Tackling Hermeneutical Injustices in Gender-Affirming Healthcare

As any trans person will tell you, it is a scary time to be living in the UK. One reason is that gender-affirming healthcare is becoming increasingly hard to access. In December 2024 the Health Secretary made a ban on prescribing puberty blockers to trans adolescents permanent, following the recommendation of the deeply flawed Cass Review. This ban has been criticised by several relevant professional bodies, diverges significantly from the consensus on best practice in peer countries, and flies in the face of decades-long histories of these drugs’ safe and effective use.

                                               
           

As a result, trans adolescents are being forced against their wills to undergo puberties distressingly at odds with their gender identities. Simultaneously, trans adults hoping to access gender-affirming healthcare from the NHS are being made to wait several years for their first appointment at a Gender Identity Clinic (GIC). These long wait times are taking a considerable toll on their mental and physical health. Moreover, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is no longer always sufficient since some GPs are unilaterally refusing or reversing GICs’ recommendations to prescribe hormones to their trans patients.

  

Trans identity and hermeneutical injustice

In addition, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is not always easy. Doing so is a matter of a patient rendering it intelligible to these (usually cis) doctors that they are indeed trans. This can prove difficult when the relevant doctors employ overly-narrow conceptions of transness. For instance, gay patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to be straight. 

Similarly, non-binary patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to identify as either a trans man or a trans woman. Moreover, that doctors sometimes work with such overly-narrow conceptions is a result at least in part of trans people having been deprived of opportunities to shape how people think about transness. In sum, trans adults sometimes suffer hermeneutical injustices when attempting to access gender-affirming healthcare from the NHS.

What can be done?

What should be done to prevent such hermeneutical injustices? In a recent paper, I distinguish between two sorts of strategy that might be pursued to this end. Interests-as-given strategies would take for granted trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and aim only to enable them to satisfy these interests. For instance, we might look to educate the relevant doctors or to engage in political activism aimed at propagating better-fitting conceptions of transness. 

All previously proposed strategies for preventing hermeneutical injustices are of this sort, yet it is sometimes possible to go about preventing hermeneutical injustices very differently. An interests-in-question strategy would instead look to do away with trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and thus with the possibility of these interests’ unfair nonsatisfaction. 

Consider that trans patients only have these interests in the first place because the prevailing gatekeeping model makes it a requirement on the provision of gender-affirming healthcare that trans patients first convince the relevant doctors at a GIC of their need for it. I argue on grounds of trust, privacy, and respect that the NHS ought to cease making this a requirement. One way to do so would be by switching to an informed consent model, under which pretty much all that a well-informed adult capable of consent would have to do to access gender-affirming healthcare would be to ask for it – an example of a more materialist strategy for preventing hermeneutical injustices. 

Unfortunately, in a time of intense anti-trans backlash it seems unlikely that the NHS will make such a progressive move anytime soon. We thus may need to think about what else can be done to prevent such hermeneutical injustices in the unjust meantime.

Nick Clanchy is a Postdoctoral Research Fellow with a joint appointment at the Canada Research Chair on Epistemic Injustice and Agency (UQAM) and Le Centre de Recherche en Éthique (UdeM) in Montréal, where they are also a member of the philosophy department at McGill.

Most of Nick's work is dedicated to thinking about hermeneutical injustices. They also have research interests in trans philosophy, the philosophy of love, and the work of a number of figures on the margins of philosophy - especially Roland Barthes. 

More about Nick and their work can be found here.

Workshop report: Loneliness, Metaphor & Empathy

Last week, Project EPIC held a workshop at the University of Nottingham entitled 'Loneliness, Metaphor & Empathy'. This workshop featured three talks by Project EPIC postdocs Fred Cooper (Bristol), Kathleen Murphy-Hollies (Birmingham) and Eleanor Byrne (Nottingham). 

The workshop theme reflects some current research interests of the project postdocs. All three talks teased out varieties of epistemic injustice that can arise when certain forms of suffering are marginalised by others. Fred asked what epistemic injustices might be at stake in claiming that certain experiences are inherently unknowable, Kathleen discussed the role of various prejudices in shaping how uptake-worthy we take people's claims to be, and Eleanor discussed the extent to which attempts to empathise with others can result in epistemic injustices.

Fred began the day with his talk The Naked Terror: Joseph Conrad, 'True Loneliness' and the inability to know. Fred discussed themes of loneliness in Conrad's Under Western Eyes where there is an implication that loneliness--or rather, 'true loneliness'--is characteristically unknowable. He gives us the following quote:

Who knows what true loneliness is-not the conventional word, but the naked terror? To the lonely themselves it wears a mask. The most miserable outcast hugs some memory or some illusion. Now and then a fatal conjunction of events may lift the veil for an instant. For an instant only. No human being could bear a steady view of moral solitude without going mad. 

Fred Cooper

Fred argued for a closer historical interrogation of the ways that epistemically  unjust or constraining narratives on health and ilness are sustained over time.

Kathleen then talked about metaphorical meaning and giving 'uptake' to the experiences of people with delusions and various other false beliefs. She argued argued that the content of what people say is often over-scrutinised for accuracy and truth, and that these tendencies are often exacerbated by prejudices.

Kathleen Murphy-Hollies

For example, she mentions how the claims of asylum seekers are often over-scrutinised for truth and accuracy as a result of certain prejudices. Ultimately, Kathleen's position is that even when we highly doubt that a certain belief expressed is true, there are still possible meanings to give uptake to in our engagement with them. Kathleen argued that dismissing those meanings can constitute a form of epistemic injustice, and that giving uptake to metaphorical meaning is a way of engaging with the agents' best attempts to communicate their experiences.

Some members of Project EPIC (L>R; Alice Monypenny; Fred Cooper; Ian James Kidd; Eleanor Byrne; Kathleen Murphy-Hollies)

Eleanor Byrne then closed the day with her talk about empathy. Drawing on ongoing collaborative work with Allan Køster (Danish National Centre for Grief), Eleanor discussed the limits of empathic understanding in contexts of profound suffering. She engaged with recent critiques of empathy which state that certain experiences are too alien, too profoundly catastrophic, to be understood by others. She concedes that some experiences can evade understanding, but maintains that some basic form of empathy remains possible no matter the circumstances at hand. This, she called ground empathy. 

Eleanor drew on a passage by Georg Simmel in order to argue that no matter the profound difference in your circumstances, it is always possible to empathically relate to the other person by attending to the fact that we all share the same existential fragility. Simmel writes:

All the thoughts and fates that make us suffer are actually only the occasional causes that bring about a part of the infinite potential for suffering that is inherent in us. [...] The most uncanny thing is that on such occasions we get the inkling of an immeasurable store of suffering that we carry around with us as if in a sealed vessel; a dark being that is not yet reality, but is still there somewhere, from which fate always releases certain parts, but leaves behind an inexhaustible amount. Most of the time this vessel rumbles quite quietly within us, but sometimes, when a single misery or shock opens it, it starts to move, to tremble dully, and we feel – we ourselves do not know where or what it means – this terrible treasure of potential suffering that we carry around with us that is our dowry, which can never be fully realised, cannot be exhausted by any real misery.

(Simmel 1923, Fragmente und Aufsätze)

Eleanor takes this passage to be illustrative of the inherent fragility that lies within all of us, waiting to be made salient by misfortune. It is by attending to these facts of life, the contingency of our position, that we are able to empathically relate to (if not understand) others in times of catastrophic upheaval, illness and suffering. 

This was the first official Nottingham event for Project EPIC. Keep an eye out for updates and adverts for upcoming events across Nottingham, Bristol and Birmingham.

Credibility attributions in healthcare

In this post, Kathleen Murphy-Hollies interviews Carme Isern Mas on a new exciting project, on the cognitive bases of epistemic injustice in healthcare. 

Kathleen: Can you tell us a little bit about your project?

Carme: This is a project funded by a Grífols Research Grant in Bioethics from the Fundació Víctor Grífols i Lucas. The main aim of this project is to explore whether people with somatic and psychiatric conditions are given less credibility than their healthy counterparts due to identity prejudice, and if so, to investigate under which conditions this is the case. To achieve this, we plan to use experimental methodology, particularly through vignette-based studies. 

In particular, we ask whether epistemic injustice in people with clinical diagnoses is influenced by the effect of the label of the diagnosis, the epistemic privileging of scientific and medical evidence, and the effect of the clinical context. We hope that this will allow us to complement the existing empirical evidence gathered through interviews, conversation analysis and questionnaires, among other methods.

Kathleen: Is your project interdisciplinary? How do you think that is helpful/valuable?

Carme: Yes, our project is interdisciplinary, and we believe this approach adds significant value to our research and to the broad discussion around epistemic injustice in healthcare. In particular, we aim to contribute to this philosophical and ethical discussion by exploring one of its main empirical claims, namely, that the testimony of people with somatic and psychiatric conditions is given less credibility than that of healthy people because of an identity prejudice. 

Therefore, our project aligns with the research programs of experimental philosophy (x-phi) and, more specifically, experimental bioethics (bio-x-phi), both deeply interdisciplinary. To that end, our team is composed of qualified researchers, including Alfred Archer, Ivar R. Hannikainen, and myself, with expertise in applied ethics, moral psychology, bioethics and experimental methodology.

Kathleen: What do you hope the project will accomplish/change?

Carme: There is a need for empirical research that studies the scope of epistemic injustice towards people with medical conditions and the factors that contribute to it. This project aims to fill this gap by conducting several studies based on vignettes that manipulate an agent’s kind of medical condition, their specific diagnosis, or the context in which they share their testimony, among other things. 

By examining the impact of these manipulations on credibility attributions, we aim to shed light on the role of negative stereotypes in shaping such attributions. In addition, this project might help us understand how credibility attributions vary in different contexts, including medical and non-medical settings, and across different psychiatric conditions. The results of this research might have implications for healthcare professionals, policy makers, and other stakeholders interested in promoting more equitable and fair practices in healthcare. 

By highlighting the mechanisms underlying epistemic injustice toward people with medical conditions, this study can inform the development of interventions aimed at reducing bias and improving the quality of care for these individuals.

Kathleen: What are the future plans for the project?

Carme: In addition to conducting studies, we aim to disseminate our findings through academic publications, conferences and other relevant platforms. We might also explore potential collaborations with healthcare professionals and institutions to include their valuable feedback and insights in our research.

Carme Isern Mas is an assistant professor at the University of the Balearic Islands, specializing in moral psychology, and applied ethics. 

Her research interests lie in topics such as blame, empathy, moral motivation and self-deception. She is also interested in the bioethics of mental health and the ethics of fame. 

When is dismissing a report an act of injustice?

There is a fable by Aesop called The Stag and the Fawn. The stag scares the rest of the herd with his stamping and bellowing but is terrified by the hound. Aesop tells us that this is a story about courage and cowardice but it can also be seen as a story about power relations in a group. The stag can afford to terrorise the other deer because he is more powerful and more highly respected than they are.

 

The Stag and the Fawn by Aesop  

A STAG, grown old and mischievous, was, according to custom, stamping with his foot, making offers with his head, and bellowing so terribly that the whole herd quaked with fear of him; when one of the little fawns, coming up to him, addressed him thus: Pray, what is the reason that you, who are so formidable at all other times, if you do but hear the cry of the hounds, are ready to fly out of your skin for fear?

What you observe is true, replied the stag, though I know not how to account for it. I am indeed vigorous and able, and often resolve that nothing shall ever dismay my courage; but alas! I no sooner hear the voice of a hound but my spirits fail me, and I cannot help making off as fast as my legs can carry me.

Moral: The greatest braggarts are the greatest cowards.

(Aesop's Fables, 1881, WM.L. Allison, New York)

Consider another story featuring a fawn, mother and father deer, and a mountain lion. Watch the video below, which was produced by Squideo from a script I wrote in order to illustrate what epistemic injustice is.

The Fawn and the Mountain Lion 

When is dismissing another's report an act of injustice? 

Father deer (to Mother Deer and Fawn): It’s late let's go to the lake to get some water before it gets dark.

Fawn (eyeing an acorn in the bushes): Wow I would love to gobble that up! (spotting a mountain lion): Oh no, never mind the acorn! 

Fawn (running to catch up with Mother and Father Deer down the lake): Mommy Daddy I just saw a huge mountain lion behind the bushes! We have to go, it is not safe here!

Father Deer (sceptical): If there was a mountain lion behind the bushes I would have heard the steps… you must have imagined it.

Mother Deer (concerned): I am not sure we should stay. Shouldn't we listen to Little Fawn and get back to the herd? Fawn has never lied to us before! 

Father Deer (in a patronising tone): Calm down, young ones don't distinguish reality from imagination and they always try to draw attention to themselves. (then smiling to Fawn) Why don't you get some water little Fawn, you will be thirsty otherwise! This water is delicious, so fresh!

(Mountain Lion attacks Father Deer and bites his the leg but is chased away by Owl descending on the scene with loud screchees)

Mother Deer (to Father Deer): Are you okay?

Owl (to the viewers): We sometimes dismiss a report when we don't trust the speaker due to some negative stereotype but in dismissing what the speaker has to say we pay a high price. We reject information that can be valuable to us.

Mother Deer: You are right wise owl.  In our herd, females and fawns are never listened to but little Fawn recognizes a mountain lion when he sees one! To dismiss him is not just risky, it is an injustice! He should not be silenced when he has something to say.

In this story, the fawn sees a mountain lion and warns his father that there is danger but is not believed. The reason why the fawn is not believed is important: the fawn is not known for lying, being unreliable, or seeking attention, as his mother points out. However, his father assumes that the fawn's report is not something worth acting upon, based on the assumption that fawns are likely to confuse reality with imagination and to draw attention to themselves. 

As the dismissal of the fawn's warning is motivated by stereotypes usually associated with the young, it is a case of epistemic injustice. Not an isolated case either: mother deer reflects bitterly on the fact that in a very hierarchical society like theirs, the views of fawns and females are often openly disregarded, whereas the views by the dominant males are taken seriously. What are the effects of this?

In the story we see two types of effects. First, the fawn and his mother are saddened and disappointed by the deer's lack of consideration for what they have to say. We can imagine the fawn deciding not to warn his herd in the future for fear of being ignored and ridiculed. We can also imagine the fawn internalising his father's criticism and coming to consider himself as unreliable.

Second, father deer, who ignores the warning, is attacked and wounded by the mountain lion, who runs away only when the owl screeches loudly causing a commotion. Ignoring the warning caused him harm as he could not avail himself of important information that would have prevented the mountain lion's attack.

The story is so short that there is no time to explore the further consequences of the event and the development of its characters. However, it shows some interesting features of epistemic injustice, including the pervasive and harmful nature of unquestioned stereotypes and the fact that it harms the vulnerable person whose report is dismissed but also, more subtly, the powerful person who dismisses it.

Young people are often thought to be lazy, immature, lacking resilience, and seeking attention. They are often called "snowflakes" and "drama queens" in the press. These are not harmless stereotypes as they may affect the likelihood that we listen to what they have to say and take their testimony seriously. Their capacity to acquire and share knowledge is even more severely challenged when they experience mental health problems, as their reports may be taken to be a product of their illness as opposed to a reflection of their experiences.

This is what interests me about EPIC, our project on epistemic injustice in the healthcare context: how we can make sense of the dismissal of young people who experience mental health difficulties, and how we can stop it.

This post is by Lisa Bortolotti, who is a Professor of Philosophy at the University of Birmingham and an investigator in EPIC. Among other things, Lisa creates and gathers resources to bring philosophy to everyone at The Philosophy Garden, where you find the video of The Fawn and the Mountain Lion and other videos on a number of timely issues that deserve attention.