Chronic pain is a complex condition that affects around 20% of adults worldwide, making it one of the leading causes of disability.
Defined by the National Institute for Health and Care Excellence (NICE) guidelines as an “unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”, chronic pain lasts longer than 12 weeks, beyond the expected healing period for an injury or disease. It can cause significant functional and emotional impairment, often resistant to traditional treatments or therapy.
Chronic pain can be classified as primary, where there is no clear underlying condition, or secondary, where it is due to an existing medical condition such as arthritis or endometriosis.
**This article will focus on chronic pain as experienced by those assigned female at birth, though we will touch on the unique challenges faced by non-binary and transgender individuals towards the end. For the purpose of this article, though, we will refer to ‘women’ in the context of assigned gender at birth, despite it being an over-simplified approach.**
The Pain Bias, Throughout History
The longstanding bias against women’s pain in healthcare has made it more difficult for many women to receive the care they need. Historically, women’s pain has been misunderstood, minimised, or dismissed as emotional or psychological rather than physical. This can be traced back to centuries of societal stereotypes.
For instance, the term hysteria is thought to be derived from the Greek word “hystera”, meaning uterus. The ancient Greek physician Hippocrates was one of the first to identify hysteria as a “disorder”, believing that it was caused by a “wandering uterus” and attributing women’s pain and mental health issues to this concept. In the 18th and 19th centuries, female hysteria was one of the most commonly diagnosed “disorders”. This phenomenon is a historical example of the recently coined phrase “medical gaslighting“, where healthcare professionals invalidate or ignore their patients concerns, based on uncertainty, insecurity, or bias.
Medical research has also historically underrepresented women, contributing to this bias. Clinical trials often excluded women, assuming there were no fundamental differences in the biology of men and women – except size, weight, and reproductive organs. Following the Thalidomide tragedy in the 1960s, the number of women in clinical trials dropped even further, as all women of child-bearing age were excluded (though this has since been reversed). This historical gender-blind approach to treatment and research has led to a lack of focus on women’s specific pain needs.
Unfortunately, despite advances in medicine and increasing awareness of the pain bias, there is evidence that it still persists. For example, a 2022 study published by the Journal of the American Heart Association found that women presenting to Accident and Emergency (A&E) departments were less likely to be prioritised, waiting longer to be seen than men.
Sex Disparities in Chronic Pain
The reasons behind this gender disparity in chronic pain are multifactorial, involving a combination of biological, psychosocial and sociocultural factors.
Biological Factors
Hormonal fluctuations – associated with the menstrual cycle, pregnancy, and menopause – significantly affect pain perception. For instance, conditions like fibromyalgia and chronic pelvic pain, both of which are more common in women, are often exacerbated by hormonal changes. Pregnancy, in particular, has been linked to an increased risk of musculoskeletal* and neuropathic** pain due to physical demands and hormonal changes. Musculoskeletal pain is also one of the most severe complaints during the menopause.
- Research has suggested that for biological males, higher levels of the hormone testosterone increase their pain threshold, and for females, fluctuations in oestrogen levels increase pain intensity and perception, though the exact mechanism for this remains unknown.
Moreover, neurobiological differences between men and women may also play a pivotal role. Studies indicate that pain pathways, particularly in the brain regions involved in pain processing, are activated differently in men and women.
Another biological factor, central sensitisation, where the nervous system becomes overly sensitive to pain signals, appears to be more pronounced in women, leading to heightened pain perception. This sensitivity can make women more vulnerable to chronic pain conditions.
*Musculoskeletal pain – pain affecting your bones, muscles, and joints.
**Neuropathic pain – pain originating from nerve damage or dysfunction.
Psychosocial Factors
Psychosocial elements also significantly contribute to the gender disparities in chronic pain. Anxiety and depression, which are more prevalent among women, are linked to increased pain perception and chronicity. The link between the mental health and pain though, is bi-directional – chronic pain can worsen mental health, while declining mental health can intensify pain. Furthermore, women often report experiencing more stress than men, and this stress has been shown to exacerbate symptoms of chronic pain, especially in conditions such as fibromyalgia.
Women tend to engage more in catastrophising, which involves amplifying and fixating on pain, a pattern linked to worse pain outcomes. On the other hand, self-efficacy — the belief in one’s own ability to manage pain — can mitigate the negative impact of chronic pain. Research indicates that women are more likely than men to experience catastrophising, which contributes to their higher pain levels and disability.
Gender biases in healthcare can delay diagnosis and treatment. Research has found that women are more likely than men to have their pain dismissed as “emotional” or “hysterical”, which can lead to misdiagnosis. Such biases allow for the emergence of disparities in treatment – a recent study has added weight to this claim, showing that female patients are less likely to be prescribed pain-relief medications than males for the same complaints. This can explain why women often report more severe pain: they may feel compelled to be more vocal in order to be taken seriously.
Sociocultural Influences
Beyond biology and psychology, cultural norms, gender roles and socialisation have a profound impact on how both men and women experience and report pain.
Society often expects women to “suffer in silence”, especially when they occupy caregiving roles, which they are traditionally more likely to do. In these roles, it is expected that the women’s needs are placed below those of others, thus downplaying their symptoms. This cultural expectation can delay diagnosis and treatment, further increasing the risk of chronic pain.
Women tend to express their pain more openly, whereas men are more likely to suppress it. However, men’s tendency toward peer-reinforcing stoicism can create its own problems, including the minimisation of symptoms, denial, and a delay in seeking medical attention. These differences in the expression of pain can lead to women’s pain being scrutinised more intensely, paradoxically making it seem “less valid”.
Anushay Hossain, author of “The Pain Gap”, so aptly sums it up:
“There’s a pain gap, but there’s also a credibility gap. Women are not believed about their bodies — period.”
Intersectionality and Chronic Pain in Women
It is also important to consider the concept of intersectionality when understanding the disparities in chronic pain. Intersectionality refers to the complex and cumulative way in which the effects of multiple forms of discrimination – such as racism, sexism, and classism – combine, overlap, or intersect, especially in the experiences of marginalised individuals or groups. Gender is one factor that influences chronic pain, but for marginalised groups, the complexities are compounded.
The Role of Implicit Bias
Researchers suggest that these disparities are at least in part due to implicit biases in healthcare workers, which can result in minorities receiving lower quality pain treatment. Literature is littered with evidence of this. For example, one study found that those of ethnic minorities received lesser quality pain management in chronic pain, as well as in acute, cancer and palliative pain, compared to their white counterparts. Another UK study showed that Bangladeshi-British (by 24%), Pakistani-British (by 15%) and black Caribbean-British (by 8%) women are less likely to receive an epidural during labour than white women.
Implicit bias, by definition, happens without conscious awareness. Since everyone is subject to it, healthcare workers should not be seen as solely responsible – implicit bias also influences patient’s health seeking-behaviours*. Factors such as cognitive load (the mental effort required to process information at a certain time), cultural exposure, personal background, education, language, and diagnostic uncertainty can all shape these biases.
*Health-seeking behaviour – behaviour of an individual with a health-related concern to seek an appropriate remedy.
Additional Barriers Faced
Similarly, women from low socio-economic backgrounds, those from rural areas, or LGBTQ+ individuals, as well as those of ethnic minority backgrounds, may face additional barriers. These can include a lack of research on pain on people from different backgrounds, lack of awareness of how pain can present differently in these groups, limited access to healthcare, financial constraints, or cultural stigma around seeking help for chronic pain.
For example, non-binary and transgender individuals may experience pain related to gender-affirming therapies such as Hormone Replacement Therapy (HRT) or surgeries, which can present very different to chronic pain in cisgender* women. To date, there is a lack of research on pain in these populations, meaning that they are often treated according to cisgender standards, despite their symptoms often presenting in a unique way.
These multiple layers of marginalisation can intensify the overall burden of chronic pain in women, leading to worse outcomes.
*Cisgender – where a person’s gender identity corresponds to the gender at birth.
A Call for Change
To address the gender disparity in pain management, there is a growing need for healthcare reforms to prioritise gender-sensitive pain treatment. Research must expand to include studies on gender-specific pain treatments, particularly exploring how chronic pain pathways differ between men, women, and gender-diverse individuals. Additionally, the medical field must shift towards a more inclusive approach, recognising the unique needs of people from all backgrounds.
Ongoing training for healthcare professionals should focus on mitigating unconscious bias, improving pain assessment, and offering inclusive, gender-affirming care.
Furthermore, empowering women through education and advocacy is critical. Women must be encouraged to speak up about their pain and advocate for themselves in healthcare settings, ensuring they receive the appropriate care they need and deserve.
How To Advocate For Yourself
- Track Your Symptoms: Keep a detailed record of your pain, its severity, triggers, and what treatments have worked or failed. The Nurofen pain pass tool can help with this: https://www.nurofen.co.uk/see-my-pain/pain-pass/
- Seek Clarification: If you feel dismissed, don’t hesitate to ask questions or seek clarification from your healthcare provider about your diagnosis or treatment.
- Get a Second Opinion: If you’re not comfortable with the current plan, consider consulting another doctor – you’re entitled to a second opinion.
- Join Support Networks: Connecting with others who share your experiences can provide emotional support and empowerment.
- Speak Out: Advocate for yourself and others by sharing your story on social media, in blogs, or at public events.
In Summary
By acknowledging the gendered and intersectional nature of chronic pain, we can work towards a healthcare system that listens to all patients and addresses how a patient’s pain experience may be influenced by biological, psychosocial and cultural influences. Through more research, better and ongoing training for healthcare professionals, and empowering patients, we can start to eliminate to gendered pain bias.
Chronic pain is a deeply personal and complex issue, and everyone’s experience is unique. I’d love to hear from you in the comments below – share your story, join the discussion – let’s help raise awareness so that no one’s pain is overlooked.
More Resources
If you or someone you know is living with chronic pain, the following resources can help empower you to take action, seek further information, and find community support.
Read more about endometriosis, a condition that commonly causes chronic pain in women, in our previous article here. In this article, Annabel, a 20-year-old female talks about her own struggles with chronic pain and her diagnosis.
Dr DeCaria, a specialist in pain management, argues that it is the persistence of pain, in the absence of an identifiable cause, that allows for this undiagnosed bias in the management of chronic pain. Her TED talk below is worth a watch, as she talks about how our perception impacts medical care, and how this bias extends beyond healthcare professionals:
This article from Psychology Today provides more useful strategies to help women advocate for themself: https://www.psychologytoday.com/gb/blog/how-healing-works/202306/womens-health-caring-for-yourself-and-being-your-own-advocate
Pain UK – a group of charities which help support people living with chronic pain across the UK. This article below gives you more advice on how to advocate for yourself:
The Health and Healing Narrative 
Leave a comment