Invisible Women: Data Bias in a World Designed for Men, by Caroline Criado Perez. New York: Abrams Press, 2019. 411 pages. Reviewed by B. Kent Harrison.

Being something of a feminist, I was much attracted to this book. The author is a feminist activist, has a degree in English language and literature, and was awarded the OBE by Queen Elizabeth. Her thesis is that there is a worldwide deficiency in information about women, whether intentional or simply inadvertent. A secondary thesis is that women need to combat this; they need to be activists. Her wry dedication sums it up: “For the women who persist: keep on being bloody difficult.”

The book has a preface, introduction, an afterword, and six parts divided into sixteen chapters. The introduction, entitled “The Default Male,” and the preface list several areas of concern in which this information deficiency causes problems for women, some merely inconvenient and some actually dangerous. Examples: 1) shivering in offices set to a male-normed temperature; 2) struggling to reach a top shelf set to a male height norm; 3) crashing a car whose safety features don’t account for women’s measurements; 4) medical information derived almost solely from men’s observations.

The introduction quotes Aristotle: “The first departure from type [the norm] is indeed that the offspring should become female instead of male.” (Thanks a lot, Aristotle!) It then goes on to discuss hunter-gatherer societies, leading up to the present, all the while noting the tendency to ignore women in gathering data of any kind. Again, many examples are given. The use of the gender masculine in language (he instead of he and she, etc.) is powerful enough that it often causes women to be ignored, resulting in, e.g., more male scientists being known than female scientists. Women are less likely to apply for jobs and less likely to do well in interviews for them if the positions are advertised in gender masculine language. Gendered language even overrides job titles such as “beautician.” And despite all this evidence and the laws that forbid it, employers continue to use such language.

A 2015 study showed that gender-neutral terms used in computer work—user, participant, person, designer, and researcher—are still perceived as masculine. Similar problems exist in sports, school textbooks, newspapers, across languages, etc. In 2013 the author attempted to have a female historical figure depicted on English banknotes; some men got so angry they threatened her with rape, mutilation, and death. Sigh.

Chapter 1 is entitled: ”Can Snow-Clearing be Sexist?” While data from various countries is spotty, it is still clear that more women than men walk to work or take public transport, so the condition of the roads and walkways is important. Men, the usual breadwinners, typically take no more than two public transport trips per day as a rule¸ while women—whether while shopping, taking care of children, transporting family, etc.—may take many. Thus it behooves cities to take account of this disparity. Karlskoga, Sweden, did so and actually saved money in that there were fewer hospital injuries from pedestrian falls, most of which were women. Vienna and Barcelona have good programs along these same lines. But usually, simply because the data is overwhelmingly male-dominated, women are neglected.

Zoning laws date back to antiquity. In the Industrial Revolution, a division arose between where one worked and where one lived. This was reinforced by zoning. The division has created a male bias because women have to juggle both work and family tasks to a greater degree than men in most cultures. When Rio Janeiro was planning for its Olympic Games and rebuilding much of the city, it forgot about women and forced some of them to move far distances from their work.

Chapter 2 is entitled “Gender Neutral with Urinals.” Public bathrooms are usually labelled “men” and “women,” with equal floor space. As any observant person has noticed, this doesn’t work very well. Men’s bathrooms have urinals and cubicles, while women’s have only cubicles. During intermissions in plays, for example, there is typically a long line for the women’s rooms, but none for the men’s. The author cites a study showing that women take up to 2.3 times longer than men to use the toilet—they may be menstruating, they may be pregnant, etc., may need more time—which suggests that they should have 2.3 times the floor space. But that rarely happens. When I was a graduate student in the 1950s at an all-male university, there was little bathroom space for the female employees. On a tour we took of an early Maryland public statehouse, the female guide wryly remarked that there were no bathrooms for women because they “didn’t do those things.”

The famed Barbican arts centre in London attempted to achieve gender equality by labelling the bathrooms “gender neutral with urinals” and “gender neutral with cubicles.” Oops. Men then used both while women could use only one, so the women’s queues were much longer than usual. Even in America young girls working in tobacco fields refrain from drinking water, rendering themselves prone to dehydration. “Going” out of doors can result in various medical problems: bladder and urinary infections, worm infections, cholera, hepatitis, polio, and others. Women’s difficulty in finding a private place to “go” renders them vulnerable to voyeurs, sexual harassment, or rape. They may need to go in pairs for safety.

The author discusses another matter: assaults against women in public places, such as on public transport. Congestion on buses makes it possible for men to harass or molest women in a variety of ways with impunity: women complaining about them are dismissed as troublemakers or are ignored. Men say, well, they haven’t seen it. Where there are problems with transportation, some women will find roundabout ways of traveling to their jobs; some may even quit.

Data on such matters is lacking. This is exacerbated by the fact that women do not report these incidents (rape in particular), assuming they won’t be believed or will even be blamed.

One way to approach this matter is for transit authorities to recognize they have a problem. Some women are taking matters into their own hands by forming educational and activist groups. Transit people can gather data and design solutions. That need not be costly. But they need the will to do the study. Vienna, in a slightly related matter, has instituted reforms in public parks. The city found that girls tended to avoid large open spaces, which were dominated by boys, so it subdivided the parks into smaller areas. Also, girls avoided small entrances, around which the boys congregated, so the entrances were enlarged.

Chapter 3, entitled “The Long Friday,” has to do with women’s pay. The title comes from a day in Iceland in 1975 when 90% of its women when on strike—from everything. The men were frazzled. A year later Iceland passed its Gender Equality Act, which outlawed sex discrimination in workplaces and schools. Within five years, Iceland chose the world’s first democratically elected female head of state. In 2017 the country topped the World Economic Forum’s Global Gender Gap Index for the eighth straight time. Perhaps forward women can make a difference.

The Economist has named Iceland as the best country to be a “working” woman. The book’s author wryly notes that “working woman” is a tautology. All women work. The question is, is she paid? Globally, 75% of unpaid work is done by women, who spend 3–6 hours per day on it; men spend ½ to 2 hours on it. (Specific examples are worse: in India, the values are six hours for women and thirteen minutes for men.) People ask the author, “Isn’t it getting better?” Well, no. Even in wealthy families with domestic help, the ratio is about the same. Numerous studies have shown that women do the majority of unpaid work irrespective of the proportion of household income they bring in. My daughter once had a cartoon posted in her kitchen showing three individuals with the pay they received. The first, a professional basketball player, had a salary in the millions. The second, a politician, had a respectable two to three hundred thousand. The third, a bedraggled housewife with a baby on her hip had, of course, exactly zero.

At home men watch TV, play sports, and play video games while women care for the children, cook, clean, go shopping, and do laundry. This affects women’s health. Single women tend to be healthier than married women; one study showed that husbands create an extra seven hours of housework per week for their wives Yet this isn’t a choice for women. Children must be cared for; households must be managed.

The US is one of only four countries that doesn’t guarantee paid maternity leave. Congress has attempted to fix this by tinkering with Social Security, but its efforts only reduce benefits for women. This is a major failure on the part of the United States.

Another problem is that of tenure in US universities. These universities have been trying for years to increase the number of women faculty. But the system requires faculty to produce a certain amount of research in tenure-track positions or they are fired. This is biased against women, who must care for households and have little time for their own research or for keeping up with the literature. One study focused on US economics departments, showed that these policies led to a 22% decrease in women’s chances of getting their first job because departments were skeptical that they would make tenure, while men had a 19% increase.

Chapter Four is entitled “The Myth of Meritocracy.” It begins with an interesting story. There have been very few female musicians in symphony orchestras, but in the 1970s the percentage began to go up. Why? Because of a lawsuit, orchestras had begun to conduct blind auditions, in which a screen was placed between the interviewer and the candidate. Today over 45% of the members of the New York Philharmonic are female.

Unfortunately, this is the exception. We tend to believe that judgments of work performance in our society should be based on merit and that they actually are so based. T’ain’t so. For example, an analysis of US tech companies found that women receive negative personality evaluations that men simply don’t. Women are called bossy, abrasive, strident, aggressive, emotional, and irrational.

Belief in one’s own objectivity serves to unconsciously bias men when hiring, for they often think they are judging on merit but are really judging against women. In salary increases, men are rewarded more than women.

A study of tech companies showed that more than 40% of women leave employment after ten years, compared to 17% for men. Reasons given are not for family reasons or that they didn’t enjoy work. Rather, they left because of “workplace conditions, undermining behaviour from managers, a sense of being stalled in one’s career.” Another study indicated that women left because of being repeatedly passed over for promotion or having their projects dismissed.

Those believing in the myth of meritocracy include young white males and the upper ranks of academia, particularly in the STEM (science, technology, engineering, math) fields. Also, students with emotional or other problems often seek out female professors for counseling, placing extra burdens on the professors.

In publishing, double-blind reviews of papers help women get published. But most journals and conferences do not use this policy. Citations of publications are important in judging performance; studies have shown that women’s publications are cited much less than men’s. Using initials in authors’ names instead of full names provides an advantage for women, since male reviewers tend to assume that the authors are male. Numerous world studies of academia show that female students and faculty are less likely than men to receive funding, to be offered mentoring, or even to get the job.

The author says: “Less effective male professors routinely receive higher student evaluations than more effective female teachers. Students believe that male professors hand back marking back more quickly—even when that’s impossible because it’s an online course delivered by a single lecturer, but where half the students are led to believe that the professor is male and the other half think the professor to be female.” From my own experience I know how easy it is for student evaluations of faculty to be biased. In fact, the author remarks, student comments about women are actually becoming more aggressive, even violent. In commenting about the tendency to consider brilliance to be male (e.g. Einstein,) the author remarks, “…when ‘brilliance’ is considered for a job, what is really meant is ‘a penis.’”

We teach brilliance bias to children at an early age. Five-year old girls are as likely as five-year old boys to believe women can be really, really smart. But as soon as age six (!) girls start doubting their gender, their ability to be smart. When children are asked to ”draw a scientist,” historically they have drawn men. Things are much better now but are still way off the mark.

Letters of recommendation consistently exhibit male bias. Women may be described as “warm, kind, nurturing,” less so as “ambitious, remarkable, self-confident, or outstanding.” Of course, hiring committees much prefer persons with the latter qualities.

Brilliance bias has become almost hard-wired in people. The author discusses the 1984 book Hackers: Heroes of the Computer Revolution by Steven Levy. Levy’s heroes are all brilliant, single-minded, and male. Levy speaks of “horribly inefficient and wasteful things like women…” Good grief! He says further, “How can a [male] hacker tolerate such an imperfect being?”, and is puzzled why there never was a star-quality female hacker. The author remarks, “I don’t know, Steve, [but] we can probably take a wild guess.” I note that many of the early computer programmers—including some working in the APOLLO program—were women.

Women often tend not to nominate themselves for promotion. This happened at Google. Google, to their credit, tried to fix the problem. Unfortunately, they tried to do it by fixing the women. Google has also refused to hand over pay data to the Labor Department. The problem seems to be the unconscious realization that there is a data bias.

Chapter 5 is entitled, “The Henry Higgins Effect.” Higgins, from the play My Fair Lady, you will remember, was a noted misogynist. He is baffled when his protégé-cum-victim Eliza Doolittle bites back. He grumbles, “Why can’t a woman be more like a man?” That perfectly expresses the unconscious data gaps discussed in this book. The chapter begins with the realization that pregnant women need special parking spaces. But that had to be pointed out by Facebook COO Sheryl Sandberg while working at Google offices. The author notes that it shouldn’t have taken a senior woman to point out this need.

The standard office temperature, set from 1960s male data, is too low for women. That may affect their health, sometimes seriously; some women may even die.

Women often have to perform heavy lifting. Women may become ill from such work. Research on workplace conditions is based on the “Reference Man,” a Caucasian man in his late twenties who weighs 70 kg. Levels of radiation and chemical exposure may be safe for men, but definitely are not for women. For example, in nail salons, workers, almost always female, are exposed daily to a huge range of chemicals in nail polishes, removers, etc., that may be ingested through the air or through the skin. (The author doesn’t mention it, but I am reminded of the female workers in the 1920s who painted radium watch dials and would tip the brushes with their tongues. Of course, many of them got cancer.)

Studies of air quality in nail salons rarely exceed occupational exposure limits but do not account for long term effects. The air may contain endocrine disrupting chemicals (EDCs), which are harmful. Such exposure may greatly increase the risk of breast cancer. EDCs are found in all kinds of products that women use, including menstrual pads.

In the US, roughly one million women are engaged in farm work. They must deal with equipment designed for men: hoes that are too long, handles and grips that don’t fit a woman’s hand, heavy machinery that is too big to control. In construction, bags of cement and bricks have a standard size. A leading woman’s advocate asks, “Why can’t they be reduced to sizes that women can handle?” It was only in 2011, thirty-five years after women were admitted to military academies, that uniforms were designed to accommodate women’s hips and breasts. The problem isn’t completely solved. The loads soldiers must carry are typically too heavy for women. Rucksacks, pack straps, and pistol belts are designed for men, not women. Uniforms are designed to make it easy for men to urinate; women have a difficult time with these. Attempts to make a uniform for women so it is easy for them to urinate have generally met with failure. Sigh.

Chapter 6, “Being Worth Less Than a Shoe,” begins with a description of the bisphenol A (BPA) scare of 2008, when it was realized that BPA—used in the production of clear, durable plastics—may be carcinogenic and can cause a host of other problems. There was concern for pregnant women or those who had just given birth—but overlooked were women exposed to BPA in the workplace.

But we don’t care enough. Funding has been cut for women’s health organizations and for public health. Chemical industries have fought regulation. Government studies of BPA have shown that it has an effect in 90% of cases; studies conducted by the industry have shown none. So workplace dangers continue, and women won’t make a complaint for fear of losing their jobs.

Over the last century, rights for employees have been established. But many workers are not, technically, “employees.” They are independent contractors (e.g., in nail salons) and so are easier to exploit, such as 47 year-old Qing Lin, who splashed some nail-polish remover on a customer’s patent Prada sandals. The woman demanded compensation; she received $270 in cash, taken out of Lin’s pay, and Lin was fired. She said, “I am worth less than a shoe.”

Her story appeared in the New York Times, which was conducting an investigation of abuses of nail-salon workers. It resulted in a licensing system in the city. But alas, no such protection exists for workers elsewhere in the US and in the world. A 2017 UK report on predominantly female Vietnamese workers calls them “victims of modern slavery.” Such conditions are present across the entire workforce in today’s world. The author presents, in page after page, awful examples of this sort of exploitation of women.

And of course, it doesn’t stop there: There is also sexual harassment. Harassment varies from country to country and industry to industry. For example, in Silicon Valley 90% of women had witnessed sexist behavior and 87% had received demeaning comments from males. Many had been propositioned. In a Canadian study women said they were confronted with this “every day.” Really? Not just sometimes? No. Every day! Another example is the nursing profession. Hospitals have long hallways which make it easy for other workers or patients to assault nurses. The list of such things goes on, and on, and on, and on.

Chapter 7, entitled “The Plough Hypothesis,” deals with a suggestion that societies which used the plough historically would be less gender equal than those which did not, the reason being that using the plough (plow) requires great upper body strength, which men have and women do not. Small implements like hoes can be used by women. Data, of course, is missing. National surveys usually do not tell whether the farmers are men or women. Around 2012, an unnamed organization conducted a survey on farm issues but talked only to men. Often women’s work, such as small domestic duties, child care, etc., is underreported. And women’s educational achievement may be hindered by the work they do.

Then there is the issue of “clean” stoves in the developing world. Most women in underdeveloped countries still cook on rocks, using biomass fuels. But these may be toxic, carcinogenic, or causative of other diseases. Initiatives to develop clean stoves usually haven’t gone anywhere. (One of my colleagues developed a conical stove that focused the sun’s rays on the food; it looked promising, but I don’t think it materialized.) Data is sparse. Women are being blamed for not using the stoves. They just aren’t used to new designs. But people say “fix the women, not the stoves.”

Women in Bangladesh ordered newer stoves when their husbands were not present. But when the stove dealers returned, the husbands were present and the women declined the purchase. A press release about the incident blamed the women for being backward, not the men.

The title of Chapter 8, “One-Size-Fits-Men,” is self-explanatory. Readers of this book will understand this immediately. The first example is pianos. Men have larger hands than women and have an easier time playing the piano than women. (This reviewer, a male who has small hands, agrees.)

The second example is smartphones, whose size is designed for male hands. Research shows that more women than men buy iPhones. No matter: Apple continues to make iPhones with larger screens. A solution to this problem may be voice recognition software, to get around the phone size. Uh-oh. That software is mainly designed for men. In cars the voice recognition system may work only for men’s voices, thus presenting a safety hazard for women. The solution is to fix women. Why can’t a woman be more like a man?

Besides the matter of the different voices, there is a wide variety of algorithms used for training purposes. These all use male-based data sets. Female names and terms are more likely to be associated with family than male names and terms, which tend to be associated with career.

Chapter 9, “A Sea of Dudes,” begins with an anecdote. Janica Alvarez was trying to raise funds for her start-up company. In one meeting, investors Googled her product, found a porn site, and started cracking jokes. Others were grossed out, calling her product “disgusting.” What was it? Simply a breast pump.

But the US breast pump industry is huge. With the lack of maternity leave, women at work who may be breast feeding their child need pumps. Unfortunately, the biggest supplier, Medela, isn’t very good. Its pumps are awkward and ill-fitting. So there is a need. Why don’t investors lap it up? Because it is a need they, being male, don’t perceive.

Yet data studies show that while female business owners receive less than half the investment that their male counterparts receive, women-owned start-ups generate more than twice as much revenue as men-owned start-ups. Possibly women are better suited for entrepreneurial leadership than men.

Another problem is poor pelvic-floor health in women, which is common. But again, no data. A woman researcher remarks that fifty percent of the population have a vagina, yet there are hardly any journal articles about this part of the anatomy. The current treatment for prolapse (when organs start dropping through the vagina) is a vaginal mesh, but mesh technology is problematic. Women are left in pain and may even die.

In matters of menstruation and contraception, technology hasn’t changed much since the 1950s, when the pill was introduced. Despite menstruation’s being a critical indicator of women’s health, there is little data on it.

In the tech world, the author says, “the implicit assumption that men are the default human remains king.” In 2014 Apple launched, to loud fanfare, its “comprehensive’ health-monitoring system, which could measure blood pressure and blood alcohol among other things. But they forgot a period tracker. Oops. When Apple introduced its AI, Siri, “she” could find prostitutes and Viagra suppliers, but not abortion providers. Smart watches are too big for women’s wrists and map apps can tell you which route is the fastest but not which route is the safest, which is a concern for women. Some apps are designed just to provide sex for men.

Sports tech is particularly adapted to men. Performance calculations are based on male data; that female data should be included, or even that this data exists, seems not to have occurred to most men. Gender analysis is missing from fall detection equipment, yet women take more falls than men. Fall detection apps on phones are a problem because women usually carry phones in their purses where detection of falls is harder. Another phone app, to help health workers monitor HIV patients, was a flop until a woman realized that, for safety on their daily commutes, the workers would conceal their valuables in their underwear and the phones were too big to fit in their bras.

The world of robots and virtual reality (VR) is another issue. A rather bizarre event is described in the text: a robot sexually assaulted a woman. The male inventors of the robot promptly corrected its programming to avoid that. The author discusses the problem that women tend to get motion sickness with VR, but says the reason for this is not known. One scientist has a partial answer. He says that the classic theories depend on sensory stimulation, but while in motion the body tends to be destabilized and that causes motion sickness. It also is a function of control: A driver knows where she is going, but if she is just a passenger she can’t anticipate the driver’s actions, tends to sway, and that may make her sick.

This theory excited the author. She thought, if one is sitting down while driving, even as the driver, the body tends to remain stable. But the head tends to flop around. So one needs a well-designed head rest. She was also enraged, because data concerning head rests for women apparently does not exist. She says bitterly, “This [data] gap is hardly unexpected … car design has a long and ignominious history of ignoring women.” The author goes into considerable detail about how car design has also ignored women’s needs. Even crash dummies are just scaled down male models that don’t take differences in female and male bodies into account. A safety report says, “Improved vehicle designs bring down death rates.” But then it says, “The rates include only driver deaths because the presence of passengers is unknown.” Sigh. Drivers are likely to be male, while passengers are likely to be female. Again, this is a gender data gap. Car safety research says that the quality of police crash reports is, for purposes of research, at best poor. In exasperation, the author says, “Clearly, women being 47% more likely to be seriously injured in a car crash is one hell of an inequality to be overlooking.”

Part IV is entitled, “Going to the Doctor,” and its first chapter, Chapter 10 in the book, is called “The Drugs Don’t Work.” Its beginning example made me cringe. Michelle was fourteen when she started having symptoms: painful, frequent, sometimes bloody bowel movements. At sixteen she hurt so much she told her parents; they took her to the ER. In front of her parents a doctor asked her if she was pregnant. She said no, it couldn’t be; the pain was in her intestines, and she hadn’t had sex. No matter: they wheeled her into an examination room and gave her an internal exam with a large, cold, metal speculum. It hurt so much she screamed and a nurse had to restrain her. The doctor confirmed that yes, she was not pregnant, gave her some aspirin and sent her home. Over the next ten years she had diagnoses from two male gastroenterologists, both of whom told her that her pains were in her head. (How often have we heard that!?) Finally, at age 26(!) a female GP referred her for a colonoscopy, which revealed that the entire left side of her colon was diseased; she had irritable bowel syndrome and ulcerative colitis. With the delay in proper diagnosis she now has an increased risk of developing colon cancer.

The doctors, in a sense, were not at fault. They were products of a medical system that, root to branch, discriminates against women. They are trained with a male “norm,” a “typical 70 kg man.” When women are mentioned they are spoken of as a “variation on standard humanity, “a “mutilated male” body. (Again, thanks, Aristotle!) Ovaries were female testicles; the uterus was the male scrotum. The reason they were inside and not outside the body was because of a deficiency in female “vital heat.”

Things are better in the 21st century, but there are still problems. A 2018 survey of textbooks used at prestigious universities in Europe, Canada, and the US showed that images of male bodies were used three times as much as those of female bodies. I have a nice, modern anatomy book; male images are used roughly 90% of the time. In her own survey of anatomy books, the author finds much the same thing: large scale drawings of men, with only occasional references to women. In a 2006 review of US medical schools, only 9 of 95 schools that entered data offered a women’s health course and only two (obstetrics and gynecology) were mandatory. Ten years later another review found the integration of sex- and gender-related medicine to be “minimal” and “haphazard.”

Yet there are sex differences in every organ in the body. Women are three times as likely as men to develop autoimmune diseases, which affect 8% of the population. Sex differences appear in our very cells: markers for autism, proteins, immune cells, response after a stroke, and in aging of blood vessels and response to stress. Pregnant women are particularly susceptible to HIV, SARS, and influenza.

In the 1960s doctors began prescribing thalidomide to pregnant women for morning sickness. It was considered safe because it didn’t kill rats; but it affected fetal development. Manufacturers knew this in 1959. Frances Kelsey of the FDA prevented most of its use in the US, but in other countries an estimated 10,000 babies were affected; those who survived generally had deformed limbs. This is considered to be one of the greatest medical scandals of the twentieth century.

In 1977 the FDA forbade women from participating in drug trials. Thus only men participated, and the gender data gap continues despite changes to these rules in the 1990s. A female public-health researcher received this feedback on two different grant applications: “I wish you’d stop with all this sex stuff and get back to science,” and “I’ve been in this field for 20 years and this [biological difference] doesn’t matter.” A 2014 op-ed in the journal Scientific American complained that including both sexes in experiments was a waste of time, while one in 2015 in the journal of the National Academy of Sciences said “insisting on preclinical sex differences will not address women’s and men’s health disparities.”

Some researchers advocate against using women in research because the historical data gap makes including women inadvisable (huh?). Female bodies are too complex and research on them is “too costly.” (I could go on and on with such delicious quotes from the book.)

Some address the problem of female underrepresentation in medical research by claiming there is no problem. And there is just a small number of female participants in drug trials, so conclusions are unclear. But the FDA reports that the second most common adverse drug reaction in women is that the drug simply doesn’t work—even though it works in men. So, the author asks: how many drugs that would work for women are we ruling out at phase one just because they don’t work in men?

Men would like to rule out hormonal effects in women and just use male data. But women’s hormones impact antipsychotic drugs, antihistamines, antibiotics, and heart medication; different times in a woman’s cycle may affect results. Some drugs never reach human testing because they were ruled out at the cell and animal trial stage. Possibly most galling is the fact that females aren’t even included in animal studies on female-prevalent diseases. What, indeed, were the male researchers thinking?

Two different teams studying heart attacks found that the time of day of the attack affects chances of survival. But the results on the times were opposite: in the first case the chances were better than in the second. What was the difference? Male mice were used in the first study, females in the second. Stem cells seemed unpredictable until it was realized that female cells promote regeneration and male cells don’t.

A few countries have tried to address the problem by regulation. The US has required that women be included in federally funded clinical trials. Canada and Germany have done much the same. The United Kingdom lags behind. Heart research is deficient for women compared to men. Other medical problems, too numerous to mention, are addressed in the chapter.

The other chapter in Part IV, Chapter 11, “Yentl Syndrome,” discusses women who are misdiagnosed or poorly treated because their symptoms or diseases don’t conform to those of men’s. (The title comes from the Barbra Streisand movie in which she plays a young Jewish woman who masquerades as a man in order to get an education.)

Much of this chapter duplicates material from the previous chapter. Several pages deal with heart problems in women. Other diseases are mentioned: colon cancer, dengue fever, TB, Ebola. Autism, ADHD, and Asperger’s syndrome are extensively discussed. In all these cases women present differently from men.

Women’s socialization patterns play a role. Women tend to downplay themselves and so are not listened to. Or they may not be believed. The author presents examples similar to Michelle’s in the previous chapter. Instead of believing women when they say they are in pain, people say it’s all in their heads, or that they are mad. Plato said, “Bitches be crazy.” (Remember he was Aristotle’s teacher.) Women are hysterical, irrational, and over emotional. Renowned physicist Stephen Hawking (clearly an authority on women) said, “Women are a mystery.” Sigmund Freud said much the same thing.

The author says, “The intransigence of this riddle has not gone unpunished.” Women who have shown even a little deviation from the (male) norm have been incarcerated in insane asylums. They were given hysterectomies and clitoridectomies. A US psychiatric textbook, still in use in the 1970s, recommended lobotomies for women in abusive relationships. It makes me want to throw up. Of course, we don’t do that anymore. We merely give women drugs—lots of drugs.

The Yentl syndrome may be at play here, in that so many of the stories women tell of undiagnosed or untreated pain have real physical causes that are exclusively female diseases or may be more common in women than in men. Men and women may experience pain differently. There are five times the studies on erectile dysfunction than on premenstrual syndrome. Another matter is dysmenorrhea, or period pain. How do you treat that? Midol? Viagra(!) has been suggested. But companies don’t do research on it. Male-dominated funding panels may also explain why so little money is available for research on uterine failure (of which many women, especially in third world countries, die). The author tells of some promising research by a British woman on avoiding C-sections, but her funding proposal was turned down. Why are women’s priorities so unimportant?

The author sums up these chapters with the disheartening remarks, “The evidence that women are being let down by the medical establishment is overwhelming. The bodies, symptoms and diseases that affect half the world’s population are being dismissed, disbelieved, and ignored…” Alas. But she sums up by saying, “It’s time to start dismissing women, and start saving them.” Hopefully that can take place.

Part V, Public Life, begins with Chapter 12, “A Costless Resource to Exploit.” The author notes the economic importance of a country’s gross domestic product (GDP) and then observes that the GDP has a woman problem. Determining GDP is actually a fairly subjective process. It came into being about the time of the Second World War; the originators counted everything they could think of, except they left out an important part of the economy: unpaid household work (remember the cartoon on my daughter’s refrigerator.) This was not an oversight; it was a deliberate decision not to include unpaid household work because “it would be too big a task to collect the data.” Again, men are the default human and women are a niche aberration. If one cares about accurate data this doesn’t make sense. Post WWII, US productivity seemed to go up, but it really hadn’t. Things that women used to do in the home were now substituted by market goods and services. Productivity had just shifted from the invisible feminized private sphere to the visible male-dominated public sphere.

Excluding unpaid work from the GDP could account for up to 50% of it in high-income countries up to 80% in low-income countries. These are estimates; capturing the data is difficult. But enough is known to realize that in every country women do a disproportionate share of all non-market work. The data was gathered by time-use surveys, which measure things like meal preparation or cleaning the house. It still didn’t include caring for sick adults or children, so is likely an underestimation.

Women’s unpaid work may be seen as “a costless resource to exploit.” In the UK in 2017, 86% of decade’s worth of “fiscal consolidation” cuts by the government fell on women. Figures for other countries are given. In Mexico (similar to the UK), women with young children are employed for shorter hours than those without children. For men, it is the other way round. Elder care, in an increasingly aging world, takes up women’s time; female caregivers may need to quit full-time work in order to do their caring. Also extensively discussed is the need for childcare.

Chapter 13, “From Purse to Wallet,” deals with statistics and their uses and misuses. US readers have become familiar with the term “fake news.” The author has her own term: “zombie statistic,” meaning a spurious statistic that won’t die—perhaps because it feels right. The first example given is that of youth turnout in the 2017 UK general election, which was grossly overestimated. But then the author discusses statistics relating to women—like the statement that “70% of those living in poverty are women.” No one quite knows where this originated and whether it is true. Other spurious statistics are presented. This is followed by a discussion of the US tax system, making the point that in joint returns the woman is usually overtaxed. The UK and Australia have the same problem in their joint returns. Only Finland and Sweden have strictly individualized returns. The author comments that there is a simple reason why so many tax systems discriminate against women; it is our old friend, the data gap. We don’t collect data on the effect of tax systems on women.

Chapter 14, “Women’s Rights are Human Rights,” deals with legislation relating to women’s issues. Rather obviously, women are more likely to sponsor such legislation than men. Women’s words translate into action. The chapter also considers women running for office. Unfortunately, they may experience the familiar canard, “Women are just too ambitious.” Hillary Clinton in the 2016 election was repeatedly charged with that, usually by men. But ambition was not a dirty word when it came to Donald Trump. The author relates how she grew up with the idea that being too ambitious was akin to being a bitch. The chapter goes extensively into statistics and matters relating to the election of women to public office. While there is progress, there is a long way to go. For example, women trying for office may experience harassment and threats, some of them very serious.

Chapter 15 is entitled “Who Will Rebuild?” It begins with an account of Hillary Clinton’s talk at the 1995 UN Fourth World Conference on Women. In light of then-recent world events (such as the fall of the Soviet Union), commentators minimized the importance of what Clinton was trying to say. The author notes that Clinton was talking about the systematic rape of women in Bosnia and Rwanda. It was in that talk that she said, to the delight of her hearers, “Human rights are women’s rights, and women’s rights are human rights.”

When things go wrong, the data gaps we have seen are multiplied. But it is more than just forgetting to include women’s perspectives—this can actually prove dangerous to them. Or it may be farcical: After natural disasters in India and Sri Lanka in 2001 and 2004, the replacement homes that were built did not include any kitchens. In Miami after 1992’s Hurricane Andrew, the rebuilding committee was made up of 45 men and only 11 women. It wanted to build business centers and skyscrapers when what was really needed were nursery schools and health facilities. The same short-sighted situation occurred after Hurricane Katrina in 2008.

Chapter 16, “It’s Not the Disaster that Kills You,” speaks about the irony of excluding women’s voices when things go wrong because things are already bad for them and thus they may have greater insight. Several paragraphs discuss domestic violence against women and the use of rape as a weapon against women in war, already mentioned above. The threats men face are not the same as the threats women face. Attempts to address the latter have been sporadic. For example, women are more at risk from pandemics due to gender roles and norms. Of 29 million papers published addressing the recent Ebola and Zika outbreaks, less than 1% referred to gender issues.

Climate change exacerbates the gender data gap problem, as discussed in several paragraphs. For example, weather early warning systems are often male-based; women don’t receive messages about oncoming storms. After a disaster, people may be driven into refugee camps with their attendant problems for women.

The Afterword briefly summarizes what we have been talking about. Three items from it: 1) an engaging account of a bright female mathematician, an expert in a particular kind of mathematical space, crocheting a model of the space; 2) a remark that in the failure to gather data about women, men simply make excuses; 3) a few paragraphs looking toward a solution.

The main thesis of the book—that there is a world-wide deficiency of information about women—is certainly borne out. The secondary thesis, that women need to be activists about this, is also well documented. I highly recommend the book; the reader will have noticed the enthusiastic remarks I have made throughout this review. The author writes well, engagingly, and persuasively.

Full Citation for this Article: Harrison, B. Kent (2021) "Book Review: Invisible Women by Carolina Criado Perez," SquareTwo, Vol. 14 No. 1 (Spring 2021),, accessed <give access date>.

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