Pain, psychology and culture: How our ethnic origin and culture affect perception and expression of pain

Canada is a multicultural nation. Ten years ago the percentage of foreign born in Canada was 18% (although it varied widely per province, city, urban and rural areas). Just to illustrate the point: immigrants comprised 27% of Ontario residents while in Toronto, the percentage of immigrants was 44% – higher than that of Sydney, Miami, Los Angeles or San Francisco and almost 3 times higher national average. Immigrants tend to concentrate in large cities and urban areas. Additionally, the type of immigrants to Canada has changed over the years. For example, before 1961, 92% of the immigrants arrived in Toronto from Europe. After 1990, the trend reversed, with 79% of immigrants were visible minorities originating from Asia primarily. As major events around the world shape socioeconomic conditions, the face of immigration will continue to change in our country and other countries. The recent downfall of European economies with sovereign debt has seen a surge of applications for immigration to Canada from Europe in the last couple of years. But why would a pain doctor like me, be interested in so many details on the composition of our Canadian fabric? Simply because a) research has shown differences in delivery of health care to ethnic groups and b) beliefs and reactions in regards to pain are heavily influenced by cultural background, socioeconomic status, education and sex.

According to Maryann Bates, a professor at the School of Education and Human Development at the State University of New York, there is a difference between what we call “culture” and what we call “ethnicity”. Culture involves “learned and shared styles of thought and behavior within the social structure of one’s world”. Ethnicity is different and refers specifically to the sense of “belonging in a particular social group”, members of which share traits such as religion, language, ancestry etc. within a larger cultural environment (excerpt from my book BEYOND PAIN).

Ethnic and cultural differences have a bearing on diagnosis and management of pain. Just think how different people in North America react to dental work with a whopping 99% routinely receiving local freezing as compared to only 10% of people in China. Fascinating research has documented that it is culture, not our genes, that determines how we react to pain. This, of course, is not to undermine the fact that there are many genes that may make us more vulnerable to pain. However, as in numerous other conditions, genes create vulnerability but do not determine our fate, and the environment (in this case culture) plays a major role in shaping our perception and reaction to pain.

As an immigrant myself, having come to Canada from Greece good 33 years ago, I am fascinated by the differences I see in people with chronic pain, many or most shaped by the environment from which they come and the environment in which they go. It is beyond the scope of this short paper to describe the topic properly. The interest reader can resort to my book and the research studies I have published on the topic. It is sufficient, however, to say that the way people express, interpret or react to pain is so different, that it compels myself and all health care providers to acquire an understanding and cultural sensitivity towards our patients.