Is There Gender Bias in the Treatment of Chronic Pain?
New research affirms the suggestion that women’s pain is taken less seriously than men’s.
“I picture it to feel like if someone took a meat hook and hooked it under my shoulder blade, and now I'm just hanging by my shoulder.” That’s how Parker Roberts, 27, of Los Angeles, describes her chronic pain: “A deep stabbing pain in one pinpointed spot under my shoulder blade.”
She developed this in the wake of a harrowing fall from a 15-foot cliff in July of 2016. “I was left with two broken bones in my hand, an elbow torn in multiple locations, a hip that narrowly escaped being broken, gashes and extreme bruising up my leg, hip, and back, and what we later discovered was a broken collarbone,” she remembers. But her broken collarbone wasn’t detected until three years later, after it had healed the wrong direction; the bones are now situated in a way that puts constant pressure and pain on her shoulder.
Roberts’ experience seeking treatment has been almost as burdensome as the pain itself. Her first orthopedic surgeon blamed her pain on lifestyle causes, waving his hand and saying he could see the inflammation “all throughout” her body. He told her to adjust her diet and offered ibuprofen (after offering her strong narcotics, which she expressed concern about taking due to the potential for addiction). When she came back a few months later in more severe pain than before, the same doctor patted her on the knee and said, “Buck up, kiddo.” Roberts was livid. “I was devastated and traumatized by the whole experience,” she says. “I had never felt so actively dismissed in my life and was just defeated.”
Roberts’ story is one that may feel achingly familiar to many women with chronic pain. Though women are more likely than men to experience chronic pain—21.7% of women had chronic pain in 2019, as opposed to 19% of men—they also face patriarchal stereotypes that can make it harder for them to get an accurate diagnosis and treatment. A new study in the Journal of Pain dives into how this can play out: Study participants were more likely to believe women were exaggerating their pain as compared to men and to suggest psychotherapy rather than pain medication. (Though Roberts’ doctor did suggest pain medication, she felt he provided limited options and remained insensitive to her needs.) This suggests a level of implicit bias about pain tolerance—in other words, a widely held belief that a woman’s chronic pain is all in her head.
The Chronic Pain Gender Gap
The cruel irony of chronic pain is that although it is deeply pervasive and widespread—20.9% of U.S. adults had chronic pain in 2019, according to CDC data—it is often invisible. Unlike an acute injury such as a broken bone, chronic pain occurs in places you can’t always see and without a definite origin. For some people, it’s a symptom of chronic illness like autoimmune disease. For others like Roberts, it’s a byproduct of previous trauma.
“Women and members of minority groups have been found to report more pain and receive less pain treatment,” says Elizabeth Reynolds Losin, Ph.D., author of the Journal of Pain study and director of the Social and Cultural Neuroscience Lab at the University of Miami in Coral Gables, FL. “There are potentially many factors that contribute to that, ranging from low-level things like physiological and genetic differences between groups of people—in the case of women versus men, we could be talking about hormonal differences—all the way up to stereotypes about the sensitivity of different groups and gender roles.”
Both nature and nurture play a role in someone’s relationship to pain. A 2020 study in the Journal of Pain Research found that gender identity plays a stronger role than biological sex in determining a person’s pain severity (suggesting that lived experiences shape the way we experience pain). Nonetheless, people with vaginas, regardless of gender identity, have menstrual cycles, which makes them susceptible to reproductive conditions like endometriosis or PCOS.
“Many invisible pain conditions, where the cause of pain may not be immediately physically obvious, like migraine and endometriosis, disproportionately affect women and are subject to intense stigma,” says Kathryn G. Schubert, president and CEO of the Society for Women’s Health Research. Case in point: it typically takes between four and 11 years after symptom onset to receive an endometriosis diagnosis. This also has to do with the normalization of period pain. “Women are taught to think it’s just part of being a woman,” Schubert says. “However, any pain that is so distressing that it significantly disrupts your life is not normal and should not be ignored.” What we know for sure is this: If you’re a person who does not identify as a cisgender male, you’re probably more likely to experience chronic pain.
People of color also face rampant discrimination in the healthcare system, constantly having to contend with racist stereotypes about their bodies and pain tolerance. In one study in the Proceedings of the National Academy of Sciences of the United States of America, medical students at the University of Virginia affirmed false beliefs about biological differences between Black and white people—namely, that Black people experience less pain and require less aggressive treatment. Black and brown women have the double barrier of racism and sexism to contend with when seeking compassionate medical care for their chronic pain.
Quantifying Gender Bias
Losin and her research team wanted to investigate the reason for the pain treatment gap between men and women. They used laypeople (people without medical training) as their study participants and showed them videos of real patients with shoulder injuries. Researchers asked the participants to rank the level of pain they perceived the patient to be in and recommend a treatment plan for them.
After doing this exercise twice—once in a lab and once with online participants—the researchers noticed a consistent trend: “In both studies, men were perceived to be in more pain than women,” Losin says. “What that basically means is that the pain behaviors of women (including their facial expressions) are being discounted relative to the behaviors of men.” They also included a questionnaire for participants to fill out addressing pain stereotypes. “People [felt] that women were more willing to report pain than men,” Losin reveals. “This gets into the stereotype of men being more stoic about their pain.” When recommending treatment, study participants were more likely to recommend psychotherapy for women while suggesting pain medication for men. “We think this reflects a psychologization of women’s pain,” Losin explains, “the idea that women’s pain may be coming from a less organic cause.”
Though the study participants were not medically trained, Losin believes that these results say something about societal-level bias—which can apply to doctors and medical technicians as well. “I think these stereotypes operate on an implicit level that isn’t necessarily amenable to changing with explicit training,” she says. That’s not to say we shouldn’t be working to change these stereotypes as a society—and it’s not to say that education can’t help over time—but we still have a long way to go. “More research must be done to better understand the sex and gender differences evident in pain conditions and to identify better ways to measure pain,” Schubert suggests. And on an individual level, believing women when they report chronic pain is a good first step.
How Women Can Fight for Better Care
If we can’t end gender stereotypes overnight, what can women with chronic pain do right now to get better treatment? Roberts has learned the value of speaking up, even when it results in negative reactions from clinicians. “I’ve found that sometimes you have to get loud to be heard, especially as a woman,” she says. “They may think I’m difficult, but I’ve come to realize that a lot of the conversations I’ve had about my care are not conversations [the medical provider] would have with a male patient. I genuinely believe the doctor would never have patted a male patient on the knee and told him to ‘buck up, kiddo.’” Confidence and assertiveness have gotten Roberts a long way; she has since developed a treatment regimen of injections, natural supplements, and a minimally invasive implant (all with the help of doctors whom she trusts).
Schubert urges women with chronic pain to trust what their body is telling them. “We know our own bodies best and should feel empowered and encouraged to speak up sooner,” she says. Here are a few tips for making your doctor’s visits more beneficial:
Be clear, concise, and descriptive about your pain. Provide examples of what the pain feels like, how often it occurs, and how it is limiting your life.
Explain the different remedies you have tried to help with your pain and whether anything has worked well in the past.
Bring along a trusted confidante to support and advocate for you. (This can be especially helpful it you feel your doctor isn’t listening to you; your loved one can interject to back you up.)
If needed, find a different provider.
Your experiences are your experiences, and they are valid for that very reason, no matter who tells you otherwise. “I've learned I don't have to let these [negative] conversations slide in order to keep the peace,” Roberts says. “It's not easy, and it sure as hell isn't any fun, but it's all I can do until I get the care I need.” So, she does the thing she knows best… she keeps going.
- Chronic Pain Statistics: Centers for Disease Control and Prevention. (2020.) “Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019.” cdc.gov/nchs/products/databriefs/db390.htm
- Pain & Gender Bias: Journal of Pain. (2021.) “Gender Biases in Estimation of Others’ Pain.” sciencedirect.com/science/article/pii/S1526590021000353
- Pain Experiences & Gender Identity: Journal of Pain Research. (2020.) “Sex and Gender are Not the Same: Why Identity Is Important for People Living with HIV and Chronic Pain.” dovepress.com/sex-and-gender-are-not-the-same-why-identity-is-important-for-people-l-peer-reviewed-article-JPR
- Racial Bias in Pain Treatment: Proceedings of the National Academy of Sciences of the United States of America. (2016.) “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.” ncbi.nlm.nih.gov/pmc/articles/en/
- Endometriosis: American Journal of Obstetrics & Gynecology. (2019.) “Clinical diagnosis of endometriosis: a call to action.” ajog.org/article/S0002-9378(19)30002-X/fulltext