Beyond the Pain: Unveiling the Link Between Pain Catastrophizing and Pain Disability in Endometriosis Warriors

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When I hear the word “endometriosis,” the first thing that pops into my mind is “pain”—scorching, stabbing, debilitating pain. However, endometriosis (endo) is a condition that is often described and medically treated as a fertility issue [1]. While it’s true that endo can affect fertility, this label can overshadow the significant pain and discomfort that many individuals with endo experience. It’s like calling a hurricane a “wind problem”—it doesn’t quite capture the full impact, does it?

But there’s more to this story…the pain caused by endo can lead to disability, affecting a person’s ability to perform daily tasks and maintain a satisfying level of quality of life [2-7]. It’s not just about being unable to work or go to school—it’s about the constant adjustments and accommodations that must be made to manage the pain [8-10]. It’s about the social events missed, the hobbies given up, and the constant fatigue. It’s a disability that is often invisible to others, but all too real for those living with it. 

As we splash the world with a vibrant shade of yellow for Endometriosis Awareness Month, I’d like to highlight a recent study we conducted that acknowledges the painful experiences of persons with endometriosis and extends beyond the physical pain to examine psychological and physical impacts [11]. Our study focused on pain intensity, “pain catastrophizing,” a psychological response to anticipated or actual pain, and pain disability. What we discovered was that when pain cranks the volume to moderate or higher levels, pain catastrophizing and disability start to take center stage.

This is where the disability aspect really comes into play; we found that as pain catastrophizing increased, so did the level of disability. This means that the more a person ruminates on their pain, magnifies its impact, and feels helpless against it, the more likely they are to experience disability. This disability can manifest in many ways, from difficulty performing daily activities to decreased participation in social activities.

So, what does this all mean? It’s not just about the physical pain—it’s also about how we perceive and respond to it. Think of this as being at your favourite concert; the music (pain) is blaring, but how you react (catastrophizing) can determine whether you’re crowd surfing or covering your ears.

In conclusion, our study highlights the importance of addressing both the physical and psychological aspects of endo. It’s not enough to just treat the physical symptoms—we also need to address the psychological and physical impacts. This comprehensive approach can lead to better outcomes and an improved quality of life for those living with endo.

So, as we continue to raise awareness about endo this month, let’s not forget about the importance of comprehensive care for individuals with this condition. Health care providers are urged to look at the big picture, considering not just the physical symptoms, but also the psychological and social implications of the condition.

This study is a step forward in our understanding of how endo affects individuals; it reminds us that raising awareness about endo is not just about recognizing the condition, but also understanding the complexities of the pain and disability it can cause. As we continue to learn more, we can hope for better care and an improved quality of life for those living with endo.

If you’re interested in reading an abstract on our recent publication on pain catastrophizing and pain disability in a diverse sample of persons with endo, click here. If you’re looking for the full PDF version, email us! If you’re interested in more results from our studies on endo, check out this blog and these poster presentations. For more information on endo, including what it is, who can ‘have’ it, the underpinnings of why we only have information on certain populations of people with endo, and how to receive a diagnosis, see our blog from March 2022.

Sam Levang, M.Sc. (she/her)
Ph.D. Student, Clinical Psychology
Sexual Health Research Lab
Queen’s University

 References

  1. Jones CE. The pain of endo existence: toward a feminist disability studies reading of endometriosis. Hypatia. 2016;31(3):554–71. doi: 10.1111/hypa.12248

  2. Van Niekerk L, Johnstone L, Matthewson M. Health-related quality of life in endometriosis: The influence of endometriosis-related symptom presence and distress. J Health Psychol. 2022;13591053221085051. doi: 10.1177/13591053221085051 

  3. Soliman AM, Coyne KS, Zaiser E, et al. The burden of endometriosis symptoms on health-related quality of life in women in the United States: a cross-sectional study. J Psychosom Obstet Gynecol. 2017;38(4):238–48. doi: 10.1080/0167482X.2017.1289512

  4. Ruszała M, Dłuski DF, Winkler I, et al. The state of health and the quality of life in women suffering from endometriosis. J Clin Med. 2022;11(7):2059. doi: 10.3390/jcm11072059

  5. Martins J, Ferreira G, Vilaça M, et al. Quality of life and sexual satisfaction in women with endometriosis: the moderator role of symptom severity. Psychol Sex. 2022;13(4):952–64. doi: 10.1080/19419899.2021.1943501 

  6. Márki G, Bokor A, Rigó J, et al. Physical pain and emotion regulation as the main predictive factors of health-related quality of life in women living with endometriosis. Hum Reprod. 2017;32(7):1432–8. doi: 10.1093/humrep/dex091  

  7. de Barros Meneguetti M, Silva FP, Dias GN, et al. Assessment of quality of life and psychological repercussions in women with endometriosis according to pain intensity. Psychol Health Med. 2022;1–10. doi: 10.1080/13548506.2022.2121972

  8. Culley L, Law C, Hudson N, et al. The social and psychological impact of endometriosis on women’s lives: a critical narrative review. Hum Reprod Update. 2013;19(6):625–39. doi: 10.1093/humupd/dmt027 

  9. Klein S, D’Hooghe T, Meuleman C, et al. What is the societal burden of endometriosis-associated symptoms? A prospective Belgian study. Reprod BioMed Online. 2014;28(1):116–24. doi: 10.1016/j.rbmo.2013.09.020 

  10. Simoens S, Dunselman G, Dirksen C, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod. 2012;27(5):1292–9. doi: 10.1093/humrep/des073

  11. Levang SL, Pukall CF. An investigation of associations between pain catastrophizing and pain disability in a diverse sample of persons with endometriosis. J Obstet Gynaecol Can. 2024;102340. doi: 10.1016/j.jogc.2023.102340

The Empirical Gaydar: A Path to Equity or Ethically Egregious?

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The term gaydar generally refers to a capacity to identify the sexual orientation of others (Miller, 2018). This identification may be based on dynamic (e.g., stylistic and grooming choices) or fixed (e.g., face shape) cues (Rule, 2017). Within the queer community, the utility of gaydar is clear—to identify individuals with whom platonic, romantic, and/or sexual relations may develop consensually and safely. However, there has been a persistent interest in an empirical kind of gaydar—scientific identification and classification of individuals' sexual orientation based on objective cues. From decades-ago comparisons of specific brain structures in gay and straight men (Levay, 1991), to more recent use of artificial intelligence to differentiate between the faces of gay and straight adults (Wang & Kosinski, 2018), interest in the empirical gaydar does not seem to have stalled. The growing body of gaydar research raises considerations about its implications, notably regarding stereotype reinforcement. My blog focuses on the framing of gaydar research as a way to ‘legitimize’ minority sexual orientations (e.g., gay, lesbian) as a variation of a natural and (partly) biological phenomenon. Specifically, the benefits of this view are discussed. In response, the costs of these views, notably their restrictive focus on binary sex/gender and exclusively homosexual and white identities, are weighed accordingly. Please note that I use the terms ‘homosexual,’ ‘same-gender/sex-oriented,’ ‘gay,’ and ‘lesbian’ interchangeably.

Many biological explanations of sexual orientation converge on prenatal hormone theory (PHT), which explains the development of sexual orientation as a result of the hormones that determine external genitals during fetal development (e.g., Wang & Kosinski, 2018). Simply put, PHT suggests that male fetuses who are exposed to low levels of these hormones, and female fetuses who are exposed to high levels, are more likely to have a same-gender/sex sexual orientation as adults (Vasilovsky, 2018). Accordingly, many gaydar studies have focused on variations of traits in homosexual individuals that diverge from what is normally expected for their gender. These gender-atypical traits have been assessed primarily in gay men through various ‘feminization hypotheses’ that explore gendered traits such as voice and speech patterns (Daniele et al., 2020; Suire et al., 2020), behaviours (Rieger et al., 2008), and facial structure (Wang & Kosinski, 2018).

On the one hand, providing evidence for consistent, biologically driven, early processes that underlie sexual orientation may help reduce misconceptions surrounding same-gender/sex orientations being a choice. Importantly, the potential benefits of biological beliefs about the development of same-gender/sex sexual orientations should not be understated. Indeed, believing that sexual orientation is caused by biological processes predicts more positive feelings toward individuals with same-gender/sex orientations and more support for policies aimed at supporting their legal rights, social equality, and moral acceptance (Haider-Markel & Joslyn, 2008). Further, these beliefs may contribute to a view of sexual orientation as a variable human trait, like how we view extraversion. Importantly, research into sexual interests and behaviours that adopts a lens of variation within, instead of deviations from, expected expressions of sexuality has helped destigmatize sexual minority identities and behaviours (Bullogh, 2010). Consistent with the belief of same-gender/sex orientations as biologically driven variations within normal sexuality, a common logic has been formed. Specifically, it is believed that since homosexuality is a tangible and inborn variation, homosexual individuals deserve civil and legal protection against discrimination (Vasilovsky, 2018). Following this logic, the ability of gaydar research to support this view of same-gender/sex sexual orientation may benefit individuals with these identities.

On the other hand, these purported advantages of gaydar research are not without critique. First, biological explanations are often presented to ‘legitimize’ same-gender/sex sexual orientation, however, they mostly focus on cisgender and white individuals who are classified as either exclusively homosexual or heterosexual (e.g., Rieger et al., 2008; Wang & Kosinski, 2018). As a result, any semblance of representation or legitimization excludes the large number of sexual minority individuals who are BIPOC, gender-diverse, and/or hold sexual identities that are not exclusively homosexual. Importantly, individuals not represented by this research may be in the most need of representation. For example, bisexual identities are often viewed as more negative and less stable compared to heterosexual or homosexual identities (Burke & LaFrance, 2016). The focus of gaydar research on this highly specific subset of identities ignores the intersectionality of minority identities that are present within sexually and gender-diverse populations and are no less deserving of representation than individuals who hold cisgender, white, homosexual identities.

Further, the focus on objective, deterministic features that can be used to unambiguously classify sexual orientation supports the search for ‘the cause’ of sexual minority identities—one that often funnels into PHT. This theory’s emphasis on sex binaries ultimately reinforces existing stereotypes surrounding femininity and masculinity in same-gender/sex-oriented individuals. This is reflected in the overwhelming amount of gaydar research that relies on gender atypicality to explain and quantify research findings, which often frames gay men as feminized and lesbian women as masculinized (e.g., Daniele et al., 2020; Lick & Johnson, 2014; Wang & Kosinski). This framing is not without consequence; adults who report being more gender nonconforming than their peers as children also tend to report feeling more rejected by their parents and peers (Rieger et al., 2008). The gender typicality framework of sexual orientation reinforces ideas of gender-atypicality in gay and lesbian individuals, which may contribute to negative views of homosexuality (Blashill & Powlishta, 2012). As a result of this framework, gender-related stereotypes of sexual minority identities are reinforced, and the largely unobservable social and psychological complexities that contribute to sexual orientation are ignored. What follows is an idea of sexual orientation that reduces a complex, experiential identity solely to the characteristics that can fit neatly into stereotyped categories.

The empirical gaydar reflects an area of research that is characterized by a degree of ethical ambiguity. In many ways, gaydar research has the potential to lead to lasting, positive outcomes for marginalized individuals. However, the current restrictive focus on individuals who are white, cisgender, and exclusively homosexual leaves individuals who do not fit this archetype with little of the validation or legitimization that gaydar research purportedly provides. Moreover, on one hand, the identification of natural, uncontrollable, and biologically driven variations that can be used to distinguish same-gender/sex-oriented individuals from heterosexual individuals may have positive outcomes for sexually diverse populations. Indeed, beliefs that align with these naturalistic views tend to go hand-in-hand with positive views toward gay and lesbian identities as well as greater support for their social and legal protections. However, the gender-stereotyped views of gay and lesbian men and women that are closely linked with prominent biological explanations also seem to be related to the rejection of these individuals by their families and peers. This offers up a sort of double-edged sword where biological beliefs may be linked to positive outcomes, but the stereotypes that accompany those beliefs may be a source of rejection and distress. In tandem, the feminine/masculine dichotomy that is central to much of the available gaydar research reinforces stereotyped views of lesbian women as masculine and gay men as feminine; views that can lead to prejudice. Intentional or not, the result is a view of same-gender/sex orientations that reduces individuals to their outwardly observable expressions and ignores the subjective experience of sexual identity.

 

Evan Waterman (he/him), 4th year BAH Psychology, Queen’s University

References

Blashill, A.J. & Powlishta, K.K. (2012). Effects of gender-related domain violations and sexual orientation on perceptions of male and female targets: An analogue study. Archives of Sexual Behaviour, 41, 1293-1302. https://doi.org/10.1007/s10508-012-9971-1

Bullogh, V.L. (2010). Alfred Kinsey and the Kinsey report: Historical overview and lasting contributions. The Journal of Sex Research, 35(2), 127-131. https://doi.org/10.1080/00224499809551925

Burke, S.E. & LaFrance, M. (2016). Lay conceptions of sexual minority groups. Archives of Sexual Behaviour, 45, 635-650. https://doi.org/10.1007/s10508-015-0655-5

Daniele, M., Fasoli, F., Antonio, R., Sulpizio, S. & Maass, A. (2020). Gay voice: Stable marker of sexual orientation or flexible communication device? Archives of Sexual Behaviour, 49(7), 2585-2600. https://doi.org/10.1007/s10508-020-01771-2

Haider-Markel, D.P. & Joslyn, M.R. (2008). Belief about the origins of homosexuality and support for gay rights: An empirical test of attribution theory. Public Opinion Quarterly, 72(2), 291-310. https://doi.org/10.1093/poq/nfn015

Levay, S. (1991). A difference in hypothalamic structure between heterosexual and homosexual men. Science, 253(5023), 1034-1037. https://doi.org/10.1126/science.1887219

Lick, D.J. & Johnson, K.L. (2014). Perceptual underpinnings of antigay prejudice: Negative evaluations of sexual minority women arise on the basis of gendered facial features. Personality and Social Psychology Bulletin, 40(9). https://doi.org/10.1177/0146167214538288

Miller, A.E. (2018). Searching for gaydar: Blind spots in the study of sexual orientation perception. Psychology & Sexuality, 9(3), 188-203. https://doi.org/10.1080/19419899.2018.1468353

Rieger, G., Linsenmeier, J.A., Gygax, L. & Bailey, J.M. (2008). Sexual orientation and childhood gender nonconformity: Evidence from home videos. Developmental Psychology, 44(1), 46-58. https://doi.org/10.1037/0012-1649.44.1.46

Rule, N.O. (2017). Perceptions of sexual orientation from minimal cues. Archives of Sexual Behaviour, 46, 129-139. https://doi.org/10.1007/s10508-016-0779-2

Suire, A., Tognetti, A., Durand, V., Raymond, M. & Barkat-Defradas, M. (2020). Speech acoustic features: A comparison of gay men, heterosexual men, and heterosexual women. Archives of Sexual Behaviour, 49(7), 2575-2583. https://doi.org/10.1007%2Fs10508-020-01665-3

Vasilovsky, A.T. (2018). Aesthetic as genetic: The epistemological violence of gaydar research. Theory & Psychology, 28(3). https://doi.org/10.1177/0959354318764826

Wang, Y. & Kosinski, M. (2018). Deep neural networks are more accurate than humans at detecting sexual orientation from facial images. Journal of Personality and Social Psychology, 114(2), 246-257. https://doi.org/10.1037/pspa0000098