Epistemic Injustice and Chronic Pain Reports

This post is by Veronica de Souza Campos and Daniel De Luca-Noronha who recently published a paper in the Journal of Applied Philosophy, entitled: Misunderstanding Epistemic Injustice: The Case of Chronic Pain Reports.

Migraine

Our article critiques the prevalent tendency to interpret inadequate medical responses to chronic pain reports primarily through the frameworks of testimonial and hermeneutical injustice. While these approaches—drawn largely from Miranda Fricker’s influential work—illuminate important aspects of the problem, they overlook a crucial dimension: what we term inquisitive inertia. 

Inquisitive inertia refers to the failure of healthcare professionals to actively investigate patients’ reports of chronic pain, defaulting instead to prescribing analgesics and dismissing the case. As we argue, this constitutes a form of distributive epistemic injustice, in which patients are denied access to a vital epistemic good: the right to a thorough and sustained inquiry into their condition.

Our article opens with first-person accounts of chronic pain sufferers who report years of misdiagnosis, dismissal, or inadequate treatment. Many scholars interpret such cases as instances of testimonial injustice (where a speaker is discredited due to prejudice) or hermeneutical injustice (where gaps in collective interpretive resources render certain experiences unintelligible). While these forms of injustice are undoubtedly present, the authors contend that they are insufficient to fully explain the epistemic harms experienced by chronic pain patients.

Testimonial injustice certainly plays a role, particularly for women and racial minorities, who are disproportionately undertreated due to implicit bias. However, chronic pain poses distinctive epistemic challenges that go beyond identity-based credibility deficits. Chronic pain often lacks clear aetiology, resists objective measurement, and disrupts narrative coherence. This makes it difficult to describe, even for patients who are believed, because the phenomenon itself strains linguistic expression. As such, even an attentive and impartial listener may fail to grasp the full significance of the patient’s testimony.

Back pain

Hermeneutical injustice also falls short in some respects. Although the development of richer conceptual resources for pain is important, this alone does not resolve the expressive limitations inherent in chronic pain experience. The highly individual and often ineffable nature of chronic pain resists neat categorization, and the dominant biomedical framework, which assumes a direct correlation between tissue damage and reported pain, fails to accommodate cases where no such correlation exists.

We introduce inquisitive inertia as a distinct and under-recognized form of epistemic injustice in healthcare. This occurs when healthcare providers, despite medical indications, refrain from pursuing further inquiry into the patient’s condition. Instead of investigating, they prescribe and dismiss. Such inertia is reinforced by systemic pressures: fragmented care, short consultation windows, and bureaucratic constraints that discourage deeper engagement.

Addressing epistemic injustice in chronic pain requires more than correcting biases or expanding conceptual resources. It demands structural reform that enables and obliges healthcare professionals to take chronic pain reports seriously and to investigate them with the epistemic diligence they deserve.

Veronica Campos is an assistant professor at the Federal University of Minas Gerais (Brazil) and research fellow at the Jesuit School of Philosophy and Theology (Brazil). Her main areas of interest are epistemology, philosophy of pain, and philosophy of religion. 

Daniel De Luca-Noronha is an associate professor at the Jesuit School of Philosophy and Theology. His areas of interest include philosophy of pain, philosophy of emotions, and philosophy of religion. 

Unusual Experiences and Beliefs

For Mental Health Awareness Week 2025, project EPIC organised a webinar focusing on the harms caused by negative stereotypes associated with people who have unusual experiences and beliefs. Panelists included Martino Belvederi Murri and Fiona Malpass. The event was supported by The Royal Institute of Philosophy and the Voice Collective.

Poster of the webinar

Martino is Associate Professor at the Institute of Psychiatry and Director of the School of Specialization in Psychiatry, working as a clinical psychiatrist in the Acute Psychiatric Inpatient Unit. His research integrates clinical psychiatry with advanced statistical modelling and computational psychiatry, focusing on late-life depression, early psychosis, and psychosomatics. He has a specific interest in depression phenotyping, demoralization, psychosis outcomes, physical activity interventions, cognitive factors, cannabis use.

First slide of Martino's presentation

Fiona works at Mind in Camden as the Project Development and Innovation Lead, which includes managing the Hearing Voices Projects, working with young people, prisons, forensic settings and immigration removal centres, and the London Hearing Voices network. They have a background in psychology and philosophy of mental health, as well as having personal experience of many forms of distress, including hearing voices. They use this in their work to build connections, as well as to challenge the status quo and provide provocations to ways of thinking and working.

What good support looks like
from Fiona's presentation

Both Martino and Fiona discussed whether the notion of epistemic injustice can be usefully applied to the situation of people who experience non-consensual reality, and reflected on the challenges that practices in healthcare and everyday prejudices in friends, family, teachers, and doctors may present for young people who hear voices.

The problem, according to Martino, emerges because we tend to think that if a person is suffering from a psychotic disorder or is experiencing a psychotic episode, then they are not able to judge any aspect of reality. That's a that is an unnecessary and wrong generalization. We see all the time that even when a person has a persecutory experience, they often are able to judge many, many situations. 

The job of the psychiatrist is not to assign a label of normality to people, but to help them by not increasing their suffering, relieving the harms, and reducing the risks. The most difficult challenge is to support a person in a moment of crisis, which might require depriving them for a certain time of their liberty, without negatively affecting their self-perception and their sense of dignity. Even in an involuntary admission, if possible, the person must be involved in decisions concerning their care. A humane care ultimately means respect and mutual understanding.

Forms of testimonial injustice in psychosis
from Martino's presentation

Martino concluded his presentation by discussing the existence of a paradox: although there is increasing attention to ethical and philosophical issues, there are reduced resources. Whereas healthcare professionals aim to do better, they have fewer resources at their disposal to improve care. 

Fiona talked about kind of work they do at the Voice Collective, which is based at London, Camden, but also about the collaboration with the EPIC project, thinking about agency and epistemic injustice, as it relates to young people who hear voices, or have other unusual perceptions or beliefs.

The Voice Collective works across London and the UK more broadly but has also an international reach. The bulk of the work is to support people under the age of 26, and their families, carers and supporters, with an emphasis on young people who have highly stigmatized and potentially overwhelming and distressing experiences. These experiences can be hearing voices, seeing things, tasting things, smelling things, having felt presences, having multiple senses of self, forms of dissociation, paranoia, the list goes on. 

The Voice Collective is established to provide more community grassroots care, coming from a non-clinical, non-pathologizing community perspective and adopting a pluralistic approach where many factors may be considered as relevant to people's experiences.

Factors contributing to distressing experiences 
from Fiona's presentation

They establish peer support groups for young people who have these experiences: one online group for 11 to 15 year olds; and a peer support group for an older age group, 16 to 25 year olds. Young people chat to each other, ask each other questions, and just offer solidarity and friendship to each other. Another activity is to set up advisory groups for research projects or steering groups for service development, because a big part of the Voice Collective approach is trying to help young people be heard and be listened to and have input into things to push back against the epistemic injustice that they face. The aim is to create spaces where young people's knowledge is valued.

Young people are often seen as incapable. There's often an emphasis on young people who hear voices being powerless. Their experiences are often framed as a deficit and part of a severe mental health issue. For some people voices can be massively distressing and overwhelming, but there are times where voices are helpful. Some people have very positive experiences of their voices, and neutral ones, too. So it is difficult for young people who have these less stereotyped versions of voices to talk about them for fear of their voices being seen as something inherently wrong, and an issue with them, and with how they experience the world. The healthcare system can be a very oppressive system to be part of where young people often experience a lot of coercion going along with whatever treatment pathway is recommended to them.

If you want to listen to the full presentations by Martino and Fiona, and follow the question and answer session that followed, watch the recording of the webinar below and let us know what you think.

Hermeneutical Disarmament

Hermeneutical Disarmament: How language change can undermine understanding and communication

Words and phrases enable us to understand the world and our experiences. In Epistemic Injustice, Miranda Fricker reports Wendy Sanford’s experience of depression following the birth of her child in the 1960s. Without a word to name her experience, Sanford thought that she was guilty of a “personal deficiency”. Upon learning the term postpartum depression at a workshop, Sanford’s perspective radically changed; she recognised what she was going through as a medical condition.

Changing meanings

However, words and phrases often change their meaning. Gaslighting refers to a kind of abuse in which one person causes another to doubt their own experiences. In Patrick Hamilton’s 1938 play Gas Light, Jack persuades his wife Bella that she cannot trust her perception or memory; when he takes a painting down from the wall and dims the gas lights, Jack convinces Bella that she is imagining these changes, giving him control over her. More recently, however, gaslighting is used to refer generally to lying or manipulating.

Taking these observations together reveals a problem. Words and phrases help us to understand and communicate about the world and our experiences of it. But the meaning of these words and phrases can change. When this happens, we might lose the words that we need to understand or communicate about whatever it is we want to understand or communicate about. I call this hermeneutical disarmament.

Hermeneutical disarmament

Hermeneutical disarmament: “the process by which a person is rendered less able to understand or communicate experiences, ideas, and other phenomena as a result of semantic change to the linguistic term (word or phrase) that could previously have been deployed for these purposes.” (Morgan 2025: 1076)

When the words we use change their meaning, this can leave us less able to understand and communicate about the original meaning of these words. It is clearly useful for victims of abusive manipulation (and their support network) to have a widely understood term, gaslighting, for this specific kind of psychological abuse. It helps them to understand what the victim is going through, aid existing victims, and reduce the likelihood of future victimisation. If this term disappears, because gaslighting comes to mean simply lying, then a useful tool is lost.

Words naming medical conditions can be similarly useful tools. Without the term postpartum depression, Sanford might have been unable to access relevant support and continued, mistakenly, to view her condition as a person failing.

In other cases, there is a risk that the misuse of medical terms might lead to changes in their meaning, depriving us of useful terminology. Some speakers use OCD (obsessive-compulsive disorder) to describe a particular care for cleanliness or organisation (“My flatmate is driving me crazy; she’s so OCD!”), rather than obsessions and compulsive behaviours that would warrant clinical intervention. Someone might say that they are depressed when they are feeling sad, even when they do not suffer from the often-debilitating psychological condition by this name.

When used literally, these terms serve as useful tools for people experiencing the relevant condition and those around them. They enable a person to understand what they are going through (just as postpartum depression assisted Wendy Sanford), explain this to others, and secure relevant accommodations in work and education. 

When these terms are (mis-)used to refer to something other than the medical condition in question, there is the risk that, over time, these alternative meanings might dominate, so that we lose generally understood phrases for the medical conditions. This would deprive people who suffer from these conditions and those around them of a useful tool for understanding and communicating. So, there is a risk that changes to the meaning of medical terms might inflict hermeneutical disarmament on those who experience these conditions.

Photo credit: Dustin Smith, Skywall Photography

Robert Morgan is a Lecturer and Consultant at IDEA: The Ethics Centre, University of Leeds, teaching mostly at the SWJTU-Leeds Joint School in Chengdu and at Centres for Doctoral Training around the UK. Robert’s research primarily focuses on applied sexual ethics, although he also works on topics in epistemology and metaphysics as these bear on how persons relate to each other. He is currently working on what it means for one person to touch another through something such as clothing (with Will Hornett), and on the value of interpersonal sexual activity.

 

Hermeneutical Sabotage

In today's post, Han Edgoose develops a concept of hermeneutical sabotage by engaging with the predicaments of transpeople in the UK.

As Nick Clanchy has said in a previous post on this blog, it is a scary time to be a trans person living in the UK right now. An April 2025 UK Supreme Court ruling, which defined ‘sex’ for the purposes of the Equality Act (the UK’s major piece of equalities legislation) as ‘biological sex’, has been interpreted by the Equality and Human Rights Commission (EHRC), the public body in charge of enforcing equalities legislation in the UK, as a trans bathroom ban. 

The EHRC’s interim guidance on the Supreme Court ruling not only bans trans people from using toilets and other single-sex spaces and services such as changing rooms and hospital wards that align with their identity, it also allows for them to be excluded from single-sex spaces that align with their sex assigned at birth. By severely restricting trans people’s ability to access toilets this ruling limits trans people’s ability to exist in public spaces and workplaces. 

It also curtails trans people’s ability to ensure their own health and wellbeing by restricting their access to domestic violence shelters and healthcare, and their ability to participate in sports. Shockingly, the Supreme Court judges claimed that this ruling ‘does not cause disadvantage to trans people’. 

The injustice caused by the Supreme Court ruling is not primarily epistemic. However, epistemic injustice is often a contributory factor to other injustices, and it is in this case. There are multiple ways in which the Supreme Court ruling could be understood to be committing epistemic injustice, but I’m just going to focus on one aspect of the ruling: its re-definition of the term ‘lesbian’, which, I argue, amounts to hermeneutical sabotage. 

Hermeneutical sabotage

In a paper published in the Australasian Journal of Philosophy last year, I argued that a form of epistemic injustice I name ‘hermeneutical sabotage’ is used as a tactic by harmful political movements to help them achieve their exclusionary and oppressive goals. Hermeneutical sabotage occurs (roughly) when the widely available conceptual resources for understanding the identity or experience of a marginalised group are actively worsened. 

This can be done in multiple ways, including by introducing new, prejudiced hermeneutical resources and distorting resistant hermeneutical resources developed by marginalised groups. Another way in which hermeneutical sabotage can occur is when particularly powerful people change the meaning of well-established terms, distorting the available hermeneutical resources. This is the type of hermeneutical sabotage that the Supreme Court Committed in their judgement on the term ‘lesbian’.

Hermeneutical sabotage and the definition of 'lesbian'

The Supreme Court ruling embraces the hermeneutical sabotage of the term ‘lesbian’ by accepting a definition of ‘lesbian’ that excludes all lesbian trans women, as well as lesbian cis women who are attracted to all women including trans women. 

According to the Supreme Court ruling, a lesbian is defined as a ‘female who is sexually attracted towards… other females’, (where ‘female’ is understood to refer to ‘biological sex’). This trans exclusionary view of lesbianism was embraced despite the fact that the vast majority of cisgender lesbians in the UK are supportive of trans people, and inhibits the ability of trans lesbians, as well as trans inclusive cis lesbians, to communicate an important aspect of their identity. 

This is a particularly powerful case of hermeneutical sabotage as the ruling encodes the sabotaged meaning of the term into the law. The Equality Act allows those who share a protected characteristic to organise groups and clubs that only include people who share that characteristic and exclude those who don’t. 

Excluding people on the basis of one of the protected characteristics outlined in the Equality Act is otherwise illegal. By defining lesbian in a trans exclusionary way membership clubs that include people who share the protected characteristic of ‘lesbian’ can now only include or exclude people on the basis of the sabotaged definition provided by the Supreme Court. This means that it appears to no longer be legal for a lesbian organisation in the UK to include trans lesbians or cis lesbians who are attracted to trans women. 

The hermeneutical sabotage of the term ‘lesbian’ is an epistemic injustice which inhibits the ability of trans and trans inclusive lesbians to use the word ‘lesbian’ to communicate their experiences effectively. The Supreme Court ruling not only intensifies this epistemic injustice by legally encoding the sabotaged meaning of the term ‘lesbian’, it also enacts further injustices as a consequence of this epistemic injustice that limit trans and trans inclusive lesbians’ ability to meet in organised groups and clubs, showing the clear connection between epistemic injustice and further non-epistemic injustices. 

Author bio

Han Edgoose is a lecturer at the University of Glasgow, where they also completed their PhD. They are a feminist philosopher whose research is focused on the contemporary 'trans panic' in the UK, and broader patterns of injustice and oppression. Their paper 'Hermeneutical Sabotage' is published in the Australasian Journal of Philosophy.