Abstract
After decades of feminist studies of science, it is no longer surprising to claim that science, both in its practices and in products, is gendered. Likewise, historians of medicine have done much to expose the ways gender inequality is bolstered by medical science. Medicine, where science meets practice, the laboratory meets the clinic and ‘objective’ research meets subjective suffering, displays a well-documented tradition of pathologising women’s bodies as deviant and disciplining deviant women as ill. The reach and success of this research has transformed once radical ideas into near axiomatic doxa. But the evolution of these arguments into field-specific common sense should not lull science and technology studies (STS) into stultifying complacency. It must resist any knee-jerk tendency to dismiss new research that reaches similar conclusions as ‘something everybody already knows’. Recognition of the relationship between gender, medicine, science and power should not be mistaken for complete understanding. Rather, fuller comprehension demands regular elaboration and constant vigilance, especially as this relationship changes and evolves.When it comes to how our notions of health and illness – normality and pathology – get inflected by gender ideologies, the devil is in the details.
New cases serve to flesh out these details, and Joanna Kempner’s compelling book, Not Tonight, offers such a case. Kempner examines the gendered nature of migraine science in the USA to argue, quite convincingly, that despite attempts to ground the understanding of migraine in neuroscience, it continues to be perceived and dismissed as a problem of hysterical women.
Written in clear prose, Not Tonight provides a rich analysis of migraine medicine. Kempner marshals a ‘multisited ethnography’ that makes the use of multiple methodologies (interviews, ethnography and content analysis) to observe the various stakeholders involved (headache specialists, pharmaceutical advertisers and advocates). Organised into five empirical chapters, the book effectively reconstructs the world of migraine medicine. After an introduction laying out her argument, Kempner begins her analysis with a concise and elegant history of the shifting understandings of migraine over the past 300 years. The chapter is especially adroit when illustrating the ways in which gender assumptions were written into the concept of ‘migraine personality’ to create a particular kind of migraine patient—the uptight neurotic woman. The second chapter describes the recent shift to a neurological understanding of migraine, one that attempts medicalisation through neuroscientific accounts that focus on the brain. Such attempts, argues Kempner, do not overcome or neutralise the gendered associations in migraine, but instead help reify them. The third and fourth chapters offer solid, if straightforward, content analyses, first of online patient materials (e.g. blogs) and next of direct-to-consumer advertisements (DTCAs). Here, Kempner shows how online patient communities and pharmaceutical companies, create, reinforce and/or negotiate the gendered understanding of migraine. The final empirical chapter provides an instructive comparison, comparing the case of migraine, associated with women, to that of cluster headache, associated with men, to draw a stark contrast between the two when it comes to legitimacy. The book ends with a succinct conclusion that restates its core arguments.
Not Tonight’s strengths come from the depth of its case analysis and its illumination of how migraine has been persistently constructed as a female malady. Kempner argues ‘that stakeholders’ best attempts to legitimate migraine are undermined by cultural meanings of headache and migraine that are overlaid with assumptions about gender’ (p. 18). In focusing on legitimacy—and its epistemological, moral and institutional dimensions—Kempner makes a nice contribution to the extant sociological research on medicalisation. While most of this research stresses the momentum and growing force of medicalisation—depicting it as a cultural wave drowning out alternative accounts and consuming more and more social problems under a medical purview—Kempner underscores the limits of medicalisation in the face of deep, longstanding beliefs about gender. As she puts it, ‘. . .the recent biomedicalization of migraine is not powerful enough to erase centuries of sexism in culture and in medicine’ (p. xii). Even as the understanding of migraines has shifted from a focus on problematic female personalities to dysfunctional neurocircuitry, it has not shed its gendered character. Migraine may have been medicalised, but its sufferers are still marginalised as weak, hypochondriac and hysterical women.
A strong contribution to our understanding of health, illness, gender and power, Not Tonight is a book whose sum is greater than it parts. Each chapter reflects solid, albeit standard, sociology, but none awes. However, when amassed, they produce a nuanced account of the ways in a diverse set of actors produce and negotiate a gendered experience of pain. And Kempner brings to her topic a keen eye, a mastery of a number of literatures and a deep empathetic understanding. As a migraine sufferer herself, Kempner adeptly balances any tensions that might arise between her position as a researcher and a patient. She occasionally, but sparingly, draws on her own experiences to round out a point. When Kempner inserts herself into the analysis during moments of reflexivity, the results are enlightening, never distracting.
With that said, the book has its limits. First, while Kempner does an excellent job applying theoretical concepts familiar to STS researchers (boundary work, biomedicalisation, biosociality, interactive kinds, etc.), she shows little interest in harnessing her case to elaborate, extend or revise these concepts. While such theoretical innovation is not the aim of the book, this represents something of a forfeited opportunity. Second, although the empirical base of the book is strong, the patient perspective is strangely muted. To give them some voice, Kempner cobbles together online testimony, testimony from advocates, and to a much lesser degree, her own experiences. By why not interview patients themselves to reveal how the gendering of migraine affects patient understanding and experience? This is a curious omission, one that hazards eliding the very real world stakes of her case. Third, the chapter on pharmaceutical companies is thin in its empirical support. Kempner was only able to interview two marketing executives and, as a result, the chapter leans too heavily on what is a boilerplate content analysis of pharmaceutical ads. Undoubtedly, this reflects the challenges of access to the corporate private sector, but some discussion or acknowledgement of these challenges are in order. Finally, I believe readers would appreciate an extension of the analysis beyond migraine. In particular, I wonder how this case speaks to larger issues regarding the social construction of pain, particularly how the phenomenology of pain is shaped by cultural understandings its causes, the populations with which it is associated, and the norms regarding how it should be expressed.
These quibbles aside, Not Tonight does important work in demonstrating how those whose lives are touched by migraine face a ‘legitimacy deficit’ and, in turn, have their experiences and authority questioned by critics wielding gender ideology as a weapon of marginalisation. It should be of interest to not only STS researchers but also medical anthropologists, sociologists of health and illness, gender scholars and historians of medicine. Given its compelling case study, it could serve as a useful text for an advanced undergraduate course in any of these fields.
Gone are the days when STS researchers are shocked by the use of medical science to perpetuate patriarchy. But just because Not Tonight tells a familiar story does not mean we should ignore the urgency of its lessons.