A 2012 quantitative review of experimental pain studies, drawing on the Riley and Fillingim laboratories at the University of Florida and partner institutions, reported that African American participants demonstrate consistently lower pain tolerance than non-Hispanic white participants across multiple controlled stimulus modalities, with moderate to large effect sizes (Rahim-Williams B, Riley JL 3rd, Williams AKK, Fillingim RB. Pain Medicine 2012; PMID 22390201). In a 2015 study of pediatric emergency-department visits for appendicitis published in JAMA Pediatrics, 20.7 percent of Black children received opioid analgesia compared with 43.1 percent of white children with the same diagnosis, an adjusted odds ratio of 0.2 (Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. JAMA Pediatrics 2015;169(11):996-1002; PMID 26366984).
The belief that Black patients tolerate pain better than white patients is not a folk observation. It is a constructed clinical claim with a written nineteenth-century history, contradicted by the controlled-experiment evidence, and tracked by a contemporary disparity in pain treatment that runs the opposite direction from what the belief predicts. This piece names where the claim came from, what the current data show, and what a Black patient can do at the next pain-care visit.
What controlled experiments actually show
The Rahim-Williams team meta-analyzed experimental pain studies that used standardized noxious stimuli (thermal, mechanical, ischemic, electrical) on healthy volunteers, measuring pain threshold (the stimulus intensity at which pain begins) and pain tolerance (the intensity at which the participant withdraws). African American participants showed consistently lower pain tolerance than non-Hispanic white participants, with effect sizes the authors characterized as moderate to large across modalities. Pain threshold trended in the same direction with smaller effect sizes (Pain Medicine 2012, PMID 22390201).
The mechanism for that group difference is not the relevant question here. The relevant point is that the controlled-experiment record, in which the stimulus is held constant and the response is measured directly, runs opposite to the clinical folk claim. If anything, the laboratory pain-perception literature suggests African American participants are more sensitive to controlled noxious stimuli than white participants are, not less. The clinical undertreatment of Black patients' pain, documented below, cannot be explained by a higher tolerance the patients do not have.
Where the belief came from
The medical claim that Black bodies experience pain differently than white bodies traces to nineteenth-century race science and to a specific, documented set of medical practices on enslaved Black women in the antebellum US South.
The gynecological surgical experiments performed by J. Marion Sims on enslaved Black women in Montgomery, Alabama between 1845 and 1849, conducted without anesthesia, are the canonical historical episode. Sims operated repeatedly on at least three enslaved women named in the historical record (Anarcha, Lucy, and Betsey), performing multiple procedures on each, before later performing the same operations on white patients under ether anesthesia. The historical record of those experiments and the broader medical-bondage system in which they occurred is documented at length in Harriet A. Washington's "Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present" (Doubleday, 2007) and Deirdre Cooper Owens' "Medical Bondage: Race, Gender, and the Origins of American Gynecology" (University of Georgia Press, 2017).
The nineteenth-century claims that emerged alongside this practice (that Black skin is thicker, that Black nerves are less sensitive, that Black blood coagulates more quickly) entered American medical textbooks and circulated as scientific justification for performing painful procedures on Black bodies without analgesia. None of these claims are biologically true. All three were measured as endorsed by US medical trainees in a 2016 study (Hoffman KM, Trawalter S, Axt JR, Oliver MN. PNAS 2016; PMID 27044069). Our existing piece on the Hoffman result covers the trainee study in detail. The point for this piece is that the false-biology claims the Hoffman team tested in 2014 to 2015 are direct descendants of the nineteenth-century race-science literature the historical scholarship cited above documents.
What the disparity looks like in care today
The contemporary clinical-treatment data shows the gap reliably across settings.
A 2012 systematic review and meta-analysis in Pain Medicine, drawing on twenty years of US data, found that Black patients receive opioid analgesia at significantly lower rates than white patients in non-traumatic and non-surgical pain settings, with a pooled adjusted odds ratio of 0.66 (95 percent CI 0.59 to 0.75). The disparity persisted after adjusting for socioeconomic and clinical covariates (Meghani SH, Byun E, Gallagher RM. Pain Medicine 2012;13(2):150-74; PMID 22239747).
A 2016 study of US emergency-department visits in PLoS ONE found that non-Hispanic Black patients had adjusted odds of receiving an opioid prescription ranging from 0.56 to 0.67 compared with non-Hispanic white patients for back pain and abdominal pain. The same study found no significant racial disparity in opioid prescription for fractures or kidney stones (Singhal A, Tien YY, Hsia RY. PLoS ONE 2016;11(8):e0159224; PMID 27501459).
That objective-condition contrast is the clinical fingerprint of the bias. When the diagnosis is undisputable on imaging or stone passage, the disparity disappears. When the diagnosis depends on a clinician's interpretation of the patient's self-reported pain, the disparity returns. The pattern points to clinician judgment, not patient presentation.
The pediatric data is the cleanest single illustration. Goyal and colleagues at Children's National Medical Center reviewed 940,000 emergency-department visits in the Pediatric Emergency Care Applied Research Network and identified children diagnosed with appendicitis. Of those children, 20.7 percent of Black children received any opioid analgesia compared with 43.1 percent of white children. The disparity persisted in multivariable analysis (adjusted odds ratio 0.2). Appendicitis pain is severe and not contested; the diagnosis itself is the indication for analgesia (JAMA Pediatrics 2015;169(11):996-1002; PMID 26366984).
What does not explain the gap
The undertreatment pattern in the clinical data is not explained by patient pain-reporting style. Across the experimental studies aggregated in Rahim-Williams 2012, African American participants reported pain at the same controlled stimulus at lower thresholds and lower tolerance, not higher. If the contemporary clinical gap reflected accurate calibration to patient-reported pain, the direction of the disparity would be reversed.
The gap is not explained by disease severity. Appendicitis pain in a child does not vary by race in a way that would justify a more than twofold difference in opioid administration. Back pain and abdominal pain in adults likewise do not show a race-stratified severity distribution that maps onto a 0.56-to-0.67 prescription odds ratio.
The gap is not explained by drug-seeking concern in a way that survives the objective-condition test. Singhal 2016 showed no Black-white prescription difference for fractures and kidney stones at the same EDs where back and abdominal pain showed a substantial difference. The concern about diversion does not selectively operate on subjective-presentation conditions among Black patients while sparing the objective ones; clinician judgment about which patients to trust at face value does.
What to do at the next pain-care visit
Three concrete steps for a Black patient preparing for a clinical visit where pain will be discussed.
First, describe pain by its effect on function alongside the numeric scale. The 0-to-10 score is what most clinicians chart, but functional-impact language (this pain prevents me from sleeping more than four hours, this pain stops me from walking up one flight of stairs, this pain has kept me out of work for three days) gives the clinician a structured account that does not depend on the clinician's calibration of the patient's verbal scale. Functional descriptions are harder to discount than a number alone and they belong in the chart.
Second, bring a witness to high-stakes pain-care visits, particularly emergency-department visits and pre-operative consultations. A partner, family member, or trusted friend in the room changes the dynamic of the encounter, gives the patient a second person who can later confirm what was said and prescribed, and reduces the rate at which patient concerns are dismissed without documentation. The research on race-discordant clinician encounters supports a witness as a low-cost protection against documentation gaps; it is not a guarantee, and it is a meaningful one.
Third, when possible, seek a Black or skin-of-color clinician for ongoing pain management, and ask any clinician directly about their experience with pain management in Black patients before agreeing to a treatment plan. Our provider directory is searchable by location and specialty. For emergency-department visits, the option to choose a clinician is rarely available; in that setting, asking for a patient advocate or hospital-based ombudsperson is the closest analogue and is appropriate when the patient's pain is being under-rated in the chart.
What this piece does not establish
The five primary sources cited in this piece are well-cited contributions to the pain-disparity literature; they are not the whole literature. The Hoffman 2016 study sampled white medical students and residents at one US medical school in 2014 to 2015. The Rahim-Williams 2012 review aggregated heterogeneous experimental-pain studies with varied stimulus modalities. The Singhal 2016 and Meghani 2012 odds-ratio estimates carry the confidence intervals they carry. The historical scholarship on J. Marion Sims, Anarcha, Lucy, and Betsey is documented at book length in the cited works; this piece quotes the central facts and refers the reader to the books for the full historical record.
What the piece does establish is that the clinical claim "Black patients have a higher pain tolerance" is unsupported by the controlled-experiment evidence, has a documented nineteenth-century origin in race science and slavery-era medical practice, and tracks a contemporary care gap that runs opposite to what the claim predicts. A reader walking into a pain-care visit can use that footing.
Sources
- Rahim-Williams B, Riley JL 3rd, Williams AKK, Fillingim RB. A quantitative review of ethnic group differences in experimental pain response: do biology, psychology, and culture matter? Pain Medicine. 2012;13(4):522-540. PMID 22390201. doi:10.1111/j.1526-4637.2012.01336.x.
- Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Medicine. 2012;13(2):150-174. PMID 22239747.
- Singhal A, Tien YY, Hsia RY. Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLoS ONE. 2016;11(8):e0159224. PMID 27501459. doi:10.1371/journal.pone.0159224.
- Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatrics. 2015;169(11):996-1002. PMID 26366984. doi:10.1001/jamapediatrics.2015.1915.
- Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences. 2016;113(16):4296-4301. PMID 27044069. PMC4843483.
- Wall LL. The medical ethics of Dr J Marion Sims: a fresh look at the historical record. Journal of Medical Ethics. 2006;32(6):346-350. PMID 16731734.
- Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Doubleday; 2007.
- Cooper Owens D. Medical Bondage: Race, Gender, and the Origins of American Gynecology. University of Georgia Press; 2017.
