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Why we don’t want to give up our heels, even though they hurt

Ladies who must wear certain fashionable boots should as a preliminary measure, have the three middle toes amputated. The operation would add to their comfort, would render their gait not one whit more awkward than it is at present, and would be but a very little less sensible than the Chinese practice of deforming the feet in infancy.
Treves, F. The Dress of the Period in Its Relation to Health: A Lecture Delivered on Behalf of the National Health Society. London, 1884.

Would you amputate three of your toes to fit a narrow shoe? Me neither, but maybe Treves had a point about the awkwardness of the gait. It’s not just awkward, it’s dangerous.

The puzzle is that we have known about this problem for centuries, but continue to do very little about it.

What can we do? We can treat it as a public health problem.

Although some ancient Greeks and Egyptians used to wear thick-soled clogs, Europeans have been wearing high heeled shoes in more or less their current shape since technological advances at the end of the 16th century brought in the stacked heel. Since the 19th century, most high heel-wearers have been women. For 250 years or more, doctors like Treves, following in the footsteps of 18th century orthopaedists and anatomists Winslow, Andry, and Camper, have wearily berated their patients, and published books and articles saying the same thing. In 1927 the Massachusetts Institute of Technology and the American Posture League made a film recommending wearing lower heels to keep good posture and avoid shortening of tendons. By 2015 there were over a hundred bio-mechanical studies showing negative effects of wearing high heeled shoes.

At each stage, however, the medical profession tended to blame the problem on modern fashions instead of wondering why it had persisted so long. (Chinese women had known about and welcomed the introduction of high heeled shoes as a foot-binding alternative.) Marc Linder and Charles Saltzman argue that this kind of ‘professional amnesia’ in which doctors kept ‘reinventing the diagnostic wheel’, focused too much medical attention on the biomechanics of the foot and not enough on why so many women were wearing them.

Wearing high heels is bad for you. High heel-related injuries have increased in the last decades as heel heights have risen. US figures show a doubling of such injuries treated in emergency rooms between 2002 and 2012, mainly among women aged 20–39. Prevalence rates reached nearly 20 per 100,000 women in the 20–29 age group. This does not include long-term aches and pains from a lifetime of wearing heels. In 2016, the first systematic review of the literature, published in the British Medical Journal, found that wearing high-heeled shoes was significantly associated with musculoskeletal pain, bunions and certain kinds of lower-limb injury.

In spite of these health risks, women are still encouraged or expected to wear high-heeled shoes at work and in social situations. It is difficult to find accurate figures, but US estimates suggest just over 70% of women wear high heels at some point in their lives, and over 40% of women may wear heels on a daily basis. For the 18–30 age group in the UK, a recent study found that 76% wear heels at least weekly, and nearly 20% wear them daily.

High heels are a public health problem.

Why has it taken us so long to understand this? In one of his Revisionist History podcasts, Malcolm Gladwell reminds us how long it took for health risks associated with smoking and coal miners’ asthma to be quantified and addressed as public health problems. Taking the example of American football, he explains how a growing number of player deaths are now being linked to frequent, pre-concussive brain injuries sustained during play. Because these deaths, often suicides, may happen years afterwards and outside the college environment, the connection between cause and effect has been difficult to identify and to quantify. Because college football participation burnishes student CVs and job prospects as well as college finances, many players, college administrators, and even parents, still position football at the centre of college life, and defend students’ right to play the game of their ‘choice’. For all these reasons, it is difficult to envisage the banning of college football even when it may carry significant risks.

So, what prospects for downscaling the stiletto trend, beloved of Carrie Bradshaw and Melania Trump? We have the data, but is there the will to challenge employer dress codes, and impose public health standards on heel heights? Can we make high heels less central to women’s social success and sexual identity? Can we improve the health prospects of young girls who want to act ‘grown up’?

Legal challenges have been difficult, especially where company dress codes are not written down, but informally enforced (as with the red carpet rule in Cannes).

Although worker activism has led to reductions in heel height requirements in some airlines and casinos, there has been very little litigation on this matter in the US. In the UK in 2017, Parliament collected evidence and debated a petition signed by 150,000 people protesting the dismissal of Nicola Thorp, a young woman told to leave a temp job for refusing to wear a 2–4 inch heel. Disappointingly, the UK Parliament ruled that the law against gender discrimination was adequate: what was needed was simply more information for employers and better monitoring. In contrast, the Canadian province of British Columbia has specifically prohibited employers from requiring female staff to wear high heels.

Publicity, activism and changing public opinion has prompted employers to change, even where laws are fuzzy. Women facing the requirement to wear heels at work more than halved in the year since the UK Parliamentary commission, according to a recent study. Only 8% of women 18–30 now regularly wear heels at work. A third of these women would have preferred not to, but 20% felt social pressure, and 13% were required to wear heels. High heeled shoes are still big business, but sales are down this year. Sneakers have increased their market share of sale by 37% in the US, while high heel sales have decreased by 12%, and shoe companies are expanding their lower heeled shoe ranges.

Why do we continue to wear heels at all? Shoes are not just a covering for our feet, but a social signal: a very accurate predictor of age, gender, income and (rather weirdly) also attachment anxiety. Wearing heels is sexy: it makes women seem more attractive, by reducing the stride length and increasing the rotation and tilt of the hips. Women in heels attract more attention, particularly from men, who seem more willing to approach, listen to or answer questions from higher-heeled women.

Increased attention has commercial value for employers and, for the same reason, many women choose to wear heels in social settings even when they hurt. For this reason, the UK study did not show a significant reduction in heel wear for social occasions among 18–30 year olds, even as work use decreases. Elisabeth Segran writes that the continued pain and popularity of the high heel has led feminist entrepreneurs to try and design more comfortable heels.

For the major players, here’s the kicker: why are high heeled shoes still treated more as a work of art and design than as a functional product, when we know they create health problems and can even injure others? We test pills and sportsgear for safety, but not stilettos. Why not?