Why Cope?
Motivational Goals, Pain Catastrophizing and Coping Behaviors in Women with PVD Rebecca Lennartsson & Malin Enlund Tuuvas
Örebro University
Abstract
Provoked Vestibulodynia has a prevalence of approximately 12-30% in premenopausal women, and affects women from a physiological, psychological and relation perspective. The purpose of the current study was to examine psychological correlates of PVD, which have been linked to the development and maintenance of pain. Specifically, interpersonal motivational goals, pain coping behaviors, pain catastrophizing, sexual function & satisfaction were examined. Data was collected from women aged 19-41 (N=23) who applied for participation in a treatment study. The results indicate that pain catastrophizing and avoidance sexual goals has predictive value for avoidance coping behavior, and that approach sexual goals and avoidance sexual goals has predictive value for endurance coping behavior. An extended model of fear-avoidance is presented, based on earlier research and the results of the current study. Due to the small sample size, further studies are needed to clearly establish the associations.
Key words: Provoked vestibulodynia, motivational goals, pain catastrophizing, pain coping strategies, health psychology
Supervisor: Ida Flink
Consulting supervisor: Linnéa Engman Clinical Psychology Program
Varför ha smärtsamt sex?
Motiverande mål, smärtkatastrofiering och copingbeteenden hos kvinnor med PVD1 Rebecca Lennartsson & Malin Enlund Tuuvas
Örebro Universitet
Svensk sammanfattning
Provocerad vestibulodynia har en uppskattad prevalens på 12-30% bland kvinnor innan klimakteriet, och påverkar de drabbade ur ett fysiologiskt, psykologiskt och relationellt perspektiv. Syftet med den aktuella studien var att undersöka psykologiska faktorer som korrelerar med PVD, vilka kopplats till utvecklande och vidmakthållande av smärta. Specifikt undersöks interpersonella motiverande mål, strategier för smärtcoping, smärtkatastrofiering, sexuell funktion och nöjdhet. Data samlades in från kvinnor i åldern 19-41 (N=23) vilka sökt medverkande i en behandlingsstudie. Resultaten indikerar att smärtkatastrofiering och undvikande sexuella mål kan predicera undvikande coping, samt att närmande sexuella mål och undvikande sexuella mål kan predicera uthärdande coping. Utifrån tidigare forskning och den aktuella studien presenteras en utvecklad rädslo-undvikandemodell På grund av litet stickprov behövs ytterligare studier för att säkerställa associationerna.
Nyckelord: Provocerad vestibulodyni, motiverande mål, smärt-katastrofiering, smärtcoping-strategier,
hälsopsykologi
1Psykologexamensuppsats, VT2018, Handledare: Ida Flink, Bihandledare: Linnéa Engman
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Why Cope? Motivational Goals, Pain Catastrophizing and Coping Behaviors in Women with PVD
Chronic vulvovaginal pain affects between 8 and 21% of premenopausal women (e.g., Danielsson, Sjöberg, Stenlund, & Wikman, 2003; Bachmann, Rosen, Arnold, Burd, Rhoads, Leiblum & Avis, 2006; Harlow, Kunitz, Nguyen, Rydell, Turner & Maclehose, 2014). The pain does not only affect women from a physiological perspective, but also psychologically, relationally and socially. The topic has long been disregarded and neglected in the scientific community. There is however currently an increased interest and engagement in women’s health and sexuality.
People engage in sexual activity for a multitude of reasons, for example procreation, pleasure, intimacy and due to societal or interpersonal expectations. But when sex hurts – the choice to engage or not engage in sexual intercourse, and the consequences thereof, becomes increasingly relevant to explore. In this study, we wish to further examine the motives behind why women with chronic vulvovaginal pain do or do not have painful sex.
This study aims to contribute to the knowledge regarding provoked vestibulodynia by re-examining associations previously established, as well as to fill knowledge gaps identified in earlier research. To increase the understanding of how women deal with chronic
vulvovaginal pain in interpersonal contexts, we wish to examine sexual interpersonal motivations and pain coping behaviors. More specifically, we aim to integrate two topic relevant theories; sexual interpersonal motivational theory and the fear avoidance model of pain in order to provide further insight into how women cope with vulvovaginal pain
(specifically provoked vestibulodynia). A better understanding of these associations will give researchers and health care providers alike further possibilities to prevent development of, and treat, chronic vulvovaginal pain.
Provoked Vestibulodynia & Vulvodynia
Provoked vulvodynia refers to chronic genital pain, which cannot be explained by a physical disorder. Specifically, the pain is elicited by touch or pressure (Binik, 2010), and located in or around the genitals. One of the most common subtypes of vulvodynia is
provoked vestibulodynia (formerly referred to as vulvar vestibulitis syndrome). The estimated life time prevalence of provoked vestibulodynia is 12-30% (Bergeron, Corsini-Munt, Aerts, Rancourt, & Rosen, 2015). Chronic pain can occur in different parts of the vulva, where provoked vestibulodynia is considered one of the most common diagnosis (Bergeron et al., 2015). Provoked vestibulodynia is described as cutting, burning and/or aching pain in the superficial parts of the vulva (the vulvar vestibule) when pressure/touch is applied to the area. Most women who suffer from this condition describe that the pain most commonly occur during and/or after penetration of the vulva (e.g. during penetrative intercourse or
gynecological examinations), but many also describe pain or discomfort in other contexts, such as when wearing tight trousers, bicycling or sitting (Bachmann et al., 2006; Thomtén, 2014).
Provoked vestibulodynia – etiology and biopsychosocial associations. The etiology of PVD is largely unknown. Both biological and psychological developmental paths have been explored, and a multifactorial conceptualization has emerged to explain the development and maintenance of the condition (Ekdahl, 2017). A biopsychosocial conceptualization, where biomedical aspects, psychological mechanisms and social factors interact has been
recommended, similar to other chronic pain populations (Bergeron et al., 2015; Harlow & Stewart, 2003; Vlaeyen & Linton, 2000; 2012, Adams & Turk, 2018). Even though there is still a need for further exploration of the development and maintenance of the condition, we briefly describe what is known thus far below.
Biomedical factors. Provoked vulvodynia has previously been regarded as a primarily physical or psychosexual condition, which has spurred research about its biomedical
components. In a recent literature review by Bergeron et al (2015), four risk factors were indicated as important in regards to the development of provoked vulvodynia, which is an umbrella term wherein provoked vestibulodynia resides.
Hormonal changes due to combined hormonal contraceptives may be a factor, by causing changes in the vestibular mucosa (the tissue lining the vestibule of the vagina) (Johannesson, Blomgren, Hilliges, Rylander, & Bohm-Starke, 2007). Furthermore, neurological changes may reduce pain thresholds and increase pain intensity, through sensitization of nerves in the vulva. Third, the effects of vulvovaginal infections and inflammation have been linked to development of chronic pain. Women with PVD report higher rates of previous urinary tract infections and chronic yeast vaginitis (Arnold, Bachman, Kelly, Rosen, & Rhoads, 2006). Lastly, hypertension (strength and condition) of pelvic floor muscles have been associated with different types of vulvovaginal pain conditions (Bergeron et al., 2015). Moreover, when compared with healthy controls, women with vulvodynia have been shown to be more likely to also suffer from fibromyalgia and Irritable Bowel Syndrome (IBS) (Arnold et al., 2006), which further strengthens the similarities to other pain conditions (Adams & Turk, 2018).
Psychological factors
Depression and anxiety. Women with PVD report increased levels of psychological distress (Gates & Galask, 2001; Wylie, Hallam-Jones, & Harrington, 2004) including
depressive symptoms and anxiety (Nylanderlundqvist & Bergdahl, 2003; Thomtén, Lundahl, Stigenberg & Linton, 2014) when compared to healthy controls.
the link between PVD and sexual abuse has been examined, and the findings are inconclusive. In a sample of 12-19-year olds, girls with dyspareunia reported a higher lifetime occurrence of sexual abuse (Landry & Bergeron, 2011). Other studies have not found a correlation between vulvodynia and sexual or physical abuse. Barbara Reed (in Female Sexual Pain Disorders. 1st Edition, 2008) notes that studies examining vulvodynia and sexual and physical abuse have many methodological flaws, and furthers this argument by stating
“Furthermore, despite the associations noted in some studies, it is important to keep in mind that many women with dyspareunia do not have a history of SA [sexual abuse, authors note], and many of those abused do not develop dyspareunia-related
disorders.” (pg. 216)
Sexual function and subjective arousal. For women with PVD, vaginal penetration is often painful, which logically affects sexual function if the woman wishes to engage in penetrative intercourse. When something hurts, humans are naturally inclined to shy away from it – hence vulvovaginal pain could reasonably affect how much an individual wants to engage in sexual intercourse, and how they experience their arousal. In an experimental study aiming to evaluate sexual arousal in women suffering from PVD, it is reported that there was no difference in genital arousal between controls and PVD women (Payne, Binik, Pukall et al., 2007). Even though no physiological difference was found, the women with PVD reported significantly lower subjective arousal, and had more genital and non-genital pain sensitivity. In addition, women with PVD have been shown to have a lower pain threshold (Granot & Lavee, 2005). Furthermore, Brauer and colleagues (2007), showed that even though women with PVD did not differ in their genital responsiveness to healthy controls, they experienced higher negative affect and lower subjective sexual responsiveness. Basically, they physically showed no difference in arousal to controls, but their subjective experience of this physical arousal was significantly lower than in healthy women. Lastly, women with chronic genital
pain report lower sexual function in comparison to healthy controls (Thomtén, 2014; Ekdahl, Flink, Engman, & Linton, 2018).
Social and relational factors. Since provoked vestibulodynia often develops in, and affects, the individual’s sexual context(s), previous research has examined the links between PVD and relationship factors. Studies have investigated how partners’ responses to pain, emotional expression, acceptance and pain catastrophizing influence vulvovaginal pain intensity as well as other sexual and relational aspects. Furthermore, cognitions regarding relational aspects and societal norms may influence the development and maintenance of the pain (Elmerstig, Wijma & Berterö, 2008; Thomtén, 2014).
Women’s cognitions and responses to relational factors. In a qualitative study by Elmerstig, Wijma & Berterö (2008) it is described how “feelings of guilt”, “striving to be affirmed in their [the women’s’] image of an ideal woman” and “sexual intercourse as an act of sacrifice for a partner’s sake” contribute to the choice of having intercourse despite pain. It is also described that the women placed higher importance on their partners’ satisfaction and sexual pleasure, than their own sexual pleasure or pain, which has been confirmed in other qualitative studies in the area (Juel Eckerström & Sköld, 2017; Marriott & Thompson, 2008). One could argue that social norms influence the sexual scripts and image of the “perfect woman and girlfriend”, which subsequently may influence the development and maintenance of vulvovaginal pain. In a quite recent study, 47% of women who had experienced pain during intercourse had endured the pain rather than discontinue intercourse (Elmerstig, Wijma, & Swahnberg, 2013). The most common response as to why, was that they did not want to ruin the experience for their partner or that their partner would be disappointed if they did not enjoy vaginal penetration. Hence, interpersonal factors and the goals of interpersonal relationships seemingly influence the maintenance and development of PVD.
Approach & avoidance motivational theory
Some women with PVD engage in sexual intercourse despite the pain, some do not (Engman, Flink, Ekdahl, Boersma, & Linton, in press). To learn more of what motivates these different behaviors the current study will use approach & avoidance motivational theory.
Motivational theory is a wide framework, and in the current study we assume the perspective brought forward by Impett and colleagues (2005). It is based on the theory of psychological hedonism, which in short is the idea that all our actions are attempts to approach pleasure and avoid pain (Higgins, 1998). As such, motives are distinguished from goals. The argument is made that motives are driving forces, similar to traits, and goals are more short-term desires, similar to states (Gable, 2006). In the current study, we will specifically examine approach and avoidance sexual goals, as described below.
One of the first studies to conceptualize approach and avoidance motives in the context of sexual behavior was the Cooper, Shapiro & Powers study of 1998. In a non-clinical sample, they found four dimensions of sexual motives: Self/Positive reinforcement,
Self/Negative reinforcement, Social/Positive Reinforcement and Social/Negative
reinforcement. On the social, or interpersonal dimensions they found that sexual behavior often stemmed from a desire to either avoid or achieve a goal in relation to another
person. An example of an approach interpersonal sexual goal is “I have sex to feel close to my partner” while an avoidance goal could be “I have sex with my partner to avoid conflict” (Cooper, Shapiro, & Powers, 1998). Approach and avoidance goals may seem to be opposites in the sense that a person is driven by either/or. However, it is quite possible to be motivated by approach and avoidance goals at the same time (e.g. give a partner pleasure and also avoid a conflict). Goals can vary over time and in different contexts.
Goals are of importance since they impact behavior. In the current study we want to understand how they impact sexual coping behaviors specifically. Corr (2013) suggests that
since a specific stimulus can bring out different responses (behaviors) in different people, as well as in different situations, goals and behaviors must be understood in context. For
example, an individual can interpret their partner putting a hand on their thigh while watching a movie as a show of affection or interpret the gesture as a cue that their partner wishes to have sex. Hence, an individual who is hesitant to engage in sexual intercourse due to pain may respond to the partners hand by moving away or become cognitively preoccupied with what declining their partners wish would imply. One can see then, that this very “simple” gesture (stimuli), can be interpreted in a multitude of ways depending on the context, and elicit a multitude of response behaviors. As such, intrapersonal properties (mood, previous experiences, etcetera) influence whether a stimulus elicits endurance or avoidance behavior, meaning a person’s behavior can be influenced by different goals in different situations (Corr, 2013).
It is important to understand that there is a difference between approach and avoidance goals, and endurance and avoidance coping behavior (described below). The former are our motives, what we wish to achieve in the short or long run, in other words, what we want. The latter are the means we use to achieve these goals, i.e. what we do.
Associations between sexual goals and well-being. Previous research has found that approach and avoidance sexual goals are linked to several aspects of mental and sexual health. Avoidance sexual goals (e.g. have sex in order to avoid a conflict) have been associated with lower sexual and relationship satisfaction as well as higher symptoms of depression in women with PVD (Rosen, Muise, Bergeron, Impett, & Boudreau, 2015). In contrast, higher approach sexual goals (e.g. have sex to increase intimacy and strengthen the relationship) were associated with relationship and sexual satisfaction. A recent study indicates that sexual goals and relationship goals may interplay (Rosen, Dewitte, Merwin, & Bergeron, 2017). A combination of relationship approach goals and sexual approach goals
was associated with higher levels of relationship and sexual satisfaction and lower levels of depressive symptoms, and a combination of relationship avoidance goals and sexual
avoidance goals was associated with lower relationship satisfaction and higher pain intensity during intercourse for women (Rosen et al., 2017).
Approach sexual goals have been shown to be less common in women with PVD than in their partners and healthy controls (Rosen et al., 2017). Women with PVD more commonly report avoidance sexual goals. Interestingly, studies indicate that sexual goals may to be malleable, and thus can change through psychological interventions (Muise, Boudreau, & Rosen, 2017). When considering the negative outcomes for avoidance sexual goals, this is noteworthy as these finds could be of clinical importance
As previously stated, goals are what we want, and coping is what we do - yet in this population these two factors have not been previously co-examined (Volders, Meulders, De Peuter & Vlaeyen, 2015; Flink, Engman, Ter Kuile, Thomtén & Linton, 2017). Thus, there is a need to understand the link between motivational goals and coping in women suffering from vulvovaginal pain
Coping with pain
Coping is described as patterns of internal and external behaviors used to respond to a threat or demand (Tunks & Bellissimo, 1988). It has been conceptualized as the behaviors which individuals use in order to reduce the impact of negative life stressors on their psychological well-being (Lazarus & Folkman, 1984). The concept is widely used, yet not always thoroughly defined or operationalized (Van Damme, Crombez, & Eccleston, 2008). Van Damme and colleagues (ibid.) describe that coping can be both maladaptive and adaptive, and is situationally and contextually bound. Hence, a coping behavior which is functional in one context, may be maladaptive in another, or maladaptive when used in response to a certain threat, but not another. Remember the previous example where a
person’s partner placed a hand on their thigh. Imagine that we did not know anything about the context – how would we know whether or not removing the hand or leaving it on the thigh is maladaptive or adaptive? Without knowing the context, both behaviors could be adaptive or maladaptive. Hence, context is key. In addition, a behavior which is adaptive in the short term, such as avoiding a certain behavior that produces pain, may be maladaptive in the long term. Women may for example choose to endure painful intercourse in order to gain intimacy, or avoid a conflict with their partner, or avoid intercourse to not disappoint their partner, or because the pain frightens them more than the consequences of not having intercourse. Some women might avoid relationships altogether. Subsequently, these choices may also affect the development and maintenance of future pain, as described below.
Coping with pain –Avoidance. During acute and/or chronic pain, both internal and external behaviors are produced by the individual to reduce the pain or its consequences. A theory which has emerged to explain the development of acute pain into chronic pain and the maintenance of chronic pain, is the fear avoidance model (FAM), described below.
The fear avoidance model. The fear avoidance model has been proposed to explain the development and maintenance of provoked vulvodynia (Thomtén & Linton 2013; Ekdahl, Flink, Engman & Linton, 2018; Desrochers, Bergeron, Khalifé, Dupuis, & Jodoin,
2009;2010). It stems from a biopsychosocial framework. As such, it leans on the perspective that health and illness, in addition to physiological states, are also subjective experiences influenced by psychological mechanisms and social factors. The fear avoidance model has been examined in several different chronic pain populations (for a review, see Vlaeyen & Linton, 2012). A few studies have applied it to vulvovaginal pain; some which support the model (Desrochers et al., 2010; Thomtén & Linton, 2014; Engman et al., in press), and some which do not (Davis et al., 2015).
Thomtén and Linton (2014) propose that an episode of vulvovaginal pain can lead to two possible pathways, as shown in the model below (fig 1). In pathway one, the pain experience is interpreted as a threat, which leads to increased pain catastrophizing and pain-related fear (in the model pain catastrophizing is simply called catastrophizing).
Subsequently, this increases hypervigilance which reduces arousal and lubrication, and leads to avoidance coping behaviors. This, in its turn, increases dysfunction, distress and/or disuse – which then increases the probability of another pain experience. In pathway two, the pain experience is followed by normal fear, which is then confronted and subsequently leads to a healthy adaption. Both pathways are hypothesized to be affected by partner responses (e.g. solicitous, hostile or facilitative responses).
Figure 1. The Fear Avoidance model for PVD (Thomtén &Linton, 2014)
Coping with pain – Endurance. As goals may influence how individuals cope with pain, avoidance is not the only coping strategy used by women with PVD. As previously noted, studies show that women endure sexual intercourse in order to gain other “rewards”, such as intimacy, or avoid “loss”, such as a conflict with their partner or the feeling that they are not “normal” (Elmerstig, Wijma & Berterö, 2008). Unfortunately, there is less research on
endurance coping than avoidance coping, both in chronic pain patients in general and in women with PVD. In patients with chronic back pain, there is evidence that both avoidance and endurance coping predict reduced recovery from pain over time, although the support is quite limited (Hasenbring, Hallner, Klasen, Streitlein-Böhme, Willburger & Rusche, 2012). In PVD, it has been found that women with PVD endure painful intercourse as a coping strategy (Flink, Thomtén, Engman, Hedström, & Linton, 2015; Flink I. K., Engman, Ter Kuile,
Thomtén, & Linton, 2017), and that endurance coping behavior is associated with pain intensity and pain catastrophizing (Flink et. al., 2017)
Associations between coping and sexual satisfaction and function. Many of the specific constructs in the FA-model have been linked to sexual dysfunction, sexual satisfaction and pain intensity in women suffering from provoked vulvodynia or other vulvovaginal pain conditions. Avoidance coping behavior has been shown mediate the relationship between pain catastrophizing and pain intensity in women with chronic
vulvovaginal pain (Flink et al., 2017). Fear avoidance beliefs has also been shown to predict both pain intensity and vulvovaginal pain over time, meaning that higher fear avoidance beliefs both increased the likelihood of developing vulvovaginal pain, and also predicted pain intensity (Ekdahl et al., 2018). Nevertheless, fear avoidance beliefs need to be considered in relation to contextual factors, such as partner responses.
Pain Catastrophizing
Since pain is noxious and often feared, it is not surprising that our minds attempt to reduce the risk of encountering pain, feel helpless before its effect on us, or believe that the pain will never end. Pain catastrophizing can be described as an “exaggerated negative mental set” in response to acute, previous or future pain (Sullivan, et. al., 2001). It is often
conceptualized to include three sub-components; helplessness, rumination and magnification (Sullivan, Bishop, & Pivik, 1995; Sullivan, et al., 2001). However, a recent
reconceptualization proposes that pain catastrophizing could instead be considered more similar to repetitive negative thinking (Landström Flink, Boersma, & Linton, 2013). Hence, pain catastrophizing could serve a function of emotion regulation, and thus reduce negative affect, in a similar manner as worry. Furthermore, catastrophizing as a broader concept has been examined both in anxiety disorders (specific phobia, generalized anxiety disorder) and mood disorders (Quartana, Campbell, & Edwards, 2009). In the current paper, we specifically examine pain catastrophizing – as it is relevant in regards to chronic pain disorders.
When catastrophizing emerged as a concept, magnification was at its core (Quartana et al., 2009). As a concept, it is when the individual over-values a future or current threat. To exemplify, imagine someone discovering a new mole on their arm. One might think this is something to check out with a health professional. When magnifying, one might start to think about all the terrible skin diseases this mole might become and remember other times people have found new moles which turned out to be cancerous. Thus, in pain catastrophizing, thoughts such as “this pain will just get worse” or “maybe I will not be able to ever find a partner due to my pain” and their subsequent negative outcomes are common. One can hereby see the similarities to rumination or worry, where rehashing the negative events may induce feelings of “dealing with the problem”, while the subject is actually remaining passive.
Pain and the effect of pain catastrophizing. Pain catastrophizing has been shown to be an important factor in the development and maintenance of chronic pain in a multitude of pain populations, e.g. fibromyalgia, chronic musculoskeletal pain, osteoarthritic knee pain and endometriosis (Leung, 2012; Martin, Johson, Wechter, Leserman, & Zolnoun, 2011).
Furthermore, pain catastrophizing has been linked to poorer outcomes in treatment of chronic pain (Quartana et al., 2009).
Pain catastrophizing and provoked vestibulodynia. Pain catastrophizing has been shown to predict the development of PVD, and women suffering from PVD report higher
levels of pain catastrophizing (Flink et a., 2017; Payne, Binik & Pukall, 2007; Lemieux, Bergeron, Steben & Lambert, 2013; Thomtén et al., 2014). Pain catastrophizing has also been shown to predict pain intensity over time in women with PVD (Flink et al., 2017; Desrochers et al., 2010). As previously noted, the effect of pain catastrophizing on pain intensity is mediated by avoidance behavior over time. In the same study, endurance coping mediated the effect of pain catastrophizing on pain intensity, but only cross-sectionally. Hence, the
relationship between endurance and pain catastrophizing is not as strong as between avoidance behavior and pain catastrophizing. It is further noted that endurance may be influenced by catastrophizing around other issues than the pain itself; about the relationship, future procreation or “not being normal” (Flink et al. 2017).
In conclusion
Provoked vestibulodynia is a debilitating condition which influence many parts of the affected women’s life. It has been shown to affect psychological well-being, relationships, sexual function and sexual satisfaction. Women’s sexual goals and how they deal with their pain has been shown to predict well-being, relationship satisfaction and pain outcomes over time. Both sexual goals and coping behaviors have been studied separately, however they have not been linked together. Furthermore, avoidance and endurance coping behaviors have only been examined in samples including both sub-clinical and clinical presentations of vulvovaginal pain. Thus, the current study significantly contributes to knowledge regarding how women deal with their pain, in the sense that only women who fulfill criteria for provoked vestibulodynia are included. In addition, previous research has indicated that pain catastrophizing is associated with both endurance and avoidance coping behaviors, indicating that this construct may also be important in a model aiming to explain why women endure or avoid painful intercourse.
In this study, our aim was to further the understanding of motivational goals, pain catastrophizing and coping behavior in women with PVD. More specifically, we asked the following questions:
1. What are the links between sexual interpersonal motivational goals, coping behaviors, pain catastrophizing, sexual function, sexual satisfaction and pain?
2. What is the predictive value of pain catastrophizing and avoidance sexual goals on avoidance coping behavior? Our hypothesis is that pain catastrophizing and avoidance sexual goals will predict avoidance coping behavior.
3. What is the predictive value of pain catastrophizing and approach & avoidance sexual goals on endurance coping behavior? We hypothesize that both interpersonal sexual goals will predict endurance behavior, and that pain catastrophizing will predict endurance behavior to a lesser extent than it predicts avoidance behavior.
Method
The data used in the current study is a subsample from a larger and ongoing study, “the Venus study”, which is a collaborative effort between Örebro University, Maastricht University and Leiden University. The aim of the Venus study is primarily to examine the
Figure 3. The hypothetical link between motivational goals, pain catastrophizing and endurance coping behavior.
Figure 2. The hypothetical link between approach sexual goals, pain catastrophizing and avoidance coping behavior.
effect of a CBT group treatment for PVD in women. The larger study collects data from both women and their male partners, but for the purpose of the current study, only data from the women is used.
Design
The data described in this study is a subsample of baseline data, collected between October 2017 and January 2018. The current study has a cross-sectional design, and the data used is selected measures of the baseline self-report data collected to this date at Örebro University. The age of participants ranged from 19 to 41 years of age, N=23.
Participants. Women between 18 and 45 (and their partners) were recruited through social media advertisements (Facebook and Instagram), posters at local health care centers and at the university, and via referrals from health care professionals. The recruitment process is described under “procedure”. Inclusion criteria were i) vulvovaginal pain during or after ≥80% of intercourse attempts, causing subjective distress ≥6 months, ii) current heterosexual relationship ≥3 months, iii) age 18-45, iiii) partner agreed to participate in the CBT treatment and in the study. Exclusion criteria were i) an active infection in the vulva (e.g. yeast
infection, fissures, bacterial vaginosis), ii) unprovoked vestibulodynia without concurrent vulvovaginal pain caused by penetration or pressure, iii) major psychiatric illness (e.g. severe affective disorder, current alcohol or substance use disorder, post traumatic-stress disorder related to the genitals (e.g., as a consequence of sexual abuse), iiii) current pregnancy or childbirth within the last year.
Procedure. Participants were recruited from the area around a mid-sized Swedish city. A flowchart of the recruitment process is provided below, fig 4. Individuals applied for participation by email and were subsequently contacted by a researcher. Eligibility was first assessed through a structured telephone interview, conducted by a psychologist. Prior to the telephone interview the participants received written information regarding the study, ethical
considerations and what possible participation would entail. During the telephone interview, the participants received information regarding the research project and were asked if their partner agreed to participate. Participants deemed eligible were called to a second interview at the research center where both the woman and the partner participated. The second interview was conducted by a research assistant with a bachelor in clinical psychology (one of the research assistants was one of the authors of the current study). The interview consisted of a diagnostic interview with the purpose of screening for provoked vestibulodynia, and to identify possible exclusion criteria. The diagnostic interview was constructed specifically for the study, in cooperation with a gynecological clinic in the Netherlands. The participants (and their partners) were asked about the vulvovaginal pain, other vulvovaginal symptoms in addition to questions about their relationship. The Mini International Neuropsychiatric Interview 6.0 (Lecrubier, et al., 1997) was conducted in order to screen for concurrent psychological disorders.
Participation, Exclusion and Inclusion. A flowchart of the recruitment is displayed in figure 4. Of the 60 interested women, 34 (56%) participated in the telephone interview. 25 (41%) women were subsequently interviewed at the research center, and 23 (38%) were included in the final sample. Hence, the sample consists of 23 women ages 19-41.
Figure 4. Flowchart of the recruitment process. Measures
Swedish versions of all measures were used.
Demographic information. Demographic information included age, nationality, educational level, vocational status, relationship status and duration, and if they have given birth.
Vulvovaginal Pain. Vulvovaginal pain during intercourse was measured by two questions rated on a numerical rating scale from 0-10; “Estimate the general intensity of the vulvovaginal pain that you have experienced during intercourse on a scale from 0-10 in the last 4 weeks” & “Estimate how unpleasant the vulvovaginal pain that you have experienced during intercourse, in general, on a scale from 0-10 in the last 4 weeks”. Numerical rating scales of pain intensity have been shown have to have good validity and reliability, as well as to be more practical than other similar pain rating measures (Jensen, Karoly, & Braver,
Strategies for Coping with Vulvovaginal Pain. The CHAMP Sexual Pain Coping scale (CSPCS) was used to assess how the women coped with sexual activities due to, or despite, their pain. The CSPCS consists of 8 items divided into 2 subscales, avoidance coping strategies (e.g. Because of the pain, I avoid intercourse even when I feel sexually excited) and endurance coping strategies (e.g. During painful intercourse, I try to endure because I would feel like a failure if I did not keep going). The items are rated on a 7-point Likert scale (1=never true and 7=always true). The scale has shown good internal reliability and validity (Flink et al., 2015). High scores on each subscale indicate that the coping strategy is used almost always/always, and low scores indicate almost never/never. The Cronbach’s alpha for the subscales were in the acceptable to good range (avoidance, α = .835 & endurance, α = .794) in the current sample.
Interpersonal Sexual Goals. The Approach Avoidance Sexual Goals Scale (AASG) is a 16-item self-report measure with two subscales; approach sexual goals. and avoidance sexual goals. The participant is asked to rate the importance of reasons which influence why they typically engage in sex (e.g. approach goal: “to please my partner” and avoidance goal “to avoid conflict with my partner”) on a scale from 1 “not at all important” to 7 “extremely important”. This measure was first adapted by Impett and colleagues (2005) from Cooper et als.’ (1998) six-factor, 29-item measure, and further developed by Rosen and colleagues (personal communication, N. Rosen, February 26, 2018. The AASG measures sexual interpersonal goals (personal communication, N. Rosen, February 26, 2018), hence does not provide information regarding self-directed (individual) sexual goals. The scale has shown acceptable reliability and internal validity, as shown by previous research (Muise, Impett, & Desmarais, 2013; Impett, Stachman, Finkel, & Gable, 2008; Rosen, Dewitte, Merwin, & Bergeron, 2017; Impett, Peplau, & Gable, 2005). High scores on each subscale indicate higher approach/avoidance sexual goals, low scores indicate less approach/avoidance sexual goals.
The Cronbach’s alpha for the subscales in the current sample was within the acceptable range. Avoidance sexual goals α =. 734 and Approach sexual goals α = .789.
Pain catastrophizing. One subscale of the vaginal penetration cognition questionnaire was used to measure pain catastrophizing; the “catastrophic and pain
cognitions” subscale. The vaginal penetration cognition questionnaire (VCPQ) is a brief self-report measure assessing cognitions regarding vaginal penetration. Participants are asked to rate how applicable a statement is, on a 0-6 Likert scale, with the question “I have the following thoughts about penetration” e.g. “I am scared that the penetration pain will get worse in the future”. Previous research indicates that it discriminates well between women with vulvovaginal pain (dyspareunia or vaginismus) and healthy controls (Klaassen & Ter Kuile, 2009). The measure consists of 22 items divided into 5 subscales (“control
cognitions”, “catastrophic and pain cognitions”, “self-image cognitions”, “positive cognitions” and “genital incompatibility cognitions”). The measure was constructed and validated by Klaassen and Ter Kuille (2009), and the subscale showed good validity and reliability. In the current sample, the subscale showed acceptable Cronbach’s alpha (α = .84).
Sexual Satisfaction. Overall sexual satisfaction was assessed using the Global Measure of Sexual Satisfaction (Lawrence & Byers, 1995). The measure consists of 5 items which are rated on a 7-point Likert scale. All items are bipolar in construction (good-bad, pleasant-unpleasant, positive-negative, satisfying-unsatisfying, and valuable-worthless) where participants are asked to rate “in general, how would you describe your sexual relationship with your partner?”. High scores indicate high sexual satisfaction, low scores indicate low sexual satisfaction. The measure has previously shown high internal consistency and good reliability and validity (Mark, Herbenick, Fortenberry, Sanders, & Reece, 2014). The Cronbach’s α for the current sample was excellent (α = .916).
Sexual Function. The Female Sexual Function Index was used to assess sexual function. The measure consists of 19 items assessing different domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, pain). The measure has been shown to discriminate between women diagnosed with Female Sexual Arousal Disorder, Vulvodynia and healthy controls (Rosen, et al., 2000; Masheb, Lozano-Blanco, Kohorn, Minkin, & Kerns, 2004) and has shown good reliability and validity (Meston & Derogatis, 2002).
The full-scale score is calculated using a formula where individual domain scores are multiplied by a domain factor (Bayer AG, Zonagen, Inc. & Target Health Inc., 2018). The domain scores are added in order to obtain the full-scale score. High scores indicate good sexual function, low scores indicate poor sexual function. In the current sample, the FSFI showed excellent internal consistency with a Cronbach’s α = .950.
Ethical considerations
The topic of the current study could be considered of a sensitive nature. Participants were asked to respond to questions which may be perceived as intimate, such as
psychological symptoms, trauma and sexual health (habits and function), in addition to sexual pain and history. Thus, ethical considerations were of utmost importance.
The study has been approved according to the ethical guidelines for a master thesis at the Department of Psychology at Örebro University. The larger study, from which the current sample is drawn received approval from the regional board of ethics in Uppsala [dnr2017-289]. Furthermore, the current study follows the ethical guidelines of the Swedish research council. The guidelines place emphasis on four research principles regarding information, consent, confidentiality and utilization (Vetenskapsrådet, 2002).
The participants were informed of the purpose of the study and that participation was voluntary. Prior to giving informed consent the participants got to read written information about the study and their participation. During the second interview all participants were
verbally informed about the study and what participation would entail, including their right to withdraw consent at any time without explaining why. In addition, participants were informed that if they chose to withdraw from the study, the information they had provided up until that point would remain in the study. Participants could choose to not respond to individual items in the baseline questionnaires.
No interdependence was noted or suspected between the participants of the study and the researchers/practitioners involved. Due to the small sample size, extra precaution was taken to ensure anonymity. Since one of the authors of the current study conducted the second interviews, revealing demographic information was removed from the data set before authors of the current study could view it.
Statistical Analyses
All data analysis was performed with IBM Statistical Package for the Social Sciences (SPSS) version 24.0. Cronbach’s alphas were calculated in order to ensure internal
consistency for all measures used in the sample. The data were first explored descriptively. Pearson’s product-moment correlation was conducted to assess associations between vulvovaginal pain (intensity and discomfort), avoidance coping behaviors, endurance coping behaviors, approach sexual goals, avoidance sexual goals, pain catastrophizing, sexual function and sexual satisfaction. In order to evaluate if parametric tests could be used with all variables, preliminary analyses were performed to check for linearity, normal distribution and significant outliers. Preliminary analyses showed that all significant relationships were linear, with the exceptions of the correlations between sexual function and pain catastrophizing as well as pain intensity. Not all variables were normally distributed, as assessed by Shapiro-Wilk’s test (p<.05). Specifically, sexual function and pain catastrophizing showed non-normality with a negative skew. This may be due to a small sample. Pearson’s product moment correlation has however been shown to be quite robust in regards to violations of
normality (Laerd Statistics, 2017), hence it was decided to proceed with this test despite that the assumption of normality was violated. To add more information, Kendall’s Tau was performed to assess the Pearson’s product correlations with the skewed variables, as a more robust alternative than Spearman’s Rho (Croux & Dehon, 2010).
Secondly, a hierarchical regression analysis was conducted in order to assess if pain catastrophizing and avoidance sexual goals predicted avoidance coping behavior. Preliminary tests were conducted in order to ensure no assumption violation was present. No violation of assumptions was found. As earlier mentioned, pain catastrophizing was not normally
distributed, yet normal distribution of the predictor variable is not an assumption when
conducting hierarchical regression (Field, 2009), only that the distribution of errors is normal, which the preliminary test indicated they were (Laerd Statistics, 2017). In addition, pain catastrophizing showed a linear relationship with avoidance behavior, and was not severely skewed, hence a log-transformation was not necessary.
Third, a hierarchical regression analysis was performed in order to evaluate how avoidance sexual goals and approach sexual goals predicted endurance coping behavior. Preliminary tests were conducted in order to ensure no assumption violation was present. Regarding dependence of residuals, as assessed by a Durbin-Watson statistic of 1.493, a Durbin-Watson statistic less than 1 is cause for concern (Field, 2009). Otherwise, no indication of violations of assumptions was found.
Results Associations between the study variables
Pearson’s product-moment correlations were conducted to assess the relationships between vulvovaginal pain (intensity and discomfort), avoidance coping behaviors, endurance coping behaviors, approach sexual goals, avoidance sexual goals, pain catastrophizing, sexual function and sexual satisfaction. All correlations, means and standard deviations described are
displayed in table 1. In addition, a non-parametric test was conducted for the two variables which showed a negative skew (sexual function and pain catastrophizing), and the
significance is also displayed in table 1.
Pain, Sexual function and Satisfaction
Pain intensity was linked to pain discomfort, meaning that higher ratings of how intense the pain was in general during penetration correlated strongly with how unpleasantly it was experienced. There were two interesting trends: 1) pain intensity and sexual function, where higher pain intensity ratings were associated with lower sexual function, but the non-parametric test showed no significant correlation and 2) pain discomfort and pain
T ab le 1. M eans , s tandar d de vi at ions and c or re lat ions of t he s tudy v ar iabl es
of pain catastrophizing, where the non-parametric test showed similar results and statistical significance.
Regarding sexual function, there was a strong positive association between sexual function and global sexual satisfaction. Hence, women who reported low sexual function were also likely to report low sexual satisfaction. In addition, there was an association between sexual satisfaction and pain catastrophizing – high levels of sexual satisfaction correlated with low levels of pain catastrophizing. It should be noted that pain catastrophizing and sexual function were not normally distributed, but the non-parametric alternative showed significant and similar correlations.
Goals, Behaviors and Cognitions
Sexual goals significantly correlated with coping behaviors. Avoidance sexual goals were moderately associated with both avoidance behavior and endurance behavior, where higher avoidance sexual goals were associated with higher ratings of avoidance coping behavior, but also with higher ratings of endurance behavior. Approach sexual goals correlated with endurance behavior – higher approach sexual goals correlated with higher ratings of endurance behavior. Avoidance sexual goals and approach sexual goals also correlated strongly, meaning that women with high avoidance sexual goals were likely to have high approach sexual goals, and vice versa.
Avoidance coping behavior was negatively associated with sexual function, sexual satisfaction and pain catastrophizing. Hence, higher avoidance coping behavior was
associated with lower sexual satisfaction and lower sexual function, meaning that women who reported higher ratings of avoidance coping behavior were also likely to report lower sexual function and satisfaction. Furthermore, avoidance coping was positively correlated with pain catastrophizing, thereby showing that women who reported higher ratings of avoidance coping behavior were likely to report more pain catastrophizing thoughts. As pain
catastrophizing was negatively skewed, the association was further explored using a non-parametric alternative and correlation between avoidance coping behavior and pain catastrophizing then showed a trend (p>0.89).
Pain catastrophizing, Avoidance sexual goals and their predictive value on Avoidance coping behavior.
A hierarchical multiple regression analysis was run to assess the predictive value of pain catastrophizing and avoidance sexual goals on avoidance coping behavior. Hierarchical regression analysis was used to assess if avoidance sexual goals improved the predictive value on avoidance coping behavior over catastrophizing alone. See table 2 for full details on each regression model.
Table 2.
Predicting avoidance coping behavior from pain catastrophizing and avoidance sexual goals
Avoidance Coping Behavior
Model 1 Model 2
Variable B 𝛽𝛽 B 𝛽𝛽
Constant 7.990* 2.943
1. Pain catastrophizing .401* .459 .358* .410*
2. Avoidance sexual goals .348* .393*
R2 .210* .362*
F 5.591* 5.681*
∆R2 .210 .152
∆F2 5.591* 4.768*
*Significant at p<.05
1 =VPCQ subscale Catastrophizing and Pain Cognitions 2=AASQ Subscale Avoidance
As model 1 shows, pain catastrophizing predicted avoidance coping behavior, explaining 21% of the variance in avoidance coping behavior. The full model of the
predictive value of pain catastrophizing and avoidance sexual goals on avoidance coping behavior (model 2) was statistically significant, and together avoidance sexual goals and pain catastrophizing explained 36% of the variance in avoidance coping behavior. Thus, the addition of avoidance sexual goals to the prediction of avoidance coping behavior led to a statistically significant increase in the explained variance of 15%.
Avoidance sexual goals, Approach sexual goals and predictive value on Endurance coping behavior.
A hierarchical regression analysis was conducted in order to assess the predictive value of avoidance sexual goals and approach sexual goals on endurance coping behavior. Hierarchical regression was used to assess if the predictor variables had a unique effect on the change in the outcome variable. See table 3 for full details on each regression model.
Table 3.
Hierarchical Multiple Regression Predicting Endurance coping behavior from Avoidance sexual goals and Approach sexual goals
Endurance Coping Behavior
Model 1 Model 2
Variable B 𝛽𝛽 B 𝛽𝛽
Constant -.187 .625
1. Approach sexual goals .342* .522* .274 .413
2. Avoidance sexual goals .146 .174
R2 .273* .291*
F 7.871* 4.103*
∆R2 .273* .018
∆F2 7.871* .516
*Significant at p<.05
The full model of avoidance sexual goals and approach sexual goals to predict endurance coping behavior (model 2) was statistically significant – avoidance sexual goals and approach sexual goals together explained 29% of the variance in endurance behavior. The addition of avoidance sexual goals to the prediction of endurance coping behavior led to no statistically significant change in F. In addition, no unique effects were found.
Discussion
Provoked vestibulodynia is a fairly common and debilitating affliction that impacts on the physical, mental and relational well-being of the women who suffer from it. The aim of this study was to increase the understanding of how women deal with chronic vulvovaginal pain in a relational context, by examining the links between sexual motives, pain
catastrophizing and pain coping behaviors in a clinical population. The results showed that pain experience was not associated with any of the other factors examined, but sexual
function and satisfaction were negatively associated with avoidance coping behavior and pain catastrophizing. Also, avoidance sexual goals and pain catastrophizing had predictive value for avoidance coping behavior, meaning that women who hold avoidance sexual goals also tend to use avoidance coping behavior. In addition, avoidance and approach sexual goals had predictive value for endurance coping behavior, which means that women who both had high avoidance sexual goals and approach sexual goals were also likely to use endurance coping behaviors.
Research question 1
The first research question regarded the links between motivational goals, coping behavior, pain catastrophizing, pain and sexual function and satisfaction. None of the factors were significantly associated with pain intensity or discomfort, apart from the trend between pain catastrophizing and pain discomfort, where the non-parametric test was significant. Nevertheless, both sexual satisfaction and function were negatively associated with pain
catastrophizing and avoidance coping behavior. This was not the case with endurance coping behavior and motivational goals, which were not associated with sexual satisfaction and function. Hence, women who catastrophized around pain and used avoidance coping behaviors were likely to experience lower sexual function and satisfaction.
Research question 2
The second aim was to assess the predictive value of avoidance sexual goals and pain catastrophizing on avoidance coping behavior.
Women with high avoidance sexual goals and pain catastrophizing were more likely to use avoidance coping behavior. Hence, avoidance sexual goals and pain catastrophizing were significant predictors of avoidance behavior. In addition, both factors contribute uniquely to the variance. In other words, it was likely that women who pain catastrophized, and who also held avoidance sexual goals were more likely to use avoidance coping behaviors when facing pain. The predictive value of pain catastrophizing should however be interpreted with caution, as the non-parametric alternative showed a non-significant trend, which is likely due to low power as a result of small sample size.
Research question 3
The third research question was if avoidance and approach sexual goals and pain catastrophizing held predictive value for endurance coping behavior. Pain catastrophizing was subsequently excluded from the analysis, as it did not correlate significantly with endurance coping behavior. The results showed that women who reported higher approach and
avoidance sexual goals were also likely to report higher endurance behaviors.
Both types of motivational goals had predictive value for endurance sexual behavior, although no unique effect was found. Hence, women may choose to endure sexual intercourse both to avoid negative outcomes such as pain, and also to seek positive outcomes, such as
increased intimacy or to give their partner pleasure. The fact that we do not find unique effects is likely due to that the goal variables correlate to a large degree.
The results in the light of earlier research
With regard to the first research question, our findings are mostly in line with earlier research. Previous studies indicate that pain intensity is not associated with sexual function and satisfaction in women with PVD (Aerts, Bergeron, Pukall, & Khalifé, 2016). This does not mean that women with PVD do not have a lower sexual function – the mean rating of sexual function in the current sample is well below the clinical cut-off for sexual dysfunction on the FSFI. What it does mean though, is that more pain does not equal worse sexual function per se in a clinical sample of women with PVD. This may seem surprising, yet strengthens the importance of psychological factors on the experience of pain and its consequences.
Earlier research has found that avoidance sexual goals are associated with lower sexual satisfaction, and approach sexual goals are linked to higher sexual satisfaction in women with PVD (Rosen et al., 2015). Hence, our results contradict earlier findings. It should be noted that this may be due to the small sample size.
Then, how do these findings relate to earlier models of development and maintenance of chronic vulvovaginal pain? Since previous research has indicated that pain catastrophizing is associated with both endurance and avoidance coping behaviors (Flink et al., 2017), the third hypothesis included approach and avoidance sexual goals as well as pain catastrophizing as predictors for endurance behavior. However, in part this assumption contradicts the FAM in its original form, which only includes avoidance behavior (Vlaeyen & Linton, 2000;2012).
Furthermore, endurance coping behavior has not been examined to the same extent as avoidance coping behaviors in the field of pain. The original version of FAM is logical, since both fear of pain and pain catastrophizing reasonably would incur a wish to avoid the pain.
The connection between pain catastrophizing and endurance is not as logical as the link to avoidance - if one is scared of the pain and its previous and future implications - why would pain catastrophizing lead to an individual choosing to provoke pain? Thus, we reason that there may be that other factors drive endurance coping behavior - which might be reflected in the motivational sexual goals.
It is important to remember that neither the goals nor the coping behavior variables are opposites or reflects both ends at a continuum. An individual woman can for example hold both high avoidance sexual goals and high approach sexual goals simultaneously, or both use endurance and avoidance coping behaviors to an equally high extent. In fact, a recent
longitudinal study indicates that a subgroup of women with PVD use both avoidance and endurance coping behaviors (Engman et. al., in press). This group had the lowest sexual function and satisfaction when comparing different profiles (ibid.). Thus, it is important not to reduce an individual’s goals and coping attempts to either or, but rather embrace the
complexity in motivation and coping behaviors. To illustrate, an individual could have sexual intercourse both with the goal to increase intimacy with their partner and to avoid conflict with the partner, at the same time or at different time-points.
As endurance coping behaviors, and to an even larger extent avoidance coping behaviors, theoretically have been suggested to predict development and maintenance of vulvovaginal pain (Thomtén & Linton, 2013; Engman et al., in press), our findings contribute to the understanding of this relationship. In essence, if coping plays a part in the development and maintenance of chronic vulvovaginal pain, and catastrophizing and goals partly predict coping behavior, this has implications for both prevention and treatment of vulvovaginal pain. Intuitively, one might assume that one type of coping behavior would be more adaptive and beneficial than the other. However, our findings indicate that this is not the case. Coping
behavior is complex and several factors may influence why and how women cope with vulvovaginal pain which needs to be taken in consideration in a treatment context.
Another interesting finding (or non-finding) is that there is the lack of correlation between pain intensity/discomfort and the two coping strategies. On the other hand, we did not ask why the women chose a certain coping behavior. Hence, women may choose to avoid sexual intercourse due to vaginal discomfort, on a day to day basis. Therefore, there may be correlations not visible in our data, meaning that women might endure sexual intercourse in periods of less pain and avoid it when they believe sexual intercourse would be more painful. Investigating whether or not the pain fluctuates and thus influences coping would provide further knowledge regarding “coping-profiles”. It could also be that other factors, such as pain self-efficacy or partner responses influence coping behavior to a higher degree than the pain itself. Earlier research has shown association between coping strategies and pain over time, albeit in a sample containing both individuals with subclinical and clinical vulvovaginal pain (Ekdahl et al., 2018). As such, the sample differs from this study’s sample, where the group mean pain rating is higher, which most likely is of importance for these findings
Dealing with pain in intimate interpersonal context. A difference between women suffering from PVD and other pain populations is that they often have to cope with their pain in a very intimate context. How they cope will not only affect their own well-being but also the well-being of their partner (if they have one). Furthermore, how their partner deals with the situation will in turn impact on how she experiences the pain. In the current study only women with (male) partners were included, which may influence the generalizability of the results.
Studies show that interpersonal factors are important for pain development,
maintenance and experience (Rosen et al. 2015). Partner responses have mainly been studied in different-sex couples (meaning that the partner is male). Rosen et al. (2015) describe that
how women experience their partners response can be divided into three main categories: negative (e.g. hostile, angry), facilitative (e.g. encouraging adaptive coping, such as seeking help or exploring alternative sexual activities) or solicitous (e.g. overly caring, comforting, sympathetic). Both partner’s negative and solicitous response has been associated with higher pain ratings (Desrosiers, et al., 2008; Davis, Bergeron, Sadikaj, Corsini-Munt, & Steben, 2015), and lower sexual satisfaction (Rosen, Bergeron, Glowacka, Delisle & Baxter, 2012).
In contrast, it is reasonable to assume that some women with PVD might avoid relationships altogether, in a sense choosing not to have to deal with sexual pain at all. This does not mean that they do not have pain, as it is shown that the pain might also be present in other contexts (Thomtén, 2014). Hence, endurance and avoidance in a sexual situation does not become an issue, as intimacy with a partner is not seen as an option, yet women may still endure or avoid as a coping strategy in other non-sexual contexts. Hence, more research is needed on how women cope with vulvovaginal pain in non-sexual contexts, and how goals and catastrophizing influence this coping.
Catastrophizing in other areas. Since pain catastrophizing was not as clearly linked to endurance behavior as to avoidance coping behavior, and was not associated with
endurance behavior in the current sample, other factors may drive the relationship between motivation and endurance. Could it be that catastrophizing about other factors influences the choice to endure painful intercourse? We propose that endurance coping may be driven by a fear of loss, catastrophizing about the future of/and relationships and self-image, to a higher extent than pain-related fear and pain catastrophizing, which is in line with previous
qualitative research (e.g. Elmerstig, et al., 2008; Juel Eckerström & Sköld, 2017). As is displayed in figure 5, the relationship between avoidance coping, endurance coping, fear and catastrophizing could be conceptualized as two negative circles, where the individual can alternate between the circles. Furthermore, we propose a that pain catastrophizing and pain
related fear is still present in women who endure painful sexual intercourse, but that the behavior is driven by other factors which influence the link between pain, catastrophizing, fear, endurance and sexual function, and similarly with avoidance coping, whereby other catastrophizing and fear of loss is still present, yet where the pain related fear and
catastrophizing is “stronger”. Motivational goals could be conceptualized as part of the framework around the processes - thereby influencing several of the factors in the model, as displayed below.
Figure 5. The hypothetical reconceptualization of the fear avoidance endurance model in women with PVD.
This hypothetical model is based on the current findings, in addition to earlier research and theoretical perspectives. It is based on the FAM, yet also includes endurance coping and motivational goals, and aims to conceptualize the development and maintenance of PVD, and may inspire further research in this field.
In this model, three paths are displayed; one leads to healthy adaption, another where sexual dysfunction and pain are perpetuated by endurance coping (right circle in the model), and a third where increase in sexual dysfunction and pain is driven by avoidance coping (left circle in the model). Partner responses and motivational goals should be considered as part of a framework (i.e. establishing circumstances), as they influence several of the processes in the model. The purpose of developing such a model is to theoretically conceptualize the
development and maintenance of PVD. It may increase understanding of the disorder and inspire further research and treatment development
Strengths and weaknesses
The current study has several limitations.
Sample characteristics. First and foremost, the sample characteristics reduce the generalizability of our findings. The premenopausal women participating are all in
heterosexual relationships with partners who are willing to participate in treatment, and are help-seeking in that they applied for the treatment. In addition, in order to be included in the treatment study, the couple must have had, or attempted to have, penetrative intercourse during the last year. Hence, couples who avoid sexual penetrative intercourse altogether were not included in the sample. It should be noted though, that no couple was excluded on those grounds during recruitment.
Sample size. The size of the current sample must also be taken into consideration when interpreting the results. The size can be seen as both a weakness and a strength. On one hand, small associations may not be visible in the current sample, limiting our findings. In addition, two factors showed a non-normal distribution, most likely due to the small sample size as non-significant trends were identified. On the other hand, when medium and large effect sizes are found in such a small sample it indicates that the associations are not due to type I error, and are likely to hold up in a larger sample as well.
Study design. As the current data is cross-sectional, it is not possible to infer causality (Kazdin, 2010). Hence, the current data does not provide information regarding the actual directionality of the correlations, and it may be that the coping behaviors, goals and the catastrophizing have a bidirectional relationship over time, rather than the goals and catastrophizing influencing the coping behaviors. What this study does provide though, is evidence that there are medium and large correlations between factors which have not
previously been studied, providing support for future research. From a theoretical standpoint, it also provides ample opportunities to reconceptualize the fear-avoidance model. Even though we cannot draw any conclusions about causality, our findings provide a clear direction for further research.
Measurements. In the current sample, only catastrophizing in relation to pain is assessed. In light of earlier qualitative research (Elmerstig et al., 2008) a measure of catastrophizing around other issues (e.g. relational, self-image) could have increased the understanding of the processes and relationships between motivational goals and pain coping behaviors. We hope that future research could develop such an instrument to increase the understanding of the development and maintenance of PVD.
When assessing motivational goals, the current study uses the Avoidance and Approach Sexual Goals Scale. As previously mentioned, the scale specifically measures interpersonal sexual goals, and is partly based on a larger study examining sexual goals (Cooper et al., 1998). In the larger study, the researchers also describe self [individual] sexual goals, (e.g. to experience positive emotion or avoid negative emotion, to feel pleasure) which are not included in the AASG. Therein lies a limitation for the current study, as it is likely that the individual goals also influence subsequent coping strategies. A scale assessing both
interpersonal and individual sexual goals would further the understanding regarding the link between motivational goals and coping strategies.
Conclusion
The current study explored factors related to development, maintenance and the experience of living with PVD. It provides clues for future research, and links motivational goals to coping behaviors by finding associations between factors which have shown to be important in regards to PVD, yet not previously studied together. We found that avoidance sexual goals and pain catastrophizing were associated with avoidance coping behaviors. Also, both avoidance and approach sexual goals were associated with endurance coping behavior. The findings regarding pain catastrophizing and avoidance behaviors should be interpreted with caution as the non-parametric test only showed a non-significant trend.
The way sexual goals and coping behaviors interplay may play an important role in both development and maintenance of PVD. Hence, we also provide an extended fear avoidance model, where a path relevant to endurance coping behavior is explored, which we encourage future studies to examine more thoroughly.
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