Female Sexual Pain Disorders: a Review of the Literature on Etiology and Treatment

Sexual Self Discrepancies, Sexual Satisfaction, and Relationship Satisfaction in a Cross-Sectional Sample of Women Who Experience Chronic Vaginal Pain during Sexual Intercourse

One out of three women may suffer from chronic vaginal pain during intercourse, a complex health issue that leads to lasting psychological, sexual, emotional, and relational difficulties even after initial relief. Women who experience this pain condition may compare their sexual selves to the societal norm of being pain-free. Comparisons that do not align with one's actual sexual self result in sexual self-discrepancies and may cause emotional distress. Sexual self-discrepancies may hinder sexual and relationship satisfaction for women who experience chronic vaginal pain during sexual intercourse. This mixed-method study examined the sexual self-discrepancies women reported and the degree to which their sexual self-discrepancies were related to their sexual and relationship satisfaction. Results from this cross-sectional study showed that the majority of participants experienced sexual self-discrepancies and that they experienced a significant inverse correlation between sexual self-discrepancies and sexual satisfaction. In multivariate models, sex frequency was the strongest predictor of sexual satisfaction. There were no correlations between sexual self-discrepancies and relationship satisfaction. Future measurement research should examine the role of sex frequency in the experience of sexual satisfaction. Education on maximizing pleasure and minimizing pain may aid women to cope with the negative impact of pain.

Responsiveness in the Face of Sexual Challenges: The Role of Sexual Growth and Destiny Beliefs

Implicit--or lay--sexual beliefs have been associated with how people respond to sexual challenges in romantic relationships. People who endorse sexual destiny beliefs view a satisfying sex life as the result of finding the right partner and report poorer sexual, relationship, and personal well-being when there are sexual challenges. In comparison, people who endorse sexual growth beliefs view satisfying sexual relationships as requiring hard work and effort to maintain and tend to report high sexual, relationship, and personal well-being even when facing sexual challenges. High sexual responsiveness - being motivated to meet a partner's sexual needs - is associated with maintaining high sexual satisfaction, even when couples face sexual challenges in a relationship. In the current research, we tested whether sexual growth and destiny beliefs are associated with general and sexual responsiveness and whether the associations are moderated by the presence of sexual challenges. Across three (clinical and non-clinical) samples (N = 820) facing different types of sexual challenges (Study 1 (Mage = 31.64, SD = 8.53), clinically low sexual desire; Studies 2 (Mage = 32.63, SD = 10.19) and 3 (Mage = 32.40, SD = 9.31), unmet sexual ideals; Study 3, changes in sex since the onset of the COVID-19 pandemic), we found that sexual growth beliefs were associated with higher sexual responsiveness and perceived partner sexual and general responsiveness, even when couples were coping with sexual challenges, whereas sexual destiny beliefs were not associated with responsiveness, and at times were associated with lower sexual responsiveness and perceived partner sexual and general responsiveness. This research provides initial evidence about how implicit sexual beliefs are associated with sexual and general responsiveness when couples are coping with sexual challenges in a romantic relationship.

Coping Strategies with Genito-Pelvic Pain/Penetration Disorder: A Qualitative Study

Background

Genital/pelvic pain penetration disorder (GPPPD) decreased mental and physical functioning, reduced quality of life, and reduced feelings of inadequacy and worthlessness, all of which impair the ability of women with GPPPD to enjoy sex. This qualitative study was conducted to identify which factors can reduce sexual stress and help Iranian women cope with GPPPD.

Methods

This qualitative study was conducted through the participation of 18 women with GPPPD diagnosed by a sexologist and using DSM-IV diagnostic criteria from March to July 2022, Iran. The samples were selected using the purposive sampling method and considering the maximum variation. The semistructured question guide was used as a data collection tool and data collection continued until data saturation was reached. The collected data were analyzed using conventional content analysis approach.

Results

Data analysis led to the emergence of three main themes: "problem-focused coping" which included the three categories of received social support, problem self-control, and penetration replacement; "emotion-focused coping" which included three categories: a couple's negative reaction to the problem, attachment disorder, and surrendering the problem; and "treatment-seeking" which consisted of searching and choosing a therapist to solve the problem, ineffective medical approaches, and ineffective nonmedical approaches.

Conclusion

Coping strategies in women with GPPPD were classified as "problem-focused coping," "emotion-focused coping," and "treatment-seeking." These findings indicate a need for GPPPD information and education, as well as a need for healthcare professionals to actively inquire about sexual problems and commit to serious treatment efforts. Cultural interventions that promote sexual pleasure can aid in the management of GPPPD.

"It's all my fault": a qualitative study of how heterosexual couples experience living with vulvodynia

INTRODUCTION

Vulvodynia, a chronic genital pain disorder with a high lifetime prevalence among women, has a significant negative impact on both women and their partners. Although there is a growing body of literature on the experiences of women with vulvodynia, there has been little research on the condition's implications for partners and romantic relationships. The aim of this study is to explore how heterosexual couples experience living with vulvodynia.

MATERIAL AND METHODS

Eight Norwegian women diagnosed with vulvodynia by gynecologists were recruited with their partners (couples aged 19-32 years). Data was collected via individual semi-structured interviews and analyzed using inductive thematic analysis.

RESULTS

Three main themes were identified in the analysis: Mysterious disorder, Social exclusion and Sexual expectations. The results show that the couples struggle with understanding the pain, as well as navigating their social and sexual lives. We discuss these findings in light of a new theoretical model: the fear-avoidance-endurance model of vulvodynia.

CONCLUSIONS

Heterosexual couples living with vulvodynia experience communication difficulties with partners, health professionals, and their social network. This sustains avoidance and endurance behavior, increasing pain and dysfunction over time and giving rise to feelings of powerlessness and loneliness. Social expectations regarding male and female sexuality also promote guilt and shame for both parties in couples affected by vulvodynia. Our results suggest that heterosexual couples living with vulvodynia, as well as health professionals treating them, should be helped to communicate more effectively in order to break vicious circles of maladaptive avoidance and endurance behavior.

Gynecological Cancer Survivors' Experiences of Dyspareunia and Factors Influencing Care-Seeking Behavior: A Qualitative Study

Pain during sexual intercourse, also called dyspareunia, affects most women after treatment for gynecological cancer. Previous work adopted a biomedical approach to depict dyspareunia in this population, which provided a narrow perspective of this condition. Taking into account women's experiences of dyspareunia and the factors influencing their care-seeking behaviors would provide insight to improve care in the context of gynecological cancer. The aim of this study was to describe gynecological cancer survivors' experiences of dyspareunia and factors influencing care-seeking behavior. A qualitative study was performed with 28 gynecological cancer survivors with dyspareunia. Individual telephone interviews were conducted based on the Common-Sense Model of Self-Regulation. Interviews were recorded and transcribed for analysis using the interpretative description framework. Concerning their experience, participants reported the oncological treatments as the primary cause of dyspareunia. Loss of libido, lower vaginal lubrication, and smaller vaginal cavity were described as being linked with dyspareunia. Women explained how dyspareunia and these changes had led them to engage less in, and even interrupt, sexual activity. They expressed that they were distressed, felt less of a woman, and experienced low control and/or self-efficacy. Regarding the factors influencing women's care-seeking behaviors, participants emphasized that they were provided with insufficient information and support. Balancing priorities, denial or reluctance, misbeliefs, resignation and acceptance, and negative emotions were reported as barriers, whereas acknowledgement of sexual dysfunction, desire for improvement, awareness of treatment possibilities, willingness to undertake treatment and treatment acceptability were reported as facilitators to seeking care. Findings suggest that dyspareunia is a complex and impactful condition after gynecological cancer. While this study highlights the importance of alleviating the burden of sexual dysfunction in cancer survivors, it identified factors that should be considered in the provision of services to improve care.

'My partner will think I'm weak or overthinking my pain': how being superwoman inhibits Black women's sexual pain disclosure to their partners

Black women experience persistent sexual pain that may often last longer than White women. Despite the value of sexual communication to alleviate sexual pain concerns, many women do not disclose sexual pain to their partners. Limited research explores barriers to disclosing sexual pain to partners among Black women. This study seeks to fill this gap. Relying on an integration of Sexual Script theory and Superwoman Schema, the study explored the barriers that premenopausal, cisgender Black women from the Southern USA perceived when disclosing sexual pain to their primary partners. We identified five common themes from women's open-ended responses to an online survey: (a) distressing emotions associated with disclosure; (b) limited knowledge and communication skills; (c) protecting partner's feelings and ego; (d) invading privacy; and (e) taking sole responsibility for managing sexual pain. Findings suggest a combination of intrapsychic, interpersonal and cultural factors influence Black women's perceived ability to have direct and open dyadic communication about sexual pain with their partners. Implications for Black women's sexual health and relationship outcomes are discussed.

'I don't live in my body somehow': metaphorical talk in women's accounts of vaginismus and dyspareunia

Vaginismus and dyspareunia are common sexual difficulties; they often take a long time to be appropriately diagnosed, and their origins remain unclear. This paper examines the metaphors used by women to describe bodily experiences associated with vaginismus and dyspareunia, and highlights the contribution this form of analysis can make to the study of sexuality and sexual difficulties. A secondary analysis was conducted on primary data from biographic interviews exploring women's experiences of sexual pain and difficulties with sexual intercourse. Metaphor analysis was used to analyse a data subset of 28 interviews translated from German into English. Metaphorical concepts lying at the basis of the metaphors used were identified and grouped into three themes: characterisation of sexual difficulties; split body and 'self'; and sexual agency and objectification. Results are discussed with in the context of literature regarding the function of metaphors and the utility of metaphor analysis for research, and healthcare research and interventions more generally.

An initial proof of concept: A replicated single-case study of a CBT group treatment with partner involvement for vulvodynia

Vulvodynia is common and has an immense impact on affected women and their partners. Psychological factors have been found to contribute to pain maintenance and exacerbation, and treatments addressing psychological factors have yielded positive results. This study employed a replicated single-case experimental design to examine a cognitive behavioral therapy (CBT) group treatment with partner involvement in vulvodynia. Repeated measures of pain intensity related to pain-inflicting behaviors were collected weekly throughout baseline and treatment phases. Associated outcomes were measured pre-, post- and at two follow-up assessments. Participants were 18-45-year-old women, in a stable sexual relationship with a man, experiencing vulvodynia. Five women completed the treatment consisting of 10 group sessions and 3 couple sessions. Data were analyzed through visual inspection and supplementary nonparametric calculations. The study showed promising results of the CBT treatment in alleviating pain intensity in connection to specific pain-inflicting behavior since three out of five participants showed improvements. For the participants who improved, sexual function, pain catastrophizing, avoidance, and endurance behavior changed during treatment and were maintained at follow-ups. These results warrant further study of the CBT treatment, in larger, and controlled formats.

Repetitive Negative Thinking and Sexual Functioning in Portuguese Men and Women: A Cross-Sectional Study

Objective: Repetitive negative thinking (RNT) is a transdiagnostic process involved in the development and maintenance of emotional disorders that negatively affect sexual functioning. However, empirical evidence for the role of RNT on sexual functioning is still lacking. The current study aimed to investigate the role of RNT on sexual functioning in men and women by examining differences in RNT between men and women and between individuals with and without subclinical sexual difficulties. It also aimed to investigate the predictive role of RNT on sexual function indices in men and women. Methods: A total of 424 participants (270 women) completed online a sociodemographic questionnaire and Portuguese versions of the Persistent and Intrusive Negative Thoughts Scale, the Female Sexual Functioning Index, and the International Index of Erectile Function. Results: The main findings showed that women scored significantly higher than men on the RNT. Similarly, individuals with subclinical sexual difficulties scored significantly higher on the RNT compared with individuals without sexual difficulties. RNT was a statistically significant and negative predictor of sexual functioning in women and men. The role of RNT on sexual functioning in women and men was found, with men and women with subclinical sexual difficulties more likely to express persistent and intrusive negative thoughts compared with men and women without sexual difficulties. Conclusions: In summary, RNT appears to be a negative predictor of sexual functioning in both women and men, suggesting that individuals with more intrusive and negative persistent thoughts also have more difficulty in their sexual response.

Moderators of the Relationship Between Pain and Pain-Related Sexual Disability in Women with Provoked Vestibulodynia Symptoms

BACKGROUND

Previous studies have demonstrated the deleterious effects of pain anxiety (ie, the degree to which one fears pain), stress, and solicitous partner responses (ie, expressions of sympathy and attention to one's partner's pain) on pain and pain-related disability, but little is known about whether these variables moderate the robust pain-pain-related disability relationship in individuals with provoked vestibulodynia (PVD).

AIM

We investigated whether pain anxiety, stress, and solicitous partner responses moderated the relationship between penetrative pain and pain-related sexual disability in women with PVD symptoms.

METHODS

Participants with PVD symptoms (N = 65, age range = 18-73 years) completed an online survey assessing pain anxiety (Pain Anxiety Symptoms Scale-20), perceived stress (Perceived Stress Scale), solicitous partner responses (WHYMPI Solicitous Responses Scale), penetrative pain (Female Sexual Function Index), and pain-related sexual disability (Pain Disability Index). Moderated regression analyses were performed using pain anxiety, stress, and solicitous partner responses as moderators of the relationship between penetrative pain, and pain-related sexual disability.

OUTCOMES

Outcomes in the current study included the moderating effect of pain anxiety, perceived stress, and solicitous partner responses on the relationship between penetrative genital pain and pain-related disability in sexual behavior.

RESULTS

Higher genital pain from penetrative intercourse and higher pain anxiety significantly predicted higher pain-related sexual disability, but perceived stress was not significantly related to sexual disability. Solicitous partner responses were significantly positively correlated with pain-related sexual disability. None of the moderators significantly moderated the pain-pain-related sexual disability relationship.

CLINICAL IMPLICATIONS

For women with PVD, pain anxiety and solicitous partner responses to their pain may exacerbate their pain-related sexual disability, signifying that pain anxiety and solicitous partner responses represent important targets of therapeutic intervention for women with PVD.

STRENGTHS AND LIMITATIONS

The present study extended past research on the relationships between psychological and behavioral factors and pain in women with PVD symptoms by demonstrating the deleterious relationship between pain anxiety, solicitous responses, and pain-related sexual disability. However, the study was correlational in nature, which precludes conclusions about the effect of pain anxiety, and solicitous partner responses on pain-related sexual disability.

CONCLUSION

High pain anxiety and frequent solicitous partner responses to an individual's pain predicted higher pain-related sexual disability, suggesting that it may be possible to improve the quality of life of PVD sufferers through interventions that aim to decrease pain anxiety, and solicitous partner responses, in addition to interventions that aim to decrease pain per se. Maunder L, Dargie E, Pukall C. Moderators of the Relationship Between Pain and Pain-Related Sexual Disability in Women with Provoked Vestibulodynia Symptoms. J Sex Med 2022;19:809-822.

Trajectories of Dyspareunia From Pregnancy to 24 Months Postpartum

Two distinct trajectories of dyspareunia were identified from pregnancy to 24 months postpartum; pain catastrophizing predicted inclusion in the moderate relative to minimal pain trajectory.

To identify distinct trajectories of dyspareunia in primiparous women and examine biopsychosocial risk factors of these trajectories.

The Biopsychosocial Puzzle of Painful Sex

Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The Empirical Status of the Preparation Hypothesis: Explicating Women's Genital Responses to Sexual Stimuli in the Laboratory

Research conducted in our laboratory and in other laboratories has revealed that (1) women's genital responses to visual and auditory stimuli are strongly affected by the presence of sexual cues, but that (2) specific sexual cues (e.g., gender of actors, the presence of sexual violence) often have little impact on the magnitude of the responses-that is, similar genital responses are observed to very different sexual stimuli. In addition, (3) women's genital responses do not strongly correspond with self-reported sexual partner and activity preferences, or (4) with self-reported sexual arousal during the presentation of sexual stimuli. Taken together, these facts represent a puzzle, especially considering that men's genital responses are highly affected by specific sexual cues and strongly correspond to stated preferences and self-reported sexual arousal. One hypothesis to explain female low cue-specificity and low concordance (relative to men) is the preparation hypothesis: Women's indiscriminate genital responses serve a protective function. That is, they do not indicate or necessarily promote sexual interest and motivation, but rather prepare the vaginal lumen for possible sexual activity and therefore prevent injuries that may occur as a result of penetration. We review evidence for and against this hypothesis. We conclude that the evidence is favorable but not entirely convincing, and more work is required to reach a firm conclusion. We offer directions for future research.

Persistent Genital Arousal in Relationships: A Comparison of Relationship, Sexual, and Psychological Well-Being

BACKGROUND

Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia (PGAD/GPD) is characterized by sensations of physiological genital sexual arousal (and/or other types of genitopelvic dysesthesia) that occur in the absence of subjective feelings of sexual desire.

AIMS

The aim of this study was to compare relationship, sexual, and psychological well-being in partnered individuals with and without distressing symptoms of PGAD/GPD.

METHODS

The sample (N = 65 individuals with vulvas and vaginas, N = 11 individuals with penises) of 152 partnered individuals (N = 76 with and 76 without PGAD/GPD symptoms) participated in a one-time anonymous online survey.

OUTCOMES

The questionnaires assessed relationship satisfaction (Couple Satisfaction Index-Short Form, CSI); sexual satisfaction (Global Measure of Sexual Satisfaction, GMSEX); sexual functioning (Female Sexual Functioning Index, FSFI, or International Index of Erectile Functioning, IIEF); sexual distress (Sexual Distress Scale, SDS); and psychological well-being, as determined by the presence of depression and/or anxiety symptoms (Hospital Anxiety and Depression Scale, HADS).

RESULTS

Among individuals with vulvas and vaginas, those with PGAD/GPD symptoms reported significantly lower relationship and sexual satisfaction, greater sexual distress, and more symptoms of depression and anxiety than their counterparts in the control group. In addition, these individuals with PGAD/GPD symptoms also reported significantly worse sexual functioning (arousal, orgasm, satisfaction, and pain), and they were significantly more distressed about each aspect of their sexual functioning difficulties compared to those in the control group. Among the small sample of individuals with penises (N = 11), descriptive analyses revealed that total sexual functioning scores did not differ across the PGAD/GPD symptom and control groups. In addition, 64.5% of the total sample with PGAD/GPD symptoms managed unwanted genital arousal by avoiding sex with their partner, while 55.3% managed their symptoms by having sex with their partner, and some individuals with PGAD/GPD used both strategies.

CLINICAL IMPLICATIONS

The finding that PGAD/GPD symptoms impact relationships indicates that treatment for PGAD/GPD should include consideration of the well-being of one's intimate relationship(s).

STRENGTHS & LIMITATIONS

This study added to the small literature on experiences of PGAD/GPD in relationships, and it was the first to assess sexual satisfaction. Limitations include the small sample of individuals with penises, and the cross-sectional, correlational design, which does not allow for causal conclusions to be drawn.

CONCLUSION

Results emphasize the importance of continued research of this population (and their partners) in order to improve diagnosis, intervention, and recognition within the medical community. Mooney KM, Poirier É, Pukall CF., Persistent Genital Arousal in Relationships: A Comparison of Relationship, Sexual, and Psychological Well-Being. J Sex Med 2022;19:234-248.

Improvements following multimodal pelvic floor physical therapy in gynecological cancer survivors suffering from pain during sexual intercourse: Results from a one-year follow-up mixed-method study

BACKGROUND

A large proportion of gynecological cancer survivors suffer from pain during sexual intercourse, also known as dyspareunia. Following a multimodal pelvic floor physical therapy (PFPT) treatment, a reduction in pain and improvement in psychosexual outcomes were found in the short term, but no study thus far has examined whether these changes are sustained over time.

PURPOSE

To examine the improvements in pain, sexual functioning, sexual distress, body image concerns, pain anxiety, pain catastrophizing, painful intercourse self-efficacy, depressive symptoms and pelvic floor disorder symptoms in gynecological cancer survivors with dyspareunia after PFPT, and to explore women's perceptions of treatment effects at one-year follow-up.

METHODS

This mixed-method study included 31 gynecological cancer survivors affected by dyspareunia. The women completed a 12-week PFPT treatment comprising education, manual therapy and pelvic floor muscle exercises. Quantitative data were collected using validated questionnaires at baseline, post-treatment and one-year follow-up. As for qualitative data, semi-structured interviews were conducted at one-year follow-up to better understand women's perception and experience of treatment effects.

RESULTS

Significant improvements were found from baseline to one-year follow-up on all quantitative outcomes (P ≤ 0.028). Moreover, no changes were found from post-treatment to one-year follow-up, supporting that the improvements were sustained at follow-up. Qualitative data highlighted that reduction in pain, improvement in sexual functioning and reduction in urinary symptoms were the most meaningful effects perceived by participants. Women expressed that these effects resulted from positive biological, psychological and social changes attributable to multimodal PFPT. Adherence was also perceived to influence treatment outcomes.

CONCLUSIONS

Findings suggest that the short-term improvements following multimodal PFPT are sustained and meaningful for gynecological cancer survivors with dyspareunia one year after treatment.

Coping with dyspareunia, the importance of inter and intrapersonal context on women's sexual distress: a population-based study

BACKGROUND

Recently known as the genito-pelvic pain/penetration disorder (GPPPD), Dyspareunia is considered a negative factor affecting a couple's sexual health. This paper analyzes pain in Dyspareunia cases and determines protective factors causing lower levels of sexual distress among patients.

METHODS

In a population-based cross-sectional study conducted in 2017, the cluster quota sampling technique was adopted to randomly select 590 Iranian married women aged 18-70 years from 30 health centers. The research tools included demographic data, a sexual distress scale, and Binik's GPPPD questionnaire.

RESULTS

In this study, the prevalence of self-report Dyspareunia, confirmed moderate Dyspareunia, and confirmed severe Dyspareunia (based on Binik's proposed criteria) were 33 %, 25.8 %, and 10.5 %, respectively. Interestingly, 32 (34 %) out of 94 women who experienced severe pain based on Binik's criteria reported no sexual distress. Compared to women with distress, they also had more positive body images, higher self-confidence, higher levels of sexual satisfaction, and more intimacy in their relationships (P = 0.000). In contrast, 8.5 % of the participants reported significant sexual distress even without confirmed Dyspareunia.

CONCLUSIONS

Improving intrapersonal characteristics such as self-confidence and body image as well as interpersonal factors such as sexual satisfaction and intimacy with a spouse can effectively treat Dyspareunia by alleviating sexual distress. The partner's role in female pain and distress management would be more critical than previously thought.

"A Woman Should Still Be a Woman" - A Grounded Theory of the Origins of Sexual Pain and Difficulties with Intercourse

The origin of women's sexual pain and difficulties with intercourse is still under-researched. The aim of this study was to examine women's constructions of origins. Twenty-eight participants previously diagnosed with vaginismus or dyspareunia were recruited via patient lists and private practices. Interviews had a semi-structured biographic-narrative format; transcripts were analyzed using Grounded Theory. Participants' narratives were constructed based on two major processes: Negotiating Womanhood and Othering the Body. They were integrated in an explanatory model. Identified processes permeated women's subjective experience and construction of the origin of their sexual difficulties, and were related to societal discourses and women's embodied experience.

A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer

BACKGROUND

Dyspareunia affects most women after treatment for gynecologic malignancies. However, to date, evidence-based interventions remain limited and no study has examined the effects of multimodal physical therapy on psychosexual outcomes in these patients.

AIM

To assess the effects of multimodal physical therapy on psychosexual outcomes including sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in women with dyspareunia after treatment for gynecologic malignancies.

METHODS

Thirty-one gynecologic cancer survivors with dyspareunia enrolled in this prospective single-arm interventional study. The participants undertook 12 weekly sessions of physical therapy incorporating education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Outcome measures were evaluated pre- and post-treatment. Paired t-tests were conducted to investigate the changes from pre-treatment (P-value ˂ 0.05) while effect sizes (Cohen's d) were calculated to measure the magnitude of the change.

MAIN OUTCOME MEASURES

Sexual distress (Female Sexual Distress Scale-Revised), body image concerns (Body Image Scale), pain anxiety (Pain Anxiety Symptoms Scale), pain catastrophizing (Pain Catastrophizing Scale), pain self-efficacy (Painful Intercourse Self-Efficacy Scale) and depressive symptoms (Beck Depression Inventory-II).

RESULTS

Significant changes were found from pre- to post-treatment for all psychosexual outcomes. Women reported reductions in sexual distress (P ˂ 0.001, d = 1.108), body image concerns (P ˂ 0.001, d = 0.829), pain anxiety (P ˂ 0.001, d = 0.980), pain catastrophizing (P ˂ 0.001, d = 0.968) and depression symptoms (P = 0.002, d = 0.636) with an increase in pain self-efficacy (P ˂ 0.001, d ≥ 0.938) following the intervention.

CLINICAL IMPLICATIONS

The results suggest that multimodal physical therapy significantly improves sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in our sample of women with dyspareunia after treatment for gynecologic malignancies. The medium to large effect sizes obtained with the high proportion of women presenting meaningful changes according to the known minimal clinically important difference or clinical cut-off underlines the significance of these effects.

STRENGTHS & LIMITATIONS

The current study used validated questionnaires to assess the psychosexual outcomes of a well-designed physical therapy intervention using multiple modalities to address the multifaceted aspect of dyspareunia in cancer survivors. This study did not include a control group, which may limit drawing definitive conclusions.

CONCLUSION

Findings showed that multimodal physical therapy yielded significant improvements in psychosexual outcomes in gynecologic cancer survivors with dyspareunia. A randomized controlled trial is indicated to confirm these results. Cyr M-P, Dumoulin C, Bessette P, et al. A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer. J Sex Med 2021;18:946-954.

Characterizing Pelvic Floor Muscle Function and Morphometry in Survivors of Gynecological Cancer Who Have Dyspareunia: A Comparative Cross-Sectional Study

OBJECTIVE

More than one-half of gynecological cancer survivors are affected by pain during sexual intercourse, also known as dyspareunia. Oncological treatments may result in pelvic floor muscle (PFM) alterations, which are suspected to play a key role in dyspareunia. However, to our knowledge, no study has investigated PFM function and morphometry in this population. The aim of the study was to characterize and compare PFM function and morphometry between gynecological cancer survivors with dyspareunia and asymptomatic women.

METHODS

Twenty-four gynecological cancer survivors with dyspareunia and 32 women with a history of total hysterectomy but without pelvic pain (asymptomatic women) participated in this comparative cross-sectional study. PFM passive forces (tone), flexibility, stiffness, maximal strength, coordination, and endurance were assessed with an intra-vaginal dynamometric speculum. Bladder neck position, levator plate angle, anorectal angle, and levator hiatal dimensions were measured at rest and on maximal contraction with 3D/4D transperineal ultrasound imaging.

RESULTS

Compared with asymptomatic women, gynecological cancer survivors showed heightened PFM tone, lower flexibility, higher stiffness, and lower coordination and endurance. At rest, they had a smaller anorectal angle and smaller levator hiatal dimensions, indicating heightened PFM tone. They also presented fewer changes from rest to maximal contraction for anorectal angle and levator hiatal dimensions, suggesting an elevated tone or altered contractile properties.

CONCLUSIONS

Gynecological cancer survivors with dyspareunia present with altered PFM function and morphometry. This research therefore provides a better understanding of the underlying mechanisms of dyspareunia in cancer survivors.

IMPACT

Our study confirms alterations in PFM function and morphometry in gynecological cancer survivors with dyspareunia. These findings support the rationale for developing and assessing the efficacy of physical therapy targeting PFM alterations in this population.

An Attachment Perspective on Partner Responses to Genito-pelvic Pain and Their Associations with Relationship and Sexual Outcomes

Although facilitative and negative partner responses are known to impact couples' adaptation to provoked vestibulodynia (PVD), a chronic genito-pelvic pain condition, it is still unknown what leads individuals to adopt or perceive such adaptative or detrimental behaviors. Attachment influences sexual and relationship adjustment, emotional reactivity and perceived support in romantic relationships, and as such could be associated with partner responses. This study aimed at examining the mediating role of facilitative and negative partner responses in the associations between attachment and relationship and sexual adjustment in 125 couples coping with PVD. Couples completed self-report questionnaires on attachment, partner responses, sexual satisfaction and distress, and relationship satisfaction. Results indicated that partners' attachment avoidance was negatively associated with facilitative partner-reported responses, which in turn was associated with partners' sexual and relationship satisfaction. Attachment anxiety in women and partners was associated with greater women-perceived negative partner responses, which in turn was associated with women's and partners' greater sexual distress and lower sexual satisfaction, and women's lower relationship satisfaction. Partners' greater attachment anxiety was also associated with greater partner-reported facilitative responses, which was associated with partners' lower and women's greater relationship satisfaction. Assessing attachment orientations may help clinicians better understand couples' dyadic coping.

Mind-body-spirit model for the medical management of female sexual well-being

PURPOSE OF REVIEW

Although healthcare providers are increasingly interested in addressing their female patient's sexual wellbeing in a holistic fashion, most do not receive training in how to conceptualize the complex interactions between mind, body and spirit that drive health and wellness, let alone how to apply empirical data in any of these dimensions to their individual patients. Here, we present a simple mind-body-spirit model, grounded in an integrative medicine approach, to help translate research on sexual functioning and satisfaction into a shared decision-making plan for the management and enhancement of women's sexual wellness.

RECENT FINDINGS

In considering the dimensions of physical and behavioral health, spirituality and sensuality, physicians can help women orient to the ways in which their sexual healthcare can address their core values and connection to others, which in turn can improve sexual satisfaction. The application of the model is outlined in a case study.

SUMMARY

Too often female sexual wellbeing is not discussed in the medical setting and this mind-body-spirit model is a tool that health care providers could use address this important aspect of well-being.

Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia

BACKGROUND AND AIM

The goal was to evaluate the moderators of mindfulness-based cognitive therapy (MBCT) and cognitive behavioral therapy (CBT) to improve dyspareunia, reduce pain catastrophizing, and improve overall sexual function in women with provoked vestibulodynia (PVD). Both treatments effectively reduced self-reported pain, sexual dysfunction, and pain catastrophizing in women with PVD.

METHODS

A total of 130 women with PVD were assigned to CBT or MBCT.

OUTCOMES

Potential moderators included (i) PVD subtype (primary or secondary), (ii) baseline pain intensity, (iii) trait mindfulness, (iv) treatment credibility, (v) relationship duration, and (vi) age. Outcomes were pain intensity, sexual function, and pain catastrophizing at 4 time points: before and after treatment and 6- and 12-month follow-up. Moderation was tested using multilevel models, nesting 4 time points within participants. The interaction of the moderator, time effect, and treatment group was evaluated for significance, and a simple slope analysis of significant interactions was performed.

RESULTS

Pain reduction across 4 time points was the greatest in women who were younger, in relationships of shorter duration, and with greater baseline pain. Treatment credibility moderated pain intensity outcomes (B = 0.305, P < .01) where those with higher treatment credibility ratings (for that particular treatment) improved more in MBCT than CBT. PVD subtype moderated pain catastrophizing (B = 3.150, P < .05). Those with primary PVD improved more in the CBT condition, whereas women with secondary PVD improved more in the MBCT condition. Relationship length moderated sexual function (B = 0.195, P < .01). Women in shorter relationships improved more with MBCT, whereas women in longer relationships improved more on sexual function with CBT. No other tested variables moderated outcomes differentially across both treatment conditions.

CLINICAL IMPLICATIONS

Women who present with high credibility about mindfulness, in shorter relationships, and with secondary PVD might respond better to MBCT whereas those with primary PVD and longer relationships might respond better to CBT.

STRENGTHS & LIMITATIONS

Clinical sample. Half the women who were not sexually active were omitted from analyses of sexual function.

CONCLUSION

Overall, treatment credibility, relationship length, and PVD subtype were found to moderate improvements differently in MBCT and CBT. These findings may assist clinicians in individualizing psychological treatment for women with PVD.

CLINICAL TRIAL REGISTRATION

This clinical trial was registered with clinicaltrials.gov, NCT01704456. Brotto LA, Zdaniuk B, Rietchel L, et al. Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia. J Sex Med 2020;17:2247-2259.

Are Depressive Symptoms and Attachment Styles Associated with Observed and Perceived Partner Responsiveness in Couples Coping With Genito-Pelvic Pain ?

Partner responsiveness is thought to facilitate relationship adjustment in couples coping with genito-pelvic pain, such as provoked vestibulodynia (PVD). Recent studies suggest that attachment and depressive symptoms may act as a filter in the perception of partner responsiveness, and a barrier to the capacity of being responsive to a partner. Given studies suggesting higher depressive symptoms and relationship insecurities in women experiencing genito-pelvic pain compared to controls, investigating the role of these factors in partner responsiveness may help couples improve their wellbeing in the challenging context of PVD. The aim of this study was to examine the associations between depressive symptoms, attachment, and perceived and observed partner responsiveness in 50 couples coping with PVD. Participants took part in a videotaped discussion and completed self-report measures of depressive symptoms, attachment, and perceived partner responsiveness. Based on the actor-partner interdependence model, results indicated that when women and partners reported greater depressive symptoms and anxious attachment, they perceived each other as being less responsive. When partners experienced greater depressive symptoms, women and partners were rated, by a trained observer, as being less responsive to each other. Targeting depressive symptoms and relationship insecurity in couple therapy could increase responsiveness in couples coping with PVD.

Self-Focused Reasons for Having Sex: Associations Between Sexual Goals and Women's Pain and Sexual and Psychological Well-being for Couples Coping With Provoked Vestibulodynia

BACKGROUND

For couples coping with provoked vestibulodynia (PVD), interpersonal sexual goals are associated with sexual and psychological functioning as well as women's pain during intercourse, however, self-focused sexual goals (eg, having sex for personal pleasure, having sex to avoid feeling bad about oneself) have not been studied in this clinical population.

AIM

The purpose of this study was to examine the associations between self-focused approach and avoidance sexual goals and women's pain during intercourse and sexual satisfaction and depressive symptoms for both women and their partners.

METHODS

Women diagnosed with PVD (N = 69) and their partners completed measures of self-focused sexual goals, sexual satisfaction, and depressive symptoms. Women also reported on pain experienced during sexual intercourse.

OUTCOMES

Outcomes included the Global Measure of Sexual Satisfaction, the Beck Depression Inventory-II, and a Numerical Rating Scale of pain during sexual intercourse.

RESULTS

When women reported higher self-focused approach sexual goals, they also reported lower pain intensity. Women's higher self-focused avoidance sexual goals were associated with their own higher depressive symptoms, whereas men's higher self-focused approach goals were associated with their own higher depressive symptoms. When controlling for frequency of sexual intercourse, there were no significant associations between women or partners' sexual goals and sexual satisfaction.

CLINICAL IMPLICATIONS

Within a clinical context where many interpersonal pressures for sex exist, interventions should target self-focused sexual goals alongside interpersonal sexual goals to improve pain and psychological adjustment.

STRENGTHS & LIMITATIONS

This is the first study to examine self-focused sexual goals among women with PVD and their partners. This study is cross-sectional, and the direction of associations cannot be inferred. Couples were in mixed-sex relationships, and results may not generalize to same-sex couples.

CONCLUSION

Findings suggest that self-focused goals are relevant to the psychological adjustment of women with PVD and their male partners and for women's pain. Corsini-Munt S, Bergeron S, Rosen NO. Self-Focused Reasons for Having Sex: Associations Between Sexual Goals and Women's Pain and Sexual and Psychological Well-being for Couples Coping With Provoked Vestibulodynia. J Sex Med 2020;17:975-984.

Biased Partner Perceptions of Women's Pain Self-Efficacy in Postpartum Pain During Intercourse: A Dyadic Longitudinal Examination

Postpartum pain during intercourse is a prevalent and distressing problem that has substantial consequences for affected couples. Partner perceptions-such as how partners perceive women's pain self-efficacy-contribute to an individual's pain experience. This study examined whether partners under- or over-estimate women's intercourse pain self-efficacy at 3-months postpartum and the implications of this bias for women's pain and couples' sexual functioning at 3- and 6-months postpartum. Women who reported pain during intercourse and their partners (N = 89 couples) completed online measures assessing pain self-efficacy (own or partner perceptions), pain intensity, and sexual functioning at 3- and 6-months postpartum. Analyses were based on the Truth and Bias Model of Judgement and Response Surface Analysis. Partners were accurate in their estimates of women's pain self-efficacy (ie, their estimates were positively correlated with women's), but they also underestimated it by perceiving women to be less efficacious than women themselves reported. When couples showed greater agreement for lower levels of pain self-efficacy at 3 months, women reported greater pain intensity and both partners reported poorer sexual functioning at 3- and 6-months postpartum. Findings may inform interventions that promote pain self-efficacy to improve partner support and couples' sexual functioning. PERSPECTIVE: When women report-and their partners perceive-low levels of women's self-efficacy for managing painful intercourse, women report greater postpartum pain during intercourse and couples indicate poorer sexual functioning. These findings suggest that interventions aimed at promoting couples' agreement at high pain self-efficacy may improve their adjustment to postpartum pain.

Vaginal Dilators: Issues and Answers

INTRODUCTION

Vaginal dilators are often prescribed to facilitate an adaptive brain-body connection to decrease anxiety and pain that can be experienced in anticipation of sexual intercourse among populations of women with sexual pain syndromes. Postmenopausal women, cancer survivors, and women with a wide variety of pelvic floor disorders who experience genito-pelvic pain/penetration disorder (GPPPD) are often advised to incorporate vaginal dilators into their pelvic floor rehabilitation program and treatment regimens to enable penetrative intercourse with less pain. However, little is known about the behaviors of dilator users, what treatment protocols are most effective, how patients are currently using their dilators, and how effective are clinicians in helping their patients achieve success with their dilation therapy.

METHODS

A recent PubMed literature search was performed using the key words vaginal dilator, vaginal dilator therapy, sexual quality of life, vaginal stenosis, vaginal dilation, vaginismus. A total of 29 English articles were reviewed and summarized. Articles were excluded for the following reasons: not in English and unrelated to dilator therapy.

MAIN OUTCOME MEASURE

This article will summarize the current research on vaginal dilators and discuss needs for future research to maximize patients' compliance and success with this treatment. Much of the summary data regarding user behavior will come from the early survey data with Milli, a novel, patient-controlled electronic dilator that slowly expands 1 mm at a time from its smallest diameter, 15 mm to a maximum diameter of 40 mm. Milli is currently being used by more than 1,000 women, and 3-month follow-up data were recorded on 335 of those patients.

RESULTS

Dilators exist in multiple forms (plastic, latex, and medical grade material), may come individually or in sets, and many have special features such as vibration or the ability to be heated or cooled before use. Little is known about patients' use of dilators and the Milli's 3-month survey serves as an insight to patient dilator behavior. The most common medical goals for patients undergoing dilation treatment were return to penetrative intercourse and pain reduction during coitus. Patients were dilated on average 2.72 days/week; 56.8% of patients had suffered from sexual pain for 2 or more years and 36.3% had previously used static dilators. More than 70% of Milli users purchased Milli and are using Milli without the direct guidance of a clinician. The most common emotions patients used to describe their treatment were not only "anxious," "frustrated," but also "empowered" and "optimistic." The most common dilatory session duration was 6-10 minutes, mostly in the evening/bedtime (68.3%), located in the bedroom (96.8%). Adjunctive treatment included the following: vaginal moisturizers, local estrogen products, coital lubricants, and genital pelvic floor physical therapy. During the dilation sessions, women most often watched TV/videos, practiced mindfulness, or listened to soothing music. Factors that showed trends toward improved patient outcomes were length of dilation treatment (greater than 3 months) and use of meditation and soothing music. Factors not associated with improvement trends were as follows: when/where patients dilated and patient demographics including age, race, or religious preferences.

CONCLUSION

Patients who purchase dilators have often suffered with their condition for a long time and had difficulty finding a competent health-care clinician well versed in sexual pain syndromes that can help them. When patients did find a clinician, there were no clinically proven standardized protocols or formalized guidelines to give to patients about how to best use their dilators. Larger long-term interventions investigating a standardized dilation protocol are planned in future studies to better elucidate the effective and optimal dilation treatment plans. Liu M, Juravic M, Mazza G, et al. Vaginal Dilators: Issues and Answers. Sex Med Rev 2021;9:212-220.

Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges

INTRODUCTION

Chronic vulvar pain is a multidimensional condition with great variability in clinical presentation among affected women. In a companion article, part 1, we reviewed and recommended assessment and measurement tools for vulvar pain and related outcomes with a view toward improving consistency and comparison across studies. Yet methodological challenges to conducting research with this population remain and can further hinder conclusions regarding etiology and treatment.

AIM

To discuss methodological challenges to conducting vulvar pain research alongside recommended solutions.

METHODS

The expert authors reviewed the scientific evidence related to the study of vulvar pain and made decisions regarding methodological challenges and mitigation strategies via discussion and consensus.

MAIN OUTCOME MEASURE

We articulated key challenges to conducting research in this area and formulated recommendations for mitigating these challenges.

RESULTS

Challenges to the field include selection and sample biases, heterogeneity of the condition, inclusion of the partner, and neglect of the multidimensional aspects of vulvar pain. 2 key recommendations are more careful and detailed tracking and characterization of research samples and greater multidisciplinary collaboration to better capture the complexity of chronic vulvar pain.

CLINICAL IMPLICATIONS

This methodological critique points to several challenges to clinical research with populations struggling with chronic vulvar pain and makes suggestions for how to mitigate these issues.

STRENGTH & LIMITATIONS

Comments in this expert review raise awareness regarding core challenges to the study of vulvar pain and can inform study design of clinical research with this population. The content of this review is based on expert knowledge and opinion rather than a formal systematic review or extended consultation process.

CONCLUSION

A careful reflection upon methodological challenges facing clinical research of vulvar pain and ways to mitigate such challenges is crucial for improving the quality, generalizability, and uptake of research findings. Rosen NO, Bergeron S, Pukall CF. Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges. J Sex Med 2020; 17:595-602.

Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches

Vulvodynia is a common, recurrent, vulvar pain condition with debilitating consequences for affected women's health and quality of life. The heterogeneity of women suffering from vulvodynia as well as its uncertain and likely multifactorial etiology pose a significant challenge to identifying any kind of "gold standard" treatment. Thus, treatment providers must be well versed in the various options and the evidence for each. In this review, we begin with pharmacological treatments, followed by non-pharmacological treatments, surgery, and finally multimodal treatments. For each approach, we briefly discuss the method, mechanism of action, and empirical support for the treatment. In sum, pharmacological treatments that may be beneficial but require further research include antinociceptive agents (lidocaine, capsaicin), anti-inflammatory agents (corticosteroids, interferon), neuromodulating medications (anticonvulsants and antidepressants), hormonal agents, and muscle relaxants (e.g., botulinum toxin). There is strong evidence to support and recommend non-pharmacological interventions including psychological therapy, pelvic floor physical therapy, as well as surgery (i.e., vestibulectomy for provoked vestibulodynia) for the treatment of vulvodynia. We conclude this review with a discussion of issues that may have hindered progress of treatment efficacy and effectiveness, and recommendations for moving the field forward.

A Descriptive and Longitudinal Analysis of Pain During Intercourse in Pregnancy

INTRODUCTION

Pain during vaginal intercourse in pregnancy has largely been ignored despite physiological and psychological components of pregnancy that may be associated with its onset and persistence.

AIM

The current study aimed to determine the prevalence and the characteristics of clinically significant pain during intercourse in the second (18-24 weeks) and third (32-36 weeks) trimesters of pregnancy.

METHODS

Pregnant women (N = 501) recruited from a local women's hospital completed an online survey in the second and third trimesters of their pregnancy regarding the presence, intensity, and characteristics of pain during intercourse. Women with clinically significant pain (ie, pain greater than or equal to 4 of 10 on a numerical rating scale) were grouped according to whether the pain was resolved, persistent, or new onset across the 2 pregnancy time points. Following guidelines outlined by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), we conducted a descriptive analysis assessing the intensity and characteristics (eg, quality, onset, degree of improvement over time, and treatment strategies utilized) of clinically significant pain during intercourse.

MAIN OUTCOME MEASURE

The main outcome measures in this study were the prevalence, intensity, and characteristics of clinically significant pain during intercourse.

RESULTS

Overall, 21% of pregnant women (106/501) reported clinically significant pain during intercourse. We found that 22% (N = 16/106) of women who had this pain at 20 weeks reported that it had resolved at 34 weeks, 33% (40/106) reported persistent pain at both time points, and 46% (50/106) reported new onset of pain during intercourse at 34 weeks. The majority of women across all pain groups reported that the pain began during pregnancy and remained at the same intensity. Most women reported not using any pain management strategies to cope with their pain.

CLINICAL IMPLICATIONS

One in 5 women experienced clinically significant pain during intercourse in pregnancy, with the majority of women not seeking treatment.

STRENGTHS & LIMITATIONS

This study is the first to comprehensively assess and describe the prevalence and characteristics of clinically significant pain during intercourse across 2 time points in pregnancy using IMMPACT guidelines. Small sample sizes in our pain groups may limit the generalizability of pain characteristics.

CONCLUSION

Findings suggest that many pregnant women in this study experienced significant pain during intercourse in pregnancy. Understanding the characteristics of this pain may improve its identification by health care providers and inform better prevention and treatment recommendations. Rossi MA, Mooney KM, Binik YM, et al. A Descriptive and Longitudinal Analysis of Pain During Intercourse in Pregnancy. J Sex Med 2019;16:1966-1977.

The Clinical Utility of the Vulvar Pain Assessment Questionnaire: A Pilot Study

OBJECTIVE

The aim of the study was to document treatment-seeking experiences of women with chronic vulvar pain, comfort communicating about pain, and test the clinical utility of the screening version of the Vulvar Pain Assessment Questionnaire, screening version (VPAQscreen).

MATERIALS AND METHODS

Patients scheduled for an appointment with the Program in Vulvar Health at Oregon Health and Science University were invited to complete the VPAQscreen and answer descriptive questions about previous treatment-seeking experiences and communication with health care providers. Clinicians provided provisional diagnoses based on VPAQscreen summaries, final diagnoses based on gynecological examination, and commented on alignment with clinical observations. Patients gave feedback on the accuracy and helpfulness of the VPAQscreen summary, characteristics of the questions asked, and whether their comfort communicating increased.

RESULTS

Participants reported previously seeing approximately 5 medical doctors and 2 other health care providers and perceived them as lacking knowledge of vulvar pain syndromes. Providers indicated that VPAQscreen summaries aligned with clinical presentations and suggested provisional diagnoses with more than 80% accuracy. Participants reported that VPAQscreen summaries were helpful and accurate in summarizing symptoms. Most reported that the number, range, and readability of VPAQscreen questions were good or excellent. More than half reported that completing the VPAQscreen increased comfort when speaking with their Oregon Health and Science University physician.

CONCLUSIONS

Patients with vulvar pain often endure a lengthy process of consulting multiple clinicians before securing care. The VPAQscreen was more than 80% accurate in predicting diagnosis at this specialty clinic and was useful in assisting patients with expressing symptoms. The applicability of the VPAQscreen in general practice is unknown, although it shows promise.

Sensory processing of women diagnosed with genito-pelvic pain/penetration disorder: a research proposal

Objectives

The study objectives are to describe the sensory processing patterns of women diagnosed with genito-pelvic pain/penetration disorder (GPPPD), to explore the level of anxiety when both GPPPD and sensory processing disorder (SPD) are present and to investigate participants’ experience of participating in a sensory-based home programme.

Methods

A descriptive two-phased study design will be used. Phase one is a quantitative, cross sectional non-experimental descriptive study, using the Adolescent/Adult Sensory History (ASH) and Hospital Anxiety and Depression Scales (HADS) to obtain data from purposive sampling. Phase two is an exploratory qualitative study involving participants who were identified with SPD in phase one. They will participate in a sensory-based home programme and their experience thereof will be established during semi-structured interviews.

Outcomes

Descriptive studies are known to be useful in planning health services and to develop hypotheses for future testing. This study could improve practitioners’ understanding of GPPPD and SPD and make alternative, non-invasive, non-pharmacological treatment options available to better assist these patients. The study could further clarify the role of the occupational therapist in sexuality. Exploring participants’ anxiety has important implications for treatment protocols in occupational therapy and assisting in describing the signs and symptoms of GPPPD.

Genito-Pelvic Pain Through a Dyadic Lens: Moving Toward an Interpersonal Emotion Regulation Model of Women's Sexual Dysfunction

Researchers and clinicians alike widely acknowledge the inherently interpersonal nature of women's sexual dysfunctions given that both partners impact and are impacted by these difficulties. Yet theoretical models for understanding the role of interpersonal factors in women's sexual dysfunctions are severely lacking and have the potential to guide future research and inform more effective interventions. The most widely studied sexual dysfunction in women that has espoused a dyadic approach by including both members of affected couples is genito-pelvic pain/penetration disorder (GPPPD). In this article we use the example of GPPPD to introduce a novel interpersonal emotion regulation model of women's sexual dysfunction. We first review current knowledge regarding distal and proximal interpersonal factors in GPPPD. Then, we describe our theoretical model and consider relevant pain and sex-related research on emotion regulation processes-emotional awareness, expression, and experience-in the context of GPPPD, including sexual function, satisfaction, and distress. Next, we review how existing theories from the fields of chronic pain and sex and relationships research have informed our model and how our model further builds on them. Finally, we discuss the implications of our model and its applications, including to other sexual dysfunctions in women.

Sexual Distress Mediates the Associations Between Sexual Contingent Self-Worth and Well-Being in Women With Genitopelvic Pain: A Dyadic Daily Experience Study

Provoked vestibulodynia (PVD), a common cause of women's genitopelvic pain, is associated with poorer psychological and sexual well-being in affected couples. Greater sexual contingent self-worth (CSW)-defined as self-esteem that is dependent on the perceived success or failure of a sexual relationship-has been linked to poorer well-being in a cross-sectional study of couples coping with PVD. This study aimed to examine whether daily sexual distress mediated the associations between greater sexual CSW and lower sexual satisfaction and greater anxiety, depressed mood, and women's pain in affected couples. Women (N = 125) diagnosed with PVD and their partners completed the Sexual CSW Scale and then online daily surveys for eight weeks measuring sexual distress, sexual satisfaction, anxiety, depressed mood, and women's pain during intercourse. Multilevel analyses were based on the actor-partner interdependence model (APIM). For women who had higher sexual CSW (compared to lower sexual CSW), on sexual activity days when their sexual distress was higher, they reported lower sexual satisfaction and greater anxiety, depressed mood, and pain (compared to their average level across all sexual activity days). Findings suggest that daily sexual distress may be one pathway between greater sexual CSW and poorer day-to-day well-being in women with PVD.

The Mediating Role of Sexual Behavior in Event-Level Associations Between Sexual Difficulties and Sexual Satisfaction in Newlywed Mixed-Sex Couples

INTRODUCTION

Many sexual difficulties encountered by couples in their day-to-day lives, although of insufficient intensity and persistence to warrant a clinical diagnosis of sexual disorder, are nevertheless frequent and a source of individual and relational distress.

AIM

The aim of this study was to assess the event-level associations between couples' everyday, subclinical sexual difficulties (specifically, low subjective sexual arousal, low physiological sexual arousal, and genito-pelvic pain), the range of sexual behaviors that these couples engage in, and their sexual satisfaction.

METHODS

70 Newlywed participants (35 couples, average age = 25.6 years, SD = 3.2 years; average duration of relationship = 5.4 years, SD = 3.4 years) individually completed daily diaries about sexual difficulties, range of activities performed during sex, and sexual satisfaction over the course of 5 weeks. Analyses were guided by the actor-partner interdependence model.

MAIN OUTCOME MEASURE

The main outcome was sexual satisfaction, measured at the event-level on a 5-point Likert scale using a single-item question.

RESULTS

On days of sexual activity, men and women's difficulties with subjective sexual arousal were associated with lower sexual satisfaction in both partners (actor and partner effects). This association was mediated by the range of couples' sexual behaviors, such that lower subjective arousal was associated with a more restricted range of sexual activities, which in turn was associated with lower sexual satisfaction. Men's and women's difficulties with physiological sexual arousal, and women's genito-pelvic pain, were each associated with their own lower sexual satisfaction. No partner effects were observed for these sexual difficulties, nor were they mediated by the range of couples' sexual activities.

CLINICAL IMPLICATIONS

The study's results highlight how couples' sexual difficulties can interfere with same-day sexual satisfaction, and how for subjective sexual arousal, this interference is reflected by a more restricted range of sexual behaviors.

STRENGTH & LIMITATIONS

Strengths of the study include the daily diary methodology, which allowed a focus on event-level sexual activities with minimal retrospective bias. Further, the dyadic analyses allowed both intra-individual and inter-individual effects to be assessed. Limitations include the lack of a more general measure of sexual desire and of a more diverse sample, in terms of age, race, and sexual orientation.

CONCLUSION

These findings underscore the importance of treatments that include both partners, and that target the types as well as range of sexual activities in which couples engage. Jodouin J-F, Bergeron S, Janssen E. The Mediating Role of Sexual Behavior in Event-Level Associations Between Sexual Difficulties and Sexual Satisfaction in Newlywed Mixed-Sex Couples. J Sex Med 2018;15:1384-1392.

When Self-Worth Is Tied to One's Sexual and Romantic Relationship: Associations with Well-Being in Couples Coping with Genito-Pelvic Pain

Contingent self-worth (CSW; the pursuit of self-esteem via a particular domain in one's life) impacts well-being based on one's perceived success or failure in the contingent domain. In a community sample, individuals with sexual problems reported greater sexual CSW-self-worth dependent on maintaining a sexual relationship-than those without problems. Couples coping with provoked vestibulodynia (PVD), a genito-pelvic pain condition, perceive failures in their sexual relationship, which could be associated with more pain and poorer well-being. In contrast, relationship CSW-self-worth dependent on the overall romantic relationship-may act as a buffer against adverse outcomes. Eighty-two women with PVD and their partners completed online standardized measures of sexual and relationship CSW, sexual distress and satisfaction, relationship satisfaction, and depressive symptoms, and women reported their pain intensity. Analyses were based on the actor-partner interdependence model. Women with PVD who reported greater sexual CSW experienced more sexual distress and pain. Additionally, when partners reported greater sexual CSW, they were less sexually and relationally satisfied and more sexually distressed, and women had greater depressive symptoms and lower relationship satisfaction. In contrast, when partners reported higher relationship CSW, they were more sexually and relationally satisfied and less sexually distressed, and women reported lower depressive symptoms and greater relationship satisfaction. Results suggest that couples' (particularly partners') greater sexual CSW is linked to poorer sexual, relational, and psychological well-being in couples affected by PVD, whereas partners' greater relationship CSW is associated with better well-being. Thus, sexual and relationship CSW may be important treatment targets for interventions aimed at improving how couples adjust to PVD.

Avoiding or enduring painful sex? A prospective study of coping and psychosexual function in vulvovaginal pain

BACKGROUND

Recurring vulvovaginal pain is common, with evident effects on affected women's lives. Little is known about how affected women cope with painful sexual activities and how coping relates to pain intensity and psychosexual functioning over time. This prospective study explored the impact of avoidance and endurance on sexual function over time. Additionally, patterns of coping were studied on an individual level to increase knowledge about coping and its relation to psychosexual functioning.

METHODS

One hundred and seventeen women, 18-35 years old, with recurring vulvovaginal pain answered questionnaires at two measurement points, five months apart, assessing avoidance and endurance coping, pain intensity and psychosexual functioning. A multiple regression model explored the predictive value of avoidance and endurance on sexual function over time. Cluster analyses investigated patterns of coping and stability within the clusters. These subgroups were compared on psychosexual outcomes.

RESULTS

Avoidance at baseline was the only significant predictor of sexual function five months later. Distinct and stable subgroups with different patterns of coping were identified, where avoidance and endurance coping were used both separately and combined. Women who both avoided and endured had the most unfavourable outcomes in terms of psychosexual functioning.

CONCLUSIONS

Avoidance of sexual activities was related to reduced sexual function over time, which calls for attention and clinical interventions targeting avoidance. Additionally, women who both avoid and endure sexual activities despite pain possibly need tailored interventions, as women with this coping pattern reported the lowest levels of psychosexual functioning.

SIGNIFICANCE

In this prospective study, avoidance of sexual activities predicted sexual function over time, when controlling for pain intensity. Subgroups of women using distinct patterns of coping were identified. Those who both avoided and endured had the lowest levels of psychosexual functioning.

Communal motivation in couples coping with vulvodynia: Sexual distress mediates associations with pain, depression, and anxiety

OBJECTIVE

To examine the role of a novel motivational perspective-sexual communal motivation-in women's pain during intercourse and both partners' distress in couples coping with vulvodynia, a prevalent gynecological pain condition. Our goal was to test whether sexual communal strength (i.e., motivation to meet a partner's sexual needs) and unmitigated sexual communion (i.e., prioritization of a partner's sexual needs in neglect of one's own needs) were indirectly associated with pain, depression, and anxiety via sexual distress.

METHODS

Couples (N=101) completed daily surveys about their sexual communal motivation, sexual distress, anxiety, depression, and women reported on their pain during intercourse. Using multilevel modeling, we examined how daily fluctuations in sexual communal motivation were directly and indirectly (via sexual distress) associated with pain and psychological distress.

RESULTS

On days when women with vulvodynia reported higher sexual communal strength, they reported less pain and anxiety, and on days when they reported higher unmitigated sexual communion, they reported more pain, more anxiety, and both partners reported more depressive symptoms. Daily associations between women's unmitigated sexual communion and greater pain, depression and anxiety were mediated by sexual distress.

CONCLUSIONS

Being motivated to meet a partner's sexual needs was associated with less pain and anxiety for women with vulvodynia, but when this motivation excluded a focus on one's own needs, there were detrimental consequences for women's pain and both partners' depressive symptoms. Interventions for improving women's pain and the psychological well-being of affected couples should target motivational factors and sexual distress.

Psychosocial impact of endometriosis: From co-morbidity to intervention

Endometriosis-associated pelvic pain is a major health concern in women of childbearing age. Controlled studies have shown that endometriosis can adversely affect women and their partners' general psychological well-being, relationship adjustment and overall quality of life. Furthermore, women with endometriosis report significantly more sexual dysfunctions compared to healthy women. Empirical studies indicate that specific psychosocial factors may modulate pain experience, pain-related distress and treatment outcome. Research on psychosexual interventions in endometriosis treatment is limited but shows to be effective in reducing endometriosis-related pain and associated psychosexual outcomes. An individualized, couple-centered, multimodal approach to care, integrating psychosexual and medical management for endometriosis, is thought to be optimal.

Daily Anxiety and Depressive Symptoms in Couples Coping With Vulvodynia: Associations With Women's Pain, Women's Sexual Function, and Both Partners' Sexual Distress

Vulvodynia is a idiopathic vulvovaginal pain condition that interferes with the sexual and mental health of affected couples. Research has underscored that psychological factors, such as anxiety and depression, are associated with its development and maintenance and related sexual impairment. However, the daily role of anxiety and depressive symptoms in the pain and sexuality outcomes of couples coping with vulvodynia is not well understood. Using a dyadic daily experience method, 127 women (mean age = 26.21, SD = 6.24 years) diagnosed with vulvodynia and their partners (mean age = 27.44, SD = 7.29 years) reported on anxiety and depressive symptoms, pain, sexual function, and sexual distress over a period of 8 weeks. Multilevel modeling was used to examine how daily deviations in anxiety and depressive symptoms from a participant's own mean were associated with pain, sexual function, and sexual distress. On days of sexual activity, when women reported higher anxiety and depressive symptoms (compared with their average), they reported greater pain and lower sexual function. On days of sexual activity, when women reported higher depressive symptoms, they reported greater levels of sexual distress, and when partners reported higher anxiety and depressive symptoms, women as well as partners reported greater levels of sexual distress. Results suggest that daily anxiety and depressive symptoms play a role in women's experience of vulvodynia-related pain, women's sexual function, and the couple's sexual distress. Targeting daily anxiety and depressive symptoms could enhance the efficacy of psychological interventions for vulvodynia.

PERSPECTIVE

This article examines the daily associations between anxiety and depressive symptoms, women's pain, sexual function, and sexual distress among couples coping with vulvodynia. Findings contribute to refine the biopsychosocial model of pain, showing that daily affective factors are associated with pain and sexual well-being.

Understanding the Sexual Satisfaction of Women With Provoked Vestibulodynia and Their Partners: Comparison With Matched Controls

Provoked vestibulodynia (PVD)-a recurrent, localized vulvar pain-interferes with couples' sexual relationships as evidenced by lower sexual satisfaction compared to controls. Little is known about what components of sexual satisfaction contribute to this lower satisfaction. Using the Interpersonal Exchange Model of Sexual Satisfaction (IEMSS), we compared the sexual exchanges (sexual rewards and costs, relative sexual rewards and costs, balance of sexual rewards and costs, balance of relative sexual rewards and costs, equality of sexual rewards and costs) and sexual satisfaction of 50 women with PVD and their male partners to 50 matched-control couples. We also compared women with PVD and their partners on these same components. Participants completed standardized measures of sexual exchanges and sexual satisfaction. Women with PVD and their partners reported lower relative sexual rewards, a less favorable balance of relative sexual rewards to costs, and lower sexual satisfaction than controls, although differences were larger for women. Women with PVD also reported lower levels of sexual rewards, higher levels of sexual costs, a less favorable balance of sexual rewards to costs, and lower equality of sexual costs, than control women. Findings identify IEMSS exchange components that may contribute to overall lower satisfaction in couples affected by PVD.

Anxiety Mediates the Relation Between Childhood Sexual Abuse and Genito-Pelvic Pain in Adolescent Girls

Previous research has demonstrated associations between child sexual abuse, anxiety, and genito-pelvic pain, but no study to date has examined whether sexual abuse may be associated with genito-pelvic pain through victims' elevated anxiety. The present study aimed to determine whether anxiety mediates the relationship between child sexual abuse and genito-pelvic pain. Using self-report questionnaires, data were gathered from 218 sexually active adolescent girls recruited from seven metropolitan high schools. As expected, results revealed a significant indirect effect of sexual abuse on the development of genito-pelvic pain through trait anxiety. This study thus suggests that anxiety may be one of the mechanisms by which child sexual abuse leads to an increased risk of developing genito-pelvic pain in this population.

Interpersonal Goals and Well-Being in Couples Coping with Genito-Pelvic Pain

In the context of genito-pelvic pain, consideration of interpersonal goals is particularly relevant given that couples' distress is often predicated upon the relational setting. However, relationship goals have not been examined in this population. We investigated (1) the associations between relationship goals and women's pain during intercourse as well as the sexual, relational, and psychological well-being of women with provoked vestibulodynia (PVD) and their partners and (2) the moderating role of sexual goals in these associations. Women with PVD (N = 134) and their partners completed measures of relationship goals, sexual goals, sexual satisfaction, relationship satisfaction, and depressive symptoms. Women also reported on their average pain intensity during intercourse. Women with stronger relationship approach goals reported more sexual satisfaction. When the partner pursued more relationship approach goals, both women and partners reported more sexual and relationship satisfaction and partners reported less depression. Stronger relationship avoidance goals in the partner were associated with less sexual satisfaction in women. Several significant interactions showed that the combination of relationship and sexual approach goals was associated with greater relationship and sexual satisfaction, and fewer depressive symptoms, whereas the combination of relationship and sexual avoidance goals was related to lower relationship satisfaction as well as to greater pain during intercourse for women. Targeting relationship approach and avoidance goals as well as those goals specific to sexual activity may improve the quality and efficacy of couples-based psychological interventions for PVD.

A Comparison of Approach and Avoidance Sexual Goals in Couples With Vulvodynia and Community Controls

BACKGROUND

Provoked vestibulodynia (PVD) is a prevalent form of vulvodynia that interferes with the sexual and relational functioning of affected couples. Approach and avoidance sexual goals are associated with the sexual and relationship well-being of women with PVD and their partners. However, whether sexual goals differ in couples coping with PVD compared with community couples is unknown.

AIMS

To compare the approach and avoidance sexual goals of women with PVD and their partners with a control sample of community women and their partners to build on an established motivational model and to compare the sexual goals of women with PVD with those of their partners.

METHODS

Women diagnosed with PVD and their partners (n = 161) and control couples (n = 172) completed measures of approach and avoidance sexual goals.

OUTCOME

Approach and Avoidance Sexual Goals Questionnaire.

RESULTS

Women with PVD reported lower approach and higher avoidance sexual goals than control women, whereas partners of women with PVD did not differ from control partners in their sexual goals. Women with PVD also reported lower approach and higher avoidance sexual goals compared with their partners, whereas there were no differences between partners in the control sample.

CLINICAL IMPLICATIONS

Given that avoidance sexual goals have been linked to negative sexual and relational outcomes, clinicians could strive to help couples with PVD become aware of their sexual motives, with the aim of weakening avoidance sexual goals and bolstering approach sexual goals.

STRENGTHS AND LIMITATIONS

This is the first study to empirically document differences in sexual goals between couples affected by PVD and community couples. Limitations include the study's correlational design, differences in demographic characteristics between samples, and the homogeneity of participants' sexual orientation.

CONCLUSIONS

Findings suggest that the sexual goals of women affected by PVD differ from those of community women and from their partners and support sexual goals as targets for psychological interventions to help couples coping with PVD. Dubé JP, Bergeron S, Muise A, et al. A Comparison of Approach and Avoidance Sexual Goals in Couples With Vulvodynia and Community Controls. J Sex Med 2017;14:1412-1420.

Beyond the Bedroom: Cognitive, Affective, and Behavioral Responses to Partner Touch in Women With and Without Sexual Problems

Women with female sexual problems (FSP) are more likely than unaffected women to demonstrate negative appraisals, negative affect, and avoidance of sexual activity. Research suggests affected women also experience negative affect and avoidance in response to intimate partner contact for fear it will lead to sex. This online study examined whether women with FSP (N = 157) and without FSP (N = 129) exhibited different perceptions, affective reactions, and behavioral responses to hypothetical touch occurring outside sexual activity. Women (M_age = 30.70; SD = 6.66) were randomly assigned to one of three conditions representing hypothetical interactions with their partner (affectionate, sexual, or no touch), and answered questions about their perceptions of their partner's sexual intentions and their own anticipated negative affect and behavioral avoidance. Women with FSP reported higher perceptions of sexual intent, negative affect, and avoidance in the sexual touch condition, and higher negative affect in the affectionate touch condition, than women without FSP. Results highlight that women with FSP have more negative reactions to partners' hypothetical affectionate and sexual touch than women without FSP. Interventions for FSP may benefit from targeting women's perceptions, affective reactions, and behavioral reactions to partner touch when it occurs outside of explicitly sexual contexts.

Talking About Sex When Sex Is Painful: Dyadic Sexual Communication Is Associated With Women's Pain, and Couples' Sexual and Psychological Outcomes in Provoked Vestibulodynia

Provoked vestibulodynia (PVD) is a recurrent vulvovaginal pain condition associated with psychological and sexual consequences for affected women and their partners, including lower quality of dyadic sexual communication compared to pain-free couples. Although greater sexual communication is associated with positive sexual and relational outcomes for both pain-free couples and couples experiencing painful sex, little is known about its role in women's pain and psychological outcomes, especially in a relational context. The present study examined associations between dyadic sexual communication and pain, sexual satisfaction, sexual functioning, and depressive symptoms in a sample of 107 couples in which the woman was diagnosed with PVD via a standardized gynecological assessment. Women completed a measure of pain intensity, and both members of the couple completed measures of their dyadic sexual communication, sexual satisfaction, sexual functioning, and depressive symptoms. Analyses were guided by the actor-partner interdependence model. Women and partners' own perceptions of greater dyadic sexual communication were associated with their own greater sexual satisfaction and sexual functioning, and lower depressive symptoms. Partners' perceptions of greater dyadic sexual communication were also associated with women's lower pain and greater sexual satisfaction. Results point to the importance of dyadic coping conceptualizations for both individual and interpersonal outcomes in PVD. Dyadic sexual communication may be a key treatment target for interventions aimed at improving the pain and psychological and sexual impairments of women with PVD and their partners.