Ethnic American Pain Responses
Anglo-Americans. Anglo-American chronic pain responses are often nonexpressive, as they live with pain but do not display pain behavior (Bates et al., 1995). An emphasis on individual responsibility for pain management reflects cultural values of autonomy and control of one's life. A dominant coping strategy is to isolate oneself and to be alone. Another strategy to cope with chronic pain involves staying active. The view of the physical body as the source of pain often makes treatment programs based on psychological, cognitive, or behavioral approaches ineffective and leads to an extensive reliance on surgical interventions to remove the cause of pain. Nonetheless, intra-cultural variation is also important, and some Anglo-Americans find that psychological approaches provide relief. The "old American" stoic response to pain no longer applies to many contemporary Americans, who may engage in a hedonistic use of pain killers. Euro-American providers may still have the expectation of a stoic endurance of pain rather than an open expression of suffering or indulgence in medication.
Hispanic Americans . Hispanic Americans tend to have a high degree of expressiveness of their pain and high-intensity experiences of that pain (Bates and Edwards, 1998), but general expression of pain may not always be given in clinical settings because it contradicts cultural values. The value placed on endurance in machismo inhibits men from an open expression of pain. Pain expression may be considered more appropriate for women, but there is a cultural value on silent suffering and endurance. Women in labor, however, may be vocal in their expression of pain. The arrival of the woman's husband often results in longer and louder cries, a communication to the husband of the suffering she is enduring on account of her pregnancy. Pain can play an important role in making Hispanics aware of the need to seek treatment. If there is an absence of that encourage emotional expressiveness of pain may require less attention to their symptoms than patients from cultures where stoicism and lack of pain expression are expected. The cultural background may alert providers that they need to pay attention to patients who complain minimally but are experiencing serious pain and need to take pain medication. For example, failure to emphasize pain needs to be considered in the context of a cultural tendency toward repression and denial, whereas vocal and expressive complaints need to be put in the context of cultural emphasis on expressiveness. Understanding these cultural influences is essential to correctly interpreting the significance of a patient's complaints.
Differences between U.S. norms and those of other cultural groups affect practitioners' ability to accurately interpret pain expression by ethnic clients. Culturally competent medical management of pain requires that providers be aware of their own culturally mediated pain perceptions and those of their patients, requiring a detailed psychosocial and cultural history to determine variables affecting the chronic pain experience (Bates and Edwards, 1998). Without knowledge of their own cultural expectations regarding pain management, providers are more likely to be judgmental toward pain, good health may be presumed and treatment neglected. Pain expressions may also reflect somatization, with depression expressed in bodily symptoms.
African Americans. African American responses to pain have been characterized as highly varied, reflecting diverse influences on African American illness behavior and contextual or social influences on its expression. Silent suffering may reflect a lack of confidence in providers or the perception that they will not respond to the patient's needs. Conversely, empowerment and a sense that services will be provided to those who complain or demand them may lead to a far more vocal expression of pain. African Americans may also avoid pain medication because of the fear that they might become addicted.
Native Americans . Native American responses to pain are highly varied, reflecting the more than seven hundred Native American groups present in the United States. Kramer (1996) suggests that pain in Native Americans is often undertreated. This may be the result of pan-Native American emphases on passive endurance (Winkelman, 1998). The pain reports typical of this population may be indirect and general, expressed in reflections on how they feel uncomfortable, rather than direct complaints. Communication regarding pain may be indirectly through family members or friends, who are expected to relay this information to providers.
Chinese Americans. Responses to pain of Chinese Americans include the avoidance of medication either out of fear of addiction or because of acceptance of suffering. Chinese American patients may also decline offers of pain medication, relying on providers to determine their needs. Patients will not typically complain about their pain, requiring that providers be aware of nonverbal communication indicating pain, assess patients' likely experience of pain, and provide medications rather than wait for them to be requested.
patients who express pain in culturally different ways. This can negatively affect patientprovider relations and the care and treatment provided to patients. Awareness of the cultural basis of pain responses and experiences helps practitioners suspend their culturally based evaluative frameworks and understand the cultural dynamics of clients' expression of pain.
This awareness also helps providers respond appropriately to people from cultures in which the open expression of pain is not normative. If a culture emphasizes a stoic and silent suffering attitude toward pain, a provider cannot depend solely on clients' verbal statements regarding pain or their request for pain medication in assessing their needs but must look for nonverbal signs indicative of clients' need for pain medication.
A recognition of differences among ethnic or cultural groups in pain responses is not the same as stereotypes about pain responses within groups. Within cultures, there are also important differences in pain responses. But these differences are also culturally structured, with variations related to individual difference in locus of control, socioeconomic status, age, generation, consistency of ethnic heritage, and gender (Bates and Rankin-Hill, 1994).
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