Sex and Gender Issues in Pain

  • Priya Pinto


Understanding the impact of sex and gender on pain is an important step in its assessment and management. Research in this subject has grown significantly in the last two decades, and we now have a much better sense of the complex physiologic, anatomic, neuronal, and hormonal factors that affect the experience of pain. The existence of significant biases in this arena may be responsible for disparities in care.


Sex Gender Analgesic response Pain Disparity 


  1. 1.
    American Psychological Association. APA dictionary of psychology. 2nd ed. Washington, DC: Author; 2015.Google Scholar
  2. 2.
    Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain. 2003;102(1–2):167–78.CrossRefGoogle Scholar
  3. 3.
    Wijnhoven HA, De Vet HC, Picavet HS. Prevalence of musculoskeletal disorders is systematically higher in women than in men. Clin J Pain. 2006;22(8):717–24.CrossRefGoogle Scholar
  4. 4.
    Wijnhoven HA, de Vet HC, Picavet HS. Sex differences in consequences of musculoskeletal pain. Spine. 2007;32(12):1360–7.CrossRefGoogle Scholar
  5. 5.
    Chopra A, Saluja M, Patil J, Tandale HS. Pain and disability, perceptions and beliefs of a rural Indian population: a WHO-ILAR COPCORD study. WHO-International League of Associations for Rheumatology. Community Oriented Program for Control of Rheumatic Diseases. J Rheumatol. 2002;29(3):614–21.PubMedGoogle Scholar
  6. 6.
    Guo HR, Chang YC, Yeh WY, Chen CW, Guo YL. Prevalence of musculoskeletal disorder among workers in Taiwan: a nationwide study. J Occup Health. 2004;46(1):26–36.CrossRefGoogle Scholar
  7. 7.
    Berkley KJ. Sex differences in pain. Behav Brain Sci. 1997;20(3):371–80.CrossRefGoogle Scholar
  8. 8.
    Mogil JS. Sex differences in pain and pain inhibition: multiple explanations of a controversial phenomenon. Nat Rev Neurosci. 2012;13(12):859.CrossRefGoogle Scholar
  9. 9.
    Heitkemper MM, Cain KC, Jarrett ME, Burr RL, Hertig V, Bond EF. Symptoms across the menstrual cycle in women with irritable bowel syndrome. Am J Gastroenterol. 2003;98(2):420–30.CrossRefGoogle Scholar
  10. 10.
    Leveille SG, Zhang Y, McMullen W, Kelly-Hayes M, Felson DT. Sex differences in musculoskeletal pain in older adults. Pain. 2005;116(3):332–8.CrossRefGoogle Scholar
  11. 11.
    Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995;38(1):19–28.CrossRefGoogle Scholar
  12. 12.
    Meriggiola MC, Nanni M, Bachiocco V, Vodo S, Aloisi AM. Menopause affects pain depending on pain type and characteristics. Menopause. 2012;19(5):517–23.CrossRefGoogle Scholar
  13. 13.
    Marcus DA. Interrelationships of neurochemicals, estrogen, and recurring headache. Pain. 1995;62(2):129–39.CrossRefGoogle Scholar
  14. 14.
    Dao TT, LeResche L. Gender differences in pain. J Orofac Pain. 2000;14(3):169.PubMedGoogle Scholar
  15. 15.
    Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. Guidance on the management of pain in older people. Age Ageing. 2013;42:i1–57.CrossRefGoogle Scholar
  16. 16.
    Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, Bohnen AM, van Suijlekom-Smit LW, Passchier J, van der Wouden JC. Pain in children and adolescents: a common experience. Pain. 2000;87(1):51–8.CrossRefGoogle Scholar
  17. 17.
    Stewart WF, Linet MS, Celentano DD, Natta MV, Ziegler D. Age-and sex-specific incidence rates of migraine with and without visual aura. Am J Epidemiol. 1991;134(10):1111–20.CrossRefGoogle Scholar
  18. 18.
    Sundblad GM, Saartok T, Engström LM. Prevalence and co-occurrence of self-rated pain and perceived health in school-children: age and gender differences. Eur J Pain. 2007;11(2):171–80.CrossRefGoogle Scholar
  19. 19.
    Zapata AL, Moraes AJ, Leone C, Doria-Filho U, Silva CA. Pain and musculoskeletal pain syndromes in adolescents. J Adolesc Health. 2006;38(6):769–71.CrossRefGoogle Scholar
  20. 20.
    Reyes-Gibby CC, Aday LA, Anderson KO, Mendoza TR, Cleeland CS. Pain, depression, and fatigue in community-dwelling adults with and without a history of cancer. J Pain Symptom Manag. 2006;32(2):118–28.CrossRefGoogle Scholar
  21. 21.
    Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. Br J Anaesth. 2013;111(1):52–8.CrossRefGoogle Scholar
  22. 22.
    Fillingim RB, Maixner W. Gender differences in the responses to noxious stimuli. Pain Forum. 1995;4(4):209–21. Elsevier.CrossRefGoogle Scholar
  23. 23.
    Robinson ME, Wise EA, Riley JL III, Atchison JW. Sex differences in clinical pain: a multisample study. J Clin Psychol Med Settings. 1998;5(4):413–24.CrossRefGoogle Scholar
  24. 24.
    Averbuch M, Katzper M. Baseline pain and response to analgesic medications in the postsurgery dental pain model. J Clin Pharmacol. 2000;40(2):133–7.CrossRefGoogle Scholar
  25. 25.
    Coulthard P, Haywood D, Tai MA, Jackson-Leech D, Pleuvry BJ, Macfarlane TV. Treatment of postoperative pain in oral and maxillofacial surgery. Br J Oral Maxillofac Surg. 2000;38(6):588–92.CrossRefGoogle Scholar
  26. 26.
    Taenzer AH, Clark C, Curry CS. Gender affects report of pain and function after arthroscopic anterior cruciate ligament reconstruction. Anesthesiology. 2000;93(3):670–5.CrossRefGoogle Scholar
  27. 27.
    Thomas T, Robinson C, Champion D, McKell M, Pell M. Prediction and assessment of the severity of post-operative pain and of satisfaction with management. Pain. 1998;75(2–3):177–85.CrossRefGoogle Scholar
  28. 28.
    Froehlich F, Thorens J, Schwizer W, Preisig M, Köhler M, Hays RD, Fried M, Gonvers JJ. Sedation and analgesia for colonoscopy: patient tolerance, pain, and cardiorespiratory parameters. Gastrointest Endosc. 1997;45(1):1–9.CrossRefGoogle Scholar
  29. 29.
    Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447–85.CrossRefGoogle Scholar
  30. 30.
    Craft RM, Mogil JS, Aloisi AM. Sex differences in pain and analgesia: the role of gonadal hormones. Eur J Pain. 2004;8(5):397–411.CrossRefGoogle Scholar
  31. 31.
    Melchior M, Poisbeau P, Gaumond I, Marchand S. Insights into the mechanisms and the emergence of sex-differences in pain. Neuroscience. 2016;338:63–80.CrossRefGoogle Scholar
  32. 32.
    Riley JL III, Robinson ME, Wise EA, Myers CD, Fillingim RB. Sex differences in the perception of noxious experimental stimuli: a meta-analysis. Pain. 1998;74(2–3):181–7.CrossRefGoogle Scholar
  33. 33.
    Racine M, Tousignant-Laflamme Y, Kloda LA, Dion D, Dupuis G, Choinière M. A systematic literature review of 10 years of research on sex/gender and experimental pain perception–part 1: are there really differences between women and men? Pain. 2012;153(3):602–18.CrossRefGoogle Scholar
  34. 34.
    Ellermeier W, Westphal W. Gender differences in pain ratings and pupil reactions to painful pressure stimuli. Pain. 1995;61(3):435–9.CrossRefGoogle Scholar
  35. 35.
    Berman SM, Naliboff BD, Suyenobu B, Labus JS, Stains J, Bueller JA, Ruby K, Mayer EA. Sex differences in regional brain response to aversive pelvic visceral stimuli. Am J Phys Regul Integr Comp Phys. 2006;291(2):R268–76.Google Scholar
  36. 36.
    Moulton EA, Keaser ML, Gullapalli RP, Maitra R, Greenspan JD. Sex differences in the cerebral BOLD signal response to painful heat stimuli. Am J Phys Regul Integr Comp Phys. 2006;291(2):R257–67.Google Scholar
  37. 37.
    Straube T, Schmidt S, Weiss T, Mentzel HJ, Miltner WH. Sex differences in brain activation to anticipated and experienced pain in the medial prefrontal cortex. Hum Brain Mapp. 2009;30(2):689–98.CrossRefGoogle Scholar
  38. 38.
    Hobson AR, Furlong PL, Sarkar S, Matthews PJ, Willert RP, Worthen SF, Unsworth BJ, Aziz Q. Neurophysiologic assessment of esophageal sensory processing in noncardiac chest pain. Gastroenterology. 2006;130(1):80–8.CrossRefGoogle Scholar
  39. 39.
    Derbyshire SW, Jones AK, Creed F, Starz T, Meltzer CC, Townsend DW, Peterson AM, Firestone L. Cerebral responses to noxious thermal stimulation in chronic low back pain patients and normal controls. NeuroImage. 2002;16(1):158–68.CrossRefGoogle Scholar
  40. 40.
    Bragdon EE, Light KC, Costello NL, Sigurdsson A, Bunting S, Bhalang K, Maixner W. Group differences in pain modulation: pain-free women compared to pain-free men and to women with TMD. Pain. 2002;96(3):227–37.CrossRefGoogle Scholar
  41. 41.
    Holdcroft A, Berkley KJ. Sex and gender differences in pain and its relief. In: McMahon SB, Wall KM, editors. Melzack’s textbook of pain. 2006;1181–97.CrossRefGoogle Scholar
  42. 42.
    Miaskowski C, Gear RW, Levine JD. Sex-related differences in analgesic responses. In: Fillingim RB, editor. Sex, gender, and pain. Seattle: IASP Press; 2000;209–30.Google Scholar
  43. 43.
    Miaskowski C, Levine JD. Does opioid analgesia show a gender preference for females? Pain Forum. 1999;8(1):34–44. Churchill Livingstone.CrossRefGoogle Scholar
  44. 44.
    Niesters M, Dahan A, Kest B, Zacny J, Stijnen T, Aarts L, Sarton E. Do sex differences exist in opioid analgesia? A systematic review and meta-analysis of human experimental and clinical studies. Pain. 2010;151(1):61–8.CrossRefGoogle Scholar
  45. 45.
    Keogh E, McCracken LM, Eccleston C. Do men and women differ in their response to interdisciplinary chronic pain management? Pain. 2005;114(1–2):37–46.CrossRefGoogle Scholar
  46. 46.
    Pieh C, Altmeppen J, Neumeier S, Loew T, Angerer M, Lahmann C. Gender differences in outcomes of a multimodal pain management program. Pain. 2012;153(1):197–202.CrossRefGoogle Scholar
  47. 47.
    Mowlavi A, Cooney D, Febus L, Khosraviani A, Wilhelmi BJ, Akers G. Increased cutaneous nerve fibers in female specimens. Plast Reconstr Surg. 2005;116(5):1407–10.CrossRefGoogle Scholar
  48. 48.
    Chakrabarty A, McCarson KE, Smith PG. Hypersensitivity and hyperinnervation of the rat hind paw following carrageenan-induced inflammation. Neurosci Lett. 2011;495(1):67–71.CrossRefGoogle Scholar
  49. 49.
    Korszun AN, Young EA, Engleberg NC, Masterson LO, Dawson EC, Spindler KA, McCLURE LA, Brown MB, Crofford LJ. Follicular phase hypothalamic-pituitary-gonadal axis function in women with fibromyalgia and chronic fatigue syndrome. J Rheumatol. 2000;27(6):1526–30.PubMedGoogle Scholar
  50. 50.
    Hellström B, Anderberg UM. Pain perception across the menstrual cycle phases in women with chronic pain. Percept Mot Skills. 2003;96(1):201–11.CrossRefGoogle Scholar
  51. 51.
    Unruh AM, Ritchie J, Merskey H. Does gender affect appraisal of pain and pain coping strategies? Clin J Pain. 1999;15(1):31–40.CrossRefGoogle Scholar
  52. 52.
    Thompson T, Keogh E, French CC, Davis R. Anxiety sensitivity and pain: generalisability across noxious stimuli. Pain. 2008;134(1–2):187–96.CrossRefGoogle Scholar
  53. 53.
    Ramírez-Maestre C, Esteve R. The role of sex/gender in the experience of pain: resilience, fear, and acceptance as central variables in the adjustment of men and women with chronic pain. J Pain. 2014;15(6):608–18.CrossRefGoogle Scholar
  54. 54.
    Jensen MP, Turner JA, Romano JM, Lawler BK. Relationship of pain-specific beliefs to chronic pain adjustment. Pain. 1994;57(3):301–9.CrossRefGoogle Scholar
  55. 55.
    Keefe FJ, Lefebvre JC, Egert JR, Affleck G, Sullivan MJ, Caldwell DS. The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing. Pain. 2000;87(3):325–34.CrossRefGoogle Scholar
  56. 56.
    Edwards RR, Haythornthwaite JA, Sullivan MJ, Fillingim RB. Catastrophizing as a mediator of sex differences in pain: differential effects for daily pain versus laboratory-induced pain. Pain. 2004;111(3):335–41.CrossRefGoogle Scholar
  57. 57.
    Eisenberg N, Shea CL, Carlo G, Knight GP. Empathy-related responding and cognition: a “chicken and the egg” dilemma. In: Handbook of moral behavior and development, vol. 2; 2014. p. 63–88.Google Scholar
  58. 58.
    Robinson ME, Riley JL, Myers CD, Papas RK, Wise EA, Waxenberg LB, Fillingim RB. Gender role expectations of pain: relationship to sex differences in pain. J Pain. 2001;2(5):251–7.CrossRefGoogle Scholar
  59. 59.
    Chambers CT, Craig KD, Bennett SM. The impact of maternal behavior on children's pain experiences: an experimental analysis. J Pediatr Psychol. 2002;27(3):293–301.CrossRefGoogle Scholar
  60. 60.
    LeResche L. Defining gender disparities in pain management. Clin Orthop Relat Res. 2011;469(7):1871–7.CrossRefGoogle Scholar
  61. 61.
    Alqudah AF, Hirsh AT, Stutts LA, Scipio CD, Robinson ME. Sex and race differences in rating others’ pain, pain-related negative mood, pain coping, and recommending medical help. J Cyber Ther Rehabil. 2010;3(1):63.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Wandner LD, Stutts LA, Alqudah AF, Craggs JG, Scipio CD, Hirsh AT, Robinson ME. Virtual human technology: patient demographics and healthcare training factors in pain observation and treatment recommendations. J Pain Res. 2010;3:241.CrossRefGoogle Scholar
  63. 63.
    Hirsh AT, George SZ, Robinson ME. Pain assessment and treatment disparities: a virtual human technology investigation. Pain. 2009;143(1–2):106–13.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Priya Pinto
    • 1
  1. 1.Division of Palliative Medicine and BioethicsNYU Winthrop HospitalMineolaUSA

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