Gender and pain: thinking beyond sex differences

Consider the following…

What is the first question that comes to mind when you find out someone is pregnant?

Most of us would ask “Is it a boy or a girl?” As humans, knowing whether someone is male or female is a part of how we organize information about them in our minds. Just knowing this one simple fact allows us to access a huge arsenal of stereotypes, expectations, beliefs, and attitudes that we will use to make sense of that person and their behaviour. We don’t do this because we’re bad people; it’s just how our brain files and retrieves information. But what we are learning more and more is that the gendered experience is far more complex than the male-female categories and it actually has a lot to do with our health. Gender is defined by the Canadian Institutes of Health Research (CIHR) as “the socially constructed roles, behaviours, expressions and identities of girls, women, boys, men, and gender diverse people. It influences how people perceive themselves and each other, how they act and interact, and the distribution of power and resources in society. Gender is usually conceptualized as a binary (girl/woman and boy/man) yet there is considerable diversity in how individuals and groups understand, experience, and express it.”[4]

So what does all of this have to do with pain?

We know that male-female differences are common in the pain experience, both for acute and chronic pain. However, not all of the variation between the sexes is accounted for by biology and the variation within the sexes is often greater than the variation between. This is where studying gender can help us deepen our understanding. Some of the research that has been done so far has shown that self-reported masculinity is associated with higher pain threshold and tolerance [1], systemic gender bias is present in pain treatment (e.g., women’s pain is seen as less credible) [2], and that adhering to gendered expectations about pain behaviour (e.g., men are expected to be stoic) can have detrimental effects on health and help-seeking [5].

If it’s so important, why don’t we study it? The short answer is that it’s not easy. There are many different ways of defining and understanding gender, such as gender identity, gender expression, and gender role orientation (to name a few). In our recent topical review in PAIN [3], we have a table that aims to define and provide suggestions on how to measure each of these dimensions of gender – but therein lies another issue: many measures of gender are out-of-date, created for a specific population, or are not designed for a pain context. We also have not done a good job of including gender diverse populations in our research, despite the fact that we have research suggesting that these are groups that deserve our attention (for example, transgender individuals carry a disproportionate burden of health problems, and experience discrimination and significant barriers to accessing healthcare [6–8]).

We can try to pretend that gender doesn’t matter, or that all differences are explained by sex alone. I can understand the temptation – it’s a lot easier to do a simple male-female t-test and move on (or, the even more popular option: control for sex or gender, or only recruit one sex so it doesn’t “mess up” your data). Alternatively, we could embrace the challenge of figuring out how to measure and understand this complex construct and try to integrate it into our research.

If you’re interested in learning more about how you can integrate gender and sex into your pain research, I would highly recommend the excellent resources put together by CIHR. I also recommend that you think not only about how to integrate a gender perspective into your research, but how gender might interact with other key determinants of health (such as age/developmental stage, ethnicity, socioeconomic status etc.) to influence a person’s experience of pain. I really believe this has the potential to make our work richer, more relevant, and more inclusive.

About Katelynn Boerner

Katelynn Boerner

Katelynn is currently a postdoctoral fellow in the Department of Psychiatry at the University of British Columbia in Vancouver, Canada, and is based at BC Children’s Hospital. She completed her PhD in Clinical Psychology at Dalhousie University in Halifax, Nova Scotia, Canada under the supervision of Dr. Christine Chambers. Katelynn is an aspiring clinician-scientist and a registered psychologist with an interest in gender, sex, and pain in young people.

References

[1] Alabas OA, Tashani OA, Tabasam G, Johnson MI. Gender role affects experimental pain responses: A systematic review with meta-analysis. Eur. J. Pain 2012;16:1211–1223. doi:10.1002/j.1532-2149.2012.00121.x.

[2] Bernardes SF, Lima ML. On the contextual nature of sex-related biases in pain judgments: The effects of pain duration, patient’s distress and judge’s sex. Eur. J. Pain 2011;15:950–957.

[3] Boerner KE, Chambers CT, Gahagan J, Keogh E, Fillingim RB, Mogil JS. The conceptual complexity of gender and its relevance to pain. Pain 2018;159:2137–2141.

[4] CIHR Institute of Gender and Health. What is gender? What is sex? 2014. Available: http://www.cihr-irsc.gc.ca/e/48642.html. Accessed 25 Feb 2018.

[5] Keogh E. Men, masculinity, and pain. Pain 2015;156:2408–2412. doi:10.1097/j.pain.0000000000000328.

[6] Lerner JE, Robles G. Perceived Barriers and Facilitators to Health Care Utilization in the United States for Transgender People: A Review of Recent Literature. J. Health Care Poor Underserved 2017;28:127–152. doi:10.1353/hpu.2017.0014.

[7] Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a review. Lancet 2016;388:412–436. doi:10.1016/S0140-6736(16)00684-X.

[8] Rider GN, Mcmorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics 2018;141:e20171683. Available: http://pediatrics.aappublications.org/content/pediatrics/early/2018/02/01/peds.2017-1683.full.pdf. Accessed 18 Mar 2018.