Navigating endometriosis, the gender pain gap² and racial bias from both sides of the curtain, it’s not often I catch myself looking at my reflection in the patients of the emergency department (ED), but recently, I did.

Same age. Same skin colour; she’s Aboriginal, I’m African. Both Geminis (important). Familiar hunched-over position. Hands clutching a hot pack, placed directly onto her skin (relatable).“I have endo,” she said. “Ah, yep,” I said. “This is gonna sound so weird,” she said, “but my pain feels like a hot-”…“Poker up the a**?!” We both said. Then giggled, because honestly, with endometriosis, sometimes if you don’t laugh, you’ll cry.

I am an emergency physician working on Gadigal land (Sydney) who, like my patient and one in seven of us assigned female at birth, is affected with the delightful ailment known as endometriosis. This chronic, inflammatory condition of an elusive aetiology is characterised by tissue that resembles that of the endometrium growing beyond the uterus. It can have a variety of clinical symptoms, including pelvic pain, menorrhagia, dyspareunia, infertility, fatigue and gastrointestinal disturbance.¹

I am encouraged by the considerable attention presently being given to women’s pain, because for me, endometriosis has been the reason I have repeatedly put down my stethoscope and put on a patient gown. Due to systemic medical gaslighting, women frequently receive inadequate treatment.² As a healthcare professional, I think it’s important to share my experience as a person of colour who has this condition, which has been systematically under-recognised or dismissed for us.

From Doubt to Delay

In healthcare, a phenomenon known as the gender pain gap² exists, where women’s pain is routinely downplayed when compared with men’s. The pathway to diagnosis serves as a stunning example – it takes roughly eight years to diagnose endometriosis, an acutely painful condition. Here, the gap is created from damaging gender stereotypes that reinforce notions of feminine hysteria and the belief that biological processes like menstruation entail a certain but undefined level of “normal” pain.

Personally, aside from being conditioned by society to believe that crippling menstrual pain is normal, my stoic cultural upbringing and the stigma around discussing periods contributed to the more than a decade it took for me to get diagnosed with endometriosis, which until recently, required a laparoscopy for confirmation.

As someone who has played both patient and physician roles within the ED, I know we still have work to do when it comes to improving female patients’ pain. A small-scale Australian study3 demonstrated that men were more likely to receive combined opioid and non-opioid medication as their initial analgesic (p=.049). Women were more often given their first analgesic more than 90 minutes after ED presentation, compared to men (p=.029), and experienced longer waits before receiving a second analgesic (p=.032).

I’ve observed colleagues of all genders and races react with raised eyebrows when a young woman presents in pain. I’ve been that woman, overthinking my behaviour. If I cry and scream, I’m being hysterical; if I’m blank-faced, then surely, I don’t really need that Endone?

The gender pain gap often intersects with other marginalised demographics, including gender-diverse patients, non-Caucasian individuals (like me), and people experiencing poverty, further exacerbating pain disparities.⁴

The Intersection of Pain and Prejudice

Unfortunately, systemic racism is deeply rooted within the medical profession. Although most of the data in this area comes from the US, it is shocking, and I believe it is relevant to the Australian context when it comes to treating people of colour. In an extensive study5 comparing non-white to white patients, non-white individuals were more likely to report severe pain (p < .0001). However, they were less often given analgesia (p < .0001) and less frequently received opioids (p < .0001). Among those who received pain relief, non-white individuals waited significantly longer for their medication (p = .004). A 12-year cross-sectional study⁶ with a weighted sample of 1,065,936,835 ED visits showed black patients were also 10% less likely than white patients to be admitted and were 1.26 times more likely to die in the ED or hospital. There are plenty more studies with similar findings. This scares me. At work, I often rely on System 1 thinking,⁷ but I’ve learned that even brief moments of reflection can make a difference. By recognising our unconscious patterns and staying curious about our own biases, we can take small, practical steps that contribute to fairer, more patient-centred care.

A Legacy of Exclusion, Experimentation and Erasure

Interestingly, the history of endometriosis is a melting pot of racism and classism, having once been wrongly believed only to affect Caucasian women. If you are interested in this discourse, I recommend Olga Bougie’s⁸ writings. But to provide an overview: between 1845 and 1849, the renowned “father of modern gynaecology,” and inventor of the speculum, Dr Marion Sims, performed gynaecological experiments (operations) without anaesthesia on enslaved Black women, who could not consent. These horrific acts were justified by the false notion that Black women had a much higher pain threshold than white women.⁹

In the 1920s and 1930s, Dr Joseph Meigs, another openly racist celebrity gynaecologist, claimed on TV that only women who could afford contraception developed endometriosis, dismissing its occurrence in those he called “fertile monkeys.” His interest in the condition was linked to eugenics, specifically the goal of preserving the fertility of the Caucasian race. Studies of endometriosis at that time lacked scientific rigour, and mostly excluded Black women, which further bolstered the myth that only white women could be affected by the disease.¹⁰

Even in the 1980s, endometriosis was still seen as the “career woman’s disease,” a somewhat prejudicial term for the time.11 Many early medical textbooks kept reinforcing these stereotypes until very recently; a lingering influence that I believe contributes to the stark difference in diagnosis rates in the US: 5% among Black people compared to 72% among white people.10,12 The baseless idea that people of African heritage feel less pain still exists in both the medical field and the wider community.^12,13

For every doctor caring for someone with this condition, I believe it’s crucial to understand the complex link between race and endometriosis. Healthcare systems have historically overlooked the pain of individuals who don’t match the typical image of endometriosis sufferers, so raising awareness and understanding can make a meaningful difference.

I have only recently begun researching this history myself, and it has profoundly influenced how I view my own experiences and those of my patients.

Relief Begins with Recognition

While I have sometimes felt demoralised by my experiences, I have also encountered exceptional care, reminding me how powerful compassion can be in guiding someone through illness. When clinicians take a moment to validate my pain, it is compelling. In my view, humour is a surprisingly effective remedy.

As a patient managing a chronic condition, knowledge is power. As a clinician, it’s equally important to stay informed and communicate clearly as a shared understanding can make all the difference. The RANZCOG Australian Living Evidence Guideline: Endometriosis¹ is an excellent resource to support evidence-based, empathetic care. And remember to provide written information, as it’s often difficult to absorb details when overwhelmed by pain. I advocate for patients, especially those from minority backgrounds, to discuss seeing a gynaecologist with their GP whenever they present to the ED with acute pelvic pain, as I know the desperation that can come before diagnosis.

Recognising the complex interplay between race, gender, and pain is not just an academic exercise; it is of the utmost importance to provide tangibly better treatment. I believe the silence around reproductive health discussions in African cultures also needs to be addressed at a community level. Historically, women, and particularly women of colour, have been excluded from pain research and clinical trials². This lack of diversity must end so that we can provide effective and culturally responsive care.

Living with this condition has given me a deep understanding of invisible illnesses and a profound sympathy for the anxiety and second-guessing that often accompany a visit to the ED. Endometriosis is the only time I’ve felt enough pain to wonder: “do I have appendicitis, or is it just another Tuesday?” And I’ve diagnosed appendicitis countless times in my career!

As a clinician and a woman of colour with endometriosis, I carry both the privilege of prescribing care and the burden of being dismissed. The pain gap will only close when we stop asking women to prove they’re in pain and start listening as if their lives depend on it.

Because they do.

Disclaimer: I acknowledge that endometriosis is not exclusive to women. In this piece, I use the term “women” to reflect my own lived experience, but I recognise and respect the diversity of all people affected by the condition.