Pain Dismissal and the Limits of Epistemic Injustice

Abstract

This project aims to identify and explain a phenomenon I call pain-related motivational deficit, which occurs when there is proper uptake of the epistemic contributions of a pain utterance, but defective uptake of the motivational contributions of a pain utterance. I argue that the normalization of fibroid pain in Black women, and of menstrual pain more broadly, causes a pain-related motivational deficit to be unfairly assigned to utterances about these pain experiences. I show that current ways of thinking about epistemic injustice cannot adequately explain these cases.

Dawn Heels is the creator of “My Fibroid Journey,” an Instagram live series that provides an online platform for those with uterine fibroids. ¹ At 14 years old, doctors told Heels that it was normal for teenagers to experience heavy and painful periods. In the upcoming years, Heels experienced frequent urination, extreme bloating, fatigue, a vitamin D deficiency, painful sexual intercourse, and pain in her leg, butt, and back. Again, Heels was told that what she was experiencing was “normal.” At 33 years old, after a male physician dismissed her symptoms as just “something to do with her cycle,” Heels requested a female physician and finally received an ultrasound. Heels was diagnosed with uterine fibroids. Fibroids are benign tumors made of smooth muscle cells and fibrous connective tissue that develop in the uterus. Nearly two-thirds of those with a uterus will experience fibroids by the age of 50. Not all who develop fibroids are symptomatic. However, Black women are roughly three times more likely to receive a fibroids diagnosis compared to white women, develop fibroids at an earlier age, and to experience more severe symptoms (Eltoukhi et al. 2014; Aninye and Laitner 2021).

When Heels received her fibroids diagnosis, she was told that they, too, were normal, common, and nothing to worry about. Heels’s pain utterances still failed to raise any alarm or concern: ²

Even getting my fibroid diagnosis didn’t bring relief in any way, shape, or form. I wasn’t given any information on what fibroids were, whether I needed a management plan, or to keep an eye on symptoms that may need urgent medical attention. So, whilst a name was put on my problem, that was literally it. I was in the dark and alone. (Gillespie 2024)

The idea that painful menstrual cramps are a normal, natural, inevitable part of the menstrual cycle can explain why Heels’s pain utterances were dismissed as a teenager. The higher rate of fibroid diagnoses in Black women can also explain why, even after learning that Heels’s menstrual pain had a pathological cause, her reports were still brushed off as “normal.”

Scholars tend to use normalization to refer to the process in which certain actions or conditions become accepted as “normal,” such that these actions or conditions are then taken for granted as a natural part of everyday life. Normalizing a pain experience can disrupt effective pain communication because it prevents an individual from being able to elicit the care and concern that would otherwise be given to a pain utterance. Thus, the pain that the speaker is attempting to communicate is not taken seriously in a motivational sense. In other words, the pain utterance is assigned what I call a pain-related motivational deficit. A pain-related motivational deficit occurs when there is proper uptake of a pain utterance’s epistemic contribution, or indicative content, but because of certain social processes, like normalization, there is improper uptake of the pain utterance’s motivational contribution, or imperative content. This causes a hearer to believe a speaker’s pain utterance, but still downplay or diminish the pain utterance’s motivational significance.

In this article, I argue that current ways of thinking about epistemic injustice are limited in their explanations as to how and why a pain utterance can fail to be taken seriously in a motivational sense. In section 1, I discuss ways in which normalization can restrict a hearer’s ability to interpret a certain pain experience as fit for alarm. In section 2, I provide a characterization of a pain-related motivational deficit. In section 3, I distinguish my proposal from accounts of identity-based testimonial injustice. I argue that identity-based testimonial injustice cannot account for cases in which a pain utterance is dismissed due to the kind of pain that is being communicated. In section 4, I distinguish my proposal from accounts of content-based testimonial injustice by showing that, although content-based testimonial injustice can explain the role that content-specific or pain-specific prejudices can play in pain dismissal, such accounts are restricted to explaining when improper uptake is given to a pain utterance’s epistemic contribution. In section 5, I acknowledge the similarities that my account has with accounts of hermeneutical injustice. Menstruating people, particularly Black menstruating people, are hermeneutically marginalized with respect to menstrual symptoms. ³ However, Heels’s doctors remained unalarmed, even though a diagnostic label legitimizes the epistemic contribution of a pain utterance. This suggests that something distinct from unintelligibility resulted in Heels’s pain dismissal.

1. Normalizing pain

“Normal” can refer to either the frequency of a pain experience or to the acceptance of that pain experience as the norm or standard. A pain can be unjustly dismissed when we assume, through the process of normalization, that a normal qua a common pain experience automatically equates to a normal qua an accepted and societally enforced pain experience.

Normalization occurs when a norm is constructed, and through the disciplinary power of observation, judgment, and punishment, individuals are then pushed to conform to that norm such that the “normal” is that which conforms to the norm and the “abnormal” is that which is incapable of conforming to the norm (Foucault 2007, 58). However, in a society constituted by social hierarchy, the “norm” typically reflects the interest and world perspective of the privileged. With respect to white ignorance, Charles Mills notes that:

One could say then, as a general rule, that white misunderstanding, misrepresentation, evasion, and self-deception on matters related to race are among the most pervasive mental phenomena of the past few hundred years, a cognitive and moral economy psychically required for conquest, colonization, and enslavement. And these phenomena are in no way accidental, but prescribed by the terms of the Racial Contract, which requires a certain schedule of structured blindness and opacities in order to establish and maintain the white polity. (Mills 1997, 18)

As Mills suggests, conforming to the norm is an agreement to misinterpret the world. The norm is then (mis)taken for common sense or an objective interpretation of the world, such that the norm continues to serve the interests of the privileged while ignoring or failing to serve the interests of the subordinated.

Similarly, the idea that one’s menses is necessarily debilitating was historically constructed from the patriarchal perspective of the female form as biologically inferior. The conflation of menstruation with debilitating menstrual cramps stemmed almost entirely from research conducted by male physicians who had little clinical contact with women. Moreover, the patients these male physicians interacted with were later identified as having pathological causes to their severe pain (Strange 2000). According to historian Elenor Cleghorn, the idea that menses causes disability and suffering was so normalized in the nineteenth century that those who experienced “easy enough” menstrual cramps feared that they were somehow “abnormal” (Cleghorn 2021, 277). Presently, it is still difficult for many—both medical professionals and patients—to distinguish naturally caused from pathologically caused menstrual pain.

When a pain is normalized, it is perceived as not warranting any alarm or special attention. Take for example, lifting weights at the gym. Pain is treated as a normal, natural, and inevitable consequence of building muscle—as the saying goes, no pain, no gain. When a person cries of sore arms after lifting weights, the trainer will likely believe they are in pain, but still be dismissive or downplay their pain utterance. Moreover, the normalization of pain can also be internalized, causing a person to dismiss or downplay their own pain experience. For example, when a person lifting weights perceives their own pain as “normal,” they continue to “push through.” They see their pain as an inadequate call for alarm. Similarly, patients who internalized the normalization of menstrual pain are less likely to seek help, and once a medical professional interprets a pain as menstrual-related, they are less inclined to consider other possible causes (see Seear 2009; Pettersson and Berterö 2020). Consequently, menstruating people can wait an average of seven years receive a diagnosis for gynecological conditions like endometriosis (Pettersson and Berterö 2020).

The normalization of menstrual pain is further constructed through social sanctions, like exclusion or criticism, that encourage menstruating people to adhere to a “menstrual etiquette” and hide their menstrual cycle (Seear 2009). Menstrual etiquette is the set of norms that governs how menstruating persons should behave in the public sphere. Because menstruation is stigmatized as a shameful, disgusting bodily function, a “culture of concealment” makes it impossible to know that an individual is menstruating unless they choose to disclose it or menstrual blood leaks through their clothes. However, menstrual etiquette makes talking about one’s menstrual symptoms a communication taboo; “menstruation” or “period” become dirty words. Euphemisms are a result of our inability to talk about menstruation openly. In Blood: The science, medicine, and mythology of menstruation, Dr Jen Gunter (2024) reflects on the time that she asked her ninth grade teacher if she could go to the bathroom. Originally, the teacher said no. Dr Gunter walked up to his desk to let him know that she was going to the bathroom because she was on her period and needed to change her pad. The teacher ultimately excused her from class, but not without a stern warning that she should never use those words again.

Companies that sell menstrual hygiene products have also contributed to this culture of concealment. Their products are designed with the aim of absorbing fluid and odors, being invisible through one’s clothes, and small enough to be discreetly carried and disposed of in a bathroom container (Johnston-Robledo and Chrisler 2020). Furthermore, ads for these menstrual hygiene products convey the societal expectation that menstruating persons ought to “push through.” When, in 2016, Quartz published an article suggesting that painful menstrual cramps were “almost as bad as having a heart attack,” Comedian Sasheer Zamata had the following to say:

So, we’ve been enduring this pain for years and just going to work, buttoning up, because we are trained that way. And I think these tampon commercials are detrimental. They’re always like, “oh, you’re on your period? Don’t let that stop you, girl! Get out there! Go surfing! Go play a sport! Get on a horse!” … if you saw a man bleeding uncontrollably and having a four-day-long heart attack, you wouldn’t be like, “Don’t let that stop you, get on a horse!” (Just for Laughs 2021)

Such distorted ideas and images further the suffering of menstruating people while rendering their lived experiences linguistically and culturally invisible. This culture of concealment paired with the historic normalization of menstrual cramps, I argue, creates a social imagination that causes pain-related motivational deficits to be unfairly assigned to utterances about excruciating menstrual pain.

2. Pain-related motivational deficit

To return to the case at the start of this paper, there are important aspects of Heels’s story that suggest to me that a pain-related motivational deficit was likely given to her reports of menstrual pains, and later, fibroid pains. By referring to Heels’s menstrual cramps as “normal,” the doctors believed that Heels was, in fact, in pain. They did not refer to Heels as hysterical or infer that Heels was instead experiencing anxiety. This suggests that proper uptake was given to the epistemic contributions of Heels’s pain utterance. However, despite believing that Heels was in pain, the doctors demonstrated little to no concern. The first doctor assumed Heels’s lower abdominal pain was due to menstruation and was unmotivated to take any further diagnostic steps or steps in pain-management. The second doctor discovered that the real source of the pain was fibroids, but even still, no further steps were taken to manage Heels’s pain. These actions, or lack thereof, suggests that improper uptake was given to the motivational contributions of Heels’s pain utterance.

Proper uptake is necessary for a speech act to be successfully performed (Austin 1962; Langton and Hornsby 1998). J. L. Austin defines uptake as “the understanding of the meaning and force of the locution” (1962, 116–17). The understanding of the locution can be read as either securing the recognition of the illocutionary intentions of the speaker or securing the recognition of the convention invoked by the speaker (Bianchi 2020). Searle notably subscribes to the first reading, and so does many others (e.g., Langton and Hornsby 1998; Mikkola 2019; McDonald 2021). However, along with Lance and Kukla (2013) and Kukla (2014), I subscribe to the second reading. I define uptake as the recognition of the convention invoked by a particular utterance and the concrete social response that follows. I do so because pain utterances can still function as, say, a command for alarm or concern even if the speaker did not intend for the pain utterance to have this conventional effect. Pain expressions have evolved to function as a signal that one is in pain and as a cue for assistance. Pain expressions convey this information independent of the expressive individual’s intentions or awareness of this communication (C de C Williams 2002).

In a pain-related motivational deficit, a speaker attempts to elicit concern with their pain utterance, but due to certain social conventions, this “call for alarm” is unsuccessful. The feeling of pain is itself “a call for alarm”; it is our body’s way of telling us to be alert and ready for action. Colin Klein refers to the feeling of pain as a standing imperative: “It is an imperative that remains in force as long as it continues to be issued and until it stops. In that sense, pain is like a fire alarm. The fire alarm gets you to evacuate, and stay evacuated, for as long as it rings” (2015, 16). This is because the feeling of pain is highly motivating; it cannot simply be ignored. While we conventionally refer to a pain utterance as a report or a testimony, pain utterances are also complex pain behaviors. It would be contradictory to what we take pain utterances to do if a speaker sincerely uttered “Ow!” or “my head hurts” and they were not in pain. Thus, in virtue of expressing a pain state, pain utterances have an imperative as part of their content. Wiggleton-Little (2024) calls this a pain utterance’s imperative content. Pain utterances can also express what a speaker takes to be experiential facts about the kind of pain they feel, the pain’s location, and even the intensity or duration of that pain experience. Wiggleton-Little (2024) calls this a pain utterance’s indicative content. Thus, to give proper uptake to a pain utterance, the hearer must give uptake to both the indicative and imperative content, to form a belief and to form a pro tanto reason to be alarmed, respectively.

When a hearer believes and acknowledges that the speaker is in pain but downplays the pain as “normal” or “not that bad,” this indicates that proper uptake was given to the pain utterance’s indicative content and improper uptake was given to the pain utterance’s imperative content. Dominant in the social imagination are the ideas that fibroids are common for Black women and that severe abdominal pain is common for menstruating people more broadly. Because fibroids are normal qua common in Black women, it is further assumed that fibroids are normal qua an acceptable, standard pain experience for Black women. These ideas arguably led to the undertreatment of Heels’s pain. Furthermore, under the sway of the social imagination, it is likely that the normalization of menstrual pain caused an unjust disruption of the path between performance of the pain utterance and the uptake given to the expressed pain, a process known as uptake distortion (Kukla 2014, 444). Uptake distortion occurs when the alternative uptake an utterance receives in fact constitutes it as some other kind of speech act of type B, with an unconventional output, given its input (Kukla 2014, 445). The uptake given makes the utterance’s imperative content weaker in force than what would have otherwise been produced.

Kukla provides an example of a factory floor manager who is entitled to issue orders to her majority male workers, but despite invoking the conventions that would typically make it so that her speech acts are recognized as orders, her gender makes it such that her workers recognize her as issuing a request instead. Requests typically have a lower motivational force. ⁴ Orders and commands impute an obligation to act a certain way, while a request is still successfully communicated even if the person refuses the request (Kukla 2014; McDonald 2021). Similarly, in cases of pain-related motivational deficit, the uptake given distorts the pain utterance’s imperative content from a prioritized, obligation to be alarmed to a weaker imperative state. In these cases, the hearer downgrades the pain utterance to a “false alarm,” or, say, to a request for immediate concern that a hearer is free to ignore. ⁵

While pain is an imperative to both the person in pain and the hearer of the pain utterance, the obligation to respond clearly differs. As Adam Smith notes in The theory of moral sentiments,

When I suffer some misfortune or am done some injury, my companion doesn’t naturally take the same view of this as I do. It affects me much more nearly. He and I don’t see it from the same vantage-point, as we do a picture, a poem, or a scientific theory, so we are apt to be differently affected by it. (1759, 9)

Because we have direct access to our bodies’ insistent demands for our attention and we are deeply invested in our own bodies and well-being, we have a certain obligation to respond with action to our bodies’ calls for alarm. Clearly, a hearer of a pain utterance does not have the same kind of obligation. First, a hearer is free to refuse the call for alarm in a way that the speaker in pain is not. This difference in freedom makes pain dismissal normatively significant. Just because we can ignore or refuse the call for alarm, it does not mean it is a fitting response. Secondly, in previous work, I argued that a hearer of a pain utterance has a pro tanto obligation to respond to pain utterances with concern, with concern being characterized in terms of attention, interest in the restoration of the speaker’s well-being, and a motivation to act in accordance with that interest when feasible and appropriate (2023). More specifically, I argue that a medical professional can fulfill their obligation to be concerned when they express an empathetic concern—or a genuine interest in the lived experience of the patient’s expressed pain— and when they, in good faith, use the diagnostic and treatment tools at their disposal to give attention to the patient’s pain.

To clarify, I take it that a pain-related motivational deficit is a communicative wrong that occurs when certain ideas or images in the social imagination mask the suffering of marginalized populations such that it constrains a hearer’s ability to give proper uptake to the pain utterance’s imperative content. Thus, not all improper uptake of a pain report’s motivational contribution rises to the level of a communicative wrong or injustice. For example, human error can cause a pain report to be given a motivational deficit. Human judgment, even clinical human judgment, is fallible. A hearer may innocently interpret a pain utterance about back pain to be non-alarming because they have heard others with that same injury express minimal discomfort. Secondly, having one’s attention elsewhere can also cause a pain utterance to be given a motivational deficit. Humans are limited in our attentional and motivational capacities, which means we often must be selective in what we respond to, and how quickly. A medical professional may innocently assign a pain utterance a motivational deficit because they are already inundated with, say, concern toward other patients, managing the emergency room, institutional pressures, etc. In that case, the medical professional quite literally has no concern left to give.

Also, I primarily focus on pain-related motivational deficits that occur in the clinic, but pain-related motivational deficits occur outside the clinic as well. This is well illustrated in Kallia O. Wright’s personal essay, “‘You have endometriosis’: Making menstruation-related pain legitimate in a biomedical world.” Wright recounts her over-ten-year struggle with excruciating menstrual pain while living in Jamaica. During that time, her mother responded to her pain utterances with frustration, “I had bad cramps too when I was your age, and I dealt with it like every other woman” (2019, 912); her friend responded with annoyance, “Kallia! Stop being a baby! You’re not sick” (2019, 913); and her gynecologist downplayed her pain utterance by comparing Wright to other women, “Some women just have stronger cramps than others … But more importantly, you’re not telling me anything that sounds out of the ordinary or beyond what other women experience” (2019, 913).

Lastly, it is important to note that pain-related motivational deficits are not unique to pain utterances about menstrual pain. I suspect that pain-related motivational deficits can also be given to pain utterances about labor pains, addiction withdrawals, and to Black and/or elderly speakers in pain. I suspect that even this is not an exhaustive list. Moreover, the phrase motivational deficit can describe a broader range of communicative wrongs, not just those found in pain communication. I use motivational deficit to refer to all instances in which dominant ideas in the social imagination prevents a hearer from being moved to concern by an utterance that would otherwise motivate alarm despite believing said utterance. For example, a report of domestic violence from a cisgender man might be given a motivation deficit by the attending police officers. ⁶ The orders issued by a woman CEO might be given a motivational deficit by her predominantly male employees. Thus, a pain-related motivational deficit is just one kind of motivational deficit.

3. Limits of identity-based testimonial injustice

The goal of this paper is to show how some cases of pain dismissal are omitted from popular accounts of epistemic injustice and epistemic oppression. Fricker famously defines epistemic injustice as an injustice “done to someone specifically in their capacity as a knower” (2007, 1). However, this notion of epistemic injustice collapses into the more historic notion of epistemic oppression, or the “persistent epistemic exclusion that hinders one’s contribution to knowledge production” (Dotson 2014, 1). Dotson (2012, 2014) posits that there are three forms of epistemic injustice or oppression: (1) testimonial injustice, (2) hermeneutical injustice, and (3) contributory injustice. In this section, I will argue that my account of pain-related motivational deficit can capture and explain cases in which a person’s pain utterance is not duly reciprocated or acted upon, and yet, these cases do not fit these three forms of epistemic oppressions.

I will start with testimonial injustice (as developed by Fricker 2007). Testimonial injustice is when someone is wronged in their capacity as a giver of knowledge, and this wronging can occur because of the identity of the speaker and/or the content of the testimony. Identity-based testimonial injustice, the first type of testimonial injustice, in its most common form is an identity-prejudicial credibility deficit. This is when identity-based prejudice on the hearer’s end causes the speaker to be given less credibility than what would have otherwise been given (Fricker 2007). As a result of prejudicial beliefs about the speaker’s group membership, the speaker is unfairly misperceived as unreliable or untrustworthy.

There are cases in which a failure to respond with concern follows from an identity-prejudicial credibility deficit. For example, in his book, Black doctor in a white coat, Dr Tweedy recounts telling a physician about his knee pain. Dr Tweedy was wearing a fleece pullover, sweatpants, and slightly mismatched socks. The physician asked Dr Tweedy to stand, and he grimaced in pain. Even after seeing the grimace, the physician told Dr Tweedy he was fine; that it was probably just a bruise or sprain. He did not examine Tweedy’s knee nor did the physician mention any pain management or any type of knee bracing. From the doctor’s actions, or lack thereof, it is clear that Dr Tweedy’s pain utterance failed to elicit concern. However, Dr Tweedy’s pain utterance was unfairly assigned a motivational deficit because, as a Black man, Dr Tweedy was first misperceived to be an unreliable reporter of his pain experience. This is apparent when Tweedy later signaled his medical credentials, disclosing that he had a “left third metacarpal fracture” the summer before (2015, 214). The doctor’s interpretation of Dr Tweedy then shifted. Instead of seeing Dr Tweedy as an unreliable Black man, the doctor now saw Dr Tweedy as a trustworthy physician. Consequently, the physician was suddenly alarmed: “let me take a close look at your knee” (Tweedy 2015, 214).

To return to Heels’s story, there are similarities between Heels’s and Dr Tweedy’s healthcare encounters. For both, their pain utterances were unfairly downplayed, indicating that improper uptake was given to their pain utterances’ motivational contributions. But note the difference in why their pain utterances were downplayed. For Heels, the physician’s response was likely due to a prejudice against the kind of pain she was communicating, i.e., menstrual pain or fibroid-related pain; while for Tweedy, the physician’s response was likely due to a prejudice against Tweedy’s group membership. As Tweedy notes,

But I couldn’t get out of my mind how I’d been treated as two entirely different patients. Damon Tweedy, the unknown black man, dressed like he was about to mow the lawn, couldn’t get the doctor to look him in the eye or touch him; Damon Tweedy, M.D. was worthy of personal, first-class service. (2015, 215)

Suppose Heels was instead complaining about chest pains. Although women’s chest pains, in general, aren’t taken as seriously as men’s (Lewis et al., 2019), I think it is safe to assume that a woman complaining of chest pains will be interpreted as more alarming than if that same woman were to complain of pelvic pains. ⁷ This suggests that the dismissal of menstrual pains is not the same as having a prejudicial bias against the speaker’s group membership; for if the two were one in the same, it would not matter what kind of pain Heels shared, and yet, the kind of pain expressed clearly mattered. By only appealing to a speaker’s group membership and perceived credibility, we miss the causal influence that what was communicated can have on the uptake given to a pain utterance. ⁸

4. Limits of content-based testimonial injustice

On the surface, one might think that an appeal to content-based testimonial injustice could capture and explain Heels’s dismissed menstrual pain.

A content-based epistemic injustice or testimonial injustice is when a speaker’s testimony is not given proper epistemic uptake because of prejudice against the testimony’s content, often because the testimony features social-identity-coded content—content that is either about a social group or associated with that group. As a result, the speaker’s epistemic standing and/or the testimony’s epistemic contributions are unfairly evaluated (Davis 2021). As a case example, Robin Dembroff and Dennis Whitcomb (2023) considers the lack of epistemic uptake given by the Reagan administration to HIV-related testimony provided by public health experts. Although public health experts are generally seen as credible regarding health matters, the Reagan administration perceived HIV to be “the gay disease.” They rejected the assertion of these expert testimonies due to anti-gay prejudice against the testimonies’ content (i.e., they refused to believe that HIV was a public health threat).

There are cases of pain dismissal in which the pain utterance is not taken as epistemically serious because of what was communicated and not necessarily because of the identity of the speaker. Suppose a woman is experiencing excruciating postpartum pain, so much so that her husband must speak on her behalf given that she can no longer speak for herself. When the husband shares his wife’s pain with the care team, they brush it off, “Of course she’s in pain! It’s expected, she just had a baby!” Although her husband was the one to “share” the pain with the care team, the content of the pain utterance is still about postpartum pain in women. Postpartum pain is seen as a normal, natural, inevitable part of the birthing process; postpartum pain is also associated with women, and gender stereotypes paint women as overly expressive and unreliable communicators of pain. As a result, the care team still failed to take the wife’s pain seriously even though cisgender men in our society are generally afforded more credibility.

Similarly, Heels’s pain utterances about menstrual pain, and later, fibroid-related pains, are associated with women and Black women, respectively. One could argue that the dismissal of Heels’s pain utterances is due to an improper uptake of the epistemic contributions given the gender association between women and menstruation. During the Victorian era, menstruation was considered a recurrent “disease of women”; a drain of women’s physical and mental capacities (Strange 2000). This notion that menstruation was an illness reflected the patriarchal beliefs of what a “woman” was and ought to be: naturally weak, defective, destined for childbearing, and physically and cognitively inferior to men. By conflating menstruation with disease, the experience of severe, debilitating menstrual pain became normalized and made attempts for menstruating people in pain to enter the sick role illegitimate (Jutel 2009). A sick person is excused from day-to-day duties, and is entitled to, or even expected to, seek medical care and attention. Thus, an explanation could be that people reporting excruciating menstrual pain find improper uptake given to their pain utterance’s epistemic contribution because their claims that their menstrual pain equates to being sick are deemed inconceivable. As a result, a hearer may question the reliability or credibility of a speaker who attempts to elicit concern with a pain utterance about menstrual pain, i.e., “You’re not sick. You’re fine.”

However, such an explanation relies on a faulty assumption that, when a speaker is providing a pain utterance, they are vouching for the presence of a pathological or disordered state, and that a pain utterance can only have merit if such a state is present. Often, unless the disordered state is visible from the outside, the pain sufferer does not know the cause of their pain. When a pain is experienced, one may be able to localize it, but rarely if ever are they informed of the cause of the pain via the pain experience itself (Klein 2015). Thus, the pain sufferer is not and should not be on the hook for knowing if the source of the pain is pathological in nature. The pain sufferer is only vouching for the presence of a painful feeling. Even if a pain experience is “normal” in the sense that it is caused by expected, non-pathological bodily changes, the pain experience can still disrupt a person’s quality of life and feel not normal or alarming to them. For example, painful menstrual cramps can negatively impact a person’s quality of life. One survey showed, that of the roughly 85% who reported menstrual cramps, 75.9% reported having to push themselves to continue with their daily activities, 8.3% reported that they perform fewer activities, and 6.7% reported that they could do almost no activities at all (Schoep et al. 2019). Only 9.8% of those respondents were diagnosed with a disease that could account for their symptoms. Although it is possible that many of these respondents can attribute their debilitating pain to a diseased state and may have simply not received a formal diagnosis, a 26% reduction in overall quality of life has still been observed in those with documented primary dysmenorrhic pain—pain that is caused by natural changes in the levels of prostaglandins during the menstrual cycle (Iacovides et al. 2013).

However, even if one thinks that prejudice against menstrual pain causes an unfair evaluation of the pain utterance’s epistemic contribution and/or the speaker’s epistemic standing, the same cannot be said about prejudice against fibroid-related pain. Typically, a diagnostic label adds credibility to a patient’s pain utterance within a clinic context. Diagnoses can legitimize a person’s pain utterance because it makes intelligible the fact that the expressed pain is “abnormal,” and thus, supports a person’s claim to care and concern. For example, when Wright finally received her endometriosis diagnosis, she said, “I admit I felt vindicated. I was happy to have the label” (2019, 914). Heels, on the other hand, felt that intelligibility in the form of a diagnostic label was still not enough. Her pain utterances were still not responded to with a heightened concern or an urge to relieve her pain.

Although uterine fibroids can be easily diagnosed with an ultrasound, it remains overlooked and underfunded as a public health issue. Arguably, this is because fibroids have become a racialized condition. ⁹ An estimated 26 million people between the ages of 15 and 50 have uterine fibroids in the United States, and more than 15 million of them will become symptomatic (Hartmann et al. 2017). Black women are at a three times increased risk of developing fibroids, with more than 80% of Black women developing fibroids by age 50 (Eltoukhi et al. 2014). ¹⁰ African ancestry is considered a key risk factor, making uterine fibroids a medical condition that is associated with Black bodies. In the nineteenth century, prominent scientists and physicians declared that “peculiarities” of the Black body—i.e., thicker skulls, less sensitive nervous systems—made Black people more resilient to pain. Pain was not only seen as normal qua common for Black people, but it was also seen as an enforceable bodily experience that Black people are expected to endure. As a result, Black bodies became “medical superbodies,” a body that is fit for physical labor and medical experimentation, but not one whose pain is fit for alarm or concern (Owens 2017). Such super-humanizing beliefs are still observed within our healthcare system and contribute to racial disparities in pain management (see Hoffman et al. 2016).

Super-humanizing beliefs primarily influence the merits of a pain utterance’s motivational contribution and/or a hearer’s evaluation of the speaker’s motivational standing (i.e., whether the speaker and their pain are recognized as falling within a hearer’s circle of moral concern). In the process of super-humanizing the Black body, Black people are othered. Their membership into humanity or the moral community is distorted, which in turn, distorts their pain experiences. While it is imaginable for a white person that “someone like me” experiences pain as bad, super-humanizing beliefs makes it unimaginable that the Black body can experience pain as alarming as theirs. Thus, Black people in pain, and by extension, pain utterances about conditions that disproportionately affect Black people, are readily perceived as less needing or less deserving of concern and pain relief.

Although one can theoretically separate intelligibility from an ability to motivate care and concern, the two are closely related in practice––especially clinical practice. Just as an identity-prejudicial credibility deficit or a lack of a diagnostic label can lead to a motivational deficit, a lack of alarm due to super-humanizing beliefs can result in a lack of understanding a particular pain experience. As Medina notes,

Those under the sway of this social imaginary are likely to develop epistemic habits that protect established cultural expectations and make them relatively blind and deaf to those things that seem to defy those expectations. In the first place, they will lack the motivation and intellectual curiosity to prove the evidence more fully, to ask about alternative explanations and to find out more. In other words, the social imaginary produces a strong form of epistemic laziness that blocks evidentiary explorations. This laziness becomes an epistemic obstacle in the pursuit of knowledge that can easily lead to epistemic injustices. (Medina 2013, 68)

This is observed on both the interpersonal and institutional level. For example, a medical professional under the sway of normalizing beliefs about menstrual pain may confabulate a narrative that, say, the patient is hysterical or drug-seeking to protect the cultural expectation that menstruating people ought to cope with menstrual pain. On the institutional level, research into uterine fibroids is underfunded (see Aninye and Laitner 2021). The lack of private and federal funding conveys a message to scientists that fibroid research is not an area that needs immediate attention and response. Despite the prevalence of fibroids, especially in those with African ancestry, there continue to be significant gaps in our knowledge of the disease pathology and the risk factors for developing symptomatic fibroids. A further understanding of the pathology of fibroids could, for example, lead to more curative treatment options besides a hysterectomy.

5. Limits of hermeneutical injustice and contributory injustice

I have shown that Heels’s case of pain dismissal cannot be explained by various accounts of testimonial injustice. I will now show that the remaining forms of epistemic injustice—hermeneutical injustice and contributory injustice—do not apply to Heel’s case as well.

A hermeneutical injustice (as developed by Fricker 2007) occurs if (1) the intelligibility of a particular social experience is constrained or undermined due to a lacuna in the collective hermeneutical resources, (2) this gap in the collective interpretive resources results from the hermeneutical marginalization of a group, and (3) it is in the interest of the group to have this experience understood (Fricker 2007; Fraser 2018). ¹¹ A group is hermeneutically marginalized if members of that group are prevented from equally participating in the generation and dissemination of social concepts (Fricker 2007). While it can be argued that menstruating people, and specifically, Black menstruating people, are hermeneutically marginalized, the dismissal of Heels’s fibroid pain was not due to “ill-fitting concepts” in the hermeneutical lacunae. At best, I concede that the initial dismissal of Heels’s menstrual pain could be understood in terms of either a contributory injustice or a hermeneutical clash. However, even after Heels was perceived as correctly applying “uterine fibroid pain” to her pain experience—and presuming “uterine fibroid pain” is a concept that aligns with this patient population’s interests—her doctors still deemed her pain unimportant and non-alarming. I argue that this indicates that something distinct from unintelligibility resulted in the repeated dismissal of Heels’s pain utterances.

To begin, Fricker stipulates that, in an act of hermeneutical injustice, the hermeneutical marginalization of a group produces hermeneutical lacunas, or “absences of proper interpretations, blanks where there should be a name for an experience which it is in the interests of the subject to be able to render communicatively intelligible” (2007, 160). A stock example is the absence of a concept like “sexual harassment” in the case of Camila Wood. Due to persistent and unwanted sexual advances from her boss, Wood quit her job at Cornell’s nuclear physics department. However, when applying for unemployment insurance, she could not articulate what had happened to her. Instead, she cited that she had quit for “personal reasons,” but “personal reasons” was ill-fit for the purposes of making Wood’s experiences intelligible (Fricker 2007; Fraser 2018; Clanchy 2023). ¹² As a result, Wood was denied unemployment benefits. Fricker suggests that a concept like “sexual harassment” was a hermeneutical lacuna because women were hermeneutically marginalized at the time, and such a concept wouldn’t have served men.

Although Fricker does not elaborate on her use of “ill-fit,” Rachel Fraser (2018) suggests that a concept is ill-fitting if the concept is embedded in an inferential network in which the concept leads to cognitively salient and socially licensed inferences that are either contrary to the speaker’s interests or the concept fails to lead to cognitively salient and socially licensed inferences that are strongly in the speaker’s interests. An inference is cognitively accessible if the inference can be made without significant cognitive labor; an inference is socially licensed in some social context if those in that social context are likely to recognize that inference as legitimate (Fraser 2018). Fraser argues that the concept of sexual harassment draws attention to the moral wrongness of the actions of Wood’s boss such that both the inference that Wood’s boss did something seriously morally wrong and the inference that Wood deserves unemployment benefits are cognitively accessible and socially licensed. On the other hand, “personal reasons” was ill-fit for Wood’s purposes, given “my boss did something wrong” is not an obvious and generally recognized inference from that concept.

One could counter that an appeal to hermeneutical injustice can capture and explain Heels’s case by positing that there does exist a hermeneutical lacuna regarding menstrual pain, given that the concept “painful periods” is ill-fitting for menstruating people’s purposes because it includes inferences that are strongly against this marginalized population’s interests. For example, one might think that Heels’s pain utterance failed to elicit alarm because the inference from “I have painful periods” to “I deserve heightened concern” is not cognitively accessible nor socially licensed. ¹³ Rather, “this is normal” is an inference that feels more obvious, or readily imaginable, for both the speaker and the hearer. Moreover, thanks to the concealing nature of the “menstrual etiquette,” this inference is generally recognized. However, for this explanation to apply, we must first prove that there exists a hermeneutical lacuna regarding menstrual pain, such that “painful periods” is the best concept available to menstruating people for which to make their experiences intelligible.

With regards to menstrual pain, it is not obvious there exists a shared hermeneutical lacuna. Others have critiqued Fricker for assuming in her account of hermeneutical injustice that there exists only one set of collective hermeneutical resources on which we all equally depend (see Dotson 2012; Pohlhaus 2012). ¹⁴ Thus, a hermeneutical injustice occurs when there is a lacuna in the one set of collective hermeneutical resources. Dotson (2012) notes that hermeneutically marginalized communities often have their own sets of hermeneutical resources and alternative epistemologies from which they can still conceptualize their lived experience. Unlike in Fricker’s account of hermeneutical injustice, those who experience contributory injustice can readily articulate their experiences (Dotson 2012, 32). Contributory injustice or willful hermeneutical injustice occurs when there exist different hermeneutical resources that the hearer could use to interpret a pain utterance, but the hearer refuses to acknowledge and acquire the necessary hermeneutical resources to understand the experiences of a hermeneutically marginalized population. As a result, there is a lacuna in the hearer’s hermeneutical resources but not in the speaker. The speaker can conceive and articulate their experiences despite the hearer’s inability to give their utterances epistemic uptake. However, given the fact that menstruating people have expressed difficulty in conceptualizing and articulating their excruciating menstrual pain (see Chen et al. 2018), contributory injustice is unable to explain these cases as well.

Moreover, “painful periods” is not the best concept available to both menstruating people and medical professional. Arguably, diagnostic labels like endometriosis or uterine fibroids are concepts that are better equipped to communicate the seriousness of a menstrual pain experience. Suspending the debate as to whether a pathological cause or a diagnostic label ought to have the sole power to legitimate a menstrual pain, typically “something is wrong” or “I deserve heightened concern” are inferences that are cognitively accessible and socially licensed from a diagnosis. Receiving a diagnosis should have been enough for Heels’s purpose of eliciting care and concern. Yet, even when Heels had a new available concept to make her experiences intelligible, Heels’s pain utterances still failed to elicit alarm.

Instead, one might argue that the problem is not that we lack a shared concept that is fitting for the purpose of making menstrual people’s pain experiences intelligible; rather the problem is that menstruating people are prevented from applying to their experiences those concepts in which the eliciting of alarm would be cognitively accessible and socially licensed Thus, cases like Wright and Heels can be explained by an appeal to positive hermeneutical injustice. Unlike negative hermeneutical injustice, in which important social experiences are rendered unintelligible because of a hermeneutical lacuna, positive hermeneutical injustice occurs when a speaker is prevented from applying an available and more accurate concept to their social experience dure to the presence of clashing, oppressive, and distorting concepts (Falbo 2022). Falbo gives the example of attempting to apply the concept “rapist” to someone who seamlessly fits the profile of a “golden boy”—a white, cis, heterosexual, popular athlete. Because the concept of rapist is distortedly portrayed as a creepy stranger, monster, animal—or a Black man—its application is severely constrained when the speaker attempts to apply “rapist” to someone who matches the “golden boy” profile. Falbo claims that what is going wrong here is not a lack of collective understanding with respects to the concept “rapist,” but rather a speaker is unable to identify an actual rapist in certain instances due to hermeneutical defeat (Falbo 2022). Similarly, it seems the normalization of painful menstrual cramps and the historic conflation between menstruation and being unwell restricts a menstruating person from being able to apply the concept of “abnormal” or “sick” to their excruciating menstrual pain.

While an appeal to positive hermeneutical injustice, or a hermeneutical clash, can explain the initial dismissal of Wright and Heels’s pain, such an appeal fails to explain the dismissal Heels continued to experience after receiving a uterine fibroid diagnosis. After the ultrasound, Heels was able to identify and apply “uterine fibroids” to her pain expression. However, despite this change in the intelligibility of her pain utterance, Heels’s pain still failed to elicit alarm. This suggests that a motivational deficit was assigned independent of an intelligibility deficit, and that the motivational deficit persisted despite a change in the uptake of the pain utterance’s epistemic contributions.

6. Conclusion

In summary, I hope to have shown that an unfair disadvantage with respect to a speaker’s ability to motivate alarm with their pain utterance dissociates and is distinct from the various accounts of epistemic injustice that are only able to capture and explain an unfair disadvantage with respect to a speaker’s ability to generate or share knowledge of their pain experience. Although pain-related motivational deficits occur in multiple settings, I primarily focused on pain-related motivational deficits in the clinical setting because of the potential of great physical harm. A lack of motivation to the kind of pain being communicated can lead to frustration, delayed or missed diagnoses, and inadequate or ineffective treatment (see Chen et al., 2018). A medical professional’s ability to diagnosis and treat a patient’s pain often rests on the pain utterance; this requires that the epistemic contributions of the utterance be factored into the pain assessment but also that the motivational contributions grab the medical professional’s attention in such a way that there is a desire to consider the epistemic contributions and an urge to relieve or manage the patient’s pain.