Are unconscious gender biases widening the Australian gender pain gap?

Pain is a highly complex and subjective phenomenon, characterised by high levels of inter-individual variability.^1,2 This can make it difficult to quantify and compare pain between individuals and different population groups.^1,2

Access to timely and appropriate pain management is also influenced by numerous factors, including some related to the patient, such as level of health literacy, socio-economic disadvantage, geographic location, and others related to society, including, discrimination, stigma, and gender norms.³

Considering this, there has been growing literature citing the presence of what has been termed a ‘gender pain gap’ both locally and globally.^4–11 This article shares insights from an Australian survey of healthcare professionals evaluating attitudes towards unconscious gender biases, with the aim of helping pharmacists conceptualise the gender pain gap as it applies to their own practice as well as the broader healthcare landscape.

It includes practical strategies to help pharmacists identify and address unconscious gender biases relating to the management of pain in their practice. While this article focuses on the gender pain gap as it pertains to cisgender women and men, it’s crucial to acknowledge that gender bias may similarly impact non-cisgender individuals experiencing pain.^12,13 Many of the strategies aimed at mitigating unconscious bias discussed may also be relevant for addressing disparities faced by non-cisgender individuals.^12,13

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What is the gender pain gap? 

The term ‘gender pain gap’ is usually used to refer to the disparities in the pain experience between men and women. In literature, the term encompasses ideas such as^4–8:

• inadequate management of pain in women compared to men for conditions that affect all genders
• mismanagement of pain conditions that specifically affect women
• differences in pain experiences between genders.

The gender pain gap has been demonstrated in Australian healthcare settings in relation to the diagnosis and treatment of pain.^9–11 A retrospective audit in the Australian acute care setting (n = 192) demonstrated that women presenting with acute abdominal pain received different analgesics, fewer doses of analgesics, and experienced longer wait times for analgesics to be administered compared to men.⁹ With regard to gender specific conditions, a study of Australian women with endometriosis (n = 532) indicated many felt let down by medical staff, with their pain often viewed as psychological or the reported severity being distrusted.¹⁰ Additionally, diagnosis of endometriosis in Australia has been shown to be delayed by an average of 6.4 years due to various reasons, including misunderstanding and lack of knowledge of endometriosis by healthcare professionals, misdiagnoses and normalisation of period pain.¹¹

Several factors contribute to the gender pain gap. Historically, women have been under-represented in medical research.^15,16 Initial pain studies included average male subjects with results being generalised to females, contributing to a poorer understanding of how certain pain conditions manifest or need to be managed in this demographic.^6,15,16 Differences in physiological pain pathways between men and women have now been reported, but a comprehensive understanding of these distinctions remains elusive.^17,18 While representation of female subjects has been increasing in research, many areas of medicine still lack gender-specific recommendations.¹⁹

Moreover, another key cited contributor to the gender pain gap is unconscious gender bias.^7–9

Are Australian healthcare professionals aware of gender biases in clinical practice?

Awareness of this phenomenon was evaluated in a quantitative online survey of Australian pharmacists and general practitioners (n = 305) conducted in December 2023.²⁰ The vast majority of respondents believed in the existence of unconscious biases among healthcare professionals, indicating that this is generally a well-known and accepted concept (see Figure 1). These unconscious biases were primarily reported to manifest in relation to gender, culture and race. When questioned about the existence of gender biases in the context of patient care, this was again widely acknowledged and almost half of the healthcare professionals considered it to be a widespread problem.²⁰ 

Figure 1 – Awareness of unconscious biases in a survey of Australian healthcare professionals

In the pain treatment setting, a common perception was that gender bias among healthcare professionals manifested in the form of female pain being overlooked, underdiagnosed, misdiagnosed, and taking too long to be diagnosed (see Figure 2).²⁰

Figure 2 –  Australian healthcare professional perceptions of gender bias and pain

Where does unconscious bias come from?

Unconscious bias (also known as implicit bias) often differs starkly from an individual’s conscious beliefs.²¹ It develops in early life from repeated reinforcement of social stereotypes until they become automatic.²¹ In this context, stereotypes refer to well-learned sets of associations between certain traits and a social group.²¹ For example, from a very young age, children are socialised to react to pain in certain ways; in particular, most societies discourage men from expressing their emotions while women are taught to verbalise discomfort.^6,7,22 While gender stereotypes are nuanced, a common overarching theme is the perception of men as stoic and/or rational, and that of women as emotional, dramatic and/or prone to exaggeration.^5,7

Although these social stereotypes are not consciously endorsed in healthcare settings, healthcare professionals are not immune to them.²¹ Furthermore, the uncertainty and time pressures in most healthcare settings may favour reliance on stereotypes for decision making.^21,24

Pain assessment is particularly vulnerable to unconscious
biases

Pain management is an area that may be particularly vulnerable to unconscious biases, given that pain is a subjective experience, likely influenced by biological, psychological, and social factors.²⁵ When managing pain, healthcare professionals are required to make inferences about pain authenticity and intensity.^5,8 These judgements cannot be objectively verified and can be influenced by perceiver biases based on gender, race, and other contextual factors.^5,8

For instance, a healthcare providers’ perception of a patients’ trustworthiness may impact their pain assessment and treatment decisions.²⁶ In a United Kingdom study where pain clinicians and medical students made judgements based on a video and a brief history of a patient with shoulder pain, women, especially those rated as being of low trustworthiness (ratings were provided by trainee clinical psychologists), were estimated to have less pain, and judged to be more likely to exaggerate. For treatment recommendations, men were more likely to be recommended analgesics while women were more likely to be recommended psychological treatment.²⁶

How unconscious gender bias impacts healthcare interactions for women

In the Chronic Pain Australia 2023 National Pain Survey, findings indicated that women felt they are less likely to be believed when presenting with chronic pain.²⁷ Some respondents described feelings of judgement, shame and ridicule when accessing healthcare. Many (76.3%) shared experiences of feeling ignored or dismissed.²⁷

In the present survey, healthcare professionals recognised that unconscious gender bias could potentially influence the mental health of female patients and impact their experience of pain conditions, as well as impact their interactions with healthcare providers in a negative manner (see Figure 3).²⁰

Figure 3 –  Australian healthcare professional perceptions of the impacts of gender pain bias

How can we address unconscious gender bias in pharmacy settings?

The International Pharmaceutical Federation (FIP) 2023 report on the role of pharmacists in closing the gender pain gap noted that the topic was not well covered during pharmacy education.²³ This was reflected in the present survey where most healthcare professionals, including pharmacists, noted that they had not received any training on understanding and addressing female pain experiences (see Figure 4).²⁰

Figure 4 –  Training on understanding and addressing female pain experiences in Australia

Unconscious gender bias needs to be addressed at all levels of healthcare. In the context of pain management, pharmacists play a key role – from providing medicines advice and dispensing to referring patients to other healthcare professionals as needed. As such, pharmacists need to be aware of gender stereotypes in pain management to be able to identify and address any inequities in care.²³

It is important to keep in mind that different genders have different pain management needs that change at each stage of life.³ Closing the gender pain gap doesn’t mean providing the same pain care for all genders, but rather working towards equitable care for all.

Strategies to identify and address unconscious gender bias in the pharmacy setting

Unconscious gender biases are complex, thus there is no single debiasing strategy that will work for everyone.^21,28 However, since gender biases are automatic, habitual activation of stereotypes, the first step to addressing them is for healthcare professionals to be aware of their susceptibility to them.^16,28

While it is difficult to quantify bias, these strategies may be useful for identifying unconscious gender biases:

• Implicit Association Test (https://implicit.harvard.edu/implicit/) – designed to help improve awareness of one’s own biases, preferences, and beliefs in various aspects of life (note it is not healthcare specific).²⁹
• Anonymous patient feedback – gain insight on biases specific to your practice.²⁰

Some strategies that may help to address unconscious gender biases include:

• Counter-stereotyping – imagine a person who represents the opposite of a stereotypical attribute of their group (could be imaginary, famous or from a real-life experience).^30,31
• Individuation – involves learning specific details about a person to help evaluate them based on personal attributes rather than ingrained group-based stereotypes.³¹
• Perspective taking – take on the perspective of a person who is a member of a stereotyped group (e.g. the perspective of women in pain).^31,32

These strategies can help to improve the quality of communication with patients and may prevent filling in partial information with stereotype-based assumptions.^21,23 Self-reflection when interacting with patients may also help to avoid stereotype-based assumptions – ask yourself questions such as²⁸:

• Am I making any assumptions about the patient in front of me?
• Did I consider causes besides
  anything obvious?
• Did I ask questions that would challenge, rather than confirm, my current hypothesis?
• Was I interrupted or distracted while caring for this person?
• Is this a patient I dislike or like too much for any reason?

A simple acronym such as ACE (see Figure 5) may be helpful for habitualising this process during interactions with patients seeking analgesia.

Figure 5 – ACE acronym

Finally, keep in mind that men and women tend to express pain differently due to early socialisation of pain responses,^6,7,22 and this should be considered during consultations to help avoid stereotypical categorisations.

For instance^6,7:

• Women may be more likely to be expressive and tend to explain their pain contextually (e.g. the impact of pain on their relationship or childcare duties).
• Men may be more likely to report
  pain more objectively (e.g. physical symptoms and functional limitations) rather than providing contextual information.

Key points

The gender pain gap refers to the disparities in the pain experience between genders. While a range of factors contribute to the gender pain gap, unconscious gender bias has been cited as one of the key factors.

Unconscious biases develop early in life from repeated reinforcement of social stereotypes until they become automatic. Given that pain is a subjective experience, pain management may be particularly vulnerable to unconscious biases.

The issue of unconscious gender biases needs to be tackled at all levels of healthcare. Taking small steps in the pharmacy to address it can help lay the foundations for closing the gender pain gap and ensure equitable provision of healthcare services for all patients.

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References

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Our reviewer

Dr Jacinta Johnson PhD, FANZCAP (Edu. Research), FPS, FSHP is a credentialed Advanced Practice Pharmacist. She is a Senior Lecturer in Pharmacy at the University of South Australia and Senior Pharmacist for Research within SA Pharmacy.

Conflict of interest declaration

Jacinta Johnson has received consultancy fees for development and delivery of educational materials or Advisory Group participation from Mundipharma Pty Ltd, Aspen Pharmacare Australia Pty Ltd, Reckitt Benckiser (Australia) Pty Ltd and Viatris Pty Ltd.