If you are unfamiliar with the gender pain gap, let me give an example of how it works. In 2021, I went to Planned Parenthood to get an intrauterine device (IUD). They refer to the procedure as an “implant” but having worked in a home improvement store before, I can tell you that any procedure requiring measurements and clamps is an installation.
The nurse stopped the procedure at one point and asked if I was sure I was ready for this, as I had shown signs of extreme discomfort. I was sure the pain I was feeling was normal, and so I said I was fine. When she started measuring my uterus, I passed out on the table. After I recovered, the nurse advised they could discuss a potential anesthetic with the doctor if I wanted to try again, but he would have to approve such a request, and that was not guaranteed. I did not get an IUD.
According to the CDC, approximately 20 percent of U.S. women have used an IUD (a long-term contraceptive device inserted into the uterus made of copper or plastic) to prevent pregnancy. Less than 5 percent of physicians offer a local anesthetic for IUD procedures. In a 2013 study of 200 women, the average maximum pain score they reported was 65 on a scale of 0 to 100. Providers in the study rated women’s pain at about 35. If you want to see what getting an IUD feels like, women on TikTok have taken to filming their procedures. You can check those out here but be warned, they’re pretty raw.
“In my estimation, people with uteruses have been ignored in so many ways, not when it just comes to pain control.” — Alhambra Frarey, Chief Medical Officer at Planned Parenthood of Southeastern Pennsylvania
Until the 1840s, the myriad substances that dull pain, sedate consciousness, and put people to sleep were generally known, but not utilized by medical providers. When they demonstrated the potential of anesthetics in making life-saving surgeries a viable choice and even relieving the agony of childbirth, the immediate backlash came in: Women were supposed to suffer through childbirth, religious zealots argued, because the Bible says so. Obviously.
While the idea that women deserve to suffer in pain has, for the most part, faded from modern medical practice, gender norms still color the way that providers perceive how men and women experience pain. The perception of how and to what degree women experience pain — the gender pain gap — is evident in practices and prescriptions, from surgery and injury treatment, to childbirth and chronic pain conditions. This disparity in how healthcare professionals respond to women in pain can have dire and even deadly consequences.
Does it really hurt that bad though?
Assessing pain can be complicated. When a patient approaches them in pain, providers have to listen, make a visual and physiological evaluation, draw on their experience, and take into account factors such as age, lifestyle, location, and other medical conditions. Though a relatively small amount of research has been done to quantify them, there are some physiological differences in how women and men experience pain. This is especially observed with chronic pain, associated with nerve damage and conditions like diabetes and fibromyalgia, as opposed to acute pain resulting from tissue damage, or labor during childbirth.
Ramesh Raghupathi, PhD, is a professor in Drexel University’s Department of Neurobiology and Anatomy and
deputy director of its Graduate Program in Neuroscience. He explains that there are two issues: Imaging data shows visible differences in the brain in chronic pain conditions between the sexes. Then there are gender biases in the treatment of pain by the medical community. “Part of that bias may very well have its roots in this kind of thing where women have given birth to children, and that pain is so much more than anything else,” Raghupathi says. “To me, that’s apples and oranges. It’s not the same thing and you can’t use that as a reason to say, I disregard your pain.”
While biological sex differences in chronic pain conditions are known in medicine, they have not resulted in better treatment for women, who are more likely than men to be prescribed antidepressants and referred to psychotherapy by physicians when reporting pain symptoms than pain medication or further diagnostics. This has profound effects beyond pain, leading many women to feel abandoned by providers, family members and partners who don’t believe their suffering.
“It is clear that from a physiological standpoint, there are sex differences in the way men and women feel pain,” says Dr. Michael Ashburn, the director of Pain Medicine at Penn Medicine. “But, we have not identified major changes or differences between men and women in what treatments work.”
Even women’s reproductive care is still impacted by ancient lore about women, childbirth, and their reproductive organs that assumes their pain can’t be that bad because they’re “designed” for this; that women complaining of pain are being dramatic about it; or that because women are weaker they can’t handle pain as well as men. These seemingly contradicting biases can be reconciled another way. “I’ve never really considered those theories,” says Alhambra Frarey, the new Chief Medical Officer at Planned Parenthood of Southeastern Pennsylvania. “In my estimation, people with uteruses have been ignored in so many ways, not when it just comes to pain control. Healthcare research in medicine that exclusively affects people with uteruses has not been prioritized. I think it’s about misogyny.”
This is a function of the research gap more broadly: Despite the fact that chronic pain afflicts women more than men, most of the studies on pain have been conducted on men — as has most of the research into treatments. One example: Despite just 19 percent of men experiencing erectile dysfunction, there is five times more research into that condition than on the far more common premenstrual syndrome. Talk about penis envy.
In the ER
In addition to reproductive care, emergency room visits are the most well-documented area of gender pain disparity — something I glimpsed in March, when I slipped down the stairs of my new house, hitting my spine and the bottom of my rib cage. I was unable to bend or twist; breathing hurt; and though my arms and legs were uninjured, I couldn’t push or pull with them without feeling pain. I couldn’t sit down from standing; I couldn’t stand when seated. As the pain spread from my back across my abdomen, I figured I should get checked out in case, you know, my organs were leaking.
Upon arrival at Temple University Hospital’s Emergency Room, a female registration nurse helped me into a wheelchair; a male ER nurse who wheeled me to a bed parked me there and watched me squirm to it. A male doctor ordered a CT scan and ibuprofen, but never touched me or looked at the area where I was in pain. The male nurse came back with a cup for a urine sample and directions to the restroom, where it took me about 10 minutes of painful maneuvering to pee in the cup — and all over the floor. The imaging staff were women, who helped me off the bed, onto the scanning table, and back, then brought me tissues because that ibuprofen wasn’t hacking it. Luckily, I didn’t break any bones or pop any vital organs. When I was discharged, the male ER nurse didn’t even bring me back the wheelchair.
“Establishing a best evidence standardized process for doing care within patient populations is one possible way of defeating unconscious bias based on sex or race.”— Michael Ashburn, Penn Medicine’s director of Pain Medicine
Was what felt like a callous response of my male healthcare providers because I’m a woman, in self-declared pain, but with no blood or broken bones to show for it? Temple was unable to arrange for someone to interview for this article, and did not respond to requests for comment on this incident. But it would be in line with what the research has shown about women’s experiences in the ER.
And it could have been worse — I could have been having a heart attack. An American Heart Association study found that when women arrive in ERs with chest pain, they are less likely to be triaged as emergencies, and thus wait longer. They are less likely to have an ECG ordered, and less likely to be admitted for observation. This is also true for people of color.
Women are also less likely to receive pain medication than men in the ER. In one study of ER visits for abdominal pain, women were 13 to 25 percent less likely than men to receive opioid pain relief, waited a median of 16 minutes longer to receive medication, and were 7 percent less likely to receive any pain reliever at all. Most interestingly, that study found the gender pain gap persisted regardless of the healthcare provider’s gender.
Overall, women arriving in pain at emergency rooms are dismissed more easily, receive less testing and treatment than men, and wait longer for relief and diagnoses as a result.
What can we do better?
While at Penn Medicine’s Family Planning Division, Frarey completed the Complex Family Planning Fellowship, where she participated in a randomized control trial examining local anesthetics for IUD insertions. The trial proved they were effective at relieving pain during the procedure, and Penn has since incorporated anesthetics for IUDs into its practice. When she came to Planned Parenthood, Frarey made it a priority to implement a policy offering local anesthetic for IUD insertions. Training rolled out in early 2024, and the process is nearly complete.
“I’m really glad that this truth is being elevated in the media so that more people understand that there are options out there,” says Frarey. “Patients shouldn’t have to advocate: They should be presented with all of their options as part of the informed consent process.” If providers don’t offer an anesthetic, Frarey says, patients can always request it — or, ask for a referral to another doctor who will.
In one study of ER visits for abdominal pain, women were 13 to 25 percent less likely than men to receive opioid pain relief, waited a median of 16 minutes longer to receive medication, and were 7 percent less likely to receive any pain reliever at all.
Like many systemic disparities, research also demonstrates that education on gender bias in undergraduate medical school and awareness training for medical professionals on the job results in better treatment outcomes for women experiencing pain. Part of this must include changing the way sex differences are taught in medical school. In most medical education, male biology is still treated as the default, rather than teaching students the differences between male and female bodies from the start. To achieve equity, more research into and understanding of biological sex differences is needed across the medical field — but there must also be an effort to approach treating men, women, and transgender people in a way that doesn’t center the social construct of gender and its resulting stereotypes and biases.
Unfortunately, incorporating gender bias training into medical education is easier said than done. Until the last few years, medical school was structured around two initial years of classroom learning followed by two years in clinical settings. The Association of American Medical Colleges (AAMC) decided that clinical instruction should begin on day one to improve patient care, and now much of what professors previously taught and tested students on is delivered via independent learning modules — meaning less didactic instruction on basic things like the anatomy of the kidney, for example, but also the mechanisms of pain. Immersed in clinical education during undergrad and then in residency later, medical students have less opportunity to learn explicitly about biases and could be picking stereotypes up from their mentors.
Having practiced medicine for 40 years, Ashburn recalls there were just two women in his medical school graduating class. Today, more than half of Penn’s medical school graduates are women. However, the number of women and underrepresented minorities in academic medicine is still relatively low. Patients are better served, he insists, when faculty represents the diversity in the people they care for.
More women in academic medicine could go a long way toward the effort to include women’s bodies and conditions in research goals. More women in physicians’ coats sitting at bedsides and walking residents through their paces means more understanding, compassion, and effective treatment when women tell the doctor, It hurts.
Because there is no technology for detecting pain (yet) nor a universal standard for the subjective experience that is pain, Raghupathi and others in the academic medical community recommend a gender-neutral strategy during initial triage, not only for emergency services but also for office visits and other care settings. “Let’s just talk about a cardiac event,” Raghupathi says. “The presentation in women is different than the presentation in men. But irrespective of that, I think that has to be identified as not the problem before assuming that it’s not the problem.”
Penn’s Pain Medicine department has a standardized process of care for patients with similar diseases based on best evidence. Imagine a mandatory checklist of everything known about the condition, symptoms, and treatments in ascending order which explicitly avoids any personal beliefs, traditional methods, or advice when it comes to care options. Last year, the department conducted an internal review of their compliance and patient outcomes to look at differences based on sex and race. They found none.
“That does not mean that we are perfect,” Ashburn qualifies. “What it does mean is that, at least in my mind, establishing a best evidence standardized process for doing care within patient populations is one possible way of defeating unconscious bias based on sex or race.”
This piece is part of a year-long editorial series looking at innovations to address inequities in women’s healthcare, sponsored by Independence Blue Cross.
