Internalized stigma mediates the relationship between pelvic pain severity and both depression and anxiety in women with chronic pelvic pain

Abstract

Background:

Chronic pelvic pain (CPP, i.e., pain related to the abdomen) disproportionately affects women, with about one in four women experiencing CPP worldwide. CPP has been found to be associated with numerous poor mental health outcomes (e.g., depression and anxiety). Prior research has indicated associations between CPP and stigma, yet much of this research has been qualitative.

Objectives:

The present study builds on that literature by quantitatively exploring associations between CPP severity and both depression and anxiety sensitivity, as well as exploring the moderating role of internalized stigma.

Design:

Quantitative, cross-sectional design.

Methods:

A sample of 241 adult women with CPP from the United States completed a series of questionnaires via an online survey. Hierarchical linear regression models and moderation analyses were used to determine associations among the variables of interest (i.e., CPP, depression, anxiety sensitivity, and internalized stigma).

Results:

Women who reported more severe CPP also reported more depression (b = 0.61, SE = 0.19, p = 0.002) and more anxiety sensitivity (b = 0.92, SE = 0.14, p < 0.001). These associations were moderated by internalized stigma, such that the effects of depression and anxiety sensitivity on CPP severity were stronger in women who reported more internalized stigma.

Conclusion:

Clinical implications are that providers treating women with pelvic pain should screen them for emotional distress (e.g., depression and anxiety) and intervene and/or refer them as appropriate. Future work should continue to explore the role of internalized stigma in women with CPP, as well as explore potential interventions aimed at reducing stigma.

Keywords

pelvic pain depression anxiety stigma

Introduction

Chronic pelvic pain (CPP, i.e., pain related to the abdomen) disproportionately affects women, with about twice as many women suffering from CPP compared to men.¹ It is estimated that anywhere between about 5% and 26% of women worldwide experience CPP, with a prevalence rate of 15% in women of reproductive age (i.e., 18–50 years old) in the United States.^1,2 An estimated 10% of all outpatient gynecological visits are due to CPP, and an estimated 12% of all hysterectomies are related to CPP.¹ The International Association for the Study of Pain has categorized many CPP conditions into gynecological disorders (e.g., endometriosis, dysmenorrhea, vulvar pain syndrome), urological disorders (e.g., bladder pain syndrome), musculoskeletal disorders (e.g., pelvic floor muscle pain syndrome and coccyx pain syndrome), and colorectal pelvic pain disorders (e.g., irritable bowel syndrome).³ Given the complexity of CPP, treatments typically focus on the management of painful symptoms and enhancing quality of life.⁴

Chronic pelvic pain and well-being

Numerous studies have demonstrated a link between CPP and emotional and psychological distress (e.g., depression, anxiety, and lower quality of life).^5
–9 Researchers have consistently found high rates of depression and anxiety (63%–73% and 40%–66%, respectively) in women diagnosed with CPP, with significantly higher rates in women diagnosed with CPP compared to those without CPP.^5,7 Similarly, many studies have demonstrated associations between pelvic pain and decreased quality of life factors. Researchers investigating relationships among endometriosis-related pelvic pain and well-being found symptom frequency was associated with lower reported well-being across all dimensions, including general aspects of life, standard of living, health, personal relationships, achieving in life, safety, future security, and community connectedness.¹⁰ Women with CPP reported feeling a loss of autonomy, reduced social interaction, and increased isolation,¹¹ as well as decreased physical activity and less engagement in valued activities.^12,13 In addition, CPP negatively impacts romantic relationships, with women avoiding intimacy due to their pain,¹¹ fear of losing their partner or not having a successful relationship due to their pain,¹³ fear of infertility,¹³ and some even indicating that their CPP led to divorce.¹⁴ There is also evidence that specific aspects of pelvic pain may uniquely influence well-being; for example, increased pain severity has been found to be associated with poorer physical and mental well-being.¹⁵

CPP has also been found to interfere with both work and educational activities.^6,10,14 In a national sample of women diagnosed with endometriosis, about 50% reported negative impacts on work and needed to reduce the total number of working hours due to their symptoms.¹⁴ CPP in adolescents and young adults has also been found to be linked with absenteeism in school and college.^12,16,17 Adolescents and young adults with dysmenorrhea have reported high rates of missing class due to their pain, issues with concentrating while in class, and lower test scores,¹⁶ with a more significant negative impact on education in those reporting more severe pain symptoms.^12,17

It is important to note that the cross-sectional design of these studies prevents the inference of directionality. It is certainly possible that CPP leads to negative psychosocial effects, although negative emotional states may worsen the experience and expression of CPP. Furthermore, it is also possible and perhaps even likely that confounding variables also affect these relationships.

Role of stigma

Stigma is an understudied but important aspect of women’s pain, especially pelvic pain. Goffman defined stigma as that which differentiates an individual in such a way that negatively affects their social identity.¹⁸ Essential in this definition is the relationship between attributes and stereotypes; the perceived attribute must differ from the perceived stereotype in such a way that it discredits the individual and damages their perceived social identity. As such, an attribute that stigmatizes one individual may not stigmatize another.¹⁸ More recently, Goldberg¹⁹ described stigma as both attributes and actions, defining it as separating groups based on demographic characteristics and then judging the “others” (i.e., those who differ from the norm) as “less-than” due to said differences. In this definition, stigma is considered to be detrimental to health and well-being, exacerbating existing social and health inequalities.¹⁹ A prominent example is the stigma surrounding sexually transmitted diseases. For example, HIV/AIDS-related stigma has been shown to be associated with decreased access to and increased avoidance of preventive and treatment services and negative emotional and behavioral health outcomes (e.g., lower well-being, depression, post-traumatic stress disorder (PTSD), and HIV-risky behavior).^20
–22

Research focusing on the stigma of mental illness has differentiated between experienced stigma and internalized stigma. Experienced stigma can be described as discriminatory experiences in which a person is treated differently and negatively, intentionally or unintentionally, by others due to perceived differences between them.²³ Examples of such discriminatory experiences include female employees receiving less pay than their male counterparts for the same job, refusal to provide goods and services to a homosexual couple, or prohibiting certain hairstyles in the workplace that are predominantly worn by Black and African American individuals (e.g., afros and box braids). In a study examining mental illness and stigma, an estimated 56% of individuals with schizophrenia reported experiencing stigma, which was associated with lower quality of life.²⁴ In contrast to experienced stigma, Drapalski et al.²⁵ described internalized stigma as negative beliefs that a person has adopted related to themselves, often as a result of repeated experiences. For example, a homosexual couple who were refused service due to their sexuality (i.e., experienced stigma) may internalize this experience and develop negative self-beliefs associated with their sexuality (i.e., internalized stigma). Similar to experienced stigma, higher reports of internalized stigma have been found to be associated with poorer quality of life.²⁵

Researchers have also investigated stigma in individuals with chronic pain. A recent study by Bean et al.²⁶ investigating both internalized and experienced stigma demonstrated an association between stigma and well-being, such that internalized chronic pain-related stigma was linked with a lack of social support, disability, and depression. This study also made use of qualitative methods to evaluate experienced stigma in patients with chronic pain and identified several trends in participant responses. Among these responses were those who reported stigma related to perceptions of “faking it” (i.e., others did not believe the severity or existence of their pain) and feeling the need to hide their pain. Similar results were seen in a study by Hawkey et al.,²⁷ in which women discussed how the minimization of the legitimacy and severity of CPP, and pelvic pain in general, led to the silencing and invisibility of their pain.

Women diagnosed with endometriosis (i.e., a condition associated with CPP) have reported experiencing stigma in both home and healthcare settings.²⁸ Endometriosis-related stigma has been linked with long diagnostic delays—on average, women will wait 7–11 years to receive a diagnosis of endometriosis after the onset of symptoms.⁶ There is also evidence that women who experience stigma may avoid receiving healthcare services; for example, women who have experienced endometriosis-related stigma have reported avoiding gynecological care as a result of their experiences.²⁸

Objectives

Previous work has demonstrated higher rates of psychological distress in individuals with CPP.^5
–9 Though there is some literature on CPP-related stigma, this work is qualitative and provides little information on the prevalence and relevant associations of CPP-related stigma in women.^6,28 The primary objectives of this study were to build on previous literature by (1) examining the relationship between CPP severity and both depression and anxiety sensitivity, and (2) examining the moderating role of internalized stigma on this relationship. Based on prior literature, there were two hypotheses:

Women who report more depression and anxiety sensitivity will also report more severe CPP.

Internalized stigma of pelvic pain will moderate the relationship between CPP severity and both depression and anxiety sensitivity.

Method

Participants

Participants were recruited via Amazon’s Mechanical Turk (MTurk) from March 2023 to April 2023 and completed questionnaires using Qualtrics Software. The study was advertised as a survey of women’s experiences with pain, and both women with and without CPP were eligible to complete the survey. For the purpose of the present study, only women who reported having CPP were included in the analyses. Of the 385 women who responded to the survey, had no missing data, and passed validity checks (Supplemental Figure S1), there were 241 (62.6%) who reported having CPP and were ultimately included in the present study. A post hoc power analysis was conducted using G*Power 3.²⁹ Based on our findings for Hypothesis 1 (i.e., ∆R² = 0.30) and assuming an alpha level of 0.05, a power of 0.95 was exceeded with the present sample.

Sociodemographic and self-report measures

Sociodemographic variables

Participants reported on age, education, and household income in US dollars.

Chronic pelvic pain scale

A four-item screener (Supplemental Table S1) was used to assess the possibility of having CPP. Using a yes/no response format, participants were asked to report on their pelvic pain symptoms from the past 3 months via the following questions: (1) Have you had pain or cramps in the pelvis and/or lower abdomen that have interfered with your daily activities?; (2) Have you experienced itching in your genital area that persisted for 3 months or longer?; (3) Have you experienced burning in your genital area that persisted for 3 months or longer?; and (4) Have you experienced periodic knife-like or sharp pain in your genital area that persisted for 3 months or longer? Women who answered yes to one or more of the items were assumed to indicate the possibility of having CPP and were thus included in the final sample. Items 2, 3, and 4 of the screener were adapted from the Harlow Questionnaire for Vulvar Pain items 17, 18, and 19.³⁰

Other forms of pain

A four-item screener (Supplemental Table S2) was used to assess the presence and history of other forms of pain (i.e., any pain that was not pelvic pain). Using a yes/no response format, participants were asked to report their current and past acute and chronic pain via the following questions: (1) Do you NOW have significant pain (other than pelvic pain) that has lasted 3 months or more? (2) Do you have any other significant pain NOW that has lasted 3 months or more? (3) Do you NOW have significant pain that has lasted LESS than 3 months? (4) Besides any pain just discussed, have you EVER had significant pain? Responses were dichotomized such that answering yes to one or more of the items indicated the presence of other forms of pain, and answering no to all four indicated having no other forms of pain.

Chronic pelvic pain severity

A 15-item questionnaire from the International Pelvic Pain Society’s Pelvic Pain Assessment Form (Supplemental Table S3)³¹ was used to assess CPP severity. Participants were asked to rate their level of pain over the last month using a 10-point scale (0—no pain, 10—worst pain imaginable) during the following timepoints and activities: (1) pain at ovulation (mid-cycle), (2) pain just before period, (3) pain (not cramps) before period, (4) deep pain with intercourse, (5) pain in groin when lifting, (6) pelvic pain lasting hours or days after intercourse, (7) pain when bladder is full, (8) muscle/joint pain, (9) level of cramps with period, (10) pain after period is over, (11) burning vaginal pain after sex, (12) pain with urination, (13) backache, (14) migraine headache, and (15) pain with sitting. In the present study, the CPP severity measure was found to have excellent reliability (Cronbach’s α = 0.94).

Internalized Stigma of Chronic Pain Scale

Internalized stigma of CPP was measured using the Internalized Stigma of Chronic Pain (ISCP) scale (Supplemental Table S4).³² The ISCP is a 28-item self-report questionnaire, originally developed to measure the internalized stigma in individuals living with chronic pain, but was modified for this study to specifically measure the stigma of CPP. As such, all statements referencing “chronic pain” were replaced with “pelvic pain.” Response options ranged from 1 (strongly disagree) to 4 (strongly agree). ISCP scores range from 28 to 112, in which higher scores indicate more internalized stigma. Example statements include, “I feel out of place in the world because I have pelvic pain,” and “I feel inferior to others who don’t have pelvic pain.” The ISCP has well-established reliability (Cronbach’s α = 0.90)³² and validity. In the present study, the ISCP measure was found to have excellent reliability (Cronbach’s α = 0.96).

Anxiety Sensitivity Index-3

Anxiety sensitivity was measured using the Anxiety Sensitivity Index-3 (ASI-3).³³ The ASI-3 is an 18-item self-report questionnaire, and response options ranged from 0 (very little) to 4 (very much). The ASI-3 was summed for a total score ranging from 0 to 72, with higher scores indicating greater anxiety sensitivity. Example items include, “When my chest feels tight, I get scared that I won’t be able to breathe properly,” and “I worry that other people will notice my anxiety.” This measure has well-established reliability (Cronbach’s α = 0.89)³⁴ and validity. In the present study, the ASI-3 measure was found to have excellent reliability (Cronbach’s α = 0.95).

Center for Epidemiological Studies-Depression scale

Depression was measured using the Center for Epidemiological Studies-Depression (CES-D).³⁵ The CES-D is a 20-item self-report questionnaire, and response options included 0 (rarely or none of the time: less than 1 day), 1 (some or a little of the time: 1–2 days), 2 (occasionally or a moderate amount of time: 3–4 days), and 3 (most or all of the time: 5–7 days). CES-D items were summed for a range of scores from 0 to 60, with higher scores indicating more depressive symptoms. Example items include, “I felt that I could not shake off the blues even with help from my family or friends,” and “I was bothered by things that don’t usually bother me.” The CES-D has well-established reliability (Cronbach’s α = 0.90)³⁶ and validity. In the present study, the CES-D measure was found to have high reliability (Cronbach’s α = 0.93).

Procedure

Participants first consented to participate and were informed that responses would be deidentified. Then, they completed the CPP screener to determine whether they met the criteria for CPP (i.e., those who answered yes to one or more of the items included in the final sample), followed by the other forms of pain questionnaire. Those who reported having CPP then completed the ISCP, ASI-3, CES-D, and various psychological questionnaires in randomized order, and finished the survey with a demographic questionnaire. Further, there were four validity check items (Supplemental Table S5) included intermittently in the survey to assess for attention and accuracy of responding; those who failed to answer at least 75% correctly were excluded from the study (n = 55). All participants with missing data (n = 226) were excluded from the final sample. After completion of the survey, participants received $2.00 through their MTurk account for participating in the study. STROBE cross-sectional reporting guidelines were used in the development of this manuscript (Supplemental Method).³⁷

Statistical analyses

Descriptive statistics were produced for all study variables. To test the first hypothesis (i.e., women who reported more depression and anxiety sensitivity would also report more severe CPP), hierarchical linear regression was used in which step 1 included demographic variables (i.e., age, household income, education status; Supplemental Method) and other forms of pain (i.e., self-reported pain other than pelvic pain) and step 2 included depression and anxiety sensitivity. A continuous CPP severity score was used as the dependent variable. To test the second hypothesis (i.e., that ISCP would moderate the relationship between CPP severity and both depression and anxiety sensitivity), moderation analyses were conducted using PROCESS Macro v3.5. Covariates (i.e., age, household income, and other forms of pain) were included in the analyses. SPSS version 28 was used for data analysis.

Results

Table 1 displays demographic information. The sample included women aged 20–79 (M = 38.2, SD = 11.03). Nearly half (46.9%) of the sample of women with CPP reported comorbid acute or chronic pain. Almost all (99.2%) of the sample had at least a high school diploma or general educational development (GED) credential, and over a quarter (28.2%) had at least a bachelor’s degree. Over half of the sample (53.1%) reported a household income of $49,999 or less. Table 2 displays descriptive statistics and internal consistency for all study measures (i.e., CES-D, ASI-3, ISCP, and CPP severity). Reliability analyses were conducted, and it was determined that all study measures had excellent internal consistency (Table 2).

Table 1.

Sample characteristics.

Demographic characteristics	n (%)
Total, N	241
Age, M (SD)	38.15 (11.03)
Other forms of pain	113 (46.9)
Race^a
Black/African American	45 (18.7)
American Indian or Alaskan Native	5 (2.1)
Asian	3 (1.2)
Native Hawaiian or other Pacific Islander	1 (0.4)
White	193 (80.1)
Other	3 (1.2)
Ethnicity
Non-Hispanic	214 (88.8)
Hispanic	25 (10.4)
Other	2 (0.8)
Education
No schooling completed	0 (0)
Some high school, no diploma	2 (0.8)
High school graduate, diploma, or GED	22 (9.1)
Some college credit, no degree	31 (12.9)
Trade/technical, vocational training	7 (2.9)
Associate degree	21 (8.7)
Bachelor’s degree	90 (37.3)
Graduate/professional, no degree	28 (11.6)
Graduate/professional, diploma	40 (16.6)
Income
<25,000	74 (30.7)
25,000–34,999	21 (8.7)
35,000–49,999	33 (13.7)
50,000–74,999	49 (20.3)
75,000–99,999	34 (14.1)
⩾100,000	30 (12.4)

SD: standard deviation; GED: general educational development.

Percentages total to more than 100% as respondents were encouraged to report “all that apply.”

Table 2.

Descriptive statistics for study variables.

Scale	Mean	SD	Min	Max	Cronbach’s alpha
ISCP	64.0	19.8	28	112	0.96
ASI-3	33.7	17.5	0	72	0.95
CES-D	25.5	13.4	0	60	0.93
CPP severity	77.5	34.8	0	150	0.94

Min: absolute minimum; Max: absolute maximum; ISCP: Internalized Stigma of Chronic Pain for CPP scale; ASI-3: Anxiety Sensitivity Index-3; CES-D: Center for Epidemiological Studies-Depression scale; CPP severity: Chronic pelvic pain severity scale; SD: standard deviation.

Hypothesis 1

Table 3 displays hierarchical linear regression results. Both step 1 (demographic factors) and step 2 (depression and anxiety sensitivity) were significant predictors in the model. Specifically, step 1 accounted for 22% of the variance in CPP severity scores. Both education status (continuous) and reporting at least one other form of pain (dichotomous) were positively associated with CPP severity, such that individuals with higher levels of education and who reported having other forms of pain also reported more severe CPP symptoms. Step 2 accounted for an additional 30% of the variance in CPP severity scores. Both CES-D and ASI-3 scores were positively associated with CPP severity, such that women who reported more depression and anxiety sensitivity also reported more severe CPP symptoms.

Table 3.

Hierarchical linear regression analysis predicting CPP severity with demographic variables and emotional factors.

Independent variables	b	SE	β	p-Value	∆R²
Step 1					0.22
Age	−0.04	0.21	−0.01	0.862
Income	0.01	0.70	0.001	0.984
Education	4.84	1.25	0.26	<0.001
Other pain	26.14	4.63	0.38	<0.001
Step 2					0.30
Age	0.22	0.17	0.07	0.189
Income	0.26	0.56	0.03	0.642
Education	2.82	1.02	0.15	0.006
Other pain	11.37	3.94	0.16	0.004
CES-D	0.61	0.19	0.22	0.002
ASI-3	0.92	0.14	0.45	<0.001

CPP: chronic pelvic pain; SE: standard error; CES-D: Center for Epidemiological Studies-Depression scale; ASI-3: Anxiety Sensitivity Index-3.

Hypothesis 2

Multiple regression analyses were conducted to explore the moderating role of internalized stigma in the relationships between depression and CPP severity as well as anxiety sensitivity and CPP severity. Results from the first multiple regression analysis (i.e., depression and stigma) did not indicate a significant effect of depression on CPP severity. However, there was a significant effect of stigma on CPP severity (b = 0.76, SE = 0.30, p = 0.01), suggesting that those who reported more internalized stigma also reported more severe CPP symptoms. In addition, there was a significant interaction between depression and stigma (b = 0.02, SE = 0.01, p = 0.02). Thus, the effect of depression on CPP severity depended on stigma, such that depression levels had a stronger effect on CPP severity in those who reported more internalized stigma (Figure 1). The simple slope of depression on CPP severity was significant at the 50th (b = 0.50, SE = 0.18, p = 0.007) and the 84th (b = 1.05, SE = 0.35, p = 0.003) percentiles of ISCP scores.

Figure 1.

Effect of internalized stigma on the association between pelvic pain severity and depression.

Similarly, results from the second moderation analysis (i.e., anxiety sensitivity and stigma) did not reveal a significant effect of anxiety sensitivity on CPP severity, however, there was a significant effect of stigma on CPP severity (b = 0.59, SE = 0.22, p = 0.009), suggesting that those who reported more internalized stigma also reported more severe CPP symptoms. There was a significant interaction between anxiety sensitivity and stigma (b = 0.01, SE = 0.005, p = 0.02). Thus, the effect of anxiety sensitivity on CPP severity depended on stigma, such that anxiety sensitivity levels had a stronger effect on CPP severity in those who reported more internalized stigma (Figure 2). The simple slope of anxiety sensitivity on CPP severity was significant at the 16th (b = 0.30, SE = 0.14, p = 0.03), the 50th (b = 0.59, SE = 0.12, p < 0.001), and the 84th (b = 0.83, SE = 0.19, p < 0.001) percentiles of ISCP scores.

Figure 2.

Effect of internalized stigma on the association between pelvic pain severity and anxiety sensitivity.

Discussion

This study supports and expands on the understanding of CPP in women, providing evidence of associations between pelvic pain severity and various emotional factors. These findings provide new insight into the role of internalized stigma, suggesting that associations between pelvic pain severity and emotional factors may be heightened in women who report more internalized stigma.

Associations among emotional factors and chronic pelvic pain severity

As hypothesized, both depression and anxiety sensitivity were positively associated with CPP severity. It may be that women who have more severe CPP are vulnerable to developing higher levels of depression and anxiety, or that those who have more depression and anxiety sensitivity are at an increased risk for experiencing more severe CPP symptoms. In addition, other factors (e.g., internalized stigma) may affect those relationships. These findings support and expand on prior literature generally that has indicated associations between chronic pain and psychological distress.^5
–9 Given that depression and anxiety sensitivity may be risk factors in experiencing more severe CPP symptoms, these negative emotional states should be considered in the treatment of CPP. Providers treating women with pelvic pain may consider evaluating their patients for increased depression and anxiety sensitivity and address any concerns concurrent with the treatment protocol for their pain.

Results of analyses exploring associations among CPP severity and emotional factors revealed significant associations among covariates (i.e., education and other forms of pain). Although there is little literature exploring associations between education and CPP specifically, studies exploring associations with other types of pain (e.g., back pain) have found either a negative association^38,39 or no association^40
–42 between them. As these studies have not specifically observed individuals reporting CPP, it is possible that this finding is unique to individuals living with CPP and does not generalize to other forms of chronic pain. It is also possible that women who are more highly educated are more empowered or comfortable with reporting the severity of their pain.

Stigma moderates associations among emotional factors and chronic pelvic pain severity

Based on prior literature, evidence suggests that stigma may be a potential risk factor in individuals living with CPP,²⁸ but limited research has explored this construct quantitatively as it relates to CPP.⁶ The present findings indicate that internalized stigma moderates the relationship between CPP severity and both depression and anxiety sensitivity. Specifically, the effects of depression and anxiety sensitivity on CPP severity were stronger in women who reported more internalized stigma.

To our knowledge, no intervention aimed at addressing pelvic pain stigma yet exists. There is, however, literature on stigma reduction interventions for other health-related variables (e.g., HIV, mental illness, and migraines). For example, Andersson et al.⁴³ explored the literature on interventions aimed at reducing HIV-related stigma and found an array of different approaches, including multilevel approaches (i.e., those that included community members, family and friends, caregivers, and medical professionals), holistic approaches (e.g., those that focused on support, compassion, and communication), and those that targeted specific populations (e.g., women, people of color, and children), among others. Parikh et al.⁴⁴ discussed findings in their review of the literature on stigma reduction pertaining to migraine-related stigma, suggesting that education-based (i.e., counter harmful stereotypes with factual information), contact-based (i.e., interactions among those with and those without the condition), and protest-based (i.e., addressing the injustices and expressing disapproval to the offenders) interventions were among the most common.

Although this literature provides insightful information into which intervention approaches have shown some success in reducing stigma, there is little consistency among them. Further research is needed to understand the effectiveness of different approaches, and researchers exploring CPP-related stigma may reference the literature on stigma reduction to develop and test CPP-related stigma reduction interventions.

Limitations

Several factors limit the interpretability and generalizability of these results. Participant recruitment and data collection were all conducted online, and self-report questionnaires were used; thus, it is possible that some participants were not forthright in their responses. We attempted to attenuate this by including validity check items (Supplemental Table S1) to mitigate inaccurate responses. The use of self-report instruments to collect data and measure constructs introduces the possibility of bias (e.g., social desirability and recall bias) and issues of shared method variance, thus potentially affecting study outcomes. In addition, certain demographics were underrepresented in the present sample (e.g., those with Asian or Hispanic identities), thus limiting the generalizability of these findings. Associations among race and health disparities are well documented, demonstrating that people of color, especially women of color, face greater health disparities compared to those who are White.^45,46 Thus, it is possible that racial differences may have been observed had a more diverse sample been included. In addition, given the cross-sectional study design, the directionality of associations cannot be determined.

Future directions

Results of the present study support those in prior literature regarding associations among CPP and psychological distress, and they provide new insight into the role of internalized stigma in women with CPP.^5
–9 Future work should continue to explore associations between psychological state and CPP severity in women with CPP. Given the theory that internalized stigma typically occurs as a result of experienced stigma, future work should further explore associations between psychological processes and experienced stigma in women with CPP. Researchers may consider evaluating the adverse effects of experiencing stigma in different settings, including at work, at home, and in medical settings. To address the inability to interpret directionality due to the cross-sectional design, future work should explore these associations longitudinally. Researchers may also explore other factors that may influence the severity of CPP symptoms (e.g., in specific CPP disorders such as endometriosis, bladder pain syndrome, or irritable bowel syndrome; access to medical care; race; and ethnicity). Obtaining a better understanding of the role of psychological factors on pelvic pain severity may influence intervention and treatment methods (e.g., practitioners may focus on effective ways to address mental health issues along with CPP treatment).

Conclusion

In sum, the present study found that internalized stigma moderated the association between emotional distress and CPP severity. Given these findings, providers treating women with CPP may consider screening for psychological distress and referring their patients to appropriate resources to address these concerns, concurrent with the treatment for pain. Future studies are warranted to explore the effectiveness of stigma-focused interventions in reducing stigmatization in women with CPP. Further, research exploring the role of other forms of stigma (e.g., experienced stigma) in healthcare settings is encouraged, including the examination of provider factors and their influence on treatment outcomes in women with CPP.

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sj-docx-7-whe-10.1177_17455057251344381 – Supplemental material for Internalized stigma mediates the relationship between pelvic pain severity and both depression and anxiety in women with chronic pelvic pain

Supplemental material, sj-docx-7-whe-10.1177_17455057251344381 for Internalized stigma mediates the relationship between pelvic pain severity and both depression and anxiety in women with chronic pelvic pain by Sarah E. Francis, Jamey T. Brumbaugh, Jeongwi An, Emily J. Bartley and Daniel W. McNeil in Women’s Health

Footnotes

Acknowledgements

We thank the women who participated in this study for their time, effort, and contributions to this research. This study is based on a senior honors thesis completed by the first author under the direction of the last author.

ORCID iDs

Sarah E. Francis

Jamey T. Brumbaugh

Jeongwi An

Emily J. Bartley

Daniel W. McNeil

Ethical considerations

Approval for this research was obtained from the West Virginia University Institutional Review Board (Protocol #2212691662).

Consent to participate

Informed consent was received from each participant prior to their engaging in data collection. Participants independently reviewed and signed an electronic consent form. Participants were provided with contact information of study personnel for inquiries.

Consent for publication

Not applicable.

Author contributions

Sarah E. Francis: Conceptualization; Methodology; Validation; Formal analysis; Investigation; Resources; Data curation; Writing – original draft; Writing – review & editing; Visualization; Project administration; Funding acquisition.

Jamey T. Brumbaugh: Conceptualization; Methodology; Validation; Formal analysis; Investigation; Writing – review & editing; Supervision.

Jeongwi An: Conceptualization; Methodology; Validation; Writing – review & editing; Supervision.

Emily J. Bartley: Conceptualization; Methodology; Validation; Writing – review & editing.

Daniel W. McNeil: Conceptualization; Methodology; Validation; Formal analysis; Resources; Writing – review & editing; Supervision; Funding acquisition.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the West Virginia University Department of Psychology Undergraduate Student Research Fund and the West Virginia University Eberly College Academic Enrichment Grant.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

All collected data are available upon request from the author.

Supplemental material

Supplemental material for this article is available online.

References

Lamvu

Carrillo

Ouyang

, et al Chronic pelvic pain in women: a review. JAMA 2021; 325(23): 2381–2391.

Ahangari

Prevalence of chronic pelvic pain among women: an updated review. Pain Physician 2014; 17(2): E141–E147.

Classification of Chronic Pain, Second Edition (Revised). International Association for the Study of Pain (IASP) [cited 30 September 2024], https://www.iasp-pain.org/publications/free-ebooks/classification-of-chronic-pain-second-edition-revised/

Allaire

Williams

Bodmer-Roy

, et al Chronic pelvic pain in an interdisciplinary setting: 1-year prospective cohort. Am J Obstet Gynecol 2018; 218(1): 114.e1–114.e12.

Romão

APMS

Gorayeb

Romão

, et al High levels of anxiety and depression have a negative effect on quality of life of women with chronic pelvic pain. Int J Clin Pract 2009; 63(5): 707–711.

Sims

Gupta

Missmer

, et al Stigma and endometriosis: a brief overview and recommendations to improve psychosocial well-being and diagnostic delay. Int J Environ Res Public Health 2021; 18(15): 8210.

Siqueira-Campos

VME

Da Luz

de Deus

, et al Anxiety and depression in women with and without chronic pelvic pain: prevalence and associated factors. J Pain Res 2019; 12: 1223–1233.

Sewell

Churilov

Mooney

, et al Chronic pelvic pain—pain catastrophizing, pelvic pain and quality of life. Scand J Pain 2018; 18(3): 441–448.

Facchin

Barbara

Saita

, et al Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference. J Psychosom Obstet Gynecol 2015; 36(4): 135–141.

10.

Rush

Misajon

Hunter

, et al The relationship between endometriosis-related pelvic pain and symptom frequency, and subjective wellbeing. Health Qual Life Outcomes 2019; 17(1): 123.

11.

Mellado

Pilger

Poli Neto

, et al Daily life attitudes of women with moderate or severe chronic pelvic pain. A qualitative study. Eur J Obstet Gynecol Reprod Biol 2020; 254: 109–113.

12.

Donayeva

Amanzholkyzy

Ibrahim

, et al The impact of primary dysmenorrhea on adolescents’ activities and school attendance.J Med Life 2023; 16(10): 1462–1467.

13.

Johnson

Evans

Hapangama

DK.

Chronic pelvic pain treatment understanding what matters: a social media survey. Reprod Fertil 2025; 6(1): e240038.

14.

De Graaff

D’Hooghe

Dunselman

GAJ

, et al The significant effect of endometriosis on physical, mental and social wellbeing: results from an international cross-sectional survey. Hum Reprod 2013; 28(10): 2677–2685.

15.

Brooks

Sharp

Evans

, et al Predictors of depression, anxiety and stress indicators in a cohort of women with chronic pelvic pain. J Pain Res 2020; 13: 527–536.

16.

Armour

Ferfolja

Curry

, et al The prevalence and educational impact of pelvic and menstrual pain in Australia: a National Online Survey of 4202 young women aged 13–25 years. J Pediatr Adolesc Gynecol 2020; 33(5): 511–518.

17.

Zannoni

Giorgi

Spagnolo

, et al Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol 2014; 27(5): 258–265.

18.

Goffman

Selections from stigma. Disabil Stud Read 1997; 203: 215.

19.

Goldberg

DS.

On stigma & health. J Law Med Ethics 2017; 45(4): 475–483.

20.

Nyblade

Stangl

Weiss

, et al

Combating HIV stigma in health care settings: what works?

J Int AIDS Soc 2009; 12: 15.

21.

Whetten

Reif

Whetten

, et al Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care. Psychosom Med 2008; 70(5): 531–538.

22.

Rzeszutek

Gruszczyńska

Pięta

, et al HIV/AIDS stigma and psychological well-being after 40 years of HIV/AIDS: a systematic review and meta-analysis. Eur J Psychotraumatology 2021; 12(1): 1990527.

23.

Kondrat

Sullivan

Wilkins

, et al The mediating effect of social support on the relationship between the impact of experienced stigma and mental health. Stigma Health 2018; 3(4): 305–314.

24.

Gerlinger

Hauser

De Hert

, et al Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry 2013; 12(2): 155–164.

25.

Drapalski

Lucksted

Perrin

, et al A model of internalized stigma and its effects on people with mental illness. Psychiatr Serv 2013; 64(3): 264–269.

26.

Bean

Dryland

Rashid

, et al The determinants and effects of chronic pain stigma: a mixed methods study and the development of a model. J Pain 2022; 23(10): 1749–1764.

27.

Hawkey

Chalmers

Micheal

, et al “A day-to-day struggle”: A comparative qualitative study on experiences of women with endometriosis and chronic pelvic pain. Fem Psychol 2022; 32(4): 482–500.

28.

Matías-González

Sánchez-Galarza

Flores-Caldera

, et al “Es que tú eres una changa”: stigma experiences among Latina women living with endometriosis. J Psychosom Obstet Gynaecol 2021; 42(1): 67–74.

29.

Faul

Erdfelder

Lang

, et al G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39(2): 175–191.

30.

Harlow

Vazquez

MacLehose

, et al Self-reported vulvar pain characteristics and their association with clinically confirmed vestibulodynia. J Womens Health (Larchmt) 2009; 18(9): 1333–1340.

31.

International Pelvic Pain Society. Pelvic Pain Assessment Form. 2008; Retrieved from 25 November, 2022. https://pelvicpain.org/

32.

Waugh

Byrne

Nicholas

MK.

Internalized stigma in people living with chronic pain. J Pain 2014; 15(5): 550.e1–10.

33.

Taylor

Zvolensky

Cox

, et al Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychol Assess 2007; 19(2): 176–188.

34.

Osman

Gutierrez

Smith

, et al The Anxiety Sensitivity Index-3: analyses of dimensions, reliability estimates, and correlates in nonclinical samples. J Pers Assess 2010; 92(1): 45–52.

35.

Radloff

LS.

The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1(3): 385–401.

36.

Cosco

Prina

Stubbs

, et al Reliability and validity of the center for epidemiologic studies depression scale in a population-based cohort of middle-aged U.S. adults. J Nurs Meas 2017; 25(3): 476–485.

37.

von Elm

Altman

Egger

, et al The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61(4): 344–349.

38.

Fentazi

Pester

Yamin

, et al

Why is low educational attainment linked to worse pain and function in fibromyalgia?

J Pain 2025; 27: 104764.

39.

Cano

Mayo

Ventimiglia

Coping, pain severity, interference, and disability: the potential mediating and moderating roles of race and education. J Pain 2006; 7(7): 459–468.

40.

Adamson

Hunt

Nazareth

The influence of socio-demographic characteristics on consultation for back pain–a review of the literature. Fam Pract 2011; 28(2): 163–171.

41.

Shipton

Ponnamperuma

Wells

, et al Demographic characteristics, psychosocial measures, and pain in a sample of patients with persistent pain referred to a new zealand tertiary pain medicine center. Pain Med Malden Mass 2013; 14(7): 1101–1107.

42.

Lawan

Aubertin

Mical

, et al Is educational attainment associated with the onset and outcomes of low back pain? A systematic review and meta-analysis. PLoS One 2024; 19(8): e0308625.

43.

Andersson

Reinius

Eriksson

, et al Stigma reduction interventions in people living with HIV to improve health-related quality of life. Lancet HIV 2020; 7(2): e129–e140.

44.

Parikh

Kempner

Young

WB.

Stigma and migraine: developing effective interventions. Curr Pain Headache Rep 2021; 25(11): 75.

45.

Gravlee

CC.

Systemic racism, chronic health inequities, and COVID-19: a syndemic in the making?

Am J Hum Biol 2020; 32(5): e23482.

46.

James

Moonesinghe

Wilson-Frederick

, et al Racial/ethnic health disparities among rural adults—United States, 2012–2015. MMWR Surveill Summ 2017; 66(23): 1–9.

Supplementary Material

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