INTRODUCTION: We assessed sex differences in behavioural and neural responses to rectal pain stimuli in healthy subjects.METHODS: In age- and body mass index-matched healthy subjects (n = 15 men, 15 women), rectal sensory and pain thresholds were assessed with a pressure-controlled barostat device. The blood oxygen level-dependent response during cued anticipation and painful stimulation was measured using functional magnetic resonance imaging (fMRI). Retrospective pain evaluations were accomplished with visual analogue scales. For fMRI data, region-of-interest (ROI) analyses and additional whole-brain analyses were carried out.RESULTS: There were no sex differences in rectal thresholds or pain ratings. ROI analyses revealed comparable distension-induced activation of the thalamus, somatosensory cortex, insula and dorsolateral prefrontal cortex (DLPFC). Only in additional whole-brain analyses did we find increased activation in women in DLPFC and middle temporal gyrus during pain anticipation and in the cerebellum and medial frontal gyrus during pain. A significant inverse association between rectal pain threshold and distension-induced activation in virtually all ROIs was found in women. In men, pain thresholds and insula activation were positively correlated, as were pain ratings and anterior cingulate cortex activation.CONCLUSIONS: Healthy men and women do not differ in behavioural measures of visceral pain sensitivity. The pattern of neural activation is comparable in the majority of pain-processing brain regions, although women may differ in the activation of DLPFC which could reflect sex differences in cognitive-emotional pain regulation. Women with lower pain thresholds showed greater neural responses, which may be relevant in the pathophysiology of visceral hyperalgesia.