Promoting women as pain practitioners should not be viewed as a simple checkbox.

Commentary

Pain is a deeply personal, highly individualized experience. Sex and gender profoundly affect our personal experiences and perceptions, including those with and of pain in ourselves, and in others. Thoughtful, effective pain management must therefore consider two important concepts: how being a female patient impacts the pain experience, and how the experience of female clinicians can impact pain medicine.

There is a marked female predominance across a wide variety of chronic pain conditions, including musculoskeletal and orofacial pain, fibromyalgia migraine, and abdominal and pelvic pain.1 In addition to experiencing both chronic and acute pain more often, women report greater pain intensity than men with the same pain condition2 and have been found to experience more acute post-operative pain than men undergoing the same procedures.1 These differences reflect a combination of genetic, biological/hormonal, psychological, social, and cultural factors that span different age groups, racial/ethnic categories, medical conditions, and socioeconomic classes, making the gender gap in pain patients a complex and widespread problem.

When Preclinical Research Misses the Point

The disparities between women and men suffering from pain are exacerbated by multiple gender biases that begin with basic pain research and extend all the way to the clinical treatment of pain. The classic rodent model is the cornerstone of basic science pain research, yet despite findings that male and female mice process pain differently,3 the vast majority of animal studies in pain are conducted only in male specimens.4 And, although the National Institutes of Health (NIH) Policy on the Inclusion of Women in Clinical Research has ensured that women now account for roughly half of all participants in NIH-supported clinical research, only recently has the NIH adopted the consideration of sex as a biological variable in preclinical biomedical research.5

Many pain researchers argue that requiring preclinical experiments on both male and female animals introduces variables that may be difficult to control for (eg, hormone levels), requires increased sample sizes, and exhausts precious time and resources. However, such arguments miss the larger point. A failure to consider the influence of sex on preclinical research creates substantial gaps in knowledge about pain mechanisms and potential pain treatments in women. Indeed, a number of studies have found that women and men have differential responses to pain treatments (and their side effects), ranging from epidural analgesia6 to opioid therapy.7 Gender inclusion at all levels of pain research is therefore crucial to understanding the differences between male and female pain processing, and by extension, developing effective, targeted treatments for pain.

Disparities Continue in the Exam Room

The challenges of treating women in pain do not end with pain research. Women are also treated differently when reporting pain compared to men with the same complaint. Although women are more likely to seek treatment for pain, their pain is more likely to be dismissed as “emotional” or “psychogenic.”8 A classic 1990 study found that women complaining of pain after coronary artery bypass grafting were more likely to be prescribed sedatives than analgesics compared to men.9 Decades later, gender disparities persist. A more recent study found that pain clinicians and medical students rated female patients to have less pain and to be more likely to exaggerate pain, with men more likely to be recommended analgesics, while women were recommended psychological treatment.10 In another study of patients presenting to an urban emergency department with acute abdominal pain, men and women were found to have similar mean pain scores, but women were significantly less likely to receive any analgesia, less likely to receive opioids, and waited a median of 16 minutes longer than their male counterparts to receive any pain medications.11

Women are also three times less likely than men to undergo hip or knee arthroplasty, and when they do undergo surgery, they tend to have poorer surgical outcomes.12 These data may be partly because women tend to undergo surgery later in the disease process than men, when the pain and arthritis are more severe. Although it is not entirely clear why women have surgery later, gender biases in recommended treatments may be a factor. A Canadian study found that the odds of a surgeon recommending knee replacement for knee osteoarthritis were 22 times higher for a standardized male patient compared to an identical standardized female patient.13

The contrast in pain treatment between women and men has not gone unnoticed. In a recent survey of more than 2,400 women with chronic pain, 84% reported feeling that they were treated differently by doctors because of their sex, and 90% felt that the healthcare system discriminates against female patients.14 The lay press abounds with examples of gender bias in pain treatment, with numerous authors, commentators, and even celebrities calling attention to the under-treatment of women in pain.

As clinicians interested in providing the most effective, compassionate care possible to our patients, we must be sensitive to the particular needs of all our patients—male or female. This includes paying greater attention to the gender biases within our own profession. The female predominance in pain conditions should carry no more judgment than the observation that women are more likely to have osteoporosis or iron-deficiency anemia.

Women as Pain Practitioners

Unfortunately, even with a growing awareness of the gender gap in pain treatment, there has been relatively little attention drawn to the other gender gap in pain—the lack of female clinicians in pain practice. While women currently make up half of all graduating medical students, they comprise less than one-quarter of pain medicine fellows,15 and only 18% of current pain management physicians.16 This striking lack of female representation in the field of pain medicine highlights the pervasiveness of gender bias in pain treatment—but it also presents a tremendous opportunity to address the challenges of treating women’s pain.

A growing body of evidence suggests that increased female representation in healthcare may actually lead to improved outcomes for patients. Female physicians have been found to be more likely to follow evidence-based guidelines17 and provide preventive health services,18 both key elements of effective, efficient healthcare. In addition, female physicians tend to spend more time with patients per consultation19 and provide more patient-centered care.20 Gender-related communication skills may also allow female physicians to increase patient satisfaction.21

Relatively few studies have evaluated the role of the clinician’s sex in the treatment of pain, and the limited results often reveal a complicated, multifaceted relationship between clinician sex, patient sex, and specific circumstances of the pain complaint. Although female physicians have been found to prescribe lower doses of hydrocodone for chronic back pain in primary care settings,22 they have also been more likely to provide opioids for acute pain in the emergency department.23 Physician gender has also been found to influence perceptions of men and women in pain, as well as pain treatment decisions such as medication prescriptions, invasive procedures, or referrals to psychology/psychiatry.24-26

Another reason to work toward improved gender diversity in healthcare is that some patients may have personal or cultural preferences for female physicians. Women may find it easier to communicate with female physicians, especially for sex-specific pain complaints, and there is some evidence that gender concordance, particularly between female physicians and female patients, leads to improved patient-centered care.19

Moreover, pain care involves complex, multifactorial health conditions that often require a wide range of generalists, specialists, and subspecialists to provide successful, multimodal treatment. Having gender-diverse healthcare teams may help to address different needs, provide unique perspectives, and guide treatment approaches among individual patients. Promoting women in medicine, and particularly pain medicine, should therefore not be viewed as a simple checkbox of promoting diversity for diversity’s sake. It should be a conscious effort to provide all of our patients with an opportunity to establish more effective therapeutic relationships with clinicians who face the challenges of treating pain.

Where Do We Go from Here?

Consider, for a moment, your own colleagues and referral patterns. How many female clinicians do you know? Do you tend to refer more often to male or female physicians, and does patient or physician sex (or your own) play a role in your selection process? Consider the research and articles you read, and whether they are written by men, or women, and whether their test groups include women.

Recognizing your and others’ influences of sex and gender in patients suffering from pain, as well as understanding the benefits of gender diversity among clinicians who treat pain, are important steps in pain management. By first acknowledging these gaps, we can work to bridge them together, enhancing our profession and improving the treatment of all our patients.

Also featured in this special report on Pain Care & Research in Women

Last updated on: September 5, 2018

Continue Reading:

Time to Tip the Scales in Pain Research and Care for Women