The gender pain gap continues with IUD fittings
An intrauterine device (IUD), or what is more commonly known as ‘the coil’, is a contraceptive for women (1). IUDs sit inside the uterus and change the way sperm cells move to prevent pregnancy (1). Given the location of the device, the fitting of the IUD is an invasive procedure, involving the insertion of a T-shaped plastic and copper device through the cervix and into the uterus (1). Although many women only experience slight discomfort during the procedure, others have reported excruciating pain, comparing the agony to childbirth, or to breaking a limb (2). Despite these accounts, pain medication is not usually offered for the fitting (3). Instead, women are merely advised to take ibuprofen and paracetamol before or after the procedure (3). This was the case for the BBC television presenter Naga Munchettty, whose experience is outlined below.
Naga Munchetty’s experience
Last year, Naga Munchetty spoke out about her incident with having an IUD fitted in a BBC Radio 5 Live show (2). Munchetty reported that she felt ‘violated’, and the broadcast also featured callers who spoke about their own negative experiences with the procedure (2). In their own descriptions of having IUDs fitted, the callers all stated that there was no offer of pain relief or warning about the possibility of experiencing extreme pain (2).
The gender pain gap with IUD fittings
Although anaesthetic gels or anaesthetic injections can be used on the cervix, these treatments are not usually offered (1). Therefore, since IUD fittings have the potential to induce excruciating pain, the question stands as to why these medications are not used as a standard procedure?
Historically, there is a well-documented disposition for healthcare providers to belittle women’s claims about their physical symptoms, particularly their pain (4). Instead of taking claims of women’s pain seriously, their accounts are viewed as overreactions and are systemically ignored or dismissed (4). As follows, studies have suggested that women are considered for medical treatment less frequently than men (5,6). For example, it has been reported that women with angina are less likely to receive successful treatment (43%) than men (53%) (5,6). Another study has highlighted how women are 13–25% less likely to receive painkillers for abdominal pain than men (7). In acknowledgement of this medical disregard towards women, there is concern that women’s pain is undertreated.
Due to the racial bias in healthcare, women of colour are affected the most by the gender pain gap. Healthcare providers may have an unconscious bias which can impact their delivery of care to women of colour. For example, in the US, Black women are 5 times more likely to die in childbirth than White women (8). In 2018, it was reported that Black and Hispanic women accounted for 75% of new Human immunodeficiency virus (HIV) diagnoses (9). This was suggested to be due to failures in HIV prevention and treatment programs, and gynaecological care. Additionally, Black women in the US are less likely to be prescribed preventative HIV medication compared with white women and men (10).
Why does the gender pain gap exist?
The different medical treatment of male and female pain has been explored by numerous studies, many of which investigate the differences in how men and women experience pain (11). This sizable body of current literature often fails to recognise or involve the contribution of gender-role expectations for men and women and focuses on biological mechanisms instead (11). However, several studies have found that gender-related stereotypes influence views of pain experienced by men and women (12). One of these studies found that healthcare providers often succumb to the view that women are more likely to exaggerate their pain (12). This contributes to the stereotypic view that women overreport their pain in comparison to men, and thus could explain the reason why men receive more aggressive treatment for health conditions than women (12).
These findings point toward the fact that women are believed less in their accounts of pain or are expected to tolerate this pain better than their male counterparts. Naga Munchetty also touched on this expectation to tolerate pain in the BBC Radio 5 show, where she posed the question, ‘Why are women made to feel that their pain is something to endure, not a problem to solve?’ (3). This was reinforced by a caller who was told to ‘grit her teeth’ during the process (3).
Informed consent when getting a IUD fitting
Alongside the issue of insufficient pain relief for IUD fittings, there is also a concern surrounding informed consent. It is concerning that before the procedure, women like Naga Munchetty are often told ‘this may be a bit uncomfortable,’ even though there is the possibility of experiencing extreme pain during the process, echoed by the campaigner for more appropriate pain medication in IUD fittings, Lucy Cohen (2). Cohen points out that to be capable of providing informed consent ahead of the fitting, women should be forewarned that there is a possibility of experiencing severe levels of pain (2).
Pre-procedural counselling could help improve IUD fitting experience
Interestingly, one study emphasises that the forewarning of pain in IUD fittings is crucial in reducing the physical pain of IUD insertion (13). The study which focused on the insertion experience found that there is a high prevalence and severity of preprocedural anxiety among women receiving an IUD (13). Therefore, the authors suggest that because of this severe anxiety, local anaesthetics alone are unlikely to considerably improve the experience of receiving an IUD (13). This is because they found that greater anxiety surrounding the anticipation of the procedure might be associated with increased pain perception (13). They also found that an imbalance between pain expectation and reality was extremely common, suggesting that healthcare providers may not be providing appropriate counselling about the range of pain severity which can be experienced in IUD fittings (13). As follows, they suggest that future IUD studies should investigate preprocedural counselling to improve the experience of the procedure (13).
Due to gender-based stereotypes, women have a reduced status as credible givers of knowledge about their bodies (4). These stereotypes have influenced the treatment of women in healthcare services, due to the tendency to view their accounts of pain as overreactions or exaggerations. The lack of appropriate medication offered in IUD fittings demonstrates the reluctance to acknowledge the severe pain that women can experience during the procedure (2). Consequently, having an IUD fitted can cause severely high levels of preprocedural anxiety and trauma from enduring the pain (13). Thus, it is vital that healthcare services begin to offer more sufficient pain relief for the fitting process.
- Cheung M-L, Rezai S, Jackman JM et al. Retained intrauterine device (IUD): triple case report and review of the literature. Case Reports in Obstetrics and Gynocology, 2018.1-9.
- Naga: ‘IUD fitting was a traumatic experience’ [radio broadcast]. 5 Live News Specials. Manchester: BBC; 2021 Jun 21.
- Coils / IUD / IUS – Sexual Health Oxfordshire [Internet]. Sexualhealthoxfordshire.nhs.uk. 2022 [cited 26 April 2022]. Available from: https://www.sexualhealthoxfordshire.nhs.uk/contraception/coils-iud-ius/
- Sherman BR, Goguen S, editors. Overcoming epistemic injustice: Social and psychological perspectives. Rowman & Littlefield; 2019 Jun 28.119-139.
- Daly C, Clemens F, Lopez Sendon JL, Tavazzi L, Boersma E, Danchin N, Delahaye F, Gitt A, Julian D, Mulcahy D, Ruzyllo W. Gender differences in the management and clinical outcome of stable angina. Circulation. 2006 Jan 31;113(4):490-8.
- Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley III JL. Sex, gender, and pain: a review of recent clinical and experimental findings. The Journal of Pain. 2009 May 1;10(5):447-85.
- Chen EH, Shofer FS, Dean AJ, Hollander JE, Baxt WG, Robey JL, Sease KL, Mills AM. Gender disparity in analgesic treatment of emergency department patients with acute abdominal pain. Academic Emergency Medicine. 2008 May;15(5):414-8.
- Thorne SA, Cook JL, D’Souza R. The Role of National Pregnancy Surveillance Systems in Improving Maternal Mortality and Morbidity: The Next Steps for Canada. Canadian Journal of Cardiology. 2021 Dec 1;37(12):1904-7.
- Centers for Disease Control and Prevention. HIV surveillance report, 2018 (updated). Centers for Disease Control and Prevention. 2020 May 8.
- Ya-lin AH, Zhu W, Smith DK, Harris N, Hoover KW. HIV preexposure prophylaxis, by race and ethnicity—United States, 2014–2016. Morbidity and Mortality Weekly Report. 2018 Oct 19;67(41):1147.
- Robinson ME, Gagnon CM, Riley III JL, Price DD. Altering gender role expectations: effects on pain tolerance, pain threshold, and pain ratings. The Journal of Pain. 2003 Jun 1;4(5):284-8.
- Schafer G, Prkachin KM, Kaseweter KA, Williams AC. Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain. 2016 Aug 1;157(8):1618–1625.
- Callahan DG, Garabedian LF, Harney KF, DiVasta AD. Will it hurt? the intrauterine device insertion experience and long-term acceptability among adolescents and young women. Journal of Pediatric and Adolescent Gynecology. 2019 Dec 1;32(6):615-21.
Junior Medical Writer