The following is an excerpt from The Geography of Madness: Penis Thieves, Voodoo Death, and the Search for the Meaning of the World’s Strangest Syndromes.
One day, while I was researching my recent book about cultural syndromes across the world, I was talking to my wife when she said, “Well, I got my period. I guess that explains my mood.”
I shrugged and asked: “Or does it?”
This was followed by an icy silence: The only thing worse than diagnosing PMS is suggesting it might be a cultural syndrome.
“Never mind,” I said. “We’ll go with, ‘It does.’ ”
I couldn’t blame her. After all, most people assume that when you say a condition is caused (even partly) by your culture, it’s the same as saying it’s not real. Yet that’s not what I was saying at all.
For the past few years, I had been digging into the phenomenon of so-called culture-bound syndromes, which more recently have come to be known as “cultural syndromes,” or sometimes, “cultural idioms of distress.” It was a path I started down when I traveled to Nigeria to investigate magical penis theft, in which a person believes his (or sometimes her) genitals to have been stolen via magic. This is known in the medical literatures as koro, or “genital retraction syndrome,” and versions of it have been recorded, among other places, in China, Thailand, and India.
Trying to understand koro, in turn, lead me into a labyrinth of other syndromes, many of which seem unreal to Westerners, though not to those experiencing them. People have “wind attacks” in Cambodia, where the flow of wind through the body reverses or is blocked, causing dizziness, shortness of breath, numbness, and fever. In China some people suffer from “frigophobia,” or the “morbid fear of cold … and the need to wear excessive clothing.” In parts of India you can contract “gilhari syndrome” in which patients arrive at the hospital with swelling on the back of their necks, complaining that a gilhari (a kind of lizard) crawled under their skin and terrified that they will die if the creature reaches their neck.
Eventually this path led me back to my own culture, and to our own syndromes that don’t occur in other cultures. Premenstrual syndrome was near the top of this list. And much of what I read suggested that PMS was not caused by a tide of hormones wreaking havoc on a woman’s psyche, as I’d always believed. In 1987, Thomas Johnson published an article in the journal Culture, Medicine, and Psychiatry arguing that premenstrual syndrome was a “culture-specific disorder,” noting that:
Even though there are those who strive to find congruence between bizarre symptom complexes [i.e. the culture-bound syndromes] in other cultures and Western biomedical disease entities, there has been an implication that such syndromes are ‘not real.’ Yet we unquestioningly treat our own problematic syndromes, such as PMS, as ‘real,’ striving constantly to find physiological correlates of symptoms.
One the one hand, we assume the causes of PMS are purely biological, despite not having found the mechanisms. And on the other we assume the causes of “cultural syndromes” are entirely mental, despite the fact that one’s beliefs and expectations about a condition can generate many of the same physical symptoms.
Others have elaborated on PMS’s problematic nature as an evidence-based biological condition. Researchers Lisa Cosgrove and Bethany Riddle found that women who endorsed traditional gender roles experienced more menstrual distress. “One of the most striking results,” they wrote, “was that PMS discourse has gained such cultural currency that women often expect to have PMS.” Another study found that patients “firmly believed that PMS is biologically based, and they rejected situational attributions for their distress.” In another experiment, women who were misled to believe they were premenstrual experienced more symptoms of PMS than those who were actually premenstrual but who were misled to believe they were not.
The subtext of these critiques is that PMS is “socially constructed,” meaning it’s an imaginary condition foisted on women by society, which is another way of saying PMS is “not real.” Yet just because something is a social construction does not mean we don’t experience it—it simply means that our “real” physiological symptoms can have roots in our mind as well as our body.
“We need richer tools with which to think than reality or social construction,” writes the philosopher Ian Hacking in his book, Mad Travelers: Reflections on the Reality of Transient Mental Illnesses. And one of those tools is recognition that our beliefs about PMS can become part of its cause in a kind of feedback loop (or “bioloop,” as Hacking calls it) feeding off, exacerbating, even initiating the physiological sides of the syndrome.
In other cultures, for example, menstruation has a more positive meaning and is described in positive terms. It’s not thought of as a debilitating condition that needs medical treatment. On the island of Wogeo, Papua New Guinea, menstruation is traditionally seen as so powerful and cleansing that even men are expected to menstruate. A man does this by walking into the ocean naked, inducing an erection, pushing the foreskin back, then slicing at the glans on either side with the claw of a crab. When the bleeding stops and the ocean water around the man is clear, he returns to shore, wraps his penis in medicinal leaves, and is considered cleansed. The same word is used for male and female menstruation.
According to Joan Chrisler and Paula Caplan in their overview of the history of PMS:
World Health Organization surveys indicate that menstrual cycle-related complaints (except cramps) are most likely to be reported by women who live in Western Europe, Australia, and North America. Data collected from women in Hong Kong and mainland China indicate that the most commonly reported premenstrual symptoms are fatigue, water retention, pain, and increased sensitivity to cold. American women do not report cold sensitivity and Chinese women rarely report negative affect.
In our own culture, the underlying idea behind PMS can be traced back 2,500 years to Hippocrates, the father of Western medicine, who believed that certain moods and physical disorders in women were caused by “hysteria” or the “wandering uterus,” meaning the organ literally drifted around the body, pulled by the moon, lodging in wrong places, blocking passages, causing pressures. Cures included marriage and intercourse, which supposedly worked. This notion endured for eons. But by the early 1900s, medical theories around “hysteria” were beginning to crumble. In 1908, at the meeting of the Societé de Neurologie in Paris, Joseph Babinski argued that hysteria was “the consequence of suggestion, sometimes directly from a doctor, and more often culturally absorbed.” Today, hysteria is never diagnosed, except by unwise husbands.
In 1931, however, an American gynecologist named Robert Frank revived the idea in a new guise. He published an article titled, “The Hormonal Causes of Premenstrual Tension.” Frank described symptoms that occurred in the week before menstruation: irritability, bloating, fatigue, depression, attacks of pain, nervousness, restlessness, and the impulse for “foolish and ill considered actions,” due to ovarian activity. Again, the cause was located in the uterus. Then in 1953, British physician Katharina Dalton elaborated on this, arguing the condition came from fluctuation of estrogen and progesterone. She called it premenstrual syndrome and soon symptoms grew to include: anxiety, sadness, moodiness, constipation or diarrhea, feeling out of control, insomnia, food cravings, increased sex drive, anger, arguments with family or friends, poor judgment, lack of physical coordination, decreased efficiency, increased personal strength or power, feelings of connection to nature or to other women, seizures, convulsions, asthma attacks, flare-ups in asthma, allergies, sinusitis, anxiety disorders, irritable bowel syndrome, migraines, and multiple sclerosis. If any of these symptoms were to occur in the second half of the menstrual cycle, one could be diagnosed with PMS. Estimates of the number of women afflicted ranged from 5 percent to 95 percent.
The turning point for the medicalization of PMS came in the 1980s, when three women in the U.K. were tried for arson, assault, and manslaughter, respectively. All three claimed they had diminished responsibility due to PMS, and got reduced sentences on the condition that they underwent hormone treatment. After that, according to one report, American women flooded doctors with requests for help with their PMS:
Popular groups like PMS Action were founded to promote recognition and treatment of PMS by medical professionals. Private PMS clinics began to appear in the U.S., modeled after those in the UK, and progesterone therapy was enthusiastically adopted, much to the chagrin of many gynecologists who viewed its use as ‘unscientific’ and ‘commercial’, not to mention unlicensed.
Based on all this, the 1987 version of the DSM-III included a new category: late luteal phase disorder (luteal refers to progesterone). It was proposed as a topic for further research, but despite the absence of such research, it was included in the 1994 edition of the DSM-IV under the name premenstrual dysphoric disorder, or PMDD. In 2000, Eli Lilly introduced a drug for PMDD called Sarafem, which was the same drug as Prozac (fluoxetine) but colored pink and packaged differently. Some critics noted that side effects of fluoxetine (insomnia, anxiety, nervousness, somnolence) are also symptoms of PMDD. Nonetheless in the 2013 DSM-5 it was finally given its own category as a full-fledged mental illness, even though are no biomarkers to measure it and no conclusive correlation has been found between estrogen or progesterone levels and these conditions.
As noted above, neither PMS nor PMDD occur in most cultures quite as they do in ours, if they occur at all. Yet the DSM-5 states, paradoxically, that “premenstrual dysphoric disorder is not a culture-bound syndrome and has been observed in individuals in the United States, Europe, India, and Asia. It is unclear as to whether rates differ by race. Nevertheless, frequency, intensity, and expressivity of symptoms and help-seeking patterns may be significantly influenced by cultural factors.”
The fact that it has been observed in these places and not others, and is “significantly influenced” by cultural factors, doesn’t go very far toward proving that it is not a culture-bound syndrome. As one study noted, “the more time that women of ethnic minorities spend living in the United States, the more likely they are to report PMDD. Thus, if we are to accept PMDD as a reified medical disorder, then we must also accept exposure to U.S. culture as a risk factor for contracting PMDD.”
In other words, if it is a syndrome, it’s almost certainly a cultural one.