The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain

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Diane E. Hoffmann and Anita J. Tarzian, "The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain"
Journal of Law, Medicine & Ethics, vol29, no. 1(2001): Pp. -

Pain strikes women more frequently and at more intense levels than it does men. Yet health-care providers seem less inclined to take women's complaints of pain seriously: Even though women are more likely to seek treatment for their pain than men, they are less likely to receive it.
These findings raise important questions surrounding the biological origins of pain, socialized gender differences related to pain, and possible gender bias in the treatment of pain.
In general, women report more severe levels of pain, more frequent incidences of pain, and pain of longer duration than men. Women are more likely than men to report migraines and chronic tension headaches, facial pain, musculoskeletal pain, and pain associated with osteoarthritis, rheumatoid arthritis, and fibromyalgia. Women are also more likely to develop a chronic pain syndrome after experiencing trauma.
Why does this happen? Because so many different stimuli cause pain, it is difficult to determine whether gender-based differences in how people experience and perceive pain are biological or psychosocial in nature. One modern approach is to acknowledge pain as a product of both biological and psychological factors.
Possible biological factors in pain experience and perception include:

the influence of reproductive hormones;

dissimilarities between men and women in the activation of stress-induced analgesia, which is the body's natural way of relieving pain caused by stressful situations; and

sex-based differences in the brain and central nervous system.
In addition, research into psychological factors influencing pain show that men and women differ in how they attribute meaning to their experiences with pain. For example, women tend to describe their pain within the context of how it affects their personal relationships and ability to perform child-care duties. Men, on the other hand, are more likely to wait to attend to pain until it threatens to interfere with their work duties. Their pain reports generally amount to objective descriptions of physical symptoms or functional limitations, without reference to their effect on personal relationships.
These differences in cognitive appraisal — or meaning-making — in turn affect how men and women respond to pain. For example, women tend to view seeking health care for their pain as a positive step that reflects their ability to handle their problems; men are more apt to seek health care out of fear that the problem is beyond their ability to solve.
Men and women also display different mechanisms for coping with pain. Women express their feelings, seek social support, and look for ways to take their mind off pain. They also respond more positively to taking medications or consulting a health-care provider than do men, who tend to take a more stoic approach to pain that involves accepting their situation and engaging in exercise.
Culture and socialization may also account for differences in how men and women perceive and report pain. For example, research has found that baby boys are actually more emotionally expressive than baby girls, but that boys' emotional expressiveness diminishes substantially by the time they are five or six years old. Men have reported that they feel obliged to maintain a stoic composure in response to pain, while women feel freer to express their emotions and seek social support when they are in pain.
Considering that women report greater and more frequent pain than men, and are more likely to seek health care for their pain than men, it would seem to follow that women receive more treatment for pain. That is not the case. Women appear less likely to receive pain medications than men and more likely to receive sedatives for their pain. Among patients complaining of chest pain, women are less likely than men to be admitted to the hospital. Women also appear to face more barriers when trying to obtain specialty care: They are more likely to be referred by a specialist for treatment of chronic pain at a pain clinic, compared with men, who are more likely to be directly referred by a general practitioner.
In general, women tend to receive less aggressive treatment for pain in their early encounters with health-care providers. Although men are slower than women to seek medical care for their pain, there is no evidence that men are in need of more aggressive care than women when they do seek pain treatment.
These observations suggest that health-care providers regard women's complaints of pain with more skepticism than they do men's. Women, it seems, have to "prove" that they are as sick as men in order to receive the same level of pain treatment.
It is difficult to say what accounts for these differences in perception and behavior among health-care providers, although there are many theories. Some health-care providers may believe that women have a higher natural capacity to endure pain that stems from their biological role in childbirth. In addition, the fact that women have better as well as more coping mechanisms to deal with pain than men may work against them — leading health-care providers to believe that they are better able to put up with pain and less in need of treatment. Another possible factor has to do with the subjective nature of pain: Providers may discount women's reports of pain as emotional or psychogenic in origin and therefore not real.
This article recommends steps to help correct these discrepancies in pain treatment. Medical school curricula should address ways of improving physician-patient communication concerning pain management, so that physicians-in-training learn to better elicit and respond to their patients' feelings. In additional, the Joint Commission on the Accreditation of Healthcare Organizations, which recently established pain management standards for health-care providers, should address the current bias in pain treatment of women. Finally, institutional ethics committees can educate health-care providers and encourage them to treat women more fairly and appropriately when they complain of pain. These measures will help assure that all patients with pain are treated equally effectively.