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The Inequalities of Chronic Pain


Image described in caption
A graphic overlaying dark, stormy skies with Equal Lives' logo in the top right. The words' The Inequalities of Chronic Pain' are in a jagged, pale green text box with a black outline. Surrounding the text box are five small icons in pale pink: a womb, a person seated with lightning bolts emanating from a cloud above their head, a pill and capsule, the medical cross within a circle outline, and the caduceus, a staff with two snakes coiled around it.

In the previous blog of this series, we explored the science of chronic pain and the Biopsychosocial Model that healthcare practitioners use to understand the bi-directional relationship between chronic pain and the quality of life of patients. It turns out that the whole reality of a person - biological, psychological, and social - affects their pain levels.


Reciting The Hippocratic Oath - or a modified version of - has been a long standing tradition for Medical School graduates for centuries. Interestingly, pain is the only specific symptom of disease mentioned in the original oath; 'I will soothe the pain of anyone who needs my art - and if I don't know how, I will seek the counsel of my teachers'. Most of us know the part of the oath about doing no harm, however when certain social groups of the 15.5 million people in the UK with chronic pain are over-represented, the experiences of those already marginalised contradict the oath's principle to 'do no harm'.'


Since its inception, medical science has prioritised the health of men. In part due to this, women’s anatomy has been poorly understood throughout human history. For instance, Plato believed that women had ‘wandering wombs’ - voracious, independent animals that roamed about our bodies in search of semen, making us ‘hysterical’. This belief didn’t stop with Plato; it persisted up until a couple of centuries ago. In fact, the word ‘hysteria’ is derived from the Greek 'hystera' meaning uterus. Hence, hysterectomies!


While the notion of wandering wombs might seem comical to those reading in the modern age, over time this misogynistic seed has grown into a tree, creating poorer health outcomes for women in UK to the present day. Please note for clarity, when I refer to 'women' throughout this blog, I also mean those assigned female at birth (AFAB).

Contemporary healthcare is built on a foundation of misogynistic medical literature. Women were excluded from clinical trials until the 1990s, and misogynistic bias remains largely unchecked. So, unsurprisingly, a Gender Pain Gap exists.


Image described in caption
Same motif as the first graphic but with the words '70% of people with chronic pain are women. Yet, 80% of pain medication has only been tested on men'.


Women experience higher rates of chronic pain than cisgender men. In fact, it has been discovered that women feel pain more intensely, more often, for longer periods and in more areas of the body than men. 70% of people with chronic pain are women. Yet 80% of pain medication has only ever been tested on men!


Women seeking care for their pain are more likely to have their symptoms attributed to a psychiatric origin. This means that women are more likely to be given sedatives to treat pain rather than targeted analgesic medication. Women are also less likely to be tested for organic causes for their pain in comparison to their male counterparts.


Image described in caption
Same motif as the first graphic but with the words 'Women seeking medical care for their pain are more likely to have their symptoms attributed to a psychiatric origin than men.' The pale pink icons surrounding the text box are two brains, one that says 'BPD'.

Medical reports and literature tend to equate gender and sex when studying sex differences in the experience of chronic pain. It’s unsurprising that chronic pain in LGBTQI+ identifying people has not been researched in great depth, as this group are generally under-served by medical science. However, it is something that researchers are starting to probe, and I hope to return to the research on this in a future blog.


Medical science hasn’t only centred men throughout history; it has also centred whiteness. This means that it is fallible to racial bias. Therefore, it has a huge real-world impact on minoritised ethnic groups; Black and Asian aggregated groups have poorer health outcomes when compared to their white counterparts.

Black people experience significantly higher rates of chronic pain than any other racial-ethnic group in the UK. 44% of Black people have chronic pain, compared with 35% Asian, 34% of white, 34% mixed/multiple ethnicity, and 26% any other ethnic background. Research has shown that compared to white patients, Black patients are less likely to be given pain medication, and if they are given pain medication, they’re given less.


Image described in caption
Same motif as the first graphic but with the words 'Black patients are less likely to be given pain medication than white patients, and if they are given pain medication, they’re given less'. An icon above the text a pill and capsule.

A 2007 US study found that physicians underestimated pain in 33% of non-black patients, compared to 47% of Black patients. A 2016 study found that practitioners were less likely to prescribe opioids to Black patients. A different 2016 study found that almost half of medical school students held false medical beliefs regarding Black people, such as believing that Black people have thicker skin and less sensitive nerve endings than white people.


Although beyond the scope of this blog and the topic of chronic pain, the Birthrights inquiry - an investigation into racial injustice in UK maternity care – is worth mentioning, because it provides more specific insight into the ways inequalities show up in healthcare settings. The inquiry found that Black women are five times (and Asian women, two times) more likely to die in the perinatal period than white women. The inquiry found that ‘these women and birthing people were ignored and disbelieved, were subject to racism by caregivers, were not given a proper choice or the means to give true informed consent, and were subject to coercion from caregivers, were regularly dehumanised and were disproportionately affected by structural barriers to care’.


Image described in caption
Same motif as first graphic with the words 'A 2016 US study found that almost half of medical school students held false beliefs, such as Black people have thicker skin or less sensitive nerve endings than white people', and the pale pink icon is a nerve cell.

It has long been known that to be poor is to be at higher risk of poor health outcomes. In the UK, people who experience the most disabling chronic pain are twice as likely to live in the most deprived areas of the country (30%) in comparison to the least deprived areas (15%).

Image described in caption.
A venn diagram in black against a pale green background, in one circle are the words 'Woman/Assigned female at birth', in another 'Black/South Asian', and in the bottom circle 'Working class'.

The inequalities discussed in this blog can be imagined as a Venn diagram, where these marginalised identities meet, the experience of chronic pain (and general healthcare) is especially poor. Chronic pain is a deeply political topic.


It is the responsibility of healthcare providers to understand the biases that exist in medicine and to spend time confronting their own biases. It’s uncomfortable but it’s essential work. If you’re a healthcare provider: please take people seriously when they say they’re in pain.


If you are someone from a marginalised group who lives with chronic pain, know that however you are made to feel about your pain, you deserve to be taken seriously. You are

entitled to second opinions, diagnostic testing, and access to analgesic medication.

- Arianne Brown


Sources:


1. 'The Wandering Womb: Women's Health Nursing Past & Present', Royal College of Nursing Library Exhibition https://www.rcn.org.uk/library-exhibitions/Womens-health-wandering-womb

2. 'Women’s health outcomes: Is there a gender gap?', House of Lords Library https://lordslibrary.parliament.uk/womens-health-outcomes-is-there-a-gender-gap/

3. 'Women’s involvement in clinical trials: historical perspective and future implications', Katherine A. Liu & Natalie A. Dipietro Mager https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800017/

4. Sex Inequalities in Medical Research: A Systematic Scoping Review of the Literature https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8812498/

5. 'Role of gender norms and group identification on hypothetical and experimental pain tolerance' https://pubmed.ncbi.nlm.nih.gov/17156919/

6. 'Hysterical Women, The feminist health blog exploring patient experiences of dismissive, sexist and biased healthcare' https://hystericalwomen.co.uk

7. 'Women and pain: Disparities in experience and treatment', Harvard Health Blog, https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562

8. 'Coronary Heart Disease in Women — An Ounce of Prevention' Elizabeth G. Nabel, M.D. for the New England Journal of Medicine https://www.nejm.org/doi/full/10.1056/NEJM200008243430809

9. 'Quantifying health inequalities in England' Toby Watt, Ann Raymond & Laurie Rachet-Jacquet for The Health Foundation https://www.health.org.uk/news-and-comment/charts-and-infographics/quantifying-health-inequalities

10. 'When race matters: disagreement in pain perception between patients and their physicians in primary care', The National Library of Medicine PDF version https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576060/pdf/jnma00204-0066.pdf

11. 'Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse' PLOS Journals, https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0159224

12. 'Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites' in The Proceedings of the National Academy of Sciences (PNAS), https://www.pnas.org/doi/abs/10.1073/pnas.1516047113

13. 'Systemic racism, not broken bodies: An inquiry into racial injustice and human rights in UK maternity care' Birthrights inquiry PDF version, https://www.birthrights.org.uk/wp-content/uploads/2022/05/Birthrights-inquiry-systemic-racism_exec-summary_May-22-web.pdf







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