Theory

Cultural variations in the experience of pain

Written by Agnes Raschauer

Text reference: Kohnen, Norbert (2009): Feeling and coping with pain in different cultures. In: Ruth Kutalek / Armin Prinz, eds. Essays in Medical Anthropology. The Austrian Ethnomedical Society after Thirty Years, p.321-328. LIT Verlag GmbH: Vienna.

Introduction

Generally, the experience of pain is either thought of as something purely individual or connected to biological processes that affect all human beings in a certain way. Thus, some people seem to have a high threshold for pain, while some people seem to have a lower one and might be considered oversensitive to pain. However, how humans experience pain and make sense of it, is not only subject to their individual tolerance level or simply given on the basis of biochemical reactions. Rather, experience of pain hinges on social ways of making sense of the world, which affect how bodily sensations are interpreted. In his paper, Norbert Kohnen delineates cultural variations in the concepts that underlie the experience of pain. Reviewing anthropological research, he gives a vast number of examples of how pain is experienced and processed in a culturally specific way. Being unaware of variations in how pain might be felt and expressed in different cultures can have negative effects for a medical practice, for example when a doctor thinks that a patient is not in pain when actually what happens is that the patient’s experience does not fit with the doctor’s preconceived ideas about how pain is felt.

Anthropologies demonstrating cultural variations in the experience of pain

Kohnen explains that while there are few cultural variations in the “sensation threshold [...] the lowest stimulus that results in tingling or warmth” (p. 321), the pain threshold is found to be highly variable. A very illustrative example is by Hardy et al. (1952), who reports that heat levels considered painful are experienced quite differently by people living in the Mediterranean and people living in Northern Europe. Heat levels the former define as “warm” are considered painful by the latter. The author further refers on the ground-breaking work of Mark Zborowski (1951, 1969) , who established that not only experience and expression of pain are highly variable and subject to culturally specific interpretations of the world, but also how communities deal with suffering members. He carried out anthropological research (interviewing, handing out surveys and doing observations on-site) in a veteran’s hospital ward, focusing on four patient groups: Irish Americans, Italian Americans, Jewish Americans and Old Americans. Zborowski concluded that while Irish American patients hardly talked about their pain and withdrew in isolation, Italian Americans tended to be quite outspoken about their suffering and in need of social contact. He also reported different approaches to pain in terms of how much weight a patient put on the fact that he was in pain and how much he trusted his own experiences.

Hardy, James Daniel, Harold George Wolff and Helen Goodell (1952): Pain sensations and Reactions. Baltimore: Williams & Wilkins.

Zborowski, Mark (1952): Cultural components in responses to pain. Journal of Social Issues 8: p. 16-30. Zborowski, Mark (1969): People in pain. San Francisco: Jossey-Bass.

“Cultural coping strategies”

Within anthropology the ways of handling pain that cultural communities develop are called cultural coping strategies (p. 323). These strategies build upon knowledge and traditions that have been passed down from previous generations and have long informed social practices of dealing with disease, pain and healing. They entail culturally accepted scenarios showing individuals how to act in the advent of pain and how to make sense of it. The “control beliefs” a cultural group holds on to be especially relevant for developing specific coping strategies. While the British, the Irish or people from Northern Europe are characterised as individual-oriented, with a tendency for an internal control belief, the Italian or the Turkish society are described as family-oriented with a tendency for an external control belief. This means that the former tend to focus on the individual when dealing with pain, keeping feelings inside and opting for social retreat. The latter, on the other hand, prefer the company of family members when suffering and also devise communal strategies for handling pain. Kohnen describes five distinct coping strategies and attributes each to an “ethnic and religious group” that it is characteristic for, while stressing that “all named strategies will be found proportionately within every culture” (p. 323). Among others, Kohnen names fatal strategies of coping with pain which entail attributing the ending of pain to a higher entity. As a consequence, the suffering individual has little obligation to act, i.e. to seek a doctor and to do “the right thing” in order to alleviate suffering. Sometimes magical practices are carried out which may have an impact on how the pain is experienced. Religious treatment of pain, customary e.g. among Christians or Buddhists, on the other hand conceptualises pain as a trial an individual has to endure in order to demonstrate his/her faith. A third concept is a rational treatment of pain in which pain is examined, attributed to a specific body part, monitored and subjected to professional medical treatment. An emotional approach towards pain seems out of place.

Conclusion: Attention toward cultural variations in experiencing pain needed in medical practice

Kohnen argues that treating pain as a universal, single phenomenon is detrimental to quality care. Patients might express their experience of pain in various ways: by retreating, by rationalising, by crying and demonstrating emotional distress. No one expression of pain is more valid or more indicative of a true suffering than the other. Holding on to the idea that the experience of pain and even the pain itself, as communicated by the patients, has to manifest a certain way, leads to misunderstandings, frustration and maybe even maltreatment of the patients’ conditions. “Every patient is an informant, but not every informant is a good one. Whether or not a patient is a good informant really depends on the examining doctor and how well they understand their patient and how well they are able to broaden the horizons and experiences of the informant.”.

Women and mothers: Meaning of their vulnerability in migration flows

Written by Alessandra Cannizzo

Text reference: “Donne e madri nella migrazione” (Women and mothers in migration) by Viapiana, S., Antrocom Online Journal of Anthropology, 2011; 7:1+, pp. 83-91.

Abstract

In recent years, the role of women in migration flows has also become crucial in terms of structural changes in the migrant communities. The new setting leads them to rethink their traditional values and norms when confronted with the different concepts, ideas and organisational structures of the host country, in terms of an understanding of the body and organisation of the social and health systems, etc. Migrant women are particularly affected by such re-signification and negotiation processes, especially as far as motherhood, marital relationships and bodily rituals (e.g. infibulation) are concerned.

Introduction

The paper by anthropologist Stefania Viapiana presents an interesting analysis offering practical examples on how some corporal practices and lifestyles vary according to the country and culture of the origin of the people. Firstly, the author introduces the concept of “double transit”, understood as the challenging situation experienced by the migrant woman who finds the values and norms of the host country different from hers, but also has to deal with the values of her culture of origin. Secondly, the author analyses the new challenge for migrant women fighting for autonomy from the authority of the husband in the new social context. References to eminent experts are offered in the text in an attempt to clarify some aspects of gender identity and to shed light on the meaning of practices of “female genital modifications”, taking up some cases for reflection. In the case of gender identity, some facts presented by the experts underline how in certain cultures the superiority of the man is perceived as a natural and biological matter, an idea which is greatly shared and actively contributed to by women themselves. The topic of female genital modifications is analysed through several examples indicating such practices as rituals that are preserved by women as part of the local tradition. Finally, a set of studies is presented, which highlights how some traditional practices become challenging for those women who are living as migrants in contact with Western populations.

Double transit of migrant women and aspects of ethno-psychiatry

The author offers an overview of research, including recent anthropological contributions, focusing on individual identity crisis experienced by migrants, and on the risk of overlooking gender identity issues in such contexts. A study by Levinson and Beneduce (2004) has shown that societies with lower incidences of violence against women are those where there is an efficient division of power between genders. Based on these results, the author states that conflicts arising after migration events are the outcome of changes experienced by the couple, which is modified by new life conditions. Therefore, the original idea proposed by Viapiana is that the migrant woman is fighting a new enemy that is the authority of her husband for the conquest of her autonomy in the new social context. Detailing the novelties introduced by the new setting where the migrant woman is living, the text further clarifies that the cultural identity of the woman becomes even more difficult with no support from family or from the parental group. Part of these difficulties is the fact that she is not able to resort to some of the rituals of the origin country, a circumstance that often causes psychological disorders. Many examples are related to childbirth, for instance as to the protection of the baby from demons (e.g. djinn in the Maghreb region) or special food and hygiene habits for both the baby and the future/new mother. According to Ba, it is possible to define such ceremonies as real “transition rituals” (Ba, 1994, pp. 59-72) aimed at appeasing the fears and anxieties of the woman who has just given birth and decreeing the arrival of the baby in the group. Viapiana offers her point of view on a “double transit” phenomenon, occurring when migrant women are “confronted by the novelty of the values and norms of the host country, whilst also being painfully removed from the values and practices of their culture of origin” (Viapiana, 2011, p.86, translated).

Gender identity and gender conflicts

In the second part of the publication the author expands on the theories of gender identity and gender conflicts elaborated by a range of experts and researchers, with the aim of providing a theoretical background to the explanation of cultural practices involving the body of migrant women in Western society. The anthropological theories and studies presented offer an overview of the social and cultural construction of the identity of the woman as inferior to men, symbolically and practically. The unequal relationship between men and women is also represented in the different concepts and practices around the body of the woman and her characteristics perceived as inherent “natural” handicaps, such as fragility, less weight, less stature, pregnancy and breastfeeding (Nahoum-Grappe, 1996; Héritier, 2002). In these regards, Héritier argues that the concept of otherness started from something seen as interrupting the world’s harmony, maybe a transgression (she recalls the notion of lost paradise). For instance, Western African mythology holds that women and men used to live in separate and independent groups and were able to reproduce autonomously. Afterwards, the discovery by men of women’s bodies as a source of pleasure and not related to reproduction, offended the creator divinity, which therefore forced men and women to live together. This tradition is not an isolated case as many cultures worldwide have myths where women give birth without any male contribution and are rather fecundated by natural elements (wind, sea) or by parthenogenesis. Moisseeff (1997) proposes another interesting example by stressing how the relationship between settlers and colonised populations, and in general between dominators and dominated people, has an impact and relevance especially in the spheres of sexuality, body, reproduction and gender roles. The author links the conflicts related to gender to the resistance that the developing economies oppose to the increasing cultural hegemony of more economically developed countries.

Infibulation, abscission, identity: the marks on the body

This section of the paper examines the reality of the corporal practices exercised on women’s bodies, supported by some examples from different cultural traditions. Systems of signs, mythic and ritual customs focusing on the body of the woman and her sexuality are widely present in several societies. Viapiana stresses the prevalence of such processes controlling the reproductive sphere of the woman, and carrying a wide range of meanings and purposes, for instance purification, marking the passage from childhood to womanhood, or reinstating harmony and social order in contrast with the disorderly female body. Female genital modifications are practices that could be found since before the emergence of the major world religions (Islamic, Jewish and Christian) and are a persisting ritual for the maintenance of power relations among dominant and subordinate cultures. Different rituals related to such modifications exist in different societies (Ethiopia, Saudi Arabia, Somalia, Egypt and Sudan), where infibulation prevails in order to control the sexuality and virginity of women. Sometimes, it also has the meaning of purification or is intended as the removal of a remotely-masculine body part (the clitoris) to force the female child into the “correct” sexual category (e.g. the Dogon tribe in Mali, studied by Griaule in the 1930s). Through such examples and studies, Viapiana underlines how the integrity of the body, can be listed among one of the most challenging values when it comes to the encounter of different cultures. Different rationales exist for marking the body (e.g. the regulation of power dynamics, as stated by Augé, 2002), which convey different meanings and certainly influence the psyche of the “marked” woman. The experience of infibulation is hardly revealed by migrant women; however, as the author stresses, they refer to it as a fundamental experience in their life, necessary to comply with aesthetic standards of beauty of the female body in their culture of origin (Fusaschi, 2003). Viapiana emphasises the deeply conflicting values of Western and other societies surrounding female genital modifications, a conflict that migrant women from infibulation-practising countries are bound to experience in the host country. Van der Kwaak, (1992, pp. 777-787) remarks that for instance in Somalia chastity and the control of female sexuality are deeply linked to the definition of female identity itself. In this context, infibulation has an initiation value that is expressed by both the ritual and the language used, in fact, before the surgery a girl is called gabar (“small girl”), whereas after she becomes qabar dhoocil (“infibulated girl”) and therefore “a marriageable girl” for whom the future husband will have to pay “the bride’s price”. In addition to that, the fact that girl’s hair gets shaved makes even more explicit the initiation meaning of the ritual.

Conclusion

The current immigration system introduces some challenges in the everyday life of those who flee their countries, as well as in the life of the population in the receiving countries. Undoubtedly, women are the most vulnerable in these processes, first and foremost because they are mothers and because of the different meanings attached to their bodies. As supported by Viapiana through several references to a number of studies, migrant women are called to face a “double transit”, as they must confront both the values and norms of the host country, while having to deal with the values of their culture of origin. On the one hand, the author offers in the text a critical understanding of different practices surrounding the female body in cultures other than the Western. On the other hand, she shows a great distance between the values of the migrant communities and those of the host countries (although with some commonalities, such as the binary conception of female and male), underlining an even greater difficulty for migrant women to negotiate between dominant values in their culture of origin and of those in the receiving society. To conclude the author provides food for thought allowing the clarification of the role of women in societies affected by migration. Given the variety of examples and the diversity of the authors cited, the text is an accessible introduction to the challenging aspects of cultural diversity related to health.