A recent study on chronic pain management for Canadian veterans has uncovered a critical flaw in two decades of research: Not a single one examined the impact of sex or gender on treatment effectiveness.
Experts say this is yet another example of how the health of women and gender-diverse people remains understudied, leading to generalized clinical recommendations that may not be suitable for all veterans given the fundamental differences between female and male bodies.
“I’m a huge advocate for veterans and I think we have failed them in this country,” said Ramesh Zacharias, president and CEO of the Chronic Pain Centre of Excellence for Canadian Veterans, which is behind the study.
“We have a moral contract with them and we haven’t lived up to it.”
Canadian veterans suffer from chronic pain at higher rates than the general population. A 2016 study found that 40 per cent of male veterans and 50 per cent of female veterans are affected by chronic pain, compared to 20 per cent nationally.
It was these figures that prompted the establishment in 2020 of the Chronic Pain Centre of Excellence, the independent research centre in Hamilton that’s funded by Veterans Affairs Canada.
The centre set out 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 opioid and rehabilitation treatments between January 2000 and February 2021.
None of the studies reported how information about the participants’ sex or gender was measured or included in the study’s design. The studies also did not discuss how sex and gender differences may have impacted treatment results or outcomes.
This creates a gap in care because biological traits and socially shaped gender identities can significantly influence a person’s chronic pain symptoms, access to care and health outcomes, the study said.
Joy MacDermid, one of the authors of the study, said this gap is not exclusive to veterans. Historically, women have been excluded from health-care research, leading to generalized results and conclusions.
“Women were not only excluded as participants, but often the scientists were predominantly male as well,” said MacDermid, a professor of physical therapy at Western University in London, Ont.
“And so maybe the issues that were important to women weren’t seen as important issues for science to study. That has improved, but we have catching up to do.”
About 14 per cent of the 670,000 veterans in Canada are female, according to Veterans Affairs Canada.
MacDermid said sex and gender affect how veterans experience their military service, which is why it’s so important to have tailored treatments and rehabilitation.
For example, equipment is primarily designed for male members, which can lead to physical injuries among female members since it sometimes does not fit properly. As well, female members tend to push through pain to “prove themselves” in a male-dominated field, she said.
“It places you at risk if you’re afraid to ask for help with something because you don’t want to appear weak,” said MacDermid, who received the Order of Ontario in 2024 for her contributions to patient-centred care.
As a result of the findings, the centre of excellence has incorporated sex and gender in its research grant review process, meaning researchers must now describe how sex and gender will be considered in the 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 design and practices “when appropriate,” according to its website.
Alice Aiken, a veteran of the Canadian navy and a Halifax-based researcher, said including sex and gender in health-care research is important in pursuit of better informing Canadian doctors about the unique health considerations of veterans.
She noted that she doesn’t look like a “typical veteran.” She’s never been asked by a health-care professional if she is a veteran.
“My husband, on the other hand, still kind of has a military haircut and he often gets asked if he is a veteran,” said Aiken, who is also a co-founder of the Canadian Institute for Military and Veteran Health Research.
It’s an important piece of an individual’s overall health puzzle, she said. Knowing this information gives health-care providers a fuller picture of the different exposures they have faced that could better inform diagnosis and care.
Researching specific treatments for women and gender-diverse individuals is vital to improving care and overcoming systemic barriers in the health-care system, such as dismissing or misdiagnosing symptoms, said Aiken.
“I think anyone can intuitively understand that women and men don’t have the same physiology. And probably if you’re going to recommend a drug, it should be tested on both women and men,” said Aiken.
MacDermid said Canadians owe a great debt to veterans, which is why specialized research is important.
“They’ve put their health and their lives on the line for the betterment of Canadians,” she 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 tons of hope for them,” said Zacharias, becoming emotional at times.
“We know more about pain today than we did even five years ago, and we need to bring that to the bedside and to their cafes, to the legion, to wherever they are to improve the quality of life.”
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