Chronic Pain and Inequality
The role of racism, sexism, queerphobia, ageism, and poverty in health and chronic pain
“Chronic pain is not political!” I was told this by a reader who was angry that I made a brief, better-than-nothing public declaration that “black lives matter here.” He’s boycotting PainScience.com. He’ll never buy another book, or visit my website ever again. He was outraged that I dared to write about something other than chronic pain. “Chronic pain has no politics,” he declared.
Good riddance, obviously. Begone! Evanesco! 🧙🏻♂️ Black lives still matter here.
Chronic pain is political. In a big way. Anyone who doesn’t get that does not get pain. This is something I’ve known for a long time, but I’m feeling quite sheepish that I had no content about this. I was blinkered by privilege. That is what privilege does.
But my awareness has been raised — by the Black Lives Matter movement, when it surged in 2020 in the early months of the pandemic. And “silence is compliance.”1
Why chronic pain is (extremely) political
Chronic pain is political because health and healthcare are political — it is directly and strongly affected by public policy and law, and indirectly by many other social issues that are in turn also greatly affected by public policy and law.
The biggest drivers and risk factors for chronic pain are poor overall health and fitness. For example, someone with a really stressful life, a lot of anxiety and depression, and diabetes, is at dramatically greater risk of suffering from chronic pain than someone who does not have those problems.
And guess who’s more likely to meet that description? All other things being equal, it’s the people at a disadvantage in society because of racism, sexism, and queerphobia. And then it all gets worse because of systemic prejudice in healthcare. They are more likely to suffer in the first place… and then much more likely to struggle to get good help.2
Anything you’ve ever heard about the effects of any form of prejudice on health/healthcare applies to chronic pain too. For instance, when the worst-case scenario is higher mortality — like black women dying in childbirth a lot more than white women3 — obviously there’s also going to be more chronic pain too.
Or consider that injured women are more likely to be assaulted by a boyfriend or husband.4 In other words, women might partly have more chronic pain than men because they’ve been injured by men. What a world.
Pain and prejudice specifically
Discrimination in general healthcare is clearly relevant to chronic pain in many roundabout ways, but it also affects chronic pain care directly. The Association of American Medical Colleges has a good, recent summary.5 Janice Sabin, PhD, MSW:
“Black people’s nerve endings are less sensitive than white people’s.” “Black people’s skin is thicker than white people’s.” “Black people’s blood coagulates more quickly than white people’s.”
These disturbing beliefs are not long-forgotten 19th-century relics. They are notions harbored by far too many medical students and residents as recently as 2016. In fact, half of trainees surveyed held one or more such false beliefs, according to a study published in the Proceedings of the National Academies of Science. I find it shocking that 40% of first- and second-year medical students endorsed the belief that “black people’s skin is thicker than white people’s.”
What’s more, false ideas about black peoples’ experience of pain can lead to worrisome treatment disparities. In the 2016 study, for example, trainees who believed that black people are not as sensitive to pain as white people were less likely to treat black people’s pain appropriately.
For every relatively obvious and studied source of prejudice in healthcare, there are dozens that are more insidious.
“Women wait longer for pain medication than men, wait longer to be diagnosed with cancer, are more likely to have their physical symptoms ascribed to mental health issues, are more likely to have their heart disease misdiagnosed or to become disabled after a stroke, and are more likely to suffer illnesses ignored or denied by the medical profession.”
Why don't doctors trust women? Because they don't know much about us, Jackson (The Guardian)
Disastrously dismissing women’s symptoms
If you talk to individual doctors as colleagues and people, they mostly seem like lovely people: well-trained, knowledgeable, dedicated, determined to help. Almost all of the doctors I know personally are obviously admirable and competent, with just a couple exceptions that prove the rule. But maybe my sample is skewed, because this kind of thing just keeps happening, and it’s hard to square with “most docs seem admirable and competent”:
“Doctors repeatedly told a woman stress was causing her symptoms. Then they pulled out a volleyball-size tumor.”
“It turned out to be cancer” stories aren’t hard to find, and I share them sparingly, because they can really spook people, and they can be rather unfair to doctors — who are not magic, and cannot be expected to catch everything, especially if the symptoms are relatively subtle and even the patient isn’t particularly concerned. But this case involved several serious symptoms — “bloating, constipation, diarrhea and extreme pain” — and the patient was desperate for help. So it is weird and terrible that the diagnosis was missed by multiple physicians. The story ends well, but it was still a diagnostic disaster that caused major suffering and distress. A poignant detail:
If Catton had been diagnosed before the pandemic, her parents would have dropped everything to fly thousands of miles to care for her, even if it was just for a week, she said. They would have taken her to appointments, run her errands and cuddled her.
Ovarian cancer often is hard to diagnose, but this wasn’t just a couple doctors that got it wrong: it was many. And it wasn’t just “I don’t know what’s wrong with you,” it was “I can’t think beyond the most obvious explanation” over and over again. This was exemplified by the repeated prescription of antibiotics (blatant incompetence). So, this woman’s pain was effectively ignored by “good” doctors, professionals that probably would seem like terrific people if you met them socially or collegially. Why?
I think the only credible explanation is systemic sexism: she was meaninglessly reassured by physicians who struggled to take a woman’s symptoms seriously, and low awareness of a woman’s pathology … not because they are bad people or bad doctors, but because that bias is deeply baked into our culture.
Catton said that she’s gone back to her doctors to tell them they got it wrong and, in the process, made her feel voiceless. This time, they listened. Catton said they’ve been responsive to her criticism and agreed to go through ovarian cancer awareness training to help them spot symptoms in the future.
The stigma against the undiagnosable
Everyone struggles to get good care for strange and unexplained chronic illness, which is alarmingly common, and chronic pain is one of the most common symptoms of such illnesses. Most people with unexplained widespread chronic pain are labelled with “fibromyalgia” and then dismissed; the stigma is so strong it might as well be called “hopeless weirdo disease.”
Healthcare professionals have a powerful tendency to overestimate the role of hypochondria and malingering in patients they don’t understand — both their medical understanding of the illness, and their social understanding of the patient. Most of this is unconscious, of course — just like with any other prejudice, it’s rarely overt, and routinely cloaked by paternalistic benevolence and good intentions.
Speaking from experience, an articulate, educated, middle-aged white guy can absolutely run afoul of this stigma. My social status and privileges offer only partial protection. Despite my advantages, I have found it extremely difficult to get good medical assistance for my own chronic pain problems.
So imagine how much worse it is for everyone else.
“Chronic pain is not political”? Good grief. You’d have to talk to a flat Earthers to hear a more ignorant idea.
“Social distance” — not the way we mean it in the pandemic
The term “social distancing” was hijacked by the COVID-19 pandemic. It used to exclusively refer to the chasms between social groups and classes, the many kinds of distance between rich and poor, black and white, men and women, and so on. A homeless person can be surrounded by relatively rich people close enough to touch but emotionally as out of reach as the moon. That distance has many implications for healthcare generally, and even for pain specifically. While not all social distance involves social isolation and/or loneliness, some of it sure does — and lonely people hurt more.6
Ideally, we would speak of the need to increase physical distance to protect each other from an infectious disease, while we try to actually reduce social distance to protect each other from other kinds of health problems! (And some injustice while we’re at it.)
Vaginal penetration pain disorders — a perfect storm of stigma, prejudice, and ignorance
“Gee-Tripple-Pee-Dee” pain is genito-pelvic pain/penetration disorder GPPPD, with many sub-types involving penetration resistance and/or pain with several possible mechanisms. These are not rare problems! Provoked vestibulodynia (PVD) is the most common form, occurring in about 8% of all women7 — pain with penetration, but not necessarily resistance to it. Vaginismus, on the other hand, is defined by penetration resistance (usually painful), and presumed to be muscular in nature, the vagina clamping shut, a kind of cramp.
There’s an endless debate about whether these conditions are physical or psychological or both, and
Sexism and racism in healthcare are bad enough, but that’s nothing compared to what you get when you pile on with the stigmas against both psychosomatic illness and anything to do with sex. It’s hard to imagine a more hopelessly distorted topic in all of pain medicine. GPPPD patients face multiple hurdles trying to seek medical care:
- general sexism
- general sex negativity
- more specific sexism and ignorance about women’s health and pelvic health
- misogynistic extremes that crop up with the specific phenomenon of penetration pain/resistance
- widespread ignorance of any kind of unexplained chronic pain
- prejudice against actual/perceived psychosomatic symptoms
That’s too many hurdles! Any one of those problems is enough to block good care for many patients (just ask any middle-aged white guy with unexplained chronic pain — even they struggle to get good help). The sad truth is that the vast majority of GPPPD patients fail to find medical assistance, and most simply have to rely on other resources. Fortunately, there are a lot of those. For more information, see the vaginismus page, which has many resources and a long interview with Kirsten Loop, a writer and advocate for women with pain related to sex.
The myth of feminine fragility
Sports science is full of the idea that women might get hurt more often than men, usually because they are presumed to be more structurally vulnerable in some way.
White women, anyway. Black women are perceived veeery differently. Spoiler alert: it’s not an improvement.8
This sexism/racism is more plausible in some cases than others, but mostly it’s just an obnoxious vestige of the more overt chauvinism of the past. The myth of the fragility of white women over time…
Olden times: “Ladies in athletics? Ho ho, don‘t be absurd old chap! The fairer sex is simply not designed for the manly arts. If God wanted women to play sports, he would have made them tough as old boots, but then who’d want to marry them?!”
Today: “Women can be fine athletes, but obviously they have some more injury risk factors because of their biomechanical idiosyncracies.”
There are some aspects of female anatomy and biology that are legitimately risk factors for certain injuries. Women (of any colour) will sustain more “frictional breast injuries,” for instance. But to the extent that this is true… men also have their own gender-specific vulnerabilities. I can verify that! Google “twisted testicular appendix,” if you dare.
Bottom line: There is no significant net difference between the athletic vulnerabilities of men and women. There are differences, of course, but they aren’t what “common sense” predicts, the significant ones are relatively rare, and there are few or no examples of gender-specific risk factors for the common athletic injuries: strains, sprains, stress fractures, tendinopathies, etc.
Some examples for further consideration…
A woman at the gym is doing a deadlift, and a guy tells her — mansplains — that she needs to correct her form or else her “lady bits” would eventually fall out, which is a reference to the risk of pelvic organ prolapse. (True story from a reader.) The same warning is often used to justify and sell personal training, a tactic that is just fear-mongering for profit: “Nice lady bits you got there. Shame if something were to happen to them.”
Nothing in life is perfectly safe, but lifting heavy things (bodybuilding, powerlifting) is much safer than most people assume (especially if you exclude the kooks who egregiously overdo it). The idea that women who lift suffer more pelvic organ prolapse is probably just more sexist hand-wringing and fear-mongering about how delicate women are, because a new study by Forner et al. shows that women “do not have an increased prevalence of pelvic organ prolapse symptoms.”9
There’s a popular notion that women are more vulnerable to knee pain, especially runner’s knee (iliotibial band syndrome, patellofemoral syndrome), but the evidence just does not support it. See Do Women Get More Knee Pain? Answer: not obviously, no.
For a broader view of the topic, see It’s Time to Ditch These Myths About the Female Running Body, a short evidence-based summary of myths about the vulnerability of women’s bodies to injury, which are “wrong, disempowering, and can be harmful to a female runner’s experience. Yes, women get injured. But it’s not because of how they’re built.” A well-written and competent article.
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
Related Reading (tip of the iceberg)
- Vulnerability to Chronic Pain — Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems
- The myth of feminine fragility — Sports science is full of the idea that women might get hurt more often than men.
- “Inequality is a public health issue: 10 examples,” Kamal Patel, Examine.com.
- “How we fail black patients in pain,” Janice Sabin, www.aamc.org.
- “It’s Time to Ditch These Myths About the Female Running Body,” Ellie Somers, www.runnersworld.com.
- Do Women Get More Knee Pain? — The relationship between sex and knee pain, especially runner’s knee (IT band syndrome, patellofemoral pain)
- The Vagina Bible: The vulva and the vagina—separating the myth from the medicine (book), by Jen Gunter. Amazon.com ❐
- The American Medical Association has declared that racism is an “urgent threat to public health,” and they have a new policy to prevent/fight it as of fall 2020.
- See also the Race and Medicine Collection from New England Journal of Medicine, which reflects a “commitment to understanding and combating racism as a public health and human rights crisis.”
- “Pain in persons who are marginalized by social conditions,” Craig et al, Pain, 2020.
- “Race, ethnicity, and pain among the U.S. adult population,” Shavers et al, J Health Care Poor Underserved, 2010.
- “Racial and ethnic disparities in pain: causes and consequences of unequal care,” Anderson et al, Journal of Pain, 2009.
- “The girl who cried pain: a bias against women in the treatment of pain,” Hoffmann et al, J Law Med Ethics, 2001.
- “Structural racism and health inequities in the USA: evidence and interventions,” Bailey et al, Lancet, 2017.
- “Alarming racial differences in maternal mortality,” Flanders-Stepans, J Perinat Educ, 2000.
- “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites,” Hoffman et al, Proc Natl Acad Sci U S A, 2016.
What’s new in this article?
Four updates have been logged for this article since publication (2020). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
Aug 31, 2022 — New section: “Disastrously dismissing women’s symptoms.” Plus a science update: Madden on how injured women are more likely to be assaulted by a boyfriend or husband.
2020 — Added discussion of “social” versus “physical” distance.
2020 — Editing.
2020 — Added a substantial section about the “myth of feminine fragility.”
2020 — Converted to a permanent article, and made several improvements.
2020 — Publication.
Not necessarily, but I basically agree, and so this I am going clear what my values are. I have little else to offer (in this context anyway) but I can at least acknowledge what’s going on in America (and the rest of the world too) and make it clear where I stand.
Sol Orwell, founder of Examine.com and much else:
If you own a business or lead a group of people, let me humbly suggest something: it’s worse to pretend nothing is happening.
You don’t need to offer solutions or money or some grand plan or even (empty) platitudes — just acknowledging it’s happening is appreciated.
Acting as if it’s business as usual will, I promise you, be noticed by the very people who are sick of this.
I knew as soon as I read those words — “noticed by the very people who are sick of this” — that I had to break my silence. I rarely cross the streams of business and politics, but this is 🤬 different. This is a bad time to be quiet. This is not a time for business as usual. This matters.
Black lives matter. And emphasizing that matters.
- Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009 Dec;10(12):1187–204. PubMed 19944378 ❐
- Flanders-Stepans MB. Alarming racial differences in maternal mortality. J Perinat Educ. 2000;9(2):50–1. PubMed 17273206 ❐ PainSci Bibliography 52573 ❐
- Madden K, Sprague S, Petrisor B, et al. Intimate Partner Violence During Recovery from an Orthopaedic Injury: An Exploratory, Prospective, Multicenter, Observational Cohort Study. J Bone Joint Surg Am. 2022 03;104(6):512–522. PubMed 35041623 ❐
From an editorial by Dr. Sultan Al Maskari about this paper:
“The study presents a previously unknown fact that even women with no previous intimate partner violence experience are at an increased risk for IPV during their recovery from a musculoskeletal injury.”
Doesn’t seem to matter how cynical I get: it’s never enough for this world. 😡
It’s always good to have validation in the form of hard data, but of these scientists didn’t “discover” this anymore than Columbus “discovered” America. This was news to me, a man, but it certainly won’t be news to many or most women, who are already well aware of this phenomenon, and aware that it is just one of many examples of how women are mistreated by men, and how tangled up it is with health and healthcare. For instance, men also abandon sick female partners at dramatically higher rates than the other way around. Once again, we see that pain and social justice are inseparable topics.
- www.aamc.org [Internet]. Sabin J. How we fail black patients in pain; 2020 Jan 6 [cited 20 Jun 28]. PainSci Bibliography 52546 ❐
- Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English Longitudinal Study of Ageing. Br J Pain. 2019 May;13(2):82–90. PubMed 31019689 ❐ PainSci Bibliography 52275 ❐
This study looked for a link between chronic musculoskeletal pain, and loneliness and social isolation in several thousand older adults. They found that subjects in pain were actually less likely to be socially isolated, but more likely to be lonely, an interesting apparent contradiction. However, loneliness is probably what matters: that is, social isolation isn’t a problem if you don’t feel socially isolated (lonely).
- Smith KB, Sadownik LA, Dargie E, Albert AY, Brotto LA. Multidisciplinary Treatment for Provoked Vestibulodynia: Treatment Trajectories, Predictors, and Moderators of Sexual Distress and Pain. Clin J Pain. 2019 04;35(4):335–344. PubMed 30614827 ❐
- Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr;113(16):4296–301. PubMed 27044069 ❐ PainSci Bibliography 51875 ❐ Assumptions about the fragility of women’s bodies vary dramatically with race, and black female bodies are perceived as tougher and therefore not only less deserving of the chivalric concern of the patriarchy — that’s just standard with racism in health care — but also less *needful* of it, a convenient rationalization.
- Forner LB, Beckman EM, Smith MD. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. Int Urogynecol J. 2020 Aug;31(8):1551–1558. PubMed 31813038 ❐