Pain in persons who are marginalized by social conditions

Key points

1. 01Marginalized groups face a higher prevalence of painful conditions plus extra barriers to pain management, even though access to pain care is considered a basic human right.
2. 02Bias and discrimination from health systems, providers, and even family can lead to pain reports being discounted, distrusted, or dismissed.
3. 03Poverty, unstable housing, isolation, trauma, and adverse childhood experiences compound pain and limit access to care.
4. 04Many people avoid services after unsatisfactory or harmful experiences, then turn to unregulated options or rely on themselves.
5. 05An Equity-Oriented Care framework, combining trauma- and violence-informed care, harm reduction, and cultural safety, is proposed as the way forward.

How it was conducted

Design

Topical narrative review (PAIN journal Topical Review)

Scope

Pain prevalence, discrimination, access barriers, and management for socially and economically marginalized populations

Populations discussed

People who are indigenous, immigrants or refugees, of colour, LGBTQ2S, less educated, living with mental health or substance-use challenges, or affected by violence and trauma

Proposed framework

Equity-Oriented Care across three dimensions: trauma- and violence-informed care, harm reduction, and culturally safe care

What they found

• People experiencing homelessness with a history of post-traumatic stress disorder and abuse had disproportionately high levels of persistent moderate to severe pain and pain interference.
• Indigenous peoples in Canada show higher incidence of pain and pain-related disabilities of all types, yet are less likely to seek or access treatment because their pain is more often misunderstood or minimized.
• Transgender people who are older or have disabilities have higher rates of chronic pain than their cisgender counterparts.
• Black veterans in United States Veterans Health Administration primary care were screened less frequently for the presence and severity of pain than white patients.
• Indigenous women in British Columbia were reported to avoid care for themselves for fear of their children being apprehended, particularly if perceived to be drug seeking.
• Equity-Oriented Care has been associated with better mental and physical health outcomes, and early evidence suggests greater equity in care can be achieved through low-cost organizational changes.

Limitations

• The review notes relatively few studies have measured pain prevalence in marginalized populations, reflecting methodological challenges and possibly limited research interest.
• How extensive or representative biased provider interactions are in the lived experience of marginalized people has not been established empirically.
• Tertiary pain clinic studies often exclude people with mental health or substance-use disorders, so recruitment and exclusion criteria may skew the available data.
• Systematic guidelines for care of populations experiencing both pain and social marginalization have not yet been developed, with torture survivor guidelines a rare exception.

Why it matters

For patients

If you belong to a marginalized group, your pain may be more likely to be overlooked or doubted, so it can help to seek out providers and programs that practice culturally safe, trauma-informed care.

For clinicians

Assess current life conditions and trauma history, examine your own biases, and deliver interdisciplinary, biopsychosocial care that is trauma- and violence-informed, harm-reducing, and culturally safe.

For readers

Pain inequities are driven not just by biology but by social conditions and discrimination, and addressing them requires changing how care systems treat marginalized people.