Volume X, No.

5 December 2002

Culture and Pain

A recent issue of Pain: Clinical Updates addressed questions related to ethnicity and
pain.1 This issue highlights distinctions between race, culture, and ethnicity and reviews
research on how these three factors interact to shape the experience of pain and its
treatment. The value of narrative analysis - and of qualitative research in general - is
emphasized.

Pain as a Biopsychosocial Phenomenon

The experience of pain is as old as recorded history. The ways in which people
conceptualize and treat pain have varied, however, across space and time. Historian
Roselyn Rey suggests that nociception reflects anatomy and physiology, but cultural and
social factors are the foundation for the expression and treatment of pain.2 The broad
sociopolitical context of pain has changed in the past two decades worldwide. Ministries
in many countries, the World Health Organization, the International Association for the
Study of Pain, and more recently foundations, advocacy groups, and the (U.S.) Joint
Commission for the Accreditation of Healthcare Organizations (JCAHO) have urged a
proactive approach to pain control.3 They have emphasized the notion that pain is a
biopsychosocial phenomenon that often requires interdisciplinary care. Research on the
biology and neurobiology of pain has given us new ways to think about and manage pain,
and is paralleled by research into the cultural, psychological, and social factors related to
the experience of pain and its expression, behavioral responses, health care seeking, and
receptivity to and adherence to treatment.

A Personal Perspective

In 1992–1995, the U.S. National Cancer Institute (NCI) funded the Boston Cancer Pain
Education Program (BCPEP). With its entourage of oncology nurse specialists, an
oncologist, interpreters, research assistants, and a sociologist, BCPEP marshaled the
support of hospitals, home health care agencies, and hospices in the Boston area to
address the undertreatment of cancer pain in patients from diverse cultural groups.
BCPEP educated 500 home care, hospital, and hospice nurses. In addition, it collaborated
with community representatives to develop culturally sensitive and linguistically
appropriate cancer pain education booklets for patients and families from 11 different
ethnic groups in 11 different languages.4-7 The Massachusetts Division of the American
Cancer Society (ACS) and BCPEP distributed thousands of these booklets, written at the
fourth-grade reading level, with a pain scale and a pain diary and suggestions for the use
of pharmacological and nonpharmacological pain treatments. Their enthusiastic reception
prompted the ACS to update the booklets in 2002 and post the information on a Web site
for health care workers to download for low-literacy white, African American, Latino,
Haitian, Chinese, Portuguese, Italian, Russian, Vietnamese, Laotian, and Cambodian
cancer patients.8 Generic rather than cancer pain-specific versions of these booklets are
available in Chinese, Japanese, and Spanish.

NCI continued its support by funding the Cancer Education Module for the Management
of Pain (CEMMP) program from 1995 through 2001. Our group expanded to include a
pain clinician (Daniel Carr), a problem-based learning expert (Phil Daoust), and faculty
and deans of two medical and three nursing schools. Our objective was to integrate a
cancer pain education module into the curricula of these schools. Through the CEMMP
curriculum, which addressed cultural diversity in the management of pain, I became
acquainted with issues surrounding cancer and pain for Penobscot Indian and French
Canadian patients. 9,10 In 2001, we assembled a Japanese-American focus group and
developed a cancer pain booklet for Japanese-American patients and their families.8

Because of my work in cancer and pain with 14 different ethnic groups, almost weekly I
am asked to deliver or attend a talk for health care professionals on the cultural factors
related to pain or palliative care. This demand reflects a true need of clinicians
increasingly offering treatment to immigrants who often cannot speak English and who
identify with the culture of their country of origin.

Challenges to Clinicians

Pain assessment and management can be difficult in monocultural interactions between

clinicians and patients because of differences in perspective between Western
biomedicine and lay health beliefs and practices. The design and assessment of effective
health care for culturally diverse patients, both long-term residents and new immigrants
and refugees, is even more complicated. New immigrants increasingly come to the
United States from regions such as Southeast Asia and Latin America and are even more
heterogeneous than their European predecessors.5,11 Within the same ethnic group,
individuals come from all walks of life with differing educational, occupational, and
economic status, ties to the mother country, and geographical background. All these
factors affect their ethnic identity and their cultural responses to health and illness. To
understand patients and control their pain in a health care system with an imperative for
efficiency and cost-cutting, amidst continual demographic change, can be an
overwhelming challenge.

When clinicians look to published research to acquaint themselves with the ways in
which ethnicity or culture may impinge upon the experience of pain, its expression, pain
behaviors, or coping responses, they find a vast array of disciplinary lenses, diverse
theoretical approaches that are often not made explicit, inconsistent findings, and
methodological weaknesses. Upon closer reading, however, one can see that varied
disciplines are starting to speak to each other and that a biological and social model of
pain is attainable.

Distinguishing Race, Ethnicity, and Culture

The terms "race," "ethnicity," and "culture" are often used interchangeably but represent
very different concepts. Prior to the early 1980s most definitions of "race" used in the
social sciences were biologically oriented and did not question the validity of the concept
itself.12 Starting in the mid-1980s, "race" increasingly began to be considered an
unscientific term as researchers found "no biological criteria that can be universally
applied to assign persons to specific racial groups."12 Although the scientific community
has increasingly recognized that "race" is a social construct, definitions of "race" in
biomedical sciences and public health continue to identify it with genetic
homogeneity,13,14 although some criticize the use of "race" in this context.15,16 Others
argue for the continued use of "racial" categories to examine the incidence, prevalence,
and mortality rates of conditions and diseases and health care utilization. Such usage
alerts us to disparities in health in subgroups of the population, and to racism and
institutionalized discrimination in society12 and in the delivery of health care services.

Ethnicity, derived from a Greek word meaning "tribe," connotes a group of people within
a larger society who share a common ancestral origin or social background, culture, and
traditions that are maintained between generations and provide a sense of identity.12,17 In
addition, members of an ethnic group generally have a common language and religious
tradition.17 Ethnicity can change over time and place.1 Most students of ethnicity view
self-identification as the most valid method to assign ethnic identity.

"Culture" usually refers to behavioral and attitudinal norms in addition to systems of

meaning. Culture shapes illness beliefs and behaviors, health care practices, help-seeking
activities, and receptivity to medical care interventions.18-24 Western-trained clinicians
may view the medical care system as technologically sophisticated and helpful in the
curing process. Patients, though, may fear hospitals as places to die or distrust a routine
blood test because of a belief that retaining all one’s blood is necessary to assure the
wholeness of the body. Patients may perceive a battery of tests as an inadequate
substitute for attention from the doctor, or view treatments as unhelpful because they feel
the root cause of the illness is not being addressed. Cultural factors related to the pain
experience include pain expression, pain language, lay remedies for pain, social roles and
expectations, and perceptions of the medical care system.

Race, Ethnicity, and the Treatment of Pain

Race has been an especially important factor in the experience and treatment of pain in
the history of the United States. Abolitionists’ narratives about the pain and cruelty
suffered by slaves played an important role in extending the broad culture of individual
rights that ultimately included the right to health and health care, and most recently, pain
care. It was widely believed in the 19th century that racial groups varied in their
physiological experiences to pain, with women, whites, and the rich being more sensitive
to pain than African Americans, criminals, and Native Americans, who were seen as
"virtually impervious to physical trauma."25 Indeed, a medical term was coined,
"dysaesthesia Aethiopsis" or "an obtuse sensibility of body," to describe the genetic
insensitivity to pain attributed to those of African descent.25

Increasingly, studies are reporting that minorities remain at risk for inadequate pain
control.26-30 For example, African Americans with extremity fractures were less likely
than white patients to receive emergency department analgesics, even with similar pain
complaints and after controlling for time of day and other factors.31 Patients seen at
centers that treat predominantly minorities were three times more likely than those treated
elsewhere to have inadequate cancer pain management.32 Similarly, Asian patients
received a 24% lower dose of analgesics postoperatively and had a lower mean
meperidine consumption compared with European patients.33 However, when patient-
controlled analgesia is used, Asian and Caucasian patients self-administer similar
amounts of opioids for postoperative pain.34 Interestingly, a Colombian study found
native Indians to be more prone to morphine-induced respiratory depression than
Caucasians.35 A study of 250 consecutive patients hospitalized for open reduction and
internal fixation of limb fracture found significant differences in analgesics prescribed,
with whites receiving 22 mg of morphine equivalents per day, Hispanics 13 mg/day, and
blacks 6 mg/day, even after controlling for other variables.36 While intriguing and
deserving of further research, most such studies are retrospective chart reviews with their
attendant limitations, have small sample populations, and use varying definitions of
"ethnicity."

When interpreting these studies it is difficult to know whether their findings are due to
variations in the experience of pain, in pain behavior, or in staff perception and treatment
of patients’ pain. Recent evidence suggests that the most important variable in the
undertreatment of minority pain may be differences in staff perception of patients’ pain
intensity, which may be based on myth, lack of empathy, stigma, or outright
discrimination. The treatment of a patient may be related to the ethnicity of the clinician.
Harrison and colleagues found, for example, that in a sample of 50 hospitalized patients
who received care from Arabic-speaking and non-Arabic-speaking nurses, only nurses
sharing the patient’s language gave pain ratings that were comparable to those of the
patients.37,38

Ethnic Differences in Pain Perception and Pain Response

In medical and public health as well as in the pain literature, "ethnicity" signifies group
membership. Classic studies on pain and group membership have described how ethnic
norms for appropriate pain behavior influence pain perception, interpretation, and
response.39-41 Laboratory studies have not produced consistent results on the relationship
between ethnicity and pain. If, as some studies have reported, physiological pain
thresholds do not vary substantially according to ethnicity, this gives us pause as to why
differing amounts of analgesics are ordered.42
Clinical studies do report ethnic differences in pain perception and response. For
example, Carragee and colleagues compared patients who had fixation of femoral
fractures within 1 week of injury in two U.S. hospitals with a matched group of patients
in three urban hospitals in Vietnam. Over a 15-day period, the Vietnamese patients were
given, on average, 0.9 mg of morphine equivalent units as compared to 30.2 mg given to
those in the United States. Interestingly, only 8% of the Vietnamese patients reported that
their pain control had been inadequate, whereas 80% of the American patients did so. In
addition, Vietnamese patients were more likely to have an accurate impression of how
much a femur fracture would hurt prior to the injury than did U.S. patients (76% vs. 4%,
respectively).43 Chaturvedi and colleagues found that when they presented a case scenario
to a randomly selected group of patients, there were no differences between European,
Hindu, and Sikh patients in identifying pain as cardiac in origin or in perceiving the need
to seek immediate care; however, South Asians tended to be more anxious about pain
than were Europeans.28 Faucett and colleagues found that Europeans reported less severe
postoperative pain than did black American or Latino patients.44

Jordan and colleagues found no significant differences in pain severity or negative affect
when they compared African American and Caucasian women with arthritis; however,
African Americans in this study tended to be less active.45 African Americans with
rheumatoid arthritis used more coping techniques that employed distraction, praying, or
hoping, while Caucasians used more techniques that involved ignoring pain.45

Mediators of Ethnic Variation in Pain

There are differences within cultural and ethnic groups as well as between them.19,22,46-48
Several factors affect how closely an individual identifies with his or her ethnic or
cultural group.49 These include gender, age, generation, level of acculturation,
socioeconomic status (including income, occupation, and education), level of ties to the
mother country, primary language spoken at home, degree of isolation of the individual,
and residence in neighborhoods made up of one’s ethnic group. These factors may
mediate the relationship between ethnic background and pain. For example, only female
Italian American outpatients older than 60 tended to report pain more than Anglo-
American patients.50 Similarly, Neumann and Buskila found that only the older subjects
showed significant differences in pain perception in two groups (70 Sephardic and 30
Ashkenazic) of female Israeli patients with fibromyalgia.51 Lipton and Marbach, using a
35-item scale to measure patients’ pain experience, found no significant differences
between black, Irish, Italian, Jewish, and Puerto Rican facial pain patients.52 They did,
however, find interethnic differences in emotionality (stoicism versus expressiveness) in
response to pain and in pain’s interference with daily functioning. In addition, they found
that degree of medical acculturation for black patients, degree of social assimilation for
Irish patients, duration of pain for Italian patients, and level of psychological distress for
Jewish and Puerto Rican patients mediated the pain responses of these groups.

Ethnic Differences in Responses to Pain Questionnaires

Researchers have asked whether ethnicity and culture affect the expression of pain or the
words used to describe it. When the McGill Pain Questionnaire (MPQ) was administered
to Hispanics, American Indians, blacks, and whites, all groups distinguished "pain" from
"ache" and "hurt," with "pain" rated as the most intense descriptor.53 In a study validating
the Brief Pain Inventory (BPI), the Taiwanese version of the BPI was only valid for adult
patients with high education levels or for patients at an early stage of disease.54 The BPI
was also found to be a reliable measure of pain and its impact on Hindi-speaking patients
with cancer.55 The authors stressed the need to validate the BPI in the many other
languages spoken in India.55 A study of patients treated for cancer pain using graphic
rating scales and the MPQ found no significant ethnic differences in measures of pain
sensation, but did find differences in the affective subscales of the MPQ.56 Most of the
patients in this study were fairly well acculturated into mainstream American society and
had similar stages of cancer.

Narrative, Culture, and Pain

Culture is a broad concept, and studies and essays on the relationships between culture
and pain tend to be of two main genres—culture of pain and culture in pain. The first
genre describes the ways in which society shapes the meaning and treatment of pain. The
second addresses the ways in which culture molds individuals’ perception and expression
of pain, and their coping response, behaviors, and the meanings they ascribe to pain.
Studies of ethnicity, race, or "cultural groups" and pain at best can be considered marker
studies. Belonging to a particular ethnic group makes an individual respond to pain
differently, or receive different pain treatment, but how this happens is still unclear. The
recent increase in funding for the study of sociocultural factors related to medical
conditions in general and pain in particular may allow researchers to overcome some of
the methodological limitations of earlier studies. We still may be left, however, not quite
knowing why we obtained the findings we did. Here is precisely where we can turn to
qualitative methods to examine the ways in which culture relates to pain.

Several qualitative researchers have examined pain narratives.57-59 The importance of talk
as the primary medium through which social interaction takes place is increasingly
recognized.60 Decades of work on patient-physician interactions, for example, use talk as
the primary data. It is not surprising, given this body of insightful work, that researchers
from many disciplines are now examining the ways in which individuals tell their pain
stories. Currently, the use of narratives in pain studies falls, if not neatly, into the
following categories: narratives as therapy, narratives as empathy builders, narratives as
advocacy, and narratives as windows into the meaning pain holds for individuals.

Kelley and Park, for example, relate how they used narrative approaches in group social
work with fibromyalgia sufferers, and found that such approaches helped participants to
cope and maintain identities other than as chronic pain patients.61 Ramphele displays the
power of narrative as a tool for advocacy in her story of a South African widow sharing
her pain, broadly defined, using her "political family" (the political group to which her
husband belonged) to empower her.62 We have many stories closer to home that have
been used by advocates for better pain control. From a meanings perspective, Kelley
found through analysis of transcripts of fibromyalgia patients’ group sessions and
personal journals that loss of personal identity except that of being a patient was a major
theme.63 The cultural surround of the pain experience—narratives or stories that privilege
us to grasp the meanings of pain, disease, life, and death—tells us much about what
individuals in pain are experiencing and how we can help them.64 Narratives also
illuminate concepts of what constitutes health care and what are appropriate gender, age,
and familial roles of individuals from other coexisting cultures.

Rigorous, qualitative research on the ways in which culture shapes pain, in the Western
biomedical sense of the word, is limited. Quantitative research on the relationships
between ethnicity, culture, race, and pain as mentioned above has been more plentiful,
but such research raises as many questions as it answers. These are exciting times for
clinicians or researchers working with patients who come from cultures other than their
own. We have much to learn about pain and about ourselves.

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Kathryn E. Lasch, PhD, MSSW

750 Washington Street, Box 345
New England Medical Center
Boston, MA 02111, USA
Tel: 617-636-4589; Fax: 617-636-0525
klasch@lifespan.org

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mechanisms and pain syndromes, and to help improve the care of patients with acute and
chronic pain. IASP brings together scientists, physicians, dentists, nurses, psychologists, physical
therapists, and other health professionals who have an interest in pain research and treatment.
Information about membership, books, meetings, etc., is available from the address below or on
this IASP web page: www.iasp-pain.org. Other free copies of back issues of the Pain: Clinical
Updates newsletter are available on the IASP web page.
Disclaimer: Timely topics in pain research and treatment have been selected for publication but
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Copyright © 2002, International Association for the Study of Pain®.

All rights reserved. ISSN 1083-0707.