Gender Shapes the Experience of Pain: An Interview with Kathleen Rice

“But for healthcare providers, first and foremost, it’s important to take a wider lens and consider they are not just treating a pain patient. Instead, this is a pain patient who is also a woman. What do I know about healthcare for women who are marginalized? What kind of responsibilities does this person likely have that I should ask about? Because you can make all kinds of recommendations about exercise or physiotherapy, but if you have to physically care for a child, it may not work.

“Also, it’s worth asking: Do you have a partner? Is your partner supportive? Do you feel like you can talk to your partner about your pain or what you need in order to live well with your pain? These conversations can open up new avenues for providers to try, and I think that would be welcome for both the providers and the people they are treating.” – Kathleen Rice

Kathleen Rice, PhD, is an assistant professor and the research director in the Department of Family Medicine at McGill University, Montreal, Canada, where she holds the Canada Research Chair in the Medical Anthropology of Primary Care. She studies healthcare inequities using anthropological approaches, notably ethnography, to gather data about the different forces that shape medical treatment and research.    

Here, she speaks with freelance writer Kayt Sukel about the value of medical anthropology, why gender matters in chronic pain care, and the importance of giving marginalized voices a “seat at the table” in the search for new chronic pain treatments. What follows is an edited transcript of their conversation.

You are a medical anthropologist. What is that, and how does this type of research benefit our understanding of chronic pain?

I’m a social scientist who takes an approach called ethnography, which originally comes out of anthropology. It’s now widely used in a range of disciplines, including sociology and public health, and it focuses on long-term immersion in a particular research context to really try to understand something from the inside of what is going on. I work very much in collaboration with others like Fiona Webster at Western University, who is a medical sociologist who uses institutional ethnography [a particular kind of ethnography] in her work.

Medical anthropologists like me take that approach to look at health issues like chronic pain. That’s because, as I’m sure you and your readers are aware, chronic pain is not just about the biology or neurophysiology of pain. This condition has real implications for how a person lives their life, and the experience of being a person with pain spills over into just about everything they do: Their family life, their work life, the kinds of work they may or may not be able to do, and the kinds of leisure activities they may or may not be able to pursue.

At the same time, in clinical settings, our team sees, from collaborating with clinicians and other healthcare providers, that working with chronic pain is very challenging. How do you treat something you can’t see? It’s not like measuring blood pressure or blood sugar where you can do a test and see the numbers going up or down – where you can see whether people are responding to treatment or not. There’s always this large subjective dimension to pain that’s really difficult for healthcare providers to deal with and make sense of.

Ethnography, which historically entails something called participant observation, allows us to sit in on healthcare appointments with the patient’s permission and see, as a critical outsider, how patients and providers are interacting with one another. What are the kinds of system pressures on this appointment? Is the appointment 15 minutes long, when the patient clearly needs to talk about 45 minutes’ worth of stuff? There’s also a lot to observe in terms of the space between what people say and what people do. And ethnography is a method that really aims to explore what is going on in that space so we can learn more about how chronic pain is treated.

Kathleen Rice

Tell me about institutional ethnography.

The chronic pain work we’ve done in general is institutional ethnography. It’s like traditional ethnography, where you immerse yourself as much as possible, for as long as possible, in an environment to try to understand things from a more inside point of view; we still strive for that as much as possible.

But institutional ethnography aims to do that within settings that are highly structured by “texts,” like policy documents and clinical pathways. In addition to doing observations at clinical appointments or at pain clinics, interviewing healthcare providers, and interviewing patients, we also pay really close attention to things like care pathways, or the tools used to measure and diagnose people’s pain.

Also, we recognize there are a lot of things that structure policy decisions – legal frameworks around prescribing certain categories of drugs, for example – that very much shape the personal interactions that happen at a clinic. And those things also shape what happens when a person is at home alone trying to live with their pain.

You recently had a paper, in the Journal of Pain, focused on the gendered experience of chronic pain. What was the inspiration for that study?

We didn’t actually start with an eye to look at gender at all. Fiona Webster was the lead on an institutional ethnographic study looking at the coordination of chronic pain care in Ontario, from the standpoint of healthcare providers, and I was a postdoctoral fellow working with her. Through that study, it became clear there was a large subsegment of the population living with chronic pain that was also struggling with low socioeconomic status and other challenges connected to that. The team decided to look more closely at the experiences of the people with pain in that group.

Another postdoc named Laura Connoy interviewed a lot of people who identified as struggling to make ends meet and also having chronic pain. None of the questions we asked probed for gendered experiences in any way. But, in analyzing the data, it became very clear that these people’s experiences of life with pain were so shaped by being a gendered person. So we did a secondary analysis of the data and started picking out various themes that we feel really showcased why gender should have a more prominent role in chronic pain care and chronic pain research than it currently does.

Did any of those themes surprise you?

The thing that surprised us the most was that most of what we saw has already been well documented in research on marginality and gender in general. It was just the piece of putting it together with the experience of being a person with chronic pain that we hadn’t seen before.

The good news is that, when it comes to doing something proactive to address this, a lot of the groundwork has already been done. There’s already a lot of research on gender-based violence. And, certainly, we found that a lot of women with chronic pain had pain that started or had been exacerbated by violence that took place in intimate relationships. It’s not the first time that researchers have found that gender-based violence affects women’s lives in particular kinds of ways. But it means that healthcare providers who are dealing with women who have chronic pain should be more cognizant of these connections.

What do you hope that providers take away from this study?

Like a lot of research, it left us with more questions and the knowledge that there’s a problem that needs to be addressed. We need to work with people to figure out the next steps because there’s no easy solution here.

But for healthcare providers, first and foremost, it’s important to take a wider lens and consider they are not just treating a pain patient. Instead, this is a pain patient who is also a woman. What do I know about healthcare for women who are marginalized? What kind of responsibilities does this person likely have that I should ask about? Because you can make all kinds of recommendations about exercise or physiotherapy, but if you have to physically care for a child, it may not work.

Also, it’s worth asking: Do you have a partner? Is your partner supportive? Do you feel like you can talk to your partner about your pain or what you need in order to live well with your pain? These conversations can open up new avenues for providers to try, and I think that would be welcome for both the providers and the people they are treating.

I should also add that our paper is about women. Most of the people we talked to were women. But I’d like to stress that there is also a moderate amount of research on gender and chronic pain among men. There’s also gendered challenges there, and, ideally, that’s something else that care providers should be aware of.

How would you like to follow up on this work?

Our team is currently trying to get people who are marginalized and have chronic pain more involved with research, and also to help them get a seat at the table to better advocate for themselves.

The people who tend to be most engaged, the patients who are on boards, who get involved in research, tend not to be the people who are more broadly representative of who is living with pain. They tend to be the people who know how to find those opportunities. They tend to be the people who have the right kind of language to talk to people who have a lot of education. They have a lot of confidence that their point of view is going to be heard. So we are working with groups right now to try and figure out how to collaborate more effectively with people who have chronic pain and are marginalized. We’d like them to be much more involved in finding solutions to the issues they face than they currently are. We’re working with them to try to figure out how to get them more engaged in a way that really works.

Kayt Sukel is a freelance writer based outside Houston, Texas.

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