When sex hurts: Female genital pain with sexual consequences deserves attention: A position paper

1 Introduction

The problem of sexual pain, here defined as chronic genital pain associated with pain during sexual intercourse, is an area that has been shamefully ignored by both the pain community and the health service authorities. Although about 40% of women report such pain and 30% report it during their last intercourse,^[1] sexual pain has historically not even been considered a pain problem. Rather, it has been construed as a gynaecological or urological one. Perhaps because of the taboo nature of sex, such problems have received surprisingly little attention at all. In Sweden, there is still no guideline for treatment of such problems and patients may seek or be referred to a variety of health care providers to receive treatment. Moreover, these professionals often lack the knowledge and experience of treating pain. The research community has been little better. For example, the flagship journals Pain and European Journal of Pain, two primary outlets for pain research, have only published 2 and 3 articles during the past 2 years concerning the problem of sexual pain. That is a minute fraction of all the papers published.

Nonetheless, we have an historic opportunity to take a clear leap forward. Indeed, our commentary focuses on how the pain community might embrace the area of sexual pain in women and enhance its treatment by systematically applying the principles that are so well-established in pain clinics. Add to this, more basic research on mechanisms and we envision that sexual pain, and not least those who sufferer it, suddenly have a much brighter future.

As in the general area of pain, research on pain during sexual intercourse might benefit greatly by incorporating the biopsychosocial model where psychological and social aspects may play just as important part as do biological factors. Indeed, it is difficult to conjure up a pain problem that more eloquently illustrates that social (a partner) and psychological (fear, guilt and avoidance) are crucial elements. Therefore, the need to embrace the biopsychosocial model and move forward is particularly urgent.

For many patients the road to proper treatment is rough, curvy, and uphill. We contend that because clear guidelines have not been established in the clinic, patients potentially suffer being subjected to a large array of health care providers, at worst with a lack of pain assessment and treatment skills. The problem of sexual pain appears to often go unrecognized. When it is brought forward it may be under or inappropriately treated. Yet, the pain community has a wealth of knowledge and expertise to offer. Today, research on biopsychosocial mechanisms of various other pain problems has advanced enormously and treatments have utilized this information to evolve rapidly. Guidelines for treating back pain in primary care are distinctly different today than 20 years ago with results suggesting the potential prevention of chronic problems [1]. Could the same be said for sexual pain? We are not convinced. On the other hand, the opportunity to catapult advances may be just around the corner.

In this paper we will present a background to the problem, further elaborate on the problem as we see it and offer some direction for how advances might be concretely made. We admit that this is our own view. Further, we place no blame on any specific person or institution, but rather point to an under-researched area that could benefit so radically by being welcomed into the realm of research about pain and its treatment.

2 The problem of sexual pain in women

Approximately 40% of women 20–40 years old suffer from pain during sexual encounters [2]. A recent epidemiological study in the US shows that nearly 30% of women reported pain during their last sexual intercourse [3]. Among women ≤ 30, one in five reports chronic unexplained vulvar pain [4,5], and findings indicate that the prevalence of female intercourse pain is increasing [6]. The pain is not limited to intercourse as several studies demonstrate that these women also report experiencing pain in a number of non-sexual situations, (gynaecological exam, touch of the vaginal opening, tampon insertion, physical exercise, etc. [7,8]). Therefore, describing the pain strictly as a sexual problem, threatens to lose important information about the experience of pain and its consequences in the everyday life of women. Instead, seeing the problem as a genital pain condition with debilitating sexual consequences would be more illustrative of how these conditions are experienced and how they affect its sufferers.

3 The pain in painful sex

Compared to other chronic pain problems with different types of functional limitations little is known about the aetiology of female sexual pain [9], and prospective studies do not exist. A growing body of literature suggests that recurrent sexual pain in women is a multidimensional problem that may benefit from the application of models in the pain field. Apart from gender discrimination, one reason why the area of sexual pain has lagged behind deals with the nature of the problem. On the one hand, sexual pain has been viewed strictly as a medical problem with certain diagnoses (e.g. provoked vestibulodynia), while more recently it is argued that it should be viewed as a pain problem from a biopsychosocial perspective [10]. While there are clearly biological aspects involved (e.g. vaginal floor muscle dysfunction [11], neuropathological changes), it has become apparent that psychological and social aspects are also central.

Since sexual encounters are highly emotional as well as painful for these women, the role of fear and avoidance has repeatedly been associated with female genital pain [7,12,13,14]. The fear avoidance model has played a major role in our understanding of the development and treatment of chronic musculoskeletal pain conditions [15]. In short, the model suggests that pain or a threat of injury triggers catastrophic worry, fear and avoidance which in turn lead to additional emotional distress, dysfunction and further pain experiences [16]. A recent review show that this model is in line with much of the research within female sexual pain and psychosocial factors and the similarities with findings from other chronic pain populations (e.g. musculoskeletal pain) is evident [17]. However, it is important to note that due to the major sexual consequences there are also distinct differences that might separate sexual pain from other chronic pain conditions. The emotional reactions tend to include guilt and shame to a higher extent than in other pain conditions. Also the social mechanisms are emphasized in terms of the partner’s reactions to pain in the sexual situation [17].

The interplay between cognitive, emotional and physiological mechanisms in recurrent sexual pain is not basically different from other types of chronic pain conditions. Interpretations, emotional reactions and behaviour are known to interact with the physiology of pain. However, in the context of sexual pain the role of these factors for the maintenance of the problem has to be emphasized. Once sexual encounters have been associated with pain (fear of pain), negative anticipation of threat will result in a loop where hypervigilance steals an essential part of attentional resources needed for sexual arousal [18]. Impaired sexual arousal will for many women result in absence of vaginal swelling and lubrication and in the case of sexual penetration an increased risk for pain.

An important paradox in the problem of recurrent sexual pain is that many women continue to engage in sexual intercourse despite of pain [19]. Reasons given for participating in painful sexual activities are a wish to satisfy the partner, to be a real woman and to avoid negative consequences in terms of shame and guilt [20]. The behaviour of suppressing pain in order to continue with valued activities which may in turn result in over exertion and injury is described in the Endurance Model of chronic pain [21]. To participate in painful intercourse will increase the risk of prolonged pain in several ways; by leading to mechanical pain due to a lack of sexual arousal (lubrication) and to further strengthen the link between sex and pain and therefore also result in negative anticipation/fear of pain during future sexual encounters. In addition, the experience of frequent sexual pain is commonly associated with reactions of shame and guilt which may further increase the risk of a silent suffering in terms of painfully enduring sex instead of communicating pain-related needs to a partner or to seek professional care.

Because we lack a clear understanding of the mechanisms involved, there are currently no established guidelines for assessing or treating unexplained genital pain conditions causing recurrent sexual pain in women. What further complicates the challenge with sexual pain is a seemingly different pattern of health care consumption as compared with other chronic pain populations. Among afflicted women, as many as 50% do not seek professional care for their pain [22], and among those who do contact health professionals only a minority receive a formal diagnosis for their pain [4], and few experience satisfactory treatment results [22]. While some women are offered a variety of medical treatments, only a few are offered psychological treatments, and the effectiveness of these treatments is difficult to determine given the scant number of trials and the methodological challenges involved [23]. Existing treatments are under-evaluated [24] and there are only a handful of randomized controlled trials [25,26].

Furthermore, the problem of recurrent sexual pain is a highly volatile, personal, and socially weighted experience where special consideration is required; it is far more than vaginal penetration. Because of the lack of understanding of the mechanisms, there is also a risk of over-emphasizing the role of vaginal penetration in the assessment and treatment of female sexual pain [27] and clinicians may simply fail to investigate sexual function from a broader perspective. This might seriously threaten the validity of treatment interventions since there is a risk of applying treatments designed at shaping a woman’ behaviour to fit her partner’ (and society’s) expectations on her sexual performance [28]. This highlights the risk of sexual treatment interventions being oriented towards performance in terms of a narrowly defined sexual behaviour instead of focusing on valued activities, meaning and pleasure for the individual. When specific health professionals deal with different aspects of painful intercourse, there is a risk of not appreciating the role of the socio-cultural context. While emotional responses to pain are psychological, the perception that women must allow vaginal intercourse for satisfactory sex, to please her partner and to be a “real” women are socio-cultural, and have to be identified by all practitioners [27]. The challenge in treatment deals with identification of the woman’ true values which will guide the formulation of treatment goals. From this perspective, the goal of treatment is not simply related to sexual pleasure (for the partner or perhaps even for the patient), but include a much broader set of goals that commonly involve developing an intimate relationship, emotional trust, disclosure, and what has been framed as “sensual contentment” rather than simply sexual contentment [29]. This demands a careful analysis of the problem and its consequences for each woman not just related to the sexual context, but including behavioural, emotional, cognitive, physiological and interpersonal aspects. Practitioners have to be open to a variety of treatment goals, depending on the individual analysis. However, a general pattern in psychosocial treatment of pain focuses on emotion regulation. In sexual pain it seems plausible to add components dealing with interpersonal skills and emotional processes in an intimate relationship.

In sum, there seems to be much to win by viewing the problem with recurrent intercourse pain as a chronic genital pain condition with profound negative sexual consequences. By viewing the problem as a pain problem we could win precious ground for assessing and treating it since the force of pain research would be brought to bear on it. However, although several similarities emerge with other chronic pain conditions (aetiology, pathophysiology, psychosocial correlates) there are also distinct differences that have to be regarded in the assessment and treatment in terms of emotional, physiological and social aspects of the condition and not the least the impact of the socio-cultural context in which the pain is experienced.

4 Sexual pain deserves attention

There is a growing interest in the problem of female genital pain and associated problems with sexual pain. However, publications predominately refer to the field of sex research, and the involvement from the pain community has to date been relatively low. There is still a lack of theoretical models describing both the physiological and psychosocial mechanisms involved in the development of problems with painful intercourse over time.

After half a century of assumptions about the symbolic aspects of pain associated with intercourse, a new start that takes the pain seriously and investigate its properties and multiple etiologies should be championed by the pain community. Female genital pain (and its sexual consequences) needs to lose its reputation of not being part of the field of pain in order to be prioritized in funding and in scientific publications. There is an immediate need to identify the psychosocial mechanisms involved in the transition from acute to chronic genital pain in women and to address these components in treatment using established methods. In addition, clinical trials have to be conducted in controlled settings in order to identify evidence-based interventions.

Highlights

• Sexual pain has been shamefully ignored by the pain community.

• Principles from the pain clinic need to be applied to female genital pain.

• Psychosocial aspects in sexual pain seem comparable to other types of chronic pain.

• There is a lack of understanding of the mechanisms involved in sexual pain.

• Sexual pain is far more than pain during vaginal penetration.

• Assessment and treatment have to include a broad perspective on pain.