Friends of the Nonverbal Communication Blog, this week we present the paper “Gender Biases in Estimation of Others’ Pain” by Zang, L.; Reynolds Losin, E. A.; Ashar, Y. K.; Koban, L. and Wager, T. D. (2021), where the authors carry out two experiments to know if women feel or express more pain than men, or if it happens the other way round.
Accurately estimating the pain of others based on nonverbal signals is an essential aspect of interpersonal communication, since it is the basis of empathy and care.
Acknowledging the pain of others is an increasingly valuable interpersonal skill, both for doctors and for the rest of the population.
Although pain is usually assessed through self-reports, recognition of facial expressions of pain is a very important part of the assessment.
Because expressions of pain are communicative behaviors, observers’ interpretations of those expressions are a crucial aspect of pain communication. These interpretations are affected not only by the characteristics of the expressions of pain, but also by the observer’s knowledge and biases about pain and the characteristics of those who suffer from it.
For example, several studies have shown that psychological treatment is more likely to be recommended for women suffering any kind of pain than for men, who are prescribed painkillers. Therefore, female patients take longer to receive analgesic medication. However, it is important to note that there are other studies of gender bias in pain management that show the opposite pattern, or no significant gender difference.
Despite clinical evidence of underestimation and undertreatment of pain in female patients, laboratory results on gender bias have been inconsistent and, in fact, some studies have found that women felt more pain than men, having note their facial expressions.
That is, it seems that a large part of the results in the evaluation of pain is decided by facial expressions. Therefore, controlling the objective measures of facial expressiveness in general, and of pain in particular, is an important step in stopping the bias in the perceiver.
In this context, there are also gender stereotypes related to pain, for example, that women complain more than men and do not accurately report their pain, or that men are more sensible and when they complain about their pain, it is real. These beliefs would affect pain assessment and treatment.
To delve into the subject, authors conducted two experiments. First, they compared differences in pain estimation in men and women, controlling for the same level of facial expressiveness and also controlling for patients’ self-reported pain. This is necessary because the amount of pain patients experience is highly variable, also because the facial response to pain is one of the most salient cues we use to estimate pain, and lastly, because the expressiveness of patients can affect observer estimates through empathy.
For experiment 1, 50 volunteers participated and had to watch a series of videos of faces of people experiencing pain. Each video was coded through the FACS system, and the action units AU4 (lowering of the eyebrows), AU6 and 7 (contraction of the eyelids), AU9 and 10 (contraction of the elevator) and AU43 (closure of the eyes) were especially relevant. These action units are representative of the emotion of pain.
In addition, the videos included a self-report from the patients where they rated their own pain.
The objective of this experiment was to test whether the sex of the patients affects the estimation of pain according to the observers. The hypothesis was that if the intensity of facial expressions was not controlled, female patients would be perceived as being in more pain than male patients. If, on the other hand, there were similar levels of expression and self-reported pain, it would be the male patients who would be perceived as having more pain.
The results did not support the hypotheses. Male and female patients were not perceived to have different degrees of pain before controlling pain, facial expressiveness, and patient self-reported pain. However, female patients were perceived to have less pain than male patients when facial expressions and self-reports were controlled.
The second experiment was very similar, except that opinion questionnaires about pain treatment and gender stereotypes were added.
In general, women’s pain was underestimated relative to self-reported pain, while men’s was overestimated. In addition, female patients, according to observers, would benefit more from psychotherapy than male patients.
The underestimation of pain and psychologization in the treatment of women’s pain could have very negative side effects on their health. Therefore, the existence of these stereotypes must be taken into account and act accordingly, so that both men and women receive the treatment they need and their health is not harmed.
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