Surgery Bias: Anesthesia, Pain Management, and the Female Body

The Operating Theatre Is Not Neutral

The operating theatre is one of the most controlled environments in medicine. Every variable is monitored: heart rate, blood pressure, oxygen saturation, depth of anesthesia. And yet, within this precision, a systematic bias persists: women receive less pain medication after surgery than men, wait longer for anesthesia induction, and are more likely to have their postoperative pain underestimated.

This is not a fringe finding. It is documented across multiple countries, surgical specialties, and types of procedure. A 2019 meta-analysis published in *The Lancet* found that women received significantly less opioid analgesia than men in the immediate postoperative period, despite reporting comparable or higher pain levels. The gap persists even when controlling for age, weight, type of surgery, and ASA physical status.

The operating theatre is supposed to be the most evidence-based space in medicine. But when it comes to pain, the evidence is applied unevenly.

The Anesthesia Gap

The bias begins before the surgery does. Studies have documented that women wait longer for anesthesia induction than men in comparable procedures. A 2017 study in *Anesthesiology* found that female patients were more likely to be categorized as lower priority in preoperative assessment and were less likely to be offered regional anesthesia techniques that might reduce postoperative pain.

The reasons are complex. Anesthesiologists — like all physicians — are influenced by implicit bias. The perception that women are more emotional, more anxious, and more likely to exaggerate symptoms affects clinical decision-making. A woman who reports preoperative anxiety may be perceived as less able to tolerate anesthesia, leading to conservative dosing. A man who reports the same anxiety may be perceived as appropriately cautious.

In India, where the patient-doctor relationship is often hierarchical and gendered, these biases can be particularly pronounced. A woman who asks questions about her anesthesia may be seen as difficult. A woman who reports pain may be told it is expected, that she should be patient, that she is overreacting.

When the anesthesiologist sees a woman and adjusts accordingly, that is not medicine. That is bias operating in the most vulnerable space of all.

Postoperative Pain: The Gender Gap

The most significant bias occurs in postoperative pain management. Women consistently receive less opioid medication after surgery, wait longer for analgesic administration, and are more likely to be offered non-pharmacological interventions (heat, distraction, reassurance) rather than medication.

A landmark 2008 study in *Pain* by Dr. Ronald B. Workman and colleagues found that women waited 35 minutes longer to receive analgesics for abdominal pain in the emergency department. A 2012 study in the *Journal of Pain* found that women with comparable pain scores received lower doses of opioids. The findings have been replicated repeatedly, across multiple clinical settings.

The consequences are not trivial. Undertreated postoperative pain increases the risk of complications — including chronic pain, pulmonary complications, and cardiovascular events. Women who receive inadequate pain treatment after surgery are more likely to experience prolonged recovery, reduced mobility, and diminished quality of life.

A woman wakes up from surgery in pain. The nurse assesses her, decides she looks anxious rather than painful, and administers a sedative instead of an analgesic. This happens every day in hospitals around the world.

The Cultural Dimensions

The surgery bias is not merely a clinical phenomenon. It is a cultural one. The perception that women are more emotional, more dramatic, and less reliable reporters of their own physical experience shapes how clinicians interpret their symptoms.

In Indian culture, these perceptions are reinforced by gender norms that expect women to be stoic, to endure, to complain less. A woman who advocates aggressively for pain medication may be seen as demanding or difficult. A man who does the same is seen as appropriately assertive. The social dynamics of the clinical encounter reproduce the power imbalances of the broader culture.

Research has also documented racial and caste-based dimensions of the surgery bias. In the United States, Black women receive less postoperative pain medication than white women. In India, caste-based assumptions about pain tolerance may affect treatment decisions, though this has been less studied.

The surgery bias is not one bias. It is many biases — gender, race, class, caste — converging in the most critical moment of a patient's care.

The Cardiac Surgery Exception — Or Not

Cardiac surgery is often held up as an area where gender bias in pain management is less pronounced, because the severity of the procedure demands aggressive pain control regardless of gender. But even here, the bias persists.

A 2021 study in the *Journal of Cardiothoracic and Vascular Anesthesia* found that women undergoing coronary artery bypass grafting received less opioid medication in the postoperative period than men, despite reporting higher pain scores. The finding was consistent across multiple centres and could not be explained by differences in body weight or surgical complexity.

In India, where cardiovascular disease is a leading cause of death and cardiac surgery volumes are growing, the gender bias in cardiac pain management has significant implications. Women already face delays in cardiac diagnosis and treatment; the addition of postoperative pain undertreatment compounds their disadvantage.

Even in the most serious surgeries, where pain management is critical, women's pain is assessed less aggressively and treated less effectively. The bias is not overridden by severity. It persists.

What Would Equitable Pain Management Look Like

Addressing the surgery bias requires systemic interventions. Standardised pain assessment protocols that account for gender — not by lowering the threshold for women but by ensuring that the same criteria are applied. Automated medication administration systems that do not allow implicit bias to influence dosing. Training for anaesthesia and surgical teams on gender bias in pain assessment.

In India, where the healthcare system is already strained, these changes require political will and investment. But the cost of inaction is not zero. Undertreated postoperative pain increases length of stay, increases complications, and increases healthcare costs. The economic argument for equitable pain management is as strong as the ethical one.

The surgery bias is not a minor inconvenience. It is a measurable harm that affects millions of women every year. Closing the gap is not optional. It is a clinical and moral imperative.

Every woman who goes under the knife deserves the same evidence-based care as every man. The operating theatre should be the place where bias ends, not where it is most dangerous.