Page 42 Guide to Pain Management in Low-Resource Settings

30 Angela Mailis-Gagnon

What are the consequences of Female gender is associated with greater utili-
understanding cultural diff erences? zation of health care services and higher prevalence of
certain pain conditions, while it serves as an especially
Racial and ethnic minorities are shown to be at risk signifi cant predictor of pain perceptions and coping
for poor pain assessment and inferior management in strategies. Research studies show that women use high-
acute, chronic, and cancer-related pain. Th ese diff erenc- er health care services per capita as compared to men
es in treatment may arise from the health care system for all types of morbidity and are more likely to report
itself (the ability to reach and receive services) or from pain and other symptoms and to express higher distress
the interaction between patients and health care provid- than men. Furthermore, women in a deprived socioeco-
ers, as beliefs, expectations, and biases (prejudices) from nomic situation run a higher risk for pain. So, how do
both parties may interfere with care. we explain these phenomena?
Patients may be treated by health care providers From the biological point of view, females are
who come from a diff erent race or ethnic background. more vulnerable to experimentally induced pain, show-
Th e diff erences between patients and providers may be ing lower thresholds, higher pain discrimination, and
“visible,” like age, gender, social class, ethnicity, race, or less tolerance of pain stimuli than males. Numerous
language, or “invisible,” such as characteristics below the studies have shown that female hormones, and their
tip of the “cultural iceberg” such as attitudes, beliefs, val- fl uctuations across life stages or during the month, play
ues, or preferences [2]. Dangerous consequences arising a substantial role in pain perception. Additionally, cer-
from ethnic diff erences between patients and medical tain genetic factors unique to women may aff ect sensi-
professionals have been shown in diff erent studies dem- tivity to pain and/or metabolism of certain substances.
onstrating that patients of certain ethnic backgrounds Psychologically, women also diff er from men
(Mexican American or Asian, African, and Hispanic) when it comes to coping strategies and expressions of
are less likely than Caucasians to receive adequate an- pain. For example, in one study, women with arthri-
algesia in the emergency room or be prescribed certain tis reported 40% more pain and more severe pain than
amounts of powerful pain-killing drugs such as opi- men, but were able to employ more active coping strat-
oids. However, worldwide diff erences in administra- egies such as speaking about the pain, displaying more
tion of opioids in non-white nations are not solely due nonverbal pain indicators such as facial grimacing, ges-
to health provider/patient interaction, but may relate tures like holding or rubbing the painful area or shifting
to system politics. An example is the U.S. campaign in their chair, seeking spiritual help, and asking more
against drug traffi cking, which aff ects negatively the ac- about the pain. One of the explanations for diff erences
cess of cancer patients to opioids in Mexico. in the ability to cope with the problem at hand relates to
It is indeed challenging to try to understand the greater role women have in taking care of the fam-
both the diff erences and the similarities that exist in ily. It is believed that this greater role makes women ask
people with diverse ethnocultural backgrounds, but questions or seek help in an eff ort to maintain them-
such knowledge is necessary to improve diagnosis and selves or their family in a good condition.
management of painful disorders. Ethnocultural and environmental factors also
account partially for diff erences in perceiving and re-
What is the eff ect of gender on porting pain or other symptoms. For example, a few
studies have shown higher pain perception and expres-
pain perception and expression and
sion in South (Central) Asian groups (including patients
health care utilization? from India and Pakistan), as follows:

a) A study of thermal pain responses in white Brit-
Th ere are many diff erences in pain perception and ex- ish and South (Central) Asian healthy males showed
pression between females and males. Altogether, the no physiological diff erences when subjects were tested
diff erences between genders can be attributed to a com- for warm and cold perception (this means the level at
bination of biological, psychological, and sociocultural which a stimulus was felt as warm or cold). However,
factors, such as the family, the workplace, or the group’s the South Asians showed lower pain thresholds to heat
cultural background in general (summarized by Mailis and were in general more sensitive to pain. Th e study’s
Gagnon et al. [4]). authors concluded that ethnicity plays an important