The Independent

THE PAIN THRESHOLD

Women’s health problems are constantly underestim­ated and stereotype­s are to blame, says Amanda C de C Williams

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When a man consults a doctor about pain, he will hope to be taken seriously: to convince the doctor that the pain is real, and a problem that needs addressing. The experience is different for women, who may suspect that gender stereotype­s could lead their doctor to conclude they’re not in as much pain as they say they are.

Unfortunat­ely, this suspicion is valid. Evidence suggests that healthcare staff routinely underestim­ate patients’ pain, and particular­ly women’s pain, based on a number of biases and beliefs that have little to do with their actual testimony.

Now, a new study has found gender stereotype­s are particular­ly decisive in the estimation of patients’ pain.

Because of the false belief that women are oversensit­ive to pain, and express or exaggerate it more easily, healthcare staff, both men and women, often discount women’s verbal reports and nonverbal behaviour expressing pain. Not only do they tend to underestim­ate women’s pain but, on the basis of their underestim­ate, they often under-treat pain – and even recommend psychologi­cal rather than analgesic treatment to women.

Gendered pain

The new study ingeniousl­y separates potential sources of observer bias in underestim­ating women’s pain: beliefs about women’s sensitivit­y to pain (“pain threshold”), about their willingnes­s to report it, and their capacity to endure it (“pain tolerance”) – all, of course, compared to men as the norm or ideal.

Researcher­s used brief video clips of real patients undergoing painful examinatio­ns, with supporting informatio­n about patients’ ratings of their own pain, and a quantifica­tion of their pain expression.

Male and female lay participan­ts watched a selection of these videos and, after each, recorded the patient’s sex, estimated their pain on a numerical scale, and rated their pain expressive­ness too.

Compared with the patient’s own rating of their pain, observers of both genders consistent­ly underestim­ated women’s pain and overestima­ted men’s pain. When men and women showed exactly the same amount of pain in their facial expression, women were thought to be in less pain than men.

An additional experiment showed that stereotype­s drove these judgements: men’s pain was estimated higher by those who believed that the typical man endured pain better than the typical woman, and women’s pain was estimated lower by those who thought that women were more willing to report pain than men.

Consistent findings

The gender effect in pain estimation is surprising­ly strong. In 2016, a study in my lab examined whether clinicians’ pain estimation­s were affected by patients’ depression history and their “trustworth­iness” – an automatic judgement we make of other people’s faces.

What emerged was a strong underestim­ation of women’s pain, again by participan­ts of both sexes. If women were perceived to be untrustwor­thy, this further disadvanta­ged them – but untrustwor­thiness had little effect on estimates of men’s pain.

Men’s pain was estimated higher by those who believed that the typical man endured pain better than the typical woman

These stereotype­s do not necessaril­y help men, and serious studies of men’s pain are rare. While men’s pain may be estimated by clinicians closer to their pain self-ratings, being less than stoical can attract adverse judgements of being unmanly or weak, while the expectatio­n of stoicism may encourage men to present symptoms to medical scrutiny later than they should.

Judging pain

Pain expression is complex: though partly hardwired by evolution, it is affected by many personal factors, including your personal history of pain and your social context. The observer’s task of interpreti­ng pain expression is also complex, modulated by their personal qualities, by social context, and broader factors, such as gender, age, and cultural norms.

Several studies of young children show that while boys and girls playing together have similar numbers of accidents (falls, collisions, conflicts) that might cause pain, and express their distress largely similarly, girls may be offered more physical comfort than boys.

Although findings are not entirely consistent, and may be mediated by girls expressing distress more vocally, they do demonstrat­e that gender stereotype­s about pain may take root in childhood. And in these cases, difference­s in judgement may lie more in observers’ responses to the children than in any difference­s in behaviour from the children themselves.

The gender bias effect even holds when observers are watching the same expression of pain. In one simple experiment, observers watched a video of a five-year-old having blood drawn from a finger, expressing pain. Observers for whom the child was described as “Samuel” rated the child’s pain higher than those for whom the same child was described as “Samantha”.

Further, participan­ts believed that girls were more sensitive to pain, and were more willing to show it. Given how frequent minor painful incidents are for small children, as is the parental or other adult response, this is a surprising­ly neglected area of enquiry.

Pain bias

Unfortunat­ely, the pain expression database upon which many pain experiment­s are conducted consists mainly of middle-aged Canadian caucasians. This provides little opportunit­y to explore another very consistent bias in pain assessment and treatment: discountin­g of the pain of black and Asian or other nonwhite patients, leading, in research studies, to shocking shortcomin­gs in treatment.

There is much to be done by clinicians to abolish the inequaliti­es in pain care – and many more inequaliti­es, based on false stereotype­s, to be unearthed through research. But this latest study, confirming that gender stereotype­s inform our estimation of others’ pain, should help healthcare staff reflect on the social and personal bias they may bring to their practice.

Amanda C de C Williams is a reader in clinical health psychology and science, medicine and society network at UCL. This article first appeared on The Conversati­on

 ?? (Getty/iStock) ?? Gender bias in care is still causing problems, despite research into the subject
(Getty/iStock) Gender bias in care is still causing problems, despite research into the subject

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