Gender and Racial Disparities in Pain Treatment
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The Agony of Myths: Gender and Racial Disparities in Pain Treatment
The experience of pain represents the intersection of many different aspects of medicine: body, mind, emotion, sensation, and more. This complexity, in addition to the fact that pain is not always accompanied by visible symptoms, makes it difficult for any patient to communicate the personal experience of pain to his or her healthcare providers. The challenges of expressing pain can be further hindered by preconceived notions that providers hold about different groups’ experiences of pain. Medical literature notes disparities in the treatment of pain for patient populations like women and racial minorities. Most acutely, myths about black patients and female patients have created false narratives of pain in the medical world and led to mistreatment of these groups’ pain. They experience misdiagnoses of painful physical illnesses as mental ones and providers under-prescribing pain medications. In order to rid the healthcare world of pain treatment disparities, doctors must examine their own biases about how people experience pain and listen non-judgmentally and open-mindedly to their patients.
Pain is a subjective experience (Dekkers). Though it comes from something objective—a sensory experience—each individual interprets this sensation differently (Dekkers). This has remained a perplexing problem in medicine. How does a medical provider treat a subjective experience? Doctors must ask themselves if a patient experiencing high rates of pain needs more aggressive treatment than someone reporting minimal pain from the same procedure (Coghill). Furthermore, it is difficult as a patient to communicate pain to someone who might experience it differently from him or herself. The scientific world of medicine has often attempted to make the subjective objective by quantifying pain on a scale from 1-10, as is done in the National Initiative on Pain Control’s Pain Quality Assessment Scale (Walsh). However, since pain is relative, every individual’s scale will be entirely different and based on their individual past experiences with pain.
Another common procedure at many clinics is the McGill Pain Questionnaire, which asks patients to select words from a grid to describe their pain (Walsh). These words attempt to pinpoint and evaluate the type of pain the patient is experiencing, but the words themselves, like “sickening,” “horrifying,” and “burning,” are similarly subjective and relative to the patient’s past experiences. For example, a patient who has been stabbed will likely have higher standards for describing pain as “stabbing” than one who has not had that pain experience. Finally, pain transcends words even for the person experiencing it (Dekkers). Patients tend to use gestures rather than words to communicate the type, scope, and intensity of their pain, which can be even harder to interpret than verbal cues (Rowbotham). Clearly, pain is a difficult thing for anyone to convey, and despite efforts at improving and standardizing the language we use to express it, it remains a communication issue in modern medicine.
However, for women and black patients, communicating pain involves having to overcome additional barriers in order to accurately express themselves. Healthcare providers hold preconceived notions and implicit biases about how these populations experience pain. This, in turn, leads to reduced quality of care and pain management. A plethora of studies have shown that women are generally less likely to be prescribed painkillers by their doctors. For example, a University of Rhode Island study showed that women are half as likely to be prescribed painkillers after a coronary bypass, a serious and painful surgery (“Researcher Says Women Less Likely to Get Painkillers”). Women also wait 65 minutes to receive treatment for acute pain in the ER, while men only wait 49 (Kiesel). Even more disturbing, there seems to be a fundamental misunderstanding about the physicality of women’s pain, as men are more likely to be prescribed painkillers when reporting pain, while women are more likely to be prescribed sedatives (D. Hoffman) Women also experience misdiagnosis of painful experiences more than men. A New England Journal of Medicine study showed that women are seven times more likely than men to be misdiagnosed and discharged mid-heart attack (Pope).
An abundance of anecdotal evidence speaks to the near-universal female experience of difficulty communicating pain to doctors. Starr Mirza’s story appears to be relatively common. As a teenager, she experienced dizziness and would often faint. All four doctors she saw claimed she had no physical symptoms and told her parents that she was seeking attention or experiencing psychosomatic symptoms. She finally received a diagnosis of long QT syndrome, a dangerous cardiac condition, at 23, but only once her disease had become serious enough that she was hospitalized after a heart attack (Adler). Mirza’s story represents the story of many other women who feel that they must justify their pain and convince their doctors to treat them for physical rather than psychosomatic or made-up illnesses.
Experiences like Mirza’s of being dismissed in medical settings are even more acute in black patients, especially black women. For example, black women are more likely to receive the wrong treatment for breast cancer than white women are. Furthermore, black patients with bone fractures were 66% less likely than white patients with the same ailment to receive analgesic drugs (Anderson). This disparity exists despite the fact that both populations were equally likely to have pain notations in their charts (Anderson). This suggests that doctors were aware of the black patient’s expression of pain but still took it less seriously and treated it differently than they did white pain.
The misdiagnosing of pain and under-prescribing of pain medication in women and black patients can be traced to the false and damaging narratives that are told about their pain. The most common narrative of a specifically female illness is hysteria. A quick look at any piece of Victorian literature will likely reveal a “mad” woman, like Bertha Rochester in Jane Eyre, and will represent the widespread association of this vague neurological diagnosis with women. Hysteria’s broad diagnosis of a “wandering uterus” was often used as a way to pressure women into societal reproductive and gender roles by prescribing marriage and pregnancy as a cure (Morris & Donohoe). However, many upper-class women were able to capitalize on the nebulous definition of hysteria and pretended to be hysterical as a rebellion, “a way to escape their reproductive and domestic duties” (Ehrenreich & English 150). It soon roused suspicion that women were faking this disorder because “hysterics never had fits alone, and only when there was something soft to fall on” (Ehrenreich & English). Further proving that hysteria was not actually a physical disorder, it didn’t seem to afflict anyone who couldn’t afford to take the time for the lengthy bedrest that was prescribed (Kempner).
Doctors also accused women of not simply feigning illness but dramatizing their suffering in a way that romanticized being sick and made themselves the center of attention. One doctor documented that women “[pinned] their hair in such a way that it would fall luxuriantly when they fainted” (Ehrenreich & English). Therefore, women not only wanted to be ill, but, according to doctors, they wanted to be ill for their own vanity. This historical malingering has caused healthcare providers to mistrust women who express pain. While women had long been seen as overly emotional and unreliable, the history of malingering further reduced their credibility in the medical world.
The historical narrative of hysteria has very real consequences for modern day women. The modern derivative of the mistrust in women’s experiences of illness is reflected in the language that doctors use in Mirza’s story. According to her doctors, women like Mirza are attention-seeking and use pain as a way to put themselves in the spotlight. We learn from narratives of hysteria that women perform their pain, which leads doctors to assume that women are exaggerating or even feigning their pain altogether. This, in turn, leads to an under-prescription of pain meds. We also associate women with being overly emotional, and thus, when women complain of pain, doctors tell them that it’s all in their heads or treat them with sedatives.
The narratives about black pain are similarly damaging. Black people have been super-humanized since slavery, when doctors believed that they had the magical quality of being able to withstand painful surgeries without anesthesia (E. Westervelt). This narrative continues to persist in a less obvious way through popular media: black characters in movies are often magical or even mythical, like Morgan Freeman playing God in Bruce Almighty (E. Westervelt). One study showed that medical students continue to buy into these superhuman myths about black patients and their pain. Specifically, a majority of white medical students at the University of Virginia believe that black patients have less sensitive nerve endings, that their blood coagulates faster, and that their skin is literally thicker (Somashekkar, K. Hoffman). Furthermore, medical professionals believe the racist narrative that black people are more likely to become addicted to drugs, and this has led to black patients being perceived as drug-seeking and therefore being half as likely to receive prescriptions for opioids (Singhal). Despite there being no scientific evidence for any of these “biological” myths, they somehow continue to persist in a scientific space like the healthcare world.
If Mirza’s experience and others like it are indeed widespread across the healthcare world, as is indicated by the numerous studies in various fields showing under-prescribing of pain medication and misdiagnosis of disorders in women and black patients, there must be underlying issues in the healthcare world. The aforementioned individual implicit biases and false narratives lead to larger systematic exclusions of women and black patients. Part of the problem comes from how healthcare practitioners are trained to treat pain. One nurse notes that “Health care professionals are taught that [narcotics] should be dispensed more conservatively to the expressive patients, who tend to dramatize their pain, and more liberally to stoical patients” (“Researchers Say Women Less Likely to Get Painkillers”). The same study demonstrated that women tend to express their pain differently from men and may be unfairly viewed as dramatizing their pain.
In order to combat this, we must examine how we train our healthcare practitioners to deal with pain. While training doctors to be wary about overprescribing opioids is important, especially in our current opioid addiction crisis, we must ensure that the rhetoric surrounding drug abuse does not unfairly impact women and people of color. To do so, we should pair tradition healthcare training with cultural competency training and implicit bias training. Cultural competency training will allow medical professionals to better communicate with people different from themselves, hopefully leading to increased listening and understanding when patients discuss their pain, rather than falling back on stereotypes and biases to make decisions about pain treatment. Implicit bias training, like Harvard’s Project Implicit, will allow students to address the racial and gender biases that they hold head on. In order to reduce deep seated biases that affect healthcare practitioners’ ability to give care, they must engage in long term training throughout their medical careers. Though many are skeptical of the efficacy of implicit bias training, a true effort to confront racism and sexism can only improve the ability of doctors, nurses, PAs, and other healthcare workers to communicate with all populations that they interact with (Chang).
Part of the reason that medical training is exclusive of the unique needs of women and black patients is because the research that informs it is mainly done using white male bodies. Though female and male bodies have different cells and hormones, and thus interact with drugs and other therapies differently, women have historically been excluded from clinical trials, and continue to participate at low levels today (A. Westervelt). For example, even though cardiovascular disease is the main cause of death of US women, and it is known to affect men and women differently, only about a third of cardiovascular clinical trial subjects are female (A. Westervelt). The generalization of results from research done only on men has led to disastrous results, like the suggested dosage of Ambien being too high for women, causing sleep-walking and sleep-driving in women who took too much (Adler). Pain research is no different. Although women experience pain differently from men, and 70% of chronic pain sufferers are women, 80% of pain studies are done on male humans or mice (Kiesel). With minorities, the numbers are even more stark. Though they also have unique health concerns and experience higher burdens of suffering with diseases like Alzheimer’s, they only make up 10% of NIH research subjects (Gray).
Before we can accurately treat the pain of women and black patients, we must investigate it and learn about the unique burdens they face. Including all populations that experience pain in clinical studies about pain experiences and treatment will allow medical professionals to gain a more complete understanding of pain. Rather than make assumptions about their patients based on inaccurate myths and outdated narratives, practitioners can make informed decisions based on data. They must still remember that pain is a subjective experience that individuals feel differently, and that continual provider-patient communication is essential in understanding pain. As is true with most communication problems in medicine, pain disparities can be eliminated through empathetic listening, open mindedness, and patient-directed care on the part of the healthcare provider.
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