Does Implicit Bias Color Pain Management for Men and Women?

April 09, 2021 - People may perceive pain levels in men as more acute than pain levels in women, a finding that could suggest gendered implicit bias in medicine and ultimately affect the type of medical treatment patients of different genders receive, according to researchers from the University of Miami.

These findings come as healthcare continues to explore the impact that implicit bias has had on clinical quality and overall patient outcomes. Specifically, this study suggests that women may not get as effective pain management as men because bystanders may not perceive their pain as intense.

The study, published in the Journal of Pain, involved two phases, the first of which established pain levels among actual patients. Study participants were asked to view videos of male and female patients with shoulder injuries complete rehabilitative exercises on both their injured and uninjured shoulders. Researchers asked viewers to rank the level of pain they believed each patient experienced.

The researchers were able to determine two “ground sources of truth” through these videos. Foremost, the team had access to patient reports of pain levels, which was a boon for study result accuracy, according to Elizabeth Losin, assistant professor of psychology and director of the Social and Cultural Neuroscience lab at the University of Miami and study co-author.

"One of the advantages of using these videos of patients who are actually experiencing pain from an injury is that we have the patients' ratings of their own pain," she explained in a statement. "We had a ground truth to work with, which we can't have if it's a stimulus with an actor pretending to be in pain."

The researchers also used the Facial Action Coding System (FACS), which analyzed the facial expressions of each patient on the video. FACS was able to determine a score for how much pain that patient appeared to be in.

In the second study phase, the researchers replicated each of those previous steps and added a few other survey questions for viewers. Viewers still ranked patient pain on a scale of zero to 100, but also offered up their views on how different types of people—specifically different genders—express or manifest pain. Viewers also recommended pain management drugs or psychotherapy for each patient on the video.

By and large, viewers rated pain intensity for men as higher than it was for women, even though the researchers’ notes showed each patient to be in equal levels of pain.

After picking through the phase two survey information, the researchers determined that trend to be a result of implicit bias in viewers. Most viewers believed women would be more expressive in their pain. In other words, viewers’ biases about how different genders express or experience pain led them to perceive different pain intensities.

"If the stereotype is to think women are more expressive than men, perhaps 'overly' expressive, then the tendency will be to discount women's pain behaviors," Losin said.

"The flip side of this stereotype is that men are perceived to be stoic, so when a man makes an intense pain facial expression, you think, 'Oh my, he must be dying!' The result of this gender stereotype about pain expression is that each unit of increased pain expression from a man is thought to represent a higher increase in his pain experience than that same increase in pain expression by a woman."

The researchers also found viewers were more likely to recommend psychotherapy as a pain management technique to female patients as opposed to male patients. Male patients were more likely to get painkillers as a treatment recommendation.

That tracks with previous research finding that women are less likely to get the pain medication they need than men are, Losin said.

"There's a pretty wide literature showing demographic differences in pain report, the prevalence of clinical pain conditions, and then also a demographic difference in pain treatments," Losin pointed out. "These differences manifest as disparities because it seems that some people are getting undertreated for their pain based on their demographics."

Notably, there was no difference in survey responses from male or female viewers. Both male and female viewers were equally as likely to underestimate female pain.

These study findings build on previous research about implicit bias in medicine. According to Losin, it will be important to detect that implicit bias as a first step in dismantling it.

"I think one critical piece of information that could be conveyed in medical curricula is that people, even those with medical training in other studies, have been found to have consistent demographic biases in how they assess the pain of male and female patients and that these biases impact treatment decisions," Losin remarked.

"Critically, our results demonstrate that these gender biases are not necessarily accurate. Women are not necessarily more expressive than men, and thus their pain expression should not be discounted."