In this exclusive excerpt from her new book, ‘Rage Becomes Her,’ author Soraya Chemaly looks at the way rage—expressed and suppressed—may affect women’s health.
I had a headache that lasted for years. It was there when I opened my eyes in the morning and there when I went to sleep at night. Some days my face hurt so much when I woke up that I could barely move my jaw or facial muscles. I got used to this pain being the wallpaper of life. It wasn’t until the day that my husband was seeking relief for a rare headache that I realized the exceptional day, for me, was one when I didn’t have a headache.
The doctors I consulted were full of speculations and even prescriptions, but none helped. Eventually I was diagnosed with “stress,” which, in my case, meant my jaw muscles were in a near constant state of clenching. In the end, I did what most women not only do but also are encouraged to do: live with the pain and discomfort. While most of the doctors I spoke to acknowledged that managing work and family life were contributors, no one, not once, specifically delved into the relationship between stress, pain, and anger.
Researchers attribute differences in feelings and perceptions of pain to a combination of biology, hormones, genes, and socialization. For example, the female sex hormones estrogen and progesterone have been shown to amplify pain sensations while testosterone reduces them. What is generally agreed upon, however, is that in order to treat and understand pain, we need to give up our cultural commitment to the division of body and mind. In pain, the same dualism that defines our approach to sex, gender, social organization, and labor is hurting our ability to address physical and mental health. These persistent divides mean that the way we think about women’s pain is stunningly similar to the way we think about women’s anger. As with anger, women report feeling pain in more sustained ways—more acutely and more frequently, including following medical procedures—than men do. As with anger, women’s pain is frequently minimized and ignored. As with anger, gender roles, and often racial stereotypes, shape pain. Women are expected to accept physical pain as a normal part of everyday life, whereas for men, stoicism is expected in the face of pain that might be experienced sporadically. Men demonstrate higher thresholds and tolerance for certain types of pain; women, for others. However, women, socialized to be more expressive in general, are more likely to talk about their pain. When pain is induced as part of a study, for instance, they record greater physical reactivity and sensitivity. A willingness to report pain is correlated with lower pain thresholds, so much so that a person’s openness to say that he or she is hurting eliminates what are thought of as biological sex-based differences. People who score high in “masculine” behaviors—even women—display higher pain tolerance than those who react in a more “feminine” manner, while people who score higher for femininity and feminine behaviors exhibit less pain tolerance. These findings are particularly insightful because they clearly and compellingly demonstrate that behaviors many people learn to think of as “natural” ones stemming from biological sex are actually fluid and relate, instead, to socially constructed gender norms and expectations.
For example, the study found that even the gender of the researcher matters to how men with traditional expectations think about and experience pain. Men who scored high in traditional, binary gender beliefs demonstrated higher pain tolerance when in the presence of women dressed in ways that emphasize their femininity. Pain tolerance was highest in men who were told that women are more tolerant of pain.
Regardless of sex or gender, research shows that anger is the single, most salient emotional contributor to pain. The relationship is particularly close in women because we consistently say we are feeling more stress and are less likely to externalize our anger.
Anger is not the first thing we think of when we feel stress or pain, unless there is an immediate anger-producing incident. If you trip, break a bowl, or hurt yourself exercising, your immediate response might be anger—and, accordingly, you might curse or scream loudly. Most of us understand that when we have a sharp and immediate cause of pain, we respond with anger that says that pain is wrong. But what most of us don’t think about is that when we have anger, we respond, often unconsciously, with physical pain. Unaddressed anger affects our neurological, hormonal, adrenal, and vascular systems in ways that are still largely ignored in the treatment of pain. It’s hard to overstate what this means in terms of women’s health.
All over the world, women report much higher rates of both acute and chronic pain than men do. Of the more than one hundred million Americans who report living with daily pain, the vast majority are women. (A comprehensive study involving more than 85,000 respondents in seven developing and ten developed nations found that the prevalence of chronic pain conditions in men was 31 percent but in women it was 45 percent.)
Researchers believe that the role of anger in persistent pain is probably difficult for patients to admit because of widespread denial of feelings of anger. Women in pain are often women enraged but incapable of communicating that rage constructively.
Even when we do express ourselves, gender norms shape responses. Consider cursing, something many of us who are angry or in pain, do. In her book, Swearing Is Good for You: The Amazing Science of Bad Language, Emma Byrne explains pain mitigation as one of the many benefits of swearing. Among other benefits she cites, for example, are that workplace teams who use swearing, banter, and friendly insults are more productive and cohesive. Swearing also often means a person is more respected by those around them. It is also a more direct way to communicate. When a man and a woman use the same curse words, however, the woman’s words are considered more offensive. In an effort to avoid swearing, women often fall back on euphemisms and indirect communication. Byrne posits that gendered approval and disapproval of swearing is based on social understandings of “male power and female purity.” When women curse they tilt toward the “impure,” and, in essence, are tacitly assumed to deserve punishment.
How is this tied to anger and pain? Cursing numbs pain. The relationship between pain and cursing is not one-way (for example, stubbing your toe and letting out a stream of expletives in rage). Those expletives, in turn, affect our perceptions of pain. Through a series of creative experiments, scientists have found that the stronger the curse words people use while experiencing pain the higher their tolerance for that pain. Byrne notes, depressingly, that women who curse when in pain, however, are less well cared for by those around them.
A whole spectrum of health issues is now clearly linked to how people feel and express anger, which directly affects our hormonal system, immunity against disease, heart function, muscles, and skeleton. The headache that I experienced is the result of what is called somatization, in which a mental state such as anxiety—or anger— expresses itself physically, despite there being no evidence of a known medical condition. It is particularly common in women who ignore, divert, or otherwise minimize their anger. Over time, those mismanagements are almost always unhealthy, and they frequently become physically painful.
Anger releases specific stress hormones, such as adrenaline and cortisol, in the body that have a direct impact on health. Both of these hormones provide important clarity and energy that is useful in short-term stressful or threatening situations; however, long-term elevated adrenaline and cortisol are distinctly unhealthy. Cortisol results in increased blood sugars (glucose), affects the immune system, alters digestion, and influences growth and the reproductive system. Mood, behavior, motivation, and desire are all affected. Our bodies and brains process what we think of as irritations and daily hassles in the same way they process threat. Women who repress their anger are twice as likely to die from heart-related disease. Responding with extreme rage, however, is similarly problematic. Two hours after a vitriolic outburst, the risk of a heart attack increases fivefold, and the chance of suffering a stroke, fourfold. People with chronically elevated blood pressure, or hypertension, have a notable inability to express anger confidently and effectively.
Likewise, strong, unprocessed negative emotions negatively affect our immune systems. Studies have shown that even remembering an angry experience results in a decline in antibodies, the first line of defense in fending off disease. One study concluded that within three to four days of an anger incident, people are more likely to develop the common cold. Repressed anger is now considered a risk factor for a panoply of other ailments. Women are three times more likely to develop disabling and painful autoimmune illnesses, those in which the body, in essence, attacks itself by producing self-damaging antibodies, than men are. For example, women suffer from chronic fatigue syndrome at four times the rate men do, and they are twice as likely to develop the neurodegenerative disease multiple sclerosis. They also make up more than 90 percent of people suffering from fibromyalgia, which causes sleep and mood disruptions and widespread musculoskeletal pain.
Certain cancers, particularly breast cancer, and particularly in black women, have been linked to what researchers describe as “extreme suppression of anger.” In black women, who suffer some of the highest rates of breast cancer, the illness has been correlated with perceived experiences of discrimination and the anger they cause. A twelve-year longitudinal study, which assesses change over time, found a 70 percent increase in cancer-related deaths in people with the highest scores for suppressing their negative emotions. A follow- up to a landmark 1989 study on this topic found that the survival rate for women with breast cancer who expressed their anger was twice that of women who kept their anger to themselves.
It is important to be clear that anger does not cause these illnesses, but studies repeatedly suggest, and in some cases confirm, that its mismanagement is implicated in their incidence and prevalence among women. Emotional distress is linked to multiple behaviors that, together, create a complex matrix of cause and effect that, for example, predispose a woman to have a heart attack or develop breast cancer. Improved survival seen in studies about women who expressed anger does not prove that saying “I am angry” effects a cure, but rather that the ability to think and talk about emotions, and, in the case of anger in particular, feel control over factors in one’s life, might lead to deeper understanding, more aggressive approaches to treatment, and overall healthier decisions. Women who are more expressive are also more assertive—and therefore more likely to research their treatment options and to follow their physicians’ recommendations, and so on.
The complicated nature of the problem is evident in the degree to which experiences of anger and stress, like other health issues, are racialized and classed. Economists Anne Case and Angus Deaton of Princeton University captured a lot of attention in 2015 when they described dramatically rising rates of mortality among middle-aged non-Hispanic whites. They described the primary causes—suicide, drug and alcohol abuse—as “deaths of despair.”
People with incomes below the poverty line are two times more likely to be living with chronic pain and three to five times more likely to experience regular extreme pain and mental distress. People with so-called anger issues are also at higher risk for substance abuse. Suicide, like substance abuse, is closely tied to shame. Suicide is, according to Dr. Michael Lewis, an expert in emotional and intellectual development, “likely to be the result of shame associated with rage directed inwards.” This news was treated as explosive when the research was released, but for years researchers and members of the medical profession have argued for a greater understanding of how identity—class, gender, ethnicity—profoundly impacts health. Harvard public health sociologist David R. Williams has created a scale that measures how systemic discrimination generates health inequalities. When it comes to the intersections of gender, class, and ethnicity, women of color are living with significantly degraded health and care.
HOW WE THINK ABOUT ANGER MATTERS
Ruminating on negative feelings, which accounts for women’s longer- lasting and intense experiences of anger, increases the chances that women “catastrophize”: imagining and anticipating negative outcomes. Ruminating and catastrophizing, as previously discussed, more cultivated and common in women, intensify feelings of pain. One response is substance abuse. At least one study has linked the tendency to ruminate and catastrophize to an increased likelihood of taking prescribed opioid analgesics. That likelihood, in turn, brings an increased risk of addiction. Patients who are legitimately prescribed drugs such as OxyContin can quickly develop dangerous tolerances and a greater chance of overdose. Similarly, in terms of pain, rumination, and catastrophizing, being sexually assaulted also puts a person at higher risk of substance abuse, so much so that it is a known risk factor. Unaddressed anger in the wake of assault, which tends to be processed in silence and often with shame, contributes to that likelihood.
Given the overwhelming numbers involved, it is easy to think that the root of the problem of pain differentials resides in women’s “natural” makeup. However, interesting outliers refute that idea. In her comprehensive book on the subject, A Nation in Pain, writer Judy Foreman cites a particular example: in almost all countries, women are up to three times more likely to develop irritable bowel syndrome (IBS), suggesting a biological propensity. In India, however, the ratio of men to women suffering IBS is inexplicably reversed. Men in India are not more “womanly” than men elsewhere. Differences like this one highlight inadequacies in arguing that women are biologically prone to specific ailments in the absence of social considerations.
Not all pain is created equal. In many families, as in many institutions and in the law, physical harms are “real” and count for far more than emotional and psychological ones. As the mother of a childhood friend used to say, “If there is no blood, don’t call for me.” Deborah Cox, Karin Bruckner, and Sally Stabb, coauthors of The Anger Advantage: The Surprising Benefits of Anger and How It Can Change a Woman’s Life, describe the ways in which anger in women changes in form, meaning, and effect. They describe women’s anger as moving “sideways”—diverted into relational and passive aggression, physical symptoms, and, for some people, what amounts to constant low-grade and hard-to-describe irritability. In their book, the three researcher-clinicians propose that many of the diseases and physical discomforts common to women are transformations of anger into “socially acceptable forms of distress.” Unmanaged anger makes us “feel bad.”
Such an interesting double entendre.
Excerpted from Rage Becomes Her: The Power of Women’s Anger, by Soraya Chemaly, and available now wherever books are sold.
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