University of Chicago Press, 2014, 232 pages
In her thoroughly engaging new book, Not Tonight: Migraine and the Politics of Gender and Health, Joanna Kempner argues that, despite a new clinical paradigm through which migraine has been transformed from a psychogenic to a neurobiological disorder, the condition remains “an opportunity to make jokes about moral character” (2). Grounding this assertion in the concept of a “legitimacy deficit,” (9) i.e., a gap between what sufferers experience and what biomedicine and broader society formally recognize as illness, Not Tonight demonstrates the synergistic roles that gender and perceptions of moral character can play in the lived experience of a disease condition, including its clinical management and representation. At its core, the book reveals how the virtual incompatibility between high moral character and a feminine gender impedes the social and clinical apprehension of migraine as a “real” disease condition.
Not Tonight is a fairly wide-ranging text. Across five chapters (each of which stand alone on their own merits), Kempner presents a set of interlocking variables through which the condition of migraine has thus far been understood: its social and clinical history; recent pharmaceutical advertising campaigns; online advocacy and activism; and the recent neurobiological turn in migraine care. In addition to online forums and blogs, much of Kempner’s fieldwork took place at clinical conferences where (mostly female) patients—as proxies for the specialty of headache medicine—were routinely maligned by clinicians, and where the neurobiological paradigm at the heart of her analysis has become institutionalized. In each of these spaces, Kempner highlights the gendered dimensions of migraine’s legitimacy deficit, voiced by clinicians as a “conceptual slippage between the categories of ‘psychosomatic patients’ and ‘women’” (55). Not Tonight illustrates how, in this context, both patients and providers have been seduced by the brains that are now “everywhere” (51) in migraine research and management: patients enthusiastically embrace the “migraine brain” as a “tangible object through which symptoms can be understood and … manipulated” (98-9) while clinicians enjoy the heightened (and more masculinized) status of treating an “organic disease” that is distinct from the “neurotic symptoms of women” (54).
Analyses of health conditions that, like migraine, are disproportionately experienced by women, often follow one of two trajectories: delineating how the condition itself is imbued with gendered characteristics, or how gender as a system contours the prevalence or lived experience of a disease or diagnosis. Not Tonight keeps its focus on the former dynamic, unpacking “just how feminized our understanding of migraine is” (155). In her analyses of pharmaceutical ads (Chapter 3) and cluster headache (Chapter 5), a condition related to migraine but with which more men are diagnosed, Kempner is an astute cultural diagnostician, and provides readers with a wealth of textual evidence of the gendered lenses through which migraine is largely perceived. A print advertisement, for example, in which a drug’s efficacy is measured by a woman’s ability to return to nurturing work, alongside descriptions of cluster headache as violent enough to bring “‘even the strongest of men to their knees’” (135) evince the ways that both variations of migraine are marked—indeed, almost constituted—by gender transgression.
More accurately, what Kempner expertly homes in on is how migraine patients both exceed and conform to gendered expectations: women whose headaches render them unavailable for maternal care and heteronormative sexual work still “retreat” (138) to quiet spaces where they can malinger, while men whose cluster headaches hamper their ability to work cope with the pain by violently banging their heads against a wall or floor. What these descriptions reveal is that because migraine does not map neatly onto the gendered bodies of patients, sociomedical narratives about sexed biology are recruited to do so in its place. From the high-maintenance “diva” brain (71) of a “Migraineur” (94) to the “leonine facial features” (146) of a cluster patient, descriptions of migraine adhere firmly to conventional stories about sexual difference; empirical evidence must then be contorted around these narratives in order to make clinical sense. What we see here is not only how flawed and even misogynist assumptions about sexual difference [https://genderedinnovations.stanford.edu/] can contribute to substandard care, but also how the specialty of headache medicine helps to produce the “biofictional” (Preciado 2013) categories of “men” and “women.”
Not Tonight grapples with a second puzzle—how illegitimacy clings to migraine, despite new neurobiological causal narratives—by investigating several spaces where legitimacy and moral character are actively negotiated. In online forums and other biosocial spaces, advocates promote a neurobiological understanding of migraine by “talking about their brains as entities that exist separately from themselves” (100). For many of these experts (all of whom are also patients and almost all of whom are women), the matter of migraine’s moral rehabilitation is simply one of time and education, of “pick[ing] up the slack” (88) in their medical care while providers improve their clinical skills. But the stickiness of migraine’s illegitimacy is made palpable via its consistent ability to disrupt the lives of family, friends, and coworkers who are more easily soothed by extant narratives about “perfectionist” or “stressed out” personalities than they are by biological disease. Kempner’s self-identification as a migraine sufferer is especially effective here, as she reflexively punctuates her analysis with personal and often poignant anecdotes regarding the steady streams of advice afforded migraine sufferers to, in essence, “chill out.” Clinicians’ low investments in managing the disorder’s non-neurological dimensions complement these tendencies, leading many sufferers to over-identify with narratives that prioritize the parts of their disease for which they bear little to no responsibility.
Kempner convincingly demonstrates that migraine’s legitimacy problems are significantly inflected by gender and the book alludes to how this gendered legitimacy deficit relates to discussions of sex-linked neurobiological difference; how, in other words, the migration of migraine from women’s “heads” to their “brains” might reify rather than neutralize presumptions about hierarchical sexual difference. Indeed, and as feminist critiques of neuroscience have consistently shown (Fine 2011, Jordan-Young 2011), the evidence supporting sex-specific brains is often specious and tautological: assumptions about the categorical stability of male and female distort research design, results, and claims that then systematically impose a binarized and essential reality to sex and gender (Springer, Stellman, and Jordan-Young 2012). In the final pages of the book, Kempner argues that “in a patriarchal society … the idea that society ought to safeguard and maintain women’s breasts may be more easily embraced than the parallel notion that women’s brains require the same sort of protection” (167). True as this assertion might be, it stops short of recognizing that as long as female and male are understood as biologically distinct entities, a class of “protected” women’s brains will likely incur the cost of a subordinated neurobiological status.
Focusing on the feminization of migraine, Not Tonight does not contextualize the disorder’s distribution within other forms of gender asymmetry (in the US or elsewhere), and Kempner refrains from speculating on what might make women more likely to be diagnosed (hormones; unequal distributions of pay and domestic labor; high rates of sexual and domestic violence). Indeed, Kempner appears to take gender asymmetry as a given and does not describe how it works for afflicted women beyond their medical encounters, how its structural tenacity frames the condition, or how alternative social arrangements might lead to different distributions of migraine’s symptoms. Though she acknowledges that “gender is [a] persistent” (157) cultural dynamic, and that one researcher has established a connection between child abuse and the neurobiological plasticity through which migraine might be acquired (104), these aspects of the condition remain largely unexplored. And though she repeatedly refers to a demonstrated relationship between poverty, race, and migraine, there is little analysis about the role these factors may play in the risk for or development of the disorder.
These concerns aside, Not Tonight makes a number of important contributions, including an excellent update on migraine’s character (the whole body is affected; it doesn’t always involve a headache) and current treatment approaches, and a thoughtful discussion of migraine’s “emergent politicized collective identity” (101). Though Kempner argues that a full embrace of the (compartmentalized) “migraine brain” denies advocates “the ability to politicize the[ir] disease” (104), she also demonstrates that their routine deployment of the term “disease” communicates both a biological reality and a lived experience, including how they are rendered suspect by providers, family, and broader society. And though less is discussed regarding sex and sexuality than the title might suggest, Kempner’s early discussion of sexual activity as an effective pain reduction mechanism (20), rather than a gendered avoidance of heterosexual expectations, serves to remind us that “cultural stereotypes may be more resilient than … biological knowledge” (157): “That … studies [about sexual activity] are done at all,” she argues, “is testament to the power of […] clichés about women, sex, and migraine …” (20). With assertions like this, Not Tonight allows us to see how gender and illegitimacy intersect, and how the character of people with migraine, most of whom are women, is questioned in ways that render their diagnosis and treatment less important. Migraine may well be an opportunity to make jokes about moral character. So, as it turns out, is being a woman.
Christine Labuski is an anthropologist and assistant professor of Women’s and Gender Studies at Virginia Tech, where she also directs the Gender, Bodies & Technology initiative. Her book It Hurts Down There: The Bodily Imaginaries of Female Genital Pain, tracks the emergence and physiological realization of vulvar pain conditions in the contemporary United States.
Fine, Cordelia. 2011. Delusions of gender: How our minds, society, and neurosexism create difference. New York: W.W. Norton.
Jordan-Young, Rebecca. 2011. Brain storm: The flaws in the science of sex differences. Cambridge: Harvard University Press.
Preciado, Paul B. 2013. Testo junkie: Sex, drugs, and biopolitics in the pharmacopornographic era. New York: The Feminist Press.
Springer, Kristen W., Jeanne Mager Stellman, and Rebecca Jordan-Young. 2012. Beyond a catalogue of differences: a theoretical frame and good practice guidelines for researching sex/gender in human health. Social Science & Medicine, 74(11): 1817-1824.