The Influence of Patient Sex, Provider Sex, and Sexist Attitudes on Pain Treatment Decisions

  • Adam T. Hirsh
    Address reprint requests to Adam T. Hirsh, PhD, Department of Psychology, Indiana University–Purdue University Indianapolis, 402 N Blackford St, LD124, Indianapolis, IN 46202.
    Department of Psychology, Indiana University–Purdue University Indianapolis, Indianapolis, Indiana
    Search for articles by this author
  • Nicole A. Hollingshead
    Department of Psychology, Indiana University–Purdue University Indianapolis, Indianapolis, Indiana
    Search for articles by this author
  • Marianne S. Matthias
    Veterans Affairs Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice, Roudebush VA Medical Center, Indianapolis, Indiana

    Regenstrief Institute, Inc, Indianapolis, Indiana
    Search for articles by this author
  • Matthew J. Bair
    Veterans Affairs Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice, Roudebush VA Medical Center, Indianapolis, Indiana

    Regenstrief Institute, Inc, Indianapolis, Indiana

    Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
    Search for articles by this author
  • Kurt Kroenke
    Veterans Affairs Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice, Roudebush VA Medical Center, Indianapolis, Indiana

    Regenstrief Institute, Inc, Indianapolis, Indiana

    Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
    Search for articles by this author
Published:February 26, 2014DOI:


      Research suggests that patient sex, provider sex, and providers' sexist attitudes interact to influence pain care; however, few empirical studies have examined these influences. We investigated sex (patient and provider) differences in pain treatment and the extent to which providers' sexist attitudes were associated with these differences. Ninety-eight health care providers (52% female) completed the Ambivalent Sexism Inventory and made treatment ratings for 16 computer-simulated patients with low back pain. Patient sex was balanced across vignettes. Results indicated that female patients received significantly higher antidepressant (F[1, 96] = 4.51, P < .05, η p 2  = .05) and mental health referral (F[1, 96] = 3.89, P = .05, η p 2  = .04) ratings than male patients, which is consistent with our hypotheses; however, these differences were significant only among female providers. Controlling for providers' sexism scores did not substantially alter these results, which is counter to our hypotheses. These results suggest that female providers are more likely to recommend psychosocial treatments for female than for male pain patients, and providers' sexist attitudes do not account for these differences. Research is needed to elucidate the contributors to sex/gender differences in treatment in order to reduce pain disparities.


      The results of this study suggest that patient and provider sex, but not providers' sexist attitudes, influence pain care. These findings may inform efforts to raise awareness of sex/gender differences in pain care and reduce disparities.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ăbsbring P.
        • Närvänen A.-L.
        Women's experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia.
        Qual Health Res. 2002; 12: 148-160
        • Aloisi A.M.
        • Bonifazi M.
        Sex hormones, central nervous system and pain.
        Horm Behav. 2006; 50: 1-7
      1. American Psychiatric Association: APA Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Available at Accessed July 19, 2013

        • Anand S.S.
        • Xie C.C.
        • Mehta S.
        • Franzosi M.G.
        • Joyner C.
        • Chrolavicius S.
        • Fox K.A.A.
        • Yusuf S.
        Differences in the management and prognosis of women and men who suffer from acute coronary syndromes.
        J Am Coll Cardiol. 2005; 46: 1845-1851
        • Bernardes S.F.
        • Costa M.
        • Carvalho H.
        Engendering pain management practices: The role of physician sex on chronic low-back pain assessment and treatment prescriptions.
        J Pain. 2013; 14: 931-940
        • Bernardes S.F.
        • Lima M.L.
        A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients' distress cues on nurses' judgements of chronic low-back pain.
        Psychol Health. 2011; 26: 1642-1658
        • Bertakis K.D.
        • Franks P.
        • Epstein R.M.
        Patient-centered communication in primary care: Physician and patient gender and gender concordance.
        J Womens Health. 2009; 18: 539-545
        • Bertoni A.G.
        • Bonds D.E.
        • Lovato J.
        • Goff D.C.
        • Brancati F.L.
        Sex disparities in procedure use for acute myocardial infarction in the United States, 1995 to 2001.
        Am Heart J. 2004; 147: 1054-1060
        • Burgess D.J.
        • van Ryn M.
        • Crowley-Matoka M.
        • Malat J.
        Understanding the provider contribution to race/ethnicity disparities in pain treatment: Insights from dual process models of stereotyping.
        Pain Med. 2006; 7: 119-134
        • Burgess D.
        • van Ryn M.
        • Dovidio J.
        • Saha S.
        Reducing racial bias among health care providers: Lessons from social-cognitive psychology.
        J Gen Intern Med. 2007; 22: 882-887
        • Calderone K.
        The influence of gender on the frequency of pain and sedative medication administered to postoperative patients.
        Sex Roles. 1990; 23: 713-725
        • Chou R.
        • Huffman L.
        Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline.
        Ann Intern Med. 2007; 147: 505-514
        • Chou R.
        • Qaseem A.
        • Snow V.
        • Casey D.
        • Cross J.
        Clinical guidelines.
        Ann Intern Med. 2007; 147: 478-491
        • Cleeland C.
        • Gonin R.
        • Hatfield A.
        • Edmonson J.
        • Blum R.
        • Stewart J.
        • Pandya K.J.
        Pain and its treatment in outpatients with metastatic cancer.
        N Engl J Med. 1994; 330: 592-596
        • Coiffi J.
        A study of the use of past experiences in clinical decision making in emergency situations.
        Int J Nurs Stud. 2001; 38: 591-599
        • Craft R.M.
        Modulation of pain by estrogens.
        Pain. 2007; 132: S3-S12
        • Craig K.D.
        • Poole G.D.
        Judgments of genuine, suppressed, and faked facial expressions of pain.
        J Pers Soc Psychol. 1992; 63: 797-805
        • Dawson N.V.
        • Arkes H.R.
        Systematic errors in medical decision making: Judgment limitations.
        J Gen Intern Med. 1987; 2: 183-187
        • Donovan J.M.
        • Syngal S.
        Colorectal cancer in women: An underappreciated but preventable risk.
        J Womens Health. 1998; 7: 45-48
        • Elstein A.S.
        Heuristics and biases: Selected errors in clinical reasoning.
        Acad Med. 1999; 74: 791-794
        • Fillingim R.B.
        Sex, gender, and pain: Women and men really are different.
        Curr Rev Pain. 2000; 4: 24-30
        • Fillingim R.B.
        • Ness T.J.
        Sex-related hormonal influences on pain and analgesic responses.
        Neurosci Biobehav Rev. 2000; 24: 485-501
        • Fillingim R.B.
        • King C.D.
        • Ribeiro-Dasilva M.C.
        • Rahim-Williams B.
        • Riley III, J.L.
        Sex, gender, and pain: A review of recent clinical and experimental findings.
        J Pain. 2009; 10: 447-485
        • Fiske S.T.
        What we know now about bias and intergroup conflict, the problem of the century.
        Curr Dir Psychol Sci. 2002; 11: 123-128
        • Glick P.
        • Fiske S.T.
        The Ambivalent Sexism Inventory: Differentiating hostile and benevolent sexism.
        J Pers Soc Psychol. 1996; 70: 491-512
        • Glick P.
        • Diebold J.
        • Bailey-Werner B.
        • Zhu L.
        The two faces of Adam: Ambivalent sexism and polarized attitudes toward women.
        Pers Soc Psychol Bull. 1997; 23: 1323-1334
        • Glick P.
        • Fiske S.T.
        Hostile and benevolent sexism: Measuring ambivalent sexist attitudes toward women.
        Psychol Women Quart. 1997; 21: 119-135
        • Glick P.
        • Fiske S.T.
        • Mladinic A.
        • Saiz J.L.
        • Abrams D.
        • Masser B.
        • Adetoun B.
        • Osagie J.E.
        • Akande A.
        • Alao A.
        • Annetje B.
        • Willemsen T.M.
        • Chipeta K.
        • Dardenne B.
        • Dijksterhuis A.
        • Wigboldus D.
        • Eckes T.
        • Six-Materna I.
        • Exposito F.
        • Moya M.
        • Foddy M.
        • Kim H.
        • Lameiras M.
        • Sotelo M.J.
        • Mucchi-Faina A.
        • Romani M.
        • Sakalli N.
        • Udegbe B.
        • Yamamoto M.
        • Ui M.
        • Ferreira M.C.
        • Lopez W.L.
        Beyond prejudice as simple antipathy: Hostile and benevolent sexism across cultures.
        J Pers Soc Psychol. 2000; 79: 763-775
        • Hamberg K.
        • Risberg G.
        • Johansson E.
        • Westman G.
        Gender bias in physicians' management of neck pain: A study of the answers in a Swedish national examination.
        J Womens Health Gend Based Med. 2002; 11: 653-666
        • Hamberg K.
        • Risberg G.
        • Johansson E.
        Male and female physicians show different patterns of gender bias: A paper-case study of management of irritable bowl syndrome.
        Scand J Public Health. 2004; 32: 144-152
        • Hawker G.A.
        • Wright J.G.
        • Coyte P.C.
        • Williams J.I.
        • Harvey B.
        • Glazier R.
        • Badley E.M.
        Differences between men and women in the rate of use of hip and knee arthroplasty.
        N Engl J Med. 2000; 342: 1016-1022
        • Hirsh A.T.
        • Alqudah A.F.
        • Stutts L.A.
        • Robinson M.E.
        Virtual human technology: Capturing sex, race, and age influences in individual pain decision policies.
        Pain. 2008; 140: 231-238
        • Hirsh A.T.
        • George S.Z.
        • Robinson M.E.
        Pain assessment and treatment disparities: A virtual human technology investigation.
        Pain. 2009; 143: 106-113
        • Hirsh A.T.
        • Hollingshead N.H.
        • Bair M.J.
        • Matthias M.S.
        • Wu J.
        • Kroenke K.
        The influence of patient's sex, race and depression on clinician pain treatment decisions.
        Eur J Pain. 2013; 17: 1569-1579
        • Hoffman D.
        • Tarzian A.
        The girl who cried pain: A bias against women in the treatment of pain.
        J Law Med Ethics. 2001; 29: 13-27
      2. Kahneman D. Slovic P. Tversky A. Judgment Under Uncertainty: Heuristics and Biases. Cambridge University Press, Cambridge1982
        • Kozak L.J.
        • DeFrances C.J.
        • Hall M.J.
        National Hospital Discharge Survey: 2004 annual summary with detailed diagnosis and procedure data.
        Vital Health Stat 13. 2004; : 1-198
        • Kraus S.J.
        Attitudes and the prediction of behavior: A meta-analysis of the empirical literature.
        Person Soc Psychol Bull. 1995; 21: 58-75
        • Lorber J.
        • Moore L.J.
        Gender and the Social Construction of Illness.
        AtlaMira Press, Walnut Creek, CA2002
        • Lord B.
        • Cui J.
        • Kelly A.-M.
        The impact of patient sex on paramedic pain management in the prehospital setting.
        Am J Emerg Med. 2009; 27: 525-27:529
        • Mackenzie C.S.
        • Gekoski W.L.
        • Knox V.J.
        Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes.
        Aging Mental Health. 2006; 10: 574-582
        • Maloney N.
        • Koch M.
        • Erb D.
        • Schneider H.
        • Goffman T.
        • Elkins D.
        • Laronga C.
        Impact of race on breast cancer in lower socioeconomic status women.
        Breast J. 2006; 12: 58-62
        • Mamede S.
        • van Gog T.
        • van den Berge K.
        • Rikers R.M.
        • van Saase J.L.
        • van Guldener C.
        • Schmidt H.G.
        Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.
        JAMA. 2010; 304: 1198-1203
        • McDonald D.D.
        Gender and ethnic stereotyping and narcotic analgesic administration.
        Res Nurs Health. 1994; 17: 45-49
        • McMahon Jr., L.F.
        • Wolfe R.A.
        • Huang S.
        • Tedeschi P.
        • Manning Jr, W.
        • Edlund M.J.
        Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population.
        Med Care. 1999; 37: 712-717
        • Michael G.E.
        • Sporer K.A.
        • Youngblood G.M.
        Women are less likely than men to receive prehospital analgesia for isolated extremity injuries.
        Am J Emerg Med. 2007; 25: 901-906
        • Núñez A.E.
        Transforming cultural competence into cross-cultural efficacy in women's health education.
        Acad Med. 2000; 75: 1071-1080
        • Prkachin K.M.
        The consistency of facial expressions of pain: A comparison across modalities.
        Pain. 1992; 51: 297-306
        • Racine M.
        • Tousignant-Laflamme Y.
        • Kloda L.A.
        • Dion D.
        • Dupuis G.
        • Choiniere M.
        A systematic literature review of 10 years of research on sex/gender and pain perception, Part 2: Do biopsychosocial factors alter pain sensitivity differently in women and men?.
        Pain. 2012; 153: 619-635
        • Raftery K.
        • Smith-Coggins R.
        • Chen A.
        Gender-associated differences in emergency department pain management.
        Ann Emerg Med. 1995; 25: 414-421
        • Raymond J.
        Sexist attitudes: Most of us are biased.
        Nature. 2013; 495: 33-34
        • Rhudy J.L.
        • Williams A.E.
        Gender differences in pain: Do emotions play a role?.
        Gend Med. 2005; 2: 208-226
        • Robinson M.
        • Gagnon C.
        • Riley J.I.
        • Price D.
        Altering gender role expectations: Effects on pain tolerance, pain threshold, and pain ratings.
        J Pain. 2003; 4: 284-288
        • Robinson M.
        • Wise E.
        • Gagnon C.
        • Fillingim R.
        • Price D.
        Influences of gender role and anxiety on sex differences in temporal summation of pain.
        J Pain. 2004; 5: 77-82
        • Rosen A.B.
        • Schneider E.C.
        Colorectal cancer screening disparities related to obesity and gender.
        J Gen Intern Med. 2004; 19: 332-338
        • Roter D.L.
        • Hall J.A.
        Why physician gender matters in shaping the physician-patient relationship.
        J Womens Health. 1998; 7: 1093-1097
        • Roter D.L.
        • Hall J.A.
        Physician gender and patient-centered communication: A critical review of empirical research.
        Annu Rev Public Health. 2004; 25: 497-519
        • Roter D.L.
        • Hall J.A.
        • Aoki Y.
        Physician gender effects in medical communication.
        JAMA. 2002; 288: 756-764
        • Safdar B.
        • Heins A.
        • Homel P.
        • Miner J.
        • Neighbor M.
        • DeSandre P.
        • Todd K.H.
        Impact of physician and patient gender on pain management in the emergency department—A multicenter study.
        Pain Med. 2009; 10: 364-372
        • Sherman J.W.
        • Frost L.A.
        On the encoding of stereotype-relevant information under cognitive load.
        Pers Soc Psychol Bull. 2000; 26: 26-34
        • Stutts L.
        • Hirsh A.
        • George S.
        • Robinson M.
        Investigating patient characteristics on pain assessment using virtual human technology.
        Eur J Pain. 2010; 14: 1040-1045
        • Sullivan M.J.L.
        • Tripp D.A.
        • Santor D.
        Gender differences in pain and pain behavior: The role of catastrophizing.
        Cogn Ther Res. 2000; 24: 121-134
        • Travis C.B.
        • Phillippi R.H.
        • Tonn B.E.
        Judgment heuristics and medical decisions.
        Patient Educ Counsel. 1989; 13: 211-220
        • Travis C.B.
        • Howerton D.M.
        • Szymanski D.M.
        Risk, uncertainty, and gender stereotypes in healthcare decisions.
        Women Ther. 2012; 35: 207-220
        • Weisse C.S.
        • Sorum P.C.
        • Sanders K.N.
        • Syat B.L.
        Do gender and race affect decisions about pain management?.
        J Gen Intern Med. 2001; 16: 211-2117
        • Wise E.
        • Price D.
        • Myers C.
        • Heft M.
        • Robinson M.
        Gender role expectations of pain: Relationship to experimental pain perception.
        Pain. 2002; 96: 335-342
      3. World Health Organization, Department of Mental Health and Substance Dependence: Gender disparities in mental health. Available at: Accessed August 1, 2013