The gender pain gap: why chronic pain is a social justice issue

The UK’s gender pay gap is slowly closing. But in medicine we are still looking at dramatically unequal treatment – across lines of gender, class and race.
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Image 1 of a triptych by Lottie Dunn called 'Worlds Within Worlds':Black ink drawing of an MRI of the hips on a clear surface. Very detailed lines showing the bones, arteries and the insides of the hips.

Image: from ‘Worlds Within Worlds’ by Charlotte Dunn

UK figures suggest that the country’s gender pay gap is finally closing, albeit at a frustratingly slow pace. In 2019 the Office for National Statistics (ONS) report on gendered pay disparities showed that the overall rate of pay inequality had dropped from 17.8% in 2018 to 17.3% in 2019. And while half a percentage point is not exactly ground-breaking progress, long-term stats lead the ONS to forecast that wage inequality will keep dropping, year on year.

Gender isn’t the only issue when it comes to wage inequality, though: data suggests that other important factors are race, age and class. Women over 50 remain at the greatest risk for unequal pay, while the gender pay gap between younger workers has dropped to almost zero. An ONS report from 2018 on ethnicity pay gaps showed that Pakistani and Bangladeshi workers received the lowest wages, taking home on average 20% less per hour than white British workers.

The existence of these pay inequalities highlights how pervasive discrimination still is in the UK. But most forms of wage inequality do seem to be on track to eventually disappear. However, there is a growing body of research on the gender pain gap and the impact of racial discrimination in healthcare – gaps that are largely unrecognised despite their significant impact on those of us with chronic pain.

Accessing healthcare: a game of snakes-and-ladders?

Those of us with chronic, invisible illnesses are well-versed on the challenges of accessing medical treatment with restricted energy and resources. In the UK, the limitations of an overstretched healthcare system, plagued by routine clerical errors and seemingly endless waiting lists, can feel like an infinite game of snakes-and-ladders. Many patients report years of back-and-forth between GPs and specialists just to get a diagnosis. And society continues to stereotype chronic illness patients as hypochondriacs and drug-seekers, stripping our experiences of their validity and undermining the reality of our struggles.

Women are significantly more likely to be diagnosed with chronic pain conditions than men, at 37-52% compared to 31-49% respectively. Many conditions, such as chronic migraine and fibromyalgia, also affect female patients disproportionately. Reproductive conditions like endometriosis are thought to contribute to these high rates too. But despite this, research shows that the interpretation of women’s pain by medical staff is often influenced by inaccurate gender stereotypes.

‘The Girl Who Cried Pain’ and the gender pain gap

In 2001, ground-breaking US study ‘The Girl Who Cried Pain’ examined the complex web of assumptions that play a part in the interpretation of pain. Typically, women reported more intense pain, at higher frequencies and for longer periods, than men. This does make sense: we already know women are more likely to suffer from painful chronic illnesses. Yet the study found that not only are healthcare professionals less likely to believe in women’s pain, they are more likely to prescribe women sedatives, tranquillisers and antidepressants for pain than actual painkillers.

Even when faced with positive clinical tests that prove the existence of pain-causing physical issues, physicians are considerably more likely to attribute women’s pain to psychological sources than men’s. The study found that in response to the same symptoms, healthcare professionals administered less pain medication to women than men, even after weight controls were accounted for.

In scientific studies, nurses consistently devoted more treatment time to male patients than female patients, allocating more minutes to administering analgesics and more time to delivering emotional support to men. Academics have linked this to ‘Yentl Syndrome’, in which male patients are offered more proactive treatment than women during initial diagnostic appointments, while women are expected to ‘prove’ they are as sick as male patients before they are granted the same level of care. Research backs this up: amongst patients referred to pain specialists, women are more likely to have been referred by a GP, while men, having initially received more proactive treatment, are more likely to have been referred by a specialist consultant doctor.

It’s not just the gender pain gap – black patients systematically undertreated for pain

Racial disparities in healthcare – including in the treatment of children – are also well documented. Researchers in one US study examined the effect of racial identity on the treatment of abdominal pain in children and teens in the emergency room. The study, which distinguished between non-Hispanic white children, non-Hispanic black children, Hispanic children, and children of other races, demonstrated that non-Hispanic white children were more likely to receive any painkillers than all other groups. Even when the study compared the treatment of children who reported a ‘severe’ level of pain, non-Hispanic black children, Hispanic children, and children of other races were consistently offered pain medications less frequently. The study’s authors also analysed patient length of stay (LOS) by race; non-Hispanic black children and Hispanic children were more likely to experience a prolonged LOS, defined as longer than six hours in the emergency room.

Researchers have offered several theories to explain these racial disparities. In another landmark US study from 2012, researchers conducted six experiments, all of which asked participants to rate their own pain in 18 different situations, including getting a papercut, stubbing a toe, and getting shampoo in the eye. Participants were then shown images of another person and asked to rate the pain they would expect that person to experience in the same 18 situations. Across all six experiments, white participants consistently assumed lower levels of pain when they were shown images of black people. In one of the six experiments in the same study, black people were assigned lower levels of pain even when the participants were also black, or of other non-white races. The researchers in this study hypothesised that black patients are frequently untreated because their pain is consistently underestimated by the professionals caring for them, as a result of subtle racial bias and stereotyping.

Women perform ‘moral boundary work’ to ensure pain is taken seriously

As many of the existing studies have been produced in the United States, it is thought that racially biased assumptions about the ability of working-class people of colour to pay for health insurance within the US system could influence some of these disparities. However, it is likely that blatant racist discrimination (regardless of class) is a significant factor in pain inequality. And at the intersection of gender, race and class, it’s thought social stereotypes about morality may also play a part.

US researcher Jane Pryma has suggested that women of all races and social classes engage in ‘moral boundary-work’, in which they attempt to ensure they appear credible to ‘doctors, disability bureaucrats and personal networks’ in order to legitimise their pain. But, she states, this work varies depending on the woman’s race and class and the social stereotypes attached. Regardless of race, most of the women interviewed in Pryma’s study engaged in moral boundary work as an attempt to legitimise their pain, reporting for example accusations that they failed to work hard enough to feel better. Gendered notions of hypochondria also appeared to affect women across all races in the study. But Pryma notes that black women in particular are faced with specific institutional stereotypes around benefit fraudsters and addicts. Where white women did not reference their race in terms of their moral boundary work, women of colour and particularly black women were considerably more likely to reference an intersectional moral framework concerning ‘the worthy and unworthy disabled’.

Modern medicine, the gender and racial pain gap and ‘evidence-based practice’

These studies, of which I’ve only referenced a few, demonstrate the existence of shocking disparities in healthcare and the perception of pain. Modern medicine and science are often held up as the pinnacle of rational, evidence-based practice: the fact that racist ideologies and institutional sexism hold sway over medical decision making is entirely unacceptable and represents a considerable danger to the lives of sick and disabled people.

It is vital that pay equality is achieved if we want a fairer society, but we must also face up to the glaring inequalities in pain treatment and the underlying discrimination that has created these pain gaps. Chronic illness can feel like an impossible struggle at the best of times, yet these studies suggest that the system continues to fail chronically ill women, particularly women of colour, when they are at their most vulnerable.

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Ceri Fowler is a freelance writer and postgraduate researcher based in Shropshire, living with chronic migraine. As a writer, she is interested in identity, sexuality, health, and the body. 

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