The Pain Doctor’s Dilemma

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 screenshots 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 gameplay (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 fake 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 the 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.   https://doi.org/10.1177/19485506211045887

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. https://doi.org/10.1371/journal.pone.0159224

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. https://doi.apa.org/doiLanding?doi=10.1037%2Fxge0000600
 

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. 

What Does It Feel Like To Be Sadistic?

Sadists are the stuff of Netflix serial killer documentaries. People often imagine them as depraved monsters that exist at the fringes of society. But the truth is: sadists walk among us.

Sadism is the tendency to experience pleasure when inflicting pain on others. Although sadistic tendencies have been observed among the most heinous of serial killers, the tendency to enjoy others’ suffering exists in many people to one extent or another. We know this because personality questionnaires that measure sadism reveal that “everyday” people often report some degree of sadistic impulses. These measures of sadism ask people to rate how accurately statements such as “I have hurt people for my own enjoyment” and “I enjoy making jokes at the expense of others” describe them.

However, it is unknown whether such sadistic pleasure is fleeting or long-lived, and whether negative feelings may also come into play when people behave sadistically. It may be that sadists experience the pleasure of aggression only briefly and that, in the long term, these feelings are replaced by aversive emotions. To answer these questions, my collaborators and I decided to give participants with varying levels of sadistic tendencies the opportunity to harm other people and then see how they actually felt before, during, and after the act.

We conducted eight studies involving more than 2,000 research participants in which participants could harm someone using laboratory aggression tasks. For instance, in several studies, participants could select how loud and how long to play extremely harsh noise into the headphones of another person. In another study, they could pick how much hot sauce someone who hated spicy foods had to eat.

Across our studies, the more participants indicated that they had sadistic tendencies on personality questionnaires, the more aggressive they were toward other people. This relationship between sadism and aggression held even after taking other antisocial traits such as psychopathy, narcissism, and impulsivity into account. Interestingly, sadistic participants were often just as aggressive toward innocent victims as they were toward people who had insulted or rejected them. So, it doesn’t seem like sadists lash out just at those who wrong them. Instead, sadistic aggression is indiscriminate.

Supporting the idea that sadists really do enjoy hurting other people, sadistic participants reported that they felt more pleasure during these aggressive acts than non-sadistic participants did.  

However, the sadistic pleasure experienced while being aggressive was not unconditional. In one study, we told half of our participants that their aggression actually hurt their victim (the noise blasts they administered caused the other person to have a painful migraine) or failed to actually hurt their victim (the noise blasts were just a little annoying). The graph below shows that sadists expressed more pleasure during the aggressive act only if they thought that their victim actually suffered. In fact, if sadists were told that their aggression had no harmful effect, they experienced less pleasure than non-sadistic participants did.

graph showing aggressive pleasure vs trait sadism


We also asked our participants how they felt soon after the aggressive act. Sadistic participants didn’t report any lingering afterglow from their hurtful behavior. Instead, they rated themselves higher on negative feelings such as sadness and anger.  In other words, sadistic acts may have made sadists feel good in the moment, but they made them feel bad soon after.

Taking a bird’s eye view of these results, we see that people who say they are sadistic on questionnaires actually are. They’re aggressive and they enjoy their aggressive acts—as long as their victims feel the sting. This finding has some potential uses as it shows that a source of sadistic pleasure is the victim’s pain. So, one way to take the wind out of sadists’ sails may be to show them that their victims aren’t really suffering from their actions. Yet, this counter-intuitive approach needs further testing before it is used as anything close to a clinical treatment for sadism.

But we also see that sadistic pleasure is a flash in the pan and fades quickly. In its place is the bitter aftertaste of anger and sadness. In this way, sadistic aggression looks a lot like alcohol consumption, binge eating, or risky sex—it feels good in the moment, but the buzz fades and leaves behind a hangover that people are desperate to get rid of. Just as people who are alcohol-dependent may treat a hangover with another round of drinks, sadists might respond to the post-aggression doldrums by seeking another victim.


For Further Reading

Chester, D. S., DeWall, C. N., & Enjaian, B. (2019). Sadism and aggressive behavior: Inflicting pain to feel pleasure. Personality and Social Psychology Bulletin, 45, 1252-1268.

Buckels, E. E., Jones, D. N., & Paulhus, D. L. (2013). Behavioral confirmation of everyday sadism. Psychological science24, 2201-2209.

Chester, D. S. (2017). The role of positive affect in aggression. Current Directions in Psychological Science, 26, 366-370.
 

David S. Chester is an Assistant Professor of Psychology at Virginia Commonwealth University. He studies the psychological and neurobiological forces that cause and constrain human aggression.

The Psychology of Ritualized Suffering

Human ritual behavior poses an intriguing conundrum. Throughout recorded history, people in all times and places around the world have spent great amounts of time, resources, and energy in organizing, performing, and attending collective ritual practices that, at first glance, offer no obvious benefits to their performers. In fact, certain cultural rituals even involve physical and psychological pain and suffering – think of practices like genital mutilation, piercing, cutting and self-flagellation, walking on burning embers or shoes made of nails, and other gruesome activities. Why do so many cultures have such extreme rituals that seem to go against some of our most basic instincts, such as the avoidance of pain and harm?

While anthropologists and scholars of religion have tried to understand the role of ritual in individual and social life since the very inception of their fields, psychological research has rarely focused on ritual. Given that ritual is a universal feature of all human cultures, this neglect constitutes a second noteworthy puzzle in itself. This situation, however, is beginning to change in recent years.

A number of interdisciplinary projects have brought psychologists and anthropologists together to investigate the multifaceted effects and functions of ritual practices as well as the underlying cognitive mechanisms involved. These projects are expanding psychological research beyond the narrow confines of the laboratory to conduct field experiments that increase the ecological validity of their findings. Importantly, this work is increasingly part of collaborative, interdisciplinary efforts that combine qualitative observation with innovative methodologies that bring quantification and rigorous testing of those theories.

For example, Emile Durkheim, often considered the father of sociology, argued that highly arousing collective events help cement social cohesion by producing an effect he called collective effervescence: the alignment of a crowd’s emotional states that results in a feeling of oneness with the group. One century after Durkheim’s insight, the concept of collective effervescence was one of the most touted anthropological terms, but remained untested and unmeasurable.

Using a mixed methods approach, my colleagues and I set out to study this emotional alignment during the performance of a fire-walking ritual in Spain.[i] My ethnographic observations and participant’s own testimonies seemed to support the effervescence hypothesis: “When we go up there, we all become one”, people told me. But would those subjective feelings be detectable at the physiological level? To find out, we used heart-rate monitors to measure emotional responses among performers as they were walking across burning embers, as well as among spectators who were merely watching. We found a spectacular degree of synchronicity in heart-rate patterns, which could be predicted based on the level of social proximity. That is, the closer any two local participants felt to each other, the more similar their heart rate activity was. In other words, we saw the very kind of emotional alignment that Durkheim had predicted.

Moving on to the behavioral level, my team and I conducted a study of an extreme ritual in Mauritius.[ii] This was the annual Thaipusam Kavadi ritual, where Hindu devotees of Muruga pierce their bodies with numerous needles, hooks, and skewers, carry heavy objects for hours under the burning tropical sun, and drag large chariots by chains pierced through their skin. We devised a donation task to examine the effects of ritual pain on supporting a communal goal. We found that the more pain participants felt, the more money they donated, and that this effect also extended to those who merely watched them get pierced. It appears that high-intensity rituals have cohesive effects for the entire community.

Looking at the effects of extreme rituals at the individual level, we found that prolonged suffering during a ceremony that involved walking on knives and burning coals resulted in performers feeling less tired and more euphoric after the event.[iii] And more recently, we found that participants’ psychological health increased after the performance of a painful ritual.

Overall, our quantitative results seem to support long-standing anthropological observations and theories. But how do these effects come about? Further research is needed to uncover the inner workings of ritual suffering. At a physiological level, endorphin release may be related to the euphoric sensations reported by our participants, similar to the “runner’s high” experienced by marathon runners. At the psychological level, engaging in a painful activity might retrospectively increase the personal salience of the event and feelings of affinity to those involved. And at the social level, participation in a costly ritual may signal one’s loyalty to the group: if you are willing to scar your body to celebrate your group membership, it is safe for others to assume that you are a committed and trustworthy member of that community. Thus, those who invest more heavily in their participation reap the rewards of social recognition, and groups that require such investments benefit from higher levels of cooperation.

Research on the psychology of ritual suffering has the potential to reveal valuable insights on human behavior that go far beyond religious rituals. From military drills to extreme sports and from fraternity ordeals to gang initiations, this research might shed more light on some of the ways in which human beings around the world find meaning, forge bonds, and build communities.


[i] Konvalinka et al. (2011). Synchronized arousal between performers and related spectators in a fire-walking ritual, Proceedings of the National Academy of Sciences (PNAS) 108 (20): 8514-8519.

[ii] Xygalatas et al. (2013). Extreme Rituals Promote Prosociality. Psychological Science 24(8): 1602–1605.

[iii] Fischer et al. (2014). The fire-walker’s high: Affect and physiological responses in an extreme collective ritual. PLOS ONE 9(2): e88355.


Dimitris Xygalatas is an experimental anthropologist at the University of Connecticut in the USA and visiting Associate Professor at Aarhus University in Denmark. He has previously held positions at the universities of Princeton and Masaryk, where he served as Director of the Laboratory for the Experimental Research of Religion. For more information, see www.xygalatas.com

It’s Not How Much Money You Earn That Affects Physical Pain

Most people who visit the emergency room report some kind of physical pain. Although pain is usually regarded as a physical issue, recent research has started to study pain from a much broader perspective. Indeed, pain has been found to be linked to socioeconomic factors like income, education, and employment, psychological states like stress, and a wide range of behaviors like drug use and generosity.

Research has documented that what matters for one's well-being is how much more or less a person has in comparison to others instead of how much money a person actually earns. This happens because humans tend to naturally compare themselves with similar people, for example, those who live in the same country, have the same degree, work in the same place, or even do the same tasks at work.

Social Comparisons and Pain

In one of my recent studies, I explored whether having less than others is likely to create physical pain. The data came from the Gallup World Poll and involved 1.3 million respondents from 146 countries worldwide. Respondents were asked whether they experienced physical pain the day before. In line with the idea that people care about whether their income is the highest or lowest in their comparison group, I found that people whose income ranked lower in their reference group reported greater physical pain than those whose income ranked higher.

One could think that what people actually earned was driving the link between income rank and pain because those with lower income rank also had a low level of income. To untangle this, I then took into account people's absolute level of income. The main findings held: People's relative standing in the income hierarchy mattered more for physical pain than the number of dollars earned.

What could explain these findings? It is well known that people suffer when they are worse off in comparison to a certain standard or comparison group. This means that if I have a lower income than you, I will suffer regardless of whether the income I earn allows me to have a great lifestyle. Research has documented that being relatively worse off can lead to negative feelings like envy, injustice, anger, and resentment. At the same time, neuroscientists have discovered that negative emotions and physical pain share the same brain mechanisms, proposing that negative emotions can create new pain. Having less than others may lead to negative feelings which could create physical pain.

In Both Rich and Poor Nations

I explored whether the link between pain and income differed among rich and poor populations in the world. According to standard economic reasoning, having low income should be more painful in poor than in rich countries. This is because the income of individuals at the bottom of the income distribution in poor countries is much lower than the income of those at the bottom of the income distribution in rich countries. I found the opposite. The link between income, both absolute and rank, and pain was the same across rich and poor nations. This suggests that it doesn't matter where you live: if you live in a poor country and are surrounded by poorer people you will be better off than someone who lives in a rich country and is surrounded by richer people.  

In the Workplace Too?

The role of relative income in well-being, including pain, can be found in everyday life and has particularly important consequences in the workplace. For instance, in an attempt to deal with the negative feelings that arise from having less income than others, employees may compete with their colleagues to climb the salary ladder. This competition may create a hostile working environment with negative consequences like lower job satisfaction and resignation. Employees' greater pain can also have important financial implications as pain has been found to be a key predictor of absenteeism and turnover: When those at the bottom of the salary hierarchy in the comparison group experience greater pain, the number of sick days and absenteeism rates are likely to increase.

Although pain can obviously be the consequence of a physical issue, pain can also be influenced by psychological factors. Indeed, this research uncovers that a well-known psychological aspect, namely social comparison, might have important consequences for people's pain. In a world in which the percentage of people in pain has been rising dramatically, knowing more about the determinants of pain has become increasingly relevant. Organizational leaders, scientists, and policymakers have now extra reasons to tackle inequalities to improve people's pain and overall well-being.


For Further Reading

Macchia, L. (2023). Having less than others is painful: Income rank and pain around the world. Social Psychological and Personality Science. Doi: https://doi.org/10.1177/19485506231167928


Lucia Macchia is a behavioral scientist with an interdisciplinary background. Her work involves quantitative research on human happiness, physical pain, and behavior. She is a Lecturer at City, University of London and a Visiting Fellow in the Department of Psychological and Behavioural Science at the London School of Economics.

Toddlers’ Socioeconomic Status Influences Others’ Perceptions of Their Pain

A kid stubs their toe while playing on the playground. Does how much pain they're believed to feel depend on how much money their parents make? This may sound like a crazy idea, but in earlier research, we found that people believed that adults with lower socioeconomic status felt less pain and required less pain treatment than adults with higher socioeconomic status. Now we asked, do people similarly judge children with lower socioeconomic status as feeling less pain than children with higher socioeconomic status?

In our research, participants viewed school profiles depicting male children with low and high socioeconomic status and judged how much pain each child would feel following various injuries (for example, he gets an injection in his arm or he knocks his head on the corner of a piece of furniture). Each school profile conveyed some basic information like the child's name and birthdate, as well as some socioeconomic information like household income and the type of school they attended (public or private). Every time, we found that children with lower socioeconomic status were the ones expected to feel less pain. This view was prevalent in judgments of older 6-8 year old children and even extended to children as young as 3-4 years old. Why might this be?

The Relationship Between Perceived Hardship and Pain Insensitivity

Why would people assume children from lower social class backgrounds feel less pain than others? Our earlier work and work from researchers at the University of Virginia found that when adults are perceived to have lived a harder life, they are also assumed to feel less pain. In other words, people seem to strongly endorse the age-old adage that "what doesn't kill you makes you stronger."

We were interested in whether the belief that hardship toughens may also apply to children. This time, participants rated children on how hard they thought their life had been and how much adversity they thought they had overcome before rating the children's pain sensitivity. Indeed, people perceived young children with lower social class as having lived harder lives and therefore as feeling less pain. Thus, beliefs about the toughening effects of poverty appear to be pervasive and influence perceptions of how much pain young children feel.

Consequences for Pain Treatment

People believed children as young as 3-4 years old felt relatively less pain if they were from lower socioeconomic status backgrounds, but do these beliefs actually impact responses to children's pain? In a final experiment, participants judged how much pain treatment children with lower and higher socioeconomic status would require following different injuries. Pain treatment could be no pain treatment at all, up to strong opioid (for example, morphine) treatments. Participants believed children with lower socioeconomic status would require less intensive pain treatment than children with higher socioeconomic status, and this pain treatment bias was accounted for by perceptions of pain sensitivity. In other words, children with lower social class were seen as feeling less pain and therefore as needing less intensive pain treatment than children with higher social class following the same injuries.

Beyond Pain

Although the implications for pain treatment are clear, these beliefs may extend across many contexts. For example, teachers may offer shorter extensions to students with lower socioeconomic status who get injured, caretakers may be less worried about lower socioeconomic status children's pain and thus may not seek care, or coaches may be harsher to or overplay child athletes from lower-class backgrounds.

There is still much to learn, but these findings help shed light on just how pervasive class-based pain stereotypes may be. Given that young children may often rely on others around them to seek care and advocate for them, understanding that perceivers may apply class-based pain stereotypes in judgments of children is imperative.


For Further Reading

Summers, K. M., Paganini, G. A., & Lloyd, E. P. (2022). Poor toddlers feel less pain? Application of class-based pain stereotypes in judgments of children. Social Psychological and Personality Science, 19485506221094087. https://doi.org/10.1177/19485506221094087

Summers, K. M., Deska, J. C., Almaraz, S. M., Hugenberg, K., & Lloyd, E. P. (2021). Poverty and pain: Low-SES people are believed to be insensitive to pain. Journal of Experimental Social Psychology, 95, 104116. https://doi.org/10.1016/j.jesp.2021.104116


Kevin M. Summers is a graduate student of psychology at the University of Denver in the Affect, Social, and Cognitive area. Kevin's research examines the mechanisms underlying group-based biases in person perception and the downstream consequences for differential treatment in a variety of contexts.