For 20 years, doctors told Diana Falzone her pain was normal.
“Well, that’s just how it is for some women,” she remembers one saying after she began experiencing unusually heavy and “very, very painful” periods when she was 12 or 13. “Some women have it harder than others.”
During another visit, she recalls rating the severity of her pain at a 10 on a 10-point scale. “You’re a 10?” the provider asked her. “Are you sure you’re a 10 pain?” She was told she could take Advil and Tylenol and use a heating pad. “And, you know, ‘good luck,’” she says.
When she was 32, following years of periods that made her sick and multiple ovarian cyst ruptures, she went to the hospital after experiencing a sudden pain while working that felt “like I had a serrated, hot knife just cutting through my sidewall,” she says. A general practitioner told her she probably had “the flu” and a “hormonal imbalance.” She pressed to see a gynecologist and was told to go to her regular provider the following day. When she did, she was given a pack of birth control pills, told to “bleed it out” and once again sent home.
It was only after she sought out a specialist in reproductive health that she was finally diagnosed with what she describes as a “severe” case of endometriosis — one that has not only brought her decades of pain, but also impacted her fertility and caused her to lose an ovary, fallopian tubes and her appendix.
Falzone, a journalist and endometriosis advocate, is one of more than 50 million Americans who grapple with chronic pain, the vast majority of whom are women. Women bear a disproportionate amount of pain over the course of their lives. They’re more likely to suffer from a wide array of painful conditions, including not only those that involve the female reproductive system, like endometriosis, but also everything from rheumatoid arthritis to fibromyalgia to migraines. Hundreds of studies have shown that they’re more sensitive to pain than men. They report feeling pain more often and more intensely.
They’re also more likely to seek help for their pain than men are. And yet: Far from healing pain’s gender gap, the health care system appears to be making it worse.
Women in pain are left to sit longer in hospital waiting rooms, according to research and firsthand accounts shared with The Hill over the past three months; they’re prescribed fewer painkillers; they’re told “that’s just how it is” or that they should “bleed it out.” Their concerns are dismissed or downplayed by health care providers; they go undertreated. And their pain goes on.
“There seem to be disparities at the level of the pain sufferer that are probably some combination of life experiences and some physiological factors,” says Elizabeth Reynolds Losin, the director of the Pennsylvania State University Social and Cultural Neuroscience Lab.
“But then there are also disparities in treatment that are coming from the physician or other kind of clinician,” she says. “And in some cases these disparities are compounding one another.”
‘You’ve been told it’s all in your head’
In a 2021 study, Losin and her colleagues asked participants to estimate the pain of real patients based on video clips. They found that even when men and women rated the intensity of their pain at the same level and displayed the same degree of suffering in their facial expressions, the female patients were perceived to be in less pain.
“In other words,” Losin says, “women’s pain behaviors are being discounted.”
The participants in the study were also more likely to recommend that men receive pain medication, and that women undergo psychotherapy — responses that indicate women’s pain is being viewed as “more psychological in origin,” Losin explains.
Falzone says patients with chronic conditions like herself often have to wage a “really unfair” battle against dismissiveness and psychologization from doctors.
“People that suspect they have endometriosis or suspect they have some sort of chronic disease, they always have to advocate for themselves, and that’s a crappy position to be in when you’re in terrible amounts of pain,” she says. “You feel defeated. You’ve been told it’s all in your head or whatever, and then you’re supposed to have the fortitude to keep trying to find doctors who might tell you that you’re crazy again.”
Women whose pain stems from more acute conditions confront similar problems.
Kisha Stewart, who suffered a heart attack when she was 31, recalls a nurse assuring her that she was just experiencing anxiety while she was in the midst of it.
Stewart had begun feeling “heavy, sharp chest pain” when she was out to dinner. “It felt like I was being crushed, like my chest was in a vise,” she says. She went to the hospital and told the nurse working at reception that she felt the pain in her chest, in her neck, in her jaw, that she couldn’t breathe. She also told her she’d had a baby two weeks earlier and had gone out for the first time that evening.
The nurse “kind of rolled her eyes,” Stewart recalls, and told her, “‘It’s just anxiety. You’ll be fine. Just go home, rest, go be with your baby.’”
Stewart, who was a nursing assistant at the time, insisted something was “really terribly wrong” and that she wasn’t leaving. The nurse told her she could sit in the waiting room. She was there for 15 to 20 minutes, “still experiencing that intense, sharp pain, that crushing sensation,” before she was called back.
Women — and particularly Black women like Stewart — generally wait longer to be seen by emergency room staff when they’re experiencing chest pain, the most common heart attack symptom, a 2022 study found. “Minutes count when someone has a heart attack,” senior study author Harmony Reynolds observed in a statement. And on average, women face waits 11 minutes longer than men, and nonwhite women wait 15 minutes longer than their white counterparts.
Women who go to the emergency room with chest pain are also less likely than men to be prescribed heart medication, admitted to the hospital or even kept in the emergency room for observation, the study found.
Stewart, for her part, was eventually brought back into triage, and an older nurse who passed by realized she was having a heart attack. She was treated; she survived.
“If I had listened to the receptionist at the desk, which a lot of people tend to do, I wouldn’t be here today,” she says.
‘Women are more undertreated’
Losin and her colleagues conducted their 2021 study with laypeople, not doctors. But other studies have found that health care providers and trainees are similarly more likely to recommend that female pain patients be given antidepressants or psychological treatment.
And while some research has shown little or no disparity between the amount of pain medication men and women receive in certain circumstances, a number of studies have found that doctors are less likely to give women higher strength analgesia — or any analgesia — in a range of situations: in the emergency room, at a cancer pain clinic, during emergency medical care for extremity injuries before they arrive at the hospital.
When women who go to the emergency room for help do get analgesia, they also generally wait longer than men before receiving it, according to multiple studies.
Unlike those settings, gynecology offers little ground for comparison between male and female patients. But there, too, women’s pain is often underestimated and ineffectually treated.
Studies have found that doctors significantly misjudge their patients’ pain during gynecological procedures such as hysteroscopies and IUD insertions. Both have regularly been performed with little or no pain medication at all, though they’re severely painful for a number of women. Some describe having an IUD placed as one of the most painful experiences of their life.
Amid public outcry, the Centers for Disease Control and Prevention for the first time urged doctors last month to counsel patients about pain management prior to IUD insertions.
Pain researchers stress that treatment is inadequate across the board. “Both sexes are undertreated for pain,” says Diane Hoffmann, the director of the law and health care program at the University of Maryland Law School.
“But,” she added, “women are more undertreated.”
Hoffmann dug into research on sex and gender disparities in pain treatment two decades ago for the widely cited 2001 study “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain”; in 2023, she co-authored another paper examining what — if anything — had changed in the intervening years.
A number of studies she looked at for the latter paper stripped away other variables and demonstrated that “there’s not another good explanation” for differences in treatment other than “some sort of bias related to sex,” she says. “Studies are showing that healthcare providers are still making different choices in treatment, even when everything else is the same except for sex.”
She posits that the different sources of patients’ pain may also play a role in the disparities. The types of pain most prevalent in men “are more clearly attributable to a known cause with a known pain accompaniment,” such as injuries, she notes, in contrast with many of the chronic pain conditions that disproportionately affect women.
These conditions have historically been underfunded and understudied, contributing to a lack of understanding and effective treatments. Endometriosis, which affects roughly 11 percent of reproductive-age girls and women in the U.S., is among that group. So are migraines, which afflict more than 17 percent, and fibromyalgia, which is estimated to occur in about 7.7 percent of women but was long dismissed by many doctors as “hysteria” and “not real.”
“Many of those conditions are hard to diagnose. There’s not a clear test for them. There’s not a clear understanding of the mechanism,” Hoffmann says. “So physicians really do have to believe the patient, but also … when physicians can’t find a clear biological or physiological basis for the pain, they are much more reluctant to prescribe medication for it.”
Diagnoses and treatments for a wide array of conditions are also primarily based on male biology and experiences, because female research subjects have historically been underrepresented in both preclinical and clinical studies — even in areas of health research that disproportionately affect women.
One of those areas is pain itself.
‘We continue to ignore female pain biology’
Though research has for decades indicated that women experience pain both more than and differently from men, pain researchers have overwhelmingly worked with men, male animals and male cell lines up until very recently.
Roughly 80 percent of rodent studies published in Pain, the leading journal in the field, in 2015 used only male research subjects, according to an analysis by McGill University psychology professor Jeffrey Mogil. That proportion marked “little difference” from the period between 1996 and 2005, he observed.
Mogil, who has been studying sex differences in pain since the early 1990s, posits that the historic exclusion of female research subjects was in part a result of “pure inertia,” combined with an expectation by many researchers that female rodents would show more variability due to their fluctuating hormone levels. (That expectation was “perfectly reasonable,” he says — though it “turns out to be empirically false” and “if anything, it’s the males that have more variability.”)
Roger Fillingim, the director of the University of Florida’s Pain Research and Intervention Center of Excellence, suggests another explanation.
“A bunch of old white men like me are responsible for creating the culture of biomedical research, and historically we only care about other white men,” says Fillingim, who has been studying sex and gender disparities in pain for decades. “I don’t know that people consciously think that way, but I think it creates this sort of not-so-benign ignorance and apathy where people don’t even think of that as a topic.”
Whether the long-standing focus on male research subjects has impacted pain treatments — and if so, to what degree — is not wholly clear.
Some research indicates that opioids are slightly more effective in women, but also that women experience more side effects when using them, Fillingim says.
“Other treatments have not been studied as systematically in terms of sex differences,” he adds. “And we, frankly, don’t have good evidence that any other specific treatments are more or less helpful for women versus men.”
“There’s a paper or two or three that you’ll find,” Mogil notes. But in general, he says, “it looks like there are no major sex differences in existing drugs.”
He stresses, however, that considering such differences will be critical in developing new and better chronic pain medication.
“We’re not managing chronic pain effectively at all. We need new drugs,” he says. “And those new drugs, if sex differences are ignored, are either not going to be developed at all, or they’re going to fail.”
The percentage of studies including female research subjects has surged in the past decade due in large part to requirements from the National Institutes of Health and its Canadian counterpart that preclinical studies consider sex as a variable. Mogil found that by 2019, the share of male-only studies in Pain had dropped to 50 percent.
The amount of research specifically looking into sex and gender differences in pain has ballooned in the same period, offering growing insight into variations in everything from genes to hormones to brain structures to coping mechanisms.
“We had a long way to go, but we’re getting there,” Mogil says. He notes, however, that male bias is far from gone.
“A full 50 percent of studies are still using only male subjects,” he points out. “That number should be essentially zero.” And even studies that do include female research subjects often compound the field’s male focus, he says.
“Because of the preexisting data only on males, we make hypotheses that then end up only being true in males,” he explains, “and those hypotheses beget new hypotheses that end up only being true in males. And what we do is we get further and further along studying male pain biology while we continue to ignore female pain biology. That’s the sort of hole that we have to dig ourselves out of.”
Hoffmann, meanwhile, points to another persistent disparity: one that exists not within research, but rather between what researchers are finding and how pain is being treated.
“I think some of the more distressing things have to do with the education of health care providers, particularly medical students: that they are not getting the message that there are differences in how men and women experience pain, such that women need to be believed and maybe even more aggressively treated than men,” she says.
In the two decades since she co-authored the “Girl Who Cried Pain” study in 2001, progress has been made “in understanding the differences and that there are differences,” she says.
But, she adds, “it hasn’t done anything, I don’t think, to change treatment.”
This is the first in a two-part series on sex and gender disparities in pain. Read the second part here.