A child's finger is pricked at a doctor's office, and the child cries out. "Ow! Ah! Oh!"
How much pain adult Americans think the young patient is suffering will depend on whether they believe the child to be a girl or a boy, according to a study published this month in the Journal of Pediatric Psychology. Those who know the distressed patient as “Samuel” will infer that he is in more pain than those who know the patient as “Samantha,” even though Samuel and Samantha are in fact the same 5-year-old, whose shoulder-length blond hair, red T-shirt and gym shorts don’t immediately suggest male or female characteristics.
The child’s finger-prick test was captured in a short video played for 264 adults, men and women between the ages of 18 and 75. On average, participants told that they were watching a boy’s reaction to his prekindergarten doctor’s visit rated his pain, on a scale from 0 (no pain) to 100 (severe pain), as 50.42, while those instructed that the patient was a girl rated her pain as 45.90. When researchers controlled for explicit gender stereotypes — the belief that boys are more stoic — the difference vanished, suggesting that biases about the willingness of male versus female children to display pain were behind the belief that this particular boy was truly in dire straits because he was moved to cry out.
The results, in what lead author Brian D. Earp described as a "new research area," contribute to growing understanding of sex differences in pain, a topic that has mainly been studied in the context of adults. They add further dimensions to the exploration of pain assessments biased by race, based on dubious notions about biological differences between blacks and whites. And they suggest a possible need for a course correction in pediatric care, where health care providers may exhibit the same biases that influence the general public.
"Adults have a lot of authority and agency in saying, 'This is how I feel.' We express ourselves in nuanced ways," Earp, the associate director of the Yale-Hastings Program in Ethics and Health Policy, said in an interview with The Washington Post. "But young children, and how they're attended to, depends on the judgments of adults in the room. Understanding the structure of those judgments is important for equitable health care."
In a finding that surprised the paper's authors, the downgrading of female pain was driven by female participants, who were more likely than men to say that the pain of the subject was less severe when told she was a girl.
"This is a big mystery," Earp said. "We're spitballing to come up with a reason."
A similar dynamic seemed to appear in a 2014 study that the new paper takes as its model, in which a sample of disproportionately female nursing and psychology students viewed the same video as in the recent study and rated Samuel as experiencing more pain than Samantha, despite the identical behavior. That those training to be medical providers were among the participants suggests crossover to the health-care profession. Their responses bolster the idea that gender bias about how children express pain influences even those "who are in a position to be making healthcare decisions," Earp said.
"It's a preliminary result, but we're pretty sure there's a there there," he said.
The lead author of the earlier study, Lindsey Cohen, a professor of psychology at Georgia State University, said in an interview that he had long wondered if their results, published in the journal Children's Health Care, would hold up among men.
It appears that they don't. In the new study, the gender of the young patient had no effect on assessments offered by 156 male participants, among several hundred who viewed the video.
The discovery is in "some tension," the paper notes, with the conclusions of related experiments, though not on the central finding that the pain of boys is taken more seriously. For instance, a 2008 study found that fathers rated the pain of their sons higher than that of their daughters in a cold pressor test, in which a subject immerses a hand in a container of ice water. Mothers showed no difference.
Meanwhile, research has shown that young children don't experience pain differently on account of gender in the way that the adult population does, both in terms of sensitivity and clinical risk. The sex hormones thought to account for the difference are not present before puberty. Studies of how adults nevertheless come to different conclusions about the pain of children have mainly been limited to the attitudes of their parents, who enjoy a unique vantage point.
The new study accesses a wider audience. And the apparent biases of the women it surveyed came as no surprise to Kate Manne, a philosopher at Cornell University and the author of "Down Girl: The Logic of Misogyny." She said it was the logical conclusion of women rating their own pain as less severe.
"Since there's more pressure on women to be appropriately sympathetic to pain, and since we're biased in the direction of taking male pain more seriously, it makes sense that women are at least as bad if not worse," Manne said.
The results, while not surprising, were "really sad," she observed. "We should be troubled by the fact that seemingly all else equal, perceived gender plus a few gender stereotypes are enough to have a little girl's pain responded to with less concern."
If boys do tend to understate their own pain, Earp said, there might be good reason to see the same behavior as reflecting more intense pain in a male subject, one who has been led to believe, "Boys don't cry."
But Manne pointed to research casting doubt on the idea that young boys have already learned to bottle up their emotions. Some analysis has found, by contrast, that boys are more likely than girls to express negative emotions in childhood, a pattern that reverses only in adolescence.
"It's still possible that we socialize boys to be stoic, but that pernicious norm doesn't appear to be very potent," she said. "Then the results start to look really disturbing, because there's no basis for thinking the boy was actually in any more pain."
Earp said he would like his next study to introduce the factor of race, which has been explored — revealing a "view in the back of people's heads that black people have literally thicker skin," he said — but rarely in combination with gender bias, especially among children.
Stark examples exist of the consequences, for both adults and children, of racially biased assessments of pain. Some of them have been documented by the American Medical Association's Journal of Ethics. African Americans and Hispanics have been shown to receive lower doses of pain medication than whites. They wait longer in emergency rooms for pain medication. Their pain needs have been taken less seriously in hospice care. Though studies have shown that African Americans report greater back pain, clinicians record the opposite. Minority and low-income children encounter more difficulty getting oral pain evaluated and treated.
To Earp, this pattern suggests that the way adults interpret the pain of children could have consequences for their health, prompting the question, “What are the real-life treatment implications of this cognitive bias?”