Sex and Gender Differences in Pain: A Chat With Edmund Keogh

Editor’s Note: This interview originally appeared on the IASP Pain Research Forum, and has been lightly adapted for RELIEF.

Edmund Keogh

Edmund Keogh, PhD, is a professor of psychology in the Department of Psychology at the University of Bath, UK, and is the deputy director of the Centre for Pain Research there. His main research area is the psychology of pain, with a particularly strong interest in sex and gender differences in pain, including the role of emotions and coping. Keogh recently spoke by phone with Lincoln Tracy, a research fellow from Monash University, Melbourne, Australia, to discuss his journey into pain research, his interest in the social aspects of the pain experience, and his love of music from the 1980s. Below is an edited transcript of their conversation.

What first got you interested in science?

I remember my first day in psychology as part of my bachelor of science degree. I was absolutely enthralled by everything I was hearing, and I thought, “Right, this is for me; this is what I want to do.” I was captured from that day onward. Pain first captured my attention in my second-year biopsychology course unit, when we had a six-week block of material on pain.

However, I didn’t start my research by focusing on pain. For my PhD, I was looking at the way in which anxiety influences cognitive processes. In particular, I was interested in how anxiety affected attentional processing. After I finished my PhD, I became very interested in the concept of anxiety sensitivity, which refers to the fear of bodily sensations related to anxiety. For example, a rapidly beating heart following exercise—a sensation that can be associated with anxiety—could be interpreted as an impending heart attack. There’s quite a close link there to pain, as an anxiety-causing bodily sensation that needs to be interpreted. So I think the foundations for a career in pain were all there, even though I didn’t know it at the time.

Throughout your career, you’ve done a lot of research on sex and gender differences in pain. What made you interested in this area?

After I finished my PhD, I was looking for some new and interesting ideas. There were a few studies starting to emerge suggesting that there might be sex differences in anxiety sensitivity. So it all came together for me from these studies and the interest I had in pain research. This area was absolutely fascinating, and I wanted to develop this research even further. This led to my first experimental pain study, which was on sex differences in anxiety sensitivity and pain perception.

You recently published a paper with [pain psychology researcher] Christopher Eccleston and one of your PhD students, Rhiannon Edwards, which looked at the interpersonal relationship men and women had with an observer, and how that affected the way they responded to experimentally induced pain. How did this study come about?

This was Rhiannon’s PhD work. In this series of studies, Rhiannon wanted to investigate how the person you are with at a time when you’re in pain influences your experience of pain. We know that there are biological, psychological, and social influences on pain. There has been a lot of work on the biological and psychological aspects, but the social aspects haven’t received as much attention. Therefore, there’s a clear gap in our knowledge, and we’re slowly beginning to see more research focusing on the social context in which pain occurs.

For example, when working with children and adolescents, parental effects are very important. When pediatric pain studies recruit parents, many studies find they get more mothers than fathers volunteering. This creates an issue, a possible bias. This has certainly been recognized, and is being addressed, but it shows that there are issues with methodology and recruitment that need to be overcome in human studies. But there is definitely evidence suggesting that whom you have with you exerts an important effect on the experience of pain.

This paper showed that having an observer in the room with a study participant who was exposed to experimental pain resulted in an increase in pain threshold [the point at which people report they feel pain] and tolerance [the ability to withstand pain]. This was particularly true for male participants when the observer was a male friend. Was there anything about these results that surprised you?

Yes—it was almost more surprising what we didn’t see, compared to what we did observe. If anything, we expected that when the observer was a stranger, there would be a more pronounced effect on pain threshold and tolerance, but there wasn’t. But probably the most interesting thing was that when participants were allowed to choose a friend to bring along to the testing session, all the male participants brought a male friend, and all the female participants brought a female friend. Whether that was just a coincidence, I don’t know, but we certainly didn’t instruct people to do that. Regardless, it was an interesting observation that may have had an effect on the outcome.

What’s the most interesting study you have been involved with during your career?

One of the most fascinating studies was one that I undertook in the early 2000s. We were looking at women’s experiences of elective caesarean sections, particularly in the context of pain prior, during, and after the procedure. At the time, I was very interested in anxiety sensitivity, and whether this [predicted who would go on to develop] post-operative pain. What was really interesting about this study was that it looked at the social context, the role of the birth partner, and the anxiety within these settings.

It was an incredibly emotive experience just being involved in this study as a human being and getting to see the emotions that both the women and their birth partners were going through. This study really touched me, and emphasized the role of psychology in pain. It highlighted the importance of the social context—the support that the whole medical team was giving throughout the entire process. I come back to this study time and time again, as it really reminds me of the importance of psychology and social context.

What projects are you working on now?

Over the past four or five years I’ve been slowly chipping away at trying to understand the social communication of pain, particularly with respect to nonverbal communication—that is, the way in which we communicate pain to other people through nonverbal signals, including facial expressions, vocalizations, body movements, and posture. While this certainly isn’t a new idea, there really is a lot of interesting research around this.

I’ve become quite interested in whether or not sex and gender play a role not only in how we communicate pain to others, but also in the way in which we might interpret and respond to these cues in others. I’m really trying to bring all these ideas together and think about how this line of research is relevant to real-life situations, such as during interactions between healthcare professionals and patients. If you look beyond pain to more emotion-based research, then these differences definitely do exist. So a big question for me at the moment is whether the same sort of thing happens in the context of pain.

Looking forward to the next five or 10 years, what is there about the psychology of pain that you would like to know that we don’t currently understand?

I would like to see a much greater emphasis on individual differences, and sex and gender are just two such examples. I’d like to see a change in research practice in terms of designing studies that take the possibility of sex and gender differences into consideration. However, it’s also really important that studies look at whether there are no differences. The absence of a difference is often just as important as a difference, and it is really important that we know these things. The differences between the sexes are becoming more commonly acknowledged, but it is important that this is taken into account when we recruit participants into clinical trials and report our findings.

From my own experience, I was recently involved in a marvelous systematic review [a type of scientific article that analyzes a number of published papers in a particular area of research] led by Katelynn Boerner, along with Christine Chambers and Christopher Eccleston [all pain psychologists]. We focused on whether there were sex differences in psychological treatments for pain in adolescents. It is very telling when you look at the results, because you soon realize how difficult it is to do these kinds of reviews. It’s not standard practice to report similarities or differences between male and female study participants. It’s very difficult to conduct this sort of work, so I would like to see this more detailed reporting integrated into standard practice.

If you could be at a dinner party with anyone from history, dead or alive, whom would you want at the table with you?

That’s an easy one. From my discovery and subsequent love of music from the 1980s, I would love to have David Bowie at the table with me. Since his death in 2016, I’ve enjoyed listening to anecdotes about the different aspects of his life, and what he was like outside of the public domain. He always seemed to laugh a lot, having fun and enjoying himself. And of course there is the creative side, the innovation and seeking out change, the new ideas and new ways of thinking. These are things we can aspire to not only in our lives, but in our research, too.

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