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The Impact of Sexism and Gender Stereotypes on the Legitimization of Women's Low Back Pain

Open AccessPublished:April 13, 2022DOI:https://doi.org/10.1016/j.pmn.2022.03.008

      Abstract

      Background

      Low back pain is the worldwide leading cause of disability and, even though women's pain experience is more severe, frequent, and enduring, female patients are often underdiagnosed and undertreated. Health professionals’ gender stereotypes and social norms may underlie the downgrading of pain.

      Aim

      This pilot study aimed to examine the legitimation of low back pain by health professionals in relation to the sex of the patient as well as their gender awareness and the relationship between them.

      Method

      This study had a cross-sectional design. Eighty health professionals and students selected by convenience answered a 4-part online questionnaire. The eligibility criteria for participants were: aged >18 years, students in the last course of nursing/medicine or a physician/nurse, and Spanish-speaking. The questionnaire comprises: (1) a between-subjects virtual clinical low back pain case with four random versions (female/male patient and evidence/non-evidence of pathology); (2) the Spanish version of Nijmegen Gender Awareness Scale (S-NGAMS); (3) Ambivalent Sexism Inventory (ASI); and (4) Ambivalence toward Men Inventory (AMI).

      Results

      The total score of legitimation of low back pain correlated negatively with gender role ideology and sexism scales (when the virtual patient was female), as well as the subscales of willingness to offer support and credibility.

      Conclusions

      Both sexism and gender role ideology could undermine the legitimation of low back pain, the willingness to offer support, and credibility only in female patients. The results showed a possible gender bias in low back pain assessment in health professionals. Low gender sensitivity and high sexism must be treated as modifiable risk factors for health inequities in pain care.
      According to the World Health Organization (

      World Health Organization (WHO). (2021a). Health systems. Equity. Retrieved April, 2022, from https://www.who.int/health-topics/health-equity#tab=tab_1

      ) health equity includes the absence of unfair and avoidable or remediable differences in health between socially, economically, demographically, or geographically defined population groups. Despite this, in recent decades, several studies have highlighted gender bias in health care in general, and specifically in pain management (
      • Earp B.D.
      • Monrad J.T.
      • LaFrance M.
      • Bargh J.A.
      • Cohen L.L.
      • Richeson J.A.
      Featured article: Gender bias in pediatric pain assessment.
      ;
      • Samulowitz A.
      • Gremyr I.
      • Eriksson E.
      • Hensing G.
      Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain.
      ;
      • Schäfer G.
      • Prkachin K.M.
      • Kaseweter K.A.
      • Williams A.C.
      • de C.
      Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness.
      ).
      Pain is considered by the International Association for the Study of Pain (IASP) “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (

      International Association for the Stufy of Pain (IASP). (2021). IASP terminology. Retrieved May 21, 2021, from https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Pain

      ). There is a broad classification of pain, as proposed by
      • Cole B.E.
      Pain management: Classifying, understanding, and treating pain.
      which classifies it by anatomic location, body system, duration, severity, frequency, and etiology. Among all types of pain, low back pain (LBP) is the worldwide leading cause of disability (

      World Health Organization (WHO). (2021b). Musculoskeletal conditions. Retrieved May, 2021, from https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions

      ) and it is associated with a high affectation of physical function, daily activities, health-related quality of life, work, social, and family relationships, as well as high costs to the health care system (
      • Dueñas M.
      • Ojeda B.
      • Salazar A.
      • Mico J.A.
      • Failde I.
      A review of chronic pain impact on patients, their social environment and the health care system.
      ). In this regard, 19% of Europeans suffer chronic pain (
      • Breivik H.
      • Collett B.
      • Ventafridda V.
      • Cohen R.
      • Gallacher D.
      Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment.
      ) and specifically, back pain is the second most prevalent chronic disease in Spain (

      Ministry of Health, Consumer Affairs and Social Welfare. (2018). ENSE Encuesta Nacional de Salud de España 2017. Retrieved September, 2021, from https://www.mscbs.gob.es/estadEstudios/estadisticas/encuestaNacional/encuestaNac2017/ENSE17_pres_web.pdf

      ). Furthermore, 23.5% of women and 15.8% of men aged >15 years suffer LBP in this country (

      Ministry of Health, Consumer Affairs and Social Welfare. (2018). ENSE Encuesta Nacional de Salud de España 2017. Retrieved September, 2021, from https://www.mscbs.gob.es/estadEstudios/estadisticas/encuestaNacional/encuestaNac2017/ENSE17_pres_web.pdf

      ).
      Several investigations observed that although pain experience is more severe, frequent, and enduring in women (
      • Bartley E.J.
      • Fillingim R.B.
      Sex differences in pain: A brief review of clinical and experimental findings.
      ;
      • Gallach Solano E.
      • Bermejo Gómez M.A.
      • Robledo R.
      • Izquierdo Aguirre R.M.
      • Canos Vardecho M.A.
      Determinantes de género en el abordaje del dolor crónico.
      ) pain is under-treated and underdiagnosed in female patients (
      • Bernardes S.F.
      • Lima M.L.
      A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain.
      ;
      • Lillrank A.
      Back pain and the resolution of diagnostic uncertainty in illness narratives.
      ;
      • Mogil J.S.
      Equality need not be painful.
      ;
      • Schäfer G.
      • Prkachin K.M.
      • Kaseweter K.A.
      • Williams A.C.
      • de C.
      Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness.
      ;
      • Siddiqui A.
      • Belland L.
      • Rivera-Reyes L.
      • Handel D.
      • Yadav K.
      • Heard K.
      • Eisenberg A.
      • Hwang U.
      A multicenter evaluation of the impact of sex on abdominal and fracture pain care.
      ). According to the review by
      • Samulowitz A.
      • Gremyr I.
      • Eriksson E.
      • Hensing G.
      Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain.
      , women with chronic pain reported feeling mistrusted and psychologized. Women also, received less pain relief, less pain medication with opioids, and more antidepressants.
      Therefore, the legitimation of pain by health professionals is crucial in the management of such suffering, being the legitimation of pain defined as the recognition and value placed on the pain that a person suffers. The lack of legitimation of pain leads to the undertreatment of that pain and perpetuates the condition, influencing the quality of life of those who suffer from it (
      • Lillrank A.
      Back pain and the resolution of diagnostic uncertainty in illness narratives.
      ;
      • Toye F.
      • Seers K.
      • Barker K.L.
      Meta-ethnography to understand healthcare professionals’ experience of treating adults with chronic non-malignant pain.
      ). Social norms could influence the legitimation of pain in health professionals (
      • Bernardes S.F.
      • Lima M.L.
      A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain.
      ;
      • García Dauder D.
      Perspectiva de género en Psicología.
      ;

      Velasco Arias, S. (2009). Recomendaciones para la práctica clínica con enfoque de género. Retrieved May, 2021, from https://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/pdf/equidad/recomendVelasco2009.pdf

      ), leading to sexist stereotypes and low gender awareness, especially when the pain is not accompanied by diagnostic evidence (
      • Bernardes S.F.
      • Lima M.L.
      A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain.
      ;
      • Siddiqui A.
      • Belland L.
      • Rivera-Reyes L.
      • Handel D.
      • Yadav K.
      • Heard K.
      • Eisenberg A.
      • Hwang U.
      A multicenter evaluation of the impact of sex on abdominal and fracture pain care.
      ). The legitimation of pain in men may be associated with stereotypes of strength and less seeking help, while in women it may be associated with weakness, instability, and greater demand for health care, so that pain in women is related to psychogenic causes and classified as less urgent (
      • Samulowitz A.
      • Gremyr I.
      • Eriksson E.
      • Hensing G.
      Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain.
      ).
      Although there are studies that have evaluated gender bias and the legitimation of pain in health professionals (
      • Bernardes S.F.
      • Lima M.L.
      A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain.
      ;
      • Daugherty S.L.
      • Blair I.V
      • Havranek E.P.
      • Furniss A.
      • Dickinson L.M.
      • Karimkhani E.
      • Main D.S.
      • Masoudi F.A.
      Implicit gender bias and the use of cardiovascular tests among cardiologists.
      ;
      • Salgado D.M.
      • Vogt D.S.
      • King L.A.
      • King D.W.
      Gender Awareness Inventory-VA: A measure of ideology, sensitivity, and knowledge related to women veterans’ health care.
      ;
      • Verdonk P.
      • Benschop Y.W.M.
      • de Haes H.C.J.M.
      • Lagro-Janssen T.L.M.
      From gender bias to gender awareness in medical education.
      ), we have not found any that have done so jointly. Therefore, the purposes of this pilot study were to examine the health professionals’ legitimation of LBP depending on the sex of the patient and to analyze the relationship between such legitimation, gender awareness, and ambivalent sexism levels.

      Methods

      Participants and Design

      This study had a cross-sectional design. Eighty health professionals and students were selected by convenience. Being aware that the sample size is limited, the data analysis section would take into consideration not only statistical significance values, but also effect sizes. For the present study, the eligibility criteria for participants were: to be over 18 years of age; to be students of the last course of nursing/medicine or to be a physician/nurse; and to be Spanish-speaking. The participants of the study were recruited by sending them an e-mail offering to participate in the study. Those who consented to participate in the study received a new email with the questionnaire to be filled in. Specifically, 66.25% of the participants were nurses, 17.5% were studying nursing, while the other 16.25% were physicians. The average age of the sample was 31.10 (standard deviation [SD] = 10.06), with ages between 20 and 63. Most of the sample had Spanish nationality (96.3%) and 83.8% resided in the province of Guipuzcoa (Basque Country). Table 1 shows participants’ demographic characteristics.
      Table 1Participant Demographic Characteristics
      MDSDN (total = 80)%Range
      Age (years)31.610.0620-63
      20-406784.7
      41-631214
      DK/NA11.3
      Gender
      Female7188.8
      Male911.2
      Country of birth
      Spain7796.2
      Colombia22.4
      Peru11.4
      Profession
      Nursing6783.7
      Medicine1316.3
      Years of profession7.607.830-34
      ≤106277.5
      11-191012.5
      ≥20810
      MD = mean deviation; SD = standard deviation; DK = Don´t know; NA = Not available.

      Procedure

      An e-mail and/or mobile phone link was sent to access the online questionnaire to those people who gave their consent to participate in the study. Respondents filled a socio-demographic data questionnaire, clinical case-related questions, and sexism and gender awareness scales. This research has been approved by the Ethics Committee for research with human beings of the University of Basque Country (CEISH UPV/EHU; M10_2019_139) and the Clinical Research Ethics Committee of the Basque Country (CEIm; PI2019152).

      Instruments

      Legitimation of pain based on a clinical case

      A virtual clinical case of a patient with chronic LBP was created ad hoc based on the original study by
      • Bernardes S.F.
      • Lima M.L.
      A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain.
      (Appendix 1). Four different versions were created according to sex (woman/man) and evidence of pathology (with herniated disc/without evidence of pathology). Each participant answered to one of the following cases: case 1: Man with chronic LBP, without a diagnosis of evidence of pathology; case 2: Woman with chronic LBP, without a diagnosis of evidence of pathology; case 3: Man with chronic LBP and a diagnosis of evidence of pathology (herniated disc); case 4: Woman with chronic LBP and a diagnosis of evidence of pathology (herniated disc). The choice of clinical case was random for each participant. After reading the clinical case, the participants proceeded to answer 16 items using a Likert scale ranging from 1 (nothing) to 7 (exaggerated). The items corresponded to the following subscales: (1) psychological attributions to the pain (e.g., To what extent do you believe this patient's pain is caused by psychological factors?); (2) disability (e.g., To what extent do you believe this pain interferes with this man's professional life?); (3) willingness to offer support (e.g., To what extent would you be willing to help this patient ambulate?); and (4) credibility of the pain (e.g., To what extent do you feel the pain reported by this patient is credible?). All factors showed an adequate internal reliability (psychological attributions to the pain α = 0.77; disability α = 0.78; willingness to offer support α = 0.87; and credibility of the pain α = 0.76).

      Gender awareness in health professionals

      According to a study currently under review (J. Aliri et al., unpublished data, August 2021) the Spanish adaptation of the Nijmegen Gender Awareness in Medicine Scale (S-NGAMS) was used to assess gender awareness in health professionals. This scale is composed of three subscales: gender sensitivity (GS), gender role ideology towards patients (GRI-patient), and gender role ideology towards doctors (GRI-doctors). First, GS is a 14-item scale that assesses health care professional attitudes towards gender concerns in health care (e.g., for effective treatment, physicians should address gender differences in etiology and consequences of disease); higher scores in this subscale mean higher gender sensitivity. Second, GRI-patient is an 11-item measure assessing gender stereotypical thinking about patients (e.g., male patients better understand the approach of physicians than female patients); higher scores in this subscale mean that health professionals have a more stereotypical thinking. GRI-doctors subscale was excluded from this study aimed to analyze the gender ideology based on the sex of the patients. Each measure of gender awareness was based on a five-point Likert scale response ranging from (1) totally disagree to (5) totally agree. Both factors showed an excellent internal reliability (GS α = 0.80; and GRI-patients α = 0.89).

      Sexism in health professionals

      The Ambivalent Sexism Inventory (ASI) and the Ambivalence Sexism Toward Men Inventory (AMI) assess sexism ambivalence towards women and men respectively, attending to hostile and benevolent sexism (
      • Glick P.
      • Fiske S.T.
      The Ambivalent Sexism Inventory: Differentiating hostile and benevolent sexism.
      ,
      • Glick P.
      • Fiske S.T.
      The ambivalence toward men inventory. Differentiating hostile and benevolent beliefs about men.
      ). The reduced versions of the S-ASI (12 items: e.g., women trying to gain power by controlling men) and S-AMI (12 items: e.g., men behave like children when they are sick) were used (
      • Rodríguez Castro Y.
      • Lameiras Fernández M.
      • Carrera Fernández M.V.
      Validación de la versión reducida de las escalas ASI y AMI en una muestra de estudiantes españoles.
      ). Half of the items of the ASI assess hostile sexism towards women (HS) and the other half, benevolent sexism towards women (BS); and in the same vein, half of the items assess hostility towards men (HM) and the other half benevolence towards men (BM). Each measure of ambivalent sexism was based on a five-point Likert scale response ranging from (1) totally disagree to (5) totally agree. Higher values in all the scales and subscales indicate more sexism. The psychometric properties of the Spanish adaptations of those short versions were adequate (
      • Rodríguez Castro Y.
      • Lameiras Fernández M.
      • Carrera Fernández M.V.
      Validación de la versión reducida de las escalas ASI y AMI en una muestra de estudiantes españoles.
      ). In the present study, the following indices of internal consistency were observed: HS α = .88, BS α = .80, ASI α = .83, HM α = .84, BM α = .73, and AMI α = .76.

      Analyses

      Spearman correlations were used to examine the relationships between the LBP legitimation, gender awareness subscales, and the ambivalent sexism scales. Secondly, we conducted a multivariate analysis of variance to examine the differences in scores between four clinical cases. All analyses were performed using SPSS version 26. Pairwise deletion was used to handle missing data.

      Results

      Correlations Among Gender Awareness, Ambivalent Sexism, and Legitimation of Low Back Pain

      The correlations among LBP legitimation, S-NGAMS subscales, S-ASI, and S-AMI scales are presented in Table 2. These correlations were only significant when the patient sex was female. In the clinical case, when the patient was a woman, legitimation of LBP was negatively correlated with GRI-patient and sexism scales; that is, professionals with higher levels of LBP legitimation had lower scores in both GRI-patient and ambivalent sexism scales. Concretely, willingness to offer support and credibility subscales were the ones that showed the highest negative correlations with GRI-patient and ambivalent sexism scales. No relation was found between LBP legitimation and sexism or gender role ideology when the patient of the clinical case was male.
      Table 2Correlations Between Legitimation of LBP and Subscales of the Spanish Version of Nijmegen Gender Awareness Scale (S-NGAMS) and Ambivalent Sexism Scales (ASI, AMI)
      Female patientS-NGAMS GSS-NGAMS GRI-patientS-ASI HSS-ASI BSS-ASI TotalS-AMI HSS-AMI BSS-AMI Total
      LBP legitimation (total score)–0.01–0.37
      p < .05.
      –0.29–0.34–0.38
      p < .05.
      –0.26–0.59
      p < .001. LBP = low back pain; S-ASI = short form of Ambivalent Sexism Inventory; S-AMI = short form of Ambivalent Sexism toward Men Inventory; GS = gender sensitivity; GRI-patient = gender role ideology towards patient; HS = hostile sexism; BS = benevolent sexism.
      –0.40
      p < .05.
      Psychological attributions–0.10–0.05–0.27–0.200.150.09–0.24–0.01
      Disability–0.23–0.21–0.18–0.200.26–0.27–0.42
      p < .05.
      –0.31
      Willingness to offer support–0.04–0.38
      p < .05.
      –0.37
      p < .05.
      –0.37
      p < .05.
      –0.44
      p < .05.
      -0.24-0.63
      p < .01.
      -0.41
      p < .05.
      Credibility0.28–0.46
      p < .01.
      –0.09–0.37
      p < .05.
      –0.27–0.41
      p < .05.
      –0.28–0.41
      p < .05.
      Male patientS-NGAMS GSS-NGAMS GRI-patientS-ASI HSS-ASI BSS-ASI TotalS-AMI HSS-AMI BSS-AMI

      Total
      LPB legitimation (total score)0.17–0.25–0.23–0.05–0.120.04–0.050.03
      Psychological attributions0.01–0.11–0.13–0.07–0.06–0.13–0.12–0.10
      Disability–0.01–0.25–0.15–0.12–0.09–0.07–0.11–0.11
      Willingness to offer support0.06–0.16–0.130.01–0.06–0.13–0.06–0.12
      Credibility0.26–0.26–0.17–0.04–0.070.220.010.18
      Correlations are shown at the top when the clinical case is a female patient, at the bottom when the case is a male patient.
      a p < .05.
      b p < .01.
      c p < .001.LBP = low back pain; S-ASI = short form of Ambivalent Sexism Inventory; S-AMI = short form of Ambivalent Sexism toward Men Inventory; GS = gender sensitivity; GRI-patient = gender role ideology towards patient; HS = hostile sexism; BS = benevolent sexism.

      Analysis of Variance of the Clinical Cases

      Table 3 shows the average scores and the standard deviations obtained for each clinical case. The average scores for the subscale of psychological attributions ranged from 18.25-19.00; for disability produced from 18.69-19.88; for willingness to offer support from 18.94-19.94; and for credibility from 18.38-19.65. The multivariate analysis of variance does not show significant differences between these groups in any of the variables (F (4, 12) = 0.16; p > .05).
      Table 3Means and Standard Deviations for Total LBP Legitimation Scores and Their Subscales
      Case 1Case 2Case 3Case 4
      MSDMSDMSDMSD
      LBP legitimation74.6312.73778.9876.8711.0276.7119.30
      Psychological attributions18.634.3219.004.0818.254.2018.592.65
      Disability18.694.6619.233.0419.673.2919.883.46
      Willingness to offer support18.944.9119.412.8919.673.4119.943.33
      Credibility18.385.2419.361.9419.293.4619.654.21
      Range of theoretical scores in legitimation of LBP 16-112; Psychological attributions 4-28; Disability 4-28; Willingness to offer support 4-28; and Credibility 3-21. Case 1: man without a diagnosis of evidence of pathology, Case 2: woman without a diagnosis of evidence of pathology, Case 3: man with a diagnosis of evidence of pathology, and Case 4: woman with a diagnosis of evidence of pathology.
      M = mean; SD = standard deviation; LBP = low back pain.

      Discussion

      This pilot study was aimed to examine the legitimation of LBP in health professionals of both sexes and to study its association with gender awareness and ambivalent sexism. The correlation analysis showed significant relationships of the LBP legitimation with sexism and gender role ideology in women. More specifically, results indicate that both sexism and gender role ideology toward patients could undermine the willingness to offer support and credibility only in female patients. In this sense,
      • Bernardes S.F.
      • Lima M.L.
      A contextual approach on sex-related biases in pain judgements: The moderator effects of evidence of pathology and patients’ distress cues on nurses’ judgements of chronic low-back pain.
      found that nurses perceived women patients’ pain as less credible, disabling, and less severe in the absence of evidence of pathology. Probably because of the small sample size within the four clinical case groups, we have not found any significant difference depending on the presence or absence of herniated disc.
      Interestingly, both sexism towards women and men were shown to be detrimental to the legitimation of LBP in female patients, but not in males. The notion that sexism towards men does not affect credibility nor willingness to offer support to men but can impair health a professional's attitude towards women may be understood considering social mandates. On the one hand, socially established masculinity mandates include authority and domination, protective stereotypes when considering the plausibility of a suffering man (
      • García Dauder D.
      Perspectiva de género en Psicología.
      ). On the other hand, in the collective imaginary women are considered providers and not recipients of health care, while men are considered to need a more proactive care from health professionals (
      • Soto-Gordoa M.
      • Arrospide A.
      • Millán E.
      • Calvo M.
      • Igartua J.I.
      • Esnaola S.
      • Ganzarain J.
      • Mar J.
      Gender and socioeconomic inequalities in the implementation of the Basque programme for multimorbid patients.
      ). In addition, women stereotypes of hysterical, complaining, and not waiting to get better, as well as the belief that women can tolerate more pain than men as a result of women's biological role in childbirth could be related to the negative association between sexist stereotypes and pain legitimation we found in females (
      • Hoffmann D.E.
      • Tarzian A.J.
      The girl who cried pain: A bias against women in the treatment of pain.
      ;
      • Samulowitz A.
      • Gremyr I.
      • Eriksson E.
      • Hensing G.
      Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain.
      ). Indeed,
      • Samulowitz A.
      • Gremyr I.
      • Eriksson E.
      • Hensing G.
      Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain.
      address a tendency in health professionals to lessen the legitimation of pain in women, due to mistrust and the inclination to ascribe psychological attributions to them.

      Clinical Implications

      More than ever, the importance of the role of nursing in pain management is undisputed (
      • Mahfudh S.S.
      Nurse's role in controlling cancer pain.
      ). The new legal framework in Spain regulated by the 1308/2018 Royal Decree broadens the competencies of nurses concerning the prescription of drugs subject to medical prescription. Furthermore, nurses are responsible for assessing the patient's pain, administering analgesia on demand, and they may increase the dose as needed (

      Royal Decree 1302/2018. (2018). Boletín Oficial del Estado, 256, 23th october, 102636 a 102643. Retrieved December, 2021, from https://www.boe.es/boe/dias/2018/10/23/pdfs/BOE-A-2018-14474.pdf

      ). Despite national and international political efforts to introduce a gender perspective in health care and the protocols and guidelines established for the care of pain in patients, this research indicates that bias is still present in our health system and nurses. The gender bias in pain attention results in several consequences like inequality in health care, increase in health care costs, and the perpetuation of the suffering of the patients (
      • Dueñas M.
      • Ojeda B.
      • Salazar A.
      • Mico J.A.
      • Failde I.
      A review of chronic pain impact on patients, their social environment and the health care system.
      ).
      Given the extensive research on gender bias in health care, it would be interesting for institutions and members of the health care system to reflect on it, understanding this gender bias as an area of improvement for the different members of the health care system. The first step for equity in pain attention or other health problems attention is to try to recognize and address the effects of unintentional gender bias in their practices. Therefore, it is necessary to train and sensitize health professionals on gender and health in order to detect biases and restructure these mental habits. In addition, the analysis of data in relation to the health status of the population may be of interest to detect possible gender biases in health care.
      As a limitation, it must be taken into account that the data obtained correspond to a specific population, mostly White and belonging to a health system based on the National Health System, so it cannot be extrapolated to other populations. In addition, our sample was small and most of them were women and nurses. For future research, it could be interesting to analyze the same variables in a wider sample, taking into account the professional´s gender and their profession.

      Conclusions

      Low gender sensitivity and high sexism influence the low back pain assessment in health professionals. Promoting equity in pain care by addressing gender bias as a modifiable risk factor, as well as in the education and protocol development could decrease gender inequalities.

      Declaration of Competing Interest

      The authors have no conflicts of interest to report.

      Acknowledgments

      The authors of the present research are grateful to the N-GAMS original authors Petra Verdonk, Yvonne W. M. Benschop, Hanneke C. J. M. De Haes, and Toine L. M. Lagro-Jans for providing us the original items of the scale and giving us permissions to use, modify, or translate N-GAMS scale. In addition, the authors would like to thank Dr. Gasca Jimenez for proofreading some of the translations. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Appendix. Supplementary materials

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