“Brave men” and “emotional women”: gender bias and pain

by Carolyn Thomas   @HeartSisters     July 7 , 2019

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)

“Given the amount of people suffering from pain and the dominance of women with pain diagnoses, it should be of great value to review, analyze, and compile research on gender norms and gender bias in pain treatment.”

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. 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” (release date: July 15, 2019) likes to say:

“Women make up more than half the population. So why do we call their heart attack symptoms ‘atypical’?”

.

Brave Men: 

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:

  • stoic
  • autonomous
  • 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).”

Emotional Women: 

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.
  • hysterical
  • emotional
  • complaining
  • not wanting to get better
  • malingerers
  • 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 physical 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 much 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?

See also:

The freakish nature of cardiac pain – Part 1 of a 3-part series on cardiac pain

Brain freeze, heart disease and pain self-management – Part 2 of a 3-part series on cardiac pain

Chest pain while running uphill – Part 3 of a 3-part series on cardiac pain

The chest pain / panic connection

When you ignore pain because you’re used to it…

What is causing my chest pain?

The chest pain of angina comes in four flavours

How does it really feel to have a heart attack? Women survivors tell their stories

Why does your arm hurt during a heart attack?

How women can tell if they’re headed for a heart attack

85% of hospital admissions for chest pain are NOT heart attack

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.

4 thoughts on ““Brave men” and “emotional women”: gender bias and pain

  1. As a nurse and a caregiver for someone with cancer, what I have noticed is not so much gender bias but the lack of a really good assessment tool for pain.

    Pain is real but because of its nature … it can’t be measured by a blood test….It has to be reported by a patient subjectively….In general use is a 1 to 10 scale comparing current pain to the worse pain you have ever felt or can imagine.

    What if the worse pain a man or a women has ever felt was a stubbed toe? What if the worse pain was the crushing pain of a heart attack or childbirth? It seems the 1-10 scale cones up short.

    I found my friend with bone cancer always rating her pain a 4 or 4.5. Finally I showed her the Emoji faced Pain scale and found out her 4.5 was actually more of a 7!! Needing much more medication than she was getting.

    Years ago when I worked in surgical ICU…I constantly had to encourage men to “ stop trying to be a hero” and take their pain meds so they could walk, deep breathe and cough to get well. Most women were better at requesting their pain meds… but there were still both men and women that thought taking pain meds was a sign of weakness…. or were afraid they would get addicted if they took pain meds.

    Surgery hurts! Angina hurts! Anyone who thinks they can tell ME I’m not in as much pain as I think I am …. is in for a good tongue lashing.

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    1. Thank you for this, Jill. You raise so many solid point about pain in general. I worked in hospice palliative care for several years, and observed what you describe: patients in severe pain who somehow saw taking medication for pain as a sign of weakness.

      Sometimes this translated as: “It’s pretty bad right now, but it might get worse, so I’ll just wait until I REALLY need the drugs”. What we learned, however, is that it’s almost ALWAYS better to try to stay on top of moderate pain, rather than waiting for it to become unbearable – and then trying desperately to knock it back down.

      Same thing with patient-controlled pain pumps (amazing technology in which patients control exactly how often to deliver ‘breakthrough’ IV doses of their prescribed pain meds) which ironically ends up using significantly less medication than in the bad old days when nurses were ordered to administer regular doses every four hours (meaning patients would have to wait in agony for the last hour or more). That heartless policy seems like the Dark Ages now…

      The important message to patients: “Don’t be a hero!”

      Speaking of fear of addiction: the oncologists told my family at my Dad’s bedside (he had metastatic lung cancer) that they were “reluctant to give him morphine because it is addictive”NINE HOURS before he took his last breath.

      But at least he wasn’t an addict when he died…

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    1. Thanks for sending that link, Jane – I hadn’t seen this yet, although I do know that Professor Chris Gale has had a unique interest in studying the gender gap in cardiology. For example, as the BHF says:

      “Professor Chris Gale has led multiple studies that have shown the gaps in diagnosis and care between women and men which he shared at the event. A recent study shows that women who suffer a heart attack are 50% more likely than men to be given a wrong initial diagnosis. As he said: ‘We need to work harder to shift the perception that heart attacks only affect a certain type of person. Typically, when we think of a heart attack patient, we see a middle-aged man who is overweight, has diabetes and smokes. This is not always the case; heart attacks affect the wider spectrum of the population – including women.’

      “This misconception is dangerous – research has shown that women are dying due to unequal heart attack care. In isolation the differences in care that women receive may appear small, but even in a high performing health system like the UK, small deficits in care across a population add up to reveal a much larger problem and a significant loss of life.”

      This is a discouraging conclusion – or as I like to quote SCAD heart attack survivor Laura Haywood-Cory: “Sucks to be female – better luck next life!!”

      Like

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