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.

A Young Person's Reflections on Exploring Epistemic Injustice Creatively

In this post Anaya, a member of the Bristol Young People's Advisory Group, reflects on her participation in a creative workshop that took place in July 2026. The workshop explored how young people and children are, or aren't, heard and taken seriously.

'Hope' by Anaya. Her description of the work: 'My artwork's name is Hope. This links to epistemic justice because it shows a child struggling to voice their thoughts because they are silenced in a contrast of a black and white world. The yellow light displayed in their mind is hope because it demonstrates that children have colourful thoughts in comparison to our black and white world so if we listen to kids then it will benefit us. The yellow throughout the art mimics light appearing in the darkness which is symbolic of the hope a child's voice can give'.

I have always been aware that whenever children tend to share information with adults, they get ignored because adults believe they are wiser and more knowledgeable. They disregard kids’ views because of a prejudiced belief that every child is immature and unaware, so nothing they say must ever be taken into account. However, I was not aware that this is known as Epistemic Injustice, so this session educated me.

It was an eye opener to discover more reasons as to why adults do this, like they don't want to take accountability for their actions or they genuinely believe they are superior just because of their age. I believe this is very backwards thinking that needs to be improved, as everyone deserves to feel heard and seen. This session did exactly that, as it accepted my views and made me feel valued.

It allowed me to communicate my message through art and it was truly fascinating to see what powerful messages artworks can deliver. I chose to do an art piece about the contrast of light and dark. This mirrors a child's thoughts because they believe the whole world is dark and inconsiderate as it doesn't listen to them. The child's mind, however, is light because it possesses many great ideas just like adults do. My message is the hope that a child's light will be brought into the world of research, therefore making it better and more inclusive to multiple perspectives and lives.

I enjoyed participating in this workshop because it included other young people and addressed the message directly to us to help us become aware of the epistemic injustice surrounding us. In doing that, it made us all feel very comfortable and empowered. After we each completed our own artwork, we went around in a circle and explained the choices we made and why we did them. I loved doing this because it provided a deeper insight for both the researchers and kids involved about perspectives. The diversity in the artwork helped me understand how my peers see the world and how important it is that those views get heard.

Research tends to focus on adults, so it doesn't always work for kids. Workshops like this help research to move forward and progress because they allow it to become more inclusive to everyone. Listening to kids improves many projects that people are completing, especially if they link to young people. This workshop was truly an amazing experience that allowed me to express my opinions in exceptional ways, so I hope that the people involved know they've truly made a difference!

The workshop Anaya took part in is informing a upcoming EPIC Event: Doing Justice to Children’s Voices Tickets, Tuesday, November 3 • 6:30 PM–8:30 PM |Eventbrite. The event is free and all are welcome! Please register via the link above if you want to join us.

Workshop Report: Trust and the Affective Dimensions of Health and Healthcare

 In this post, Sofia Martellini reports back from a workshop on Trust and Affective Justice at the University of Bristol.

Source: Wellcome Collection

On June 9^th, Project EPIC and the Centre for Health, Humanities and Science co-sponsored an afternoon of guest lectures and group discussions, on the theme of Trust and the Affective Dimensions of Health and Healthcare.

While my talk highlighted one aspect of epistemic injustice in healthcare, the wide range of expertise exhibited by the other speakers brought diverse and interesting perspectives on the meaning of Trust and Affectivity.

Professor Havi Carel opened with a provocation: we walk through the world with a deep, unspoken faith in our bodies. We quietly, blindly believe that we're going to be ok and we are capable of doing what we want with our bodies. Illness has the capacity to shatter this tacit certainty, even more so in critical or end-of-life conditions, where our body becomes uncapable of the most basics of actions. She distinguished bodily doubt in everyday illness  from radical bodily doubt; the kind that sets in at the extremes of experience. Here, continuity collapses entirely, the body becomes entirely medicalized, subjectivity dropping away as the body is treated as an object from those around it. Her discussion of ICU experiences, also sourcing from her own personal experience, where passivity is total and people simply have things done to them, was particularly striking.

Dr Ross Pain then turned our attention to Indigenous healthcare in Australia, where outcomes between white and indigenous people remain deeply inequitable. Different contexts have different ways of understanding and processing pain, and Dr Pain highlighted philosophy’s tendency of overgeneralizing in order to arrive to a theoretical explanation. When philosophical concepts like epistemic injustice travel across different cultural contexts, do they actually fit? His notion of the "fittingness condition" asks us to reckon honestly with the limits of our conceptual tools.

Drawing on my time in the LeTs-Care research project, I argued that informal caregivers are victims of hermeneutical injustice, since they lack the shared concepts to make sense of, and communicate, their own experience. In Mediterranean contexts especially, there is often no culturally resonant word for "caregiver" at all; caring is only a part of family duty, invisible and unnamed. My proposed PhD aims to address this through phenomenological interviews and a broader look at how care appears across different cultures, asking whether these radically different ways of understanding care are given any epistemic recognition in the policies that are supposed to help caregivers today.

Doctoral fellow Anna Pathmanathan then brought the discussion to the clinic and the prescription pad, presenting research on antibiotic prescribing disparities across minoritized ethnic populations in primary care. Combining large-scale data with patient and prescriber interviews, her work surfaces how systemic inequity can hide in plain sight, encoded in everyday clinical decisions. The doctor-patient trust relationship varies across social status, culture and other variables, filled with prejudices and epistemic inequalities: understanding how this complex dynamic works can bring light to the issue of overmedicalization, still much present in the UK.

Finally, Cristina Ganz examined communication-based epistemic injustices in doctor-patient relations, mapping how discursive, epistemic, and affective injustices layer on top of each other in clinical interactions. Her clear framework showed how different ways of addressing patients corresponded to different kinds of epistemic injustice and separating them allows us to understand how to better direct the dialogue between doctor and patient.

The variety and depth of  different interventions showed how an apparently simple concept like trust can be conjugated in meaningful but diverse ways, tied to the notion of epistemic injustice. From the creation of a theoretical concept such as radical bodily doubt, to empirical research projects meant to show trust relationships and the issues of philosophy when applied to real cases of trust loss, epistemic injustice and trust intertwine throughout different disciplines and cases. This event made me realize even more intensely how fundamental interdisciplinarity is for better research and progress, especially in fields where theory and practice come into contact. 

Without culturally specific, in-depth empirical research, philosophers can risk falling into overgeneralization, as Dr Ross Pain showed; on the other hand, through philosophically developed concepts such as epistemic injustice, negative clinical experiences can be better understood. By sharing our experiences and projects, our collective understanding of epistemic injustice, trust and affective dimensions can grow throughout different disciplines, bringing progress and new solutions to epistemic injustice issues all over the world.

Sofia Martellini is a Philosophy PhD candidate at the University of Bristol, supervised by Professor Havi Carel and Wilhelm Dagmar. Her research sits at the intersection of epistemic injustice, phenomenology and ethics of care, with a particular focus on informal caregiving and the hermeneutical gaps that leave carers without adequate concepts to make sense of their own experience. She holds degrees in Philosophy from KU Leuven and Applied Ethics from Utrecht University and has been involved in the LeTs-Care European research project. She spoke at the CHHS & EPIC workshop in June 2026.

Contagion’s complexities: When persuasive theory takes priority

 In today’s post, Veronica Heney considers how skewed hermeneutical resources – in intimations of contagion around valid discussions of self-harm – can frame multiple layers of epistemic injustice.

Self-harm’s relation to culture – to society, to sociality, to cultural texts, to the arts – is most frequently framed through the theory (and ensuing fear) of contagion. From policy to public discourse and academic research, there is a recurrent fear both that seeing self-harm will lead to people beginning to self-harm, and that individuals discussing self-harm with their peers (primarily in healthcare or educational settings) will lead people to begin self-harming.

My assessment of the psychological theories and evidence behind social contagion as a broad theory is that it is not nearly as thorough or well-grounded as the theory’s popularity might lead us to believe. A much-referenced contemporary epidemiological study examined a large dataset and drew conclusions about the relative contagiousness of a wide range of phenomenon from smoking to obesity to depression to divorce to sexuality to tastes in music. This collection of research is repeatedly used to prove that social contagion exists – yet (as acknowledged by the researchers) it only evidences correlation not causation, and fails to account for any number of confounding factors.

Specific evidence on self-harm is similarly patchy. Sarah Chaney has pointed out that initial contagion research focused on the spread of self-harm in hospital wards, and often drew on small samples or used a flawed study design. Nevertheless, publications either drew unduly strong conclusions, or were cited in ways that ignored their limitations and extended their conclusions far beyond institutional healthcare settings.

Despite the flawed evidence base, literature review papers are often published stating definitively that self-harm is contagious. Even more concerningly, this supposedly well-established fact has expanded beyond the interpersonal to incorporate the realm of media and the internet, where conclusions are drawn based on general concepts in social psychology (such as script theory and disinhibition theory) and empirical research on suicide, without any acknowledgment that the state of play with regards to self-harm might be very different indeed.

First, all this epistemically weak evidence is taken very seriously, in part because it is quantitative, and therefore taken to be objective, firm fact. Almost none of this evidence involves in-depth qualitative research with people who self-harm specifically exploring experiences of contagion. As a result, the evidence about self-harm and contagion is knowledge in which people who self-harm function as an object of knowledge, but are never permitted to author knowledge. 

This is, precisely, an example of epistemic injustice. What we know – or worse, what it is taken for granted that we know, but in fact might not be true at all – is knowledge that denies and silences the insight, experience, and expertise of people who self-harm. It is striking how easy it is to disregard people who self-harm, to trust psychology, neuroscience, and other medicalised frameworks and not to question what these approaches miss.

Second, it is important to notice that while this is an epistemic failing, it is one which has very tangible consequences. An interesting pre-cursor to the now widely-discussed social-media ban for young people was the Online Safety Act, which came into effect in 2023. The act introduced an offence which prohibited the deliberate encouragement of self-harm. While the offence itself seemed to prohibit bullying or coercion, it was framed by MPs and by campaigners as a response to recommendations from the Law Commission on the ‘glorification’ of self-harm online, and to recent inquest reports from the deaths of young people who engaged with self-harm content online and later died by suicide. 

I was involved in a campaign led by my friend and colleague Courtney Buckler to encourage lawmakers to specify that the offence would apply only to ‘malicious’ content (which we agree should be prohibited). We felt cruel bullying should be distinguished from other content which might be deemed encouragement – for instance posts in which people shared positive feelings around their own self-harm, or harm minimisation resources designed to help people self-harm safely, and reduce the risk of unintentional serious injury.

The Conservative Party politicians who had proposed the law did not take our advice and we have yet to see what the consequences of this unnecessarily broad law might be. But I worry about how fears of contagion, fears of anything that frames self-harm positively, might be used against people who self-harm to limit what we can say, what we can share, and what we can know. I am frustrated that these fears are built up from so shaky an evidence base, and I am certain that to truly understand how people who self-harm may or may not be influenced by the world around them – by their friends, by social media posts, by TV shows or by anything else – we need to start by talking to them, listening to them, and placing them at the centre of the knowledge we create about self-harm. 

My new project, Re-Knowing Self-Harm, tries to do just that, drawing on a range of different creative methods to rethink the relationship between self-harm and culture. I’ll be running a lived experience reading group around social contagion, and together we’ll decide how we might do research that begins with people who self-harm, rather than leaving them on the periphery of knowledge-making about their own lives.

Further Readings

Chaney, S., 2017. Psyche on the Skin: A History of Self-harm. Reaktion Books.

Christakis, N.A. and Fowler, J.H., 2013. Social contagion theory: examining dynamic social networks and human behavior. Statistics in medicine, 32(4), pp.556-577.

Jarvi, S., Jackson, B., Swenson, L. and Crawford, H., 2013. The impact of social contagion on non-suicidal self-injury: A review of the literature. Archives of suicide research, 17(1), pp.1-19.

Whitlock, J., Purington, A. and Gershkovich, M., 2009. Media, the internet, and nonsuicidal self-injury.

Open letter on self-harm and the Online Safety Bill: A call for caution, nuance, and care - NSUN website

Veronica Heney is Assistant Professor for Medical Humanities at Durham University, and co-lead of the Narrative Practices Lab at Durham Research Platform for Medical Humanities. Her work brings together social science and literary studies methods to explore narratives and experiences of madness and mental distress. She is co-founder and Research Lead of Make Space, a user-led collective which facilitates conversations about more generous, nuanced, and caring ways to support those with experience of self-harm.

Veronica Heney

Acquired Brain Injury and Epistemic Injustice

 In this post, incoming Birmingham PhD student Kate Lynch gives an overview of her research on epistemic injustice and acquired brain injury.

As I began reading the literature on epistemic injustice in healthcare during my MRes, I expected to find work addressing brain injury. Instead, I was struck by its absence. This led me to explore epistemic injustice in relation to encephalitis, through a philosophical analysis of existing empirical research.

Encephalitis is an acute inflammation of the brain, usually caused by infection or an autoimmune response. Although outcomes vary, some people continue to live with long-term cognitive, behavioural, and emotional changes following the illness. For these individuals, encephalitis results in an acquired brain injury, placing it at the intersection of illness and injury, where differing social and clinical assumptions about each category make it a particularly illuminating case.

My MRes explored experiences across both the acute and long-term stages of encephalitis, asking whether they could be understood through the framework of epistemic injustice. I began with testimonial injustice, the idea that identity prejudice can lead a person to receive less credibility than they deserve, or even to have their capacity as a knower overlooked entirely. I argued that this can help explain some of the experiences reported by encephalitis survivors. Assumptions about what it means to live with a brain injury can shape how seriously a person's testimony is taken, while neurobiological evidence is often afforded greater authority. My argument wasn’t that clinicians should rely less on biomedical evidence, but that evidence-based frameworks can sometimes leave insufficient space for survivors' experiential knowledge. When people are disempowered as knowers in this way, testimonial injustice can arise.

I then turned to hermeneutical injustice, the idea that people can be disadvantaged when they lack the shared concepts needed to understand and communicate their experiences. I found this particularly relevant beyond the acute stage of encephalitis. Once the acute stage had passed, survivors were no longer considered to 'have encephalitis' in the clinical sense. Yet there was no widely recognised concept for what it meant to live with its lasting cognitive, emotional, and behavioural consequences. As a result, many people were left without the conceptual resources needed to make sense of this new stage of their lives. Both frameworks are helpful in making sense of disempowerment and failures of self-understanding in the context of encephalitis.

My PhD will build directly on this work. While encephalitis will be an important case study, I want to extend my focus beyond encephalitis to brain injury more generally. Rather than drawing solely on existing empirical research, I hope to work directly with people living with brain injury through semi-structured interviews, using interpretative phenomenological analysis (IPA) to explore how they experience being heard, understood, and involved in their own care.

As I began thinking about the next stage of this research, I found myself reflecting on the question that first drew me to brain injury. I remain keen to explore how epistemic injustice manifests across different forms of brain injury, but I have also become increasingly interested in injury itself. Looking back at my MRes, I realised that the relative absence of brain injury from the epistemic injustice literature reflects a broader tendency within the medical humanities, where injury has often received less philosophical attention than illness.

This has become another motivation for my PhD. Alongside exploring epistemic injustice in brain injury, I hope the project will contribute to a growing conversation about the place of injury within the medical humanities. If injury raises many of the same questions about identity, testimony and lived experience as illness, what might we learn by bringing it more fully into these discussions?

Further readings:

Atkin, K., Stapley, S. and Easton, A. (2010). No one listens to me, nobody believes me: Self-management and the experience of living with encephalitis. Social Science & Medicine, 71(2), pp.386–393. https://doi.org/10.1016/j.socscimed.2010.04.011

Easton, A. (2016). Life After Encephalitis. Psychology Press.

Kidd, I. J., Spencer, L., & Carel, H. (2022). Epistemic injustice in psychiatric research and practice. Philosophical Psychology, 38(2), pp.503–531. https://doi.org/10.1080/09515089.2022.2156333

Kate Lynch is a PhD student in Philosophy at the University of Birmingham and a researcher on project EPIC. She is conducting a case study exploring how epistemic injustice manifests in brain injury contexts. Her broader research interests lie in social epistemology and the philosophy of cognitive science. 

Epistemic injustice, disposability, and disrespect in inquests and fitness to practise proceedings

In this post, Professor Sara Ryan discusses the epistemic problems of public engagement in legal processes intended to facilitate listening. 

Inquest and fitness to practise processes are both fundamentally designed for the public good; the former involving a coroner-led investigation into unexpected deaths and the latter, an examination into the skills, knowledge, character and health of individual health or social care professionals by their relevant regulatory body such as the General Medical Council or the Nursing Midwifery Council. My research with members of the public involved in these processes found that each at times generated avoidable secondary trauma. This finding undermines their aims to safeguard life, ensure accountability, and uphold standards and confidence.

Public members play a central role in these processes, typically motivated by preventing others from having similar experiences. Families come to these unfamiliar spaces as novices with the expectation that their stories and their personhood matter. Instead, disrespect is repeated and amplified. Entangled within both processes is ignorance and epistemic injustice as the knowledge of families is discounted by the coroner and regulatory bodies. For example, coroners may not understand the context of a young autistic person and prioritise the views of an expert witness who works within a medical deficit model, focusing on what was ‘wrong’ with the person rather than their actual life. A fracture is generated between public expectations that they will be listened to and the aims of coroners and regulatory bodies which hold the power to make key decisions about what is and is not included in hearings and how participants are treated. 

The core focus for regulatory bodies is the construction of a robust case against the registrant and ensuring relevant people in the moment are in place to perform their role as witnesses. We found families are subjected to disposability and dismissal; of their evidence in statement form and spoken word, and are consequently treated with a lack of humanity and care. The coroner seeks to answer a small set of questions in relation to the person who died, and while family wellbeing is a central consideration, this does not always translate in practice. Inquests can become overly detached and expert-dominated – a form of technocratic accountability – which means the person who died can be dehumanised and their family excluded from being fully involved in the process of finding out what happened and why.

Accountability and change are key drivers for bereaved families, yet discrediting the person who died, or family members, seems to be an accepted strand of current practices suggesting epistemic injustice can be the default mode of  these processes. Experiences could leave participants so dissatisfied or distressed they questioned the purpose of getting involved. One participant, for example, described her experience as a witness in a fitness to practise hearing more distressing than the death of her child, while another described feeling ‘rock bottom’. 

Both contexts are, in effect, contested epistemic arenas. Overt, subtle and mundane mechanisms, including inequalities around legal funding and epistemic authority, silence families, underlining their overall lack of institutional power. A lack of information, support and expectation management can generate pre-hearing feelings of frustration and foreboding. We found evidence of what Sarah Ahmed calls ‘words that get under the skin as the use of language, or wrong spelling of a name, caused distress. Forms of communication were problematic as the name of the deceased person was spelled wrong and regulatory staff were described as ‘computer people’ offering no dialogue or acknowledgement of the harm participants had experienced. 

We found little evidence of kindness and empathy. Instead, families are expected to endure patterns of micro-violences including the insensitive and adversarial actions of legal representatives and court formalities. The epistemic landscape in both contexts can be further dominated by independent experts’ epistemic privilege in relation to their professional position, regardless of what they know or understand. For example, a lack of understanding of autism, mental health issues or even the Mental Capacity Act was raised by some participants.

We conclude that coronial inquests and fitness to practise hearings, as currently constituted, are inherently unjust. Far from delivering truth or accountability for the public good, they become sites of further dehumanisation, compounding original harm through epistemic injustice, dismissal, disposability and micro-violences. These processes will continue to generate avoidable secondary trauma until systemic reform centres respect, kindness, empathy, and genuine care instead of procedural ends.

Ahmed, S., 2021. Complaint!, Duke University Press.

Ryan S, Ribenfors F, Mikulak M, Coles D. Between epistemic injustice and therapeutic jurisprudence: Coronial processes involving families of autistic people, people with learning disabilities and/or mental ill health. Sociol Health Illn. 2025 Feb;47(2):e13855. https://doi.org/10.1111/1467-9566.13855. 

Sara Ryan is a Professor of Social Care, Manchester Metropolitan University, and her research focuses on the lives and deaths of people with learning disabilities and autistic people. 

Epistemic Injustice in dialogue with phenomenological psychopathology

In this post, Lea Nickel explores the potential and limitations of phenomenological psychopathology for better valuing the experiences of people diagnosed with mental health problems.

Image credit: Wellcome Collection

People who are suspected of having or have been diagnosed with a mental disorder are often stereotyped in ways that undermine their credibility. The concept of epistemic injustice is an important analytical tool for capturing these experiences. Testimonial injustice can manifest itself in the form of prejudiced overgeneralization of statements and behaviour. An example would be when all statements made by a person with delusions are seen as delusional, therefore, interpreted as part of the delusional belief system. 

Another form of testimonial injustice is “diagnostic overshadowing”, which describes the tendency to attribute physical symptoms to a pre-existing diagnosis of a mental disorder. Hermeneutic injustice is fuelled by the dominant status of the third-person biomedical perspective on experiences and the excess credibility of psychiatric knowledge. These forms of injustice not only hinder individual recovery but also contribute to the structural discrimination of people with mental disorders. This highlights the need for a more inclusive incorporation of the experiences of those impacted.

I see phenomenological psychopathology as a suitable starting point for this. Rooted in Husserl's vision of phenomenology as a ‘rigorous science’ that strives for knowledge without preconception, phenomenological psychopathology is focused on the exploration of patients' first-person experiences. By actively bracketing assumptions and deep-rooted prejudices and empowering patients to develop their own interpretative frameworks, the factors contributing to epistemic injustice are reduced. In the following, however, I will examine one possible limitation of phenomenological psychopathology with regard to improving epistemic injustice.

When we deal with epistemic injustice in the psychiatric context, identity biases that affect people because of their mental disorder are central. We call those sanistic prejudices. Sanism, like other “isms”, is based on deeply rooted social constructs and structures that aim to disadvantage or exclude certain groups, and thus contribute to the maintenance of social inequalities. However, forms of discrimination rarely occur in isolation. If a person is impacted by sexism, racism, classism, ageism, ableism, homophobia, or transphobia, then these oppressive mechanisms also operate in the context of mental disorders. 

This can only be captured by an intersectional approach, which leads us to a closer inspection of the “phenomenological reduction” used in phenomenological psychopathology. In general, this means questioning assumptions about the person as well as their symptoms and possible diagnoses, in order to follow Husserl’s call to get “to the things themselves”. This, however, can lead to certain dimensions of experience, such as racialized and gendered experiences, being lost. As a result, differences in experience due to the different situations of those affected cannot be reflected. If the experiences of marginalized people are taken as a basis for knowledge without reflection and without naming the oppressive structures that produced these experiences, these very structures can be re-naturalized. In the context of phenomenological psychopathology, this could be countered through an “intersectional unfolding” as proposed by Spencer (2024). Here, the various social positionings and their effects can be addressed.

An interesting starting point for this is the connection between rationality and femininity. Historically, the feminine – and consequently women – have been pathologized as unstable, hysterical, deceitful, and irrational. What such an intersectional unfolding can look like is shown in Ruth Bankey's paper “La Donna è Mobile: Constructing the irrational woman”. She shows, based on intensive conversations with women impacted by agoraphobia with panic attacks, that their experience can be described as a fear of embodying the hysterical image, characterized by excessive femininity, loss of control, and potential “madness”. While phenomenological reduction carries the risk of perpetuating a kind of ignorance and thus upholding seemingly neutral conditions of experiences an intersectional framework allows clinicians to recognize how overlapping identities shape experiences of distress.

In general, the sexist ideas surrounding mental disorders make it difficult for marginalized people to understand their experiences beyond these discriminatory constructions. Thus, in order to fully analyse epistemic injustice in the psychiatric context, there must be an awareness of the intersections of different axes of discrimination. This addition would facilitate the capturing of different experiences and structures of meaning that arise from different social positions. Not only can phenomenological psychopathology be fruitful for combating epistemic injustice in the psychiatric context, the debate on epistemic injustice can be used to renew phenomenological psychopathology and make it more epistemically just.

Lea Nickel

Lea Nickel is a PhD candidate in the Department of Medical Ethics and History of Medicine at the University Medical Center Göttingen, Germany. Her dissertation is focused on the influence of AI on doctor-patient communication. Her research interests lie in the fields of ethics of AI, empirical ethics and epistemic injustice. She is particularly keen on amplifying patients’ perspectives in the design, evaluation, and implementation of AI-based technologies in medicine. 

She wrote her master’s thesis on epistemic injustice in the psychiatric context: “Reden ist Silber, Zuhören ist Gold. Phänomenologische Psychopathologie im Dialog mit epistemischer Ungerechtigkeit” [Talking Is Silver, Listening Is Gold: Phenomenological Psychopathology in Dialogue with Epistemic Injustice]. In November 2025 she was awarded the Prize for “Philosophy and Ethics in Psychiatry and Psychotherapy” by the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology for a shortened version of her thesis (2026).

When symptoms are silenced: Understanding epistemic injustice in women’s healthcare

In this post, Shame and Medicine’s Farina Kokab explores the epistemic dimensions of her work on women’s reproductive health.

Image credit: Wellcome Collection

Across healthcare systems, women prepare themselves for consultations knowing that the burden of proof often rests on them. Experiences of dismissal are not isolated incidents but reflect a long-standing pattern in which women’s symptoms are questioned, reframed, or minimised. This pattern cuts across chronic pain, reproductive health, and autoimmune conditions, and is intensified for women from marginalised ethnic and socioeconomic backgrounds. What appears, on the surface, to be a communication gap is better understood as a form of epistemic injustice embedded within medical training, clinical cultures, and organisational structures.

Dismissal rarely appears as an outright refusal to believe a patient. It often manifests in subtle behaviours that cumulatively undermine credibility: the shift in tone, the sigh, the avoidance of eye contact, the referral that leads nowhere, or the decade-long delay in diagnosing endometriosis. These are all moments through which women begin to question their own interpretations of their bodies. Within biomedical frameworks that privilege measurable evidence, women’s complex, fluctuating, and often invisible symptoms are easily reattributed to mood, stress, or hormones. Such explanations position the problems within the woman rather than within the condition, leaving her responsible for both her suffering and the failure to resolve it.

This dynamic is particularly stark in reproductive healthcare. After childbirth, women managing tears, surgeries, and complications are frequently sent home with minimal support, relying on limited resources, and the expectation that over-the-counter analgesia will suffice. Requests for help may be interpreted as exaggeration or dependency, reinforcing long-standing assumptions about feminine emotionality. In these contexts, women learn that speaking up carries risk: the risk of being labelled difficult, anxious, or attention-seeking. Silence, then, becomes a strategy for self-preservation, even as it delays or obstructs care.

Epistemic injustice offers a useful lens for understanding these experiences. Testimonial injustices occur when women’s accounts are given reduced credibility because of gendered assumptions about reliability, exaggeration, or emotional instability. Hermeneutical injustice appears when women lack the shared social or clinical language to articulate phenomena such as birth trauma, reproductive coercion, or chronic fatigue. Without interpretive frameworks that recognise these experiences, women struggle to make themselves intelligible within clinical encounters, and clinicians struggle to interpret their narratives in ways that guide action. Dismissal, in this sense, is not merely a failure of empathy but an epistemic harm with direct clinical consequences.

Structural conditions further shape these encounters. Time-pressured appointments encourage heuristic thinking, and organisational incentives prioritise throughput over deliberative listening. Clinicians often face their own emotional burdens when they cannot offer solutions, especially to patients who repeatedly seek reassurance or validation. Intersectionality compounds these challenges: women who are racialised, working class, migrants, or young are more likely to be stereotyped and thus more vulnerable to epistemic exclusion and exhaustion.

Women respond to these credibility deficits with considerable efforts. They rehearse their accounts before appointments, bring advocates to support their claims, modify the way they describe pain, conduct their own research, or seek alternative providers. These adaptive strategies illuminate the labour required simply to be heard and highlight the structural gaps within the system. They show that credibility must be worked for, rather than assumed, and that women often navigate healthcare environments that are neither receptive nor prepared for their stories.

Improving these dynamics requires more than individual goodwill. Listening must be treated as a clinical skill, central to diagnosis and care planning. Women’s interpretations of their own bodies should be given meaningful space, especially in contexts of diagnostic uncertainty. Organisational cultures that support curiosity, collaborative reasoning, and shared decision-making can reduce the epistemic burden placed on patients. Emerging work by female clinicians and advocacy groups demonstrates that alternative models are possible.

Ultimately, attending to epistemic justice is not just optional; it is necessary for safe and equitable care. Recognising women as credible knowers of their own bodies is a foundational step towards transforming healthcare encounters from sites of dismissal into spaces of understanding.

References:

Fricker, M (2007). Epistemic Injustice: Power and the Ethics of Knowing. Oxford University Press

Werner, A., & Malterud, K. (2003). “It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors” Social Science & Medicine, 57(8), 1409-1419

Hoffman, D.E., & Tarzian, A.J. (2001). “The girl who cried pain: a bias against women in the treatment of pain” Journal of Law, Medicine & Ethics, 29(1), 13-27

Farina Kokab

Farina is an experienced Qualitative Researcher with an interest in theoretical and conceptual framing of health inequalities, specifically women’s reproductive health. Her background in Psychology and Social Research enable her to undertake inter-disciplinary research and teaching. She is currently working as a Research Fellow on the Wellcome-Funded project, Shame and Medicine.

Epistemic injustice in phenomenological research in psychiatry

In today’s post, Karlijn van Vlerken summarises a talk she gave as part of the 2025 PhenoLab Summer School in Phenomenology of Mental Health in Foligno, Italy. 

Image credit: Marcus Spiske, Unsplash.

The promise of phenomenological research

Lived experience is increasingly recognized as an invaluable source of knowledge for the field of psychiatry. Voices that were historically denied as epistemic agents are now more often included in psychiatric research, practice, and policy-making, due to the advocacy of psychiatric survivors and activists. Phenomenological research focuses on the first-person perspective, and puts the unique knowledge derived from first-hand experience of a mental disorder at the very centre of the research. 

This way, subjective and lived experiences are prioritized as legitimate forms of knowledge. Phenomenology offers a space to articulate the inarticulable, to express disruptions to our ordinary ways of being, even when they are difficult to put into words. Phenomenological research can therefore identify and address epistemic injustice in psychiatry, helping move towards the realization of epistemic justice (Kidd et al. 2025). However, if not carefully conducted, there are also ways in which phenomenological research can be epistemically problematic. 

Potential problems of phenomenological research

Firstly, we should be aware of the selection bias that is often present in the inclusion of participants for phenomenological research in the psychiatric context. In order to participate in phenomenological interviews, people need a certain level of linguistic and conceptual ability (Scrutton 2017). They need to be reflective, articulate, and comfortable talking about their experience. 

People with learning disabilities or cognitive impairments are often excluded from phenomenological research, both implicitly and explicitly. Ironically, these are traits that are strongly linked to certain mental disorders. This is called ‘elite capture’: the knowledge produced comes from the most privileged participants, while others are left out (Okoroji et al. 2023).  In addition, typically only individuals who recognise or agree with their psychiatric diagnosis are included in the research. 

Another tendency in phenomenological research is the heavy use of technical and very specific language and an over-reliance on metaphor. While this serves a purpose and is to some extent part and parcel of phenomenology, it must also be clear that some people do not or cannot relate to some more complex formulations. You can think of people that have certain cognitive disabilities, but also persons that experience concretism (when figurative language is interpreted literally) who may struggle to grasp the abstract meaning behind complex and metaphorical language.

There are also several epistemic harms that can arise from how empathic understanding is used in phenomenological psychopathology. For example, epistemic co-opting can occur when a clinician or a researcher assumes a level of subjective understanding of a patient's lived experience that they simply cannot possess (Spencer and Broome 2023). In doing so, they co-opt something that doesn't belong to them, which can harm the patient by undermining their role as a self-defining knower. A related risk is epistemic objectification, which occurs when someone is treated merely as a source of information rather than as an epistemic agent with interpretive authority. 

These problems can lead to the empowerment of more educated sufferers, but also to further epistemic marginalization of the experiences of individuals with learning disabilities or other cognitive dysfunctions, or members of other groups routinely excluded from research participation, or vulnerable to exploitation when they are included. In turn, this can tap into different kinds of discrimination and negative stereotyping which can aggravate epistemic harms. 

Pragmatic suggestions 

First, research should facilitate and find creative and artistic ways to evidence non-linguistic forms of expressing experience alongside the linguistic forms that are widely present in most phenomenological research. 

The second thing that can be important to mitigate potential epistemic risks in phenomenological research is to be reflective of one’s own limitations and be transparent about them in research reports. Although it might not be possible to completely overcome selection bias in phenomenological research, it is necessary to be clear about who is and who is not included in the research and why. 

Third, co-production and joint research between experts by experience and academics and clinicians has the potential to contribute towards more level degrees of epistemic agency between all the actors. 

Lastly, in order to prevent epistemic losses, researchers need to put explicit effort into translating their findings into resources and tools that can actually be used by people experiencing mental disorders and that can help them express their experiences and first-person knowledge. 

Karlijn van Vlerken is a PhD candidate at the Erasmus University in Rotterdam, the Netherlands. She studied medicine and philosophy, and worked in psychiatric care for two years. Her current research focuses on phenomenology of postpartum psychosis. 

Alleviating Epistemic Injustice with Strategies from “Science and Values”

This post by Kevin Elliott unpacks the value disagreements that lie at the heart of many epistemic injustices in health care and policy

One of the reasons that epistemic injustice is challenging to tackle in medical contexts is that it can be difficult to decide how to handle situations where non-specialists challenge the views of the mainstream medical community. In some cases, non-specialists may have very important insights, whereas in other cases, they may be guided by misinformation. It’s understandable that medical experts want to resist misinformation, but how can they tell the difference between the two cases?

In an article published recently in Topoi, I argued that recent scholarship in the philosophy of science could help with tackling this challenge. Philosophers of science working on the topic of “science and values” have been exploring the wide array of value-laden choices that scientists make in the course of their research. These choices are value-laden in the sense that they have consequences for society, but they can’t be settled just by appealing to evidence and logic. When non-specialists disagree with medical experts because they are handling these sorts of value-laden choices differently, it suggests that the non-specialists’ perspectives should be taken seriously and explored further. 

Consider three important kinds of value-laden choices: (1) research questions and framing; (2) background assumptions; and (3) standards of evidence. First, non-specialists might approach problems differently from the mainstream medical community because they are asking different questions. For example, Maya Goldenberg contends that most public health experts who make claims about vaccine safety are focused primarily on their overall costs and benefits for society as a whole. She argues that some parents are unconvinced by the experts’ assurances of safety because they are worried that particular vaccines might pose significant risks to their specific children based on their unique characteristics. The parents might accept that the overall costs and benefits of vaccines are favorable for society as a whole, but they might doubt that the experts have adequately studied the risks of vaccines in all sub-populations.

Second, non-specialists might draw different conclusions than specialists because they adopt different background assumptions. For example, sociologist Gwen Ottinger  describes how communities living near industrial facilities in Louisiana have struggled to convince regulators to take their concerns about air pollution seriously. This is partly because of a difference in background assumptions: according to Ottinger, the regulators assume that they should focus on average pollution levels over an extended period of time (say, 24 hours or more), whereas community members argue that they sometimes experience lasting health effects from short-term spikes in pollution over much shorter periods of time.

Third, specialists and non-specialists might disagree because they demand different amounts or kinds of evidence. For example, sociologist Steven Epstein points out that many AIDS activists criticized the U.S. Food and Drug Administration (FDA) in the 1980s and 1990s for being too slow to approve new drugs. The activists felt that the FDA demanded too much evidence before declaring drugs safe and effective, especially considering that AIDS patients were willing to take risks because they were likely to die otherwise.

When non-specialists make these kinds of choices differently from medical experts, it does not automatically mean that the non-specialists are correct, of course. For example, vaccine-hesitant parents might be asking a question that has already been addressed. For instance, experts may have already assessed the risks to children just like theirs and found them to be insignificant. Or the background assumptions accepted by non-specialists might be highly implausible compared to the background assumptions accepted by the mainstream medical community.

Nonetheless, even in cases where non-specialists make implausible choices, clarifying these differing choices can still foster greater understanding and richer dialogues between medical professionals and non-specialists. By clarifying these choices, philosophers of science can help non-specialists communicate more effectively about why they disagree with professionals, and they can help professionals interpret the perspectives of non-specialists in more sympathetic ways. In some cases, medical professionals might even change their minds. For example, AIDS activists ultimately convinced the FDA to adopt an expedited approval process for some drugs, and they altered the ways some clinical trials were designed.

Admittedly, not all cases will turn out as well as the AIDS case. There will be some cases where those who question mainstream medical views are simply misinformed or operating in bad faith. But in order to promote a medical system that combats epistemic injustice, we need to explore ways to promote dialogue and mutual understanding in the face of disagreement. The philosophy of science can help with this task.

Note: This post is adapted from a post written for the blog of the American Philosophical Association, “Threading the Needle: Can We Respect Local Knowledge While Resisting Misinformation?”

Author bio

Kevin Elliott is a Red Cedar Distinguished Professor in Lyman Briggs College, the Department of Fisheries and Wildlife, and the Department of Philosophy at Michigan State University. His research focuses on the philosophy of science and practical ethics, with an emphasis on the roles that ethical and social values play in scientific research, particularly in the environmental health sciences. His books include Values in Science (Cambridge University Press, 2022) and A Tapestry of Values: An Introduction to Values in Science (Oxford University Press, 2017).

ADHD, Attachment Theory and Epistemic Injustice

In this week's post, Bozena Zoric summarises the argument of her recently published book ADHD, Attachment Theory and Epistemic Injustice

When I first started working as an NHS Consultant Paediatrician 30 years ago, I quickly realised that the mothers of children with ADHD that I met faced a serious problem. Their efforts to share information regarding their children's health and development were often misinterpreted because some professionals had negative stereotypes about these mothers. My impression of the mothers was that they were caring women wanting help for their children who were struggling at school. These children had already seen professionals in Child and Adolescent Mental Health Services (CAMHS)  teams. The issues children had were hyperactivity, problems concentrating, impulsivity, and some also had behavioural difficulties. These are all features of ADHD.

The diagnosis given by CAMHS was one of insecure attachment. I realised that children had ADHD, which is a developmental problem. The mothers were blamed unjustly for causing ADHD symptoms through insecure attachment.

Twenty years after I first encountered mother blame in ADHD diagnosis, I embarked on a scholarly journey to review how attachment theory relates to ADHD and appraise the evidence for this injustice towards mothers. I realised that this injustice continues in many different ways to this day.

The origins of attachment theory

Attachment theory originated in the UK in the 1950’s and 60’s. It was described by the child psychiatrist John Bowly, who initially used it as a diagnostic and therapeutic framework for emotionally disturbed children, but it eventually evolved into a theory about personality development. Bowlby said that attachment is an ‘innate process which, in an adequate rearing environment, leads to a stable sense of attachment security’. Attachment security depends on attunement and responsive interaction of a primary carer (in Bowlby’s view, a mother) toward a child, especially in emotional contexts. Sensitive attunement then fosters healthy personality development and provides a blueprint for future relationships.

Bowlby’s ideas about the emotional development of children and personality formation were widely followed in UK psychiatry. Bowlby believed that mothers must be re-educated to ensure the successful treatment of children with developmental and mental health issues. He pioneered family guidance clinics at the Tavistock Clinic in 1946, an institution that remains influential to this day. Bowlby’s followers, such as Alan Sroufe, a well-known attachment researcher, describe a child suffering with poor attachment as ‘a fidgety, impulsive child with poor concentration’.

However, there was and continues to be little evidence that attachment style was related to ADHD. A recent systematic research review by Jean-Francois Wylock and colleagues found no evidence of an association between attachment style and developing ADHD. Other factors, such as associated conditions, cognitive difficulties or contextual factors, were more relevant. They explored this further in an original study, which found that the behaviour and executive functioning of the children influence attachment rather than causing their ADHD symptoms.

 

ADHD and attachment theory in mental healthcare today

Nevertheless, the injustice towards mothers of children with ADHD continues. It is an example of epistemic injustice as professionals dismiss mothers’ perspectives and underestimate their capacity to produce and share knowledge. Having a child with ADHD symptoms, behavioural issues and educational challenges leads to conscious or unconscious prejudice towards them about how emotionally attuned they were to their children.

My conversations with mothers and family members who have been the target of this illustrate the profound self-blame and guilt this can cause.

For example, one mother told me of what it was like after her 10-year-old son was diagnosed with ADHD: ‘it was all my fault and my husband works quite long hours and if there is something wrong with the children it must be me’

Attachment difficulties may not be overtly mistaken for ADHD as often as they were 30 years ago but the parenting courses mothers are expected to attend even before their children are assessed for ADHD are often based on attachment theory, continuing to imply mothers’ blame even though  it is the educational institutions that should change their attitude to children with ADHD and be more supportive of their needs.

A mother of an adopted boy with ADHD, who was presumed to have attachment difficulties and was subsequently diagnosed with autism as well, told me:

I was brainwashed in thinking I need better parenting skills and kept going on parenting courses because I was told Bobby had attachment difficulties [as well as ADHD]. I blamed myself, and I felt blamed and I also blamed his biological parents. But I now know that he has got two genetically determined conditions as both ADHD and autism are in his biological family.

This needs to stop. Blame needs to be replaced by understanding children’s needs, celebration of neurodiversity and support for children with ADHD and their families. Valuing a difference rather than having a deficit and a disorder perspective will lead to a more positive experience of ADHD for individuals and society as a whole. I often use the name ‘Concentration Activity Neurodiversity’ (CAN) when I talk to my patients to emphasise that, with the right support, there should be no deficit or disorder in their functioning. The families with whom I spoke wish for ADHD in their children to be identified early and for the services to provide a just and non-blaming approach in managing ADHD and associated conditions.

Author bio

Bozena Zoritch qualified as a medical doctor from University of Zagreb, Croatia in 1982. She was appointed Consultant Paediatrician in NHS in 1997 and led one of the largest ADHD clinics in the UK for 20 years. She has published in biomedical research before engaging with medical humanities as a PhD student in 2016 at Birkbeck, University of London. She still works for an NHS provider in Surrey as a Consultant in the field of ADHD and autism. She is passionate about ensuring high-quality services for children with neurodiversity through clinical and academic endeavours.