The meanings of pain: an exploration of women's descriptions of symptoms

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Abstract

A grounded theory study with repeated semi-structured interviews was conducted to explore the meaning of the illness experiences of women patients, impaired by biomedically undefined musculoskeletal pain. Twenty female patients were recruited at an urban primary health care centre in northern Sweden, where two of the researchers work as family physicians. In this paper we focus on considerations of patient pain and analyze the findings from aspects linking together body, gender, and society.

Four categories of symptom description were identified: bodily presentations, explanatory models, consequences of pain for the patient's activities, and consequences for her self-perception. The bodily symptoms signaled loss of control. The explanatory models consisted of physical damage and strain injuries, but were also psychological and self-blaming. The consequences of pain were described as negative consequences for the women's everyday life that challenged their self-perception as women. The participants' search and need for legitimization of their illness experiences, and the expectations placed on doctors as legitimizing agents was evident. To achieve the desired shared understanding in consultations, doctors must be aware of and consider not only physical signs and symptoms, but also the patients' gendered concerns and psycho-social circumstances.

Introduction

The experience of pain lies at the intersection of biology and culture Kern, 1987, Morris, 1991. Part of the problem in pain management is that scientific medicine has reduced the experience of pain to `an elaborate broadcasting system of signals, rather than seeing it as molded and shaped by the individual and their particular socio-cultural context' (Bendelow and Williams, 1995). The `medicalization' of pain has resulted in a split between body and mind.

The problem of medical knowledge appears when making pain operational. The main difficulty is that it is a person's private experience, to which no one else has direct access. Physicians shape their pain theories `by constructs, by intellectual categories that both depend on but also generate the codes for perceiving illness' (Baszanger, 1992). Baszanger describes two poles of pain management; one aiming at `curing through techniques', the other at `healing through adaptation'. These poles of pain-managing attitudes are also recognized in consultation research. In the `doctor-oriented approach' disease and biomedical skills are significant, and in the `patient-oriented approach' the patient's experiences, expectations and worries are the focus Byrne and Long, 1976, Pendleton et al., 1984, Tuckett et al., 1985. There is consensus in family medicine that the patient-oriented approach is preferable. It results in more patient satisfaction, compliance, and improved health Bass et al., 1986, Stewart et al., 1989.

Pain is widely recognized as a complex phenomenon. Nevertheless, medical models often end up in reductionism and medico-centrism, since they look for expert explanations in biological facts (Armstrong, 1987). Baszanger showed that for physicians there was a hierarchy of explanation levels. A common view when concluding the results of investigations and consultation was to consider cellular pathology as `something', whereas illness-provoking, psycho-social circumstances were `nothing'.

Although pain is the experience of the sufferer the voice of the subject is often lost. There have been attempts to reclaim the experience of pain from exclusive biomedical jurisdiction. How pain beliefs are shaped in social interaction, and how emotions, perceptions of pain and social characteristics are embodied, has been focused on by social constructionists, anthropologists as well as phenomenologists Kern, 1987, Morris, 1991, Delvecchio Good et al., 1992, Turner, 1996. Kleinman asserts that illness for the individual always has a meaning (Kleinman, 1988), and Stacey expressed it: “People's ideas are logical and valid in their own right, although they may not be consonant with biomedical science or with any other organized healing system” (Stacey, 1988).

One way to examine these issues is by a qualitative exploration of the patients' own experiences. Illness narratives can give access to aspects of suffering that are obscured in biomedical curricula Kleinman, 1992b, Shapiro, 1993, Garro, 1994. The multidisciplinary approach, anthropological, sociological, psychological and philosophical attempts to understand pain, has bridged the gap between biology and culture. However, the impact of gender on pain is only beginning to be acknowledged in medicine (Bendelow, 1993).

In the feministic discourse there have also been tensions between biology and culture, objectivism and relativism, essentialism and constructivism. The separation of `sex' and `gender' served the purpose of moving away and distinguishing them from views which explained differences between the sexes and also social norms as biologically and physiologically caused, and `natural'. This distinction was problematic, and more recent theories conceive of gender as both biologically and socially constructed (Butler, 1993).

An individual's acknowledgment of being categorized in either sex has vast implications for personal self-perception and behavior, and `gender' is the accomplishment of social situations and doings, from early childhood and thereafter Davies, 1989, Jones, 1993. Gender is consciously, unconsciously and continuously performed in interactions between individuals in different social, cultural and political settings West and Zimmerman, 1987, West, 1993. For example, a female is sex classified according to her genes and reproductive organs. But for a woman performing her `gender', it is both her body, the organs, hormones, anatomy and the lived experiences that interact; her expectations and her response, accepting or challenging, at home, at work and among friends. Her adjustment to womanliness and motherhood depends not only on her hormones, but also on circumstances of up-bringing, media influences, social class, the labor market, insurance systems and the legislative system.

In most human societies there is a `gender order' implying that women are subordinated to men. It is overtly displayed for instance in statistics concerning income, position and power Doyal, 1995, Sainsbury, 1996, but it is also hidden and variable. For each individual, female as well as male, the lived experience shows how gender order is maintained, challenged, varied and/or changed. An individual might present and motivate certain behavior, as a matter of personal `free choice', but the choice can in fact be a result of restricted circumstances dependent on culture, or on class or political legislation.

Instead of seeing empirical sex/gender differences as proof of different anatomical or psychological characteristics, for instance lower pain thresholds in women, a gender perspective could give the analytic starting point for questions about why they appear (West, 1993). Bendelow contributed to the understanding of pain, gender, culture and embodiment in an interview study on pain endurance (Bendelow, 1993). It was shown that in `lay' understanding women were attributed superior capacities about enduring pain, often linked to their reproductive functioning. It is remarkable that women's great exposure to pain, for instance in birth labor, did not imply that women's pain experiences were to be acknowledged and taken seriously, but rather taken as a part of their `nature' and duty.

The patient's presentation of symptoms is of course the starting point for the diagnostic process in the consultation. The physician deals with ambiguous representations of experiences, in the presentation of a history, during the examination, and in the interpretation of laboratory tests and technical results. There is a selection process, a medical bias as well as a gender bias, involved in the information exchange Rudebeck, 1992, Salmon and May, 1995b, Hamberg et al., 1998b. One problem in the consultation is whether patient and doctor are talking about the same things and are sharing the same interpretative framework and conceptual worlds (Lunde, 1990).

Considering patients' perceptions a valuable source for understanding, we have interviewed a group of women and analyzed what they told us from a gender perspective. In a former paper we analyzed the consultation experiences and elucidated emotions of uncertainty and distrust. The physicians were perceived as masterful, and the women patients coped by using strategies such as somatizing, pleading, martyrizing, mystifying and condemning (Johansson et al., 1996). The analysis exposed a consultation arena framed by biomedical discourse, positional power and sex stereotypes.

The aim of this paper is to interpret the meaning in the women's descriptions of pain from a gender perspective. By letting the women talk freely in semi-structured interviews and by a qualitative analysis of the transcripts, the purpose has been to give voice to the everyday experiences of a group of women with biomedically undefined pain. We have explored the women's narratives, their experiences and expectations, and the theories they developed to account for their circumstances. We have tried to understand the beliefs about pain and how they are adopted in a societal context where sex segregation and inequalities are challenged.

Section snippets

Participants

Female patients visiting a health care center in northern Sweden and sick-listed

Symptom descriptions

Open coding of the transcripts led us to realize that the descriptions of pain were intertwined threads of recurring themes. When exploring the text we could divide the content into four main categories: `bodily presentations', `explanations', `consequences for daily work' and `consequences for self-perception'.

Discussion and analysis from a gender perspective

To sum up the findings, the women in this study described their pain by intertwining bodily presentations, explanatory models and negative consequences in their everyday life. The meaning of the bodily presentations — with the pain being a threat, unpredictable, deconstructive, invasive, alien and dispersed — was expressed as a `lack of control'. The explanatory ideas presented by the women designated them as `victims of an undiscovered disease', caused by repetitive strain injuries,

Acknowledgements

This study was supported by grants from the Swedish Council for Planning and Coordination of Research (Forskningsrådsnämnden) and the Umeå Medical District, County of Västerbotten, Sweden (Primärvårdens forsknings- och utvecklingsmedel).

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