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Advances in Social Sciences Research Journal – Vol. 9, No. 1
Publication Date: January 25, 2022
DOI:10.14738/assrj.91.11543. Kasapoglu, A., & Yel, C. (2022). Relational Sociological and Intersectional Research About Pain: The Case of Turkey. Advances in
Social Sciences Research Journal, 9(1). 236-251.
Services for Science and Education – United Kingdom
Relational Sociological and Intersectional Research About Pain:
The Case of Turkey
Dr. Aytul Kasapoglu
Professor of Sociology, Baskent University Department of Sociology
ORCID: https://orcid.org/0000.0002-3456-2947
Dr. Cigdem Yel
Research Assistant, Sivas Cumhuriyet University Department of Sociology
ORCID: https:// orcid.org/ 0000-0001-8392-5399
ABSTRACT
Until recent years, there has been an alternative search for pain, which has been
studied in accordance with the Specificity Theory and the Bio-medical Model.
Among these, the bio-psychosocial model and the relational and intersectionality
approaches compatible with it come first. The Primary aim of this study is to apply
alternative models to the deficiencies of the bio-medical model and to show their
contributions. For this purpose, physical, psychological, cognitive and social factors,
which Gate Control Theory accepts as components of pain, were comparatively
examined based on the life stories of seven participants, four of whom were women,
with an average age of 75 years. In the light of the principles of relational and
intersectional approaches that reject essentialism, focus on uncertainties, and try
to reveal difference and diversity, the findings are discussed with the relevant
current literature. Research findings show that as the participants get older, their
physical problems increase and they experience health problems. While some of the
participants, who are generally alone after the loss of their spouses, live alone, some
of them stay with their children. Since Anatolian traditional culture does not
encourage institutional care much, the disadvantages of living with children, such
as loss of power in subordinate or weaker social status, as well as the advantages of
living with children, carry them to liminal status. It has been observed that the
women in the research are more successful in managing their emotions and
reframing the pain they have suffered better than the men, with the resignation
stemming from the traditional culture as well as the struggles they have fought
throughout their long lives. As a result, it has been tried to contribute to science by
showing the advantages of the holistic view of alternative models, as well as the
deficiencies of the bio-medical model, which is the basis of classical Western
medicine, through examples from outside the West.
Keywords: Pain, Bio-psycho-social Model, Relational Sociology, Intersectionality, Gate
Control Theory, Turkey.
INTRODUCTION
Sociology of health, as a sub-branch of applied sociology, is constantly renewing itself, and as it
is understood from the approaches emerging in medicine and psychology, it both affects and is
affected by them reflexively [1, 2, 3, 4]. In this context, intersectionality [5] and stand point
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Kasapoglu, A., & Yel, C. (2022). Relational Sociological and Intersectional Research About Pain: The Case of Turkey. Advances in Social Sciences
Research Journal, 9(1). 236-251.
URL: http://dx.doi.org/10.14738/assrj.91.11543
theory [6, 7] as well as relational perspective [8,9] are also applied by sociologists in the field
of health.
While the bio-medical model, which also overlaps with classical sociology, and its machine
model based on soul-body duality, were rejected, interest in subjects that had never been
studied before began to increase. It can be said that body sociology is the foremost among them
[10].
Classical sociology's dualist point of view, accepting the separation of soul-body such as society- individual, subject-object delayed body studies. Because, especially by religions, the body is
regarded as mundane and temporary and is ignored. In fact, the inner body is seen as superior
in terms of mind and spirit by making a distinction between inner and outer body. Even though
social change is explained with organismic views that benefit from biology, it does not turn into
a very powerful approach in sociology [11].
In fact, Michel Foucault's [12] view of establishing the relationship between economy and body
by comparing pre-modern and contemporary societies has been widely adopted. According to
him, while monarchs and sovereign power were important in agricultural societies, power
based on discipline became important with industrialization. Both individuals and society were
put under surveillance for the purpose of disciplining. The bodies of individuals have begun to
be disciplined through education and health institutions. It can be said that the importance of
body studies in sociology has increased with the view that individuals are disciplined in
hospitals, prisons and schools in what Foucault calls biopolitics. In fact, there is bio-politics in
the family, in the army, in industrial enterprises such as factories and in the service sector. In
fact, with the emergence of health and care issues in current popular culture, the real object of
the consumer society has started to be bodies. Foucault's [12] process-based bio-policy design
as hierarchical observation, normalizing judgment, and finally examination is still largely
maintained today. Although people are constantly encouraged to do checkups, they internalize
it and see it as normal and even feel guilty when they do not. In fact, the trilogy of knowledge,
technology and control, unfortunately, means controlling people with the information collected
through technology. That's why Foucault's saying "knowledge is power" has a great meaning.
The relational sociologist Norbert Elias [13] and his work titled Civilizing Process can also be
considered a turning point in terms of body sociology. In the process of socialization,
rationalization and individualization, people become civilized. However, civilized bodies are
problematic and the most important reason for this is rationality replacing emotions. In other
words, detachment from emotions and surrender to rationality lead to discomfort by
controlling the bodies. For example, eating, drinking, laughing, belching, blowing, making love
no longer occur freely, but are bound to the rules of courtesy. As a matter of fact, Elias, who
examined the Rules of Courtesy books by years, revealed that social change is mostly related to
the rules brought to the bodies.
More recently, Brian Turner and his Regulating Body [14] are actually inspired by Foucault.12
According to him, primarily reproduction, medical surveillance, restraint and physical
representation are all interventions aimed at regulation of the body. Reproduction provides
sexual control, while restrain controls desires and passions. Therefore, it is among the
important topics of body sociology. However, recently, there are some important studies that
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show that the studies on the body are quite different. These are studies that see the body as a
database, archive and source of bio-information. There is a transformation from bio-power to
bio-value. For example, the work called Visible Human Project is based on examining and
experimenting of the body [15].
THEORETICAL FRAMEWORK
This study was conducted in accordance with the Bio-psycho-social model. The biomedical
model has been criticized since the 1970s. These critics include systems theorists such as
Bertalanffy (1972), new physicists such as Capra (1983) and Wilber (1982), feminists such as
Bordeaux (1987), phenomenological viewers such as Leder (1984), and Soffer (1987) and
Watson, who are included in the holistic literature (1987) are more traditional philosophers
[16].
The Cartesian philosophy, on which the bio-medical model is based, is actually in harmony with
Newtonian physics, reducing the body to mechanistic and organic processes, and most
importantly, separating it from the mind. On the other hand, those who oppose this view today
accept that the mind and biological processes are interdependent. In fact, those who challenged
Cartesian dualism now accept that the individual is not only placed in his social environment,
but that the environment affects certain diseases. The most basic example of this is chronic pain.
Because the subject of chronic pain or suffering is seen as the most important phenomenon in
the test of mind-body duality. The recognition that there are physical and mental diseases that
do not fit the biomedical model and the questioning of the scientific and social responsibility of
medicine and psychiatry have led to the need for a new model search [17]. The first attempts
also came from psychiatrists and one of the first studies corresponding to the need for a holistic
approach was the "Bio-psycho-social" (BPS) Model [1, 2]. BPS mainly deals with both disease
and illness, and considers the mutual and complex interaction of biological, psychological and
social factors. Considering that the main field of study of sociologists is illness rather than
disease, this distinction becomes more important. As it is known, while illness is an objective
biological event, illness is the subjective experience of the patient [10]. To make an analogy
here, nerves transmit a damage in the body to the brain by stimulating it, in other words, when
pain stimuli are perceived, the disease is mentioned. On the other hand, the feeling of pain
subjectively as a result of this warning is illness. Briefly, as seen in this example, while the
damage to the nerves is conceptualized as a disease, the pain suffered in this case is
differentiated using a different concept as illness. In particular, the illness is affected by the
genetic structure of the person, previous learning experiences, current psychological state and
socio-cultural characteristics. The biopsychosocial model has therefore been developed by
psychiatrists working specifically on chronic pain.
In particular, Engel [1,2], who worked as a psychiatrist at Rochester University on chronic pain
and thought that modern medicine and psychiatry are in crisis, studies the subjects of physical
problem, psychological tension, illness behavior and patient role, pain, complaint, suffering
behavior. He made very important contributions by developing a holistic model, which was
later used by sociologists in the sociology of health and illness [18]. According to Engel [1], the
biopsychosocial model includes the interaction of biological, cognitive, bodily, and emotional
processes and their relations with the immune system. In addition, genetic features are the
most fundamental. In other words, biological factors are not ignored but are associated with
psychological factors. In the social dimension, there are activities of daily living, sources of
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Kasapoglu, A., & Yel, C. (2022). Relational Sociological and Intersectional Research About Pain: The Case of Turkey. Advances in Social Sciences
Research Journal, 9(1). 236-251.
URL: http://dx.doi.org/10.14738/assrj.91.11543
environmental tension, interpersonal interaction, family environment, social support and
isolation, social expectations, cultural factors, health insurance, previous treatment processes
and working life. Therefore, the 2000 citations to the work of Engel [1], who is considered the
father of North American psycho-somatic medicine since his first article was published in the
journal Science, can be interpreted as an indication that the traditional biomedical approach is
more inadequate today than it was 30 years ago and has begun to be criticized.
According to Yamada [19], Engel's most important contribution is that he showed that
confusion or difficulty at any level of the hierarchical biopsychosocial system can be effective
at other levels as well. Yamada [19], who cares about the culture, nation state and ecosystem at
the top of his model, studies diabetes in the Marshal Islands and shows that biological
consequences such as ecological destruction, evacuation of the population, weight gain,
metabolic changes and diabetes occur in the island people due to economic dependence. In
other words, it has been clearly demonstrated by this study that social and environmental
factors are effective in the emergence of the disease.
The theoretical background, which has been observed to be applied in a wide area as
intersectionality, which is in harmony with the bio-psycho-social model and relational
sociology [20], is also relevant to our study. In fact, although intersectionality studies date back
to ancient times, it has gained popularity again thanks to BPS and especially those who are
interested in health inequality [21]. The issue of intersectionality arose from movements in
the United States in the 1980s to make laws neutral and objective towards race and therefore
African and Asian immigrants [22]. Because it is clear that domination is created due to
discrimination in the society, especially over gender and race, among the components of the
social stratification system. Because each individual's position within this stratification system
affects his/her life chances as much as his/her worldview. In fact, the experiences of these
oppressed and exploited individuals and groups in time and space differ enormously. As a
matter of fact, recently, intersectionality studies in everyday life [23], have been widely used in
all of the hierarchy, hegemony and exclusion arising from race, gender, class, sexuality. In
particular, the claims that the strongest theoretical contribution to women's studies is
intersectionality have become widespread [21, 24, 25]. In addition, in the macro-level analysis
of health inequality, the interaction of economy, education, politics and administrative factors
is called structural intersectionality.5
RESEARCH DESIGN
Problem and Aims
As a result of insufficiencies arising from the execution of many studies in the field of health in
accordance with the Bio-medical Model, people cannot be helped in a short time for many
illnesses, especially pain. However, pain has psychological and other dimensions as well as
physiological. The main problem of this research is that the factors that affect this pain are not
sufficiently known and taken into account. In this context, the following questions were tried to
be answered within the limits of this article as sub-problems:
a) What are the alternative models in the investigation of illness such as pain?
b) How can these models be applied in pain investigation?
c) Which factors are more effective on whom and at what levels?
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Importance and limitations
There are several studies using the Bio-psychosocial Model. Relief of social anxiety and
substance abuse [4], the relationship between aging and dementia [26], combating chronic pain
[27], osteopathic practices [28], and combating with chronic diseases [29], are the examples
and their contributions undeniable. However, the use of both relational and intersectional
sociological perspectives in the four-dimensional evaluation of pain as cognitive, socio-cultural,
environmental and psychological, beyond being a physical phenomenon is the contribution of
this study to the existing literature.
Thus, starting from the bio-psycho-social model [1], which challenges the bio-medical model,
which is the basis of Western medicine, the fact that it was made in a different society than the
West increases its importance as a cross-cultural study. Finally, instead of the acute pain of
young people, it is important that the research deals with the chronic pain of the elderly
participants, whom the researchers had the opportunity to closely monitor, in the process, and
thus demonstrates the intersection of various factors.
Like any research, this study also has some limitations. Pain, which is the subject of research,
directly points to one's own intimate area [26]. Therefore, questioning this concept requires
sensitivities. However, the fact that the researchers reported some observations about the
participants they knew before, as well as the fact that the participants were old and expressed
their experiences more comfortably, played an important role in overcoming this limitation.
Method
In the study, which assumes that social reality is multi-layered, narratives, one of the qualitative
research traditions, were used [30]. The data reported in the findings were collected in the style
of life history rather than autobiography or biography [31, 32]. Each of the participants whose
life histories were taken in the study was accepted as a case. For this reason, the study also has
the feature of a case study [30]. The analyzes were then carried out by coding according to the
factors in Melzack and Wall's (1965) Door Control Theory [33]. As it is known, thin neurons
transmit pain to the brain rapidly, whereas thicker neurons transmit pain later under the
influence of cognitive, social or psychological stimuli. Therefore, it should be underlined that it
is not satisfied only with the physiological dimension. On the other hand, it should be noted that
this approach is based on the assumption that reality is multi-layered, far from being one- dimensional.
In addition, in order to fulfill the requirements of the relational perspective and
intersectionality approach, the life stories of seven people, four of whom are women, over 75
years old, formed the universe of the research, with the thought that there are different women
and different men, rather than being essentialist. It is not possible to generalize the data
obtained by purposive and therotical sampling to a larger population than the participants. In
the presentation of the report, it should be noted that the dualism arising from the
differentiation between men and women is for analytical duality, as the relational sociologist
Margaret Archer [34] emphasized.
RESULTS
The Bio-psychosocial Model not only draws attention to the fact that pain is a complex
phenomenon that is affected by biological (illness processes), psychological (thoughts, beliefs,
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Research Journal, 9(1). 236-251.
URL: http://dx.doi.org/10.14738/assrj.91.11543
and emotions) and social (family, work environment, sociocultural environment) factors. It also
emphasizes that it is the dynamic process that produces the changes in these mechanisms [35].
In this context, in the article, physiological features representing characteristic disease
processes; psychological features representing the changes before and during the disease
process; cognitive features representing mental processes such as perception, understanding,
comprehension, interpretation; environmental features representing family, profession, and
social environment are reported as a total of four tables.
Table 1. Physical characteristics of the cases
Case 1 She is an energetic woman who loves to do sports, pays attention to her diet, and
always maintains her form. She has a genetic condition that manifests itself with
involuntary movements other than mild stomach and intestinal disorders. She has
been treated by neurologist for many years. Since she lost her swallowing reflex, she
is trying to hold on to life only with the enteral feeding system. She did not have
children because she knew about her illness.
Case 2 He devastated his body by overexerting it. He thinks that his knees were worn out
because he carried heavy weights in his youth. He had surgery on his knees in his old
age, but he could not regain his old health and was condemned to walk with a
walker. He has had high blood pressure since he was young. He also takes some
sedative pills.
Case 3 Since she had been working hard since her early youth, her body was physically
very tired. There are advanced rheumatic swellings and arteriosclerosis, especially
in the legs. However, the main victimization of her was that she fell as a result of
high blood pressure and suffered a stroke. She is currently unable to walk and her
physical therapy is still ongoing.
Case 4 He suffered from deep depression in his middle age with a diagnosis of bipolar.
Later, he was diagnosed with atypical HSP. He started to be fed with pureed foods
because of the risk of choking on the dishes by going into the trachea. He started to
drink his waters with the addition of thickener. He has lost a lot of weight in his last
years. He had a severe infection, increased CRT, but could not receive regular
treatment under pandemic conditions.
Case 5 Generally, she is a healthy woman who is active and committed to life. She
constantly diets in order not to gain too much weight, she pays attention to what she
eats and drinks. However, she was given ready-made supplements because she
could not be fed well in her last years. Although she was healthy, they did not have
children because her husband was older and sick.
Case 6 Throughout his life, he felt the effects of his asthma, which was inherited from his
family. Especially in winter, coughing attacks are more common. He has a weak and
powerless body. However, he tries to maintain his routine and not to care much
about diseases, even during periods of intensification of his illness. As he got older,
he developed dementia.
Case 7 When viewed from the outside, the woman who has a strong and durable body is
also very hardworking. However, she has a body that is prone to weight gain. In
recent years, she has faced problems such as high blood pressure, diabetes and fatty
liver. Although she is active during the day, these problems cause heart palpitations
and difficulty in breathing, which are felt intensely from time to time in her daily life.
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Table 2. Psychological characteristics of the cases
Case 1 Despite being a high-level bureaucrat, she has an extremely humble personality. Her
speech, sitting, standing and dressing are highly dependent on the rules. Although she
comes from the upper income group, she is very frugal. She never wears expensive
brands, she wears skirts and jackets that she has tailor-made according to her taste.
She is a conservative woman who goes to work with socks and closed shoes even on
summer days. She does not like and does not do housework. She tries to do her job in
the best way possible. She has an identity that knows how to enjoy life.
Case 2 He is a very thoughtful and exrovert personality. He is everyone's father. He is very
kind hearted and helpful. He comes from a large and educated family. He has always
supported his sister and brother, their children. However, he has been very angry with
them in recent years. He regrets the sacrifices he has made in the past. He always says
that he will commit suicide. In fact, he is seriously depressed, but does not accept it.
In recent years, he does not want to go out of his house and does not accept guests.
Case 3 The fact that she lost her wife was also a process that pushed her into loneliness.
Another issue affecting her psychology is that she lives with her son and daughter-in- law. On the one hand, this situation is positive in terms of not being alone and having
someone who takes care of him. However, she feels powerless from time to time due
to the need for their care. Despite everything, the general psychology of the woman is
happy, she has a funny personality that spreads joy around her and makes her visitors
laugh.
Case 4 He is known as benevolent and good-hearted. He is very well-intentioned and sincere.
He is constantly in search. He traveled constantly in order to promote his duty, and
tried to establish new businesses by gaining new skills at a late age in order to
improve himself. On the one hand, while achieving significant success in his
profession, he was sometimes deceived by those who took advantage of his naivety.
He experienced the first significant psychological destruction immediately after these
material and moral losses. He spends his last days at home in agony, despite the great
care of his wife.
Case 5 She is a benevolent person who worked in health-related social associations in her
youth. Generally very meticulous and well-groomed. She loves to chat. She exhibits
her handicrafts at home. Seeing the children of her brothers and sisters as her
children, she gave them all her love. She says that she does not get bored of sitting
alone after her husband’s death, and she does her shopping when she needs it. When
she was old and unable to walk, she moved in with them. She never complained or
said that she was sick or tired. She even made jokes on the days when she could stand
up slowly with a cane.
Case 6 He is a cheerful, playful, funny person who makes interesting jokes, hangs out with
people. In addition, he has a reckless nature that does not like to take serious
responsibilities in his daily life. He married his wife in love. The death of his wife
before him was very difficult for him. It was almost as if he could not bear this pain
and life became a burden to him. He became more and more introverted and isolated
from loneliness.
Case 7 The fact that her husband was bedridden at home for a long time as a result of his
stroke and then passed away, in a way, dragged her into loneliness. However, living at
home with her son and family, her grandchildren made her happy again. It is good for
her to take care of plants at home and chat with her neighbors. She has good
intentions, good relations with her environment, appreciated, extremely honest,
empathetic, helpful and patient.
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As in the second and third cases, bodily physical distress comes from overloading the body from
a young age [41]. The second case, the woman's working from an early age, is related to factors
such as socio-economic, cultural and gender. Because housework and working life are not
balanced and more responsibilities can be placed on women's shoulders according to gender
stereotypes. Therefore, we encounter the effect of socio-cultural factors again.
In the third case, besides physical exertion, factors such as cultural loyalty to siblings and
respect for elders were effective. He was socially isolated as well as devastated his body and
psychology. Isolation, which was his own choice, wore him down even more. His knees could
not carry him, he could not go out biological factors include physical factors that affect health.
All systems that make up the body, such as the immune system and nervous system, have a
complex structure and are interrelated.
In the fourth case, a different neurological disease complaint is observed. Until this disease
appears, the social and environmental conditions of the person are quite diverse and rich.
Therefore, in this case, the most frustrating person was the lack of communication and the lack
of cultural diversity to which he was accustomed. Considering the effects of various restriction
measures taken around the world due to the Covid-19 pandemic on elderly people [42,43],
being in crowded environments is risky for them on the one hand, and isolation from social
communication negatively affects their psychology [44]. When other cases were examined, it
was observed that chronic diseases such as asthma and blood pressure were quite common.
In the fight against diseases, the physical endurance of people and their immune systems can
also be effective. Regular exercise helps to protect the resistance of the immune system, which
weakens with aging [45]. There may be differences in the ways of coping with pain and
controlling emotions, as well as in the causes of pain. In combating pain, directing attention to
other issues, developing a positive perspective instead of negative thoughts about the disorder,
applying relaxation techniques, and benefiting from religious or spiritual resources are among
the methods used [46].
In this study, women's coping with aches and pains and their circumstances was stronger than
men. Men were more psychologically withdrawn and more affected by the lack of
communication. On the other hand, it is seen that women exhibit an approach of being more
committed to life and accepting the situation as it is. It can be said that women are more
experienced in recognizing social pressures earlier in the socialization process and developing
their own solution strategies for this [47].
Feminist Standpoint Theory which focuses on the connection between women's own life
experiences and knowledge, tries to explain how women resist as much as they are oppressed,
often how they have to consent, sometimes even how they suppress and depend on each other
[7].
It deals with the dynamics of individual, group and social identity. He argues that women's life
experiences provide pluralistic identities [48]. According to Gate Control Theory, social
structure and environmental features act as a gate in the control of pain. So much so, that even
in moments when social communication is interrupted, ties with life can be achieved, just like
the scent of a flower or the harmony of a sound, resistance to biological/physical pains.