Abstract
Pain during intercourse or dyspareunia is poorly understood, although it is a common complaint among women. Epidemiological studies indicate that the prevalence ranges from 12 to 21% among premenopausal adult women, and its incidence is thought to be increasing [1,2]. In the Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR), the symptom criterion for dyspareunia is defined as “recurrent or persistent genital pain associated with sexual intercourse” [3]. However, many women also report pain during nonsexual activities, and therefore, it also impacts on general mental and physical wellbeing and relationship adjustment [4,5]. Dyspareunia, together with vaginismus (a recurrent and persistent involuntary spasm of the musculature of the outer-third of the vagina that interferes with sexual intercourse [3]), is included in the diagnostic category of sexual pain disorders in the DSM-IV as a subcategory of sexual dysfunctions. The sexual pain disorders are thereby the only pain disorders outside of the diagnostic category of ‘pain disorder’ in the DSM-IV. They are also the only pain diagnoses primarily defined by the activity they are interfering with, namely, intercourse. In addition, the sexual pain disorders are specified using categories such as ‘lifelong/acquired’, ‘general/situational’ and ‘psychological/combined factors’, which differs from how the pain component in other pain conditions are commonly specified in terms of pain location, timing and pain quality [6]. Taken together, this suggests that there is something unique about sexual pain disorders that requires a separate classification and model of explanation.
However, there is an increasing focus on the pain component of sexual pain, spurring the arguments that sexual pain is best viewed from a biopsychosocial perspective as a pain disorder [7]. The biopsychosocial perspective of pain is based on the complex interactions between physiological processes, psychological mechanisms and the changing social context [8]. It has paved the way for advances in the understanding of how acute pain may develop into persistent pain, as well as how clinicians might treat and prevent this [9]. Examining dyspareunia from a biopsychosocial perspective is an upcoming trend within the field of sexual pain [10]. Sexual dysfunctions have successively been viewed as multifactorial conditions from a biopsychosocial perspective by both clinicians and scientists [11]. However, there is still a lack of theoretical models describing the psychosocial mechanisms involved in the development of dyspareunia. In addition, there is an urgent need to better understand the central components necessary to successfully treat sexual pain. Fortunately, advances have been made in the field of pain and models established there might be generalized to sexual pain in order to increase our understanding.
To describe the psychological processes involved in the transition from acute to chronic pain in musculoskeletal disorders (e.g., back pain and neck–shoulder pain), Vlaeyen and Linton developed the fear-avoidance (FA) model, shown in
The fear-avoidance model.
The aim of the review is threefold. First we will examine how the view on intercourse pain has changed during the last 20 years from sexual dysfunction to a focus on pain. Here we will examine how the conceptualization of dyspareunia as a pain problem demands the generalization of knowledge and models that are well known from other pain problems. Second, we will review how well the research on psychological factors in dyspareunia fit with the FA model as a theoretical frame of reference. Third, we will underscore important limitations in the research on sexual pain and outline future directions for research and clinical applications. In the present review, the focus is on the experience of pain during sexual penetration and is therefore not guided by specific diagnostic labeling. The literature was searched for terms including dyspareunia, vulvodynia, provoked vestibulodynia, vulvar vestibulitis and/or sexual pain. Pelvic pain literature was, however, not included since this term is not as clearly described as pain during intercourse, although this may be a common symptom.
Dyspareunia: from sexual dysfunction to persistent pain
The view of dyspareunia has gone through important changes during the last decade and the pendulum has swung towards a conceptualization with a greater focus on it as a pain problem best understood from a biopsychosocial perspective, rather than the previous categorization as a psychosexual disturbance diagnosed as a sexual dysfunction. In 2005, a well-cited paper by Binik questioned the DSM categorization of sexual pain as sexual dysfunction and instead proposed that dyspareunia should be viewed as a pain disorder. In addition, the separation of sexual pain from other pain disorders has been discussed since their presentations show several similarities [7,17]. The DSM-IV defines sexual dysfunctions in terms of a dysfunction in one of the various phases of the sexual response cycle (i.e., desire, arousal and orgasm). Dyspareunia has been associated with other types of sexual dysfunctions (e.g., lack of arousal and difficulties reaching orgasm) [19,20]. However, women with sexual pain have not been found to differ from normal populations with regard to physiological genital responsiveness to sexual stimuli, although women with dyspareunia commonly report lower subjectively experienced sexual arousal [21]. This was interpreted as women with dyspareunia primarily suffering from pain conditioned to the sexual situation, rather than pain caused by an insufficient sexual response. Payne et al. assessed the influence of sexual arousal on genital and nongenital sensation in women with vulvar pain compared with controls [22]. They also examined the theory that painful intercourse is associated with insufficient sexual arousal. Participants underwent genital and nongenital sensory testing at baseline and in response to erotic and neutral stimulus films. Their data suggest that, contrary to some theories, women with vulvar pain are not lacking in physiological sexual arousal. However, lack of subjective sexual arousal may yet be implicated in vulvar pain during intercourse [21,22]. Indeed, the anticipation of pain directly acts to disturb both the physiological and psychological sexual response, and thereby results in further sexual dysfunctions [23]. These findings indicate that although women with dyspareunia commonly report comorbid sexual dysfunctions, their physiological sexual arousal is not reduced and their subjective experience of dyspareunia might be more closely associated to the pain context rather than to sex. Since intercourse is experienced as painful, the sexual situation will likely be conditioned to pain, which may disturb both the physiological and psychological sexual response, and thereby results in further sexual dysfunction as described above [23]. Thus, the association between dyspareunia and sexual dysfunctions may be the result of repeated experiences of sex associated with pain and fear of pain. The fearful reaction in turn negatively affects desire, arousal and lubrication.
The DSM-IV definition of sexual pain rests on the fact that these disorders are defined by their interference with intercourse. However, women suffering from sexual pain disorders commonly report pain in a wide variety of activities such as during tampon- or finger-insertion, gynecological examinations, when wearing tight clothes, during mental stress and in physical activities such as horse riding or bicycling [20,24]. Research has also shown that pain during intercourse has similar experiential, psychophysical and neurological properties to other pain syndromes [25–31]. In addition, many women suffering from dyspareunia report pain before their first intercourse experience, at younger ages from their first attempt to insert a tampon [32]. It appears that stimulation of the painful area produces pain regardless of the activity. Other nongenital pain conditions may also interfere with sexual function. For example, lower back pain may limit a man's pelvic motility during intercourse, thereby hindering him to achieve sufficient stimulation to reach orgasm. Yet sexual impairment is not considered central to this diagnosis since the pain is not genital. Describing pain during intercourse as a sexual disorder, therefore, limits the pain to a certain context, which results in an inadequate picture of the problem.
Due to the lack of reliability for the current DSM-IV diagnoses of vaginismus and dyspareunia and the inability to differentially diagnose them, a revision of the sexual pain diagnoses has been proposed for the upcoming fifth edition of the DSM. A new diagnostic category is proposed; ‘genito–pelvic pain/penetration disorder’. This revision still focuses on penetration but combines dyspareunia and vaginismus in the same diagnostic category by listing pain, fear and muscle tension as key symptoms in the diagnosis, in line with the arguments presented by Binik [7].
The International Society for the Study of Vulvovaginal Disease (ISSVD) has come up with a classification of vulvovaginal pain that is in line with the last decade's findings on genital pain among women. The ISSVD specifies ‘pain related to a specific disorder’ and ‘vulvodynia’, where the latter can be specified as generalized or localized and further described as provoked, unprovoked or mixed. The pain might be provoked by sexual or nonsexual stimulation or by both [33]. The categorization formulated by the ISSVD has thereby brought the terminology in line with that for other types of chronic pain syndromes. This change opens the door to the examination of similarities with other chronic pain conditions. Such comparisons are preferably guided by the use of theoretical and empirical validated pain models to generate hypotheses for future studies regarding central factors and causal mechanisms in pain development. Examining the relevance of the FA model in sexual pain might, therefore, contribute to increased knowledge regarding psychological mechanisms in dyspareunia and shed light on possible treatment methods.
An FA perspective on sexual pain among women
If sexual pain is to be described as a pain syndrome rather than as a sexual dysfunction, psychological mechanisms must be entertained as part of the biopsychosocial perspective. In this section, the authors consider the growing literature on psychosocial factors in sexual pain and relate them to the concepts of the FA model in the order in which they appear in the model (
Injury: pain-eliciting stimuli
In the FA model, the typical pain/fear eliciting stimuli in musculoskeletal pain is in most cases a specific injury, and thereafter pain is elicited by thoughts of reinjury, specific movements and so on. In sexual pain, attention has been directed toward the role of earlier traumas both in terms of sexual and/or physical abuse and as medical conditions causing physiological processes associated with pain. History of sexual and physical victimization has been the most examined etiologic psychosocial variable in dyspareunia. However, studies predominately refute an association [34–36]. Among women suffering from dyspareunia, there are findings that indicate that the association between pain and earlier trauma is mediated by the woman's own associations between her symptoms and the trauma. Women who perceive a link between their dyspareunia and past sexual abuse report worse sexual functioning than those who do not [37]. From a biomedical perspective, traumas could also predispose women to genital pain. For example, repeated yeast infections and urinary tract infections are reported to be linked to the development of sexual pain [38,39]. These factors might trigger an inflammatory process that leads to nociceptor sensitization in the vulvar region, causing pain during intercourse [40]. In addition, many young women with dyspareunia report pain onset during their first use of a tampon [32]. This might indicate an increased sensitivity in the nerve endings of the vagina, which for some women might also result in painful intercourse at the first attempt. Several findings have demonstrated increased innervation in women with vulvodynia as compared with nonaffected women [41–44]. This demands careful study of the psychophysiological mechanisms in dyspareunia over time.
In the absence of earlier traumas, the primary pain-eliciting stimuli for many women suffering from sexual pain is their first attempt to engage in intercourse. This could be due to a lack of sexual desire, arousal and consequently a lack of lubrication that increases the risk of painful penetration. Thereby, there is a risk that sexual situations in the future might be conditioned to fear of pain. When studying the function of pain, the original biomedical trigger is not of primary interest. In the FA model, the fear and avoidance are thought to be related to the experience of pain itself, and not only to the initial injury. Therefore, a handful of painful intercourse experiences are enough for a woman to develop fear and avoidance reactions to pain and an increased risk of recurrent pain irrespective of the initial type of trigger.
Catastrophizing
Pain is defined as an experience involving cognitive, emotional and motivational aspects [6]. Cognitive aspects involve how pain is perceived and interpreted and what attributions are associated with this perception. A common negative mental set present during actual or anticipated painful experience is catastrophizing [45]. Pain catastrophizing is characterized by pain-related helplessness, rumination about pain and magnification of the pain problem. Lately it has been suggested that pain catastrophizing represents a behavior pattern of repetitive negative thinking [46]. Catastrophizing has been linked to heightened disability, in order to predict disability and to predict pain and illness behavior [47–49]. The tendency to engage in pain catastrophizing has been found in dyspareunia [31,50], where a higher level of pain catastrophizing is associated with increased pain ratings [18], and negatively impacts the experience of intercourse [51]. Women with dyspareunia demonstrate levels of pain catastrophizing equal to those typical of individuals suffering from other chronic pain conditions [20]. Even in postmenopausal dyspareunia, where the pain is often regarded as a symptom of age-related hormonal changes, pain catastrophizing together with symptoms of depression and state-trait anxiety were among the most important predictors of vestibular pain [52]. In addition, among women suffering from sexual pain, a negative attributional style has been found to predict psychological, sexual and dyadic adjustment, independent of pain intensity [53]. In summary, although the research is sparse, catastrophizing appears to be an important element in the experience of sexual pain.
FA beliefs
According to the FA model, pain beliefs characterized by fear and avoidance play a vital role in the development of a chronic pain condition. These beliefs could be viewed as mirroring an overarching belief that ‘hurt equals harm’. Evidence supports the theory that FA beliefs are significant predictors of future disability in patients suffering from acute back pain [54,55]. Within sexual pain, research has also shown that compared with no-pain controls, women with dyspareunia report more fear of pain [22], and pain-related fear has also been identified as a significant predictor of increased pain sensitivity in this group [18]. In the sexual pain disorders, harm-avoidance beliefs have been associated with increased avoidance of sexual penetration [56]. In qualitative studies of couples living with vulvar pain, three common patterns of coping with pain and sex have been described: becoming nonsexual (complete avoidance of sexual intimacy), enduring painful intercourse and using alternatives to vaginal sex [57]. For women suffering from sexual pain, intercourse and sexual intimacy will be conditioned to fear of pain. In addition, sexual activity might over time be associated with negative emotions of shame, guilt and emotional distress, and many women and their partners describe that sexual activities are avoided, resulting in poorer sexual function [18] and decreased sexual satisfaction [58]. Avoidance of threat is a powerful mechanism in maintaining phobic reactions. By avoiding feared situations, habituation and fear reduction will not be experienced and correction of phobic beliefs will not take place. However, avoidance is not described in all women suffering from sexual pain. Instead of avoiding intercourse and thereby pain, many women continue having sexual intercourse despite of pain [4,56,59]. In a study of young women suffering from dyspareunia, several motives for continuing having intercourse despite pain were identified [60]. These women described a need to be affirmed in their image of an ideal women, which included willingness for sexual intercourse, being perceptive of the partner's sexual needs and satisfying these needs. In a similar study, Gordon and colleagues reported that women suffering from dyspareunia continued sexual activity despite significant levels of pain because of guilt and fear of losing their partner [61]. The behavior of ignoring and suppressing pain while activities are assumed, despite a worsening of symptoms, is identified as endurance coping [62] and has been described in other pain populations and associated with prolonged sick leave and functional disability [63]. Pain endurance in most pain conditions will result in physical tear of the painful area and threaten to worsen symptoms. Additionally, conditioning of the pain-eliciting activity and pain will be strengthened. To continue having intercourse despite the pain, in the absence of adequate arousal and lubrication, increases the risk of prolonged pain and maintenance of fear, catastrophizing and avoidance.
In the FA model shown in
Hypervigilance
Related to fear and avoidance is the tendency to over-attend to environmental stimuli that are perceived as threatening. In individuals suffering from pain, a specific attentional bias, which is a hypervigilance for pain-related information, is commonly described [66]. Hypervigilance for pain sensation is associated with increased pain ratings, avoidance and catastrophizing [67]. Payne and colleagues were the first to study attentional processes in women with dyspareunia using an implicit measure [17]. They showed that women with dyspareunia were hypervigilant to pain-relevant information as measured with an Emotional Stroop task. Desrochers showed that higher levels of hypervigilance, fear of pain and catastrophizing were related to increased pain in women suffering from dyspareunia [18]. Pain catastrophizing is also assumed to be influenced by threatening illness information [12]. The tendency to misinterpret bodily symptoms and to fear signs of anxiety is called anxiety sensitivity [68] and is known to negatively affect the ability to shift attention away from pain-related stimuli among chronic pain patients [69]. Anxiety sensitivity and somatically focused anxiety have been examined in dyspareunia and have been found to be related to a higher frequency of intercourse pain among younger women [70].
Disuse, disability & distress
Vlaeyen and Linton describe the development of disuse, disability and depression as negative consequences of fear and avoidance [12]. Disuse syndrome refers to the physiological and psychological effects of a reduced level of physical activity in daily life in terms of physical deconditioning as a consequence of reduced use of the musculoskeletal system and impairments in muscle coordination, leading to ‘guarded movements’. No study has, to the authors' knowledge, directly assessed the physical negative effects of avoidance in dyspareunia. However, there has been frequent studies of the activity of the pelvic floor musculature (PFM) in sexual pain, showing pelvic floor hypertonicity (i.e., increased tension) [20,71]. A recent study by Gentilcore-Saulnier and collegues showed significant PFM dysfunction among women with vulvodynia as compared with nonaffected women both in terms of higher PFM tone, decreased PFM flexibility and lower PFM relaxation capacity [72]. They also studied the effects of physical therapy addressing PFM dysfunction and reported post-treatment improvements on a majority of outcome measures such as PFM pain responsiveness, less PFM tone and improved muscle flexibility and relaxation. Reissing and colleagues describe that the hypertonicity of the PFMs may further exacerbate the pain experienced by affected women [71]. They posit that tension of the PFM works as a protective response and over time develops into an increased resting tone. When intercourse is attempted, the tensed pelvic floor will further increase the pain, and therefore perpetuate the response. Hypertonicity then acts to maintain and exacerbate dyspareunia. Increased PFM activity has also been related to experience of threat [73]. It could be hypothesized that an effect of fear in sexual pain, equivalent to that of disuse syndrome in musculoskeletal pain, might be an increased muscle activity in the pelvic floor and a diminished ability to control this activity. Hypertonicity may also precede dyspareunia, and might therefore be viewed both as a pain trigger in the initial phase of sexual pain as well as a factor closely associated with the course of pain, fear and avoidance. Interventions targeting pelvic floor muscle dysfunction have proven successful in the treatment of dyspareunia, resulting in decreases in pain ratings, pain frequency, pain interference with intercourse and fear of vaginal penetration [74,75]. The specific role of sexual avoidance on pelvic floor muscles in dyspareunia over time is, however, not known.
In sexual pain as compared with other pain, there is a possible additional effect where fear and hypervigilance may negatively affect the physiological mechanisms involved in sexual arousal [59,76–78]. Over time, repeated experiences of sexual pain may produce fear and anticipation of pain and thereby disrupt the sexual response, leading to inhibited desire, arousal and lubrication and may result in greater genital pain [23]. This disruption occurs through the anticipation of pain, which in turn may result in self-monitoring during sexual activity. Self-monitoring is known to inhibit the sexual response [79,80]. Attempts of sexual intercourse in the absence of adequate sexual arousal will result in increased friction of the vulva and a high risk of increased pain experience and maintained fear of pain. It has been proposed that this perpetuating cycle of disrupted sexual sequelae should be pronounced and added to the FA model when applied to the sexual pain disorders [23].
In addition to disuse syndrome, increased disability will be a natural behavior consequence of fear and avoidance in terms of perceived limitations due to pain. In dyspareunia, this commonly includes decreased sexual frequency, reduction of the sexual repertoire and the development of sexual dysfunctions [19]. In some couples, when intercourse is avoided because of pain, no alternative sexual behaviors are developed that will result in a lack of sexual intimacy [57].
Depression is included in the FA model as a negative emotional consequence of avoidance behavior. Depression is the single most examined psychological factor in association to pain, and has been described both as a result of chronic pain and as a predictor of the development of sustained pain [81]. In a recent review, a model including catastrophizing and emotion regulation is proposed to explain the link between depression and pain [82]. It hypothesizes that flare-ups of pain trigger catastrophic worry, which in turn strains the individual's emotion regulation system. Negative behavioral emotion regulation (e.g., avoidance) results in a downward spiral of negative effects, pain and mood-related disability and, in the long run, a consequent relapse. According to the FA model, long-term avoidance of activity can result in a more general withdrawal from positive reinforcers, leading to mood disturbances such as irritability, frustration and depression [12]. It is well known that women with dyspareunia are more psychologically distressed than women without this type of pain [83,84], with depressive symptoms being associated with more severe pain reports [52]. Due to methodological limitations in earlier studies, there has been less certainty about the influence of mental health as an antecedent risk factor. However, a recent study using case–control pairs of women with and without vulvodynia demonstrated that DSM-IV-diagnosed antecedent depression and anxiety disorders influence the risk of vulvodynia and that vulvodynia increases the risk of both new and recurrent onset of psychopathology [85]. These findings indicate the need for further studies using prospective designs on the experience of dyspareunia and mental health. As shown in the FA model, negative effects are associated with both, initially by fueling catastrophizing, and in a later stage of the process as a consequence of fear and avoidance. The findings by Khandker et al. could, therefore, be incorporated in the model [85]. In addition, the emotional reactions to sexual pain, due to the type of avoidance, might be somewhat different compared with other types of pain and include stronger reactions of guilt and shame. Women suffering from dyspareunia describe that, when sexual intimacy is avoided, negative effects in terms of guilt and shame evolves and fuel the feeling of being an ‘inadequate partner’ [86]. However, these nuances of the emotional response to sexual pain deserve further examination.
Conclusion & future avenues for research
Dyspareunia: persistent pain viewed from a FA perspective
This review suggests that there is support for the idea that dyspareunia can be fruitfully viewed from a biopsychosocial perspective that focuses on the psychosocial aspects of the experience of pain. In fact, accumulating evidence underscores the central role of the experience of pain and points to the possible application of psychosocial models. In addition, there are striking similarities between the sexual pain diagnoses, such as dyspareunia, and other long-term pain problems (e.g., back pain) in terms of the psychosocial correlates, the development of disability and the the impact on quality of life.
The authors' contrast of the findings on psychosocial factors in dyspareunia with the FA model show surprising concordance. Several components of the model have been associated with sexual pain and there is increasing evidence that cognitive, affective and behavioral aspects of the pain experience are as essential to the experience of genital pain as any other types of sustained pain [23,52]. Here, the focus is not on the diagnostic debate regarding dyspareunia as a sexual dysfunction or not, but rather on how to approach the pain component in this disorder from a theoretical perspective, which so far has been lacking within the field of sexual pain. In summary, there is accumulating evidence that the central components of the FA model may also be involved in dyspareunia. However, the precise role in pain development cannot be described based on the findings on psychosocial factors in sexual pain presented here. Therefore, there is a need to further explore the FA model scientifically to determine whether it makes sense in the development of sexual pain and to understand the interactions between biological mechanisms, emotional status and behavioral patterns in the early phases of these pain disorders. What can be concluded is that the experience of pain in terms of cognitive, emotional and behavior aspects in dyspareunia seems central to the development of a sustained problem and that it affects both sexual function and the general wellbeing of a woman and her partner. Therefore, a continued exploration of pain, pain-related fear and strategies for handling these is highly warranted among women suffering from dyspareunia.
Adjustment of the FA model to sexual pain
Although there seems to be several shared mechanisms between the sexual pain disorders and other long-term pain diagnosis in terms of the FA model, there are also probable differences. Therefore, some adjustments to the FA model appear to be necessary to accommodate sexual pain.
First, it could be hypothezised that interpersonal aspects of sexual pain and the consequences they have for a couple might be more prominent than in other types of pain. From a biopsychosocial perspective, all pain experiences have a social dimension constantly influencing the changing dynamics of pain. Such social processes can be described both in terms of the individual's pain behaviors, the response to these behaviors by others, the sociocultural context in which pain (and sex) are experienced and reported, and assumptions about pain (and sex) in this context. From a FA perspective, cognitive and emotional behaviors related to pain may play a role in how pain is perceived and reacted upon both by the person suffering from pain and by the partner. Pain catastrophizing can be a mutual and shared behavior in a couple and avoidance behavior in the person suffering from pain may be reinforced in different ways by the behavior of a partner. In dyspareunia, pain interferes with one of the most intimate social situations there is: sex. Yet, to date, data on the role of the partner in dyspareunia are sparse. Recently, Smith and Pukall reviewed the literature on associations between pain and relationship adjustment, and sexual satisfaction for women with vulvodynia and their partners [58]. This review found lower sexual satisfaction, but normal relationship adjustment, among women with pain compared with healthy controls. Similar findings were reported for studies examining the partners' reactions to dyspareunia; lower levels of sexual satisfaction, but lack of support for relationship maladjustment when compared with partners of nonaffected women. However, solicitous partner responses are associated with both pain intensity and sexual satisfaction among women suffering from sexual pain [87]. Male partner attributions of female vulvar pain have also been related to dyadic adjustment [88]. In sexual pain, a partner who interprets the pain and sex-avoidant behavior as an indication of lack of interest/attraction/commitment may exert pressure or withdraw. Both of these reactions can exacerbate the situation [89]. In addition, sexual function of the partner may also be negatively affected, adding to experiences of guilt and lowered sexual satisfaction in the woman. To fully capture the complexity of dyspareunia, further studies of the role of the partner are needed and the relevance of including such factors has to be evaluated when applying the FA model to this condition. Based on the findings reported above, an addition to the FA model is proposed in terms of partner responses to FA behavior of the woman. Such responses are related both to emotional components; sexual function/satisfaction and future pain as illustrated in
A possible adjustment of the fear-avoidance model to sexual pain.
Another adjustment of the FA model when applied to sexual pain deals with the physiological mechanisms of sexual arousal and the influence of fear on these processes. According to the FA model, fear of pain results in hypervigilance to pain sensations, which demands attentional resources and thereby threatens to disrupt sexual arousal and the sexual response [23]. In women, lack of arousal and lack of lubrication increases the risk of friction and pain during sexual intercourse and may thereby maintain catastrophizing, fear and negative experiences of sex. In addition, fear is related to hypertonicity of the pelvic floor, resulting in increased pain ratings during intercourse [20], and for many women develops as a partial or total inability to participate in any form of vaginal penetration.
In summary, the psychological constructs in the FA model are compelling for sexual pain, but there is a dire need for further research. The FA model provides impetus and can guide research to examine how psychological factors impact on sexual pain. Certain adjustments regarding dyadic context, the consequences of fear on sexual arousal and in terms of emotional consequences might be necessary. An adjustment of the FA model to sexual pain is proposed by including aspects that seem to differ between these pain diagnoses and other long-term pain (
Implications & future needs
Using the FA model for describing and understanding the development of dyspareunia may have important contributions to the field of sexual pain among women, both in terms of the identification of the causal mechanism in the etiology and in terms of developing treatment interventions. Until recently, few controlled experimental studies had been conducted within the field of dyspareunia, and therefore there is still a lack of evidence on causal factors and descriptions from a biopsychosocial perspective in the development of genital pain among women. By offering a theoretical basis, the FA model will guide the formulation of future research hypotheses, and thereby structures and facilitates future longitudinal, clinical and experimental studies. The model includes a few well-established, clearly defined and inter-related concepts, and is a valuable tool in mirroring the active mechanisms in the development of sexual pain. Future studies will serve the purpose of mapping the psychosocial characteristics of dyspareunia and its association to other pain problems.
To further examine the relevance of the model, there is a true need to apply it in the clinic. This should be carried out by both investigating specific concepts (e.g., fear and catastrophizing) and by evaluating interventions targeting such concepts. Treatment programs built on cognitive–behavioral therapy have been evaluated in a small number of studies and findings seem to indicate that these interventions may affect pain severity and sexual function [90,91]. In line with the FA model, avoidance, pain catastrophizing and self-efficacy have been identified as predictors of treatment outcome [92]. In addition, a number of studies have been conducted among women suffering from vaginismus showing promising effects of exposure treatment targeting avoidance and fear of penetration [65,93,94]. However, there is still a lack of controlled treatment studies, where specific interventions are implemented and evaluated within the sexual pain disorders. A well-controlled study by Bergeron et al., where cognitive–behavioral therapy was compared with surgical treatment (vestibulectomy) and biofeedback among women with dyspareunia, showed interesting results [24]. At short-term follow-up vestibulectomy showed a clear superiority [24]. However, when a 2.5-year follow-up was carried out, cognitive–behavioral therapy seemed to catch up and showed similar results to the surgical treatment [90]. Therefore, there is a need to more precisely evaluate specific interventions from the psychosocial perspective of genital pain. By viewing such pain from a FA perspective, interventions relating to all parts of the model should be applied and evaluated (e.g., decatastrophizing, exposure for fear and alternative coping strategies for pain) and possible additions have to be implemented in the program based on the adjustment of the model to sexual pain (e.g., relaxation techniques, acceptance of emotional distress and communication skills training).
One specific treatment developed from research on the FA model is exposure in vivo [95]. This treatment aims to reduce fear and anxiety for threatening stimuli, for example, certain movements for back pain patients. It is considered the treatment of choice for chronic back pain patients suffering fear and avoidance [14]. Exposure addresses the specific variables believed to maintain a pain problem and has been used in treatment of vaginismus with promising results [93,94]. In sexual pain among women, exposure has to be handled with great care and not as a tool that in any way threatens the integrity of the woman. Exposure interventions might include exposure for threatening thoughts, self-monitoring of pain sensations and communication about pain and sex with partner and healthcare personnel. Such interventions are also to be used in combination with working towards a healthy adaptation to the pain in terms of developing alternative sexual behaviors that focus on sexual pleasure for both partners and to establish sexual satisfaction as a main goal. The authors, therefore, suggest further development of treatment protocols for the female sexual pain disorders.
In summary, continued support for the FA model in sexual pain may have important implications both in terms of theoretical guidance of future studies, and by contributing to the development of effective treatment interventions by sharing methods from the treatment of other pain. By focusing on the FA model, there is considerable data from the area of musculoskeletal pain that would be relevant to replicate for the concepts of the FA model in vulvodynia. To follow women over time while screening for fear, avoidance and additional factors of interest, and to assess sexual pain is an important method to outline the temporal role of these concepts in the course of sexual pain. Psychological interventions are of great interest to further understand the mechanisms involved in the course of dyspareunia. In addition, women consulting healthcare for genital pain may also be screened for fear and avoidance and the course of their pain may thereafter be followed to see if these factors (i.e., musculoskeletal pain) may promote the transition from acute to chronic pain.
The field of female sexual pain has long been an under-researched area and the need for future resources cannot be overemphasized. Although showing high figures in prevalence estimates, only 60% of women suffering from these disorders seek professional care and of these only 40% receive a formal diagnosis [2]. This clearly mirrors two challenges for professionals working with genital pain; many women suffer in silence, probably due to shame, guilt and lack of knowledge; and the expertise in female sexual pain disorders is still lacking. This is an area in great need of attention both in terms of research resources, educational interventions in healthcare and by spreading knowledge to the general population on genital pain, psychosocial factors and treatment.
Future perspective
The classification for vulvodynia made by the ISSVD and the proposed changes for the upcoming edition of the DSM-V reflect that the field of sexual pain is moving. Among scientists and clinicians, a general adaptation of a biopsychosocial perspective on female sexual pain disorders leaves behind the division of real physical pain as separated from psychological pain states. This has started to open up for studies on mechanisms involved in pain development and in the treatment of sexual pain that for a long time was lacking. To link the FA model to sexual pain implies several interesting hypotheses regarding the influence of psychosocial factors in dyspareunia. A continued interest and application of biopsychosocial pain models to sexual pain will further strengthen future ideas for research and present ideas for innovative methodologies to answer difficult questions that still have not been answered. To follow women over time both in the general population, and in clinical samples, while screening for sexual pain, fear, avoidance and its consequences is an important method to outline the temporal role of these factors in the course of dyspareunia. In addition, psychological interventions are of great interest to further understand the mechanisms involved in the course of dyspareunia.
Executive summary
Female sexual pain is common and there is preliminary evidence that the prevalence in women under 30 years is increasing.
Sexual pain disorders have been kept aside from other long-term pain conditions, viewed as something else. Therefore, the field has not taken part in findings on pain from other areas.
There is an urgent need to understand the development of and treatment for sexual pain, and theoretical models are lacking.
Genital pain is not only sexual, but reported in many situations.
General arousal ability is not affected, indicating that a sexual deficit might not be the cause of pain.
Dyspareunia is better understood as genital pain with negative consequences for sexual function in terms of arousal, lubrication and orgasm, in line with the International Society for the Study of Vulvovaginal Disease classification.
In the transition to chronic pain, catastrophizing, fear and avoidance have been identified as central components. These have all been described in the context of sexual pain.
Fear and avoidance in sexual pain seem to predict increased sexual dysfunction, negative emotional reactions to pain and increased pain ratings.
Applying the fear-avoidance model on sexual pain holds potential gains both in terms of future studies on pain development and in terms of clinical work.
Many women do not seek care for their pain, which is a challenge for professionals who are evaluating treatment programs.
Specific addition to the theory of fear and avoidance might be needed within the context of dyspareunia in terms of partner responses, consequences on sexual arousal and the specific type of emotional reactions in terms of shame and guilt.
There is an urgent need for experimental studies examining potential working mechanisms in the development of sexual pain and predictors of that pain experience.
The fear-avoidance model has the potential to guide future studies in sexual pain by its firm empirical validity within other long-term pain conditions.
However, there is a long way before female sexual pain is viewed as the debilitating health problem it is for women. This has to be recognized by the woman herself, her partner and among professions in general. There is also considerable work to be carried out before evidence-based treatment is available for women suffering from sexual pain, and this includes knowledge from different professionals to mirror the multifactorial phenomenon of sexual pain. In the coming decade we will hopefully see an increasing interest in female pain in general as women are over-represented in a majority of pain conditions. In addition, there is an increased recognition of female sexuality in the general community and the role of sexual health for quality of life. Continuous funding for treatment studies on female sexual pain will increase our knowledge on the interacting mechanisms involved in the course of dyspareunia in terms of biomedical reactions, psychological mechanisms and social processes.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.