Gender differences in pain: Do emotions play a role?

doi:10.1016/S1550-8579(05)80051-8

Gender Medicine

Volume 2, Issue 4, December 2005, Pages 208-226

https://doi.org/10.1016/S1550-8579(05)80051-8 Get rights and content

Abstract

Background:

Research suggests that the influence of gender on the processing and experience of pain is a result of several mechanisms. One mediating variable is emotion, which may modulate pain through an interaction of valence (pleasant-unpleasant) and arousal (calm-excited).

Objective:

This review examines whether gender differences in the experience and processing of emotion contribute to differences in the modulation and perception of pain.

Methods:

An English-language search of MEDLINE and PsycINFO was conducted from 1887 to May 2005. Additional literature was obtained from reference lists of articles retained in the initial search.

Results:

Emotion appears to influence pain through a valence-by-arousal interaction. Specifically, negatively valenced emotions with low to moderate arousal (eg, anxiety) enhance pain, whereas negatively valenced emotions with high arousal (eg, fear) reduce pain. In contrast, positively valenced emotions always reduce pain, as long as minimal arousal is achieved. Some evidence suggests that women are more sensitive than men to threat-related stimuli and thus experience more negative affect than men. This would generally lead to enhanced pain perception in women. It is also possible that women are more likely than men to experience negative affect with high arousal (intense fear) and thus pain inhibition. However, the relatively lower base rate of intense negative emotions is not likely to contribute much to gender differences in pain. Evidence also suggests that men may be more sensitive to positive events, particularly sexual/erotic stimuli, which may lead to more positive emotion-induced pain reduction in men, relative to women.

Conclusions:

This review suggests that gender differences in the experience of pain may arisefrom differences in the experience and processing of emotion that, in turn, differentially alter pain processing. Specifically, the system associated with negative affect may be more attuned to threatening stimuli in women, and the system associated with positive affect may be more attuned to pleasurable stimuli in men. However, there is a paucity of research directly addressing this issue; much of the research on this topic has failed to test a comprehensive model of emotion, failed to use adequate manipulation checks, or failed to use within-subject experimental designs that control for intra- and interindividual differences. Therefore, it is concluded that additional research is warranted.

References (141)

UnruhA.M.
Gender variations in clinical pain experience
Pain
(1996)
FillingimR.B. et al.
Gender differences in the responses to noxious stimuli
Pain Forum
(1995)
SkljarevskiV. et al.
The nociceptive flexion reflex in humans—review article
Pain
(2002)
FillingimR.B. et al.
Sex-related hormonal influences on pain and analgesic responses
Neurosci Biobehav Rev
(2000)
SmithS.S.
Female sex steroid hormones: From receptors to networks to performance—actions on the sensorimotor system
Prog Neurobiol
(1994)
RollmanG.B.
Gender differences in pain. Role of anxiety
Pain Forum
(1995)
DavidsonR.J. et al.
The functional neuroanatomy of emotion and affective style
Trends Cogn Sci
(1999)
RobbinsT.W. et al.
Neurobehavioural mechanisms of reward and motivation
Curr Opin Neurobiol
(1996)
SchultzW.
Dopamine neurons and their role in reward mechanisms
Curr Opin Neurobiol
(1997)
KuzminA.V. et al.
Naloxone inhibits the reinforcing and motivational aspects of cocaine addiction in mice
Life Sci
(1997)

NelsonE.E. et al.

Brain substrates of infant-mother attachment: Contributions of opioids, oxytocin, and norepinephrine

Neurosci Biobehav Rev

(1998)

van FurthW.R. et al.

Sexual motivation: Involvement of endogenous opioids in the ventral tegmental area

Brain Res

(1996)

CalejesanA.A. et al.

Descending facilitatory modulation of a behavioral nociceptive response by stimulation in the adult rat anterior cingulate cortex

Eur J Pain

(2000)

RainvilleP.

Brain mechanisms of pain affect and pain modulation

Curr Opin Neurobiol

(2002)

HelmstetterF.J. et al.

Lesions of the amygdala block conditional hypoalgesia on the tail flick test

Brain Res

(1993)

FendtM. et al.

Lesions of the central gray block the sensitization of the acoustic startle response in rats

Brain Res

(1994)

de WiedM. et al.

Affective pictures processing, attention, and pain tolerance

Pain

(2001)

AkinsT. et al.

Visual and verbal models of information processing and cognitively-based coping strategies: An extension and replication

Behav Res Ther

(1983)

BruehlS. et al.

Two brief interventions for acute pain

Pain

(1993)

WeisenbergM. et al.

The influence of film-induced mood on pain perception

Pain

(1998)

WeisenbergM. et al.

Humor as a cognitive technique for increasing pain tolerance

Pain

(1995)

ZelmanD.C. et al.

The effects of induced mood on laboratory pain

Pain

(1991)

WhippleB. et al.

Elevation of pain threshold by vaginal stimulation in women

Pain

(1985)

Martinez-GomezM. et al.

Analgesia produced by vaginal self-stimulation in women is independent of heart rate acceleration

Physiol Behav

(1988)

BobeyM.J. et al.

Psychological factors affecting pain tolerance

J Psychosom Res

(1970)

CornwallA. et al.

The effect of experimentally induced anxiety on the experience of pressure pain

Pain

(1988)

RhudyJ.L. et al.

Fear and anxiety: Divergent effects on human pain thresholds

Pain

(2000)

von GraffenriedB. et al.

The influence of anxiety and pain sensitivity on experimental pain in man

Pain

(1978)

WeisenbergM. et al.

Relevant and irrelevant anxiety in the reaction to pain

Pain

(1984)

DellemijnP.L.I. et al.

Do benzodiazepines have a role in chronic pain management?

Pain

(1994)

DaltonJ.A. et al.

Fear, alexithymia, and cancer pain

Pain

(1989)

RhudyJ.L. et al.

Fear-induced hypoalgesia in humans: Effects on low intensity thermal stimulation and finger temperature

J Pain

(2004)

RhudyJ.L. et al.

Negative affect: Effects on an evaluative measure of human pain

Pain

(2003)

WillerJ.C. et al.

Electrophysiological evidence for a release of endogenous opiates in stress-induced ‘analgesia’ in man

Brain Res

(1980)

WillerJ.C.

Anticipation of pain-produced stress: Electrophysiological study in man

Physiol Behav

(1980)

WillerJ.C. et al.

Diazepam reduces stress-induced analgesia in humans

Brain Res

(1986)

RileyJ.L. et al.

Sex differences in the perception of noxious experimental stimuli: A meta-analysis

Pain

(1998)

BerkleyK.J.

Sex differences in pain

Behav Brain Sci

(1997)

BerkleyK.J. et al.

Afferent fibers supplying the uterus in the rat

J Neurophysiol

(1988)

RobbinsA. et al.

Estrous cycle variation of afferent fibers supplying reproductive organs in the female rat

Brain Res

(1992)

DuvalP. et al.

Substance P and neurokinin A variations throughout the rat estrous cycle; comparison with ovariectomized and male rats: I. Plasma, hypothalamus, anterior and posterior pituitary

J Neurosci Res

(1996)

DeKockM. et al.

Postoperative P.C.A. in abdominal surgery. Analysis of 200 consecutive patients

Acta Anasthesiol Belg

(1991)

SartonE. et al.

Sex differences in morphine analgesia: An experimental study in healthy volunteers

Anesthesiology

(2000)

ZubietaJ.K. et al.

Gender and age influences on human brain mu-opioid receptor binding measured by PET

Am J Psychiatry

(1999)

ZubietaJ.K. et al.

Mu-opioid receptor-mediated antinociceptive responses differ in men and women

J Neurosci

(2002)

SmithY.R. et al.

Brain opioid receptor measurements by positron emission tomography in normal cycling women: Relationship to luteinizing hormone pulsatility andgonadal steroid hormones

J Clin Endocrinol Metab

(1998)

FieldsH.L. et al.

Central nervous system mechanisms of pain modulation

LeDouxJ.E.

Emotion circuits in the brain

Anna Rev Neurosci

(2000)

BerglundL.A. et al.

Desensitization of brain opiate receptor mechanisms by gonadal steroid treatments that stimulate luteinizing hormone secretion

Endocrinology

(1988)

BerglundL.A. et al.

Alterations in brain opiate receptor mechanisms on proestrous afternoon

Neuroendocrinology

(1988)

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Review articleGender differences in pain: Do emotions play a role?

Abstract

Background:

Objective:

Methods:

Results:

Conclusions:

Pain

Pain Forum

Pain

Neurosci Biobehav Rev

Prog Neurobiol

Pain Forum

Trends Cogn Sci

Curr Opin Neurobiol

Curr Opin Neurobiol

Life Sci

Neurosci Biobehav Rev

Brain Res

Eur J Pain

Curr Opin Neurobiol

Brain Res

Brain Res

Pain

Behav Res Ther

Pain

Pain

Pain

Pain

Pain

Physiol Behav

J Psychosom Res

Pain

Pain

Pain

Pain

Pain

Pain

J Pain

Pain

Brain Res

Physiol Behav

Brain Res

Sex differences in the perception of noxious experimental stimuli: A meta-analysis

Pain

Sex differences in pain

Behav Brain Sci

Afferent fibers supplying the uterus in the rat

J Neurophysiol

Estrous cycle variation of afferent fibers supplying reproductive organs in the female rat

Brain Res

Substance P and neurokinin A variations throughout the rat estrous cycle; comparison with ovariectomized and male rats: I. Plasma, hypothalamus, anterior and posterior pituitary

J Neurosci Res

Postoperative P.C.A. in abdominal surgery. Analysis of 200 consecutive patients

Acta Anasthesiol Belg

Sex differences in morphine analgesia: An experimental study in healthy volunteers

Anesthesiology

Gender and age influences on human brain mu-opioid receptor binding measured by PET

Am J Psychiatry

Mu-opioid receptor-mediated antinociceptive responses differ in men and women

J Neurosci

Brain opioid receptor measurements by positron emission tomography in normal cycling women: Relationship to luteinizing hormone pulsatility andgonadal steroid hormones

J Clin Endocrinol Metab

Central nervous system mechanisms of pain modulation

Emotion circuits in the brain

Anna Rev Neurosci

Desensitization of brain opiate receptor mechanisms by gonadal steroid treatments that stimulate luteinizing hormone secretion

Endocrinology

Alterations in brain opiate receptor mechanisms on proestrous afternoon

Neuroendocrinology

Review article
Gender differences in pain: Do emotions play a role?