed by systems more powerful than us as individuals. Still, too, it is often the case that the louder we shout about our pain, the more we are told that we’re causing trouble and the less likely we are to be taken seriously. Knowing why this is still the case in so many areas of society gives us something to work with and rally against.

This is a book about reclaiming meaning, about drawing a connecting thread between what history has told us about who and what we are, all the ways in which our so-called excesses have been watched and contained, and the peace that can be found in trying to accept our inherent variability rather than forever striving to be or feel a certain way. A better understanding of what goes on inside us, of the connection between our bodies and minds, is an important part of that. So, too, is a greater awareness of all the external factors that may affect our bodily experiences, including the way modern medicine still doesn’t take the variance of women’s pain—or the voice describing that pain—seriously.

There is power in knowing ourselves better. We are not postbiology. We are protecting no one by pretending that we don’t bleed. We are not reducing ourselves or undoing all the equality women have fought for by learning to embrace our messy selves. In fact, I’d say we’re doing the opposite. So let’s start by going inside the body.

Intelligent Flesh

It is impossible to be knowledgeable of every process happening inside us. There’s just too much to comprehend. I start to feel a bit dizzy if I try to imagine it all: what my liver producing bile looks like; the wavelike contractions moving food along my gut; how the hot blood pumping around the sixty-thousand-odd miles of arteries, vessels, and capillaries would sound if I could hear it. Unless we practice medicine or study the human body in a regular, rigorous way, we probably take for granted that every tiny chemical reaction in the body, every bacterial invasion that’s fought away by our white blood cells, every process that keeps our internal conditions controlled—our water content, temperature, and blood sugar levels, for example—is just happening because of the innate intelligence of the body. Why wouldn’t we?

Our skin and everything beneath it start doing their jobs from the moment when we’re born. It’s enough, as an atheist, to make you understand faith in God. How does it all know what to do? Components of us go wrong, sometimes terribly, because every machine is fallible. But generally speaking, aided by what we feed and water them with, our factories of flesh keep us going, each bit doing its special job, until it all grinds to a halt one day. Have you ever felt a quiet awe watching a cut heal? At how, without conscious instruction, the skin starts regrowing almost instantly to prevent that vulnerable porthole to the inner world from filling with bugs that could cause trouble? (I used to obsess over scabs when I was younger, looking at the lattice of clotted blood, like a tiny purple square of shredded wheat, under a magnifying glass.) I never had any such reverence for my reproductive organs until I did the egg freezing. The ones on the inside anyway.

The Female Animal

Having a womb is a source of wonder for many of us, but it can also feel like a curse. The spectrum of potential pain and distress by virtue of having these organs is big. Our reproductive systems are a kind of black magic, our wombs life-brewing cauldrons. But within the wonder of our nature is the reality that every woman, from puberty onward, will experience some kind of physical and emotional turbulence around her reproductive system. As the writer Ariel Levy said in an interview to promote her magnificent book The Rules Do Not Apply, written after her visceral account of miscarrying (“Thanksgiving in Mongolia”) appeared in the New Yorker (a piece of writing that affected me like nothing else I’ve read, before or since): “Every woman is not going to decide to have children, every woman is certainly not going to lose a child, but at some point in her life almost every woman will have some kind of epic drama around menstruation, fertility, infertility, birth, menopause… something to do with this business of being a human female animal. It’s part of life and it’s not something that gets written about much. I felt like it was important to do that.”¹

I feel it’s incredibly important to do that. This animality of ours is one of society’s last taboos. Discussing the realities of periods, miscarriage, the viscera of birth, infertility, endometriosis, or menopause is still, in twenty-first-century Western society, with all its discourse on equality and progression, often whispered behind the palm of a hand. Or not at all. This is in contrast to our conversations about mental health, which are becoming wider by the day. But these processes affect women’s mental health in so many unignorable ways. If we are, gradually, coming to grips with the idea that mind is body and body is mind and that, at its core, the term mental health really equates to how we live and interact with others, what connections are we making about the patterns of mental distress in women?

In his book The Stressed Sex: Uncovering the Truth About Men, Women, and Mental Health, Professor Daniel Freeman, a clinical psychologist at Oxford University, shared the results of twelve large-scale studies carried out across the world since the 1990s on gender patterns in mental health issues. Freeman’s study found that women are up to 40 percent more likely than men to develop mental health issues. The findings, based on analysis of epidemiological studies from the UK, United States, Europe, Australia, and New Zealand, also suggest that women are approximately 75 percent more likely than men to report having recently suffered from depression and around 60 percent more likely to report an anxiety disorder.² This study garnered significant press attention, and it was interesting to see how widely—and to what end—that 40 percent statistic traveled. Simplistic headlines at the time suggested women were more at risk of mental distress than men. Could it really be that we are inherently more vulnerable, and if so, why?

Freeman certainly wasn’t suggesting anything as definitive. His study was large and, by looking at the general population, controlled for men being less likely to seek help for psychological problems than women. But the research is not a formal meta-analysis, generally thought of as the gold standard of evidence. There were no specific conclusions. Also, disparities between rates of mental health issues are now well established in research, and there is not, as far as I can see from my literature searches, significant evidence in the overall rates of mental health issues across lifetimes or any robust explanations about gender imbalance. So what we have is a body of evidence that tells us that women might suffer more, with no precise reason as to why. Perhaps, though, it’s impossible to be precise.

Freeman said that a mix of factors were likely contributing to gender differences in mental health, relating to environment and societal factors as well as biological. “Mental health issues are complex, they do arise from a range of factors, but we should highlight the environment, because we know discrepancies are greatest where the environment has the greatest role,” he said. “Where we think it has an effect is particularly on women’s self-esteem or self-worth: women tend to view themselves more negatively than men, and that is a vulnerability factor for many mental health problems.” This may be true. In all fields of brain study, it is accepted that mental distress is not caused by one thing in isolation. The electrical, chemical brain is not extricable from the subjective mind. What we talk about is multicausality, a fancy word for explaining that lots of different factors contribute to how we feel mentally. Therefore, when we talk about processes happening in a woman’s body that place us at “increased risk” of depression or anxiety, it seems not just blindingly logical but respectful to consider the ecosystem that body exists in. Part of that ecosystem is a deep-seated stigma attached to the word hormones, but within it, too, is a disconnect between the lived realities of being a woman and what aspects of those realities are actually shared, explored, and investigated.

As someone training in the field of psychology with a keen interest in women’s health, I do believe that the biological bias of research in the field can be harmful. I believe, like Freeman, we should cast our attention to environmental factors. However, we also cannot ignore the significant impact hormonal fluctuations can have on a woman’s mental health across her life-span. Biology is part of the picture.

The problem with discussing female biology is that it really has been stigmatized for so long. In the twenty-first-century Western world, it is sweet fantasy to say that all the myths, misinformation, and ickiness surrounding female reproductive processes have been—finally—banished into the fusty past. It’s a bit silly, really, because the word hormonal applies as much to a testosterone-charged city banker as it does to a woman about to have her period. The metabolic processes of all organisms can only take place in very specific chemical environments, and in the human body, hormones (from the Greek participle “ὁρμω̃