Gender and the body language of pain

It is now well established that men and women show general differences in how they report and experience pain – women tend to report more pain, with greater severity and frequency than men. Examples are numerous, and range from laboratory-based pain induction studies on healthy adults through to epidemiological and clinical investigations of chronic pain. Recent studies show a greater female vulnerability to post-surgical pain (Tighe et al., 2014), and a higher incidence of persistent pain in women compared to men (Kennedy et al., 2014).

The question naturally turns to why these gender differences occur. Explanations are likely to reflect the biopsychosocial nature of pain. However, most have focused on biological (e.g., sex hormones) and psychological mechanisms (e.g., pain-related catastrophizing; gender-role expectations and beliefs), with less attention placed on social factors.

Fortunately, we are currently seeing a social (research) revolution, with greater recognition that pain does not happen in isolation. There is increasing awareness that pain assessment and treatment involves social interactions and negotiations e.g., between healthcare providers and patients, parent and child etc. How pain is communicated to others is also important, and we know this occurs through both verbal and nonverbal channels. Thus, alongside self-reports, we can also measure pain through a range of nonverbal cues, including facial expressions (grimaces), nonverbal vocalisations (cries, groans) and certain body postures and movements (guarding). This is particularly important when we consider situations where it is not possible for patients to verbally communicate to others about their internal, subjective pain state such as pre-verbal children, and patients with dementia. Attempts are now being made to isolate and measure these nonverbal cues in a reliable and objective manner.

These issues are relevant to our understanding of gender differences in pain, and I believe there is much to be gained by taking a social communication approach (Keogh, 2014). Indeed, the well-established gender differences in nonverbal communication that have been found in the general area of emotion expression research, corroborate the idea of using a social communication approach in pain. In emotion expression research, women seem to be more expressive and better at recognising a range of core emotional expressions than men, for example, women are more likely to smile than men. Whilst pain and emotion are not the same, they do seem to operate through similar nonverbal channels. It would, therefore, seem sensible to at least consider whether male-female differences exist in the generation and recognition of pain expressions.

So what does the evidence tell us for pain? Unfortunately, there are relatively few studies that set out to directly explore gender differences in nonverbal pain communication. Of the studies that have been conducted, most focus on facial expressions of pain, where an interesting pattern is starting to emerge. Whilst there are few reports of gender differences in the generation of facial expressions of pain, there may be differences in how such expressions are recognised. However, the nature of this difference is still unclear, since a range of methods and approaches are used to measure such interactions. Furthermore, we do not know whether gender differences exist in other nonverbal channels of pain communication, such as in vocal and body expressions.

Rather than view these unanswered questions as problematic, I view this as an exciting new direction for gender and pain research. What a nonverbal approach brings to the fledgling area of male-female pain communication is a range of tried and tested techniques that allow us to consider the dynamic nature of social exchanges between individuals within the context of pain. For example, we are currently developing new body posture stimuli sets (Walsh et al., blog post here), which will hopefully enable us to look at gender differences in the recognition of pain and core emotions. Such an approach also leads us to consider interpersonal factors in more detail, as well as whether the gender context is important for pain. For example, do male and female healthcare providers pick up on different types of verbal and nonverbal information, and if so, what effect does this have on choices around treatment? We might also find gender pays a role in understudied groups of patients, especially children, where nonverbal behaviours are critical.

In sum, I believe that we are on the cusp of an exciting point in our understanding of gender-related issues in pain. Taking a pain communication approach should help us understand more about why there may be gender differences in pain and pain behaviour. In addition, I hope that those with primary interests in pain communication consider the gender context in more detail, thus adding an extra dimension to their work.

About Ed Keogh

Ed KeoghEd is Deputy Director of the Bath Centre for Pain Research and a Reader in the Department of Psychology, both based at the University of Bath in the United Kingdom. His primary research interests are in understanding why there are sex/gender differences in pain, with a focus on psychological factors. He also has interests in pain communication, and the role of attention in our perception and experience of pain. He is currently co-chair of IASP’s Special Interest Group on Sex, Gender and Pain.

References

Kennedy J, Roll JM, Schraudner T, Murphy S, & McPherson S (2014). Prevalence of persistent pain in the U.S. Adult population: new data from the 2010 national health interview survey. J Pain 15 (10), 979-84 PMID: 25267013

Keogh, E. (2014). Gender differences in the nonverbal communication of pain: A new direction for sex, gender, and pain research? Pain, 155 (10), 1927-1931 DOI: 10.1016/j.pain.2014.06.024

Tighe, P., Riley, J., & Fillingim, R. (2014). Sex Differences in the Incidence of Severe Pain Events Following Surgery: A Review of 333,000 Pain Scores Pain Medicine, 15 (8), 1390-1404 DOI: 10.1111/pme.12498

Walsh, J., Eccleston, C., & Keogh, E. (2014). Pain communication through body posture: The development and validation of a stimulus set Pain, 155 (11), 2282-2290 DOI: 10.1016/j.pain.2014.08.019

Comments

  1. John Quintner says:

    Ed, my problem is with your use of the phrase “the biopsychosocial nature of pain”. According to my philosophical friends, being in pain is a brute fact – something that cannot be explained. “Biopsychosocial” is but one way that we have chosen to help us understand the experience of another person. It does have its limitations.

  2. Excelent article and even better comments!

  3. Thanks for your writing Ed. I know the gender debate in health is well known along with the need to consider psychosocial dynamics of pain whether working with male, female or transgender, so I’m interested in the next questions that might come from your inquiry.

    Perhaps rather than “Is there a gender difference in the way we experience pain?” research could dive straight into “How do health care providers develop their capacity to tune into the cues that enable better health care?”

  4. It may seem flippant, but if you’re looking for experts in non-verbal pain expression & identification, look at your local vet.

    Their clients are not only verbally unable to express pain, but many instinctively conceal it.

  5. David Buchanan says:

    I just do not know where to start with this…

    Firstly let me apologise to all the women out there who suffer chronic/persistent pain… Yes I thought we were past this kind of rubbish as well… Sadly it would seem not…

    Rubbish? – well, look at the language that’s being used for a start…

    Firstly he trots out it is well established — then goes on to say that sadly there are few studies… Cake and eat it too? It’s the ol trick… masquerade speculation as theory then reveal there’s not even evidence for a hypothesis but hang on – it’s already been established… add a bit catastrophization – the ol chestnut – and well you women really are a problem…

    What he means is that there is a groundswell of clinicians who find women present with and are happy to discuss their pain experience – whereas – guess what men tend to be more stoic… Enter social factors… Redolent of the dreaded Ferrari et al ‘studies back in the 80s and 90s – they found that whiplash injuries (read persistent pain of a central sensitised nature) occurred in certain countries where compensable claims existed or had latin back syndrome. Oh dear…. an association does not constitute causality as one of the great fallacies dictates: post hoc ergo propter hoc. That is to say – I’m holding a rock and there are no tigers around therefore this rock keeps tigers away or women are not men therefore it is well established they experience pain differently. Really?

    And before outrage is conferred upon these points how is describing this rubbish as rubbish any different to describing someone’s pain state as catastrophising? For mine there is more evidence for the former as the redoubtable Owen Williamson pointed out over ten years ago – is pain ever normal, can it ever be measured objectively and absence of evidence for pain is not evidence of absence of pain.

    Isn’t it time we really started to question the poor frames of some psychological endeavour? From a flawed premise – women feel pain differently to men (tell that to any women giving birth!) to but there’s a paucity of evidence – this circular argument now gives this man the magic ingredients to research something that was entirely constructed in the beginning. But what really worries me is the damage this will do to women in the meantime who will naturally enough trust this expertise as being ‘expert’ and say the ol patricahial catchphrase “oh it’s because I’m a woman.” Just as the quite rightly repudiated Ferrari et al research had Italians say “It’s because I’m Italian and I want more money’. And before we know it the real flaw in all this pops out – the pain is all in yr mind! And we all now know how discredited that Cartesian premise is? Surely?

    Best David Buchanan PhD

    cs ben-eitan Reply:

    Thank you Dr Buchanan. Well stated. In my 12+ years experience I have found that women will come for pain relief after they have suffered, or rather, denied their pain or their right to complain of pain — long past the levels that men seem to find intolerable.

  6. Esther de Ru says:

    The funny thing is that I have always found (clinic 40+yrs) that men suffer much more and talk about pain more then women do. Could this be because of my gender?