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Does gender bias influence how people assess children’s pain?

recently published paper in the Journal of Pediatric Psychology has attracted much media attention for its analysis of a subject that has long been debated: how do our beliefs about male-female differences influence our decision-making? Specifically, do our beliefs about the pain expressions of boys and girls influence our assessment of their pain experience?

The authors found that when adult participants were shown the same video of a young child undergoing a painful procedure, those who were told the child was a boy rated the child as experiencing more pain than those who were told the child was a girl. However, when the analyses controlled for gender biases related to pain expression (i.e., the belief that boys display less pain in their expressions than girls), the difference was no longer present. The results suggest that the observed difference in pain ratings is likely driven by gender biases on the part of the adult observers.

Below Katelynn Boerner (co-author of a recent commentary on this work in the Journal of Pediatric Psychology) dives deeper into these findings with the study’s lead author, Brian Earp.

Katelynn Boerner: The fact that your findings appeared to be driven by female participants is fascinating. What do you make of this?

Brian Earp: Because this was an unexpected finding, we don’t know what to make of it—yet. But it is consistent with the sole previous study about this issue, which involved a preponderance of female participants: 85% of the sample (the researchers recruited from nursing students and psychology majors, who are disproportionately female). So it is possible that their result, too, was driven by female participants. As it happens, the male participants in our study actually rated the pain of the child when it was described as a girl higher than that of the same child when it was described as a boy (albeit not to a statistically significant degree). This is the opposite pattern of results compared to the female participants So there is certainly something interesting going on.

When I was asked by journalists what could explain this female-only bias in rating the “boy” pain higher, I emphasized that any explanation would be entirely speculative. Our study was not designed to answer that question. But the work of philosopher Kate Manne is a potential avenue for further exploration, in particular her theory of misogyny as spelled out in her book, Down Girl: The Logic of Misogyny. One aspect of her account is that women and girls may, generally speaking, be socialized to give heightened attention to the needs of males in patriarchal cultures, in part because it is usually adaptive for those with less power to be attuned to the interests of those with more power. If so, it could be the case that females are primed to be especially sensitive to signs of distress or discomfort among males, such as pain-displays, even when the males are still young boys. This is definitely an idea worth testing in future studies.

However, a word of caution is in order. Some media outlets went running with this speculative possibility and emphasized that our initial experiment might be seen as “yet more evidence” of widespread sexism or misogyny (that is, roughly speaking, prejudicial or unjust treatment of females). Such an interpretation was bolstered by headlines saying that our study showed that people “take girls’ pain less seriously” than that of boys. But that phrasing is ambiguous, and on one interpretation, it isn’t what the experiment showed. To be precise, we found that female participants, but not male participants, rated the pain of a gender-ambiguous child as more serious (as in, more severe or intense) when the child was described as a boy. This doesn’t mean that they took the pain of the “boy” more seriously, in the sense that they believed him to be more credible (as erroneously suggested by the New York Times); and it doesn’t mean they judged the “girl” to be overreacting, much less that her pain should be dismissed.

In simplest terms, if you believe that someone is underplaying the pain they feel, it is rational to infer that they are experiencing more pain than they are outwardly showing.

In fact, our finding is equally compatible with (female) participants having judged the “girl” as displaying pain accurately, and the “boy” as displaying pain inaccurately—i.e., underplaying the pain he really was feeling (perhaps due to the relative stoicism that is widely believed to be expected of boys). Indeed, when we controlled for participants’ explicit belief that boys in general display less pain than girls do, the main effect disappeared. In simplest terms, if you believe that someone is underplaying the pain they feel, it is rational to infer that they are experiencing more pain than they are outwardly showing. That wouldn’t have anything to do with sexism or misogyny: in fact, it might just mean that the female participants in our study were better than the male participants at drawing a reasonable inference about a child’s experience of pain. In any event, we did not measure the extent to which participants cared about the pain of the child or believed the child to be a credible reporter.

KB: Other judgment studies have found differences in pain assessment based on other individual factors, such as medical experience/training and parental experience. Do you think such factors may have had any impact on your results?

BE: We did not assess medical experience or training, so we cannot speak to that issue. However, we are planning a replication study among healthcare providers and we will take clinical experience into account. With respect to parental experience, we did record whether participants were parents or not, but we have not done a separate analysis looking at that factor because it was not part of our pre-registered analysis plan. That being said, our data are available here, so anyone interested in looking at that variable in an exploratory way should feel free to do so.

KB: Part of what makes your findings so compelling is that there is not clear evidence for sex differences in the pain experience of children that young. This means the fact that adults are rating the pain of boys and girls differently is likely not based on a true male-female difference in the pain experience of children. How much do you think gender biases imposed by adults, and gender-based socialization in general, impact the sex differences in pain that we see emerge later in adolescence and adulthood?

BE: It is true that existing studies do not reliably support clinically significant differences in “objective” pain tolerance thresholds among boys and girls before puberty. In fact, in our study, participants reported beliefs that are consistent with this: they did not report believing that boys and girls experience different levels of pain. But they did report that boys and girls display different levels of pain, with boys, in general, believed to display less pain than girls. And that may be a reasonable belief. Insofar as boys really are socialized to display less pain than they feel, it might be true that—all else being equal—a given display of pain corresponds to a higher level of felt pain in boys when compared to girls. But there is not a lot of research on this, and it would be very hard to establish empirically. So, we confined ourselves to what participants believe is true of boys as compared to girls when it comes to display of pain. And again, when we controlled for this belief in our statistical model, it eliminated the overall difference in ratings for pain experience. How this bears on sex differences in pain experience, treatment, and so on, that emerge in later adolescence and adulthood is not something we can answer with our existing data.

KB: The fact that the gender of the child in the video was ambiguous enough to be interpreted as female or male is a necessary strength of your experimental design, but also raises a question about how gender expression impacts the biases that influence our decision-making. Do you think you would have found the same results if you used video clips of a more stereotypically masculine boy or feminine girl?

BE: This is an excellent question, and it is something we want to address in follow-up research. A difficulty, of course, is that if a child is more obviously or stereotypically male (or masculine) or female (or feminine), then it would be much harder to do a controlled test where one-and-the-same video or display of pain could be attributed to a boy or girl depending on condition. But it is something our research group has been thinking about and we are considering various ways we might investigate this issue

KB: What do you think physicians and other health professionals should take away from your research?

BE: The main thing they should take away is that our finding is preliminary. It needs to be replicated using a wider array of stimuli, and in studies with healthcare professionals as participants, before we can say with confidence what the real-world implications might be. What we hope to have done is call attention to a very important issue that should be studied in depth in a medical context, so that—if our finding does turn out to have clinical significance—appropriate measures could be taken to ensure fair and adequate treatment of children’s pain regardless of their sex or gender.


Featured image credit: Children Sandbox by qimono. Public Domain via Pixabay. 


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