Psychological factors in genital pain: The role of fear-avoidance, pain catastrophizing and anxiety sensitivity among women living in Sweden

Johanna Thomtén; Andreas Karlsson

doi:10.1016/j.sjpain.2014.01.003

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Psychological factors in genital pain: The role of fear-avoidance, pain catastrophizing and anxiety sensitivity among women living in Sweden

Johanna Thomtén and Andreas Karlsson

Published/Copyright: July 1, 2014

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From the journal Scandinavian Journal of Pain Volume 5 Issue 3

Abstract

Objectives

One in five women under the age of 30 report recurrent genital pain and pain during sexual intercourse. Female genital pain negatively affects sexual and general health, as well as dyadic function and quality of life. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, there is still a lack of theoretical models describing the psychosocial mechanisms involved in the development of genital pain. Originally developed to outline the transition from acute to chronic back pain, the fear avoidance (FA) model has lately been proposed as a possible tool in illustrating the mechanisms involved in genital pain. However, only few studies have empirically tested the components of the FA model empirically. The aim of the present study is to examine fear avoidance beliefs, pain catastrophizing, and symptoms of depression and anxiety among women reporting genital pain, and to relate these concepts to sexual satisfaction/function and the characteristics of pain.

Methods

The study was a population-based study using a postal questionnaire administered to 4052 women (age 18–35). Of these 944 (response rate: 23%) took part in the study.

Results

Genital pain of six months duration was reported by 16.1% of the women. Women with pain reported elevated levels of symptoms of anxiety, fear avoidance beliefs, pain catastrophizing and anxiety sensitivity. Symptoms of anxiety also predicted pain in the explanatory model together with vaginal tension and fungal infection. Vaginal tension has previously been described as a fear-response to painful intercourse and the results thereby seem to give further support to viewing genital pain from a fear avoidance perspective. Furthermore, fear avoidance beliefs seem to be of similar importance as lack of desire for the experience of sexual satisfaction and could also predict pain during specific activities among women with pain. The results also indicate that sexual satisfaction is related to a specific pain-related fear, rather than a heightened level of general anxiety.

Conclusions

The study had a low response rate, but still indicates that genital pain is common and is associated with several aspects of fear and avoidance. In sum, the results support the FA model by giving strong support for fear reactions (vaginal tension) and fear avoidance beliefs, and moderate support for negative affect. In the model negative affect drives pain catastrophizing.

Implications

It seems that the experience of genital pain among women in the general population is common and could be associated with increased levels of anxiety and fear-avoidance beliefs. However, the associations should not be understood in isolation from physiological mechanisms but seem to indicate interactions between, e.g. fungal infections, negative appraisals of pain and symptoms, lack of sexual function and satisfaction and increased pain experience. It is possible that psychological mechanisms work in the transition from acute physiological pain to chronic psychologically maintained pain in terms of secondary reactions to, e.g. repeated fungal infections by adding emotional distress, fear of pain and avoidance behaviours.

Keywords: Genital pain; Women; Fear avoidance; Pain catastrophizing; Anxiety; Sexual satisfaction

1 Introduction

Female genital pain is a common and debilitating experience that affects sexuality, general health, dyadic adjustment and quality of life among its sufferers [1]. Genital pain resulting in painful intercourse affects between 10 and 21% of premenopausal adult women [e.g. 2–6], and one in five women under the age of 30 report recurrent pain associated with sexual intercourse [7,8].

Multiple physiological mechanisms may underlie the experience of female genital pain (irritation of nerves, abnormal responses to irritation or inflammation, allergic reactions, muscle spasms, infections, hormonal changes, etc.). According to the classification made by The International Society for the Study of Vulvovaginal Disease, (ISSVD), female genital pain may be categorized as ‘pain related to a specific disorder’ or as ‘vulvodynia’ (when the physiological underlying mechanisms are unknown). Vulvodynia can be specified as generalized or localized, provoked, unprovoked or mixed. The pain might be provoked by sexual or nonsexual stimulation or by both [9]. According to the ISSVD terminology, describing genital pain as simply sexual is therefore misleading and the condition is better referred to as a genital or vulvovaginal pain condition. From a psychological perspective, the focus has been on pain that interferes with sexual activity which has been viewed in terms of a sexual dysfunction not primarily focusing on the symptom of pain. The diagnostic definitions have changed over time, and today, pain-related fear is given a central role in the Diagnostic and Statistical Manual of Mental Disorders, DSM-V [10]. During the last decade there has been an increased interest in the pain component of female genital pain, emphasizing the similarities with other pain syndromes in terms of experiential, psychophysiological and neurological characteristics [11,12,13,14,15,16,17]. This has spurred the arguments that genital pain and painful intercourse is best viewed from a biopsychosocial perspective associated with a multifactorial aetiology [18]. Sexual dysfunctions are gradually more regarded as multifactorial conditions from a biopsychosocial perspective both by clinicians and scientists [19]. However, there is still a lack of theoretical models describing the psychosocial mechanisms involved in the development of genital pain. There is also an urgent need to better understand the central components necessary to successfully treat chronic genital pain. Fortunately, advances have been made in the field of musculoskeletal pain and models established there might be generalized to genital pain.

To describe the psychological processes involved in the transition from acute to chronic pain in musculoskeletal disorders Vlaeyen and Linton [20] developed the fear-avoidance (FA) model, shown in Fig. 1. The central idea in the model is that catastrophic thoughts, fear, muscle tension, and hypervigilance set the stage for avoiding pain-related situations. Avoidance in turn results in disability, disuse and depression. The model allows good predictions regarding the development of persistent pain as well as the prediction of poor treatment results for patients with musculoskeletal pain [21,22]. The FA model has lately been advanced as a model for the understanding of female genital pain [23,24,25].

Fig. 1

The fear-avoidance model of pain.

Adapted from Vlaeyen and Linton [20].

Central elements of the FA model also seem to be relevant also to the understanding of female genital pain. Pain catastrophizing has been reported among women with genital pain [13,17], showing similar levels as in other pain conditions [26] and associated with higher pain ratings and more negative experiences of intercourse [27,28]. In addition, women with genital pain report higher levels of fear of pain [29], and pain-related fear is known to predict increased level of pain sensitivity in this group [27]. In a recent review, on psychological factors in genital pain [30] results show sufficient concordance with the FA model to merits its use. Therefore, the experience of painful intercourse could be described within the framework of classical conditioning. Because intercourse is experienced as painful, the sexual situation will likely be conditioned to fear of pain which may disturb both the physiological and psychological sexual response and thereby increases the risk for further sexual dysfunctions [25].

Although recent advances have been presented within the field of female genital pain, previous research is mainly limited to strictly chosen clinical samples often referred to specialty clinics. In addition, a majority of studies examining genital pain and associated factors still suffers from an unbalanced view of the problem as either psychological or physical. The current study is one of few conducted as a questionnaire study among women from the general population and including psychological, physical and sexual aspects of intercourse pain.

The aim of the present study is to examine fear avoidance beliefs, pain catastrophizing, and symptoms of depression and anxiety among women reporting genital pain, and to relate these concepts to sexual satisfaction/function and the characteristics of pain. There is a dearth of studies that have empirically examined components of the FA model in sexual pain. Therefore, the need for cross-sectional data seems essential.

2 Method

2.1 Design

The study is a cross-sectional postal survey using a representative census sample.

2.2 Participants and setting

The sample consisted of 4252 randomly chosen women (18–35 years) from two midsized Swedish municipalities. After the exclusion of 200 participants who could not be reached (wrong addresses/had moved), the final sample consisted of 944 women (response rate 23%). In the current sample 152 women (16.1% of the respondents) suffered from chronic genital pain (6 months).

The subjects were divided into three groups depending on their age (18–23, 24–29, 30–35). The size of the age groups was weighted with respect to the number of individuals within that specific age-range and the relative size of the two cities.

2.3 Measures

The questionnaire included standardized self-report inventories and a number of questions created especially for this study. Areas covered were among others; demography, general health, gynaecological health, genital pain and sexual function.

Anxiety and depression was measured using The Hospital Anxiety and Depression Scale (HADS) [31], a 14-item standardized self-report inventory used to screen for anxiety (7 items) and depression (7 items). The scale has good psychometric properties and has shown to be reliable measure of the magnitude of emotional disorder [32,33]. A reliability analysis of the current sample shows a Cronbach’s alpha at .73 for anxiety and .73 for depression.

Anxiety sensitivity, the tendency to fear anxiety-related bodily sensations and the belief that such sensations lead to aversive consequences was measured with the Anxiety Sensitivity Index (ASI) [34]. The ASI was originally developed as a 16 item unique predictor of panic attacks, post-traumatic stress, and ordinary fears or phobias. The index has sound psychometric properties [35]. Cronbach’s alpha for the current sample was .86.

Pain catastrophizing was measured using the Pain Catastrophizing Scale (PCS) [36] which is a 13-item scale designed to measure pain-related catastrophic thoughts. The PCS reflects thoughts and feelings that may arise when people experience pain (e.g. “There is nothing I can do to reduce the intensity of the pain”, “I keep thinking about how much it hurts”). Respondents are asked to rate to what extent they have thoughts and feelings when they experience pain (0 = not at all; 4 = all the time). PCS has been shown to have good psychometric properties [36]. Cronbach’s alpha for the present sample was .88.

Fear avoidance beliefs was measured with the Fear Avoidance Beliefs Questionnaire (FABQ) [37]. The scale contains statements about pain that reflect pain-related fear and avoidance behaviour (e.g. “I must not engage in activities that might increase my pain”). The version of FABQ that was used in this study was slightly adjusted to intercourse pain and some items were rephrased to address fear-avoidance beliefs in a sexual context. The original scale has been evaluated for validity and reliability in several types of pain, (e.g. neck pain), and has shown good psychometric properties [38]. Cronbach’s alpha for the current version was .76.

Genital pain was measured by several items specifically created for the present study. The main question asked whether the woman had experienced genital pain/burning sensations of the vaginal entrance/opening lasting for at least one month, experienced during the last three months (yes/no). Persistent pain was defined as pain during six months or more. This limit was set to exclude women with more transitory pain problems (infections) and instead include women with chronic pain.

Duration of pain was measured by a 6-point scale (ranging from ‘never’ to ‘always’). Pain-related activities were measured in relation to several different activities in terms of how often the woman experienced pain in those situation (multiple choice ranging from ‘always’ to ‘never’).

Sexual function: Questions on sexual function included sexual frequency (non-penetrative sexual activity with a partner, penetrative sex with partner and sexual masturbation without a partner), e.g. “How often do you have sexual intercourse with a partner?” Sexual dysfunctions included questions on other sexual problems such as difficulties/inability to have an orgasm, lack/absence of desire, lack/absence of sexual arousal, and tightening of the pelvic floor muscles hindering sexual intercourse.

Sexual satisfaction was measured with a 10-point scale (“How satisfied are you with your sexual life during the last month?”). A rate of 0 represented a very unsatisfactory and a rate of 10 a very satisfactory sex life.

2.4 Procedure

Data were collected during eight consecutive weeks. A questionnaire together with detailed information of the study was sent to each subjects’ home address. The women were invited to take part in the study by responding to the questionnaire by post. A reminder together with a second questionnaire was sent out to those that did not answer the first survey. No incentives were offered for participating, but women with genital pain who took part in the study were offered the possibility of participating in a psychological treatment study for persistent genital pain. All women were volunteers, and by participating, gave their informed consent. Confidentiality was emphasized. The study was approved by the ethical committee at Umeå University (Dnr. 2011-303-31Ö).

2.5 Statistical analysis

The data were examined in terms of mean differences in psychological factors between women with and without genital pain. In a second step, based on those variables differing between the two groups, a logistic regression was performed in order to identify factors associated with genital pain among all women in an explanatory model. This analysis included anxiety sensitivity, symptoms of anxiety and reports of fungal infections.

In a similar fashion, a multivariate linear regression analysis of sexual satisfaction among those women suffering from persistent pain was performed. This analysis included fear avoidance beliefs, symptoms of anxiety, pain catastrophizing and anxiety sensitivity. In the multivariate analysis, known risk factors in terms of physiological factors were introduced as control variables, (fungal infection and vaginal muscle tension in model 1), and (sexual dysfunctions and pain duration in model 2).

In the final part of the analyses, associations between the psychological concepts of interest and specific pain-related activities were examined by means of logistic regression analyses. These analyses included fear-avoidance beliefs, pain catastrophizing, symptoms of depression/anxiety, and anxiety sensitivity.

3 Results

To determine which factors were to be included in the explanatory models of genital pain and sexual satisfaction mean differences were calculated for women with and without pain regarding psychological factors of interest.

3.1 Psychological factors in genital pain

As seen in Table 1, women with and without pain differed in most measured psychological factors except for depressive symptoms. (Fear-avoidance beliefs were only completed by those reporting pain. Mean differences could therefore not be examined.) The level of pain catastrophizing did not reach clinical levels compared to previous studies on this concept in female genital pain [26].

Table 1

Pain catastrophizing, anxiety, depression and sexual satisfaction among women with and without sexual pain (n = 837).

Variable	With pain (n = 152)	Without pain (n = 685)	M ^diff	p-Value
PCS	19.85 (11.51)	16.10 (10.44)	3.75	.004
HADS-A	12.48 (2.28)	11.46 (2.59)	1.02	.000
HADS-D	9.31 (1.90)	9.11 (1.61)	.20	.213
ASI	16.69 (8.60)	14.56 (8.73)	2.13	.007
Sexual sat.	5.92 (2.54)	6.70 (2.50)	.78	.001

PCS, Pain Catastrophizing Scale; HADS-A/D, Hospital Anxiety and Depression Scale-Anxiety/Depression; ASI, Anxiety Sensitivity Index; Sexual sat., sexual satisfaction.

3.2 Factors associated with genital pain

In the explanatory models, to control for factors known to be associated with genital pain, fungal infection and vaginal muscle tension were included in the first step of the model, explaining 18.1% of the variance in genital pain (Nagelkerke R²). In the second step, psychological factors of interest were added (anxiety sensitivity, symptoms of anxiety, pain catastrophizing). As seen in Table 2, the model explained 22% of the outcome. Among the psychological variables, symptoms of anxiety were associated with an increased risk of reporting genital pain, of similar size as was fungal infection. The most important predictor was to report vaginal muscle tensions which were associated with a fourfold risk of experiencing pain during intercourse.

Table 2

Associations between psychological factors and genital pain among all women (n = 944).

Variable	B	SE	OR	p-Value	95% CI
Fungal infection	1.02	.30	2.78	.001	1.55–4.97
R ² = .08
Vaginal muscle tension	1.42	.34	4.14	.000	2.11–8.13
R ² = .18
HADS-A	.18	.07	1.20	.006	1.05–1.37
ASI	.03	.02	1.03	.129	0.99–1.07
PCS	.012	.02	.99	.455	0.96–1.02
R ² = .22

PCS, Pain Catastrophizing Scale; HADS-A/D, Hospital Anxiety and Depression Scale-Anxiety/Depression; ASI, Anxiety Sensitivity Index.

3.3 Factors associated with sexual satisfaction

To further outline the role of psychological factors in genital pain, a multiple regression was performed to examine potential associations with sexual satisfaction among those women reporting persistent genital with painful intercourse (six months). To control for potential contribution of additional factors, pain duration, and sexual dysfunctions (lacking arousal, desire, orgasm difficulties and pelvic floor muscle dysfunction) were also introduced into the first block of the model (explaining 11.8% of the variance in sexual satisfaction, Nagelkerke R²).

Among women suffering from persistent genital pain, lack of desire and fear avoidance beliefs were associated with their sexual satisfaction (see Table 3). No other psychological factors were related to sexual satisfaction in the present sample. The model explained 20% of the variance in sexual satisfaction (Nagelkerke R²).

Table 3

Associations between psychological factors and sexual satisfaction among women with sexual pain (n = 152).

Variable	B	SE	β	p-Value
Pain duration	−.01	.01	−.02	.868
Lack of desire	−1.57	.58	−.32	.008
Orgasm diff	−.87	.81	−.18	.291
Lack arousal	−.21	.96	−.04	.843
Vaginal muscle tension	−.10	.74	−.02	.892
R ² = .118
FABQ	−.08	.03	−.32	.007
HADS-A	−.01	.12	−.01	.970
ASI	.06	.04	.19	.168
PCS	−.01	.03	−.01	.958
R ² = .20

FABQ, Fear Avoidance Beliefs Questionnaire; HADS-A/D, Hospital Anxiety and Depression Scale-Anxiety/Depression; ASI, Anxiety Sensitivity Index; PCS, Pain Catastrophizing Scale.

3.4 Pain-related activities and associated factors

In a final step of the analysis the explanatory value of fear avoidance beliefs, pain catastrophizing, symptoms of anxiety and anxiety sensitivity in relation to specific pain-inducing activities were explored.

Fear avoidance beliefs seem to be associated with experiencing pain during sexual intercourse (B = .06, SE = .01, β = .51, p ≤ .000). This model explained 22.3% of the variance in pain during intercourse (Nagelkerke R²). A weaker but significant positive association also emerged for fear avoidance beliefs and non-penetrative sexual activities (B = .03, SE = .01, β = .21, p ≤ .05). This model explained 9% of the variance in pain (Nagelkerke R²).

In contrast, pain during tampon insertion was linked to heightened symptoms of anxiety (B = .14, SE = .06, β = .26, p ≤ .02). This model explained 12.6% of the variance in pain (Nagelkerke R²).

4 Discussion

The study examined the potential associations between psychological factors, related to the FA model, and female genital pain. The relation between these factors, sexual satisfaction and pain-related activities among women with pain were further explored.

Comparing women with and without pain showed genital pain to be clearly linked to heightened anxiety, fear avoidance beliefs, pain catastrophizing and anxiety sensitivity. This indicates that genital pain in the present sample was associated with emotional distress characterized by negative expectations in terms of fear/anxiety rather than with depressive symptoms. In the explanatory model of genital pain, symptoms of anxiety were identified as a predictor. Additionally, vaginal tension (that hinders intercourse) made a considerable contribution to the model with a fourfold risk of reporting genital pain. This type of muscle tension has been described as a fear-response to painful intercourse [39]. Fungal infection more than doubled the risk of reporting genital pain. This replicates previous results showing that fungal infection and genital pain are closely associated factors [2,40,41]. Taken together, these results show that beyond known risk factors psychological variables add to the model which explains 22% of the variance in genital pain. Furthermore, fear avoidance beliefs seem to be of similar importance as lack of desire for the experience of sexual satisfaction and could also predict pain during specific activities among women with pain. Moreover, sexual satisfaction does not seem to be associated with a heightened level of general anxiety, but rather with a specific pain-related fear.

In sum, the results support the FA model by giving strong support for fear reactions (vaginal tension) and fear avoidance beliefs and moderate support for negative affect in terms of symptoms of anxiety. According to the model anxiety drives pain catastrophizing. In addition, some support was found for pain catastrophizing. Taking a classical conditioning perspective, fungal infection could be viewed as a factor producing unconditioned response in terms of increased sensitivity/vaginal tension leading to an unconditioned response of pain and over time to a conditioned response of fear, worry and anxiety.

As described by the FA model, elevated levels of symptoms of anxiety might reflect an increased negative affectivity that in later stages of the model drives catastrophizing, fear of pain and avoidance [20]. In a recent case–control study, anxiety symptoms, specified by the DSM diagnostics, were shown to predict vulvovaginal pain and vice versa [42]. Several forms of anxiety disorders are known to be associated with pain [43], and commonly described through shared vulnerabilities and mutual maintenance factors [44]. In female genital pain, a crucial situation is that of sexual intercourse which for most women is associated with severe pain. When intercourse becomes associated with pain, it seems plausible that the anticipation of sex might increase self-focused attention and thereby possibly disrupt essential parts of the physiological and psychological sexual response [23,45]. This anticipation of threat and reactions of self-focused attention are typical components in several anxiety conditions (e.g. panic disorder, social phobia) and could be part of the association found between genital pain and symptoms of anxiety. Self-monitoring during sexual activities is known to negatively affect the sexual experience [46,47] and might increase the risk for intercourse pain due to lack of sexual arousal. However, data presented here could not outline any causal mechanisms, but merely indicates the presence of anxiety-related symptoms in persistent genital pain. Anxiety reactions might also work in combination with other risk factors such as fungal infections by resulting in stressful reactions and thereby increase the risk for persistent problems with infections and consequent pain.

Fear avoidance beliefs were associated with pain-related activities among women with persistent pain, and predicted pain both during non-penetrative sex and during penetrative sexual intercourse. Women suffering from genital pain are known to report more fear of pain than their pain-free controls [48], and pain-related fear has been found to predict increased pain sensitivity in this group [27]. In women experiencing pain during sexual intercourse harm avoidance beliefs have also been associated with increased avoidance of sexual penetration [49]. Avoidance of threat/emotional distress is a powerful mechanism in maintaining fear-reactions. By avoiding feared situations, habituation and fear reduction will not take place and correction of fearful beliefs is not possible. However, the specific fear avoidance beliefs associated with genital pain need to be carefully examined in order to reflect both the sexual situation and other pain-related activities. In the present study pain during tampon-insertion was examined. However, the fear-avoidance measure was only adapted for the sexual situation which might have biased the results. This is further discussed below.

Consistent with previous research [50], women with persistent genital pain reported lower sexual satisfaction than those free of pain. Among those factors related to the FA model, only fear avoidance beliefs were associated with sexual satisfaction. Instead the role of sexual dysfunction in terms of lack of desire was central to the degree of sexual satisfaction. When sexual stimuli becomes conditioned to pain, resulting in fear and a disturbed sexual response, lack of desire might be viewed both as a consequence (of fear) and as a maintaining factor by increasing the risk for pain since sexual intercourse is performed despite lack of arousal and low sexual motivation. Genital pain is commonly linked to sexual dysfunctions such as of lack of arousal and difficulties reaching orgasm [26,51]. However, female genital pain is not associated with repaired genital responsiveness although women with pain report less positive feelings in response to erotic stimuli [52]. As mentioned earlier, this might imply that the experience of sexual dysfunction in genital pain could be viewed as a consequence of the conditioned fear-response and avoidance of sexual stimuli [53]. In addition, lack of desire also negatively affects the course of pain by lowering sexual motivation and increasing avoidance of sexual activities. Due to lack of lubrication and swelling and increased pelvic floor muscle tone, low sexual desire and arousal will increase vaginal friction and the risk of pain during penetration [53]. This is in line with the FA model where dysfunction is both a consequence of avoidance, and also further drives the experience of future pain.

Although the level of pain catastrophizing differed between women with and without genital pain it was not associated with pain or sexual satisfaction in the explanatory model. This is inconsistent with previous studies [17,13,26,27,28]. In the present study, only women with experiences of long term pain problems were asked to answer the items on pain catastrophizing. This might have led to range restriction leading to lack of association. On the other hand, among those women reporting genital pain, the levels of pain catastrophizing were clearly lower than in previous studies within this pain population. The present study asked for experiences of genital pain in general and not specifically focused on intercourse pain. It is plausible that the specific experience of painful intercourse generates stronger catastrophizing than when genital pain in general is regarded.

Symptoms of depression were unrelated to the experience of genital pain in the present data. Depressive symptoms have been linked to genital pain (during sexual intercourse) in some previous studies [42,54,55,56]. However, these studies have mostly included clinical samples and therefore reflect genital pain of higher severity, frequency and durations. In an acute pain problem, fear will be the immediate situational response associated with pain during intercourse. Anxiety will develop as an anticipatory reaction to pain, therefore associated with the problem, but not the most central factor in the sexual situation. In a recent review [57], a model including catastrophizing and emotion regulation are proposed to explain the link between depression and pain. It hypothesizes that flare-ups of pain trigger catastrophic worry which in turn strains the individual’s emotion regulation system. Negative behavioural emotion regulation (e.g. avoidance) results in a downward spiral of negative affect, 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 [20]. It is possible that symptoms of depression will be more central in clinical samples. The present study used a subclinical sample which might explain the lack of association. In sum, results presented here shows that genital pain is primarily associated with a psychological profile characterized by fear/anxiety rather than by depressive symptoms. This is in line with the FA model since fear of pain and negative affectivity concerning somatic sensations are central aspect of the model [20]. In addition, research on the role of depression in pain, seem to identify this factor as a long-term consequence of avoidance rather than as a primary predictor.

4.1 Limitations

Although the study adds to the knowledge on genital pain and psychological factors, it suffers from a number of methodological limitations which need to be considered when evaluating the results. First, the response rate of the study was 23% which seriously may bias the results and makes the study unsuitable for prevalence estimates. There are only few questionnaire-based studies on female genital pain using a similar approach as the current study. Harlow et al. [5] present data on female genital pain with a 67% response rate. However, their study used a web-based survey during a 55 months screening period with two separate mailings for reminders and a telephone follow-up. A number of studies using questionnaires on female genital pain are based on university or high school student samples where questionnaires were administered in a classroom setting [e.g. 25]. This implies a clearly different setting than that obtained in a postal survey procedure and often result in higher response rates than that of the current study. However, the problem with low response rates in the study of female sexual dysfunctions is not new. In 2001–2002, “The Global Study of Sexual Attitudes and Behaviours” investigated female sexual dysfunctions in 29 countries [58]. Response rates reported ranged from 15% to 33%, with an average response rate of 19%, which is very similar to that of the current study. In a review by Hayes and colleagues [59] several factors are identified as associated the response rates in the study of female sexual dysfunctions. More recent studies and studies that only included women over 50 years of age had lower response rates. The use of face-to-face interviews was associated with a higher response rate. Studies that did not include questions regarding desire difficulties achieved higher response rates than those that did include such questions. The current study thereby captures several of the characteristics identified by Hayes et al. which may explain the problem with a large attrition. In addition, the response rate of the current study is comparable to another population based study on a sensitive subject, domestic violence [60]. In that study, carried out in the same geographical region, response rates were of a comparable magnitude (32%). Furthermore response rates were lower in the younger age groups which is in line with the trend reported here.

In addition, the present study included avoidance behaviour as a central component. In order to fully outline avoidance-tendencies, the questionnaire had to include details about sexual behaviours/habits that commonly are not targeted in similar studies on genital pain. This is regarded as highly private information for many individuals and might seriously have threatened the woman’s willingness to take part in the study irrespective of her relation to symptoms of genital pain. Unfortunately we cannot tell whether it is women with or without pain (or both) who chose not to participate. There might be subgroups among those women with pain that due to higher or lower pain-related distress feel more or less motivated to take part in the study. Due to the cross-sectional design of the current study, we cannot draw any such inferences. Based on the low response rate and the low frequency of health care consumption in this group it is tempting to suggest that the issue of female sexual pain or female sexual function in general is still a difficult topic, and it may generate distress not only among those afflicted, but also among many women in general since it addresses areas such as sexual function and intimate health.

However, the number of women who reported persistent pain in this study (15.1%) is in line with previous studies where prevalence figures are reported ranging from 10 to 20% [2,3,4,5,6].

Finally, the measure of fear-avoidance beliefs was rephrased to concern genital pain with sexual consequences and therefore only given to those women who reported genital pain. This limits the number of factors that could be included in the explanatory models. In addition, many women with genital pain report pain-related consequences also in other aspects of their lives which might be relevant to include when examining fear avoidance beliefs.

5 Conclusions and future needs

The current study is one of few that address female genital pain in the general population including physiological, psychological and sexual aspects of the problem. It seems that the experience of genital pain among women in the general population is common and could be associated with increased levels of anxiety and fear-avoidance beliefs. However, the associations should not be understood in isolation from physiological mechanisms. Fungal infections, negative appraisals of pain and bodily symptoms, lack of sexual function and satisfaction and an increased pain experience seem to interact with each other. It is possible that psychological mechanisms play their major role as secondary reactions to e.g. repeated fungal infections by adding emotional distress, fear of pain and avoidance behaviours. To further outline the temporal associations and maintaining mechanisms prospective studies in both the general population and in clinical settings is highly warranted. There is also a need to more closely study the pain-component, not limited only to sexual situations and not by using sex-related measures but to capture the broader picture of genital pain in terms of pain-related function, social adjustment and psychological consequences.

Highlights

Genital pain is associated with anxiety, fear avoidance and pain catastrophizing.
Vaginal tension is closely associated with genital pain.
Fear avoidance beliefs are associated with sexual satisfaction.
Sexual satisfaction is associated with a specific pain-related fear.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.05.002.

Örebro University, School of Law, Psychology and Social Work, 701 82 Örebro, Sweden. Tel.: +46 63 16 53 42.

Sources of funding

None declared.
Conflicts of interest

None declared.

References

[1] LoFrisco BM. Female sexual pain disorders cognitive behavioral therapy. J Sex Res 2011;48:573–9.Search in Google Scholar

[2] Arnold LD, Bachmann GA, Rosen R, Kelly S, Rhoads GG. Vulvodynia: characteristics and associations with comorbidities and quality of life. Obstet Gynecol 2006;107:617–24.Search in Google Scholar

[3] Danielsson I, Sjöberg I, Stenlund H, Wikman M. Prevalence and incidence of prolonged and severe dyspareunia in women: results from a population study. Scand J Public Health 2003;31:113–8.Search in Google Scholar

[4] Fisher W, Boroditsky R, Bridges M. The 1998 Canadian Contraception Study. Can J Hum Sex 1999;8:161–230.Search in Google Scholar

[5] Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pa have we underestimated the prevalence of vulvodynia? Am Med Women’s Assoc 2003;58:82–8.Search in Google Scholar

[6] Berglund A, Nigaard L, Rylander E. Vulvar pain, sexual behavior and genital infections in a young population: a pilot study. Acta Obst Gyn Scand 2002;81:738–42.Search in Google Scholar

[7] Mercer CH, Fenton KA, Johnson AM, Wellings K, Macdowall W, McManus S. Sexual function problems and help seeking behaviour in Britain: a national probability sample survey. Br Med J 2003;327:426–7.Search in Google Scholar

[8] Lauman EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. J Am Med Assoc 1999;281:537–44.Search in Google Scholar

[9] Moyal-Barracco M, Lynch PJ. 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. J Reprod Med 2004;49:772–7.Search in Google Scholar

[10] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. – text revision Washington, DC: APA; 2000.Search in Google Scholar

[11] Bushnell MC, Villemure C, Strigo I, Duncan GH. Imaging pain in the brain: the role of the cerebral cortex in pain perception and modulation. J Musculoskeletal Pain 2002;10:59–72.Search in Google Scholar

[12] Giesecke J, Reed BD, Haefner HK, Giesecke T, Clauw DJ, Gracely RH. Quantitative sensory testing in vulvodynia patients and increased peripheral pressure pain sensitivity. Obstet Gynecol 2004;104:126–33.Search in Google Scholar

[13] Granot M, Yarnitsky D, Friedman M, Zimmer EZ. Enhancement of systemic pain perception in women with vulvar vestibulitis. Br J Obstet Gynecol 2002;109:863–6.Search in Google Scholar

[14] Lowenstein L, Vardi Y, Deutch M, Friedman M, Gruenwald I. Vulvar vestibulitis severity-assessment by sensory and pain testing modalities. Pain 2004;107:47–53.Search in Google Scholar

[15] Pukall CF, Binik YM, Khalife S, Amsel R, Abbott F. Vestibular tactile and pain thresholds in women with VVS. Pain 2002;96:163–75.Search in Google Scholar

[16] Pukall CF, Payne KA, Binik YM, Khalife S. Pain measurement in vulvodynia. J Sex Marital Ther 2003;29:111–20.Search in Google Scholar

[17] Pukall CF, Payne KA, Kao A, Khalife S, Binik YM. Dyspareunia. In: Balon R, Segraves RT, editors. Handbook of sexual dysfunctions. New York, USA: Taylor & Francis; 2005. p. 249–72.Search in Google Scholar

[18] Weijmar Schultz W, Basson R, Binik Y, Eschenbach D, Wesselmann U, Van Lankveld J. Women’s sexual pain and its management. J Sex Med 2005;2:301–16.Search in Google Scholar

[19] Leiblum S. Principles and practice of sex therapy. 4th ed. NY: The Guilford Press; 2007.Search in Google Scholar

[20] Vlayen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85:317–32.Search in Google Scholar

[21] Nicholas MK, George SZ. Psychologically informed interventions for low back pain: an update for physical therapists. Phys Ther 2011;91:765–76.Search in Google Scholar

[22] Vlayen JWS, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 2012;153:1144–7.Search in Google Scholar

[23] Basson R. The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle. J Sex Med 2012;9:2077–92.Search in Google Scholar

[24] Bergeron S, Rosen NO, Morin M. Genital pain in women: beyond interference with intercourse. Pain 2011;152:1223–5.Search in Google Scholar

[25] Landry T, Bergeron S. Biopsychosocial factors associated with dyspareunia in a community sample of adolescent girls. Arch Sex Behav 2011;40:877–89.Search in Google Scholar

[26] Reissing ED, Binik YM, Khalife S, Cohen D, Amsel R. Vaginal spasm, pain and behavior: an empirical investigation of the reliability of the diagnosis of vaginismus. Arch Sex Behav 2004;33:5–17.Search in Google Scholar

[27] Desrochers G, Bergeron S, Khalife S, Dupuis M, Jodoin M. Fear avoidance and self-efficacy in relation to pain and sexual impairment in women with provoked vestibulodynia. Clin J Pain 2009;25:520–7.Search in Google Scholar

[28] Pukall CF, Baron M, Amsel R, Khalifé S, Binik YM. Tender point examination in women with vulvar vestibulitis syndrome. Clin J Pain 2006;22:601–9.Search in Google Scholar

[29] Payne KA, Binik YM, Amsel R, Khalife S. When sex hurts, anxiety and fear orient attention towards pain. Eur J Pain 2005;9:427–36.Search in Google Scholar

[30] Thomtén J, Linton SJ. A psychological view of sexual pain among women: applying the fear-avoidance model. J Women Health 2013;9:1–13.Search in Google Scholar

[31] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361–70.Search in Google Scholar

[32] Bjelland I, Dahl AA, Tangen Haug T, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res 2002;52:69–77.Search in Google Scholar

[33] Lisspers J, Nygren A, Söderman E. Hospital Anxiety and Depression Scale (HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997;96:281–6.Search in Google Scholar

[34] Kemper CJ, Lutz J, Bähr T, Rüddel H, Hock M. Construct validity of the Anxiety Sensitivity Index-3 in clinical samples. Assessment 2012;19:89–100.Search in Google Scholar

[35] Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 1986;24:1–8.Search in Google Scholar

[36] Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: development and validation. Psych Assess 1995;7:524–32.Search in Google Scholar

[37] Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157–68.Search in Google Scholar

[38] Lee K-C, Chiu TTW, Lam T-H. Psychometric properties of the Fear-Avoidance-Beliefs Questionnaire in patients with neck pain. Clin Rehab 2006;20:909–20.Search in Google Scholar

[39] Van der Velde J, Everaerd W. The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther 2001;39:395–408.Search in Google Scholar

[40] Ridley CM. Vulvodynia: evolution of classification and management. J Eur Acad Dermatol Venereol 1996;7:129–34.Search in Google Scholar

[41] Arnold LD, Bachman GA, Rosen R, Rhoads GG. Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with nested case control study. Am J Obstet Gynecol 2007;196:128e1–6e.Search in Google Scholar

[42] Khandker M, Brady SS, Vitonis AF, MacLehouse RF, Stewart EG, Harlow BL. The influence of depression and anxiety on risk of adult onset vulvodynia. J Women Health 2011;20:1445–51.Search in Google Scholar

[43] Asmundson GJG, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: state of the art. Depress Anxiety 2009;26:888–901.Search in Google Scholar

[44] Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psych Rev 2001;21:857–77.Search in Google Scholar

[45] Both S, Laan E, Spiering M, Nilsson T, Oormens S, Everaerd W. Appetitive and aversive classical conditioning of female sexual response. J Sex Med 2008;5:1386–401.Search in Google Scholar

[46] Dove NL, Wiederman MW. Cognitive distraction and women’s sexual functioning. J Sex Marital Ther 2000;26:67–78.Search in Google Scholar

[47] van den Hout M, Barlow D. Attention, arousal and expectancies in anxiety and sexual disorders. J Affect Disord 2000;61:241–56.Search in Google Scholar

[48] Payne KA, Binik YM, Pukall CF, Thaler L, Amsel R, Khalife S. Effects of arousal on genital and non-genital sensation: a comparison of women with vulvar vestibulitis syndrome and healthy controls. Arch Sex Behav 2007;36:289–300.Search in Google Scholar

[49] Borg C, Peters ML, Schultz WW, de Jong PJ, Vaginismus:. heightened harm avoidance and pain catastrophizing cognitions. J Sex Med 2012;9:558–67.Search in Google Scholar

[50] Desrochers G, Bergeron S, Landry T, Jodoin M. Do psychosexual factors play a role in the etiology of provoked vestibulodynia? A critical review. J Marital Ther 2008;34:198–226.Search in Google Scholar

[51] Masheb RM, Lozano-Blanco C, Kohorn EI, Minkin MJ, Kerns RD. Assessing sexual function and dyspareunia with the Female Sexual Function Index (FSFI) in women with dyspareunia. J Sex Marital Ther 2004;30:315–24.Search in Google Scholar

[52] Brauer M, Laan E, ter Kuile MM. Sexual arousal in women with superficial dyspareunia. Arch Sex Behav 2006;35:191–200.Search in Google Scholar

[53] Spano L, Lamont JA, Dyspareunia: a symptom of female sexual dysfunction. Can Nurse 1957;71:22–5.Search in Google Scholar

[54] Kao A, Binik YM, Amsel R, Funaro D, Leroux N, Khalife S. Biopsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment. J Sex Med 2012;9:2066–76.Search in Google Scholar

[55] Brotto LA, Basson R, Gehring D. Psychological profiles among women with vulvar vestibulitis syndrome: a chart review. J Psychosom Obstet Gynecol 2003;24:195–203.Search in Google Scholar

[56] Sackett S, Gates E, Heckman-Stone C, Mee-Ran Kobus A, Galask R. Psychosexual aspects of vulvar vestibulitis. J Repr Med 2001;46:593–8.Search in Google Scholar

[57] Linton SJ, Bergbom S. Understanding the link between depression and pain. Scand J Pain 2011;2:47–54.Search in Google Scholar

[58] Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E, Wang T. Sexual problems among women and men aged 40–80y: prevalence and correlates identified in the global study of sexual attitudes and behaviors. Int J Impot Res 2005;17:39–57.Search in Google Scholar

[59] Hayes D, Bennett C, Dennerstein L, Gurrin L, Fairly C. Modeling response rates in surveys of female sexual difficulty and dysfunction. J Sex Med 2007;4:286–95.Search in Google Scholar

[60] Costa D, Soares JJF, Lindert J, Hatzidimitriadou E, Karlsson A, Sundin Ö, Toth O, Ioannidi-Kapolou E, Degomme O, Cervilla J, Barros H. Intimate partner violence in Europe: design and methods of a multinational study. Gaceta Sanitaria 2013;27:558–61.Search in Google Scholar

Received: 2013-11-11

Revised: 2014-01-08

Accepted: 2014-01-11

Published Online: 2014-07-01

Published in Print: 2014-07-01

Articles in the same Issue

https://doi.org/10.1016/j.sjpain.2014.01.003

Keywords for this article

Genital pain; Women; Fear avoidance; Pain catastrophizing; Anxiety; Sexual satisfaction