March 19, 2024

Getting real about women’s health – The pain gap: it is, indeed a “thing”

For the second blog in our series, we turn our attention to how women’s experience of pain is managed in our health system, and as you might expect from a system where bias can sometimes feel built into everything from tools to clinician conversations – it’s not great. But there is a lot to unpack, and a role for comms here so let’s dive in. 

 

It’s now well accepted that there is a problem when it comes to women’s experience of pain and how the medical system deals with it. Research has shown that healthcare professionals “routinely underestimate,” and this appears to be based on a number of biases and beliefs that have little to do with a patient’s actual testimony (1). Three years ago, a research paper showed that gender biases are likely behind this due to the false belief that women are oversensitive to pain, and express or exaggerate it more easily (if you read our first blog in the series, you may notice that gendered stereotypes seem to be a theme in the state of women’s health). The result is that healthcare staff (male and female) often discount women’s reports of pain and nonverbal behaviours expressing pain (2). And it gets worse, the research also demonstrated the consequences, with these healthcare professionals often under-treating pain – for example offering psychological interventions or sedatives rather than analgesia (3).

Gender is not the only factor at play here. Data that is over 10 years old showed a correlation between healthcare professionals’ unconscious racial biases and how they managed patients’ pain, with doctors being less likely to prescribe appropriate pain medication for Black patients (4). Later, a meta-analysis of twenty years of studies showed that Black/African American patients were 22% less likely than white patients to receive any pain medication (5). The intersectionality of gender and race further complicates the perception and management of pain for women of colour. Stereotypes about race and gender can result in compounded biases, influencing how pain is assessed and addressed.  We can see how this plays out for Black, Asian and women from other minority ethnic backgrounds during childbirth in data published last year which showed that these women were significantly less likely to receive an epidural compared to white women (4). The reasons why this is the case are complex, with the study’s authors identifying that the differences in the maternity care “given to women with different ethnicity may arise from barriers to information and knowledge, as well as barriers to choosing how, and where, care is provided. There can also be empathy biases from healthcare professionals, such as the interpretation of the labour pain from different ethnic groups.“

Ignoring the evidence

Women’s experiences of pain continue to be minimised and dismissed, despite evidence showing that women experience pain more than men, experiencing a greater number of pain instances across their life-span than men, occurring in more bodily areas and with greater frequency (6). Women also suffer with almost all chronic pain conditions to a much greater extent than men, and not only do they suffer from chronic pain more frequently but they also experience it more intensely and for longer periods compared to men (7).

This is in addition to female-specific pains, particularly in the pelvic region, including painful periods (dysmenorrhea) and endometriosis.

“Before receiving my PMDD diagnosis, a GP simply wrote it off as IBS. This in spite of coming to the appointment with months and months of symptom logs, showing that it wasn’t just debilitating cramps: it was significant breast swelling and tenderness, joint pain and fatigue that made daily tasks seemingly impossible, intense mood swings, anxiety, paranoia – all turning my life upside down during my luteal phase to resolve a few days after my period began. The attempts to advocate for myself didn’t seem to matter. I was simply told to change my diet, take paracetamol, and get on with it.”

Earlier this year NICE’s guidance updates to include sterile water injections into the back as a recommended pain management option during childbirth caused consternation. The explanation offered was that while the mechanism was not fully understood, it’s likely that the injections offer a placebo effect. However, some doctors have referred to the injections as “pseudoscience” or pointed out (via a letter to the BMJ) that implementing this guidance may displace the role of true analgesia, “further causing patients to suffer unnecessarily.” Further, “Patient autonomy to choose their treatment should be at the centre of management; however, giving patients, in pain, a physiologically inert substance in the hopes that their placebo effect can manage the pain is poor practice and may be borderline unethical when there are proven strategies to manage their pain.”

“I was repeatedly dissuaded from having an epidural during a painful and complicated birth. While I was keen to try non-invasive methods of managing the contractions I got to the point where the pain was intolerable, and gas and air wasn’t cutting it. It felt undignified to have to beg for an epidural and point out it wasn’t “intensity”, it was pain, and severe pain at that.”

“Small pinch” – or much more?

A number of videos have recently gone viral on TikTok and Instagram that speak to the frustration of the dismissal of women’s pain (examples here and here). Intrauterine devices/systems (IUD or IUS) are notorious for often being placed without anaesthetic, with women simply being advised to take ibuprofen before their appointment and being told they can return to their day as normal. This is despite the fact that studies show how effective minimally invasive pain management strategies such as lidocaine-prilocaine cream can be (8). Cervical punch biopsies are subject to the same fate. The procedure is often done without the use of local anaesthetic, with the sensation being described as a “mild pinching or scratching,” with many women being told they can return to their day as normal with only “mild period discomfort” (9). While experiences vary, a look online will

While well-meaning, phrases such as “small pinch,” “light pressure,” and “mild discomfort” can often feel incongruous with lived experience.

What can we do?

At a systemic level there is likely a need for re-examination of the protocols for procedures such as IUS placement to reconsider if analgesia should be routinely offered. Undoubtedly there is a healthcare practitioner education need here. Education on empathetic engagement with female patients to help them prepare for painful procedures, screening for pain, and selecting evidence-based and effective management options needed.

But there is also a role for us as healthcare communications practitioners. The language we use to prepare women for medical interventions is important. We do women no favours by shying away from the fact that some interventions are painful. Patient-facing materials must be co-created with the communities who have experienced the intervention to make sure that the information is clear and understandable. We have to challenge ourselves, and our clients, to make sure that the patient voice is viscerally present in campaigns to engage women on the topic of pain management.

Campaigns that highlight the pain gap, such as Nurofen’s See My Pain report and accompanying campaign also play an important role in raising the public’s awareness of the issue and the need for change.

As well as educating healthcare professionals and improving information for patients, healthcare communications can also support women to advocate for themselves. Building confidence to challenge advice, improving health literacy so people can find the evidence to back up their challenge, and accessible advice from trusted sources can help women find their voice in a healthcare setting.

Communicating something subjective like pain still remains difficult. Healthcare professionals need to be educated on how different biological, hormonal, and social factors can influence how women may perceive and discuss their pain. But to support conversations around pain, a patient-centric approach remains paramount. Healthcare communications can help to foster shared decision-making between patients and clinicians, and can help advise women on how best to articulate their experiences of pain and its impact, in a way that healthcare professionals may listen.

 

In our upcoming blog, we will delve into the misinformation surrounding women’s health. Watch this space.

 

 

Curious about how you can start closing the gender health gap in measurable ways, rather than just words on a page? Team members at Curious Health have expertise across a variety of conditions and therapies in women’s health and experience in crafting insights-driven, community-led campaigns that resonate. Get in touch for a chat by emailing [email protected]

 

 

 References:

1. UCL (2022) Analysis: Women’s pain is routinely underestimated, and gender stereotypes are to blame, UCL News. Available at: https://www.ucl.ac.uk/news/2021/apr/analysis-womens-pain-routinely-underestimated-and-gender-stereotypes-are-blame Last accessed: March 2024.

1. Zhang, L. et al. (2021) ‘Gender biases in estimation of others’ pain’, The Journal of Pain, 22(9), pp. 1048–1059. doi:10.1016/j.jpain.2021.03.001. Last accessed: March 2024.

1. Annalise Weckesser Reader in Medical Anthropology (2023) Women’s pain is often not believed – here’s how to make your voice heard when seeking help, The Conversation. Available at: https://theconversation.com/womens-pain-is-often-not-believed-heres-how-to-make-your-voice-heard-when-seeking-help-207866 Last accessed: March 2024.

1. Sabin, J.A. and Greenwald, A.G. (2012) ‘The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: Pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma’, American Journal of Public Health, 102(5), pp. 988–995. doi:10.2105/ajph.2011.300621. Last accessed: March 2024.

1. Meghani, S.H., Byun, E. and Gallagher, R.M. (2012) ‘Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States’, Pain Medicine, 13(2), pp. 150–174. doi:10.1111/j.1526-4637.2011.01310.x. Last accessed: March 2024.

1. University of Bath (2005) Women feel more pain than men, research shows, ScienceDaily. Available at: https://www.sciencedaily.com/releases/2005/07/050705004113.htm Last accessed: March 2024.

1. Casale, R. et al. (2021) ‘Pain in women: A perspective review on a relevant clinical issue that deserves prioritization’, Pain and Therapy, 10(1), pp. 287–314. doi:10.1007/s40122-021-00244-1. Last accessed: March 2024.

1. Whitworth, K., Neher, J. and Safranek, S. (2021) ‘Effective analgesic options for intrauterine device placement pain’, Canada Family Physician, 66(8), pp. 580–581.

1. NHS. Colposcopy – What happens on the Day, NHS. Available at: https://www.nhs.uk/conditions/colposcopy/what-happens/. Last accessed: March 2024.