“How can you stand those women??” Understanding the dislike of fibromyalgia patients as epistemic injustice and epistemic dysfunction

In today's post, Davy Tennison unpacks the role of medical dislike in the treatment of fibromyalgia patients. 

Fibromyalgia (FM) is a chronic illness primarily of pain and fatigue. The illness is contested and lacks legitimacy, and FM patients lack credibility in medical spaces. A recent study in UK FM care found that doctor-patient relationships are often fraught and unproductive, with patients not believed or listened to (epistemic injustice). FM patients are also vulnerable to structural epistemic injustice that points to epistemic dysfunction in the medical system. Essentially: “No one wants to look after the fibro patient.”

I think this epistemic injustice can be understood as mediated by dislike. Specifically, a dislike-disgust-distrust feedback loop that furthers dislike of FM patients and further undermines their credibility. This feedback loop also invites moralising attitudes towards patients and punitive reactions that I call Doctor Knows Best moves.

Dislike-disgust-distrust feedback loop

Negative reactions from healthcare providers regarding FM patients include:

“They should all be shot”, “Let’s hope she doesn’t come back. I can’t stand her, she’s a fibromyalgic”

“They are patients… towards whom I feel rejection”, “Oooh how can you stand those women??”

“I always have this doubt […] It’s like you want to shake them and say: [pause] 'Snap out of it already! '” These examples display a range of feelings including dislike, disgust and distrust – but how are they connected?

FM is stereotyped as a women’s illness so I could talk about cultural and misogynistic, links between women’s bodies and disgust – but as I don’t want to play into the undue feminisation of FM, I’ll focus on viewing disgust as the emotion of social rejection. Disgust reactions change how we view and treat others. And when combined with other prejudices (such as towards social groups) it can cause us to not only dehumanize others but see them as immoral. This is where distrust comes in. People triggered with a disgust reaction have an aversion to those who violate norms, seeing them as suspicious and untrustworthy.

How are FM patients norm violators? Briefly, FM patients can’t be cured and seldom get meaningfully “better” – which denies the doctor the role of healer. The doctor also likely knows very little about FM, and in fact patients often feel forced into a “patient expert” role – upending the usual role of who have the epistemic high-ground in the relationship.

So, FM patients, as norm violators, are disliked, found disgusting, and moralised against. And that moralising takes the place of distrusting and disbelieving them (seen as epistemic injustice). There is a punitive side to disgust, as the motivation to act morally comes with the motivation to punish those who do not.

These actions are also likely viewed as moral because in our dislike-disgust-distrust framework, FM patients are conceptualised as deserving of, or inviting them. In fact, FM stereotypes echo moralizing sentiments, e.g. views of patients as lazy, malingering, drug-seekers, etc. Similarly doctors label FM patients in ways that position them as morally wrong: noncompliant, difficult, heartsink.

I label these reactions, along with other instances of epistemic injustice faced by FM patients as Doctor Knows Best moves – and conceptualise them specifically as tactics of epistemic oppression.

Doctor Knows Best moves

In “Down Girl, Down Girl: The Logic of Misogyny” (2017), Kate Manne conceptualises misogyny as the policing arm of the patriarchy, and describes misogynistic “Down Girl” moves that serve a punitive, moralising function – shaming women for perceived moral errors. Within a misogynistic environment Down Girl moves punish not just the violation of gendered norms, but any well-entrenched social norm.

A Doctor Knows Best move is a hostile or dismissive reaction from a doctor to an FM patient. It’s epistemic injustice, yes, but its more than that. It’s a kneejerk reaction to protect the epistemic institution of medicine, bolster the doctor’s position, and put the patient back in their place - which suggests an underlying, more systemic epistemic dysfunction in medicine.

This plays out in the FM doctor-patients relationship in ways such as:

Patients commonly reporting doctors sighing, looking annoyed with them, rolling their eyes etc.

Doctors try to avoid FM patients and report referring them away for this reason

On a more structural level, negative stereotypes and judgements of FM patients are passed down in e.g. medical schools (via the “hidden curriculum”.

This is a manifestation of an unjust and broken doctor-patient relationship, and an epistemic dysfunction in the institution of medicine.

It is an issue of epistemic injustice, yes, but it manifests as poor treatment of patients, making it a crucial issue of social injustice for FM patients today. 

Further reading:

Kelly, D. R. (2011). Yuck! : the nature and moral significance of disgust / Daniel Kelly. MIT Press.

Kidd, I. J., & Carel, H. (2017). Epistemic Injustice and Illness. Journal of Applied Philosophy, 34(2), 172–190. https://doi.org/10.1111/japp.12172 

Manne, K. (2017). Down girl : the logic of misogyny / Kate Manne. Oxford University Press. http://dx.doi.org/10.1093/oso/9780190604981.001.0001

PACFiND Study: https://www.abdn.ac.uk/iahs/academic/epidemiology/our-research/studies-list/pacfind/

Davy Tennison is a PhD student in UCL's Science & Technology Studies Department. Their work focuses on chronic contested illnesses, epistemic injustice in healthcare and the doctor-patient relationship.

Likeability, Silence, and Power: Affective and Epistemic Injustice in Perinatal Care

In this post, Cristina Ganz discusses her work with midwives on the epistemic dimensions of reproductive violence.

Over the past three years, Mara Floris, Noemi Paciscopi and I have run a series of focus groups with Italian midwives. What we wanted was simple: to hear, in their own words, how they experience a phenomenon that happens all over the world and that we now tend to call “obstetric violence”.

One midwife told us about Maria (not her real name, of course), a pregnant woman who spent a long time in hospital, reporting severe pain:

I hadn’t been working there for very long, just a few months, but the colleagues’ experience had been like: “They call a lot, they ring for everything!”. She was a woman who, even for a short movement – like coming in to get a fetal monitoring – needed a wheelchair. She was otherwise healthy, and it wasn’t really clear what was wrong with her. Basically, all of us thought it was too much, that there was some kind of discomfort that went beyond physical well-being at that stage of pregnancy.

It turned out Maria had pneumonia: her pain was real, her requests had been entirely reasonable all along. This story is, in many ways, a textbook case of epistemic injustice – and more specifically, testimonial injustice. Maria’s testimony rested on what Lauren Freeman calls epistemic privilege: the direct, first-hand access we all have to our own bodily sensations. Nobody else can feel our pain the way we do. And yet healthcare professionals gave more weight to the medical tests: everything looked fine on paper, and the pain she reported was written off as psychosomatic.

Why does this happen? Cohen Shabot points to a double prejudice. Women are often seen as irrational and overly emotional, a bias historically tied to their reproductive bodies – think of the old diagnosis of “hysteria”, where the uterus was invoked and blamed for pathologising expressions of femininity deemed unconventional. During pregnancy, that reproductive body becomes even more central, and pregnant women end up seen as even more irrational, vulnerable, out of control – incapable, basically, of making sound decisions about themselves.

Rosalind Ekman Ladd made this point back in 1989, using the example of informed consent during labour: women sign it beforehand, but once labour actually starts, they’re rarely allowed to change their mind – as if pain and fear had made them unfit to decide for themselves anymore. Yet we don’t apply that logic anywhere else: a patient with severe burns, in agony, terrified, can still refuse treatment on the spot. So, as Ladd puts it, the issue was never really pain and fear making people incapable of deciding. The issue is whose pain and fear we’re willing to trust.

Miranda Fricker explains this kind of injustice as based on negative identity-based prejudice: it leads listeners to underestimate – or, as José Medina adds, sometimes overestimate – a speaker’s competence and sincerity. What we want to suggest here is a small but meaningful adjustment to that picture. We think identity-based prejudice doesn’t only chip away at how sincere someone seems – it affects, more broadly, how warm they seem. This comes from a different field entirely: social psychology, and specifically the Stereotype Content Model (SCM).

The SCM, developed by Fiske and colleagues, explains how stereotypes shape the way we see other people and groups. Whenever we size someone up, we’re implicitly asking two questions: do they mean to help or harm me, and are they capable of following through? These map onto two dimensions of social judgment: warmth and competence. Warmth covers sincerity, friendliness, benevolence: whether someone’s intentions are good or bad. Competence covers intelligence, skill, capability: whether they can actually act on those intentions.

Put the two together, and you get a fairly reliable map of how we stereotype different groups, and how we feel about them as a result. People we see as both warm and competent tend to earn our admiration and respect. People we see as neither tend to get contempt and hostility. Competent but cold groups often provoke envy, and warm but incompetent groups tend to be met with pity, sympathy, and a kind of paternalism.

This is where the SCM adds something useful to Fricker’s picture. Sincerity is only one piece of something broader: warmth. We’re generally more inclined to trust people who come across as warm in this fuller sense, and more suspicious of those who don’t. And once you look at warmth as a whole, you notice there’s more going on in Maria’s case than sincerity alone can capture. Not only was her pain considered untrustworthy, unlike the medical tests, and her competence cast into doubt, her symptoms dismissed as psychological rather than physical (“She was otherwise healthy… all of us thought it was too much, that there was some kind of discomfort that went beyond physical well-being at that stage of pregnancy”) – she was also seen as demanding, whiny, difficult to deal with (“They call a lot, they ring for everything!”). In SCM terms: low warmth, low competence.

Widening Fricker’s account from sincerity to warmth gives us a sharper lens for spotting exactly where and how credibility breaks down. And that, ultimately, is why this framework matters beyond Maria’s case. Looking at obstetric violence through the combined lens of epistemic injustice and the Stereotype Content Model doesn’t just help us understand what happened to her: it gives us a sharper tool for understanding what happens, more broadly, whenever patients walk into a hospital room and aren’t quite believed.

Suggested readings

Chadwick R (2020) Practices of silencing. Birth, marginality and epistemic violence, in Childbirth, Vulnerability and Law: Exploring Issues of Violence and Control, a c. di Camilla Pickles and Jonathan Herring, London and New York: Routledge.

Cohen Shabot S. (2021) “You are Not Qualified—Leave it to us”: Obstetric Violence as Testimonial Injustice. Human Studies 44: 635–653.

Ekman Ladd R. (1989) Women in Labor: some Issues about Informed Consent. Hypatia 4(3): 37-45.

Fiske ST, Cuddy AJC, Glick P & Xu J. (2002) A model of (often mixed) stereotype content: Competence and warmth respectively follow from perceived status and competition. Journal of Personality and Social Psychology, 82(6): 878–902. https://doi.org/10.1037/0022-3514.82.6.878.

Freeman L (2015) Confronting diminished epistemic privilege and epistemic injustice in pregnancy by challenging a “panoptics of the womb”, Journal of Medicine and Philosophy 40(1): 44–68.

Cristina Ganz holds a Bachelor’s and Master’s degree in Philosophy. She is currently a PhD candidate in Philosophy of Language and Epistemology at Università Vita-Salute San Raffaele (Milan), with a research project titled “Public Policies and Institutional Strategies for Identifying and Countering Misogyny: The Role of Communication in Obstetric-Gynaecological Care”. The project aims to improve communication between pregnant, birthing, and postpartum individuals and healthcare staff, with particular attention to epistemic, discursive, and affective injustice.

Navigating dislike in healthcare: October takeover

In today's post, EPIC's Fred Cooper introduces a series of blogs on like and dislike in health care, and their epistemic consequences.

Image credit: Wellcome Collection

In his famous meditation on general practice in the 1960s, A Fortunate Man, John Berger asked how his subject, Dr John Sassall, can have his measure taken. ‘We find ourselves without a scale of standards for judging or assessing one another’, Berger argues; ‘the only standard which remains is that of personal liking – or its commercial variant, which is Personality.’ Berger liked Sassall – a pseudonym for his own GP, John Eskell – immensely, but he recognised something impoverished and flat in the tyranny of that metric.

Berger’s subject, Eskell, was the kind of GP who thought deeply about his relationship with his patients, and understood the complexities of his role as witness and consoler, meeting the ‘patient’s deep, unformulated expectation of fraternity’ in illness and injury. His apartness, Berger observed, barred him from the benefits of that cultivated – but no less authentic – fraternity, while allowing him to confer them on all of his patients, regardless of his personal impression of them.  

Contrary to Berger’s romanticised view of Eskell, and of general practice more broadly, his contemporaries seemed to have more trouble. In their 1976 study, Doctors talking to Patients, Patrick Byrne and Barrie Long conducted a close linguistic analysis of dozens of tape-recorded medical consultations, paying particular attention to how doctors’ individual questioning styles opened up or shut down lines of enquiry vital to correct diagnosis. While different doctors frequently had entrenched and observable styles, whether paternalist and taciturn, open and curious, or somewhere in between, the researchers also found a significant degree of variation by practitioner. Some interactions were easy, marked by mutual respect; others more abrupt, resigned, frustrated, and these were far less likely to allow the patient to really speak.

Inscrutable in these interviews, there is distinct politics to who gets to be liked by who, or who can and can’t access the kinds of easy geniality increasingly expected to smooth interactions along; what Teow Lim Goh describes as ‘the dehumanising politics of likability’. One curt greeting in Byrne and Long’s study, ‘you again’, gives us one clue to a set of relations probably more likely to fray than most: those between the doctor and the ‘repeat attender’, the frequent patient with no clear physical cause for their troubles. T.F. Main’s 1957 essay, The Ailment, argued that protracted, mysterious, and refractory complaints introduced novel psychodynamic problems into medical care: in his words, ‘the patient’s attendants are pleased neither with him nor themselves and the quality of their concern for him alters accordingly.’ Main discerned a pattern, again in his words, of ‘old unsettled interpersonal scores hitherto unrecognized’, including ‘guilts, angers, envies, resentments, unspoken blamings, alliances and revenges’, ‘shown now to have both animated some of the nursing procedures offered these patients, and to have been concealed behind them.’

We can see some of these concerns surfacing again in the early 1990s, in Darryl Watts and Gethin Morgan’s formulation of the concept of ‘malignant alienation’. Detailing a rapid epistemic and relational breakdown between doctor and patient, which the authors recognised as a common factor in a number of potentially preventable suicides, the article carried the subheading ‘dangers for patients who are hard to like.’ This marked a subtle – but vital – shift in emphasis on who, precisely, is bringing their baggage into the consultation room.

The next three entries in the EPIC blog unpick questions of dislike – and their epistemic consequences – across three significant pressure points in healthcare. Cristina Ganz, in her work on midwives and obstetric violence; Davy Tennison, in their research on the medical dislike of fibromyalgia patients as epistemic injustice and epistemic dysfunction; and Hugh Robertson-Ritchie, in his reflection on ME/CFS and the frictions generated by incompatible aetiological interpretations. The essays address an area of experience which has so far been black-boxed by epistemic injustice researchers, being supposedly too unknowable or idiosyncratic to make any kind of systematic sense from. Attending critically to like and dislike can take us further than simple bad luck, revealing significant – and unjust – disparities in experiences or outcomes that might otherwise elude analysis.

John Berger and Jean Mohr. 1967. A fortunate man. The story of a country doctor. London: Allen Lane.  

P. Byrne and B. Long. 1976. Doctors Talking to Patients. London: HMSO.

Teow Lim Goh. 2019. The Dehumanizing Politics of Likability. Los Angeles Review of Books. August 21. https://lareviewofbooks.org/article/dehumanizing-politics-likability/.

T. F. Main. 1957. The Ailment. British Journal of Medical Psychology, 30: 129-145. https://doi.org/10.1111/j.2044-8341.1957.tb01193.x

D. Watts and G. Morgan. 1994. Malignant alienation. Dangers for patients who are hard to like. The British journal of psychiatry: the journal of mental science, 164(1): 11–15. https://doi.org/10.1192/bjp.164.1.11. 

Fred Cooper is a historian of medicine, and a senior research associate at EPIC. He leads an EPIC case study on loneliness and epistemic injustice.