Country-level gender inequality and sex disparities in adolescent chronic pain: A 47-country analysis

Objective: To examine how country-level gender inequality relates to adolescent chronic pain prevalence and sex disparities. Methods: We linked country-level Gender Inequality Index (GII) and lifetime prevalence of intimate partner violence (IPV) against women to 2017/18 Health Behavior in School-aged Children data from 244,097 adolescents ages 11–15 in 47 countries. Relative sex disparities in pain prevalence (female:male prevalence ratio [PR]) were examined with modified Poisson regression with country-cluster-robust standard errors; absolute disparities (prevalence difference [PD]) with multilevel linear probability models. Results: Chronic pain prevalence ranged from 32.30% to 58.72% across countries (overall 44.32%; I² = 98.36%). Female–male PDs ranged from 0.29 to 18.26 percentage points (pooled 13.28; I² = 79.80%); PRs ranged from 1.01 to 1.69 (pooled 1.36; I² = 83.71%). Higher GII was associated with greater pain prevalence (PR = 1.11, 95% CI: 1.04, 1.19) yet smaller sex disparities, due to steeper increase in boys' pain prevalence as GII increases. Higher IPV prevalence, though unrelated to overall pain prevalence, was associated with larger female–male percentage-point differences (β = 1.28%, 95% CI: 0.16%, 2.39%). Conclusions: Structural gender inequality shapes both the population burden of adolescent chronic pain and sex disparities, underscoring the relevance of structural context and the need for more research in lower-income countries.