Consented, p.12
Consented, page 12
Plato taught that the uterus was a beastly organ, “subject to the desire to make children,” a restless creature that wandered through the body, causing sickness if deprived of pregnancy.22 This idea of a troublemaking, nomadic, and feral uterus, which frames the female body as structurally hysterical (hysteria is derived from hystera, the Greek word for uterus), can be traced back to the oldest medical text in human history, the Ebers Papyrus.23 The treatment? Pregnancy24—what else! Three and a half millennia later, this belief still lurks in women’s healthcare. People suffering from endometriosis are still told to “just get pregnant” as a treatment or even a cure,25 even though pregnancy offers nothing but an illusion of improvement by temporarily abating some symptoms and a rocky road ahead, with a higher risk pregnancy.26
Childlessness and childfreeness, therefore, have always been regarded as diseases to be cured by childbearing. Following this logic, a uterus and the person attached to it are only as valuable as their ability to produce children. Medical statistics prove as much. In the US, only one in thirty-six women younger than forty-five has had a hysterectomy. But after forty-five, the age when women are typically deemed “too old” to have a baby, that number skyrockets. By age seventy-five, the tentacles of hysterectomy have reached every other woman.27
I suppose my friend and American politicians weren’t telling me what to do with my body. They were just encouraging me to live a full, healthy life before it was too late. How sweet.
The three tearful women in my exam room were living proof of this uterine determinism: Sydney’s uterus, even in the process of miscarriage, was deemed more valuable than her life. My refusal to be a mother rendered me wasteful of my uterus, nullifying all my other accomplishments. Julie was denied the right to live free of her suffering until she had birthed enough children and was deemed too old for more. But even then, her voice was drowned out by the echoes of a system that saw her body as property.
If my life’s purpose is to leave a legacy, it won’t be my womb. Let it be my words. And let them outlive the objectifying forces in medicine, and in the larger society.
No One Spared
To be fair, uterus-having and egg-producing bodies aren’t the only ones objectified according to their reproductive organs. Though to a lesser extent, sperm-producing bodies fall victim to the same approach. The Viagra myth is a glaring example.
Sildenafil (the generic name for Viagra) was originally developed by Pfizer in the late 1980s to treat chest pain caused by blood vessel blockages. But when clinical trials revealed that it caused penile erections as a common side effect, the company shifted direction. By the early 1990s, research on sildenafil focused solely on treating erectile dysfunction (ED), eventually leading to its rebranding as Viagra in 1998.28 The rest, as they say, is his-story.
Viagra’s marketing targeted not only older men with ED but also younger, healthy men pressured by impossible sexual expectations promoted by the drug company. Campaigns portrayed the drug as a magic bullet for instant sexual performance and saturated movies, TV, and advertisements.29 Their message was seductive: Viagra was no ordinary medicine that simply gave men erections; it was a lifestyle upgrade and the embodiment of sexual desire itself.30 And it worked. Within weeks of Viagra’s US launch, more than one million prescriptions were filled.31 In 2003, Viagra generated $1.87 billion in global sales, with $1.1 billion of that in the United States. Finally, in 2004, the FDA ordered Pfizer to pull the ads, deeming the drug’s effects overstated and its messaging dangerously misleading.32
This medicalization of ED pathologizes what could be a natural part of aging or personal relationships, reducing men to the mere mechanics of their bodies.33 Viagra marketing leaned heavily into the idea that sexual performance was synonymous with vitality, masculinity, and even worthiness. But what about the relationships, or the emotional aspects of intimacy? Let’s let the facts answer those questions.
About half of Viagra users don’t refill their prescriptions, with approximately 30% abandoning the drug after just one prescription, and 50% by year three.34 People discontinue using Viagra for various reasons, including cost, unmet expectations (often exaggerated—such as a near-instantaneous and guaranteed solution to their ED issues), and loss of interest in sex, among others.35 Additionally, prolonged sex without sufficient lubrication can cause physical injury.36 Viagra users and their partners often learn quickly that a firm erection doesn’t necessarily translate into better intimacy,37 of which penetrative sex is only a small part. On the contrary, the drug-induced, inorganic changes to sexual practice can be unwelcome in relationships, often sidelining the woman’s experience. All of this can lead to miscommunication, fear of infidelity, conflict, and even marital problems.38
In the end, perhaps it’s the soft parts of intimacy that matter most: the emotional connection, the vulnerability, and the shared, authentic experience.
Unfortunately, modern medicine’s fixation on the physical often neglects this fundamental truth. The lack of comprehensive sexual health education in medical schools—education that emphasizes both sexual function and emotional connection—leaves many physicians unequipped to have meaningful conversations with patients. This gap perpetuates the objectification of the human body, reducing it to a set of organs that need fixing. And this issue goes beyond men taking Viagra.
A few years ago, I asked the health educator in my clinic to talk to a patient about the importance of cultivating intimacy to improve sexual health. It quickly became clear how unprepared she was for such a conversation. While helping me with English-to-Spanish translation, she struggled to find the word for foreplay. The twenty-one-year-old college graduate’s face turned beet red. This made my fifty-something female patient, who was already surprised to hear her primary care doctor talk about sex, feel even more awkward. To make matters worse, having only discussed such topics a handful of times, I was no sexual health expert myself. The awkwardness was palpable, and the Google Translate–aided conversation, if we could even call it that, was far from helpful. We ended the discussion as soon as possible, and the health educator and I never spoke of it again.
This lack of preparedness isn’t surprising considering that fewer than half of North American medical schools offer clinical exposure in sexuality education.39 Most curricula focus on pregnancy prevention and sexually transmitted infections, while education on sexual function and dysfunction is either scant or absent.40 As a result, nearly half of primary care physicians don’t routinely ask about ED.41 Only 15% of patients reported having a specific discussion with their cardiologist about sexual difficulties before receiving a Viagra prescription.42 Even among urologists, who prescribe the majority of Viagra,43 most don’t consider themselves very competent in discussing the topic.44
The myth of Viagra and the lack of competency among its prescribers to discuss embodied experiences reflect how medicine views the human body. It hasn’t gone so far as to turn people into mere sexual objects (we have societal rape culture to do that part), but it has certainly reduced sex to a biomedical process and the body to a machine requiring maintenance.
Sitting in the most awkward exam room of the year, I rummaged through my brain for better ways to support my patient’s sexual health. The first thing that came to mind was: Who should I refer her to? Urology? Gynecology? Psychology? Then it dawned on me: It was me. I was her primary care doctor, specializing in family medicine. And what’s more central to family than healthy relationships? What better department to care for something so fundamentally human than primary care?
But the fact that I instinctively thought to refer her out speaks volumes. It reflects the greatest flaw in modern medicine: its compulsion to divide the human body into parts. Each part is assigned to a separate department, and each department is responsible for its slice of the body. Isolate the liver, the brain, the heart, and the kidneys, and we may deepen our scientific knowledge. But if we forget to put them back together, we hollow out the care of the whole human.
Welcome to My Department
Having spent the first twenty years of my life in Beijing, a city with nearly twenty-two million people, I craved greenery and space. So, when I moved to the US, I settled in smaller areas. The trade-off, however, was the absence of a Chinese community. Despite having done part of my training in Peking University and being certified in medical Mandarin, I seldom had Mandarin-speaking patients. That changed a few years ago when I met Wang Auntie.*
Wang Auntie was in her forties. When she saw my name and picture on the list of doctors taking new patients in the local newspaper, she made an appointment right away.
“您好, 您好, 王阿姨” (“Greetings, greetings, Wang Auntie!”) I greeted her, bowing as I extended my hands.
In Chinese culture, we call anyone from our parents’ generation “auntie” or “uncle” and those from our grandparents’ generation “grandpa” or “grandma,” even though we aren’t related. We do this because we honor our elders deeply, equating the sky and earth with our parents. As the Chinese idiom goes: 天地 (sky and earth) 父母 (father and mother). Our shared bloodline connects us all.
Wang Auntie took my hands. “Little Zha Doctor, my life is really bitter right now,” she said, her voice tinged with sadness and her hands cold as ice, “I think I need my thyroid removed. Could you refer me to endocrinology?”
Wang Auntie was tall but thin, her straight hair streaked with gray. After smiling briefly when we first met, her expression quickly returned to one that looked like she had just bitten into something acrid. More alarmingly, she skipped the usual greetings Chinese people often exchange when meeting each other overseas: Which province are you from? How do you write your last name? How long have you been in the US? Where are your parents? Did you eat breakfast/lunch/dinner?
I clicked on the surgical history tab in Wang Auntie’s medical record and saw a long list, including appendectomy (appendix removal) three years ago, hysterectomy with bilateral oophorectomy (uterus and ovaries removal) one year ago, and most recently, cholecystectomy (gallbladder removal) just last month. And now, she wanted yet another organ removed. But there was no indication of thyroid tumor or disorder. And “my life is really bitter” certainly wasn’t a surgical indication. In Mandarin Chinese, the word bitter (苦) is often used to describe hardship in life. And taking out the thyroid wasn’t going to fix a hard life.
Something felt really wrong. So, I decided not to refer her immediately. Instead, I asked more questions, trying to understand her life beyond her symptoms. Slowly, the pieces of her story emerged.
Wang Auntie was from a poor village in China. Ten years ago, desperate to support her three-year-old daughter, she traveled to a large city on the West Coast after a “friend” told her about opportunities to make money in America. She initially thought she’d work for a few months and return home, but the reality of life in a foreign country proved far harder than she had imagined. Too ashamed to go back empty-handed, she sent every penny she earned back home, barely scraping by herself. She was becoming more and more depressed, which made her increasingly vulnerable to criminals.
Three years ago, she met someone online who offered to help her relocate to a small city in another state, where the cost of living was much lower and her less-than-minimal wages might stretch further. That was the beginning of her real nightmare. She was given a job in an Asian massage parlor. Her boss controlled every aspect of her life, confiscating her passport, restricting her freedom, and paying her only meager wages. She was forced to work as a custodian on top of her work as a massage therapist, with no escape in sight.
I later learned, after calling an agent of the National Human Trafficking Hotline on her behalf, that these were all signs of labor trafficking.45
“Sometimes the customers make requests that I couldn’t satisfy,” Wang Auntie said, lowering her head as strands of salt-and-pepper hair slipped down to cover her face. “So I don’t get any tips from them.” She didn’t say it explicitly, but I sensed these “requests” were sexual.
“When was the last time you saw your daughter?” I asked her once.
“Ten years ago. My daughter is thirteen now. When I abandoned her, she was only three.” Big drops of tears rolled out of Wang Auntie’s sunken eyes. “I’m a bad mother. I don’t have the face to see her ever again.”
In human trafficking and sex trafficking, shame is a common tool of control, especially for Asian women.46 The guilt she carried for leaving her daughter and failing to achieve the American Dream kept her trapped in silence. And the words she used—abandoning, bad mother—suggested she had been gaslit by those who exploited her labor and body.
In her medical record, I found numerous visits for vague complaints: constipation, headaches, weight loss, and more. Human trafficking victims are often high utilizers of the healthcare system, presenting with many vague complaints and inconsistent stories.47 While physicians can play a crucial role in identifying victims, we often fail to recognize their repeated cries for help.48 I can’t help but think this failure stems in part from how fragmented our healthcare system has become, and how we are all too busy treating broken parts to notice a life unraveling.
In January 2025, I asked the #AskThePatient community on X if they felt healthcare had become too fragmented.49 Of the 800+ people who responded, 98.9% said yes. One woman shared how her cardiologist dismissed her concerns about uterine bleeding: “I only deal with the heart,” he told her, drawing a little box in the air. That box showed up in Wang Auntie’s chart too, many times. A referral to general surgery three years ago resulted in an appendectomy. A consultation with OB-GYN last year led to a hysterectomy and oophorectomy. And this month, under the advice of gastroenterology, she received a cholecystectomy. All three referrals were made by different clinicians—two from urgent care, and one from primary care—and none spoke to each other.
So, each year, a different department subtracted an organ from Wang Auntie’s body. Even she came to believe that cutting out parts might cure her bitterness. No one had added up the clues to suspect anything else—something much, much worse than appendicitis, gallstones, or thyroid problems.
Healthcare fragmentation hurts patients. It means contradictory medical advice from different specialists, medication errors, unnecessary tests, misdiagnoses, and rising costs for both patients and the system.50 In a system that metaphorically and literally divides up patients’ bodies, who is supposed to stitch it all back together?
A line in Wang Auntie’s gastroenterology consultation notes offered a clue: In addition to GI symptoms, patient also complained of frequent headaches. Consider neurology referral. Follow up with PCP. In other words: Not my department. Go to your family doctor. Next patient.
Fine. Let’s put the PCPs in charge.
Well, that’s going to be difficult, because primary care is in crisis. The United States remains the only Western industrialized nation that divides primary care into three separate disciplines: family medicine, internal medicine, and pediatrics.51 In recent years, despite an overall uptrend in the number of medical students graduating in the US,52 only 12.6% entered family medicine.53 Among internal medicine and pediatric graduates, only 12.4% and 36.5%, respectively, chose primary care careers.54 The most recent reports from the Association of American Colleges estimated a shortage of between 20,200 to 40,400 primary care physicians by 2036.55 Imagine it’s raining. Instead of giving you one large umbrella, we hand you three smaller ones. If you hold them just right, you might stay dry. But where they fail to overlap, water pours through. And then, before you reach shelter, we tell you to hurry up because the umbrellas are about to shrink.
The system actively disincentivizes PCPs from doing what they were trained to do. High patient volume, soaring burnout, increasingly subspecialized (fragmented) care, and pressure from insurance companies all push PCPs toward quick referrals rather than in-depth treatment or thoughtful follow-ups.56 A 2019 Cornell study asked physicians and patients why they thought healthcare was so fragmented. Physicians admitted that it was easier to refer patients out than to solve all their issues because they simply didn’t have the time. After the referrals, many didn’t hear back from the specialists who referred to other specialists without consulting or informing them. Patients reported that they didn’t realize having a PCP meant having someone to coordinate and consolidate their care. Many didn’t even know what primary care was supposed to do.57
Can we blame them? (We don’t blame patients. Period.) When the system sidelines us and our own colleagues route around us, we become invisible both to our patients and to ourselves. This invisibility reveals another consequence of fragmentation: the rise of medical elitism.
Primary care is the lowest-paid branch of medicine, carrying a lifetime earning gap of $1 million to $3 million compared to other fields.58 It is often treated as the least prestigious.59 As a country doctor, I experience this firsthand. Remember Katie from Chapter 1? The ER physician openly dismissed my judgment, putting me down on the expertise hierarchy. One of the most memorable moments of my early career was a classmate sneering, “Why would you want to go into family medicine?” In a top-tier medical school where only a few match into family medicine each year, her tone was hurtful but not surprising.
When PCPs are overburdened, underpaid, and underestimated, it’s no wonder referrals become easier than resolution. Primary care clinics turn into referral machines. Yet evidence shows that countries with strong, centralized primary care consistently outperform ours in health outcomes.60 Because when primary care collapses, everyone gets soaked.
