Pain, especially chronic pain, is a transdermal phenomenon in that it occurs not only within an individual nervous system, including the brain, but also within a social and cultural environment. “Our concepts of pain, impairment, and disability,” writes Wilbert E. Fordyce, “must consider environmental factors as well as the person.”¹⁴ Clinical practice frequently reduces environmental factors to three main stressors—employment, family, and alcohol or drugs—but this trio can serve as placeholder for a more extensive mix of sociocultural variables. The fundamental question is whether the sociocultural environment merely influences pain that already exists as a purely biologic phenomenon, simply modulating it, or, alternatively, if the sociocultural environment (beyond mere influence and modulation) helps to construct and to constitute pain.

The difference between influence and construction is important, but its significance for assessment and treatment is unclear because chronic pain often reflects multivariate influences. Some pain—often called psychogenic—seems produced almost wholly by the brain or with little more than an innocuous trigger from the environment. In one study, researchers attached volunteers to an electrical stimulator and told them that its current might possibly produce a headache. Volunteers were not told that the stimulator was set to produce nothing beyond a low humming sound. The result? Half the volunteers reported pain.¹⁵ The environment need not cause or trigger pain in the way a hammer blow impacts a thumb. Positive or negative influences from the sociocultural environment may be as indirect as a whisper. Researchers, utilizing the molecular gaze, recently found that simply looking at the picture of a romantic partner reduced moderate pain by 40%.¹⁶ The sociocultural environment, in contact with human consciousness, may not create or construct pain, but it clearly possesses a resource for pain management too important to neglect or dismiss, and its importance increases in proportion to acceptance of the now widespread recognition that distinguishes between nociception and pain.

The transmission of nociceptive impulses may at times generate autonomic responses, the human equivalent of a rodent’s tail flick, but nociception alone does not constitute human pain. Pain, according to the prestigious International Association for the Study of Pain (IASP), is “always subjective” and “always a psychological state.”¹⁷ The subjective, psychological quality of pain, as human consciousness interacts with the sociocultural environment, is true in spades of chronic pain.

The crucial point here is that most pain specialists today attribute a significant role to the sociocultural environment—a truly historic change in thinking about pain and pain management.

Moreover, the new managers of pain, from a sociocultural perspective, are now doctors and health care professionals, working within complex interrelated systems in which health care costs in 2014 rose to 17.5% of the U.S. Gross Domestic Product.¹⁸ Pain management now cannot be cordoned off from the surrounding medicalized culture and subcultures, where the molecular vision of life has (selectively but broadly) replaced a reliance on shaman, priest, or astrologer. This pervasive medicalization of pain, however, is not without consequences, especially when medical care seems to fail patients. Pain medicine thus is not a neutral or inevitable byproduct of scientific knowledge but rather a presence within the new sociocultural environment that influences pain. Many patients today, that is, experience
pain only within a context that includes various specialists who deal with pain, from orthopedists, oncologists, and neurologists to acupuncturists, homeopaths, and practitioners of alternative and complementary medicine. Pain specialists cannot excuse themselves from discussion as if they were mere impartial technicians, objective researchers, or altruistic caregivers—who assess and treat pain but do not affect how patients understand or experience it. Lous Heshusius, a Canadian academic born in The Netherlands, suffered excruciating chronic pain in the aftermath of an automobile accident. Over an 11-year period, she lists some 240 appointments with doctors and specialists; nearly 500 appointments with alternative professionals; a dozen appointments for tests and assessments; and countless hours keeping track of prescriptions, bills, and insurance.¹⁹ Pain specialists are among the key players in the new sociocultural environment that not only indirectly influences pain but also helps constitute the chronic pain patient’s predicament.

The new active role for pain specialists is certainly driven by patient demand but not solely by patient demand, nor are its effects inconsequential. When clinicians employ evidence-based practices, chart pain as the fifth vital sign, or “game” insurance systems on behalf of their patients, such actions contribute to the maintenance of a significant sociocultural environment within which patients now experience pain. Although pain medicine did not invent insurance providers or disability systems, it operates today within a field of economic compensation that sets patients in a new relation to their pain. In a controversial recommendation, an IASP task force argues that chronic nonspecific low back pain in the workplace, in the absence of an organic lesion and under specified circumstances, should be reclassified not as a medical problem but as “activity intolerance.”²⁰ Activity intolerance is less a diagnosis than a tone-deaf counter-narrative meant to contest the implicit sociocultural narrative that regards chronic low back pain as redeemable for disability payments or for time off. The almost seamless but culturally mandated transition from person-in-pain to pain patient—whose inner life is now under the implicit surveillance of the molecular gaze—also involves an invisible agenda of forms to fill out, waiting rooms, secretaries, insurance companies, drugs, side effects, referrals, more waiting rooms, indignities, task forces, protocols, and still more waiting rooms.²¹ It situates pain and the pain patient within a web of sociocultural relations that reframe pain as transdermal.

A molecular vision of life enfolds the modern pain patient within layers of unappreciated irony. That is, while patients increasingly adopt the expectations of a molecular gaze, pain medicine finds increasing evidence to support nonmolecular and sociocultural understandings of pain. Culture and biology both contribute to pain, of course, as the standard biopsychosocial model implies, but patients committed to the molecular gaze fail to grasp the extent to which human pain is not only always subjective but also always intersubjective. It intersects with shaping social systems from family, church, and nation to jobs and prisons, just as it meshes with variable cultural practices and beliefs from stoic dispassion to pharmaceutical trials. Such sociocultural environments are not necessarily material locales, like a doctor’s office, but bear more resemblance to internalized, individual subsets of what anthropologists would call a lifeworld—a lifeworld that we experience as a state of body, mind, and emotion. Consciousness is the hard-to-define locus of such complex states, and chronic pain (as a classic mind/body state) is thus inextricable from the individual, intersubjective lifeworlds that shape as well as frame it.

The clearest instance of how sociocultural environments shape as well as frame pain comes in long-standing medical undertreatment for pain.^22,23 The hospital, that is, constitutes a distinctive microenvironment that demonstrates how sociocultural forces help alter the experience of pain. The prestigious 1996 SUPPORT study found that 50% of hospitalized seriously ill or dying patients failed (according to family members) to receive adequate pain medication.²⁴ Hospitals, like doctors, belong to the larger sociocultural environment where both drug abuse and fear of opioids have a strong presence, and the hospital as a distinctive microenvironment in some sense reproduces the mixed or self-contradictory beliefs and practices that surround it. Anesthesia belongs to the sociocultural environment of the hospital, where it is accepted as necessary, just as illegal street drugs belong to the environment of the street, where other necessities prevail. Pure pain—pain free from all direct or indirect sociocultural influences, including the artificial, scientific subculture of the laboratory—is a pain that exists nowhere except in theory. Pain as it inhabits the social world outside the laboratory proves always open to the modifying environmental influences of (among other often imprecise categories) race, ethnicity, sex, gender, and age.

Racial disparities in the assessment and treatment of pain are the focus of numerous medical studies.²⁵ Differences in pain tolerance provide conflicting data, as in laboratory studies about racial tolerance for thermal pain.²⁶ Some facts, however, are incontrovertible. In New York City, nonwhite patients who lived in disadvantaged neighborhoods (often black and Hispanic) had substantially less access to pharmacies than did white patients in more affluent neighborhoods. The pharmacies in disadvantaged areas moreover did not maintain adequate stocks of pain medication.²⁷ A sociocultural environment that reduces access to analgesia has an indirect but powerful impact on pain. Although reduced access does not directly cause pain, sociocultural practices that unfairly burden racial and ethnic minority populations indirectly both maintain currently unrelieved pain and, in effect, permit the emergence of new pain that does not exist in primarily white, affluent, more pharmacofriendly communities. There is even neurologic evidence indicating brain and autonomic correlates with empathetic responses to pain in persons of other races.²⁸ Fortunately, studies are now underway to improve clinician awareness concerning pain management disparities.^29,30

Race and ethnicity, then, are frequently discussed in recent studies on pain—but discussion is often impeded by failures to clarify underlying concepts. Classic articles describe ethnocultural differences in the perception of pain and of chronic pain.^31,32 Numerous researchers report ethnic differences in the prevalence and severity of pain, and they find interethnic differences in tolerance levels for clinical and experimentally induced pains. For example, attitudes toward pain show sharp differences along ethnic lines among surgical patients in Australia.³³ Cancer pain among southwest Native Americans has its own specific ethnic signature.³⁴ Race affects how we view others’ pain.³⁵ It influences analgesia use in pediatric emergency departments.³⁶ It affects analgesic access for acute abdominal pain in the emergency department.³⁷ Among patients with arthritis and rheumatic conditions, race and ethnicity even impact treatment outcomes.³⁸ Yet, exactly what are ethnicity and race?

Pain specialists need to engage with recent thinking about how to understand race and ethnicity. Bio-anthropologists contend that there is no genetic signature for race. In general, there is more genetic variation within (so-called) races than across races, which means that race and ethnicity are primarily sociocultural rather than genetic categories.³⁹ Skin color alone links population groups as diverse as their languages: say, Italians and Swedes, Scots and Russians, and Belgians and Croats. Blackness, as a supposed racial marker, links West Africans with the
historically very different East Africans, as well as with Haitians, African Americans, some Hispanics, and various hyphenated groups identified, roughly, by the mere color of their skin. Migration, intermarriage, and global travel have produced a wave of mixed-race offspring. The census term “Asian” has a different meaning in Europe than in America, and census data in Western democracies now define race and ethnicity not through genes, skin color, or geography but rather as a matter of self-identification. In a movement away from reductive ideas of racial science, the most helpful recent turn in health care discussion emphasizes population groups, where biology and genetics are relevant but far from determinative. “Key, here,” as Nikolas Rose explains, “is not so much race, but the belief that a particular community has specific health needs that may have a genomic basis, and that research on the genomic basis is essential if these needs are to be met.”⁴⁰

Pain assessment and pain management are caught up in the shifting sociocultural and historical web of attitudes and practices that envelop race and ethnicity. Over half of Hispanics who presented at emergency rooms with long bone fractures, for example, were twice as likely as similar white patients to go without pain medicine.^41,42 Hispanic ethnicity, according to a recent prospective 10-year evaluation, continues to impact pain management decisions in the emergency department.⁸ We need not posit conscious racism on the part of health care providers, although its presence in medicine (whether conscious or nonconscious) is well documented.^43,44 It is enough to observe that medical degrees do not confer immunity from nonconscious acts of discrimination that reflect the racism of a surrounding culture. This fact should be cause for vigilance in health care settings. Although many blacks carry a gene that puts them at risk for sickle cell disease, their need for pain relief too often runs up against tacit medical stereotypes of drug-seeking behavior.^45,46 Like the infamous Tuskegee syphilis experiments on black airmen, the history of sickle cell pain warns that sociocultural biases concerning race and ethnicity—not race or ethnicity themselves—pose a significant continuing danger to the achievement of color-blind, discrimination-free, equitable pain management. A means to identify and combat racial bias in pain treatment is now an urgent ethical issue in medicine.¹⁰

Telltale absences of equitable pain management unfortunately continue to appear in multiple medical sites not limited to the pain clinic. African American cancer patients in nursing homes were 63% more likely than whites to receive no pain treatment.⁴⁷ Other minorities with cancer pain also experience inadequate pain relief.⁴⁸ The unequal worldwide distribution and consumption of morphine means that medication for pain is far more available to first-world and mostly white patients than to nonwhites in the developing world.^49,50 This difference is not mainly a function of income, although in the United States, there is a strong association between pain prevalence and socioeconomic position.⁵¹ The US campaign against illegal drug trafficking makes inadequate pain relief for Mexican patients also political in origin.⁵² Pain management teams, as they confront questions about clinical policy and research design, need to recognize that race and ethnicity are ill-defined, socially explosive classifications with little basis in genetic science. The laudable recent interest in developing “cultural competence” among health care professionals who treat patients in pain cannot allow generic descriptions of group traits to replace a focus on the individual patient.⁵³ Geronimo was not a typical Chiricahua Apache, and modern Apaches may share few cultural connections with modern southwestern pueblo peoples. Stereotypes based on race or ethnicity—often flawed or at least slippery concepts—are the enemy of good pain medicine.

Sex and gender raise additional complications in assessing sociocultural influences on pain. Sex differences appear real, if limited. Animal studies indicate differences between male and female rodents in pain processing, including a greater efficacy of µ-opioids in males. In humans, κ-opioids produce significantly greater analgesia in women than in men.⁵⁴ Even among women only, red-haired women (in a study that did not test men) show increased sensitivity to thermal pain and reduced responsiveness to subcutaneous lidocaine because of specific mutations of the melanocortin-1 receptor.^55,56 Biologically based sexual differences clearly play a role in women’s pain across a range of chronic pain conditions from migraine to irritable bowel syndrome, although the precise mechanisms are often unclear.⁵⁷ Sex steroid hormones in men and women appear to modulate different nociceptive behaviors. Pregnancy, for example, whatever the television-dramatics associated with morning sickness and labor pain, creates an antinociception that involves δ-opioid and κ-opioid but not µ-opioid systems.⁵⁸ Such biologic differences, however, are likely modest when compared with the exaggerated and shifting sociocultural representations of female and male pain—from Freudian hysteria to John Wayne machismo—that undoubtedly have a shaping influence on the experience of pain.

Pain researchers have been slow to investigate potential differences due less to sex than to gender. Sex, that is, depends on the biology of male/female difference, whereas gender splinters the standard male/female binary into a rainbow of orientations from gay and lesbian to bisexual and transgender. One prominent argument in the field of gender studies holds that gender is largely performative, meaning, gender—no matter how individual, eccentric, or dependent on hormone therapies—constitutes a quasi-public social role.⁵⁹ The women whom Charcot in the 19th century photographed in his famous hysteria wards clearly “performed” their illness for the camera, even if unknowingly, and today women tend to perform specific gender roles (e.g., as overextended caregivers) that are sociocultural and not entirely unrelated to pain. Caregivers, for example, are at increased risk for multiple maladies, from depression to heart disease. Men, too, perform certain gender roles directly or indirectly related to the capacity to endure pain, where the power to endure pain is a sociocultural rather than biologic trait. A pain treatment program that recognizes the complicating sociocultural role of gender—in addition to well-known differences in sex, race, and ethnicity—will be best equipped to grasp the multiple lines of influence, both biologic and psychosocial, that so often converge in chronic pain.

Age might stand as an icon for the multiple biologic and sociocultural convergences that influence chronic pain. Pediatrics and geriatrics both depend on biologic changes that accompany human growth, but childhood and old age are both also the site of numerous, tacit, culturally specific expectations. Pain research has devoted considerable resources to children, whose limitations in language and in perception require ingenious techniques for assessment. Techniques such as drawings that indicate the location and intensity of pain depend equally on the biologic facts of human linguistic development and on the sociocultural skills and learning associated with graphic design. Pain treatment geared to children also requires, in addition to carefully age-adjusted medications, an attention to childhood fears and feelings that belong to particular cultures. Much like ethnicity and race, age (especially cultural stereotypes of the elderly) has an impact on pain management decisions.⁶⁰ Even in the emergency department, there appear to be disparities in pain treatment afforded to younger and older adults.⁶¹ Old age, however, whether defined by chronology alone or by organic and developmental changes, has received less attention than childhood in pain research, although the new field of palliative medicine is bringing rapid change.⁶² Indeed, one area in particular need of increased study is pain at the end of life.⁶³ Dying is clearly a biologic process, but the funeral industry alone indicates how far death and dying are endowed with significance
that is both economic and sociocultural. American and European medical attitudes clearly differ about continuous deep sedation until death.⁶⁴ Clear ethical guidelines on pain treatment at the end of life are greatly needed. Edmund Pellegrino,⁶⁵ a giant of modern bioethics, defines the challenge to modern endof-life pain medicine in what resembles a blunt, if indirect, ultimatum: “Not to relieve pain optimally is tantamount to moral and legal malpractice.”

Why is it important for medicine to recognize the sociocultural influences on human pain as reflected in race, ethnicity, sex, gender, and age? First, although drugs and surgery sometimes erase or control pain associated with clear organic sources, many conditions such as chronic nonspecific low back pain expose the limits of drugs and surgery, especially where sociocultural influences—such as family, job, and disability—are involved. Furthermore, organic lesions do not map exactly onto pain. Most adults who complain of back pain have lumbar disk disease, but so do many adults without pain complaints.⁶⁶ In America, long-term functioning of patients treated for back pain is similar whether doctors prescribe medication and bed rest or self-care and education.⁶⁷ Pain simply does not provide an accurate report of tissue damage. “The truth is that pain is a very poor reporting system,” writes Patrick Wall. He adds, “The doctrine that pain is a useful signal needs heavy qualification.”⁶⁸ The erroneous belief that pain is a reliable alarm system not only justifies countless unnecessary surgeries but also cannot begin to explain why the two strongest signs predicting that an American worker will develop chronic back pain are job dissatisfaction and unsatisfactory social relations in the workplace.^69,70 It is as if the American low back is wired directly into the sociocultural work environment. A study covering 18 countries found large international variation in the prevalence of disabling forearm and back pain among occupational groups carrying out similar tasks.⁷¹

Second, the recognition of sociocultural influences on pain opens up possibilities for system-wide changes in pain management. In 1999, a memorandum directed to over 1,200 sites required the entire U.S. Veterans Health Administration to make policy and procedural changes implicit in the new principle that pain is the fifth vital sign.⁷² In one VA outpatient clinic, this change produced no measurable improvement in pain management quality.⁷³ The possibilities for system-wide change are impressive, however, especially when hospital accreditation now depends on requirements to chart pain levels. A similar requirement altered policies in pain management and in palliative medicine throughout all the hospitals in the vast southwest region of the U.S. Indian Health Service.⁷⁴ Such changes acknowledge that pain management belongs to a surrounding sociocultural environment that includes the changing subculture of medicine. Systemic changes in pain management thus affect not only individual patients but also the wider sociocultural environments (from clinics and hospitals to digital media reports) within which both patients and nonpatients understand and experience pain.

The IASP in its glossary of terms describes pain as “always subjective” and “always a psychological state.”¹⁷ Pain, by implication, may change when a person’s subjective, psychological state changes sufficiently. Systemic changes in the sociocultural environment of medicine—including efforts to reduce provider bias based on age, gender, sex, ethnicity, and race—can materially alter individual experience and help relieve pain. Such changes also recognize that a patient’s race, ethnicity, sex, gender, and age have demonstrable effects on the experience of pain. Suppose that a woman from a minority group in a low-income neighborhood repeatedly fails to receive adequate pain medication from her local pharmacy. Frustration, humiliation, and rage, compounding the fear that she may already feel about her health, constitute a significant change in her subjective state not unrelated to pain. Fear, as researchers show, elevates pain intensity.⁷⁵ Pain specialist Mark Sullivan⁷⁶ argues that pain itself is best understood as an emotion. Patient education and improved access to care offer two additional and specific areas for systemic change, with consequences that promise a difference in both the psychology of individual pain patients and in the surrounding, interpenetrating sociocultural environments within which people of any sex and gender—patients, doctors, nurses, adults, children, workers—understand and experience pain.

Pain varies across individuals, cultures, and times. This strong claim contradicts the universalist view that pain is a changeless sensory signal, identical in everyone, everywhere. Dental research has identified an effect of culture on pain sensitivity.⁷⁷ Culture, of course, is a broad general concept and not a sufficient explanation for pain or for pain sensitivity. In women, sensitivity to a variety of experimental thermal, mechanical, and chemical pain-producing stimuli has a proven genetic contribution.⁷⁸ Individual variations in reported pain intensity produced by exposure to an identical noxious stimulus correlate directly with altered brain patterns, which can hardly be explained solely as an effect of culture.⁷⁹ Most researchers agree, however, that pain includes both sensory and affective components, and affective components of pain show wide variation across individuals and cultures. The 1950s era surgically lobotomized patients could still feel pain, reportedly, but said that the pain no longer bothered them. It may require a philosopher to decide if pain that fails to bother us still counts as pain. (It will not show up at pain clinics.) It did require philosophers to compile a volume of essays entitled Cultural Ontology of the Self in Pain⁸⁰ (a rough translation: The Self in Pain as a Cultural Being). Pain that is both affect-free and culture-free constitutes almost a self-contradiction because researchers agree that personal emotions—far from being bio-hardwired at birth—are fundamentally cultural.⁸¹

Real-world pain, then, is characterized by an affective quality of aversiveness open to wide modulation. This aversiveness depends on corticolimbic networks, much as anxiety correlates with activity in the septohippocampal system.⁸² Emotions associated with aversiveness, however, also in part socially constructed and socially modified, need not prove static or unresponsive to additional sociocultural input. Stoic philosophers in the age of Nero exalted the use of reason to overcome pain, and many Greek texts retell the story of the Spartan boy (trained in courage and in military discipline) who remains silent as a fox hidden in his cloak gnaws him to death. Athletes, dancers, yogis, and religious celebrants continue to demonstrate how minds and emotions, as shaped by differing sociocultural environments, help to modify pain and pain behavior. Such sociocultural environments are not neutral containers for bodies in pain—like stage sets—but rather, the setting and its sociocultural forces shape the pain. Even pain clinics and research labs are, in a specialized sense, sociocultural spaces. They help to shape expectations and to reinvent pain as surely as ancient religions shaped and reinvented pain through authoritative teachings about demonic possession and original sin. Whatever the surrounding culture teaches us or shows us about pain (including false information, erroneous recommendations, and harmful tales) holds the power to modulate what we feel—for better or worse—with direct and indirect implications for the medical discipline of pain management.

Culture as a crucial force in shaping human pain across various eras, disciplines, and practices, from legal punishment
to religion, is a subject of wide-ranging books and articles.^83,84,85 An evidence-based pain medicine can draw particularly persuasive data from cross-cultural studies. For example, researchers compared chronic low back pain patients in Japan with a similar group in the United States and found the Japanese patients to be significantly less impaired in social, psychological, vocational, and avocational function.⁸⁶ A cross-cultural comparison matching Portuguese chronic pain patients with English-speaking chronic pain patients showed strong similarities in associations between psychosocial factors and measures of pain experience: intensity, physical function, and psychological function.⁸⁷ Just as various psychosocial factors may differ across cultures, psychosocial factors themselves (likely rooted in particular cultures) regularly affect the experience of pain. Of course, pain evoked in a lab or studied in reviews of medical literature may not replicate everyday pain experienced outside various controlled environments, and real-world sociocultural environments include not only visible institutions such as families, schools, and workplaces but also less visible currents of thought and feeling conveyed in advertisements, songs, sports, and personal interactions. Even parental models have an influence on how individuals understand specific pain events.⁸⁸ Aboriginal people in Australia deal with pain in culturally specific ways.^89,90 Hispanics and non-Hispanics show significant differences in their knowledge about hospice care, with a resulting impact on pain management at the end of life.⁹¹ Although similar illustrations might be greatly multiplied, they all tend to demonstrate how cultural attitudes and understandings permeate the experience of pain, especially chronic pain. Nowhere is the interpenetration of culture and chronic pain so clear as in the growing medical literature on so-called pain beliefs.