The painful truth

That the sexes handle pain differently won't arrive as news to any woman who has nursed a man through a mild respiratory infection, while feeling pain, from say, multiple fractures.

MARNI JACKSON reports on an emerging new science – men, it seems, can't even begin to feel your pain'

A post-op ward in a hospital, late at night.

A man and a woman, roughly the same age, are lying in separate rooms on either side of the hall. One moans, the other sighs in her sleep. They're both recovering from bypass surgery, and both are in pain. How much, of course, is debatable, since pain is so invisible and subjective. Our methods of assessing it are also rather quaint. But on a scale of 1 to 10, the woman gives her pain an 8. She helpfully describes it in detail -- it's deep and burning, she says, and more intense at night.

Across the hall, the man just lies there. He suffers in silence. When pressed, he tells the attractive nurse on duty that his pain is "maybe a 4."

"Just a flesh wound, ma'am." Guess who got more morphine.

In the emerging new science that looks at gender differences in pain, some studies show that after surgery, men will ask for, and receive, more morphine for their pain. And while it's true that everyone, regardless of their sex, tends to be undertreated for pain, the female patient may come in for even more neglect.

This was one of the topics explored recently at the Tenth World Pain Congress in San Diego, where Dr. Anita Unruh, of Dalhousie University, joined other researchers to discuss sex, pain and gender. Women, Ms. Unruh says, have "more severe levels of pain, more frequent pain, and pain of longer duration than men. Women are more likely than men to report migraines and chronic tension headaches, facial pain, musculoskeletal pain, and pain from osteoarthritis, rheumatoid arthritis, and [the all-body misery of] fibromyalgia."

The good news here is that women talk about pain more easily than men, go to the doctor sooner, and seek out different types of therapy. But the fact that women are more likely to express pain doesn't seem to help -- talking about pain is easily confused with complaining. Sometimes nurses and doctors will automatically assess a woman's "real pain" as a notch or two below the level she rates it at. And the people caring for the the strong, silent guy may overestimate the pain he's in -- because he's obviously the type to tough it out.

It is fiendishly hard to get a grip on pain and gender -- so many factors, from genes to family history and social expectations, feed into our experience of pain and our response to it in someone else. It turns out that even the "attractive nurse" in our hospital scenario is a factor, because sexual attraction plays a role in pain too.

At the conference, a provocative little study by Dr. Roger Fillingim, of the University of Florida, explored how the interview setting, including the sex of the person asking questions, affected the way people reported their pain (and as a result, what sort of treatment they received.) When the men in the study were interviewed by "attractive women," they tended to rate their pain lower than when they spoke to someone less physically appealing.

"Just a flesh wound, ma'am."

Perhaps men ignoring pain is some dim biological echo -- after all, a caveman in pain could be injured, and unable to fend off the sabre-toothed tigers. This could affect his ability to attract a mate. Men may still consider it unmanly -- unattractive -- to admit to, or talk about their pain.

Oddly enough, when women interviewed men about their pain over the phone, there was no problem. The guys were happy to rattle on about their arthritic knee or cluster headaches to some stranger. But when it came to men talking to other men -- well, that was harder. They clammed up.

Ed: "So, Bob, I understand you've been in daily back pain now for three years. Can you describe it to me?"

Bob. "It's not too bad. No biggie."

Ed: "Every day, though. Gee, that must be tough."

Bob: "Not really."

Ed: "Anything else you want to add?"

Bob. "Nope."

End of interview.

Women are more verbal about pain than men. This is not strictly a sex difference -- after all, we all have tongues and mouths -- but part of the cultural side of gender. (This area of pain science prefers to make a tricky distinction between the biological matter of sex differences, and the whole sociocultural baggage of gender.)

Dr. Karen Berkley, a neuroscientist with the University of Florida who has studied male and female pain for 35 years, believes that gender -- like age or ethnic differences -- is one of the important ways that pain reveals its defining characteristic -- its variability. "Everyone's pain is different."

She told me about a study she did involving labour pain among Israeli and Bedouin women that revealed another aspect of pain treatment. Israeli doctors rated the Israeli women in their care as having pain around 8 out of 10, but they rated the Bedouin women giving birth at 41/2. And the Bedouin doctors did the same, giving lower pain ratings to the Israeli women than to their own Bedouin patients. Ethnic differences -- not to mention prejudice -- can enter into the way we respond to pain in others.

We listen more closely to some people than we do to others, in the matter of pain. And sometimes our beliefs about the opposite sex play a role in this. The assumption that just because women put up with menstrual cramps and childbirth they must have a higher pain threshold turns out to be wrong, for instance. "Women in general have a lower threshold and lower pain tolerance than men," Mr. Fillingim says. Even in a 1999 Gallup poll, one in four women reported that their feet hurt. (Nota bene, Manolo Blahnik.)

Some women who live with chronic pain discover that the hormonal shift that comes with pregnancy and breast-feeding can act as a natural painkiller. It seems the female body biochemically adapts to help the woman deal with the discomforts of carrying a baby -- and that can dampen existing pain. It's not likely, however, that pregnancy-as-analgesic will catch on. And hormone levels in women are far more likely to increase pain than to lessen it.

Migraine in women is related to the menstrual cycle, and according to Dr. Linda LeResche of the

University of Washington, low levels of estrogen at certain points in the menstrual cycle have been linked to generally higher levels of pain in women.

It's almost as if each woman is actually a series of individuals, with different responses, depending on her age or reproductive status. But medicine tends to to be gender-blind and age-indifferent. (The good news -- sort of -- is that after menopause, migraine in women usually tapers off.)

But men suffer in other ways, and the pain picture for men is more complicated. If parents encourage a small boy not to cry or seek comfort when he is hurt, he learns to override the message of pain -- which can be dangerous. Pain is there to protect us. Ignoring pain, toughing out injuries, avoiding trips to the doctor, can set a man up for the development of chronic pain problems. If early pain isn't treated promptly, it can reorganize the nervous system to feel pain long after the body has healed and there is no organic cause. This is the puzzle of neuropathic pain, which is devastating to live with and difficult to treat.

So the macho approach to pain, is, shall we say, counterproductive. It may only invite more pain. Some may say -- so what? Men don't seem to want to carry beaded handbags either. And the fact that men and women handle pain differently won't arrive as news to any woman who has nursed a man through a mild respiratory infection, while feeling pain, from say, multiple fractures.

Isn't it obvious that women, with bodies that equip them for childbearing, are bound to experience more pain, and that this will give them a different outlook on suffering? What can we learn about male and female pain that is helpful, rather than just offering grist for new stereotypes?

Ms. Berkley sees something positive in the gender gap in suffering.

"I think that pain is the nervous system's plan for action," she says. "It alerts us to danger and tells us to get in gear and do something about it. Women's lower pain threshold and their willingness to acknowledge pain may actually be a protective mechanism that contributes to their health. The fact is, women are smarter about pain. The first aspect of dealing with a problem is to recognize it, and what women are doing is recognizing a problem earlier -- which gives them more of a means to deal with it. Responding to pain may not be a weakness, but an adaptive strength."

And as we learn more about gender, she adds, the way we treat pain may change. "We may end up seeing males being diagnosed one way and females being diagnosed another, or females treated with one kind of pain reliever and males with another. It won't be that absolute," Ms. Berkley says, "but we will be able to use the factor of sexual difference as a way of individually designing treatments that are better for people of both sexes."

     So the phrase "I feel your pain" is wrong. It isn't possible to feel someone else's pain, because everyone experiences it differently. Some go through a lot of agony from "minor" causes. Other people sail through horrendous procedures unscathed. A very few unlucky ones, with a rare disorder called congenital analgesia, are born unable to feel pain at all -- and they die young, unable to sense and respond to threats to their health.

For a long time, medicine hasn't known how to respond to this state of affairs. The subjectivity of pain has made it suspect. Doctors want things they can see, measure and standardize, and treat with the same size of pill. My Advil is your Advil.

But what if -- as some research now suggests -- men and women metabolize painkillers quite differently, or require different dosages? Are women already being prescribed pain medication that has been tested only on men in the clinical trials? It was only a year ago, in April, 2001, that the Institute of Medicine and the U.S. Department of Health and Human Services recommended that sex differences be taken into account in the design and analysis of health studies. Eight of the 10 prescription drugs that were taken off the market between January, 1997 and February, 2001, caused more negative effects in women than in men.

The study of pain used to concern itself mostly with the mechanics of it in the body -- cells and neurotransmitters and A and C fibres. It was all about finding a certain central pain switch, or a pain pill, or a pain centre in the brain.

But the more holistic or "biopsychosocial" model is gaining currency. "A biocultural model tells us that pain is always biological and always cultural," David Morris says in Illness and Culture.This perspective focuses more on the patient's experience, and on the quality of the doctor-patient relationship.

The study of sex differences is now part of this shift away from pain as a wiring problem in the body to the issue of suffering in individuals, and how medicine should go about addressing it.

Anita Unruh began her talk at the congress with an anecdote. "I had left my purse back in class and when I went back to get it, there were two men in the office. As I overheard them talking, a third man joined them, and he was limping. 'Still limping there, eh Joe,' one of them said. 'Well, I just had surgery two weeks ago,' Joe replied. 'Two weeks!' they said, 'bit of a wuss then, aren't you?' The two men chuckled, and a slightly chagrined Joe joined the laughter. It was all very good-natured."

Nevertheless, Ms. Unruh thought the story revealed a number of things about the way we think about other people's pain. "It implies a kind of intolerance of pain, a behaviourial inhibition of pain, and an appraisal of pain as a challenge -- as something to be overcome."

She added, "I can't really think of a situation in which women would speak in this way to another woman in pain.

"Girls appear to feel free to express their pain, and boys may receive more negative consequences if they do. Girls also anticipate more pain when it comes to needles or other painful procedures. If you think about that, it could be a problem of girls being more afraid," she said, "but it could also be that if you anticipate more pain, you prepare yourself to cope better with pain when it occurs to you."

Dr. Anna Maria Aloisi, an Italian physiologist who does research into hormones, thinks that smell affects the way we feel pain. She did an experiment in which she exposed both men and women to a pleasant, lemon-scented oil. The scent made women feel less pain, but had absolutely no effect on men. (Well, that explains Lemon Pledge, I thought. Unfortunately, no one tested the effect of Cuban cigars on pain in men.)

Dr. Linda LeResche, an epidemiologist at the University of Washington who has studied the role hormones play in depth, reports that differences in pain between boys and girls only really show up with the onset of puberty, when girls start to experience more headaches, cramps and other kinds of pain. Women suffer from more temporamandibular disorders (TMD) -- pain around the neck and jaw, and Ms. LeResche has found this occurs more often when estrogen levels are higher. And to add another black mark to the growing list of potential side effects of hormone replacement therapy, Ms. LeResche has found that women who take HRT report more jaw and neck pain.

In this area of research, the gender-study folk can be rather wary of the biological-difference bunch. "It's so difficult to tease out biology from culture," Ms. LeResche acknowledges. This is a science in its infancy, still figuring out the rules. "But there is one truism that always comes up in this area," she says "which is that every cell in the body knows its sex."

Ms. Berkley is a scientist who toils away in the rats-and-mice line of pain research while maintaining a curiosity about pain's other voices. She is one of the pioneers in this area, and she keeps her options open.

"I've taught pain for a long time, and I always teach it at the lower grades on purpose." she says. "I like to include personal anecdotes, literature and theatre in my class. I even mark people on their anecdotes, and we study novels like Ethan Fromme to learn about pain from a non-scientific perspective."

She can't bear any talk about fixed pain pathways or certain pain receptors in the brain. "How can you label a line in the brain as a perception?" she asks.

Recently, Ms. Berkley has been doing a lot of experiments involving "crosstalk between internal organs." Pain that affects one part of the body can somehow increase pain levels in other areas, or even increase a general sensitivity to pain. Women with severe menstrual cramps, for instance, will sometimes tend to have more muscle pain all over. The presence of endometriosis can also make the pain of kidney stones worse -- but no doctor would think to put these two factors together in a diagnosis. Nor do doctors bother to ask questions about menstrual cycles if a woman comes in with a pain problem.

But pain makes strange connections.

"The other interesting thing is that sometimes women are hurt by a lack of pain. Before menopause, women are more likely than men to have false-positive chest pain -- pain that feels like a heart attack, but isn't. After menopause, women experience more silent heart attacks, with no pain at all.

"Women not only seek out treatment more quickly, but they will try all sorts of different things -- they'll get the right drugs, but they'll also go for a massage or do acupuncture or go talk to a friend. If a doctor can't help them, they go about finding things that will."

And it's a good thing they do shop around. Pain is too frustrating, time-consuming and costly for most doctors to deal with in any depth, and they receive little training in how to treat it. The new Centre for Pain Studies at the University of Toronto is trying to change this by developing a new curriculum that teaches medical students more about pain.

In the meantime, multidisciplinary pain clinics are a good place to start -- but their waiting lists are long. People who live with chronic pain eventually realize that medicine is not going to wave a wand over them, nor should they expect it to. Living with pain is a trial-and-error experiment of investigating different medications, looking for a compassionate therapist and figuring out how to get some pleasure out of life, despite being in pain.

Women tend to be more enterprising in this regard. But if men grow up thinking they are better off ignoring pain, they are more likely to become passive to a medical system that won't ask them to speak up.

I was talking to a friend on the phone about all this and she said, "I know exactly what you mean. I've been working with a crew of guys, doing house renovation. They're always hurting themselves, sometimes badly, and they just refuse to go to a doctor. One of them got a gigantic splinter in his hand, and he asked me to dig it out with a box cutter! "You should have it checked out at a clinic," I told him. "Nah," he said "the box cutter is fine." They have this joke whenever someone on the crew gets hurt. "Shall I go to emergency, or The Legion?" they ask. "The Legion, the Legion," they chant.

Early experience of pain may also differ between the sexes. Dr. Joel Katz, a Toronto professor of anesthesia and a pioneer in pain research, published a study last month reporting that babies who have repeated needles in the heel as newborns are more sensitive to pain six months later. In other words, early insults leave a kind of cellular memory in the body. This would explain the enduring controversy around circumcision.

Anna Tadio, another Toronto researcher, did a study in 1997 that compared the pain responses of baby boys who had been circumcised with and without anesthesia. Six months later, the boys who hadn't been anesthetized cried more when they were given their first inoculations. The cultural value of circumcision is going to have to be weighed against the possibility that we are creating new opportunities for pain later in life.

In other words, we may forget pain (or try to), but our body doesn't. Pain can change us, alter our nervous system, and our chemistry. Early neglected pain can even affect whether we embrace life, or flinch from it. In many ways, pain seems almost as complex and mysterious as that other intricate mind-body phenomenon, love.

The science in this area has made huge progress in the past 50 years, and it is exploding in every direction now. But our assumptions about who feels pain, and why, and how much, are still misguided. Norman Cousins, who wrote about the power of laughter to affect healthin The Anatomy of Health,has even called our ignorance around pain another form of illiteracy.

"We know very little about pain," he says, "and what we don't know makes it hurt all the more."

Marni Jackson is the author of the just-published Pain: The Fifth Vital Sign. Her Web site is http://www.marnijackson.com

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