By: Theresa Schroeder, PhD, BSN, RN and Jason Hageman, MD
Reprinted from the fall 2019 issue of The Ohio Family Physician.
Pain is subjective which makes it inherently difficult for physicians to effectively treat. We rely on the patient’s reporting of their pain, while also using our own experience and knowledge, to filter that information and decide on a treatment plan. We use all of the information available to best serve our patients. However, a major factor behind inadequate pain treatment is the difference in perception of the severity of pain between the patient and the physician.1 While a mismatch in the impression of a patient’s pain by the physician can impact all patients, women in particular are at a higher risk of having a mismatch between her perception of pain and her physician’s perception. As physicians, we like to think that the gender of our patient does not influence our decision-making. Unfortunately, research does not support this. Implicit bias, negative attitudes, stereotypes, or prejudices about a group that unconsciously influence our actions, has been found to impact how we interact with our patients and the care we give them.2
Women are one such group where negative stereotypes can influence how we view them and their pain since women are stereotypically viewed as more likely to dramatize or exaggerate their pain. These views can lead to the belief that women do not have as much pain as they report. A recent news article underlines this point by telling the story of women in the military that had their pain repeatedly ignored by their military physician.3 The women were told that the pain they were experiencing was a normal “female problem.” One woman was prescribed contraceptives because the physician believed the issue was painful period cramps—it was not. The source of her pain ended up being a large ovarian cyst that required surgical removal. All the women interviewed for the article described having debilitating pain that was brushed aside by their physician. These women’s experiences are affirmed by research findings that indicate that women’s pain is often misunderstood and devalued.
One recent study asked adult participants to watch a video of a child having a finger stick and then assess how much pain the male or female child experienced based on the reaction of the child.4 Since the child was not asked to rate his or her level of pain, the participants’ rating of the child’s pain was purely subjective. The male patients were rated as experiencing higher pain compared to the female patients. The researchers concluded that the gap in rated pain by the participants was due to beliefs that boys are more stoic and that girls are more sensitive and emotive, thus suggesting implicit biases about boys and girls. To put it more plainly, the girls were viewed as being dramatic in response to the pain. This study asked participants who were not healthcare professionals to subjectively rate the pain. It did not take place within a healthcare setting nor were the participants trained in treating pain. However, research indicates that those working within the healthcare setting assess men’s and women’s response to pain differently.
In a study of 362 nurses, 27% of the nurses believed that men felt greater pain than women. The nurses in the study believed that women were more tolerant of pain and less distressed by pain.5 The beliefs about women’s pain have also been found to influence the prescribing practice of physicians. Multiple studies focusing on post-operative care of abdominal surgery, coronary bypass, and appendectomies found that women are prescribed less pain medications post-operatively than men.6 These men and women had undergone the same procedure, yet the physicians ordered less pain medication for their female patients. Furthermore, physicians perceive the origin of women’s pain to be different than men’s pain. Physicians and other healthcare professionals are more likely to equate women’s description of pain to psychological problems versus physical problems, leading to women being prescribed a sedative or an antidepressant for their complaint.7
These findings may lead some to question: do women experience different or less pain compared to men and therefore need less pain medication? Ironically, or sadly, this is not the case. In fact, research finds that women are more sensitive to painful stimuli and therefore, experience greater pain than men.8 The cause of why women experience greater pain from the same stimuli compared to men is not fully understood, but the difference is well supported.9 This means women should receive more pain medication not less.
What do the findings from the various studies tell us about women’s pain and its treatment? It tells us that women are viewed as more dramatic and more likely to exaggerate their actual pain level. Women are more likely to have their reported pain dismissed as psychological and not physical. Women receive less pain medication compared to men after the same surgical procedure even though women are more sensitive to pain stimuli than men. Simply put, beliefs about women and implicit bias has led to their pain being undertreated.
As mentioned previously, implicit bias is unconscious, meaning we are not aware we hold beliefs or stereotypes about women that impact how we care for them. So what can be done to remedy actions that we are unaware we are doing? There are few measures that can be taken. The first step is to recognize that you may have implicit biases, stereotypes, or prejudices. If you would like to better understand your own implicit biases, the Implicit Association Test, available online at https://www.hopkinsmedicine.org/odcc/implicit_association_test.html, is a tool that can help you identify your blind spots. Acknowledging that your view of the female patient’s pain may be influenced by biases can help you better treat her. A second action is to counter-stereotype, or think about if the patient were a man, how might you treat the patient’s pain. A third action is to remember the relationship between you and your patient is a partnership. View her as an individual and a partner that you are collaborating with to address her unique needs.
Due to stereotypes and beliefs widely held about women, female patients are at a higher risk of having their pain inadequately treated. We, as physicians, have the ability to change this by recognizing potential biases that impact our management of pain in women.
References available online at https://www.ohioafp.org/news-publications/the-ohio-family-physician-references.