Chronic Pain and Inequality

“Chronic pain is not political!” I was told this by an angry reader. He’s boycotting PainScience.com; he’ll never buy another book, or visit my website ever again; he was outraged that I had dared to mention something in passing about the effect of racism on healthcare for pain patients.

“Chronic pain has no politics,” he declared. Wrong! Chronic pain is political in a big way, and anyone upset about that is part of the problem. Good riddance to that guy, obviously. Begone! Evanesco! 🧙🏻‍♂️

But for every jackass who’s pissed off about it, there are a hundred who just don’t get it — and you don’t get it, you do not get pain. And that is very common, of course.

I always understood it, but I still fell short of doing anything with it — I’d written nothing about it for the first fifteen years of writing about pain. I knew, but I wasn’t prioritizing it. I was blinkered by privilege. That is what privilege does! That is the how systemic racism, sexism, and other prejudices have their effect — by making the people who have pain just as invisible as the pain itself.

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 but strongly affected 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, and stressful life events (trauma) are notoriously correlated with pain. For example, someone with a really challenging 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, queerphobia, and ageism. And then it all gets worse because of systemic prejudice in healthcare specifically. They are more likely to suffer in the first place… and then much more likely to struggle to get good help.2

And even if they could find good help, there’s also hardly any research that applies to them to guide care: their problems and their treatments aren’t studied, even though they are often genuinely different.

And so it’s no surprise that not only is chronic pain linked to the kinds of stressful life events that are more common in people affected by prejudice, but that link is the strongest in the people most affected by it — in the people who are most angry and frustrated.3

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 women4 — 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.5 In other words, women might partly have more chronic pain than men because they’ve been injured by men. What a world.

We know many troubling things, but we don’t know enough! Many clinical trials don’t even report who they are studying, and those that do show that they aren't studying nearly as many racial/ethnic minorities.6

“Chronic pain is not political”? Good grief. You’d have to talk to a flat Earther to hear a more ignorant idea.

Pain and prejudice specifically and directly

Discrimination in general healthcare is clearly relevant to chronic pain in many roundabout ways, but it also directly affects chronic pain care. The Association of American Medical Colleges has a good, recent summary.7 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.

But 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

When I talk to individual doctors in my personal life as people, they usually seem admirable and competent, with rare exceptions that prove the rule. But maybe my sample is skewed, because this kind of thing just keeps happening to people, 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 Hannah 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.

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.

Why do so many pain patients say their symptoms were ignored?

I think the main credible explanation for Hannah Catton’s experience 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. Another example…

Eileen Davidson, a Canadian advocate for patients with pain, describes what is was like for her to struggle with rheumatoid arthritis for much too long before diagnosis:

For years I knew there was something seriously wrong with me but no one would listen to me when I brought it up. I thought it was all in my head. I thought I was crazy. I thought I was being dramatic. So did others. In reality though, I was living with a serious autoimmune disease.

As usual, “no one would listen” is a major feature of the story. It’s shocking how much suffering is caused by healthcare professionals ignoring pain and other subjective symptoms. It’s bizarre to me that we’re still struggling with this, that taking people seriously is apparently such a reach for so many healthcare professionals that it’s a major feature of nearly every story of chronic pain/illness.

There are no excuses, but there are bad reasons, and they go beyond systemic prejudices.

The alchemy of limited resources, prejudice, and the irresistibly convenient scapegoat of psychosomatic symptoms

I think another major factor is the widespread belief that pain can be psychosomatic. The mind is all-too-easy to blame. But hypochondriac pain is either quite rare or doesn’t exist at all. (Lying about symptoms—malingering—is also extremely rare. Ain’t nobody got time for that!)

You know what’s not rare? All the diseases that cause pain and/or malaise for years before diagnosis! (Even rare ones, because rare diseases are collectively common.)

But why even bother to blame the mind?

One more major factor in choosing to trivialize a patient is “bad triage.” Healthcare is hard, resources are always stretched thin, and most doctors are juggling a lot of priorities and dilemmas… and so they are often keen on any seemingly legit reason to de-prioritize a patient, or at least to make them someone else’s problem (referring).

And now we return to prejudice and discrimination. If you’re going to avoid taking any patients seriously, who gets chosen? Why, the “difficult” and “weird” ones, of course! The queers and the freaks and the hysterical ladies! The people with weird subjective symptoms you can’t personally relate to!

Even super straight white guys may be selected for convenient dismissal as fey weirdos.8

Most of this discriminative filtering is unconscious, of course, and usually at least cloaked by paternalistic benevolence and good intentions.

Don’t get me wrong: prejudice is an adequate explanation for not taking patients seriously all by itself, and it should not to be underestimated. Plenty of clinicians are more than sexist enough to be dismissive of women even if they only saw one patient daily. But the pick-your-battles pressure is always going to make bigotry more seductive.

And you will see the same behaviour even where prejudice is unlikely to be an active ingredient, however. Prejudice pours gasoline on the fire, but the fire is the irresistibly convenient scapegoat of psychosomatic symptoms — and it can burn any kind of patient.

The stigma against the weirdest kinds of pain

If you think it’s hard for people to get the symptoms of serious pathologies taken seriously, you should see what happens to people with pain that actually can’t be explained, and/or is more subtle — and there’s plenty of it.

For instance, most people with unexplained widespread chronic pain are labelled with “fibromyalgia” and then dismissed; the stigma against this kind of pain is so strong it might as well be called “hopeless weirdo disease.” (It’s important to understand that fibromyalgia is not an explanatory diagnosis — it’s just a label for pattern of symptoms with many possible and unproven causes, and very few solutions.9)

As discussed above, the mind-blaming itch is strong even with dramatic symptoms of serious diseases … but it gets dialed up to another level with weird symptoms of mysterious diseases, with any patient that healthcare professionals struggle to relate to — either their medical understanding of the illness and/or their social understanding of the patient.

Speaking from experience, even an articulate, educated, middle-aged white guy can also easily 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.

The power of “social distance” (not the way we meant it during the pandemic)

Lovely sad-dog photo by Max Singh on Unsplash

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.10

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 women11 — 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 of course there’s also a long, shameful history of stigma and attributing these problems to “frigidity” and other according-to-men feminine failings.

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

“It is a common saying that women are delicate creatures, flowers, eggs, anything that may be crushed in a moment’s carelessness. If I had ever believed it, I no longer did.”

Circe, by Madeline Miller (a book that is all about very unfragile women)

Sports science is full of the idea that women might get hurt more often than men, usually because are presumed to be more structurally and/or physiologically vulnerable in some way. More delicate. (To men who think women are “delicate creatures”: uh, have you ever met any women?!)

An important caveat: White women are perceived as delicate. Black women are perceived veeery differently. Spoiler alert: it’s not a healthier perception.12

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. A dramatic re-enactment of the evolution of the myth of feminine fragility:

Olden times: “Ladies in athletics? Ho ho, don’t be absurd old chap! Ladies are not designed for the manly arts. If God wanted the fairer sex to be sporting, He would have made them as tough as old boots. But then who’d want to marry them? Har har!”

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. For instance, women are going to sustain more “frictional breast injuries.”13 But of course men also have vulnerabilities: Google “twisted testicular appendix,” if you dare. (I have personal experience with that one!)

Bottom line: There is no major, 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…

Lifting

True story from a reader: she was at the gym doing a deadlift, and a guy told her — mansplained — that she needed to correct her form or else her “lady bits” would eventually “fall out.” That was a reference to the risk of pelvic organ prolapse (POP), the bulging of pelvic organs into the vagina, where they are quite unwelcome.

Nothing in life is perfectly safe, but lifting heavy things is safer than most people assume. Even the heaviest things, as in bodybuilding and powerlifting. And even for women.

For instance, the idea that women who lift suffer more POP is probably just more sexist hand-wringing and fear-mongering about how delicate women are, because a study by Forner et al. shows that women who do heavy lifting “do not have an increased prevalence of pelvic organ prolapse symptoms.”14 In fact, they are less likely to have POP symptoms than women who are inactive or only lift light weights — and not just a little bit less, but four times less!

That difference probably shows the effect of doing enough lifting to be a risk, but not enough to get strong enough to mitigate that risk. So the data suggests the possibility that lifting is both the danger and the solution.

Strength probably protects against POP. And lifting heavy weights is probably better than doing kegels!15

Another example: osteoporosis. This disease causes literal fragility of the bones, and there is of course some need to be cautious with that, but definitely not too cautious! In fact, high-intensity resistance and impact training will actually build bones back up again.16 But the diagnosis greatly inflames the myth of feminine fragility, and women are often told to avoid not only the fairly robust exercise they actually need, but even trivial strains from twisting and bending — an absurd level of caution for all but the most extreme cases.

“There is more risk for women to not lift heavy.”

Molly Galbraith, author of Creator of the GGS Academy (“Girls Gone Strong”)

Running

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 Is Knee Pain More Common in Women? 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.

Mariana Molinari decided to get stronger after two years of chronic post-pregnancy back pain, and because she was “leaner than recommended for health.” She knew next to nothing about lifting, and got going mostly with the help of a book, and started to get stronger … and the back pain disappeared! “It was a little weird to see my body change but feeling so strong and so good.” She fell in love with lifting, and especially of “being able to do things I never thought possible.” After many years, she became a trainer so she could help others discover the same thing. “It’s like the prescription that I feel we all need to keep up with life. I can do things at 56 that I couldn’t do in my 20s.” You can do online training with Mariana at Strength Sisters 101.

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:

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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.

Other sources

• “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.
• Is Knee Pain More Common in Women? — 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.”

Scientific papers

• “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.

Notes

1. 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.

2. 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 ❐
3. Jin J, Yarns BC. The impact of stressful life events on centralized pain and pain intensity: A combined model examining the mediating roles of anger and perceived injustice among racially minoritized adults with chronic pain. J Pain. 2024 Jul:104642. PubMed 39067581 ❐

   A new study in the journal Pain linked chronic pain to the kinds of stressful life events that are probably more common in people affected by racism, and the results also imply that anger and perceived injustice make the pain worse.

   Interesting. But this research needs a strong nerdy warning: ⚠️ Caution, may contain harmful assumptions about causality.

   We’ve known for ages that stressful experiences are strongly associated with chronic pain, but the mechanisms are still murky, and racial minorities have been virtually ignored in that research. Jin and Yarns tried to close that gap a little, examining the link in several hundred Black, Latin, and Asian people.

   They were also looking for psychological factors that might tinker with the strength of that link, specifically anger and perceived injustice. So they not only reported pain in those who’d had stressful life events, but even more in those were the most pissed off about them.

   Unfortunately, a study like this can’t show that social injustice and its psychological consequences are actually “causing” chronic pain. Trying to suss out how variables are related (mediators, moderators) is putting the cart before the horse when we don’t understand the casual relationships in the first place, which can’t be determined by looking at a group of people at one point in time (cross-sectional data). Researchers tend to pay lip service to their limitations, but wink wink, nudge nudge imply the causality that they believe in anyway.

   And so Jin and Yarns make a recommendation like this:

   This could guide psychological intervention to focus on anger and perceived injustice especially when addressing centralized pain.

   Yes, it could, but “could” is doing too much work there. We should probably be really careful about saying to people — or even “just” implying, which is how most gaslighting works — that their outrage over injustice is hurting them until we are really sure that is actually a thing. Because it might well be wrong, and because it would just be more injustice.

   The arrow of causality may well point the other way: that is, the pain causes anger and frustration in proportion to the intensity of the awful experiences and poor healthcare caused by clashes with systemic racism.

4. Flanders-Stepans MB. Alarming racial differences in maternal mortality. J Perinat Educ. 2000;9(2):50–1. PubMed 17273206 ❐ PainSci Bibliography 52573 ❐
5. 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.

6. Boyd T, Chibueze J, Pester BD, et al. Age, Race, Ethnicity, and Sex of Participants in Clinical Trials Focused on Chronic Pain. The Journal of Pain. 2024 Mar 16.

   Boyd et al. concluded that both reporting and representation, although improving, continues to be poor despite efforts to improve the situation, and specifically “Black, Indigenous, and People of Color (BIPOC) remain underrepresented in clinical pain trials.” Women are actually represented in the research surprisingly well, over-represented even — but that doesn’t remotely mean that women’s health is what’s getting studied (and it’s probably not). Read more about this paper.

7. www.aamc.org [Internet]. Sabin J. How we fail black patients in pain; 2020 Jan 6 [cited 20 Jun 28]. PainSci Bibliography 52546 ❐
8. Toxic masculinity is the other side of the sexism coin. Men keen on manliness are quick to turn on men who aren't — and weakness, sensitivity, and worry are feminine traits.
9. "Fibromyalgia" is a diagnosis, but it sheds no light on the nature of the beast. It doesn’t explain the condition any more than “UFO” explains a strange object in the sky. Seeing an unidentified flying object doesn’t mean you have seen aliens, and a “diagnosis” of fibromyalgia doesn’t imply any specific cause either: it’s just the word we use to describe feeling a certain way, badly enough, for long enough. Two cases of fibromyalgia might have completely different causes, for all we know. For much more detail on this topic, see A Rational Guide to Fibromyalgia.
10. 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).

11. Smith KB, Sadownik LA, Dargie E, Albert AYK, 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 ❐
12. 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.
13. Brisbine BR, Steele JR, Phillips EJ, McGhee DE. The Occurrence, Causes and Perceived Performance Effects of Breast Injuries in Elite Female Athletes. J Sports Sci Med. 2019 Sep;18(3):569–576. PubMed 31427880 ❐ PainSci Bibliography 49714 ❐

    This survey of several hundred female athletes from a few dozen sports found that 36% reported breast injuries and 21% thought that their breast injury hurt their performance. Larger breasts were associated more more injuries of all kinds; impact injuries were more common in contact/combat sports, and frictional injuries were more common in older women.

14. 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 ❐

15. A reader asked me how to exercise to reduce the risk of pelvic organ prolapse (POP). Specifically she wanted to know:

    “Anything beyond kegels?”

    Yes! Kegels are all about clenching the pelvic floor in isolation, but they are as awkward and tedious as ear-wiggling practice for many, and we don’t even know if they actually prevent POP — there are zero clinical trials. (Hey, science! Study women more!) A fresh episode of Sawbones reviews kegels in detail (medical information + comedy).

    But those muscles go to work almost automagically with any exercise that needs core stability, so here’s another hypothesis: the best path to POP prevention is to do whatever naturally engages the pelvic floor muscles.

    Like, say, lifting heavy things.

    Carefully at first, of course! And not just on general principles, but specifically because the trick is to get through early training without getting hurt — if we can trust our science clues.

    It’s all about baby steps, of course: you train for any challenge with simpler, tamer versions of it. For example, to prepare for a big dose of fall firewood-schlepping, start in the summer with kegels and easy, tidy squats and deadlifts (stooping lifts), which challenges some of the same muscles in a tidier way, safely toughening you up until you can easily oomph your way through exercises that approach the challenge of, say, moving a big pile of firewood.

    There is no “evidence-based” POP prevention protocol, but I do think this is a science-informed strategy.

16. Watson SL, Weeks BK, Weis LJ, et al. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res. 2018 Feb;33(2):211–220. PubMed 28975661 ❐