‘Women’s pain’ – not just ‘women’s pain’

Women really do get a rough deal when it comes to pain. We live with the myth that because women experience pain in childbirth and (often) with periods of course women can ‘deal with it.’

Until recently women and female animals haven’t been included in pain research, and guess what? Women and female animals don’t have the same biological system for processing nociception.

Men are told ‘don’t be a girl’ about their pain.

Women are told they ‘look too good’ to be experiencing pain.

Women don’t get taken seriously when they ask for help with their pain – and get given more psychological labels and help instead of appropriate investigations and effective analgesia.

I’ve just reviewed a whole heap of research papers looking at the differences between men and women, boys and girls and pain. It doesn’t make for happy reading, and even though I was fully aware of the disparity I have been thunderstruck at how pervasive pain in women is dismissed.

Let’s look at some facts for women in New Zealand.

https://minhealthnz.shinyapps.io/nz-health-survey-2021-22-annual-data-explorer/_w_37711963/#!/explore-indicators

This survey asks the question: Do you have chronic pain that is present almost every day, but the intensity of the pain may vary, and has lasted, or is expected to last, more than six months. This includes chronic pain that is reduced by treatment?

By comparison, Asthma (diagnosed and treated) – 11.4%; Diabetes – 5.2%; Chronic Pain – 22.6%

BUT there is NO national priority for chronic pain, and more women than men report it.

Want more? What’s the major area of pain for women in Aotearoa? According to the Global Burden of Disease, the most significant contributor to years lived with disability for women in New Zealand is – no, not endometriosis, not menstrual pain, but low back pain, followed by migraine. We hear a lot about endometriosis, but rather less about the overall problem of pain for women.

https://vizhub.healthdata.org/gbd-compare/

In reviewing international data I came across this study looking at 11,000 patient records, and evaluating the differences in reported pain intensity between men and women receiving care for the same diagnoses (Ruau et al., 2012).

This was gobsmacking to me. We KNOW that women are more likely to develop chronic pain (many of the studies show a 2:1 prevalence for women with chronic pain – see Fitzcharles et al., 2021) – but are clinicians aware that women report higher pain intensity, lower pain threshold and lower pain tolerance than men in acute pain? For an excellent review of sex differences in neurobiology, take a look at this paper by Presto and colleagues (2022).

But wait, sadly there’s more.

When women seek help for their pain, from childhood their pain is minimised and managed less assertively than men. Here are some examples from my recent wandering through the literature.

Girls are thought to be experiencing less pain than boys…

Earp et al., (2019) replicated a previous study showing that when clinicians were asked to watch a video and rate how much pain a child was experiencing when having a fingerprick blood test. The child’s gender was considered ‘ambiguous’ (so not easily identified as either a boy or a girl) but the participants were told either a boy’s name or a girl’s name, and asked to rate the pain. There were a whole bunch of other questions asked, but I’ll cut to the chase. No, Virginia, your pain is not as bad as Larry’s, and the gender of the observer was irrelevant. The authors said: “if the belief that boys tend to display less pain than girls is what is driving the relevant inferential process—that is, that this particular “boy” must really be in pain—then controlling for that belief should make the between-subjects difference in pain sensation ratings diminish or disappear. Indeed, this is what we find.”

Naamany and colleagues (2019) found that women attending the emergency department with acute renal colic (nasty pain for sure) reported higher pain intensity BUT men were given analgesics more frequently including opioids and more drugs overall than women.

Men reporting cardiovascular-related chest pain were 2.5 times more likely to be referred to a cardiologist than women….(Liaudat et al., 2018).

AND I wasn’t aware that one in three women quit doing daily activities because of menstrual symptoms, but 50% of them never mention this to family/friends or seek healthcare (Schoep et al., 2019).

Folks, it doesn’t get any better and actually gets a whole lot worse when we’re talking about chronic pain…

Samulowitz and colleagues (2018) carried out an exhaustive review of gender disparity in pain literature. It’s well worth a read (but keep the tissues handy, and watch your blood pressure if you are of ‘gentle disposition’). Essentially the findings show that women are actually biologically more sensitive to nociception, are more willing to report pain and apparently it’s more socially acceptable for women to be experiencing pain. BUT women are assigned ‘psychological’ rather than somatic causes for their pain, struggle for legitimacy, have their appearance scrutinized (‘you look too well to be in pain’), are prescribed less and when given analgesia are given less effective pain relief, fewer opioids but more antidepressants (though that could be because women are 2:1 more likely to have nociplastic pains), and give more mental health referrals instead of active rehabilitation. Even the recommendations for rehabilitation differ depending on gender (Wiklund et al., 2016).

Frankly, it’s outrageous.

It sucks to find that women’s pain continues to be trivialised, and women get given poorer treatment. We must change this because, duh, it’s a fundamental human right to be given access to pain management. It’s also a fundamental right to be treated with the same respect and diligence irrespective of your sex or gender. The flow-on effects of ineffective, inappropriate and inadequate pain management on women are profound.

Begin by getting loud about this. Look at your own assumptions. Be willing to question your treatment if you’re a woman. Be willing to review your practice, both men and women.

Earp, B. D., Monrad, J. T., LaFrance, M., Bargh, J. A., Cohen, L. L., & Richeson, J. A. (2019). Featured Article: Gender Bias in Pediatric Pain Assessment. Journal of Pediatric Psychology, 44(4), 403-414. https://doi.org/10.1093/jpepsy/jsy104

Fitzcharles, M.-A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098-2110. https://doi.org/10.1016/s0140-6736(21)00392-5

Clerc Liaudat, C., Vaucher, P., De Francesco, T., Jaunin-Stalder, N., Herzig, L., Verdon, F., Favrat, B., Locatelli, I., & Clair, C. (2018). Sex/gender bias in the management of chest pain in ambulatory care. Womens Health (Lond), 14, 1745506518805641. https://doi.org/10.1177/1745506518805641

Naamany, E., Reis, D., Zuker-Herman, R., Drescher, M., Glezerman, M., & Shiber, S. (2019). Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting. Pain Management Nursing, 20(6), 633-638. https://doi.org/https://doi.org/10.1016/j.pmn.2019.03.004

Presto, P., Mazzitelli, M., Junell, R., Griffin, Z., & Neugebauer, V. (2022). Sex differences in pain along the neuraxis. Neuropharmacology, 210, 109030. https://doi.org/10.1016/j.neuropharm.2022.109030

Ruau, D., Liu, L. Y., Clark, J. D., Angst, M. S., & Butte, A. J. (2012). Sex differences in reported pain across 11,000 patients captured in electronic medical records. Journal of Pain, 13(3), 228-234. https://doi.org/10.1016/j.jpain.2011.11.002

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management, 2018. https://doi.org/https://doi.org/10.1155/2018/6358624

Schoep, M. E., Nieboer, T. E., van der Zanden, M., Braat, D. D. M., & Nap, A. W. (2019). The impact of menstrual symptoms on everyday life: a survey among 42,879 women. American Journal of Obstetrics & Gynecology, 220(6), 569 e561-569 e567. https://doi.org/10.1016/j.ajog.2019.02.048

Wiklund, M., Fjellman-Wiklund, A., Stalnacke, B. M., Hammarstrom, A., & Lehti, A. (2016). Access to rehabilitation: patient perceptions of inequalities in access to specialty pain rehabilitation from a gender and intersectional perspective. Glob Health Action, 9, 31542. https://doi.org/10.3402/gha.v9.31542

Women, partner violence and pain

As the potential for greater repression of women’s autonomy grows (Afghanistan, United States, Mexico), along with racist and misogynist statements from business leaders (DGL CEO Simon Henry) it’s timely to look at pain in women. We already know that more women than men present with persistent pain (Blyth, n.d.), while women who are seen for their pain are more often misdiagnosed, offered psychiatric medication or psychological intervention only and have their experiences dismissed as “hysterical, fabricated, or nonexistent” (Samulowitz, et al., 2018). My daughter, when attending Emergency Department was offered a paracetamol and told “there’s no cure for being a woman” when seeking help for an ovarian cyst. Period pain is considered “normal” (Drabble et al., 2021). Pain in women is not a sexy topic.

Intimate partner violence is common among women. 27% of women who have had a partner report violence perpetrated against them. 24% of young women aged between 15 – 19 years report violence. Low-income countries reporting higher levels of intimate partner violence, and while data was not available for the past two years of covid-19 disruption, it’s expected that higher levels of violence are probable (Sardinha et al., 2022).

What about the intersection between partner violence and persistent pain? (BTW violence is defined as emotional, physical, or sexual harm experienced in a current or former intimate relationship and includes stalking, psychological aggression such as coercion, as well as physical and sexual violence).

Persistent pain is one of the most commonly reported health consequences of intimate partner violence (Walker, 2022), and women are more likely to be the recipients of partner abuse than men. Yet – open conversations about violence and persistent pain in women, recognising the signs and symptoms of partner violence in people seeking help for persistent pain, and adequate approaches to treatment are rare. Women may not disclose their situation for fear of being stigmatised, labelled unfairly, or having their pain – and their situation – trivialised.

Walker and colleagues (2022) carried out a systematic review of studies exploring the types of pain women experienced in association with partner violence, the severity of that pain, and the impact of pain on the person. They found that while pelvic pain was common amongst women who had been sexually abused, women also reported chest pain, back pain, neck pain, arthritis, and stiffness in joint or muscles, more frequent headaches, and more back pain – furthermore, women who had experienced partner violence reports higher pain severity, with 75% of women indicating moderate to severe pain, and the longer a women had been in an abusive relationship, the more likely they were to report higher intensity pain.

Interestingly, disability from persistent pain wasn’t measured often – only two studies from 12 included in the final review – but women with persistent pain from partner violence reported higher pain-related disability. They also reported worse impact on their mental health – more PTSD, anxiety and depression, with depression being one of the key mediator between a history of partner violence and ongoing pain.

The authors of this study (Walker et al., 2022) point out that it’s likely that women who have sustained partner violence and experience persistent pain are “not being adequately identified and responded to in clinical settings” – and that the fear of not being believed and the stigma of being on the receiving end of partner violence likely limits how many women openly discuss their situation.

Isn’t it time to get women’s pain prioritised? To get political about systems and processes that fail women? Isn’t it time to shift the narrative around women’s menstrual pain? To acknowledge that women are not mini men?

Finally, when we consider pain rehabilitation, we need to not only recognise that women have different priorities and goals for their lives than men, we also need to understand that doing rehabilitation is more complex for women than men – women report more difficulty prioritising their own rehabilitation over other responsibilities in their life (Côté & Coutu, 2010). Women may not even be referred for rehabilitation as often as men (Stålnacke et al., 2015). It’s time to prioritise understanding the lived experience of women as they pursue help for their persistent pain – and then do something different.

Blyth, F. (n.d.). Chronic pain in Australia: A prevalence study. Retrieved May 12, 2019, from http://www.ncbi.nlm.nih.gov/ pubmed/11166468

Daniel Côté & Marie-France Coutu(2010)A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?,Disability and Rehabilitation,32:2,87-102,DOI: 10.3109/09638280903026572

Drabble, S. J., Long, J., Alele, B., & O’Cathain, A. (2021). Constellations of pain: a qualitative study of the complexity of women’s endometriosis-related pain. British Journal of Pain, 15(3), 345-356.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018. https://doi.org/10.1155/2018/6358624

Sardinha, L., Maheu-Giroux, M., Stöckl, H., Meyer, S. R., & García-Moreno, C. (2022). Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. The Lancet, 399(10327), 803-813.

Stålnacke, B., Haukenes, I., Lehti, A., Wiklund, A., Wiklund, M. et al. (2015)
Is there a gender bias in recommendations for further rehabilitation in primary care of patients
with chronic pain after an interdisciplinary team assessment?.
Journal of Rehabilitation Medicine, 47(4): 365-371
http://dx.doi.org/10.2340/16501977-1936

Walker, N., Beek, K., Chen, H., Shang, J., Stevenson, S., Williams, K., Herzog, H., Ahmed, J., & Cullen, P. (2022). The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review. Trauma Violence Abuse, 23(2), 490-505. https://doi.org/10.1177/1524838020957989

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:

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.