Medical gaslighting: a working definition and some reflections

What is it, who gets to decide, and what functions does it serve?

Photo description: stock photo of a young doctor holding out his hand palm out as if it say "Stop!" Photo credit: 'Man wearing a mask' by SHVETS production at pexels.com.

Medical gaslighting is widespread and devastating. It’s a topic that has gotten a fair bit of attention in recent years, but in my view we still don’t talk it anywhere near enough.

Whenever you discuss a newish concept, it’s helpful to have a definition. There are a few definitions of medical gaslighting out there, but as far as I can tell they were mostly created by doctors or psychologists. This is a problem. Clinicians and patients have very different perspectives on this topic, and patients should be the ones who get to decide what medical gaslighting is and isn’t. With this in mind, I decided to try my hand at creating my own definition.

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Working definition: Medical gaslighting occurs when a medical professional tells a patient something medical about themselves which isn't true, and which falls outside of how we would reasonably expect the medical system to function, with the effect of making a medical problem seem less serious than it truly is and/or of denying medical tests or treatment.

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I’d like to give a couple of examples to show how this definition could be used.

Example 1: Breast cancer

A woman is in the very earliest stage of breast cancer; a tiny cluster of cancerous cells has appeared in her breast. There is no lump, because the cluster of cells is far too small to see or feel. The woman goes to a routine breast cancer screening, but the tiny cluster of cancerous cells is not detected. The doctor says: "Good news, you're all clear."

In this example the doctor has told the patient something medical about herself that isn’t true, and it has the effect of denying (or at least postponing) medical treatment. However this isn't an example of medical gaslighting, because in this case the mistake was really unavoidable. Medicine isn't perfect, and even a doctor who does everything right will still sometimes get things wrong. The doctor in this case did everything we would reasonably expect a doctor to do, so it isn't gaslighting.

Example 2: Endometriosis

A young woman goes to a doctor complaining of agonising period pain. The pain is actually there all the time, but during her period it gets so bad she is forced to take time off work and spend several days lying in bed. She uses over-the-counter pain medications but these have little effect.

The doctor is certain that there is nothing wrong with the young woman. He reassures her that she is fine and that "a little pain is normal". Several months later the young woman sees another doctor, is referred to a specialist, undergoes a laparoscopy, and is diagnosed with endometriosis.

The first doctor’s behaviour in this example is absolutely medical gaslighting. He told the patient something medical about herself that was untrue - that her pain was due to ordinary period cramps. This untruth had the effects of making a medical problem seem less serious than it truly was, and of denying medical care. And, in this case, it was not a reasonable mistake for a doctor to make. It is not normal for period cramps to cause pain so severe the patient describes it as "agonising", and it is certainly not normal for period cramps to leave a person bedbound for days at a time. Patients should reasonably be able to expect that doctors will not make a mistake like this.

Side note: this is a mistake that doctors make all the time. That doctors do it routinely does not make it acceptable, in fact it indicates that there are profound flaws in the medical system. Gaslighting patients with undiagnosed endometriosis may be unofficial standard practice, but it shouldn't be.

Good intentions don’t matter

My definition of medical gaslighting doesn't say anything about the motivations of the doctor. In the endometriosis example, the doctor had good intentions; he really believed the patient had nothing wrong with her, and he gave what he thought was the correct advice. He did not intend to deceive his patient or deny needed medical care. If he had known she had endometriosis he would certainly have referred her to a specialist. It was an honest mistake. But it was still not an acceptable one.

While I’ve said the doctor is honest, I think we need to take a moment to ponder this particular type of “honesty”. The doctor’s belief that there’s nothing wrong with the patient is not medically justified; he has not ruled out all the possible causes of her pain. On the other hand this belief serves a functional purpose: it makes the doctor’s job easier; instead of trying to understand the symptoms and provide medical treatment (hard) he can just dismiss the patient and usher her out of his office (easy). Furthermore, the doctor’s belief that there is nothing wrong with the patient, although honest, only makes sense if he believes that young women tend to lie or exaggerate their symptoms, in other words, it’s sexist.

Side note: when we consider what to do about this type of problem, I don’t think it’s useful to focus on blaming the individual doctor. This type of sexism is entrenched in the medical system. Medical students and junior doctors learn it from their lecturers and senior colleagues. Institutions like medical schools and hospitals should be required to address and correct medical sexism, and other prejudices, in a systemic way.

Psychological trauma

My definition of medical gaslighting doesn’t mention the psychological trauma it often causes. I do think this trauma is incredibly important to talk about. However medical gaslighting doesn’t always lead to trauma. A lot of people experience medical gaslighting and are perfectly fine; they shrug their shoulders, go to a different doctor the next day, and get the help they needed. The gaslighting was an unpleasant and inconvenient experience, maybe even a scary one, but it didn’t result in long-term mental health problems. It’s still medical gaslighting even if the patient didn’t develop PTSD.

However it is very common for medical gaslighting to result in psychological trauma which adversely affects the patient’s life long after the medical visit is over. This is most likely to occur when the medical problem is serious, and when the patient is repeatedly gaslit. A person with a life-altering medical condition who is gaslit by one doctor after another for months or years is very likely to develop PTSD, for obvious reasons.

There is no situation in which medical gaslighting is acceptable

When I read articles about medical gaslighting written by clinicians, I get the impression these writers think gaslighting is understandable or even justified in certain circumstances; for instance when a doctor is very busy and cannot spend enough time with patients, or when, for one reason or another, a doctor cannot provide the kind of medical help the patient expects. Some articles even go so far as to say that doctors have no other choice than to gaslight their patients in certain circumstances. This is simply wrong; medical gaslighting is never acceptable. The problems of under-staffed, under-resourced and poorly-functioning medical systems are very real, and it is very true that patients often expect their doctors to do things the doctors simply cannot do. However none of this excuses a doctor who tells a patient that their debilitating pain is "not that bad" or that their life-altering physical symptoms are caused by "anxiety". A doctor who finds themself unable to help their patient should be clear and honest about this. Instead of gaslighting, the doctor could use phrases like:

• "I'm sorry, I can't help you."

• "I don't know what's causing your symptoms, and I'm afraid I can't take this any further."

• "I'm sorry but I can't refer you to a specialist at this time."

Reading these phrases, it's easy to see the real, fundamental reason why doctors gaslight their patients. Gaslighting occurs because a clinician is (rightly or wrongly) denying medical care, and they don't want to have an argument about it. By belittling and dismissing the patient, by calling into question the patient's ability to understand their own body and their own experiences, the doctor can cow the patient into silence. Medical gaslighting destroys a patient's self-confidence and self-belief, making it harder for them to speak up for themself. It's a psychological attack that can have devastating long-term consequences for the patient, but it makes the doctor's life easier for a few minutes.

Medical gaslighting allows doctors to refuse to acknowledge deep flaws in the medical system

I think it’s interesting to consider how medical gaslighting allows doctors to avoid acknowledging the ways in which medical systems and institutions are broken. Consider an honest, not-prejudiced and not-self-deluding doctor who refuses to gaslight her patients. This doctor would from time to time find herself having to say: “I’m sorry, I just can’t help you.” When the patient asks “Why not?” the honest doctor might reply:

• “I don’t understand your symptoms, and I don’t have time to research them.”

• “It takes an hour to work out a management plan for your condition, but I’m only allowed to spend fifteen minutes.”

• “I’m under a lot of pressure to reduce the number of referrals.”

• “I know you’re sick, but there are people who are even sicker, and resources are limited. You won’t be able to receive treatment until your symptoms get worse. I’m sorry, but that’s just how the system works.”

If doctors were honest (and not prejudiced or self-deluding), their honesty would force them to acknowledge that the medical system does not always work as it should. It’s easy to think of reasons why this would be uncomfortable for them. By dismissing patients and writing them off as attention-seekers, exaggerators or malingerers, doctors can put the blame for any conflict squarely on the person who is most vulnerable and least able to fight back: the patient. This allows them to conveniently avoid having to criticise powerful systems and institutions.

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This was a long post, thanks for reading! Does my understanding of medical gaslighting match up with yours? Are there forms of gaslighting I failed to consider? Let me know in comments or on social media.