By Maddie Ruud
As a woman 3½ years into a constant, severe headache, I think, talk, and read a great deal about pain. I also think, talk, and read a great deal about gender. Strangely enough, it took me a long time to think and talk about the two issues together—how they intersect, interact, and influence each other. Before I attended the 6th Annual Women In Pain Conference this September, most of the exchanges I had relating to the experience of being a woman in pain involved modestly deflecting offhand comments from (female) friends to the effect that my (male) partner probably wouldn’t be dealing with my chronic pain condition half as well as I am. But in the weeks both preparing for and following the conference, I made it my mission to discover just how large a role gender plays in the experience, expression, and treatment of pain.
In a conversation about pain and gender, the first (and sometimes only) touchpoint for most people is childbirth. We’ve probably been arguing about how well men would bear up under the pain of labor as long as we’ve had the language to do so, but the issue never seems to lose its charge. Last May, this video of men experiencing simulated contractions went viral, prompting strong reactions from both sides of the debate. Comments on social media ranged from women expressing glee over the perceived validation to men asserting that women don’t know what “real pain” is (with examples from being kicked in the testicles to passing a kidney stone). There was intelligent discussion too, with many people showing new appreciation for their own mothers and some men even voicing a willingness or desire to have the experience themselves. But this video and the similar Dutch video that preceded it have by no means put the issue to rest—and besides, the influence of gender on pain is not limited to gendered activities like bearing children.
Up until the 1990s, there was almost no study on gender differences in the experience of pain, but thanks in part to the National Institutes of Health Revitalization Act of 1993, the requirement for inclusion of women in medical research has led to a number of interesting discoveries. In fact—and in contrast to popular feminine lore—studies show that on average, men have a higher pain threshold and tolerance than women do. They also indicate that women experience pain more intensely than men. But as with most sweeping generalizations about gender, these assertions can’t exactly be taken at face value.
Since pain is subjective, research relies on individual reporting, for example, rating the experience of pain on a scale from 1 to 10. And when you’re relying on reporting for your data, there is a lot of wiggle room between the subject’s experience of pain and what he or she describes to the researcher. Each of us brings baggage when it comes to expressing pain, and much of that baggage is gender role-related. There is a pervasive expectation that men are (or should be) more stoic and women more expressive, which may mean that men feel subconscious pressure to minimize their pain while women feel more comfortable readily admitting it. Studies also show that the gender of the person administering the experiment matters in how subjects report. According to a 2004 study, people endure pain longer in the presence of an administrator of the opposite sex, and men indicate a higher level of pain when tested by a female administrator than a male. We carry the pressure to perform gender with us everywhere, even into the experience of pain.
When it comes to gender bias, medical practitioners are no more immune than the rest of us. If women report more pain than men, it would stand to reason that women are more extensively treated for pain, but unfortunately, the opposite is true. Women are much more likely to have their suffering dismissed as emotional or psychological, and mounting evidence shows massive inequality in medical care, from the type and dosage of medication prescribed to the amount of credibility the patient is assigned. In one study, nurses were directed to read a vignette about a patient and estimate the amount of time and medication he or she would need to treat said patient. Using the same vignette with only the gender of the patient changed, nurses planned significantly more time for administering painkillers and providing emotional support to male patients than female.
Your looks also play a part in how much treatment you receive. Physically “attractive” patients are perceived by doctors to be functioning better than physically “unattractive” patients. This may skew treatment even further, as women often feel overwhelming pressure to present themselves as sexually appealing, even in the midst of incredible pain. Attending the Women In Pain Conference, I heard over and over a common refrain: one of the biggest barriers to having one’s pain taken seriously is the fact that one doesn’t necessarily “look sick,” which directly conflicts with the desire to maintain one’s image. As Caroline Knapp wrote in Appetites: Why Women Want: “Mastery over the body—its impulses, its needs, its size—is paramount; to lose control is to risk beauty, and to risk beauty is to risk desirability, and to risk desirability is to risk entitlement to sexuality and love and self-esteem.” Thus, women in pain are faced with an impossible choice: either risk your sex appeal and all its perceived benefits, or risk the credibility of your pain experience.
I am now approaching my fourth year with chronic pain, and when I look back on my own treatment journey, I shudder. My first neurologist told me pointedly in my very first visit, “You don’t look like you’re in pain,” and even included this very unscientific and unspecific observation in his written summary of the appointment. At the time (and for a long while after), I thought it was my fault, a failure on my part to overcome a compulsion acquired partly as a result of my mother’s disdain for “drawing attention” to one’s ailments. I thought I needed to work harder to “prove” my pain. I even doubted my own experience, wondering if somehow I was exaggerating or catastrophizing—perhaps even completely manufacturing—the sensations that are very real to me, but invisible to the outside world. In the end, I learned that the problem did not lie with me, my pain, or my ability to express it. It lay with the doctor, his bias, and his lack of understanding.
Although one should never feel the need to perform pain for a doctor, performing a lack of pain has consequences as well. Perhaps unsurprisingly, performing health looks a lot like performing female gender. Since I am mostly homebound and comfort is key, I don’t usually spend a lot of time on my appearance, but when I do go out, I feel compelled to pluck my eyebrows and make sure every stray hair on my head is secured. I make a conscious effort to smile and laugh enthusiastically, despite my pain. I ask many questions and show unending interest in friends’ lives, attempting to downplay my own struggles and avoid complaint. The desire to protect others (and my own ego) prompts me to make myself and my pain less threatening—that is, more female.
While we have learned much about pain (and specifically, gender and pain) in the last decade, neuroscience is still in its infancy. One day there may be a definitive test that can objectively measure pain. In the meantime, I believe the best thing a person in pain can do is to be as honest as possible about the experience… and try his or her darnedest to refrain from filtering that experience through expectations of gender. You are the judge of your own pain, and in a fair trial, gender bias should never have the last word.
Images in compilation photo courtesy of http://www.foodphotosite.