Ms. Edwards is the author of the recent New York Times article The Gender Gap in Pain that exposes an apparently ubiquitous bias in healthcare; that symptoms experienced by women, especially pain symptoms, are mainly due to psychological and emotional causes. Ms. Edwards, an accomplished author and writing teacher at Northeastern University, is no stranger to pain herself. She suffers from a rare genetic lung disease for which she endured years of medical pooh-poohing before receiving proper diagnosis and treatment. In her article for the Times, she candidly discusses the evidence for this pervasive attitude, bringing into the limelight a phenomenon that has been plaguing medicine since before the days of St. Teresa of Avila, a saint and mystic who suffered debilitating pain due to chronic illness.
Last year Dr. Carolyn Bernstein and I co-edited a textbook published by Springer, Pain in Women: A Clinical Guide with the goal of educating medical professionals about the diagnosis and treatment of pain disorders that exclusively or primarily affect women, such as pelvic pain, vulvodynia, and fibromyalgia. By dealing scientifically with the underlying biological basis of these conditions, the textbook dispels lingering myths that they are primarily psychological in origin. Due to its technical nature, Pain in Women will never make the New York Times Bestseller list, but its significance and necessity to the medical community is driven home by Ms. Edwards’ article, which will fortunately reach a wider audience.
My textbook is introduced with a story from my medical school days, one that played a strong role in shaping who I later became as a physician. The story involves a patient, who came into the Emergency Department (ED) during one of my first clinical rotations complaining of severe, recurrent abdominal pain. She had been in the ED three times in the last two months with similar complaints, each time having been sent home with some medicine and advice to follow up with her primary care physician. Her husband, a truck driver, was on the road frequently and she was home alone when the pain started. This time, she was finally admitted for a diagnostic work-up. When the resident in charge of my medical team evaluated her with me in tow, she was writhing on the gurney with tears in her eyes, her agony palpable before even touching her belly. After a cursory examination, my resident took me aside and explained how she was a classic example of the “hysterical female patient”. In his estimation, she was clearly “drug-seeking”, “attention-seeking”, or both, probably due to her husband’s prolonged work-related absences. The next day, a large cancerous mass was found in the proximal portion of her colon, a location frequently missed in those days by the then commonly performed screening sigmoidoscopy, that only partially imaged the colon, as opposed to a full colonoscopy, the screening test of choice today.
This experience sensitized me throughout the remainder of my medical school and residency training, raising my awareness of how men and women experience and express pain differently, how these symptoms are then interpreted by medical professionals, and how these interpretations may be translated into differing diagnostic testing, recommendations, and treatments. I wondered at the glaringly obvious biological differences between men and women, and how, despite these, clinical variation between the sexes was hastily attributed to psychological factors. In studying pediatrics, we learned that “children are not little adults”. Instead, they require a unique diagnostic and management approach taking into account their developmental stage and how they differ physiologically. Yet, all around me, women were being treated as men, except with different sex organs, their medical “differentness” being either ignored or shunned. The idea of Women’s Health, now a popular catchphrase in medicine, was an unfamiliar concept at that time.
In 2001, the Institute of Medicine (IOM) issued a report entitled “Exploring the Biological Contributions to Human Health: Does Sex Matter?” that identified the study of sex-based differences in human health conditions as a key area for future research. These were remarkable recommendations given that prior to 1993 (not so long ago in the history of medicine), the FDA excluded women from Phase I and Phase II clinical trials to avoid potential risks to childbearing potential. Following this report, in 2007 the International Association for the Study of Pain (IASP) declared the Global Year Against Pain in Women. The IASP’s consensus report urged pain researchers to study sex-related differences in pain in a controlled and concise fashion to help translate their findings more readily into a clinical setting.
Research in this area has burgeoned over the last decade. The fact that biologically driven differences in pain exist between the sexes is now accepted by the majority of Pain Medicine specialists. However, translating this basic science research into clinically useful information takes time. In addition, attitudes prove more challenging to alter than knowledge. Unfortunately, many pain conditions that primarily affect women remain poorly understood, and in medicine when a condition or symptom falls into this category, the psyche becomes an easy scapegoat. We need, not only more research to uncover the mechanisms involved in pain conditions affecting women, but also reform in medical education. Our future doctors need to learn about pain mechanisms and sex-based differences in pain early on in their medical training when their minds are most open to influence. For this to happen, more of us need to speak up and speak out, as medical professionals, patients, and the public. We can’t be afraid to discuss and explore these unpopular and controversial topics.