AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. August 2002, Volume 4, Number 8.

Journal Discussion

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Who's Really Hurting?

A recent journal article proposes a gender-sensitive approach to pain management that acknowledges men's and women's differing needs for pain treatment.

Susanna Smith

Women have been labeled the fairer sex, the weaker sex, the emotionally driven and irrational sex. Over the past century successive waves of women's rights movements have tempered these stereotypes, offering women more freedoms and opportunities. But in many ways Western society has become so conscious of being politically correct and asexual in preference that we run the risk of failing to recognize the important differences in the sexes.

Men and women are not the same. They are anatomically distinct, biologically different; and they have diverse styles of thinking and communicating. In a recent literature review, "The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain," Dianne E. Hoffman and Anita J. Tarzian highlight one significant difference in the sexes by suggesting that men and women feel and deal with pain differently. Furthermore, this study suggests that "women are more likely than men to be undertreated or inappropriately diagnosed and treated for their pain" [1].

Pain is a subjective phenomenon that cannot be readily quantified; therefore physicians rely largely on patients' self-reporting to determine the severity of their pain. Only in the past decade has the medical research field recognized that women and men may experience illness and pain differently. In fact recent clinical pain studies found women reported more severe and frequent pain and pain of longer duration than men. Other studies suggest that women may have a varying level of pain tolerance, reflecting changes in hormone levels during their menstrual cycles.

Besides hormonal differences, structural differences between the central nervous systems and brains of men and women may affect how members of that sex feel pain. One structural difference this review cites is tissue thickness and sensory receptor density in women that may make their skin more sensitive to pain than men's. Although the disparities between men's and women's responses to pain are well documented, it is unclear whether these differences are rooted in biology or in coping strategies and pain expression, or in both.

Physiological influences and the attribution of meaning to pain may also play a part in sex-related experience and expression of pain. Studies have found that women are more likely to report and seek treatment for pain. One reason for this could be that women more frequently experience pain in the absence of illness, eg, in childbirth and menstruation. Therefore they seek treatment for pain as a means of sorting "normal biological pain . . . from potentially pathological pain, whereas men do not need to go through this sorting process" [1]. Despite higher incidence of pain reports, and their increased susceptibility to pain, women are systematically treated less aggressively than men for their pain. Women's pain complaints are often written off as emotional responses, which explains the finding that women are prescribed psychotropics more often in pain treatment whereas men are given analgesics.

The undertreatment of pain in women may also be due to the widely held but false notion that women have higher pain tolerance than men. The fact that women do undergo normal biological processes that are painful may have given rise to this generalization. Studies have also found that women have more pain coping mechanisms, such as seeking social support, relaxation, or distraction whereas men more often deny they are in pain or deal with pain through tension reducing behaviors such as consuming alcohol. But women's ability to deal with pain better should not be translated into the idea that they experience less pain when many studies point to the opposite conclusion.

Social mores also influence the way men and women report pain. In most Western societies it is more culturally acceptable for women to report pain than for men to do so; the social norm for men encourages a stoic response. One study reported that the sex of the inquiring researcher affected the way male participants responded in a laboratory setting. Although men report pain less frequently, it seems they are taken more seriously when they do seek pain treatment; women, who report pain more frequently, are often described as anxious.

Women's ability and readiness to verbalize their feelings and describe their pain may lead physicians to discredit the severity of their pain. One report suggested that women's style of communication may not fit neatly into the traditional format of the physician interview, leaving women in chronic pain vulnerable and "rebuffed by physicians in their attempts to express the multiple ways in which their pain affects the quality of their lives and their ability to function" [1].

Hoffman and Tarzian go on to make an argument for just treatment in pain management, suggesting that a more equitable approach would be "sex-specific, gender-sensitive pain management treatments," as an acknowledgement of men and women's different pain treatment needs.

Questions

  1. Does the sex of your doctor affect how you report pain or how your pain is treated?
  2. As a clinician, are you likely to think that a man who reports pain must "really be hurting," perhaps hurting more than a woman who reports pain?
  3. What needs to be changed in medical education to make physicians more responsive to pain reports of women patients?
  4. Why is emotional pain largely discounted as invalid pain, or pain not warranting the physician's full attention?
  5. Should there be a different patient interview model for men and women that reflects the different communication styles of the sexes?

Reference

  1. Hoffman DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law, Med, Ethics. 2001;29:13-27.

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