A new study by researchers at Yale and Georgia State University found that explicit gender stereotypes may bias physicians’ assessments of children’s pain.

The team found that under identical clinical circumstances and identical reactions of pain, a male child was rated as experiencing more pain than a female one. Led by philosophy and psychology joint doctoral student Brian Earp GRD ’22, the paper was published on Jan. 4 in the Journal of Pediatric Psychology.

“Pain is an inherently private experience, and children are especially at the mercy of other people’s judgments, which makes it all the more important to examine biases in pediatric pain assessment,” said Joshua Monrad ’20, the second author of the study.

There is no doubt that gender expectations, stereotypes and biases are prevalent in most aspects of everyday life, Monrad said. But there has been little research into their actual effects in pediatric pain assessment. The team wanted to expand on existing literature by replicating a 2014 study, in which adult participants rated a child undergoing a medical procedure as feeling more pain when the child was described as a boy as compared to a child described as a girl.

To determine whether perceived gender affects how adults judge children’s pain, the team showed adult participants a short video in which a 5-year-old child — whose gender characteristics were deemed ambiguous between male and female — receives a prick on the finger and clearly displays pain  by saying “Ow!” After watching the video, participants were told that the child was either “Samuel” or “Samantha.”

The team then asked participants to rate how much pain the child sensed and displayed, how typical the child was in these respects and how much they agreed with explicit gender stereotypes concerning pain response.

The study found that the child was rated as experiencing more pain when it was described as a boy. The bias was found predominantly in female — not male — observers, which undermines the idea that female physicians are less affected by implicit gender bias, said Lindsey Cohen, a psychology professor at Georgia State University and co-author of the study.

The child was also rated as sensing and displaying pain in a manner that is typical for a girl, but greater than what is typical for a boy, according to the study. This difference could reflect societal norms that boys should be stoic, which leads participants to believe that the boy must be in more pain if he is displaying it overtly. Controlling for explicit gender stereotypes, however, eliminated this difference, the study showed.

According to Cohen, the findings from both papers suggest that gender biases might be explicit — consciously recognizable — as well as implicit, or unconscious.

“An interesting result in our findings was that the implicit bias effect was related to people’s explicit beliefs about gender stereotypes,” Monrad said. “So a way to combat biases would be to have more honest conversations about the stereotypes that we hold and that we perpetuate regarding the experiences of children of different genders.”

To counteract these biases — which can lead to inaccurate medical judgments — there needs to be more research about the nature and extent of potential biases in pain assessment and healthcare more generally, Monrad said. If further research supports the team’s findings, the next step would be to engage in  discussions with physicians and healthcare providers about how to avoid negative consequences of biases.

Cohen, who was first author on the 2014 study, agreed that data on biases should be incorporated into healthcare training, specifically in any modules focused on pediatric pain assessment.

Compared to girls, boys are more socialized to not express pain, said April Bailey GRD ’20, who studies gender stereotypes and biases. Although more evidence is needed to support this study, it strengthens the theory that an individual’s gender factors into how their pain is perceived by others. One way to combat these subtle biases is to base decisions on objective factors, such as the type of injury, rather than subjective judgments of a patient’s pain intensity, Bailey noted.

According to Bailey, who was not involved in the study, there are parallels between the study and others showing that women experience longer wait times in emergency rooms and that caregivers play “rougher” with young boys than girls.

“Psychological research has the potential to really change how we understand human behavior if it’s done right,” Monrad said. “Considering how important the issue of gender biases is, I am glad that we made sure to conduct our studies very carefully.”

Monrad added that it has been humbling to see how much media attention the research has recently received. He hopes the team can contribute to further research and important conversations.

In 2016, 84 percent of children in the U.S. aged 5 to 11 years were in excellent or very good health, according to the National Center for Health Statistics.

Eui Young Kim | euiyoung.kim@yale.edu