rush hour

Men and women: we’re different.


Men are outnumbered by women when it comes to having chronic pain. I don’t know the actual figures, but in almost every epidemiological study of chronic pain, it’s women who are more likely to have chronic pain .  Despite this, women can have a hard time getting appropriate pain management – receiving instead a range of treatments for anxiety and depression (Bernardes, Costa & Carvalho, 2013).  This can mean it’s more difficult for women to recover from their pain, or to return to better functioning, but at the same time it can make the whole experience of having chronic pain rather more isolating for men.

Notions of masculinity are fairly well-defined in popular media. I used Google to search for a definition of “what is masculinity”, and this is what I found:

masculinity

So imagine if you’re a man and you have chronic pain. You feel exhausted, every time you move it hurts, you don’t sleep well, you have to ask for help to do things, and on top of that when you go to the medical centre to find out what’s going on, you’re confronted by a waiting room full of mothers with preschool children, stacks of aging women’s magazines, posters of breast examination and cervical smear testing, and even the reception staff are all women!

Ahlsen, Menghoel and Solbraekke from University of Oslo in Norway have published three really interesting papers looking at the narratives of men seeking treatment for muscle pain. They point out that because chronic pain is not often linked to anything that can be identified in physical imaging, or examination, people with it can feel they’re labelled as weak, sick, whiners, lazy or faking (Ahlsen, Menghoel & Solbraekke, 2012, p. 316).  These are not the terms we usually associate with being a man!

What is it like for men to attend a pain management programme? What are they looking for from being involved in rehabilitation? Is it different from what women are looking for? All good questions because the answers will directly influence how well we as treatment providers can  meet their needs. Can we do better?

In the first study by this group of researchers, Ahlsen, Menghoel and Sobraekke (2012) identify from the outset that men attending a pain management rehabilitation centre found their experience of participating quite different from their earlier treatment experiences. While early treatment had left these men feeling isolated and abandoned, being in a chronic pain specialist service was experienced as “the best place” and for these men “finally receiving medical based expert treatment”.  This makes me wonder what it was about the early treatment that left these men feeling so alone, and furthermore, what it was about a specialist service that made the difference.

These researchers found three broad types of narrative: “rebuilding a self”, “being comforted” and “being connected” to describe how men participating in this treatment felt.

Rebuilding a self – Initially, many men experience significant loss of social role and respect. By being surrounded by experts who accompany him as he learns more about his pain and begins to engage in exercises to “rebuild” his strength and health, he can rebuild an identity without the feelings of shame that he can otherwise have.

Being comforted – Some men “just get by”, keep on keeping on, perhaps engaging in short bursts of treatment that rarely have long-term impact. Men attending a comprehensive programme that includes psychological help, can feel it is acceptable to talk about what it is like to have chronic pain but not be able to grieve. Being able to talk about these otherwise hidden effects of pain provides comfort and support.

Being connected – Some men experience being “pushed from pillar to post” as each health professional has trouble clearly identifying what is going on. For some men this feels like no-one really knows what is going on, and attending a pain management centre becomes the best way to put all the pieces of the pain puzzle together, connecting each part to the whole, to make meaning of what is going on. By being connected again, he can solve his need for support, the company of others, and make progress.

In a second study by Ahlsen, Menghoel and Sobraekke (2012), stories men tell of having chronic pain and trying to make sense of what is happening is analysed using a narrative theoretical framework. This approach to analysis views what people say as attempts to make meaning on their experiences by telling them as stories, interpreting their experiences by looking back to the past, and projecting into the future as we do when we tell stories.

In this study, men describe working very hard in demanding environments, having difficulty with physical limitations, struggling with what is happening in their personal lives but trying to explain these events in terms of “objective facts” such as heredity, physical events, and the demands on them – but relatively little about what it is like to be men with pain. In other words, the narrative of being a man with pain is to try to “be rational”, to “be self-controlled”, to “be a man”. Because, of course, big boys don’t cry.

At the same time, we can interpret, as Ahlsen, Menghoel and Sobraekke (2012) do, that men actually DO feel vulnerability, loss, distress – but have difficulty being able to express this within the kind of stories we expect men to tell, and the kinds of roles men are thought to play in our society.

The lucky last in this trio of papers about men and pain, Ahlsen, Bondevik, Mengshoel and Solbraekke (2014)  present a further study of gender in rehabilitation, and argue that women’s stories demonstrate the ways they are trying to “transcend” their former identity, moving from experiences of chaos towards becoming more autonomous, while men’s stories tend more towards attempts to “find a solution”, often more closely aligned to a medical context in which they saw themselves with a future that depends on receiving health care.

This is at odds with the way we see male and female healthcare seeking. Most times, we see more women than men seeking treatment, with men being stoic (perhaps even stubborn?!), and trying to manage their health alone without help.

Why is this important?

So much of health research especially in chronic pain, is viewed in terms of biomedical and psychological frames. The social is rather less studied. Gender identities are both biological but also socially determined. The ways we view men and women depend on our own constructs of what it means to be a man or a woman in our own sociocultural setting.

Most of our healthcare culture, particularly a biomedical one, is focused on ways to “get rid of pain” or the source of the pain, to help people “return to normal”, to “get better”. As these authors put it, to enact a “restitution” story where people go through chaos, make sense of it all, put it all back together and get on with life, independent once more ( Ahlsen, Bondevik, Mengshoel and Solbraekke, 2014, p. 361).

From the studies these researchers have conducted, it seems that men tend more towards a slightly different story – I seek help, it gets fixed, and I go off – but I continue to have need for health professional support.  Maybe men in particular need to have the legitimisation of their pain through getting a label from a health professional to help them justify their decision to reshape their ideal of masculinity. The men in these studies seem to need to find a way to get “independence and control” that is so important in our society’s version of masculinity.

What does it mean for us?

I can’t pretend that reading these studies is easy. I’m a woman, I live in a world in which being a woman or a man is infused with all manner of expectations, and because I’m embedded in it, I don’t always notice that this is what’s happening. Culture is like that: it’s about what feels “normal” – until you’re confronted with something that doesn’t fit.

What I think it means for me is to learn much more about ways we can help each man learn to reframe what it means to be masculine in his own mind.  Is it OK for a man to ask for help? Is it OK for a man to need support? What is it like for a man to identify as someone who can’t “do it all”? To have a body that doesn’t “do what it should”?

Can we help men put their own puzzle of pain together? Do we need to look at the language we use? Perhaps part of the current explosion in “pain neurophysiology education” is one way that men can feel that their pain is understandable, that it’s not their personal weakness but it’s just how their body functions? Instead of messy emotional stuff, perhaps learning about the mechanics of pain neurobiology is a little like learning about a complex computer or machine.

Do we need to think about the language of rehabilitation too? What of the focus, for men, on how their bodies function? Should we think more about gently encouraging men to look at accommodating a different body, maybe reduce the talk of a “battle” against pain, “overcoming” pain, the narratives of “fighting with” or “winning”?

Against a pain problem that revs itself UP when people begin pushing against it, do we need to move towards a more Zen notion of fluidity, power expressed as going with, flowing – perhaps a more appropriate model of martial arts like Tai Chi, Qi Gong, or even Aikido?

 

Ahlsen, B., Bondevik, H., Mengshoel, A., & Solbrække, K. (2014). (Un)doing gender in a rehabilitation context: a narrative analysis of gender and self in stories of chronic muscle pain Disability and Rehabilitation, 36 (5), 359-366 DOI: 10.3109/09638288.2013.793750

Ahlsen, Birgitte, Mengshoel, Anne M., & Solbraekke, Kari N. (2012). Troubled bodies-troubled men: A narrative analysis of men’s stories of chronic muscle pain. Disability and Rehabilitation: An International, Multidisciplinary Journal, 34(21), 1765-1773.

Ahlsen, Birgitte, Mengshoel, Anne Marit, & Solbraekke, Kari Nyheim. (2012). Shelter from the storm; men with chronic pain and narratives from the rehabilitation clinic. Patient Education and Counseling, 89(2), 316-320.

Bernardes, Sonia F., Costa, Margarida, & Carvalho, Helena. (2013). Engendering pain management practices: The role of physician sex on chronic low-back pain assessment and treatment prescriptions. The Journal of Pain, 14(9), 931-940.

6 comments

  1. Bronnie, the questions you pose in your penultimate paragraphs are well worth a comment or two.

    Despite broad agreement that “pain” is a sensory and emotional experience, our society attempts to reify it. The reification (making an abstract concept into a concrete “thing”) of illnesses into diseases for diagnostic and therapeutic purposes has been in fashion since the mid-17th century. [Fuks, 2009]

    The reified entities we call diseases have tended to acquire “military” metaphors, enabling them to invade the body, overcome its defenses, and take up permanent occupation. The clinician, and to a lesser extent the patient, have been cast into the roles of valiant fighters against the reified disease.

    However, I suggest that pain cannot be so reduced. To conceptualise it as a “thing” (a reified disease) with agentive (causative) properties leads only to fallacious arguments that do not take us any closer to understanding the predicament of patients of either sex.

    Your final suggestion that we attempt to reframe the experience points the way towards a resolution of the language problem.

    Reference: Fuks A. The military metaphors of modern medicine. Available at: http://www.inter-disciplinary.net/wp-content/uploads/2009/06_fuks.pdf

    1. I so agree John. In so many parts of our treatment of pain, the narrative is about “abolishing”, “winning”, “fighting”, “getting rid of” – but people don’t “get rid of” what they have experienced, and that’s what having pain is: an experience. I like the language of ACT which talks of “making room for”, “allowing”, “bringing it with you” and I think this is the kind of language that might be more useful. Instead of seeing pain as “a black dog” in the way that depression has, perhaps we need to think of a “shadow side” of self and see it as simply part of the human condition.

  2. Thanks for this brilliant post Bronnie. It helps me reflect on these issues when I am working. We do have such embedded ideas about the roles of both men and women, and keeping fluid helps us all.

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