‘We have failed them’: Studies overlook sex, gender in veteran pain care

A recent study on chronic pain management for Canadian veterans has exposed a serious flaw in two decades of research: none examined the effect of sex or gender on the effectiveness of treatment.

Experts say it’s another example of how the health of women and gender-diverse people is under-studied, leading to generalized clinical recommendations that may not be appropriate for all veterans given the fundamental differences between female and male bodies.

“I’m a huge advocate for veterans and I think we’ve failed them in this country,” said Ramesh Zacharias, president and CEO of the Chronic Pain Center of Excellence for Canadian Veterans, which is behind the study.

“We have an ethical contract with them and we have not lived up to it.”

Canadian veterans suffer from chronic pain at a higher rate than the general population. A 2016 study found that 40 percent of male veterans and 50 percent of female veterans are affected by chronic pain, compared to 20 percent nationally.

These were the data that inspired the establishment of the Chronic Pain Center of Excellence in 2020, Independent Research Center in HKAMILTON is funded by Veterans Affairs Canada.

The center began work to determine how widely researchers have considered the impact of sex and gender on pain management in veterans. The research looked at 21 studies on opioids and rehabilitation treatment between January 2000 and February 2021.

None of the studies described how information about participants’ sex or gender was measured or incorporated into the study design. The studies also did not discuss how sex and gender differences might have affected treatment outcomes or outcomes.

The study says this creates gaps in care because biological characteristics and socially shaped gender identity can significantly influence a person’s chronic pain symptoms, access to care, and health outcomes.

Joy McDiarmid, one of the study’s authors, said this difference is not exclusive to veterans. Historically, women have been excluded from health care research, leading to generalized results and conclusions.

“Not only were women excluded as participants, but often the scientists were also predominantly male,” said McDiarmid, a professor of physical therapy at Western University in London, Ontario.

“And so perhaps the issues that were important to women were not seen as important issues to study in science. There has been improvement, but we have further progress.”

According to Veterans Affairs Canada, about 14 per cent of the 670,000 veterans in Canada are women.

McDiarmid said gender and sex influence how veterans experience their military service, which is why it is so important to have tailored treatment and rehabilitation.

For example, equipment designed primarily for male members may cause physical injury to female members because it sometimes does not fit properly. At the same time, she said, female members have to endure pain to “prove themselves” in a male-dominated field.

“If you’re afraid to ask for help with something because you don’t want to look weak, it puts you at risk,” said McDiarmid, who will receive the Order of Ontario in 2024 for her contributions to patient-centred care.

As a result of the findings, the Center of Excellence has included gender and sex in its research grant review process, meaning researchers are now required to explain how gender and sex will be considered in research.

The Canadian Institutes of Health Research, the federal agency responsible for funding health and medical research, already requires applicants to integrate sex and gender into their research designs and practices “when appropriate,” according to its website.

Alice Aiken, a Canadian Navy veteran and Halifax-based researcher, said incorporating sex and gender in health care research is important to better inform Canadian doctors about veterans’ unique health considerations.

He said she did not look like a “typical veteran”. No health care professional ever asked him if he was a veteran.

“On the other hand, my husband still gets a military haircut and is often asked if he is a veteran,” said Aiken, who is also co-founder of the Canadian Institute for Military and Veteran Health Research.

It’s an important part of a person’s overall health puzzle, he said. Knowing this information gives health care providers a complete picture of the different risks they face that can better inform diagnosis and care.

Researching treatments specific to women and gender-diverse individuals is important for improving care and overcoming systemic barriers in the health care system, such as dismissing symptoms or misdiagnosing them, Aiken said.

“I think anyone can intuitively understand that the physiology of women and men is not the same. And perhaps if you’re going to recommend a drug, it should be tested on both women and men,” Aiken said.

McDiarmid said Canadians owe a huge debt to veterans, which is why the special research is important.

“They have put their health and their lives on the line for the well-being of Canadians,” he said.

Zacharias said half of the patients he treats in his practice are veterans, many of whom come to him “broken with no hope.”

“But to me, there’s a lot of hope for them,” Zacharias said, becoming emotional at times.

“We know more about pain today than we did five years ago, and to improve quality of life we ​​need to bring it to the bedside and into their cafes, into the military, wherever they are.”

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