The Pain Gap: Why Doctors Still Don't Believe Women's Bodies

The Pain No One Believes

In 2018, a study published in the *Proceedings of the National Academy of Sciences* delivered a finding that should have reshaped medicine: women in emergency departments wait an average of 65 minutes to receive pain medication for abdominal pain, compared to 49 minutes for men. Women receive less opioid medication overall. Women are more likely to be prescribed sedatives rather than analgesics.

These findings were not new. They were the latest in a decades-long body of research documenting a systematic gender bias in pain management. The so-called "pain gap" — the difference in how men's and women's pain is assessed and treated — is one of the most well-documented and least addressed inequities in modern medicine.

When a woman says she is in pain and a doctor reaches for a psychiatric referral instead of a prescription, that is not medicine. That is ideology operating under a white coat.

The Biology and the Bias

The biological dimension of pain is complex. Women and men experience pain differently, in part because of hormonal differences, differences in pain processing, and differences in the immune response. Oestrogen, which fluctuates throughout the menstrual cycle, pregnancy, and menopause, modulates pain sensitivity. Women generally have higher pain thresholds but lower pain tolerance — they can detect pain at lower intensities but find sustained pain harder to bear.

These biological differences should, in theory, lead to more nuanced clinical assessments of pain in women. Instead, they have been used to dismiss women's pain as hormonal, emotional, or exaggerated. The very complexity of women's pain biology has been weaponised against them.

In India, the situation is compounded by gender norms that discourage women from asserting themselves in medical encounters. A woman who insists she is in pain may be seen as difficult, dramatic, or attention-seeking. A man who demands pain medication is more likely to be seen as appropriately assertive.

The pain gap is not just about biology. It is about whose pain is taken seriously and whose is not.

Endometriosis: The Twenty-Year Delay

Endometriosis — a condition in which tissue similar to the uterine lining grows outside the uterus, causing severe pain, inflammation, and often infertility — is perhaps the most damning example of the pain gap. An estimated one in ten women of reproductive age has endometriosis, making it as common as diabetes. Yet the average time from symptom onset to diagnosis is seven to ten years in high-income countries and significantly longer in low-income ones.

The delay is not because endometriosis is difficult to diagnose. It is because women's pelvic pain is routinely normalised. Doctors tell women that period pain is normal, that they should take paracetamol, that they are being dramatic. Studies consistently show that women with endometriosis visit an average of seven to ten healthcare providers before receiving a correct diagnosis. Many are told their pain is psychosomatic. Many are diagnosed with irritable bowel syndrome instead.

In India, where discussions of menstrual pain are already taboo, the delay is even more pronounced. A 2023 survey by the Endometriosis Society of India found that the average time to diagnosis was over twelve years. Many women reported being told by family members and doctors alike that their pain was exaggerated, that they should learn to tolerate it, that it would improve with marriage or pregnancy.

Twelve years of pain dismissed as normal. Twelve years of being told that your body's distress is your imagination. That is not a diagnostic delay. That is institutional betrayal.

Heart Attacks and the Female Presentation

The gender bias in pain management extends to the most life-threatening conditions. Heart attacks present differently in women than in men. While men typically experience the classic symptoms — crushing chest pain, left arm pain, shortness of breath — women are more likely to present with atypical symptoms: fatigue, nausea, back pain, jaw pain, and a general sense of unease.

Because medical training has historically focused on the male presentation of heart disease, these symptoms are frequently missed. A 2018 study in the *British Medical Journal* found that women were 50 percent more likely than men to receive an incorrect initial diagnosis when having a heart attack. The consequences are fatal: misdiagnosis of heart attack increases mortality risk significantly.

In India, where cardiovascular disease is the leading cause of death and women's heart disease is systematically underdiagnosed, this bias has devastating consequences. Women are less likely to be referred for cardiac testing, less likely to receive invasive procedures, and more likely to die of heart attacks that were diagnosed too late.

A woman having a heart attack does not clutch her chest and collapse like in the movies. She feels tired, sick, and uneasy. And the doctor reaches for a prescription for anxiety.

The Psychological Reductionism

One of the most insidious aspects of the pain gap is the tendency to attribute women's pain to psychological causes. Women with chronic pain conditions are significantly more likely than men to be diagnosed with depression, anxiety, or somatisation disorder. The implication is clear: the pain is not real; it is in the woman's head.

This psychological reductionism has a long history in medicine. The concept of hysteria — the idea that women's physical symptoms were caused by emotional instability — was a cornerstone of medical practice for centuries. While hysteria as a formal diagnosis has been abandoned, its legacy persists in the assumption that women's bodies are unreliable narrators of their own experience.

In India, where mental illness carries enormous stigma, the psychological attribution is particularly harmful. A woman told that her pain is psychological may avoid seeking further medical treatment. She may internalise the belief that she is imagining her symptoms. She may suffer for years without receiving appropriate care.

When medicine tells a woman her pain is psychological, it is not offering an alternative explanation. It is offering an excuse to ignore her.

Race, Caste, and the Pain Gap

The pain gap does not operate in isolation. It intersects with race, caste, and class in ways that multiply its effects. Black women in the United States receive less pain medication than white women for comparable conditions. In India, Dalit women face compounded dismissal — their pain is devalued both because they are women and because they are Dalit.

Research by Dr. Hoffman and colleagues at the University of Virginia found that a significant proportion of medical students and residents held false beliefs about biological differences between Black and white patients — including the belief that Black people have thicker skin, less sensitive nerve endings, and higher pain tolerance. These beliefs translate directly into prescribing patterns.

In India, caste-based assumptions about pain tolerance and endurance are deeply embedded in medical culture. A woman from a lower caste who presents with pain is less likely to receive aggressive treatment, less likely to be referred to a specialist, and more likely to be told to manage with home remedies.

The pain gap is not one gap. It is many gaps, layered on top of each other, each one making the next worse.

What Would Equitable Pain Management Look Like

Addressing the pain gap requires both systemic change and individual accountability. Medical education must include comprehensive training on gender bias in pain assessment. Clinical guidelines must be updated to reflect the evidence on gender differences in pain presentation. Hospitals must implement protocols that ensure women receive timely and appropriate pain treatment.

In India, where the healthcare system is already under strain, these changes require political will and investment. But they are not optional. Every year, millions of women suffer unnecessarily because the medical system was not built to believe them.

The pain gap is not an accident. It is the result of a medical system designed by men, for men, that has never been forced to account for women's bodies.

Closing the pain gap means acknowledging that women's pain is real, that it is serious, and that it deserves treatment. It means dismantling the assumption that women are unreliable reporters of their own experience. And it means building a medical system that treats women as experts in their own bodies, rather than as problems to be diagnosed and dismissed.