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Chronic Pain and Inequality

The role of racism, sexism, queerphobia, and poverty in health and chronic pain

Paul Ingrahamupdated

“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. 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.

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.4 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.

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.

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

Lonely dog is lonely.

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.5

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.)

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.6

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…

Lifting

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.”7

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 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

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

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.

Related Reading (tip of the iceberg)

Other sources

Scientific papers

What’s new in this article?

Oct 6, 2020 — Added discussion of “social” versus “physical” distance.

September — Editing.

July — Added a substantial section about the “myth of feminine fragility.”

June — Converted to a permanent article, and made several improvements.

June — Publication.

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. Flanders-Stepans MB. Alarming racial differences in maternal mortality. J Perinat Educ. 2000;9(2):50–1. PubMed #17273206 ❐ PainSci #52573 ❐
  4. www.aamc.org [Internet]. Sabin J. How we fail black patients in pain; 2020 Jan 6 [cited 20 Jun 28].
  5. 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 #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).

  6. 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 #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.
  7. 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 ❐