The male fatigue disorder that became a female disorder
February 20, 2014
At the end of the 1800s long-term fatigue was thought to be a
typically male disorder. Today it is viewed as a typically female
disorder which goes by the name of myalgic encephalomyelitis (ME) or
chronic fatigue syndrome (CFS). Credit: colourbox.com
Previously, long-term fatigue was considered a male disorder caused by
societal pressures. Today, women comprise the majority of ME patients,
and they feel that their condition is their own fault.
Throughout history some people have suffered from a lack of energy and
long-term, physical fatigue. Today these symptoms are classified as
myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS).
It is commonly thought that chronic fatigue has mainly psychological
causes and that it affects perfectionistic women who cannot live up to
their own unreasonably high standards.
This has not always been the case. Just over 100 years ago, it was
primarily upper-class men in intellectual professions who were
affected. "Neurasthenia," as the condition was called at the time, was
a physical diagnosis with high status.
No longer legitimate
"The medical understanding of long-term fatigue has changed.
Previously, the condition was viewed as a typically male disorder; now
it is perceived as a typically female disorder. The diagnosis of
neurasthenia, which has a male connotation, was changed to the ME
diagnosis, which has a female connotation," explains Olaug S. Lian, a
sociologist and professor at UiT The Arctic University of Norway.
Together with Hilde Bondevik of the University of Oslo, Lian has
studied how the view of women and perceptions of the body, gender and
femininity in two different historical periods have been manifested in
the medical understanding of long-term chronic fatigue.
"Long-term fatigue was viewed as a legitimate disorder, a result of
the heroic efforts of the upper-class male. Today, it is a
stigmatizing disorder, understood as an expression of women's lack of
ability to cope with their lives, a kind of breach of character," says
Not only has the fatigued patient changed gender. Previously, doctors
believed that long-term fatigue was a neurological, physical disorder,
while today it is categorized primarily as psychological in nature.
And while in the past, society was thought to be the cause of the
disorder, today the individual is supposedly to blame.
What happened to cause this change?
Upper class diagnosis
At the end of the 1800s neurasthenia was the most widespread diagnosis
for long-term fatigue. Neurologists believed the condition was caused
by a physical, neurological disease that affected the entire body,
causing intense, long-term fatigue.
Although women were also diagnosed with the disorder, the typical
patient was a man, and not just any kind of man. He was "civilized,
refined, and educated, rather than of the barbarous and low-born and
untrained," according to neurologist George Beard.
Society was to blame
Doctors at the time believed that the cause of the disorder could be
found in a rapidly changing society - urbanization, industrialization
and women's entry into working life.
Quite simply, modern civilization ran roughshod over the nervous
system of upper class men, who were overstimulated by too much
pressure and activity, and too little sleep and rest.
"It was regarded as both legitimate and understandable that even the
'great men' could fall apart as a result of long-term, difficult
intellectual work. It was viewed as positive that the body sent
signals when the burden was too great. The body was viewed as an
electrical fuse box and the thinking was that it was better for one
fuse to burn out rather than for the house to catch on fire," says
Different genders, different causes
The comments about the diagnosis also revealed past understandings of
biological gender differences. Women could get neurasthenia from
sexual frustration, while men could get it from excessive sexual
activity, including masturbation.
Moreover, there was a connection between gender and class.
"To simplify a bit, we can say that it was mainly middle class men and
working class women whose diagnosis of neurasthenia was explained by
overwork. For working-class men, it was due to sexual escapades, and
for middle-class women the cause given was heredity or 'women's
issues'," explains Lian.
The fall of neurasthenia
Neurasthenia lost its popularity as a diagnosis in the early 1900s.
One reason for this was that psychiatry became a medical field in its
"Psychiatry took neurasthenia with it and changed its definition from
a physical to a psychological condition. Since women were regarded as
psychologically weaker and therefore more disposed to mental illness,
the disorder became a female problem," says Lian.
Fight over definitions
Today, ME is the most common name for the disorder, defined as
long-term, intense fatigue that cannot be directly linked to a
well-defined illness and that does not disappear with rest. The
condition is chronic, it cannot be cured with medical treatment and
there is disagreement as to the cause.
"The lack of scientifically generated findings, medical explanations
and effective treatment make ME a diagnosis with low status and low
legitimacy within the medical community," says Lian.
Currently, the main theory is that ME results from an inability to
handle stress and that perfectionistic people - the "good girls" - are
especially at risk. The debate about how ME should be understood and
explained is highly polarized between those who believe that it is an
illness caused by infections or vaccination, and those who believe
that ME has mainly psychological causes.
"I would like to see some humility about what we actually know about
the disorder and not present value judgments as facts. Doctors must
also be honest and acknowledge that we have very little hard-and-fast
knowledge about this condition," states Lian.
Blame and shame
The two historical periods have almost identical depictions of the
phenomenon of long-term fatigue, although the names are different. But
there is one important difference: the disorder is no longer regarded
as a legitimate, anticipated outcome of overwork.
"Today, the medical community is searching for explanations of ME at
the individual level. The ME patient is depicted as a woman with
five-star goals and four-star abilities - with character traits that
make it hard for them to cope with their own lives," says Lian.
"When the entire problem is seen as the patient's fault, the person
experiences blame and shame because it is the patient, not society,
that is the cause of the illness. It is therefore the individual who
is responsible for coping with the illness, such as by changing her
own thought patterns," says Lian.
Wrong kind of tired
She points out that the ability to cope with one's own life is an
important value in Western culture. Mental disorders, however, are
associated with weakness. The current understanding of long-term
fatigue is also linked to how we think about tiredness, according to
"There are strong norms for when you are allowed to be tired and worn
out and how you are supposed to show tiredness in daily life. If you
have been awake all night with a sick infant, you have a good reason
to be tired at work. Other reasons are less legitimate. Workplace
reports of absence never state that someone is at the psychologist,
while it is completely acceptable to say that someone is at the
"Being tired for the wrong reasons is seen as a sign of weakness,
which must be overcome and hidden. It is in this context that we must
understand the medical theories on a lack of coping ability and the
objections of ME patients to these theories," says Lian.
She believes such norms often make ME patients feel that the
psychological explanation is a burden, although doctors do not
necessarily mean for it to have this affect.
"What is it about the ME debate that makes the opposing sides so obstinate?"
"The doctors and patients talk past each other. The doctors think that
an ME diagnosis is value neutral, but the patient hears 'it's my fault
that I am sick and it's my responsible to get better'. But although
most people feel that mental disorders have lower value than somatic
disorders, it is not a given that the doctors do," says Lian.
Gendered explanation disappeared?
Although about three of four people who are diagnosed with ME today
are women, the explicit, biology-based, gendered explanations have
disappeared from the debate, according to Lian.
"This may simply be because today we put greater focus on gender
equality - which makes it less legitimate to claim that women are
naturally inferior to men," says Lian.
However, she believes that the ME diagnosis embodies a view of women
that has long historical roots.
"The profile of the upper class woman from the 1800s who cannot cope
with pressure and stress both inside and outside the home is still
with us today," says Lian.
"How can your analysis contribute to the current debate about ME?"
"We show how the medical understanding of fatigue and lack of energy
is impacted by the norms and values of society at large, for example,
that medical knowledge reflects the view of women in our culture.
Norms and values combine with biomedical knowledge in a way that makes
it difficult to see what is what," says Lian.
More information: Lian, Olaug S. and Hilde Bondevik: Diagnosenes
sosiologi: Medisinske forståelser av utmattede kvinner - før og nå.
Sosiologisk tidsskrift 4.2013. Universitetsforlaget, Oslo
Provided by Information Centre for Gender Research in Norway