Sex Representation and User Preferences in Pain Drawing Body Charts in Back Pain Research: Multimethod Study

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 This study aims 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 multimethod 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 the 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 the inclusion criteria. Most (103/108, 95.4%) did not report the sex of the body charts used, and only 5.6% (6/108) included both male and female charts. Experts showed fair to moderate agreement (Fleiss κ=0.306; Gwet AC1=0.456) in assessing the sex of charts, with most charts assessed as male based on majority ratings (59/108, 54.6%) and classified as male-biased relative to the sex distribution of study participants (76/108, 67.7%). 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% (181/248) of White participants viewed it as sex-neutral, compared to 42.5% (17/40) of participants from smaller racial groups ( χ ² $_{2}$ =15.9; P =.001). Female participants slightly preferred female charts (85/154, 55.2%); male participants preferred sex-neutral ones (88/144, 61.1%). Nonetheless, most female participants (82/154, 53.3%) and male participants (107/144, 74.3%) 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.