Cultural Differences in Pain Perception and Management

First, it is essential to acknowledge that “culture” is multifaceted and can be defined in various ways. However, it is necessary to incorporate it into the context of pain, as numerous sociocultural factors can significantly impact pain perception. These factors include attitudes and beliefs (e.g., pain expectancy and acceptance), language, expression and learned pain response, social roles and expectations, gender, faith, spirituality, socioeconomic status, perceived discrimination, level of integration, membership in cultural groups, environmental influences, and medication usage patterns [10].

Indeed, multiple studies have identified cultural disparities in pain sensitivity. For instance, a review revealed that African Americans exhibited higher pain sensitivity than white Americans. They were more likely to recognize pain and to perceive the same stimulus as more painful [10]. In another study involving 122 women from Saudi Arabia, Sweden, and Italy, it was observed that Italian participants were the most sensitive to painful stimuli. In contrast, Swedish participants had the lowest pain sensitivity [1].

Cultural Influences

Coping-Strategien

One potential explanation for these disparities could be the culturally distinct coping strategies employed to manage pain. Research has shown that African Americans tend to employ techniques such as  “pray and hope” and “distraction” more frequently than their white American counterparts. At the same time, they use the “ignore the pain” strategy less often than white Americans [9].

Language

The impact of language on pain perception has been extensively examined. For instance, how pain is described can vary significantly across different languages. A study comparing American and Nepali pain patients revealed similarities and significant differences in how these patients conveyed their pain experiences. Notably, Nepali patients tended to utilize a more substantial number of metaphors when describing their pain. It is essential to consider these linguistic variations when documenting pain experiences. Nevertheless, it can be challenging to isolate the specific influencing factors because respondents in such studies often differ in socioeconomic status, cultural background, ethnicity, educational attainment, and language considerations [11].

Expectations

Eigene Erwartungen haben einen Einfluss. So gibt es beispielsweise einen Zusammenhang zwischen der eigenen Gender-Rolle und dem Schmerzempfinden. Je stärker eine Person an Geschlechtsunterschiede in der Schmerzempfindung glaubt, desto mehr wird sie sich selbst entsprechend verhalten [2]. Gender-Rollen und Erwartungen bezogen auf das Schmerzempfinden können wiederum je nach Kultur unterschiedlich stark ausgeprägt sein [5].

Prejudices

Regrettably, environmental bias can also be a contributing factor. For instance, individuals with black skin often experience systematic underestimation of their pain, resulting in suboptimal treatment outcomes [7]. A study has revealed that biological distinctions do not primarily drive the disparities in reported pain between black and white Americans.  Instead, the key factors are experienced discrimination and diminished trust in the study’s healthcare provider [8].

Endometriosis

To date, a limited number of studies have examined the connection between culture and factors such as endometriosis symptoms, endometriosis-related pain, or the utilization of specific treatments.

One review did indicate variations in the diagnosis rates of endometriosis among different ethnic groups, including black, white, Asian, and Hispanic women [3]. However, it remains unclear whether the actual occurrence of endometriosis differs among these groups or if it is less frequently recognized in some. This ambiguity raises potential concerns. A historical examination of texts on endometriosis reveals significant biases. In the past, endometriosis was often characterized as affecting high-achieving and affluent women with private health insurance who tend to marry and have children later. Racial biases led to the perception that its occurrence in black women was unusual, resulting in frequent misdiagnoses.

Typically, our endometriosis patients seem to have a strong will to succeed. They are usually well-dressed and have a slim figure – Buttram (1979).

While overtly racist and sexist views are fortunately less prevalent in contemporary society, it is essential to recognize that past assessments may still exert a conscious or subconscious influence on current clinical care practices, potentially contributing to disparities in diagnostic rates [3]. Notably, when exclusively focusing on women seeking infertility treatment, there were no discernible differences in the frequency of endometriosis diagnoses among black, white, Asian, and Hispanic women. Therefore, it is crucial for healthcare providers to critically examine their preconceptions and approach patients with an open mindset. This becomes even more imperative when considering that women often endure an average waiting period of seven years before receiving a diagnosis [4,6].

Summary

In summary, a range of sociocultural factors can exert mutual influence on pain perception, with existing studies shedding light on some of these factors while leaving others unexplored.

As a result, it is crucial to consider cultural disparities, particularly when assessing pain. Those providing care to individuals and their loved ones in the context of pain management should remain vigilant to potential variations in pain perception and, when necessary, implement appropriate interventions.

Ultimately, pain should always be approached as a highly individualized experience, recognizing the multifaceted nature of its determinants and the need for tailored care.

References

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Al-Harthy M, Ohrbach R, Michelotti A, List T. The effect of culture on pain sensitivity. J Oral Rehabil. 2016 Feb;43(2):81–8.
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Alabas OA, Tashani OA, Tabasam G, Johnson MI. Gender role affects experimental pain responses: A systematic review with meta-analysis. European Journal of Pain [Internet]. 2012 [cited 2021 Aug 24];16(9):1211–23. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/j.1532-2149.2012.00121.x
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Bougie O, Yap MI, Sikora L, Flaxman T, Singh S. Influence of race/ethnicity on prevalence and presentation of endometriosis: a systematic review and meta-analysis. BJOG. 2019 Aug;126(9):1104–15.
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Bougie O, Healey J, Singh SS. Behind the times: revisiting endometriosis and race. Am J Obstet Gynecol. 2019 Jul;221(1):35.e1-35.e5.
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Defrin R, Shramm L, Eli I. Gender role expectations of pain is associated with pain tolerance limit but not with pain threshold. Pain [Internet]. 2009 [cited 2021 Aug 24];145(1):230–6. Available from: https://journals.lww.com/00006396-200909000-00035
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Farland LV, Horne AW. Disparity in endometriosis diagnoses between racial/ethnic groups. BJOG. 2019 Aug;126(9):1115–6.
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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 19;113(16):4296–301.
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Losin EAR, Woo C-W, Medina NA, Andrews-Hanna JR, Eisenbarth H, Wager TD. Neural and sociocultural mediators of ethnic differences in pain. Nat Hum Behav. 2020 May;4(5):517–30.
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Orhan C, Van Looveren E, Cagnie B, Mukhtar NB, Lenoir D, Meeus M. Are Pain Beliefs, Cognitions, and Behaviors Influenced by Race, Ethnicity, and Culture in Patients with Chronic Musculoskeletal Pain: A Systematic Review. Pain Physician. 2018 Nov;21(6):541–58.
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Rahim-Williams B, Riley JL, Williams AKK, Fillingim RB. A quantitative review of ethnic group differences in experimental pain response: do biology, psychology, and culture matter? Pain Med. 2012 Apr;13(4):522–40.
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Sharma S, Pathak A, Jensen MP. Words that describe chronic musculoskeletal pain: implications for assessing pain quality across cultures. J Pain Res. 2016;9:1057–66.
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Teresa Götz