Feminist perspectives on the social construction of chronic fatigue syndrome

Will psychology ever 'join hands' with disability studies? Opportunities and challenges in working towards structurally competent and disability-affirmative psychotherapy for energy limiting conditions

Despite sustained efforts among critically informed scholars to integrate thinking from disability studies into psychology, the psy disciplines continue to largely neglect the lived experience of disabled people and overlook disability as a form of social inequity and valued culture. In this article, I make a renewed case for integrating thinking from disability studies into psy, in particular within the psychotherapy professions and in the case of 'energy limiting conditions', a grass-roots concept that includes clinically and socially marginalised chronic illness such as Long COVID. Drawing on my experience as a disabled practitioner, and situating this within extant literature on disability and psy, I take an autoethnographic approach to exploring opportunities and challenges in bridging the interdisciplinary divide. I argue that unacknowledged institutional ableism within psy reproduces and is reinforced by physical and attitudinal barriers for disabled practitioners and service users, engendering under-representation of disability in psychotherapy professions and lacunae in disability-affirmative conceptual resources. Additionally, I propose that hermeneutical lacunae are bolstered by documented defensive clinical practices pertaining to disability. After discussing a wealth of opportunities for integration offered by disability studies, and noting the institutional failure within psy to embrace disability-related demographic and epistemic diversity, I question whether ongoing epistemic and social exclusions within the psy disciplines constitute a case of 'willful epistemic ableism'. Drawing on theorising vis-à-vis epistemic injustice and epistemologies of ignorance, I signal a form of systematic, actively maintained and structurally incentivised (motivated) non-knowing that results in collective failure among dominant groups to recognise established hermeneutical resources of the disabled community and allies. I conclude with suggestions of how this form of epistemic injustice might be mitigated.

Loss, shame and secrecy in women's experiences of a vulval skin condition: A qualitative study

Vulval lichen sclerosus (LS) is a chronic dermatological condition affecting the anogenital area, causing intense itching, pain and bleeding. It can change the terrain of the vulva, causing loss of vulval anatomy and altered texture and appearance of the skin. There has been little research into how women experience the materialities of a dermatological vulval disease. We aimed to understand experiences of living with LS, using a feminist lens to examine the influence of societal attitudes towards women's bodies and the vulva. We conducted qualitative interviews with 20 women with vulval LS, taking a critical feminist grounded theory approach. While we found that women's experiences of vulval LS symptoms was normalised as a part of womanhood, there was a silencing of speech about the vulva generally, and vulval symptoms more specifically. This caused profound shame and loneliness, and was a barrier to disclosing and seeking help for vulval symptoms, leading to delayed diagnosis and disease progression. Loss of vulval architecture resulted in a loss of (feminine) self and the sense of a body which was whole.

Long Covid at the crossroads: Comparisons and lessons from the treatment of patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)

Whilst parallels have been drawn between Long Covid and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), there is a well-documented history of negative stereotyping and marginalisation of patients with ME/CFS. A socio-politically oriented comparison of scientific, clinical and societal responses to Long Covid and ME/CFS is thus important to prevent similar harms arising among Long Covid patients. We identify four reasons for injustices in the treatment of ME/CFS patients, and discuss the risk of Long Covid following a similar trajectory. We conclude with policy and practice recommendations to help prevent such injustices arising again, including consideration of critical reflexivity in medical education.

The circuit of symbolic violence in chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME) (I): A preliminary study

OBJECTIVE

How can it be that a disease as serious as CFS affecting such a large number of people could be so unknown to the general population? The answer given to this question is based on Pierre Bourdieu's analyzes of symbolic violence.

METHOD

The "letters to the editor" by CFS patients to three national Spanish newspapers were subjected to various qualitative and quantitative analyzes.

RESULTS

Based on the qualitative analyzes and their theoretical interpretation, 13 mechanisms of symbolic violence were identified: non-recognition, institutionalized un-care, condescension, authorized imposition of illegitimate verdicts, delegitimization, disintegration, imposition of discourse, euphemization, silencing, invisibilization, isolation, uncommunication, and self-blaming. Multiple Correspondence Analysis made it possible to identify that the structural mechanisms (non-recognition, disintegration) were combined with the most symbolic ones, which came to the forefront producing the observed effects of symbolic violence. The 13 clusters obtained in the Agglomerative Hierarchical Clustering confirmed this result.

How do women suffering from multiple chemical sensitivity experience the medical encounter? a qualitative study in Spain

PURPOSE

Multiple Chemical Sensitivity is a condition principally suffered by women. As with fibromyalgia and chronic fatigue syndrome, Multiple Chemical Sensitivity is usually included among the so called "contested illnesses", defined as illnesses whose cause, diagnosis, prevalence and even existence are subject to controversy. This article seeks to explore how women with Multiple Chemical Sensitivity experience this contested illness, through their own descriptions of diagnostic processes, search for treatment and encounters with different health professionals. We aim to observe these experiences in detail and to identify aspects that could improve care for Multiple Chemical Sensitivity sufferers.

METHOD

Qualitative design. We performed personal in-depth interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7.

SUBJECTS/PATIENTS

22 women diagnosed with Multiple Chemical Sensitivity in Spain.

RESULTS

Two main categories were identified in the interviews: (1) unavoidable barriers: patients' exposure to chemicals and the absence of treatment, and (2) Skepticism on the part of care providers and lack of recognition in the process of diagnosis.

CONCLUSION

Training and above all awareness raising strategies are needed to address health professionals' prejudices regarding the existence of contested illnesses such as Multiple Chemical Sensitivity. These prejudices hinder diagnosis and medical follow-up, and add negative emotions to the physical limitations already suffered by patients.IMPLICATIONS FOR REHABILITATION Multiple Chemical SensitivityIt is important to promote a compassionate and empathetic attitude among health providers, in order to avoid rejection and delegitimization of the experiences of women with Multiple Chemical Sensitivity.Multiple Chemical Sensitivity protocols should be developed and implemented to give skills to health professionals to assist patients with Multiple Chemical Sensitivity.These protocols should include avoidance of exposure to chemicals present in healthcare facilities.Training programs for health providers should include not only knowledge, but awareness raising about the characteristics and severity of contested illnesses such as Multiple Chemical Sensitivity.Health providers should avoid stigmatizing patients by psychologizing their symptoms and be aware of the existence of stereotypes regarding women suffering from Multiple Chemical Sensitivity.

The biopolitics of CFS/ME

This paper argues that Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) constitutes a biopolitical problem, a scientific object which needs to be studied, classified and regulated. Assemblages of authorities, knowledges and techniques make CFS/ME subjects and shape their everyday conduct in an attempt to increase their supposed autonomy, wellbeing and health. CFS and CFS/ME identities are however made not only through government, scientific, and medical interventions but also by the patients themselves, a biosocial community who collaborates with scientists, educates itself about the intricacies of biomedicine, and contests psychiatric truth claims. CFS/ME is an illness trapped between medicine and psychology, an illness that is open to debate and therefore difficult to manage and standardise. The paper delineates different interventions by medicine, science, the state and the patients themselves and concludes that CFS/ME remains elusive, only partially standardised, in an on-going battle between all the different actors that want to define it for their own situated interests.

Unexpected findings and promoting monocausal claims, a cautionary tale

Stories of serendipitous discoveries in medicine incorrectly imply that the path from an unexpected observation to major discovery is straightforward or guaranteed. In this paper, I examine a case from the field of research about chronic fatigue syndrome (CFS). In Norway, an unexpected positive result during clinical care has led to the development of a research programme into the potential for the immunosuppressant drug rituximab to relieve the symptoms of CFS. The media and public have taken up researchers' speculations that their research results indicate a causal mechanism for CFS - consequently, patients now have great hope that 'the cause' of CFS has been found, and thus, a cure is sure to follow. I argue that a monocausal claim cannot be correctly asserted, either on the basis of the single case of an unexpected, although positive, result or on the basis of the empirical research that has followed up on that result. Further, assertion and promotion of this claim will have specific harmful effects: it threatens to inappropriately narrow the scope of research on CFS, might misdirect research altogether, and could directly and indirectly harm patients. Therefore, the CFS case presents a cautionary tale, illustrating the risks involved in drawing a theoretical hypothesis from an unexpected observation. Further, I draw attention to the tendency in contemporary clinical research with CFS to promote new research directions on the basis of reductive causal models of that syndrome. Particularly, in the case of CFS research, underdetermination and causal complexity undermine the potential value of a monocausal claim. In sum, when an unexpected finding occurs in clinical practice or medical research, the value of following up on that finding is to be found not in the projected value of a singular causal relationship inferred from the finding but rather in the process of research that follows.

Differentiating Multiple Sclerosis from Myalgic Encephalomyelitis and Chronic Fatigue Syndrome

Multiple Sclerosis (MS), Myalgic Encephalomyelitis (ME), and Chronic Fatigue syndrome are debilitating chronic illnesses, with some overlapping symptoms. However, few studies have compared and contrasted symptom and disability profiles for these illnesses for the purpose of further differentiating them. The current study was an online self-report survey that compared symptoms from a sample of individuals with MS (N = 120) with a sample of individuals with ME or CFS (N = 269). Respondents completed the self-report DePaul Symptom Questionnaire. Those individuals with ME or CFS reported significantly more functional limitations and significantly more severe symptoms than those with MS. The implications of these findings are discussed.

Attitudes regarding chronic fatigue syndrome: the importance of a name

Undergraduates from diverse academic backgrounds and medical trainees were assessed regarding their attitudes about and familiarity with chronic fatigue syndrome (CFS). We explored whether different names given to chronic fatigue syndrome (CFS, myalgic encephalopathy, or Florence Nightingale disease) were associated with differences in attributions regarding its cause, nature, severity, contagion, prognosis, and treatment. Participants' attributions toward the illness varied with the names used to characterize it. Participants prompted with the myalgic encephalopathy name were more likely to attribute a biomedical cause to the illness, and less likely to consider patients as candidates for organ donation than those prompted with the CFS name. Although the medical trainees were less likely to consider the patient as malingering, and more likely to view the illness as leading to poorer quality of life and a poorer prognosis, they were also more likely to consider the illness a form of primary depression, more likely to think the patient would attempt suicide, and less likely to consider associated cognitive symptoms as severe. The implications are discussed.

Fatigue as a major predictor of quality of life in women with autoimmune liver disease: the case of primary biliary cirrhosis

OBJECTIVES

Fatigue is a nearly universal symptom of many chronic diseases, yet it is often poorly understood and underappreciated as a factor in quality of life (QOL). Generally, clinicians have relied on subjective measures of fatigue, if they consider it at all. This study uses well-validated instruments to examine fatigue as a predictor of QOL in women with primary biliary cirrhosis (PBC), an autoimmune, chronic liver disease.

METHODS

Eighty-one women with PBC completed a survey that included measures of fatigue (Fatigue Impact Scale) and QOL (SF-36) as well as demographic variables (age, education) and medical information (symptoms, stage of illness, time since diagnosis). QOL results for the sample were compared with those of a nationally normed U.S. population. Bivariate and multivariate analyses were conducted to identify contributors to variation in QOL.

RESULTS

Compared with national norms, QOL for this PBC population was significantly impaired. When all variables with bivariate significance in relation to QOL were included in multivariate analyses, results showed fatigue to be the primary predictor of QOL, including all 8 QOL scales and the 2 summary scales. Regression results, dominated by fatigue, explain 25-59% of the variance in QOL.

CONCLUSIONS

Fatigue has profound effects on every aspect of life for women with PBC-physical, social, emotional, and psychological. The results lead to recommendations for health care providers to assess fatigue in their patients with PBC and to take steps, where warranted, to mitigate its effects.

Environmental issues and work: women with multiple chemical sensitivities

Multiple chemical sensitivities (MCS) is an acquired condition in which exposure to low levels of chemicals causes symptoms in multiple organ systems. Some 12%-16% of the U.S. population has some level of chemical sensitivity, 80% of whom are women. Attempts to reduce chemical exposures leads to enormous life difficulties at home, school, and workplace. We base our article on an ethnographic study of MCS in the United States and Canada. We describe here themes related to work issues in terms of a general trajectory of becoming sick from work exposures, coping with toxic physical environments and dealing with coworkers and, when unable to continue working, applying for workers' compensation, or disability status, or both.

The role of an online community for people with a rare disease: content analysis of messages posted on a primary biliary cirrhosis mailinglist

BACKGROUND

This study focuses on the role of an Internet-based group for people who have an autoimmune liver disease, primary biliary cirrhosis. Primary biliary cirrhosis is a relatively rare disease, affects primarily women in their 40's and older, and is not well understood. The PBCers Organization (PBC stands for primary biliary cirrhosis) provides electronic mailinglists (listservs) and informational resources for those with primary biliary cirrhosis.

OBJECTIVES

(1) to identify the issues of greatest importance to those posting to the listserv, specifically the relative importance of biomedical, socioemotional, and organizational/systems messages; (2) to compare frequency and content of posts by people at different stages of disease; (3) to identify how people with primary biliary cirrhosis represent the psychosocial challenges and dilemmas (role and identity change, uncertainty, and stigma) identified in the social-scientific literature as key elements of the experience of chronic disease.

METHODS

The paper is based on content analysis of messages posted during two months to the Daily Digest listserv for people who have primary biliary cirrhosis. To analyze the posts, we developed a coding system with three major categories--biomedical, socioemotional, and systems/organizations--and 12 codes in each category.

RESULTS

A total of 275 people posted 710 messages. Of the 250 people for whom information on gender was available, 239 (95.6%) were women and 11 (4.4%) were men. Analysis of 710 messages posted to the listserv revealed a predominance of requests for and reports of biomedical information, such as health care providers (32.7%), medications (30.9%), tests and procedures (25.8%), and symptoms (25.7%), combined with very frequent expressions of emotional support. The most frequent single topics were peer support (included in 40.6% of all posts) and positive emotions (25.3%). Posters who reported fewer years since diagnosis were more likely to be seeking biomedical information than those who were further in time from their diagnosis (r= -.241, P<.001, n=313). Those in later stages posted an average of 3.87 messages, compared to an average of 2.64 for people in earlier stages (t= 1.786, P=.08, n=90), which is different from what we expected. No relation between years since diagnosis or age and number of messages was found. Contrary to our expectations, the topics reflecting issues of role change/identity (2.9%), stigma (0.7%), and thoughts about the future (3.9%), all identified in social-scientific literature as key concerns for people with chronic illness, appeared infrequently in this set of messages.

CONCLUSIONS

Messages exchanged on this particular mailing list have a biomedical, rather than socioemotional or organizational, emphasis. The Internet offers a highly valued opportunity for those with rare diseases to connect with, learn from, and provide support to others having similar experiences. Research that compares those with primary biliary cirrhosis, who are involved in an Internet support group and those who are not, would be an important next step to better understanding the role of the Internet among patients with chronic liver disease and the implications of it in the course of their illness.

Gender-Biased Diagnosing of Women's Medical Complaints: Contributions of Feminist Thought, 1970–1995

With the advent of second-wave feminism during the 1970s, a significant body of literature emerged describing sexist practices in women's health care. Gender-biased diagnosing-the notion that somatic complaints by female medical patients are more likely to be labeled by physicians as psychosomatic-became a concern that garnered considerable attention in Europe and the United States because of the increased health risks it posed for women. This article examines the impact of feminist knowledge on this topic during the quarter century spanning 1970-1995. Analysis of the literature reveals feminist perspectives played a critical role in uncovering and problematizing gender bias in women's health care.

Multiple chemical sensitivities: stigma and social experiences

Multiple Chemical Sensitivity (MCS), an intolerance to everyday chemical and biological substances in amounts that do not bother other people, is a medically contested condition. In addition to symptoms and the ongoing difficulties of living with this condition, this hidden and stigmatized disability strongly impacts social relationships and daily life. Based on an ethnographic study, this article introduces the context of MCS in terms of cultural themes, the media, and the economic power of industries that manufacture the products that make people with MCS sick. Participants' experiences with family members and friends, in work and school settings, and with physicians exemplify the difficulties of living with MCS. I dedicate this article to Joan Ablon, my professor and mentor, whose work has always inspired my thinking and research topics.

Chicken or the egg? The biological-psychological controversy surrounding hyperemesis gravidarum

Women's somatic complaints are more likely to be labeled by physicians and other health care professionals as psychologically based when the condition has an obscure etiology. Perhaps because of this, there are a number of medical conditions which have been under investigated and where erroneous assumptions about them exist. Hyperemesis gravidarum (HG)--severe nausea and vomiting during pregnancy--is an example of such an illness. HG remains a puzzling condition for both physicians and patients because there is no known cause or cure. By its very nature, HG has a clearly established biological cause--pregnancy. Yet, because the exact causal pathophysiological mechanism is unknown, the organicity of the pregnant state is either minimized or ignored. This paper examines how HG is characterized in the literature and the empirical basis for psychogenesis. Analysis of the literature reveals a tension in the discourse such that both biologic and psychologic approaches to HG have existed in parallel tracks throughout history. Still, results support that sociocultural factors rather than scientific evidence have shaped the overarching and predominant illness paradigm of psychogenesis. Implications for women's health care and HG, in particular, are presented.