My little granddaughter Everly Rose is mesmerized by her “owies”. Every bruise, scrape, or even the tiniest scratch inflicted while playing with her kitten, Homie, requires a healing kiss and an equally healing Band-Aid, which can then be proudly pointed out to every stranger we pass on the street. One morning, after I’d had a hard fall while out with my walking group, she carefully examined the dark scab and asked me, very seriously, “Did you cry?” I told her that I’d thought about crying at the time, but then I patted myself all over, realized I wasn’t badly hurt, and so I decided not to cry.
She thought about this explanation for a long while, as if it had never occurred to her that not crying was even an option. Is that because Rosie is a little girl – and not a boy? A Swedish study helps to answer that question.(1) .
Children like our Everly Rose learn very early in life what’s expected of them when they experience pain.
From childhood, according to this study, little boys and little girls are socialized along gender norms on how to respond to pain. For example, research has found that boys and men are generally taught to be tough, tolerate pain, and sustain painful experiences, while girls and women are socialized to be sensitive, careful, and to verbalize discomfort.(2)
As the Swedish researchers explained, we learn what can happen as we grow older:
“Chronic pain is common in all western societies, but women dominate most diagnoses related to chronic pain, and research has consistently shown differences between the sexes, like the perception, description and expression of pain, the use of coping strategies, and the benefit of different treatments.(3)
As a person living with the chronic chest pain of refractory angina, I often say that I experience the kind of daily pain that would have most normal people dialing 911. Every day. But like many others with chronic pain, I’ve learned to tolerate what would likely be considered intolerable symptoms because daily pain begins to feel almost “normal”, as I wrote more about here:
Still, one of the most significant obstacles to appropriate pain treatment is what the Swedish researchers call gender blindness.
As in many other areas of health care, pain treatment decisions for women are results of a “non-awareness of the fact that a great deal of knowledge is based on research performed in men only.”
And this gender blindness can hurt both sexes, as this study reports:
“Gender-blindness can lead to women’s needs being overlooked, as seen in coronary heart disease, but can also mean that men’s needs are unnoticed, as seen in their under-diagnosed depression.”
Among pain patients, masculine attributes like strength, endurance, and stoicism appear to be valued higher than feminine attributes like sensitivity and expressing discomfort.(4) In fact, the Swedish study pointed to one reason called andronormativity.
This means that masculinity and male values as “normal” in medicine to such an extent that femininity and female values are invisible and need to be highlighted in order to simply be recognized.(5)
Andronormativity explains a lot.
This has consequences for how male behaviour is seen as “normal” – even in conditions that affect both men and women.
To the surprise of nobody who regularly reads Heart Sisters, the Swedish study explains that even though angina is common in both male and female heart patients, women’s angina symptoms have been called “atypical”– meaning not like men’s pain, positioning men’s pain as the norm.
But as my paramedic/researcher friend Cristina d’Allesandro, part of the filmmaking team behind the new documentary film, “A Typical Heart“, likes to say:
“Women make up more than half the population. So why do we call their heart attack symptoms ‘atypical’?”
Research cited by the Swedish team included some interesting findings about how men and women seeking medical help are generally perceived by health care professionals. For example, men were often described like this:
- in control
- tolerating pain
- denying pain
- taking health risks even when they led to increased pain
Men with osteoporosis, for example, described how they hid their “weakness” in public. They preferred to risk increased pain and even new fractures rather than following the doctor’s advice about not doing heavy lifting. And as one man explained his reluctance to admit needing medical help:
“You don’t like to make a fuss because it’s a macho thing just to say you’re being the strong and silent type. You’ll endure it, you can take it. So if there is something wrong, you won’t talk to anyone about it. You have to be bedridden or half dead before you’ll go (to the doctor’s).”
Unlike descriptions of men, who are almost always described independently from women, many pain studies describe women in comparison to men, e.g:
- more sensitive to pain than men
- more willing to report pain than men
- more socially acceptable for women to show pain and talk about it
- more used to internal pain because of menstruation and child birth
- have greater body awareness compared to men
- pain without an external cause is “a natural characteristic of women’s bodies”(2) Yes. Seriously.
- not wanting to get better
- fabricating the pain (as if it is all in her head)
- looking good (Some women were mistrusted when they looked too good, e.g. You can’t be sick, You don’t look ill, You always look so healthy, You are so young)
Other studies have shown that woman with chronic pain are at higher risk to be assigned psychological rather than physical causes for their pain.(6) This is also true in cardiology; a Cornell University study (Chiaramonte et al), for example, found that heart attack symptoms presented in the context of a stressful life event were identified by physicians as psychological in origin when presented by women, but cardiac when presented by men.
Here’s a disturbing finding that might feel familiar to any woman whose symptoms have been dismissed, ignored or minimized: the Swedish researchers wrote that “medically unexplained” conditions often go along with an unwillingness among professionals to believe the women’s symptoms in the first place.
In a Canadian study, for example, general practitioners and specialists were interviewed about their patients diagnosed with fibromyalgia (a condition which affects women more than men). Most physicians regarded fibromyalgia patients as malingerers, time consuming, and frustrating. Some clinicians even held the patients accountable for their pain.(7) More info in Dr. Barbara Keddy’s important book, Women and Fibromyalgia: Living With an Invisible Dis-Ease
Sadly, the conclusions of the Swedish researchers confirmed that they’d found
“gender bias in the initial patient encounter, along with gender bias in pain treatments.” They added:
“Our results confirmed this paradox: compared to men, women have more pain, and it is more accepted for women to show pain, and more women are diagnosed with chronic pain syndromes. Yet paradoxically, women’s pain reports are taken less seriously, their pain is discounted as being psychological or nonexistent, and their medication is less adequate than treatment given to men.”
“Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing equitable care that is more capable to meet the needs of all patients, men and women.
NOTE FROM CAROLYN: I wrote more about cardiac pain in women in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 20% off the list price).
Q: How can gender bias be addressed so that women’s pain symptoms are taken more seriously?
1. Anke Samulowitz, Ida Gremyr, Erik Eriksson, and Gunnel Hensing, “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, vol. 2018, Article ID 6358624, 14 pages, 2018.
2. R. B. Fillingim, C. D. King, M. C. Ribeiro-Dasilva, B. Rahim-Williams, and J. L. Riley, “Sex, gender, and pain: a review of recent clinical and experimental findings,” Journal of Pain, vol. 10, no. 5, pp. 447–485, 2009.
3. E. J. Bartley and R. B. Fillingim, “Sex differences in pain: a brief review of clinical and experimental findings,” British Journal of Anaesthesia, vol. 111, no. 1, pp. 52–58, 2013.
4. S. F. Bernardes, E. Keogh, and M. L. Lima, “Bridging the gap between pain and gender research: a selective literature review,” European Journal of Pain, vol. 12, no. 4, pp. 427–440, 2008.
5. S. Philpott, P. M. Boynton, G. Feder, and H. Hemingway, “Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study,” Social Science & Medicine, vol. 52, no. 10, pp. 1565–1575, 2001.
6. D. E. Hoffmann and A. J. Tarzian, “The girl who cried pain: a bias against women in the treatment of pain,” Journal of Law, Medicine & Ethics, vol. 28, no. 4, pp. 13–27, 2001.
7. S. M. Hayes, G. C. Myhal, J. F. Thornton et al., “Fibromyalgia and the therapeutic relationship: where uncertainty meets attitude,” Pain Research and Management, vol. 15, no. 6, pp. 385–391, 2010.