{"paper_id":"12d2e026-9010-4bf2-888f-77d0977b7b50","body_text":"Psychology & Health\nISSN: 0887-0446 (Print) 1476-8321 (Online) Journal homepage: www.tandfonline.com/journals/gpsh20\nSelf-compassion and health-related quality of life\nin individuals with endometriosis\nChelsea M. Skinner & Roeline G. Kuijer\nTo cite this article: Chelsea M. Skinner & Roeline G. Kuijer (2025) Self-compassion and health-\nrelated quality of life in individuals with endometriosis, Psychology & Health, 40:9, 1479-1496,\nDOI: 10.1080/08870446.2024.2325506\nTo link to this article:  https://doi.org/10.1080/08870446.2024.2325506\n© 2024 The Author(s). Published by Informa\nUK Limited, trading as Taylor & Francis\nGroup\nView supplementary material \nPublished online: 12 Mar 2024.\nSubmit your article to this journal \nArticle views: 4703\nView related articles \nView Crossmark data\nCiting articles: 6 View citing articles \nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=gpsh20\n\nPsychology & health\n2025, Vol. 40, No . 9, 1479–1496\nSelf-compassion and health-related quality of life in \nindividuals with endometriosis\nChelsea M. Skinner and Roeline G. Kuijer\nschool of Psychology, speech and hearing, University of c anterbury, christchurch, New Zealand\nABSTRACT\nObjective: International research highlights the detrimental impact \nof endometriosis on health-related quality of life (HRQoL), yet few \nstudies have examined positive resources such as self-compassion \nand resilience as correlates. This cross-sectional study aimed to \nexamine the relationship between self-compassion and HRQoL in \nindividuals with endometriosis in Aotearoa New Zealand. Resilience \nand perceived symptom severity were examined as potential \nmediators.\nMethods and measures:  Six hundred and three individuals with \nendometriosis completed an online questionnaire measuring \ndemographic and endometriosis-related information, endometriosis \nsymptoms (number and severity), HRQoL, self-compassion and \nresilience.\nResults: In line with international research, the current sample \nreported significant impairment in all aspects of HRQoL. As \nexpected, those with higher levels of self-compassion reported less \nimpairment in HRQoL, and this relationship was partially mediated \nby perceived symptom severity (all aspects of HRQoL). Resilience \nmediated the relationship between self-compassion and two aspects \nof HRQoL (emotional wellbeing and control/powerlessness).\nConclusion: These findings confirm that HRQoL is significantly \nimpaired in individuals with endometriosis in Aotearoa New \nZealand and point to the potential role of self-compassion and \nresilience as protective factors in encouraging positive coping \nstyles to manage symptoms and maintain high HRQoL. Interventions \ntargeting self-compassion may be a promising tool to improve \nwellbeing in individuals with endometriosis.\nIntroduction\nEndometriosis is a chronic, gynaecological condition where tissue that is similar to \nthe lining of the uterus (endometrium) is found in places outside the uterus (Kennedy \net  al., 2005). It is a common condition estimated to affect between 5% and 11% of \nreproductive-aged females and those assigned female at birth (Adamson et  al., 2010; \n© 2024 t he a uthor(s). Published by Informa UK limited, trading as taylor & Francis group\nCONTACT chelsea M. skinner   chelsea.skinner@pg.canterbury.ac.nz  s chool of Psychology, speech and hearing, \nUniversity of c anterbury, Private Bag 4800, christchurch 8140, New Zealand.\n supplemental data for this article can be accessed online at https://doi.org/10.1080/08870446.2024.2325506.\nhttps://doi.org/10.1080/08870446.2024.2325506\nt his is an o pen a ccess article distributed under the terms of the c reative c ommons a ttribution-Nonc ommercial-NoDerivatives license \n(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, \nprovided the original work is properly cited, and is not altered, transformed, or built upon in any way. t he terms on which this article \nhas been published allow the posting of the a ccepted Manuscript in a repository by the author(s) or with their consent.\nARTICLE HISTORY\nReceived 20 November \n2023\nAccepted 26 February \n2024\nKEYWORDS\nEndometriosis; quality of \nlife; self-compassion; \nresilience; symptom \nseverity\n\n1480 C. M. SKINNER AND R. G. KUIJER\nRowlands et  al., 2021). Common symptoms include pain with periods (dysmenorrhoea), \nchronic non-menstrual pelvic pain, painful intercourse (dyspareunia), abnormal bleed -\ning between cycles, bowel and bladder problems, fatigue, and infertility (Kennedy \net  al., 2005). Although these symptoms are frequently reported, there is considerable \nvariability in symptom presentation, with some individuals experiencing no symptoms \n(asymptomatic) while others report multiple and severely debilitating symptoms \n(Vercellini et  al., 2007). There is currently no cure for endometriosis and management \nfocuses on symptom relief with varying degrees of success (Becker et  al., 2017; Ferrero \net  al., 2018).\nThe negative impact of endometriosis on psychological wellbeing and health-related \nquality of life (HRQoL) has been well-documented, with negative effects found on all \naspects of quality of life, including physical, psychological, occupational, and inter -\npersonal functioning (e.g. Culley et  al., 2013; De Graaff et  al., 2013; Facchin et  al., \n2015; Soliman et  al., 2017, 2020; Tewhaiti-Smith et  al., 2022). The extent to which \nHRQoL is impaired depends on several factors, including the number of symptoms \nexperienced and the severity of those symptoms. For example, in two large \ncross-sectional samples, Soliman et  al. ( 2017, 2020) found that HRQoL scores decreased \nas endometriosis symptom severity and the number of symptoms reported increased. \nMoreover, a study by Facchin et  al. ( 2015) found that women with endometriosis who \nexperienced pelvic pain had significantly poorer quality of life compared to those \nwith asymptomatic endometriosis. A recent study conducted in Aotearoa New Zealand \nfound that the experience of chronic pelvic pain symptoms, regardless of diagnosis \n(endometriosis, other underlying condition, no formal diagnosis), severely impacted \nquality of life in the areas of work, education, and relationships (Tewhaiti-Smith \net  al., 2022).\nAlthough symptom severity and the number of symptoms reported are clearly \nimportant predictors of HRQoL, it is also clear that some individuals are better able \nto maintain high levels of HRQoL than others. Understanding how HRQoL and psy -\nchological wellbeing may be improved in individuals with endometriosis is crucial as \nmedical interventions alone are often inadequate. A growing evidence base suggests \nthat self-compassion may be an important resource in coping with chronic illness \n(Sirois & Rowse, 2016). Self-compassion consists of six components: self-kindness \nversus self-judgment (being kind, non-judgemental and understanding towards oneself \nin difficult times), mindfulness versus overidentification (being in touch with difficult \nexperiences in a mindful and accepting manner) and common humanity versus iso -\nlation (recognising that struggles and personal shortcomings are common to all \npeople) that combine to create a self-compassionate frame of mind (Neff, 2003a, \n2003b, 2023). Self-compassion is generally operationalised as a stable, trait-like con -\nstruct (Medvedev et  al., 2021; Neff, 2003a, 2003b, 2023), but can also be raised via \ninterventions (Kılıç et  al., 2021; Neff & Germer, 2013; Neff, 2023). Self-compassion has \nbeen consistently related to higher psychological wellbeing in the general population \n(Marsh et  al., 2018; Zessin et  al., 2015). Self-compassion has also been associated with \nimproved outcomes in people with chronic health conditions, including increased \nHRQoL (e.g. Nery-Hurwit et  al., 2018; Pinto-Gouveia et  al., 2014), higher psychological \nwellbeing (e.g. Prentice et  al., 2021), and less pain-related disability (e.g. Edwards \net  al., 2019). Research examining self-compassion in individuals with endometriosis \nis scarce. The few studies that have been done show that higher self-compassion is \n\nPSyCHoL oGy & HEALTH 1481\nrelated to lower levels of depression, anxiety, endometriosis-related distress, and fewer \nendometriosis-related symptoms (Van Niekerk et  al., 2022), greater HRQoL in the \ndomain of emotional wellbeing (Van Niekerk et  al., 2023), and less sexual distress \n(Sullivan-Myers et  al., 2023).\nThere are several ways in which self-compassion may be related to improved psy -\nchological wellbeing and HRQoL. one mechanism may be through increased resilience. \nResilience has been defined as the ability to bounce back from stressful events (Smith \net  al., 2008) and has been found to be associated with better HRQoL and psycholog -\nical wellbeing in individuals with chronic health conditions, including endometriosis \n(e.g. Lubián-López et  al., 2021; Nery-Hurwit et  al., 2018; Romaniuk & oniszczenko, \n2023). When considered together, several studies have found that self-compassion \nand resilience are both uniquely associated with improved physical and mental health \n(Asensio-Martínez et  al., 2019 ; Bag et  al., 2022 ). Individuals who are more \nself-compassionate tend to use more adaptive coping skills, including emotion-focused \nstrategies such as acceptance and positive reframing and problem-focused coping \nstrategies such as planning and seeking instrumental support (Ewert et  al., 2021; \nSirois et  al., 2015) and are better able to regulate their emotions (Terry & Leary, 2011), \nall of which may promote resilience (Bluth et  al., 2018). For example, recognising that \nothers have gone through similar experiences and that one is not alone in suffering \n(common humanity vs. isolation dimension of self-compassion) may make it easier \nfor an individual with endometriosis to seek support which in turn may promote \nresilience. In a study among individuals with multiple sclerosis, Nery-Hurwit and col -\nleagues (2018) found that resilience mediated the relationship between self-compassion \nand HRQoL.\nAnother way through which self-compassion may be related to HRQoL is through \nperceived severity of symptoms. In research with individuals with chronic pain, low \nself-compassion has been associated with greater pain-related catastrophising and \nfear and lower pain acceptance (Edwards et  al., 2019; Wren et  al., 2012). These findings \nare especially relevant since high pain-related catastrophising and anxiety have been \nfound to be important factors related to impairment in HRQoL in individuals with \nendometriosis (McPeak et  al., 2018; van Aken et  al., 2017).\nThe main aim of the current study was to examine the relationship between \nself-compassion, resilience, perceived symptom severity, and HRQoL in individuals \nwith endometriosis. Although ample research has shown that self-compassion is \nrelated to better HRQoL in chronic illness populations, research investigating \nself-compassion in endometriosis is lacking. In addition, the mechanisms through \nwhich self-compassion may influence HRQoL are not well understood. Based on pre -\nvious research, we expected that individuals with higher levels of self-compassion \nwould report higher levels of HRQoL, and we expected perceived symptom severity \nand resilience to mediate this relationship.\nResearch on HRQoL of individuals with endometriosis in Aotearoa New Zealand is \nscarce. The only study recently conducted (Tewhaiti-Smith et  al., 2022) did not use a \nvalidated instrument to measure HRQoL making comparisons with the international \nliterature difficult. Therefore, a secondary aim of the current study was to assess \nHRQoL with the well-validated Endometriosis Health Profile (EHP)-30 (Jones et  al., \n2001) to better understand the impact endometriosis has on individuals in Aotearoa \nNew Zealand.\n\n1482 C. M. SKINNER AND R. G. KUIJER\nMethod\nParticipants and procedure\nThe sample consisted of 603 individuals from Aotearoa New Zealand with a self-reported \ndiagnosis of endometriosis. Participants were recruited over a period of one month \nthrough Aotearoa New Zealand endometriosis organisations such as Endometriosis \nNew Zealand and Endo Warriors Aotearoa (social media and website) and advertising \non social media (Facebook and Instagram) in June 2021. Participation in the study \ninvolved completing an online survey. Participants provided informed consent before \npartaking in the survey. Those who completed the survey were entered into a draw \nto win one of six 50 NZD supermarket vouchers. Inclusion criteria for the study were: \n(1) having been diagnosed with endometriosis via laparoscopic surgery or having \nreceived such a diagnosis from a medical professional without surgery, (2) aged \nbetween 18 and 45 years and (3) living in Aotearoa New Zealand. Seven hundred and \nfifteen individuals completed the survey. o ne hundred and twelve did not meet the \ninclusion criteria and were therefore excluded from data analysis ( n = 97 experienced \npelvic pain but had not been diagnosed with endometriosis, n = 4 were aged outside \nthe age range, and n = 11 did not live in Aotearoa New Zealand). The study was \napproved by the University of Canterbury Human Ethics Committee (HEC2021/40).\nMeasures\nDemographic and endometriosis-related information\nGender, age, ethnicity, education, and employment status were measured. Participants \ncould identify with more than one ethnic group in the questionnaire. Following the \nMinistry of Health’s ethnicity data protocol (Ministry of Health, 2017), participants \nwere assigned into an ethnic group using a hierarchy of prioritisation: (1) Māori, (2) \nPacific, (3) Asian, (4) Middle Eastern, Latin American and African, and (5) European \n(Ministry of Health, 2017). Endometriosis-related information collected included diag -\nnostic procedure (through laparoscopic surgery or being told by a health professional \nwithout surgery), time since diagnosis (in years), and diagnostic delay (measured on \na six-point scale ranging from up to 1  to 8+ years ).\nEndometriosis symptoms: number and severity\nParticipants were asked to indicate whether they were experiencing eight common \nendometriosis-related symptoms (e.g. pain with periods, bowel problems; see Table 1  \nfor the full list; Kennedy et  al., 2005) and rate the severity of these symptoms (1 = mild, \n2 = moderate, 3 = severe, 0 = do not experience/not applicable ). Based on this measure, two \nscores were generated: a frequency measure (a simple count of the number of symp -\ntoms scoring 1 or higher; range 0–8) and a perceived severity measure (the sum of the \nseverity ratings averaged over the number of symptoms; range 0–3).\nHRQoL\nHRQoL was measured with the EHP-30 disease-specific instrument (Jones et  al., 2001), \nan extensively validated measure of quality of life in those with endometriosis (Bourdel \n\nPSyCHoL oGy & HEALTH 1483\net  al., 2019). The core instrument includes 30 items assessing five domains: pain (11 \nitems), control and powerlessness (6 items), emotional wellbeing (6 items), social \nsupport (4 items), and self-image (3 items). Items are measured on a five-point scale \nranging from 1 ( Never) to 5 ( Always) and are assessed in relation to the past 4 weeks. \nExamples of questions include ‘During the last 4 weeks, how often because of your \nendometriosis have you felt unable to cope with the pain?’ and ‘During the last \n4 weeks, how often because of your endometriosis have you felt alone?’ . Items are \nsummed to form subscales for each domain and are then standardised on a scale \nfrom 0 to 100, where 0 indicates the best possible health status and 100 the worst \nTable 1.  Demographic and endometriosis-related information.\nPercentage ( M) Frequency ( SD)\ngender\n Female 98.5% 594\n Male 0.2% 1\n g ender diverse 1.35% 8\na ge (years) (18–45) 29.48 6.84\nethnicity\n e uropean 83.6% 504\n Māori 11.9% 72\n Pacific 1.2% 7\n o thera 3.3% 20\neducation\n No qualification 3.0% 18\n s econdary school 30.5% 184\n Post-school degree 12.8% 77\n University degree 49.9% 301\n o ther 3.8% 23\nemploymentb\n Full time 43.9% 265\n Part time 24.2% 146\n Unemployed 4.5% 27\n s tudent 21.1% 127\n homemaker 8.8% 53\n s elf-employed 8.1% 49\n Unable to work 6.6% 40\nDiagnosis\n t hrough laparoscopy 90.2% 544\n o ther 9.8% 59\nt ime since diagnosis (years) 6.45 5.51\nDiagnostic delay\n Up to 1 year 12.8% 77\n 1–2 years 15.1% 91\n 3–4 years 18.2% 110\n 5–6 years 16.3% 98\n 7–8 years 11.3% 68\n 8+ years 26.4% 159\nendometriosis symptoms (% yes)\n Pain with periods (dysmenorrhea) 97.4% 587\n Bowel problems 97.2% 586\n Painful intercourse 81.9% 494\n sub-fertility/infertility 37.0% 223\n t iredness/low energy 96.2% 580\n a bnormal menstrual bleeding 82.3% 496\n Pain in other areas, e.g. lower back 93.0% 567\n Pain at other times, e.g. ovulation 94.4% 569\nNumber of symptoms (0–8) 6.80 1.02\nPerceived severity of symptoms (0–3) 2.01 0.42\naa sian, Middle eastern, latin a merican and a frican combined.\nbPercentages do not add up to one hundred and total frequencies exceed 603 due to participants being able to \ntick more than one response.\n\n1484 C. M. SKINNER AND R. G. KUIJER\npossible health status. Cronbach’s alpha for each of the subscales in the current study \nwas as follows: pain .95, control and powerlessness .92, emotional wellbeing .89, social \nsupport .88, and self-image .89. A summary score (EHP-30 Core summed scale) can \nalso be calculated by producing one overall score combining the five domains into \none single score, again ranging from 0 to 100.\nThe core instrument can be expanded with six modules, measuring quality of life \ndimensions that may not be relevant to all participants with endometriosis. The \nmodules are work life, sexual intercourse, relationship with children, relationship with \nhealth professionals, treatment, and infertility. The modules are described in the \nSupplementary material .\nSelf-compassion\nThe Self-Compassion Scale-Short Form (Raes et  al., 2011 ) was used to measure \nself-compassion. This 12-item scale is a shortened version of the 26-item \nSelf-Compassion Scale (Neff, 2003a). The scale correlates .97 with the full scale (Raes \net  al., 2011) and is a validated and reliable measure of self-compassion with excel -\nlent internal consistency and strong temporal stability (Medvedev et  al., 2021; Raes \net al., 2011).\nItems are rated on a five-point scale ranging from 1 ( Almost Never ) to 5 ( Almost \nAlways). Examples of statements include ‘I try to be understanding and patient towards \nthose aspects of my personality I don’t like’ (self-kindness), ‘When something upsets \nme, I try and keep my emotions in balance’ (mindfulness) and ‘I try to see my failings \nas part of the human condition’ (common humanity). Negatively worded items were \nreversed scored so that higher scores indicate higher levels of self-compassion on all \nitems. The 12 items were summed and then averaged to form a scale. Cronbach’s \nalpha was .85 in the current study.\nResilience\nThe Brief Resilience Scale (Smith et  al., 2008) was used to assess an individual’s ability \nto bounce back or recover from stress. The scale includes six brief statements rated \non a five-point scale ranging from 1 ( Strongly Disagree ) to 5 ( Strongly Agree ). Example \nitems include ‘I tend to bounce back quickly after hard times’ and ‘I take a long time \nto get over setbacks in my life’ . Negatively worded items were reversed scored. The \nsix items were summed and then averaged to form a scale. Higher total scores reflect \ngreater resilience. The scale is a well-validated measure of resilience that is widely \nused and consistently demonstrates good to excellent reliability (McKay et  al., 2021; \nSánchez et  al., 2021; Smith et  al., 2008; Windle et  al., 2011). Cronbach’s alpha was .87 \nin the current study.\nAnalyses\nPrior to analysis, normality assumptions were checked for each variable. Number of \nsymptoms, years since diagnosis, and diagnostic delay were skewed and/or had high \nkurtosis and were therefore log transformed. Following descriptive and correlational \nanalyses, the PR oCESS macro for SPSS by Hayes ( 2018) was used to run mediation \n\nPSyCHoL oGy & HEALTH 1485\nanalyses with 10,000 bias-corrected bootstrap samples. Separate analyses were run \nfor the EHP-30 Core summed scale and each of the Core subscales (i.e. pain, control \nand powerlessness, emotional wellbeing, social support, self-image) as dependent \nvariables. In these analyses, self-compassion was the predictor variable, and perceived \nsymptom severity and resilience, the mediator variables (Model 4 in PR oCESS). Age, \nlevel of education, and number of symptoms reported were consistently and signifi -\ncantly related to the EHP-30 Core subscales and Core summed scale (see Table 2 ) \nand were therefore included as covariates in the analyses. Although number of symp -\ntoms reported and perceived severity of symptoms were highly correlated ( r = .73), \nnone of the variance inflation factors in the multiple regression analyses exceeded \n2.5. Analyses with the EHP-30 Modules are reported in the Supplementary Material .\nResults\nDescriptive analyses\nDemographic and endometriosis-related information is presented in Table 1. Participants \nin the study predominantly identified as female (98.5%), were of European ethnicity \n(83.6%), and were on average 29 years old ( SD = 6.8). The majority was educated \nbeyond secondary school level (62.7%) and most were employed, either full-time \nTable 2.  c orrelations and descriptive statistics for the key variables in the study.\n1 2 3 4 5 6 7 8 9\n1. Pain 1.00\n2. c ontrol and \npowerlessness\n.79*** 1.00\n3. emotional \nwellbeing\n.66*** .69*** 1.00\n4. s ocial support .61*** .72*** .66*** 1.00\n5. s elf-image .56*** .61*** .58*** .69*** 1.00\n6. ehP-30 c ore \nsum\n.83*** .89*** .83*** .87*** .83*** 1.00\n7. s elf-compassion −.22*** −.30*** −.46*** −.38*** −.34*** −.40*** 1.00\n8. Resilience −.17*** −.26*** −.36*** −.24*** −.22*** −.29*** .53*** 1.00\n9. s ymptom \nseverity\n.47*** .43*** .39*** .37*** .39*** .48*** −.16** −.13** 1.00\n10 Number of \nsymptoms\n.21*** .20*** .22*** .24*** .25*** .27** −.08 −.02 .73***\n11. a ge −.28*** −.23*** −.23*** −.17*** −.17*** −.25*** .19*** .14*** −.08\n12. e ducation −.27*** −.23*** −.29*** −.23*** −.18*** −.28*** .17*** .21*** −.15**\n13. e thnicity .12** .07 .09* .11** .14*** .12** −.02 −.01 .07\n14. Diagnosis .05 .01 .05 .03 .01 .03 .05 −.03 −.02\n15. y ears since \ndiagnosis\n−.12** −.17*** −.07 −.12** −.13*** −.14*** .07 .07 .05\n16. Diagnostic \ndelay\n.06 .11** −.01 .13*** .12** .10* −.01 −.04 .12**\nM 50.23 61.45 49.67 58.73 62.23 56.49 2.74 3.02 2.01\nSD 20.69 24.38 21.08 25.79 27.22 20.21 0.61 0.79 0.42\nRange 0–100 0–100 0–100 0–100 0–100 0–100 1–5 1–5 0–3\nN 601 602 602 601 601 599 602 602 603\nNote: ethnicity: 1 = e uropean, 2 = non-e uropean; Diagnosis: 1 = laparoscopy, 2 = other. ehP-30 c ore sum = summary \nscore of the five ehP-30 c ore subscales (pain, control and powerlessness, emotional wellbeing, social support, \nself-image) combined.\n*p < .05.\n**p < .01.\n***p < .001.\n\n1486 C. M. SKINNER AND R. G. KUIJER\n(43.9%) or part-time (24.2%). The vast majority of participants were diagnosed via \nlaparoscopic surgery (90.2%) and the average time since diagnosis was 6.5  years \n(SD = 5.5). More than half of the sample (54.0%) waited more than 5  years to receive \na diagnosis. Participants reported experiencing on average 6.8 (out of 8; SD = 1.02) \ncommon endometriosis symptoms with some of the symptoms reported by nearly \nall individuals in the sample (e.g. pain with periods, bowel problems, tiredness/low \nenergy, see Table 1 ). on average, participants reported the symptoms to be of mod -\nerate severity ( M = 2.01, SD = 0.42).\nTable 2  displays the correlations and descriptive statistics for the key variables in \nthe study. Mean scores on the EHP-Core subscales ranged from 49.67 to 62.23 with \nleast impairment reported on the emotional wellbeing subscale and highest impair -\nment on the self-image subscale. Mean scores on the EHP-Modules ranged from 41.57 \nto 77.55 ( Supplementary Material ) with least impairment reported on the relationship \nwith children scale and most impairment on the infertility scale. For all subscales \n(Core and Modules), the average scores exceeded 40 indicating at least moderate \nimpairment on all subscales.\nParticipants with higher levels of self-compassion and resilience reported significantly \nless impairment on the EHP-30 Core summed scale and each of the Core subscales. \nThey also perceived their symptoms to be less severe, although these correlations were \nsmall. Participants who reported experiencing more symptoms and who perceived those \nsymptoms to be more severe reported higher levels of impairment on quality of life \n(EHP-30 Core summed scale and subscales). older participants and participants with \nhigher education reported less impairment on quality of life (EHP-30 Core summed \nscale and subscales). They also reported higher levels of self-compassion and resilience. \nThere were a few significant but small correlations (all <.18) between ethnicity, years \nsince diagnosis, and quality of life, with non-European participants and participants \nwho had been diagnosed a shorter time ago reporting more impairment on the EHP-30 \nCore summed scale and some of the Core subscales. Finally, longer diagnostic delay \nwas significantly related to higher impairment on some of the Core subscales and \nhigher perceived severity of symptoms although these correlations were very small (all \n<.14). Correlations with the EHP-Modules showed a similar pattern although not all \ncorrelations were significant due to reduced power (see Supplementary Material ).\nMediation analyses\nTable 3 presents the findings of the mediation analyses for the EHP-30 Core subscales \nand summed scale. In each analysis, age, education, and number of symptoms reported \nwere controlled for. Self-compassion was found to be a significant predictor of per -\nceived severity of symptoms and resilience (X → M in Table 3 ). Self-compassion and \nthe covariates explained 55% of the variance in perceived severity of symptoms and \n29% of the variance in resilience. Perceived severity of symptoms mediated the rela -\ntionship between self-compassion and the EHP-30 Core summed scale and all five \nsubscales (i.e. none of the confidence intervals for the indirect effect of perceived \nseverity of symptoms included zero, and the M → y paths for severity of symptoms \nwere all significant). Resilience mediated the relationship between self-compassion \nand the subscales control and powerlessness and emotional wellbeing (i.e. the \n\nPSyCHoL oGy & HEALTH 1487\nTable 3.  Mediation analyses of self-compassion and ehP-30 c ore subscales and ehP-30 c ore summed scale.\ntotal effect Direct effect Indirect effect\nb 95% cI b 95% cI b 95% cI X → M M → y\nehP-30 c ore sum −10.67*** [−12.99, −8.34] −8.56*** [−11.04, −6.08] total −2.11 [−3.58, −0.64]\n(R2 = .39***) M1 −1.22 [−2.15, −0.35] −0.05** 22.82***\nM2 −0.88 [−2.08, 0.32] 0.64*** −1.38\nPain −4.48*** [−7.01, −1.95] −2.89*** [−5.54, −0.24] total −1.59 [−3.24, −0.03]\n(R2 = .33***) M1 −1.52 [−2.65, −0.49] −0.05** 28.29***\nM2 −0.11 [−1.34, 1.20] 0.65*** −0.11\nc ontrol and power −9.05*** [−12.05, −6.05] −5.90*** [−9.12, −2.68] total −3.15 [−5.14, −1.31]\n(R2 = .29***) M1 −1.52 [−2.68, −0.45] −0.05** 28.52***\nM2 −1.64 [−3.28, −0.08] 0.65*** −2.52*\nemotional WB −13.37*** [−15.76, −10.99] −10.47*** [−13.10, −7.83] total −2.91 [−4.50, −1.42]\n(R2 = .36***) M1 −0.90 [−1.63, −0.27] −0.05** 16.86***\nM2 −2.01 [−3.43, −0.71] 0.65*** −3.11**\ns ocial support −13.58*** [−16.65, −10.50] −12.14*** [−15.60, −8.68] total −1.43 [−3.36, 0.49]\n(R2 = .26***) M1 −0.99 [−1.85, −0.28] −0.05** 18.67***\nM2 −0.44 [−2.22, 1.34] 0.65*** −0.68\ns elf-image −12.98*** [−16.28, −9.69] −11.45*** [−15.15, −7.75] total −1.54 [−3.54, 0.48]\n(R2 = 25***) M1 −1.17 [−2.15, −0.36] −0.05** 22.06***\nM2 −0.36 [−2.18, 1.49] 0.65*** −0.56\nNote: M1 = perceived symptom severity, M2 = resilience. Number of bootstrap samples = 10,000. a nalyses controlled for age, education and number of symptoms. ehP-30 c ore \nsum = summary score of the five ehP-30 c ore subscales combined.\n*p < .05.\n**p < .01.\n***p < .001.\n\n1488 C. M. SKINNER AND R. G. KUIJER\nconfidence intervals for the indirect effect of resilience did not include zero, and the \nM → y paths for resilience were significant). The amount of variance explained in the \ndependent variables ranged from 25% (self-image subscale) to 39% (EHP-30 Core \nsummed scale; see Table 3 ). The direct effect of self-compassion on impairment in \nquality of life (EHP-30 Core summed scale and subscales) remained significant for all \ndependent variables indicating that mediation was partial rather than full.\nTo illustrate, the mediation model of self-compassion and the EHP-30 Core summed \nscale is depicted in Figure 1. Participants with higher levels of self-compassion reported \nless impairment in quality of life and this relationship was partly mediated by per -\nceived severity of symptoms: Participants with higher levels of self-compassion per -\nceived their symptoms to be less severe which was in turn related to less impairment \nin quality of life. The findings for the pain, social support, and self-image subscales \nwere similar and are therefore not depicted.\nFor two of the EHP-30 subscales (emotional wellbeing and control and powerless -\nness), both perceived symptom severity and resilience mediated the relationship \nbetween self-compassion and quality of life. To illustrate, the findings for impairment \nin emotional wellbeing are presented in Figure 2 : Participants with higher levels of \nself-compassion perceived their symptoms to be less severe and reported higher \nlevels of resilience which in turn were both related to less impairment in emotional \nwellbeing.\nAnalyses with the EHP-30 Modules as the dependent variables found similar results: \nsymptom severity was found to be a consistent mediator in the relationship between \nself-compassion and the EHP-30 Modules, whereas resilience was a significant mediator \nfor one subscale only (treatment module; see Supplementary Material ).\nDiscussion\nThe current study showed that all aspects of HRQoL were impaired in individuals \nwith endometriosis in Aotearoa New Zealand. In line with previous international \nresearch, dimensions most strongly impaired were control and powerlessness, sexual \nintercourse, and fertility (e.g. Chaman-Ara et al., 2017; Chauvet et al., 2017; Sullivan-Myers \nFigure 1. Mediation model of self-compassion and the ehP-30 c ore summed scale (summary score \nof the five ehP- c ore subscales combined). a ge, education and number of symptoms were included \nas covariates. Unstandardised estimates are reported. Unmediated direct effect in parentheses. \n**p < .01. ***p < .001.\n\nPSyCHoL oGy & HEALTH 1489\net  al., 2021). In the current study, high impairment was also found on the self-image \ndimension. Although this dimension seems to be less impaired in other samples \n(Chaman-Ara et  al., 2017; Chauvet et  al., 2017; Soliman et  al., 2020), our findings are \nin line with recent findings from Australia (Sullivan-Myers et  al., 2021, 2023; see \nSupplementary Material ). The meta-analysis by Chaman-Ara et  al. ( 2017) included \npapers published between 2001 and 2015. Increased impairment on the self-image \ndimension may in part reflect changes over time, for example, due to increases in \nsocial media use and the associated negative effects on body image (akin to self-image; \nde Valle et  al., 2021). Another explanation may lie in cultural differences. For example, \nRodgers et  al. ( 2011) found that Australian students reported perceiving more peer \nand media influence regarding physical appearance, higher levels of appearance \ncomparison, and higher levels of internalisation of media ideals than French students. \nMoreover, a meta-analysis by Saiphoo and Vahedi ( 2019) showed that the link between \nsocial media use and body dissatisfaction was stronger in Australia compared to other \ncountries (Saiphoo & Vahedi, 2019). Australia is geographically close to Aotearoa New \nZealand and the two countries share similar cultural values which may explain the \nhigher scores on the self-image dimension in the current sample.\nParticipants in the current study also reported high impairment on the treatment \ndimension (assessing satisfaction with treatment). The latter may reflect the fact that \nthere are numerous barriers to accessing health care and treatment for endometriosis \nin Aotearoa New Zealand (Tewhaiti-Smith et  al., 2022).\nThe main purpose of the current study was to examine the relationship between \nself-compassion and HRQoL and shed light on the possible mechanisms through \nwhich self-compassion may influence HRQoL in individuals with endometriosis. As \npredicted, self-compassion was significantly related to quality of life: Individuals \nwith higher levels of self-compassion reported less impairment on all dimensions \nof HRQoL in the current study. These findings add to the small number of studies \nthat have examined the link between self-compassion and psychological wellbeing \nin individuals with endometriosis (Sullivan-Myers et  al., 2023; Van Niekerk et  al., \n2022, 2023) and support findings from the wider literature that self-compassion \nmay be an important resource for people coping with chronic health conditions \n(Sirois & Rowse, 2016).\nFigure 2.  Mediation model of self-compassion and the ehP-30 emotional Wellbeing subscale. a ge, \neducation, and number of symptoms were included as covariates. Unstandardised estimates are \nreported. Unmediated direct effect in parentheses. ** p < .01. ***p < .001.\n\n1490 C. M. SKINNER AND R. G. KUIJER\nThis study suggests that one way through which individuals with high \nself-compassion may cope better is through rating their symptoms as less severe. \nPerceived symptom severity was found to partially mediate the relationship between \nself-compassion and all core aspects of HRQoL (and some of the modules—see \nSupplementary Material ). Importantly, the number of symptoms reported was con -\ntrolled for in these analyses. These findings are in line with research showing that \nhigher self-compassion is related to less pain catastrophising and higher pain accep -\ntance in individuals with chronic pain (Edwards et  al., 2019; Wren et  al., 2012). \nSelf-compassion entails being non-judgemental and kind to oneself, and not ove -\nridentifying with painful thoughts and experiences (Neff, 2003a, 2023), both of which \nmay reduce pain interference and foster maintenance of quality of life despite expe -\nriencing pain.\nLess consistent support was found for resilience as a mediator. Although this study \nfound a strong relationship between self-compassion and resilience as seen in other \nstudies (see Bag et  al., 2022; Bluth et  al., 2018; Nery-Hurwit et  al., 2018) and a sig -\nnificant relationship between resilience and all aspects of HRQoL in the bivariate \nanalyses (i.e. correlations), resilience was only found to mediate the relationship \nbetween self-compassion and two of the core aspects of HRQoL: control/powerlessness \nand emotional wellbeing. These findings are not in line with Nery-Hurwit et  al ( 2018) \nwho found that resilience mediated the link between self-compassion and a composite \nHRQoL score (assessing physical, mental and social health) in individuals with multiple \nsclerosis. However, Nery-Hurwit et  al ( 2018) only examined one mediator (resilience) \nin isolation. It is possible that perceived severity of symptoms is a more robust medi -\nator than resilience. Another possibility is that high resilience is more beneficial for \npsychological aspects of quality of life than for physical or social aspects. Indeed, \nresearch in individuals with chronic conditions other than endometriosis has shown \nthat resilience tends to be more strongly related to the mental health aspects of \nquality of life than physical aspects (e.g. Harms et  al., 2019; Taylor et al, 2018). Key \naspects of resilience are cognitive flexibility (e.g. using more adaptive coping, including \npositive reappraisal and acceptance and less maladaptive coping, including rumina -\ntion), and experiencing more positive and less negative affects (Southwick et  al., 2005) \nall of which may be more strongly related to indicators of emotional wellbeing and \nfeelings of lack of control and powerlessness than other aspects of HRQoL. Future \nresearch, preferably longitudinal, is needed to examine whether perceived severity of \nsymptoms is a more robust mediator than resilience in the relation between \nself-compassion and HRQoL in individuals with endometriosis. In addition, the current \nstudy assumed that higher self-compassion was related to lower perceived severity \nof symptoms due to less pain catastrophising and/or more pain acceptance. However, \nfuture research should formally examine these constructs as potential mediators.\nAnother finding worth mentioning is, that in line with previous research, individuals \nwho reported experiencing more symptoms and perceived these symptoms to be \nmore severe, reported higher impairment on HRQoL (EHP-30 Core summed scale and \nall subscales; e.g. Soliman et  al., 2017, 2020; Tewhaiti-Smith et  al., 2022). This highlights \nthat it is not the presence of endometriosis lesions themselves that impairs quality \nof life but rather the symptoms experienced due to having endometriosis (Facchin \net  al., 2015).\n\nPSyCHoL oGy & HEALTH 1491\nThis study had several strengths. It had a large sample size and used a validated \nmeasure of quality of life. It also added more knowledge about individuals living with \nendometriosis in Aotearoa New Zealand where there is currently little existing research. \nThe study also had some limitations. Firstly, the sample was recruited via social media \nplatforms which may have introduced selection bias. Individuals experiencing more \nsevere endometriosis symptomatology may be more likely to seek information on the \ninternet and follow endometriosis organisations, resulting in an overrepresentation \nof individuals experiencing high impairment (De Graaff et  al., 2015). The current \nsample reported on average higher impairment than samples recruited via secondary \nand tertiary care centres (Chaman-Ara et  al., 2017), but similar levels of impairment \nto samples recruited via social media and endometriosis organisations (Chauvet et  al., \n2017; Sullivan-Myers et  al., 2021; see Supplementary Material ). De Graaff et  al. ( 2015) \npoint out that samples recruited via tertiary and secondary care providers are probably \nnot representative either. This may be especially relevant for Aotearoa New Zealand \nwhere there are numerous barriers to accessing health care for endometriosis \n(Tewhaiti-Smith et  al., 2022). Secondly, information about endometriosis diagnosis \nwas self-reported, rather than being verified against medical records. Moreover, whilst \nthe number was small, some participants did not have a diagnosis through laparo -\nscopic surgery which is the only way to confirm an endometriosis diagnosis. Thirdly, \nsimilar to the few other studies that have looked at self-compassion and HRQoL in \nendometriosis, the current study was cross-sectional which limits the ability to deter -\nmine causality. Finally, although the EHP-30 is a well-validated scale, a limitation is \nthat it is based on the last 4  weeks which may not accurately reflect the impact of \nendometriosis on quality of life. Future research should measure endometriosis symp -\ntoms and quality of life daily to determine whether day-to-day variability in symptoms \ncovaries with changes in quality of life.\nThe current findings suggest that self-compassion may be a relevant area for \nintervention in individuals with endometriosis. Self-compassion interventions have \nbeen successful in reducing stress, anxiety, and depression in the general popula -\ntion (Ferrari et  al., 2019; Neff & Germer, 2013; Sommers-Spijkerman et  al., 2018) \nand in those with chronic health conditions, including chronic pain (Austin et  al., \n2021 ; Kılıç et  al., 2021 ). In addition to reductions in depression and anxiety, a \nmixed-method review of compassion-based interventions (e.g. Mindful \nSelf-Compassion, Compassion-Focused Therapy) for individuals with chronic health \nconditions found that many participants reported improvements in acceptance of \ntheir condition/pain, increased emotion regulation skills and reduced feelings of \nisolation (Austin et  al., 2021). A recent study by Torrijos-Zarcero et  al. ( 2021) found \nthat Mindful Self-Compassion (an 8-week protocol-standardised intervention \ndesigned by Neff & Germer, 2013) improved levels of self-compassion, pain accep -\ntance, pain interference, catastrophising and anxiety in individuals with chronic \npain. The programme outperformed the comparison condition (Cognitive Behaviour \nTherapy) on all measures. Given the high levels of impairment in self-image in the \ncurrent sample, a self-compassionate writing intervention focussed on body \nimage-related issues originally developed for breast cancer patients may also be \nrelevant (Sherman et  al., 2018 ). As quality of life is shown to be impaired and \naccess to treatment in Aotearoa New Zealand has its challenges (Tewhaiti-Smith \n\n1492 C. M. SKINNER AND R. G. KUIJER\net  al., 2022), further research is needed to determine the role that self-compassion \n(including compassion-based interventions) could play as a protective factor in \nmanaging the debilitating pain and other symptoms that come with \nendometriosis.\nDisclosure statement\nThe authors report there are no competing interests to declare.\nFunding\nA PhD scholarship funded by Lottery Health Research, New Zealand, was awarded to the \nfirst author.\nData availability statement\nThe data that support the findings of this study are available on request from the corresponding \nauthor. The data is not publicly available due to ethical restrictions.\nReferences\nAdamson, G. D., Kennedy, S., & Hummelshoj, L. ( 2010). Creating solutions in endometriosis: \nGlobal collaboration through the World Endometriosis Research Foundation. Journal of \nEndometriosis , 2(1), 3–6. https://doi.org/10.1177/228402651000200102\nAsensio-Martínez, Á., oliván-Blázquez, B., Montero-Marín, J., Masluk, B., Fueyo-Díaz, R., \nGascón-Santos, S., Gudé, F., Gónzalez-Quintela, A., García-Campayo, J., & Magallón-Botaya, R. \n(2019). Relation of the psychological constructs of resilience, mindfulness, and self-compassion \non the perception of physical and mental health. Psychology Research and Behavior \nManagement, 12, 1155–1166. https://doi.org/10.2147/PRBM.S225169\nAustin, J., Drossaert, C. H. C., Schroevers, M. J., Sanderman, R., Kirby, J. N., & Bohlmeijer, E. T. \n(2021). Compassion-based interventions for people with long-term physical conditions: A \nmixed methods systematic review. Psychology & Health , 36(1), 16–42. https://doi.org/10.1080\n/08870446.2019.1699090\nBag, S. D., Kilby, C. J., Kent, J. N., Brooker, J., & Sherman, K. A. ( 2022 ). Resilience, \nself-compassion, and indices of psychological wellbeing: A not so simple set of relation -\nships. Australian Psychologist , 57(4), 249–257. https://doi.org/10.1080/00050067.2022.208\n9543\nBecker, C. M., Gattrell, W. T., Gude, K., & Singh, S. S. ( 2017). Reevaluating response and failure \nof medical treatment of endometriosis: A systematic review. Fertility and Sterility , 108(1), \n125–136. https://doi.org/10.1016/j.fertnstert.2017.05.004\nBluth, K., Mullarkey, M., & Lathren, C. ( 2018). Self-compassion: A potential path to adolescent \nresilience and positive exploration. Journal of Child and Family Studies , 27(9), 3037–3047. \nhttps://doi.org/10.1007/s10826-018-1125-1\nBourdel, N., Chauvet, P ., Billone, V., Douridas, G., Fauconnier, A., Gerbaud, L., & Canis, M. ( 2019). \nSystematic review of quality of life measures in patients with endometriosis. PloS One , 14(1), \ne0208464. https://doi.org/10.1371/journal.pone.0208464\nChaman-Ara, K., Bahrami, M. A., Moosazadeh, M., & Bahrami, E. ( 2017). Quality of life in wom -\nen with endometriosis: A systematic review and meta-analysis. World Cancer Research Journal , \n4(1), e839. https://doi.org/10.32113/wcrj_20173_839\nChauvet, P ., Auclair, C., Mourgues, C., Canis, M., Gerbaud, L., & Bourdel, N. ( 2017). Psychometric \nproperties of the French version of the Endometriosis Health Profile-30, a health-related \n\nPSyCHoL oGy & HEALTH 1493\nquality of life instrument. Journal of Gynecology Obstetrics and Human Reproduction , 46(3), \n235–242. https://doi.org/10.1016/j.jogoh.2017.02.004\nCulley, L., Law, C., Hudson, N., Denny, E., Mitchell, H., Baumgarten, M., & Raine-Fenning, N. ( 2013). \nThe social and psychological impact of endometriosis on women’s lives: A critical narrative \nreview. Human Reproduction Update , 19(6), 625–639. https://doi.org/10.1093/humupd/dmt027\nDe Graaff, A. A., D’Hooghe, T. M., Dunselman, G. A. J., Dirksen, C. D., Hummelshoj, L., WERF \nEndoCost Consortium, Simoens, S., Bokor, A., Brandes, I., Brodszky, V., Canis, M., Colombo, G. \nL., DeLeire, T., Falcone, T., Graham, B., Halis, G., Horne, A. W., Kanji, o ., Kjer, J. J., … Wullschleger, \nM. ( 2013). The significant effect of endometriosis on physical, mental, and social wellbeing: \nResults from an international cross-sectional survey. Human Reproduction , 28(10), 2677–2685. \nhttps://doi.org/10.1093/humrep/det284\nDe Graaff, A. A., Dirksen, C. D., Simoens, S., De Bie, B., Hummelshoj, L., D’Hooghe, T. M., & \nDunselman, G. A. J. ( 2015). Quality of life outcomes in women with endometriosis are high -\nly influenced by recruitment strategies. Human Reproduction , 30(6), 1331–1341. https://doi.\norg/10.1093/humrep/dev084\nde Valle, M. K., Gallego-García, M., Williamson, P ., & Wade, T. D. ( 2021). Social media, body \nimage, and the question of causation: Meta-analyses of experimental and longitudinal evi -\ndence. Body Image , 39, 276–292. https://doi.org/10.1016/j.bodyim.2021.10.001\nEdwards, K. A., Pielech, M., Hickman, J., Ashworth, J., Sowden, G., & Vowles, K. E. ( 2019). The \nrelation of self-compassion to functioning among adults with chronic pain. European Journal \nof Pain , 23(8), 1538–1547. https://doi.org/10.1002/ejp.1429\nEwert, C., Vater, A., & Schröder-Abé, M. ( 2021). Self-compassion and coping: A meta-analysis. \nMindfulness, 12(5), 1063–1077. https://doi.org/10.1007/s12671-020-01563-8\nFacchin, F., Barbara, G., Saita, E., Mosconi, P ., Roberto, A., Fedele, L., & Vercellini, P . ( 2015). Impact \nof endometriosis on quality of life and mental health: Pelvic pain makes the difference. \nJournal of Psychosomatic Obstetrics and Gynaecology , 36(4), 135–141. https://doi.org/10.3109\n/0167482X.2015.1074173\nFerrari, M., Hunt, C., Harrysunker, A., Abbott, M. J., Beath, A. P ., & Einstein, D. A. ( 2019). \nSelf-compassion interventions and psychosocial outcomes: A meta-analysis of RCTs. Mindfulness, \n10(8), 1455–1473. https://doi.org/10.1007/s12671-019-01134-6\nFerrero, S., Evangelisti, G., & Barra, F. ( 2018). Current and emerging treatment options for en -\ndometriosis. Expert Opinion on Pharmacotherapy , 19(10), 1109–1125. https://doi.org/10.1080/\n14656566.2018.1494154\nHarms, C. A., Cohen, L., Pooley, J. A., Chambers, S. K., Galvão, D. A., & Newton, R. U. ( 2019). \nQuality of life and psychological distress in cancer survivors: The role of psycho-social re -\nsources for resilience. Psycho-oncology , 28(2), 271–277. https://doi.org/10.1002/pon.4934\nHayes, A. F. ( 2018). PR oCESS. https://www.processmacro.org/index.html\nJones, G., Kennedy, S., Barnard, A., Wong, J., & Jenkinson, C. ( 2001). Development of an endo -\nmetriosis quality-of-life instrument: The Endometriosis Health Profile-30. Obstetrics and \nGynecology, 98(2), 258–264. https://doi.org/10.1016/S0029-7844(01)01433-8\nKennedy, S., Bergqvist, A., Chapron, C., D’Hooghe, T., Dunselman, G., Greb, R., Hummelshoj, L., \nPrentice, A., & Saridogan, E. ( 2005). ESHRE guideline for the diagnosis and treatment of \nendometriosis. Human Reproduction, 20(10), 2698–2704. https://doi.org/10.1093/humrep/dei135\nKılıç, A., Hudson, J., McCracken, L. M., Ruparelia, R., Fawson, S., & Hughes, L. D. ( 2021). A sys -\ntematic review of the effectiveness of self-compassion-related interventions for individuals \nwith chronic physical health conditions. Behavior Therapy , 52(3), 607–625. https://doi.\norg/10.1016/j.beth.2020.08.001\nLubián-López, D. M., Moya-Bejarano, D., Butrón-Hinojo, C. A., Marín-Sánchez, P ., Blasco-Alonso, \nM., Jiménez-López, J. S., Villegas-Muñoz, E., & González-Mesa, E. ( 2021). Measuring resilience \nin women with endometriosis. Journal of Clinical Medicine , 10(24), 5942. https://doi.org/10.3390/\njcm10245942\nMarsh, I. C., Chan, S. W. y., & MacBeth, A. ( 2018). Self-compassion and psychological distress in \nadolescents- A meta-analysis. Mindfulness , 9(4), 1011–1027. https://doi.org/10.1007/\ns12671-017-0850-7\n\n1494 C. M. SKINNER AND R. G. KUIJER\nMcKay, S., Skues, J. L., & Williams, B. J. ( 2021). Does the Brief Resilience Scale actually measure \nresilience and succumbing? Comparing artefactual and substantive models. Advances in \nMental Health , 19(2), 192–201. https://doi.org/10.1080/18387357.2019.1688667\nMcPeak, A. E., Allaire, C., Williams, C., Albert, A., Lisonkova, S., & yong, P . J. ( 2018). Pain cata -\nstrophizing and pain health-related quality-of-life in endometriosis. The Clinical Journal of \nPain, 34(4), 349–356. https://doi.org/10.1097/AJP .0000000000000539\nMedvedev, o . N., Dailianis, A. T., Hwang, y.-S., Krägeloh, C. U., & Singh, N. N. ( 2021). Applying \ngeneralizability theory to the self-compassion scale to examine state and trait aspects and \ngeneralizability of assessment scores. Mindfulness , 12(3), 636–645. https://doi.org/10.1007/\ns12671-020-01522-3\nMinistry of Health. ( 2017). HISo 10001: 2017 ethnicity data protocols. Ministry of Health. https://\nwww.health.govt.nz/system/files/documents/publications/hiso_10001-2017_ethnicity_  \ndata_protocols_21_apr.pdf\nNeff, K. D. ( 2003a). The development and validation of a scale to measure self-compassion. Self \nand Identity , 2(3), 223–250. https://doi.org/10.1080/15298860309027\nNeff, K. D. ( 2003b). Self-compassion: An alternative conceptualization of a healthy attitude \ntoward oneself. Self and Identity , 2(2), 85–101. https://doi.org/10.1080/15298860309032\nNeff, K. D. ( 2023). Self-compassion: Theory, method, research, and intervention. Annual Review \nof Psychology , 74(1), 193–218. https://doi.org/10.1146/annurev-psych-032420-031047\nNeff, K. D., & Germer, C. K. ( 2013). A pilot study and randomized controlled trial of the Mindful \nSelf-Compassion program. Journal of Clinical Psychology , 69(1), 28–44. https://doi.org/10.1002/\njclp.21923\nNery-Hurwit, M., yun, J., & Ebbeck, V. ( 2018). Examining the roles of self-compassion and resil -\nience on health-related quality of life for individuals with multiple sclerosis. Disability and \nHealth Journal , 11(2), 256–261. https://doi.org/10.1016/j.dhjo.2017.10.010\nPinto-Gouveia, J., Duarte, C., Matos, M., & Fráguas, S. ( 2014). The protective role of self-compassion \nin relation to psychopathology symptoms and quality of life in chronic and in cancer patients. \nClinical Psychology & Psychotherapy , 21(4), 311–323. https://doi.org/10.1002/cpp.1838\nPrentice, K., Rees, C., & Finlay-Jones, A. ( 2021). Self-compassion, wellbeing, and distress in ad -\nolescents and young adults with chronic medical conditions: The mediating role of emotion \nregulation difficulties. Mindfulness, 12(9), 2241–2252. https://doi.org/10.1007/s12671-021-01685-7\nRaes, F., Pommier, E., Neff, K. D., & Van Gucht, D. ( 2011). Construction and factorial validation \nof a short form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy , 18(3), \n250–255. https://doi.org/10.1002/cpp.702\nRodgers, R., Chabrol, H., & Paxton, S. J. ( 2011). An exploration of the tripartite influence mod -\nel of body dissatisfaction and disordered eating among Australian and French college wom -\nen. Body Image , 8(3), 208–215. https://doi.org/10.1016/j.bodyim.2011.04.009\nRomaniuk, A., & oniszczenko, W. ( 2023). Resilience, anxiety, depression, and life satisfaction in \nwomen suffering from endometriosis: A mediation model. Psychology, Health & Medicine , \n28(9), 2450–2461. https://doi.org/10.1080/13548506.2023.2197649\nRowlands, I. J., Abbott, J. A., Montgomery, G. W., Hockey, R., Rogers, P ., & Mishra, G. D. ( 2021). \nPrevalence and incidence of endometriosis in Australian women: A data linkage cohort study. \nBJOG: An International Journal of Obstetrics and Gynaecology , 128(4), 657–665. https://doi.\norg/10.1111/1471-0528.16447\nSaiphoo, A. N., & Vahedi, Z. ( 2019). A meta-analytic review of the relationship between social \nmedia use and body image disturbance. Computers in Human Behavior , 101, 259–275. https://\ndoi.org/10.1016/j.chb.2019.07.028\nSánchez, J., Estrada-Hernández, N., Booth, J., & Pan, D. ( 2021). Factor structure, internal reliabil -\nity, and construct validity of the Brief Resilience Scale (BRS): A study on persons with serious \nmental illness living in the community. Psychology and Psychotherapy , 94(3), 620–645. https://\ndoi.org/10.1111/papt.12336\nSherman, K. A., Przezdziecki, A., Alcorso, J., Kilby, C. J., Elder, E., Boyages, J., Koelmeyer, L., & \nMackie, H. ( 2018). Reducing body image-related distress in women with breast cancer using \na structured online writing exercise: Results from the My Changed Body randomized con -\n\nPSyCHoL oGy & HEALTH 1495\ntrolled trial. Journal of Clinical Oncology: Official Journal of the American Society of Clinical \nOncology, 36(19), 1930–1940. https://doi.org/10.1200/JC o .2017.76.3318\nSirois, F. M., Molnar, D. S., & Hirsch, J. K. ( 2015). Self-compassion, stress, and coping in the \ncontext of chronic illness. Self and Identity , 14(3), 334–347. https://doi.org/10.1080/1529886\n8.2014.996249\nSirois, F. M., & Rowse, G. ( 2016). The role of self-compassion in chronic illness care. Journal of \nClinical Outcomes Management , 23(11), 521–527.\nSmith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P ., & Bernard, J. ( 2008). The Brief \nResilience Scale: Assessing the ability to bounce back. International Journal of Behavioral \nMedicine, 15(3), 194–200. https://doi.org/10.1080/10705500802222972\nSoliman, A. M., Coyne, K. S., Zaiser, E., Castelli-Haley, J., & Fuldeore, M. J. ( 2017). The burden of \nendometriosis symptoms on health-related quality of life in women in the United States: A \ncross-sectional study. Journal of Psychosomatic Obstetrics and Gynaecology , 38(4), 238–248. \nhttps://doi.org/10.1080/0167482X.2017.1289512\nSoliman, A. M., Singh, S., Rahal, y., Robert, C., Defoy, L., Nisbet, P ., & Leyland, N. ( 2020). \nCross-sectional survey of the impact of endometriosis symptoms on health-related quality \nof life in Canadian women. Journal of Obstetrics and Gynaecology Canada , 42(11), 1330–1338. \nhttps://doi.org/10.1016/j.jogc.2020.04.013\nSommers-Spijkerman, M. P . J., Trompetter, H. R., Schreurs, K. M. G., & Bohlmeijer, E. T. ( 2018). \nCompassion-focused therapy as guided self-help for enhancing public mental health: A \nrandomized controlled trial. Journal of Consulting and Clinical Psychology , 86(2), 101–115. \nhttps://doi.org/10.1037/ccp0000268\nSouthwick, S. M., Vythilingam, M., & Charney, D. S. ( 2005). The psychobiology of depression \nand resilience to stress: Implications for prevention and treatment. Annual Review of Clinical \nPsychology, 1(1), 255–291. https://doi.org/10.1146/annurev.clinpsy.1.102803.143948\nSullivan-Myers, C., Sherman, K. A., Beath, A. P ., Cooper, M. J. W., & Duckworth, T. J. ( 2023). Body \nimage, self-compassion, and sexual distress in individuals living with endometriosis. Journal \nof Psychosomatic Research , 167, 111197. https://doi.org/10.1016/j.jpsychores.2023.111197\nSullivan-Myers, C., Sherman, K. A., Beath, A. P ., Duckworth, T. J., & Cooper, M. J. W. ( 2021). \nDelineating sociodemographic, medical and quality of life factors associated with psycho -\nlogical distress in individuals with endometriosis. Human Reproduction , 36(8), 2170–2180. \nhttps://doi.org/10.1093/humrep/deab138\nTaylor, K., Scruggs, P . W., Balemba, o . B., Wiest, M. M., & Vella, C. A. ( 2018). Associations between \nphysical activity, resilience, and quality of life in people with inflammatory bowel disease. \nEuropean Journal of Applied Physiology , 118 (4), 829–836. https://doi.org/10.1007/\ns00421-018-3817-z\nTerry, M. L., & Leary, M. R. ( 2011). Self-compassion, self-regulation, and health. Self and Identity , \n10(3), 352–362. https://doi.org/10.1080/15298868.2011.558404\nTewhaiti-Smith, J., Semprini, A., Bush, D., Anderson, A., Eathorne, A., Johnson, N., Girling, J., \nEast, M., Marriott, J., & Armour, M. ( 2022). An Aotearoa New Zealand survey of the impact \nand diagnostic delay for endometriosis and chronic pelvic pain. Scientific Reports , 12(1), 4425. \nhttps://doi.org/10.1038/s41598-022-08464-x\nTorrijos-Zarcero, M., Mediavilla, R., Rodríguez-Vega, B., Del Río-Diéguez, M., López-Álvarez, I., \nRocamora-González, C., & Palao-Tarrero, Á. ( 2021). Mindful self-compassion program for \nchronic pain patients: A randomized controlled trial. European Journal of Pain , 25(4), 930–944. \nhttps://doi.org/10.1002/ejp.1734\nVan Aken, M. A. W., o osterman, J. M., van Rijn, C. M., Ferdek, M. A., Ruigt, G. S. F., Peeters, B. \nW. M. M., Braat, D. D. M., & Nap, A. W. ( 2017). Pain cognition versus pain intensity in patients \nwith endometriosis: Toward personalized treatment. Fertility and Sterility , 108(4), 679–686. \nhttps://doi.org/10.1016/j.fertnstert.2017.07.016\nVan Niekerk, L., Dell, B., Johnstone, L., Matthewson, M., & Quinn, M. ( 2023). Examining the \nassociations between self and body compassion and health related quality of life in people \ndiagnosed with endometriosis. Journal of Psychosomatic Research , 167, 111202. https://doi.\norg/10.1016/j.jpsychores.2023.111202\n\n1496 C. M. SKINNER AND R. G. KUIJER\nVan Niekerk, L., Johnstone, L., & Matthewson, M. ( 2022). Predictors of self-compassion in en -\ndometriosis: The role of psychological health and endometriosis symptom burden. Human \nReproduction , 37(2), 264–273. https://doi.org/10.1093/humrep/deab257\nVercellini, P ., Fedele, L., Aimi, G., Pietropaolo, G., Consonni, D., & Crosignani, P . G. ( 2007). \nAssociation between endometriosis stage, lesion type, patient characteristics and severity of \npelvic pain symptoms: A multivariate analysis of over 1000 patients. Human Reproduction , \n22(1), 266–271. https://doi.org/10.1093/humrep/del339\nWindle, G., Bennett, K. M., & Noyes, J. ( 2011). A methodological review of resilience measure -\nment scales. Health and Quality of Life Outcomes , 9(1), 8. https://doi.org/10.1186/1477-7525-9-8\nWren, A. A., Somers, T. J., Wright, M. A., Goetz, M. C., Leary, M. R., Fras, A. M., Huh, B. K., Rogers, \nL. L., & Keefe, F. J. ( 2012). Self-compassion in patients with persistent musculoskeletal pain: \nRelationship of self-compassion to adjustment to persistent pain. Journal of Pain and Symptom \nManagement, 43(4), 759–770. https://doi.org/10.1016/j.jpainsymman.2011.04.014\nZessin, U., Dickhäuser, o ., & Garbade, S. ( 2015). The relationship between self-compassion and \nwell-being: A meta-analysis. Applied Psychology: Health and Well-Being , 7(3), 340–364. https://\ndoi.org/10.1111/aphw.12051","source_license":"public-domain-us","license_restricted":false}