Not tonight

Joanna Kempner, Not Tonight: Migraine and the Politics of Gender and Health.Chicago: University of Chicago Press, 2014. Paperback, 232 pp., $27.50. ISBN: 9780226179155.

Not Tonight: Migraine and the Politics of Gender and Health is a multisited ethnography byJoanna Kempner that examines how migraine headaches – despite its biomedicalization and the current understanding of the phenomenon as a neurological disease – still deals with a ‘legitimacy deficit’ (p. 10). As a disease that disproportionately affects women, doctors and society at large question the pain involved and associate it with ‘feminine’ characteristics like neuroticism and hysteria, which leads to migraines often being trivialized. The book is written in the field of medical anthropology and sociology, focuses mostly on the United States, and is a compelling contribution to understanding the role notions of gender play in medicine.

Kempner starts by clarifying the continuous questioning throughout history of the legitimacy of migraines, noting it is a disease where pain is not observable and ‘interrupts mind/body dualisms in ways that can make it hard for others to understand’ (p. 3). She gives an impressive overview of medical diagnosing and framing of migraines, which convincingly shows the impact of medical structures on how the phenomenon of migraines has been seen throughout time, reinforcing social structures along gendered cultural norms. In the eighteenth and nineteenth centuries, migraines were seen as a disease associated with a ‘nervous temperament’ and symptoms of hysteria, both long associated with women. In the 1940s came psychological explanations of the ‘migraine personality’ (seen as perfectionist and morally good for men, and as ‘unwilling to accept the female role’ (p. 40) for women). More recently, there has been a shift towards biomedical explanations of migraines as a neurovascular disease of a ‘broken brain’ (p. 48). This medical framework has removed responsibility and agency from the patient, as migraines are seen today less as something one could do much about and more as something medical located in the brain. This has helped the disease become increasingly accepted as ‘real’. Biomedical discourse has thus changed the dominant cultural perceptions of migraine headaches, and prevailing explanations have shifted from the mind to the brain.

However, Kempner argues that ‘biomedicalization has not been enough to legitimize migraine, since – even as a “brain disease” – migraine remains plagued by gendered images, metaphors, and stereotypes’ (p. 23). She asserts that because the brain is closely associated with personhood, the change from ‘migraine personality’ to ‘migraine brain’ did little to change the dominant gendered discourse of migraine, as the disease is still associated with personality characteristics often seen as ‘feminine’. These gendered associations are also reinforced by pharmaceutical advertisements targeting migraine sufferers. These consistently portray migraine patients as middle-class white women unfit to fulfil their task as mothers due to their pain, offering a pill as a quick solution for what is in fact a chronic condition. Pharmaceutical industries heavily rely on gender stereotypes to sell their drugs, which in turn can affect public understandings of migraine and how people with migraines are treated. In this way, Kempner shows that the power of sociocultural structures of gender and personhood is larger than the power of medicalization, as gendered notions are reinforced in medical and pharmaceutical perceptions of migraine.

Kempner not only pays attention to the structural forces that are (somewhat) changing the perception of migraines but also looks at the agency of activist communities of people who get migraines. On the one hand, these people actively try to influence public opinion on migraines, strive for legitimization, and call for their pain to be recognized as a ‘real’ neurological disease. On the other hand, by using this biomedical framework, these activists also remove agency from the person, as they construct migraine as a brain disease that they have no control over. According to Kempner, these activists often describe migraines as characteristic of a certain kind of person, incidentally attributing ‘unflattering feminized characteristics to their brains’ (p. 102) and in turn reinforcing gendered stereotypes of migraines. Activists thus use their agency to achieve legitimacy, but thereby also give agency to migraine itself. Kempner therefore goes against the Foucauldian idea of medicalization as an almighty structure that reduces people’s agency to influence health outcomes. She shows that agency is in fact involved in the navigation of medicalization processes, even as it may reinforce existing structures.

Unfortunately, Kempner sometimes remains vague and uncritical about what makes elements of migraine ‘gendered’. For example, how exactly ‘migraineurs’ (a term people with migraines use to refer to themselves in the United States) reinforce gendered stereotypes by framing themselves as a ‘particular “kind” of person’ (p. 102) remains unclear. She did not ask these people what characteristics this ‘“kind” of person’ has, nor does she analyse how these people link this to gender or relate it to other literature on gender stereotypes. Moreover, with regards to advertisements, she questions why situations that appeal to men, such as corporate events or football games, are not depicted in migraine promotions. She does not question or explain what makes these situations ‘masculine’ and other situations (such as weddings) ‘feminine’, and implies that adding these supposedly ‘masculine’ situations to existing ‘feminine’ situations is a way to get rid of gendered thinking. I wish she had explained and problematized what gendered thinking is, and that she had paid more attention to how people with migraines speak about their experiences with it, instead of reinforcing clichés of femininity and masculinity herself.

In addition, I would have liked to see more analysis around the gendered, raced, and classed aspects of migraine, exploring for instance how these factors affect medical help-seeking behaviour and possible diagnosis. Kempner alludes to the possible impact of these factors in her conclusion, but it would have been interesting to read more about how gender, race, and class structures actually influence the agency people have in navigating their symptoms, thereby incorporating more social context. She critiques activist narratives for lacking social context, but such context is in fact partly missing from her own book as well.

All in all, this is an important book, as it makes clear that medicalization is not an absolute structural power. Instead the work shows that, despite people having agency and despite medicalization efforts from the medical industry and migraine sufferers, sociocultural ideas of gender and personhood still largely structure the ‘legitimacy deficit’ of migraines as a disease. Kempner’s remarkable research can therefore be seen as a way of introducing possible solutions to the legitimacy issue of migraines: embracing medicalization is not enough, and agents should rather challenge these gendered structures of pain.

About the author

Maria Siermann is a graduate student in the research master’s programme in social sciences at the University of Amsterdam. Her main interests are medical anthropology and gender and sexuality studies. She is interested in the anthropology of reproduction, particularly as related to assisted reproductive technologies with third-party involvement.