GENDER DIFFERENCES IN PAIN PERCEPTION: How the Treatment of Pain is Affected

Maggie Schutte

Doodles by Abby Greenberg

Pain is subjective. There is no concrete, standardized method with which to measure “pain.” The perception of pain, too, is nearly impossible to evaluate in others, yet by acknowledging the complex nature of pain as more than just its biological basis, it becomes clear that pain relies on both body and mind to encompass biological, psychological, and cultural influences on pain. These factors are interdependent in the conceptualization of the causes of pain, providing a more understandable method with which to perceive and compare pain. Why? Over the past few decades, the discussion of and innovative research on gender differences in pain perception has gained notable traction. The research community agrees that there are clear differences between the experience of pain for men and womxn, with womxn generally reporting greater, more frequent, and longer-lasting pain. When comparing the treatment of pain for men and womxn, though, womxn are more likely to receive less adequate treatment compared with men. The issue this creates is one of severe undertreatment, misdiagnosis, and underdiagnosis among womxn. The treatment of womxn by healthcare professionals can be skewed and harmful due to the gender-based biases and stereotypes held against both womxn and the validity of womxn’s pain experiences. Because of these biases, it is more likely that healthcare professionals will disregard a womxn’s self-report of pain unless objective evidence arises - a practice aligned with the very outdated medical model focused on objective pain. The lack of education of healthcare professionals on this topic resulted in the widespread ineptitude of the treatment of pain throughout the world. So as to acknowledge possible solutions to these issues, it is important to first discuss the factors of pain perception in order to then understand why men and womxn have differences in their experiences with pain. This will also help explain why and how womxn are treated for their pain inadequately, along with why genderbased biases exist in relation to pain treatment.

Until a few decades ago, clinical research studies around the world still excluded womxn from participating. This inevitably led to a complete lack of education and understanding about the gender differences in fundamental health-care knowledge such as disease prevalence, progression, and response to treatment. Since 1993, the National Institute of Health’s legislation mandating the inclusion of womxn and minorities in research has helped encourage innovative research on sex and gender-based differences in pain responses.

Around the mid 1990s, roughly half of the existing studies documented no significant difference between gender-based responses to pain, while the other half generally found womxn to have slightly lower pain thresholds and higher pain ratings. As studies continued to advance, increasing empirical evidence signaled that a clear difference existed between gender-based responses to pain was observed. The question shifted soon after to focus on why these experiments were producing such results. Specifically, were the differences in pain perception based on biological differences, psychological influences, or something else entirely?

There are any number of potential biological explanations for gender-based differences in the response to pain. Studies using reproductive hormones, for example, have shown their clear influence on sex-based pain as they are used in processes like the menstrual cycle, during which a womxn’s pain sensitivity increases for part of the cycle. Another known contributor is the brain and central nervous system. Neural mechanisms such as networks and impulses sent to the brain are known to contribute to sex-based differences in perceptual, emotional, and behavioral responses to painful stimuli. Finally, a particularly interesting physiological study researched cerebral blood flow while levels of heat stimuli were applied to the subjects’ arms. The results were important because the authors concluded that the observed gender-based differences in pain from the study were not exclusively a result of physiological differences in male and female brains. Instead, the authors thought they might also have been influenced by the emotional or cognitive responses - both of which differ between men and womxn - that are responsible for brain activation differences between genders.

Physiological differences certainly play a useful hand in understanding sex differences for pain perception, but to obtain a holistic view of how pain is perceived it is essential to understand the psychological basis for pain as well. Referring to the early research on pain perception and gender-differences, the experimental designs did not account for social context at all. Psychological research on pain perception, however, focuses on multiple factors as possible influences on the response to pain such as biological, psychological, and cultural distinctions between genders. For example, if some stimuli were to biologically contribute to an experience of pain, then the cognitive awareness of and emotional response to pain will influence the body’s physiological responses. Cognition and awareness are simultaneously shaped by any psychosocial and cultural influences. In essence, pain perception must be based on the interdependence of body and mind.

In terms of the psychosocial and cultural influences, there are a few psychological factors necessary to understand. First, what’s called the “cognitive appraisal of pain” or simply “meaning-making” refers to the allocation of meaning to some instance which can then influence said person’s behavioral response to that event. The types of meanings attributed to a pain experience differ depending on gender, gender role expectations, age, race, etc… of the individual. A good example of “meaning-making” is when womxn experience immense pain as a part of their natural biological processes of menstruation and childbirth, and must learn to differentiate this normal biological pain from potentially harmful pain through the attribution of meaning. Men do not have this issue.

Second, another important factor is “the interplay between behavior and the value systems of a culture,” also called socialization. Childhood exemplifies this when young children are socialized to observe and react to pain in specific ways. Boys, for example, are still warned from expressing their emotions in many places. Similarly, in a pain perception research study, the male participants reported that they “felt an obligation to display stoicism in response to pain.” This is further translated to interactions among genders, where a study also found that the gender identity of the researcher influenced the male pain response, with less pain reported in front of a female researcher as compared to a male one. The gender identity of the researcher had no effect on the responses from the female participants.

The historical socialization of men and womxn in terms of a womxn’s competence has clawed its way to keep up with contemporary society while picking up other rude generalizations along the way. The old-as-time stereotypes like ‘womxn are weaker than men’, ‘womxn exaggerate and complain more than men’, and ‘womxn are more sensitive than men’ still exist. There’s also a long history of perceiving womxn’s opinions as emotional, hysterical, or immature, and in terms of medical decisions, a womxn’s moral identity can often be overlooked, ignored, or not recognized. These themes prevail in healthcare systems all over the world, and some still claim these stereotypes as fact.

These and other gender-based biases both can, and previously have, led to healthcare professionals overlooking serious pain and missing emergent injuries or chronic disease, attributing any abdominal pain to the menstrual cycle without further investigation, or telling patients their injury is fictional and diagnosing them as such. Womxn are more likely to have their pain translated to psychogenesis whether it’s the cause of their pain or not. The possibilities are perverse and dangerous, which is why this can’t continue. This issue has led to the misdiagnosis, undertreatment, or even no diagnosis of womxn across the world, and it’s not going away anytime soon.

For example, the following are excerpts from research studies which highlight significant differences in pain medication along with “inadequate treatment” given to men and womxn in the same medical situations.

Research excerpts on gender-gaps in pain treatment:

Study #1: When studying the administration of pain medication following abdominal surgery and controlling for patients’ weight, the authors found that physicians prescribed less pain medication for women 55+ than for men 55+, and that nurses prescribed less pain medication for women aged 25-54 than for men of the same age.

Study #2: “Calderone found that male patients undergoing a coronary artery bypass graft received narcotics more often than female patients, although the female patients received sedative agents more often, suggesting that female patients were more often perceived as anxious rather than in pain.”

The judgement of “inadequate treatment” for the following two studies was made based on strict World Health Organization guidelines:

Study #3: “In a 1994 study of 1,308 outpatients with metastatic cancer, Cleeland and colleagues found that of the 42 percent who were not adequately treated for their pain, women were significantly more likely than men to be undertreated (an odds ratio of 1:5).”

Study #4: “In another study of 366 AIDS patients, Breitbart and colleagues found that women were significantly more likely than men to receive inadequate analgesic therapy.”

Based on the research excerpts, do the personal perceptions of healthcare professionals affect the patient’s likelihood to be adequately treated? Studies have shown that in addition to gender, physical attractiveness has been found to influence a healthcare professional in their treatment of a patient’s pain. An in depth study on the topic even found that “physically unattractive patients were more likely to be perceived as experiencing greater pain than more attractive patients, and that the more attractive patients were more likely to be viewed as able to cope with their pain.” Results showed that this applied more to female patients to the extent that the patient’s attractiveness clearly affected the healthcare professional’s perception of their patient’s actual pain. This was referred to by the authors as the ‘beautiful is healthy’ stereotype.

The perception of womxn in particular by healthcare professionals is interesting to debunk. For example, a research study of nurses indicates that 50% of participants thought womxn could tolerate more pain than men. This notion is contradictory to both the stereotypes and older research studies, however explanations for this result focus on the assertion that “womxn’s biological role in childbirth makes them more capable of withstanding significantly more pain than men.” To expand on this idea, in her study on pain, gender, and culture, Bendelow found that womxn are repeatedly understood to be equipped with a “natural capacity to endure pain” given their reproductive nature. On another note, emotional disorders will sometimes heighten womxn’s pain, yet often a healthcare professional’s bias against the validity of psychological contributors to pain will cause them to undertreat and overlook that patient’s physical and emotional pain. Although womxn are more likely to have their pain attributed to emotional causes, it is unknown how much emotional factors actually do influence someone’s pain experience. The following excerpts are mini case-studies in which the gender-bias towards womxn is obvious.

Case-Studies: Prospective Patients and Gender-Bias

Study #1: “A recent prospective study of patients with chest pain found that women were less likely than men to be admitted to the hospital. Of those hospitalized, women were just as likely to receive a stress test as men. The authors attributed this to the notion that womxn are more likely to be treated less aggressively in their initial encounters

with the health-care system until they ‘prove that they are as sick as male patients.’ Once they are perceived to be as ill as similarly situated males, they are likely to be treated similarly.” In terms of a heart attack, for example, a womxn’s symptoms are entirely different and less obvious than that of a male heart attack, revealing how dangerous the mentality is especially in regard to chest pain

Study #2: “Of chronic pain patients who were referred to a specialty pain clinic, men were more likely to have been referred by a general practitioner, and women, by a specialist. The results suggest that women experience disbelief or other obstacles at their initial encounters with health-care providers.”

Study #3: “These findings are consistent with those reported by Elderkin-Thompson and Waitzkin, who reviewed evidence from the American Medical Association’s Task Force on Gender Disparities in Clinical Decision-Making. Physicians were found to consistently view women’s (but not men’s) symptom reports as caused by emotional factors, even in the presence of positive clinical tests.”

There are too many case-studies like these to count, and they all reference situations affected by gender-bias specifically in relation to womxn’s pain. The stories in the first two excerpts could very easily have turned fatal or very ill for no scientific reason.

For Western medicine in particular, healthcare professionals are trained to focus on any objective evidence or signs of injury. An example of this is seen in a study of nurses: The results revealed that the nurses would incorrectly expect their patients to have elevated vitals, expressions of pain, or some evidence of pain when the patients reported moderate to severe pain. In this instance, because no such pain is clearly evidenced, the nurse might make the mistake of assuming the patient is lying or exaggerating. In another example, womxn are more likely to be inadequately treated by a healthcare professional, at least initially, because they will lower the importance of a womxn’s self-report of pain along with any emotional or psychological pain contributors, while instead making their primary focus any objective evidence of pain.

This model of emphasizing objective (biological!) indicators of pain simply overshadows and deemphasizes womxn’s subjective, experiential self-reports. Based on literature on womxn’s healthcare, womxn’s “subjective experiences of illness and treatment are frequently ignored.” An adequate medical model, therefore, would instead be to refrain from assumptions about the patient’s behavior and simply classify the patient as a credible reporter of their own pain so as to avoid the possibility of undertreatment or misdiagnosis.

Finally, the current consensus of research indicates that womxn receive less total treatment for their pain than men. Given that the majority of research for this topic indicates that womxn experience pain more frequently, womxn are more sensitive to pain, and womxn are more likely to report pain, there is no good answer for why womxn are not treated at least as much and as thoroughly as men. The difference in treatment stems from assumptions and/or biases about men and womxn in terms of their pain sensitivity and/ or the credibility given to a womxn’s self-report of pain. Furthermore, the subjective nature of pain undermines both credibility and communicated pain levels resulting in less adequate treatments.

In order to solve the issue of self-reporting pain and questioning a patient’s credibility, future research is beginning to explore and develop diagnostic techniques in order to verify and validate a patient’s report of pain. Until such a time as pain can truly be “measured,” the fact that pain perception is influenced by psychosocial and cultural factors make a patient’s self report of their pain the most accurate to diagnose. It is important to acknowledge the existence of psychological and emotional pain contributors as opposed to solely biological, and it is essential this can be applied to males as well in order to derail the inevitable societalization of children that continues to promote old stereotypes. It is necessary to educate healthcare professionals in order to rid the medical community of assumptions, biases, and a lack of knowledge of gendersensitive treatments due to ignorance. Overall, a fair and adequate method to treat pain must first recognize that men and womxn can have different needs for their treatment, and then develop into a sex-specific, gender-sensitive pain management treatment method.