As a physician, I aim to provide the best medical care and alleviate suffering. Navigating medicine in a complex, gender-biased environment, I have moments of regret. In my days of ignorance, I remembered jotting down ‘psychogenic chest pain’ on a clerking sheet having not found any identifiable cause for her persistent chest pains. Mrs. N’s monthly hospital admissions gained her notoriety among the cardiologists and most would groan in dismay being asked to see her. That day, her cardiac markers were within the normal limits and her electrocardiogram did not show any peculiarities that warrant further investigation. Following a discussion with the cardiologist, I headed back to Mrs. N. I am not proud of what I had written on her clerking sheet, but at least, I told her the truth, “I do not know the cause of your chest pain, but you can be rest assured it is not due to life-threatening diseases such as a heart attack or a clot in your lung, that could cause your early demise.” I ended the consultation by also telling her to not hesitate to come back to the hospital should she experience further chest pains. Mrs. N thanked me for my honesty and for not dismissing her pain.
I do not believe that most people enjoy calling the ambulance and arriving in the hospital to be dismissed by the on-call physicians every month. Waiting long hours in the Emergency Department is not exactly anyone’s or Mrs. N’s definition of a good night out.
Why are we so quick to psychologise what we do not know? Women already have a history of not being believed. In many instances, women’s pain experience is too often ascribed to women’s catastrophising attitudes (Samulowitz, Gremyr, Eriksson, & Hensing, 2018), despite women experiencing enhanced pain sensitivity from most forms of experimentally induced pain (mechanical, electrical, thermal, ischemic, chemical) (Pieretti et al., 2016), higher pain levels following intramuscular injection of glutamate and hypertonic saline (non-analgesic substances), and experience pain longer (Fillingim, King, Ribeiro-Dasilva, Rahim-Williams, & Riley, 2009). Undeniably, social and cultural factors influence how pain is experienced in that boys are taught to toughen up and girls taught to seek help (Myers, Riley, & Robinson, 2003) which further entrenches unhelpful gender stereotypes. Sadly, women who sought pain relief do not get pain relief and are labelled ‘hysterical’ and ‘emotional’ because they are believed to be exaggerating their pain while men get pain relief possibly after an acceptable period of time trying to imagine the pain away, because these men are seen as ‘brave’ (Samulowitz et al., 2018). In 1990, Calderone reported the higher frequency of sedatives prescribed to women versus the higher frequency of pain relief prescribed to men post-cardiac surgery. Not much has changed since then. This damaging gender pain stereotypes account for the 13-25% of women who were less likely to receive opioid analgesia and the longer duration of wait for analgesia compared to men for the treatment of acute abdominal pain in an emergency department (Chen et al., 2008). One of the reasons it takes 6-12 (Nnoaham et al., 2011) years for endometriosis, a common gynaecological condition affecting 1 in 10 women (Zondervan et al., 2018) worldwide, to be diagnosed is the normalisation of menstrual pain in our society. Accounting for racial factors, sadly, the false belief that Black people experience less pain compared to whites is an idea that still persists among medical professionals in the 21st century (Hoffman, Trawalter, Axt, & Oliver, 2016).
When standard laboratory tests are within the normal range, is there truly ‘nothing wrong’? Should positive psychology be the first-line treatment for symptomatic women with normal laboratory tests? An alternative explanation would be that the standard laboratory tests were unable to measure the abnormalities caused by the disease. Mrs. N is an example of a patient diagnosed with Medically Unexplained Symptoms (MUS). MUS is supposed to be a diagnosis of exclusion after all possible, necessary investigations have been exhausted, however, a female patient presenting with back pain is more likely to be diagnosed with MUS compared to a male patient presenting with the same complaint (Claréus & Renström, 2019). Compared to men, women are three times more likely to be diagnosed with MUS (Schaefert et al., 2012) especially when psychological factors coexist (Chiaramonte & Friend, 2006). The MUS diagnosis prevents further investigations to be explored (Claréus & Renström, 2019). For example, after a decade of being diagnosed with myalgic encephalomyelitis, another disease under the MUS banner, a patient was finally diagnosed with non-dilated cardiomyopathy with echocardiogram and cardiac MRI (magnetic resonance imaging) following my encouragement to pursue a formal diagnosis of postural orthostatic tachycardia syndrome. Indeed, the MUS label prevented the patient’s decade-long chest pains and severe postural light-headedness to be taken seriously. With all these problems, is it right for UK’s NICE (National Institute for Health & Care Excellence) to produce a guideline recommending psychological treatment and anti-depressants for chronic pain? While care is taken to look at the best available scientific evidence, has anyone cared to look at potential biases on how patients are diagnosed?
The stigma associated with MUS must not be underestimated. Derogatory terms such as ‘frequent flyers’, ‘thick folder patients’ are common monikers for these patients and unfortunately, the medical profession is responsible for the propagation of this stigma. This uninspiring narrative prevents the best medical care that these patients deserve (Greco, 2012).
I cannot stress enough that patients find the terms ‘psychogenic’ (Ding & Kanaan, 2017) or ‘MUS’ offensive (Marks & Hunter, 2014) as the terms are seen to imply that the symptoms they are experiencing are fictitious in which a psychiatric or psychological treatment would be first choice. The term MUS further propagates the dualistic view of the mind and body – in which if the disease cannot be proven to originate from the body, it must be from the mind (Marks & Hunter, 2014). More acceptable terms are ‘Persistent Physical Symptoms’ and ‘Functional Symptoms’ (Marks & Hunter, 2014; Ding & Kanaan, 2017) as it says exactly what it is on the tin and does not try to assign a psychological cause to the symptoms.
To me, I would rather say “I do not know” than blaming the unruly subconscious of the patient, which, by the way, cannot be demonstrated by any tests.
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Calderone, K. L. (1990). The influence of gender on the frequency of pain and sedative medication administered to postoperative patients. Sex Roles, 23(11), 713–725. https://doi.org/10.1007/BF00289259
Chen, E. H., Shofer, F. S., Dean, A. J., Hollander, J. E., Baxt, W. G., Robey, J. L., … Mills, A. M. (2008). Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain. Academic Emergency Medicine, 15(5), 414–418. https://doi.org/10.1111/j.1553-2712.2008.00100.x
Chiaramonte, G. R., & Friend, R. (2006). Medical students’ and residents’ gender bias in the diagnosis, treatment, and interpretation of coronary heart disease symptoms. Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association, 25(3), 255–266. https://doi.org/10.1037/0278-6220.127.116.11
Claréus, B., & Renström, E. A. (2019). Physicians’ gender bias in the diagnostic assessment of medically unexplained symptoms and its effect on patient-physician relations. Scandinavian Journal of Psychology, 60(4), 338–347. https://doi.org/10.1111/sjop.12545
Ding, J. M., & Kanaan, R. A. A. (2017). Conversion disorder: A systematic review of current terminology. General Hospital Psychiatry, 45, 51–55. https://doi.org/10.1016/j.genhosppsych.2016.12.009
Fillingim, R. B., King, C. D., Ribeiro-Dasilva, M. C., Rahim-Williams, B., & Riley, J. L. 3rd. (2009). Sex, gender, and pain: a review of recent clinical and experimental findings. The Journal of Pain, 10(5), 447–485. https://doi.org/10.1016/j.jpain.2008.12.001
Greco, M. (2012). The classification and nomenclature of “medically unexplained symptoms”: conflict, performativity and critique. Social Science & Medicine (1982), 75(12), 2362–2369. https://doi.org/10.1016/j.socscimed.2012.09.010
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113
Marks, E. M., & Hunter, M. S. (2014). Medically Unexplained Symptoms: an acceptable term? British Journal of Pain, 9(2), 109–114. https://doi.org/10.1177/2049463714535372
Myers, C. D., Riley, J. L. 3rd, & Robinson, M. E. (2003). Psychosocial contributions to sex-correlated differences in pain. The Clinical Journal of Pain, 19(4), 225–232. https://doi.org/10.1097/00002508-200307000-00005
Nnoaham, K. E., Hummelshoj, L., Webster, P., D’Hooghe, T., de Cicco Nardone, F., de Cicco Nardone, C., … World Endometriosis Research Foundation Global Study of Women’s Health consortium. (2011). Reprint of: Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertility and Sterility, 96(2), 366-373.e8. https://doi.org/10.1016/j.fertnstert.2019.08.082
Pieretti, S., Di Giannuario, A., Di Giovannandrea, R., Marzoli, F., Piccaro, G., Minosi, P., & Aloisi, A. M. (2016). Gender differences in pain and its relief. Annali Dell’Istituto Superiore Di Sanita, 52(2), 184–189. https://doi.org/10.4415/ANN_16_02_09
Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management, 2018, 1–14. https://doi.org/10.1155/2018/6358624
Schaefert, R., Hausteiner-Wiehle, C., Häuser, W., Ronel, J., Herrmann, M., & Henningsen, P. (2012). Non-specific, functional, and somatoform bodily complaints. Deutsches Arzteblatt International, 109(47), 803–813. https://doi.org/10.3238/arztebl.2012.0803
Zondervan, K. T., Becker, C. M., Koga, K., Missmer, S. A., Taylor, R. N., & Viganò, P. (2018). Endometriosis. Nature Reviews Disease Primers, 4(1), 9. https://doi.org/10.1038/s41572-018-0008-5