Editor’s note: Katelynn Boerner, PhD, RPsych, is a postdoctoral fellow in the Department of Psychiatry at the University of British Columbia in Vancouver, Canada, and is based at BC Children’s Hospital. She completed her PhD in clinical psychology at Dalhousie University in 2017. Her research examines how individual and social factors such as gender, sex, family factors, and mental health influence the development of pain and physical symptoms in young people. Recently, Boerner was the first author of “Conceptual complexity of gender and its relevance to pain,” a topical review published in PAIN. In this PRF interview, Boerner chats with Dara Bree, a postdoctoral fellow at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, US, to discuss her article and her work in the area of gender and pain. Below is an edited transcript of their conversation.
Before we talk about gender and its relevance to pain, could you first describe what gender is and how it differs from sex?
There are probably as many different definitions of gender as there are people. But I’ve always liked the definition that the Canadian Institutes of Health Research uses, which describes gender as referring to the roles, behaviors, expressions, attitudes, and identities that help to define women, men, boys, girls, and gender-diverse people. I tend to think of gender as the way people understand their own identity, which may or may not reflect sex. Sex refers to the biology that people are born with.
We usually think of gender in our everyday life as being binary, for example, being a woman or a man. But gender is very diverse and fluid in the way that individuals and different cultures understand it, and in how it’s expressed. There’s quite a number of different ways that you can conceptualize it.
Gender can be something that you identify with, but it can also be a way that you behave or express yourself, or a particular set of beliefs. So it’s quite broad, and we tend to think of gender as being distinct from sex, but in truth we know the two actually interact with each other and have a lot of overlap.
How did you become interested in this topic?
I was originally interested in sex differences in pain because there’s quite a bit of literature on that in adult pain, but not very much in pediatric populations. So that was a gap I was looking to fill as part of my PhD.
In my attempts to do so, I noticed that an even bigger gap in our knowledge relates to how gender plays into the pain experience. I tried to incorporate some measures of gender into my doctoral dissertation, and it actually proved extremely challenging, because there are so few well-validated measures of gender, particularly in children.
That really got me interested in how we can use this more nuanced view of sex and gender to move the field forward. But I experienced firsthand some of the issues that researchers are running into, which made me understand why this doesn’t show up in the literature as much as we’d like it to.
What are some of the issues you encountered in studying gender in the context of pain?
Pain is certainly not the only field that’s struggled with how to incorporate gender. One of the biggest challenges is the number of different ways that you can define gender, which then leads to a number of different ways that you can measure it; it’s a rapidly shifting and evolving field, not only in pain but in sociology, and in medicine in general.
Even as someone who’s quite interested in gender and tries to keep up on the literature, the field shifts so frequently that even just a couple of weeks after the topical review came out, there were some aspects of the terminology I might have written about differently. So it feels like a moving target. As we’re heading toward making our research more inclusive, a willingness to accept some of this ever-shifting nature of how we define and measure gender has to come along with it.
Another challenge is how to be more inclusive of gender-diverse populations in our research. We know that these are groups who typically have had a lot of difficulty accessing healthcare because of discrimination and stigma. As a result, they’re not always very well represented in our research.
You mentioned the challenge of measuring gender. Is asking people what gender they identify with a reliable way of measuring it? What other methods can researchers use?
Asking people about their gender identity is a very good first start that any researcher could use. Some of the other areas beyond gender identity include expression, which is the behavioral or observable expression of one’s gender; gender role orientation, referring to how much an individual demonstrates characteristics that are considered to be typically associated with a certain gender; and gender ideologies, which are the beliefs and expectations for a specific gender. But that’s where we really need more work to develop better self-report tools and methods of measurement.
There are questionnaires that have been used in the past to look at masculinity or femininity, but they were developed decades ago, and our understanding of what typical masculine or feminine behavior looks like has changed a lot since that time.
Certainly, just asking people what their experience is of their own gender is a really good beginning, and it doesn’t have to be that complicated. If researchers are concerned about not being inclusive enough or not having the right terms in their multiple-choice questions on gender, just having an option for “other” for someone to fill in is appropriate.
What do we know about the relevance of gender to pain?
We know a small bit, particularly from studies that have looked at measures of masculinity and femininity, and the associated pain outcomes. Masculinity appears to be particularly relevant for understanding men’s pain; people who endorse more stereotypically masculine characteristics tend to report decreased pain sensitivity. More recent research has shown that masculinity is also associated with an increased willingness to participate in pain research among men.
But this really highlights one of the gaps in our knowledge: Masculinity seems to be a pretty good predictor of pain outcomes for men, but femininity doesn’t seem to be quite as strong a predictor for women.
Another area where there has been some work is in describing the impact of gender biases on pain treatment. There has been documented gender- and sex-related bias in some healthcare providers in how they assess a person’s pain or what they attribute the pain to. Women tend to have their pain attributed more to psychological issues than men, and there also seems to be a bias in the willingness to provide analgesics or in what types of referrals are made.
I think this is in an area that hasn’t really been investigated as much as it should in relation to pain, not just from the perspective of patient gender, but also provider gender. If your experience of being a male versus female health provider is different, then that might impact the way in which you provide care. It’s certainly an interesting area that we could be looking at more.
In your review you mention that differences within sexes with regard to pain are often greater than those than between sexes and that gender may explain some of this variability. Could you elaborate on that?
The sex differences that we see in the adult pain literature are generally pretty robust and consistent. But we also know that it’s just one of many individual differences that can account for the pain experience. Just because we tend to see differences between men and women doesn’t mean that there aren’t any differences within women or within men and how they experience pain.
Since we think of gender as being more of a spectrum or a continuum, we wondered if that might explain some of the variability within sexes that we’re seeing, because there are many different ways to experience being a man or a woman, and many different ways of identifying as one.
What I hoped in writing the review is that it might encourage people to think beyond doing t-test comparisons for looking at males versus females and think about some of the nuances that might help us better understand what’s going on.
How feasible is it to include gender as a variable in experimental pain studies?
It’s very feasible, and the more that we start to try to do it, the more feasible it will become. Like we discussed earlier, just asking the question of how people gender identify is a very feasible first start!
It’s something that we could do by just asking and reporting it, even if that’s not the focus of the study, just to get in the practice of how to incorporate this data and to make it a little bit more salient for researchers who might not have it at the forefront of their minds.
One of the challenges that we’ll need to address in doing that is how to manage data if you are interested in looking at sex versus gender. For example, you may have a smaller representation of gender-diverse people in your sample, and it may raise some questions around how to handle that from a statistical perspective.
There are lots of really good guidelines, not necessarily specific to pain but helpful nonetheless, particularly from the Canadian Institutes of Health Research. There are also a number of other good resources, including the Sex and Gender Equity in Research guidelines that people can access if they want to ensure that gender is being covered in their research.
Considering how long it took for sex differences to become an established part of pain research and the resistance with which it was initially met, do you foresee similar resistance to the introduction of gender into pain studies?
I could envision some pushback, but what is important is to help people to see the relevance of gender to their work. Certainly, those of us who are interested in sex and gender feel it’s very relevant, but we also recognize that it’s one of many individual difference variables that researchers are increasingly being asked to include in their studies.
It’s important to measure and report these things, but you don’t necessarily have to be doing all of the analyses yourself. Just being willing to share data with those who are interested in doing, for example, meta-analyses on sex and gender issues in pain is really helpful to move the field forward. Not everybody has to be an expert in sex and gender to contribute to this movement.
What are some of the key outstanding questions on the relationship between gender and pain that need to be addressed?
One of the biggest questions is how to address the systemic gender biases in pain care. As we’re starting to understand a little bit more about these biases, figuring out how we can put something into practice that’s going to allow us to address them is crucial. Providing pain care to gender-diverse populations and ensuring that they have the same access to pain care that everybody else does is a big challenge on the horizon.
I work with kids, and there is a particularly big gap in the pediatric literature on gender differences in pain, but taking a developmental perspective is really important. This is because we know that the way you understand and experience your gender is shaped by things that start from very early in life.
Boys and girls are generally raised differently, and all of these influences, particularly if you think about shifts in your identity as you transition into adolescence, are really important in understanding that trajectory. I would really push for research that takes a more developmental perspective to understanding not just how sex differences emerge over time, but how gender is important in understanding that.
Is there anything else you would like to add?
I would like to put out a call to action to have more researchers consider gender in their studies, and I think any of us who work in the area are more than happy to collaborate or consult on how to ask some of these questions.
We should also be making use of our colleagues in other disciplines. Other areas of healthcare are perhaps a little further along in addressing how gender is impacting different types of health issues; fields such as medical sociology have done a lot of good work here. Gender is definitely an area where we should make an effort to step out of our silos a little bit and pull in non-pain researchers and people with lived experience of pain and gender diversity for some interesting discussions and to make our work more relevant.