One size fits… male?

Patient and doctor

‘Man-flu’ memes and the celebration of women’s endurance hide the reality that the medical world routinely downplays women’s pain and disease. Miriam Calleja takes a closer look.

We often hear that women are more tolerant to pain than men. Many are also proud of it. However, in the famous game-changing paper titled ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’ the authors Diane E. Hoffman and Anita J. Tarzian found that contrary to popular belief, women report more severe levels of pain, more frequent pain, and pain that lasts longer than men’s. Three Maltese women found out the hard way that confiding in medical practitioners does not always lead to help.

Culture and gender frame our behaviour around pain perception. Boys were, and some still are, told not to express pain by crying or showing emotion. Girls were told to calm down and not make a fuss. Pain meant weakness. Our language lacks the vocabulary to adequately describe pain. In ‘On Being Ill’, Virginia Woolf writes: ‘English which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache… The merest schoolgirl, when she falls in love, has Shakespeare and Keats to speak for her; but let the sufferer try to describe a pain in his head to a doctor and language at once runs dry.’

Gendering pain

By analysing a number of studies, Hoffman and Tarzian found that women are ‘more likely to be treated less aggressively in their initial encounters with the healthcare system until they prove that they are as sick as male patients.’ This is a phenomenon known as the Yentl Syndrome. In other words, doctors may brush female pain off as fabricated or exaggerated. This can impact diagnosis, disease progression, and treatment plans — delaying care and fueling mistrust.

Prescribing uterus removal when a woman was ‘rebellious’ may seem like ancient history, but that bias has not fully retreated. Until the early 1990s, women were mostly excluded from clinical research studies and trials in medicine. What we knew about the body, about disease, and about medicine was based on men. Drugs that didn’t work on men, but might have worked on women, were discarded. With incomplete data, the medical world may have lost opportunities to improve women’s health. Have today’s healthcare professionals been trained to counter this gender bias? 

Another doctor later referred Karen for an MRI, and the tumour was detected — a life or death analysis.

Antonia* doubts that. As a teenager she developed digestion problems and nausea every time she ate. When she complained, her family doctor downplayed the problem and suggested that she should just stop eating for a couple weeks. After this shocking response she ignored the issue for a long time, suffering in silence. Another doctor chalked it down to ‘growing pains’ and did not recommend a colonoscopy, even though Antonia asked for it.

Having received no satisfying response from her visits to medical professions, Antonia decided to do her own research, discovering that her symptoms matched the description of a condition called Crohn’s. Because of her constant discomfort and pain Antonia had no choice but to persist until she was granted testing and the correct treatment after years of suffering. This means that two doctors would have left her inflamed digestive system untreated, risking further damage.

Illustration by Gabriel Izzo

‘It is just a phase’

Women are often told that their ailments are due to stress or other emotional factors. A little rest would solve the problem; it is just a ‘phase’. Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests (see e.g. Samulowitz et al. 2018 study and numerous articles in the New York Times, The Atlantic and elsewhere). Thankfully, there are enough doctors who look beyond textbook-like symptoms. They make it a point to listen and investigate as much as necessary. Yet the burden of finding a practitioner ready to listen lies with the patient.

Karen visited her gynaecologist complaining of headaches and substantial weight gain. Test results revealed a high prolactin level, which is normally produced during pregnancy or right after giving birth. Yet when Karen asked to be referred for an MRI to investigate for tumours in the pituitary gland, the doctor refused, telling her that she was ‘making a fuss’. Another doctor later referred Karen for an MRI, and the tumour was detected — a life or death analysis. 

Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests.

Gynaecologists feature often when discussing gender bias. Without systematic training to counter biases, women are left to ‘shop around’ for a gynae that doesn’t shame them or belittle their wishes. This is surprising for a profession specialising in women’s health. 

Reproductive issues open another can of worms. Some women who decide not to have children are treated as though they don’t know what they’re doing. Their doctors imply that the patient will inevitably change their mind, or try to guilt the patient into considering the feelings of a hypothetical man they might meet.

You would think that commitment to bear biological children would be respected, but women who undergo IVF are often treated with insensitivity too. Sandra* and her husband had a harrowing story to tell me. Sandra’s gynaecologist decided to immediately hurry her to IVF after the first visit about their concerns at not being able to conceive. The gynaecologist was rarely present for her many appointments at hospital, leaving Sandra to be passed from one doctor to another, internally examined by various doctors without explanation or prior request for consent. With the exception of one doctor, none of them introduced themselves. All along she tried to ask questions, but was kept in the dark about the situation, going along with the doctors’ instructions but losing trust. The outcome of the first procedure was unsuccessful, and because of how traumatising all this felt, the couple decided not to try again.

Unlearning the bias

Pain is subjective and difficult to measure. An individual’s tolerance to pain is affected by various factors, and pain perception may change with time and experience. Pain causes distress, which makes it difficult to measure objectively. So how can overworked doctors make the best possible assessment?

In her thesis titled ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals’ (University of Malta, 2008), Maria Campbell studied pain perception in other healthcare professions in Malta back in 2008, finding out that outdated attitudes have not been challenged. She writes, ‘Incomplete knowledge, outdated attitudes, myths, and misconceptions about pain and its management contribute to unsafe, inadequate, and inappropriate pain management.’ Medical practitioners wanted to be more up-to-date: ‘The need for information in the form of leaflets, seminars, and continuing education was echoed in the overall answers (90%) of the close-ended question and in the statements declared by participants.’ But before this training becomes systemic, the radical act of listening to women is a good place to start. 

* Name has been changed

Further reading:

Fassler, J. ‘How Doctors Take Women’s Pain Less Seriously’. The Atlantic. October 2015.

Hoffman D.E., Tarzian, A.J. ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’. Journal of Law, Medicine & Ethics, Vol. 29, pp. 13-27, 2001.

Campbell, M. ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals.’ University of Malta. June 2008. 

Burnout

In airplane safety demonstrations, we are always told to put oxygen masks on ourselves before we help others. If we are not well, how can we help others efficiently? Dr Patrick Barbara writes about burnout among Malta’s mental health professionals and what we can do to resolve this worldwide issue.

Mental health professional ‘Joe’ works in the Maltese hospital’s  services. He feels emotionally drained and at the end of his rope. In the morning, he wakes up dreading his workday. The passion for it has dissipated. Maybe, he thinks, it’s time to quit.

Dr Patrick Barbara

Dr Aloisia Camilleri and I explored the concept of burnout in professionals working within our mental health system. The research project itself was born from the notion that to support those who need care, service providers themselves need to have good mental health. 

To understand job-related burnout, it is best to see it as a spectrum. People can be happy, satisfied, and fully engaged, or they can be completely disinterested and disengaged. This framing helps us understand that there are differing degrees of burnout, while also highlighting that different definitions of burnout can lead to different results.

In our research, burnout was defined as a process where a person’s psychological resources are gradually depleted as a result of prolonged stress at work. This then manifests in emotional exhaustion, depersonalisation, and loss of personal accomplishment. The person feels worn out, fatigued, detached, and cynical about their job. Ultimately there’s a sense of inability to cope, and low morale sets in. This is the ultimate lose-lose situation where both the employee and the patients suffer as the organisation loses efficiency.

For the study, we invited 322 professionals to participate anonymously. The roles they occupied varied and included psychiatry doctors, nurses, occupational therapists, psychologists, psychotherapists, and social workers. In the end, 230 agreed to answer our standardised questionnaires. The results were in line with those of similar studies conducted abroad.

Emotional exhaustion scored highly (40.4% of respondents), as did poor personal accomplishment (30.4%). A fifth (18.3%) experienced high depersonalisation levels, while 13.9% scored high on all three features of burnout.

What causes burnout is complex and difficult to explain. The healthcare environment and the systems operating within it do tend to put healthcare workers at risk. They suffer from time pressures, emotional intensity, role conflict, and difficult relationships between employees and management.

Research suggests that people at risk of experiencing burnout often experience a mismatch between their personality and abilities and the role they are in. This mismatch is subjective, depending on the individual as much as it is related to any particular job. So while it can mean that a person has chosen a job outside of their natural abilities, it can also mean that there may be a discrepancy in expectations between the person and the organisation. So this is not just an issue of too much work. Other central elements include control, values, community, fairness, and rewards.

To prevent or resolve some of the issues associated with burnout, people need to have a sense of control at work. They need to feel rewarded (not just financially, but also socially) and treated fairly. They need to feel that they are part of a community that communicates in a civil manner and shares the same or at least similar values. Since this job-person mismatch is a subjective experience, a positive outlook towards work also helps avoid burnout. Our research showed that people who have a better ‘match’ in one factor tend to score better in the other factors as well.

So how can burnout be addressed? Awareness is the first step towards recovery. Education is essential for people to recognise and identify burnout. Practising mindfulness can prove to be an excellent tool for anyone. By becoming more in tune with our own thoughts and emotions, evaluating them in a non-judgemental way, we can avoid falling down the slippery slope towards an unhealthy mental state.

Keeping boundaries and a correct work-life balance is another point. Having time for life outside work and being passionate about other activities is critical. Whether it’s exercise, writing, or creating art, cultivating other interests keeps our worlds varied and occupied. It creates a situation where there are other things to focus on when difficult times come.

From an organisational perspective, we need to work harder to recognise that employees are the most important resource at any workplace. They need to be supported and involved in decision making as much as possible.

Burnout is linked to other mental health conditions such as depression and anxiety. Any employee who experiences mental health problems that impinge on one’s life must feel that they are not alone and help is available. Most people spend the majority of their day and life at work so we need to make sure that it is experienced as positively as possible.