Men, Women and Pain-Chronic Fatigue Research France

Men, Women And Pain:
Are All Things Equal?
Politics of Pain, Part two

By: Anne-Marie Vidal, MPA

Thirty-one years ago people talked about the financial disparity between the earnings of men and women. Women earned $.59 for every dollar men made for equivalent work. This economic inequity was much protested and fought. Ten years ago, women were earning seventy-five cents for every dollar men were making. Recently I heard the economic inequity gap was about 15 cents. For more than 30 years, women have fought for 26 cents on every dollar. Now women face a different type of inequity; this time in the doctor’s office where our battle for equal treatment now has to be fought on a slightly different front—the issue of whether women have a pain threshold equal to that of men and do we handle our pain well?

The claims that women are not the equal of men in dealing with discomfort surprised me and prompted me to carefully examine the material necessary to write this article. During the past ten years medical research has conducted studies that assert that men may be the stronger sex, when it comes to pain. A very significant presentation was made at the 20th meeting of the American Pain Society in the spring of 2001 that stated that men and women had different pain thresholds with that of women being slightly lower. Various tests in terms of tight blood pressure cuffs or the application of a thermal stimulus were cited. While animal experimentation has been conducted, pain threshold represents a seldom-studied area of medical research and one that was scarcely reviewed before 1986. A June paper titled “The Influence of Gender and Ethnicity on Management of Chronic Pain Disorders” by Patricia Brucheknthal, MS, RN, ANP-C evaluated research into the role gender and ethnicity have in chronic pain. The conclusions on gender are those that are examined here and what they might mean for those of suffering with chronic pain disabilities such as Fibromyalgia, Chronic Fatigue and Immune Dysfunction, and Chronic Myofascial Pain Syndromes.

As I read the medical reports, I found that the research conducted by Roger Fillingm, PhD (University of Florida) who studies the differences of pain response has been referred to in a number of medical journals. The work of his collaborator Linda LeResch, Sc, D, University of Washington, was equally well quoted in the medical periodicals.

Their efforts served as the basis for a WebMD, article dated April 30, 2001 by Bob Calandra that fairly trumpeted the news that the conventional wisdom that woman tolerated pain better than men had been disproved. A short paragraph made Calandra’s article particularly memorable:

“The trouble with that theory is -- it's wrong. And now men have the science to prove it. “

Calandra’s decision to assign the science to the male of our species speaks volumes about his biases while reflecting societal interpretation of the research’s meaning. It is particularly interesting that “men have the science” since Dr. LeResch, a woman, conducted the much of the study he quotes. The fact that the difference of pain levels is slight is not nearly as emphasized as the alleged fact that men can take more pain. However, the researchers say themselves that the way our body systems interpret pain and the way we express it is bound up in cultural norms and messages. Even more to the point is does this “men can take it’ stance, serve men well?

Dr. Juan Cortes, an infectious disease specialist with a busy Brooklyn, NY practice said, that men are conditioned not to show their hurts “Young boys are told ‘Be a Man, don’t cry’ while girls are comforted when they are in tears. Yes, women will speak up when a blood pressure cuff is too tight, but they can take pain and they handle it better than men.”

That men believe they have to maintain a “public strength, show-no-pain” stance is no surprise. At times the results of this cultural norm of have been tragic for male sports stars. Timothy Gower, columnist for the LA Times, pondered the “tough guy norm” that makes it easy for men to avoid doctors on July 8 when reporting the death St. Louis Cardinal’s pitcher Darryl Kile. Kile’s father had died of heart disease in his early 40s; sadly the pitcher had been on the phone with his brother the evening prior and complained of chest pain. Tragically, Kile did not seek medical attention and was found dead the next morning at the age of 33.

Gower’s sensitive and sensible article speaks to the heart of these popular notions regarding men and pain; he notes that while only half of male sufferers of migraine headache seek medical care, nearly three quarters of women with the condition do. He quotes New York Stony Brook University Hospital psychologist Harold L. Pass, "It's inculcated in men that we have to be the breadwinner, have to be strong, can't acknowledge weakness, as a result, men tend to minimize medical symptoms when they first appear." In other words, by the time the average man seeks a doctor’s care his problem is likely to have become more serious and it is not difficult to infer a relationship between this and the statistic that indicates the average woman will live seven years longer than her male counterpart.

For men with chronic pain, the societal image of the strong man makes seeking and obtaining medical help even more complicated. My on-line conversations with men who have Fibromyalgia indicate that they, like women, encounter difficulties when trying to discover the reason for their pain. They are just as likely to have their pain wrongly attributed to an injury or stress, as a woman is to hear that her problems are “all in her head.” (Men will hear the “all in your head” scenario –just not as often as women.)

Over the last 5 years, the percentage of the FMS patient population that is male has been revised upward several times and is now thought to be as high as 45%. Even Dr. Mohammed B. Yunus, a well respected researcher and expert on the care of Fibromyalgia patients, concluded that men had fewer and less painful tender points, milder morning fatigue, and less Irritable Bowel Syndrome when compared to female patients. Despite the statistical correctness of his research, male patients were less than appreciative of his conclusions.

An e-mail friend responded, “My personal CONCLUSION of this is that Dr. Yunus has been chewing on his electric blanket at night, one time too many times.” Other men repeatedly assured me that their pain was severe, rotating, and debilitating.

Social Conditioning or Physical Difference?

Our society does encourage women to seek regular health care. Women are taught to look after their bodies from adolescence; conversely, boys only seem to go to the doctor if they are really sick, need a physical or are thought to have broken a bone. We live in a country that encourages an annual wellness exam for Women but has no similar insurance benefit for young or middle-aged men. Nor do Medical assistance programs for low-income males in any state cover such an exam. Additionally, while women may seek the help of gynecologist for pelvic pain, where does a man go when he has pelvic pain?

Yet women are judged because they do go to the doctor’s office and the fact that they do report their medical conditions. LeResch’s research stated that women are more likely to have 1 or more reported pain over a their life span; and are more prone to have 3 or more multiple pain conditions before age 65. This finding was considered a significant part of the argument that women do have a lower pain tolerance.

So, do women have a lower pain threshold than men or are women encouraged to speak out on the issue of their pain and are we well-served when we do? Dr. Haim Mandelbaum of New York Hospital’s Pain Management Center in Brooklyn said that his experience with patients did not support the premise that men endured pain better. “Everyone is different and pain levels do differ…but men do not seem to have less pain or to handle it better…(the) women encountered are often “too busy working and/or caring for their families to attend to every pain …they tend to ignore minor pain and keep functioning.”

At present, medical science affirms that pain severity by sex goes beyond feeling the pain, it is a question of how the sexes perceive pain, describe it and then cope with it stated by Lynne Lamberg, a JAMA contributor in an article “Venus Orbits Closer To Pain Than Mars, RX For One Sex May Not Benefit The Other.” Ms. Lamberg’s report covers a National Institute of Health’s conference on gender and pain. It seems that beyond the type of pain, its severity, and duration, doctors should consider whether a man or a women is reporting the pain. Gender consideration should not mean that doctors assume women exaggerate pain or that if a woman cries her issues are not physical but emotional. (However, that doctors’ perspectives of their patients’ pain are filtered through their own race and gender bias is already known and documented, see Politics of Pain –Ed.)

At this conference Karen Berkley, PhD, a McKenzie Professor of Neuroscience at Florida State University described pain as reaching beyond an unpleasant message from our nervous system to our brain but instead pain represents” an ensemble act," with “cellular, molecular, genetic, physiological, psychological, and social factors all interpreting the signal before there is an experience that we recognize as pain.” Professor Berkeley adds “that the burden, variance, and variability of the pain experience are greater for females than males.” Strangely a woman’s bodies have more ways to channel the pain. Socially we will describe it and cope with it differently, Dr. Berkley states.

A cyber friend, Michael Alsup, who wrote me, provided a descriptive example:

“Consider a man and woman both doing carpentry: Both hit their thumbs with the hammer. The Man: swears, grabs thumb for a second, and then goes back to work. The Woman yells: "AHHHGGGG!!!!!" grabs thumb, goes for ice, can't use it the rest of the day. Compare this to another scenario. Both a husband and wife get a severe case of the flu. Man is bedridden, but in most cases, the woman, equally ill, gets up, and not only takes care of the man, but the kids who are the shared responsibility of both as well as herself. I know, these are not solid examples that apply to every man and woman, but rather cliché’s that do hold true in the majority of cases, as most cliché’s do” Michael who has Fibromyalgia felt that the studies were comparing apples and “hummingbirds.”

Another issue affecting the study of pain by sexual category is that the menstrual cycle appears to enhance pain or to increase its intensity. Certain types of pain such as migraine headaches are more pronounced in women in their reproductive years. At present just how much hormones affect pain is undetermined. One study, by William Isenberg, MD, PhD and an instructor in obstetrics and gynecology of University of California found that female rats had lower pain thresholds than males. When male rats had female hormones transferred to them, their pain tolerance levels lowered. However, this study is not likely to be sufficient to make a positive statement that sex hormones impact pain sensation although this evidence certainly warrants a closer scientific review and could have impact on treatment in a doctor’s office.

Despite the anatomical and physical variations in pain the JAMA review concluded that the actual degree that a women’s pain response is said to be stronger than a man’s is not so great as difference’s in tolerance within the same sex. However, this conclusion was the final statement in the article, prompting me to wonder why so much is made over a man’s greater “strength but so little is said about the fact that his pain endurance is by scientific standards really not so much greater than a women’s?

In the Medicine Cabinet…

That women and men respond to medications differently is known. Recently an Aug. 31 HealthScout article by Janice Billingsley sighted several research conclusions of “Gender discrimination in the Medicine Cabinet” even when the same drug helps both men and women, they may not react to it similarly. While Sherry Marts of the Society for Women’s Health Research says, “It’s cause for concern… it is really crucial to look for the differences (between male and female response) in clinical trials and post-trial research.” So far there haven’t been a lot of serious problems, she adds.

A significant part of the list of drugs on which Billingsley’s article quotes Dr. Raymond Woosley, vice president of Health Sciences at University of Arizona, includes pharmaceuticals that treat rapid and irregular heartbeat. There are at least 50 medications that put women at risk for irregular heartbeat and particularly a condition known as Torsades De pointes. Ironically, the drugs in question are used to treat irregular heartbeat.

Drugs with the possibility of this side effect include: Cardioquin, Quinaglute, Corvert, Norpace as well as the anti-depressants Prozac and Zoloft and antibiotic Erythromycin in intravenous form. All of these drugs carry a warning of increased risk of Torsades des Pointes according to Woosley. Also of interest was that women might not need medicine of the narcotic strength that men appear to need. Post surgical treatment of women and men with the drug Nubain found that it had a far greater analgesic affect on woman than men. It has also been noted in numerous studies that women report more side effects when given morphine for pain suggest as feeling “thick headed” “nausea” or vomiting. Interestingly women recover from the negative side affects quicker than the men who report them.

Where it Really Hurts…

Given that research insists that women have more pain complaints and a lower threshold for pain, are we at risk of facing bias when we consult a doctor regarding our pain? According to Dr. Christine Miaskowski, chair of the physiological nursing department of University of California in San Francisco, the answer is emphatically, “Yes.” Dr Miaskowski, who was quoted extensively the New York Times Sunday Feature “Hurting More, Helped Less” by Nancy Wartik, relayed the experience of a patient who had considerable lingering pain; although she had sought medical assistance, and had saved the medications she had been given, “mostly anti-anxiety drugs like Valium and she’d decided if we could not help her, she was going to commit suicide.” Dr. Miaskowski to the Times.

According to the NYT, Dr. Miaskowski is part of a growing contingent in medicine that have stated concern that the risk a woman’s pain will be ignored is greater than a man’s. Their apprehension is supported by a report in the Journal of Law, Medicine and Ethics titled “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain,” that appeared last year. This report concluded that complaints of pain by women “are taken less seriously than men’s and women received less aggressive treatment than men for their pain.”

This is not a surprise to chronic pain patients who are women. One woman, Kay commented, she disagreed “that both men and women with pain are treated the same by doctors. We don't have our pain taken seriously, (are) seldom given adequate
medicine for it, and told to ‘learn to live with it.’ After all pain like many other symptoms of chronic disorders are ‘subjective!’” She has been told “Too many times that I probably read about the symptoms then my mind created it, or because of the anxiety the pain or symptom "feels worse than it really is"! How often is a man told that?

Yes I know that anxiety increases pain, but also some days the pain increases the anxiety. Which came first?” she asks.

Dr. William S. Breitbart, chief of Psychiatry at the Memorial Sloan-Kettering Cancer Treatment Center in New York City, quoted a 1996 study of 350 patients with AIDS related pain conducted at Kettering found that “being female doubled the risk of being under medicated for pain.” In a study that included former IV substance abusers, one would think that that would have been the over riding criteria and not gender, Dr. Breitbart has remarked.

Doctors have recently come to understand that we live in a conflicted period. One when the World Health Organization and the American Pain Society urge proper pain medication and pain management yet, at the same time. the war on drugs has made some prescription pain killers a major target. All too often the fact that the doses substance abusers take are 6 and 7 times higher than a pain patient would take is lost in the hysteria. Now the struggle for adequate pain medication is compounded by gender bias.

Once again, women face a fight for equality, this time in the doctor’s office. We once had to pursue the vote, equal education, and battle job discrimination; we now must campaign for fair medical treatment. We must be calm, and well spoken when dealing with doctors and be able to present articles documenting their own biases against adequately treating women for pain. This is one time where emotions are a handicap and appearing rational and calm our best approach.

Is it fair? Of course, not, but women are strong enough to do it. And a final note: despite wading through pages of material on men’s superior ability to abide pain, in not one journal or periodical did I find an actual number or quantification of this difference. Now, that is surprising!

Sources:

Billingsley, Janice; “Sex Discrimination In The Medicine Cabinet

Certain Drugs Produce Different Side Effects, Depending On Your Gender” HealthScout Newswire, August, 31,2002

Calandra, Bob, “Gender: Some Painstaking Differences” WebMD Medical News, April 30, 2001

Gower, Timothy, “Avoiding Doctors, A Guy Thing,” Los Angeles Times, July 8 2002

Lamberg, Lynne, “Venus Orbits Closer to Pain Than Mars, Rx for One Sex May Not Benefit the Other”, Journal of the American Medical Association Review of the American Pain Society Conference, Spring 2001

Wartik, Nancy, “Hurting More, Helped Less?” New York Times, July 1,2002

“Girls' and Boys' Differing Response to Pain Starts Early in Their Lives”, Journal of the American Medical Association, News Briefs citing Working of Patricia McGrath, MD, Sept. 1998