Advertisement

Sociocultural Context and Pre-Clinical Pain Facilitation: Multiple Dimensions of Racialized Discrimination Experienced by Latinx Americans are Associated With Enhanced Temporal Summation of Pain

  • Kaitlyn T. Walsh
    Affiliations
    Department of Psychological and Brain Sciences, Texas A&M University, College Station, Texas
    Search for articles by this author
  • Brandon L. Boring
    Affiliations
    Department of Psychological and Brain Sciences, Texas A&M University, College Station, Texas
    Search for articles by this author
  • Namrata Nanavaty
    Affiliations
    Department of Psychological and Brain Sciences, Texas A&M University, College Station, Texas
    Search for articles by this author
  • Hanan Guzman
    Affiliations
    Department of Psychological and Brain Sciences, Texas A&M University, College Station, Texas

    Diversity Science Research Cluster, College Station, Texas
    Search for articles by this author
  • Vani A. Mathur
    Correspondence
    Address reprint requests to Vani A. Mathur, PhD, Assistant Professor of Diversity Science and Well-Being, Diversity Science Research Cluster Department of Psychological and Brain Sciences, Texas A&M Institute for Neuroscience, 4235 TAMU, College Station, TX 77843-4235.
    Affiliations
    Department of Psychological and Brain Sciences, Texas A&M University, College Station, Texas

    Texas A&M Institute for Neuroscience, College Station, Texas

    Diversity Science Research Cluster, College Station, Texas
    Search for articles by this author
Open AccessPublished:June 23, 2022DOI:https://doi.org/10.1016/j.jpain.2022.06.004

      Highlights

      • Sample in context: 120 Latinx Americans living in Texas (2016–2020).
      • Racialized discrimination was more pervasive than reported national average.
      • Multidimensional discrimination is associated with temporal summation of pain.
      • Suggests racism-related pre-clinical sensitization before chronic pain onset.
      • May reflect unrepresented pain risk and burden among Latinx Texans.

      Abstract

      The experiences of injustice and their impacts on pain among Latinx Americans are overlooked and understudied. Multidimensional and consequential experiences of racialized discrimination are common for Latinx Americans but have not been considered as factors relevant for enhanced pain experience or risk. In this study, we focused on the experiences of Latinx Americans living in Texas by assessing multiple dimensions of racialized discrimination (total lifetime discrimination, racialized exclusion, stigmatization, discrimination in the workplace or school, and racism-related threat and aggression) and a laboratory marker of central sensitization of pain (temporal summation of mechanical pain, MTS). Among 120 adults who did not have chronic pain, nearly all (94.2%) experienced racialized discrimination. Accumulated lifetime experience of racialized discrimination, as well as the frequency of each dimension of discrimination assessed, was associated with greater MTS. Results suggest that a process of discrimination-related central sensitization may start early, and may reflect enhanced pain experiences and pre-clinical chronic pain risk. Though replication is needed, results also indicate the discrimination and pain burden among Latinx Texans, and Latinx Americans broadly, are likely under-represented in the scientific literature.

      Perspective

      Racialized discrimination is multidimensional. Latinx Texans experience frequent discrimination that is associated with enhanced temporal summation of pain in the laboratory. Results indicate the importance of societal factors in pain processing and may reflect a mechanism of racism-related pre-clinical central sensitization observable before chronic pain onset.

      Key words

      Introduction

      Racism is a primary driver of health inequity.
      • Williams DR
      • Lawrence JA
      • Davis BA
      Racism and health: Evidence and needed research.
      Interpersonal discrimination is one way that racism patterns health and disease along socially constructed demographic lines.
      • Krieger N
      Measures of racism, sexism, heterosexism, and gender binarism for health equity research: From structural injustice to embodied harm - An ecosocial analysis.
      ,
      • Williams DR
      • Lawrence JA
      • Davis BA
      Racism and health: Evidence and needed research.
      Greater frequency of racialized discrimination experiences are associated with subclinical markers of morbidity (eg, increased systemic inflammation, elevated blood pressure, blunted cortisol reactivity) as well as increased risk of chronic health conditions (eg, cardiovascular disease) and all-cause mortality.
      • Barnes LL
      • Mendes De Leon CF
      • Lewis TT
      • Bienias JL
      • Wilson RS
      • Evans DA
      Perceived discrimination and mortality in a population-based study of older adults.
      ,
      • Beatty Moody DL
      • Waldstein SR
      • Tobin JN
      • Cassells A
      • Schwartz JC
      • Brondolo E
      Lifetime racial/ethnic discrimination and ambulatory blood pressure: The moderating effect of age.
      ,
      • Cuevas AG
      • Ong AD
      • Carvalho K
      • Ho T
      • Chan SW
      • Allen JD
      • Chen R
      • Rodgers J
      • Biba U
      • Williams DR
      Discrimination and systemic inflammation: A critical review and synthesis.
      ,
      • Dolezsar CM
      • McGrath JJ
      • Herzig AJM
      • Miller SB
      Perceived racial discrimination and hypertension: A comprehensive systematic review.
      ,
      • Lewis TT
      • Williams DR
      • Tamene M
      • Clark CR
      Self-reported experiences of discrimination and cardiovascular disease.
      ,
      • Ong AD
      • Williams DR
      • Nwizu U
      • Gruenewald TL
      Everyday unfair treatment and multisystem biological dysregulation in African American adults.
      ,
      • Sims M
      • Diez-Roux A.V.
      • Dudley A
      • Gebreab S
      • Wyatt SB
      • Bruce MA
      • James SA
      • Robinson JC
      • Williams DR
      • Taylor HA
      Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.
      ,
      • Thames AD
      • Irwin MR
      • Breen EC
      • Cole SW
      Experienced discrimination and racial differences in leukocyte gene expression.
      Among Black Americans, more frequent and pervasive (ie, across contexts) experiences of racialized discrimination are associated with greater clinical pain severity and interference
      • Burgess DJ
      • Grill J
      • Noorbaloochi S
      • Griffin JM
      • Ricards J
      • Van Ryn M
      • Partin MR
      The effect of perceived racial discrimination on bodily pain among older African American men.
      ,
      • Dugan SA
      • Lewis TT
      • Everson-Rose SA
      • Jacobs EA
      • Harlow SD
      • Janssen I
      Chronic discrimination and bodily pain in a multiethnic cohort of midlife women in the Study of Women's Health Across the Nation.
      ,
      • Edwards RR
      The association of perceived discrimination with low back pain.
      ,
      • Mathur VA
      • Kiley KB
      • Haywood C
      • Bediako SM
      • Lanzkron S
      • Carroll CP
      • Buenaver LF
      • Pejsa M
      • Edwards RR
      • Haythornthwaite JA
      • Campbell CM
      Multiple levels of suffering: Discrimination in health-care settings is associated with enhanced laboratory pain sensitivity in sickle cell disease.
      ,
      • McClendon J
      • Essien UR
      • Youk A
      • Ibrahim SA
      • Vina E
      • Kwoh CK
      • Hausmann LRM
      Cumulative disadvantage and disparities in depression and pain among veterans with osteoarthritis: The role of perceived discrimination.
      ,
      • Mickle AM
      • Garvan C
      • Service C
      • Pop R
      • Marks J
      • Wu S
      • Edberg JC
      • Staud R
      • Fillingim RB
      • Bartley EJ
      • Sibille KT
      Relationships between pain, life stress, sociodemographics, and cortisol: Contributions of pain intensity and financial satisfaction.
      ,
      • Walker Taylor JL
      • Campbell CM
      • Thorpe RJ
      • Whitfield KE
      • Nkimbeng M
      • Szanton SL
      Pain, racial discrimination, and depressive symptoms among African American women.
      and laboratory pain.
      • Goodin BR
      • Glover TL
      • King CD
      • Sibille KT
      • Cruz-Almeida Y
      • Staud R
      • Bradley LA
      • Pham QT
      • Sotolongo A
      • Herbert MS
      • Sanden SH
      • Redden DT
      • Fillingim RB
      Perceived racial discrimination, but not mistrust of medical researchers, predicts the heat pain tolerance of African Americans with symptomatic knee osteoarthritis.
      ,
      • Mathur VA
      • Kiley KB
      • Haywood C
      • Bediako SM
      • Lanzkron S
      • Carroll CP
      • Buenaver LF
      • Pejsa M
      • Edwards RR
      • Haythornthwaite JA
      • Campbell CM
      Multiple levels of suffering: Discrimination in health-care settings is associated with enhanced laboratory pain sensitivity in sickle cell disease.
      Specifically, laboratory evidence that discrimination is associated with pain facilitation (ie, temporal summation of pain) among Black Americans with chronic pain implicates racialized discrimination in the inequitable burden of pain experienced by Black Americans.
      • Mathur VA
      • Kiley KB
      • Haywood C
      • Bediako SM
      • Lanzkron S
      • Carroll CP
      • Buenaver LF
      • Pejsa M
      • Edwards RR
      • Haythornthwaite JA
      • Campbell CM
      Multiple levels of suffering: Discrimination in health-care settings is associated with enhanced laboratory pain sensitivity in sickle cell disease.
      ,c.f.
      • Bulls HW
      • Goodin BR
      • McNew M
      • Gossett EW
      • Bradley LA
      Minority aging and endogenous pain facilitatory processes.
      Other work has either collapsed across discrimination experiences based on any aspect of personal identity (eg, gender, ethnicity)
      • Brown TT
      • Partanen J
      • Chuong L
      • Villaverde V
      • Chantal Griffin A
      • Mendelson A
      Discrimination hurts: The effect of discrimination on the development of chronic pain.
      ,
      • Gee GC
      • Spencer MS
      • Chen J
      • Takeuchi D
      A nationwide study of discrimination and chronic health conditions among Asian Americans.
      ,
      • Hahm HC
      • Ozonoff A
      • Gaumond J
      • Sue S
      Perceived discrimination and health outcomes: A gender comparison among Asian-Americans nationwide.
      ,
      • Mickle AM
      • Garvan C
      • Service C
      • Pop R
      • Marks J
      • Wu S
      • Edberg JC
      • Staud R
      • Fillingim RB
      • Bartley EJ
      • Sibille KT
      Relationships between pain, life stress, sociodemographics, and cortisol: Contributions of pain intensity and financial satisfaction.
      ,
      • Ong AD
      • Goktas S
      • Reid MC
      More than hurt feelings: The wear and tear of day-to-day discrimination in adults with chronic pain.
      ,
      • Terry EL
      • Fullwood MD
      • Booker SQ
      • Cardoso JS
      • Sibille KT
      • Glover TL
      • Thompson KA
      • Addison AS
      • Goodin BR
      • Staud R
      • Hughes LB
      • Bradley LA
      • Redden DT
      • Bartley EJ
      • Fillingim RB
      Everyday discrimination in adults with knee pain: The role of perceived stress and pain catastrophizing.
      ,
      • Vang ZM
      • Chau S
      • Kobayashi K
      • Owen MJ
      • McKenzie-Sampson S
      • Mayrand-Thibert J
      • Brass G
      Pain and functional limitations among midlife and older Canadians: The role of discrimination, race and sense of belonging.
      or aggregated experiences of racialized discrimination across populations (eg, combining experiences of people with diverse minoritized and privileged racialized identities),
      • Groenewald CB
      • Murray CB
      • Palermo TM
      Adverse childhood experiences and chronic pain among children and adolescents in the United States.
      ,
      • Ziadni MS
      • Sturgeon JA
      • Bissell D
      • Guck A
      • Martin KJ
      • Scott W
      • Trost Z
      Injustice appraisal, but not pain catastrophizing, mediates the relationship between perceived ethnic discrimination and depression and disability in low back pain.
      identifying associations with worse clinical pain outcomes, but precluding specific investigation of racialized discrimination within racialized groups.
      • Mathur VA
      • Trost Z
      • Ezenwa MO
      • Sturgeon JA
      • Hood AM
      Mechanisms of injustice: What we (don't) know about racialized disparities in pain.
      ,
      • Williams DR
      • Lawrence JA
      • Davis BA
      • Vu C
      Understanding how discrimination can affect health.
      Only 4 prior studies have examined within-group associations between racialized discrimination and pain among Latinx Americans: clinical research indicates an association with greater bodily pain in heterogeneous samples of Latinx Americans,
      • Bakhshaie J
      • Rogers AH
      • Mayorga NA
      • Ditre J
      • Rodríguez-Cano R
      • Ruiz AC
      • Viana AG
      • Garza M
      • Lemaire C
      • Ochoa-Perez M
      • Bogiaizian D
      • Zvolensky MJ
      Perceived racial discrimination and pain intensity/disability among economically disadvantaged Latinos in a federally qualified health center: The role of anxiety sensitivity.
      ,
      • Carlisle SK
      Perceived discrimination and chronic health in adults from nine ethnic subgroups in the USA.
      ,
      • Dugan SA
      • Lewis TT
      • Everson-Rose SA
      • Jacobs EA
      • Harlow SD
      • Janssen I
      Chronic discrimination and bodily pain in a multiethnic cohort of midlife women in the Study of Women's Health Across the Nation.
      although the only laboratory study found an unexpected negative association with mechanical temporal summation.
      • Rassu FS
      • McFadden M
      • Aaron R V
      • Wegener ST
      • Ephraim PL
      • Lane E
      • Brennan G
      • Minick KI
      • Fritz JM
      • Skolasky RL
      The relationship between neighborhood deprivation and perceived changes for pain-related experiences among US patients with chronic low back pain during the COVID-19 pandemic.
      However, national or acontextual samples may obscure relevant diversity, and laboratory studies examining the relationship between pain and geographically and historically situated racialized discrimination experienced by Latinx Americans are lacking. Further, all prior studies in pain research have adopted a unidimensional conceptualization of discrimination.
      Multi-level and multi-faceted racialized discrimination are a part of everyday life for many Latinx Americans.

      Krogstad JM, Lopez G: Roughly half of Hispanics have experienced discrimination. Available at:https://www.pewresearch.org/fact-tank/2016/06/29/roughly-half-of-hispanics-have- experienced-discrimination/. Accessed December 5, 2020.

      Anti-Latinx discrimination is closely tied to racist and xenophobic attitudes toward immigrants, and harmful stereotypes about Latinx criminality that pervade the dominant American cultural narrative.
      • Chavez LR
      The Latino threat: Constructing immigrants, citizens, and the nation.
      This is exemplified by othering and dehumanizing labels, such as “illegal”, that are widely applied to Latinx individuals solely based on perceived racialized identity (“racialized illegality”).
      • García SJ
      Racializing “Illegality”: An intersectional approach to understanding how Mexican-origin women navigate an anti-immigrant climate.
      The racialized discrimination of Latinx individuals has deep historical roots and is institutionalized – appearing in modern practices, policies, and laws (eg, targeted deportation, restricted access to assistance services, suppression of legal rights). In Texas, despite the fact that many Mexican American families have longer histories on this land than the United States itself,

      Benavides A, Jr.: Tejano – Texas State History Association Handbook of Texas. Available at: https://www.tshaonline.org/handbook/entries/tejano. Accessed October 20, 2021.

      ,

      De León A: Mexican Americans – Texas State History Association Handbook of Texas. Available at:https://www.tshaonline.org/handbook/entries/mexican-americans. Accessed October 20, 2021.

      Mexican Americans continue to face high levels of institutionalized racialized discrimination (eg, segregation,
      • Walter R
      • Foote N
      • Cordoba H
      • Sparks C
      Historic roots of modern residential segregation in a Southwestern metropolis: San Antonio, Texas in 1910 and 2010.
      environmental injustice,
      • Cushing LJ
      • Vavra-Musser K
      • Chau K
      • Franklin M
      • Johnston JE
      Flaring from unconventional oil and gas development and birth outcomes in the eagle ford shale in South Texas.
      ,
      • Johnston JE
      • Chau K
      • Franklin M
      • Cushing L
      Environmental justice dimensions of oil and gas flaring in South Texas: Disproportionate exposure among Hispanic communities.
      voter suppression

      Ura A: Gov. Greg Abbott signs Texas voting bill into law overcoming Democratic quorum breaks. Available at:https://www.texastribune.org/2021/09/01/texas-voting-bill-greg-abbott/. Accessed October 20, 2021.

      ), as well as interpersonal discrimination and racialized violence (most notably the deadly 2019 domestic terrorist attack in El Paso

      Silva C: “White supremacy, racism”: Remembering the El Paso massacre that targeted Latinos. Available at:https://www.nbcnews.com/news/latino/white-supremacy-racism-remembering-el-paso-massacre-targeted-latinos-rcna1580. Accessed October 20, 2021.

      ).
      Within this critical context, we examined the relationship between experiences of different dimensions of racialized discrimination and a preclinical marker of pain facilitation (ie, temporal summation of mechanical pain; MTS) among Latinx Americans living in Texas. We intentionally focused on the specific experiences of this population, recognizing the importance of historical and contextual factors that shape racialized discrimination experiences. This focus is consistent with recent calls for antiracist, diversity, and justice approaches to pain research.
      • Booker SQ
      • Bartley EJ
      • Powell-Roach K
      • Palit S
      • Morais C
      • Thompson OJ
      • Cruz-Almeida Y
      • Fillingim RB
      The imperative for racial equality in pain science: A way forward.
      ,
      • Janevic MR
      • Mathur VA
      • Booker SQ
      • Morais C
      • Meints SM
      • Yeager K
      • Meghani SH
      Making pain research more inclusive: Why and how.
      ,
      • Letzen JE
      • Mathur VA
      • Janevic MR
      • Burton MD
      • Hood AM
      • Morais CA
      • Booker SQ
      • Campbell CM
      • Aroke EN
      • Goodin BR
      • Campbell LC
      • Merriwether EN
      Confronting racism in all forms of pain research: Reframing study designs.
      ,
      • Mathur VA
      • Trost Z
      • Ezenwa MO
      • Sturgeon JA
      • Hood AM
      Mechanisms of injustice: What we (don't) know about racialized disparities in pain.
      ,
      • Morais CA
      • Aroke EN
      • Letzen JE
      • Campbell CM
      • Hood AM
      • Janevic MR
      • Mathur VA
      • Merriwether EN
      • Goodin BR
      • Booker SQ
      • Campbell LC
      Confronting racism in pain research: A call to action.
      Our primary aim was to determine the relationship between discrimination and mechanisms of pain facilitation. We hypothesized that, overall, more frequent experiences of racialized discrimination would be associated with enhanced MTS. Although different dimensions of racialized discrimination have emerged as particularly impactful in other health domains (eg, racialized rejection was the strongest predictor of post-traumatic stress among Latinx and Black Americans living in Los Angeles),
      • Chin D
      • Loeb TB
      • Zhang M
      • Liu H
      • Cooley-Strickland M
      • Wyatt GE
      Racial/ethnic discrimination: Dimensions and relation to mental health symptoms in a marginalized urban American population.
      this is the first study to consider multiple dimensions of discrimination in the context of pain. Thus, our secondary aim to examine the relationship between different dimensions of racialized discrimination and MTS was exploratory.

      Method

      We conducted a secondary analysis of data collected across 6 cross-sectional studies focused on social factors and pain conducted between 2016–2020. All studies were conducted in the same laboratory, on the same equipment, using the same training and standardized protocols, and the same measures of mechanical temporal summation of pain and discrimination. Four of these studies involved on-campus recruitment and predominantly student samples, 1 study recruited non-student members of the local community, and 1 study involved open recruitment of both people on campus and the broader, local community. Student samples were recruited in 2 ways: via fliers posted on campus and through the undergraduate psychology participant pool. Students in the participant pool voluntarily choose studies in which they would like to participate (using an independent system that is not connected to participant data) and have the option to complete alternative assignments in lieu of research participation. Community samples were recruited using fliers posted in local businesses (eg, laundromats, barber shops, restaurants), Craigslist, and through relationships built with individual community members and community organizations. Individuals were not permitted to participate in more than 1 study, ensuring the independence of samples. Data were extracted to test the specific hypothesis that experiences of racialized discrimination would be associated with mechanical temporal summation amongst Latinx Americans. Therefore, only available data from Latinx participants on these variables are included here.

      Participants

      Eligibility criteria included being at least 18 years of age, no recent or current chronic or acute pain, and no use of pain medications within the past 3 days. All studies were approved by the Texas A&M University Institutional Review Board, participation was confidential, and participants either received course credit or monetary compensation at a rate of $12 to $20 per hour (depending on the study) for their time. Prior to any study procedures, all participants were screened for eligibility and completed a detailed in-person informed consent process.
      One hundred and twenty-one Latinx American adults enrolled and completed studies inclusive of study variables for extraction. However, 1 participant was excluded from the present analysis sample because they did not complete the discrimination questionnaire resulting in a final analysis sample of 120 participants (20.08 ±3.88 years old, 61.7% female, 38.3% male, 70.8% from studies with on-campus recruitment, 26.7% from a study that included both community and campus recruitment, 2.5% from a study of non-student community members) that completed both the discrimination questionnaire and mechanical temporal summation procedure. Studies conducted later in the data collection window solicited more specific information on Latinx ethnic identity. Of the 68 participants for whom this more detailed information was available, 69.1% identified as Mexican, 4.4% as Salvadorian, 4.4% Brazilian, and <3% (n≤2) as each of the following: Puerto Rican, Cuban, Argentinian, Bolivian, Columbian, Costa Rican, Nicaraguan, Panamanian, Peruvian, and Venezuelan.

      Terminology Statement

      We considered several terms to describe the population we aimed to represent in this research (ie, Latinx, Latinu, Latine, and [email protected]), prioritizing those that were most inclusive and representative of the diverse identities present in our local community. Consistent with the American Psychological Association's inclusive language guidelines

      American Psychological Association: Equity, diversity, and inclusion framework. Available at:https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines.pdf. Accessed 2021.

      we ultimately selected Latinx at this time, though acknowledge criticisms and limitations of this term (eg, inconsistent with grammatical norms in Spanish and potential exclusion of indigenous identities) and commit to reexamine and update our language choice in future work.
      • Vidal-Ortiz S
      • Martínez J
      Latinx thoughts: Latinidad with an X.
      ,
      • Zentella AC
      Limpia, fija y da esplendor”: Challenging the symbolic violence of the Royal Spanish Academy.

      Measures

      Perceived Experiences of Discrimination Questionnaire

      One hundred and twenty participants completed all items of the Perceived Experiences of Discrimination Questionnaire-Community Version (PEDQ-CV). The PEDQ-CV is a 17-item self-report survey that assesses experiences of racialized discrimination, which has been previously validated among Latinx/Hispanic American student and community samples.
      • Brondolo E
      • Kelly KP
      • Coakley V
      • Gordon T
      • Thompson S
      • Levy E
      • Cassells A
      • Tobin JN
      • Sweeney M
      • Contrada RJ
      The perceived ethnic discrimination questionnaire: Development and preliminary validation of a community version.
      This questionnaire measures the overall lifetime experiences of racialized discrimination as well as 4 distinct dimensions of discrimination including racialized exclusion/rejection (“…have others ignored or not paid attention to you?”), stigmatization/devaluation (“…have others hinted that you must be lazy?”), workplace/school discrimination (“…have you been treated unfairly by coworkers or classmates?”), and racism-related threat/aggression (“…have others threatened to hurt you?”). Participants reported the frequency of each experience due to their presumed racialized or ethnic identity on a scale from 1 (never) to 5 (frequently). Higher ratings indicated greater experiences of racialized discrimination. All items were averaged to obtain a total score of overall lifetime experiences of racialized discrimination and subscale items were averaged to obtain subscale scores. The PEDQ-CV demonstrated good internal reliability within our sample (overall lifetime: α = .90; racialized exclusion/rejection: α = .77; stigmatization/devaluation: α = .79; workplace/school discrimination: α = .75; racism-related threat/aggression: α = .84).

      Mechanical Temporal Summation

      Stimuli for the MTS procedure were administered to the middle phalange of the middle finger using weighted punctuate probes with a flat contact area of .2mm in diameter. Using a previously reported procedure
      • Mathur VA
      • Kiley KB
      • Haywood C
      • Bediako SM
      • Lanzkron S
      • Carroll CP
      • Buenaver LF
      • Pejsa M
      • Edwards RR
      • Haythornthwaite JA
      • Campbell CM
      Multiple levels of suffering: Discrimination in health-care settings is associated with enhanced laboratory pain sensitivity in sickle cell disease.
      participants first rated their pain in response to a single stimulus, and then their maximum pain in response to a series of 10 stimuli delivered at a rate of 1 stimulus/second, on a 0 (no pain) to 100 (worst pain imaginable) scale. A 128mN probe was used in all 6 studies, and MTS values were available for all 120 participants. MTS was calculated as the difference in pain ratings between the series of 10 stimuli and the single stimulus. Larger positive MTS scores indicate pain sensitization and greater summation of pain.

      Other Measures

      All participants also provided demographic information including self-identified sex, age, and race. We also extracted data on more specific racialized, ethnic, or cultural identity and/or familial nation of origin to improve the description and representation of the heterogeneity included within this Latinx American sample. Across studies, this was sometimes assessed via open-ended response to one of the following questions (“In terms of ethnic group, I consider myself to be…”; “What ethnic and racial group do you consider yourself?”; “What is your Nationality?”; “I was born in…”; “My mother was born in…”; “My father was born in…”; “My mother's ethnicity is…”; “My father's ethnicity is…”) or via a follow-up question given to those identifying as Latinx American (ie, “Do you culturally identify with any of the following: Cuban, Dominican, Mexican, Puerto Rican, Salvadorian, Multiple ethnicities (please specify), Not listed (please specify), No”).

      Data Analysis

      We conducted descriptive statistics on sample characteristics and to quantify the prevalence of discrimination experiences. We specifically examined the percentage of participants who reported no lifetime discrimination or no experience with any of the specific domains of discrimination (average total or subscale score = 1) relative to those who reported discrimination experiences (average total or subscale score >1). Before conducting inferential statistics, variables were examined for normality and outliers were identified using graphical plots. The scores for 1 participant were identified as outliers on the following variables: overall lifetime discrimination and the race-related stigmatization/devaluation and threat/aggression subscales. We decided to retain the data from this individual to most accurately represent the range of discrimination experiences and to support external validity, but report results with and without this outlier where applicable. No other outliers were identified. MTS scores were logarithmically transformed for inferential statistical analyses to reduce a positive skew, which resulted in the removal of a single data point (the only negative MTS score) from inferential statistics. Data from this individual are, however, included in all other analyses. Although study procedures for collecting the variables of interest were identical across included studies, to probe for potential history effects or effects of other study components, we explored potential main effects of study (using dummy codes) on MTS prior to primary analyses. No main effect was found, and therefore all data are considered together. We also probed for potential effects of sex and age on MTS and report those relationships in the Results section.
      Inferential statistics were conducted using the continuous discrimination frequency scores and log-transformed MTS scores. Bivariate Pearson correlations were conducted between MTS and the overall lifetime experiences of discrimination score, as well as each of the discrimination subscale scores. When indicated, multivariate linear regressions were used to determine the relationship between discrimination and MTS controlling for participant sex and age as potential confounds.

      Results

      Frequency of Discrimination Experiences

      Almost all participants (94.2%) reported experiences of racialized discrimination within their lifetimes (Table 1). Similarly, all dimensions of discrimination, except for racism-related threat and aggression, were experienced by the majority of participants. Participants in this sample also reported nearly the full range of frequencies of discrimination detectible using the PEDQ-CV (Table 1).
      Table 1Sample Characteristics and Descriptive Results
      NMinMaxMeanSDPrevalence
      Age120184620.083.88
      Sex
      Female74
      Male46
      Racialized Discrimination
      The PEDQ-CV assesses the frequency of experiences of overall lifetime (total score) and 4 distinct dimensions (subscales) of racialized discrimination.
      Any discriminationNo experience of this type of discrimination
      Overall Lifetime Discrimination12014.351.710.5994.2%5.8%
      Exclusion/Rejection12014.52.280.8887.5%12.5%
      Stigmatization/ Devaluation120151.590.7163.3%36.7%
      Workplace/School Discrimination12014.251.730.7671.7%28.3%
      Threat/Aggression12014.51.300.5737.5%62.5%
      Temporal Summation
      Positive scores indicate summation/pain facilitation, whereas negative scores represent attenuation/habituation. The remaining participants demonstrated neither summation nor habituation (ie, their pain ratings were identical in response to a single stimulus and repeated stimuli).
      SummationHabituation
      128mN stimulus120-1586.089.3272.5%.8%
      NOTE. Untransformed (raw) values are presented in the table.
      The PEDQ-CV assesses the frequency of experiences of overall lifetime (total score) and 4 distinct dimensions (subscales) of racialized discrimination.
      low asterisk Positive scores indicate summation/pain facilitation, whereas negative scores represent attenuation/habituation. The remaining participants demonstrated neither summation nor habituation (ie, their pain ratings were identical in response to a single stimulus and repeated stimuli).

      Frequency of Mechanical Temporal Summation of Pain (MTS)

      The majority of participants demonstrated temporal summation, and variability in the degree of summation was observed across individuals (Table 1).

      Associations With Potential Covariates

      Age and sex were not significantly associated with overall lifetime discrimination or any of the specific dimensions of discrimination assessed (Age: -.060 < r <.021, .514< P<.870; Sex: -.590<t <1.663, .099< P<.806) nor MTS (Age: r = -.015, P =.868; Sex: t(117) = 1.717, P =.089).

      Associations Between Discrimination and MTS

      Greater frequency of overall lifetime discrimination experiences was associated with enhanced MTS (r = .292, P =.001). Exploratory analyses indicate a similar pattern – though varying in magnitude – across separate dimensions of discrimination, such that greater frequency of racialized exclusion/rejection (r = .215, P = .019), stigmatization/devaluation (r = .232, P =.011), workplace/school discrimination (r = .271, P = .003), and racism-related threat/aggression (r=.262, P = .004) were all associated with greater MTS (Fig 1). This association was stronger when the outlier was excluded from relevant analyses (overall lifetime: r = .319, P<.001; racialized stigmatization/devaluation: r = .258, P = .005, and racism related threat/aggression: r =.305, P<.001) indicating the relationship was not driven by this single data point. These relationships also remain after controlling for participant age and sex using the full sample (overall lifetime: β = .284, P = .002; racialized exclusion/rejection: β = .220, P = .016; stigmatization/devaluation: β=.213, P = .021; workplace/school discrimination: β=.276, P = .002; racism-related threat/aggression: β =.249, P = .006), and when excluding the one outlier from relevant analyses (overall lifetime: β = .307, P = .001; stigmatization/devaluation: β=.235, P = .012; threat/aggression: β=.287, P = .002).
      Figure 1
      Figure 1Latinx American experiences of racialized discrimination are associated with enhanced mechanical temporal summation of pain. Overall lifetime (A) and dimensions of discrimination (B-E) were assessed using the Perceived Ethnic Discrimination Questionnaire-Community Version. Raw, untransformed values (N = 120) are presented in the figure. The dark gray shaded area depicts the 95% confidence interval. All correlations are statistically significant (P < .05).

      Discussion

      In this study, we showed that multiple dimensions of the racialized discrimination experiences of Latinx Americans living in Texas are associated with enhanced mechanical temporal summation in a sample of young adults without chronic pain. The results of this study are noteworthy for several reasons.
      First, they highlight the magnitude of pain-relevant racialized discrimination experiences among Latinx (predominantly Mexican) Americans within an important historical, sociopolitical, and geographical context. This focus revealed a burden of racialized discrimination greater than previously reported in national samples. Experiences of racialized discrimination in this community were pervasive – nearly all (94.2%) participants experienced racialized discrimination. The local focus of our study decreased the heterogeneity of place and context that is present in national samples, thus it is possible that previous national statistics diluted the prevalence of and obscured regional differences in discrimination experiences of Latinx Americans. Texans, in particular, experience anti-Mexican discrimination that is rooted in a violent history over the land that is now Texas, shaped by the legacy of this history that has been culturally and structurally maintained.
      • Carrigan WD
      • Webb C
      The lynching of persons of Mexican origin or descent in the United States, 1848 to 1928.
      ,
      • De León A
      They called them greasers: Anglo attitudes towards Mexicans in Texas, 1821-1900.
      ,
      • Martinez MM
      The injustice never leaves you: Anti-Mexican violence in Texas.
      Another potential contributing factor is that the present sample included many young, non-immigrant, college students who on average – perhaps due to levels of relative privilege or sense of safety, or due to generational effects – are more likely to disclose racialized discrimination than older adults, immigrants, and people without college educations.

      National Public Radio, Robert Wood Johnson Foundation, Harvard T.H. Chan School of Public Health: Discrimination in America. Available at: https://www.rwjf.org/en/library/research/2017/10/discrimination-in-america–experiences-and-views.html. Accessed October 20, 2021.

      Another important consideration is the sociopolitical climate and historical context during data collection (2016–2020). Policy changes during this time likely exacerbated and enhanced experiences of overt and vicarious discrimination for Latinx Texans (eg, expanded deportation, uncertainty and erosion of the DACA program, family separation at the Texas border). National polls indicated that Latinx Americans experienced more racialized discrimination during this time period and concern or uncertainty about their place in America.
      Latino Decisions, African American Research Collaborative, Asian American Decisions
      American Election Eve Poll.
      ,

      Lopez MH, Gozalez-Barrera A, Krogstrad JM: More Latinos have serious concerns about their place in America under Trump. Available at:https://www.pewresearch.org/hispanic/2018/10/25/more-latinos-have-serious-concerns-about-their-place-in-america-under-trump/. Accessed October 20, 2021.

      Though likely attributable to these and other causes, such a high prevalence of discrimination indicates compounding racialized injustice. Given the relationship with pre-clinical pain facilitation identified in this study, this likely also points to an enhanced pain burden among Latinx Texans that is under-represented in the scientific literature.
      Second, results add to the small but growing literature on the pain experiences of Latinx Americans. Although starkly understudied, prior research indicates an average profile of greater risk, yet lower reports, of chronic pain among heterogeneous samples of Latinx Americans as well as Mexican Americans in particular.
      • Hollingshead NA
      • Ashburn-Nardo L
      • Stewart JC
      • Hirsh AT
      The pain experience of Hispanic Americans: A critical literature review and conceptual model.
      ,
      • Hollingshead NA
      • Vrany EA
      • Hsueh L
      • Stewart JC
      Hirsh AT: Language use and generation status are associated with chronic pain differences in Mexican Americans.
      However, this ostensible paradox is clarified by structural, cultural, and generational factors that influence pain reporting and access to care and that may ultimately contribute to the underestimation of Latinx American pain burden.
      • Hollingshead NA
      • Vrany EA
      • Hsueh L
      • Stewart JC
      Hirsh AT: Language use and generation status are associated with chronic pain differences in Mexican Americans.
      ,
      • Ng BW
      • Nanavaty N
      • Mathur VA
      The influence of Latinx American identity on pain perception and treatment seeking.
      Hollingshead and colleagues recently demonstrated that linguistic assimilation (use of English relative to Spanish) and generational status of Mexican Americans were associated with greater chronic pain risk as well as greater insurance coverage and access to care – suggesting that multigenerational Mexican Americans may be more likely to receive a chronic pain diagnosis, and that factors associated with acculturation may increase pain risk.
      • Hollingshead NA
      • Vrany EA
      • Hsueh L
      • Stewart JC
      Hirsh AT: Language use and generation status are associated with chronic pain differences in Mexican Americans.
      Acculturation and generational status are known to also be associated with increased experiences of racialized discrimination and discrimination-related health burden.
      • Gee GC
      • Ryan A
      • Laflamme DJ
      • Holt J
      Self-reported discrimination and mental health status among African descendants, Mexican Americans, and other Latinos in the New Hampshire REACH 2010 Initiative: The added dimension of immigration.
      ,
      • Perez D
      • Sribney WM
      • Rodríguez MA
      Perceived discrimination and self-reported quality of care among Latinos in the United States.
      Prior literature has also demonstrated increased mortality and morbidity with each generation among Latinx Americans living in the United States, compared to first-generation Latinx immigrants; what has sometimes been referred to as the Latino Health Paradox.
      • Abraído-Lanza AF
      • Chao MT
      • Flórez KR
      Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox.
      ,
      • Markides KS
      • Eschbach K
      Aging, migration, and mortality: Current status of research on the Hispanic paradox.
      However, it is important to note that the Latino Health Paradox and preferential attributions to acculturation are often described within harmful narratives of individual responsibility related to “lifestyle choices” – to the exclusion of societal factors such as racism
      • Mathur VA
      • Trost Z
      • Ezenwa MO
      • Sturgeon JA
      • Hood AM
      Mechanisms of injustice: What we (don't) know about racialized disparities in pain.
      ,
      • Viruell-Fuentes EA
      Beyond acculturation: Immigration, discrimination, and health research among Mexicans in the United States.
      • Viruell-Fuentes EA
      • Miranda PY
      • Abdulrahim S
      More than culture: Structural racism, intersectionality theory, and immigrant health.
      • Viruelle Fuentes EA
      • Schulz AJ
      Toward a dynamic conceptialization of social tiest and context: implications for understanding immigrant and Latino health.
      Current results demonstrate accumulated discrimination experiences are associated with temporal summation of pain – a marker of central sensitization - which may reflect an increased risk for chronic pain. Taken together with prior findings, these results may reflect an enhanced pain burden among Latinx Americans that increases over time and across generations as a result of accumulated racialized discrimination exposure.
      Third, the current study considers and demonstrates the complexity and multi-dimensional nature of racialized discrimination. This addresses a limitation of the extant literature on racialized discrimination and pain that has relied on unidimensional or disambiguated measures. In the present study, a similar pattern of discrimination-related pain facilitation was observed across dimensions, indicating that all forms of discrimination are associated with enhanced pain. However, differences in the magnitude of this relationship suggest some experiences may more powerfully contribute to enhanced pain. For example, the relationship between frequency of discrimination experiences and mechanical temporal summation was strongest for those reporting experiences of racism-related threat or aggression – the most severe and violent dimension assessed using the PEDQ. However, important future directions may focus less on which types of experiences are the strongest predictors of pain facilitation, and rather on ensuring the multidimensional nature of discrimination is considered, and that relevant experiences are not normalized, erased, or ignored.
      Fourth, results add to growing literature on discrimination-related pain facilitation. Temporal summation of mechanical pain has been previously linked with discrimination in clinical contexts among people with chronic pain (ie, Black Americans with sickle cell disease
      • Mathur VA
      • Kiley KB
      • Haywood C
      • Bediako SM
      • Lanzkron S
      • Carroll CP
      • Buenaver LF
      • Pejsa M
      • Edwards RR
      • Haythornthwaite JA
      • Campbell CM
      Multiple levels of suffering: Discrimination in health-care settings is associated with enhanced laboratory pain sensitivity in sickle cell disease.
      ), but here we demonstrate a similar relationship with multiple dimensions of lifetime racialized discrimination experiences in a non-chronic pain sample of Latinx Americans. Rhudy and colleagues have recently reported subclinical spinal sensitization associated with experiences of discrimination among Native Americans without chronic pain.
      • Güereca YM
      • Kell PA
      • Kuhn BL
      • Hellman N
      • Sturycz CA
      • Toledo TA
      • Huber FA
      • Demuth M
      • Lannon EW
      • Palit S
      • Shadlow JO
      • Rhudy JL
      The relationship between experienced discrimination and pronociceptive processes in Native Americans: Results from the Oklahoma Study of Native American Pain Risk.
      ,
      • Rhudy JL
      • Hellman N
      Adverse life events, spinal sensitization, and chronic pain risk.
      However, association with temporal summation of pain evoked using electric stimulation was not observed in their study, attributed to robust descending inhibition in their sample. Nonetheless, taken together, these studies suggest a process of discrimination-related central sensitization may start early and enhance the pain experiences and pre-clinical chronic pain risk of racialized groups.
      There are some limitations that should be considered when interpreting the current findings. First, as an exploratory study, replication is needed. Our prioritization of external validity (ie, inclusion and representation of the lived experiences of racialized discrimination within our community) led us to a correlational design; however, this necessarily has lower internal validity than an experimental design, prohibiting causal inferences based on this study alone. Nonetheless, the use of a highly controlled laboratory protocol protects against some potential confounding. Future research may also probe different pain mechanisms using quantitative sensory testing techniques beyond MTS. Additionally, although this study focused on a more specific population in space and time, the experiences of Latinx Americans are not identical, and individual experiences of discrimination within our sample are likely influenced by unexamined factors (eg, colorism).
      • Hunter M
      The persistent problem of colorism: Skin tone, status, and inequality.
      There are also limitations to our measurement of racialized discrimination. Although the strength of the PEDQ-CV is its multi-dimensional assessment, we expect important dimensions relevant to our specific population of interest are not included in currently validated measures. As discussed above, vicarious racialized discrimination was likely high for many participants during the time of data collection, however this important dimension is not included in this measure. Future qualitative research and community-informed measure development within context would provide a more comprehensive representation of these and other experiences (eg, generational trauma from histories of structural racism) as well as language diversity and preferences. The current research was limited in that it was conducted exclusively in English.
      Finally, it is important to consider racialized discrimination as but one component of a system of multi-level racialized injustice – with patterns of oppression that are repeated and recreated across contexts, interpersonal interactions, structures, and cultural narratives and practices.
      • Mathur VA
      • Trost Z
      • Ezenwa MO
      • Sturgeon JA
      • Hood AM
      Mechanisms of injustice: What we (don't) know about racialized disparities in pain.
      Adopting multidimensional and multilevel conceptualizations and assessment of racialized discrimination may support situation of these experiences within the larger system of injustice. Extensions of this conceptual approach will consider intersecting injustice exposures (eg, intersections across levels, and with other forms of injustice based on intersectional identity), that shape lived experiences of pain. Importantly, interventions and solutions to decrease inequity in pain risk and burden must necessarily focus on structural and societal change as upstream factors that permit racialized discrimination.

      Acknowledgments

      We thank Humza Ahmed for technical support, Katherine Jaffe for assistance with citation management, and the following undergraduate research assistants for their valuable contributions to building community partnerships, participant recruitment, and data collection: Mollie Adams, Marguerite Anderson, Magdalena Banda, Lane Bannwart, Montae Bermudez, Kyisha Butcher, Jane EM Carter, Leslie Chaffin, Matthew Cline, Madison Cortez, Alida Demeter, Paul Forks, Xochitl Fuentes, Meredith Gary, Nevita George, Meron Haley, Melinda Hale, Jordan Hayes, Travis Hyatt, Catherine Kuykendall, Hanggi Lee, Hannah Hutchins Lewer, Jamie Loasby, Megan Marsico, Mitra Nair, Avery Nennmann, Sarah Peoples, James Connor Price, Nathan Ramsey, Ria Rao, Darby Salge, Cassidy Seale, Rahul Sirigiri, Evelyn Stewart-Johnson, Jennifer Van Horn, Sanya Varma, and Fallon Wenck.

      References

        • Abraído-Lanza AF
        • Chao MT
        • Flórez KR
        Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox.
        Soc Sci Med. 2005; 61: 1243-1255
      1. American Psychological Association: Equity, diversity, and inclusion framework. Available at:https://www.apa.org/about/apa/equity-diversity-inclusion/language-guidelines.pdf. Accessed 2021.

        • Bakhshaie J
        • Rogers AH
        • Mayorga NA
        • Ditre J
        • Rodríguez-Cano R
        • Ruiz AC
        • Viana AG
        • Garza M
        • Lemaire C
        • Ochoa-Perez M
        • Bogiaizian D
        • Zvolensky MJ
        Perceived racial discrimination and pain intensity/disability among economically disadvantaged Latinos in a federally qualified health center: The role of anxiety sensitivity.
        J Immigr Minor Heal. 2019; 21: 21-29
        • Barnes LL
        • Mendes De Leon CF
        • Lewis TT
        • Bienias JL
        • Wilson RS
        • Evans DA
        Perceived discrimination and mortality in a population-based study of older adults.
        Am J Public Health. 2008; 98: 1241-1247
        • Beatty Moody DL
        • Waldstein SR
        • Tobin JN
        • Cassells A
        • Schwartz JC
        • Brondolo E
        Lifetime racial/ethnic discrimination and ambulatory blood pressure: The moderating effect of age.
        Heal Psychol. 2016; 35: 333-342
      2. Benavides A, Jr.: Tejano – Texas State History Association Handbook of Texas. Available at: https://www.tshaonline.org/handbook/entries/tejano. Accessed October 20, 2021.

        • Booker SQ
        • Bartley EJ
        • Powell-Roach K
        • Palit S
        • Morais C
        • Thompson OJ
        • Cruz-Almeida Y
        • Fillingim RB
        The imperative for racial equality in pain science: A way forward.
        J Pain. 2021; 22: 1578-1585
        • Brondolo E
        • Kelly KP
        • Coakley V
        • Gordon T
        • Thompson S
        • Levy E
        • Cassells A
        • Tobin JN
        • Sweeney M
        • Contrada RJ
        The perceived ethnic discrimination questionnaire: Development and preliminary validation of a community version.
        J Appl Soc Psychol. 2005; 35: 335-365
        • Brown TT
        • Partanen J
        • Chuong L
        • Villaverde V
        • Chantal Griffin A
        • Mendelson A
        Discrimination hurts: The effect of discrimination on the development of chronic pain.
        Soc Sci Med. 2018; 204: 1-8
        • Bulls HW
        • Goodin BR
        • McNew M
        • Gossett EW
        • Bradley LA
        Minority aging and endogenous pain facilitatory processes.
        Pain Med. 2016; 17: 1037-1048
        • Burgess DJ
        • Grill J
        • Noorbaloochi S
        • Griffin JM
        • Ricards J
        • Van Ryn M
        • Partin MR
        The effect of perceived racial discrimination on bodily pain among older African American men.
        Pain Med. 2009; 10: 1341-1352
        • Carlisle SK
        Perceived discrimination and chronic health in adults from nine ethnic subgroups in the USA.
        Ethn Health. 2015; 20: 309-326
        • Carrigan WD
        • Webb C
        The lynching of persons of Mexican origin or descent in the United States, 1848 to 1928.
        J Soc Hist. 2003; 37: 411-438
        • Chavez LR
        The Latino threat: Constructing immigrants, citizens, and the nation.
        2nd ed. Stanford University Press, Stanford, CA2013
        • Chin D
        • Loeb TB
        • Zhang M
        • Liu H
        • Cooley-Strickland M
        • Wyatt GE
        Racial/ethnic discrimination: Dimensions and relation to mental health symptoms in a marginalized urban American population.
        Am J Orthopsychiatry. 2020; 90
        • Cuevas AG
        • Ong AD
        • Carvalho K
        • Ho T
        • Chan SW
        • Allen JD
        • Chen R
        • Rodgers J
        • Biba U
        • Williams DR
        Discrimination and systemic inflammation: A critical review and synthesis.
        Brain Behav Immun. 2020; 89: 465-479
        • Cushing LJ
        • Vavra-Musser K
        • Chau K
        • Franklin M
        • Johnston JE
        Flaring from unconventional oil and gas development and birth outcomes in the eagle ford shale in South Texas.
        Environ Health Perspect. 2020; 128 (077003-1-077003-9)
        • Dolezsar CM
        • McGrath JJ
        • Herzig AJM
        • Miller SB
        Perceived racial discrimination and hypertension: A comprehensive systematic review.
        Heal Psychol. 2014; 33: 20-34
        • Dugan SA
        • Lewis TT
        • Everson-Rose SA
        • Jacobs EA
        • Harlow SD
        • Janssen I
        Chronic discrimination and bodily pain in a multiethnic cohort of midlife women in the Study of Women's Health Across the Nation.
        Pain. 2017; 158: 1656-1665
        • Edwards RR
        The association of perceived discrimination with low back pain.
        J Behav Med. 2008; 31: 379-389
        • García SJ
        Racializing “Illegality”: An intersectional approach to understanding how Mexican-origin women navigate an anti-immigrant climate.
        Sociol Race Ethn. 2017; 3: 474-490
        • Gee GC
        • Ryan A
        • Laflamme DJ
        • Holt J
        Self-reported discrimination and mental health status among African descendants, Mexican Americans, and other Latinos in the New Hampshire REACH 2010 Initiative: The added dimension of immigration.
        Am J Public Health. 2006; 96: 1821-1828
        • Gee GC
        • Spencer MS
        • Chen J
        • Takeuchi D
        A nationwide study of discrimination and chronic health conditions among Asian Americans.
        Am J Public Health. 2007; 97: 1275-1282
        • Goodin BR
        • Glover TL
        • King CD
        • Sibille KT
        • Cruz-Almeida Y
        • Staud R
        • Bradley LA
        • Pham QT
        • Sotolongo A
        • Herbert MS
        • Sanden SH
        • Redden DT
        • Fillingim RB
        Perceived racial discrimination, but not mistrust of medical researchers, predicts the heat pain tolerance of African Americans with symptomatic knee osteoarthritis.
        Heal Psychol. 2013; 32: 1117-1126
        • Groenewald CB
        • Murray CB
        • Palermo TM
        Adverse childhood experiences and chronic pain among children and adolescents in the United States.
        Pain Rep. 2020; 5: e839
        • Güereca YM
        • Kell PA
        • Kuhn BL
        • Hellman N
        • Sturycz CA
        • Toledo TA
        • Huber FA
        • Demuth M
        • Lannon EW
        • Palit S
        • Shadlow JO
        • Rhudy JL
        The relationship between experienced discrimination and pronociceptive processes in Native Americans: Results from the Oklahoma Study of Native American Pain Risk.
        J Pain. 2022; 00: 1-19
        • Hahm HC
        • Ozonoff A
        • Gaumond J
        • Sue S
        Perceived discrimination and health outcomes: A gender comparison among Asian-Americans nationwide.
        Women's Heal Issues. 2010; 20: 350-358
        • Hollingshead NA
        • Ashburn-Nardo L
        • Stewart JC
        • Hirsh AT
        The pain experience of Hispanic Americans: A critical literature review and conceptual model.
        J Pain. 2016; 17: 513-528
        • Hollingshead NA
        • Vrany EA
        • Hsueh L
        • Stewart JC
        Hirsh AT: Language use and generation status are associated with chronic pain differences in Mexican Americans.
        J Immigr Minor Heal. 2022; 24: 342-350
        • Hunter M
        The persistent problem of colorism: Skin tone, status, and inequality.
        Sociol Compass. 2007; 1: 237-254
        • Janevic MR
        • Mathur VA
        • Booker SQ
        • Morais C
        • Meints SM
        • Yeager K
        • Meghani SH
        Making pain research more inclusive: Why and how.
        J Pain. 2021; 23: 707-728
        • Johnston JE
        • Chau K
        • Franklin M
        • Cushing L
        Environmental justice dimensions of oil and gas flaring in South Texas: Disproportionate exposure among Hispanic communities.
        Environ Sci Technol. 2020; 54: 6289-6298
        • Krieger N
        Measures of racism, sexism, heterosexism, and gender binarism for health equity research: From structural injustice to embodied harm - An ecosocial analysis.
        Annu Rev Public Health. 2020; 41: 37-62
      3. Krogstad JM, Lopez G: Roughly half of Hispanics have experienced discrimination. Available at:https://www.pewresearch.org/fact-tank/2016/06/29/roughly-half-of-hispanics-have- experienced-discrimination/. Accessed December 5, 2020.

        • Latino Decisions, African American Research Collaborative, Asian American Decisions
        American Election Eve Poll.
        2020 (Available at) (Accessed 2021)
      4. De León A: Mexican Americans – Texas State History Association Handbook of Texas. Available at:https://www.tshaonline.org/handbook/entries/mexican-americans. Accessed October 20, 2021.

        • De León A
        They called them greasers: Anglo attitudes towards Mexicans in Texas, 1821-1900.
        University of Texas Press, Austin, TX1983
        • Letzen JE
        • Mathur VA
        • Janevic MR
        • Burton MD
        • Hood AM
        • Morais CA
        • Booker SQ
        • Campbell CM
        • Aroke EN
        • Goodin BR
        • Campbell LC
        • Merriwether EN
        Confronting racism in all forms of pain research: Reframing study designs.
        J Pain. 2022; 00: 1-20
        • Lewis TT
        • Williams DR
        • Tamene M
        • Clark CR
        Self-reported experiences of discrimination and cardiovascular disease.
        Curr Cardiovasc Risk Rep. 2014; 8: 365
      5. Lopez MH, Gozalez-Barrera A, Krogstrad JM: More Latinos have serious concerns about their place in America under Trump. Available at:https://www.pewresearch.org/hispanic/2018/10/25/more-latinos-have-serious-concerns-about-their-place-in-america-under-trump/. Accessed October 20, 2021.

        • Markides KS
        • Eschbach K
        Aging, migration, and mortality: Current status of research on the Hispanic paradox.
        Journals Gerontol Ser B. 2005; 60: S68-S75
        • Martinez MM
        The injustice never leaves you: Anti-Mexican violence in Texas.
        The Harvard University Press, Cambridge, MA2018
        • Mathur VA
        • Kiley KB
        • Haywood C
        • Bediako SM
        • Lanzkron S
        • Carroll CP
        • Buenaver LF
        • Pejsa M
        • Edwards RR
        • Haythornthwaite JA
        • Campbell CM
        Multiple levels of suffering: Discrimination in health-care settings is associated with enhanced laboratory pain sensitivity in sickle cell disease.
        Clin J Pain. 2016; 32: 1076-1085
        • Mathur VA
        • Trost Z
        • Ezenwa MO
        • Sturgeon JA
        • Hood AM
        Mechanisms of injustice: What we (don't) know about racialized disparities in pain.
        Pain. 2022; 163: 999-1005
        • McClendon J
        • Essien UR
        • Youk A
        • Ibrahim SA
        • Vina E
        • Kwoh CK
        • Hausmann LRM
        Cumulative disadvantage and disparities in depression and pain among veterans with osteoarthritis: The role of perceived discrimination.
        Arthritis Care Res (Hoboken). 2021; 73: 11-17
        • Mickle AM
        • Garvan C
        • Service C
        • Pop R
        • Marks J
        • Wu S
        • Edberg JC
        • Staud R
        • Fillingim RB
        • Bartley EJ
        • Sibille KT
        Relationships between pain, life stress, sociodemographics, and cortisol: Contributions of pain intensity and financial satisfaction.
        Chronic Stress. 2020; 4: 1-12
        • Morais CA
        • Aroke EN
        • Letzen JE
        • Campbell CM
        • Hood AM
        • Janevic MR
        • Mathur VA
        • Merriwether EN
        • Goodin BR
        • Booker SQ
        • Campbell LC
        Confronting racism in pain research: A call to action.
        J Pain. 2022; 00: 1-15
      6. National Public Radio, Robert Wood Johnson Foundation, Harvard T.H. Chan School of Public Health: Discrimination in America. Available at: https://www.rwjf.org/en/library/research/2017/10/discrimination-in-america–experiences-and-views.html. Accessed October 20, 2021.

        • Ng BW
        • Nanavaty N
        • Mathur VA
        The influence of Latinx American identity on pain perception and treatment seeking.
        J Pain Res. 2019; 12: 3025-3035
        • Ong AD
        • Goktas S
        • Reid MC
        More than hurt feelings: The wear and tear of day-to-day discrimination in adults with chronic pain.
        Pain Med. 2021; 22: 2925-2930
        • Ong AD
        • Williams DR
        • Nwizu U
        • Gruenewald TL
        Everyday unfair treatment and multisystem biological dysregulation in African American adults.
        Cult Divers Ethn Minor Psychol. 2017; 23: 27-35
        • Perez D
        • Sribney WM
        • Rodríguez MA
        Perceived discrimination and self-reported quality of care among Latinos in the United States.
        J Gen Intern Med. 2009; 24: 548-554
        • Rassu FS
        • McFadden M
        • Aaron R V
        • Wegener ST
        • Ephraim PL
        • Lane E
        • Brennan G
        • Minick KI
        • Fritz JM
        • Skolasky RL
        The relationship between neighborhood deprivation and perceived changes for pain-related experiences among US patients with chronic low back pain during the COVID-19 pandemic.
        Pain Med. 2021; 22: 2550-2565
        • Rhudy JL
        • Hellman N
        Adverse life events, spinal sensitization, and chronic pain risk.
        Pain, Anisthetics and Analgesics: Book 3. Elsevier, San Diego, CA2020
      7. Silva C: “White supremacy, racism”: Remembering the El Paso massacre that targeted Latinos. Available at:https://www.nbcnews.com/news/latino/white-supremacy-racism-remembering-el-paso-massacre-targeted-latinos-rcna1580. Accessed October 20, 2021.

        • Sims M
        • Diez-Roux A.V.
        • Dudley A
        • Gebreab S
        • Wyatt SB
        • Bruce MA
        • James SA
        • Robinson JC
        • Williams DR
        • Taylor HA
        Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.
        Am J Public Health. 2012; 102: S258-S265
        • Terry EL
        • Fullwood MD
        • Booker SQ
        • Cardoso JS
        • Sibille KT
        • Glover TL
        • Thompson KA
        • Addison AS
        • Goodin BR
        • Staud R
        • Hughes LB
        • Bradley LA
        • Redden DT
        • Bartley EJ
        • Fillingim RB
        Everyday discrimination in adults with knee pain: The role of perceived stress and pain catastrophizing.
        J Pain Res. 2020; 13: 883-895
        • Thames AD
        • Irwin MR
        • Breen EC
        • Cole SW
        Experienced discrimination and racial differences in leukocyte gene expression.
        Psychoneuroendocrinology. 2019; 106: 277-283
      8. Ura A: Gov. Greg Abbott signs Texas voting bill into law overcoming Democratic quorum breaks. Available at:https://www.texastribune.org/2021/09/01/texas-voting-bill-greg-abbott/. Accessed October 20, 2021.

        • Vang ZM
        • Chau S
        • Kobayashi K
        • Owen MJ
        • McKenzie-Sampson S
        • Mayrand-Thibert J
        • Brass G
        Pain and functional limitations among midlife and older Canadians: The role of discrimination, race and sense of belonging.
        J Gerontol Ser B. 2021; : 1-12
        • Vidal-Ortiz S
        • Martínez J
        Latinx thoughts: Latinidad with an X.
        Lat Stud. 2018; 16: 384-395
        • Viruell-Fuentes EA
        Beyond acculturation: Immigration, discrimination, and health research among Mexicans in the United States.
        Soc Sci Med Pergamon. 2007; 65: 1524-1535
        • Viruell-Fuentes EA
        • Miranda PY
        • Abdulrahim S
        More than culture: Structural racism, intersectionality theory, and immigrant health.
        Soc Sci Med Pergamon. 2012; 75: 2099-2106
        • Viruelle Fuentes EA
        • Schulz AJ
        Toward a dynamic conceptialization of social tiest and context: implications for understanding immigrant and Latino health.
        Am J Public Health. 2009; 99: 2167-2175
        • Walker Taylor JL
        • Campbell CM
        • Thorpe RJ
        • Whitfield KE
        • Nkimbeng M
        • Szanton SL
        Pain, racial discrimination, and depressive symptoms among African American women.
        Pain Manag Nurs. 2018; 19: 79-87
        • Walter R
        • Foote N
        • Cordoba H
        • Sparks C
        Historic roots of modern residential segregation in a Southwestern metropolis: San Antonio, Texas in 1910 and 2010.
        Urban Sci. 2017; 1: 19
        • Williams DR
        • Lawrence JA
        • Davis BA
        Racism and health: Evidence and needed research.
        Annu Rev Public Health. 2019; 40: 105-125
        • Williams DR
        • Lawrence JA
        • Davis BA
        • Vu C
        Understanding how discrimination can affect health.
        Health Serv Res. 2019; 54: 1374-1388
        • Zentella AC
        Limpia, fija y da esplendor”: Challenging the symbolic violence of the Royal Spanish Academy.
        Chiricú J Lat Lit Arts, Cult. 2017; 1: 21
        • Ziadni MS
        • Sturgeon JA
        • Bissell D
        • Guck A
        • Martin KJ
        • Scott W
        • Trost Z
        Injustice appraisal, but not pain catastrophizing, mediates the relationship between perceived ethnic discrimination and depression and disability in low back pain.
        J Pain. 2021; 21: 582-592