1. Introduction

At the beginning of the 21st century, the growing success of graphic narratives appears beyond debate, as ^{Chute (2008}), among many others, already highlighted over a decade ago. The abundance and diversity of titles available in the market, the introduction of collections by mainstream newspapers, the growing trend of adapting classic texts or even the emergence of transmedia processes, which take the universe of graphic narratives to the cinema or even to video games, for example, reinforce this perception.

This article focuses on exploring the communication potential of this medium, which encompasses both traditional comic strips, popularised mainly in printed newspapers, and graphic novels, often published in deluxe editions. In today’s global media market, what is the reach and strength of this genre? Considering its basic features - the link to popular culture, the blend of visual and textual elements, its accessibility with a supposedly low literacy threshold, and its rapid and widespread circulation - how well-suited is the graphic narrative medium for tackling controversial issues of contemporary societies, like advocating human rights and combating inequality and prejudice?

The comic book anthology Nódoa Negra (Bruise; ^{Lopes et al., 2018}), curated by Dileydi ^{Florez and published in 2018} by the Portuguese publisher Chili com Carne, is the basis for our reflection. It aims to explore the graphic narrative’s potential to represent themes as difficult, complex and ambiguous (^{Williams, 2012}, p. 21) as the experience of pain, specifically female pain.

After a brief overview of the volume under analysis, we explain the concept of graphic narrative as a communication and language form/strategy to explore its capacity for constructing narratives on complex and often conflicting topics. Among these topics, our particular focus lies on female pain, a subject that is frequently rendered invisible or even negated, both within cultural and medical contexts. These issues are illustrated in the last section, where we analyse a set of narratives in Nódoa Negra (^{Lopes et al., 2018}) that have female pain as their main theme, looking at how language (text and image) is used to represent the physical and emotional experience of pain.

By intersecting graphic narrative, representation, and female pain, we hope not only to contribute to a better understanding of the place and impact of graphic narratives in culture and communication studies but also to demonstrate their potential in the medical humanities, a multidisciplinary field that intersects art, literature, and medicine to improve healthcare practices (^{Bleakley, 2015}).

2. Nódoa Negra: Brief Overview

The initiative of Nódoa Negra (^{Lopes et al., 2018}) is credited to Dileydi Florez, who took on the challenge launched by the association Chili com Carne during their annual competition “Toma Lá 500 Paus e Faz uma BD!” (Take 500 Quid and Make a Comic) and coordinated the production of the work, winner of the 2017 edition, and published in 2018 by the publisher of the same name.

As described in the back-cover blurb, the anthology was driven by a “desire to explore the plasticity and different interpretations of pain as a theme” (^{Lopes et al., 2018}), contemplating not only physical but also emotional pain. There were 11 artists (some renowned, some emerging) who accepted the challenge, as did the journalist and literary critic Sara Figueiredo ^{Costa (2018}), who authored the introductory text “Escala Sem Dó” (Scale With No C), the only one written in prose; at the time, all 12 authors were working in Portugal (^{Moura, 2019}). All the stories are graphic narratives - more specifically, comic strips - and are all single-authored, which means that they are the outcome of individual projects by the respective creators, who take up the challenge of representing pain - a particularly complex and difficult experience to express, as explained below - through images and/or text, in a personal and/or fictional tone.

Nódoa Negra (^{Lopes et al., 2018}), entirely authored by women, can be seen as a statement in response to the prevalent male authorship within the realm of comics and graphic narratives, a pattern that extends to Portugal. It is worth noting that the world of graphic narratives, especially commercial comics, is consistently linked to the male universe: both in creation, with a predominance of authors and illustrators, and in consumption, particularly among readers of different age groups. For example, in Variantes: Uma Homenagem à BD Portuguesa (Variations: A Tribute to Portuguese Comics), published in 2022, among the 35 authors honoured, only two are women.

Florez, the driving force behind this collaborative project, endorses this intention to claim a female space as she expresses her affinity for comics created by women and highlights the influence of authors such as Power Paola or Julie Doucet (^{Ribeiro, 2018}). Sara Figueiredo Costa underscores the significance of this project being exclusively created by women, considering the historical invisibility of female authors in comics: “It has mainly to do with a space that is not claimed, and that is often denied” (^{Ribeiro, 2018}, para. 7).

However, according to Costa, this trend has been changing (^{Ribeiro, 2018}). This ongoing change was evident in the 2022 edition of Festival Amadora BD, where efforts were made to provide greater visibility to comics created by women. ^{Moura (2019}, p. 109) further highlights a movement of openness, particularly at the start of the 21st century, with the emergence of new female authors and illustrators, including the work under analysis here. These developments build upon earlier efforts to create female spaces in comics, such as the fanzines Gasp from 1992 or All-Girlz from 2011-2012. However, a quick browse through commercial bookshops is enough to notice the blatant gender imbalance in the authorship of the works displayed on the shelves. Notwithstanding the relevance of the theme of gender representation in the context of graphic narratives, it will not be the main focus of this reflection.

Despite being entirely created by women, Nódoa Negra is not limited to depicting female pain. It offers a comprehensive perspective of an experience that, as Florez recalls, is “common to every human being ( ... ) and it must come to light” (^{Ribeiro, 2018}, para. 1). While some narratives address pain more broadly or metaphorically, others are anchored in the physical and cultural experience of the feminine (namely “Pequeno Almoço com Sísifo” [Breakfast With Sisyphus] by Marta Monteiro, “Distimia” [Dysthymia] by Inês Cóias, “Bons Costumes” [Good

Customs] by Sílvia Rodrigues, “Siento y Sangro” [I Feel and Bleed] by Dileydi Florez, and “O Castigo” [The Punishment] by Bárbara Lopes), portraying experiences such as childbirth, menstrual pain, or the pain caused by the weight of patriarchy. For our purposes, our analysis will focus on these five stories, defined here as graphic narratives.

3. Graphic Narrative as a Form of Communication and Social Intervention Strategy

In this reflection, we adopt the concept of graphic narratives, aligning with ^{Chute (2008}) and ^{Davis (2019}), among others, to encompass the wide variety of media that can thus be classified, including comics. Such narratives adopt a hybrid format, involving verbal and visual resources in a given spatial and time context, involving two forms of reading: textual and visual (^{Chute, 2008}, p. 452).

Comics, in particular, are characterised by the juxtaposition of images and text in a specific sequence, aiming to tell a story or elicit an aesthetic reaction in the recipient, as described by ^{McCloud (1994}, p. 20). The author, however, emphasises the open and unfinished nature of such a definition, always in the process of revision, transformation and reinvention (p. 23).

According to ^{Groensteen (1999/2007}), the basic and essential characteristic, although not sufficient, of graphic narratives would be the “iconic solidarity”, that is, the existence of a set or sequence of interdependent images that can exist independently yet coexist through their association with one another. Hence, the notion of graphic narratives as a communication system becomes highly relevant. It is important to note that the author advocates the prevalence of images over text, asserting that graphic narratives function as a language by encompassing a collection of mechanisms for creating meaning.

Like ^{Groensteen (1999/2007}), ^{Davis (2019}) analyses the perspective of graphic narratives as communication. However, he does not argue for the predominance of image over text. Drawing from Halliday’s approach to the concept of language, which refers to the coexistence of three metafunctions - ideational, interpersonal and textual - the author argues that graphic narratives play these same roles.

Accordingly, the idea of language does not entail the definition of its own syntax, that is, defined grammatical rules, but rather the ability to construct representations of the world and values (ideational metafunction), identities and relations between subjects (interpersonal metafunction) and the organisation and production of meaning (textual metafunction). This approach forms the basis of the so-called systemicfunctional linguistics (^{Gouveia, 2009}).

This description of graphic narratives alone highlights the communicative potential of the genre but does not exhaust it. From the standpoint of culture and communication studies, such media objects are closely associated with the field of entertainment and popular or mass culture, but without neglecting the perspective of humour, satire, criticism and social intervention since they became popular in the pages of newspapers (^{Round, 2014}).

Concerning their reception, there is a prevailing perception that graphic narratives, especially in their mainstream iterations, are designed for a lower literacy level and are easily understandable to a broad audience - which characterises, in a way, popular and mass culture, strongly anti-elitist. This perception is further reinforced by resorting to images, easy-to-read texts, straightforward and linear narratives, and the construction of recognisable stereotypes, where roles of heroes, villains, and victims are readily apparent (^{Chute, 2008}).

Furthermore, associating such objects with entertainment may reduce readers’ resistance to their content. This dimension will be resumed later as we analyse the graphic narratives’ potential to discuss fracturing social issues where consensus is difficult to reach. Before moving forward, it is worth emphasising the significance of the concept of literacy in its broad sense and digital and media literacy, in the strict sense, which requires the acquisition and/or development of analytical and communication skills necessary for life in society in this 21st century (^{Hobbs, 2010}).

^{McCloud (1994}) believes that the essential element of graphic narrative language is the panel, dividing space and time. It forms the first unit of meaning. The sequence and the relation between panels, with the necessary empty spaces built between them, are the thread of the reading - here in the broad sense. Keeping that in mind, ^{Groensteen (1999/2007}) emphasises the active role of the reader, who is encouraged to participate and collaborate in constructing meaning, bridging gaps, and filling in absences within the narrative.

Based on the perspective of social semiotics, as defined by ^{van Leeuwen (2005}), the relation between image and text, which forms a double semantic code, is an intrinsic element in the process of meaning construction. Taken out of its context - that is, analysed separately and regardless of image resources - the text has its meaning potential changed (^{Miodrag, 2011}). ^{Davis (2019}) proposes an alternative approach that acknowledges the combination of text and image, highlighted by the use of the term “image-text” as the focus of the analysis, reintroducing the concept of “utterance” (pp. 278-280), which seems to us the most suitable to encompass the enormous variety of communication strategies compatible with the universe of graphic narratives.

In addition to the commercial versions, there is a large supply of alternative narratives, both fiction and non-fiction, with the release of autobiographical, historical or journalistic works. Examples of such works include Marjane ^{Satrapi’s (2000/2007}) Persepolis, Art ^{Spiegelman’s (1991/2014}) Maus, and Joe ^{Sacco’s (2020}) Paying the Land. In Portugal, the newspaper Público, which regularly publishes graphic novels, recently launched the Coleção Novela Gráfica VI (VI Graphic Novel Collection), which includes works such as Ao Som do Fado (To the Sound of Fado) by Nicolas ^{Barral (2021/2020}) and As Paredes Têm Ouvidos (The Walls Have Ears) by Giorgio ^{Fratini (2008/2020}). These works address, each in its way, the period of the Portuguese civil dictatorship, with an emphasis on the repressive and violent role of International and State Defence Police.

This random selection of disparate references briefly illustrates ^{Chute’s (2008}, p. 460) claim as he ponders on the acknowledgement of graphic narratives as an influential cultural vehicle in contemporary times. Moreover, at least partially, it subverts the narrow notion that the literacy level required by this media object would be elementary.

It is well-known that the media field is currently experiencing a period of rapid and profound changes. In this ever-evolving landscape, which increasingly operates in global spaces characterised by the proliferation of languages, cultures, experiences, and sensibilities, graphic narratives seem to adapt remarkably well as a language and a communication strategy (^{Grossberg et al., 2006}; ^{Hall, 1992/2014}).

The accessibility of graphic narrative, common to popular and mass culture, coupled with the relative ease of translation to overcome language barriers, the form’s versatility - which encourages innovation - and the speed and ease of reading, all contribute to making graphic narratives an apt and compatible communication strategy in the present day.

The fast pace of life, the need for constant innovation, the rapid obsolescence of everything (people, products, ideas, values), and the adoption of a somewhat superficial notion of authenticity are some hallmarks of this contemporary world, where attention has become a valuable commodity. In this universe, graphic narratives seem to circulate with a certain ease and captivate a broad and diverse audience, including the younger generation already used to the hybrid and multimodal language of social networks, which combine text and image and incorporate sound and movement.

While graphic narratives’ potential for communication seems indisputable, their ability to promote debate on controversial and complex social issues, including gender issues, namely the representation and recognition of female pain, the focus of this reflection, remains unexplored. To reflect on this theme, we draw on the concept of representation and explore some recurring strategies in graphic narratives. Our interest lies not in exhausting their possibilities but in ascertaining the existence of such an ability.

According to ^{Chute (2008}, p. 459), consistent with ^{McCloud’s observations (1994}), the language of graphic narrative effectively juxtaposes the past and present, thereby challenging traditional and dominant modes of narrative construction. Add to that its ability to blur the boundaries between what can be said and what can be shown, in other words, the possibility of showing what cannot be said and saying what cannot be shown.

Our starting point is acknowledging that any interaction with reality is inevitably mediated. This mediation occurs through language, which is understood here comprehensively to encompass the diverse communication methods that characterise the present day. Thus, based on cultural studies, all language consists of some form of representation, and representing implies the double movement of selecting and cutting (cf. ^{Hall, 1992/2014}; ^{Potter, 1996}; ^{Thompson, 1995/2004}).

That said, the direct corollary of such a statement is that this representation has no possible neutrality. Putting the ontological universe aside and adopting a pragmatic perspective, we are not interested in discussing the existence of an a priori reality, which cannot be apprehended except through representation. We speak here of the socio-discursive construction of reality (^{Potter, 1996}).

Hence the relevance of representation: identifying which representations are constructed, by whom and with what value involves analysing issues of agency and submission and power relations that structure our societies (cf. ^{Castells, 1997/2007}; ^{Hall, 1992/2014}). The power to represent and be represented, and our ability to participate in these processes, shows our social position in this stratified and unequal world we call our own. Indeed, it is not coincidental that ^{Castells (2009/2013}) emphasises the potency of communication in the network society. Nevertheless, this reflection does not align with the current context of the discussion.

The construction of identities, stereotypes, and stigmas is significantly influenced by the communicative context in general and the media in particular - and graphic narratives are part of this universe. The lack of representation of women in commercial versions has already been pointed out, as well as the sexist bias of many of these representations (^{Brown & Loucks, 2014}), but this is only part of the story. Once again, it is crucial to consider the immense diversity of published works. The object selected as a case study in this analysis serves as an exemplar of this vast diversity.

In her research on the representations of gender-based violence in Italian graphic narratives, ^{Mandolini (2020}) explores such possibilities and warns of the risks inherent in representation. The primary challenge is twofold: firstly, how to represent trauma while adhering to an ethical framework that avoids gratuitous depictions of sexist violence; and secondly, how to steer clear of constructing rigid and inflexible roles for victims and perpetrators, women and men, which could perpetuate the notion of women as victims and male violence.

Another notable perspective is the growing use of the language of graphic narratives due to their “recognised narrative and didactic abilities” for disseminating science and academic discourse, as ^{Mandolini and Mookherjee (2022}, p. 3) rightly point out. For instance, they refer to the work of Mookherjee and Najmun Nahar, who published Birangona in 2019. This work compiles a series of guidelines on how to collect oral testimonies related to sexual violence in war situations. In this sense, analysing the comic book Nódoa Negra (^{Lopes et al., 2018}) to explore the representation of pain in women underscores the didactic qualities of this narrative genre in the field of science, namely medicine, where there are several discrepancies regarding the recognition and treatment of pain.

4. Female Pain: Challenges and Complexities

When discussing pain, we are referring to an experience that, despite its transversality and universality, remains a polyvalent concept that is challenging to define, as pointed out by ^{Boddice (2014}, p. 1): while, on the one hand, pain represents an inner state (physiological and neurological), on the other hand, it requires recognition from others. Not only does pain fall into different typologies (physical and psychological), but it also entails a certain experience, expression and recognition, which, in turn, differ according to gender¹.

Regarding the experience of pain, it is estimated that women are more affected by pain compared to men: according to ^{Barbosa and Cardoso (2022}, p. 17), apart from having a higher risk of chronic pain, women are more prone to developing clinical pain conditions such as endometriosis, dysmenorrhoea, among others.

As for the recognition of pain, it is worth noting the gender disparities observed in the healthcare context. In the United States, for example, ^{Banco et al. (2022}, p. 5) note differences in the urgent hospital treatment of women and men with chest pain: women experience longer waiting times and are prescribed fewer tests or drugs. ^{Chen et al. (2008}, p. 415) reported the same type of disparity in acute abdominal pain, namely in the prescription of analgesics, where women are less likely (up to 25%) to be prescribed and administered painkillers.

In the context of Portugal, where approximately 28% of women live with chronic pain, ^{Barbosa and Cardoso (2022}, p. 17) present a comparable situation, as women report experiencing belittlement of their complaints on multiple occasions. ^{Barbosa and Cardoso (2022}) also refer to women’s tendency to accept discomfort and normalise suffering, as they find that pain treatment is inadequate for several reasons: “either because women and some health professionals still neglect pain, or because it is difficult to act on its cause” (p. 20).

This point aligns with ^{Bartley and Filligim’s (2013}) perspective, as they suggest that the disparities between women and men in their recognition and treatment of pain are due not only to biological factors but also to gendered psychosocial processes, including, as ^{Bever (2022}) emphasises, the absence of women from scientific research over time.

It is worth mentioning that the prevalence of distinct gender norms in how pain is experienced and perceived can be one explanation for these discrepancies. ^{Samulowitz et al. (2018}, pp. 5-6) suggest that in the case of chronic pain, these norms are entrenched in an andronormative hegemonic paradigm, whereby male pain is associated with characteristics such as strength, endurance and stoicism, while female pain is understood as emotional and hysterical.

The pervasive influence of gender stereotypes in the recognition and treatment of pain has detrimental effects on both genders, as ^{Barbosa and Cardoso (2022}, p. 17) point out: in men, the assumption of stoicism causes them to belittle their own pain, while women being associated with supposed physical and psychological fragility, risk having their pain undervalued.

Because of this stereotypical approach, female pain is often linked to psychological causes (even when the underlying cause is purely physical) and is therefore discredited. ^{Hossain (2021}) underscores this aspect and states that there is a gap between men and women in recognising pain and that female pain is often negated.

In fairness, the distinction between physical and psychological pain has been widely contested. Based on a study by Eisenberger, Lieberman and Williams, the neuroscientist ^{Panksepp (2003}, p. 237) argues that psychological pain resulting from loss or social exclusion activates the same brain circuits as physical pain. This acknowledges the legitimacy of psychological pain and places it on an equal footing with physical pain.

Meanwhile, ^{Biro (2014}, pp. 53-54) challenges the extent to which certain affective states (such as rejection, grief or loss) might trigger pain similar to that caused by physical injuries. Despite the prevailing interpretation of pain as solely a physical phenomenon, heavily influenced by Cartesian dualism, ^{Biro (2014}, p. 54) emphasises the shift that occurred in the mid-twentieth century when the influence of psychological factors on pain modulation started to be observed.

Hence, the conventional definition of pain has been revised to accommodate its inherent complexities. According to the website of ^{Associação Portuguesa para o Estudo da Dor (Portuguese Association for the Study of Pain; n.d}.), translating the definition presented by its counterpart in the United States of America, the International Association for the Study of Pain, pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (para. 3). However, as ^{Biro (2014}, p. 55) points out, even though this redefinition includes the emotional and subjective dimension, it remains anchored in physical pain. It does not directly account for psychological pain. In fact, in the current scientific discourse, psychological pain is referred to another category (^{Biro, 2014}), that of “suffering” and “anguish” (p. 55), which makes it an oxymoron or a metaphor.

The complexity of pain is expressed in the volume under analysis, namely in the attention that Nódoa Negra (^{Lopes et al., 2018}) devotes to its different manifestations, including a reference to the neuroscientist Jaak Panksepp in the introductory text, “Escala Sem Dó”, by Sara Figueiredo ^{Costa (2018}), who at one point states:

a few reflections later, the blow comes; what hurts us really hurts us, whether there is physical trauma or not ( ... ). No one asks us to quantify the other pains that do not derive from the cut, the physical shock or the damaged organs. “From 0 to 10, how much does feeling completely alone and lost hurt?” If it were asked, and if we tried, we would stumble over the impossibility of the answer and the imprecision of the words. (pp. 7-8)

Besides recognising the legitimacy of psychological pain, ^{Costa (2018}) points out a fundamental aspect of pain by referring to the “impossibility of answer” and the “imprecision of the words” (pp. 7-8): its challenging relationship with verbal language. Thus, referring specifically to severe physical pain, ^{Scarry (1987}, p. 4) argues that, rather than resisting verbalisation, pain destroys language by causing regression to a pre-linguistic state, to the sounds and cries emitted before language learning.

While ^{Scarry (1987}) argues that pain is not only ineffable but also annihilates language itself, ^{Boddice (2014}, p. 1) states that it is possible to express pain but that this expression is inevitably imprecise because it is emotional and subjective. For Boddice, this indefinite translation of physical experience into words, gestures, and art is a way of converting our subjective experiences into metaphors. This process allows us to understand what we feel.

^{Schweizer (1997}, p. 2) also upholds the possibility of representing pain, stating that art and pain are analogous as they both exist in a pre-linguistic space, and their meaning is present in their non-referential dimension, in their subjective temporality and their irreducible specificity. The artistic expression of pain, according to ^{Schweizer (1997}, pp. 3-4), is inherently paradoxical, as it is as impossible as necessary, which aligns with the words of ^{Costa (2018}) in Nódoa Negra regarding the attempt to represent pain:

that may be where the urge to tell stories comes from, with words or pictures or both. And perhaps the will is almost always the need, but the choice of words tends to fall towards the cliff where we best pretend to balance. “From 0 to 10, how much better does it feel to put the pains you cannot bear into a narrative?”. (p. 8)

This brief reflection on pain underscores the magnitude of the challenge embraced by the group of authors, including Costa: to represent pain in its many different manifestations through the hybrid language that characterises graphic narrative.

5. Nódoa Negra and the Representation of Female Pain

As a collaborative project that includes several explorations of pain, Nódoa Negra (^{Lopes et al., 2018}) naturally has some common points. Besides the theme, the absence of colour in the entire volume (except for the front and back covers) stands out graphically, which gives it visual coherence. The choice of black and white also creates a certain sobriety and refinement, suggesting as well a connection with the title - Nódoa Negra translates to “bruise” - as if the narratives were bruises on the skin of the paper.

Another shared aspect is the setting of these narratives, which often take place in indoor and domestic spaces, with a prevalent focus on life’s everyday and mundane aspects. While on the one hand, the preponderance of the domestic, the common, and the everyday refer to the conventional sphere of the feminine, which is here reconfigured into a place of experimentation, on the other hand, and according to ^{Moura (2019}), it creates a space suitable for the representation of pain, a “platform for exposing pain, in its most diverse aspects and implications” (p. 111).

The narratives in Nódoa Negra (^{Lopes et al., 2018}) adopt an inclusive perspective by representing not only different genders but also various age groups and different types of pain. However, given the purpose of our reflection, we have selected five specific stories to analyse the use of the double semantic code text-image to express pain - physical and/or emotional - in women.

The first story under analysis, “Pequeno-Almoço com Sísifo”, by Marta Monteiro, is marked by non-referentiality, not addressing a particular typology of pain directly. Yet this vagueness is not visually matched, as the graphic style is linear and the strips have a symmetrical and sequential pattern (two panels per strip, same size, text and image above, image below; Figure 1), with alternating focus on a bowl of food and a human figure. Although this figure is somewhat androgynous, the upper panels portray a different visual representation of a female body.

There is a tension (and fusion) between the human and animal dimensions, where ants and snails gradually invade the everyday activity of breakfast until ants cover the human figure and the bowl is filled with snails (which, in the meantime, have come out of their shells). Both ants and snails can be interpreted as visual metaphors evoking discomfort, dehumanisation, and a certain sense of repulsion, reflecting ^{Boddice’s (2014}, p. 1) observation regarding the translation of the subjective experience of pain into metaphor.

Among the eight upper panels, six have very brief sentences, almost all of which are erased, and show us the path of a snail. The sentences transcribed here (“Everyday moment”; “I wait impatiently”; “for you to leave.”; “In the morning”; “I’m scared I’m afraid to wake up”; “and have you back.”; pp. 23-29) refer to a repeated and uncomfortable cycle, reinforced by the reference to the mythological figure of Sisyphus. For its part, erasure suggests a struggle to express and hesitation, creating different layers of meaning. This strategy refers to ^{Derrida’s (1967/1997}) use of this term to emphasise the impossibility of closure, that is, of determining a single and final meaning. Furthermore, the elision refers to the challenges inherent in the representation of pain, in line with ^{Scarry (1987}).

As for the sequential images of the snail in the upper panels, the movement and the transformation cycle they represent are worth mentioning. Initially, we see the snail moving, slowly carrying its shell, to at one point abandon it and make room for a female figure, who now carries it (Figure 1). The shell, a symbol of body and home, is here a heavy burden that is (un)burdened daily.

For its part, “Distimia” (pp. 31-37), by Inês Cóias, refers to psychological pain, as the title suggests, which is a persistent depressive disorder (^{American Psychiatric Association, 2013}, p. 168). The central character is female, visible in both images and text. Unlike the previous story, “Distimia” is visually more diffuse, following a less symmetrical pattern, with variations in the inclusion of text; the relationship between text and image is nevertheless complementary.

The story portrays memories of a previous experience when it (dysthymia) imprisoned the character, isolating her in a world apart, marked by emptiness, loneliness and anxiety, with music as her only companion. The suffering is not explicit but suggested by the struggle for expression (“the things I couldn’t tell were buried somewhere else”, p. 35) and the trail of physical violence (“like the hole in the door opened with a hammer that the mother later covered with adhesive paper imitating wood”; p. 35).

As it follows the thread of memory, the narrative is fragmented and episodic, with no clear order of events but several episodes interspersed with analepsis and prolepsis: we begin in college, go through childhood, and end up in the present moment. In this kaleidoscopic journey, there is a deliberate distortion of events, made explicit in words (“the episodes are staged and relived, in an entangled thread of situations that multiply and unfold”; p. 36) and in images, namely in the distorted television at the beginning (as if what follows was a film, also unclear).

Although the story does not follow a diachronic narrative line, there is a closure in the visual circularity created by the repetition of the same organisation of the strips at the beginning and end and by the repeated presence of the eyes. While in the beginning, the eyes appear half-closed, closed in on themselves and the character’s inner world, in the end, there is a metamorphosis in which the eyes are not only open but transformed into an autonomous entity, with leaves and roots that turn out to be wings and allow it to fly freely, suggesting change and liberation (Figure 2) - as if our gaze, what we see and how we see, could set us free.

Also, “Bons Costumes” (pp. 69-80), by Sílvia Rodrigues, focuses on psychological pain, but in a different order. While dysthymia is a disorder resulting from biochemical, genetic and environmental factors (^{American Psychiatric Association, 2013}, p. 170), the psychological pain portrayed in “Bons Costumes” is caused by the corset of patriarchal tradition.

Unlike “Pequeno-almoço com Sísifo” and “Distimia”, “Bons Costumes” follows a clear narrative line, guided by the vision of an omniscient narrator. The story focuses on the character L. (using initials is significant here, referring to anonymity but maximising the potential for identification), a conventional housewife responsible for the household and family chores that take up all her time. However, L. carves out a subversive place of freedom in this domestic space of blurred features, full of grotesque figures (very suggestive of the aesthetics of the painter Paula Rego; see Figure 3): the little room of plants, which she calls a “jungle” (p. 72).

L. received a conventional education, as the narrator reports, based on a rigorous attribution of roles (the woman as altruistic, selfless, “the heart of the family” and of the house, both of which are her sole responsibility; p. 73); however, L. has resisted through plants since her childhood, collecting cacti behind her mother’s back. Later, after she marries, L. takes up this space of freedom. Still, her husband, M., is equally condemnatory of his wife’s idiosyncrasy, criticising her for devoting herself to something that is of no use, that is, to a task that, as a woman, should not interest her.

This subversive need to appreciate the pointless continues when L. moves to the city, now expressed in an obsession with caged pigeons. Like the little plant room, synonymous with domesticated nature, the pigeons represent imprisonment with which L. identifies: “L. photographed the pigeons incessantly like someone taking selfies ( ... ) Maybe it was because, despite all the comforts, they too had no escape” (p. 80). L.’s domestic space is a prison, a cage that keeps her immobile and numb and from which she wants to get out, purposely pricking herself on the cacti to remind herself that she has a body that feels: “the search for a physical pain that would move her away from this constant numbness was nothing new” (p. 78; Figure 3). Imprisoned and voiceless (in fact, the narrator speaks for her), L. resists by projecting herself onto plants and pigeons, also living bodies deprived of freedom.

While “Bons Costumes” focuses on the psychological pain caused by the weight of patriarchy, the following two stories - “Siento y Sangro” by Dileydi Florez (pp. 81-94) and “O Castigo” by Bárbara Lopes (pp. 95-106) - deal explicitly with physical pain in women, namely polycystic ovary syndrome (PCOS) and labour.

Among the narratives in the volume, “Siento y Sangro” is the least ambiguous, using a more referential language underpinned by a linear graphic style and a consistent organisation of four panels per strip. Unlike “Bons Costumes”, this story is narrated in the first person, with abundant use of subtitles and speech, noise and thought balloons; in this story with women and about women, they all have a voice and a speaking space.

“Siento y Sangro” recounts a situation in the past where a mundane social episode - cooking with friends - is interrupted by intense pain caused by PCOS. Despite the prevailing atmosphere of everyday routine, there is an effort to infuse the narrative with seriousness. By setting a specific date (“in November 2017, Nata and Tere agreed to make pizzas and invited me”; p. 82), the author bestows significance upon this occurrence, elevating it beyond the mundane and making it worthy of attention.

Incorporating medical information about PCOS (depiction of the female reproductive system, causes, aggravating factors, and mechanism of action; refer to Figure 4) imparts educational value to the narrative. This transforms it into a conduit for disseminating scientific knowledge, offering an innovative approach to teaching and learning about the disease (^{Williams, 2012}, p. 21).

Moreover, the intersection between first-person narrative and medical information contributes to making female pain more credible, exemplifying the potential of graphic narrative to represent and recognise a painful but often overlooked experience, as stated at one point: when one of her friends asks the main character if she wants to go to the emergency room, she replies: “no, thanks... They won’t do anything but prescribe pills” (pp. 87-88).

Thus, “Siento y Sangro” is likely to raise awareness among healthcare professionals, as it creates a bridge between knowledge about the disease (in this case, PCOS) and understanding of the subjective experience of that same disease (^{Williams, 2012}, p. 21), thus aligning with the purpose of medical humanities: the humanisation of healthcare (^{Bleakley, 2015}). Hence, besides emphasising the potential of graphic storytelling in health, “Siento y Sangro” meets the recent popularity of the concept of “graphic medicine” in the production of graphic narratives, as outlined by ^{Czerwiec et al. (2015}). By materialising a female body that feels and bleeds, intersecting art and medicine, Florez’s narrative contributes to the acknowledgement and knowledge of PCOS, making this experience valid and worthy of attention by those who read it.

In “O Castigo”, this intersection between artistic and scientific language is further pursued, exploring the various dimensions - religious, historical and medical - of labour. The combination of art, culture, medicine, and history stems from using different languages that, nonetheless, do not clash. Lopes provides historical and scientific information through quotations from the Bible (p. 97) and factual references (pp. 98, 102), which not only lends legitimacy to the narrative but also creates cultural resonance.

Of all the narratives, “O Castigo” is the one that includes the most text, which sometimes covers a free space on the page and sometimes is inside the panel. The strips present a variable and organic organisation, interspersing sequential tiers with panels that cover the entire strip. Furthermore, the strong and fluid lines and textured images are open to multiple interpretations. There is, for example, a sequence of various representations of the vulva at different stages of cervical dilation (Figure 5). The sequence, composed of two vertical tiers, each with three panels of dark and light images, shows us various stages of cervical dilation and a gradually intensifying light, which refers to a more poetic designation of labour: giving birth (translated from “dar à luz”, a Portuguese phrase that means “giving birth”, but literally translates into “giving light”).

This alignment between aesthetics, medicine, and history creates a favourable environment for reading the account of a particularly painful experience, labour, and the attempts, over time, to alleviate this pain. As the title suggests, childbirth is seen as a deserved punishment in Judeo-Christian cultures. Drawing on the religious validation of female pain, the narrator lists various attempts to alleviate this suffering over time, from ancient times, with herbal remedies and placebos, to the 18th century, with the use of forceps and substances such as ether and chloroform - attempts that were opposed by the Church, which was averse to the possibility of painless childbirth.

In this timeline, the author highlights Queen Victoria, dedicating two full strips to her, since in 1853, the Queen used sedatives for the first time, administered by a doctor, thus encouraging women to seek medical assistance when giving birth. This episode is depicted in theatre style, as if it were a “story within a story”, using speech balloons in direct speech and English, interspersed with the narrator’s subtitles, as if involving the reader.

However, even in medicine, it was a minefield, evident from the use, at the beginning of the 20th century, of a combination of morphine and scopolamine, which made women aggressive - and, consequently, the target of aggression (pp. 102-103). Consider the image of a woman in labour (Figure 6), flooded with light and pain in the centre of the panel, surrounded by dark and frightening figures (a doctor in the middle, several nurses around) as if they were supernatural (or inhuman) entities.

This landscape has gradually changed, as procedures such as epidural or caesarean sections now allow for less painful childbirth. In the final strip, we come across a more personal reflection: “my grandmothers didn’t have access to these options - no one even asked them whether or not they wanted to contribute to the multiplication of man on earth. It is great to see how much things have changed since then for Eve’s descendants” (p. 106). This caption and the image of a serene woman cradling a baby on her lap bring the narrative to a positive conclusion, contrasting with the initial harshness.

Besides expanding the spectrum of representation of the experience of pain, transcending narrative linearity, the intersection between text-image, personal narrative, medicine, and history in “O Castigo” provides context to the (physical and cultural) childbirth experience. This demonstrates the potential of graphic storytelling for health professionals and, above all, for society at large, as ^{Williams (2012}) argues, by allowing readers to identify with the narrative and encouraging learning.

Despite the shared focus on pain, none of the five examined narratives perpetuates patterns of victimisation or assigning blame. Within these narratives, there are neither heroes nor villains, but women who feel, respond, and navigate different - physical, cultural, and historical - spaces. Drawing from the personal as (inevitably) political, the various experiences represented transcend the limits of the private space of the body by entering the public sphere, serving, in the words of ^{Moura (2019}), as “a scalpel for analysing systemic violence in our societies” (p. 112).

Rather than conforming to the often narrow spaces of comic books for children, the narratives of Nódoa Negra (^{Lopes et al., 2018}) provide a sphere of experimentation and expression, involving the reader in this endeavour. On the one hand, we have the comic book format itself, which calls for an active collaboration from the reader in creating meanings, sequencing panels and filling empty spaces, as ^{Groensteen (1999/2007}) describes. On the other hand, the theme of pain suggests openness and vulnerability, which calls not only for an active reading but also for an ethically conscious reception of the experience of the “other”, as emphasised by ^{Scarry (1987}, p. 6). Hence, it is a responsible reading, in ^{Attridge’s (2004}) conception, a way of reading that, besides calling for action, is welcoming and receptive to the “other” (pp. 130-131). At a time when, as ^{Sontag (2003}) points out, overexposure to the suffering of others creates “compassion fatigue” (p. 111), it is urgent to look at pain with empathy in an essentially creative and imaginative work.

6. Conclusion

The ability and flexibility to construct representations - whether of spaces, characters and/or ideas - provided by the graphic narrative, based on the combination of its language features (“image-text”) and its communication potential, was here demonstrated by the diversity of strategies adopted by the different authors, as well as by the spectrum of interpretations open to readers.

Our reflection contributes to the variety of perspectives on the work under analysis, which has predominantly focused on the issue of the all-female authorship of Nódoa Negra (^{Lopes et al., 2018}) since twelve women seize the power to represent and be represented. It is also important to consider the themes they explore - in this case, female pain - and, as such, to foster the reflection on the (often restricted) position women hold in a patriarchal society.

We hope our interpretation of Nódoa Negra (^{Lopes et al., 2018}) from a multidisciplinary perspective has contributed to a deeper understanding of its texture. Firstly, it illustrates the graphic narrative’s cultural and communicational relevance, emphasising its ability to address issues as complex and difficult to express as grief. Secondly, it demonstrated the potential of graphic narrative in the field of health by opening a forum to debate different perceptions of the body in society. Finally, the specific focus on pain in women brought to light gender inequalities around the recognition, treatment, and perception of pain, thus calling for greater (and necessary) awareness by health professionals and society.