Pain in Men

Pain in Boys and Men Across the Lifespan

• Boys are at increased risk for injuries during childhood (Morongiello et al., 2021) and men are also reported to engage in riskier behaviours (Pinkhasov et al. 2010).
• Before puberty, boys and girls report similar levels of pain, with boys reporting lower rates of both clinical and experimental pain in adolescence onward (Boerner et al. 2014)
• Some conditions that affect only individuals assigned male at birth are associated with significant pain, including testicular cancer, prostate cancer, and prostatitis.
• While most chronic pain conditions are more prevalent in women, some specific pain conditions (e.g., cluster headache) are experienced more in men (Fischera et al. 2008).
• In trials of psychological therapies for pediatric pain, boys represent only a third of the total adolescents recruited into trial, and while most treatment effects were similar across sexes, boys with nonheadache chronic pain did not demonstrate post-treatment effects on functional disability (Boerner et al., 2017)
• Men are more likely to experience substance use disorders, and sex differences have been reported in rates of prescriptions for opioids, side effects, and drivers of substance use (Davis et al. 2021; Manubay et al. 2015).

The Role of Testosterone in Understanding Pain

• Testosterone is the primary sex hormone in males. In research across animals and humans, testosterone has been found to have an antinociceptive (pain-reducing) effect (Vollert et al., 2022). However, findings are inconsistent across all designs (Zhuo et al. 2023).
• In boys, advanced puberty and pubertal asynchrony increase the risk of pain (Li et al., 2023).
• Preliminary evidence suggests that testosterone replacement therapy may be associated with reduced pain in men with late-onset hypogonadism (Kato et al. 2020).

The Role of Masculinity in Understanding Pain

• Masculinity describes attributes, behaviors, roles, and qualities stereotypically associated with boys and men. Traditional male role norms and masculinity in Western society prioritize stoicism, strength, independence, courage, competition, aggression, and assertiveness. These constructs appear to be important for understanding morbidity and mortality differences and health behaviors in pain (Keogh 2015).
• Masculinity is not specific to men and can be experienced by, and influence the pain of, women and gender-diverse people.
• Experimental research has found that identifying with masculine traits is associated with a higher pain threshold (Alabas et al. 2012)
• Higher masculine identification has been associated with increased participation in experimental pain research in males but not females (Feijo et al. 2017).
• Research has also described a demasculinizing effect of living with chronic pain, particularly forms of pain traditionally associated with women (Sallinen et al. 2019)
• This challenge to masculinity can affect men’s mental health. Male primary care patients with vertebral fractures (associated with older women) have been found to be at increased risk of self-harm compared to matched patients without fractures. However, it should also be noted that men with increased fracture risk also often have additional risk factors such as steroid use and smoking (Prior et al., 2021).
• Internal and/or external pressure to perform the protector and provider role in the family can cause men to feel they have no choice but to push through the pain and continue working to fulfill the breadwinner role (Flurey et al, 2017)

Help-Seeking Behaviours

• There is no consistent evidence of men seeking help for pain less than women in both everyday pains, such as back pain and headaches (Hunt et al., 2011), or for early symptoms of serious conditions, such as cancer (Wang et al., 2014). However, gender differences may exist in the reasons for delaying help-seeking.
• Traditional masculine role norms are associated with reduced help-seeking behaviors for health concerns (Leone et al. 2017), specifically in pain (Keogh & Boerner, 2020).
• Men with fibromyalgia-type pain have reported being “afraid of being looked upon as a whiner” and, therefore, putting up with a large amount of pain before seeking help. Some men continued working to the point they collapsed and were hospitalized (Paulson et al., 2002).
• Masculine norms in some cultures may emphasize the expectation for men to resist seeking help for pain until it can no longer be avoided. Interviews with Aboriginal Australian men described a culture of staying ‘strong and silent’ in the face of illness and managing their own health without medical assistance for as long as possible (Newman et al., 2017)
• Other barriers to help-seeking for men include embarrassment, anxiety, distress, or fear of using healthcare services (Yousaf et al., 2013).
• Men are described as using more avoidance-focused pain coping approaches (Racine et al. 2015), and are more likely to use alcohol to cope with pain (Riley & King, 2009). Such coping styles may begin earlier in development; a preference for distraction-focused pain coping is also observed in boys (Keogh & Eccleston, 2006; Lynch et al., 2007).

Socio-cultural/Intersectional Considerations​

• Masculinity is a social construct. This means that how masculinity is understood, experienced, and expressed differs across societies, cultures, and generations (Lease et al. 2013).
• Understanding how masculine gender identity, roles, and expressions influence pain must also consider other identities and social positions the individual experiences.
• It may be particularly important for Black men to present themselves as strong and invulnerable to pain – both to live up to masculine values within their own communities and to avoid being perceived as an easy target for racially motivated aggression (Campbell & Mobray, 2016).
• Cultural memory of historic unethical experiments can lead to mistrust of medical professionals amongst marginalized groups, which can affect their experiences of healthcare and willingness to seek help.
• Additionally, both explicit and implicit bias still exist in healthcare through inadequate care and dismissal of symptoms or suffering, a lack of respect, or a lack of power to negotiate in healthcare interactions. Some healthcare staff stereotype minoritised ethnic groups, characterising them as ‘irrational, difficult, frustrating, emotional, or dramatic’. Minoritised groups can also receive inadequate support for treatment choices such as pain medications. This can result in a loss of trust in healthcare, higher unmet needs, and subsequent delays in help-seeking (Hamed et al., 2022).
• Some men experience direct discrimination due to their sexuality. Men who have sex with men in Rwanda described discrimination and humiliation (“They told me to go home and repent because I’m a sinner” (Isano et al., 2023)). While such overt discrimination may be less common in Western countries, discriminatory behaviors or heteronormative assumptions from healthcare professionals can still cause reluctance to disclose their sexual orientation or gender identity to health professionals and affect their care. For example, a man with prostate cancer described delaying surgery until he found a surgeon willing to perform nerve-sparing surgery (Doran et al., 2018).

Summary

Both biological and social factors contribute to men and boy’s experience and expression of pain over development. Constructions of masculinity play a key role in pain behaviors regardless of sex, and the impact painful conditions can have on men’s mental wellbeing. While there is no consistent evidence that men are poorer at seeking medical help for painful conditions than women, there are gender differences in the motivations and barriers to help-seeking, which require different interventional approaches. Men are not a homogenous group, and the socio-cultural context cannot be ignored, with some cultures placing more emphasis on subscribing to masculine norms than others. Additionally, men from marginalized groups may face additional barriers to accessing and benefitting from support for painful conditions.