From racism, classism, ageism, and sexism to cultural and language barriers, the axes of patient identity and provider privilege are spread far and wide in the medical community. How to move the power imbalance to improve patient outcomes when managing chronic pain.
Research has robustly demonstrated that marginalized or minority patients present with higher pain prevalence rates and experience less adequate assessment, treatment, and favorable outcomes compared to their majority counterparts. 1-3 Incorporating cultural competence - also referred to as cultural humility or cultural responsiveness - into clinical practice has been introduced as a vital method to address these health disparities. 4,5 Traditional approaches to diversity training often focus on promoting clinician awareness of social and cultural influences on patients' health outcomes. 6 More recently, the approach has emphasized providers' commitment to self-reflection, self-critique of bias and discrimination, and attention to power imbalances in the clinician-patient relationship. 7
Intersectionality: Understanding Axes of Identity and Privilege
Another development toward cultural responsiveness includes an understanding of a patient's multiple cultural identities, referred to as intersectionality. Intersectionality describes the simultaneous experience of categorical and hierarchical identity classifications including, but not limited to race, class, gender, sexuality, and nationality (see Figure 1 below). This figure is an adaptation from Kathyrn P. Morgan's (1996) model of intersecting axes of privilege, domination, and oppression. Intersectional theory asserts that people are often disadvantaged by multiple sources of oppression. An intersectional approach allows for the complex conceptualization of multiple cultural identities to address health disparities. Initially, the work of intersectionality was developed to address the unique experiences of Black women relative to both Black men and white women; the concept has since been expanded to address a range of social identities. 8
Intersectionality requires a shift in provider thinking from dominant frameworks to frameworks that are mindful of how one's positions of culturally sanctioned privilege and/or oppression operate within an interpersonal patient-provider context. The first step is to recognize the ways in which these axes of identity and structural inequalities come together sometimes to yield unexpected (to the provider) pain presentations. Past research has demonstrated that cultural identities impact access to treatment, patient-provider communication, treatment planning, response to treatments, and health outcomes for chronic pain patients. 9 The opportunity to address this oppression exists in all levels of medical care with the goal of increasing accessibility of care, improving the predictability of getting appropriate care (patient expectations), and enhancing feelings of safety for all patients with chronic pain. Thus, it is important for practitioners to understand the nuanced way pain can be communicated and assessed across identities. It is important for healthcare providers to reflect on their own biases and stereotyping, and how this may inhibit assessment and treatment decisions.
The following is a brief review of the literature, as it currently stands, about the relationship between each axis of privilege and chronic pain. Of note, the authors acknowledge that each axis could serve as a sole focus of its own article. This summary is to create broad awareness and motivate providers to self-assess personal biases in order to enhance cultural responsiveness.
Axes of Privilege in Chronic Pain Management
Sex differences in pain sensitivity have been well documented, such that cisgender women often report greater sensitivity than cisgender men. A recent study also found that cisgender women's pain is more often psychologized, leading to stigma, and noted the greater stoicism of cisgender men. 10 Clinical reports highlighting sex differences often equate gender and sex. This is a particularly critical oversight for those whose gender identity is different than their genetic sex. When it comes to transgender and/or gender nonbinary individuals, increased pain, especially in the areas of the body that change as a result of cross-sex hormone treatment, is often experienced. 11 There is also data that supports the notion that gender identity may also play a significant role in pain sensation. One recent study found that transgender women and cisgender women reported similar increases in chronic pain severity compared to cisgender men. 12 These results indicate that treatment should be based on both gender identity and genetic sex distinct variables.
There is genetic and biological support for variability in the experience of pain. 13 Nevertheless, cultural values also significantly inform the expression of nociception. 14 Importantly, racial discrimination has been found to increase pain conditions and pain sensitivity. 15-18 Despite this, all marginalized patients are less likely to be prescribed pain medication compared to their white counterparts. 19 The following is a more focused summary of the literature for chronic pain management and its effect on marginalized populations in the US (see also, our report on treating pain in under-resourced areas.):
- Asian/Pacific Islanders: Research reports, on average, greater pain sensitivity in Asian patients compared to other racial/ethnic minoritized groups.20 However, Asian patients have been found to be less likely to receive a pain assessment when compared with white patients.19 Racial discrimination for Asian patients has also been associated with pain conditions and indicators of pain.21 Further, findings suggest that psychological distress is often communicated as physical pain in Asian populations.
- Black/African Americans: Patients who are Black have been found to have higher rates of pain and pain sensitivity, particularly in instances of racial discrimination and as the result of systemic racism in the US.15-18 There are many myths and stereotypes that are prominent among medical students and residents regarding a Black patient's experience of pain.3 Thus, Black patients have been found to experience the highest rates of analgesic treatment disparity compared to other racial/ethnic minoritized groups, receiving significantly less opioids across pain types and treatment settings22 despite not being more at risk of pain medication dependence.23 (See also disparities in multiple sclerosis.)
- Latinx/Hispanic/Latinos: Latinx individuals report higher pain levels when compared to white patients on standardized pain stimuli.24 Racial discrimination was found to have a significant, indirect effect on pain intensity and disability via anxiety sensitivity in a sample of Spanish-speaking Latinos.25 While Latinos have been found to value stoicism in the face of pain, it is also common for Latinas (females) to moan and cry as an expression of pain.26 Providers might see these unfamiliar expressions as exaggerations of pain and interpret them as medication seeking, when they may actually be culturally sanctioned expressions of pain.
- Indigenous/Native Americans: Pain anxiety in indigenous populations has been found to contribute to increased pain.27 Native Americans had the highest rates of physician-perceived pain exaggeration.28 In contrast, a recent investigation found that Native Americans were less pain sensitive than their white counterparts in their pain responses.29 The actions of providers and patients described have been found to leave Native Americans' pain undertreated.28
Little research exists about the prevalence rates of chronic pain disorders among LGBTQIA individuals. Past research has shown that sexual orientation (hetero-, homo-, bi-sexual) disparities in chronic pain were partially explained by associated factors, including childhood abuse, depressive symptoms, suicidal ideation, lack of social support, and self-esteem. 30 The biggest hurdle for this community is finding appropriate medical care. Anti-LGBTQIA discrimination and heterosexism have been noted by medical students, yet they report a high level of comfort and confidence providing healthcare to LGBTQIA patients. 31
Ableism is defined as discrimination or prejudice against individuals with disabilities. In the realm of pain medicine, many providers downplay the experience of their patients as faking or exaggerating without an adequate understanding of pain and its mechanisms. This translates into denying a disability because it is " invisible." 32 Outcome studies have been complicated by the discrepancies between pain, impairment, and disability inherent in chronic pain populations. 33 To assist with these discrepancies, the World Health Organization released an International Classification of Illness in 1980, which outlined the difference between the terms "pathology," "impairment," "disability," and "handicapped." These guidelines were later revised in 2000. 34 (More on ableism and disability justice in mental health from a psychiatrist's perspective.)
The impact of education on health outcomes has been found to be significant. 35 In fact, a recent study found that patients in the US who are without a college degree report more chronic pain than those who are college graduates. Findings suggest that lower education attainment many times is linked to socioeconomic stressors that can lead to chronic pain and/or barriers to access to adequate healthcare services. 36
Class status, or socioeconomic status (SES), has been found to have a stronger impact on the risk of chronic pain compared to other axes of privilege, such as those based on race/ethnicity. 37 Midlife and older adults with greater wealth are less likely to experience high impact chronic pain 37 and also have access to higher quality healthcare. 22 Similar to bias with pain patients based on race or ethnicity, providers appear more suspicious of medication seeking in lower SES patients. For example, they more often use opioid contracts with low SES compared to high SES patients. 38
Ageism is defined as prejudice or discrimination on the grounds of a person's age. Providers are urged to discuss options for pain medicine with their patients. However, some older adults might deny pain if preferred terms, such as 'discomfort,' 'aching,' or 'soreness,' are not applied in the assessment. 39 Asking simple, concrete questions, one at a time, at a slow pace will help increase the accuracy of the pain assessment. Furthermore, pain behaviors need to be evaluated and observed, including facial expressions, rigid or tense body movements, changes in interpersonal interactions (including aggression and withdrawal), changes in routines, and mental status changes. 40 Conditions such as dementia may make pain assessment more complex (more on opioids and aging adults). Including family members and caretakers in the assessment process can help increase accuracy. 41 See Herr, et al, for a review of several pain assessment tools for use with older adults with dementia. 42
There is a lack of research on pain treatment in non-English speaking patients. 43 While bringing a third party to interpret can be beneficial, providers experience this as an additional complexity that challenges communication accuracy. 44 To increase quality of care to non-English speaking patients, providers should reflect on their initial reactions to select languages and accents and note any biases. Providers should aim to use professional interpreters or technology to increase communication accuracy. Furthermore, nonverbal assessment measures can also be used, such as the Wong-Baker Faces Pain Rating Scale, which has been translated into more than 50 languages. 45 (See also, shortage of Spanish-speaking providers.)Religion and Prevailing Beliefs in the Patient Room
The most common religion in the world continues to be Christianity, with Islam as the world's second largest religion. Yet, many health practitioners are unfamiliar with Islam and other religions/prevailing spiritual beliefs. Muslims, for example, may not want to take medications that impair cognitive abilities without an understanding of their necessity. 46 Importantly, " religious coping,"or how the individual is making use of religion to understand and deal with stressors, has been found to be an effective treatment for Muslim women with chronic pain from fibromyalgia 47 and breast cancer. 48 Research that investigates the impact of Abrahamic religions on pain is lacking. One exception, albeit several decades old, found that patients who are Jewish have been found to have similar responses to pain as other ethnic groups. 49 More research is needed to better serve the unique needs of patients from minoritized religious identities.
How to Improve Chronic Pain Assessment and Treatment Across the "-isms" of Our Society
People who are indigenous, recent immigrants or refugees, of color, LGBTQIA, less well-educated, living with mental health or substance-use challenges, or have experienced violence and trauma, among others, are vulnerable to a higher prevalence of painful medical conditions relative to nonmarginalized people. While one cultural identity might be most salient for a patient, the ways in which multiple identities come together, or intersect, has been found to be an important predictor of pain communication and provider bias and discrimination, significantly impacting the quality of assessment and treatment. For example, imagine two different patients are female-bodied and come from the same marginalized ethnic group. However, one identifies as heterosexual, middle-class, and is older than the other patient who identifies as homosexual, working class, and in an earlier stage of life. They may have similar sex and cultural identities yet differ across several other axes. In such circumstances, attention to intersectionality will lead the provider to acknowledge the patient's uniqueness and understand the need to listen and act with cultural responsiveness. Through this collaboration, clinicians can learn about the impact of their patient's cultural identities on chronic pain expression and pain experiences and will be able to more accurately and effectively assess and treat pain in their patients.
- Marginalized patients are often at a higher risk of physician bias and treatment discrimination, resulting in undertreated pain symptoms.
- Cultural intersectionality is important in understanding patients' communication about pain.
- Accurate pain assessment and treatment requires clinicians to gain self-awareness into their own cultural identities and risks of bias for minoritized patients, especially those with multiple minoritized identities.
Incorporating cultural competence and humility into clinical practice has been the medical field's approach to confronting health disparities. Providers need to utilize strategies for decreasing their own biases, which include an increased self-awareness around personal values and bias toward others' values and an awareness of the spectrum of pain experiences that are expressed effectively. 4,5 It is also important for clinicians to be familiar with the research contradicting the myth that marginalized patients are more likely to exaggerate pain and seek medication compared to white patients. While important, these approaches have been criticized for failing to fully address broader structural and institutional systems that perpetuate inequality and shape health outcomes. 7 Moreover, a compassionate system that values equity with accountability is needed. 50