Is There a Gender Self-Advocacy Gap? An Empiric Investigation Into the Gender Pain Gap

Abstract

There are documented differences in the efficacy of medical treatment for pain for men and women. Women are less likely to have their pain controlled and receive less treatment than men. We are investigating one possible explanation for this gender pain gap: that there is a difference in how women and men report their pain to physicians, and so there is a difference in how physicians understand their pain. This paper describes an exploratory study into gendered attitudes towards reporting uncontrolled pain to a physician. This exploratory study provided subjects with a vignette describing a situation in which their pain is not being treated adequately and asked them questions about their attitudes towards self-advocacy and the strategies they would likely use to express themselves. We found that women scored higher than men on measures of patient likelihood to self-advocate. Women also reported intending to use more varied self-advocacy strategies than men. This suggests it is unlikely that patient’s communication styles are to blame for the gender pain gap.

This is a preview of subscription content, access via your institution.

Figure 1.

Notes

  1. 1.

    There are very little data on pain treatment for nonbinary people. This is a gap in the literature which we will not address directly, but it bears noting that while the gender disparity that we seek to explain is well documented, there may be other gender-based pain disparities which are understudied and which nothing here addresses. This is outside of the scope of this study, but is also very important to investigate.

References

  1. Adams, S., T. Case, J. Fitness, and R. Stevenson. 2017. Dehumanizing but competent: The impact of gender, illness type, and emotional expressiveness on patient perceptions of doctors. Journal of Applied Social Psychology 47(5): 247–255.

    Google Scholar 

  2. Alabas, O.A., O.A. Tashani, G. Tabasam, and M. Johnson. 2012. Gender role affects experimental pain responses: A systematic review with meta-analysis. European Journal of Pain 16(9): 1211–1223.

    CAS  PubMed  Google Scholar 

  3. Anderson, K., C. Green, and R. Payne. 2009. Racial and ethnic disparities in pain: Causes and consequences of unequal care. The Journal of Pain 10(12): 1187–1204.

    PubMed  Google Scholar 

  4. Ankawi, B., P.M Slepian, L.K. Himawan, and C.R. France. 2017. Validation of the pain resilience scale in a chronic pain sample. The Journal of Pain 18(8): 984–993.

    PubMed  Google Scholar 

  5. Barry, M.J., and S. Edgman-Levitan. 2012. Shared decision making—The pinnacle of patient-centered care. New England Journal of Medicine 366(9): 780–781.

    CAS  PubMed  Google Scholar 

  6. Bernardes, S.F., E. Keogh, and M. Lima. 2008. Bridging the gap between pain and gender research: A selective literature review. European Journal of Pain 12(4): 427–440.

    PubMed  Google Scholar 

  7. Borkhoff, C.M., G.A. Hawker, H. Kreder, R.H. Glazier, N. Mahomed, and J.G. Wright. 2008. The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. Canadian Medical Association Journal 178(6): 681–687.

    PubMed  Google Scholar 

  8. Buhrmester, M., T. Kwang, and S. Gosling. 2011. Amazon’s Mechanical Turk: A new source of inexpensive, yet high-quality, data? Perspectives on Psychological Science 6(1): 3–5.

    PubMed  Google Scholar 

  9. Carr, D.B., D. Reines, J. Schaffer, R.C. Polomano, and S. Lande. 2005. The impact of technology on the analgesic gap and quality of acute pain management. Regional Anesthesia and Pain Medicine 30(3): 286–291.

    PubMed  Google Scholar 

  10. Cavalier, J., Hampton, S., Langford, R., Symes, L., and Young, A. 2018. The influence of race and gender on nursing care decisions: A pain management intervention. Pain Management Nursing 19(3): 238–245.

    PubMed  Google Scholar 

  11. Ciaramella, A., and P. Poli. 2015. Pathogenetic psychosomatic mechanisms in chronic pain: Gender differences among syndromes. Journal of Psychosomatic Research 78(6): 597.

    Google Scholar 

  12. DiCecco, R., U. Patel, and R.E. Upshur. 2002. Is there a clinically significant gender bias in post-myocardial infarction pharmacological management in the older (> 60) population of a primary care practice? BMC Family Practice 3: 8.

    Google Scholar 

  13. Duffy, F.D., G. Gordon, G. Whelan, K. Cole-Kelly, and R. Frankel. 2004. Assessing competence in communication and interpersonal skills: The Kalamazoo II report. Academic Medicine 79(6): 495–507.

    PubMed  Google Scholar 

  14. Edwards, L. 2013. The gender gap in pain. The New York Times, March 16, Opinion section, 16.

  15. Epstein, R.M., P. Franks, K. Fiscella, et al. 2005. Measuring patient-centered communication in patient–physician consultations: Theoretical and practical issues. Social Science & Medicine 61(7): 1516–1528.

    Google Scholar 

  16. Fillingim, R., C.D. King, M.C. Ribeiro-Dasilva, B. Rahim-Williams, and J.L. Riley. 2009. Sex, gender, and pain: A review of recent clinical and experimental findings. The Journal of Pain 10(5): 447–485.

    PubMed  PubMed Central  Google Scholar 

  17. Fishbein, M. 2003. Using theory to design effective health behavior interventions. Communication Theory 13(2): 164–183.

    Google Scholar 

  18. Fishbein, M. 2000. The role of theory in HIV prevention. AIDS Care 12(3): 120–126.

    Google Scholar 

  19. Fishbein, M., A. Bandura, H.C. Triandis, F. Kanfer, M. Becker, and S.E. Middlestadt. 1992. Factors influencing behavior and behavior change: Final Report—Theorist’s workshop. Rockville, MD: National Institute of Mental Health.

    Google Scholar 

  20. Fishbein, M., and J. Cappella. 2006. The role of theory in developing effective health communications. Journal of Communications 56(1): 1–17.

    Google Scholar 

  21. Fishbein, M., H.C. Triandis, F.H. Kanfer, M. Becker, and S.E. Midelstadt. 2000. Factors influencing behavior and behavior change. In Handbook of Health Psychology, edited by A.S. Baum, T.A. Revenson, and J.E. Singer, 1–17. London: SAGE Publications.

    Google Scholar 

  22. Frosch, D.L., F. Légaré, M. Fishbein, and G. Elwyn. 2009. Adjuncts or adversaries to shared decision-making? Applying the Integrative Model of Behavior to the role and design of decision support interventions in healthcare interactions. Implementation Science 4(1): 73.

    PubMed  Google Scholar 

  23. Green, C.R., and T. Hart-Johnson. 2010. The adequacy of chronic pain management prior to presenting at a tertiary care pain center: The role of patient socio-demographic characteristics. The Journal of Pain 11(8): 746–754.

    PubMed  Google Scholar 

  24. Greenspan, J.D., R.M. Craft, L. LeResche, et al. 2007. Studying sex and gender differences in pain and analgesia: A consensus report. Pain 132(1): S26–S45.

    PubMed  PubMed Central  Google Scholar 

  25. Gutnik, L.A., A. Hakimzada, N. Yoskowitz, and V. L. Patel, 2006. The role of emotion in decision-making: A cognitive neuroeconomic approach towards understanding sexual risk behavior. Journal of Biomedical Informatics 39(6): 720–736.

    PubMed  Google Scholar 

  26. Hampton, S.B., J. Cavalier, and R. Langford. 2015. The influence of race and gender on pain management: A systematic literature review. Pain Management Nursing 16(6): 968–977.

    PubMed  Google Scholar 

  27. Harden, R., S. Connolly, A. Kirsling, et al. 2015. Placebo effects in analgesic medication trials in two chronic pain models: Gender and pain disorder moderators. Journal of Pain 16(4): S91.

    Google Scholar 

  28. Hawker, G.A., J.G. Wright, P.C. Coyte, et al. 2000. Differences between men and women in the rate of use of hip and knee arthroplasty. New England Journal of Medicine 342(14): 1016–1022.

    CAS  PubMed  Google Scholar 

  29. Howard, R.F. 2010. Treating chronic pain. Paediatrics and Child Health 20(2): 94–95.

    Google Scholar 

  30. Hsu, K., and D.K. Iwamoto. 2014. Testing for measurement invariance in the Conformity to Masculine Norms-46 across White and Asian American college men: Development and validity of the CMNI-29. Psychology of Men & Masculinity 15(4): 397–406.

    Google Scholar 

  31. Ishikawa, H., and E. Yano. 2008. Patient health literacy and participation in the health-care process. Health Expectations 11(2): 113–122.

    PubMed  PubMed Central  Google Scholar 

  32. Jonsdottir, T., H. Jonsdottir, and S. Gunnarsdottir. 2015a. Gender differences in chronic pain related health care utilization. Scandinavian Journal of Pain 8(1): 50–51.

    Google Scholar 

  33. Jonsdottir, T., H. Jonsdottir, E. Lindal, G.K. Oskarsson, and S. Gunnarsdottir. 2015b. Predictors for chronic pain-related health care utilization: A cross-sectional nationwide study in Iceland. Health Expectations 18(6): 2704–2719.

    PubMed  Google Scholar 

  34. Kempner, J. 2017. Invisible people with invisible pain: A commentary on “Even my sister says I’m acting like a crazy to get a check”: Race, gender, and moral boundary-work in women’s claims of disabling chronic pain. Social Science & Medicine 189: 152–154.

    Google Scholar 

  35. LeResche, L. 2011. Defining gender disparities in pain management. Clinical Orthopaedics and Related Research 469(7): 1871–1877.

    PubMed  PubMed Central  Google Scholar 

  36. Lloyd, G. 1996. The man of reason. Women, knowledge, and reality: Explorations in feminist philosophy 2: 149–165.

    Google Scholar 

  37. Lombana, W.G., and S.E. Gutiérrez Vidal. 2012. Pain and gender differences: A clinical approach. Colombian Journal of Anesthesiology 40(3): 207–212.

    Google Scholar 

  38. Mackenzie, R., and J. Watts. 2011. Including emotionality in tests of competence: How does neurodiversity affect measures of free will and agency in medical decision making? American Journal of Bioethics: Neuroscience 2(3): 27–36.

    Google Scholar 

  39. Miller, A. 2018. Gender disparities in diagnosis and pain management. MA dissertation, Temple University. http://search.proquest.com/docview/2043978340/.

  40. Morris, M.C., L.S.Walker, S. Bruehl, A.L. Stone, A.S. Mielock, and U. Rao. 2016. Impaired conditioned pain modulation in youth with functional abdominal pain. Pain 157(10): 2375.

    PubMed  PubMed Central  Google Scholar 

  41. Paolacci, G., J. Chandler, and P.G. Ipeirotis. 2010. Running experiments on Amazon Mechanical Turk. Judgment and Decision Making 5: 411–410.

    Google Scholar 

  42. Parent, M.C., and B. Moradi. 2011. An abbreviated tool for assessing conformity to masculine norms: Psychometric properties of the Conformity to Masculine Norms Inventory-46. Psychology of Men & Masculinity 12(4): 339–353.

    Google Scholar 

  43. Parent, M.C., and B. Moradi. 2011b. An abbreviated tool for assessing feminine norm conformity: Psychometric properties of the Conformity to Feminine Norms Inventory–45. Psychological Assessment 23(4): 958–969.

    PubMed  Google Scholar 

  44. Payne, D. 2004. Pain treatment often inadequate. Medical Post 40(7): 71.

    Google Scholar 

  45. Power, T.E., L.C. Swartzman, and J.W. Robinson. 2011. Cognitive-emotional decision making (CEDM): A framework of patient medical decision making. Patient Education and Counseling 83(2): 163–169.

    PubMed  Google Scholar 

  46. Ries, E. 2014. Treating pain head-on. PT in Motion 6(19): 16.

    Google Scholar 

  47. Roter, D., and S. Larson. 2002. The Roter Interaction Analysis System (RIAS): Utility and flexibility for analysis of medical interactions. Patient Education and Counseling 46(4): 243–251.

    PubMed  Google Scholar 

  48. Samulowitz, A., I. Gremyr, E. Eriksson, and G. Hensing. 2018. “Brave Men” and “Emotional Women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management 2018(3): 1–14.

    Google Scholar 

  49. Sánchez-López, M., and I. Cuéllar-Flores. 2011. Comparison of feminine gender norms among Spanish and American college women. Psychology 2(4): 300–306.

    Google Scholar 

  50. Schulman, K.A., J.A. Berlin, W. Harless, et al.1999. The effect of race and sex on physicians’ recommendations for cardiac catheterization. New England Journal of Medicine 340(14): 1130.

    Google Scholar 

  51. Shapiro, D.N., J. Chandler, and Mueller, P.A., 2013. Using Mechanical Turk to study clinical populations. Clinical Psychological Science 1(2): 213–220.

    Google Scholar 

  52. Stavropoulos, F., and B.A. Hastie. 2007. Chronic facial pain in the female patient: Treatment updates. Oral and Maxillofacial Surgery Clinics of North America 19(2): 245–258.

    PubMed  Google Scholar 

  53. Stocker, M., and E. Hegeman. 1996. Valuing emotions. Cambridge: Cambridge University Press.

    Google Scholar 

  54. Street, R.L., Jr. 2013. How clinician–patient communication contributes to health improvement: Modeling pathways from talk to outcome. Patient Education and Counseling 92(3): 286–291.

    PubMed  Google Scholar 

  55. U.S. Census Bureau. 2013. Race for the population 18 years and over from the 2010 US Census of Population and Housing: Summary. Washington, DC: U.S. Government Printing Office.

    Google Scholar 

  56. Unruh, A.M. 1996. Gender variations in clinical pain experience. Pain 65(2-3): 123–167.

    CAS  PubMed  Google Scholar 

  57. Uri, O., S. Elias, E. Behrbalk, and P. Halpern. 2015. No gender-related bias in acute musculoskeletal pain management in the emergency department. Emergency Medicine Journal of Emergency Medicine 32(2): 149–152.

    Google Scholar 

  58. Weiner, S. J., A. Schwartz, G. Sharma, et al. 2013. Patient-centered decision making and health care outcomes: An observational study. Annals of Internal Medicine 158(8): 573–579.

    PubMed  Google Scholar 

  59. Weisse, C.S., P.C. Sorum, K.N. Sanders, and B.L. Syat. 2001. Do gender and race affect decisions about pain management? Journal of General Internal Medicine 16(4): 211–217.

    CAS  PubMed  PubMed Central  Google Scholar 

  60. Zimmermann, C., L. Del Piccolo, J. Bensing, et al. 2011. Coding patient emotional cues and concerns in medical consultations: The Verona coding definitions of emotional sequences (VR-CoDES). Patient Education and Counseling 82(2): 141–148.

    PubMed  Google Scholar 

Download references

Acknowledgement

Thank you to Dr. Michael Nair-Collins for assistance with funding and for guidance in designing and analysing this research.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Sara K. Kolmes.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kolmes, S.K., Boerstler, K.R. Is There a Gender Self-Advocacy Gap? An Empiric Investigation Into the Gender Pain Gap. Bioethical Inquiry 17, 383–393 (2020). https://doi.org/10.1007/s11673-020-09993-8

Download citation

Keywords

  • Bioethics
  • Pain management
  • Gender
  • Gender pain gap
  • Empirical
  • Patient self-advocacy