Addressing Implicit Bias in Women’s Health

When Jenna Benyounes, DNP, CNM, WHNP-BC, meets with a new patient at her practice, she always asks if they have seen any other providers about their health issue. When patients sought help for conditions related to pelvic pain, she noticed a trend. 

“On average most of our patients have seen eight other providers before they got to me,” Benyounes said. “A lot of patients end up finding me online or in talking through friends. It’s not always a referral from another provider.” 

“Just because it is common does not mean that it is normal.”

— Jenna Benyounes, DNP, CNM, WHNP-BC

Benyounes, who is a faculty member at the Georgetown University School of Nursing & Health Studies, explained that women’s pain is often dismissed at first. A woman with severe cramps and pelvic discomfort may be told that it is normal to experience pain during menstruation, when in reality the patient has undiagnosed endometriosis. 

“Just because it is common does not mean that it is normal,” Benyounes said. 

Research has shown that women experience a higher prevalence of chronic pain and high-impact chronic pain. However, because of medical bias, women’s chronic pain conditions sometimes go untreated, which contributes to health disparities. 

While many providers like Benyounes are working to address the issue of gender bias in health care, some patients are learning how to advocate for themselves.

What Is Medical Bias?

The term “medical bias” is used to refer to situations where a health care provider’s implicit bias causes them to unconsciously vary in the quality of care given to a patient based on factors such as race and gender. Medical bias contributes to health disparities among marginalized social groups.  

While the prevalence of implicit bias in health care can be a result of a provider’s personal attitudes and beliefs, it can also be affected by larger systems and society as a whole. 

For example, Benyounes noted that although she addresses issues related to race and gender bias in courses she teaches, these topics are not always standard practice in higher education institutions.  

“It is not required curriculum for medical schools; it is not required curriculum for OB/GYNs, midwives, or nurse practitioners,” Benyounes said.  

To better address inequity in women’s health, it is important for health care providers and patients alike to understand the many ways bias affects quality of care.  

Understanding Bias: Glossary of Terms

Gender bias: unequal treatment based on a person’s gender

Health disparity: preventable difference in resources and opportunities to maintain optimal health that is experienced by marginalized populations

Health equity: when all people with the ability to achieve optimal health

Implicit bias: act of applying attitudes toward people or associating stereotypes with them without conscious knowledge of doing so

Intersectionality: connection between social groupings, such as race and gender, as these factors apply to an individual or group facing discrimination

Marginalized population: groups of people that experience exclusion and discrimination on social, political, and economic levels 

Medical bias: occurrence of implicit bias in the health care field

Racial bias: unequal treatment based on a person’s race


How Women Are Affected by Medical Bias

A 2018 Centers for Disease Control and Prevention (CDC) study on the prevalence of chronic pain indicates that approximately 50 million Americans suffer from chronic pain daily or almost daily. The data showed a higher prevalence of chronic pain reported among women compared to men. 

A 2020 HealthyWomen report on chronic pain in women (PDF, 4.1 MB) shows that several conditions linked to chronic pain are experienced at a higher rate by women:  

  • chronic fatigue syndrome
  • fibromyalgia
  • temporomandibular disorders
  • osteoarthritis
  • rheumatoid arthritis
  • migraine

Women are also at risk for health conditions unique to reproductive health, such as endometriosis, that can result in chronic pelvic pain.  

In addition to experiencing pain differently than men, women may also have a different experience during health care visits. 

The International Association for the Study of Pain (IASP) “Real Women, Real Pain” campaign (PDF, 2.4 MB) attributes this to the lack of understanding among providers of how men and women differ in the way they feel and perceive pain. 

When women ask about how to diagnose and manage their pain, Benyounes said they are more likely to be dismissed and have their symptoms attributed to mental or emotional issues. 

“[Women] are finally willing to bring up their pain, and they feel like they’re just being placated,” Benyounes said. “We know that there is such a systemic impact, mentally and economically, when pain that people experience goes unaddressed.” 

Women of color may experience even worse outcomes as a result of the combination of gender and racial bias. Many misconceptions about how an individual’s race affects their tolerance for pain stem from the early days of health care and are unconsciously applied by today’s providers. 

In a 2019 study on bias in pain management, researchers found that white health care professionals were less likely to perceive pain on the faces of Black patients as compared to white patients.

“If you have a provider who looks like you, you’re typically going to get better care because there’s going to be less implicit bias, and hopefully, somebody who understands what you’ve been going through.”

— Jenna Benyounes, DNP, CNM, WHNP-BC

Additionally, authors of a CDC paper issuing guidance on prescribing opioids for chronic pain noted that members of racial and ethnic minority groups could be at risk for inadequate pain treatment.

When the intersectionality of race and gender is applied to the issue of implicit bias in health care, women of color may experience sexism and racism in a way that white women and men of color do not, creating unique challenges when seeking treatment for chronic pain. 

Benyounes referenced treatment options provided to women for fibroids, which can cause pain, discomfort, and heavy bleeding. Research has shown Black women are almost four times more likely than white women to have a hysterectomy to treat fibroids. Benyounes explained that white patients are more frequently offered prescriptions and minor procedures before resorting to surgery, while Black women are more often offered a hysterectomy as their first option for treatment. 

“The medicine that we practice today is rooted in patriarchy,” Benyounes said. “But it also has systemic racism in pieces of it.” 

How to Address Gender Bias in Pain Management 

Benyounes noted that there are some systemic changes currently in motion to address medical bias, including efforts to increase diversity within the health care field. 

“If you have a provider who looks like you, you’re typically going to get better care because there’s going to be less implicit bias, and hopefully, somebody who understands what you’ve been going through,” Benyounes said. 

While health care professionals are ultimately responsible for providing the same standard of care to all patients, women can also take steps to advocate for themselves when they feel their concerns are overlooked. 

How Can Patients Advocate for Themselves?

Keep a journal. Track your symptoms and factors that may or may not be associated with your experience of those symptoms (e.g., what triggers the pain, what helps manage the pain). This can provide useful information for your provider. 

Ask for copies. Keep lab results, imaging, visit summaries, and other information related to the diagnosis and treatment process of a chronic pain condition, which can be helpful to bring to a new provider.

Ask for a referral. If you feel your provider is not serving your needs, you can ask for a referral to a specialist who may be more equipped to address a specific health issue.   

Find a new provider. If the steps you’ve taken to advocate for yourself haven’t helped in working with your existing provider, it is OK to seek care from a new provider. 

Questions to Ask Your Provider About Chronic Pain 

Benyounes said it is also important to be engaged and ask questions for more productive visits with a provider. Examples of how to frame questions include the following:

  • Can you help me understand where my chronic pain is coming from? 
  • Can you explain how this treatment option is going to address my chronic pain? 
  • What would be the next step if this treatment does not work?
  • Are there alternative treatment options?
  • Can you describe how this test works and what information it will look for? 
  • Can you help me understand why additional testing would not be useful?

Further Reading on Women’s Health From Georgetown University School of Nursing & Health Studies

Please note that this article is for informational purposes only. Individuals should consult their health care provider before following any of the information provided.

Citation for this content: Nursing@Georgetown, the online Women’s Health Nurse Practitioner program from the Georgetown University School of Nursing & Health Studies