The girl who cried pain: A bias against women in the treatment of pain

Journal of Law, Medicine and Ethics

Volumn 29, Issue 1, 2001, Pages 13-27

  Hoffmann, Diane E ^a   Tarzian, Anita J ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; EMPIRICAL APPROACH; EMPIRICAL RESEARCH; FEMALE; HEALTH PERSONNEL ATTITUDE; HUMAN; PAIN; PAIN ASSESSMENT; PALLIATIVE THERAPY; PATHOPHYSIOLOGY; PROFESSIONAL PATIENT RELATIONSHIP; PSYCHOLOGICAL ASPECT; SEX DIFFERENCE; SOCIAL PSYCHOLOGY; STANDARD; UNITED STATES; WOMEN'S HEALTH;

EMPIRICAL APPROACH; PROFESSIONAL PATIENT RELATIONSHIP;

ATTITUDE OF HEALTH PERSONNEL; EMPIRICAL RESEARCH; FEMALE; HUMANS; PAIN; PAIN MEASUREMENT; PALLIATIVE CARE; PREJUDICE; SEX FACTORS; UNITED STATES; WOMEN'S HEALTH;

EID: 0035294190     PISSN: 10731105     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1748-720x.2001.tb00037.x     Document Type: Article

References (157)

1. See R. Payne, "Practice Guidelines for Cancer Pain Treatment: Issues Pertinent to the Revision of National Guidelines," Oncology, 12, no. 11A (1998): 169-75; M. McCaffery, "Pain Control: Barriers to the Use of Available Information," Cancer, 70, no. 5 (supplement) (1992): 1438-49; R. Bernabei et al., "Managing Pain in Elderly Patients with Cancer," JAMA, 279, no. 23 (1998): 1877-82. See also P. Wall and M. Jones, Defeating Pain, The War Against a Silent Epidemic (New York: Plenum, 1991).
2. See R. Payne, "Practice Guidelines for Cancer Pain Treatment: Issues Pertinent to the Revision of National Guidelines," Oncology, 12, no. 11A (1998): 169-75; M. McCaffery, "Pain Control: Barriers to the Use of Available Information," Cancer, 70, no. 5 (supplement) (1992): 1438-49; R. Bernabei et al., "Managing Pain in Elderly Patients with Cancer," JAMA, 279, no. 23 (1998): 1877-82. See also P. Wall and M. Jones, Defeating Pain, The War Against a Silent Epidemic (New York: Plenum, 1991).
3. See R. Payne, "Practice Guidelines for Cancer Pain Treatment: Issues Pertinent to the Revision of National Guidelines," Oncology, 12, no. 11A (1998): 169-75; M. McCaffery, "Pain Control: Barriers to the Use of Available Information," Cancer, 70, no. 5 (supplement) (1992): 1438-49; R. Bernabei et al., "Managing Pain in Elderly Patients with Cancer," JAMA, 279, no. 23 (1998): 1877-82. See also P. Wall and M. Jones, Defeating Pain, The War Against a Silent Epidemic (New York: Plenum, 1991).
4. See R. Payne, "Practice Guidelines for Cancer Pain Treatment: Issues Pertinent to the Revision of National Guidelines," Oncology, 12, no. 11A (1998): 169-75; M. McCaffery, "Pain Control: Barriers to the Use of Available Information," Cancer, 70, no. 5 (supplement) (1992): 1438-49; R. Bernabei et al., "Managing Pain in Elderly Patients with Cancer," JAMA, 279, no. 23 (1998): 1877-82. See also P. Wall and M. Jones, Defeating Pain, The War Against a Silent Epidemic (New York: Plenum, 1991).
5. See K.L. Calderone, "The Influence of Gender on the Frequency of Pain and Sedative Medication Administered to Postoperative Patients," Sex Roles, 23 (1990):11-12, 713-25.
6. See P.L. Walker and D.C. Cook, "Brief Communication: Gender and Sex: Vive la Difference," American Journal of Physical Anthropology, 106, no. 2 (1998): 255-59, who underscore maintaining the distinction between "sex" (the anatomical or chromosomal categories of male and female) and "gender" (socially constructed roles that are related to sex distinctions). It should be noted that while isolating the influence of sex and gender on pain response and treatment is the focus of this article, we do not mean to dismiss the powerful influence of class, race, culture, education, and other such variables that likely affect pain response and treatment.
7. See S.J. Blumenthal and S.F. Wood, "Women's Health Care: Federal Initiatives, Policies, and Directions," in S. Gallant and G.P. Keita, eds., Health Care for Women: Psychological, Social & Behavioral Influences (Washington, D.C.: American Psychological Association, 1997): 57-71.
8. See National Institutes of Health Revitalization Act of 1993, Pub. L. No. 103-43, 107 Stat. 22 (June 10, 1993).
9. A.M. Unruh, "Gender Variations in Clinical Pain Experience," Pain, 65 (1996): 123-67.
10. See K.J. Berkley, "Sex Differences in Pain," Behavioral & Brain Sciences, 20, no. 3 (1997): 371-80.
11. See R.B. Fillingim and W. Maixner, "Gender Differences in the Responses to Noxious Stimuli," Pain Forum, 4, no. 4 (1995), 209-21.
12. Id. at 209.
13. A.M. Unruh, "Why Can't a Woman Be More Like a Man?," Behavioral & Brain Sciences, 20, no. 3 (1997): at 467.
14. See T.D. Carr, K.L. Lemanek, and F.D. Armstrong, "Pain and Fear Ratings: Clinical Implications of Age and Gender Differences," Journal of Pain and Symptom Management, 15, no. 5 (1998): 305-13; B.S. Krogstad, A. Jokstad, and O. Vassend, "The Reporting of Pain, Somatic Complaints, and Anxiety in a Group of Patients with TMD Before and 2 Years After Treatment. Sex Differences," Journal of Orofacial Pain, 10, no. 3 (1996): 263-69; O. Plesh et al., "Gender Difference in Jaw Pain by Clenching," Journal of Oral Rehabilitation, 25, no. 4 (1998): 258-63 (corroborating that women have a higher incidence than men of temporomandibular pain). See also C.R. France and S. Suchowiecki, "A Companion of Diffuse Noxious Inhibitory Controls in Men and Women," Pain, 81, no. 1-2 (1999): 77-84 (finding that women exhibited significantly lower pain thresholds than men and reported significantly greater pain in response to both ischemia and electrocutaneous noxious stimulation).
15. See T.D. Carr, K.L. Lemanek, and F.D. Armstrong, "Pain and Fear Ratings: Clinical Implications of Age and Gender Differences," Journal of Pain and Symptom Management, 15, no. 5 (1998): 305-13; B.S. Krogstad, A. Jokstad, and O. Vassend, "The Reporting of Pain, Somatic Complaints, and Anxiety in a Group of Patients with TMD Before and 2 Years After Treatment. Sex Differences," Journal of Orofacial Pain, 10, no. 3 (1996): 263-69; O. Plesh et al., "Gender Difference in Jaw Pain by Clenching," Journal of Oral Rehabilitation, 25, no. 4 (1998): 258-63 (corroborating that women have a higher incidence than men of temporomandibular pain). See also C.R. France and S. Suchowiecki, "A Companion of Diffuse Noxious Inhibitory Controls in Men and Women," Pain, 81, no. 1-2 (1999): 77-84 (finding that women exhibited significantly lower pain thresholds than men and reported significantly greater pain in response to both ischemia and electrocutaneous noxious stimulation).
16. See T.D. Carr, K.L. Lemanek, and F.D. Armstrong, "Pain and Fear Ratings: Clinical Implications of Age and Gender Differences," Journal of Pain and Symptom Management, 15, no. 5 (1998): 305-13; B.S. Krogstad, A. Jokstad, and O. Vassend, "The Reporting of Pain, Somatic Complaints, and Anxiety in a Group of Patients with TMD Before and 2 Years After Treatment. Sex Differences," Journal of Orofacial Pain, 10, no. 3 (1996): 263-69; O. Plesh et al., "Gender Difference in Jaw Pain by Clenching," Journal of Oral Rehabilitation, 25, no. 4 (1998): 258-63 (corroborating that women have a higher incidence than men of temporomandibular pain). See also C.R. France and S. Suchowiecki, "A Companion of Diffuse Noxious Inhibitory Controls in Men and Women," Pain, 81, no. 1-2 (1999): 77-84 (finding that women exhibited significantly lower pain thresholds than men and reported significantly greater pain in response to both ischemia and electrocutaneous noxious stimulation).
17. See T.D. Carr, K.L. Lemanek, and F.D. Armstrong, "Pain and Fear Ratings: Clinical Implications of Age and Gender Differences," Journal of Pain and Symptom Management, 15, no. 5 (1998): 305-13; B.S. Krogstad, A. Jokstad, and O. Vassend, "The Reporting of Pain, Somatic Complaints, and Anxiety in a Group of Patients with TMD Before and 2 Years After Treatment. Sex Differences," Journal of Orofacial Pain, 10, no. 3 (1996): 263-69; O. Plesh et al., "Gender Difference in Jaw Pain by Clenching," Journal of Oral Rehabilitation, 25, no. 4 (1998): 258-63 (corroborating that women have a higher incidence than men of temporomandibular pain). See also C.R. France and S. Suchowiecki, "A Companion of Diffuse Noxious Inhibitory Controls in Men and Women," Pain, 81, no. 1-2 (1999): 77-84 (finding that women exhibited significantly lower pain thresholds than men and reported significantly greater pain in response to both ischemia and electrocutaneous noxious stimulation).
18. See Berkley, supra note 7.
19. Id.
20. Id.
21. See M.A. Giamberardino et al., "Pain Threshold Variations in Somatic Wall Tissues as a Function of Menstrual Cycle, Segmental Site and Tissue Depth in Non-Dysmenorrheic Women, Dysmenorrheic Women and Men," Pain, 71 (1997): 187-97.
22. See R.B. Fillingim et al., "Ischemic But Not Thermal Pain Sensitivity Varies Across the Menstrual Cycle," Psychosomatic Medicine, 59 (1997): 512-20.
23. See A.G. Glaros, L. Baharloo, and E.G. Glass, "Effect of Parafunctional Clenching and Estrogen on Temporomandibular Disorder Pain," Journal of Craniomandibular Practice, 16, no. 2 (1998): 78-83.
24. See T.T. Dao, K. Knight, and V. Ton-That, "Modulation of Myofascial Pain by the Reproductive Hormones: A Preliminary Report," The Journal of Prosthetic Dentistry, 79 (1998): 663-70.
25. Id. at 667.
26. Id.
27. See B.S. McEwen, S.E. Alves, K. Bulloch, and N.G. Weiland, "Clinically Relevant Basic Science Studies of Gender Differences and Sex Hormone Effects," Psychopharmacology Bulletin, 34, no. 3 (1998), 251-59, in which the authors present a review of studies depicting the array of neurochemical and structural effects of ovarian hormones, including their influence on cognitive function and pain sensitivity. Female rats showed less opioid-mediated stress-induced analgesia than male rats when exposed to a variety of stressors, and male rats demonstrated greater swim stress analgesia and less predator-evoked analgesia than females.
28. See J.S. Mogil et al., "Identification of a Sex-Specific Quantitative Trait Locus Mediating Nonopioid Stress-Induced Analgesia in Female Mice," The Journal of Neuroscience, 17, no. 20 (1997): 7995-8002.
29. Fillingim and Maixner, supra note 8, at 214.
30. See A.M. Aloisi, M. Zimmermann, and T. Herdegen, "Sex-Dependent Effects of Formalin and Restraint on c-Fos Expression in the Septum and Hippocampus of the Rat," Neuroscience, 81, no. 4 (1997): 951-958. See also A.M. Aloisi, "Sex Differences in Pain-Induced Effects on the Septo-Hippocampal System," Brain Research Reviews, 25, no. 3 (1997): 397-406.
31. See A.M. Aloisi, M. Zimmermann, and T. Herdegen, "Sex-Dependent Effects of Formalin and Restraint on c-Fos Expression in the Septum and Hippocampus of the Rat," Neuroscience, 81, no. 4 (1997): 951-958. See also A.M. Aloisi, "Sex Differences in Pain-Induced Effects on the Septo-Hippocampal System," Brain Research Reviews, 25, no. 3 (1997): 397-406.
32. See E.A. Mayer et al., "Review Article: Gender-Related Differences in Functional Gastrointestinal Disorders," Alimentary Pharmacology & Therapeutics, 13, no. 2 (supplement) (1999): 65-69.
33. See P.E. Paulson et al., "Gender Differences in Pain Perception and Patterns of Cerebral Activation During Noxious Heat Stimulation in Humans," Pain, 76 (1998), 223-29.
34. Berkley, supra note 7.
35. Berkley, supra note 7.
36. Unruh, supra note 6.
37. See G.J. De Vries and P.A. Boyle, "Double Duty for Sex Differences in the Brain," Behavioral & Brain Sciences, 92, no. 2 (1998): 205-13.
38. One difficulty in interpreting evidence from research studies is the individual variability of the pain response. Greater variability makes research on pain responses more difficult, as it decreases power and thus increases the likelihood of having insignificant results due to an insufficient number of subjects studied. This has been recently corroborated in a meta-analysis by Riley and colleagues, who determined that only seven of thirty-four studies reviewed on gender differences in pain response had adequate sample sizes. This implies that gender differences have been underestimated rather than overestimated in pain research. See J.L. Riley III et al., "Sex Differences in the Perception of Noxious Experimental Stimuli: A Meta-Analysis," Pain, 74 (1998): 181-87.
39. G. Bendelow, Pain and Gender (New York: Prentice Hall, 2000): at 17, citing V. Neisser, Cognition and Reality (San Francisco: Freeman, 1976): at 214.
40. G. Bendelow, Pain and Gender (New York: Prentice Hall, 2000): at 17, citing V. Neisser, Cognition and Reality (San Francisco: Freeman, 1976): at 214.
41. Duncan describes how Cartesian (i.e., Descartes') mind-body dualism is inaccurately equated with medical reductionism, the latter of which tends to dismiss mind (psychology) and favor body (physiology) in the diagnostic encounter. See G. Duncan, "Mind-Body Dualism and the Biopsychosocial Model of Pain: What Did Descartes Really Say?," Journal of Medicine and Philosophy, 25, no. 4 (2000): 485-513. A more holistic approach is supported somewhat by Melzack and Wall's gate-control theory of pain, in which a neural mechanism in the spinal cord is thought to function like a gate to control the flow of nerve impulses into the central nervous system. Whether sensory transmission is increased or decreased (causing, respectively, a greater or lesser pain intensity perception) is influenced by cognitive and emotional input such as anxiety, mood state, attention, and past experiences. Bendelow and Williams state that the gate-control theory "signals the end of the mind/body split with regard to pain." However, these authors acknowledge that currently "the biological remains dominant over the social." Indeed, Duncan points out that the contemporary biopsychosocial model of pain does not entirely escape mind-body dualism. See also R. Melzack and P. Wall, The Challenge of Pain (Harmondsworth, England: Penguin, 1988); G.A. Bendelow and S.J. Williams, "Transcending the Dualisms: Towards a Sociology of Pain," Sociology of Health and Illness, 17, no. 2 (1995): 139-65, at 143.
42. Duncan describes how Cartesian (i.e., Descartes') mind-body dualism is inaccurately equated with medical reductionism, the latter of which tends to dismiss mind (psychology) and favor body (physiology) in the diagnostic encounter. See G. Duncan, "Mind-Body Dualism and the Biopsychosocial Model of Pain: What Did Descartes Really Say?," Journal of Medicine and Philosophy, 25, no. 4 (2000): 485-513. A more holistic approach is supported somewhat by Melzack and Wall's gate-control theory of pain, in which a neural mechanism in the spinal cord is thought to function like a gate to control the flow of nerve impulses into the central nervous system. Whether sensory transmission is increased or decreased (causing, respectively, a greater or lesser pain intensity perception) is influenced by cognitive and emotional input such as anxiety, mood state, attention, and past experiences. Bendelow and Williams state that the gate-control theory "signals the end of the mind/body split with regard to pain." However, these authors acknowledge that currently "the biological remains dominant over the social." Indeed, Duncan points out that the contemporary biopsychosocial model of pain does not entirely escape mind-body dualism. See also R. Melzack and P. Wall, The Challenge of Pain (Harmondsworth, England: Penguin, 1988); G.A. Bendelow and S.J. Williams, "Transcending the Dualisms: Towards a Sociology of Pain," Sociology of Health and Illness, 17, no. 2 (1995): 139-65, at 143.
43. Duncan describes how Cartesian (i.e., Descartes') mind-body dualism is inaccurately equated with medical reductionism, the latter of which tends to dismiss mind (psychology) and favor body (physiology) in the diagnostic encounter. See G. Duncan, "Mind-Body Dualism and the Biopsychosocial Model of Pain: What Did Descartes Really Say?," Journal of Medicine and Philosophy, 25, no. 4 (2000): 485-513. A more holistic approach is supported somewhat by Melzack and Wall's gate-control theory of pain, in which a neural mechanism in the spinal cord is thought to function like a gate to control the flow of nerve impulses into the central nervous system. Whether sensory transmission is increased or decreased (causing, respectively, a greater or lesser pain intensity perception) is influenced by cognitive and emotional input such as anxiety, mood state, attention, and past experiences. Bendelow and Williams state that the gate-control theory "signals the end of the mind/body split with regard to pain." However, these authors acknowledge that currently "the biological remains dominant over the social." Indeed, Duncan points out that the contemporary biopsychosocial model of pain does not entirely escape mind-body dualism. See also R. Melzack and P. Wall, The Challenge of Pain (Harmondsworth, England: Penguin, 1988); G.A. Bendelow and S.J. Williams, "Transcending the Dualisms: Towards a Sociology of Pain," Sociology of Health and Illness, 17, no. 2 (1995): 139-65, at 143.
44. Unruh, supra note 6, at 157.
45. See R.S. Lazarus and S. Folkman, Stress, Appraisal, and Coping (New York: Springer, 1984), as cited in A. O'Leary and V.S. Helgeson, "Psychosocial Factors and Women's Health: Integrating Mind, Heart, and Body," in S.J. Gallant, G.P. Keita, and R. Royak-Shaler, eds., Health Care for Women: Psychological, Social and Behavioral Influences (Washington, D.C.: American Psychological Association, 1997): 25-71.
46. See R.S. Lazarus and S. Folkman, Stress, Appraisal, and Coping (New York: Springer, 1984), as cited in A. O'Leary and V.S. Helgeson, "Psychosocial Factors and Women's Health: Integrating Mind, Heart, and Body," in S.J. Gallant, G.P. Keita, and R. Royak-Shaler, eds., Health Care for Women: Psychological, Social and Behavioral Influences (Washington, D.C.: American Psychological Association, 1997): 25-71.
47. Unruh, supra note 6.
48. Id. at 158.
49. R. Weir et al., "Gender Differences in Psychosocial Adjustment to Chronic Pain and Expenditures for Health Care Services Used," The Clinical Journal of Pain, 12 (1996): 277-90, at 287.
50. Unruh, supra note 6, at 149, citing L. Astor-Dubin and C. Hammen, "Cognitive Versus Behavioral Coping Response of Men and Women: A Brief Report," Cognitive Research Therapy, 8 (1984): 85-90; C. Brehms and M.E. Johnson, "Problem-Solving Appraisal and Coping Style: The Influence of Sex-Role Orientation and Gender," The Journal of Psychology, 123 (1989): 187-94; J.E. Holm et al., "The Role of Stress in Recurrent Tension Headache," Headache, 26 (1986): 160-67; A.A. Stone and J.M. Neale, "New Measure of Daily Coping: Development and Preliminary Results," Journal of Personality & Social Psychology, 46 (1984): 892-906; L.M. Verbrugge, "Sex Differences in Complaints and Diagnoses," Journal of Behavioral Medicine, 3 (1980): 327-55; A.J.J.M. Vingerhoets and G.L. Van Heck, "Gender, Coping and Psychosomatic Symptoms," Psychological Medicine, 20 (1990): 125-35.
51. Unruh, supra note 6, at 149, citing L. Astor-Dubin and C. Hammen, "Cognitive Versus Behavioral Coping Response of Men and Women: A Brief Report," Cognitive Research Therapy, 8 (1984): 85-90; C. Brehms and M.E. Johnson, "Problem-Solving Appraisal and Coping Style: The Influence of Sex-Role Orientation and Gender," The Journal of Psychology, 123 (1989): 187-94; J.E. Holm et al., "The Role of Stress in Recurrent Tension Headache," Headache, 26 (1986): 160-67; A.A. Stone and J.M. Neale, "New Measure of Daily Coping: Development and Preliminary Results," Journal of Personality & Social Psychology, 46 (1984): 892-906; L.M. Verbrugge, "Sex Differences in Complaints and Diagnoses," Journal of Behavioral Medicine, 3 (1980): 327-55; A.J.J.M. Vingerhoets and G.L. Van Heck, "Gender, Coping and Psychosomatic Symptoms," Psychological Medicine, 20 (1990): 125-35.
52. Unruh, supra note 6, at 149, citing L. Astor-Dubin and C. Hammen, "Cognitive Versus Behavioral Coping Response of Men and Women: A Brief Report," Cognitive Research Therapy, 8 (1984): 85-90; C. Brehms and M.E. Johnson, "Problem-Solving Appraisal and Coping Style: The Influence of Sex-Role Orientation and Gender," The Journal of Psychology, 123 (1989): 187-94; J.E. Holm et al., "The Role of Stress in Recurrent Tension Headache," Headache, 26 (1986): 160-67; A.A. Stone and J.M. Neale, "New Measure of Daily Coping: Development and Preliminary Results," Journal of Personality & Social Psychology, 46 (1984): 892-906; L.M. Verbrugge, "Sex Differences in Complaints and Diagnoses," Journal of Behavioral Medicine, 3 (1980): 327-55; A.J.J.M. Vingerhoets and G.L. Van Heck, "Gender, Coping and Psychosomatic Symptoms," Psychological Medicine, 20 (1990): 125-35.
53. Unruh, supra note 6, at 149, citing L. Astor-Dubin and C. Hammen, "Cognitive Versus Behavioral Coping Response of Men and Women: A Brief Report," Cognitive Research Therapy, 8 (1984): 85-90; C. Brehms and M.E. Johnson, "Problem-Solving Appraisal and Coping Style: The Influence of Sex-Role Orientation and Gender," The Journal of Psychology, 123 (1989): 187-94; J.E. Holm et al., "The Role of Stress in Recurrent Tension Headache," Headache, 26 (1986): 160-67; A.A. Stone and J.M. Neale, "New Measure of Daily Coping: Development and Preliminary Results," Journal of Personality & Social Psychology, 46 (1984): 892-906; L.M. Verbrugge, "Sex Differences in Complaints and Diagnoses," Journal of Behavioral Medicine, 3 (1980): 327-55; A.J.J.M. Vingerhoets and G.L. Van Heck, "Gender, Coping and Psychosomatic Symptoms," Psychological Medicine, 20 (1990): 125-35.
54. Unruh, supra note 6, at 149, citing L. Astor-Dubin and C. Hammen, "Cognitive Versus Behavioral Coping Response of Men and Women: A Brief Report," Cognitive Research Therapy, 8 (1984): 85-90; C. Brehms and M.E. Johnson, "Problem-Solving Appraisal and Coping Style: The Influence of Sex-Role Orientation and Gender," The Journal of Psychology, 123 (1989): 187-94; J.E. Holm et al., "The Role of Stress in Recurrent Tension Headache," Headache, 26 (1986): 160-67; A.A. Stone and J.M. Neale, "New Measure of Daily Coping: Development and Preliminary Results," Journal of Personality & Social Psychology, 46 (1984): 892-906; L.M. Verbrugge, "Sex Differences in Complaints and Diagnoses," Journal of Behavioral Medicine, 3 (1980): 327-55; A.J.J.M. Vingerhoets and G.L. Van Heck, "Gender, Coping and Psychosomatic Symptoms," Psychological Medicine, 20 (1990): 125-35.
55. Unruh, supra note 6, at 149, citing L. Astor-Dubin and C. Hammen, "Cognitive Versus Behavioral Coping Response of Men and Women: A Brief Report," Cognitive Research Therapy, 8 (1984): 85-90; C. Brehms and M.E. Johnson, "Problem-Solving Appraisal and Coping Style: The Influence of Sex-Role Orientation and Gender," The Journal of Psychology, 123 (1989): 187-94; J.E. Holm et al., "The Role of Stress in Recurrent Tension Headache," Headache, 26 (1986): 160-67; A.A. Stone and J.M. Neale, "New Measure of Daily Coping: Development and Preliminary Results," Journal of Personality & Social Psychology, 46 (1984): 892-906; L.M. Verbrugge, "Sex Differences in Complaints and Diagnoses," Journal of Behavioral Medicine, 3 (1980): 327-55; A.J.J.M. Vingerhoets and G.L. Van Heck, "Gender, Coping and Psychosomatic Symptoms," Psychological Medicine, 20 (1990): 125-35.
56. P.A. Thoits, "Gender Differences in Coping with Emotional Distress," in J. Eckenrode, ed., The Social Context of Coping (New York: Plenum, 1991): 107-38, as cited in O'Leary and Helgeson, supra note 35, at 30.
57. See A.M. Unruh, J. Ritchie, and H. Merskey, "Does Gender Affect Appraisal of Pain and Pain Coping Strategies?," The Clinical Journal of Pain, 15, no. 1 (1999), 31-40.
58. See I. Jensen et al., "Coping with Long-Term Musculoskeletal Pain and Its Consequence: Is Gender a Factor?," Pain, 57 (1994): 167-72.
59. Unruh, supra note 6, at 149. See also S.P. Buckelew et al., "Health Locus of Control, Gender Differences and Adjustment to Persistent Pain," Pain, 42 (1990): 287-94; F.J. Keefe et al., "Analyzing Pain in Rheumatoid Arthritis Patients," Pain, 46 (1991): 153-60; and J. Strong, R. Ashton, and A. Stewart, "Chronic Low Back Pain: Towards an Integrated Psychosocial Assessment Model," Clinical Psychology, 69 (1994), 1058-63.
60. Unruh, supra note 6, at 149. See also S.P. Buckelew et al., "Health Locus of Control, Gender Differences and Adjustment to Persistent Pain," Pain, 42 (1990): 287-94; F.J. Keefe et al., "Analyzing Pain in Rheumatoid Arthritis Patients," Pain, 46 (1991): 153-60; and J. Strong, R. Ashton, and A. Stewart, "Chronic Low Back Pain: Towards an Integrated Psychosocial Assessment Model," Clinical Psychology, 69 (1994), 1058-63.
61. Unruh, supra note 6, at 149. See also S.P. Buckelew et al., "Health Locus of Control, Gender Differences and Adjustment to Persistent Pain," Pain, 42 (1990): 287-94; F.J. Keefe et al., "Analyzing Pain in Rheumatoid Arthritis Patients," Pain, 46 (1991): 153-60; and J. Strong, R. Ashton, and A. Stewart, "Chronic Low Back Pain: Towards an Integrated Psychosocial Assessment Model," Clinical Psychology, 69 (1994), 1058-63.
62. O'Leary and Helgeson, supra note 35; Unruh, supra note 6; Weir et al., supra note 38. There is some evidence, however, that health-care utilization rates do not differ among elderly men and women and that older females tend to report lower levels of health-care utilization than older males. See K. Hunt et al., "Are Women More Ready to Consult Than Men? Gender Differences in Family Practitioner Consultation for Common Chronic Conditions," Journal of Health Services and Research Policy, 4, no. 2 (1999), 96-100. See also J.L. Riley, G.H. Gilbert, and M.W. Heft, "Orofacial Pain Symptom Prevalence: Selective Sex Differences in the Elderly?," Pain, 76, no. 1-2 (1998), 97-104.
63. O'Leary and Helgeson, supra note 35; Unruh, supra note 6; Weir et al., supra note 38. There is some evidence, however, that health-care utilization rates do not differ among elderly men and women and that older females tend to report lower levels of health-care utilization than older males. See K. Hunt et al., "Are Women More Ready to Consult Than Men? Gender Differences in Family Practitioner Consultation for Common Chronic Conditions," Journal of Health Services and Research Policy, 4, no. 2 (1999), 96-100. See also J.L. Riley, G.H. Gilbert, and M.W. Heft, "Orofacial Pain Symptom Prevalence: Selective Sex Differences in the Elderly?," Pain, 76, no. 1-2 (1998), 97-104.
64. Miaskowski reports that women report more visits to health-care providers on retrospective assessment, but on prospective studies, men and women seek health care at the same rate. Researchers have attributed this difference to the possibility that men are more reluctant than women to admit visiting health-care providers or less likely to remember such visits. See C. Miaskowski, "The Role of Sex and Gender in Pain Perception and Responses to Treatment," in R.J. Gatchel and D.C. Turk, eds., Psychosocial Factors in Pain: Critical Perspectives (New York: The Guildford Press, 1999): 401-11, at 406. In one prospective study, E. Berkanovic, C. Telesky, and S. Reeder found that perceived efficacy of health care, perceived seriousness of one's symptom, and reported disability from that symptom were more highly correlated with health-care utilization than was gender, although older women were found to have accessed a physician more than men. "Structural and Social Psychological Factors in the Decision to Seek Medical Care for Symptoms," Medical Care, XIX, no. 7 (1981): 693-709.
65. Miaskowski reports that women report more visits to health-care providers on retrospective assessment, but on prospective studies, men and women seek health care at the same rate. Researchers have attributed this difference to the possibility that men are more reluctant than women to admit visiting health-care providers or less likely to remember such visits. See C. Miaskowski, "The Role of Sex and Gender in Pain Perception and Responses to Treatment," in R.J. Gatchel and D.C. Turk, eds., Psychosocial Factors in Pain: Critical Perspectives (New York: The Guildford Press, 1999): 401-11, at 406. In one prospective study, E. Berkanovic, C. Telesky, and S. Reeder found that perceived efficacy of health care, perceived seriousness of one's symptom, and reported disability from that symptom were more highly correlated with health-care utilization than was gender, although older women were found to have accessed a physician more than men. "Structural and Social Psychological Factors in the Decision to Seek Medical Care for Symptoms," Medical Care, XIX, no. 7 (1981): 693-709.
66. Bendelow, supra note 32. See also G. Bendelow, "Pain Perceptions, Emotions and Gender," Sociology of Health and Illness, 15 (1993): 273-94; W. Pollack, Real Boys: Rescuing Our Sons from the Myths of Boyhood (New York: Henry Holt & Co., 1998).
67. Bendelow, supra note 32. See also G. Bendelow, "Pain Perceptions, Emotions and Gender," Sociology of Health and Illness, 15 (1993): 273-94; W. Pollack, Real Boys: Rescuing Our Sons from the Myths of Boyhood (New York: Henry Holt & Co., 1998).
68. Pollack, supra note 46, at 11.
69. Miaskowski, supra note 45, at 404.
70. See F.M. Levine and L.L. De Simone, "The Effects of Experimenter Gender on Pain Report in Male and Female Subjects," Pain, 44 (1991): 69-72.
71. See D.J. Davidson and W.R. Freudenburg, "Gender and Environmental Risk Concerns: A Review and Analysis of Available Research," Environment and Behavior, 28, no. 3 (1996): 302-39.
72. Women have been found to be more other-directed in conversation and to frequently seek support and validation in their communication encounters. Men have been found to be more goal-directed and status-conscious in communication and to give advice more often. See D. Tannen, Yottjust Don't Understand: Women and Men in Conversation (New York: Ballantine, 1990).
73. C. Miaskowski, "Women and Pain," Critical Care Nursing Clinics of North America, 9, no. 4 (1997): at 467.
74. Unruh et al., supra note 41. See also Bendelow, supra note 32.
75. Miaskowski, supra note 45.
76. See B.S. Faherty and M.R. Grier, "Analgesic Medication for Elderly People Post-Surgery," Nursing Research, 33, no. 6 (1984): 369-72.
77. Calderone, supra note 2. Frequency of pain medication dosing was studied rather than the amount of analgesic being dosed since the latter is related to body weight and men might be administered higher doses based on body weight, not gender bias.
78. See J.E. Beyer et al., "Patterns of Postoperative Analgesic Use with Adults and Children Following Cardiac Surgery," Pain, 17, no. 1 (1983), 71-81, as cited in Miaskowsi, supra note 45. Miaskowski cautions readers that most studies that have looked at gender differences in post-operative pain medication administration did not evaluate whether men and women received adequate amounts of analgesic medication. See Miaskowsi, supra notes 45 and 52.
79. See C.S. Cleeland et al., "Pain and Its Treatment in Outpatients with Metastatic Cancer," N. Engl. J. Med., 330, no. 9 (1994): 592-96.
80. W. Breitbart et al., "The Undertreatment of Pain in Ambulatory AIDS Patients," Pain, 65, no. 2 (1996), 243-49.
81. See D.D. McDonald, "Gender and Ethnic Stereotyping and Narcotic Analgesic Administration," Research in Nursing and Health, 17 (1994): 45-49. McDonald, however, did not control for patient weight and thus could not rule out that men were given more narcotic analgesics based on greater body weight.
82. However, Raftery and colleagues found that female patients admitted to the emergency room reported more pain than males, were perceived by health-care providers to experience more pain, received more pain medications and more potent analgesics, and were less likely to receive no pain medications. Patient perception of pain and pain severity was the strongest predictor of number and strength of medications given for pain. The sex of the patient or health-care provider did not predict the number, type, and strength of medications received. Thus, health-care provider gender biases may fluctuate by geographical region or medical specialty. See K.A. Raftery, R. Smith-Coggins, and A.H. Chen, "Gender-Associated Differences in Emergency Department Pain Management," Annals of Emergency Medicine, 26, no. 4 (1995): 414-21.
83. See V. Elderkin-Thompson and H. Waitzkin, "Differences in Clinical Communication by Gender," Journal of General Internal Medicine, 14 (1999): 112-21.
84. See P.A. Johnson, L. Golman, and E.J. Orav, "Gender Differences in the Management of Acute Chest Pain: Support for the 'Yentl Syndrome,'" Journal of General Internal Medicine, 11 (1996): 209-17.
85. Weir et al., supra note 38. "Specialist" was not defined, and the possibility exists that some women were referred by a gynecologist who was considered a "specialist," but served as the woman's primary care provider.
86. See D.Z. Lack, "Women and Pain: Another Feminist Issue," Women and Therapy, 1 (1982): 55-64, as cited in Unruh, supra note 6, at 159.
87. Elderkin-Thompson and Waitzkin, supra note 62. In addition, Crook and Tunks found that women with persistent pain were significantly more likely than men with persistent pain to receive psychotropic drugs from their family practitioner. See J. Crook and E. Tunks, "Women with Pain," in E. Tunks, A. Bellissimo, and R. Roy, eds., Chronic Pain: Psychosocial Factors in Rehabilitation (Malabar, Florida: R.E. Krieger Publishing Company, 1990): 37-48.
88. See M. McCaffery and B.R. Ferrell, "Does the Gender Gap Affect Your Pain Control Decisions?," Nursing, 22, no. 8 (1992): 48-51.
89. See D. McDonald and R.G. Bridge, "Gender Stereotyping and Nursing Care," Research in Nursing and Health, 14 (1991): 373-78.
90. See T. Hadjistavropoulos, B. McMurty, and K.D. Craig, "Beautiful Faces in Pain: Biases and Accuracy in the Perception of Pain," Psychology and Health, 11 (1996): 411-20.
91. Id. at 417. The hypothesis that stereotyping based on attractiveness may actually influence individuals' pain responses (i.e., attractive individuals learn to actively cope better with pain and thus experience less pain intensity, and unattractive individuals learn more passive pain coping mechanisms and experience greater pain intensity) was considered.
92. See T. Hadjistavropoulos, H.D. Hadjistavropoulos, and K.D. Craig, "Appearance-Based Information about Coping with Pain: Valid or Biased?," Social Science and Medicine, 40, no. 4 (1995): 537-43; H.D. Hadjistavropoulos, M. Ross, and C.L. von Baeyer, "Are Physicians' Ratings of Pain Affected by Patients' Physical Attractiveness?," Social Science and Medicine, 31 (1990): 69-72.
93. See T. Hadjistavropoulos, H.D. Hadjistavropoulos, and K.D. Craig, "Appearance-Based Information about Coping with Pain: Valid or Biased?," Social Science and Medicine, 40, no. 4 (1995): 537-43; H.D. Hadjistavropoulos, M. Ross, and C.L. von Baeyer, "Are Physicians' Ratings of Pain Affected by Patients' Physical Attractiveness?," Social Science and Medicine, 31 (1990): 69-72.
94. See S.M. Ebert, X. Liu, and R.L. Woosley, "Female Gender as a Risk Factor for Drug-Induced Cardiac Arrhythmias: Evaluation of Clinical and Experimental Evidence," Journal of Women's Health, 7, no. 5 (1998): 547-57. See also P.M. Thompson and J.L. Wolf, "The Sexual Revolution in Science: What Gender-Based Research Is Telling Us," Journal of Investigative Medicine, 47, no. 3 (1999): 106-13.
95. See S.M. Ebert, X. Liu, and R.L. Woosley, "Female Gender as a Risk Factor for Drug-Induced Cardiac Arrhythmias: Evaluation of Clinical and Experimental Evidence," Journal of Women's Health, 7, no. 5 (1998): 547-57. See also P.M. Thompson and J.L. Wolf, "The Sexual Revolution in Science: What Gender-Based Research Is Telling Us," Journal of Investigative Medicine, 47, no. 3 (1999): 106-13.
96. See R.W Gear et al., "Gender Difference in Analgesic Response to the Kappa-Opioid Pentazocine," Neuroscience Letters, 205, no. 3 (1996): 207-09; R.W. Gear et al., "Kappa-Opioids Produce Significantly Greater Analgesia in Women Than in Men," Nature Medicine, 2, no. 11 (1996): 1248-50. See also L.D. Jamner et al., "Pain Inhibition, Nicotine, and Gender," Experimental and Clinical Psychopharmacology, 6, no. 1 (1998): 96-106 (finding that nicotine had a direct pain-inhibitory effect in men but not in women); M.E. Robinson et al., "Sex Differences in Response to Cutaneous Anesthesia: A Double Blind Randomized Study," Pain, 77 (1998): 143-49 (finding that men responded differently from women to the pain inhibitory effects of a local anesthetic, e.g., locally anesthetized men rated a pressure stimulus as less painful than anesthetized women).
97. See R.W Gear et al., "Gender Difference in Analgesic Response to the Kappa-Opioid Pentazocine," Neuroscience Letters, 205, no. 3 (1996): 207-09; R.W. Gear et al., "Kappa-Opioids Produce Significantly Greater Analgesia in Women Than in Men," Nature Medicine, 2, no. 11 (1996): 1248-50. See also L.D. Jamner et al., "Pain Inhibition, Nicotine, and Gender," Experimental and Clinical Psychopharmacology, 6, no. 1 (1998): 96-106 (finding that nicotine had a direct pain-inhibitory effect in men but not in women); M.E. Robinson et al., "Sex Differences in Response to Cutaneous Anesthesia: A Double Blind Randomized Study," Pain, 77 (1998): 143-49 (finding that men responded differently from women to the pain inhibitory effects of a local anesthetic, e.g., locally anesthetized men rated a pressure stimulus as less painful than anesthetized women).
98. See R.W Gear et al., "Gender Difference in Analgesic Response to the Kappa-Opioid Pentazocine," Neuroscience Letters, 205, no. 3 (1996): 207-09; R.W. Gear et al., "Kappa-Opioids Produce Significantly Greater Analgesia in Women Than in Men," Nature Medicine, 2, no. 11 (1996): 1248-50. See also L.D. Jamner et al., "Pain Inhibition, Nicotine, and Gender," Experimental and Clinical Psychopharmacology, 6, no. 1 (1998): 96-106 (finding that nicotine had a direct pain-inhibitory effect in men but not in women); M.E. Robinson et al., "Sex Differences in Response to Cutaneous Anesthesia: A Double Blind Randomized Study," Pain, 77 (1998): 143-49 (finding that men responded differently from women to the pain inhibitory effects of a local anesthetic, e.g., locally anesthetized men rated a pressure stimulus as less painful than anesthetized women).
99. See R.W Gear et al., "Gender Difference in Analgesic Response to the Kappa-Opioid Pentazocine," Neuroscience Letters, 205, no. 3 (1996): 207-09; R.W. Gear et al., "Kappa-Opioids Produce Significantly Greater Analgesia in Women Than in Men," Nature Medicine, 2, no. 11 (1996): 1248-50. See also L.D. Jamner et al., "Pain Inhibition, Nicotine, and Gender," Experimental and Clinical Psychopharmacology, 6, no. 1 (1998): 96-106 (finding that nicotine had a direct pain-inhibitory effect in men but not in women); M.E. Robinson et al., "Sex Differences in Response to Cutaneous Anesthesia: A Double Blind Randomized Study," Pain, 77 (1998): 143-49 (finding that men responded differently from women to the pain inhibitory effects of a local anesthetic, e.g., locally anesthetized men rated a pressure stimulus as less painful than anesthetized women).
100. See J. Mogil, "Does He Feel Her Pain? Maybe Not," University of Illinois Alumnae LAS Newsletter, Spring (1999): at 7.
101. Weir et al., supra note 38, at 278, stating that "several current hypotheses from the biological perspective are that pain perception is probably related to sensory factors rather than differences in attitudes or emotional responses, and that endogenous pain inhibition may be affected by hormonal variation."
102. Although episodes of acute, severe pain will often be associated with an increase in heart rate or blood pressure, and increased heart rate is used in some studies (e.g., with infants) as a proxy measure of pain, others discourage clinicians from relying on these physiological measures as evidence of a patient's pain. See M. McCaffery and B.R. Ferrell, "How Vital Are Vital Signs?," Nursing, 22, no. 1 (1992): at 45 ("No firm clinical evidence exists to support the assumption that moderate to severe pain is always accompanied by a change in vital signs.").
103. Unruh, supra note 39.
104. O'Leary and Helgeson, supra note 35; Unruh, supra note 6; Weir et al., supra note 38.
105. Unruh, supra note 6, at 159. See also P.P. Katz and L.A. Criswell, "Differences in Symptom Reports Between Men and Women with Rheumatoid Arthritis, "Arthritis Care & Research, 9, no. 6 (1996): 441-48.
106. Id. at 441.
107. Miaskowski, supra note 45, at 406.
108. McCaffery and Ferrell, supra note 67.
109. Bendelow, supra note 32, at 130. See also Nurofen, Pain Relief Study (London: Kings Fund, 1989), as cited in Bendelow, supra note 32, at 36.
110. See E.E. Johansson et al., "The Meanings of Pain: An Exploration of Women's Descriptions of Symptoms," Social Science and Medicine, 48, no. 12 (1999), 1791-1802.
111. Fillingim and Maixner, supra note 8.
112. Bendelow, "Pain Perceptions, Emotions, and Gender," supra note 46, at 286.
113. Bendelow, supra note 32, at 53-55.
114. Id. at 115-16.
115. Crook and Tunks, supra note 66, at 38.
116. Unruh, supra note 39.
117. See L.M. Verbrugge, "Females and Illness: Recent Trends in Sex Differences in the United States," Journal of Health and Social Behavior, 17 (1976): 387-403, as cited in Weir et al., supra note 38, at 288. Bendelow also describes how women's more predominant involvement in the domestic sphere has associated them more with the "natural" world in the form of bodily functions, whereas men have been more involved in the "public world of work and therefore 'higher' cultural and mental processes." The perception thus may exist that men's "higher" functioning, if interrupted by the presence of pain, should receive a higher priority for medical intervention. See Bendelow, supra note 32, at 131.
118. N.L. Marshall states, "combining work and family has become the norm for women rather than the exception." N.L. Marshall, "Combining Work and Family," in S.J. Gallant, G.P. Keita, and R. Royak-Shaler, eds., Health Care for Women: Psychological, Social and Behavioral Influences (Washington, D.C.: American Psychological Association, 1997): 163-74, at 163.
119. McCaffery and Ferrell, supra note 76.
120. Johansson et al., supra note 84, at 1792.
121. See I. Baszanger, "Deciphering Chronic Pain," Sociology of Health and Illness, 14 (1992): 181-215, as cited in Johansson et al., supra note 84, at 1792.
122. Studies have found that the most significant predictor of inadequate pain relief is a discrepancy between the patient and physician regarding the severity of the patient's pain. See Cleeland et al., supra note 58.
123. R. Dresser, "What Bioethics Can Learn from the Women's Health Movement," in S.M. Wolf, ed., Feminism & Bioethics (New York: Oxford University Press, 1996): 144-59, at 147, citing S. Sherwin, No Longer Patient: Feminist Ethics and Health Care (Philadelphia: Temple University Press, 1992): at 193.
124. R. Dresser, "What Bioethics Can Learn from the Women's Health Movement," in S.M. Wolf, ed., Feminism & Bioethics (New York: Oxford University Press, 1996): 144-59, at 147, citing S. Sherwin, No Longer Patient: Feminist Ethics and Health Care (Philadelphia: Temple University Press, 1992): at 193.
125. Id. at 147.
126. J.A. Parks, "Why Gender Matters to the Euthanasia Debate: On Decisional Capacity and the Rejection of Women's Death Requests," The Hastings Center Report, 30, no. 1 (2000): 30-36, at 33.
127. S.H. Miles and A. August, "Courts, Gender and the 'Right to Die,'" Journal of Law, Medicine & Health Care, 18 (1990): 85-95.
128. Id.
129. Parks, supra note 99. See also K.H. Rothenberg, "Gender Matters: Implications for Clinical Research and Women's Health Care," Houston Law Review, 32, no. 5 (1996), 1201-72.
130. V.M. Grace, "Problems of Communication, Diagnosis, and Treatment Experienced by Women Using the New Zealand Health Services for Chronic Pelvic Pain: A Quantitative Analysis," Health Care for Women International, 16 (1995): 521-35.
131. Id. at 525.
132. Id.
133. See Sherwin, supra note 97, at 48. See also J.F. Smith, "Communicative Ethics in Medicine: The Physician-Patient Relationship," in S.M. Wolf, ed., Feminism & Bioethics (New York: Oxford University Press, 1996): 184-215, at 194 ("Women who do speak assertively are often taken to be domineering rather than dominant, emotional rather than rational, biased rather than authoritative, and complaining rather than assertive."). Kate Nicholson, a disability lawyer who is writing a book about her experiences living with chronic neuropathic pain, and who commented on an earlier version of this manuscript, expressed concern that acknowledging gender differences in pain response might lead to gender stereotyping. She made a point of trying to report her pain to health-care providers factually and unemotionally, and recalled one female pain specialist's comment to her, "You are not crazy; you're not like my other patients." Additionally, she recalled a male acquaintance's adamant demand from emergency room staff to give him something for his acute pain ("You SOB's, you are giving me something for pain and you're giving it to me right now!"). He got the pain medication. Yet Nicholson was aware that if she had done something similar, "I'd have been perceived extremely differently, in all likelihood."
134. See Unruh, supra note 6, at 158, summarizing the literature on this point.
135. See Crook and Tunks, supra note 66, at 37, citing G. Engel, "'Psychogenic' Pain and the Pain-Prone Patient," American Journal of Medicine, 26 (1959): 899-918.
136. See K.J. Lennane and R.J. Lennane, "Alleged Psychogenic Disorders in Women - A Possible Manifestation of Sexual Prejudice," N. Engl. J. Med., 288 (1973): 288-92, as cited in Unruh, supra note 6, at 158.
137. Women are four times as likely as men to be diagnosed with a major depression, and twice as likely as men to be diagnosed with a general depression, although rates vary with ethnicity and culture. Possible reasons for this may include that women are more willing to seek help and thus may be diagnosed more frequently; there may be biological differences that predispose women to developing depression (e.g., effects of reproductive hormones); or women may be more likely to suffer from depression due to external stressors (e.g., the effects of sexism, domestic violence, lower pay, and relationship stressors). See F.M. Culbertson, "Depression and Gender," American Psychologist, 52, no. 1 (1997), 25-31. See also O'Leary and Helgeson, supra note 35. Also, female chronic pain patients are more likely than male chronic pain patients to be diagnosed with and treated for depression. See W.E. Haley, J.A. Turner, and J.M. Romano, "Depression in Chronic Pain Patients: Relation to Pain, Activity, and Sex Differences," Pain, 23 (1985): 337-43 .
138. Women are four times as likely as men to be diagnosed with a major depression, and twice as likely as men to be diagnosed with a general depression, although rates vary with ethnicity and culture. Possible reasons for this may include that women are more willing to seek help and thus may be diagnosed more frequently; there may be biological differences that predispose women to developing depression (e.g., effects of reproductive hormones); or women may be more likely to suffer from depression due to external stressors (e.g., the effects of sexism, domestic violence, lower pay, and relationship stressors). See F.M. Culbertson, "Depression and Gender," American Psychologist, 52, no. 1 (1997), 25-31. See also O'Leary and Helgeson, supra note 35. Also, female chronic pain patients are more likely than male chronic pain patients to be diagnosed with and treated for depression. See W.E. Haley, J.A. Turner, and J.M. Romano, "Depression in Chronic Pain Patients: Relation to Pain, Activity, and Sex Differences," Pain, 23 (1985): 337-43 .
139. See A.H. Vallerand, "Gender Differences in Pain," Image: Journal of Nursing Scholarship, 27, no. 3 (1995): at 237.
140. Smith, supra note 106, at 190.
141. See D.L. Roter and J.A. Hall, "Gender Differences in Patient-Physician Communication," in S.J. Gallant, G.P. Keita, and R. Royak-Shaler, eds., Health Care for Women: Psychological, Social & Behavioral influences (Washington, D.C.: American Psychological Association, (1997): 57-71.
142. Smith, supra note 106.
143. Female physicians, however, have been found to spend more time with patients, engage in more positive talk, ask more questions, and elicit more responses from patients. See Roter and Hall, supra note 113. See also J.
144. Hadjistavropoulos, McMurtry, and Craig, supra note 69; Hadjistavropoulos, Hadjistavropoulos, and Craig, "Appearance-Based Information about Coping with Pain: Valid or Biased?," supra note 71; Hadjistavropoulos, Ross, and von Baeyer, "Are Physicians' Ratings of Pain Affected by Patients' Physical Attractiveness?," supra note 71.
145. Hadjistavropoulos, McMurtry, and Craig, supra note 69; Hadjistavropoulos, Hadjistavropoulos, and Craig, "Appearance-Based Information about Coping with Pain: Valid or Biased?," supra note 71; Hadjistavropoulos, Ross, and von Baeyer, "Are Physicians' Ratings of Pain Affected by Patients' Physical Attractiveness?," supra note 71.
146. See S.A. Selfe, Z. Matthews, and R.W. Stones, "Factors Influencing Outcome in Consultations for Chronic Pelvic Pain," Journal of Women's Health, 7, no. 8 (1998): 1041-48.
147. In a Connecticut focus-group study with chronic pain patients, participants reported visiting multiple physicians (quoting "60 to 100") in order to find a diagnosis and a practitioner with whom they felt comfortable. See S. Grantham and M. Robbins, The Connecticut Pain Management Initiative: Focus Group Report (Boston: John Snow, Inc., February 11, 2000).
148. Marshall, supra note 92.
149. About 55 to 65 percent of those who consult complementary practitioners are women, the highest users being those aged 35 to 60. See C. Zollman and A. Vickers, "ABCs of Complementary Medicine: Users and Practitioners of Complementary Medicine," British Medical Journal, 319, no. 7213 (1999): 836-38; and E. Ernst, "Prevalence of Use of Complementary/Alternative Medicine: A Systematic Review," Bulletin of the World Health Organization, 78, no. 2 (2000): 252-57 .
150. About 55 to 65 percent of those who consult complementary practitioners are women, the highest users being those aged 35 to 60. See C. Zollman and A. Vickers, "ABCs of Complementary Medicine: Users and Practitioners of Complementary Medicine," British Medical Journal, 319, no. 7213 (1999): 836-38; and E. Ernst, "Prevalence of Use of Complementary/Alternative Medicine: A Systematic Review," Bulletin of the World Health Organization, 78, no. 2 (2000): 252-57 .
151. Controversy over use of the term "alternative" rather than "complementary" medicine demonstrates the point being made here. The former describes therapies that are not sanctioned by conventional medicine and which patients choose instead unconventional medical therapy. The latter views such therapies as complementing conventional medical therapies. The goal would be for women (as well as men) to have access to both traditional and non-traditional therapies for pain management, with a focus on a holistic approach that provides optimal pain relief. This holistic approach is the accepted standard for many pain clinics and inpatient pain teams, but adequate access to such care is limited for many individuals - either because the pain teams and clinics are not available in their area or they do not get the referral they need.
152. Davidson and Freudenberg conclude that women in general, as a result of their socialization, are not as likely to develop a distinction between themselves as individuals and the world around them, whereas men are socialized to objectify and control their environment and to define themselves as separate from the world around them. Men would thus be more apt to try to separate biological and psychosocial pain etiologies, whereas women would tend to view them more holistically. See D.J. Davidson and W.R. Freudenburg, "Gender and Environmental Risk Concerns: A Review and Analysis of Available Research," Environment and Behavior, 28, no. 3 (1996): 302-39. This theory is affirmed by Bendelow's findings that women spoke of pain experiences more holistically as compared to men and that "men were significantly less inclined to think that the emotional component of pain perception had any importance." See Bendelow, supra note 32, at 90.
153. See D.S. Kwolek et al., "Gender Differences in Clinical Evaluation: Narrowing the Gap with Women's Health Clinical Skills Workshop," Academic Medicine, 73, no. 10 (supplement) (1998): S88-90.
154. That is, women may: (1) have their pain complaints erroneously dismissed as being emotionally-based and therefore "not real" when there is no significant psychological component to the pain; (2) have the likely psychological components that accompany chronic pain be misidentified by health-care providers as the cause, rather than the result of their unrelieved pain, leading to a discounting of the pain; or (3) have the psychological problem that is the source of their pain be discounted and not adequately addressed. All three are inappropriate and reveal a disdain for psychosocial contributors to pain over evidence of organic causation. See Duncan, supra note 33.
155. Bendelow found that men who were given an opportunity to discuss the emotional aspects of their pain experiences did so and were grateful for the opportunity, even though they did not initially acknowledge emotions as contributing to their pain. See Bendelow, supra note 32, at 90-94.
156. Johansson et al., supra note 84, at 1800.
157. Some institutions have already begun addressing the impact of JCAHO pain management standards. See C. Pasero, M. McCaffery, and D.B. Gordon, "Build Institutional Commitment to Improving Pain Management," Nursing Management, 30, no. 1 (1999): 27-33.