If you are a woman, chances are you’ve been dismissed at some point when seeking healthcare. In a UK government survey, 84% of women [1] reported experiencing this. Dismissal can come in many forms. It may present in the form of not being believed, having the impact of symptoms you report minimised (“it’s not that bad”), not being offered further follow-ups or investigations, not having questions answered along with so many other potential variations.
As a health psychologist specialising in functional gut disorders and a range of women’s health urogynaecological and urogenital conditions (including chronic urinary tract infections, endometriosis and bladder pain syndrome), I hear iterations of the same theme coming through in my assessments. Beyond the familiar narrative of women experiencing symptoms, presenting to services with varying degrees of success at getting further investigations in a timely manner only to be left confused and without treatment options at the other end, is another more penetrating story, with huge implications for health trajectories. This story’s central narrative is around fear and isolation. Both of these things have a drastic impact on health[2][3][4].
Horror story
Imagine you suddenly notice scratches appearing in real-time on your arm. Initially, you think it must be some sort of reaction and rationalise it. You don’t alert anyone to begin with and try to ignore it. However, one day you witness these scratches deepen, as though you are being cut into with an object, but nobody is there and you’re not doing it. With this, you feel immense pain and fear. You cannot account for what is happening and you don’t know how to prevent it.
As you tell your closest friend, they observe the scratches, but they didn’t see them appear and find it hard to believe your account of how it happened. They look concerned and advise you to go to the doctor. When you do go to the doctor you tell them what happened, already feeling nervous as you are aware that your friend did not seem to believe you. The doctor takes a look and says that they can’t see much. “Are you sure you didn’t cut yourself? Have things been tough lately? How are you sleeping?” You describe again what happened in as much detail as you can, hoping to prompt some understanding and symptom matching within their realms of medical knowledge but the effect seems to be quite the opposite. You leave with a recommendation for therapy and a prescription for anxiety medication. You have no way of knowing what could account for these spontaneously appearing scratches and whether they will happen again or whether they will become more severe.
The scary reality
Although the above may resemble some sort of supernatural horror story, it is far from that. If you swap out spontaneously appearing visible scratches, to any other physical symptom you can think of, this is the experience many women go through. To have an affliction which causes physical discomfort and/or pain is hard and scary enough. To be told that nothing can or will be done because your account of that experience is doubted is devastating. How can you hope for relief or comfort if the medical world doesn’t acknowledge your experience? How can you navigate life with so much uncertainty, not knowing what will come next time the symptoms come; whether they will worsen, maybe even have the capacity to be fatal?
How fear impacts health
Pain and physical discomfort are automatically, neurobiologically scary experiences. They take your body out of its usual equilibrium. This alarms (or at least alerts) your body even before you are consciously aware or worrying about it. This is a process called “neuroception”.
“Neuroception describes how neural circuits distinguish whether situations or people are safe [or] dangerous” [5].
Anxiety and fear therefore can impact health through a number of mechanistic pathways. These include the fight or flight stress response pathways underpinned by autonomic nervous system activity. Pain processing pathways are also implicated as the perception of a threat can result in the mobilisation of neurotransmitters involved in pain perception and amplification. There is no one “pain pathway”. Instead, a number of neural networks appear to play a role in the communication between psychological experiences and painful sensory experiences as evidenced by neuroimaging studies. These include the dopamine, opioid and endocannabinoid systems. Another pathway through which fear (or anxiety/worry) may impact physical discomfort is through bodily hypervigilance. Increased bodily hypervigilance is a complex process in itself. Put simplistically as the brain perceives a physical experience to be a potential threat, it sets the rest of the nervous system to work to get more sensory information to further inform calculations on how it may respond. We experience this as heightened pain or sensory awareness.
All of the processes described have to ability to potentially exacerbate or prolong pain or discomfort. It’s also important to note that the central nervous system and immune system work in tandem, communicating with one another. It is well-established that the more taxed our mental resources are due to chronic stress, the more burdened our immune system also becomes. Psychoneuroimmunology (PNI) research has demonstrated how chronic psychological stress can slow wound healing [6] and increase inflammation [7]. The mechanisms underpinning this have important potential implications for health outcomes
How isolation impacts health
Isolation broadly speaking refers to the experience of being without help or feeling alone. Isolation and loneliness often go together. Isolation and loneliness are significant risk factors for poor health outcomes including risk and coronary heart disease [8]. Loneliness also has a medium to large negative effect on a broad spectrum of other health outcomes, the largest effect being on mental health outcomes [9]. Reviews have demonstrated loneliness is a significant risk factor for mortality (regardless of cause) [10]. This finding is startling. The lonelier a person is, the younger they are likely to die and conversely, the less lonely, the longer they are likely to live. Such research shows the interconnectedness of our psychological experiences with our physical health.
The sum total effect of dismissal on health
The brief summary of the research into the role of stress, fear, loneliness and isolation shows how the experience of dismissal both in and outside of the healthcare system, can negatively impact health outcomes. Dismissal also has practical implications. If healthcare practitioners don’t perceive a patient’s presentation to warrant further investigation, the process stops there. Even if the patient pushes for second opinions and explores other avenues, this initial appraisal can cause significant delays. These delays can mean that health deteriorates. Disbelief within the healthcare system can also result in misdiagnoses, leading to ineffective and perhaps harmful treatments or lack thereof. We’ve seen from the Cumberlege report [11] the degree of devastation this has caused for women who complained of issues after pelvic mesh surgery, only to be ignored resulting in disability and in some cases death.
The sum total effect of dismissal on health is therefore potentially huge. It is an issue that needs to be taken seriously within the healthcare system. The recently published 100-page document on the Women’s Health Strategy for England, however, does not seem to consider this particular issue in depth. A future blog post will explore this in more detail. In the meantime, it is important for patients to be empowered to spot dismissal and feel equipped in tackling it. For this reason, we have developed the “Dealing With Dismissal” free resource pdf. You can download your copy here and we encourage you to share it widely.
If you have felt dismissed, what do you think would help to tackle this? You can leave a comment or further the discussion over on Instagram.
References [1] https://www.gov.uk/government/consultations/womens-health-strategy-call-for-evidence/outcome/results-of-the-womens-health-lets-talk-about-it-survey
[2] Leigh-Hunt, N., Bagguley, D., Bash, K., Turner, V., Turnbull, S., Valtorta, N., & Caan, W. (2017). An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public health, 152, 157-171. [3] Park, C., Majeed, A., Gill, H., Tamura, J., Ho, R. C., Mansur, R. B., ... & McIntyre, R. S. (2020). The effect of loneliness on distinct health outcomes: a comprehensive review and meta-analysis. Psychiatry Research, 294, 113514 [4] Rogers, A. H., & Farris, S. G. (2022). A Meta‐analysis of the Associations of Elements of the Fear‐Avoidance Model of Chronic Pain with Negative Affect, Depression, Anxiety, Pain‐related Disability and Pain Intensity. European Journal of Pain [5] Porges, S. W. (2004). Neuroception: A subconscious system for detecting threats and safety. Zero to Three (J), 24(5), 19-24. [6] Gouin, J. P., & Kiecolt-Glaser, J. K. (2011). The impact of psychological stress on wound healing: methods and mechanisms. Immunology and Allergy Clinics, 31(1), 81-93. [7] Szabo, Y. Z., Slavish, D. C., & Graham-Engeland, J. E. (2020). The effect of acute stress on salivary markers of inflammation: A systematic review and meta-analysis. Brain, behavior, and immunity, 88, 887-900. [8] Valtorta, N. K., Kanaan, M., Gilbody, S., Ronzi, S., & Hanratty, B. (2016). Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart, 102(13), 1009-1016. [9] Park, C., Majeed, A., Gill, H., Tamura, J., Ho, R. C., Mansur, R. B., ... & McIntyre, R. S. (2020). The effect of loneliness on distinct health outcomes: a comprehensive review and meta-analysis. Psychiatry Research, 294, 113514. [10] Park, C., Majeed, A., Gill, H., Tamura, J., Ho, R. C., Mansur, R. B., ... & McIntyre, R. S. (2020). The effect of loneliness on distinct health outcomes: a comprehensive review and meta-analysis. Psychiatry Research, 294, 113514. [11] https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf