April 30th, 2007: How Men Cope with Pain—Don’t pity me or I’’ll break

Let me begin with an incident in my family.
As always, my youngest son, Gabriel, had pulled out the plastic inside bucket from his diaper pale and was hauling it through the house. (The bucket is actually never used for diapers, but has merely devolved—you might also say”evolved”—into another of his toys. When Gabriel tried to take the bucket down to our basement, he fell down a few steps and scratched his cheek on the sharp edge of the bucket. He cried, but only for a very short time. Approx. 10 seconds longer than it took to get to him, pick him up and speak to him calmly. He had a pretty bad gash on his cheek. It was bleeding and needed quite a bit of dabbing until the bleeding stopped. Gabriel seemed unconcerned now, not paying attention to the fall, the gash or the scare anymore. He was playing again.
His brother, Jacob, watched with obviously growing fascination. I had a feeling I knew what he would ask me. Five minutes later, after some equally obvious heavy processing, he remarked: “It didn’t take long for Gabriel to stop crying. But that is a pretty bad cut. I don’t think I could or would have stopped crying so quickly. Why did he not cry longer?”

He was right! Gabriel’s reaction and coping with the pain and shock he must have felt during and after the fall was remarkably short. However, I told Jacob: “You had very similar responses to pain and shock when you were Gabriel’s age. And so did Noah.” He had a hard time believing me. How can you not cry in pain and be scared for a while when you have a bleeding gash on your cheek, he wondered.

So, here are some of the questions that emerge from this story:

How did he cope so fast?
How might he have perceived his fall and hurt?
How did my reaction to his fall affect his sense of pain?
How can we make sense of the discrepancy between his felt pain and our perceived sense of his felt pain?

My sense is that, in order to understand his reaction and that of many other males in similar situations (independent of their age), we need to distinguish between how males experience physical pain and how they experience emotional pain. Yes, in many cases both pains are experienced at the same time, but they are, nevertheless, two quite distinct phenomena. I even think it’s possible that we have misunderstood this difference as either to mean that men don’t really experience emotional pain at all or that they should deal with their emotional pain in the same way they seem to be able to deal with physical pain, i.e., tough it out.

And, then, there is a third phenomenon around male pain: it’s about the question of how men feel about the pain they’re experiencing. My experience is that men, almost invariably experience their pain, at least to some degree, as shameful. I will discuss the consequences of this shame in more detail later, after we will have gained a better understanding of the different ways in which men are said to experience physical and emotional pain.

The Difference between Emotional and Physical Pain in Men

Recent findings in the study of the effects of sex-hormones on brain development seem to be suggesting that men’s genetic and physical constitution makes them, overall, less sensitive than females to their own pain and that of others. Central to this suggestion is the realization that the brain does not only respond to hormones associated with the reproductive cycle (estrogens and androgens), but that it is indeed shaped by them throughout all stages of brain development, i.e., the life-time of the human being.

One of the starting points for these studies is the significant discrepancy between males and females when it comes to reports of pain and pain-related diagnoses. Females report pain more often and tend to be more frequently diagnosed with diseases such as fibromyalgia, migraines, etc. Females also tend to be more frequently diagnosed with depression and anxiety disorders whereas men are more frequently diagnosed with alcoholism and other addiction disorders.

Here is a summary of some of the research that has been published on this issue between 2002 and 2006.

In an article titled “Autism linked to Male Sex Hormones” published in 2004, Simon Baron-Cohen explains the idea that “autism might be an extreme of the male brain”. Traits of persons with autism such as trouble holding steady eye-contact, social difficulties as well as hyper-focusing are, according to Baron-Cohen, possibly only the extremes of how males behave anyway.

In an article titled “Revenge Replaces Empathy in Male Brain” a team of British Researchers is credited with finding that males seem more likely than females to experience a condition they call “Schadenfreude” (i.e., one’s relief at someone else’s deserved misfortune).

Meir Steiner and her team at McMaster University are finding that early exposure to higher levels of testosterone seems to affect pain-sensitivity and morphine sensitivity in males and females.

Jon-Kar Zubieta at the University of Michigan has been studying gender-differences in response to pain-stimulation. He has found that men seem to be able to release higher levels of endorphins and enkaphalins that tend to suppress strong sensations of pain. However, during higher levels of estrogen production in the female reproductive cycle females ability to suppress pain matched that of males and, in some cases, even surpassed it.

Lisa Galea at the University of British Columbia has found that different levels of estradiol in the male and female brain affects both brain-development (specifically, development in the memory related parts of the brain (dentate gyrus)) and the preservation of newly formed brain-cells. Whereas in males estradiol’s protective function of brain-cells is only temporary, it seems to last for a life-time in females. These findings might have implications for males ability to retain information specifically also about painful events.

Empathy centers in the brains of female participants lit up just as they had when they watched the "fair" players endure pain.
"However, these empathy-related responses were significantly reduced in males when observing an unfair person receiving pain," the researchers noted.
What's more, "this effect [in males] was accompanied by increased activation in reward-related areas, correlated with an expressed desire for revenge," they added.
These reward areas include more primitive brain regions such as the striatal system[1] and


the nucleus accumbens,[2] they said.
This means that "for men, at least, the brain's reward system is activated when there's punishment of the bad guys," said neuroscientist Dr. Paul Sanberg, director of the Center for Excellence for Aging and Brain Repair at the University of South Florida College of Medicine in Tampa. "These are the same areas that are involved in reward for drugs and other things we want badly."
In fact, a similar brain-imaging study reported in Science last August found that revenge activates neurological centers linked to other strong urges, such as cocaine abuse or sexual attraction.

I believe that this research has great potential to explain the relatively short period of time it took Gabriel to recover from the pain of his fall and the scratch he sustained in the process. But it would be too easy to assume that his quick “recovery” also meant that his feelings about the fall had returned back to normal. In fact, even though he seemed okay and went back to playing he seemed just a tad more clingy and more easily frustrated for about two hours after the fall. Clearly, his emotional resilience had not yet returned to its pre-fall state. He seemed to feel more threatened by being alone, more vulnerable and unprotected, perhaps.

My observation about Gabriel, my other sons as well as many other boys in similar situations was that they seemed to perceive the absence of someone who recognized their mishap as more painful than the actual pain they were in. But, and I consider this to be crucial, someone recognizing the mishap did not mean, and still does not mean, that we could simply shower them with compassion, soothing sounds and a surplus of loving care. Nor does it mean that they would want to be held more than before. They resented that and more than once I had to learn that too much of that kind of recognition might lead to a quick change from needing recognition of some kind from me to being extremely angry at me.

Compare, for example, this situation I observed at a local day-care:

A four year old boy is hurt while playing on the jungle gym.
He cries and is holding his left leg.
Soon a female adult notices him, approaches and asks in a somewhat anxious voice: “What happened?”
Interestingly, the boy moves away from her. He is still crying but, strangely, seems to be aggressive at the same time.
The adult, not noticing his change in mood apparently, pursues him and grabs him: Don’t run away, let me look at your leg. Perhaps you need a band-aid.”
The boy growls at her, then hits her hard on the hand she is using to hold him.
The adult gets mad. She had let go when he hit her, but now grabs him again, harder and puts him in time-out without further tending to his leg.
Later, she discusses this incident with the boy’s parents questioning whether they have noticed an increased tendency in the boy to be aggressive with females.

The obvious question arising from this is “could it be that for boys too much care and compassion is perceived as threatening, perhaps even as more dangerous as the actual pain, threat or embarrassment”? But, one might ask, isn’t it intuitive to say that someone who fell or hurt himself in some other way will require and be open to being doted on? Won’t they welcome the loving, even if at times exaggerated attempts of their parents to “fix things”?

Most men I have come to know in my work and socially would agree with this boy’s reaction. It is okay to have someone recognize their pain. It is okay for someone to say they noticed. But it is not okay to have someone gush about it. That, actually, is uncomfortable and angering. Gushing and an exaggerated worry about health and related issues, in fact, seems to sent many boys and men directly into denial about even minor pains they might perceive.

Compare this anecdote from an interaction with a client I call Ted. As a child Ted had been severely and for many years abused by his father. It was Ted’s second session with me. We had begun to talk about his family of origin and he was in the process of explaining to me how his father executed corporeal punishment for Ted.

Ted: He would pull his belt out of his pants with a kind of grandiose gesture. Then let the belt snap a few times making a loud cracking sound.

Martin: You must have been so scared!

Ted: Actually, I was used to it. It was his ritual.
Well, so he would ask me to lie across a chair and begin to strap me. Always, he counted his blows. But I never knew how many I would get. The most I remember was fifty.

I could tell Ted was getting upset and felt it was necessary that I understood.

Martin: You must have been in a lot of pain.

Ted: Not really. (Squinting, swallowing). Continuing in a terse voice:
I just felt like killing him.

I made the same mistake twice in this exchange. I “overstated” what seemed “obviously” to be going on for Ted, both at the time of the beating and at the time of our session. I was fortunate that Ted didn’t just get up and leave thinking I would never understand him well.

To be sure, overstating doesn’t mean that Ted wasn’t scared or that he wasn’t in a lot of pain at the time of the beating. Overstating means that I zeroed in on those emotional and physical elements in a typical therapist’s fashion. In the process, I came close to suffocating Ted emotionally with the feelings and sensations from his relationship with his father. Ted needed space. He needed for me to be a good listener, but a matter-of-fact one, not one that would amplify his own feelings.

Problems with Mirroring

It took me a while to understand this, however. I blundered into similar situations with Ted a few times more before, one day, he stopped, looked at me and said:

“I hate telling you these things, because when I’m done and see your reaction I usually feel worse than I did before.”

I was just getting ready to make some smooth remark about how therapy often makes you feel worse before it makes you feel better, but I stopped myself. “when I’m done and see your reaction” he had said. So, I was “causing” him to feel bad? It almost angered me, to be confronted with what felt like Ted’s imperviousness to my well-meaning reflection on his pain. But there was not doubt he felt more in pain now than he did when he came in. What about mirroring, I thought? Am I not supposed to reflect back to him his emotional state? Is his reaction to me not simply the denial of his own emotional fracturedness?

It gradually dawned on me that I had not simply mirrored his own emotional state. Had I done that, I would have not “forced” the issue, but rather, like a real mirror, reflected back his own quite matter-of-fact narration of these incidents with his father. Quite likely I had not even necessarily exaggerated the pain he once and still felt about this, but I had minimized his ability to cope and deal with his pain. I had missed that, in telling me his story, he was demonstrating to me how he had been coping.

Mirroring someone’s pain is like taking a picture of that person at his worst moment. Boys and men I have found, hate, truly hate, looking at those pictures of themselves. Proceeding with that strategy becomes counterproductive fast as—in an attempt to show that they can “deal with it and cope”—men will often respond by hardening the wall of stoic determination they first created to protect themselves from the immediacy of their own pain. Ted’s responses to me—stoic remarks such as “not usually”, “not really”—highlight this phenomenon. He was determined not to let me handicap him, “make me weep” (as he said on another occasion). And, I believe, he was even more determined not to allow me any “Schadenfreude” at his at his expense.


What Can Take the Place of the Mirror?

My sense is that this strong reaction to “gushing” is, at least in part, caused by the perceived threat it presents to the man’s ability to prevail despite his pain. “Just because I’m crying doesn’t mean I’m weak. Don’t make me weak, don’t weaken my resolve to be strong.” It is my strong sense, too, that men’s strong need to retaliate, i.e., to cause pain to that which has caused them pain, is partially related to the reassertion of one’s self and one’s strength. You will likely be able to recall scenes from movies, books and plays where male characters, in a fight for dominance, are confronting each other “to the last”. In other words, even if they will have to suffer the ultimate pain, death, they will suffer it heroically, i.e., with honor and assertiveness.

It is quite likely that, as a male therapist facing my male clients, I have to be aware that simply by virtue of being male I am already a mirror of sorts. As that mirror I reflect back not only what I say back to the client, but also the entirety of the male behavioral code and patterns. I am a potential enemy, a wolf, clothed in the sheepskins of a therapist. For a boy or man to admit to another man that he is in pain, both physical and/or emotional, is dangerous. And, to be perfectly clear about this, it’s not that I am dangerous because I want to know about my client’s feelings. My danger to a male client lies in the possibility of me, a male, using his weakness against him.

Being aware of this helps me see that as a male therapist one of my foremost tasks is to demonstrate that I come in peace, not to attack. My first task is not to understand all the details and ins and outs of that male client’s psyche, but it is to connect with him in a climate of males that honor rather than threaten each other.

The “Lacking” Male

The strong interiority of many men’s emotional life surrounded by the exteriority of their will and determination to survive has led to many false conclusions about who men are emotionally. There has been, for a while, a general sense that men are simply in “denial” of their own pain and that of others. This is a view that is often held by women, but there are quite a few men, too, who have jumped to the same conclusion, essentially criticizing men for denying their pain rather than confronting it.

In her recent book, The Female Thing, Laura Kipnis describes this view as a

“fixation on the idea that men are lacking something, something crucial. Men are emotionally closed, they’re not receptive or empathetic, they can’t access their inner feelings—unlike the women issuing the complaints, whose openness and receptiveness were central to their self-conception. Men have no insides! Everything’s external with them! In other words, the obverse of classic male castration anxiety—you remember, the old story that girls are incomplete in some way, because the boy’s reaction to discovering that girls don’t have penises is the unconscious fear that he might lose his too.”

Kipnis concludes that females who describe men in such terms might in turn be suffering from their own “castration” anxiety, compensating for it by describing men as lacking in emotional wherewithal. If Kipnis is right, one may conclude that men who worry or agree they don’t have feelings or, worse, believe they’re somehow incomplete—that such men are doubly hit by castration issues: they are emotional eunuchs who suffer from anxiety of the potential loss of their penises.

My thought is that we will need to step far away from both our conceptions of female emotions as well as from our female conceptions of emotions in order to understand how men feel and, furthermore, how they cope with negative feelings, i.e., emotional pain.

To clarify: the term “female emotions” means that emotions are largely part of the female way of understanding and dealing with the world. In the traditional way of thinking the term is really a doubling as emotions are thought of as the quintessential way in which females express themselves.

“Female conceptions” of emotions means that whether or not we even identify something as an emotion has, traditionally, largely been defined if a given expression meets the differential criteria of fragility and expressiveness.

Having emotions—especially painful ones—and being male means that what we feel and how we feel what we feel will come mediated in quite sophisticated and complex ways by our strong need to survive. This is why high-stress situations, for men, lend themselves to an even stronger tendency to interiorize their emotions as their need to survive the stress will require their gathering and focusing their energy away from the felt emotions. Self-induced shame may be one of the strategies men use to recover quickly from accidents, pain and embarrassment. The question is, if this connection between interiorizing of emotions in order to survive increasing stress is simply a process that puts emotions on hold. Or could it be that stress survival bears in itself, perhaps, also the possibility of a different kind of processing of emotions?

The Problem of Shame
At its most basic shame is our covering-up reaction to being exposed in ways that leave us feel vulnerable to the attacks of others. I continue to ask myself, if shame is, perhaps, one of the major ways in which men process physical and non-physical pain. Rather than just describing one situation let me summarize situations men have described to me in which they have felt shame:


Hitting your head on a cabinet
Being caught speeding
Not being able to locate your keys
Being involved in an accident (no matter how)
Not making enough money
Not being able to get and/or maintain an erection
Being told that their clothes don’t match
Being told that they are not that important as fathers
Being told that real men cry/don’t cry
Being prevented from fighting back
Being rendered powerless
Not being able to endure pain/stress/adversity
Being stared at for too long.
Being told that they’re not allowed to feel like victims/being told that they are victims

This list could truly go on forever. The emotional response to all of the items is shame, i.e., covering it up. Why are men so prone to being shamed? If shame is so prevalent among men, does it have an evolutionary purpose? As it turns out shame about pain, in males, seems to have a twofold purpose: inward and outward.

a) it is supposed to cover up the embarrassment of the initial injury/pain. In this case, pain is often followed by a stoic response.
b) it can also decrease the time it takes the male to strike back at the cause of the pain. In this case the pain is often followed by an aggressive act.

Boys and men learn early that pain, both emotional and physical, means that they somehow screwed up. Boys are supposed to be vigilant, aware, and ready to fend off assaults. If they feel pain it means they have, somehow, failed to provide, for themselves or others, the kind of impervious protective wall they’re expected to build. Some might even go as far as saying that this is not a learned behavior but hard-wired into the male pain-response system. Shame, in one sentence, increases vigilance and decreases recovery time from pain and thereby increases the chances that the protective wall will still be built in time.

This kind of shame, called forth by the internal male response system to pain, is related but different from what happens when males are shamed. When men feel shamed they can feel inadequate in two ways:

a) inadequate in that they overlooked the thing that caused another to shame them
b) inadequate in that they didn’t recover fast enough from their own pain; or are forced to stay with their pain longer than they can bear.

Shame, brought to men from the outside, messes with an already delicate balance of pain and internal shame about this pain. It either puts into question the male’s internal system by asking didn’t you feel enough shame to avoid this pain; or when it comes in the form of too much compassion or sympathy, it is perceived as an attempt to obliterate the male’s internal recovery system and undermines their trust in themselves.


Why Did Gabriel Cry So Little?

a) He is a boy and, given the research discussed in the beginning, his response to his pain might have been mediated by his testosterone.
b) His pain was noticed immediately as was the “bad bucket” that was “kicked” as punishment.
c) Nobody exaggerated concern/care/compassion

a) This means: sometimes painful things happen to me. I am not always safe.
b) Others watch out for me and “bad things” get punished. I am kept safe.
c) Nobody is scared or concerned about what I do. I am trusted to be safe.


My experience working with men and observing many boys at play is that too little and too much care can activate a male’s internal shaming system and reinforce either a stoic or aggressive response. We might be shaming boys and men by expecting they overcome their pain quickly (as in the example of my son Gabriel). We might not be paying enough attention to them, because they avert their eyes more quickly, seem to break eye-contact and not look at us directly. But we might easily overdo it as in the case with boy on the play-ground. Finding the mid-point between not enough and too much care, i.e., finding the point where we don’t present an extra challenge to the males concern with survival and vigilance but instead can provide real care and get to know the male in question, finding that point is a delicate and complicated thing.





[1] Metabotropic dopamine receptors are present both on spiny neurons and on cortical axon terminals. Second messenger cascades triggered by activation of these dopamine receptors can modulate pre- and postsynaptic function, both in the short term and in the long term. The striatum is best known for its role in the planning and modulation of movement pathways but is also involved in a variety of other cognitive processes involving executive function. In humans the striatum is activated by stimuli associated with reward, but also by aversive, novel, unexpected or intense stimuli, and cues associated with such events. Recent fMRI evidence[citation needed] suggests that the common property linking these stimuli, to which the striatum is reacting, is saliency under the conditions of presentation. A number of other brain areas and circuits are also related to reward such as frontal areas.
For sources regarding saliency of the reward pathway(thought to be related to dopamine) one can look to the work of Dr John Salmone (storrs Connecticut early to late 90's) and wolfram Schultz. The ventral tegmental Da neurons that innervate portions of the striatum have long been accepted to be the site of rewarding feeling. Intracranial stimulation ICS studies from the 60's show implants in this brain area will elicit bar pressing form rats for many hours at a time. However the collective works of researchers in the 90's show that blocking Da receptors does not remove rewarding sensations, rather it effects how much the animal is willing to work, more motivation to seek reward rather than reward itself

[2] In the 1950s, Olds and Milner implanted electrodes into the septal area of the rat and found that the rat chose to press a lever which stimulated it. It continued to prefer this even over stopping to eat or drink. This suggests that the area is the 'pleasure center' of the brain.[2]
Although the nucleus accumbens has traditionally been studied for its role in addiction, it plays an equal role in processing many rewards such as food, sex, and video games. A recent study found that it is involved in the regulation of emotions induced by music [3] , perhaps consequent to its role in mediating dopamine release. It also has roles in timing, and has long been considered to be the limbic-motor interface (Mogensen).