Gender and pain care: what research shows about dismissal, disparities and diagnostic delay

Many people with persistent pelvic pain describe waiting years for an explanation, and many describe feeling that their symptoms were not taken seriously. Researchers have studied this from several directions: how long diagnosis takes, how patients describe their appointments, whether pain treatment differs by sex or by race and ethnicity, and whether any teaching or care-process change narrows those gaps. The findings are real but uneven. Delay in endometriosis diagnosis is documented in many countries, with averages from about 4 to 10 years depending on the study ^{[1] [2] [3]}. Some pain-treatment differences appear consistently, especially by race and ethnicity in US emergency departments, while differences by sex are less consistent ^{[4] [5]}. Most studies are observational, so they describe patterns and cannot show why a pattern exists. This article reports what the studies measured, in whom, and where their limits lie.

Why this question is hard to study

Four different things are often grouped under the word "dismissal." One is delay, measured as time from first symptoms to a recorded diagnosis. A second is a difference in treatment, measured as who receives a medication, test or referral. A third is a judgment, such as how much pain an observer believes another person is in. A fourth is an experience, which is how a patient describes being listened to. Each is measured differently, and a finding in one does not carry over to another.

Delay can arise at several points. One Dutch study divided it into patient delay, general practitioner delay and gynecologist delay ^[15]. A person may wait before seeking care, a first-line clinician may consider other explanations first, and a referral may take time. A systematic review of studies published since 2018 found 17 observational studies reporting times to diagnosis between 0.3 and 12 years. The figure depended on how time to diagnosis was defined (overall, primary or clinical), on location and on the population studied ^[16]. A single average such as "7 years" describes one definition in one group.

Most delay studies enroll people who eventually received a diagnosis, often at a specialty clinic or by surgery. People not yet diagnosed are absent from the numbers, and one Austrian and German study noted possible selection bias because it included only surgically treated patients ^[2].

Finally, sex and gender are different ideas. Sex differences in pain can reflect biology, and gender differences can reflect expectations about how people express or cope with pain. Reviews of this literature discuss both ^[17], and describe a strong evidence base for sex differences in laboratory pain studies, with mixed findings on responses to treatment ^{[18] [19]}. A difference in how women and men are treated may therefore reflect clinical need, patient preference, biology, bias or a mixture, and most study designs cannot tell these apart.

How long endometriosis diagnosis takes

Several studies have measured the interval between symptom onset and diagnosis. They differ in country, health system, sampling and method, and the figures should be read as separate snapshots.

An international study enrolled 1,418 premenopausal women aged 18 to 45 at 16 centers in 10 countries. All were having laparoscopy to investigate symptoms or for sterilization, and none had a prior surgical diagnosis of endometriosis. The delay between symptom onset and surgical diagnosis was 6.7 years, arising mainly in primary care. It was longer in centers where care was mostly state-funded (8.3 years) than elsewhere (5.5 years). Delay was positively associated with the number of pelvic symptoms and with a higher body mass index ^[1].

A cross-sectional questionnaire study in tertiary centers in Austria and Germany included 171 patients with histologically confirmed endometriosis. The median interval from first symptoms to diagnosis was 10.4 years, and 74 percent had received at least one false diagnosis. Misdiagnosis, a mother viewing menstruation as a negative event, and a patient's own normalization of painful periods were each associated with longer delay. The study found no association between delay and either the type of endometriosis or oral contraceptive use ^[2].

In a retrospective Brazilian cohort of 200 women with surgically confirmed endometriosis, interviewed at one university clinic, the median time from symptom onset to diagnosis was 7.0 years. The median was 12.1 years when symptoms began at age 19 or younger and 3.3 years when they began at 30 or older. It was 4.0 years for women whose main complaint was infertility and 7.4 years for those whose main complaint was pelvic pain ^[6].

A Dutch study of 139 patients at one hospital, using telephone interviews, reported a median of 89 months (7.4 years). The authors divided this into a median of 7 months of patient delay, 35 months of general practitioner delay and 5 months of gynecologist delay. Longer delay was associated with young age at onset, use of oral contraceptives or analgesics prescribed by the general practitioner, alternative diagnoses considered by the general practitioner, and cyclic symptoms. Subfertility as a presenting symptom was associated with faster diagnosis ^[15].

A review of records from four general practices in south-east England found a median of 9.0 years from first presentation to diagnosis. One third of women had consulted their general practitioner six or more times, and 39 percent had been referred to a gynecologist two or more times before a positive diagnosis ^[20].

Not every recent estimate is as long. A US online survey of 638 respondents aged 18 to 49 who reported a physician's diagnosis or suspicion of endometriosis found a mean of 4.4 years from symptom onset to diagnosis. Time from first consultation to diagnosis was shorter for respondents aged 40 to 49 than for those under 18, and for diagnoses made by obstetrician-gynecologists than by other clinicians (21.5 versus 40.3 months). The survey relied on self-report, and the authors were affiliated with a pharmaceutical company ^[3].

Taken together, these studies support a picture of long delay, shorter in some settings and longer in younger patients and those with pain as the main complaint. Differences in definitions can produce very different numbers for similar experiences.

What studies associate with delay

The studies above, and others, have looked for factors that go with longer delay. Three points recur.

The first is how the clinical pathway works. In the Dutch study, delay concentrated at the general practitioner stage and was longer when other diagnoses were considered or when hormonal medicines or analgesics were prescribed first ^[15]. The English record review found repeated consultations and negative investigations before diagnosis ^[20]. A qualitative study of women attending a pelvic pain clinic reported that delays occurred at patient and medical levels: women and family doctors normalized symptoms, hormones suppressed symptoms, and nondiscriminatory investigations were relied on ^[21]. None of these studies shows that a given treatment choice was wrong. They describe which sequences were associated with a longer wait.

The second is patient characteristics. Younger age at onset and pelvic pain as the main complaint were associated with longer delay in two studies ^{[6] [15]}. The 2025 systematic review reported that delay was still present and concluded it was primarily driven by physicians, while calling for standardized definitions, more awareness and targeted diagnostic interventions ^[16]. That is the review authors' conclusion from observational studies they rated as of poor to good quality.

A third point concerns the diagnostic process itself. A European guideline on endometriosis describes a diagnostic process that challenges laparoscopy and histology as gold standard diagnostic tests ^[22]. Delay studies built on surgically confirmed samples measure time to a surgical diagnosis, so their figures reflect that pathway ^{[2] [6]}. The sources reviewed here include no trial showing how changing guidance alters real-world delay.

Chronic pelvic pain and what women report about care

Chronic pelvic pain is a broader category than endometriosis. The American College of Obstetricians and Gynecologists describes it as a common, burdensome and costly condition that disproportionately affects women. Its practice bulletin addresses pain that is not fully explained by identifiable pathology of the gynecologic, urologic or gastrointestinal systems, and states that the complexity of this care can be addressed through longer visit time and multidisciplinary teams ^[23]. That is a statement about the structure of care, and it appears in a guideline written for clinicians.

Patient-reported experience has been studied mostly with qualitative methods, in which researchers interview a small number of people or run focus groups and look for themes. These methods show how an experience feels and what people say mattered. They are not designed to show how common an experience is.

A systematic review and synthesis of qualitative research on endometriosis combined 18 papers reporting 11 studies. Participant numbers in the individual studies ranged from 15 to 61 women, all recruited from support groups and specialized clinics, and all studies were in high-income, Anglophone countries. The review identified four themes (life, symptoms, medical experience and self) and noted little or no inclusion of adolescents, postmenopausal women, women from low socioeconomic backgrounds, women who do not identify as white, and non-heterosexual women ^[7].

A focus group study conducted at a hospital in Melbourne, Australia, reported the experiences of 61 women with endometriosis and described struggle, loss and a "medical merry-go-round." The authors reported that the worst experience women described was the encounter with health professionals and the ways their symptoms were trivialized and dismissed ^[8]. A Swedish interview study of nine women with laparoscopy-confirmed endometriosis found two contrasting themes, being treated with ignorance and being acknowledged. The authors described the experience of care as "double-edged" because the same women described both destructive and constructive encounters ^[24]. A 2026 interview study of 50 people with surgically diagnosed endometriosis in South Australia reported personal barriers, including self-normalization of symptoms and stigma around menstrual health, and systemic barriers, including symptom dismissal and insufficient education about endometriosis within healthcare ^[25].

In an interview study of 32 women attending a pelvic pain clinic in south-east England, 28 of whom were later diagnosed with endometriosis, participants described what a diagnosis gave them: language to discuss their condition, possible ways to manage symptoms, reassurance that symptoms were not caused by cancer, access to social support, and legitimacy for absences from work and social obligations ^[21].

Beyond endometriosis, a qualitative study at a US ambulatory endometriosis center ran focus groups with 22 women aged 18 to 55 who had chronic pelvic pain, grouped by whether they screened positive for a history of sexual trauma. Participants in both groups reported delay in diagnosis and repeated dismissals, which they described as clinicians not listening, too little time in appointments, and what they saw as redundant testing ^[9]. A reanalysis of focus groups with 57 women with interstitial cystitis or bladder pain syndrome reported provider disbelief and pain dismissal, and strategies such as rotating specialists, "testing" physicians and self-advocacy ^[26]. A 2026 narrative review of 14 qualitative studies of women with chronic pelvic pain found reports of pain being normalized and dismissed, and a wish for validation even when no definite physical cause was found. It found no study that examined the specific words clinicians use ^[27].

Several cautions apply to this body of work. Participants were usually recruited through clinics or support groups, so they may differ from people who never joined either. Accounts are retrospective, from people who already had a diagnosis. Clinicians were not interviewed in the studies described here, so the other side of each appointment is missing. The findings are best read as consistent descriptions of how many patients in these samples experienced care, and not as measurements of how clinicians behave.

Do women and men receive different pain treatment?

The most cited quantitative study of sex differences in emergency analgesia followed 981 consecutive adults with acute, nontraumatic abdominal pain, 65 percent of them female, at one urban emergency department in the United States between 2004 and 2005. Men and women had similar mean pain scores. Women were less likely to receive any analgesia (60 percent versus 67 percent) and less likely to receive opiates (45 percent versus 56 percent). After controlling for age, race, triage class and pain score, women remained 13 to 25 percent less likely to receive opioid analgesia, and women waited longer (median 65 versus 49 minutes). There was no sex difference in non-opioid analgesia. The authors suggested gender bias as a possible explanation and suggested that standardized protocols might reduce the gap ^[10]. The study was observational and from a single site, so it cannot show why the difference occurred.

A multicenter observational study of 842 patients with moderate to severe pain at 16 US and three Canadian hospitals reached a different picture. Overall analgesic administration did not differ significantly between women and men (63 percent versus 57 percent), and women with severe pain were more likely to receive analgesics. The authors reported that provider gender was associated with decisions and that pain relief did not differ by gender ^[28].

A 2025 mixed-method systematic review of factors influencing emergency department pain management included 109 studies, with 30 in a meta-analysis of race, age and sex. It found no evidence of a significant difference between the sexes in the likelihood of receiving analgesics ^[5]. That review also noted that the lack of standardized factors and outcome measures limited how firmly associations could be identified.

These three studies illustrate a real disagreement in the literature. One possible reading is that sex differences in emergency analgesia vary by setting, condition, era and method, so that a difference seen in one hospital for one complaint may not generalize. Another is that pooling across many pain conditions can hide differences in particular ones. The studies cited here do not settle which is right. They also concern acute pain in emergency departments, and none of them examines chronic pelvic pain in outpatient care.

Experiments on how pain is judged

Experimental studies isolate the effect of patient characteristics by showing the same clinical information with different patient demographics.

In two experiments with lay participants (50 and 200 people), observers watched videos of patients with chronic shoulder pain and estimated pain intensity. Observers underestimated female patients' pain compared with male patients, after controlling for the patients' self-reported pain and facial expressiveness. The average effect was 2.45 points on a 0 to 100 scale. Observers' beliefs about whether women or men are more willing to express pain predicted the bias, and observers judged women as more likely to benefit from psychotherapy and men from pain medicine ^[11]. The effect was small in size, the observers were lay volunteers, and the study used short clips.

A study of pain clinicians and medical students had judges view a video of a patient in pain with a brief history. Women, especially those rated as low in trustworthiness, were estimated to have less pain and to be more likely to exaggerate it. Men were more likely to be recommended analgesics, and women psychological treatment. The study also found that clinicians' pain estimates were higher than students' and that clinicians showed less skepticism, and the authors noted that effects of depression history were inconsistent and hard to interpret ^[29].

Not all experiments point the same way. An online study of 193 nurses and physicians using virtual patients found that virtual male patients and virtual African American patients were rated as having greater pain and were more likely to be offered opioids than their counterparts, with the sex difference larger among nurses than physicians ^[30]. A cross-national study of 75 American and 104 Jordanian undergraduate students found the opposite direction for sex: both groups rated pain higher in virtual females and in older virtual patients ^[31]. These studies used virtual patients and students or small professional samples, so they reveal decision tendencies in a controlled setting, and they cannot be read as a count of what happens in clinics.

Biology complicates the picture

Reviews of experimental and clinical studies describe that most people with chronic pain are women, and that sex differences in laboratory pain sensitivity are well documented, with explanations ranging from hormones and genes to socialization and expectations ^[18]. One review also found that evidence about sex differences in responses to drug and non-drug treatments is inconsistent ^[19]. This means a difference in how women and men are treated can partly reflect real differences in pain or in treatment response. It also means that biological difference is not, on its own, an explanation for a gap in how seriously reports of pain are taken. The research does not allow a simple statement in either direction.

Race and ethnicity in pain treatment

Research on racial and ethnic differences in pain treatment is larger and more consistent than research on sex differences, especially for US emergency departments. Most of it concerns acute pain and conditions other than gynecologic ones, which limits how directly it applies to pelvic pain.

Meta-analyses and national-data analyses give broader estimates. A meta-analysis of US studies from 1989 to 2011 found that Black and African American patients experienced the largest number and magnitude of analgesic disparities. For opioid prescription in non-traumatic and non-surgical pain, odds ratios were 0.66 for Black patients and 0.70 for Hispanic patients, relative to White patients, and the gap did not appear to be closing over time ^[32]. An analysis of national emergency department survey data from 1993 to 2005 found that White patients with pain-related visits were more likely to receive an opioid (31 percent) than Black (23 percent) or Hispanic (24 percent) patients, with differences persisting after adjustment for pain severity (adjusted odds ratio 0.66 for Black patients) ^[33]. A 2019 meta-analysis of 14 studies found Black patients less likely than White patients to receive analgesia for acute pain (odds ratio 0.60, 95 percent confidence interval 0.43 to 0.83), while the estimate for Hispanic patients (0.75, 0.52 to 1.09) had an interval that included no difference ^[4]. The 2025 systematic review found African American patients less likely to receive analgesics (odds ratio 0.80) and opioids (0.62), and Hispanic patients less likely to receive opioids (0.83) ^[5].

The pattern is not uniform across conditions. A study of national data from 2007 to 2011 compared conditions without objective markers of pain (toothache, back pain, abdominal pain) with conditions where pain is expected (fractures, kidney stones). Non-Hispanic Black patients were less likely to receive an opioid prescription at discharge for back pain and abdominal pain, with adjusted odds ratios from 0.56 to 0.67, but not for toothache, fractures or kidney stones ^[34]. In children with appendicitis, an analysis of national survey data from 2003 to 2010 found that Black children with severe pain were less likely to receive opioids than White children, though the confidence intervals were wide and in the full model there was no overall racial difference in any analgesia ^[35].

Most of these studies are observational and use administrative or chart data, so they adjust for what was recorded and cannot adjust for what was not, such as clinician judgment in the room, patient preferences or concerns about opioid misuse. They show that a difference exists in recorded prescribing. They do not show the reasons.

An experimental study offers one proposed mechanism. White laypeople, and White medical students and residents, were asked to rate pain and make treatment recommendations for hypothetical Black and White patients. About half of the medical students and residents endorsed at least some false beliefs about biological differences between Black and White people, such as differences in skin thickness. Participants who endorsed more of these beliefs rated a Black patient's pain as lower and made less accurate treatment recommendations. Participants who did not endorse them showed no bias in treatment recommendations ^[12]. This was a vignette study, and its participants were not representative of all clinicians.

A systematic review of implicit bias in healthcare professionals identified 42 articles. Thirty-five of them found evidence of implicit bias, and all studies that examined correlations found a positive relationship between level of implicit bias and lower quality of care. The authors described that evidence as correlational and called for more research in real care settings, because many studies used vignettes ^[36].

Race and ethnicity in endometriosis diagnosis and surgery

Fewer studies address race and ethnicity within endometriosis itself. A systematic review and meta-analysis of 20 studies found that, compared with White women, Black women were less likely to be diagnosed with endometriosis (odds ratio 0.49, 95 percent confidence interval 0.29 to 0.83) and Asian women were more likely to be diagnosed (odds ratio 1.63, 1.03 to 2.58). For Hispanic women the estimate was 0.46 with a wide interval (0.14 to 1.50). There was substantial heterogeneity across studies. The authors concluded that diagnosed prevalence appears to be influenced by race and ethnicity and that little literature exists on symptoms, treatment access, preferences and response ^[37]. A lower diagnosed prevalence could reflect true differences in disease, differences in access to diagnostic care, differences in how symptoms are interpreted, or a combination. The review cannot separate these.

A US cohort study used surgical quality data from 11,936 patients undergoing endometriosis surgery between 2010 and 2018 (65 percent White, 7.3 percent Black or African American, 8.2 percent Hispanic). After adjustment, Hispanic, Black, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native patients had higher odds of surgical complications. Hysterectomies were more likely to be performed by open surgery in several groups, and oophorectomy was more likely among Hispanic and Black women, especially at younger ages ^[38]. The study compared recorded procedures, surgical routes and 30-day complications. It was not designed to examine why a given operation was chosen or offered, and it says nothing about people who did not reach surgery.

A retrospective cohort at one academic center in the midwestern United States examined 4,480 adolescents aged 10 to 21 seen by a gynecologic subspecialist for dysmenorrhea or chronic pelvic pain. Only 54 had laparoscopy, 47 scheduled and 7 emergent. Black patients were less likely than White patients to receive any laparoscopy (odds ratio 0.20, 95 percent confidence interval 0.03 to 0.69), and Asian patients were also less likely. The confidence intervals are very wide because the number of operations was small ^[39]. Laparoscopy rates do not measure whether surgery was clinically appropriate, and the study does not establish how common the difference is elsewhere.

What explanations have been proposed

Authors offer several overlapping explanations. None has been shown to account for the differences fully.

Normalization of symptoms is one of the most consistent themes in delay and qualitative studies ^{[2] [21] [25]}. Painful periods are common, and both patients and clinicians may regard them as expected. Normalization is not necessarily dismissal, since it can arise from limited education, family and community attitudes, and the lack of agreed definitions of "normal" pain. Interview data from Australia also suggest that women may conceal menstrual problems because of social norms ^{[40] [41]}.

Stereotypes and bias are supported by experiments in which observers rate pain differently by patient sex and race, with some link to stereotypes or false beliefs ^{[11] [12]}. A systematic review describes evidence of implicit bias among healthcare professionals, mostly correlational ^[36]. Whether such tendencies produce measurable differences in a given appointment depends on context.

Health-system factors include funding and time. In the international study, delay was longer in centers where care was mostly state-funded ^[1]. The ACOG bulletin notes that chronic pelvic pain care is complex and that longer visit time may help ^[23]. Participants in the US focus groups described too little time and repeated testing as part of their sense of being dismissed ^[9]. These are system features that the studies cannot attribute to any individual clinician.

In short, the literature supports describing delay, differences in recorded treatment and patient reports of dismissal as real observations. It supports bias as one proposed contributor among several, and it does not support attributing any single difference to intent or to a specific clinician.

What interventions have been studied

Evidence on what reduces these gaps is thinner than evidence that the gaps exist.

Education about bias in pain care has been tested in small studies. A randomized study of 100 medical students compared a brief educational intervention (theory on implicit bias in pain assessment, empirical evidence and reflection on clinical scenarios) with a control group that received the lesson after the study. Both groups completed a pain recognition task twice, and the authors reported improvements in response times, pain intensity ratings and treatment recommendations in the education group across stimulus categories, irrespective of race or facial trustworthiness. Repeated exposure to the task also changed responses in both groups ^[13]. The outcome was a laboratory task shortly after the lesson, and the study did not follow students into practice.

A 90-minute online course on racial disparities in pain management was tested in 605 medical students with a pre-post design. Agreement with 19 of 20 items about the existence of disparities and implicit bias rose after the course ^[42]. The study measured attitudes and knowledge on a questionnaire, had no control group, and did not measure patient care.

A broader caution comes from a meta-analysis of 492 studies (87,418 participants) of procedures that change implicit measures. It found that implicit measures can be changed, but effects are often relatively weak, mostly short-term, and produced trivial changes in behavior. Changes in implicit measures did not mediate changes in explicit measures or behavior ^[14]. The analysis was not specific to health care.

Standardized protocols for analgesia have been proposed as a way to narrow gaps. The Chen study of women with abdominal pain suggested that standardized protocols may ameliorate the discrepancy, but that study did not test a protocol ^[10]. The sources reviewed here include no trial showing that a protocol reduced a documented gender or racial gap.

For endometriosis delay specifically, authors have proposed teaching programs for doctors, public awareness campaigns, and tools to prioritize patients for investigation ^{[2] [41] [43]}. The symptom-based models were built among 1,396 women already scheduled for laparoscopy. Prediction of endometriosis of any stage was relatively poor (area under the curve 68.3), while stage III and IV disease was predicted with good accuracy (84.9), and the authors invited validation in other populations ^[43]. The reviewed sources contain no trial showing that an awareness campaign, an education program or a prediction model shortened delay in practice.

What this does not tell you

These studies describe groups. They do not describe any one person's care, and they cannot say whether a particular appointment, delay or prescribing decision reflected bias, clinical judgment, limited access, system constraints or something else.

Averages for time to diagnosis depend on definitions and on who was enrolled. Most delay studies include only people who eventually had a diagnosis, often at specialist centers, and many rely on memory.

Emergency department analgesia studies concern mostly acute pain and do not apply directly to chronic pelvic pain or outpatient care. Qualitative studies show what some participants described and do not measure how common those experiences are.

Observational studies of race, ethnicity and sex adjust for recorded variables and not for everything that matters. A statistical association is not proof of intent, and it is not proof of absence of bias.

Experiments with vignettes, video clips and virtual patients test hypothetical decisions by volunteers, students and some clinicians. They do not predict behavior in real encounters.

Nothing here is advice on diagnosis, testing or treatment, and nothing here indicates what any reader has. Symptoms such as persistent pelvic pain have many possible causes, and a person with concerns about their own symptoms or care would need to discuss them with a clinician who can assess their situation.

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