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Transcript — Programme 108: Gender Differences

How men and women expe­ri­ence pain, arm­ing your­self with the right infor­ma­tion, and not being embar­rassed about your condition

To lis­ten to this pro­gramme, click here.

This edition’s been part fund­ed by the Women’s Fund for Scotland.

Do women and men expe­ri­ence pain dif­fer­ent­ly, or is it only our atti­tudes towards pain that dif­fer? In this edi­tion of Air­ing Pain, Paul speaks to health­care pro­fes­sion­als about their find­ings with the lit­er­a­ture sur­round­ing chron­ic pain and the chang­ing out­looks when it comes to seek­ing help.

Deputy Direc­tor of the Bath Cen­tre for Pain Research, Pro­fes­sor Ed Keogh, speaks about his review of men’s health lit­er­a­ture in the con­text of chron­ic pain, and found that women are more like­ly to report pain in more body regions in their life­time com­pared to men. He con­sid­ers whether this is due to bio­log­i­cal or social/emotional rea­sons, but empha­sis­es that the vari­a­tion with­in males and females is much greater than the vari­a­tion between the sexes.

Can the gen­der roles soci­ety push­es on us affect how we deal with our pain? Senior clin­i­cal psy­chol­o­gist of the Nation­al Spe­cial­ist Pain Ser­vice in Bath Dr Gauntlett-Gilbert talks to Paul about how the soci­etal expec­ta­tions of how we han­dle pain can feed into depres­sion and guilt.

Spe­cial­ist phys­io­ther­a­pist at UCL Hos­pi­tals’ Pain Man­age­ment Cen­tre Katrine Petersen dis­cuss­es the lack of lit­er­a­ture on men’s pain, espe­cial­ly pelvic pain, as well as her expe­ri­ences in using phys­io­ther­a­peu­tic strate­gies in the con­text of chron­ic pain syn­dromes.

Issues cov­ered in this pro­gramme include: CBT: cog­ni­tive behav­iour­al ther­a­py, chron­ic pro­sta­ti­tis, dif­fer­ence, uro­gen­i­tal pain, pelvic pain, chron­ic pri­ma­ry pain, depres­sion, men and women, men’s pain, men­stru­a­tion, prostate can­cer, pro­sta­ti­tis, rela­tion­ships, research, sex dif­fer­ence, social fac­tors, tes­tic­u­lar pain and wom­en’s pain.

Paul Evans: This is Air­ing Pain, a pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain, and for health­care professionals.

I’m Paul Evans. And this edi­tion has been fund­ed by the Women’s Fund of Scotland.

Jere­my Gauntlett-Gilbert: Men will very often speak of their loss of a role in the fam­i­ly, the fact that they can’t pro­vide any­more, they can’t be a bread­win­ner any­more. That they can’t go out to work or pro­vide that kind of lead­er­ship or phys­i­cal help around the house that they hope to.

Katrine Petersen: If you con­sid­er how women have accessed health­care for pelvic issues such as men­stru­a­tion, first sex­u­al encounter, con­tra­cep­tion, preg­nan­cy, smear tests. Women are just used to talk­ing about the abdom­i­nal pelvic area.

Evans: Do men and women expe­ri­ence pain dif­fer­ent­ly? In terms of under­stand­ing, what’s known about men’s pain falls short of what we under­stand about women’s pain? In 2015, psy­chol­o­gist Pro­fes­sor Ed Keogh, who is the deputy direc­tor of the Bath Cen­tre for Pain Research at the Uni­ver­si­ty of Bath, com­plet­ed a selec­tive review of men’s health lit­er­a­ture to con­sid­er them with­in the con­text of men’s pain. Under the head­ing ‘Men, Mas­culin­i­ty and Pain’, its pur­pose in tak­ing a men’s health approach to pain was to view exist­ing evi­dence in a dif­fer­ent way, and to iden­ti­fy poten­tial gaps in our under­stand­ing, not just of men’s pain, but of women’s pain too.

Ed Keogh: There are sex and gen­der dif­fer­ences, for exam­ple we know that men are dif­fer­ent in terms of the amount of pain they expe­ri­ence and report. Here we know that, for exam­ple women tend to report more pain, in more body regions over their life­time in com­par­i­son to men. So we know that there are these dif­fer­ences, and we are quite inter­est­ed in some of the rea­sons why there are differences.

Evans: So you’re talk­ing about the occur­rence of pain, rather than the sever­i­ty of pain?

Keogh: Well it’s all types of pain, so it’s actu­al­ly pain con­di­tions. So, if you look at some pain con­di­tions and look at men and women, how rep­re­sent­ed are they in the clin­ic, we know for some con­di­tions women are com­ing in with more pain, so headache and low­er back pain, those sorts of pains. We typ­i­cal­ly find num­bers are high­er in women in com­par­i­son to men in the clin­ic. In addi­tion to that we also know for exam­ple, in lab­o­ra­to­ry pain induc­tion type envi­ron­ments, so induc­ing pain, there are dif­fer­ences in the amount of pain report­ed. The pain thresh­olds, the pain tol­er­ance lev­els tend to be dif­fer­ent in men and women. I think the key ques­tion is why are there differences?

Evans: Well first of all, we men, as no doubt you’ll say, we feel pain more than women.

Keogh: Well the evi­dence is actu­al­ly con­trary to that. In fact if you look at the amount of pain that’s being report­ed then cer­tain­ly women are report­ing more pain in com­par­i­son to men. Now that’s not to say that men aren’t expe­ri­enc­ing pain. Men are in pain, they are suf­fer­ing and we cer­tain­ly do need to do things about this.

Evans: So what’s going on there then?

Keogh: I think this comes back to the expla­na­tions around why there might be these sex and gen­der dif­fer­ences in pain. So we know there are dif­fer­ences, why are there dif­fer­ences? Some of the expla­na­tions are very bio­log­i­cal, so we know there may be sex hor­mones may be involved in medi­at­ing some of the differences.

But as we also know, sex and gen­der, there are more bio­log­i­cal fac­tors, but also social and emo­tion­al fac­tors, and psy­choso­cial fac­tors are also impor­tant. So we are quite inter­est­ed in the way these psy­cho­log­i­cal and social fac­tors have an impact on, both the expe­ri­ence and also the report­ing of pain, and we think that might be par­tic­u­lar­ly impor­tant for both men and women.

Evans: I would take a stab at it and say we don’t like going to the doc­tors, we are not as open about our own bod­ies as women are?

Keogh: Yes, the whole men’s health agen­da around how men are not going to the doc­tors, not explain­ing to oth­ers, things about their pain, about their health con­di­tions. We’ve sort of moved into the pain area and asked, if there are lim­i­ta­tions in how well men are report­ing health expe­ri­ences, does that then trans­late into pain clin­ics as well? Are men not very good at report­ing pain? Men’s health lit­er­a­ture is begin­ning to high­light that there are these dif­fer­ences, and there are pos­si­ble expla­na­tions around why men may be under-report­ing health con­di­tions. When we start look­ing at pain, rel­a­tive­ly lit­tle research has actu­al­ly looked at men and the way in which they report pain itself.

Evans: Could some­thing to do with it be that, if I sit in the wait­ing room of my GP prac­tice I’m bom­bard­ed with posters about women in pain, there are only two posters that I can think of about male only pain: tes­tic­u­lar can­cer, and I can’t even think of the sec­ond one?

Keogh: Yeah I think there’s a lot of expec­ta­tions around pain and who expe­ri­ences pain. In fact women are much bet­ter at going to their GPs and talk­ing about health con­di­tions includ­ing pain. Pain is much more reg­u­lar, of course for a num­ber of women, so men­stru­al cycle relat­ed pain, for exam­ple, is very com­mon. Of course, women then are there­fore more able to dis­cuss this more reg­u­lar­ly. When it comes to males and male pain, it’s not as nor­malised if that makes sense. And so there­fore there maybe inhi­bi­tion around dis­cussing these sort of experiences.

Evans: The inter­est­ing thing about what you said ear­li­er, is the word mas­culin­i­ty, which is – well, masculinity’s being a man.

Keogh: Exact­ly, this is what’s inter­est­ing, we’re not talk­ing about sex dif­fer­ences, dif­fer­ences between men and women. We know there are dif­fer­ences between men and women. But the vari­a­tion that occurs with­in males, and with­in females, is much greater than the vari­a­tion between the sex­es. So we need to under­stand this, and one of the expla­na­tions could be some­thing along the lines of gen­der. Which is the social norms, the con­cep­tu­al­i­sa­tion of what it means to be mas­cu­line, what it means to be fem­i­nine. We think some of these are very impor­tant in terms of how peo­ple dis­cuss, and how they behave in front of oth­ers when it comes to pain.

Evans: And I said tongue in cheek, that we feel pain worse than women do, well of course, that was tongue in cheek. But there is the expres­sion man-flu, and the gen­er­al feel­ing that a man will stay in bed, it will be flu and not a cold. Do we con­fine our pain to the peo­ple we know?

Keogh: There’s a cou­ple of things embed­ded with­in that. I’ll start off with how media, soci­ety, rep­re­sents the expres­sion of pain. I think this is a very good exam­ple of the way in which the expres­sion of emo­tions, the expres­sion of pain can actu­al­ly be inhib­it­ed in some ways. So, actu­al­ly, if you think about the way in which we devel­op as chil­dren, whether or not cry­ing as a boy is pun­ished in some ways, through say­ing “don’t act like that”, etc. Whether that’s being played out in the way in which men actu­al­ly express their emo­tions, express painful con­di­tions. That might be reflect­ed there.

Again, from the men’s health lit­er­a­ture, what we actu­al­ly know is that in terms of social sup­port there do seem to be dif­fer­ences, espe­cial­ly as we age. So the men’s health lit­er­a­ture cer­tain­ly indi­cates that lat­er on in life, in terms of the sup­port net­works that are around, women have very good social sup­port net­works out­side of the home. Where­as men on the oth­er hand tend to restrict it more with­in the home. So the prob­lem is, if you lose your part­ner then for women there is actu­al­ly a social sup­port net­work around them, but for men it’s not there as much. So we have to think about ways in which we can get men that sort of help. One of the exam­ples that is being used and devel­oped in a num­ber of coun­tries has been the men’s shed move­ment, which is a way of get­ting men togeth­er, through activ­i­ties, but actu­al­ly that could be a very good medi­um by which you could actu­al­ly start talk­ing about oth­er sorts of issues, such as health relat­ed issues, of which we can of course include pain.

Again, in terms of men’s health lit­er­a­ture, where you’ll see lots of empha­sis now on recog­nis­ing how there might be dif­fer­ences in how you might approach men and women, espe­cial­ly around health con­di­tions and get­ting men to actu­al­ly go to their GPs to talk to peo­ple about their con­cerns, espe­cial­ly around pain and oth­er health con­di­tions. Talk about it, don’t leave it to the last moment, which of course can some­times hap­pen. So I think by mak­ing it much more accept­able to talk about emo­tions and feel­ings, and the way in which pain affects you in going to be good for men and women.

Evans: That’s Pro­fes­sor Ed Keogh, Deputy Direc­tor of The Bath Cen­tre for Pain Research at the Uni­ver­si­ty of Bath.

Now, he talked about pain being an expres­sion of hurt and vul­ner­a­bil­i­ty, and that maybe men are less like­ly than women to come to terms with those feel­ings. But what about oth­er self-con­scious emo­tions, like shame, embar­rass­ment or humil­i­a­tion? Jere­my Gauntlett-Gilbert is a Senior Clin­i­cal Psy­chol­o­gist at The Nation­al Spe­cial­ist Pain Ser­vice in Bath.

Jere­my Gauntlett-Gilbert: His­tor­i­cal­ly in chron­ic pain research and prac­tice, peo­ple have always been inter­est­ed in under­stand­ing things like depres­sion in pain, things like anx­i­ety. But it also real­ly seems true that peo­ple with chron­ic pain live with a con­di­tion that is poor­ly under­stood, they don’t always get nice, encour­ag­ing respons­es from oth­er peo­ple. And there­fore they’re very often in a posi­tion where they’re con­stant­ly feel­ing embar­rassed, self-con­scious. “What’s wrong with you?” “I’ve got a bad back”. It’s a rub­bish answer. And so we just became inter­est­ed in that from our clin­i­cal expe­ri­ence, and then want­ed to do some research on it.

Evans: From my own expe­ri­ence, I have chron­ic pain, I have fibromyal­gia, some­times you’re embar­rassed to smile in com­pa­ny, just in case peo­ple think you’re bet­ter, or they judge you.

Gauntlett-Gilbert: I think it’s true isn’t it, because all of these con­di­tions, they fluc­tu­ate in their sever­i­ty, so peo­ple have bet­ter days and worse days. And one of the risks of that is, peo­ple see some­body on a good day, and they say, “What’s wrong with you then, you’re obvi­ous­ly fine”. And so it’s that kind of incom­pre­hen­sion which does make peo­ple very ner­vous. They’re just not well under­stood con­di­tions, they’re not seen as legit­i­mate. Fibromyal­gia being a case in point, peo­ple don’t take it seri­ous­ly, it’s not leukaemia.

Evans: You have to look ill to be ill.

Gauntlett-Gilbert: Yes, this is true. One of the oth­er things that hap­pens around try­ing not to feel embar­rassed, or try­ing not to feel ashamed, is peo­ple try­ing des­per­ate­ly not to look ill. Lots of peo­ple spent a lot of their time try­ing to put on a good face, or only going out when they feel fine. And it’s the flip side of what you were just say­ing, the embar­rass­ment dri­ves peo­ple to either try and make damn sure that peo­ple under­stand how ill they are, or because they feel so mis­un­der­stood they put a ter­ri­bly brave face on things and only go out when they feel well.

Evans: Embar­rass­ment, I’ve nev­er felt embar­rassed about my con­di­tion. But I can see what you’re say­ing, that if I don’t look ill enough then I will be judged as a shirk­er, a malingerer.

Gauntlett-Gilbert: I think it’s a real prob­lem for peo­ple with pain, cos you’re damned if you do and damned if you don’t. Peo­ple might well see you look­ing in pain, look­ing vis­i­bly uncom­fort­able and judge you as ham­ming it up. Or peo­ple see you on a good day, or when you’re try­ing to put a good face on things, and say “Well, what’s wrong with him?”

Evans: And I think for peo­ple who are in work with chron­ic pain, there is the impres­sion if you take sick leave you are sick, but when you go back to work you are better.

Gauntlett-Gilbert: Com­plete­ly, yeah, for some rea­son we’ve got this mod­el, which prob­a­bly does work for the flu, that you’re either sick or you’re well. Which just doesn’t apply to the kind of con­di­tions you see in chron­ic pain. And it’s a real shame because very often peo­ple are almost pun­ished for get­ting back to work, peo­ple who strug­gle back to work, half time, do a grad­ed return. Instead of being treat­ed with respect for their effort, they are almost hur­ried along, “Why can’t you improve it quicker?”

Evans: “If you can’t do all the work then why are you here?”

Gauntlett-Gilbert: [laugh­ing] That has a ring of authen­tic and painful truth about it, yes. That’s one of those things, and I think that peo­ple end up being implic­it­ly pun­ished and then employ­ers say some things which can’t be legit­i­mate or legal some­times about health and safe­ty, not sure we can have you around here cos you don’t look ter­ri­bly safe on that chair. And the upshot is, although prob­a­bly nobody is try­ing to do the bad thing, is that peo­ple with chron­ic pain end up almost get­ting a lit­tle bit pun­ished for their very brave attempts to go back as much as they can and do as much as they can, which isn’t perfect.

Evans: The flip side of some­body in that sit­u­a­tion is that they pun­ish them­selves, because they don’t want the employ­ers to man­age their con­di­tion, they want to keep their employ­ers at arm’s length, if you like, because “I can man­age this myself, don’t get involved. Because if you get involved you’re going to cut my work down to half, and some­body else will look at me and say, what’s he doing here”. So it’s not just employers.

Gauntlett-Gilbet: Peo­ple can, as you say, keep employ­ers at arm’s length because they are try­ing to self-man­age, though pos­si­bly try­ing to self-man­age in a wor­ried way. Like you say, wor­ried what the employ­er will do. But also a lot of peo­ple with chron­ic pain are just, before they ever had pain they were peo­ple with very high stan­dards, peo­ple who want to do a good job, they’re peo­ple who dis­like the idea of half mea­sures. And these are tem­pera­men­tal things, human beings were human beings before they got pain. And a lot of peo­ple with chron­ic pain have real­ly strong val­ues for them­selves, and strong val­ues for their work­ing lives, and actu­al­ly gen­uine­ly hate hav­ing to do what they feel is a half effort because of pain. So either because of fear of what their employ­er will do, or because of their own stan­dards for them­selves, they can end up real­ly flog­ging them­selves I think.

Evans: Is there a gen­der dif­fer­ence for peo­ple with chron­ic pain? Do men act dif­fer­ent­ly from women?

Gauntlett-Gilbert: I think it dif­fers in form. Men will very often speak, and it’s a lit­tle stereo­typ­i­cal, but a lit­tle true, of their loss of a role in the fam­i­ly, the fact that they can’t pro­vide any­more, they can’t be a bread­win­ner any­more. That they can’t go out to work, or pro­vide that kind of lead­er­ship, or phys­i­cal help around the house that they hope to. In many ways that’s not a mil­lion miles from women, who are used to hav­ing, again stereo­typ­i­cal­ly, these are stereo­types, more of a car­ing role, who val­ue their abil­i­ty to look after oth­er peo­ple, to be a moth­er, to help oth­er peo­ple, and who have strong val­ues around nur­tur­ing oth­er peo­ple, they feel pret­ty ghast­ly too. So I think the form is dif­fer­ent, but I don’t know if under­neath it’s all that different.

Evans: Per­haps men and women seek help in dif­fer­ent ways?

Gauntlett-Gilbert: I think so, I mean it’s a leg­endary issue in the broad­er lit­er­a­ture, of men’s ter­ri­ble health­care seek­ing behav­iour, and ten­den­cy to avoid things.

Evans: The shame, and the guilt, and the anx­i­ety, for some­one who has chron­ic pain, depres­sion and guilt, they all feed into the chron­ic pain and the chron­ic pain feeds into all that, it’s that cycle of pain, isn’t it? And you need to break that cycle. So which comes first do you say?

Gauntlett-Gilbert: Anoth­er ques­tion is which can you change eas­i­est? None of these things are easy to change, but if a per­son has got chron­ic pain then the chances are they have a pret­ty nasty, unpre­dictable set of symp­toms which comes and goes, and there’s not a right lot you can do about it. Per­haps it’s just my bent as a psy­chol­o­gist, it always seems to me that per­haps you could get in there with the emo­tions, using some psy­cho­log­i­cal tech­niques that we use. It’s not easy because peo­ple were able to feel shame, or were able to feel low long before they had chron­ic pain, these are things which every­body feels a lit­tle bit of their whole lives. So I don’t think you can ever wave a mag­ic wand and get peo­ple to a point where they nev­er feel shame or guilt, and I’m not sure it would be a good idea if you did. I rather think that’s what psy­chopaths are like, so shame and guilt is prob­a­bly not nec­es­sar­i­ly a bad thing. But, yes we’re cer­tain­ly exper­i­ment­ing with using fair­ly estab­lished, noth­ing rad­i­cal, but estab­lished psy­cho­log­i­cal tech­niques and cur­rent psy­cho­log­i­cal ther­a­pies to see if we could tar­get those things directly.

Evans:  So what are those therapies?

Gauntlett-Gilbert: You’ve got to ask your­self, if peo­ple are liv­ing with an obvi­ous­ly vis­i­ble con­di­tion, some­body who is using a stick, has chron­ic pain, and they’re liv­ing in a soci­ety which isn’t always kind to peo­ple with dis­abil­i­ties, I cer­tain­ly wouldn’t go down the line of think­ing we could get peo­ple to some love­ly pos­i­tive think­ing world, in which they nev­er feel embar­rassed. I think that’s prob­a­bly unre­al­is­tic. Instead we tend to use more accep­tance based approach­es, which kind of acknowl­edges that these unpleas­ant emo­tions are there, and they will be there. And until there’s a rev­o­lu­tion and every­body becomes nice to peo­ple with dis­abil­i­ties, and I don’t know when that’s com­ing, until that hap­pens then peo­ple may have to find ways to car­ry their embar­rass­ment with them, whilst they get on with the stuff they care about. You can tell there is not a should in that, I don’t think peo­ple should put up with their embar­rass­ment, but very often these are the bar­gains which are in front of peo­ple with long term con­di­tions. Either do it and risk feel­ing embar­rassed, or don’t risk feel­ing embar­rassed but nev­er do it.

So we’re look­ing at accep­tance based, and mind­ful­ness based tech­niques in the psy­cho­log­i­cal ther­a­pies that might, if a per­son choos­es it, help them be able to be a lit­tle bit more embar­rassed and car­ry on doing what they care about as well. It’s not an easy sell, it would be a great deal eas­i­er to sell the love­ly pos­i­tive idea that you could walk around your life free from shame, but I’m not sure that’s always real­is­tic. And so that’s one of the ways we tend to go at things.

Evan: The accep­tance side of things I guess is accept­ing you have a con­di­tion, and that it’s some­thing you have to live with, but the con­di­tion isn’t the dri­ver of your life?

Gauntlett-Gilbert: I think that’s right. I think there’s accept­ing that you have the con­di­tion. And the oth­er thing, when you’re talk­ing about what dri­ves your life, and what makes you do things, and what stops you doing things, is that if you can accept that you might feel a bit rot­ten while you are doing this, you might blush, you might feel like a bit of an idiot, peo­ple aren’t real­ly tak­ing you seri­ous­ly, but that is some­thing you aren’t hap­py with but are will­ing to take as the price of doing some­thing that you care about. Then that’s the kind of accep­tance that we’re talk­ing about. It’s a tricky busi­ness, but it’s an hon­est, psy­cho­log­i­cal approach. And also one that makes it clear that dif­fi­cult emo­tions aren’t dan­ger­ous them­selves, they’re just uncom­fort­able. And if we choose to then some­times we can make the choice to do more of our lives and have that discomfort.

Evans: Jere­my Gauntlett-Gilbert senior clin­i­cal psy­chol­o­gist at the Nation­al Spe­cial­ist Pain Ser­vice in Bath.

We’re talk­ing about gen­der dif­fer­ences in the expe­ri­ence of chron­ic pain, and we’ve talked about emo­tion­al or psy­cho­log­i­cal dif­fer­ences between the sex­es, but phys­i­cal­ly and bio­log­i­cal­ly — and this is not new sci­ence — men and women are dif­fer­ent. We also dif­fer in our will­ing­ness to dis­cuss or own up to prob­lems, par­tic­u­lar­ly if those prob­lems are lead­ing to pain in the pelvic region.

Katrine Petersen is spe­cial­ist phys­io­ther­a­pist at the Uni­ver­si­ty Col­lege Lon­don Hospital’s pain man­age­ment cen­tre. So what do we men suf­fer from that women don’t?

Katrine Petersen: That’s a real­ly good ques­tion, because there’s so lit­tle lit­er­a­ture on it. We’ve got some data our­selves on the ser­vice we run for chron­ic abdom­i­nal pelvic pain. That’s a def­i­n­i­tion and term that we have devel­oped because it fits the pop­u­la­tion that we see, but when you actu­al­ly look at the lit­er­a­ture it’s very dif­fi­cult to define exact­ly, but we have a list of syn­dromes, pain syn­dromes, based around the pelvic area and the abdom­i­nal area that we see.

So typ­i­cal­ly male pelvic pain will be described in the lit­er­a­ture often as chron­ic pro­sta­ti­tis, so men will get pain in that area affect­ing poten­tial­ly their blad­der and uri­nary fre­quen­cy and sex­u­al func­tion. And often they will go to urol­o­gy and have their prostates checked.

Evans: There’s a gen­der dif­fer­ence here isn’t there? Men don’t talk about their pri­vate parts, or any­thing below their navel at all.

Petersen: Absolute­ly. So it used to be quite dif­fi­cult to get men com­ing for­ward, but I recent­ly looked at our data on patients attend­ing our chron­ic abdom­i­nal pelvic pain clin­ics and it turns out that we near­ly have a third of patients who are men. So they are start­ing to come for­ward. One of the rea­sons why men don’t come for­ward is if you con­sid­er how women have accessed health­care for pelvic issues, such as men­stru­a­tion, first sex­u­al encounter, con­tra­cep­tion, preg­nan­cy, smear tests, women are just used to talk­ing about the abdom­i­nal pelvic area, where­as men real­ly have no par­tic­u­lar rea­son to go unless they have a problem.

Chron­ic pro­sta­ti­sis or chron­ic prostate pain syn­drome is one of the typ­i­cal syn­dromes that we see, but we also penile pain, tes­tic­u­lar pain, non-spe­cif­ic pelvic pain and rec­tal pain, lots of dif­fer­ent con­di­tions all affect that par­tic­u­lar area.

Evans: Now prostate is some­thing that pos­si­bly many men will recog­nise, through tests for prostate can­cer and things like that.

Petersen: Exact­ly. So typ­i­cal­ly patients will go to urol­o­gy for that par­tic­u­lar con­cern of prostate can­cer, because that’s some­thing that gets talked about. What doesn’t get talked about is when patients have pain from an uniden­ti­fi­able cause, or non-pathol­o­gy, non-bac­te­r­i­al symp­toms that they are get­ting that very much look like an infec­tion, for example.

Evans: So who do you see?

Petersen: So that’s also a very good ques­tion. I have men come into my clin­ic with very spe­cif­ic pain such as tes­tic­u­lar pain, penile pain, and I have had patients come through the door look­ing at me, say­ing “I have no idea what you could pos­si­bly do for me”. Because in the tra­di­tion­al sense phys­io­ther­a­py would be about work­ing from a mus­cu­loskele­tal mod­el of exer­cise and poten­tial­ly some man­u­al ther­a­py to stretch and relieve mus­cles, where­as I much more come from a chron­ic pain mod­el. So once we have exclud­ed any bac­te­r­i­al infec­tion, any­thing can­cer­ous, any form of pathol­o­gy, we’re now work­ing with a chron­ic pain mod­el. So I use the same strate­gies that I would use for any oth­er pain con­di­tion, I just have to include things like uri­nary fre­quen­cy and urgency, bow­el move­ment and sex­u­al func­tion, but again using the same strate­gies as I would do for any oth­er pain con­di­tion as a pain man­age­ment physiotherapist.

Evans: So as a physio, what do you do?

Petersen: Good ques­tion again [laugh­ter], because once it comes to pain man­age­ment peo­ple get a bit more con­fused. So we are trained in cog­ni­tive behav­iour­al ther­a­py, most of us who work in pain man­age­ment. Because the tra­di­tion­al med­ical mod­el where you look at the end organ and try­ing to fix some­thing doesn’t tend to work. So we need to look at a much more com­plex mod­el in terms of chron­ic pain, first of all work­ing out why the patient is here to see us, and often it’s because they have some real, good ques­tions about why am I pain. And they have some good ques­tions about what can I do, is it ok for me to exer­cise, is it ok for me to bend, am I going to cause any fur­ther dam­age. And I think phys­io­ther­a­pists are very well placed because they’ve got the cred­i­bil­i­ty of assess­ing risk in terms of move­ment and dam­age to tis­sues ver­sus what can you get back to in terms of activity.

So, a lot of what I do is talk­ing about how does pain work in your body, why is it ok for you to have sex­u­al inter­course, why is it ok to let your blad­der fill even though it’s painful, why is it ok for you to get on with your life basically.

Evans: It seems like a reas­sur­ance thing, rather than treat­ment, per­haps the treat­ment is the reassurance?

Petersen: Well, absolute­ly. So the newest research that’s com­ing out in terms of what you might term as reas­sur­ance, what we might call explained pain, or help­ing the patient to recon­cep­tu­alise pain as not being due to dam­age or a pathol­o­gy or a bac­te­ria, but actu­al­ly due to a dys­func­tion in the ner­vous sys­tem. That can real­ly help patients to shift the way they live their life, or improve the qual­i­ty of their life. But the newest research also show that it prob­a­bly has a real impact on neu­ro­plas­tic­i­ty, so we can poten­tial­ly actu­al­ly change the ner­vous sys­tem by pro­vid­ing those expla­na­tions and get­ting the patient think­ing dif­fer­ent­ly about their pain.

Evans: Now neu­ro­plas­tic­i­ty, that’s a fan­cy term for rewiring the brain?

Peter­son: Rewiring the whole ner­vous sys­tem. So we tend to not just talk about the brain, but the brain’s influ­ence on the spinal cord, and on the periph­er­al ner­vous sys­tem, so the hyper­sen­si­tiv­i­ty in the periph­er­al recep­tors is impor­tant. So we shouldn’t just be talk­ing about the brain, we should also be talk­ing about the con­nec­tion between the brain and the painful struc­ture and all the con­nec­tions that could be affect­ed by neuroplasticity

Evans: So as a man, as in many men, if I had enough courage to come to you, a woman as well, about prob­lems down below and you start­ed on at me and said, “This is all in the mind, this is all in the head” — I mean how do you bridge that gap?

Petersen: It very much depends on the patient and what knowl­edge and beliefs they already have. By the time they come to see me they’ve already seen one of our pain con­sul­tants, who will have intro­duced them to the con­cept of chron­ic pain. Often they will have seen one of our pain nurs­es, talk­ing about med­ica­tion, they will also have intro­duced them to the con­cept of chron­ic pain. They may also have attend­ed what we call an infor­ma­tion ses­sion for peo­ple with chron­ic abdom­i­nal pelvic pain, which is this unique oppor­tu­ni­ty for men to be in a forum with oth­er men with sim­i­lar prob­lems. And again we talk about chron­ic pain mech­a­nisms, prac­ti­cal strate­gies to man­age pain long term. And that real­ly means that by the time they come to see me I can sit them down indi­vid­u­al­ly and ask them, what do you think of that mod­el, does that fit with your symp­toms, does that fit with what you’ve been told, is there any­thing we need to recon­cep­tu­alise so to speak, or help you under­stand? Of course some patients will say “This is not for me, I’m still look­ing for a med­ical solution”.

Evans: I know very few men who would admit to hav­ing pelvic pain.

Petersen: I think you’re absolute­ly right and hence why it’s so impor­tant to air it today for exam­ple, but also get the infor­ma­tion out there, that there are ser­vices that can help, there are a large pro­por­tion of men out there with chron­ic pelvic pain and abdom­i­nal pain, and it can be treat­ed in the same way as any oth­er chron­ic pain con­di­tion. And it should be recog­nised, and hope­ful­ly if we can val­i­date it and nor­malise it for men, they’re much more like­ly to come for­ward and talk about it.

Evans: What advice would you give to men who have pain who are per­haps too shy to talk about it?

Petersen: Well, one of the things that Doc­tor Williams, one of our research psy­chol­o­gists, did was look at what’s avail­able on the inter­net. So my first advice is don’t go on the inter­net, because unfor­tu­nate­ly there is very lit­tle out there and the infor­ma­tion is not good, and not real­ly in line with cur­rent practice.

In the study that Williams did she also asked men, after they’d had con­sul­ta­tions, what were their main con­cerns. And I was inter­est­ed to hear that men weren’t nec­es­sar­i­ly over­ly con­cerned about a sin­is­ter dis­ease such as can­cer, they were actu­al­ly just more con­cerned about a prop­er expla­na­tion. And that does require in the first instance an exam­i­na­tion and rul­ing out any sin­is­ter dis­ease. But then it does require prob­a­bly a pain spe­cial­ist to enable patients to ful­ly under­stand the mech­a­nisms, because the last thing we want is going straight from, “You haven’t got can­cer, it’s all in your head”, that’s not helpful.

I also have to say that lots of GPs will not know what to do with pelvic pain. They wouldn’t know where to send them. But there is a pelvic pain net­work, which is a char­i­ty, which I would rec­om­mend peo­ple look at as well, because that will list pelvic pain ser­vices that you can say to your GP, I know there’s a pelvic pain ser­vice here, please could I at least have a chance of being assessed there and see what’s going on.

Evans: So being fore­armed with a lit­tle bit of good infor­ma­tion to help your GP help you is a good idea?

Petersen: Yes, most cer­tain­ly. The GP will be main­ly con­cerned with rul­ing out any seri­ous under­ly­ing pathol­o­gy or dis­ease, after that it is hard for GPs to know exact­ly what to do because these ser­vices for chron­ic male pelvic pain are few and far between. But there are ser­vices out there that will see men and sup­port them with what is essen­tial­ly a very dif­fi­cult condition.

Evans: Katrine Peter­son, spe­cial­ist phys­io­ther­a­pist at Uni­ver­si­ty Col­lege Lon­don Hospital’s pain man­age­ment centre.

I’ll just remind you that whilst we in Pain Con­cern believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound, based on the best judg­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well­be­ing. He or she is the only per­son who knows you, your cir­cum­stances and there­fore the appro­pri­ate action to take on your behalf.

Don’t for­get that you can down­load all edi­tions of Air­ing Pain from Pain Concern’s web­site, which is painconcern.org.uk. For Pain Concern’s YouTube chan­nel, just put Pain Con­cern and YouTube into your search engine, and the same applies to Facebook.

Now at the start of the pro­gramme we heard Pro­fes­sor Ed Keogh talk­ing about gen­der dif­fer­ences in the expe­ri­ence of chron­ic pain, and so to end this edi­tion of Air­ing Pain how rel­e­vant is this study of men, mas­culin­i­ty and pain to women?

Keogh: When you start think­ing about gen­der and you start talk­ing about mas­culin­i­ty and fem­i­nin­i­ty, well actu­al­ly these are very flu­id terms. They apply equal­ly to both men and women, ok quite clear­ly when we think about men we’ll be think­ing about mas­culin­i­ty, but these ways of think­ing, the beliefs we have, the norms we have, they’re rel­e­vant to both men and women. So I think by look­ing at the men’s health lit­er­a­ture this real­ly does apply to women’s pain as well as men’s pain. There’s a lot we can learn here that will hope­ful­ly help both men and women who are in pain.


Con­trib­u­tors:

  • Dr Ed Keogh, Deputy Direc­tor of Bath Cen­tre for Pain Research, Bath University
  • Katrine Petersen, Spe­cial­ist Phys­io­ther­a­pist at Uni­ver­si­ty Col­lege Lon­don Hospital’s Pain Man­age­ment Centre
  • Dr Jere­my Gauntlett-Gib­ert, Senior Clin­i­cal Psy­chol­o­gist of the Nation­al Spe­cial­ist Pain Ser­vice in Bath.

More infor­ma­tion:

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