The U.S. is amidst a health crisis involving inequitable pain care: Black Americans receive substandard and less aggressive pain treatment than White Americans. One study indicates that Black patients entering an Emergency Department are about half as likely to be prescribed opioids to cope with their pain when compared to their White counterparts.

Some race differences in the amount or quantity of pain treatment can be traced to prejudice, stereotypes, and gaps in provider empathy. And in addition to this national tendency for Black patients to receive less intensive pain treatment, Black patients also receive less appropriate treatments. For example, according to recent research, Black patients are subjected to higher rates of unnecessary surgery and are more frequently prescribed opioid drugs for migraine symptoms although this is not a guideline-directed treatment.  

How Race And Pain Expression Interact

Medical clinicians treating pain are asked to make quick and accurate decisions about who needs intervention, and of what intensity. Because pain is a subjective experience, these decisions are, in part, based on patients’ nonverbal signals such as facial expressions. Making such decisions is difficult, and we found that how difficult it is depends in part on the target person’s race.  

The research had two phases. First, we made videos of Black and White men and women (“expressers”) while they were showing genuine or feigned pain. This was done while they actually were in pain that we created (with their permission) using a pressure algometer--think of this as a pressure gun that can deliver increasing pressure. In this case, we placed the device on a bone in the expresser’s hand. We also videoed them while they were only pretending they were experiencing the painful pressure. In the photos below, which are screen shots from the videos, the expresser on the left was in genuine pain and the photo on the right is the same expresser showing pretend pain.

two images of black man
two images of a white man

Then, we recruited viewers who identified as Black or White to engage in a pain detection task where they guessed whether each expression was “real” or “fake.”

Expressers’ Race Made A Difference

Viewers in our studies struggled more to distinguish real from faked expressions of pain in videos of Black relative to White expressers (regardless of viewers’ own racial identity).

The videos described above are an unsatisfying parallel to the pain expressions accompanying more serious injuries or medical conditions. So, we created a second version of the pain detection task with more intense pain expressions. Participants viewed images of Black and White men’s professional soccer players who had been seriously injured during game play (for example, anterior cruciate ligament rupture, broken tibia) or were faking injury to receive a favorable call (“flopping” or “diving”). Real pain expressions were those in which the player left the field, an injury was documented, and in which the player missed subsequent matches for the injury incurred. For faked expressions, no injury was reported and there was evidence that the expression wasn’t genuine (the player was punished for “simulation” [flopping/diving], the player admitted to flopping/diving, the player immediately returned to play). Again, participants struggled more to distinguish real from fake expressions of pain when judging Black soccer players compared to when judging White soccer players.

Back To The Doctor’s Office

How might an inability to discriminate pain authenticity translate into disparate medical care?

We showed our lab created videos to a sample of clinicians who, as part of their jobs, regularly recommend or prescribe pain treatment. These clinicians similarly struggled to discern real from faked expressions on the faces of Black relative to White expressers, suggesting that trained clinicians may be similarly susceptible to race deficits in pain authenticity detection.

We also explored consequences of this pain authenticity deficit for hypothetical pain care recommendations (this time, made by college students rather than clinicians). As in previous research, Black individuals were recommended less intensive hypothetical pain care than White individuals. Importantly, we also found that greater hypothetical pain care was suggested for White individuals expressing real versus fake pain but Black individuals got the same recommendations whether their expressions were real or fake.

Equitable Pain Care And Beyond

Although we focus on implications for equitable pain care, the applications of this work extend well beyond healthcare. Incorrect judgments of friends', colleagues', or strangers' pain authenticity could also be consequential. For example, a referee could be swayed by a player’s “dive” or “flop” and issue a wrongful penalty, or a judge could rule that a pain-expressing plaintiff be compensated for damages they did not incur. Furthermore, misjudging authentic pain as fabricated may lead to equally, or arguably more, serious consequences. A referee could ignore an injured player, or a judge could fail to validate a victim’s suffering.

For Further Reading

Lloyd, E. P., Lloyd, A. R., McConnell, A. R., & Hugenberg, K. (2021). Race deficits in pain detection: Medical providers and laypeople fail to accurately perceive pain authenticity among Black people. Social Psychological and Personality Science.

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301.

Mende-Siedlecki, P., Qu-Lee J., Backer, R., & Van Bavel, J. J. (2019). Perceptual contributions to racial bias in pain recognition. Journal of Experimental Psychology: General, 148(5), 863-889.

E. Paige Lloyd is an Assistant Professor of Psychology at the University of Denver. She examines impression formation with a focus on how response biases and the ability to accurately read others’ cues can manifest in discrimination and inequitable treatment.