The Journal of Pain, Vol 7, No 12 (December), 2006: pp 915-928

Available online at www.sciencedirect.com

Sex Differences in Facial Encoding of Pain

Miriam Kunz,*, Andreas Gruber,* and Stefan Lautenbacher*
*Physiological Psychology, Otto-Friedrich University Bamberg, Germany.

Department of Psychiatry and Psychotherapy, Philipps University Marburg, Germany.

Abstract: There is substantial evidence that men and women differ in their perception and experience of pain. However, research on sex differences in pain has mainly relied on self-report ratings,
whereas little is known about sex differences in facial expression of pain. The aim of the present
study was to investigate: 1) whether men and women differ in their facial expressiveness of pain; and
2) whether sex modulates the relationship between self-report and facial pain responses when tonic
experimental pain is applied. Forty young and pain-free individuals (male n 20, female n 20) were
investigated for their subjective and facial responses to tonic heat stimulation at both painful and
nonpainful levels. Tonic heat stimulation was tailored to the individual pain threshold. Self-report
was assessed via visual analog scales. Facial expression was objectively examined using the Facial
Action Coding System. Correlation analyses for the relationship between self-report and facial
expression of pain were conducted. Men and women differed neither in self-report ratings nor in
facial responses during tonic heat stimulation. However, sex had a considerable impact on the
relationship between these variables. Whereas no significant correlations at all were found for men,
we obtained several significant correlations in woman. For that reason, future studies investigating
the relationship between self-report and nonverbal pain behaviors should consider sex as an important modulating factor.
Perspective: The findings of the present study suggest that facial responses to pain can be used as
estimates of the intensity of subjective pain in women better than in men.
2006 by the American Pain Society
Key words: Sex, facial expression, self-report, pain, FACS.

he literature on sex differences in pain perception

is sizeable. Numerous studies have been conducted
over the years and although contradictory results
were found, the majority of findings point to an increased pain sensitivity in women compared with men
regarding subjective pain report.11,24,25,27,34 36 It has
been hypothesized that this sex difference in pain perception might be due to complex interactions between
biologic (eg, hormonal), social (eg, developmental), and
psychologic (eg, emotion) factors.12,13
So far, research on sex differences in pain perception
has mainly relied on self-report ratings, although pain is
conveyed through a variety of verbal and nonverbal reactions. Little is known about sex differences in nonverReceived February 7, 2006; Revised April 17, 2006; Accepted April 21,
2006.
Supported by an FNK grant of the University of Bamberg.
Address reprint requests to Miriam Kunz, Physiological Psychology, OttoFriedrich University Bamberg, Markuspl.3, 96045 Bamberg, Germany.
E-mail: miriam.kunz@ppp.uni-bamberg.de
1526-5900/$32.00
2006 by the American Pain Society
doi:10.1016/j.jpain.2006.04.012

bal expressions of pain. Compared with self-report ratings, nonverbal pain reactions have been found to be less
subject to conscious distortions because of their more
reflexive and automatic nature,15 and therefore the assessment of nonverbal pain responses might add useful
information to the understanding of sex differences in
pain perception.
The facial expression of pain has been considered to be
the most prominent nonverbal pain behavior.8,32 Sex differences in facial responses to pain have hardly been
investigated and only in very few studies on facial expression of pain was sex included in analyses. Whereas
in 2 studies no significant sex differences in facial expression of pain were found,7,33 Guinsburg et al14 reported
increased facial pain responses in female neonates. However, systematic investigations of sex differences in facial
expression of pain in adult subjects have been lacking so
far.
With regard to facial expression of other emotional
states, men and women have appeared to differ substantially in their emotional expressiveness, with women being facially more expressive.5,19 Furthermore, sex has
915

916
been found to have a considerable impact on the relationship between self-report and facial expression of
various emotions. Lang et al23 reported that facial expression of emotions corresponded much better to selfreport in women than in men. Because definitions of
pain suggest that affective reactions are a substantial
component of pain (eg, Merskey and Bogduk30), it seems
very likely that sex moderates the relationship between
self-report and facial responses to pain. This question has
not been answered so far.
In summary, the aims of the present study were to
investigate: 1) possible sex differences in facial expressiveness to painful stimulation; and 2) whether sex has an
impact on the relationship between self-report and facial expression of pain.
We used tonic heat stimulation at both nonpainful and
painful levels as the method of pain induction. Tonic
experimental heat pain offers many advantages. First, it
resembles clinical pain more closely than experimental
phasic pain because of greater similarities in quality,
temporal pattern, and underlying physiologic mechanisms.6,18,26 Second, tonic pain stimulation allows for investigating possible changes in facial expression of pain
over time, of which little is known. Third, tonic heat pain
stimulation allows for easy variation of stimulus intensity. Accordingly, response variations over time and
across stimulus intensities can be separately analyzed,
and covariations can be related to the exact source of
variance. Correlation analyses between self-report and
facial expression of pain were computed in 3 ways: across
stimulus intensities (type 1), over time (type 2), and between aggregated pain responses (type 3). Forth, tonic
heat pain stimulation is not likely to produce sex differences in facial expression of pain, which are simply due to
sex differences in the subjective experience of pain, because heat pain is the pain induction method with the
lowest probability of generating sex differences in the
subjective experience.34 Accordingly, any sex differences
in facial expression of pain can thus be attributed to a
specific, sex-related, mechanism.

Materials and Methods

Subjects
Forty young subjects (female n 20, male n 20)
mostly students of psychology between the ages of 20
and 36 years (mean age for women 24.5 years (SD 3.1),
mean age for men 25.1 years (SD 3.5); t .58; P .564)
were recruited via advertisements posted in the university buildings. None had taken any analgesic medication
or alcohol for at least 24 h before the test session. All
subjects were drug free. Exclusion criteria included all
kinds of acute or chronic diseases. Nine women took oral
contraceptives. Of the remaining women, 36% were in
the first third, 18% in the second third, and 46% in the
third third of their menstrual cycle when studied. All
subjects either were paid for participation or received
course credits. The study protocol was approved by the
local ethics committee of the medical faculty of the Uni-

Sex Differences in Facial Encoding of Pain

versity of Marburg. All subjects gave written informed
consent.

Materials and Procedure

The investigation took place in a sound-attenuated
room. The subjects were carefully familiarized with the
methods to be used before the start of the assessment.
During the whole session, which lasted for approximately 2 h, subjects sat upright at a small table.

Apparatus
Heat stimuli were delivered by use of a Peltier-based,
computerized thermal stimulator (Medoc TSA-2001;
Medoc, Ramat Yishai, Israel) with a 3 3 cm2 contact
probe.

Procedures
Heat stimulation. Tonic heat stimuli were administered either at painful or at nonpainful intensities to the
ventral surface of the right or left thigh. This was done
according to the Tonic Heat Pain Model protocol.26 Small
heat pulses with an amplitude of 1.3C were administered at a constant frequency of 30 pulses per minute.
For painful heat, the pulses were tailored to have a base
of 0.3C below the individual pain threshold and a peak
temperature of 1C above it. For nonpainful heat, the
procedure was the same with the exception that the
peak was 1C below and the base 2.3C below the individual pain threshold. There were 3 experimental blocks
for painful heat and 3 blocks for nonpainful heat. In each
block, the duration of tonic heat stimulation was 10 min.
The temperature increased from baseline with a heating
rate of 0.5C/s to the preset temperatures. The same rate
applied for return to baseline.
Because tonic thermal stimulation was tailored to
the individual pain threshold, assessment of heat pain
threshold preceded tonic stimulation. Heat pain
threshold was determined using the method of adjustment. Subjects were asked to adjust a temperature
starting from 38C, using heating and cooling buttons,
until they obtained a level which was barely painful. A
constant press of the buttons resulted into a heating
or cooling rate of 0.5C/s. Following a familiarization
trial, there were 6 trials and the average of the last 5
trials were used to determine the threshold estimate.
Heat pain thresholds were assessed separately for each
body side.
The order of stimulation was: for the right body side,
assessment of heat pain threshold (block 1), painful
heat (block 2), nonpainful heat (block 3), and nonpainful heat (block 4); and for the left body side, assessment of heat pain threshold (block 5), painful heat
(block 6), painful heat (block 7), and nonpainful heat
(block 8). We always started with the right body side.
Body sides could be assumed to be comparable in our
study, because no side differences were observed regarding pain thresholds [T(39) 1.72; P .15]. To
avoid local sensitization the site of heat stimulation on
the ventral surface of each thigh was changed after

ORIGINAL REPORT/Kunz et al
each stimulation. The 4 sites per thigh were defined by
dividing the skin surface into a distal and proximal
part, and then dividing each of these into a right and a
left section. The stimulation sites were changed in a
clockwise fashion always starting at the distal sites.
The intervals between blocks were approximately 5
min.
Self-report. The subjects were asked to rate the
intensity of the tonic heat stimuli in intervals of 1 min
during tonic heat stimulation (between seconds 55
and 60 of each 1-min epoch). This procedure resulted
into 10 ratings per block, thus yielding 30 ratings for
painful heat and 30 ratings for nonpainful heat in total. Self-report was assessed by a horizontal visual analog scale (VAS) of 100 mm. The scale was labeled with
a verbal anchor of faintly painful in the center so
that all nonpainful sensations were asked to be rated
below 50 and all painful ones above 50.28
Facial expression of pain. The face of the subject
was videotaped throughout the entire session. The camera was placed in front of the subject at a distance of
approximately 4 meters. Before each block with tonic
heat stimulation, subjects were reminded to look at a
fixation point (an abstract picture being positioned behind the camera) to ensure a frontal view of the face.
Subjects were also instructed not to talk during pain induction unless they were asked to provide the self-report
ratings.
The Facial Action Coding System (FACS)9 was used to
assess facial expression. The FACS is based on anatomic
analysis of facial muscle movements and distinguishes
44 different action units (AUs). However, we used an
abbreviated version of FACS, focusing on 4 AUs: brow
lowering (AU 4), tightening of the orbital muscles surrounding the eye (AUs 6/7), nose wrinkling/upper lip
raising (AUs 9/10), and eye closure (AU 43). These 4 AUs
have been found to represent a common facial response to pain. Prkachin33 reported that the bulk of
facial information about pain is transmitted by these
AUs when considering the results obtained by different pain induction methods. The intensity for each AU
was rated on a 5-point scale. The intensity and duration of these 4 AUs were rated by 2 coders who had
been trained by an official FACS coder. The rate of
correspondence between the 2 coders was assessed
and the training was continued until the rate of correspondence reached the level of trained coders (.80).
Time segments of 55 seconds (facial expressions were
not coded during self-report rating) were selected for
scoring. In total, 30 segments of painful heat (3 times
tonic heat pain stimulation of 10 minutes) and 30 segments of nonpainful heat stimulation (3 times tonic
heat stimulation of 10 minutes) were analyzed.
The Observer Video-Pro (Noldus Information Technology) was used to facilitate FACS coding. The Observer is a
professional software package for the analysis of observational data. It allows coding behavior by means of keystrokes that correspond to a user-defined coding
scheme.

917

Statistical Analysis
Sex Differences in Pain Threshold,
Self-Report, and Facial Expression
The effect of sex on pain thresholds was investigated
by computing analyses of variance with repeated measurements with 1 between-subject factor (sex) and 1
within-subject factor (stimulation side [right, left]). To
evaluate sex differences in VAS ratings and facial expression during tonic heat stimulation, analyses of
variance with repeated measurements were used with
1 between-subject factor (sex) and 3 within-subject
factors (condition [nonpainful heat, painful heat],
stimulation block [3 blocks for each intensity], and
minute [1-10]).

Sex-Modulated Relationship Between

Self-Report and Facial Expression
To investigate the influence of sex on the relationship
between self-report and facial expression, pain correlation analyses were computed for the whole subject
group and separately for each sex group.
As explained in the preceding, three different types
of correlation analyses were used to pick up the different sources of variance and covariance (Fig 1). Type 1
helped to assess the relationship between self-report
and facial expression of pain across different stimulus
intensities. For that purpose, we computed the mean
values of self-report ratings and facial responses per
block of tonic stimulation (Fig 1). These means were
then entered into a correlation analysis. There were 6
blocks and 40 subjects in total (20 subjects when sexes
were analyzed separately), yielding correlation coefficients for 240 (120) pairs of values. Type 2 helped to
assess the relationship between self-report and facial
expression of pain over time and within the same stimulus intensity. This was achieved by conducting a type
of time series analysis, a cross-correlation analysis limited to lag 0. Subjective and facial responses across 30
segments of either nonpainful or painful tonic heat
stimulation were entered into a correlation analysis
(analyses were conducted separately for each stimulus
intensity). For each stimulus intensity there were 30
segments and 40 subjects in total (20 subjects when
sexes were analyzed separately), yielding correlation
coefficients for 1,200 (600) pairs of values (Fig 1). Type
3 helped to compare our findings to previous studies in
which usually only 1 stimulus intensity was used to
investigate the relationship between self-report and
facial expression of pain.8,16,17,33 For that purpose,
correlation analyses of aggregated responses were
conducted. Aggregation was achieved by computing
mean values of self-report and of facial expression of
pain across all 3 painful heat blocks (see Fig 1). The
nonpainful intensity was excluded because nonpainful
stimuli have never been included in earlier studies.
Additionally, multiple regressions were conducted
to test statistically whether sex moderates the relationship between self-report and facial expression of

918

Sex Differences in Facial Encoding of Pain

Type 1: Across different stimulus intensities

Mean response

Mean response

Mean response

Mean response

Mean response

Mean response

Self-report
FACS

Mean response

Mean response

Mean response

Mean response

Mean response

Mean response

Heat & Pain

trials

Self-report
FACS

Type 2: Within same stimulus intensity

Heat trials

Self-report
FACS

Pain trials

Self-report
FACS

Type 3: Aggregated

Mean response

Self-report

Pain trials

FACS
Mean response

Figure 1. Schematic representation of the 3 types of correlation analyses conducted to investigate the relationship between
self-report and facial expression of pain. See text for more detailed information on the 3 types of correlation analyses.

Results of Analysis of Variance for the Effect of Sex, Condition, Stimulation

Block, and Minute on Visual Analog Scale (VAS) Ratings and Facial Responses During Tonic
Heat Stimulation

Table 1.

FACTORS
SEX

VAS ratings
AU4brow lowering
Intensity
Duration
Product score
AUs 6/7eye tightening
Intensity
Duration
Product score
AUs 9/10nose wrinkling
Intensity
Duration
Product score
AU 43eye closing
Intensity
Duration
Product score

CONDITION

STIMULATION BLOCK

F(DF)

F(DF)

.1 (1,38)

.180

39.6 (1,38)

<.001

9.8 (2,76)

<.001

7.8 (9,342)

<.001

.1 (1,38)
.6 (1,38)
.9 (1,38)

.433
.433
.348

5.8 (1,38)
2.9 (1,38)
4.3 (1,38)

.021
.095
.049

4.7 (2,76)
1.6 (2,76)
1.8 (2,76)

.012
.203
.162

1.8 (9,342)
1.3 (9,342)
1.1 (9,342)

.101
.215
.345

.1 (1,38)
.1 (1,38)
.1 (1,38)

.783
.719
.698

12.1 (1,38)
5.3 (1,38)
5.7 (1,38)

.001
.026
.021

5.0 (2,76)
1.7 (2,76)
2.0 (2,76)

.009
.179
.138

1.2 (9,342)
1.4 (9,342)
1.4 (9,342)

.248
.157
.166

.3 (1,38)
2.0 (1,38)
1.8 (1,38)

.590
.158
.183

2.1 (1,38)
1.8 (1,38)
1.5 (1,38)

.147
.188
.237

.9 (2,76)
.2 (2,76)
.6 (2,76)

.386
.810
.506

.3 (9,342)
.8 (9,342)
.8 (9,342)

.965
.573
.604

.4 (1,38)
.2 (1,38)
.1 (1,38)

.548
.894
.813

2.4 (1,38)
1.8 (1,38)
1.3 (1,38)

.124
.181
.248

.8 (2,76)
.3 (2,76)
.8 (2,76)

.445
.679
.447

.4 (9,342)
.8 (9,342)
.7 (9,342)

.879
.598
.697

NOTE. Significant results are marked as bold.

F(DF)

MINUTE
F(DF)

ORIGINAL REPORT/Kunz et al

919

Table 2. Correlations Between Self-Report of Pain and AU 4 (Brow Lowering) for Men, Women,
and All Subjects
MEN

Across different stimulus intensities (type 1)

Intensity
Duration
Product score
Within same stimulus intensity (type 2)
Nonpainful heat
Intensity
Duration
Product score
Painful heat
Intensity
Duration
Product score
Aggregated for painful heat only (type 3)
Intensity
Duration
Product score

WOMEN

.05
.01
.03

.594
.916
.717

.19
.32
.33

.04
.03
.03

.352
.540
.400

.03
.02
.02
.05
.17
.17

ALL
P

.034
<.001
<.001

.12
.15
.14

.076
.022
.033

.12
.11
.14

.004
.010
<.001

.08
.04
.07

.009
.137
.019

.542
.688
.685

.04
.10
.10

.295
.013
.013

.03
.07
.06

.240
.024
.053

.835
.468
.483

.08
.59
0.51

.726
.006
.023

.01
.10
.01

.968
.532
.935

NOTE. Significant results are marked as bold.

pain, following the procedure by Baron and Kenny.3

Although larger sample sizes are recommended
(at best over 200) to have reasonable power when
testing for such moderator effects,1 we were interested in whether the moderator effect of sex (on the
relationship between self-report and facial expression
of pain) was strong enough that even in our relatively
small sample size significant effects are obtained.
Moderation was determined by calculating cross-prod-

uct interaction terms between sex and facial responses. For each analysis, hierarchic regression was
conducted, entering the predictor variables sex and
facial responses at the first step and then the product
terms of the two predictor variables at the second
step. A significant change in R2 between steps was
taken as an indicator of a significant interaction. To
reduce the number of analyses, these multiple regression analyses were only conducted when the differ-

Correlations Between Self-Report of Pain and AUs 6/7 (Eye Tightening) for Men,
Women, and All Subjects

Table 3.

MEN

Across different stimulus intensities (type 1)

Intensity
Duration
Product score
Within same stimulus intensity (type 2)
Nonpainful heat
Intensity
Duration
Product score
Painful heat
Intensity
Duration
Product score
Aggregated for painful heat only (type 3)
Intensity
Duration
Product score
NOTE. Significant results are marked as bold.

WOMEN

ALL

.20
.13
.15

.032
.161
.097

.39
.34
.33

<.001
<.001
<.001

.29
.24
.25

<.001
<.001
<.001

.08
.06
.06

.048
0.133
.181

.07
.12
.13

.084
.002
.001

.08
.09
.09

.009
.002
.002

.10
.07
.08

.011
0.088
.054

.31
.33
.31

<.001
<.001
<.001

.20
.20
.20

<.001
<.001
<.001

.13
.05
.07

.577
.823
.769

.57
.46
.42

.009
.043
.064

.33
.24
.25

.039
.124
.119

920

Sex Differences in Facial Encoding of Pain

Table 4. Correlations Between Self-Report of Pain and AUs 9/10 (Nose Wrinkling) for Men,
Women, and All Subjects
MEN

Across different stimulus intensities (type 1)

Intensity
Duration
Product score
Within same stimulus intensity (type 2)
Nonpainful heat
Intensity
Duration
Product score
Painful heat
Intensity
Duration
Product score
Aggregated for painful heat only (type 3)
Intensity
Duration
Product score

WOMEN

ALL

.07
.05
.04

.437
.578
.707

.21
.17
.18

.025
.069
.053

.14
.11
.12

.028
.089
.072

.03
.01
.03

.482
.776
.531

.03
.08
.07

.547
.056
.071

.03
.05
.05

.359
.063
.064

.08
.07
.10

.053
.075
.014

.12
.09
.13

.004
.017
.001

.09
.07
.09

.002
.025
.003

.01
.04
.13

.974
.881
.586

.14
.12
.16

.563
.630
.490

.07
.06
.09

.656
.709
.567

NOTE. Significant results are marked as bold.

ence in correlation coefficients between males and females (Tables 2-5) was larger than .40.
With regard to analyses of variance and multiple regression analyses, findings were considered to be statistically
significant at .05. However, because of the large number of simple correlations being computed, an alpha level
of .001 was required to be judged significant in this case.

Results
Effect of Sex on Self-Report
Heat pain thresholds in men (right side: 44.5 1.5; left
side: 44.1 1.8) and women (right side: 44.2 1.3; left
side: 44.0 1.5) did not differ significantly from one
another [F(1,38) 0.3; P .590]. Furthermore, VAS rat-

Table 5. Correlations Between Self-Report of Pain and AU 43 (Eye Closing) for Men, Women,
and All Subjects
MEN

Across different stimulus intensities (type 1)

Intensity
Duration
Product score
Within same stimulus intensity (type 2)
Nonpainful heat
Intensity
Duration
Product score
Painful heat
Intensity
Duration
Product score
Aggregated for painful heat only (type 3)
Intensity
Duration
Product score
NOTE. Significant results are marked as bold.

WOMEN

ALL

.12
.07
.07

.203
.444
.440

.17
.18
.21

.072
.056
.024

.14
.10
.10

.035
.123
.115

.08
.02
.03

.046
.593
.549

.11
.14
.14

.007
.001
.001

.10
.09
.09

.001
.003
.002

.07
.02
.02

.083
.611
.680

.08
.05
.08

.067
.268
.059

.07
.03
.04

.015
.282
.228

.04
.02
.01

.859
.948
.953

.06
.05
.15

.816
.825
.532

.04
.02
.04

.794
.887
.830

ORIGINAL REPORT/Kunz et al
70

VAS ratings

60

921
Male
Female

Non-Painful Heat
= 16,90
= 16,42

= 17,30
= 17,90

= 18,94
= 13,84

faintly painful

50

40

30

70

Painful Heat

VAS ratings

60

faintly painful

50

40

= 19,92
= 18,62

= 20,80
= 17,08

= 20,41
= 18,94

30

1 - 10

1 - 10

1 - 10

minutes

Figure 2. Mean values of visual analog scale (VAS) ratings of perceived intensity during tonic heat stimulation at nonpainful and
painful intensities.

, mean of standard deviations for each block of stimulation.

ings during tonic heat stimulation did not differ significantly between sexes (Table 1 and Fig 2). Neither were
any of the interactions involving sex significant (interaction effects are not displayed in Table 1).
We did find a significant effect for condition (Table
1), with painful heat stimulation leading to higher pain
ratings than nonpainful heat (Fig 2). Stimulation block
also had a significant effect on self-report ratings (Table
1), with ratings tending to increase from the first stimulation of 10 min to the second and then to decrease from
the second to the third both at nonpainful and at painful
levels. However, this tendency to increase and decrease
was more pronounced for nonpainful heat stimulation
as indicated by a significant interaction between condition and stimulation trail [F(2,76) 6.4; P .003].
There was also a significant effect of the factor minute
(Table 1) and a significant interaction effect for
minute and condition [F(9,342) 16.7; P .003],
with self-report ratings decreasing for nonpainful heat
and increasing for painful heat over the 10 min of stimulation (Fig 2). None of the other interactions were significant.

Effect of Sex on Facial Expression

Men and women did not differ significantly in their
facial expressiveness during tonic heat stimulation (Figs
3-6). For AUs 4, 6/7, 9/10, and 43, we did not find any
significant sex effects (Table 1). Furthermore, none of
the interactions involving sex reached the level of significance (interaction effects are not displayed in Table 1).
We found a significant effect of the factor condition for AUs 6/7 and partially for AU 4 (Table 1), with
painful heat stimulation leading to increased facial
expressiveness compared with nonpainful heat (Figs 3
and 4), thus suggesting pain specificity. The intensity
and duration of AUs 9/10 and 43, however, did not
increase significantly from nonpainful to painful heat
stimulation (Table 1).
Except for the intensity of AUs 4 and 6/7, which tended
to decline across stimulation blocks, stimulation block
and minute did not have any significant effects on
facial responses during tonic heat stimulation (Table 1
and Figs 3-6), indicating that facial expression did not
differ over time. None of the interactions were significant.

922

Sex Differences in Facial Encoding of Pain

18
16

Male
Female

Non-Painful Heat

AU 4 (product score)

14
12

= 3,93
= 3,60

10

= 3,84
= 3,23

= 8,70
= 1,86

= 11,31
= 4,26

= 9,99
= 2,35

8
6
4
2
0

18

Painful Heat

16

AU 4 (product score)

14

= 12,52
= 12,83

12
10
8
6
4
2
0

0 - 10

0 - 10

0 - 10

minutes

Figure 3. Mean values of AU 4 (brow lowering) (product scores) during tonic heat stimulation at nonpainful and painful intensities.

, mean of standard deviations for each block of stimulation.

Sex-Modulated Relationship Between
Facial Expression and Self-Report
Because only AUs 4 and 6/7 increased significantly from
nonpainful heat to painful heat stimulation, indicating
pain specificity in the Tonic Heat Pain Model used, we
refrained from combining the 4 AUs to 1 merged score
but instead computed correlation analyses separately for
each AU. We did, however, generate product scores (duration intensity) for each individual AU. Substantial
differences in the size of correlation coefficients between the 4 AUs were found. Regardless of the type of
correlation analyses used, AUs 4 and 6/7 showed the
strongest relationship to self-reported pain ratings. The
size of correlation coefficients did not differ systematically between intensity, duration and the product score
(intensity duration) of facial responses.

AU 4 Self-Report (Table 2)
The association between AU 4 and self-report differed
substantially between men and women. Whereas men
showed no relationship at all between AU 4 and selfreported pain ratings, moderate correlations could be
found for women. However, given our stricter value of

.001, only 3 correlations reached the level of significance

in women. (Applying the conventional value of .05
would have yielded 10 significant correlations in women
vs none in men.) Nevertheless, correlation coefficients
were continuously higher for women than for men.
Computing correlations for both sexes combined yielded
no noteworthy correlation coefficients.
In 2 parameters (duration and the product score of
aggregated responses to painful heat [type 3]), the difference in correlation coefficients between men and
women was larger than .40. Therefore, only for these 2
parameters were multiple regressions conducted to test
statistically whether sex moderates the relationship between AU 4 and self-report. The results are displayed in
Table 6. In both parameters a significant change in R2
was found, thus pointing to a significant moderator effect of sex on the relationship between self-report and
facial expression of pain.

AUs 6/7 Self-Report (Table 3)

The association between AUs 6/7 and self-report also
differed substantially between men and women.
Whereas men showed no noteworthy correlations be-

ORIGINAL REPORT/Kunz et al

923

Male
Female

18

AU 6/7 (product score)

16

Non-Painful Heat

14
12

= 4,96
= 7,70

= 5,66
= 6,30

= 9,41
= 2,91

10
8
6
4
2
0
18

AU 6/7 (product score)

16

Painful Heat
= 20,21
= 21,47

= 13,14
= 12,90

= 14,05
= 18,43

14
12
10
8
6
4
2
0

0 - 10

0 - 10

0 - 10

minutes

Figure 4. Mean values of AUs 6/7 (eye tightening) (product scores) during tonic heat stimulation at nonpainful and painful
intensities.

, mean of standard deviations for each block of stimulation.

tween AUs 6/7 and self-report, women showed moderate correlations. Intriguingly, 7 correlations reached the
level of significance in women despite our stricter value
of .001. (Applying the conventional value of .05 would
have yielded 10 significant correlations in women vs 3 in
men). Computing correlations for both sexes combined
yielded only small correlation coefficients.
In 2 parameters (intensity and duration of aggregated
responses to painful heat [type 3]), the difference in correlation coefficients between men and women was
larger than .40. Therefore, multiple regressions were
conducted for these 2 parameters to test statistically
whether sex moderates the relationship between AUs
6/7 and self-report. The results are displayed in Table 6.
No significant change in R2 was found.

AUs 9/10 Self-Report (Table 4)

We found only small differences between women and
men in the association between AUs 9/10 and self-report
ratings. Whereas men showed no relationship at all between AUs 9/10 and self-report ratings, low correlations
could be detected for women. However, only 1 of these
correlations was significant. (Applying the conventional

value of .05 would have yielded 4 significant correlations in women versus 1 in men). Nevertheless, correlation coefficients were continuously higher in females
than in males. Computing correlations for both sexes
combined yielded no noteworthy correlation coefficients. Because the difference in correlation coefficients
between men and women was always smaller than .40,
no multiple regressions were computed.

AU 43 Self-Report (Table 5)
No substantial sex differences in the relationship between AU 43 and self-report ratings could be found.
However, we still found slightly higher correlation coefficients in women than in men, and 2 of the correlations
reached the level of significance in women. (Applying
the conventional value of .05 would have yielded 4
significant correlations in women versus 1 in men). Computing correlation for both sexes combined yielded no
noteworthy correlation coefficients. Because the difference in correlation coefficients between men and
women was always smaller than .40, no multiple regressions were computed.

924

Sex Differences in Facial Encoding of Pain

18

Male
Female

16

AU 9/10 (product score)

Non-Painful Heat
14
12
10
8
6

= 0,23
= 0,39

= 0,52
= 2,74

= 0,93
= 0,77

= 0,16
= 5,05

= 0,29
= 7,69

4
2
0
18
16

AU 9/10 (product score)

Painful H eat
14
12
10

= 0,74
= 11,53

8
6
4
2
0

0 - 10

0 - 10

0 - 10

m inutes

Figure 5. Mean values of AUs 9/10 (nose wrinkling) (product scores) during tonic heat stimulation at nonpainful and painful
intensities.

, mean of standard deviations for each block of stimulation.

Difference Between Types of Correlation

Analyses
We found no substantial differences between the 3
types of correlation analyses regarding the size of correlation coefficients when considering all subjects combined. There was a slight tendency for type 1 analyses to
result in the highest correlation coefficients. Considering
the correlation coefficients separately for the 2 sexes,
type 3 analyses tended to the extremes with the highest
correlation coefficients for women and the lowest for
men (in some cases even with a negative sign).

Discussion
The major findings of the present study are that males
and females differed neither in their subjective responses to pain nor in their facial expressiveness of pain,
but sex had a notable influence on the relationship between self-report and facial expression of pain, at least in
some AUs, with women showing a stronger relationship
between the two domains. We discuss these findings in
this order.

Sex Effects on Self-Report

We did not find significant sex differences in subjective
responses to heat pain. Heat pain thresholds as well as
suprathreshold ratings did not differ between men and
women. Earlier studies on sex differences in heat pain
sensitivity have yielded contradictory results. Whereas
some authors reported sex to have a considerable impact
on heat pain sensitivity,2,29,10 others found no effects.13,25,27 Riley et al34 pointed out in a meta-analysis
that, in contrast to pressure and electrical pain, sex differences in the perception of heat pain are much smaller
and more variable. Therefore, our finding of no sex difference in subjective responses to heat pain does not
contradict previous findings.

Sex Effects on Facial Expression

We found no sex differences with regard to facial expression of pain. Men and women were equally facially
expressive during tonic heat stimulation at nonpainful
and at painful intensities. These observations are in accordance with previous findings of no sex differences in
the facial expressiveness of pain7,33 but in contrast to
findings for other emotions (eg, experimentally induced

ORIGINAL REPORT/Kunz et al

925

18

M ale
Female

16

AU 43 (product score)

Non-Painful Heat
14
12

= 043
= 1,62

10

= 2,46
= 4,40

= 3,49
= 1,70

= 9,17
= 1,91

= 5,45
= 1,91

8
6
4
2
0
18

AU 43 (product score)

16
14

P a in fu l H e a t

12
10

= 1,60
= 5,21

8
6
4
2
0

0 - 10

0 - 10

0 - 10

m in u te s

Figure 6. Mean values of AU 43 (eye closing) (product scores) during tonic heat stimulation at nonpainful and painful intensities.
mean of standard deviations for each block of stimulation.

Testing the Moderating Effect of Sex on the Relationship Between Self-Report and
Facial Expression of Pain

Table 6.

STEP
1
2
1
2
1
2
1
2

VARIABLES (DEPENDANT
SELF-REPORT)

VARIABLE:

AU 4brow lowering duration

Sex
AU 4brow lowering duration sex
AU 4brow lowering product score
Sex
AU 4brow lowering product score
sex
AU6/7eye tightening duration
Sex
AU6/7eye tightening duration sex
AU6/7eye tightening intensity
Sex
AU6/7eye tightening intensity sex

NOTE. Significant changes in R2 are marked as bold.

bETA

.10
.04
1.16
.01
.04
1.14

.61
.25
2.48
.05
.26
2.19

.26
.07
.51
.33
.07
.57

1.60
.46
.87
2.15
.46
1.05

R2

Total R2

.012

.012

.23

.144
.002

.156
.002

2.23
.04

.117

.119

1.62

.067

.067

1.32

.019
.113

.086
.113

1.13
2.35

.026

.139

1.94

926
sadness, happiness), for which women have been found
to be facially more expressive than men.5,19 It is likely
that the predictable and controllable way of experimental pain induction produces a rather low level of affective
responding. Therefore, the findings derived from other
emotions (such as psychologic stressors as sadness and
fear) may not be applicable to more physical stressors
such as pain.

Sex-Modulated Relationship Between

Facial Expression and Self-Report
It is interesting that, although women and men differed in neither self-report ratings nor facial expressiveness of pain during tonic heat stimulation, sex had a
notable influence on the relationship between selfreport and facial expression of pain. Regardless of the
type of correlation analyses conducted, higher correlation coefficients were constantly found for women.
Whereas no significant correlations at all were found for
men, we obtained several significant correlations in
women. This impression was strengthened when multiple regression analyses were conducted to test statistically whether sex has a modulating effect on the relationship. We found significant moderator effects of sex
on the relationship between self-report and facial expression of pain for AU 4 (brow lowering). As a reminder,
AUs 4 and 6 (tightening of the orbital muscles surrounding the eye) proved to be pain specific in our protocol
with tonic heat pain. Admittedly, only in two out of
many correlations did sex significantly moderate the relationship. However, given our relatively small sample
size (sample sizes of over 200 are recommended to ensure reasonable power when testing for moderator effects)1 these significant effects nevertheless suggest that
sex has a substantial influence on the relationship between self-report and facial expression of pain.
Why is it that women show a greater coherence between self-report and facial responses to pain? Developmental theories suggest that men and women have
learned different rules for the expression of emotions
(for a review see Brody4). Boys are thought to gradually
acquire an understanding of display rules through socialization processes that direct them to express emotions
that signal independence and to hide emotional vulnerability.31 Girls, on the other hand, are believed to be
reinforced to express positive emotions as well as emotions that signal vulnerability.22 Following this line of
reasoning, it appears possible that females learn signaling the intensity of subjective pain by nonverbal pain
expression more efficiently than males. However, this
explanation is only speculative and further research is
necessary to answer this question.
Our finding that sex moderates the relationship between subjective and facial pain responses is also of practical relevance. It suggests that facial responses to pain
can be used as an estimate of the intensity of subjective
pain in women better than in men. However, this does
not mean that men do not communicate their pain experience through facial expression, because men and

Sex Differences in Facial Encoding of Pain

women were equally expressive during tonic heat stimulation. It can be assumed, rather, that males do not
linearly encode the pain intensity they are experiencing.
Consequently, the facial expression of pain in men may
only indicate whether pain is experienced or not. However, we cannot rule out another possibility, namely,
that no significant correlation between self-report and
facial expression of pain was found in men because the
relationship is of a nonlinear character. Future studies
are needed to clarify this aspect.
Numerous studies have been conducted that investigated the relationship between self-report and various
kinds of nonverbal pain responses (eg, brace, guard,
rub). Labus et al21 pointed out in a recent meta-analysis
that the strength of the relationship varies as a function
of several factors, including acuteness and type of pain,
time of assessment, and number of nonverbal responses
studied. The influence of sex on this relationship has
been neglected so far. According to our data, in future
studies on the coherence between verbal and nonverbal
pain behaviors sex should be considered as an important
modulating factor.

Habituation of Facial Expression

In the present study, facial expression of pain was not
found to vary systematically over time of tonic pain stimulation. This observation differs from a report by Craig
and Patrick,8 who found facial activity to be strongest at
the onset of noxious stimulation and to habituate over
time. However, in that study, subjects were not familiarized with the pain stimulus (cold-pressor test) before
stimulation and therefore startle and orienting responses may have added to the pain responses, which
increased facial activity at the beginning of stimulation.
Finding no attenuation in facial responses to pain over
10 min of tonic heat pain stimulation might be relevant
for diagnosing pain. The risk appears rather low that the
indicative nonverbal signs of pain can be missed because
of the observer entering too late.
However, given the high degree of unsystematic variability in facial responses over time within a group of
individualswhich is in part due to changes in the number of subjects being facially responsive at a given time
(eg, in the present study, at one point in time 90% of the
subjects were facially responsive whereas at another
point in time only 60% showed facial responses) observations of nonverbal pain behavior should be based on
more or longer time periods. The data sampling over 10
observation periods (of 1 min each) appeared sufficient
in the present study

Type of Correlation Analyses

In assessing the relationship between self-report and
facial expression of pain, it is necessary to be aware
which sources of variation and covariation are to be included in analysis. Pain responses vary according to stimulus intensity and over time at the same stimulus intensity. These variations can be explicitly included in analysis
or they can be reduced by aggregating responses. Given

ORIGINAL REPORT/Kunz et al

927

these arguments, it may seem surprising that the correlation coefficients obtained by the three different types
of correlation analyses (Fig 1) were not very different.
However, our effort was rewarded by the certainty that
we did not miss certain aspects of the relationship between self-report and facial expression of pain. The analysis including more than one stimulus intensity produced
tentatively the highest correlation coefficients. This finding corroborates our hypothesis that approaches with
multiple stimulus intensities are to be preferred to approaches with only one intensity, which we derived from
data obtained by phasic pain stimulation.20
Regardless of the type of correlation analyses conducted we found substantial differences between the 4
AUs (at least for women and for both sexes combined).
Whereas AUs 4 and 6/7 produced small to moderate correlations with self-report ratings, AUs 9/10 and 43 produced only negligible correlations. Therefore, AUs 4 and
6/7 seem to be the most qualified AUs for encoding the
subjective pain experience, at least when tonic heat pain
of moderate intensity is applied.
As a limitation of the present study, the small sample
size has to be acknowledged. When looking for moderator effects, much larger sample sizes are recommended
to guarantee adequate power. However, owing to the
time- and effort-consuming procedure of FACS coding in

this study, it was not possible to investigate a much

larger sample size. Another limitation might have been
that some subjects gave ratings indicative for slight pain
under nonpainful heat in a few segments of tonic
stimulation and some others gave ratings likely indicative for nonpain under painful heat, potentially confounding our physical distinction of two experimental
conditions. However, facial responses during nonpainful segments rated as nonpainful did not differ significantly from those during nonpainful segments rated
as painful. The same applies for the comparisons between facial responses during painful segments rated
as painful and those during painful segments rated as
nonpainful. Consequently, it seems justified to conduct
analyses as a function of the two physically defined experimental conditions.
In summary, the present study found evidence to suggest that men and women do not differ in their facial
expressiveness of pain. However, sex appeared to have a
notable impact on the relationship between selfreport and facial expression of pain, with women showing a stronger relationship than men. For that reason, in
future studies, in which the relationship between selfreport and nonverbal pain behaviors is investigated, sex
should be considered as an important modulating factor.

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