Like every organ in the human body, the uterus is exposed to its own physiological vulnerabilities: cancer, malformations, and various pathologies. Nevertheless, the medical profession and society as a whole can amplify these vulnerabilities and create new ones, which they then tend to naturalize. Whether it stems from biological characteristics or social constructs, this representation of a fragile uterus tends to function as a metonymy for the vulnerability of the bodies that carry it.

A physiologically vulnerable organ

The uterus can be affected by various pathologies, including cancer and endometriosis. Cervical or uterine cancer is the most common cancer of the female reproductive system. Originating in the uterine cells, in 90% of cases it is caused by a persistent infection with HPV (Human Papillomavirus), a widespread sexually transmitted virus. A vaccine, suitable for both sexes, is available to combat this infection, but it is not widely available in all countries. Endometriosis, on the other hand, causes extremely painful periods and can lead to fertility problems. Other conditions exist, such as prolapse, also known as organ descent. The condition can affect other parts of the digestive, urinary, or reproductive systems, but the term is commonly used to refer only to the uterus, obscuring other organs that may be affected, besides potential male patients.

The organ can also be subject to congenital malformations, as evidenced in modern times by an engraving of the “extraordinary womb” (fig. 1) in a 1683 brochure by Pierre Dionis, surgeon to the Dauphine Marie-Anne Victoire, Louis XIV’s eldest son's wife. One of her ladies-in-waiting, Madame Arsan, who was six months pregnant, died after several painful episodes. Queen Marie-Thérèse of Austria, together with the Dauphine, then asked Dionis to open the body, and he removed the entire genital area (from vulva to ovaries) for closer observation, thereby providing the first evidence of an ectopic pregnancy with rupture of the fallopian tube. The queen requested the removed organ so that she and her ladies-in-waiting could examine it more closely. While this work paved the way for research into uterine malformations, it also bears witness to the scopic drive that the uterus is subject to, especially when it is pathological (see the notice “(Un)cover this uterus that I ought not see”). This phenomenon intensified in the 19^th century with all kinds of inventions, such as Pozzi forceps (fig. 2), used to better see the organ and treat it, named after their inventor Samuel Pozzi, often presented as the father of modern gynaecology. Today, they can be found in every gynaecologist’s or midwife’s office, but the pain they can cause has prompted debate about how they should be used (for example, when inserting an IUD).

Historically, it is indeed the notion of an intrinsically fragile organ that prevails, supporting the thesis of the “natural” vulnerability and inferiority of the beings who carry it. Among ancient ex-votos, the uterus is virtually the only internal organ to be represented. Most often, it takes the form of a hollow terracotta object; the folds on the walls illustrating the belief that the organ retained sperm in this way (fig. 3). Medical and philosophical texts from as early as the 5^th-4^th centuries BC consider it to be defective, no doubt reflecting the common concerns of men and women of their time. Since ancient times, the uterus has been thought of as “sick”: it requires special care to fill it, empty it, keep it in place, etc., and failure to provide such care would result in poor health, infertility, disability in unborn children, and, of course, hysteria.

A medically vulnerable organ

The uterus is not only physiologically vulnerable, it is also vulnerable in the eyes of the medical profession. Fascinated by the organ and at the same time keeping it at a distance, doctors contributed to weakening its care.

This is evidenced by the contemporary “discovery” of endometriosis, which was recognized and acknowledged very late: the disease, discovered in 1860, was given its name in 1927 and only entered medical school curricula in 2020. This shows, once again, that medical research differs depending on the gender of patients and that bodies with uteruses receive less care. Furthermore, the refusal to recognize what patients say adds violence to vulnerability (see the notice “Violence against the uterus”). Information campaigns have only existed in France for a few years, largely driven by the many associations that bring together people with the condition, to encourage screening and help patients manage their pain, symptoms, and related pathologies. Government and association communications rarely use the organ as a visual aid; most common images are those of women holding their stomachs and/or heads to express pain, or the yellow ribbon (fig. 4), which has become the symbol of the fight against the disease and is worn mainly in March, the month when many information events are provided.

The medical world is also responsible for the widely-held perception in contemporary societies of a particularly defective organ, the source of various “female” pathologies, including the much-vaunted hysteria. The idea that this was caused by the wandering of the uterus dates back to ancient times. It was believed that if, while traveling through the body, the uterus encountered the respiratory tract, it could exert pressure that caused suffocation: the hysterical crisis. This primarily affected women who did not have a sexual partner (virgins or widows) and whose uterus was considered dehydrated. Galen (greek physician of the 2nd century AD), for his part, believed that blood retention was responsible for the disease, which therefore mainly affected young girls awaiting their first period. In both cases, marriage and, above all, pregnancy were prescribed as a saving therapy. In the Middle Ages, hysteria, still associated with the organ’s movements, became “the work of the devil.” It was only very gradually, starting in the modern era and definitively with 19^th-century neurologist Jean-Martin Charcot’s work, that it moved out of the field of gynaecology and into that of psychiatry and then psychoanalysis.

The disease was then no longer correlated with the uterus and its movements. Having become a neurological pathology, it was no longer gendered. The concept was then radically questioned in the second half of the 20th century and abandoned by most practitioners. Nevertheless, it still surfaces in everyday language, since the adjective “hysterical” remains a largely gendered insult.

The 19^th century also ushered in rapid progress in research into cancers, particularly breast and uterine cancers, which were the best known at the time. However, therapeutic trials were soon criticized due to the development of cervical ablation in France in the 1820s and 1830s.These procedures were regularly performed by surgeon Jacques Lisfranc (1790-1847) and involved a brutal, bloody protocol that often resulted in death.

Heated debates then ensued among surgeons about the usefulness of these operations and the instruments to be used. The procedure involved inserting forceps into the cervix, pulling it up to the vulva, and cutting out the cancerous part or the entire cervix, which caused intense pain due to the pulling, as well as risks of tearing, prolapse, vaginal perforation, infection, and haemorrhage. A plate from the Traité des maladies des femmes (Treatise on Women’s Diseases) (fig. 5) in 1838 shows the gynaecological instruments that could be used for this type of operation, including the utéroceps (no. 5 in the figure), an eight-pronged forceps for grasping the cervix, and the hysterectomy knife (no. 7), a forceps equipped with a small blade for cutting the cervix. Details 6 and 8 illustrate how they work.

There are several reasons for these desperate and mutilating surgeries: the supposed etiology* of these cancers—degenerate sexuality—their risk of spreading throughout the body, and their incurability. Thus, helpless doctors often resorted to the ultimate solution of amputation. The vulnerability of the organ at that time, as today, lay at the intersection of scientific and medical knowledge and gender stereotypes.

A socially vulnerable organ

Finally, due to political and/or economic choices, the uterus is more generally seen as an organ whose vulnerability is socially organized (see the notices “An organ of globalization” and “Feminist demands and the uterus”). The restrictions on abortion rights in the United States in recent years are only the tip of the iceberg in this regard. Even in countries that allow abortion, such as Italy, there are many obstacles that stand in the way of exercising this right: the closure of health services and the increase in doctors invoking the conscience clause are leading to serious regional inequalities in healthcare. In the south of the country, which is poorer and more conservative in terms of customs, with a strong Catholic heritage, the number of facilities and practitioners is falling dramatically, forcing women to seek abortions in the north or even in other countries.

More generally, the neoliberal economic policies pursued for the past 40 years in Western countries have led to a crisis in healthcare facilities. The number of hospitals is declining: French maternity wards have fallen from more than 700 in 2000 to 430 in 2020. A report by Professor Ville to the Academy of Medicine at the end of February 2023 recommends transforming around 100 small maternity wards (fewer than 1,000 births per year) into perinatal centres, providing care for women only before and after childbirth. This forces women to travel longer distances and spend more time and money on their pregnancies, and increasingly giving up part of their care. The crisis also affects healthcare workers. Hospital midwives recently denounced the violence inflicted on women in departments lacking staff and resources. In Périgueux, at the end of 2021, nurses at the public hospital, for example, appropriated the image of Rosie the Riveter, associating it with a uterine pun to denounce the deterioration of their working conditions and the quality of care provided (fig. 5).

Paradoxically, attempts, particularly in public policy, to recognize new rights for women can lead to the overexposure of these physiological fragilities and the validation of these socially constructed vulnerabilities. In such contexts, granting differentiated rights, such as menstrual leave, as was recently the case in Saint-Ouen and Spain (2023), or somewhat earlier in Zambia (2015) and Japan (1947), also runs the risk of enshrining in law an inequality between people with uteruses and others, and reinforcing the naturalization of the organ and its inclusion in a paradigm of vulnerability.

Bibliography :

A. Carol, « Une sanglante audace : les amputations du col de l’utérus au début du xix^e siècle en France », Gesnerus, 65, 2008, p. 176-195.

E. Nicol, « Face aux cancers féminins : dévoiler et porter le fer (xix^e siècle) », Histoire, médecine et santé, 1, 2012, p. 35-46.