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    of 6
    Sex Differences in Common Pain Events: Expectations and Anchors Michael E. Robinson, *' Christine M. Gagnon,** Erin A. Dannecker,** Jennifer L. Brown,** Rebecca L. Jump,** and Donald D. Price* Abstract: This study examined (1) the effects of sex-related stereotypes in commonly experienced, potentially painful events and (2) differences in events representing the worst pain sensation imaginable for the typical woman and the typical man. Undergraduates (63 women and 58 men) «completed the Situational Pain Questionnaire as the typical woman would and as the typical man ‘would, The participants also answered 2 open-ended questions regarding the worst pain sensation imaginable forthe typical woman and for the typical man. Our findings demonstrate that sex-related stereotypes extend to common pain events and that men and women expected that men would report less pain for common pain events than women. This suggests a gender-role related learning history that i relatively consistent for both sexes, The worst pain sensation imaginable was perceived to be different for typical men and women. Both sexes chose injury asthe class of events men would find most painful and childbirth and menstrual pain as the class of events women would find most painful. Implications ofthis finding for common pain scaling approaches are discussed, The results of this study were obtained from a fairy uniform group of undergraduate men and women, which may limit the generalizability of our findings. ‘© 2003 by the American Pain Society Key words: Pain, sex differences, expectations, anchors. nara eve of experimental pain simi Ae“ thet more than 759 ofthe tlevont publshedinesigetors detected a se fe ‘ence on at least 1 pain measure.* A meta-analytic review Hiabne determined tht te eect aes of thesexat femme for veinus pin neers sndpalesinaleare moderate to large (Cohen's ds = .46 to 1.18)."* In addi ton oreviewafepdemiologlestudlesof common est ram pat errs the empanreported tet endogenous pein ocuredmore equa sndintersl and nmore locations for women as compared with men.” Further- gender olecxpecatonsof pant Gender ele epee tons of Pah quetionnate (GREP found that both wnan and wate aught a er anu ial ‘endure more pain than the typical woman." Given the ‘eceived December 18, 2001; Revised May 8, 202; Accopted June 4, 2002 From the “Department of Clinical and Heath Psychology, Meknight Brain Insitute, and Department of Anesthesiology, Unvestyof Fonds, nd ‘Canter tor Pain Rerearchand Benavorl Hedi, Caine Supgort for this research was proved from grants 1RO1 (DE 13208 {HAa) rom the National Inttate of Dental ard Craiotal Resear fang A15¥4H57131 fom tha National inetute of Mental Health QE) nd fram grant sF32(ANO8EDS 01) (AD) rom the Nallonal Institutet ‘rennin Mutevloseleta ane Skin izes, ‘ates reprint requests to Mehoel E. Robinson. PaO. Department of nat and Heatth syeno ogy PO Box iOOTeS HSG Unversity of Pri, [Sdnese, FLSZET0 0165. € malt merobingu ed 12003 by the Armerican Pain Society 1526590072003 $30.00 + 0 ok t0.1054jp2003-4 sex differences in experimental and endogenous pain, an examination of the scaling procedures used to evalu- ate sex differences is warranted, Important psychophysical scaling issues have received considerable attention in the area of taste perception. Genetic differences including variation in the ability to perceive strongest imaginable oral sensation have been Teported.'® Interestingly, Bartoshuk et al’ have found sexdifferences, with women having more taste buds and women being more likely to perceive stronger tastes than men. Few studies have examined how participants Use pain scales. An investigation by Manning et al'® found divergence among the types of painful events that represented scale end points for undergraduate stu dents. Inconsistent meanings for the end points of pain scales have implications for the reliability and validity of pain measurement. similarly, wide variation in the pro- «ess of developing a rating was shown by Williams et al™™ through semistructured interviews with pain manage- ment patients. It was also shown that inpatients were covertly relabeling scale points and that the end points selected for the rating scales affected responses. This later finding resembles the resuit of an earlier study by Seymour et al?” in which the maximal end point of worst pain imaginable produced an adequate distribution of responses with less variation in interpretation by dental pain patients than the other possible maximal end points that were examined The objectives of this investigation were to examine the relationship of sex-related stereotypes to common 40 The Journal of Pain, Vol 4, No 1 February), 2003: pp 40-45 ORIGINAL REPORTS/Robinson etal painful events and to examine ditferencesin the types of events that would represent the worst pain sensation imaginable for the typical woman and typical man. At present there are no data indicating what men and women perceive as stereotypical events representing the worst pain imaginable for each sex. Demonstration of sex-related differences in typically experienced painful events and in the use of different painful events for the ‘maximal end point of arating scale may be an important first step in trying to explain some of the differences between men’s and women’s pain reports without re- sorting to explanations of sex (first-order biologic) dif- ferences in pain processing Materials and Methods Participants Participants were 117 undergraduate students re- cruited from a southeastern university psychology sub- ject pool. There were 63 (54%) women and 54 (46%) men inthe sample. The participants’ mean age was 19.20 (SD 1,78) years, and their mean years of education was 13:51 ®D ~ 1.09). The distribution for participants’ race was as follows: 70.5% white, 13.7% black, 8.5% Hispanic, 65% Asian, and 0.9% other, The distribution of race di not differ significantly among the sexes (chi square (4) = 3.02, p~ 558), The mean age for men was 19.76 (SD = 2.27) years, and the mean age for women was 18.71 (SD = 0.98) years, which was statistically significant (Fy) = 10.91, p = .001, »? = .09), The mean years of education for men were 1374 (SD = 1,22) and 13.32 (SD = 93) for women (F, ») = 454, p = .035, n° = 04). Although the sexes differed significanty for both age and education, the effec sizes were rather smal Procedure ‘One hundred seventeen participants anonymously completed a demographic questionnaire, 2 versions of the Situational Pain Questionnaire (SPQ), and answered 2 open-ended questions regarding worst pain sensation imaginable. The University Institutional Review Board approved all procedures, and all participants gave in- formed consent to participate. This study protocol con- formed to the ethical guidelines for the 1975 Declaration of Helsinki. Materials Demographic Questionnaire Participants provided information pertaining to their age, race, sex, work status, and education. SPQ 30-Item Version The SPQ assesses the amount of pain individuals think they would experience in a number of different situa- tions. The questionnaire consists of 15 events that are considered to be relatively painful signals) and 15 non- painful events (blanks). itemsarerated by using scale of 1 not noticeable to 10 worst possible pain. All partic a ants were asked to complete 2 versions (sex version) of the SPQ with the following instructional sets: “Please complete this questionnaire as you think the typical woman would” and “please complete this questionnaire ‘asyou think the typical man would.” Both versions of the {questionnaire were scored by using a computerized scor- ing system, based on a model of nonparametric Sensory Decision Theory,” which provided scores for both dis- crimination (P(A)) and response bias (6), The discrimina- tion score (P(A)) indicates the extent to which individuals were able to differentiate between painful and rela: tively nonpainful situations, The response bias (B) score indicates the degree to which both types of situations ‘were perceived as painful or the willingness to report the painful situations as painful. Examples of painful events include “yau get a tooth drilled without a pain killer, “you fall from a 6-foot ladder and hit the cement floor,” and “you spill some boiling water on your hand.” Exam- ples of nonpainful items include “you get a mosquito bite,” “you get out of breath trying to catch a bus,” and “your teeth are examined by a dentist in a check-up.” Open-Ended Questions ‘Two open-ended questions were asked of each partic ipant, One question asked participants to describe an event they associated with the worst pain sensation imaginable for a typical woman. The second question asked participants to describe an event they associated with the worst pain sensation imaginable for a typical man. Participants could provide multiple responses to both questions. ‘Three judges determined that each of the responses could be adequately placed into 1 of the following 8 categories: giving birth, menstrual, injury illness, dental, surgery, emotional, and specific anatomic site, Of the 336 total responses provided, only 48 (14.3%) were iden- tified as belonging to the iliness, dental, surgery, emo- tional, or specific anatomic site categories. Thus, the in- vestigators chose to reduce the categories to the following: giving birth, menstrual, injury, and other. ‘These categories were subsequently used by 2 additional judges, who were unaware of the initial categorizations, to recategorize responses. Analyses Two 2-way analyses of variance (ANOVAS) were con ducted to examine possible sex differences in dscrim- inability ((4)) and response bias (8) scores for both ver ions of the SPQ. For the responses to the open-ended questions about worst pain sensation imaginable, the inter-rater agree iment was evaluated by determining Cohen's kappa. Kappas were.96 for responses given for a typical woman, 82 for responses given for atypical man, and 92 fora responses. ter these calculations were completed, cat egorization of the items on which the raters disagreed (01 = 18) was reevaluated jointly by both raters to deter- mine each item's final categorization. The frequencies of ‘occurrence af each category for the typical woman and Table 1. Mean and SDs by Sex for Willingness to Report Pain (B) and Ability to Discriminate Between Painful and Nonpainful Events (P(A)) as Measured by the SPQ Sex Differences: Pain Expectations and Anchors SPQ Vessow Mase Fowsie se PA) ® Pa) © Male 082(007) 480¢1.07) 9811006) 5:94(080) Female 080(005) 465(1-19) 0811005) 5.44(1.08) the typical man were determined, and chi-square analy- ses were performed to assess differences between fe- male and male participants. in addition, Fisher's z-test for differences between proportions was used to exam- ine possible differences in the categories used for typical women as compared to the categories used for typical men, Results Descriptives for both P(A) and B are provided in Table 1. A2-way ANOVA was conducted to evaluate sex differ- ences on the discriminability scores (P(A) of both the male and female versions of the SPQ. Sex was a between subjects factor (male vs female), and discriminability scores served as a repeated measures factor (P(A) - male version vs P(A) - female version). The main effect for sex was nonsignificant (F,yy5= 1.72, p=.193, »? = 02), and both the main effect for P(A) and interaction for sex by P(A) were nonsignificant (F, 15 = 0.35, p = 554, »? = .00; Frans = 2.02, p = .158, n* = .02, respectively). These results suggest that men and women were equally able to discriminate between painful and nonpainful events and that there was consistency between men and Women regarding sex-role stereotyped discriminability. In addition, a 2-way ANOVA was conducted to exam- ine sex differences on the response bias scores (8) of both the male and female versions of the SPQ. Subject's sex was a between subjects factor, and sex version (typical ‘man of typical woman) served as a repeated measures factor. The ANOVA yielded a large main effect for sex version (F, 1,5 = 90.24, p = .000, x? = .44). Both the main effect for sex and the sex-by-sex version interaction were nonsignificant (F,,.15 = 3.84, p = .053, 97 = .03; Fy ase = 3.11, p= .081, n? = 03). Consistent with previous reports using a different instrument,"* men and women per- celved the typical woman as more likely to report pain than the typical man. A sex (male vs female) by category (birth vs menstrual vs injury vs other) chi-square test was conducted to eval- uate whether men and women differed in their re- sponses for worst pain sensation imaginable for the typ- ical woman. Before the analyses were performed, all of the responses were first categorized according to their content. The procedures used in grouping the responses are provided in detail in the Methods section. The result Figure 1. Sex comparisons of the events endorsed by male and ‘female respondents as the worst pain sensation imaginable for typical women ‘was nonsignificant (chi-square (3) = 5.29, p = .152), indi cating that men and women provided like responses for ‘the worst pain sensation imaginable for the typical ‘woman. Also, the sex (male vs female) by category (injury vs other) chi-square for worst pain sensation imaginable for the typical man was nonsignificant (chi-square (1) = 1.84, p = .175). Thus, these results show that the men and women in our study labeled the worst pain sensation imaginable in a similar way for the typical man and the ‘typical woman. The endorsements by men and women are shown separately for the typical woman and the typ- ical man in Figs 1 and 2, and the most frequently en- dorsed categories for both men and women are dis- played in Fig 3. Furthermore, Fisher's z-test for proportions was used to determine whether there were any significant differ- fences between men and women in their responses given for the open-ended questions about worst pain sensa- tion imaginable for the typical man as compared to their responses for the typical woman. The results indicated ‘that both men and women provided “birth” and "men- strual” responses significantly more often for the typical ‘woman (59%) than for the typical man (0%) (z = 7, P< (01), whereas they gave an “injury” response signifi cantly more often for the typical man (69.9%) as com- pared to the typical woman (22.5%) (z = 4.9, P<.01).No significant difference (typical woman, 26.6% vs typical Figure 2. sex comparisons of the events endorsed by male and female respondents as the worst pain sensation imaginable for typical men ORIGINAL REPORTS/Robinson etal Zi woe ure 3. Sex comparisons of the 3 most frequently endorsed fategorias by men and women of the worst pain sensation limaginable events for both the typical man and the typical ‘man, 30.1%) was found for the category “other (2 = 1.05, P > 05) Discussion Results from this study support our previous findings"® that men and women have different expectations for pain responding. Robinson et al" found that both men and women perceived women as more willing to report pain, more sensitive to pain, and less likely to endure pain than men. Thus, the findings from our current study demonstrated that sex-related expectations of pain re- sponding extend to commonly experienced, potentially painful events. Furthermore, both men and women ap- pear to have similar perceptions of each sex's expected pain responding, suggesting a gender-role related learn- ing history that is relatively consistent for both sexes. Both men and women in our samples expected that men would report less pain than women to a variety of pain- ful events, although there appear to be no differences in, the ability of both sexes to discriminate between events of graded pain intensity. This pattern of results suggests a social learning difference between sexes consistent with previous findings that men are less willing to report an event as painful."® This is also consistent with findings suggesting that women have a greater number of pain role models" and that men may be reticent to report pain to avoid negative emotional consequences.” The other major finding of this study raises issues with respect to the use of common pain scaling approaches. In general, itis expected that subjects will choose idiosyn- cratic anchors for numeric scales and visual analog scales, (VAS). We rarely know what a given subject's worst pain sensation imaginable is or what types of painful events they have experienced. This variability represents some unknown portion of the error variance and is usually not 2 problem when interpreting statistical analyses. How- ever, the possibilty of systematic differences in anchors between groups does pose a potential problem. Men and women, to a large extent, choose different types of pain events for worst pain sensation imaginable, Both men and women thought injury was the class of events, that men would find most painful. Forwomen, male and 43 female participants overwhelmingly endorsed childbirth and menstrual pain as the worst pain imaginable. Obvi ‘ously, this is a class of events that men can never experi- ence and are therefore unlikely to use as an anchor. Even in women who have not experienced childbirth there very likely to be a large difference in their socialization and expectations regarding childbirth and menstrual re- lated pain when compared to men. We do not know how this socialization shapes experienced pain or one’s ex- pectations for pain. There is some evidence that the ex- perience of childbirth alters pain expectations,® but we do not know how the lore about childbirth pain and vicarious learning affects pain expectations. Most trou bling are the anecdotal and published reports that child- birth pain, in particular is one of the experiences with the highest reported pain intensity." If we consider the possibility that women use a higher intensity pain event as their anchor for worst pain sensation imaginable com pared to men and if they actually use this event as an ‘anchor in scaling pain intensity, then reported sex differ- ences may be influenced by systematic differences in the types of pain events and hence anchors used by subjects, Given an average half a standard deviation difference between male and ferale pain ratings,"® but different maximal anchors, sex differences might be larger than current laboratory experimental pain studies have indi cated ‘The existing literature is mixed with respect to whether subjects are influenced by past pain events when using at least some types of pain scales. Dunbar et al* found that ‘women gave nearly identical mean visual analog scale (VAS) ratings of standard heat stimuli during late preg- nancy, labor, and post partum. If childbirth pain system- lly changes the anchor that women use as the worst ‘pain sensation imaginable and hence the way they use VAS, then these women should have changed their mean ratings of experimental pain during labor or after deliv- ery. In contrast, Hapidou and DeCatanzaro” demon- strated that nulliparous women had lower pain thresh- ‘olds than parous women. Which set of results is more pertinent to the examination of sex differencesin anchor Use is unclear without further study. ‘Another relevant area of research involves the compar- ison of chronie pain patients to normal control subjects. Price and Harkins"? demonstrated no differences in the stimulus response functions of low back pain patients, myofascial pain dysfunction patients, and agelsex matched pain-free volunteers in VAS ratings of thermal stimulation, suggesting that the history of having spe-

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