Misogyny in Chinese Medicine

Originally published on March 5, 2019

As a scholar who has closely studied and translated the works of Sun Simiao and early Chinese gynecological literature for several decades, the time has finally come for me to clear up mistaken views about this important figure and his work that I encountered some years ago. Given Sun Simiao’s significant contributions to Chinese medicine and to gynecology, he deserves to have someone speak up for him. Here is the link to a video in which these mistakes were expressed:

“Sun Si-miao's Saying About 10 Men As Opposed to One Woman” (https://youtu.be/UOi-Z6LUg0o)

I first watched this video when I had recently finished my first book, a translation of Sun Simiao’s gynecological writings. This book was the result of my dissertation research for a PhD in Chinese Studies and Medical Anthropology, took many years to complete, and ended up being almost 800 pages long. Seeing this video, the errors were immediately obvious to me. I heard indirectly from Mr. Flaws that he did not feel that having a conversation with me would be valuable as I am not a clinical practitioner of Chinese medicine. Too bad. I am very aware of the fact that historical accuracy does not depend on being a clinician, and that being a clinician does not make one a specialist in history.

That opportunity missed, I would still like to clear things up so that well-meaning students and practitioners can avoid repeating attitudes, information, and diagnostic and therapeutic approaches that continue to be colored by this mistaken perspective. And I think the time has come for a fundamental overhaul in the field, to truly express the spirit of the classical Chinese writings on gynecology. If we are really going to develop, promote, and practice Chinese gynecology as part of a sophisticated clinical practice, let us do it right! Let us truly look at what the classical texts on the subject have to offer before we jump onto the integrative medicine bandwagon or limit ourselves to a paint-by-numbers approach to matching a limited number of formulas to a limited number of patterns and then proclaim that it is ever so simple. Yes, that version of Chinese gynecology may be easy, both to teach and to learn and even to test and justify to insurance companies, and it may be a great introduction for the beginning practitioner, and it may even be better than what biomedicine has to offer in many instances. But please, let us not ignore the treasures that await those who are willing to dig deeper!

This blog is written in defense of Sun Simiao, of Tang dynasty China, and of the incredible treasure trove of classical Chinese gynecology. To begin with, I disagree with Bob Flaws’ conclusion that Chinese gynecology is “really very easy" and want to fill out Sun Simiao’s reasoning to explain why. Here is the famous line that is the supposed source of the video linked above in its original source, located quite intentionally and powerfully in the very beginning of the introduction to Sun Simiao’s three volumes (!) on gynecology, which make up about one tenth and the first and biggest single section in his famous 30-volume medical encyclopedia called the Bèi Jí Qiān Jīn Yào Fāng 備急千金要方 (“Essential Formulas to Prepare for Emergency Worth a Thousand in Gold”):

The reason for the existence of separate methods for women is that they are different because of pregnancy, childbirth, and flooding damage (i.e., heavy vaginal bleeding). Therefore, women’s diseases, in comparison with men’s, are ten times more difficult to cure….

Therefore, specialists in nurturing life should particularly instruct their sons and daughters to study these three volumes of methods for women until they comprehend them thoroughly. Then what would there be to worry or fear even in the face of a harvest of unexpected surprises? Now, the Four Virtues are the pivot around which daughters set up their life. Bearing children is the adult role in women’s destiny and fate. If you do not understand this clearly, how could you prevent premature and wrongful death? Neither, for this reason, can servants engaged in childrearing afford not to study them. Thus, they should routinely write out a copy and carry it on their person, clutched to their bosom, in order to guard against the unexpected.

夫婦人之別有方者，以其胎妊生產崩傷之異故也。是以婦人之病，比之男子 十倍難療。。。。

故養生之家，特須教子女學習此三卷婦人方，令其精曉，即於倉卒之秋，何憂畏也。夫四德者，女子立身之樞機。產育者，婦人性命之長務。若不通明於此，則何以免於夭枉者哉。故傅母之徒亦不可不學，常宜繕寫一本，懷挾隨身，以防不虞也。

Those of you who want to read the entire introductory essay can do so here. Anybody with a basic education in literary Chinese can confirm that the grammar of this statement, especially of the second sentence, is quite straightforward and easy to follow, with no wiggle room for alternate interpretations. I assume it is obvious that women’s diseases being ten times more difficult to cure than men’s is quite a different statement than Bob Flaws’ version:

“… the famous Tang dynasty doctor says that he would rather treat ten men than one woman, and would rather treat ten women than one baby.”

Regarding the second half of this statement, about treating ten women rather than one baby, that is pure fiction. And I do know this because I have also translated Sun Simiao’s writings on pediatrics in another multi-year project that ended up as a two-volume book set of almost 900 pages. Here is what Sun Simiao actually did say about pediatrics in his introduction to those two volumes, which follow the ones on gynecology:

故今斯方﹐先婦人、小兒﹐而後丈夫、耆老者﹐則是崇本之義也。然小兒氣勢微弱﹐醫士欲留心救療﹐立功瘥難。今之學者﹐多不存意﹐良由嬰兒在於襁褓之內﹐乳氣腥臊﹐醫者操行英雄﹐詎肯瞻視。

The present collection of treatments is arranged by placing the treatments for women and children first, and those for men and the elderly afterwards. The significance of this structure is that it venerates the root.

Nevertheless, the force of qì is still feeble in small children, and medical gentlemen need to take great care to rescue and cure them and meritoriously offer their services to help them recover from serious conditions. The majority of present-day scholars fail to hold on to this intention. For this reason, when infants in swaddling clothes are concerned, surrounded by the foul stench of breast milk, how dare we look down on those doctors who carry out heroic acts?

Hopefully, the statements above in combination with the sheer size and sophistication (4 or 5 out of 30 volumes total, depending on the edition) and central position of the information on women and children at the very beginning of his encyclopedia, right after the introduction and in front of the general section, can convince you that Sun Simiao cared deeply about the medical treatment of women and children. As a matter of fact, his influence was so strong in this regard that we can follow the view of countless generations of Chinese doctors and medical authors that Sun Simiao stimulated the formation and subsequent explosion of publications on gynecology and pediatrics as two of the most popular and treasured medical specialties in the following Sòng dynasty, far earlier than anything comparable in the West.

That settled, let us return to the video above and address some of the arguments raised there. As he states himself, Bob Flaws explains two things in this video. First he gives the reason why he needs to talk about this line by Sun Simiao:

“This saying is an often-quoted saying, but it shows how Chinese medicine has evolved and that although it is important to be familiar with the premodern literature, the idea of basing one’s practice entirely on the premodern literature would, in my experience, be a huge mistake!”

Times have certainly changed since the publication of the video in 2010. We only need to recall the current popularity of “classical Chinese medicine” in titles for seminars and academic programs in the West. The resurgence of a classics-based approach to diagnosis and treatment is also happening in China, expressed most vividly perhaps by the bestseller status of Dr. Liu Lihong’s Sīkǎo Zhōngyī 思考中醫 (“Investigating Chinese Medicine” and forthcoming in an English translation as “Classical Chinese Medicine”). So fortunately, there is no longer a need for me to defend the value of studying the classics. I will return to this point in my conclusion to this blog, however, because it is relevant for the state of Chinese gynecology in the West.

The second question Bob Flaws intends to address in his video is the reason why Sun Simiao would have said that he would rather treat ten men than one woman. Here is a transcription from his video:

“This is because women have this whole other side to their life: their menstrual cycle. And therefore they have symptoms and issues that men don’t have. They have their menses and all of the things that can go wrong with menstruation. They have all of the conditions that can go wrong with being pregnant,… postpartum,… menopausal complaints. So Sun thought that all of this made for way too much complexity and men, because they don’t have any of this, are preferable to treat.”

Besides correcting the mistranslation and resulting misrepresentation of Sun Simiao’s attitude toward women, I feel the need to address the sentiments expressed here and the misogyny that I see in them. From my perspective, the view of menstruation and the procreative potential of women as negative and weakening is not a traditional Chinese sentiment at all, but a direct reflection of the typical modern Western attitude that is still far too prevalent in popular, biomedical, and unfortunately also Chinese medical literature. And that is why I am writing this blog! The statement above says nothing about Sun Simiao’s views or about classical Chinese medicine, but it says everything about Bob Flaws’ and the dominant Western biomedical and cultural view of women, menstruation, and their creative and fertile potential.

Those of you who have heard me lecture on the Chinese view of menstruation and female blood know my passionate conviction that as friends and practitioners of Chinese medicine, we can contribute so much to a critical and innovative conversation around a positive view of the female body. Whether with friends, patients, family, students, or neighbors, at schools, in clinic, around the family dinner table, on playgrounds and hair salons and track meets, or even with random strangers on the bus, or in professional settings, at biomedical conferences, in public health offices, and yes, at Chinese medicine conferences, the possibilities are endless. Anybody who has grown up or raised a girl in our current Euro-American culture has experienced the toxicity around norms of female beauty, vulnerability and weakness, and emotionality. And just to repeat an insight that seems quite obvious these days, misogyny, like racism, xenophobia, homophobia, or any other form of discrimination and hatred, ultimately hurts not just girls and women but also boys and men, not just the victim but also the perpetrator. In far too many areas of our contemporary women’s healthcare, women are routinely deprived of the most knowledgeable and appropriate healthcare and medical advice because of cultural blinders and misogynistic values that encourage both practitioners and patients to ignore the consequences on women’s long-term health for the sake of potential fetuses and children, to name just one example. This is a preventable tragedy with costs for all of society down the road. Chinese medicine has the potential to change that!

Nothing could be further from the truth than two of Bob Flaws’ statements from his video: first, that traditional Chinese doctors greatly disliked treating women, and second, that “gynecology is a relatively easy specialty to work in and shows how Chinese medicine has developed.” These mistaken beliefs strike me as the unfortunate result of Orientalism (for more on this term and the way I use it, here’s an old blog I wrote), which is on full display towards the end of the video when Bob Flaws proclaims:

Now don’t get me wrong. I LOVE Sun Simiao and on some days you might even catch me thinking that I am an incarnation of Sun Simiao, that I lived as Sun Simiao in a previous life. I have visited his hermitage, burned incense, and done prostrations at his temple, but on this issue he wasn’t working with the full information we have today.

Obviously Sun Simiao was working with a different set of information because he lived in early medieval China. The supposed misogyny of traditional Chinese culture is a common sentiment in Western popular culture, repeated ad nauseam by some leading figures in the profession of Chinese medicine to this day, usually in order to support their claims of the “evolution” of medicine and the superiority of their own teachings as the culmination and integration of traditional Chinese knowledge with contemporary Western science, the fruit of the enlightened advanced society we live in today. How many of these enlightened teachers have actually bothered to read and study the gynecological classics? Or have even thoroughly studied traditional Chinese culture, politics, society, and literature, to create an informed understanding of the position of women, and of the attitudes of male doctors and healers to the female body and to menstruation? Rather than denigrating Chinese traditional gynecology as backward in a foregone conclusion, and basing that evaluation on the purported misogyny of traditional Chinese culture, why don’t we let the sources speak for themselves?

I have been working full-time on a translation of a gynecological text called “A Hundred Questions of Gynecology” from 1220 CE for the past year, finally wrapping up many years of translation work with this text. Given the size of the text and the number of formulas, it will result in four volumes of more than a thousand pages total. Over and over in this text, the author Qí Zhòngfǔ affirms the importance of the menstrual period as the foundation of women’s health. In a healthy woman, it is abundant, pain-free, and cyclical, in attunement with the waxing and waning of the moon, reflecting a perfect balance between Qi and blood, heat and cold, Yin and Yang, the microcosm of the human body and the macrocosm. In a healthy female body, the monthly release of blood stops only when descending to nurture a fetus in the womb during pregnancy or when ascending to become breastmilk that feeds the baby.

A recent inquiry on a Facebook page called “Scholars of Chinese Medicine” shows the contrast in attitude between traditional texts and some contemporary practitioners: A female practitioner asks specifically for classical resources to better advise a patient in her early 40s who is still breastfeeding two older children, aged 2 and 6, and who just found out that she is pregnant again and “presented with a typical blood deficient constitution.” This practitioner states in her question that the patient is clearly not healthy but is rejecting this licensed practitioner’s medical advice to stop breastfeeding her older children. Here is a word of warning from the thirteenth-century text I have been working on that directly speaks to this issue:

Men have Jīng as their root, and women have blood as their source... And if women are not attuned, the old blood will fail to exit and the new blood will flow incorrectly, whether soaking into the bones or transforming into swellings. They may also fail to bear children even though they have intercourse. If they have excessive intercourse with men, the result will be dribbling desiccation, which will make them vacuous. If they give birth to and breastfeed multitudes of children, the result will be blood desiccation, which will kill them. By observing [male and female patients’] Jīng and blood, you have already figured out most [of what there is to know about that particular patient].

And this is what a contemporary practitioner posts in response to the sincere question on Facebook:

The sum total of the answer in my office (unless the patient was having severe health issues) would have been...

"OK."

On to the next...

Rather than menstruation being a negative, weakening aspect of women’s health, a deviation from the physiological norm of the male body as it was (and all too frequently still is) seen in Western medicine and popular culture, here is how the Hundred Questions of Gynecology describes menstruation, incorporating a well-known quote from the Yellow Emperor’s Inner Classic:

When girls reach their fourteenth year, the tiānguǐ arrives, the kidney Qì peaks, the Chōngmài streams forth, and the Rènmài flows through. The blood gradually builds up and descends in response to its proper timing, normally appearing once every three ten-day cycles. Missing this timespan indicates disease. Therefore we call it jīnghòu (“menstrual period”).

Specifically, the word jīng here means constancy, and the word hòu refers to the fact that it signifies the periodicity of Yīn and Yáng in the entire body. Healthy constant Qì awaits its period and then arrives, just like the periodicity of the tides, which resonates with their proper timing.

Because the genuine Qì of Heaven assists in streaming and flowing through, it runs once a month. In a state of harmonious balance, it does not lose this timing. It is for this reason that we call it jīnghòu (“menstrual period”), or alternately “moon water.”

Bob Flaws is correct in asserting that traditional gynecology considers the female body to be complex and in need of separate prescriptions, which, I may add, is the basic premise of any gynecology, Western or Eastern. But the result of this view in China was not to turn away from treating women and to ignore these challenges, but the exact opposite: An increased focus on women’s health that inspired the creation of a highly developed literature with sophisticated theoretical, diagnostic, and therapeutic discussions that are unmatched in Western medical history and unfortunately remain mostly untranslated. This is partly because of their sheer volume and partly because they require advanced medical skills to appreciate. It is my hope that my forthcoming book will start to address this omission and stimulate and support a resurgence of traditional Chinese gynecology. To conclude this blog, I leave you with a line from Sun Simiao’s famous statement of medical ethics:

In all cases, when you treat disease as an eminent physician, you must quiet your shén and fix your intention, you must be free of wants and desires, and you must first develop a heart full of great compassion and empathy. You must pledge your desire to rescue all sentient beings indiscriminately from their suffering.

凡大醫治病，必當安神定志，無欲無求，先發大慈惻隱之心。誓願普救含靈之苦。