Accepted for/Published in: JMIR Human Factors
Date Submitted: Apr 17, 2025
Date Accepted: Dec 28, 2025
Sex Representation in Pain Drawing Body Charts in Back Pain Research and User Preferences: A Multi-Method Study
ABSTRACT
Background:
Pain drawing (PD) body charts are widely used in back pain research, but the representation of sex in these charts has not been systematically evaluated.
Objective:
To evaluate sex representation in PD body charts used in back pain research, assess the perception of a newly designed sex-neutral body chart, and explore user preferences for sex representation in PD body charts.
Methods:
We conducted a multi-method study comprising: (1) a scoping review to assess sex representation and the reporting of sex in PD body charts in back pain literature; (2) an expert opinion study where anatomy experts evaluated the perceived sex of extracted body charts; and (3) a survey among a representative sample of UK adults with and without back pain to assess perception of a newly designed sex-neutral body chart and explore preferences for sex representation in PD body charts.
Results:
From 349 full-text papers, 108 articles met inclusion criteria. Most (103/108; 95.37%) did not report the sex of body charts used, and only 5.56% (6/108) included both male and female charts. Experts showed fair to moderate agreement (Fleiss’ kappa = 0.306; Gwet’s AC1 = 0.456) in assessing the sex of charts, with most charts assessed as male based on majority ratings (59/108, 54.63%) and classified as male-biased relative to the sex distribution of study participants (76/108, 67.65%). The newly designed sex-neutral body chart was perceived as sex-neutral by 68.5% (204/298) of survey participants across diverse groups. However, perceptions varied by racial group: 73.00% (181/248) of White participants viewed it as sex-neutral, compared to 42.50% (17/40) of participants from smaller racial groups (χ² = 15.88, p = 0.001). Female participants slightly preferred female charts (85/154; 55.19%); males preferred sex-neutral ones (88/144; 61.11%). Nonetheless, most participants (53.25% (82/154) of females, 74.31% (107/144) of males) considered the option to choose between male, female, and sex-neutral chart versions unimportant.
Conclusions:
Our study reveals reporting gaps and a predominant male bias in the representation of sex in PD body charts used in back pain research. The newly developed sex-neutral body chart was widely perceived as sex-neutral, offering a promising step toward more inclusive pain assessment. However, variations in perception across racial groups highlight the need for cultural considerations in design. These findings underscore the potential of sex-neutral and culturally sensitive body charts to enhance the inclusivity and equity of back pain research and clinical practice. Clinical Trial: OSF (https://osf.io/pbuch/)
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