Understanding Health and Pain Through the Gender Regime: A Multilevel Framework from a Sociological View

Abstract

The influence of sex and gender on health is a relevant topic in both social research and health studies. However, the complexity of considering sex and gender jointly with multiple dimensions of the social structure (labor market, violence, traditions and culture, health system, etc.) requires an analytical framework. The present study employs the gender regime as a theoretical framework for health studies. It primarily draws upon the theoretical contributions of Walby and Connell, engaging with the challenges encountered in theoretical, methodological and empirical debates. Despite the diverse roots of these two perspectives, broadly utilizing the gender regime is promising for research. The health evidence demonstrates the potential of this framework to facilitate a more nuanced understanding of the distinct characteristics, experiences and resources that are specific to men and women. Studies of pain and illness also illustrate the contribution of the gender regime for both science and public policy related to health and well-being. A multi-level framework for health and pain has been developed using a sociological interpretive synthesis and a critical review. The present study puts forward a model and classification of components with an application to human health in which the gender regime is significant.

1. Introduction

The term “gender regime” has been used extensively since the 1990s (Connell 1987; Walby 1996; Schofield and Goodwin 2005; Guerrina et al. 2023; Klammer 2023). Its conceptual foundations have been developed by various feminist movements with the aim of understanding how social structures and institutional dynamics place women and men in hierarchical roles. It is framed within theories about gender relations, which argue that the interactions and power relations between people are affected by gender at macro, meso, and micro levels. Gender regime refers to the social organization surrounding gender that are inscribed in norms, institutional dynamics, and power relations (Walby 1996; Lorber 1994; Connell 2012) and the persistence of a masculine order that permeates the social and institutional framework (Acker 1990; Walby 2009).

This also occurs in health, where gender relation concepts ensure that inequalities can be addressed (Álvarez-Dardet 2014). Thus, considering the gender regime spotlights how women and men are exposed to different health risks and adopt healthier lifestyles in different ways, as well as interacting differently with health professionals and services, and experiencing their illnesses differently. The specific case of pain—whose scope goes beyond strictly biomedical—is also revealed as an experience deeply mediated by social and cultural factors (Kirmayer 2008; Lavielle et al. 2008; Grol-Prokopczyk 2017; Abrutyn 2023; Biedma Velázquez et al. 2022, 2024), making it essential to incorporate the gender regime.

Gender regime constitutes a key analytical tool for addressing social inequalities in any area through a structural perspective; as its capacity is not only explanatory, but also transformative, especially in the design and implementation of public policies (Acker 2006). However, the analytical scope of this concept requires deep reflection on the theoretical foundations developed by some scholars. Despite sharing some common features, they are based on different premises about what gender means and also involve a wide range of methodological approaches. Although their contributions may seem to clash with one another, their lines of thought can enrich the understanding of health from social and gender perspectives and allow complementarity of visions. However, conceptual clarification is essential to identify the factors that make up the gender regime and to develop an effective methodology for its use in empirical research. The purpose of our research is to review and develop the concept of gender regime from a theoretical and methodological perspective, assessing its explanatory capacity in the fields of health and pain, so that it can be employed as a basis for future empirical investigations.

A multilevel framework for health and pain was developed through a sociological interpretive synthesis and a critical review. This approach emphasizes the social and gender dimension of health in general, and of pain in particular, highlighting how gendered power relations, institutional dynamics, and interactional norms shape exposures, experiences, clinical encounters, and access to care. This perspective aligns with insights from medical anthropology and public health, facilitating their translation into empirical designs and policy instruments.

We are convinced that this approach can provide significant advances in equality. To achieve this, its explanatory ability must be tested, and its capacity must be verified to materialize the concept of gender regime in robust quantitative and qualitative indicators and measures for identifying gender relations in health, which are interwoven in the institutional area, the social domain, and in interpersonal interactions. For this reason, a comprehensive framework emerging from the theoretical and methodological discussion will be presented herein, enriched by research in health in which the gender dimension is present. This paper is based on theoretical research, understood as that which involves the critical review, systematization, and reconceptualization of a construct previously developed (Fernández-Alarcón 2006; Elgueta and Palma 2010).

The text is structured in various sections that ensure that we can progress from the conceptual foundations to the analytical and practical implications of the proposed approach. First, a genealogy of the concept of gender regime is presented. This section separately outlines the theoretical contributions of two authors in its development: Sylvia Walby and Raewyn Connell. The following two sections examine gender regime insights in health and pain research. In the next section, a theoretical and methodological proposal is discussed, aimed at materializing the analytical potential of gender regime in health, with special attention given to its implications for equality. Finally, the main conclusions are presented.

2. Materials and Methods

This article presents theoretical research rooted in sociology and a feminist perspective developed through a critical review and interpretive synthesis of the gender regime to understand health and pain. Given the primarily sociological orientation, the analysis draws mainly on the works of Sylvia Walby and Raewyn Connell. This theoretical framework foregrounds the social and gender dimension of health and pain and is complemented by insights from other domains.

The corpus was constructed iteratively through purposive searches across multidisciplinary academic sources, together with key policy, indicators, and measurement documents. It was further enriched by the inclusion of seminal works and recent theoretical contributions. The selection was guided by conceptual relevance, prioritizing publications that theorize gender regimes or are closely related to constructs, approaches, and evidence that illuminate health or pain through social structures and gender relations.

A critical, concept-based interpretive synthesis was applied, using constant comparison and conceptual mapping to integrate structural–institutional and relational–interactional perspectives. This analytic process provided the organizing framework for the article.

3. Results

3.1. Genealogy of the Construct of Gender Regimes

Relational gender theory focuses on interpersonal interactions within institutions and social structures, where power dynamics and hierarchies are created and maintained, reproducing inequalities. Its theoretical development has evolved through authors and schools of thought. Some scholars emphasize personal interaction, illustrating how individuals negotiate and recreate roles, expectations, and opportunities beyond hegemonic models (Lorber 1994; West and Zimmerman 1987; Fenstermaker and West 2002). Others highlight the historical and social processes that shape gender relations, both at the interpersonal and structural levels (Jónasdóttir 1994; Hawkes et al. 2025).

In all these theories, gender regime has become a powerful analytical tool for examining how gender relations influence, structure, and perpetuate inequalities between women and men (Gottfried et al. 2023). Its value lies, first, in its capacity to analyze gender differences through the structural, cultural, political, and economic dimensions that shape societies and states. Second, it provides a framework for understanding the social order in terms of gender, with the aim of influencing public policies to advance equality.

In 2006, Joan Acker explicitly introduced the term inequality regimes to refer to the “interrelated practices, processes, actions, and meanings that result in and maintain class, gender, and racial inequalities within particular organizations” (Acker 2006, p. 443). However, in earlier studies, she had already laid the theoretical groundwork for understanding how the (male) gender is embedded in organizational structures (Acker 1990).

Theories about gender regime reveal a productive tension between the structural and the interactional, expressed in the diverse theoretical perspectives proposed by different authors. From a structural perspective, the analyses of authors such as Acker (2006) and Walby (2007, 2020) focus on the roles of patriarchy, the state, public policy, and institutions in the unequal organization of gender relations. They emphasize macro-structural issues and characterize societies based on indicators of participation in different areas of society (employment, education, etc.). Factors such as gender-based violence, the sexual division of labor, education, and political representation are understood as structural expressions of the patriarchal order (Walby 2020).

In contrast, scholars such as West and Zimmerman (1987), Connell (2012), and van Oost (2003) propose an interactional approach, where gender norms and expectations guide everyday practices within a hierarchical order. In this view, gender is constructed in specific contexts through social relations, where gender practices—although shaped by norms, roles, and environments—are dynamic. The distribution of power and authority according to gender is not invariable but is instead negotiated and transformed depending on the social and cultural context. Despite differences among authors, gender is envisaged as the product of a collective, relational experience shaped by power systems operating at economic, political, and cultural levels. As MacKinnon (1989) argued, gender should not be viewed merely as a culturally constructed difference, but rather as a hierarchical stratification system that profoundly arranges the social order.

3.1.1. Gender Regime and Patriarchy

In Theorizing Patriarchy (Walby 1989), Sylvia Walby conceptualizes gender regime as the specific form that patriarchal domination takes in each society. From this perspective, patriarchy is not a homogeneous or universal system but instead acquires diverse historical and geographical configurations. In this initial formulation, Walby identifies six patriarchal structures that sustain inequality between women and men: household production, paid employment, the patriarchal state, male violence, interpersonal relations, and culture. These structures operate in an interconnected manner, limiting women’s access to resources and decision-making across multiple domains of social life. In more recent works, such as Social Theory and Gender (Walby 2020), Walby reframes her approach, proposing an analytical model based on four broad institutional domains: the economy, politics, civil society, and violence. This model aims to integrate a structural and intersectional perspective that articulates gendered power dynamics at multiple levels—macro, meso, and micro—encompassing both the state and non-state social actors and allowing for comparative analyses between groups (Walby 1994, p. 1340). However, the empirical approach based on this framework is unsuccessful at addressing the three levels as a whole, as will be shown later. The ultimate objective of this proposal is to inform public policy to advance gender equality.

In her methodological formulation, Methodological and Theoretical Issues in the Comparative Analysis of Gender Relations in Western Europe, Walby (1994) advocated for more precise indicators than those available at that time. She pointed out the scarcity of data and the difficulty of handling certain aspects of gender relations. While data on fertility and labor market participation may assist with conceptualizing some of the proposed subsystems, it is more challenging to find indicators that report on cultural dimensions or examine the dynamics of gender subordination. Another limitation she identifies concerns the unit of analysis: most indicators provide information at the level of nation-states, which is insufficient to address how gender relations operate across categories such as nationality, ethnicity, race, religion, or linguistic community. Walby is aware that the proposed indicators stem from a particular “cultural baggage,” and thus recommends that they should be openly developed and accompanied by a clear statement of motivations and a critical examination of “apparently paradoxical contradictions.”

The Gender Equality Index of the European Institute for Gender Equality (EIGE), where Walby served on the advisory board (personal communication by email) has been the benchmark tool par excellence. The index has undergone its own historical evolution. Initially, it was structured around seven main dimensions: work, money, knowledge (education), time, power (participation in decision-making positions), health, and violence (EIGE 2023). The latest report adds a thematic focus on the Green Deal. The Gender Equality Index reflects dimensions of inequality based on Walby’s proposal, employing a macrosocial perspective centered on data aggregated at the state level.

In her theoretical framework, Walby (2020) distinguishes between neoliberal and social-democratic public gender regimes, depending on the extent to which feminist policies influence economic and political development. In her view, a deeper form of gender democracy (broad democracy) makes the consolidation of a social democratic regime more likely than that of a neoliberal one. Along these lines, Walby (2020) criticizes interpretations that limit gender analysis to the private sphere—family as the sole unit of analysis—and instead advocates a public approach that articulates the gender regime across the four main institutional domains: the economy, politics, civil society, and violence. Previously, she had argued for moving beyond approaches focused narrowly on a limited number of variables and warned against a postmodernist stance that denies the possibility of a common frame of reference: “A better analysis is one which is between these extremes, more complex than that of a monolithic model of patriarchy, while not abandoning macro concepts” (Walby 1994, p. 1339).

Walby (2020) distinguishes between private and public gender regimes, proposing that the former be brought into the institutional (macro and meso) sphere. However, this transition does not necessarily result in improved living conditions for women, since public gender regimes may reproduce new forms of inequality under the guise of neutrality or progress (Acker 1990). For instance, in the domains of health and labor, the integration of women into the labor market has not been accompanied by institutional recognition of menstrual pain. While one might expect their increased public presence to prompt a collective resignification of menstruation, it continues to be treated as a personal matter and relegated to the private sphere. The absence of public policies to address menstrual management reinforces the structural inequality experienced by many women, by obscuring the material and symbolic costs of menstruating in contexts of precarity or high labor demands (Azcue and Patiño 2018), as highlighted by feminist movements that demand its proper regulation.

Violence, the fourth institutional domain in Walby’s framework, enables a direct connection between gender regimes and the analysis of pain and health. Gender-based violence is understood as a structural practice that regulates women’s bodies through harm and operates as a mechanism of social control that reinforces patriarchal hierarchy (Walby 2020; Segato 2003). Numerous studies have demonstrated that many women who experience gender-based violence develop chronic pain, psychosomatic disorders, and trauma-related sequelae (World Health Organization 2012; Uvelli et al. 2024; Torrado and Padrón 2024).

3.1.2. Gender Regime Embodied in the Social Order

In Gender and Power (Connell 1987), Connell defines gender regimes as the structure of gender relations within a specific institution. Later, in Gender in World Perspective (Connell 2009), she expands the concept to a global level, integrating it into the analysis of globalization and transnational power relations. This scalability enables her, in Gender, Health and Theory: Conceptualizing the Issue, in Local and World Perspective (Connell 2012), to apply the concept specifically to the field of health, examining how gender regimes structure the access to care, and care risks and practices across diverse contexts.

From a relational approach, gender is understood as a multidimensional phenomenon that simultaneously affects economic, power, affective, and symbolic relations (Connell 2009). These dimensions operate in an integrated manner at the intrapersonal, institutional, and structural levels, shaping the overall social order. Within this framework, the everyday practices of men and women—such as paid labor, domestic work, sexuality, and parenting—are neither random nor individual. Instead, they are embedded in hierarchical social dynamics that reproduce structural inequalities (Connell 2012). Far from conceiving of gender as an individual or solely cultural category, Connell understands it as a socially embodied structure, where “bodies are both agents and objects” of social practices (Connell 2009, p. 67). From this relational theory, gender regimes are conceptualized as institutionalized and embodied forms of social organization that structure relations between genders in specific contexts (Connell 2012).

The relational theory of gender also incorporates a symbolic and representational dimension: people not only act from their material positions, but also within the expectations, rules, and power relations they occupy in the social hierarchy. Connell’s perspective engages in historical dialogue with theories of representation (Goffman 1959) and symbolic interactionism (Mead 1934), which emphasize how identities are constructed, represented, and negotiated in daily interactions under shared symbolic frameworks.

This perspective articulates how gender inequalities are shaped in specific domains—such as health—not solely as a result of biological factors or individual choices, but through institutional regimes that unevenly distribute access to healthcare resources, the recognition of needs, and caregiving responsibilities (Connell 2012). Connell points out how these inequalities are deeply embedded in both organizational and symbolic structures, molding the bodies and experiences of women and men in different ways.

One key dimension of Connell’s approach is her conceptualization of hegemonic masculinity. Connell introduces this concept in Gender and Power (Connell 1987) to describe a type of socially dominant masculinity, associated with being strong, self-sufficient, successful, heterosexual, and with emotional self-control. This culturally exalted construction not only subordinates women but also establishes hierarchies among men themselves. Although it may not be the most common form of masculinity, it is the most socially valued, which reinforces its normative power and structural influence. In 2021, Connell et al. revisited the concept of “hegemonic masculinity” to respond to critiques and enrich the term (Connell and Messerschmidt 2021). Finally, they presented it as a model that is neither universal nor static, but rather a socially situated and dynamic construction that is under debate.

From this perspective, health cannot be addressed outside of gender order: risk, care, and suffering are distributed according to power dynamics anchored in specific gender regimes. Connell’s relational theory thus offers essential analytical tools for envisioning structural transformations aimed at equity and social justice in health, positioning gender as a key dimension in the production and reproduction of inequalities.

A key empirical contribution for understanding gender regimes within institutional settings is the study by Schofield and Goodwin (Schofield and Goodwin 2005), which examines public policy development in New South Wales. Using a qualitative methodology based on interviews, the authors identify three types of institutional regimes that map how gender relations are structured and contested within public institutions: (i) the regime of male hegemony, characterized by low female participation and a strong concentration of power in male hands; (ii) the regime of feminist presence and male backlash, where the incorporation of a feminist perspective coexists with active resistance and internal tensions; (iii) the regime of negotiated inclusion, which involves a partial redistribution of roles and power, opening possibilities for greater levels of equity (Schofield and Goodwin 2005). This study operationalizes Connell’s theoretical framework on gender regimes and highlights the need to develop an analytical language capable of capturing the institutional dynamics that either sustain or challenge gender inequalities.

While qualitative research is particularly useful for understanding and explaining relational dynamics, it is quite weak in terms of its generalization when compared to quantitative methodologies. The small sample sizes and context-dependent results often limit the extent to which findings can be generalized (Elgueta and Palma 2010; Yin 2015). Nevertheless, from a feminist perspective, arguments have claimed that this limitation is offset by the methodological emphasis on lived experience, the visibility of women’s agency, and the analysis of change processes within specific structural contexts, thus linking theory and praxis for emancipatory purposes (Acker et al. 1983).

3.2. Incorporating the Gender Regime in the Study of Health

Health depends on biomedical, psychological, and social factors. The World Health Organization (World Health Organization 1948) defined health as a state of well-being subject to mental, physical, and social conditions, which were reiterated by the 2005 Commission on Social Determinants of Health. This means that socioeconomic, cultural, and political dimensions structurally influence health, molding both exposure to risk factors and access to protective resources.

However, its application within the biomedical field has remained largely nominal. Scientific knowledge continues to prioritize biological factors, focusing predominantly on the human body (usually male), relying on technological and pharmaceutical interventions to restore health, and at best proposing health education and promotion programs (Krieger 2003; Ruiz and Verbrugge 1997). In epidemiology and health economics, well-being is often linked to welfare regimes and the state’s capacity to mobilize health resources for its citizens (Gottschall 2023; Eikemo et al. 2008). This is a significant step, where public policy positively influences citizens’ health, and they may benefit from the healthcare provided by institutions. Yet, cultural and social norms have largely been ignored in most studies, so there is no subsequent translation into health policy. Walby (1994) speaks of the difficulty of incorporating the social dimension into research for public policy due to the theoretical approach of disciplines that deem them less important, or the challenges in establishing a comprehensive framework of understanding that integrates all dimensions. Employing the gender regime as an analytical framework also casts a critical lens onto the patriarchal and masculine order of society.

Using gender regime as a basis for this analysis helps to demonstrate how health and pain are structured differently for women and men, not only physically, depending on their position in the social hierarchy, daily practices, and power relations. The factors of sex and gender have been recognized as vital social determinants of health (Hawkes et al. 2025; Krieger 2003; Ruiz and Verbrugge 1997; Regitz-Zagrosek 2012). Biomedical research has begun to uncover biological health factors of men and women that reveal how gendered relations are intertwined with social, political, economic, and cultural structures. Moreover, the gender regime contributes to analyzing how the social order in terms of gender shapes health and illness in the workplace, in cities, and in social environments, producing measurable outcomes (e.g., disease probability, healthy lifestyle, access to adequate healthcare).

One illustrative example of the impact of the gender regime on health is provided by the study conducted by Springer and Mouzon (2011), who apply Connell’s concepts of hegemonic masculinity within the framework of relational gender theory. Using an empirical methodology and a hegemonic masculinity scale, they analyzed the relationship between masculinity and health practices among men over the age of 65. The findings show that the men who most strongly internalize hegemonic masculinity ideals are significantly less likely to engage in preventive care, such as physical exams, prostate screenings, or flu vaccinations. Moreover, contrary to what could be expected, a high socioeconomic status does not mitigate these negative effects and, instead, even intensifies them. This result suggests that hegemonic masculinity functions as a counterforce that neutralizes—or even reverses—the health benefits traditionally associated with higher socioeconomic status.

The sexual division of labor reveals distinct health risks, disease prevalence, or work-related injuries. Paid labor—the backbone of social order—has historically been associated with the concept of health. From Parsons’s theory on the welfare system—from the sick role to medical leave—there has been a continuous association that links health to the ability to perform an economic function (González-Ramos 2024a). This reasoning reinforces gender inequalities, since men and women hold different positions in the labor market and in care roles. Women without paid employment lack a similar recognition as “sick person” working in the formal labor market.

Other work-related examples include the different incidence of traumatic accidents, for example, the rate is higher among men in the industrial sector, and there are more musculoskeletal injuries among women in cleaning and caregiving jobs (INSST 2023). Women’s health disadvantages are also related to unequal unemployment, first-job training, and career interruptions (Cambois et al. 2017), meaning the social system plays a fundamental role in health and well-being. In Walby’s (Walby 2020) words, the shift of gender regimes from public to private spheres affects women’s health. The sexual division of labor shapes inequalities for women in formal employment, time allocation, and mental fatigue (Hochschild and Machung 2012). The double shift has significant mental and physical health impacts on women (Koura et al. 2020; Palumbo et al. 2017; Fishta and Backé 2015). Although employment can lead to positive effects on women’s health, other risk factors emerge from new female roles in the labor market. The rise of teleworking intensifies negative impacts by frequently merging professional and care duties, affecting workloads and free time (Eurofound 2022; Lamolla and González Ramos 2018).

Gender regimes also explain the complexity of diverse experiences in healthcare. WHO statistics (World Health Organization 2021) show that women continue to be underdiagnosed and treated worse by health systems. Gender disparities exist in the reasons and times that men and women go to the doctor, waiting times, and the types and numbers of diagnostic tests performed (Sun et al. 2023). A notable example is endometriosis, which, according to EIGE (EIGE 2023), takes an average of seven years to diagnose after symptom onset. In contrast, men often receive faster and more effective treatment for cardiovascular diseases compared to women (Vogel et al. 2021).

These disparities are underpinned by cultural stereotypes and gender scripts that operate institutionally and are unconsciously internalized by professionals and patients (van Oost 2003; Boni-Le Goff and Le Feuvre 2017). Culture—which defines the roles and habits of men and women differently—influences how diseases are experienced and prevented, and how they develop. The gender regime also leads to an understanding of guidelines for self-care and healthy habits, according to Lipsky et al. (2021). They found that women generally maintain better oral hygiene than men, who have twice the rate of oral cancer.

According to Acker (1990), health systems are not neutral for men and women, providing resources for them under different guidelines. The health system identifies which female illnesses are prioritized, which symptoms are deemed serious, and how available resources are allocated. Kavanagh et al. (2023) argue that health systems configure power relations through differentiated treatment in providing services. Gupta et al. (2019) note that historically marginalized groups lose collective power, leaving their health needs unmet.

The gender regime clarifies the historical and cultural evolution of certain diseases. A very illustrative example is heart disease, which at the turn of the twentieth century was considered almost exclusively male, while today it is the leading cause of death for Western countries, including women (EIGE 2023; World Health Organization 2021). This change can partly be explained by the transformation of the social and labor roles taken on by women, who have been entering environments that demand fast-paced work and values of success and competition traditionally associated with men.

Taken together, this body of research shows that health and illness are deeply structured by the gender regime that operates distinctly between men and women, due to their different positions in the social order, and also different in categories of age, race and ethnicity, beliefs, and values. Recognizing the role that social and gender factors have on health demands an intersectional perspective to understand how these variables interact, producing dissimilar layers of vulnerability. This viewpoint, already present in Acker’s (2006) work, has recently been resumed by The Lancet Commission on Gender and Global Health (Hawkes et al. 2025), which emphasized the need for greater precision in research and a bolder integration of this lens in public health decision-making. Health conditions, risk factors, and the provision of care vary across social groups depending on gender, socioeconomic status, age, ethnicity, and position within family and social structures permeated with male chauvinism (Hawkes et al. 2025).

The complementarity of the approaches detailed in the Section 3.1.1 and Section 3.1.2 is especially valuable for constructing a comprehensive, holistic framework that can tackle research questions on health while accounting for gender regimes. Walby’s structural characterization of gender regimes offers analytical tools to understand macrosocial inequalities that determine the allocation of health resources. Meanwhile, Connell’s relational perspective delves into the subjective, experiential dimensions of health and pain. Integrating both approaches enables more robust, multidimensional analyses that account for the influence of social, political, and economic structures, as well as the culturally mediated interactions, organizational dynamics, values, and expectations for specific groups (Cockerham 2013). Both the understanding and knowledge of illnesses and the behavior of people that deal with pain and health are defined by the gender regime in operation.

3.3. Evidence on Pain and Gender Regimes

Historically, pain research has been dominated by an androcentric model—even in animal experimentation—which has limited understanding of the genomic and neurological foundations of pain in women (Mogil 2012). At a biological level, significant sex-based differences have been documented in the immune cells involved in pain transmission, highlighting the need to consider sex as a critical variable from the earliest stages of biomedical research, in both animal models and human studies (Clayton 2016). This sex-biased perspective in biomedical experimentation has resulted in an incomplete evidence base, hindering the development of accurate diagnoses and effective treatments that are appropriately tailored to the distinct characteristics and circumstances of diverse populations (González-Ramos 2024a, 2024b; Jenkins and Newman 2020).

Feminists have long questioned a purely biological interpretation of pain, arguing that differences in how women and men experience pain are shaped by gender inequalities and power relations (Hoffmann and Tarzian 2001; Samulowitz et al. 2018). In fact, the influence of gender regimes on pain can be traced through a range of studies that handle the proposed subsystems, showing how diverse structural axes—such as education, job position, income, gender, race, and ethnicity—shape painful experiences in unequal ways.

In the domain of knowledge, Zajacova et al. (2020) show a steep education gradient in pain: adults with lower schooling report substantially more pain, with women consistently exhibiting higher prevalence across educational levels. From a socioeconomic status (SES) perspective, longitudinal evidence indicates that sex modifies the SES–pain relationship: in an 8-year cohort from Stockholm, social factors (low SES, household load, job strain) showed different—and at times opposite—associations with chronic pain by sex (Prego-Domínguez et al. 2021). Women are also disproportionately affected by precarious employment and unpaid workloads, which may contribute to the higher incidence of chronic pain (Zajacova et al. 2021). In a multilevel analysis across 52 countries, Zimmer et al. (2022) found that gender inequality (GII) and income inequality (Gini) are significantly associated with population pain prevalence (Zimmer et al. 2022). Regarding pain perception and treatment, studies document gender bias: clinicians and lay observers tend to underestimate women’s pain and women are less likely to receive timely analgesics, with a greater propensity toward psychosomatic framing or sedatives (Hoffmann and Tarzian 2001; Zhang et al. 2021). Beyond recognition and prescribing biases, improving shared decision making shows a causal reduction in disabling chronic pain—with stronger effects among women (Brown et al. 2024).

These findings strengthen the value of the structural and intersectional approaches of pain analysis. From an intersectional perspective, variables such as age, sex, ethnicity, place of birth, and language shape not only pain experience but also its perception, legitimacy, and institutional response (Nahin 2015). This suggests that gender regimes not only structure access to healthcare resources but also influence how pain is interpreted, addressed, and validated—depending on who experiences it and under what social conditions.

Gender scripts impose differentiated norms and expectations regarding expressions of pain and suffering, which in turn influence the responses of the people surrounding them, including in the healthcare system. In many sociocultural contexts, men are expected to adopt stoic attitudes and suppress expressions of pain, whereas women are permitted—or even expected—to be more emotionally expressive (Zhang et al. 2021; Sharman et al. 2019). These differences influence how suffering is interpreted and treated by healthcare providers, indirectly affecting access to appropriate resources. As key scholars in the sociology of health have noted (Sen and Östlin 2008; Lorber and Moore 1997), disparities in assessing pain cannot be explained solely by symbolic discourse or social interactions, as they are rooted in structural inequalities in access to care, the legitimacy given to symptoms, and the distribution of caregiving responsibilities.

The pathologization of women’s pain and the legitimization of men’s pain reinforce persistent inequalities in diagnoses and safe and appropriate interventions. The social hierarchy of suffering determines which types of pain are recognized as legitimate and which are dismissed or underestimated (Biedma Velázquez et al. 2022). Gender mandates act as behavioral guidelines that affect how pain is experienced, expressed, and managed, generating significant differences between women and men.

Miller and Newton (2006) argue that self-efficacy and socialization processes over the course of the life cycle determine differing patterns in the expression of suffering according to sex, which may reinforce biases in diagnoses and effective treatment. Differences in pain perception and response are mediated by external factors such as cultural norms, social customs, religious beliefs, and level of education. Religion, as a cultural manifestation deeply rooted in specific social groups, offers symbolic and practical frameworks for coping with and enduring pain (Biedma Velázquez et al. 2019). Culture plays a fundamental and multidimensional role in the experience of pain (Morris 1991). Although not recent, the incorporation of cultural and symbolic dimensions in the study of pain is crucial for understanding how—beyond formal structures like the sexual division of labor or power hierarchies—gender scripts are unconsciously internalized and shape differentiated behaviors (Boni-Le Goff and Le Feuvre 2017). These scripts dictate, for instance, that men should conceal pain and project strength, while women are assigned the caregiver role and are permitted emotional expression. Emotional and symbolic relationships govern the ways in which men and women’s pain is understood and managed. This rationale is reproduced on a macro level, perpetuating the patriarchal social order, and at meso and micro levels, reinforcing daily practices and familial organization (Walby 2020).

Incorporating gender regimes into pain analysis is essential for guiding healthcare strategies aimed at reducing gender biases in pain treatment (Hoffmann and Tarzian 2001; Samulowitz et al. 2018; Sharman et al. 2019). First, in relation to the organization of care systems, which unequally regulate informal labor and time distribution between women and men with different characteristics (socioeconomic status, ethnicity, values, etc.). Second, in terms of the allocation of healthcare resources allocated to men and women suffering from chronic painful conditions, often shaped by diagnostic bias and unequal treatment pathways.

4. Discussion

The preceding sections have outlined both the potential of the gender regime concept and the body of health research that supports the existence of a relationship between health and gender regimes. The conceptual framework of the gender regime allows for a nuanced approach that can, for example, differentiate health impacts among individuals situated within the same legal and political context and the same healthcare system, but who are nevertheless exposed to varied health risks, degrees of access to care, and cultural, ethnic, origin, and age differences. We have argued for the relevance of using the concept of the gender regime to analyze the social dimension of health and have presented both conceptual and empirical literature that justifies its incorporation into the understanding of both health and pain.

The methodological challenge of collecting high-quality data that go beyond state-level indicators was also pointed out—evidence capable of capturing the intersectional characteristics of individuals, thus enabling robust quantitative analyses while incorporating comprehensive insights into the mechanisms by which power relations, symbolic dynamics, and emotional structures operate—elements typically accessed through qualitative methodologies. In this section, we propose a conceptual and methodological configuration of the dimensions that comprise the gender regime, with the aim of facilitating its application in future research, whether theoretical or empirical.

Figure 1 illustrates the factors that constitute a gender regime in health and pain, using Walby and Connell’s approach. The concentric layers reflect the systemic relationship between various domains. At its core, the gender regime functions as a central axis that radiates outward, influencing social norms, institutions, formal and informal power relations, the socio-economic and political structure, and the representation and symbolization of gender relations.

Several axes cut across opportunities, risks, expectations, and caregiving—both self-care and that provided by welfare regimes and healthcare systems—considering factors such as race, ethnicity, age, sexual orientation, and health condition (e.g., chronic illness or disability), all of which are influenced by the gender regime. In parallel, religious systems, the labor market, and public policy—as well as power relations shaped by the gender regime—configure the material conditions, behaviors, and values related to health and to the individual and collective (familial, social, institutional) management of pain.

The labels within the concentric layers represent individual health and illness outcomes, according to risk indicators, nutritional patterns, and lifestyles. Cockerham (2013) argues that health-related lifestyles are shaped by conscious choices made within a set of options available to one’s social class, understood as a cluster of intersectional factors governed by sex, age, ethnicity, and socio-political, economic, and health structures, among others. In this model, the range of available choices is mediated by the gender regime. Likewise, these labels include gendered outcomes related to the regulation of illness (e.g., sick leave, benefits, the legitimacy of medical consultations) and the legitimacy of pain (García et al. 2023).

A further purpose of Figure 1 is to reveal the complexity and multidirectional interactions of the dynamics among components by integrating the various interpretations of gender regime previously discussed. By situating the gender regime at the core—shaping norms, institutions, and the social structure—the surrounding layers illustrate the conventional spheres of health analysis from a macro-social perspective. These include the subsystems embedded within the gender regime framework, the EIGE gender equality indicators, and other sociological dimensions. Classical epidemiological and public health studies typically assess the rate of work disability, prevalence of chronic diseases, and healthcare access in relation to socioeconomic status and welfare state types, to name just a few. When health research addresses gender differences, it usually focuses on a limited set of these variables.

The diagram (Figure 1) provides a visual tool for mapping the potential interconnections among all of these dimensions, representing a complex methodological challenge. It does not imply that all dimensions must be incorporated simultaneously in each study, but rather that their interdependence and mutual influence—rooted in the gender regime—should be acknowledged and analytically considered.

National statistical health measurements collect individual-level raw data reflecting country-wide patterns in healthcare systems, labor markets, education, and so forth—for example, rates of accidents, births, disease incidence, disability-related retirement, hospital beds per capita, etc. Other studies rely on self-perceived health, health-related behaviors, and subjective opinions regarding health and lifestyle. In both cases, showing gender-based distribution is not the same as addressing the implicit complexity of the gender regime. These data draw close to showing the real-life health conditions of the population but fall short of capturing how gender regimes impact the health of men and women.

From a methodological perspective, surveys gather both objective and subjective information across these dimensions, while qualitative research can delve deeper into the nature and influence of the material and symbolic processes that shape them. Qualitative methodologies are particularly suited to capturing the complexity and relational nature of gender dynamics in institutional contexts. Nevertheless, their ability to generalize findings in other contexts remains limited (Schofield and Goodwin 2005). Following Walby’s approach, the development of indicators capable of comparing the impact of gender regimes across social groups remains an unresolved issue (Walby 1994). She states that “the comparative analysis of gender relations demands better data sources than currently exist and more sophisticated conceptualization” (Walby 1994, p. 1353). However, most empirical studies continue to analyze these variables in isolation, despite their intrinsic interrelation, which hinders a comprehensive understanding of how gender regimes affect health outcomes.

From a critical perspective, it is acknowledged that gender regimes operate in complex and interwoven ways across multiple geographic scales (regional, national, continental) and over time (historical and evolutionary). They often take on hybrid or transitional forms (Guerrina et al. 2023; Walby 1994; Gottschall 2023), emphasizing the need to reconsider “ideal types” to accommodate these “hybrid realities,” recognizing that gender regimes are dynamic and contingent configurations rather than closed systems. Accordingly, it is essential to develop robust methodological tools that allow for the empirical operationalization of these configurations and their measurable impacts on health and disease.

Table 1. Dimensions integrated for studying health from a gender regime-centered perspective (own work).

Dimension	Areas to Develop Sensitive Indicators
Work	Risk at work
	Chronic illness at work
Economic status	Financial independence
	Access to medicine and health services
	Disability pension
	Poverty ratio
Education	Formal education degree
	Habits and lifestyle
Law	Development of equity norms
Time	Self-care/day
	Time spent on care and household
Power position	Subordination
	Stress
	Supervision duties
	Emotional relationships
Health	Self-perception
	Behavior (healthy or unhealthy)
	Access to the health system and resources
	Healthy life years in absolute value at birth
Violence	Physical
	Sexual
	Psychological and symbolic

presents a preliminary proposal that encompasses the subsystems proposed by EIGE, Schofield, and Goodwin, alongside traditional frameworks in epidemiology and the sociology of health (Schofield and Goodwin 2005; EIGE 2023). The integration of Walby’s and Connell’s frameworks into the gender regime concept combines a macro–meso–micro approach that considers institutional structures and relations, emotional relationships, and relations of subordination. It offers a robust analytical tool for testing complex quantitative methodologies while preserving the depth of qualitative insight through microstructural dimensions. Walby’s framework provides insights into how public policies and health systems may affect gender inequalities, while Connell provides a lens to understand the meanings attributed to pain and its expression in everyday life. Combining both perspectives fosters the design of more equitable and context-sensitive knowledge about health interventions.

As Walby suggests, it is helpful to reflect on the paradoxical contradictions experienced in women’s health due to shifts from public to private domains (Walby 2020). While such transitions—such as women’s access to leadership positions—may appear as advances in gender equality, they often occur within patriarchal structures that exacerbate gender-specific health problems, such as heart disease linked to certain working conditions. Another example is aesthetic pressure, which disproportionately affects women in societies where “bodies are both agents and objects” of social practices (Connell 2009; Hawkes et al. 2025). Affective and symbolic relationships exert a significant influence on women’s health across various domains—media, social and professional expectations, etc.—which translate into health risks. These practices, based on implicit norms regarding “ideal bodies,” contribute to concealing women’s pain, particularly when it does not conform to masculinized biomedical models (Connell and Messerschmidt 2005; Criado Pérez 2019).

Based on this conceptual and methodological approach, we propose four key directions for advancing knowledge:

• Considering the gender regime as a multifaceted and complex structure that comprehensively integrates health inequality relations: Health cannot be analyzed as a mere series of social factors; it requires a rethinking of each concept, assigning it meaning derived from the recognition of gendered oppression. Illnesses are often better understood with evidence when linked to occupational injuries or conditions that hinder paid labor (Russell and Schofield 1986). Joan Acker’s “gendered organization” approach (Acker 1990, 2006) provides a useful articulation between structure and identity, especially in the context of work and bodies. Her framework suggests how gender relations that materialize in seemingly neutral institutional practices—such as clinical guidelines or care protocols—ignore sex and gender (González-Ramos 2024a).
• Refining and synthesizing multiple indicators: There is a critical need to develop more accurate composite indicators to measure the relative influence of each factor in multivariate and multilevel models. Table 1 offers an initial framework to explore this potential. Gottschall (2023) points out the complementary nature of welfare and gender regimes. Thus, it is essential to investigate the extent to which health, illness, and pain depend on state-level organization (welfare regimes) or gender regimes that regulate norms, care systems, resources, risks, and legitimacy. Exploring gendered relations through national statistical sources will enhance our understanding of how each layer influences different health conditions, and decision-making related to epidemiology and health strategies, also proposing more tailored measures based on theoretical baggage. As Walby (1996) suggests, it could be particularly useful to compare regions and social groups influenced by the same welfare regime but different gender regimes. For example, regions with complex cultural and political traditions within countries like Spain, Switzerland, and the UK. Expanding the methodological toolkit to include non-Western models, as advocated by the United Nations (UN DESA 2016), could enhance analytical and comparative capabilities.
• Designing gender-sensitive analytical tools and questionnaires: It is essential to move beyond the economic incentives that dominate national health accounting systems. For example, we possess substantial knowledge about cancer—an illness that, in its most severe forms, disrupts daily life and generates substantial healthcare costs. Yet we know comparatively little about migraines, even though in 2019, the WHO identified them as the third leading cause of disability-adjusted life years worldwide. Consequently, indicators, survey questions, and qualitative research protocols should be designed and problematized to account for comparisons that are more sensitive to possible differences due to gender regimes. Rohlfs et al. (2000) advocate for the systematic inclusion of a gender perspective in survey design and analysis to better understand health inequalities. Accurately identifying the population’s needs is the first step toward developing effective health policies.
• Examining the complex factors that influence the gendered social order to plan more efficient equality-centered public policies: Health policies, programs, and services must be conceptualized through this lens of gendered and social complexity that underlies illness, pain, and health—mediated by individuals’ sex and social position. This complexity leads to ambiguities stemming from fragmented interests, expectations, and differential access to resources among men and women, reflecting the layered structure of societies’ gender regimes (see Figure 1). For instance, social practices such as fasting may be motivated by spiritual, aesthetic, or character-building reasons—all of which affect health, even when health is not the primary motivation. Most social processes do not impact health directly but influence risk and benefit patterns that shape health pathways.

5. Conclusions

This work provides a theoretical and methodological discussion on the concept of gender regime in the field of health to develop a broader understanding of health and pain from a relational gender perspective. A gender regime approach makes it possible to visualize and understand how social, institutional, and interpersonal structures affect both health and illness, broadly conceived. It affects which health conditions we are most likely to experience, how we interpret these conditions, and which resources we can access, since economic, labor, educational, cultural, violence-related, and care-related subsystems all define these outcomes. Moreover, it allows pain to be conceptualized as both a biological and social experience, permeated by norms, expectations, and power relations. Integrating this gender perspective into pain analysis helps reveal how social hierarchies are not only reproduced through institutions but are also inscribed in bodies, directly impacting the experience of pain and the well-being of women and men.

Gender regimes should be understood as historically situated, context-specific configurations that operate across multiple levels (micro, meso, and macro), either reinforcing or challenging existing inequalities. In this sense, the current model takes advantage of work carried out in this area by Walby, Connell, and other scholars, despite their diverse approaches. In any field of knowledge—whether politics, economics, or health—gender regimes represent a powerful analytical tool with the potential to shape public policy. A rigorous theoretical review of their construction, development, and application is a condition for advancing gender equality in health and, ultimately, for informing evidence-based policymaking.

In addition, the conceptual and methodological framework developed herein paves the way for more integrative studies capable of addressing the intertwined complexity of gender and other social factors. This would improve the sensitivity and efficacy of healthcare interventions and deepen our understanding of pain experiences among women and men. The inherent complexity of gender regimes calls for a reassessment of simplistic analytical frameworks and the development of tools capable of capturing the multidimensional and multi-scalar nature of this social configuration, thereby contributing to real change in the population’s health and well-being.

Finally, a deeper understanding of how gender regimes affect health would clarify the broader implications of gender regimes on health to know their implications on the road toward equality, paving the way for better public policies—on labor, social protection, politics, and the economy—that are centered on well-being and health.