March 12, 2021, by School of Medicine

50 at 50: Women in Medicine – Pain Inequality: A Healthcare Bias  

Although we are fortunate in the UK to be protected by the NHS, we unfortunately still are plagued with implicit biases which can be detrimental to the beneficence of patients. Healthcare inequality is a broad term used to call attention to the way medicine is unjustly researched, practised, taught and highlighted to the public. The term ‘bias’ is used to refer implicit stereotypes, prejudices and raises serious concerns in healthcare. Healthcare bias can discriminate between socioeconomic background, gender, race, ethnicity, age, sexual orientation and a vast other range of people but one of the most pervasive biases in medicine is gender, especially surrounding the inequality of pain management.

Hysteria was a common diagnosis for women especially during the Victorian Era and it wasn’t until 1980 that the term was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM). The term was coined in response to the belief that women were overly emotional towards their symptoms and conditions. Though the term is not used commonly today, it remains an implicit bias that women cannot handle their physical and emotional pains due to complex hormonal cycles or are perhaps imagining their conditions in their heads. As a result, many women go years and years without a diagnosis where they suffer physically, mentally, socially and economically. In the National Pain Report of 2014, an online national survey of 2,600 women with different chronic pain conditions showed that ‘65% felt that their pain was being given inadequate attention because they were female, and 91% believed that the health-care system discriminated against women. Nearly half of the women were told that their pain was psychological and 75% were told they must learn to deal with the pain.’

A 2014 study from Sweden highlighted that women who arrive in an emergency department and report having acute pain are less likely to be considered urgent and therefore wait significantly longer to see a doctor on triage. Meanwhile, in the US a study was found that men wait 49 minutes on average to receive analgesics for pain where women wait for 65 minutes. But is it just implicit bias or is it that women’s presentation for diseases can differ to men? For instance, women are far more likely than men to leave an emergency hospital consultation with anti-anxiety medication for chest pain rather than their male counterparts who are more likely to be investigated for cardiovascular pathologies. What is perhaps not reinforced enough in medical education is that women can present with other symptoms such as fatigue, nausea, jaw or neck pain when having a heart attack, where men are more likely to present with the ‘textbook’ chest pain radiating to the left arm. This phenomenon is known as Yentl Syndrome- this, along with the concept that women are dramatic has resulted in ‘women being up to 3 times more likely to die following a serious heart attack than men as a result of receiving unequal care and treatment’ (American Heart Association).

It would be forthright of me to underpin every healthcare professional to practice with a gender bias in terms of pain when that is not the case. Healthcare professionals come from all walks of life and are most commonly, compassionate and empathetic towards any of their patient’s pleas. Consequently, we can’t only look towards the clinical workforce to reframe bias, as the research level also has seismic effects in the complacency towards the female experience. Women seem to suffer from pain and also from the side effects from drugs because the data is ‘designed’ towards men. Often when research is carried out, the data is carried out on males and then the results are translated for women. Unfortunately, this stems from the fact that women are regarded as far too complex hormonally therefore it seems a longer process to include women accurately in research and the fact that there is inherently less investment in female related issues compared to male related issues. It’s extremely concerning that when we carry out medical research, even at the cellular level, we are testing only or predominantly on males; it enhances the concept that the ‘standard body’ is male. This leads to the aforementioned Yentl Syndrome but also causes women to have far more side effects to drugs because the data is not studied for them. This is a harrowing concept which can have deleterious consequences such as lack of compliance, suffering to the side effects or even complete abandonment of treatment. Even more concerning is that diseases and conditions that women are far more likely to acquire such as autoimmune diseases and chronic pain disorders have not been a research priority and so many women have to suffer for so long. It takes on average more than 7 years for a diagnosis of endometriosis because painful periods are considered ‘normal’ and the process of diagnosis is complex as our current investigative measures can be ambiguous in their findings, whilst there is not enough research into new methods.

Another area to explore in pain inequality may be the presence of female doctors throughout levels of leadership. Though in the UK, female medical students actually just about outnumber male medical students (seen clearly at our own Nottingham Medical School), in the workforce, women are underrepresented in senior leadership. This has clinical implications but also of course leads to the ever frustrating pay gap where women are earning 18.9% less than men (this is based on a full-time equivalent mean pay comparison by the BMA). The King’s Fund found that two thirds of the women in their study ‘felt a greater pressure to prove themselves than their male counterparts…they struggled with a culture of an old boys’ network and attitudes to women leaders.’ When our leadership is not reflective of our patients and workforce, we immediately face barriers in progressing to a more understanding patient management that treats all patients fairly. Without people from all aspects of life throughout all levels of leadership in a healthcare setting, we will find more and more that patients’ will be dismissed of their plight. This not only chips away at the trust between the patient- doctor relationship but can also cause serious risk to the beneficence of patients.

I’ve often noticed that when we take part in the discussion surrounding women’s rights and equality, it can feel as though the narrative is pushed towards one type of woman. In reality, just like anyone else, the female experience varies, for instance by the intersection of gender and racial bias. The combination of both gender and racial bias brings the risk of pain inequality to an even greater calibre. The distressing reality of the intersection of these biases causes black women to be twice as likely to have stroke and are five times more likely to die in childbirth. Dr Nagla Elfaki, a doctor at Havering Redbridge University Hospitals says that ‘black people do not have a genetic propensity to die. But the consequences of systemic oppression and institutionalised racism, including poverty, poor housing and poor health literacy, combined with inherent biases within medicine have a cumulative and devastating effect on health outcomes.” It’s tremendously dangerous and disheartening that biases are so ingrained in our institutions, that not only can we be disregarded for pain on the onset of illness, but by the way our societies are unfairly built, healthcare can be regarded so frivolously that it is seen as compromisable.

In conclusion, we seem to be coming back to a common rhetoric. Without accurate representation of our society in workforces, literature, data, media etc, we’ll continue to find it difficult to find any kind of equality and implicit biases will continue to impede people’s quality of life. Our institutions are rigged with short cuts and historical social practices that we know are detrimental to our societies. This past Monday was International Women’s Day, so now more than ever I encourage you to think to yourself if you have ever felt that your experiences in healthcare as a woman have ever been unfair? The discussion still remains open, with many other contingent concepts that have not been explored today, as much of this article centres around Western Medicine, which of course is not the only way of life and the debate can go much further. If we have learnt anything in this past year, it is that our health, both mental and physical are some of the most important values of life. Everyone should feel they have fair access to healthcare and feel their needs as a patient are being understood. If pain does not discriminate, neither should healthcare.

By Malaikah Mir, Medicine student

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