Background & Aims
Ethnic and racial differences in experimental pain sensitivity (Kim et al.,2017) and disparities in pain treatment (Morales & Young, 2021) are well documented, primarily comparing African-American (AA) (Asian/Hispanics) and non-Hispanic whites (NHW). In Germany, people from Turkey are one of the largest immigrant groups. When they experience chronic pain, there is a tendency to perceive them as overly expressing and exaggerating their pain, putting them at risk for under-treatment. Thus far, there has been a lack of investigation into the pain experience and expression of immigrants with a Turkish background. Studies on ethnicity also often overlook acculturation. Acculturation refers to the process of adopting elements of a foreign culture, and an individual can be acculturated to both the original and foreign cultures. Our aim was to experimentally explore the impact of ethnicity and acculturation on pain experience and expression in adults with a Turkish immigrant background.
Methods
N=40 students with a Turkish background (TUR; born in Germany, parents born in Turkey and as adults having migrated to Germany) and 40 German (GER) students, matched by age (M= 23.83 yr, SD= 3.2) and gender (67% female), participated. In order to rule out education as a confounder, only students were recruited. Among the TUR participants, 50% were German acculturated (TUR-Ger), while the other 50% were Turkish acculturated (TUR-Tur) using the Vancouver Index of Acculturation (Ryder et al., 2000). Participants underwent a cold pressor test (CPT; 3°C; max. duration: 3 min) with a baseline (5 min) prior to hand immersion. Subjective pain intensity 10 s after hand immersion, pain tolerance (latency of hand withdrawal), pain-related facial expression (e.g. brow lowering) 20 s after hand immersion, blood pressure (BP) and perceived stress during the CPT were obtained as outcome measures. Pain-specific facial expression was coded using the FACS (Ekman Friesen, 1978).
Results
TUR-Ger participants rated their pain intensity at 10 s after hand immersion as significantly higher than the GER participants. Ratings of TUR-Tur participants fell in between these groups. Moreover, TUR-Ger participants reported significantly more stress during the CPT than both TUR-Tur and GER participants. Among those participants removing their hand prior to the maximum duration (3 min), hand withdrawal latency did not differ significantly between groups, although moderate effects sizes indicated that both TUR groups had shorter latencies than the GER participants. In all three groups between 65 and 80% of the participants withdrew their hand before the end of immersion time. Facial pain expression increased significantly from baseline up to 20 s after hand immersion with no difference between the three groups. BP during the CPT was significantly higher than during baseline, with no significant group differences, thus ruling out a differential impact of BP on the pain response.
Conclusions
Consistent with the literature on greater pain sensitivity in AA compared to NHW, TUR participants reported higher pain intensity than their GER counterparts. Moreover, moderate effect sizes for lower pain tolerance in TUR compared to GER participants were observed. Interestingly, the German acculturated TUR participants were the most pain sensitive, and reported greater stress during the CPT. However, they did not exhibit more facial pain expression, suggesting suppressed rather than enhanced pain expression (Karmann et al., 2015), which may even account for their heightened stress levels. This might also reflect higher stress level in 2ndgeneration immigrants as found previously (Tonsing, 2014). A limitation might be the highly educated and young sample. However, the participants were carefully matched to ensure equal exposure to German culture. This study is one of the first to compare ethnicities outside the US, and one of very few to objectively assess pain expression.
References
Ekman, P., & Friesen, W. V. (1978). Facial Action Coding System: A Technique for the Measurement of Facial Movement.
Karmann, A. J., Lautenbacher, S., & Kunz, M. (2015). The role of inhibitory mechanisms in the regulation of facial expressiveness during pain. Biological Psychology, 104, 82-89.
Kim, H.J., Yang, G.S., Greenspan, J.D., Downton, K.D., Griffith, K.A., Renn, C.L., Johantgen, M., & Dorsey, S.G. (2017). Racial and ethnic differences in experimental pain sensitivity: Systematic review and meta-analysis. Pain, 158, 194-211.
Morales, M.E., & Yong, R. (2021), Racial and ethnic disparities in the treatment of chronic pain. Pain Med, 22, 75-90.
Ryder, A.G., Alden, L., & Paulhus, D.L. (2000). Is acculturation unidimensional or bidimensional?: A head-to-head comparison in the prediction of demographics, personality, self-identity, and adjustment. J Pers Soc Psychol, 79, 49-65.
Tonsing, K. N. (2014). Acculturation and adaptation of first- and second-generation South Asians in Hong Kong: South Asians in Hong Kong. International J Soc Welfare, 23(4), 410–420.