Cognitive Therapy and Research, Vol. 24, No. 1, 2000, pp.

121-134

Gender Differences in Pain and Pain Behavior:

The Role of Catastrophizing
Michael J. L. Sullivan,1,3 Dean A. Tripp,2 and Darcy Santor1

This research examined gender differences in catastrophizing and pain in 80 healthy

students (42 women, 38 men) who participated in an experimental pain procedure.
Participants completed the Pain Catastrophizing Scale (PCS; Sullivan, Bishop &
Pivik, 1995) prior to immersing one arm in ice water for 1 minute. Participants were
later interviewed to assess the strategies they used to cope with their pain. Independent
raters examined videotape records and coded participants pain behavior during and
following the ice water immersion. Results showed that women reported more intense
pain and engaged in pain behavior for a longer period of time than men. When PCS
scores were statistically controlled, gender was no longer a significant predictor of
pain or pain behavior. For women, the helplessness subscale of the PCS contributed
unique variance to the prediction of pain and pain behavior. For men, none of the PCS
subscales contributed unique variance to the prediction of pain and pain behavior.
Discussion addresses the social learning factors that may contribute to gender differences in pain. Discussion also addresses the limitations and clinical implications of
the findings.
KEY WORDS: pain; pain behavior; catastrophizing; gender differences.

There is a growing literature suggesting that gender is an important determinant

of pain experience (Lautenbacher & Rollman, 1993; Levine & De Simone, 1991;
Unruh, 1996). The findings of several clinical and experimental investigations suggest that women experience more frequent and more intense pain than men (Crook,
Rideout, & Browne, 1984; Lautenbacher & Rollman, 1993; Taylor & Curran, 1985).
Currently, the factors that contribute to gender differences in pain experience are
unclear. The primary purpose of the present research was to examine the role
of catastrophizing in mediating gender differences in pain experience and pain
behavior.
1

Departments of Psychology and Psychiatry, Dalhousie University.

Department of Psychology, Dalhousie University.
3
Correspondence should be addressed to Dr. Michael Sullivan, Department of Psychology, Dalhousie
University, Halifax, Nova Scotia, B3H 4J1.
2

121
0147-5916/00/0200-0121$18.00/0 2000 Plenum Publishing Corporation

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GENDER DIFFERENCES IN CLINICAL PAIN

Although research findings have been mixed, the available literature generally
supports a relation between gender and pain. Numerous studies have shown that
women are more likely than men to experience pain in response to a variety of
medical conditions and aversive medical procedures (see Unruh, 1996, for a review).
For example, women report more frequent tension and migraine headaches than
men (Rasmussen, 1993; Rasmussen & Breslau, 1993). Women report more frequent and intense musculoskeletal pain than men (Andersson, Ejlertsson, Leden,
& Rosenberg, 1993; Hasvold & Johnsen, 1993). Pain due to arthritic conditions
such osteoarthritis, rheumatoid arthritis, and fibromyalgia is also reported more
frequently by women than men (Verbrugge, Lepkowski, & Konkol, 1991).
Women also differ from men in their behavioral responses to pain. For example,
women report more health care utilization than men (Taylor & Curran, 1985; Von
Korff, Wagner, Dworkin, & Saunders, 1991). In several studies, women have been
shown to take more sick days than men in response to pain, and women are more
likely than men to go on short-term disability following the onset of a pain-related
condition (Crook, 1993; Hertzberg, 1985; Taylor & Curran, 1985; Verbrugge, 1985).
Although the clinical pain literature can provide useful insights on the relation
between gender and pain, the results of clinical studies examining gender differences
in pain and pain-related behavior can be difficult to interpret. For example, genderrelated differences in comfort with help seeking may yield gender difference in
reports of pain and disability, and yet be unrelated to actual pain experience.
Interpretive difficulties also arise when one considers the lack of consistency in
reported findings on gender differences in clinical pain. Several investigations have
failed to show evidence of gender differences in clinical pain (Faull & Nicol, 1986;
Larson, 1991; Lester, Lefebre, & Keefe, 1994; Manahan et al. 1985). It is possible
that self-selection or referral biases associated with different clinical settings may
influence the probability of detecting gender differences in pain experience. Heterogeneity of samples with respect to the nature and severity of the condition giving
rise to pain may also decrease the power to detect gender differences. To circumvent
these interpretive difficulties, investigators have attempted to examine the relation
between gender and pain experience in asymptomatic individuals in response to
experimental pain procedures.

GENDER DIFFERENCES IN EXPERIMENTAL PAIN

Research has revealed significant gender differences in pain experience in
response to a wide range of experimental pain procedures. In one of the largest
studies, Woodrow, Friedman, Siegelaub, and Collen (1972) examined gender differences in pain tolerance to mechanical pressure on the Achilles tendon. Their sample
consisted of over 41,000 members of a private health insurance plan who were
asked to undergo physical examination. A motor-driven pressure device was affixed
to the subjects Achilles tendon, and subjects were asked to tolerate the discomfort
as long as possible. Results showed that men tolerated almost twice the pressure

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applied to the Achilles tendon (M 28.7 pounds per square inch) than women
(M 15.9 pounds per square inch). It has also shown that women have lower pain
thresholds for pressure applied to fingers and toes (Brennum, Kjeldsen, Jensen, &
Jensen, 1989), and to a wide range of muscle groups (Fisher, 1987; Jensen, Rasmussen, Pedersen, Lous, & Olesen (1992).
Feine, Bushnell, Miron, and Duncan (1991) examined gender differences in
response to a noxious heat stimuli in a sample of young adults consisting of 20 women
and 20 men. Subjects were asked to rate the intensity of pain they experienced from
thermal electrodes placed on their upper lip. Results showed that women rated the
heat stimulus as more painful than men. Interestingly, women also showed more
discrimination between heat stimuli of varying intensities than men (see also Goolkasian, 1980). Weisenberg, Tepper, and Schwarzwald (1995) have recently reported
lower pain tolerance in women in response to immersing one arm in a container
of ice water. In the latter study women also reported higher levels of anxiety than
men and obtained lower scores on a measure of perceived ability to cope with pain
(i.e., self-efficacy).
Although the results of the investigations described above suggest that, across
a variety of painful stimuli, women report higher levels of pain than men, several
investigations have failed to detect significant gender differences in pain (Clark &
Mehl, 1971; Harkins & Chapman, 1977; Kenshalo, 1986; Lautenbacher & Strian,
1991; Neri & Aggazani, 1984; Sullivan, Bishop, & Pivik, 1995; Sullivan, Rouse,
Bishop, & Johnston, 1997). The basis for the inconsistencies in findings is unclear.
Lautenbacher and Rollman (1993) have suggested that certain types of painful
stimulation such as pressure pain or electric shock may be more likely to reveal
gender differences than heat or cold. Levine and De Simone (1991) have suggested
that the sex of the experimenter may be a significant factor determining observed
gender differences in pain. It has also been suggested that sample sizes are frequently
too small to detect gender differences (Sullivan et al. 1995).
The inconsistencies in findings highlight the possibility that a correlate of
gender, as opposed to gender itself, may be the variable that accounts for the
observed relation between gender and pain experience. Cross-study variations in
pain-related correlates of gender may exaggerate gender differences in some circumstances and obscure them in others. There is a basis for predicting that gender
differences in catastrophizing may mediate the relation between gender and pain experience.

THE ROLE OF CATASTROPHIZING

Clinical and experimental investigations have shown that catastrophizing is
associated with heightened pain experience (Heyneman, Fremouw, Gano, Kirkland, & Heiden, 1990; Jensen, Turner, Romano, & Karoly, 1991; Keefe, Brown,
Wallston, & Caldwell, 1989; Rosenstiel & Keefe, 1983; Spanos, Radtke-Bodorik,
Ferguson, & Jones, 1979; Spanos, Brown, Jones, & Horner, 1981; Sullivan & DEon,
1990; Sullivan et al. 1995). On the basis of a factor analytic study, Sullivan et al.
(1995) suggested that catastrophizing could be viewed as a conceptually integrated

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concept that comprised three related components: rumination, magnification, and

helplessness (Sullivan et al. 1995, study 1). Sullivan et al. (1995) suggested that
rumination and magnification may be related to primary appraisal processes where
individuals may focus on and exaggerate the threat value of a painful stimuli (cf.
Lazarus & Folkman, 1984). Helplessness may be related to secondary appraisal
processes where individuals negatively evaluate their ability to deal effectively with
painful stimuli.
Research has shown that women engage in catastrophic thinking to a greater
degree than men. Sullivan et al. (1995, study 1) reported that women obtained
higher scores than men on the rumination and helplessness subscales of the Pain
Catastrophizing Scale (PCS; Sullivan et al. 1995). No gender differences were found
for the magnification subscale of the PCS. These findings have been replicated in
a recent re-examination of the psychometric properties of the PCS (Osman, Barrios,
Kopper, Hauptmann, Jones, & ONeill, 1997). Research on coping with chronic
pain has also shown that women are more likely to catastrophize than men (Jensen,
Nygren, Gamberale, Goldie, & Westerholm, 1994).
The present study examined the role of catastrophizing in mediating the relation
between gender and pain experience. Men and women were asked to immerse one
arm in a container of ice water and to provide ratings of their pain experience.
Participants were videotaped during the procedure to allow for coding of pain
behaviors. The following predictions were made:
1. Women will report higher levels of pain than men in response to ice water immersion.
2. Women will display more pain behavior than men in response to ice water immersion.
3. Women will score higher than men on the measure of catastrophizing.
4. When levels of catastrophizing are statistically controlled, the relation between gender and pain will no longer be significant.
This study also explored the relations among gender, coping, and pain, and
examined the components of catastrophizing that were most strongly associated
with heightened pain experience in women and men.

METHOD
Participants
Forty-two women and 38 men who were enrolled in an Introductory Psychology
course at Dalhousie University participated in the research. Participants ranged in
age from 19 to 28 years (M 20.5; SD 5.4). Course credit was awarded for
participation. Individuals who were suffering from a medical condition associated
with persistent pain such as migraine headache or back pain, or from other conditions that may be adversely affected by the pain procedure (e.g., cardiovascular
problems, previous experience of frostbite) were not considered for participation.

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125

Apparatus
A cold pressor apparatus was used consisting of an insulated container, measuring 30 40 30 cm, divided into two compartments separated by a wire mesh.
The entire container was filled with water, and one compartment was filled with
ice. The other compartment was equipped with a moveable armrest used to immerse
a participants arm in the ice water. Water temperature was maintained at 2 to
4C. Participants were videotaped during the procedure using a Hitachi VM-2300A
VHS video camera positioned behind a one-way mirror. Participants were aware
that they were being videotaped, but they could not see the video camera.
Measures
The Pain Catastrophizing Scale (PCS; Sullivan et al. 1995)
The PCS is a self-report measure of catastrophic thinking associated with pain
that consists of 13 items describing different thoughts and feelings that individuals
may experience when they are in pain. The PCS instructions ask participants to
reflect on past painful experiences, and to indicate the degree to which they experienced each of 13 thoughts or feelings when experiencing pain, on 5-point scales
with the endpoints (0) not at all and (4) all the time. The PCS yields a total score
and three subscale scores assessing rumination, magnification, and helplessness.
The PCS has been shown to have high internal consistency (coefficient alphas: total
PCS 0.87, rumination 0.87, magnification 0.66, helplessness 0.78; Sullivan
et al. 1995).
Pain
An 11-point Likert-type rating scale was positioned on the wall directly in
front of the participants. Participants gave verbal reports of their current pain by
choosing numbers between (0) no pain and (10) extreme pain.
Pain Behavior
Initially, our intent was to classify participants pain behaviors according to
the system described by Keefe and Block (1982) for use in chronic pain patients
during physical examination (i.e., guarding, rubbing, grimacing, sighing). However,
the pain behavior coding system required some modification to account for the focus
(e.g., pain in the immersed arm) and the constraints (e.g., immobility) associated with
the cold pressor procedure. After extensive pilot testing, the following pain behavior
categories and criteria were derived:
1. Action involving the immersed arm (coded only for the period following the
ice water immersion)abnormally stiff, or rigid movement of the immersed
arm; touching, rubbing, or holding the hand or arm; flexing, shaking, or
stimulating the fingers, hand, or arm.
2. Action not involving the immersed arm.rocking, bending, neck arching,
bouncing.
3. Grimacingobvious facial expression of pain, including furrowed brow,

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narrowed eyes, tightened lips, and corners of the mouth pulled back or
clenched.
4. Vocalizationsgrunting, gasping, or sighing.
Two judges blind to the experimental hypotheses independently coded the
videotapes. Judges provided a frequency count and recorded the duration of each
of the four categories of pain behaviors both during the ice water immersion and
the 3-minute period following the immersion. For the classification of pain behaviors,
the mean percentage agreement for the two judges across the four categories was
84%. Disagreements were resolved through discussion. For the duration of pain
behaviors, the mean correlation for the two judges ratings across the four categories
was r 0.91. Due to the low frequency of pain behaviors across categories, a
composite index of pain behavior duration was derived by summing duration across
pain behavior categories.
Coping Interview
At the end of the session, participants were interviewed concerning the ways
they tried to cope with the pain of the cold pressor procedure. Participants were
asked the following questions, What thoughts or feelings did you experience during
the ice water immersion? How did you try to cope with the pain you were
experiencing? and Did you engage in any mental strategy or did you do anything
to control or decrease your pain? The coping interview was similar to that used
in previous research on coping with cold pressor pain (Spanos et al. 1979; Sullivan
et al. 1995).
Two judges who were blind to the experimental hypotheses transcribed participants responses to the interview, and coded responses into one of eight coping
categories. Coping categories included (1) coping self-statements (I told myself I
could do this.), (2) distraction (I tried to think of other things, like studying or
what I had to do tomorrow.), (3) suppression (I tried not to think about the
pain.); (4) relaxation (I tried to breathe deeply and relax.), (5) sensory focus
(I thought mostly about how my arm was feeling.); (6) reinterpreting sensations
(I tried to think of it as cooling down on a hot day.), and (7) catastrophizing (I
couldnt believe that it could hurt so much.). After reviewing participants responses, one additional category was included: (8) No thoughts (I didnt think
about anything.). Responses were first unitized according to thematic content and
sentence structure, and were then classified into one of the coping categories. Mean
percentage inter-rater agreement across coping categories was 78% with a range
of 66% (suppression) and 100% (no thoughts). Only one participant reported using
sensory focus and relaxation and both coders agreed on the classification.
Procedure
Participants were told that the study was concerned with the relation between
thoughts and physical discomfort. They were assured that the procedure would not
result in physical injury and were made aware that they would receive course
credit even if they did not complete the study. There were no cases of participant
withdrawal. All participants were tested by a female experimenter.

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127

Prior to the pain procedure, participants completed the PCS. To regulate arm
temperature, participants immersed their dominant arm in a container of room
temperature water for 5 minutes. Participants were then instructed to place their
arm on the moveable armrest of the cold pressor apparatus, to lower their arm
into the ice water, and to keep their arm immersed for a period of 1 minute. They
were signaled, by a voice on a tape recording, to give two verbal ratings of their
current level of pain at 30-second intervals during the water immersion. At the end
of 1 minute, they were signaled to remove their arm from the ice water. Participants
were videotaped for an additional 3 minutes following removal of their arm from
the cold pressor.
RESULTS
Pain Ratings
As shown in Table I, men and women did not differ significantly in the pain
ratings they provided during the room temperature water immersion, t (78) 0.47,
(ns). However, during the ice water immersion, men reported significantly less pain
than women, t (78) 2.2, p 0.05.
Pain Behavior
During the ice water immersion, women displayed pain behaviors for significantly longer duration than men, t (78) 2.5, p 0.01. During the 3 minutes
following the ice water immersion, women continued to display pain behavior for
a longer duration than men, t (78) 2.5, p 0.01.
The total number of different occurrences of pain was marginally higher for
women (M 3.0, SD 1.3) than for men (M 2.5, SD 1.2), t (78) 1.7,
p 0.07. Chi-square analyses revealed that the probability of displaying specific
pain behaviors did not vary as a function of gender.
Table I. Pain Ratings and Pain Behavior During and After the Ice
Water Immersion

Pain ratings
(room temperature
water immersion)
Pain ratings
(ice water immersion)
Pain behavior duration
(ice water immersion)
Pain behavior duration
(postimmersion)

Men
(N 38)

Women
(N 42)

2.1 (1.0)

2.0 (1.1)

ns

6.3 (1.7)

7.2 (1.5)

0.05

1.2 (3.4)

5.1 (8.8)

0.01

45.5 (35.6)

65.4 (35.3)

0.01

Note: Pain ratings were made on an 11-point scale with the anchors (0)
no pain and (10) extreme pain. Pain behavior duration is measured in
seconds. Numbers in parentheses are standard deviations.

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Table II. Components of Catastrophizing as a Function of Gender
Catastrophizing
PCS
PCS
PCS
PCS

Total
Rumination
Magnification
Helplessness

Men
(N 38)

Women
(N 42)

17.6
7.3
3.7
6.9

26.6
10.7
4.0
11.7

(10.3)
(3.8)
(2.7)
(4.8)

(10.4)
(3.2)
(2.2)
(5.6)

p
0.001
0.001
ns
0.001

Note: Numbers in parentheses are standard deviations. PCS

Pain Catastrophizing Scale.

Catastrophizing
Consistent with previous research (Osman et al. 1997; Sullivan et al. 1995,
study 1), men scored significantly lower on the total score of the PCS than women,
t (78) 3.8, p 0.001. As shown in Table II, men scored significantly lower on
the rumination, t (78) 4.3, p 0.001, and the helplessness, t (78) 4.1, p
0.001, subscales of the PCS. There were no gender differences on the magnification
subscale of the PCS, t (78) 1.1, (ns).
Correlations between the different subscales of the PCS and the pain measures
were computed separately for men and women (Table III). For both men and
women, the rumination (men, r .49, p 0.05; women, r .44, p 0.05) and
helplessness (men, r .48, p 0.05; women, r .56, p 0.01) subscales of the
PCS were significantly correlated with pain ratings during the ice water immersion.
The magnification subscale was correlated with pain ratings during the ice water
immersion for men (r .48, p 0.05) but nor for women (r .25, ns). Direct
Table III. Correlations Between PCS subscales and Pain Measures
for Men and Women
Pain ratings and pain behavior
Men (N 38)
PCS Total
Rumination
Magnification
Helplessness

Women (N 42)
PCS total
Rumination
Magnification
Helplessness

Room temp.
immersion

Ice water
immersion

Pain beh.
duration

0.18
0.53 a
0.33 a
0.30
0.49 a
0.41 a
0.04
0.48 a
0.09
0.17
0.48 a
0.34 a
Pain ratings and pain behavior
Room temp.
immersion

Ice water
immersion

Pain beh.
duration

0.19
0.21
0.03
0.21

0.51 a
0.44 a
0.25
0.56 b

0.34 a
0.22
0.18
0.41 b

Note: Room temp. immersion Pain ratings during the room temperature
water immersion; ice water immersion pain ratings during the ice water
immersion; pain beh. duration total duration of pain behavior (in
seconds) during and after the ice water immersion.
a
p 0.05.
b
p 0.01.

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129

regression analyses revealed that, for women, the helplessness subscale contributed
the greatest proportion of unique variance to the prediction of pain (semi partial
corr .43, p 0.001). For men, none of the subscales contributed significant unique
variance to the prediction of pain, and among the three subscales, helplessness
contributed the lowest proportion of unique variance to the prediction of pain (semi
partial corr 0.002, ns).
The helplessness subscale was significantly correlated with duration of pain
behavior for both men (r .34, p 0.05) and women (r .41, p 0.01). The
rumination subscale was significantly correlated with duration of pain behavior for
men (r .41, p 0.05) but not for women (r .22, ns). The magnification subscale
was not correlated with duration of pain behavior for either men or women.
Coping with Pain
The frequencies of different coping strategies reported by men and women
during the postimmersion interview are presented in Table IV. Due to the modest
sample size, and the relative infrequency of spontaneously initiated coping strategies, gender analyses could be performed on only six of the eight coping categories.
Chi-square analyses (or Fishers exact test when expected frequencies were less
than 5) were used to examine the relation between gender and coping. Distraction
was the most frequently reported coping strategy but did not vary significantly as
a function of gender. Four men and no women reported having no thoughts during the ice water immersion, 2 4.6, p 0.05. Twenty-three women and 13
men reported catastrophizing thoughts during the ice water immersion, 2 3.4,
p 0.06. No other differences approached statistical significance.
There were few significant relations between coping strategy use and pain
experience. Experiencing no thoughts during the ice water immersion was inversely
correlated with duration of pain behavior, r .25, p 0.05. Reinterpreting pain
sensations was inversely, but not significantly, correlated with pain ratings during
the ice water immersion, r 0.13, ns. Reports of catastrophic thinking were
significantly correlated with pain ratings during the ice water immersion, r .27,
p 0.01.
Mediational Hypotheses
Baron and Kenny (1986) suggest using three regression equations to test mediational hypotheses: (1) regressing the mediator (catastrophizing) on the independent
Table IV. Coping Strategies Reported During the Postimmersion Interview

Coping self-statements
Reinterpreting sensations
Distraction
Suppression of pain-related thoughts
No thoughts
Catastrophic thinking

Men

Women

3
2
22
6
4
13

7
2
21
7
0
23

1.4
0.0
0.5
0.2
4.6
3.4

ns
ns
ns
ns
0.05
0.06

Note: One participant reported using relaxation and one participant reported using sensory focus.

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variable (gender), (2) regressing the dependent variable (pain) on the independent
variable (gender), and (3) regressing the dependent variable (pain) on both the
independent variable (gender) and the mediator (catastrophizing). It is argued that
if the independent variable no longer has any effect at all when the mediator is
controlled, a mediational hypothesis is supported (see also Holmbeck, 1997).
The results of the first regression analysis revealed that gender was a significant
predictor of level of catastrophizing, R 0.40, F (1, 18) 15.1, p 0.001. A second
regression analysis revealed that gender was a significant predictor of pain intensity,
R 0.24, F (1, 78) 4.8, p 0.05. When gender and catastrophizing were entered
simultaneously as independent variables, catastrophizing (beta 0.55, p 0.001),
but not gender (beta 0.01, p 0.85) contributed significant unique variance to
the prediction of pain ratings.
The mediating role of catastrophizing was also examined for duration of pain
behavior. The first regression analysis was identical to the one above showing that
gender was a significant predictor of level of catastrophizing. A second regression
analysis revealed that gender was a significant predictor of pain behaviour, R
0.30, F (1, 78) 8.2, p 0.005. When gender and catastrophizing were entered
simultaneously as independent variables, catastrophizing (beta 0.35, p 0.005),
but not gender (beta 0.16, p 0.13) contributed significant unique variance to
the prediction of pain behavior. The results of these analyses support the position
that catastrophizing mediates the relation between gender and pain, and gender
and pain behavior.

DISCUSSION
In the present study, women reported more intense pain and displayed pain
behavior for longer duration than men in response to a cold pressor procedure.
Women also scored higher on a measure of catastrophic thinking than men. When
level of catastrophizing was statistically controlled, gender no longer contributed
significantly to the prediction of pain intensity or duration of pain behavior.
The processes that give rise to gender differences in catastrophizing are as yet
unclear. A number of investigators have discussed catastrophizing as a traitlike
variable, citing findings showing that levels of catastrophizing are stable across
periods ranging from 2 to 8 months (Keefe et al. 1989; Sullivan et al. 1995). Others,
however, have suggested that catastrophizing can be readily changed by instructing
individuals to use more adaptive coping strategies (Spanos et al. 1981; Vallis, 1984).
If catastrophizing is a traitlike variable, it may arise as a function of social learning
forces that give rise to other gender-typed traits (e.g., expressiveness versus instrumentality). If catastrophizing is more situationally determined, then more research
attention will need to be given to clarifying the characteristics of situations that
foster or inhibit catastrophic thinking.
The components of catastrophizing that revealed gender differences were rumination and helplessness. This finding is consistent with research on depression
showing that women are more likely to engage in ruminative thinking than men,
and that rumination interferes with effective problem solving (Nolen-Hoeksema,
1993). In research on depression, ruminative responding has been discussed as

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131

a maladaptive response to stressful situations (Nolen-Hoeksema, 1987, 1993). In

contrast, Unruh (1996) has suggested that women may attend to pain sooner than
men because the illness, disease, or condition giving rise to pain may result in more
interference of gender-related social roles. Pain may have implications for womens
ability to meet household, parenting, and occupational responsibilities. For men,
pain may only be of significance if it threatens to interfere with occupational responsibilities.
The present study is the first to show that women display more pain behavior
than men in response to an experimental pain procedure. Although several clinical
investigations have reported that women are more likely than men to engage in a
variety of illness behaviors such as health care visits, medication intake, and time
off work, previous research has not examined the relation between gender and pain
behavior in response to experimental pain procedures (Unruh, 1996).
Both pain behaviors and illness behaviors have been discussed in terms of their
role in minimizing pain, and communicating distress (Bonica, 1977; Fordyce, 1976;
Keefe, Bradley, & Crisson, 1990; Keefe & Gil, 1986). The communicative function
of pain behavior may be particularly relevant to explaining gender differences in
pain behavior. Recent theory and research suggest that women are more likely
than men to adopt a communal and emotionally expressive orientation toward
dealing with stress situations (Coyne & Fiske, 1992; Endler & Parker, 1994; Lyons &
Sullivan, 1998; Lyons, Sullivan, Ritvo, & Coyne, 1995). Through heightened displays
of distress and by communicating an inability to deal effectively with a painful
situation, women may be maximizing the probability that potential caregivers or
companions will maintain proximity or offer support or assistance. Conversely,
when men adopt a stoic presentation during painful situations, they may minimize
the probability that others will offer support or assistance.
Women did not differ from men in their repertoire of coping strategies. Other
than catastrophizing, the only coping strategy that revealed gender differences was
having no thoughts during the ice water immersion. Four men reported having no
thoughts during the ice water immersion, and these men also reported less pain
than women. One possibility is that the individuals who reported having no thoughts
may have been engaging in denial of their cognitive experience as well as denial
of their pain experience. Alternately, having no thoughts may be adaptive insofar
as it reduces the probability of experiencing catastrophic thoughts (Turk & Rudy,
1992; Spanos et al. 1979).
Proceeding from the assumption that the primary goal of coping is to reduce
distress, then the clinical implications of the present study are clear. Given that
catastrophizing accounts for gender differences in pain experience, and catastrophizing is associated with increased physical and emotional distress in response to
painful stimulation, interventions should be aimed at reducing catastrophizing.
Indeed, clinical interventions for persistent pain disorders specifically focus on
reducing catastrophizing in teaching clients how to cope more effectively with
persistent pain (Turk, Meichenbaum, & Genest, 1984; Turk & Rudy, 1992). Both
clinical and experimental studies have shown that reductions in catastrophizing are
associated with reductions in pain (Spanos et al. 1979; Turner & Clancy, 1986).
However, if the goals of coping go beyond the reduction of distress, then the
clinical implications of the present study become less straightforward. If women

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and/or individuals who catastrophize prefer an interpersonal or communal approach

to coping, then reducing catastrophizing may not be an appropriate target of intervention. The expression of distress may be a necessary component of an interpersonal or communal approach to coping. Specifically, expressions of distress signal
the need for assistance (Lyons et al. 1995; Lyons & Sullivan, in press). If interpersonal goals are primary, then an argument can be made for the adaptiveness of
catastrophizing in coping with pain. It is also important to note that, to the extent
that catastrophizing is associated with expressions of distress and help-seeking
behavior, it may be quite adaptive in facilitating the early detection and treatment
of illness. This line of reasoning suggests that the relative adaptiveness of catastrophizing may be contextually determined.
It may be premature to make strong statements about the nature of interventions best suited for alleviating the physical and emotional distress of individuals
who catastrophize, and indeed, whether catastrophizing itself should be a target of
intervention. The literature that is emerging suggests that, in order to maximize
the impact of interventions for pain control, it will be necessary to devote more
attention to understanding the goals of coping with pain, and to elucidating the
contextual factors that impact on these goals. If men and women have different
goals when faced with aversive situations, they will likely also differ in the thoughts
and behaviors that are initiated to attain those goals. Further research examining
the determinants of catastrophizing may facilitate the development of interventions
that can be tailored to individual needs.
Finally, caution is warranted in generalizing the present findings beyond the
experimental context within which they were generated. The study sample consisted
of healthy, well-educated students who tend to be underrepresented in clinical
samples. In addition, the cold pressor procedure used in the present study differs
in many ways (e.g., degree of threat/harm, duration of experience, interference
with activities) from painful experiences that individuals face in their day-to-day
lives, and also from the painful experiences that lead them to seek out medical
assistance. Replication with a clinical sample would be required before the theoretical or clinical implications of the present findings can be discussed with confidence.

ACKNOWLEDGMENTS
The authors thank Mr. Mark Ryer and Ms. Heather Waite for their assistance
in data collection and coding. The authors also thank Drs. Joyce DEon, Mary
Lynch, Anita Unruh, and three anonymous reviewers for their comments on a
previous version of the paper. This research was supported by a grant from the
Social Sciences and Humanities Research Council of Canada.

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