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Perspective
18 www.acms.org
The 1944 classic psychological thriller
lm Gaslight tells the story of the ctional
character Paula and her new husband
Gregory, who goes about the task of
isolating her and leading her to believe
that she is insane. He accomplishes this
by dimming and brightening the gas lights
in their house and then insisting that she
had been imagining it. The objective was
to compromise her sense of self and
environment, leading her to accept his
distorted reality and doubt her sanity. In
more recent terminology, “gaslighting”
is a colloquial term used to describe the
manipulative strategies of abusive people
in intimate interpersonal and institutional
relationships. (1)
Although gaslighting has been
considered a psychological syndrome,
in many ways it is fundamentally a social
phenomenon. Although engaging in
abusive mental manipulation certainly
has aspects of psychological interplay,
it occurs because of social inequities.
Perpetrators of gaslighting utilize
gender-based stereotypes, social
inequalities, and institutional
vulnerabilities against their victims.
Gaslighting tactics can damage the
victim’s sense of reality, independence,
identity, and social support. (2)
Gaslighting occurs within power-
imbalanced personal relationships.
Although often recognized in domestic
violence situations, it can occur in other
types of interpersonal relationships.
Barton and Whitehead devised the
term ‘gaslighting’ in a 1969 Lancet
article that conceptualized involuntary
hospitalization as a form of abuse. (3) The
term was later popularized in a 2007
book by psychotherapist Robin Stern
in which she explained gaslighting as
a phenomenon of mutual participation
between perpetrator and victim. Although
Stern wrote that gaslighting was
gender-neutral, her case studies all
involved a male partner as the
gaslighter and a female as the target.
The best measurable data currently
available offers evidence that
gaslighting is a common characteristic
of domestic violence. (4)
Whereas, psychological theories
suggest that gaslighting occurs in an
isolated dyad, the sociologic hypothesis
assumes a more complicated etiology,
with the primary origin evolving from
power imbalances, and a secondary
requirement of a close interpersonal
or institutional relationship binding the
victim and perpetrator. Consequently,
the victim cannot readily or easily dismiss
the gaslighting efforts. Trust and coercive
interpersonal tactics bind the victim to the
perpetrator. The sociologic hypothesis
of gaslighting suggests that it exists in
the presence of pervasive inequalities
of allocation of social, political, or
economic power. (2)
The social concept of gaslighting in
the context of health care also reects
a broad power dynamic and institutional
inequality. Medical gaslighting is a
symptom of a larger problem within
health care, which being the continued
privilege of biomedical expertise
overriding and sometimes invalidating
the interpretation of actual individual
experiences. (1)
Central to the relationship of
gaslighting and health care is the concept
of ‘biopower’ established by French
philosopher Michael Foucault. Biopower
refers to the regulatory technologies
of institutions used to govern human
life. He describes the ways that health
messaging promotes a specic and
idealized image of health and of the body
in which people conform and aspire to
achieve. Medical gaslighting can be
seen as an extension of ‘biopower’ within
health care. An example might include
a health care provider’s premature
interpretation of a patient’s physical
symptom as being solely of
supratentorial etiology. (5)
Philosopher and gender theorist
Judith Butler authored the concept
of ‘performativity’ as the process by
which social norms are constructed
through repetitive informal practices.
Performativity suggests that social reality
is not canon, but is instead continually
created and reinforced through language,
gesture, and symbolic social cues.
Butler also wrote of performativity and
autonomy as being ‘code-constructed’ in
Gaslighting and Health care
TimoThy Lesaca, mD
Perspective
19
ACMS Bulletin / January 2023
the therapeutic relationship. This concept
has applicability in the doctor-patient
relationship, in the sense that biopower
as established by institutional norms is
maintained through performativity. (6)
In contemplating the interactions
between patient and doctor during a
clinical appointment, the social norms
that might allow for medical gaslighting
now become clearer. The doctor begins
the appointment typically by asking
in some manner what is the patient’s
concern. At that point, the doctor’s
power is briey suspended, allowing the
patient to bring forth his or her personal
observations. The doctor, representing
the ‘biopower’ of the institution of
medicine, is empowered afterwards to
pronounce what is real and what is not.
Operating from the hierarchical construct
that science is the nal verdict, the doctor
can make an interpretive pronouncement
of reality for which the patient has limited
options to refute. In the context of Butler’s
research, this relationship is performative.
Within a performative interaction, there
is opportunity for resistance, which
would not be without potential negative
consequence to the patient, depending
upon the doctor’s reaction. Within these
performative interactions, resistance is
uncommon regardless of the patient’s
individual experiences, considering
that the nature of the visit involves the
doctor establishing the questions, the
timeline, the sequence of events, and
the examination. At that point, the patient
has limited paths for resistance. (7)
Although the terminology of medical
gaslighting is contemporary, it is not a
new concern, as claims of invalidation,
dismissal, and disregard of patient health
concerns, particularly of female, ethnic
minority, LGBTQ+, and underprivileged
patients, are of long-standing concern.
Gaslighting is a function of power
dynamics, and medical gaslighting is
an example of how power dynamics
operate within the health care institution.
Butler’s theory of performativity allows
for renewed insight into the ways that the
biopower of modern medicine is reied as
the authority in healthcare relationships,
yet her research also provides an
opportunity for understanding when and
how these relationship dynamics should
be challenged and balanced by individual
experiences. In addition, the applicability
of these insights can apply to other
potential examples of gaslighting within
the health care community, as in the
relationships between administrators and
employees, supervisors and supervisees,
physicians and nurses, and medical
specialists and primary care providers. (8)
In conclusion, gaslighting is unique,
and is differentiated from other forms
of interpersonal misconduct within
health care, as it does not involve public
humiliation, specic threats, or obvious
insults. The destructive effects of all
forms of gaslighting can be malignantly
devastating to all aspects of life.
Gaslighting is intrinsically subtle and
intimate. These characteristics make
even more dangerous.
(1) Sweet, P. L. (2019). The sociology
of gaslighting. American Sociological
Review, 84(5), 851-875.
(2) Ferraro, Kathleen J. 2006. Neither
Angels nor Demons: Women,
Crime, and Victimization. Boston:
Northeastern University Press.
(3) Barton, Russell, and J. A. Whitehead.
1969. “The GasLight Phenomenon.”
The Lancet 293(7608):1258
(4) Stern, Robin. [2007] 2018. The
Gaslight Effect: How to Spot and
Survive the Hidden Manipulation
Others Use to Control Your Life. New
York: Harmony Books
(5) Foucault, M. (1998). The history of
sexuality--The will to knowledge,
Volume 1, 1976. Trans. Robert Hurley.
Penguin.
(6) Butler, J. (1990). Gender trouble:
Feminism and the subversion of
identity. Routledge.
(7) Sebring, J. C. H. Towards a
sociological understanding of medical
gaslighting in western health care.
Sociology of Health & Illness. 2021;
00:1–14.
(8) Fraser, S. The toxic power dynamics
of gaslighting in medicine. Can. Fam.
Physician Med. Fam. Can. 2021, 67,
367–368
The opinion expressed in this column is that of
the writer and does not necessarily reect the
opinion of the Editorial Board, the Bulletin,
or the Allegheny County Medical Society.
