Jennifer L. DelVentura, Ph.D., ABPP
Jennifer L. Steiner, Ph.D., ABPP
In a widely-shared article published in the Atlantic in 2015, titled “How Doctors Take Women’s Pain Less Seriously,” author Joe Fassler tells of his wife Rachel’s visit to the ER after she is suddenly stricken with excruciating abdominal pain, later revealed to be a life-threatening ovarian torsion . The article tells of their agonizing 14-hour wait in the ER for evaluation and treatment while Rachel’s pain is dismissed (“You’re just feeling a little pain honey”), undertreated, and summarily misdiagnosed as kidney stones without full examination. While Rachel survives the experience, she describes being left with “the trauma of not being seen,” and suffers physical and emotional scars in the aftermath. This story is notable not because of the long wait in the ER, which is often routine, but because it points to a more insidious problem in how we view and respond to women’s pain in healthcare.
Ample research indicates that gender biases impact our treatment of patients with pain, including how we interpret the nature and severity of that pain. Take for example a study examining how clinicians perceive patient reports (verbal and nonverbal) of pain severity . In the study, clinicians viewed video of male and female patients, all with shoulder pain and all undergoing painful manipulation procedures. Despite similar conditions and presentation, female patients were judged to be in significantly less pain than their male counterparts and were seen as significantly more likely to exaggerate their pain. Indeed, the more a female patient was perceived to be exaggerating her pain the lower the clinicians judged her actual pain to be, while the same relationship did not hold true for male patients (e.g., perceived exaggeration did not significantly impact judgments of pain severity) .
In a similar study in children, Yale researchers showed clinicians video of a child crying in pain during a fingerstick blood test and asked the clinicians to judge the pain the child experienced . The child, whose observable gender characteristics were ambiguous, was referred to by either a male or female name. The authors found that the “boy” child was judged to be experiencing significantly more pain than the “girl” despite identical circumstances (in fact, the same child). Perhaps more unexpectedly, it was largely the women clinicians’ ratings that drove the observed biases in pain ratings, making clear that women are not immune to gender biases.
Extending this further, research demonstrates that gender can play an influential role in how clinicians diagnose and treat pain. A few studies have tested this by asking providers to evaluate case vignettes of patients that vary only in gender (and in some cases race) of the fictional patient. When the patient is identified as female, providers are more likely to reference psychosocial factors in the case history , more likely to offer nonspecific diagnoses (e.g., “myalgia”) , more likely to recommend antidepressants or mental health referrals [5, 6], and less likely to prescribe higher doses of pain medications (compared to when the patient is identified as male; ). Here too, women providers often demonstrated as much, if not greater, influence of gender bias in decision-making [4, 5].
This apparent underestimation and under-treatment of women’s pain occurs in the context of decades of research demonstrating that women are disproportionately burdened with pain. Globally, women are diagnosed with chronic pain conditions at higher rates than men  and often report greater severity of pain on average compared with men with those same chronic pain conditions . Even in healthy (chronic pain free) individuals, women appear to be more pain-sensitive (have lower pain thresholds/tolerances) across a range of stimulus types (pressure, thermal, electrocutaneous [9, 10]) compared with men. 1
The factors underlying these differences are manifold, including biological, psychological, and sociocultural influences. And some of these factors may also function to disadvantage men suffering with pain. For example, evidence suggests women are viewed as more willing to express pain compared with men  and doing so is less inconsistent with traditional gender roles , and hence more acceptable. Likewise, women are known to access healthcare at higher rates than men , perhaps contributing to underrepresentation of men seeking medical care for pain. Thus, one could postulate that men suffer similarly from pain but are more reluctant to endorse or seek care for it, due to fear of stigma.
While the above is hardly an exhaustive review of the evidence, it is clear that observed gender differences in pain experience and pain care are consistent, concerning, and complex. Lack of acknowledgement and attention to these differences risks invalidating women’s pain experience, as well as underdiagnosing and undertreating their pain symptoms. And yet, this should not be interpreted as an attempt to place blame or suggest harmful intent on the part of providers. Indeed, such biases are often wholly unconscious. This was illustrated in a study of race and gender influences on treatment-planning in medical trainees, in which not only did race and gender factors significantly influence decision-making for at least 30% of the trainees, but at least 50% of them were unaware their biases . As human beings, we all rely on mental heuristics when short on time, pulled in too many directions, feeling pressured, or dealing with ambiguous situations [15, 16]—as is common in any pain management setting. But these heuristics are fallible and, simply put, it is our responsibility as ethical providers to work to recognize these biases and then to reduce harmful effects of them.
So how do we begin to address these issues? In the words of Sir Francis Bacon, ipsa scientia potestas est–knowledge itself is power . Educating ourselves about disparities in pain and pain treatment is an important first step. This includes practicing conscious self-reflection on biases and heuristics in decision-making as well as seeking out experiences and educational opportunities that help us learn to challenge them. At a broader level, evidence-based and patient-centered care can be supported through further development and use of clinical assessment tools normed for gender and minority populations as well as expanding gender and multiculturally-sensitive curricula in medical and graduate training. Lastly, future research should work to validate and disseminate methods for reducing impact of biases in health care. Social and cognitive psychology research supports a multimodal approach to bias-reduction that includes enhancing provider motivation for change, an emphasis on patient individuation vs. categorization, increasing perspective-taking, and improving provider-patient collaboration . These strategies will be discussed in more detail in a future issue of this newsletter.
1 Colloquial wisdom asserts just the opposite, on the basis of women’s ability (and willingness) to tolerate the immense pain of childbearing. The duration (e.g., acute vs. chronic), perceived cause, and one’s appraisals of pain significantly impact the pain experience. For an interesting review of pain coping factors, see: 11. Jensen, M.P., et al., Coping with chronic pain: A critical review of the literature. Pain, 1991. 47M: p. 249.
1. Fassler, J., How Doctors Take Women’s Pain Less Seriously, in The Atlantic. 2015.
2. Schafer, G., et al., Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 2016. 157(8): p. 1618-25.
3. Earp, B.D., et al., Gender Bias in Pediatric Pain Assessment. J Pediatr Psychol, 2019.
4. Hamberg, K., et al., Gender bias in physicians’ management of neck pain: a study of the answers in a Swedish national examination. J Womens Health Gend Based Med, 2002. 11(7): p. 653-66.
5. Hirsh, A.T., et al., The influence of patient sex, provider sex, and sexist attitudes on pain treatment decisions. J Pain, 2014. 15(5): p. 551-9.
6. Hollingshead, N.A., et al., Impact of race and sex on pain management by medical trainees: a mixed methods pilot study of decision making and awareness of influence. Pain Med, 2015. 16(2): p. 280-90.
7. Fillingim, R.B., et al., Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain, 2009. 10(5): p. 447-85.
8. Ruau, D., et al., Sex differences in reported pain across 11,000 patients captured in electronic medical records. J Pain, 2012. 13(3): p. 228-34.
9. Racine, M., et al., A systematic literature review of 10 years of research on sex/gender and experimental pain perception – part 1: are there really differences between women and men? Pain, 2012. 153(3): p. 602-18.
10. Rhudy, J.L., et al., Are there sex differences in affective modulation of spinal nociception and pain? J Pain, 2010. 11(12): p. 1429-41.
11. Jensen, M.P., et al., Coping with chronic pain: A critical review of the literature. Pain, 1991. 47M: p. 249.
12. Robinson, M.E., et al., Gender role expectations of pain: relationship to sex differences in pain. Journal of Pain, 2001. 2(5): p. 251-7.
13. Williams, J. and D. Best, Cross-cultural views on men and women, in Psychology and Culture, W. Lonner and R. Malpass, Editors. 1993, Pearson.
14. Bertakis, K.D., et al., Gender differences in the utilization of health care services. J Fam Pract, 2000. 49(2): p. 147-52.
15. Wigboldus, D.H., et al., Capacity and comprehension: Spontaneous stereotyping under cognitive load. Social Cognition, 2004. 22(3): p. 292-309.
16. Kahneman, D., S.P. Slovic, and A. Tversky, eds. Judgment under uncertainty: Heuristics and biases. 1982, Cambridge University Press.
17. Bacon, F., Meditationes Sacrae. 1597: Londini. : Excusum impensis Humfredi Hooper.
18. Burgess, D., et al., Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med, 2007. 22(6): p. 882-7.