Gender Stereotypes Explain Disparities in Pain Care and Inform Equitable Policies

Abstract

Despite women experiencing and reporting more pain than men, women receive less intensive and effective treatment for their pain. The current work leverages the well-developed social psychological literature on gender stereotypes, specifically stereotypes of emotionality, to understand gender biases in pain care. Specifically, gender stereotypes about emotionality may generate beliefs that women dramatize, overemphasize, or even fabricate their experiences of pain relative to men. This mistrust in women’s experiences of pain could undermine efficacy and equality of care. Research needs to directly examine the role of provider stereotype endorsement in pain care disparities, how these stereotypes influence patient–provider interactions, and whether these stereotypes may be implicit in health care policies. Established interventions and potential policy reform could combat gender-emotionality stereotypes and thereby mistrust of women’s reports in the context of pain treatment.

Keywords

health care disparities gender stereotyping emotions trust health care policy interventions

Emotionality stereotypes may propagate distrust in women’s reported pain and thereby disparate care. Identifying how stereotypes influence patient–provider interactions and how policy or medical training maintain them could help mend inequality in pain care.

Key Points

In well-documented gender disparities in pain care, women receive less intensive and less accurate treatment than men, despite reporting more pain and being perceived as more sensitive to pain.

Social and societal factors shape gender disparities, though published empirical work has yet to define specific mechanisms.

Gender stereotypes about emotionality are particularly pervasive and robust. These stereotypes imply distrust of women, particularly in contexts of emotional expression.

As gender stereotypes of emotionality influence trust, and trust determines quality of care, emotionality stereotypes also likely contribute to gender biases in pain treatment. In initial evidence, stereotype endorsement moderates trust in women’s (relative to men’s) pain.

Counterstereotyping and perspective-taking interventions might reduce stereotype activation, undermine endorsement, or increase empathy.

Sponsors and researchers should prioritize this research. Awaiting evidence, interventions, and policy reform can aim at ameliorating gender disparities in pain care.

Introduction

Disparities in health and health care persist in the United States. Minority and stigmatized groups experience poorer physical health while receiving inferior care. Disparities afflict several low-status groups (e.g., race, socioeconomic status, immigrant status, age—and, of particular interest, to the current work—gender: Hoffmann & Tarzian, 2001; Samulowitz et al., 2018). Despite being a wealthy and technologically advanced nation, the United States has among the world’s worst health care inequality (Blendon et al., 2002; Chokshi, 2018). For example, among wealthy countries (e.g., Germany, United Kingdom), U.S. women report the most negative outcomes—greatest burden of chronic illness, most avoiding needed health care due to cost, most difficulty affording care, least satisfaction with care, highest rates of maternal mortality, and lowest rated quality of care—across the 10 countries examined (Gunja et al., 2018).

The current work aims to contribute to the conversation on gender-based health inequality by illuminating avenues for investigation and intervention. The current work leverages a well-developed social psychological literature on gender stereotypes of emotionality to understand gender disparities in pain care. This focus on pain care is purposeful and practical. Pain-treatment disparities are prominent and consequential (Meghani et al., 2012). Indeed, harmful health consequences result from pain care that is both inadequate (e.g., unmet pain needs are the foremost cause of disability in the United States; Kennedy et al., 2014) and excessive (e.g., rising opioid epidemic; Wilkerson et al., 2016).

Second, this focus on pain draws on expertise in emotion perception (Baker et al., 2016; Deska et al., 2018; Lloyd et al., in press; ten Brinke & Adams, 2015; ten Brinke et al., 2012). Although debated, pain is often characterized as an emotion (Craig, 2003; Porreca & Navratilova, 2017) and, at the very least, is accompanied by a unique facial expression (Prkachin, 1992). Thus, biases in perceiving emotional expression are likely to extend to pain. The current work develops this perspective on disparate pain care by examining how gender-based emotionality stereotypes influence pain perception and thereby treatment. To this end, evidence indicates gender disparities in pain treatment. Furthermore, stereotypes about emotionality may inform pain perception with consequences for treatment. Finally, the current perspective generates policy insights.

Gender Disparities in Pain Treatment

Pain in the United States has an annual cost greater than that of cancer, heart disease, and diabetes combined (Gaskin & Richard, 2012). Women’s burden of chronic pain is greater than men’s burden, with an estimated 54.9% of women versus 48.5% of men experiencing chronic pain in 2010 (Gerteis et al., 2014). Despite women reporting greater pain, women receive pain care that is less intensive (Chen et al., 2008; Lord et al., 2009; Roger et al., 2000) and effective than men’s treatment (Chen et al., 2008; Hoffmann & Tarzian, 2001; Lord et al., 2009). For example, women in pain are less likely to receive analgesia and opiates (Chen et al., 2008), but more likely to receive antidepressant prescriptions (Hirsh et al., 2014; Lord et al., 2009) and mental health care referrals (Bernardes et al., 2013; Hirsh et al., 2014) than comparable men. Taken together, gender biases pervade quantity and type of pain treatment administered, resulting in women being more likely to receive inadequate care.

Explanations for Gender Biases in Pain Treatment

Accumulating evidence that women receive less intensive and effective pain treatment than men has fueled interest in determining whether to attribute these disparities to patient-level differences (e.g., sex differences in biology, gender differences in care seeking). Initial examinations of gender disparities in pain care focused on patient-level explanations, including differences in biological pain response systems (e.g., reproductive hormones, brain and nervous system function; Berkley, 1997; Fillingim & Maixner, 1995; Unruh, 1996) and health care utilization practices (Green & Pope, 1999; Owens, 2008; Vaidya et al., 2011). However, these explanations fall short in accounting for treatment disparities in the United States. In fact, the evidence on biological and behavioral differences cited above (Fillingim & Maixner, 1995; Owens, 2008) indicates women likely feel more pain and seek more health care support than men. Thus, women might plausibly receive more intensive and more efficacious care than men—an expectation opposite to national trends in pain care.

As a result, explanations of gender disparities in care shift to consider the role of providers. For example, sexist attitudes shape clinical decision making (Anand et al., 2005; Bernardes & Lima, 2011; Daugherty et al., 2017). Similarly, providers’ sexist attitudes might play a role in pain-treatment disparities. However—although female, compared to male, patients were more likely to receive antidepressant and mental health referrals instead of pain treatment—providers’ sexism scores did not explain these biases (Hirsh et al., 2014).

Stereotypes also theoretically could contribute to gender disparities in pain care (Samulowitz et al., 2018; Wandner et al., 2012). Whereas sexism represents gender-based prejudice, which is affective in nature, stereotypes are cognitive—representing culturally salient and individually endorsed beliefs (Devine, 1989). To date, scant empirical work examines whether gender stereotype endorsement covaries with pain care. However, stereotype endorsement (similarly to sexism) does predict gender biases in general health care (Chiaramonte & Friend, 2006; Travis et al., 2012). Furthermore, stereotypes apparently contribute to disparate pain care for individuals of other stigmatized identities (i.e., racial minority and low socioeconomic status; Burgess et al., 2006; Hoffman et al., 2016; Hoffman & Trawalter, 2016; Summers et al., 2020). Specifically, stereotypes depict individuals who are Black or relatively low in socioeconomic status as less sensitive to pain; they thereby receive less intensive (Hoffman & Trawalter, 2016; Summers et al., 2020) and accurate (Hoffman et al., 2016) pain care.

Stereotyping as a determinant of race- and class-based pain care disparities highlights the need for empirical investigations examining gender stereotyping as a route to gender-based pain care disparities. The current work next leverages gender stereotypes of emotionality to understand gender disparities in pain care.

The Current Perspective: Emotionality Stereotypes as Route to Pain Care Disparities

Gender Stereotypes about Emotionality

Gender influences perceptions of emotions (e.g., happiness) and emotional expressions (e.g., crying; Barrett & Bliss-Moreau, 2009; Becker et al., 2007; Hutson-Comeaux & Kelly, 2002). Stereotypical beliefs about emotionality across gender tend to have robust effects 2 to 4 times stronger than other commonly held gender stereotypical beliefs (i.e., differences in personality or cognitive abilities; Brescoll, 2016). Although gender stereotypes of emotionality are nuanced, one overarching theme is that women are allegedly more emotional than men (Hess et al., 2000; Shields, 2007). In one study (Plant et al., 2000), perceivers (regardless of their own gender) believed women experienced and expressed most emotions (e.g., amusement, fear, sadness) more intensely than men (anger and pride being the only exceptions). Target gender also influences attributions of emotion (Barrett & Bliss-Moreau, 2009): When perceivers had situational causes for a target’s emotional expression, perceivers attributed dispositional causes (i.e., being emotional) for feminine targets, but situational causes (i.e., “having a bad day”) for masculine targets. Finally, perceivers more readily identify expressions of happiness, fear, and sadness on feminine, compared to masculine, faces (Becker et al., 2007; Bijlstra et al., 2014; Hugenberg & Sczesny, 2006). Although emotion recognition, evaluation, and attributions are multiply determined, stereotypes about emotionality are one contributing factor (supplemented by perceiver prejudice and target facial morphology; Deska et al., 2018; Hess et al., 2009; Hugenberg & Sczesny, 2006).

Consequences of Emotionality for Interpersonal Trust

Stereotypes of women as emotional and emotionally expressive may seem harmless, or even positive (e.g., women being more readily evaluated as happy); however, a longstanding lay belief in the Western cultures is that emotion detracts from rational thought (Shields, 2007). Indeed, implicit associations between male/female and thinking/feeling show gendered associations with rationality; that is, participants hold robust male/thinking and female/feeling associations (Pavco-Giaccia et al., 2019). Similarly, women, but not men, are expected to react irrationally and dramatically due to emotion (Zammuner, 2000).

Stereotypes of women as emotionally expressive and thereby irrational also bleed into assumptions about authenticity. Women’s emotional expressions are more likely to be characterized as dramatizations and exaggerations than men’s (Kelly & Hutson-Comeaux, 2000). Moreover, women’s emotional expressions are, in many cases, less trusted. For example, women serving as trial witnesses are more likely to receive mistrusting and gender intrusive questions (e.g., if they had a history of victimization; Daftary-Kapur et al., 2014) and to be judged as less credible and trustworthy (Larson & Brodsky, 2010; Schuller et al., 2001) than comparable men. Perceivers trust women’s emotional statements about relationships (i.e., friendships, enemies) less than men’s. In a lie detection task, participants (regardless of gender) set a more lenient threshold for labeling women as liars as compared to men (Lloyd et al., 2018). Thus, across domains, gender stereotypes of emotionality, particularly emotional authenticity, may have negative implications for trust in women. The current work considers consequences for trust in women in the context of equitable pain care. If women are stereotyped as emotionally reactive (Citrin et al., 2004; Plant et al., 2000) and inauthentic (Warner & Shields, 2009), they may be viewed as exaggerating, dramatizing, or even lying about pain—and thereby trusted less in pain care settings.

The Role of Trust in Pain Treatment

To this point, trust in health care settings carries implications for treatment decisions, patient–clinician interaction success, and patient well-being (Hall et al., 1995; Halligan et al., 2003; Thom et al., 2011). For example, clinician trust in their patient predicted prescription of opioids for chronic pain in HIV patients (Thom et al., 2011). Treating a patient’s pain requires clinician inferences about pain authenticity and intensity—judgments that cannot be objectively verified. Thus, whereas treatment for mending a broken bone may be straightforward, treatment of the accompanying pain depends on provider interpretation, varying widely from no treatment to administration of controlled substances (Boccio et al., 2014; Minick et al., 2012). Given the subjective nature of pain, pain judgments may be particularly vulnerable to biasing influences of gender stereotypes.

Gender Stereotypic Biases in Pain Perception

Providing evidence that gender-based emotionality stereotypes may impact provider trust, women in chronic pain were viewed as hysterical, emotional, complaining, and were mistrusted and psychologized (for review, see Samulowitz et al., 2018). Furthermore, medical students judged female patients, compared to men, as more likely to exaggerate their pain (Schäfer et al., 2016). Thus, women’s displays and disclosures of pain are more likely to be met with skepticism and doubt. This may manifest in differential interpretations of pain expression and thereby pain treatment. Perceivers, regardless of their own gender, failed to quickly and accurately identify expressions of pain on the faces of female as compared to male targets (Riva et al., 2011).

Gender Stereotypes about Emotionality and Pain Perception

No research yet explicitly links endorsement of gender stereotypes about emotionality with gender biases in pain perception or treatment. To close this gap, our lab is examining the role of gender-emotionality stereotypes in perceptions of pain expression authenticity (Paganini et al., 2020). Perceivers, regardless of their own gender, expected female targets would exaggerate their pain to a greater extent than male targets (conceptually replicating Schäfer et al., 2016). Providing converging evidence with previous work (Hirsh et al., 2014), neither benevolent nor hostile sexism was associated with biases in judgments of pain sensitivity, expressivity, or exaggeration. However, participants’ endorsement of gender-based emotional authenticity stereotypes did predict biases in expected pain exaggeration (i.e., participants who most strongly endorsed women [compared to men] as emotionally inauthentic showed the strongest expectations for women [relative to men] to exaggerate pain).

Taken together, extant research and preliminary results suggest that gender stereotypes of emotional authenticity may result in mistrusting women’s pain. Given that these views appear to be pervasive in medical providers and lay participants alike, stereotyping women as emotionally inauthentic may explain the paradox wherein women report more pain yet receive less treatment.

Policy Implications, Recommendations, and Interventions

Stereotypes about emotional authenticity could contribute to gender biases in pain care, potentially offering new insights into pain-treatment disparities and avenues for intervention. To this point, many previously tested interventions for treatment inequality focus on prejudice reduction (Devine et al., 2012; FitzGerald et al., 2019; Teal et al., 2010). Prejudice reduction interventions have been shown effective in certain circumstances (Teal et al., 2010) and have been employed in medical education curricula (van Ryn et al., 2015). However, to-date, data do not support sexism or prejudice contributing to gender disparities in pain care (Hirsh et al., 2014; Paganini et al., 2020), so these interventions, while broadly beneficial, may be ill-equipped to ameliorate gender disparities in pain treatment.

Instead, interventions that focus on reducing stereotype activation or application may be useful in combating gender biases in pain care, to the extent that biases are influenced by stereotypes. Before discussing potential strategies for intervening on stereotype activation or application (which may inform policy for medical education and practice), notable limitations of these strategies are that they are often short-lived (FitzGerald et al., 2019) and often lack mundane realism or clear applicability outside the laboratory (Paluck & Green, 2009). Thus, these interventions may fail to provide stable, long-term change without ongoing administration or adaptation to the health care setting.

Counterstereotyping

Counterstereotyping procedures (i.e., facilitating stereotype-discrepant associations) yield—at least short-term—benefits in bias reduction (FitzGerald et al., 2019; Lai et al., 2014, 2016). Such strategies—presenting physicians with narratives of patients who are counterstereotypic women (e.g., in control of her emotions, hesitant to report pain) or conditioning counterstereotypic associations (e.g., women as trustworthy, women as stoic)—may usefully combat the influences of gender stereotypes on pain care.

Recommended policy adjustments also include exercising caution in the creation of medical education materials depicting cases of inauthentic or dramatized pain. Of course, medical students must gain exposure to instances of drug seeking and dramatization of pain; an estimated 130 people die from opioid overdose everyday (Wilson et al., 2020), and many instances of opioid use disorder connect to drug treatments administered by providers (Kolodny et al., 2015). However, who is depicted in cases of inauthentic pain can propagate gender stereotypes.

Perspective-Taking

A second priority for future research is the role of empathy in gender biases in pain care. Although little empirical work has examined empathy and pain care with a focus on gender, empathy is a vital factor in racial pain care disparities (Chiao & Mathur, 2016; Drwecki et al., 2011). Indeed, differences in empathy predict race disparities in recommended pain care (Drwecki et al., 2011). Empathy may or may not play a similar role for gender disparities in pain care, but expressions deemed inauthentic or dramatized would likely elicit less empathy. To this point, judgments of expression authenticity relate to pain-treatment recommendations (Lloyd et al., 2020). Specifically, target race (Black, White) effects on pain-treatment recommendations were mediated by judgments of pain expression authenticity, thereby implicating trust—a central theme here—as a novel explanation for race disparities in pain-treatment accuracy.

To the extent that women are judged as inauthentic, and inauthenticity attenuates empathy, interventions designed to motivate empathy may be valuable. A perspective-taking intervention for increasing empathy—for both lay participants and nurses—found that a randomly assigned perspective-taking task eliminated racial biases in pain treatment (relative to a control condition; Drwecki et al., 2011). Thus, perspective-taking exercises may be one route toward greater pain-treatment equity if employed in advance of interacting with stigmatized or minority patients.

Furthermore, given the potential benefits of perspective taking, inclusion of more women as prescribing providers could be another route toward pain care equity. Indeed, taking the perspective of one’s own group members often comes naturally (Simpson & Todd, 2017). Therefore, encouraging compositional diversity in medicine via offering scholarships, including more perspectives (e.g., women, minorities) in admissions committees, and turning a critical eye on gendered institutional norms could yield progress toward pain care equity.

Caveat

The recommendations in this analysis are based on a literature focused heavily, almost exclusively, on perceptions and outcomes associated with White, middle-, or upper class women. While woman across different social group memberships (e.g., race, socioeconomic status) may face distrust in pain care, to assume that these disparities or their implications are comparable for all women, especially those with multiple stigmatized identities, is unfounded. A growing emphasis in both social psychology (Remedios & Snyder, 2015; Warner, 2008; Williams & Fredrick, 2015) and health sciences (Kawachi et al., 2005; Richman & Zucker, 2019) considers intersectional identities in bias and disparities research, as multiple salient aspects of patient identity likely influence providers’ decisions. Therefore, creating effective and just social and health policies must actively incorporate the perspectives of women from diverse racial, ethnic, sexual, and socioeconomic backgrounds.

Conclusion

In closing, well-documented pain care disparities disadvantage women in the U.S. Gender-emotionality stereotypes have consequences for trust and thereby represent a priority for future research aimed at understanding gender disparities in pain care. If the current analysis holds, then policy reforms and established interventions could serve to combat gender-emotionality stereotypes and thereby mistrust of women. However, research on how gender-emotionality stereotypes impact pain perception and care is lacking, and the existing evidence overlooks intersectional identities. Both sponsors and researchers should prioritize the work critical to understanding psychological mechanisms of disparate pain care and thereby clarify reform strategies.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Gender Stereotypes Explain Disparities in Pain Care and Inform Equitable Policies

Abstract

Keywords

Tweet

Key Points

Introduction

Gender Disparities in Pain Treatment

Explanations for Gender Biases in Pain Treatment

The Current Perspective: Emotionality Stereotypes as Route to Pain Care Disparities

Gender Stereotypes about Emotionality

Consequences of Emotionality for Interpersonal Trust

The Role of Trust in Pain Treatment

Gender Stereotypic Biases in Pain Perception

Gender Stereotypes about Emotionality and Pain Perception

Policy Implications, Recommendations, and Interventions

Counterstereotyping

Perspective-Taking

Caveat

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References