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.
