The Intersection of Pain and Culture ____________________________________________________________
Alternatively, gate control theory has been used to explain the link between culture and pain. According to this theory, pain is not merely a physiologic response to tissue damage; rather, reactions to pain are based on expectations and perceptions stored in one’s memory [2; 122; 124; 126; 128; 129; 130]. Biologically, pain is moderated by a gating mechanism whereby cells block pain in the nervous system. Messages are sent to the brain to “open” or “close” these blocking mechanisms, and cultural memories can affect whether the pain impulses reach the brain [2]. PAIN EXPECTANCY AND ACCEPTANCE There are two main aspects of pain experience: expectancy and acceptance [48]. Pain expectancy refers to an individual’s expectation or anticipation of pain as inevitable and/or inescapable [48]. The inherent degree of pain expectancy will vary from individual to individual. Pain acceptance is an individual’s attitude toward pain—the extent one is willing and able to handle and endure pain [48]. Cultural beliefs and norms can influence both pain expectancy and acceptance, as evidenced by studies illustrating differences in pain perception and tolerance in various racial/ethnical groups. In general, research indicates that African Americans tend to experience pain more intensely and tolerate pain less than their White counterparts [137]. In one study, African American college students rated thermal pain stimuli more unpleasant compared with their White counterparts, but the underlying mechanisms to explain these racial differences are unclear [49]. Another experimental study found that African American women were more sensitive to pain compared to their White counterparts [159]. Some studies have shown that, compared with children from other racial groups, African American children require higher doses of morphine to alleviate pain [137]. These differences may be due to genetic differences in CYP450 2D6 pathway, which is responsible for metabolizing opioids [137]. An experimental study was conducted to examine the extent to which ethnic identity predicts pain sensitivity to three differ- ent types of pain—thermal, cold, and ischemic—among African American, Hispanic, and non-Hispanic White adults [50]. The researchers found that African American and Hispanic participants demonstrated lower tolerance to cold and heat pain compared to their White counterparts. The researchers suggest that chronic stress, socialization in exhibiting pain, and acculturation could all play a role in explaining such ethnic differences [50]. In a study that compared pain levels of Latino and White adults, a pain stimulus was administered (i.e., a blood pres- sure cuff was inflated and held for three minutes). In general, Latinos reported greater pain compared to their White coun- terparts [138]. A separate study examined the role of accultura- tion on pain perception in a sample of undergraduate Asian American and White students [51]. Research participants were engaged in a cold pressor task (immersing their non-dominant
hand in a cold-water bath for as long as tolerable) to trigger acute pain. Pain response was higher for first-generation Asian Americans, who removed their hands earlier than other study participants, demonstrating lower pain tolerance. This find- ing was replicated in a 2018 study that found higher levels of acculturation among Asian American participants correlated with greater heat pain tolerance [160]. Again, it was speculated that acculturative stress and chronic stress pertaining to immi- gration (including experiences with discrimination and racism) made this group more sensitive to pain [51]. This sensitivity could be triggered by physiologic exhaustion and reduced coping mechanisms resulting from such chronic stress [51]. Differences in pain acceptance or tolerance may also be explained by how likely individuals are to report pain. Some cultural groups may be less likely to disclose pain because they do not want pain medication or because they fear stigmatiza- tion [194]. Others adhere to a more holistic view of health, whereby pain is a symptom of an imbalance of physical, social, emotional, and spiritual factors. Differences can also be accounted for by implicit or explicit biases regarding some patient groups. For example, a study of medical students found that they attributed a perceived higher tolerance to pain among Black patients to less-sensitive nerve endings; some thought it was due to their thicker skin compared to White patients [195]. LANGUAGE USED TO EXPRESS PAIN The terms used to describe pain are also influenced by culture. Women tend to use more expressive language when communi- cating pain, tending to use words such as “throbbing,” “sharp,” and “stabbing” [161]. Men tend to use less expressive language, perhaps due to cultural norms supporting stoicism for men. For example, in a study with Somali women, the participants used the same word to describe a host of painful circumstances ranging from cuts and fevers to childbirth, because the Somali term xanuun means both pain and illness [52]. In another study, terms such as “pain,” “ache,” and “hurt” were used by Hispanics, Native Americans, African Americans, and White Americans to refer to painful events or conditions [53]. How- ever, the terms conveyed a different level of pain severity and intensity depending on the race/ethnicity of the subject. In a study conducted to explore racial differences in descriptors employed by African American and White American patients who had experienced myocardial infarction, African Americans were more likely to use “atypical” descriptions for their pain, such as “sharp” or “miseries” [54; 55]. One study found that older African Americans tended not to use the word “pain,” as this term is reserved for severe discomfort, and instead used the terms “hurt” or “sore” [16]. More bothersome pain was described as “nagging” or “miserable.” Similarly, the Hmong language does not have a word for “pain,” so they use the word “hurt” because it is the closest in translation [196]. In another study, healthcare practitioners reported that Hmong patients employed minimal or no descriptors or adjectives for their pain, making it difficult for practitioners to evaluate pain intensity [197].
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