Pain management is one of the most critical challenges in health and is essential for patients' physical health, quality of life, and mental well-being. A new study published in the prestigious journal PNAS reveals that pain treatment, like many other areas of life, is biased in favor of men and discriminates against women.
The research was led by PhD candidate Mika Guzikevich and Prof. Shoham Choshen-Hillel from the School of Business Administration and the Federmann Center for the Study of Rationality at the Hebrew University, Dr. Tom Gordon-Hecker from Ben-Gurion University's Faculty of Management, and Dr. Alex Gileles-Hillel from Hadassah Medical Center and the Hebrew University’s School of Medicine.
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Study reveals that pain treatment is biased in favor of men and discriminates against women
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Covering a six-year period from 2014 to 2019, the researchers analyzed 21,851 discharge letters from patients who visited emergency rooms in Israel and the U.S. with pain complaints—17,576 from Israel and 4,275 from the U.S. Using statistical methods, they examined whether female patients were less likely to receive painkillers compared to male patients, even for identical complaints and reported pain levels.
The study found that women were about 10% less likely to be prescribed painkillers than men for the same pain complaints. Additionally, nurses were less likely to document women's pain complaints in the electronic medical system, and women waited an average of 30 minutes longer for pain treatment in the ER than men. These findings remained statistically significant even after accounting for patient, physician, and ER characteristics, and were similar in both Israel and the U.S.
Prof Choshen-Hillel explained the background of the study: "Two years ago, we published a significant study on the impact of night shifts on administering painkillers in the ER. We found that tired doctors gave fewer painkillers and were less sensitive to patients' pain because they themselves were tired. This meant that patients did not receive the appropriate pain treatment they deserved. It was important to us to ensure that what we found was truly an effect of fatigue and not other factors. We controlled statistically for many variables, including the patient's background, the number of patients in the ER, and the patient's gender. Then my PhD student, Mika Guzikevich, suggested examining how the patient's gender affects the results when we control for all other parameters, independent of night shifts."
Prof. Shoham Choshen-HillelPhoto: Idit WagnerThe researchers assumed there was already evidence of gender discrimination in pain treatment, but were surprised to find otherwise. "We thought it was already known," said Prof. Choshen-Hillel. "But Mika conducted a comprehensive review and found that it wasn't. Women claim this, and there are even books about women not receiving proper pain treatment, but there were no systematic scientific data to prove it. We realized this is a crucial topic. Just because women claim it doesn’t necessarily make it true, and it's important to scientifically verify this to raise awareness and address this discrimination."
"The picture that emerged was unfortunately very stark and clear," noted Prof. Cheshin-Hillel. "In all our metrics, we found that women are discriminated against compared to men and receive less treatment than medical guidelines recommend. This means fewer painkillers of all types, both mild and strong." Dr. Gordon-Hacker added, "We also found that male and female doctors were equally biased. They all treated women's pain less effectively. This may be due to similar stereotypical perceptions."
The researchers conducted an additional experiment to examine these stereotypical perceptions. In this experiment, 109 nurses from an American hospital read a clinical story about a patient, either male or female, presenting to the ER with a defined pain complaint, and were then asked to rate the pain intensity.
"We were shocked to find that despite identical details for both the male and female patient, the nurses rated the female patient's pain as less severe," explained Prof. Choshen-Hillel. "This finding supports our hypothesis that pain treatment bias stems from stereotypical perceptions that women report pain in a 'hysterical' and exaggerated manner. Psychological studies show that people, including non-professionals, tend to perceive women's pain as less severe. When a woman says her pain level is nine out of ten, it's often assumed she's exaggerating. We find that even doctors and medical staff, who aim to provide the best care, are not immune to these stereotypes."
Dr. Alex Gileles-Hillel, Prof. Choshen-Hillel's research partner and spouse, added, "We found differences also when looking at the type of complaint. For clear complaints like a broken hand or trauma, the gender difference in treatment was minimal. The explanation is that we deal with complaints where the cause isn't visible to the doctor. If a patient comes with a bone protruding from their leg, it's clear where the pain is and how severe it is. In contrast, if someone says they have a headache with no physical findings, it’s up to my judgment and how much I believe them."
The researchers highlighted the significant implications of this phenomenon for women seeking medical treatment. "The consequences are enormous," said Prof. Choshen-Hillel. "Improper pain treatment has severe health and psychological consequences. This is well-documented in the literature. It also says a lot about our society, how we dismiss women's pain, not just in healthcare but in all human interactions."
Dr. Gileles-Hillel agreed: "Inadequate pain treatment has documented consequences, including the development of chronic pain, leading to significant health and economic costs. From our studies with doctors, we know they are unaware of the extent of this issue. I look at patients with the same eyes, or at least I hope I do. However, all psychological research on cognitive biases shows that we often act differently from what we believe. Our research clearly shows this."
Dr. Alex Gileles-HillelPhoto: Hadassah Medical CenterHow can this be corrected?
Prof. Choshen-Hillel suggested, "Our proposal is to implement a simple reminder for doctors when treating patients diagnosed with high pain levels. Just remind them of the guidelines and ask if they're sure they don't want to prescribe painkillers. I believe doctors want to treat everyone correctly, without intentional bias. If we remind them of the guidelines, I hope it will lead to more equitable treatment. We’d welcome collaboration with a hospital willing to test this with us." Dr. Gileles-Hillel added, "Overall, our goal should be a more equal society, and this clearly shows we're not doing enough. One solution is to raise awareness and establish more structured protocols."
The study also involved Professors Shlomo Israel and Anat Perry from the Hebrew University, Prof. Moshe Shai from the Hebrew University and King's College London, Dr. David Rechtman and Dr. Shaden Salameh from Hadassah Medical Center, and Prof. David Gozal from Marshall University in the U.S.