Chronic Fatigue Is No Joke, But Too Many Games Still Treat It Like One

Content Warning: This article discusses issues around medical neglect

In August 2020, indie developer Cellar Door Games released Rogue Legacy 2, a sequel to their irreverent 2013 roguelike. When the player character dies during a run, they are replaced by one of their descendants, each time receiving randomly-selected traits that change something about the gameplay or the game’s aesthetic. Some of the options are personality traits like “clumsy” and “charismatic” or belief systems like “pacifist” and “vegan.”

But out of several dozen traits, nearly half are potentially disabling real-world conditions. These include life-threatening ones like Congenital Insensitivity to Pain and Osteogenesis Imperfecta, as well as “comedic” takes on Obsessive-Compulsive Disorder (“breaking things restores mana”) and Super IBS (“your class talent is replaced with super fart”). One in particular hit a little too close to home for me: Chronic Fatigue Syndrome, the common name for Myalgic Encephelomyelitis or ME/CFS.

In the game, the trait slows player actions using a cooldown but adds a gold bonus as a reward, presumably for dealing with such a frustrating condition. Seeing my life reduced to a game mechanic in this way brought into sharp relief feelings I have struggled with for nearly a decade. When I had to quit the Chemistry Ph.D. I was working on in 2011 due to unexplained illness, I never imagined I would still be sick in 2020. Even after a trip to the Mayo Clinic, I have more questions than answers. I am fatigued, yes, but when I push through my tiredness (say, by cooking or playing board games for a few hours), I experience severe post-exertion exhaustion (“malaise”) and neurological overloads (“crashes”) where I can’t move or speak for several hours.

Today, I still have unexplained bouts of joint and muscle pain, debilitating brain fog, and the inability to stand for more than a few minutes at a time without risking severe “payback” over the next several days. Without any FDA-approved treatments, my best option is to “pace” my activities and rest as much as possible, so I spend most of my days in bed and limit outings to once every couple of weeks.

This hasn’t been ideal (especially before the pandemic), but I’ve adapted. I work part-time as a writer from a laptop in bed and use mobility aids when I go out to limit flare-ups. I play MMOs and RPGs with friends on good days and Candy Crush by myself on bad ones.  I have a very understanding spouse and a snuggly dog who thinks she’s a cat. Still, my few productive hours a week never feel like enough. On the days I’m forced to rest so I don’t make myself sicker, my mind fills with ableist whispers passed down through culture and media: Lazy. Useless. Slacker. Fraud.

I’ve worked hard to overcome these internalized accusations, but every time I encounter them in the wild, it’s a fresh shock to the system. It could be worse, I’ll admit; Rogue Legacy 2 fixed an initial bug that caused the cooldown to apply to all actions, including attacks, which made the character functionally useless. But the player’s reward for enduring this challenge is still extra gold, which —whether the developers intended it or not—furthers the all-too-common narrative that chronically ill and invisibly disabled people are trying to game the system. This narrative, introduced decades ago by a handful of doctors and unscientific media speculation, allows our society to ignore complicated conditions, block research funding, and gaslight patients (content note: includes examples of medical gaslighting, death due to medical neglect, and references to suicide). Even the CDC recognizes that the illness “might not be taken seriously” by some healthcare providers.

But games like Rogue Legacy are intentionally a bit flippant—it’s just a joke, right? Not in the case of an illness once derisively nicknamed “yuppie flu” that continues to be treated as psychosomatic, despite its physical basis being reported since at least the 1950s. After being unable to explain several outbreak clusters of a mysterious, polio-like illness in the previous decades, two psychiatrists published a paper in 1970 reclassifying ME/CFS as primarily psychological, explicitly (in large part) due to its prevalence in women. Despite decades of evidence to the contrary, this reclassification was widely accepted by popular culture and medical institutions. “Myalgic Encephelomyelitis” became “Raggedy Ann Syndrome” and then “Chronic Fatigue Syndrome,” and research progress ground to a halt.

Even today, despite heroic strides on the part of a few researchers, we don’t fit under any specialty, very few doctors are familiar with our symptoms, and it can take an average of 5 years to receive a diagnosis. Until recently, the official treatment for exertion intolerance in the UK was essentially more exertion, plus therapy, an approach that left many patients more severely disabled than before. A significant portion of people with ME/CFS are unable to work, and as of 2014, the condition received less than $5 of NIH research funding per patient per year—less than hayfever. It is also difficult for chronically ill people to qualify for federal disability due to fluctuations in symptom severity, leaving many reliant on family or partners for support. This makes Rogue Legacy 2’s gold bonus especially painful.

This history of marginalizing complex, multisystem illnesses has come back to haunt us on a global scale. At a press conference in July 2020, Dr. Anthony Fauci highlighted the similarities between ME/CFS patients and COVID-19 “long-haulers” who don’t seem to be recovering despite months of rest. This has prompted more interest from congress and researchers, but because ME/CFS has been treated as a joke in our culture for so long, we have very few resources to offer the thousands of people who may soon end up in or adjacent-to our community.

Given this background, Rogue Legacy 2 certainly isn’t the first game to take a reductive approach to invisible disabilities. A surprising number of tactical RPGs including XCOM and Valkyria Chronicles have trait or potential systems that either explicitly use real-world medical conditions as traits or come uncomfortably close. Action games like Watch Dogs: Legion and simulation games like Crusader Kings 3 use disabilities in this way as well.

Even if they come with a bonus, disabilities and disability-related coding are almost always considered “negatives” in these systems. For example, in Watch Dogs: Legion, players are tasked with recruiting Londoners to insurgency group DedSec. Some character classes, like Decorated Soldier and Retired Police Engineer, automatically have “reduced mobility,” which makes it impossible to sprint or stealth and takes up a permanent attribute slot. Some players enjoy recruiting these characters as a “challenge,” but they are treated as objectively less effective than able-bodied characters with similar skills. Even games like XCOM 2, where negative traits are removable, communicate a similar message: disabilities are penalties to be avoided. They make characters less valuable, which inadvertently encourages players to replace disabled characters when better alternatives become available.

Feudal-age sim Crusader Kings 3 is a more complicated case. It also uses real-world disabilities and illnesses as traits, but in some ways, it acknowledges the many intersecting effects such conditions can have on a person’s life. It even incorporates elements of the social model of disability, which emphasizes society’s role in “disabling” people through stigma and inaccessibility. Illness and disability change the way the character is perceived by others, independent of any changes to their innate physical abilities. This more holistic approach helps avoid the reductionism of “chronic fatigue = stamina debuff” seen in other games. CK3 also makes its subtext clear: it might be advantageous to assassinate a sickly heir, but it’s not good or noble, which highlights the unfairness of the period’s social structure rather than reinforcing it.

When other games use real-world conditions as what amounts to flavor text, even if the descriptions are sympathetic, they contribute to existing social narratives instead of subverting them. Valkyria Chronicles uses its NPC “potentials” in this way. “Nature lover,” “city kid,” and “daredevil” are things many players can personally relate to, which increases the feeling of connection to their squad. But the game also includes real-world physical conditions described as “bad back,” “frail body,” and, yes, “chronic fatigue.” These traits are essentially shorthand that invites players to fill in the characterizations with their own biases and outside (usually inaccurate) media portrayals. The game does not challenge those biases in any way, even if it isn’t outright mocking disabling conditions.

Representing disabilities through game mechanics is a delicate balancing act. Structures that treat characters with limited mobility or fatigue as suboptimal will always “bake-in” an ableist, capitalist value system and encourage us to sideline disabled characters in order to win. This is by design; these systems mimic real-world ableist and capitalist structures that force disabled and chronically ill people to the margins. They can’t do anything else as long as our definition of “optimal” remains intact. Game mechanics are not neutral in this environment; they influence the way we frame our own lives and the lives of others.

When I first got sick, the negative-trait interpretation of my illness would have fit like a glove. So many of the things I loved and identified with—exploring new cities on foot, riding my bike to work, working in an office—became impossible due to my reduced stamina and strength. But once I realized there was no quick fix for my severe energy limitations, I knew I had to find a way to build a life for myself. I had to learn to exist in this body as a complete person, not a “regular” person with reduced stats.

It’s hard to explain in a world full of disability narratives dominated by limitation and loss, but even though I spend 23 hours of most days in bed, I’m not missing out on life. This is my life. It’s a part of the human experience, even if it’s considered less valuable by a system that demands 110% of our energy in exchange for survival. While I would love to see more creative, thoughtful representation of disabled characters in games, what I really want is to see game worlds and mechanics that are big enough to hold those experiences without minimizing them for able-bodied consumption.

It doesn’t have to be complicated. I know that there’s a place for me when I see diverse characters whose strengths and limitations are honored and accepted. I know I’m not an afterthought when there are well-designed structures in place to care for people’s physical needs, whether they are wheelchair-accessible ramps or giant factories producing prosthetics. It’s wonderful in the rare cases this inclusion is made overt, but all I need to love a world is to be able to imagine myself playing a meaningful role in it. Maybe I’m riding (reclining?) shotgun on deep space cargo runs, slinging stories in a pirate hideaway, or just knitting away on the couch in the Sims (even if I am still considered “lazy”). In order to build these worlds, we must reckon with the stories told by genres and mechanics and practice subverting ableist systems that are all too real.

Elizabeth K. Hinnant is a chronically-ill freelance writer, knitter, and one-time chemist whose Atlanta office consists of a day-bed, a dog bed (for a corgi/shepherd mix named Heidi), and a desk that is entirely for decoration. She can be found on Instagram at @ElizabethKHinnant.