The Dynamics of Epistemic Injustice: Situating Epistemic Power and Agency

Every day in the context of work, school, family, or social interactions, we are constantly using, producing, and transmitting information and knowledge: answering a question, proposing an idea, writing a paper, using concepts and representations to interpret our personal experience or describe social interactions. 

To put it in philosophical terms, we are exercising our epistemic agency: that is, we are doing various things (‘agency’) with knowledge (‘epistemic’), such as using it, producing it, transmitting it. We exercise our epistemic agency successfully when we are adequately believed and understood as a result: that is, when we receive appropriate levels of credibility and intelligibility. However, individual and societal biases – related to our social identity, for instance – can interfere with the exercise of our epistemic agency. 

For example, someone may not believe me or fail to recognize my competence and abilities because I am a woman (i.e., I might receive diminished levels of credibility because of my interlocutors’ conscious or subconscious gender biases); or it might be difficult for me to convey my experience of disability because mainstream interpretive tools, such as concepts and social representations of disability, are inadequate to capture this marginalized experience, which as a result might remain largely misunderstood or misrepresented (i.e., I might receive diminished levels of intelligibility because of societal biases regarding disability in the mainstream pool of interpretive resources). 

Some individuals are given less credibility due to some feature of their identity (e.g. their gender) and this impacts their epistemic agency.

When individual or societal biases give rise to these sorts of credibility and intelligibility deficits, the person thereby faces epistemic injustice. Epistemic injustice is problematic because it undermines individuals’ exercise of their epistemic agency, or their capacity to use, produce, or transmit knowledge, which is central to our everyday lives, interactions, and exchanges.

The foregoing is a very brief and therefore very general glimpse of the large literature on epistemic injustice that has developed since the publication of Miranda Fricker’s 2007 book, which introduced the term ‘epistemic injustice’. My new book, titled The Dynamics of Epistemic Injustice: Situating Epistemic Power and Agency, makes three main contributions to this important literature on epistemic injustice and agency.

As the above suggests, the literature has so far focused on propositional knowledge and verbal modes of expression: oral or written contributions, the (lack of) production, use, or understanding of certain concepts, and so on. Philosophers, however, also recognize other kinds of knowledge besides propositional knowledge (or knowing that), namely non-propositional or experiential knowledge, including practical knowledge (or knowing how) and tacit, embodied, or affective knowledge (or knowing what it’s like). 

The cover of Amandine Catala's
The Dynamics of Epistemic Injustice:
Situating Epistemic Power and Agency.

Yet very little has been said about the non-propositional dimensions of our epistemic agency, or about non-propositional forms of epistemic injustice. This is the first contribution of my book: it provides a pluralist account of knowledge, epistemic agency, and epistemic injustice that takes into account not only their propositional but also their non-propositional aspects.

The second contribution of the book is that it provides a systematic account of epistemic agency and epistemic power. The literature often asserts that epistemic injustice is problematic because it undermines epistemic agency, and that epistemic injustice involves differential allocations of epistemic power. But the literature says almost nothing about what exactly epistemic agency and epistemic power are. Yet many fascinating and crucial questions arise if we want to grasp these two notions more precisely. 

The book offers a systematic account of epistemic agency that specifies its objects, expressive modes, contributing factors, and different stages, as well as a systematic account of epistemic power that identifies three types of epistemic power along with their various sites and mechanisms at both the individual and the structural levels.

Finally, the third contribution of the book is that it starts from case studies that bring up new forms of epistemic injustice. These case studies include deliberative impasses in divided societies, colonial memory, academic migration, the underrepresentation of members of non-dominant groups in certain fields, the marginalization of minoritized minds like intellectually disabled people, and the underdiagnosing of autistic women. 

Examples of the new forms of epistemic injustice that these case studies reveal include meta-epistemic injustice, testimonial domination, hermeneutical domination, meta-epistemic filtering, linguistic epistemic injustice, and existential hermeneutical injustice, among others.

Together, these three contributions yield a more complete and precise picture of epistemic injustice, power, and agency, thereby equipping us to more effectively and thoroughly address problematic yet transformable dynamics of epistemic injustice.

Amandine Catala is a Full Professor in the Department of Philosophy at Université du Québec à Montréal (UQAM), where she holds the Canada Research Chair on Epistemic Injustice and Agency. She is a Senior Research Associate at the African Centre for Epistemology and Philosophy of Science at the University of Johannesburg. Her research interests include epistemic injustice and agency, epistemic repair, neurodiversity, linguistic justice, and decolonization. Her book, The Dynamics of Epistemic Injustice: Situating Epistemic Power and Agency, was published by Oxford University Press in 2025.

Scripts, Standard Minds, and Unjust Treatment in Healthcare Settings

Today's post comes from Gen Eickers and summarises their recent book on social scripts and their importance in healthcare:

In healthcare, epistemic and other forms of injustice are seen when patients’ lived experiences or knowledge are dismissed or undermined, resulting in unjust treatment. One key factor in this may be the role of scripts — specific normative knowledge structures that healthcare providers, for example, apply when interacting with their patients.

How do scripts work? In Scripts and Social Cognition: How We Interact with Others (Routledge, 2025), I argue that social interactions are normatively structured and that scripts, due to their reliance on social norms, provide an apt resource for explaining how we navigate the social world. Social interactions are subject to (context-sensitive) conditions of social appropriateness. 

Scripts allow us to retain extensive information about social interactions—including what is and isn't socially appropriate in each situation. That is, scripts serve as guidelines for social behavior that specify expectations about others’ behavior as a function of their identity, situational context, the cultural setting, and respective roles in that context. 

My script account, spelled out in Scripts and Social Cognition, introduces social forces (i.e., social structures, norms, and roles) to explore what structures social interaction, and to gain an understanding of whether and how scripts are related to social norms, structures, and roles. In so doing, it also sheds light on the ways that social categories, such as gender, disability, and class, impact social interaction. As social norms are stored in scripts, scripts also enshrine various biases. 

These impact our social interactions and the way we understand other people. So, scripts not only capture how to behave as someone in an institutional social role (e.g., an academic) in a framed social situation (e.g., a colloquium), but scripts also capture how to behave as a person with a specific social identity (e.g., a disabled trans man) or social group membership in a specific context. 

This accounts for the social structures in which social interactions are embedded and addresses the issue that members of less dominant social groups (such as queer, trans, Black, disabled, mad communities) are particularly subject to interactive injustice. That is, members of less dominant social groups may often find themselves to not be perceived, interpreted, or treated as equal social agents in social interactions. In this way, scripts can be considered loci of social knowledge, and sometimes they may be loci of unjust treatment.

Scripts that guide interactions in healthcare settings are often shaped by medical norms and cultural assumptions about health, which, in turn, can lead to the (further) marginalization of patients’ voices. Unjust treatment in healthcare settings may arise when the concept of a 'standard mind' is narrowly defined but universally applied. In a lot of healthcare or medical contexts, mental health and health in general is viewed through a standardized lens that excludes many subjective experiences that don't conform to norms around health, and, thus, don't fit this standard. 

When such 'non-standard minds' express their lived realities, their experiences are often disregarded. For a specific interaction within a healthcare setting this might mean: when a patient expresses symptoms that don't align with the standard scripts a healthcare professional has, the patient's account may be dismissed as unreliable, and care may be denied.

Consider, for example, a trans person seeking support by healthcare professionals in order to receive hormone replacement therapy. Healthcare professionals often rely on DSM or ICD categorizations of transness, which define transness via gender dysphoria, i.e., a negatively valenced experience, sometimes even framed as suffering. 

This dysphoria framework is shaped by norms around health and is taken to be the standard model for how trans minds work. But not all trans people experience their transness via dysphoria, or through a dysphoria framework. 

In such cases, the standard scripts applied by mental health professionals don't fit, and as a result, patients may be denied authority over their own experiences; an injustice that disproportionately affects those in multiply marginalized groups. Though I think our minds, standard or not, do have tools to do better: scripts can be combined and adjusted – for example, by gaining awareness of trans realities, different scripts may emerge about how to interact with trans people. The standard healthcare script, thus, may be complemented by scripts pertaining to gender equality.

Gen Eickers’ research is located in the philosophy of mind and emotion and the philosophy of technology as they intersect with social epistemology, social ontology, and trans and feminist philosophy. They  approach philosophical research in an interdisciplinary way, including sociology and social psychology in their work. They work primarily on scripts, social norms, social interaction, emotion, injustice, transness and gender, and social media.

Epistemic Justice in Mental Healthcare

This week we announce the publication of an edited collection which is entirely open access: Epistemic Justice in Mental Healthcare: Recognising agency and promoting virtues across the lifespan (Palgrave 2024), edited by myself, Lisa Bortolotti. The book is an output of project EPIC, featuring eight new chapters exploring epistemic justice in mental health. 

Epistemic Justice in Mental Healthcare

In the Preface (downloadable here), Matthew Broome and I frame the discussion as a way to affirm the role of the mental health patient as a person, an agent, and a collaborator. When we are mental health patients, we are persons because we are more than our health or our diagnosis, we have needs and interests that matter and that affect the way in which our health impacts our lives. 

We are also agents, because despite the vulnerabilities of our status as patients, we have a perspective that matters and the capacity to contribute to positive change. Crucially to the success of clinical encounters, we are partners in the project of addressing our health issues. We can collaborate with healthcare professionals by sharing our experiences and participating in decision making.

Chapter 1, Being understood: epistemic injustice towards young people seeking support for their mental health, is authored by Michael Larkin with members of the Agency Projects team including lived experience researchers from McPin. It addresses some of the factors that make clinical interactions unsuccessful, offering some suggestions for improving clinical communication. The focus is on ensuring that young people are understood and supported at times of crisis, that they are not blamed for the difficulties they face, and that they are not reduced to a diagnostic label.

Chapter 2, Challenging stereotypes about young people who hear voices, is authored by myself, Lisa Bortolotti, Kathleen Murphy-Hollis, Fiona Malpass, and young people from the Voice Collective. It highlights three stereotypes associated with voice hearing that have harmful consequences for young people's relationships and opportunities to thrive, in the family, the school, and the clinic. These are incompetence, dangerousness, and diversity leading to exclusion. The chapter illustrates the impact of these stereotypes based on the young people's experiences, and encourages further empirical research in this area.

Chapter 3, Reacting to demoralization and investigating the experience of dignity in psychosis: reflections from an acute psychiatric ward, authored by a team led by Martino Belvederi Murri, addresses the unique challenges to epistemic justice that emerge in an acute ward, where coercion may be used. The use of coercion may engender situations that are detrimental for individual dignity and morale. One such effect is demoralization, which may increase the risk of suicide. The chapter provides an overview of the work on these topics and offers some suggestions for strategies that might improve the experience of psychiatric inpatient care.

Chapter 4, Not all diagnosis are created equal: Comparing depression and borderline personality disorder diagnoses through the lens of epistemic injustice, authored by Jay Watts, examines four aspects of epistemic injustice: objectification, moral agency, trivialization, and narrative agency. It compares personality disorder and depression, arguably the least and most popular diagnoses with patients in psychiatry. The analysis emphasises the importance of epistemic injustice as a tool in critically evaluating the usefulness of specific psychiatric diagnoses, encouraging a shift in clinical training to embrace reflective practices and restructure power dynamics in clinical encounters. 

Chapter 5, Resisting perceptions of patient untrustworthiness, authored by Eleanor Palafox-Harris, argues that a beneficial therapeutic relationship between patient and clinician requires mutual trust. In order to effectively treat someone, a clinician has to trust the patient’s reports of their symptoms but many psychiatric diagnoses are stereotypically associated with traits that indicate untrustworthiness (such as irrationality). In this chapter Palafox-Harris illustrates how psychiatric labels can signal stereotypes of untrustworthiness, reducing patients' perceived epistemic credibility.

Chapter 6, Preserving dignity and epistemic justice in palliative care for patients with serious mental health problems, with Luigi Grassi as lead author, considers the challenges faced by people with serious mental disorders who are at the end of life and promotes a person-centred approach, which can increase the sense of personal dignity and epistemic justice. Dignity Therapy can be applied in palliative care settings, offering people an opportunity to reflect upon crucial existential and relational issues and prepare their legacy.

Chapter 7, Promoting good living and social health in dementia, with Rabih Chattat as lead author, explores the notion of good living in the case of dementia and highlights the role of social health in preserving wellbeing. Discrimination impacts people with dementia in diagnosis disclosure, advance care planning, and decision making. The chapter critically examines the labelling of the behaviour of people with dementia as problematic and pathological even when it is a reaction to difficulties in communication.

Chapter 8, Ameliorating epistemic injustice with digital health technologies, authored by Elisabetta Lalumera, discusses the potential of digital phenotyping for ameliorating epistemic injustice in mental health. There is a concern that the evidence digital health technologies gather may overshadow individual experiences but, through a fictional case study, Lalumera portrays digital phenotyping as way to support shared decision-making. 

The book aims to help understand how the demands of epistemic justice relate to and complement recent research on agency in youth mental health, person-centred care, dignity therapy, stigmatising diagnoses, good living, social health, and access to digital technologies. As illustrated in the figure below, people seeking help should preserve crucial roles as agents and collaborators with valuable perspectives, multiple interests and needs, the capacity to contribute to positive change, and the capacity for shared decision making.

The mental health patient as an agent

Genocide Denialism and the Epistemology of Ignorance

Last week, Melanie Altanian started a post in parts last week, on her new book, The Epistemic Injustice of Genocide Denialism (Routledge 2024), which is open access. Here she focuses on genocide denialism, prolonged trauma, and retraumatization.

Cover of the book by Melanie Altanian

Denialism, prolonged trauma, and re-traumatization

When confronted with the topic of Turkish genocide denial, the respondents of Kalayjian et al.’s (1996) study expressed a range of negative emotions, including resentment, hatred, and anger/rage, which are appropriate responses to “a perception that the moral order has been violated, with no recompense having followed this disruption” (Miller and Miller 1987, 198). Denial also presents an insult to painful memories, thus constituting a further humiliation that is likely to re-traumatize survivors and force them to silence themselves regarding their experiences.

Survivors may also wilfully suppress their memories, as it would bring back all the pain and terror of their experiences. This may go along with constrictive behaviour in an attempt to create some sense of safety and to control their pervasive fear. However, by avoiding situations that remind them of the past trauma, or initiatives that involve future planning and risks, they “deprive themselves of those new opportunities for successful coping that might mitigate the effect of the traumatic experience” (Herman 2015 [1992], 59). This includes isolating themselves or remaining silent about their traumatic experience.

Importantly, survivors’ feelings of fear, distrust, and isolation are compounded when they are in an environment of incomprehension or hostility towards them and their testimonies. This creates a vicious cycle, as the shattered self “can be rebuilt only as it was built initially, in connection with others” (Herman 2015 [1992], 74). Rendering traumatic experiences intelligible to oneself and relevant others are essential steps towards resolution and closure.

These considerations have cross-generational significance. As a descendant of Armenian genocide survivors who escaped to France, Janine Altounian (1999, 339) describes from a psychoanalytic perspective the “two-fold collective trauma” that is transmitted to descendants and which they must deal with:

[F]irst, the extermination of the descendants’ families and the annihilation of their ancestors’ native land and cultural referents; and second, the dispersion of their parents, escapees stripped of their territorial and linguistic roots and of any narcissistic foundation for their psychic survival, throughout the Western world, in countries where the denials and silences of Realpolitik hold sway.

Altounian draws on her own experience receiving and processing this transmission. The task, she says, requires being “equipped with the psychic and linguistic apparatus necessary” (Altounian 2017, 70). Borrowing from the language of the host culture, the testimony of the descendant thus may benefit from an institutional context that lends authority to that language; “the privilege of his current status […] allows him to live in a time and under political conditions that tolerate his testimony” (73). This marks the role of the descendant as a witness-translator.

We can, then, see how an institutional context of genocide denialism inhibits practices required for successful trauma recovery, thus prolonging trauma across generations, encouraging ongoing constrictive behaviour, and entrenching a range of negative affects. 

As I argue in the book, genocide denialism presents an epistemology of ignorance that weaponizes genocide survivors and their descendants’ dependency on available shared concepts, meanings, and other epistemic resources they can authoritatively draw on to render their testimonies tolerated, credible, intelligible, and thereby effective. The aim is to terrorize them further and to sustain domination.

Melanie Altanian is assistant professor for epistemology and theory of science at the University of Freiburg. Her research focuses on issues in social and political epistemology, moral philosophy, and social philosophy.

Epistemic Microaggressions in Healthcare

In its relatively short history, the growing literature on epistemic injustice in healthcare has come a long way in highlighting the distinctly epistemic dimensions of medical encounters that can lead to a variety of injustices for patients. Such injustices are often the result of differences in relationships of institutional, professional, and social power (Kidd and Carel 2017, Freeman and Stewart 2024, Stewart and Freeman, 2022). 

This literature is mostly focused on how phenomena such as testimonial injustice and hermeneutical injustice render patients epistemically vulnerable. Additionally, it has helped to illuminate some of the ways in which patients from marginalized groups have their epistemic agency constrained, undermined, or ignored as they attempt to make claims about their bodies, identities, or health status to healthcare professionals. However, this literature has only recently started to attend to some of the more subtle, covert, and insidious mechanisms of epistemic dismissal.

 
In our recently published book, Microaggressions in Medicine, we engage with some of these seemingly subtler forms of epistemic (and other) types of injustice and harm in medical contexts. Let’s zoom out to mention the overall aims and goals of the book before zooming back in to focus on the epistemic dimensions of these injustices.

The two main theoretical aims of Microaggressions in Medicine are to reconceptualize how microaggressions have been understood by psychologists and philosophers and to introduce a new conceptualization of microaggressions that we call a harm-based account. 

Our harm-based account categorizes microaggressions according to the kind of harm that results for those who experience them. As such, we propose and argue for the following three kinds of microaggressions: epistemic microaggressions that result in epistemic harm, emotional microaggressions that result in emotional harm, and self-identity microaggressions that result in harms to one’s sense of self.

Microaggressions in Medicine (2024)

There are three applied aims of the book. 

• Using first-personal narratives, case studies, and testimonies of patients who are members of marginalized groups, we develop this harm-based account within medical contexts. 
• Analyzing these case studies, we illuminate the serious and enduring harms of microaggressions and argue that they can ultimately lead to delaying or avoiding medical care, damaged trust relations with healthcare professionals, and ultimately worse health outcomes for patients who experience them. 
• We introduce practical tools and strategies to help healthcare professionals reduce microaggressions in their practices and institutions, thereby diminishing harm caused to patients.

In what follows, and drawing on chapter 4 of the book, we focus on epistemic microaggressions, epistemic harm, and discuss why attending to epistemic microaggressions is an important part of the larger picture of epistemic injustice in healthcare.

In medical contexts, epistemic microaggressions are intentional or unintentional verbal or gestural slights made by healthcare professionals that dismiss, ignore, or otherwise fail to recognize claims that patients make about their bodies or health. Epistemic microaggressions result in epistemic harm to recipients (here, patients), namely, harm to them in their capacity as knowers. 

One example of an epistemic microaggression that we develop in the book is the story of what happened to the famous sociologist, professor, writer, and MacArthur “genius” award winner, Tressie McMillan Cottom. Despite her social standing and countless intellectual and academic achievements, as a self-described fat, Black (and at the time, pregnant) woman, Cottom knew that given her identity, she would face an array of discriminations. For this reason, she carefully chose her physicians. Or so she thought.

When she was four months pregnant, bleeding and experiencing acute pain, Cottom knew that something was terribly wrong. Yet when she and her then husband arrived at her doctor’s office, instead of being seen immediately or being sent directly to the emergency department, she was told to sit patiently in the waiting room. When she finally got to see her doctor, he looked at her and quickly said that she was probably just too fat and that for “women like her,” spotting was typical at this stage of pregnancy. She was sent home.

When, later that night, her pain escalated, the on-call nurse assured her over the phone that because the pain was in her bowel and not her lower back, that it was probably constipation and that she should try to go to the bathroom. After three days of such pain and no sleep, Cottom went to the hospital, where she was told that she’d probably just eaten something that was “bad” for her. 

After insisting that she get an ultrasound, it showed the fetus, in addition to two large tumors. Upon seeing this, the nurse scolded Cottom: “You should have said something” (Cottom 2019, 84). Soon thereafter, Cottom went into early labor. She gave birth to her daughter, who died soon after she was born (ibid., 85). While making plans for how to handle her daughter’s remains, another nurse said: “Just so you know, there was nothing we could have done since you never told us that you were in labor” (ibid.).

There are countless microaggressive harms that Cottom experienced. It’s important to underscore however, that the result of those microaggressions was nothing micro. Our analysis focuses on how racialized and gendered epistemic microaggressions combine in ways that are unique to Black women (what we call the misogynoir of microaggressions).

In this case, it was clear that Cottom knew that there was something wrong, tried to convey this knowledge to her healthcare team, and continued to be viewed as lacking credibility with regards to her knowledge of her body. As a result of the entrenched biases and stereotypes about Black women, Cottom experienced a panoply of racialized gendered epistemic microaggressions. 

As a pregnant Black woman who was bleeding and in pain, her bleeding was attributed to her fatness. Then, her pain in her bowel was dismissed as being the consequences of something “bad” that she’d eaten, where “bad” has racist undertones about the kinds of food that Black people eat. Finally, after the death of her newborn daughter, she was blamed for not having spoken up sooner, with the implication that the death was in part her fault and could have been prevented had she spoken up.

Cottom is powerless relative to the healthcare professionals.

Her knowledge of her body is ignored.

Repeatedly, healthcare professionals assumed they knew better.

On account of her race, gender, and body size, Cottom suffered the epistemic harm of not being recognized as a credible knower, the practical harms of severe physical pain, the death of her daughter, as well as the enduring trauma of the whole experience.

These consequences are macro and tragic. But we are most concerned with the epistemic racialized gendered microaggressions that contributed to them. Cottom’s credibility as a knower was denied due to her race, gender, and body size and as a result, her knowledge claims were ignored or dismissed.

The racialized gendered epistemic microaggressions that Cottom experienced are reflections of imbalances in epistemic and other sorts of social power that themselves mirror broader patterns at play both within and beyond healthcare contexts. Healthcare workers belong to an elite professional class. They’re assumed to have epistemic authority within and beyond that context. They often exert epistemic power over their patients by blocking them from making meaningful contributions to clinical exchanges. This epistemic situation both reflects and reifies assumptions about power in the epistemic domain. For example, it makes clear who creates, controls, and deploys knowledge and who doesn’t; who is “rational” or “objective” and who isn’t (cf. Code 1991).

The epistemic microaggressions on which we have focused, combined with more macro and explicit stereotypes and assumptions about Black women, result in epistemic harms to patients: they’re denied the full status of knower, which is central to human dignity and value (Fricker 2007; Pohlhaus Jr. 2017; Dotson 2011). 

Because the epistemic contributions of patients who are members of marginalized groups are routinely blocked, over time this can result in patients coming to doubt their own epistemic capacities, especially as microaggressions add up and their harms accumulate (Evans and Mallon 2020). As we saw and as we develop further in our book, epistemic microaggressions can also lead to harmful health and other consequences.

As Cottom’s case makes clear, epistemic microaggressions are harmful to the epistemic status and agency of marginalized patients. A complete understanding of epistemic justice and injustice in healthcare and the myriad ways they manifest must include attention to the subtle epistemic dismissals and indignities that epistemic microaggressions reflect.

Heather Stewart is Assistant Professor of
Philosophy at Oklahoma State University.

Lauren Freeman is a Professor of 

Philosophy at University of Louisville.