Background & Aims

Racial bias in pain recognition is well documented. Clinical and laboratory studies show that pain is under-recognized and under-diagnosed in Black compared to White patients (e.g., Anderson, 2009; Lin et al., 2020; Mende-Siedlecki et al., 2022; Staton et al., 2007). Disparities extend to painkiller prescriptions (e.g., Becker et al., 2011; Olsen et al., 2006). Independent studies demonstrate that inferences from facial appearance, including trustworthiness, impact emotion recognition, doctors’ judgments, and priority treatment in emergency units (Bagnis et al. 2020, 2023). This study aims to deepen our understanding of the interplay between racial bias and facial appearance-based inferences of trustworthiness when decoding others’ pain. We explore the effects that facial trustworthiness and skin color have on pain recognition in individuals with different levels of heart rate variability (HRV), used as a proxy for the biological predisposition to recognize emotional states in others.

Methods

Given the relevance of this study for healthcare, 68 (37 women, 31 men, aged 19-31 years, M = 20.73, SD = 1.90) medical students from the University of Bologna were recruited. The sample size was determined using G*Power software, indicating that 56 participants were required for a statistical power of 0.95 and alpha = 0.05. After the HRV assessment, participants took part in a pain recognition task in which they watched video clips of White and Black faces, with different levels of perceived trustworthiness, transitioning from a neutral to an intense expression of pain. They stopped the videos as soon as they recognized the pain, rated the intensity of the pain, and indicated the likelihood of treatment. The response times in ms, the perceived intensity, and the likelihood of therapy on Likert scales (0 = not at all intense/likely to 10 = extremely intense/likely) were recorded and analyzed. Implicit racial bias was measured using the Implicit Association Test.

Results

Pain was recognized slower (F(1,64) = 28.80, p < .001, ?p2 = .31), and estimated as less intense in Black compared to White faces (F(1,64) = 50.25, p = .001, ?p2 = .44), and this was reflected in the likelihood of recommending therapy (F(1,64) = 30.84, p < .001, ?p2 = .33). Pain recognition was faster for untrustworthy-looking White faces compared to trustworthy ones, while perceived trustworthiness had a minimal impact on pain detection in Black faces (F(1,64) = 5.72, p = .02, ?p2 = .08). However, untrustworthy-looking faces were estimated to express more pain, particularly for Black faces (F(1,64) = 14.88, p < .001, ?p2 = .19). These biases were particularly exhibited in individuals with Low-, rather than High-tonic HRV (F(1,64) = 7.58, p = .008, ?p2 = .11). IAT scores were found not to be statistically significant.

Conclusions

Present data show how the interplay between invariant facial features, such as skin color, and facial appearance-based inferences of trustworthiness can influence pain recognition in medical students. The results confirm the existence of racial disparities in pain perception and treatment recommendations and support the notion that perceptual bias plays a central role in this issue (Lin et al., 2020; Mende-Siedlecki et al., 2019; 2022). The alignment of appearance-based attributions of trustworthiness with the intrinsic valence of a face also emphasizes the shift from configural face processing to feature-based processing in the perception of pain in Black faces. The current data add to the body of evidence supporting the role of HRV as an indicator of the ability to recognize facial expressions and behavioral intentions of others, suggesting an increased susceptibility to racial bias in pain recognition in individuals with lower HRV (Bagnis et al., 2023; Quintana et al., 2012).

References

Anderson, K. O., Green, C. R., & Payne, R. (2009). Racial and ethnic disparities in pain: Causes and consequences of unequal care. The Journal of Pain, 10(12), 1187–1204. https://dx.doi.org/10.1016/j.jpain.2009.10.002

Bagnis, A., Caffo, E., Cipolli, C., De Palma, A., Farina, G., & Mattarozzi, K. (2020). Judging health care priority in emergency situations: patient facial appearance matters. Social Science & Medicine, 260, 113180. https://doi.org/10.1016/j.socscimed.2020.113180

Bagnis, A., Ottaviani, C., & Mattarozzi, K. (2023). Face your heart: resting vagally mediated Heart Rate Variability Shapes Social Attributions from facial appearance. Current Psychology, 1-9. https://doi.org/10.1007/s12144-023-04339-0

Becker, W. C., Starrels, J. L., Heo, M., Li, X., Weiner, M. G., & Turner, B. J. (2011). Racial differences in primary care opioid risk reduction strategies. The Annals of Family Medicine, 9(3), 219-225. https://doi.org/10.1370/afm.1242

Lin, J., Drain, A., Goharzad, A., & Mende-Siedlecki, P. (2020). What factors fuel racial bias in pain perception and treatment?: A meta-analysis across 40 experimental studies. https://doi.org/10.31234/osf.io/nky37

Mende-Siedlecki, P., Goharzad, A., Tuerxuntuoheti, A., Reyes, P. G. M., Lin, J., & Drain, A. (2022). Assessing the speed and spontaneity of racial bias in pain perception. Journal of Experimental Social Psychology, 101, 104315. https://doi.org/10.1016/j.jesp.2022.104315

Olsen, Y., Daumit, G. L., & Ford, D. E. (2006). Opioid prescriptions by US primary care physicians from 1992 to 2001. The Journal of Pain, 7(4), 225-235. https://doi.org/10.1016/j.jpain.2005.11.006

Quintana, D. S., Guastella, A. J., Outhred, T., Hickie, I. B., & Kemp, A. H. (2012). Heart rate variability is associated with emotion recognition: Direct evidence for a relationship between the autonomic nervous system and social cognition. International journal of psychophysiology, 86(2), 168-172. https://doi.org/10.1016/j.ijpsycho.2012.08.012

Staton, L. J., Panda, M., Chen, I., Genao, I., Kurz, J., Pasanen, M., Mechaber ,A.J., Menon, M., O’Rorke, J., Wood, J., Rosenberg, E., Faeslis, C., Carey, T., Calleson, D., Cykert, S. (2007). When race matters: disagreement in pain perception between patients and their physicians in primary care. Journal of the National Medical Association, 99(5), 532. https://doi.org/10.17615/xbk1-am15

Presenting Author

Arianna Bagnis

Poster Authors

Arianna Bagnis

PhD

University of Bologna

Lead Author

E-mail

Topics

  • Racial/Ethnic/Economic Differences/Disparities