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Friday 5 June 2020

Gender and Pain

Have you ever considered how your identity could influence how you feel pain? How your pain is perceived by others? Or how much of your pain experience is understood by the scientific and clinical communities?

Is it safe to assume that most of you haven’t?

Amongst many other contributing factors, our sex and gender may have a profound impact on pain and our pain experience. While we may have a better understanding of sex differences in pain perception, how gender ties into this is not fully understood. However, researchers are now beginning to understand that gender does impact our pain experience, and may play a significant role in how pain is differentially assessed and treated between men and women. This phenomenon has been deemed the ‘gender pain gap’: a gap in our understanding of women’s health issues which has lead to the inappropriate pharmaceutical treatment of men and women, and not taking women's health seriously.

The Gender Unicorn by TSER.

To better understand the gender pain gap, it’s critical to acknowledge the difference between sex and gender. Sex and gender are often (mis)used interchangeably. But they are not the same, nor are they independent.

Biological sex is assigned at birth, and is based on the presentation of male or female external genitalia; i.e. do you have a penis or a vagina? It is typically thought of as a binary (male or female), and your genetics ultimately determine your sex: traditionally, two X chromosomes for females, and one X and one Y chromosome for males. However, we now know that biological sex is more complicated than that. In animal studies, males and females have unique sex differences in their pain processing systems. We also know that sex hormones, which differ between the sexes, contribute to pain experience[1]. After the menopause, when a woman’s circulating female sex hormones drop, we see a much smaller difference in sex differences in pain. We still don’t fully understand (or consistently acknowledge) sex differences in the research community, so we’ve got a lot of ground to cover in determining how sex contributes to the gender pain gap.

Gender, on the other hand, refers to the roles and socially constructed norms of ‘maleness’ and ‘femaleness’. Gender can be used to refer to a wide range of different, but interrelated constructs.  It is multi-faceted; we each have our own gender identity. Our gender identity may contribute to how we think we should respond to pain, and engage in certain pain behaviours, such as avoiding a painful stimulus, rubbing the affected area, or grimacing[2].

This piece will largely focus on how gender influences pain.

Chronic pain conditions, such as fibromyalgia, rheumatoid arthritis, and lupus, affect more women than men globally. In fact, 80-90% of people diagnosed with fibromyalgia are women. And it’s not an isolated case: shockingly, more women than men live with a chronic pain condition. Women on average experience more severe and longer lasting pain than men. While there are biological underpinnings to this, such as sex hormones that would make women more likely to develop certain chronic pain conditions, gender may also play a role in how we understand this pain. One explanation could be how attitudes towards one’s pain differs between the genders. Pain catastrophising describes a negative attitude towards pain, and a tendency to ruminate, magnify, or feel helplessness about it. It is a well-known predictor of pain intensity[3] in those suffering chronic pain. In a study focussed on back pain, women were more likely to catastrophise their pain as a coping mechanism. The reason why was not understood. So, could pain catastrophising be part of the observed gender difference in pain severity, or duration? Perhaps. It remains to be further explored.

In a review published only a couple of years ago[4], gender norms and expectations were examined amongst those with chronic pain. They found that women received less effective pain relief and more antidepressants, and were referred to a mental health service more often than men. What could explain these discrepancies? Probably a multitude of factors! Firstly, women are more likely to be deemed ‘hysterical’ or, more modernly, ‘overly emotional’. Since they are more likely than men to discuss their pain, and many female-specific pains such as child birthing or menstrual pain are internal/not visible, women are more likely to have their pain psychologised. Men, on the other hand, are deemed to be more stoical, and maybe it is that this stoicism leads to men underreporting their pain. And perhaps, when they do express pain, it is taken more seriously than women’s. Additionally, it was only in 1998 that the FDA mandated that drug testing had to demonstrate safety in both sexes. To this day, many drugs have only been tested on men or male rodents, or, if women are included, not enough have been recruited to sufficiently identify whether there are observable differences.

What does this mean in the real world? When we don’t take women’s pain as seriously, what are the downstream effects?
The pain scale is a useful tool for evaluating where a person sits on their own tolerance scale. By SVG images.

As a current DPhil student studying endometriosis-associated pain, I am part of a research group that is acutely aware of gender pain gap effects. Endometriosis is a chronic inflammatory condition that affects 10% of women of reproductive age. While there are many symptoms and comorbidities associated with it, the predominant symptom is pain. More specifically, pelvic pain. Unfortunately, we don’t know much about endometriosis; it’s very cause is still an enigma. When women present in clinic with the disease, they often report not being taken seriously. They are told that their pain is in their head. This stigma has led to an average 7.5-year diagnostic delay in the UK! The fact that we simply just do not understand the biology of the disease also contributes to the delay. What’s more, many symptoms of endometriosis are not unique to the disease and it’s tough to diagnose without surgical confirmation. To learn more about endometriosis, the Endometriosis CaRe Centre research group in Oxford has recently developed this great resource for those living with endometriosis during the COVID-19 pandemic.


An interview: in conversation with Professor Ed Keogh

Aside from many of the clinical implications of the gender pain gap, I wanted to better understand from a research perspective how this gap is perpetuated. I had the privilege of interviewing Professor Ed Keogh from the University of Bath, a researcher focusing on the psychology of pain with a particular interest in gender and sex differences in pain. In conversation with Professor Keogh, key considerations for pain research emerged.


Pain is subjective

How an individual experiences pain is not entirely based on the stimulus causing the pain. As Professor Keogh highlighted, pain is a complex experience influenced by previous experiences, your emotions, and things like gender norms and expectations. Professor Keogh’s earlier work demonstrated that people who fear pain exhibit a selective attentional bias towards it. That is, for people who are afraid of pain, they focus more attentively on the painful situations in their life, and, therefore, may have more negative experiences of pain than someone who does not fear it[6].


Reporting issues: do you mean gender or sex?

Katelynn Boerner, one of Keogh’s collaborators, and other colleagues examined all research articles published in 2017 in PAIN (the leading scientific journal for, you guessed it, pain research). She examined how many articles focused specifically on, or even included, sex and gender. Their results were shocking; 56% referenced sex, and only 16% referenced gender. Of those referring to gender, more than 75% were actually talking about sex, by definition. Nearly one third of these articles used sex and gender interchangeably[6].


How we measure pain: do we have the means to adequately assess gender in pain research?

Currently, there are a few standardised tools used in research to understand gender in its entirety and complexity. Additionally, the measures of psychological constructs of gender are not really pain specific. Professor Keogh and I discussed the need to develop these types of tools. By doing so, we standardise how data on gender is collected in pain research, and simplify the process of data analysis for those studying gender in pain specifically. The question remains, however, as to whether or not we will ever get a measure that fully captures gender.


Pain influences gender

This is an idea I hadn’t considered before my conversation with Professor Keogh. While it’s apparent that gender influences how we experience pain, pain may directly impact how we express gender, or feed into stereotypical gender norms. To give an example, men are stereotypically expected to provide, either for themselves or for their family, and are typically less likely to ask for help. If a man suffers from a chronic pain condition that occasionally leaves him immobile and unable to work, this may hinder his ability to provide for his family, and require him to seek additional help and support from others. Ultimately, this may challenge his self-identity and perception of himself as a man.

My conversation with Professor Keogh revealed how much impressive and much needed research is happening around the world on this topic. However, we still have a way to go. Firstly, there’s an urgent need to develop standardised tools for assessing sex and gender in research. Perhaps a new project for Keogh and colleagues (?). Upon development, we need everyone doing research to include sex and gender in their work, not just those interested in gender and sex. It’s cancer researchers, it’s those running clinical trials, it’s those studying gynaecological conditions like endometriosis. If we all adequately and uniformly record sex and gender in our work, we’ll not only ensure that our research results are more robust, but we can also contribute to better and more personalised clinical care.

If you’re interested in learning more about sex, gender, and the role they play in pain, here are some great resources to explore. I also highly recommend reading some of Professor Keogh’s work, especially if sex, gender, and pain are of interest to you from a research standpoint.

why don't all references have links?

[1] Vincent K, Tracey I. Hormones and their Interaction with the Pain Experience. Rev Pain. 2008;2(2):20–24. doi: 10.1177/204946370800200206.
[2] Boerner KE, Chambers CT, Gahagan J, Keogh E, Fillingim RB, Mogil JS. Conceptual complexity of gender and its relevance to pain. Pain. 2018. doi: 10.1097/j.pain.0000000000001275.
[3] Leung, Lawrence. Pain catastrophizing: an updated review. Indian journal of psychological medicine 34.3 (2012): 204. doi: 10.4103/0253-7176.106012.
[4]  Keogh E, Ellery D, Hunt C, Hannent I. Selective attentional bias for pain-related stimuli amongst pain fearful individuals. Pain. 2001. doi:10.1016/S0304-3959(00)00422-X.
[5]  Samulowitz A, Gremyr I, Eriksson E, Hensing G. "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 Res Manag. 2018;2018:6358624. Published 2018 Feb 25. doi:10.1155/2018/6358624.

[6] Liu KA, Dipietro Mager NA. Women’s involvement in clinical trials: Historical perspective and future implications. Pharm Pract (Granada). 2016. doi:10.18549/PharmPract.2016.01.708.


Danielle Perro Author Bio

Danielle is a second year DPhil student in the Nuffield Department of Women’s and Reproductive Health. There she studies endometriosis-associated pain, to determine how we can best characterise women living with disease-related pain.

Read more about Danielle's work and associated research.

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