The gender pain gap in prehospital analgesia: the role of patient and provider gender – an analysis of 106,888 helicopter emergency medical service (HEMS) missions

Abstract

Background

Pain management is a core ethical principle in emergency medicine, yet gender-related differences in analgesic treatment have been reported. This study examines whether patient and emergency physician gender influence prehospital pain management.

Methods

This retrospective observational cohort study included all primary helicopter emergency medical service missions conducted by DRF Stiftung Luftrettung in Germany between January 2012 and June 2025. Adult patients (≥ 18 years) with a Glasgow Coma Scale score ≥ 11 and without airway management were analyzed. Pain severity was assessed using the Numeric Rating Scale (NRS). Patient characteristics, analgesic treatment, and emergency physician gender were analyzed using descriptive statistical methods. The study was approved by the Ethics Committee Freiburg (25-1272-S1, August 19th 2025).

Results

A total of 106,888 cases was included, of which 38.5% were female and 61.5% male. Initial pain severity was comparable between genders, with a similar distribution across NRS categories. Despite this, women received analgesic treatment less frequently than men (62.0% vs. 66.9%; p < 0.001), whereas a greater effect is seen when particularly examining the use of opioid analgesics (50.0% vs. 57.1%; p < 0.001). This finding is consistent across all pain severity subgroups. Pain scores at patient handover were similar for women and men, indicating comparable pain levels at the end of prehospital care.

Conclusions

Despite comparable pain intensity, women received analgesic and opioid treatment less frequently than men in prehospital care, indicating potential gender-based inequalities in pain management. These findings underscore the need for strategies to ensure equitable analgesic treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12916-026-05131-0.

Background

The adequate treatment of pain is a fundamental component of medical ethics and, particularly in emergency medical practice and represents one of the primary therapeutic goals [1]. Sex- and gender-specific differences in medical care have become an increasingly recognized topic in health research. Especially in pain management, studies have shown that women and men not only experience pain differently, but are being offered diverse treatment [2–4]. A recent study, addressing the frequency and intensity of pain therapy in emergency departments, revealed that pain in women was treated less frequently and less intensively [5]. In prehospital emergency medicine, where clinical assessment and decision making are to be made under pressure and in a time sparing manner, gender-based differences could unintentionally lead to disparities in care [6, 7]. However, there is a lack of systematic investigations into whether, and to what extent, a patient’s and an emergency physician’s gender influences pain management [6, 8].

The term “gender pain gap” originates from public health research and refers to differences in healthcare provision between men and women with chronic pain. These disparities are not limited to Germany, but have been observed across much of Europe in varying forms [9, 10]. Whether these differences can be extrapolated to the treatment of acute pain in emergencies remains uncertain and is the subject of this study.

The objective of the study is to systematically capture and analyze gender-specific difference in prehospital pain management by emergency physicians across various medical and trauma-related conditions. This study will examine whether male and female patients receive different care in terms of the implementation and intensity of pain treatment during emergency deployments.

Methods

Study design

This retrospective observational cohort study analyzed routine documentation from all primary helicopter emergency medical service (HEMS) missions conducted between January 2012 and June 2025 at all HEMS bases operated by DRF Stiftung Luftrettung (DRF, Filderstadt, Germany) across Germany. Each HEMS crew comprises at least one pilot, a HEMS Technical Crew Member (HEMS-TC) and an emergency physician. As an integral component of public emergency medical services (EMS), these helicopters are dispatched by regional emergency control centers alongside ground-based ambulance services for primary emergency response.

Data processing

Operational data from HEMS missions are systematically recorded in a dedicated database. Mission data were documented using a standardized electronic form within the HEMSDER database system (Convexis, Germany). Since August 2022, documentation has been conducted using the NIDApad system (medDV GmbH, Fernwald, Germany). For the purposes of this study, the following parameters were extracted for analysis: patient age and gender, emergency physician gender, diagnosis, airway management, Numeric Rating Scale (NRS) scores at initial assessment and at patient handover, Glasgow Coma Scale (GCS) scores at initial assessment and at handover, and administration of pain medication.

To ensure anonymization, a name-based algorithm was applied prior to data export to determine the gender of emergency physicians based on their first names. Patients who underwent airway management were not included in the study. Airway management procedures were categorized as follows: for the NIDA system (suctioning, intubation, preexisting intubation status, nasopharyngeal or oropharyngeal tube, and controlled ventilation) and for the HEMSDER system (endotracheal suctioning, controlled ventilation, endotracheal intubation, and other airway management). In accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) protocol, Fig. 1 depicts the exclusion process for patients with a GCS score < 11, those who received airway management, and individuals younger than 18 years [11]. Analgesic administration within the DRF Luftrettung HEMS system was guided by standardized internal protocols based on Numerical Rating Scale (NRS) assessment, consistent with national prehospital pain management guidelines. These protocols remained unchanged in their fundamental principles throughout the entire study period. For this study, the pain was classified according to established methods: no pain (NRS = 0), mild pain (NRS 1–3), moderate pain (NRS 4–6), and severe pain (NRS 7–10) [12]. The gender category “diverse” (n = 22) was excluded from the analysis. This group represented a negligible proportion of the sample (< 0.1%), and physician gender was recorded as male or female [10]. Taken all together, this investigation is limited to the socially predominant binary gender discrimination „man“ and „woman” to minimize confounding factors. We are fully aware of the existential data gap and the gender-based potential mistreatment that people outside this spectrum might suffer. Yet it is necessary to clearly distinguish between the examined subgroups. Assignment to the subgroups “man” and “woman” followed the gender designation on the patient’s identity documents without further investigation of biological sex traits. Surely, in this manner, there is also no tracing of chromosomal variations going alongside one or the other phenotype [13].

Fig. 1.

Study flow chart according to STROBE protocol

Statistical analysis and ethical approval

Continuous variables were described and compared using mean and standard deviation. Nominal variables were analyzed using the Pearson Chi-Square Test. The Pearson correlation was applied for two-sided testing and effect sizes were evaluated with Cohen’s d for independent samples. A t-test for independent samples was conducted. All tests were considered significant for p values < 0.05. Analysis was conducted using IBM SPSS Statistics 29 (Armonk, NY, USA). Both documentation systems required the mandatory entry of core variables, including the NRS score, administered medication, and patient sex, at the point of care, ensuring the completeness of the primary dataset by design. Analyses were performed on complete cases; given the negligible rate of missing data in key variables, formal imputation was not applied.

The study was approved by the Ethics Committee of the Albert-Ludwigs-University Freiburg (No: 25-1272-S1, August 19th 2025) and registered with the German Register of Clinical Studies (No: DRKS00037729, August 19th 2025).

Results

After exclusions as outlined in Fig. 1, a total of 106,888 cases were included in the analysis. Of these, 38.5% (n = 41,115) involved female patients and 61.5% (n = 65,773) male patients. Pain severity at initial assessment was comparable between women and men (4.94 ± 2.6 vs. 4.94 ± 2.6; p = 0.865) and showed a relatively even distribution across the three predefined pain categories. Specifically, NRS scores of 1–3 were observed in 36.4% of women and 36.0% of men, NRS 4–6 in 31.5% and 32.6%, and NRS 7–10 in 32.1% and 31.4%, respectively (Table 1). Binary logistic regression (Table 2) demonstrated that female patient sex was independently associated with a significantly lower likelihood of receiving opioid analgesia (OR = 0.905, 95% CI [0.881, 0.929], p < 0.001), after controlling for NACA score, trauma or non-trauma missions, patient age, and sex of the EMS provider. This finding indicates that the gender disparity in prehospital opioid administration persists as an independent effect.

Table 1.

Characteristics (SD = Standard Deviation, NRS = Numeric Rating Scale)

	Female 38.5% (41,115)	Male 61.5% (65,773)	p-Value	Total 106,888
Patient age (mean, SD)	60.2 ± 21.3	53.8 ± 19.1	-
NACA (mean, SD)	3,37 ± 0.82	3.56 ± 0.86	< 0.001	3.49 ± 0.85
Any analgesia received (%, n) (Fig. 2)	62.0% 25,480	66.9% 43,997	< 0.001	65.0% 69,477
Opioids received (%, n) (Fig. 2)	50.0% 20,556	57.1% 37,571	< 0.001	54.4% 58,127
Initial NRS (mean, SD)	4.94 ± 2.6	4.94 ± 2.6	0.865	4.94 ± 2.6
Pain Group (Initial)
Pain Group NRS 1–3	36.4% 14,984	36.0% 23,682	-	36.2% 38,666
Pain Group NRS 4–6	31.5% 12,932	32.6% 21,447	-	32.2% 34,379
Pain Group NRS 7–10	32.1% 13,199	31.4% 20,644	-	31.7% 33,843
Pain Group (Handover)
No Pain	13.5% 5,566	11.8% 7,733	-	11.5% 13,299
Pain Group NRS 1–3	72.6% 29,847	74.6% 49,048	-	73.8% 78,895
Pain Group NRS 4–6	12.7% 5,225	12.7% 8,334	-	12.7% 13,559
Pain Group NRS 7–10	1.2% 477	1.0% 658	-	1.1% 1,135
Emergency Physician (EP)
Female EP	20.4% 8,383	20.0% 13,134	0.095	20.1% 21,517
Male EP	79.6% 32,732	80.0% 52,639	0.095	79.9% 85,371
Any analgesia given by female EP (%, n) (Fig. 2)	63.4% 5,315/8,383	68.6% 9,009/13,134	< 0.001	66.6% 14,324/21,517
Any analgesia given by male EP (%, n) (Fig. 2)	61.6% 20,165/32,732	66.5% 34,988/52,639	< 0.001	64.6% 55,153/85,371
Diagnosis
Traumatic	51.4% 21,118	61.4% 40,353		57.5% 61,471
Non-traumatic	47.6 19,568	37.6% 24,708		41.4% 44,276
Unknown	1.0% 429	1.1% 712		1.1% 1,141

Table 2.

Binary Logistic Regression Predicting Opioid Analgesic Administration (Step 1)

Variable	B	SE	p	OR	95% CI for OR
					Lower	Upper
NACA score	0.562	0.008	< 0.001	1.754	1.726	1.783
Trauma mechanism	0.909	0.014	< 0.001	2.481	2.414	2.550
Patient age	−0.003	0.000	< 0.001	0.997	0.997	0.998
Sex of EMS provider (female vs. male)	0.089	0.016	< 0.001	1.093	1.059	1.128
Sex of patient (female vs. male)	−0.100	0.013	< 0.001	0.905	0.881	0.929
Constant	−2.117	0.038	< 0.001	0.120	—	—

Note. OR = odds ratio; CI = confidence interval; SE = standard error; NACA = National Advisory Committee for Aeronautics severity score. Variables entered in Step 1: NACA score, trauma mechanism, patient age, sex of EMS provider, sex of patient. Reference category for sex variables: female. Cut value = 0.500

Despite the presence of comparable baseline pain levels, analgesic management differed significantly between the two genders. In the overall population (NRS 1–10), analgesia was administered to 62.0% of women compared with 66.9% of men (p < 0.001). Opioid analgesia was provided to 50.0% of female patients, whereas 57.1% of male patients received opioid treatment (p < 0.001). This pattern of lower analgesic administration among women was consistently observed across all pain severity subgroups (Fig. 2). No differential treatment by gender of the emergency physician was observed; a 5% difference in analgesia treatment was observed between female and male physicians, with lower rates among female physicians (Table 1).

Fig. 2.

(a-f) The figures depict the proportion (%) of patients receiving analgesia stratified by pain severity (mild, moderate, and severe pain). Panel (a) shows the proportion receiving any analgesia across all entities, (b) opioid analgesia across all entities, (c) patients without trauma receiving any analgesia, and (d) trauma patients receiving any analgesia. Panels (e) and (f) present the proportion receiving any analgesia across all entities, stratified by male and female emergency physicians, respectively. All differences between female and male patients were statistically significant (p < 0.001) (EP = Emergency Physician, NRS = Numeric Rating Scale)

At patient handover, pain scores again showed minimal differences between women and men, indicating comparable pain levels at the end of prehospital care (Table 1; Fig. 3).

Fig. 3.

Reduction in pain intensity stratified by initial NRS score. Pain reduction was calculated as the difference between the NRS score at handover and the initial NRS score and is presented separately for female and male patients

Discussion

The findings showed comparable levels of reported pain between the two genders found within the prehospital HEMS setting. Yet fewer analgesics, particularly fewer opioids, were administered to female patients than to their male counterparts. This data contributes to the growing body of evidence demonstrating a persistent gender pain gap in acute care, where women’s pain is less aggressively treated even when severity is similarly documented [5, 14]. The discrepancy in the attending physician’s behavior was not being alleviated by his or her own gender. These results go along with various large data sets recorded in emergency departments or after hospital discharge, both of which settings also lack a sex concordance in treatment of pain and/or the prescription of opioids [5, 15]. Sex discordance has been associated with significantly worse outcomes for women in other medical settings [16].

While observing identical numeric pain scores between genders at initial evaluation and at handover, women were treated less with analgesics and specifically with opioids. In other words, the provider’s decision to — and how to — treat pain was associated with patient gender. Nonetheless, women’s documented NRS at handover showed the same reduction in perceived pain. This finding raises questions about previous statements attributing gender-based undertreatment primarily to differences in short-term responsiveness towards analgesics, although documentation bias, differential analgesic responsiveness, and nonpharmacological interventions represent alternative explanations for the comparable handover scores that cannot be excluded with the present data and are subject to further consideration within the Limitations Sects [5, 17, 18].

The results of the multivariate analysis confirm that the observed gender disparity in prehospital opioid administration is not merely a reflection of differences in mission severity or other patient characteristics such as age. Even after controlling for mission severity, trauma and non-trauma missions, patient age, and sex of the EMS provider, female patients remained significantly less likely to receive opioid analgesia. This independent effect suggests that the disparity cannot be attributed to female patients presenting with objectively less severe conditions or different mission profiles, but instead may reflect systematic differences in pain recognition and analgesic decision-making that are not explained by the clinical variables available in this registry-based dataset; given the retrospective observational design of this study, causal mechanisms cannot be established from these data. The magnitude of this effect, while statistically robust, remains modest (OR = 0.905), reflecting an approximately 10% reduction in the odds of opioid administration in female patients. In a cohort of this size, even effects of moderate clinical relevance reach high statistical precision, and the absolute effect at the level of an individual patient is small. Nonetheless, applied across the scale of nationwide HEMS operations, a consistent 10% reduction translates into a substantial number of women potentially receiving less analgesia than clinically required each year. This effect’s consistency across all subgroups, independent of mission severity, trauma status, and provider sex, underscores its practical significance.

The lack of association between emergency physician gender and the observed treatment gap supports the notion that implicit bias and structural factors are shared across providers, rather than being confined to one gender. This aligns with experimental vignette studies showing that both male and female clinicians tend to underestimate women’s pain and are less likely to recommend potent analgesia for female patients [5, 14].

Context with existing literature

Multiple reviews and empirical studies have documented that women often receive less or delayed analgesia compared with men in emergency and procedural settings, even after adjustment for pain scores and clinical covariates. For example, large emergency department datasets from two countries demonstrated that female patients with painful conditions were significantly less likely to be prescribed any analgesic at discharge, whether opioid or non-opioid, than male patients with comparable reported pain [5, 14].

Prehospital data reflect similar patterns: when suffering from isolated extremity injury, women were less likely to receive prehospital analgesia than men and were less likely to receive morphine, despite similar or higher pain scores [19, 20]. However, some studies, which evaluated data from emergency departments, have reported no gender differences or even higher rates of analgesic use in women, emphasizing substantial heterogeneity across settings and highlighting the need for large, methodologically robust analyses such as the present HEMS study [21–23].

Potential mechanisms underlying the gender pain gap

Several mechanisms may account for the reason why women receive fewer and less potent analgesics despite similar pain assessments:

• Stereotypes and implicit bias: Women’s pain is more frequently attributed to psychological or emotional causes, which can result in underestimation of symptom severity and more conservative pharmacologic treatment [14].

• Differential risk perception: Clinicians may overestimate the risk of opioid-related adverse events in women, such as nausea or respiratory depression, or may be more hesitant to use higher doses. This may be associated with a lower threshold for withholding opioids in female patients [17].

• Communication and documentation: Studies have shown that women’s pain scores and narratives are documented less consistently, and that women may need to report higher pain levels to receive equivalent treatment [5, 14].

The finding of no difference in NRS-adjusted pain reduction between genders in this cohort suggests that once treatment is initiated, titration is broadly similar. The primary inequity appears to lie in the decision to initiate and escalate analgesia, particularly opioids. These results interfere with a smaller study of 778 patients with higher rates of insufficient pain management among patients treated by a female physician [24].

The missing gender concordance of treatment behavior strengthens the overall impression of differing perspectives on pain, which depend on the perceived patient gender, and result being disadvantageous for women. The latter has a complex, long-standing history showing a downplaying of women’s pain [25]. The notion from multiple emergency departments describing higher analgesic or opioid use whenever the provider’s gender matched the patient’s gender [26] was not observed here, a pattern that corresponds with — though does not prove — structural rather than individual-provider factors underlying the disparity.

Although comparable NRS reductions at handover were documented across both sexes despite lower opioid administration rates in female patients (OR = 0.905), any decision to withhold or administer opioids must weigh the risk of adverse effects. Opioid-induced ventilatory impairment is among the most feared of these, as it does not strictly follow linear dose-dependency [27, 28]. Neither body mass index, sex, nor age alone significantly alters the risk of apnea/hypopnea [29]. A more cautious opioid threshold in female patients would not, by itself, explain this pattern; an alternative non-causal interpretation is that physicians underestimate pain more often in female patients. A small study of 77 emergency department patients found physician-documented pain has been underestimating patient pain in 70% of cases, this happening disproportionately often among women [30], a pattern echoed in studies of interactive pain assessment [31]. Taken together, these observations are compatible with the interpretation that opioid administration tracks more closely with physicians’ subjective assessment of pain than with patients’ ratings, although documentation bias and differences in analgesic responsiveness remain plausible alternative explanations that cannot be distinguished with the present data.

Given the acuity and time sensitivity of HEMS missions, systematic differences in analgesic use by patient gender are particularly concerning. Undertreatment of pain in female HEMS patients may contribute to avoidable suffering, impaired physiological stability, and a worse overall patient experience. The lack of modification by physician gender indicates that interventions should target systems and protocols, such as standardized pain-based analgesia algorithms and decision support, rather than focusing solely on individual provider characteristics. These findings support integrating explicit, gender-neutral pain management thresholds, such as NRS-based opioid titration protocols, into prehospital guidelines, coupled with feedback and audit on gender-stratified analgesia rates for HEMS teams. Some federal-state quality control authorities have already implemented gender-neutral quality indicators for prehospital pain therapy protocols [32].

Educational initiatives addressing implicit bias in pain assessment and management, anchored in data from large prehospital cohorts such as the present study, may help narrow the gender pain gap in this high-stakes environment.

Further studies investigating the gender pain gap in specific clinical presentations or its prevalence across different age groups, as well as the consistency of these results with those of ground-based emergency medical services, will be necessary to derive additional recommendations for action in daily practice.

Limitations

A notable strength of this study lies in its heterogeneous cohort, combined with nationwide coverage and exceptionally high case numbers. However, a key limitation is the inherently subjective and inter-individual nature of pain assessment, which may introduce variability into the reported pain scores. In particular, the handover pain assessment may be influenced by the emergency physicians` desire to have achieved successful treatment. Furthermore, we cannot account for the effects on pain intensity that were potentially being modulated by the quality of the interindividual relationship between the patient and his or her medical provider. Communication-based pain reduction has been supported by substantial data from periprocedural observations [33–35]. It is yet to be determined to what extent communication per se follows a certain gender bias, and to what extent hypnotic communication is able to modulate pain intensity in outer hospital deployments. Additionally, comparable handover NRS scores in the context of lower opioid administration rates in female patients may reflect greater analgesic responsiveness, a ceiling effect in prehospital pain reduction, or a documentation bias resulting from physicians’ inclination to record scores indicative of successful treatment — all of which limit the interpretability of handover NRS values as an objective outcome measure. Taken together, these considerations preclude a straightforward causal interpretation of the comparable handover pain scores and do not diminish the clinical relevance of the observed systematic difference in analgesic administration between male and female patients.

Patients with severe clinical courses were excluded (e.g., those requiring airway management or presenting with a Glasgow Coma Scale score < 11). Consequently, this analysis is limited to conscious, adult patients with pain, and the findings may not be generalizable to critically ill, hemodynamically or respiratory unstable, or non-communicative patient populations. Provider-level characteristics beyond physician sex — including years of clinical experience, medical specialty background, and individual team composition — were unavailable in this registry-based dataset and therefore could not be included in the multivariate model.

Conclusions

Based on the findings, potential treatment inequalities are identified. Despite comparable pain intensity at initial assessment and at patient handover, women received analgesic therapy less frequently than men. This discrepancy was particularly evident in the administration of opioid analgesia, suggesting a gender-based difference in pain management. These findings highlight the need to develop targeted strategies to ensure equitable pain treatment in prehospital care.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

EMS

Emergency Medical Service

GCS

Glasgow Coma Scale

HEMS

Helicopter Emergency Medical Service

HEMS-TC

HEMS Technical Crewmember

NACA

National Advisory Committee for Aeronautics (Score)

NRS

Numeric Rating Scale

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

Author contributions

AS: Formal analysis, Investigation, Writing - Original DraftJB: Data curation, Validation, Writing - Review & EditingLH: Validation, Writing - Review & EditingFR: Data curation, Validation, Writing - Review & EditingHJB: Validation, Writing - Review & EditingSH: Conceptualization, Methodology, Software, Investigation, Resources, Project administration, Supervision, Writing - Original DraftJG: Conceptualization, Methodology, Formal analysis, Investigation, Data Curation, Visualization, Writing - Original Draft.

Funding

Open Access funding enabled and organized by Projekt DEAL. This project has received financial support from the DRF Stiftung Luftrettung.

Data availability

The dataset analyzed in this study comprises sensitive pre-hospital patient data from helicopter emergency medical service (HEMS) operations, provided by DRF Luftrettung gGmbH under a restricted data-use agreement. Public deposition is not permissible due to: the classification of the data as special-category personal health data under Art. 9 GDPR and applicable German data protection legislation; the scope of patient consent; contractual restrictions imposed by the data owner; and applicable ethical requirements. Data may be made available to qualified researchers upon reasonable request. Requests should be directed to the Scientific Advisory Board (Wissenschaftlicher Arbeitskreis) of DRF Luftrettung gGmbH via WAK@drf-luftrettung.de. Access is subject to review and approval by the WAK- Board, execution of a formal data use agreement, and compliance with applicable data protection regulations. Any approved data use is restricted to the purposes specified in the access agreement; downstream redistribution and unrestricted secondary use are not permitted.

Declarations

Ethics Approval

The trial was approved by the Ethics Committee of the Albert-Ludwigs-University Freiburg (No: 25-1272-S1, August 19th 2025) and registered with the German Register of Clinical Studies (No: DRKS00037729, August 19th 2025). This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Informed consent was not required for this retrospective study, as only anonymized data were used, and the study was approved by the appropriate ethics committee.

Consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.

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