Kelly S. Clemens
John Matkovic
Abby Odelson1,†
Eric D. Wesselmann- 1Department of Psychology, Illinois State University, Normal, IL, United States
- 2Department of Health Sciences, Illinois State University, Normal, IL, United States
Pain is an unpleasant and unavoidable part of the human experience, but the prevalence and impact of pain disproportionately impacts marginalized groups, including transgender and gender-diverse people. While there are many bases of pain, psychosocial variables, including cognitions (e.g., outcome and interpersonal expectations, social gender norms), affect (e.g., negative affectivity, emotional distress), and social factors (e.g., social exclusion) may be particularly relevant in the pain experiences of transgender individuals. The coalescence of these factors is discussed in this review, where authors specifically consider how these cognitive, affective, and social factors may contribute to pain disparities seen in transgender individuals. Patient-centered communication is presented as a potential avenue to directly mitigate the effect of these psychosocial variables on pain in transgender individuals by reducing feelings of social exclusion transgender patients may experience in the medical office, and the authors call for additional experimental research and the development of educational interventions for providers.
1 Introduction
Pain is a pervasive human experience; however, the prevalence and impact of pain varies significantly across different populations, with members of marginalized groups reporting greater pain occurrence and intensity than those without minority-group status (1, 2). Transgender individuals (i.e., individuals whose gender does not match their sex assigned at birth) in the United States, representing nearly .6% of the population aged 13 and older, or nearly 1.6 million individuals (3) have faced stigmatization and exclusion in the medical field and society broadly (4, 5). While research has considered binary sex and gender differences in pain for cisgender individuals [e.g., (6)], little research has considered gender differences in pain for transgender individuals or people who identify outside of the gender binary.
Pain experiences are shaped by a complex interplay of biological, psychological, social, and cultural factors (7–9). The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (10). Nociception, the process by which the body detects and responds to painful stimuli, can be altered by psychosocial factors, creating the subjective perception of pain through cognitive appraisals, learning, recalling past experiences, and active decision making (11). For example, individuals experiencing trauma or chronic stress may develop a heightened sensitivity to pain due to increased activity in pain-processing brain regions (12).
Understanding the complexity of pain experiences provides insight into how gender may shape those experiences. Gender refers to the dynamic internal sense of being a woman, man, a different gender or multiple genders, or having no gender at all, a definition endorsed by the American Medical Association (13). This differs from, but is often conflated with, biological sex, the multidimensional construct based on individuals' anatomical and physiological traits (14). Gender shapes how people navigate the world and their health due to influences of social gender norms, the socially constructed roles and behaviors that a culture deems appropriate for people based on gender (15). Gender shapes expectations, experiences, emotions, and behaviors, amongst other factors, through social gender norms. These, in turn, may shape pain experiences.
Transgender individuals then, may be uniquely impacted by the role of gender in shaping pain. However, pain research in the transgender community has been limited by systemic biases that often exclude them in medical and psychological research, and the broader marginalization of transgender individuals in healthcare. Specifically, many studies have focused on cisgender populations, failing to account for the unique physiological, psychological, and social stressors that transgender individuals face, including the effects of gender-affirming medical treatments [but see (16)]. Further, funding disparities, institutional barriers, and failure to oversample the transgender community also contribute to the underrepresentation of transgender individuals in pain research.
Beyond the influence of gender norms, transgender individuals often experience unique challenges in navigating the healthcare system (16), including fear of rejection, mistrust in providers, and providers' lack of knowledge about transgender identities (17). Furthermore, transgender individuals experience increased rates of mental health concerns (18) and overall more negative affectivity associated with minority stressors (19). These psychosocial barriers may exacerbate existing pain disparities and limit access to and effectiveness of pain treatment.
Our paper contributes to the literature by reviewing research on the interplay among cognitive, affective, and social factors on pain in other marginalized groups and extending it to transgender individuals. We also provide recommendations for future research and practical and evidence-driven ways to mitigate pain disparities for transgender individuals in the medical context.
2 Cognitive factors
Cognitive factors, the ways that individuals perceive, remember, think, and reason, influence an individual's experiences of pain (20), and ample evidence has emerged identifying both specific cognitive pathways [e.g., attention, self-efficacy, learning; (21)] and mechanisms by which these pathways influence nociceptive input (11). While these factors have been well-studied in cisgender individuals, we will identify those cognitive pathways which may be particularly important to the experience of transgender individuals: expectations and social gender norms.
2.1 Expectations
Pain responses are influenced by individuals' (1) expectations of experiencing pain [i.e., outcome expectations; (22)], (2) expectations around their social relationships and social context [i.e., interpersonal expectations; (23)], and (3) expectations regarding their ability to manage pain [i.e., self-efficacy expectations; (24)].
Interpersonal expectations, or future-focused beliefs regarding social interactions, may shape pain experiences directly or indirectly. Evidence indicates transgender individuals may avoid healthcare interactions due to expectations of discrimination (25), which may indirectly increase pain experiences due to delayed treatment initiation and disease progression. One study found that transgender individuals who delayed care due to fear of discrimination reported worse health than those who did not delay or delayed for other reasons (26). Other research found transgender patients expected to receive substandard care because of concerns about providers' ability to work with them on medical issues, and the acceptance of their identity (5).
Previous research demonstrated that beliefs about a physician's empathy and competence (i.e., interpersonal expectations) predict outcome expectations for medical treatments (27). While no known studies have considered pain-related outcome expectations specifically in transgender individuals, poor outcome expectations, stemming from the aforementioned interpersonal expectations around a transgender individual's beliefs about providers' ability to effectively treat their concerns, may negatively influence both pain experiences and the effectiveness of pain treatments. Evidence exists for differences in pain-related expectations in other marginalized groups, such as racial minorities. This may influence disparities in treatment and may also exist for transgender individuals (2).
Self-efficacy expectations have also been found to mediate gender differences in pain. Perceived physical self-efficacy and task-specific self-efficacy partly account for gender differences in pain response (28). Pain self-efficacy also affects pain behavior, pain-associated disability, and illness perceptions (29, 30). A survey of LGBT individuals in Taiwan reported lower self-efficacy and mental health help-seeking behavior among the LGBT sample compared to an age-matched general sample, and at least 28 of the 70 LGBT individuals surveyed were transgender (31). Importantly, the results were not stratified by gender identity, and therefore it is unclear whether the patterns observed among the overall LGBT sample apply equally to transgender respondents. Additional research looking at transgender individuals specifically is warranted. Relatedly, a more external locus of control is associated with greater headache disability (32) and is predictive of results of physical therapy targeting chronic pain (33). Emerging evidence suggests that transgender individuals may have a more internal locus of control than other members of the queer community (34), which may have implications for their pain experiences.
2.2 Social gender norms
Social norms, or the perceived, implicit rules that govern acceptable behavior, are another important pathway by which cognition may influence pain for transgender individuals. While much of the literature on gender differences in pain conflates sex and gender, evidence demonstrates that women are more pain sensitive and have a lower pain threshold than men (35). Studies have also shown that high gender identification (36) and endorsement of gendered expectations for pain (37) either wholly or partially explain this effect. Further, in a study by Robinson and colleagues (38) manipulating expectations about gendered pain tolerance eliminated gender differences. Thus, the differential influence of gender, gender norms, and sex remains in question. No known studies have examined how transgender individuals, who may have been influenced by both masculine and feminine gender norms, may experience pain because of these conflicting norms. Some research suggests that shifting salient thoughts of gender interacts with a person's tendency toward masculinity and femininity, though the nature of these interactions is complex (39). Further, other studies have identified that body image is a salient predictor of pain, and this may interact with biological sex and gender-based expectations to influence pain (40). More research is needed to understand (1) what gender norms surround pain in transgender individuals, (2) if those norms fall into existing categories of femininity and masculinity, or into novel categories, (3) what norms exist for those outside of the gender binary, and (4) how these norms influence transgender individuals.
3 Affective factors
The connection between negative affect and pain is well-established (41–43). Pain can be both a contributing factor to and a symptom of emotional distress. For example, while experiencing physical pain can increase a person's level of negative affective symptoms such as anxiety and depression (44), affect itself, and particularly negative affect, can also modulate an individual's pain perception, leading to increased pain (45–48). Affect presents an important dimension for understanding pain differences in transgender individuals, given their higher rates of negative affect than their cisgender counterparts (49), likely due to minority stress and increased rates in affective disorders.
3.1 Minority stress and pain
The minority stress model provides a framework for understanding why transgender individuals are more likely to experience negative affective consequences. Minoritized populations face external factors of discrimination more often than the majority, including social stigma, microaggressions, harassment, systemic discrimination, and violence (50). These factors significantly contribute to negative affect in marginalized groups (51–53), including transgender individuals (54, 55).
Chronic anxiety, hypervigilance, and discrimination can lead to increased levels of pain through sources such as inflammation, pain sensitivity, and migraines in transgender and other marginalized individuals (56–58). For example, racial discrimination and sexual orientation discrimination consistently predict pain (2), and sexual orientation discrimination predicts pain disparities (59). Other research suggests these pain disparities can be intensified when one has multiple marginalized identities, such as for queer persons of color (60). This is important to consider for transgender individuals, as transgender individuals are overrepresented in racial minority groups (61) and these transgender and nonbinary people of color demonstrate worse health outcomes outside of pain [e.g., (62, 63)].
3.2 Psychological distress and pain
Transgender individuals demonstrate elevated rates of mental health disorders (64, 65). The prevalence of depression amongst transgender and gender diverse adults was 51.3% in 2022, compared to 21.1% of cisgender individuals, and the prevalence of general mental distress in transgender individuals (38.9%) was also more than twice that of cisgender people [15.5%; (66)]. Similarly, rates of anxiety disorders (67) and posttraumatic stress disorder (68) are higher in transgender individuals (68). Evidence indicates strong connections among depression (69), anxiety disorders (56, 70), posttraumatic stress disorder (71) and pain. Thus, the disparities in mental health seen in transgender individuals may be involved in exacerbating disparities in pain.
Relatedly, transgender individuals who experience gender dysphoria, defined as clinically significant distress or impairment relating to gender incongruence (72), experience higher rates of stomach pain, panic attacks, and sensory issues (73), which may contribute to pain experiences. In comparison, those who experience gender euphoria have reduced negative affect and overall pain (56, 70), highlighting the potential influence of clinically relevant gender-related distress.
Discrimination and psychological distress are significant contributors to negative affect and chronic pain in this population. Understanding these factors is crucial for developing effective interventions that address the unique needs of transgender individuals. By considering the impact of affect on pain perception and experiencing physical symptoms, clinicians can develop targeted strategies for reducing suffering and improving quality of life among transgender individuals.
4 Social factors
Pain can be experienced because of physical or social injuries. Instances of social exclusion (situations in which someone feels physically or emotionally separated from others, such as being ignored) cause both hurt feelings and activates brain regions typically associated with physical pain experiences (74, 75). Further, these types of pain can have overlapping precursors and outcomes, exacerbating the individual experiences of each type (76). One common physiological explanations for this overlap involves interpersonal discrimination [a form of social exclusion; (77)] as a stressor, which thereby increases allostatic load (57), which activates the hypothalamic-pituitary-adrenal axis and sympathetic nervous system, increasing pain (78). Given the amount gender-related discrimination, microaggressions, and other forms of social exclusion transgender individuals often experience in daily life, this process may be particularly relevant (79, 80). Any exclusionary experiences within the medical context can exacerbate pain and other medical concerns.
5 A case for patient-centered communication (PCC)
Improving the communication between patients and physicians is an important goal among physicians. While prospective physicians receive training in PCC, research indicates emotional and empathetic responses are lacking in patient-physician interactions (81). Time spent on interpersonal communication training is often short, and studies have documented the need for improved communication (81).
Central to PCC is the concept of involving patients in treatment decision-making (82, 83). According to Naughton (82), PCC has three primary principles: allowing patients to fully explain their concerns, understanding the full context of patients' health, and working together with patients to reach shared treatment decision-making. Through these principles, PCC encourages physicians to embrace the role of “helper”, utilize open-ended questions, encourage patients to share concerns, and better understand the patient's point of view (83). When patients receive more patient-centric care, they report better symptom recovery, improved emotional health, and higher levels of treatment adherence (84, 85). They also report higher clinician satisfaction, satisfaction in overall care, and greater trust in their providers (86, 87). Thus, PCC can have an overall improvement on patient quality of life.
5.1 PCC and pain
Patient-centered communication has also been examined for its utility in addressing pain in patients. Research indicates that the level of PCC, and expressed empathy, can change based on whether a patient exhibits physical manifestations of pain (88). Thus, elicitation of pain and feelings from a physician is crucial to PCC. If a patient is not encouraged to fully describe pain, they may not receive the most appropriate pain care (88).
5.2 The case for PCC in transgender care
The current state of care for transgender patients presents opportunities for intentionally increasing PCC. For example, transgender patients often find patient-provider interactions lacking, feeling disrespected, invalidated, and judged by medical providers, or asked inappropriate questions (89–91). Many concerns expressed by transgender patients could be remedied through improved communication and empathy, with an emphasis on inviting the patient to be involved in treatment decisions (83, 91) and acting in accordance with standards of care for the health of transgender and gender diverse people (92). Positive patient-provider relationships, facilitated through PCC, may affirm transgender patients' identities, which in turn may protect against relevant feelings of exclusion and negative health-relevant cognitions (93). One strategy to better engage in PCC could involve measuring transgender and nonbinary patients' feelings of pain invalidation in order to address it in subsequent conversations (94).
Further, qualitative studies have shown transgender patients' needs are not being fully explored by physicians; when this occurs, a patient may have their pain missed, downplayed, or ignored (88, 90). Importantly, PCC may play a role in reducing patients' pain, improving their overall health, and improving the patient-provider relationship.
6 Conclusion
Disparities in pain experiences and management among transgender individuals represent a critical and underexplored area of healthcare inequity. Previous research has highlighted the psychophysiological underpinnings that explain the connections among cognitions (11), emotions (95), social exclusion (78), and pain. In this article, we highlight how these factors converge for transgender individuals, potentially explaining disparities in pain experiences.
Transgender individuals often report negative healthcare experiences due to discrimination and stigma (96), contributing to negative expectations about future healthcare encounters, exacerbating pain and delaying treatment. The influence of social gender norms around pain, often rooted in binary conceptions of masculinity and femininity, complicate the understanding of pain experiences as transgender individuals may experience conflicting norms. Minority stress and psychological distress, which are common in transgender individuals, can also worsen pain experiences. Finally, social exclusionary practices and microaggressions not only increase pain but also erode trust in healthcare providers, further marginalizing transgender patients.
The overlap between physical and social pain underscores the importance of addressing interpersonal discrimination and fostering inclusive environments within medical contexts. We propose that patient-centered communication (PCC) is one pathway to addressing these factors; recommending physicians invite patients into the decision-making process, make patients feel welcomed through inclusive and gender affirming language, avoid making gendered assumptions about medical care, and make efforts to understand the full context of the patient's health thereby reducing negative cognitions, affect, and experiences of social exclusion. These actions are recommended to improve patient-provider relations, build trust, and reduce feelings of patient-discrimination.
While a basis for understanding the mechanisms of the differential pain experiences in transgender and other gender-diverse people exists, there is no extant experimental research that examines these mechanisms and contextual differences. This gap needs to be addressed by future research. Additionally, care should be taken when conducting research to ensure consistent, precise language is used so research may be generalized to the broader transgender community, and ultimately, help improve transgender individuals' pain experiences. Uniformly applying terms such as gender identity, gender presentation, and adherence to gender role norms is crucial to improving access to this topic throughout the literature. Addressing these cognitive, affective, and social factors requires systemic intervention to reduce stigma. Providers need evidence-based educational interventions to ensure that all those involved in patient care are knowledgeable about the issues that transgender patients face and so that they are equipped to deal with these issues in a patient-centered way.
Medical providers and researchers should intentionally represent the experiences of transgender individuals, particularly transgender people of color. Recruiting these samples presents a challenge due to their small proportion within the general population and the historical distrust that both transgender individuals and people of color may have toward researchers. Nevertheless, we emphasize the importance of making concerted efforts to include these populations in research. We also encourage researchers to capture both gender and sex variables and intentionally oversample and recruit this population when exploring the influence of psychosocial factors on pain using previously validated measures. Future research is needed to determine and validate modifications to existing tools in transgender populations or develop new cognitive pain assessments aimed at those outside the gender binary to provide more accurate pain representations experiences in transgender populations.
Addressing pain disparities in transgender individuals demands a multifaceted approach that integrates cognitive, affective, and social perspectives with empathetic and inclusive healthcare practices, ensuring that transgender individuals receive equitable, affirming, and effective pain care. By doing so, the medical community can take a meaningful step toward mitigating health inequities and improving quality of life for transgender patients.
Author contributions
KC: Supervision, Writing – original draft, Writing – review & editing. JM: Writing – original draft, Writing – review & editing. AO: Writing – original draft, Writing – review & editing. AS: Writing – original draft, Writing – review & editing. EW: Supervision, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Campbell CM, Edwards RR. Ethnic differences in pain and pain management. Pain Manag. (2012) 2:219–30. doi: 10.2217/pmt.12.7
2. Meints SM, Cortes A, Morais CA, Edwards RR. Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Manag. (2019) 9:317. doi: 10.2217/pmt-2018-0030
3. Herman JL, Flores AR, O’Neill KK. How Many Adults and Youth Identify as Transgender in the United States? Los Angeles, CA: UCLA Williams Institute (2022).
4. Casey LS, Reisner SL, Findling MG, Blendon RJ, Benson JM, Sayde JM, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. (2019) 54(Suppl 2):1454–66. doi: 10.1111/1475-6773.13229
5. Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med 1982. (2013) 84:22–9. doi: 10.1016/j.socscimed.2013.02.019
6. Osborne NR, Davis KD. Chapter eight - sex and gender differences in pain. In: Moro E, Arabia G, Tartaglia MC, Ferretti MT, editors. International Review of Neurobiology. Cambridge, MA: Academic Press (2022). p. 277–307. Available at: https://www.sciencedirect.com/science/article/pii/S007477422200071X (Accessed 2024 November 23).
7. Bobey MJ, Davidson PO. Psychological factors affecting pain tolerance. J Psychosom Res. (1970) 14:371–6. doi: 10.1016/0022-3999(70)90003-6
8. Hampton T. A world of pain: scientists explore factors controlling pain perception. JAMA. (2006) 296:2425–7. doi: 10.1001/jama.296.20.2425
9. Soetanto ALF, Chung JWY, Wong TKS. Are there gender differences in pain perception? J Neurosci Nurs J Am Assoc Neurosci Nurses. (2006) 38:172–6. doi: 10.1097/01376517-200606000-00006
10. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised international association for the study of pain definition of pain: concepts, challenges, and compromises. PAIN. (2020) 161:1976. doi: 10.1097/j.pain.0000000000001939
11. Khera T, Rangasamy V. Cognition and pain: a review. Front Psychol. (2021) 12:673962. doi: 10.3389/fpsyg.2021.673962
12. Creech SK, Smith J, Grimes JS, Meagher MW. Written emotional disclosure of trauma and trauma history alter pain sensitivity. J Pain. (2011) 12:801–10. doi: 10.1016/j.jpain.2011.01.007
13. AMA. Issue Brief: Best Practices for sex and Gender Diversity in Medical Education. Chicago, IL: American Medical Association (2023). Available at: https://www.ama-assn.org/system/files/cme-issue-brief-sex-gender-medical-education.pdf (Accessed 2024 November 23).
14. Bates N, Chin M, Becker T. Measuring sex, Gender Identity, and Sexual Orientation. Washington, D.C.: National Academies Press (2022). Available at: https://www.nap.edu/catalog/26424 (Accessed 2024 December 5).
15. Cislaghi B, Heise L. Gender norms and social norms: differences, similarities and why they matter in prevention science. Sociol Health Illn. (2020) 42:407–22. doi: 10.1111/1467-9566.13008
16. Shuster SM. Trans Medicine: The Emergence and Practice of Treating Gender. New York, NY: New York University Press (2021).
17. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A, et al. Barriers to health care for transgender individuals. Curr Opin Endocrinol Diabetes Obes. (2016) 23:168–71. doi: 10.1097/MED.0000000000000227
18. Hajek A, König H-H, Buczak-Stec E, Blessmann M, Grupp K. Prevalence and determinants of depressive and anxiety symptoms among transgender people: results of a survey. Healthcare. (2023) 11:705. doi: 10.3390/healthcare11050705
19. Timmins L, Rimes KA, Rahman Q. Minority stressors and psychological distress in transgender individuals. Psychol Sex Orientat Gend Divers. (2017) 4:328–40. doi: 10.1037/sgd0000237
20. Nisbett RE, Schachter S. Cognitive manipulation of pain. J Exp Soc Psychol. (1966) 2:227–36. doi: 10.1016/0022-1031(66)90081-3
21. Diotaiuti P, Corrado S, Mancone S, Falese L, Rodio A, Siqueira TC, et al. Influence of cognitive orientation and attentional focus on pain perception. Int J Environ Res Public Health. (2021) 18:7176. doi: 10.3390/ijerph18137176
22. Fields HL. How expectations influence pain. Pain. (2018) 159:S3–S10. doi: 10.1097/j.pain.0000000000001272
23. Thompson CM, Pulido MD, Gangidi S, Han J, Arnold PM. Chronic pain patients’ evaluations of consultations: a matter of high expectations or expectations unmet? Patient Educ Couns. (2024) 129:108403. doi: 10.1016/j.pec.2024.108403
24. Raman S, Sharma P. Self-efficacy as a mediator of the relationship between pain and disability in chronic pain patients: a narrative review. Bull Fac Phys Ther. (2022) 27:42. doi: 10.1186/s43161-022-00101-y
25. Kcomt L, Gorey KM, Barrett BJ, McCabe SE. Healthcare avoidance due to anticipated discrimination among transgender people: a call to create trans-affirmative environments. SSM - Popul Health. (2020) 11:100608. doi: 10.1016/j.ssmph.2020.100608
26. Seelman KL, Colón-Diaz MJ, LeCroix RH, Xavier-Brier M, Kattari L. Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults. transgender Health. (2017) 2:17. doi: 10.1089/trgh.2016.0024
27. Peerdeman KJ, Hinnen C, van Vliet LM, Evers AWM. Pre-consultation information about one’s physician can affect trust and treatment outcome expectations. Patient Educ Couns. (2021) 104:427–31. doi: 10.1016/j.pec.2020.07.021
28. Jackson T, Iezzi T, Gunderson J, Nagasaka T, Fritch A. Gender differences in pain perception: the mediating role of self-efficacy beliefs. Sex Roles. (2002) 47:561–8. doi: 10.1023/A:1022077922593
29. Lau-Walker M. Relationship between illness representation and self-efficacy. J Adv Nurs. (2004) 48:216–25. doi: 10.1111/j.1365-2648.2004.03190.x
30. Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain behaviour. A prospective study. Pain. (2001) 94:85–100. doi: 10.1016/S0304-3959(01)00344-X
31. Wu C-Y, Lee M-B. Suicidality, self-efficacy and mental health help-seeking in lesbian, gay, bisexual and transgender adults in Taiwan: a cross-sectional study. J Clin Nurs. (2021) 30:2270–8. doi: 10.1111/jocn.15680
32. Nicholson RA, Houle TT, Rhudy JL, Norton PJ. Psychological risk factors in headache. Headache. (2007) 47:413–26. doi: 10.1111/j.1526-4610.2006.00716.x
33. Álvarez-Rodríguez J, Leirós-Rodríguez R, Morera-Balaguer J, Marqués-Sánchez P, Rodríguez-Nogueira Ó. The influence of the locus of control construct on the efficacy of physiotherapy treatments in patients with chronic pain: a systematic review. J Pers Med. (2022) 12:232. doi: 10.3390/jpm12020232
34. Podder P, Mukherjee T. A study on cognitive emotion regulation and locus of control in LGBT. IOSR J Humanit Soc Sci. (2016) 21(12):21.
35. Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. BJA Br J Anaesth. (2013) 111:52–8. doi: 10.1093/bja/aet127
36. Pool GJ, Schwegler AF, Theodore BR, Fuchs PN. Role of gender norms and group identification on hypothetical and experimental pain tolerance. Pain. (2007) 129:122–9. doi: 10.1016/j.pain.2006.10.008
37. Wise EA, Price DD, Myers CD, Heft MW, Robinson ME. Gender role expectations of pain: relationship to experimental pain perception. Pain. (2002) 96:335–42. doi: 10.1016/S0304-3959(01)00473-0
38. Robinson ME, Gagnon CM, Riley JL, Price DD. Altering gender role expectations: effects on pain tolerance, pain threshold, and pain ratings. J Pain. (2003) 4:284–8. doi: 10.1016/S1526-5900(03)00559-5
39. Martin RM. Influence of biological sex, trait gender, and state gender on pain threshold, pain tolerance, and ratings of pain severity. Personal Individ Differ. (2019) 138:183–7. doi: 10.1016/j.paid.2018.09.038
40. Kaya B, Boerner KE, Lord RC, Potter E, Dale C, Moayedi M. Body image, sex, gender, and pain: towards an improved understanding of pain mechanisms. Pain. (2024) 165:2673–8. doi: 10.1097/j.pain.0000000000003309
41. Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The role of psychosocial processes in the development and maintenance of chronic pain. J Pain. (2016) 17:T70–92. doi: 10.1016/j.jpain.2016.01.001
42. Feeney SL. The relationship between pain and negative affect in older adults: anxiety as a predictor of pain. J Anxiety Disord. (2004) 18:733–44. doi: 10.1016/j.janxdis.2001.04.001
43. Janssen SA. Negative affect and sensitization to pain. Scand J Psychol. (2002) 43:131–7. doi: 10.1111/1467-9450.00278
44. Ruiz-Aranda D, Salguero JM, Fernández-Berrocal P. Emotional regulation and acute pain perception in women. J Pain. (2010) 11:564–9. doi: 10.1016/j.jpain.2009.09.011
45. Ciaramella A. Mood spectrum disorders and perception of pain. Psychiatr Q. (2017) 88:687–700. doi: 10.1007/s11126-017-9489-8
46. Keefe FJ, Lumley M, Anderson T, Lynch T, Studts JL, Carson KL. Pain and emotion: new research directions. J Clin Psychol. (2001) 57:587–607. doi: 10.1002/jclp.1030
47. Kenntner-Mabiala R, Andreatta M, Wieser MJ, Mühlberger A, Pauli P. Distinct effects of attention and affect on pain perception and somatosensory evoked potentials. Biol Psychol. (2008) 78:114–22. doi: 10.1016/j.biopsycho.2008.01.007
48. Villemure C, Bushnell CM. Cognitive modulation of pain: how do attention and emotion influence pain processing? Pain. (2002) 95:195–9. doi: 10.1016/S0304-3959(02)00007-6
49. Kaufman G, Taniguchi H, Compton D. Life satisfaction and negative affect among trans men, trans women, and nonbinary individuals in a U.S. national sample. LGBT Health. (2024) 11:57–65. doi: 10.1089/lgbt.2022.0350
50. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. (2003) 129:674–97. doi: 10.1037/0033-2909.129.5.674
51. Bird CM, Webb EK, Schramm AT, Torres L, Larson C, deRoon-Cassini TA. Racial discrimination is associated with acute posttraumatic stress symptoms and predicts future posttraumatic stress disorder symptom severity in trauma-exposed black adults in the United States. J Trauma Stress. (2021) 34:995–1004. doi: 10.1002/jts.22670
52. Bostwick WB, Boyd CJ, Hughes TL, West B. Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. Am J Orthopsychiatry. (2014) 84:35–45. doi: 10.1037/h0098851
53. Farber R, Wedell E, Herchenroeder L, Dickter CL, Pearson MR, Bravo AJ. Microaggressions and psychological health among college students: a moderated mediation model of rumination and social structure beliefs. J Racial Ethn Health Disparities. (2021) 8:245–55. doi: 10.1007/s40615-020-00778-8
54. Tebbe EA, Budge SL. Factors that drive mental health disparities and promote well-being in transgender and nonbinary people. Nat Rev Psychol. (2022) 1:694–707. doi: 10.1038/s44159-022-00109-0
55. Wilson EC, Chen Y-H, Arayasirikul S, Raymond HF, McFarland W. The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support. AIDS Behav. (2016) 20:2203–11. doi: 10.1007/s10461-016-1409-7
56. Anger JT, Case LK, Baranowski AP, Berger A, Craft RM, Damitz LA, et al. Pain mechanisms in the transgender individual: a review. Front Pain Res. (2024) 5:1241015. doi: 10.3389/fpain.2024.1241015
57. Hobson JM, Moody MD, Sorge RE, Goodin BR. The neurobiology of social stress resulting from racism: implications for pain disparities among racialized minorities. Neurobiol Pain. (2022) 12:100101. doi: 10.1016/j.ynpai.2022.100101
58. Stocking SQ, Webb CK, Miller GH, Thomeer MB, Goodin BR, Sorge RE. Understanding risk of chronic pain development and related mental health disparities among transgender people: a review of current literature and future directions. J Pain. (2024):104681. doi: 10.1016/j.jpain.2024.104681
59. Zajacova A, Grol-Prokopczyk H, Liu H, Reczek R, Nahin RL. Chronic pain among U.S. sexual minority adults who identify as gay, lesbian, bisexual, or “something else”. PAIN. (2023) 164:1942. doi: 10.1097/j.pain.0000000000002891
60. Chae DH, Walters KL. Racial discrimination and racial identity attitudes in relation to self-rated health and physical pain and impairment among two-spirit American Indians/Alaska natives. Am J Public Health. (2009) 99:S144–51. doi: 10.2105/AJPH.2007.126003
61. Flores AR, Brown TNT, Herman JL. Race and Ethnicity of Adults who Identify as Transgender in the United States. Los Angeles, CA: UCLA Williams Institute (2016).
62. Smart BD, Mann-Jackson L, Alonzo J, Tanner AE, Garcia M, Refugio Aviles L, et al. Transgender women of color in the U.S. South: a qualitative study of social determinants of health and healthcare perspectives. Int J Transgender Health. (2020) 23:164–77. doi: 10.1080/26895269.2020.1848691
63. Seelman KL, Young SR, Tesene M, Alvarez-Hernandez LR, Kattari L. A comparison of health disparities among transgender adults in Colorado (USA) by race and income. Int J Transgenderism. (2017) 18:199–214. doi: 10.1080/15532739.2016.1252300
64. Hanna B, Desai R, Parekh T, Guirguis E, Kumar G, Sachdeva R. Psychiatric disorders in the U.S. transgender population. Ann Epidemiol. (2019) 39:1–7.e1. doi: 10.1016/j.annepidem.2019.09.009
65. Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, et al. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry. (2022) 34:292–359. doi: 10.1080/09540261.2022.2093629
66. Liu CH, Stevens C, Wong SHM, Yasui M, Chen JA. The prevalence and predictors of mental health diagnoses and suicide among U.S. College students: implications for addressing disparities in service use. Depress Anxiety. (2019) 36:8–17. doi: 10.1002/da.22830
67. Millet N, Longworth J, Arcelus J. Prevalence of anxiety symptoms and disorders in the transgender population: a systematic review of the literature. Int J Transgenderism. (2017) 18:27–38. doi: 10.1080/15532739.2016.1258353
68. Barr SM, Snyder KE, Adelson JL, Budge SL. Posttraumatic stress in the trans community: the roles of anti-transgender bias, non-affirmation, and internalized transphobia. Psychol Sex Orientat Gend Divers. (2022) 9:410–21. doi: 10.1037/sgd0000500
69. IsHak WW, Wen RY, Naghdechi L, Vanle B, Dang J, Knosp M, et al. Pain and depression: a systematic review. Harv Rev Psychiatry. (2018) 26:352. doi: 10.1097/HRP.0000000000000198
70. Bradford NJ, Rider GN, Spencer KG. Hair removal and psychological well-being in transfeminine adults: associations with gender dysphoria and gender euphoria. J Dermatol Treat. (2021) 32:635–42. doi: 10.1080/09546634.2019.1687823
71. Moeller-Bertram T, Keltner J, Strigo IA. Pain and post traumatic stress disorder – review of clinical and experimental evidence. Neuropharmacology. (2012) 62:586–97. doi: 10.1016/j.neuropharm.2011.04.028
72. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. 5th ed, text revision. Washington, DC: American Psychiatric Association Publishing (2022).
73. Pulice-Farrow L, Cusack CE, Galupo MP. “Certain parts of my body don’t belong to me”: trans individuals’ descriptions of body-specific gender dysphoria. Sex Res Soc Policy. (2020) 17:654–67. doi: 10.1007/s13178-019-00423-y
74. Eisenberger NI, Lieberman MD. Why rejection hurts: a common neural alarm system for physical and social pain. Trends Cogn Sci. (2004) 8:294–300. doi: 10.1016/j.tics.2004.05.010
75. Wesselmann ED, Grzybowski MR, Steakley-Freeman DM, DeSouza ER, Nezlek JB, Williams KD. Social exclusion in everyday life. In: Riva P, Eck J, editors. Soc Exclusion Psychol Approaches Underst Reducing its Impact. Cham: Springer International Publishing (2016). p. 3–23. doi: 10.1007/978-3-319-33033-4_1
76. Riva P, Wesselmann ED, Wirth JH, Carter-Sowell AR, Williams KD. When pain does not heal: the common antecedents and consequences of chronic social and physical pain. Basic Appl Soc Psychol. (2014) 36:329–46. doi: 10.1080/01973533.2014.917975
77. Smart Richman L, Leary MR. Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: a multimotive model. Psychol Rev. (2009) 116:365–83. doi: 10.1037/a0015250
78. Rabey M, Moloney N. I don’t know why i’ve got this pain!” allostasis as a possible explanatory model. Phys Ther. (2022) 102:pzac017. doi: 10.1093/ptj/pzac017
79. De Souza ER, Wesselmann ED. Subtle discrimination based on gender and gender identity. In: Nascimento IR, Neves ALM, dos Reis LN, editors. Segur E Violências Perspect Interdiscip Secur Violence Interdiscip Perspect. Curitiba, Brazil: Editora CRV Ltda (2022). p. 151–64.
80. Wesselmann ED, DeSouza ER, AuBuchon S, Bebel C, Parris L. Investigating microaggressions against transgender individuals as a form of social exclusion. Psychol Sex Orientat Gend Divers. (2022) 9:454–65. doi: 10.1037/sgd0000513
81. King A, Hoppe RB. “Best practice” for patient-centered communication: a narrative review. J Grad Med Educ. (2013) 5:385–93. doi: 10.4300/JGME-D-13-00072.1
82. Naughton CA. Patient-centered communication. Pharmacy. (2018) 6:18. doi: 10.3390/pharmacy6010018
83. Hashim MJ. Patient-centered communication: basic skills. Am Fam Physician. (2017) 95:29–34.28075109
84. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, et al. The impact of patient-centered care on outcomes. J Fam Pract. (2000) 49:796–804.11032203
85. Zolnierek KBH, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. (2009) 47:826–34. doi: 10.1097/MLR.0b013e31819a5acc
86. Handley SC, Bell S, Nembhard IM. A systematic review of surveys for measuring patient-centered care in the hospital setting. Med Care. (2021) 59:228–37. doi: 10.1097/MLR.0000000000001474
87. Elkefi S, Asan O, Yu Z, Yen T, Rowley S. Patient-centered communication’s association with trust, satisfaction, and perception of electronic health records use among newly diagnosed patients with cancer. Front Commun. (2024) 9:1391981. doi: 10.3389/fcomm.2024.1391981
88. Paul-Savoie E, Bourgault P, Potvin S, Gosselin E, Lafrenaye S. The impact of pain invisibility on patient-centered care and empathetic attitude in chronic pain management. Pain Res Manag. (2018) 2018:6375713. doi: 10.1155/2018/6375713
89. Asquith A, Sava L, Harris AB, Radix AE, Pardee DJ, Reisner SL. Patient-centered practices for engaging transgender and gender diverse patients in clinical research studies. BMC Med Res Methodol. (2021) 21:202. doi: 10.1186/s12874-021-01328-4
90. Ross KAE, Law MP, Bell A. Exploring healthcare experiences of transgender individuals. Transgender Health. (2016) 1:238–49. doi: 10.1089/trgh.2016.0021
91. von der Warth R, Metzner G, Körner M, Farin-Glattacker E. Exploring communication preferences of trans and gender diverse individuals—a qualitative study. PLoS One. (2023) 18:e0284959. doi: 10.1371/journal.pone.0284959
92. Coleman E, Radix AE, Bouman WP, Brown GR, De Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgender Health. (2022) 23:S1–S259. doi: 10.1080/26895269.2022.2100644
93. Stock ML, Gibbons FX, Beekman JB, Williams KD, Richman LS, Gerrard M. Racial (vs. self) affirmation as a protective mechanism against the effects of racial exclusion on negative affect and substance use vulnerability among black young adults. J Behav Med. (2018) 41:195–207. doi: 10.1007/s10865-017-9882-7
94. Nicola M, Correia H, Ditchburn G, Drummond PD. The pain-invalidation scale: measuring patient perceptions of invalidation toward chronic pain. J Pain. (2022) 23:1912–22. doi: 10.1016/j.jpain.2022.06.008
95. Gilam G, Gross JJ, Wager TD, Keefe FJ, Mackey SC. What is the relationship between pain and emotion? Bridging constructs and communities. Neuron. (2020) 107:17–21. doi: 10.1016/j.neuron.2020.05.024
Keywords: transgender (binary and non-binary), pain, exclusion, social pain, cognition, affect
Citation: Clemens KS, Matkovic J, Odelson A, Strain A and Wesselmann ED (2025) Psychosocial influences on pain in transgender individuals. Front. Pain Res. 6:1546526. doi: 10.3389/fpain.2025.1546526
Received: 17 December 2024; Accepted: 10 April 2025;
Published: 24 April 2025.
Edited by:
Laura Case, University of California, San Diego, United StatesReviewed by:
Troy Dildine, Stanford University, United StatesCopyright: © 2025 Clemens, Matkovic, Odelson, Strain and Wesselmann. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Kelly S. Clemens, a3NjbGVtMUBpbHN0dS5lZHU=
†These authors have contributed equally to this work