The value of equity, diversity, and inclusion principles and sex/gender considerations in pain research

Abstract

The enormity of suffering due to pain worldwide is undeniable.11 The “one size fits all” model for pain science and pain management is a poor approach to chronic pain and even for some acute pains. The promise of better pain management comes from the discovery of individual differences in the sensitivity, tolerance/coping, and experience of pain, along with the growing investment to find diagnostic, predictive, and prognostic biomarkers of chronic pain treatment outcomes.4,6,15 At the core of this framework is the concept of precision or personalized medicine, based on the need to find the right treatment for the right person at the right time, at a given place.2 The latter issue is not always considered, but an equitable system of pain management must consider the socioeconomic factors and unconscious biases related to sex, race, religion, class, and other attributes that can result in pain treatment inequities.1,7,9 Therefore, given the exciting potential of personalized medicine,2 it is of utmost importance to ensure that scientific discovery and clinical trials are able to collect and analyse data of individuals' characteristics, demographics, and personal circumstances of living conditions so that factors can be disaggregated if needed. Furthermore, we must ensure that such factors are included in databases that are used to create artificial intelligence algorithms to guide clinical decision-making. There have been decades of careful study to advance the understanding of the spectrum of sex/gender,8 as well as diversity, equity, and inclusion (DEI). This has led to a slow but steady appreciation for the complexities of these issues and improvements in some parts of the world in how pain research and management is conducted. In 2024, the International Association for the Study of Pain (IASP) designated a Global Year awareness campaign to address “Sex and Gender Disparities in Pain” and provided fact sheets for a variety of topics including “Pain and Gender Diversity—Beyond the Binary” (see https://www.iasp-pain.org/advocacy/global-year/sex-and-gender-disparities-in-pain/). Our ability to conduct scientific research and provide clinical care can be facilitated or hampered by our cultural, societal, and political environment. A positive impact can lead to advancements and ultimately improve care for those suffering with pain. However, impediments to the funding of scientific discovery and the dissemination of clinical care may ultimately lead to worse lives for those suffering with pain. Scientific advancement has always benefited from a diversity of perspectives and “out of the box” thinking. There is also tremendous value in the knowledge gained from the experiences, challenges, and solutions found to address the complexities of healthcare needs and educational programs worldwide. That is why we all can benefit from the IASP's 2025 Global Year of Pain Management, Research, and Education in Low- and Middle-Income Settings (see https://www.iasp-pain.org/advocacy/global-year/pain-management-research-and-education-in-low-and-middle-income-settings/) including fact sheets, a pain centre tool kit (https://www.iasp-pain.org/resources/toolkits/pain-management-center/), a pain camp, as well as selected articles in this journal (https://journals.lww.com/pain/pages/collectiondetails.aspx?TopicalCollectionId=27) and in PAIN Reports. The issue of “merit” is often said to be at the centre of decision-making regarding what science should do, who should do it, how it is funded, and where it can be published, but defining “merit” is not always clear. Merit is a measure of value, quality, and impact. Front and centre in judging the merit or value of science is often its novelty, quality, and sometimes the clarity of how findings are communicated. These attributes are usually clear, but impact can be less obvious if one is not fully open to adopting new approaches based on the experiences and data from other places and fields. Impact is also often seen through the lens of one's personal or professional circumstances in the present. What is much more difficult, but essential, is to apply a broader lens to consider impact across place and time that is outside of one's own experience. Adopting this broader perspective can be difficult, but the outcome can be transformative. Thus, there can be tremendous merit to incorporating perspectives from outside our specific setting into our daily practice—this is why we should all be paying attention to work coming from diverse voices and places. In 2023, the Editors-in-Chief (EiCs) of 8 American, Canadian, European, and international pain journals published a joint editorial entitled “Promoting inclusion, diversity, and equity in pain science.”10 In this article, we established 4 guiding principles with recommendations for authors, reviewers, editors, and publishers: (1) Promote inclusive and representative scholarship and fair, unbiased reviews. (2) Use language that is inclusive and minimizes bias. (3) Include representative populations in pain research and comprehensively report data for demographic variables. (4) Report demographic variables and use social frameworks for interpretations. PAIN's commitment to equity, diversity, and inclusion principles, as well as the call for consideration of the impact of sex and gender in research findings, was also emphasized in my editorial as incoming EiC.3 This year, we will be publishing updated guidelines for reporting sex and gender in basic and clinical studies published in our journal.5 Recent proclamations and executive orders by the new President of the United States pertaining to DEI, sex/gender, and merit-based hiring12–14 may have a chilling effect on the desire and ability of some working in the pain field to pursue research that incorporates all the factors that contribute to a better understanding of the individual differences in pain and nociception, and equitable access to pain care. Denial that certain diversities exist or banning the use of terminologies and classifications along spectrums does not negate the reality of personal identity and the underlying neurobiology. As EiC of PAIN, I wish to reaffirm our commitment to the value of considering diversity (including DEI and sex/gender identity) in the context of scientific advancements and translation to and development of clinical care and educational programs toward a personalized approach to pain management. Conflict of interest statement The author has no conflict of interest to declare.

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