The surgery that reveals everything that’s wrong with women’s health care

For decades, the default feminist position on hysterectomy has been skepticism—and with good reason: The history of gynecology is replete with stories of unethical doctors and gruesome experimentation, of deeply ingrained misogyny and horrific racism. But when Hunter College medical sociologist Andréa Becker started doing research on hysterectomies in 2019, she discovered that many women she talked to really, really wanted one—often because their reproductive organs were so messed up that their lives had become a living hell. 

Thus the title of Becker’s fascinating—and extremely timely—new book, Get It Out: On the Politics of Hysterectomy. Surgical removal of the uterus is “the most attractive solution to a lot of patients,” Becker says, “especially those who went undiagnosed for years or who were told over and over that their symptoms were normal and ‘just learn to live with it.’ Eventually, they reached the breaking point: No, let’s get it out.” 

Becker’s interest in reproductive health began when she was a graduate student at Vanderbilt University, doing abortion activism on the side. “I started thinking, if there’s so much stigma around terminating a single pregnancy, what would it mean to get rid of the entire uterus and lose the capacity to gestate a pregnancy altogether?” When she began digging into the academic research, she found that studies overwhelmingly focused on the medical issues around hysterectomy—which sometimes involves the removal of just the uterus, sometimes the cervix, ovaries and/or fallopian tubes as well—with almost no research into why patients choose the surgery or how it affects their lives. Becker’s book is based on the kind of qualitative research that’s been largely missing from scientific literature—in-depth interviews with scores of patients around the US, including cisgender women of all races, ages, and incomes and dozens of transgender men and nonbinary people. 

She found that the pronatalist, pro-eugenics ideologies embraced by Vice President JD Vance, Elon Musk, and their ilk are embedded in the medical profession’s biases about who should and shouldn’t be allowed to have a hysterectomy. White cis women often face serious resistance from doctors, who fret about these patients’ loss of fertility. Black and brown women, in contrast, are frequently encouraged to have the surgery, and at much younger ages. Maybe the book’s biggest surprise? Trans men have a relatively easy time convincing doctors to put them under the knife, even if the reasons are complicated. “Doctors will say, ‘Do you want your ovaries or not? You decide—it’s up to you,’” Becker says. “Or, ‘Do you want a hysterectomy? Let’s do it.’” 

Of course, that is likely to change as the Trump 2.0 administration’s extreme anti-trans policies threaten access to gender-affirming care for trans adults as well as minors. And the true impact of those cuts to access may never be known; the Trump administration has also decimated research funding for women’s and trans health, including still-mysterious underlying conditions, like endometriosis, that drive so many women to choose a hysterectomy. “The National Institutes of Health was given a list of words that they can use to slash funding or to reject a research proposal,” Becker says. “One of those words is women. So we can see [the lack of research] is going to get much worse.”

I spoke with Becker by Zoom from her home office in New York shortly before her book launch this month. Our conversation has been edited for length and clarity. 

I was surprised to learn how common hysterectomy remains in the US. 

By age 65, 1 in 5 American women will have one, according to the most recent data. That’s a crazy-high number—higher than in other parts of the Western world. But this is not just an American phenomenon. After cesarean sections, hysterectomies are the most common gynecological surgery worldwide.

In part, that’s because hysterectomy is a catch-all solution to everything that could possibly go wrong with the uterus, the ovaries, all these organs—and there’s a lot that can go wrong that we don’t understand. We’re still pretty much in the dark ages of gynecological research and gynecological practice in general. I start the book with a quote from Rachel Gross’ book, Vagina Obscura: “There are parts of your body less known than the bottom of the ocean or the surface of Mars.” It’s such a powerful statement because it’s so true. 

As I was reading your book, I kept thinking about how much pain is associated with female reproductive machinery: premenstrual syndrome, bleeding and cramps, chronic conditions like endometriosis, childbirth and all the related complications, and then eventually the changes that happen around menopause. It begins to seem as if, for girls and women, once you hit puberty, pain is your destiny. 

It’s an idea that has biblical foundations: Eve ate the apple, therefore all women should suffer. But this idea is used to justify subpar health care, too. Having a woman’s body means being in pain. The suffering that comes with having a uterus, ovaries, a cervix—it’s just become normalized.  

Yet historically and still today, women’s pain is not taken seriously: Oh, it can’t really be that bad. Women who complain about pain are “hysterical.” 

Hysteria has the same etymological root as hysterectomy—“hystera,” Greek for “womb.” Hysteria translates both to “womb disease” and to “woman’s disease,” as well as to “suffocation of the mother” and “suffocation of the womb.” There was a mainstream idea in medicine for a very long time, which lives on today in other ways, that pretty much everything wrong with a woman—her suffering, her misbehavior, her madness—was attributable to her uterus. Specifically, her uterus was “wandering”—literally roaming around her body, looking for unborn babies. All sorts of symptoms were blamed on the uterus and labeled “hysteria.”

I found a paper in the Journal of the American Medical Association from the 1950s where the researchers were trying to figure out what hysteria actually was, since it was so vaguely defined. So they surveyed institutionalized patients who had been diagnosed with it. Not surprisingly, almost all of them were women. And their symptoms—things like strange bleeding, unexplained pain, no interest in sex—just sounded like endometriosis to me.

Endometriosis comes up a lot in your book. What is it, and why is it so problematic?   

Endometriosis is a disease in which cells that are similar to the ones in the uterus start to grow elsewhere in the body, causing tumors and debilitating pain. The tumors can wrap around your ovaries or your intestines and even go to your lungs. And because these cells are very similar to uterine tissue, the pain tends to be worse during your period. But the tumors often don’t show up on an X-ray or ultrasound—you can only see them by doing a hysteroscopy, essentially putting a microscope inside your body during surgery. 

Endometriosis affects at least 10 percent of people with uteruses. But even today, a lot of endometriosis patients end up being treated as if they’re crazy. Doctors are like: “Well, nothing’s showing up on your ultrasound. I think maybe you’re just really sensitive to your period.” So on average, people go seven to 10 years without being diagnosed. But if you are trying to get pregnant and experiencing infertility issues, that time shrinks. Suddenly, doctors are investigating what’s wrong with your body, they do a hysteroscopy, and then—endometriosis! 

In fact, until surprisingly recently, endometriosis used to be called the “career woman’s disease.” You got it because you had a career when you should be having babies. So that’s another parallel with hysteria and the “wandering womb.” Both of these diseases were thought to be the consequence of failing to be a good woman, and the only cure was to finally accept that role and become a mom. Even some of the people in my book were told, “Just get pregnant; it’ll fix your issues.” There’s no evidence of that. 

The history of gynecology includes a lot of male doctors experimenting on female patients, including enslaved women. Now, scientists do hardly any research on gynecological problems. And as you point out, most of the research that is done occurs in the context of “reproductive health.” The focus is on creating healthy pregnancies and not on helping people have healthy, thriving bodies beyond the ability to produce babies. 

First of all, only 10 percent of the research budget at the NIH goes to women’s health. One review found five times more studies on erectile dysfunction than on premenstrual syndrome, even though 90 percent of people with uteruses experience PMS and a much smaller proportion of people with penises will get ED. 

And then, yes, our research and health care priorities focus on childbearing—sometimes pregnancy, sometimes the possibility that people could become pregnant, a state of “pre-pregnancy” that the sociologist Miranda Waggoner calls “the zero trimester.” At the NIH, much of the work on women’s reproductive health falls under a division called the National Institute of Child Health and Human Development. When I first heard that, I thought it was a mistake, but it’s true. And about 80 percent of the NIH funding for women’s health goes toward studying pregnancy and childbirth. So when you do the math, only about 2 percent of the total NIH budget goes toward gynecological conditions that exist outside pregnancy. 

And because of our obsession with women’s bodies as pre-pregnant, because of the lack of research, it becomes specialized knowledge to even be able to recognize gynecological conditions like endometriosis or fibroids [benign uterine tumors] that are extremely common. Every doctor should be trained to do so; at the minimum, every gynecologist. But no.

Put simply, women’s debilitating pain is dismissed and ignored, researchers don’t study it, and doctors aren’t trained to treat it. Eventually, many women say, “I’m tired of this, give me a hysterectomy—now!” But then, if they’re white, they are often told, “No, you might still want to get pregnant someday.” And if they are a woman of color, they are more likely to be told, “Okay.” You argue that this reflects a eugenics mindset that remains deeply ingrained in modern gynecological care.

When we talk about eugenics, we usually talk about who is prevented from having babies—for example, the horrible history of forced sterilization practices in the US in the 20th century and in many ways continuing today. We don’t talk as much about so-called “positive” eugenics, which is the promotion of births among groups that are deemed desirable. Studying hysterectomy across racial groups really has highlighted the two arms of eugenics for me.

When I talked to the many Black, Latina, and other women of color in my book who were pushed toward hysterectomy, they understood that their reproductive freedom was being infringed upon. This is a textbook case of eugenics. But then, when I asked white women, “How do you think your race impacted your [gynecological] care?,” they would say, “Well, I’m sure it made it a lot better.” We assume the lack of racism for white women will improve their health care. But it also made doctors want to protect their fertility at rates that other women didn’t experience. They were paternalistically barred from exercising their bodily autonomy because doctors viewed them as “more worthy” of being mothers. Doctors wanted to prevent them from opting into infertility—that invisible part of eugenics. 

I mean, it’s reflected in why we have abortion bans. It’s part of the rise of the pronatalist movement. Now they want rich, educated white women to have more babies. These are the two sides of the eugenics coin, and they reinforce each other.

Meanwhile, another of your findings blew me away: how relatively easy it is for trans men to get their uterus taken out. Keeping in mind, of course, that we’re talking about the subset of doctors who are willing to do any kind of trans care.

It’s the same organ, but when the gender of the person is different, so is their treatment by the system. In my conversations with trans men and nonbinary people, the more masculine the person was, the less doctors wanted to protect their fertility. It’s a double-edged sword. Trans people face enormous transphobia in health care. But the ones I interviewed were also given more freedom to choose hysterectomy. In my research, even teenagers were told: “Let’s just take it out. Why not? You’re not going to use it.” And then a 39-year-old white woman who’s been in chronic pain for decades is told, “Let’s wait, let’s pause.”

But at the same time, we don’t know if they actually need a hysterectomy. Because of gaps in research, a lot of trans men are told that they should have one, just to be safe, to prevent the eventual possibility of uterine or ovarian cancer, even if they don’t necessarily want one. I strongly believe that trans children and trans adults should be able to make decisions about their bodies, including hysterectomy. But at the same time, patients should be making these decisions with all of the information and with the ability to access fertility preservation if they want it, like gamete retrieval and egg freezing. There should be fully informed consent. 

People have always joked that if men needed to have abortions, then abortions would be free and universally available. How much do you think the medical attitudes toward trans patients has to do with their trans-ness versus their maleness?

This didn’t make it into the book, but I wrote an article on how, once trans men become seen as masculine, doctors treat them differently, including around pain. One guy told me that he had horrible pain when viewed as a woman, and no one took him seriously. Specifically, he had a ruptured ovarian cyst that doctors were ignoring. And then he fractured his pinkie as a man, and doctors were like, “Let’s fix this, let’s get you pain meds.” That was just such a stark difference for him. And I heard this over and over from trans men: Despite all the transphobia in medical spaces, they also experience male privilege. When they’re viewed as men in a clinical encounter, their pain suddenly matters. 

You did most of your interviews on hysterectomy early in the pandemic, which seems like a lifetime ago. So much has changed in the five years since then—the end of Roe v. Wade, the escalation in anti-trans sentiment, the Trump administration attacks on research funding and public health. How do you see the current political and social environment affecting what happens around hysterectomies?

One of the obvious impacts involves abortion bans and the denial of emergency care for miscarriages and other life-threatening pregnancy complications. We’re seeing these terrible cases of people bleeding out in the parking lot, waiting to get sicker so that they’re able to get emergency abortion care. And what happens to some of those people is that they end up having emergency hysterectomies to save their lives. We will see more of that.  

We don’t have data on this yet, but anecdotally, we’re hearing more conversations about people wanting to be sterilized as a protective measure—sometimes by having their fallopian tubes tied, sometimes by having a full hysterectomy—because they don’t want to be pregnant at all in this climate, or they’re worried about being able to access gender-affirming care in the future. 

And how about you? What are you working on next?

I’ve hit the pause on hysterectomies, as important as I think the topic is. My next project is on how men benefit from abortion. Soon, I’ll be interviewing men who’ve been involved in an unplanned pregnancy about how they think about abortion, how it improved their lives. The thinking is, our culture clearly doesn’t care how abortion has improved the lives of women, but maybe people will care about the positive impacts for cis men.

So kind of like what we were saying before: If men had abortions…

The only time that the New York Times has ever paid attention to me and my pitches was when I pitched this idea. Every other time, it’s been radio silence, but then I’m like, “abortion and men,” and they’re like, “Yes.”