Psychological, sexual, and relationship consequences

Women with vulvovaginal pain show important impairments in many life domains, primarily their sexuality, intimate relationships, and mental health. Specifically, controlled studies have shown that they report significantly less sexual desire, arousal, and satisfaction, more difficulty reaching orgasm, as well as lower frequencies of intercourse and more negative attitudes toward sexuality than pain-free controls . Research conducted in laboratory settings indicates that there are no significant differences between women with vulvovaginal pain and non-afflicted women relative to their physiological level of sexual arousal when exposed to an erotic stimulus, although women with pain tend to report more negative feelings toward the stimulus . Both quantitative and qualitative studies show that many women with vulvovaginal pain also report negative changes in their sexual self-esteem and in their body image, such as feeling less sexually desirable, feeling less confident about their sexuality, and feeling less feminine than before . Specifically, a study conducted among a community sample of 330 women showed that, in comparison to pain-free controls, women with vulvovaginal pain reported significantly more distress about their body image and a more negative genital self-image. Moreover, a more negative genital self-image was strongly and independently associated with an increased likelihood of reporting vulvovaginal pain, above and beyond anxiety . In the same community sample of women with vulvovaginal pain, worse self-image cognitions about vaginal penetration contributed uniquely to increased pain intensity, whereas worse self-image cognitions about vaginal penetration and genital self-image contributed to poorer sexual functioning. Finally, worse self-image cognitions about vaginal penetration, body image, and genital self-image each contributed independently to increased sexual distress . These findings suggest that body image and genital self-image are significantly poorer in women with vulvovaginal pain and may influence key pain and sexuality outcomes.

Although there appear to be no differences in relationship satisfaction between women with vulvovaginal pain and asymptomatic controls, and no association between relationship satisfaction and pain in women with vulvovaginal complaints , this intimate pain nonetheless puts a significant strain on romantic relationships. Indeed, the fear of losing one’s partner is noted across samples of women with vulvovaginal pain . It thus may come as no surprise that most afflicted women choose to continue engaging in vaginal penetration despite the pain and the limited satisfaction they derive from this sexual activity . The question of why women continue to have sex despite vulvovaginal pain was asked to a group of sexually active young women and adolescents. Four reasons emerged: resignation, sacrifice, guilt, and the motivation to behave in a manner consistent with the notion of the ideal woman . This situation may also become quite distressing for the partner, who may feel as though he is an incompetent lover and who may at times wonder whether he might be partly responsible for the pain. This may further complicate the dynamics of the relationship. In a study involving 38 vulvodynia couples, men’s higher levels of both internal and global attributions for the pain – that is, thinking that the pain is their fault and that it affects all life domains – were associated with their poorer relationship satisfaction, whereas global and stable attributions – thinking that the pain will never go away – were related to their lower sexual satisfaction .

As for mental health, several controlled studies involving clinical samples and using a wide variety of measures of depressive symptomatology have shown that women with vulvovaginal pain have higher depression scores than pain-free controls , although three other controlled studies were unable to detect such a difference . These contradictory findings could be attributed to the use of community samples in the latter studies, which typically report less distress. Many controlled studies have also found that these women display more state and trait anxiety than pain-free controls . Further, there is evidence suggesting that anxiety may decrease the level of physiological sexual arousal in this population . In summary, vulvovaginal pain results in several psychosexual sequelae, many of which require targeted interventions. Empirical work to date also suggests that specific psychosexual factors may maintain and exacerbate the different dimensions of vulvovaginal pain.

Psychosocial precursors/maintenance factors

To date, controlled research has shown that compared to asymptomatic controls, women with vulvovaginal pain report more anxiety , depression , and pain catastrophizing. Higher levels of hypervigilance to pain, fear of pain, and catastrophizing have been found to be significant predictors of increased pain in this population, whereas greater anxiety and avoidance are associated with poorer sexual function. In addition, lower levels of pain self-efficacy, or the belief in one’s capacity to meet the challenges of managing pain, are related to both worse pain and sexual function .

Three studies provide some evidence suggesting that psychosocial factors may contribute to the development of persistent vulvovaginal pain. A population-based survey of adult women found that sexual, physical, and psychological abuse was linked to a four- to sixfold increased risk of reporting vulvodynia in adulthood . Another large-scale cross-sectional study focusing on adolescent girls with pain during intercourse showed that they reported significantly more sexual abuse and fear of physical abuse than controls . Further, a community-based study showed that the odds of vulvodynia were four times more likely among women with antecedent depression or anxiety compared to women without . However, because this area of research is still in its infancy, most works to date have been cross-sectional. Nonetheless, taken together, findings highlight the importance of environmental variables in the development of idiopathic vulvovaginal pain and indicate that psychosocial factors may contribute to the persistence of the pain and its associated negative sequelae.

Pain during intercourse is not limited to the woman’s experience, but occurs in a relational context. In a first study on the dyadic aspects of provoked vestibulodynia conducted with 43 couples, greater partner solicitousness, that is, demonstrations of sympathy, but also greater partner hostility, that is demonstrations of anger, were significantly associated with higher levels of pain during intercourse, suggesting that partner responses, both positive and negative, may play a role in the experience of vulvovaginal pain . Results from a larger cross-sectional study of 191 couples indicated that higher solicitous partner responses – assessed from the perspective of both the woman and partner – were associated with higher levels of women’s pain intensity. Furthermore, the associations were mediated by greater patient and partner pain catastrophizing and self-efficacy . In fact, partner pain catastrophizing and self-efficacy directly predicted patient pain, suggesting that the partner’s view of the pain may modulate patient symptomatology . Lower negative partner responses were also associated with more sexual satisfaction in women, and this association was mediated by greater dyadic adjustment . Another study with a sample of 121 couples showed that facilitative partner responses – defined as partner responses that encourage a patient’s efforts at adaptive coping with the pain (e.g., decreased avoidance) – were associated with lower vulvovaginal pain and higher sexual satisfaction . Facilitative responses may be fostered in a targeted couple intervention by helping couples to focus on less painful activities, on the emotional benefits of sexual activity, and on expressing affection and pleasure during or after sexual activity.

Rosen et al. (in press) recently completed a 2-month daily diary study involving 69 heterosexual couples coping with vulvodynia . They found that a woman’s pain during intercourse increased on days when she perceived greater solicitous and negative partner responses, and when her male partner reported greater solicitous and lower facilitative partner responses. A woman’s sexual functioning and satisfaction increased on days when she perceived greater facilitative and lower solicitous and negative partner responses, and when her male partner reported lower solicitous responses. Further, a man’s sexual functioning and satisfaction decreased on days when he reported greater solicitous and negative responses. These findings highlight the influence of partner-perceived variables on women’s pain and sexual experience, as well as the impact of PVD on male partners’ sexuality. To summarize, research findings have consistently shown that facilitative responses yield positive couple outcomes and should be fostered in an intervention, whereas solicitous and negative partner responses lead to negative outcomes and should be reduced.

Other recent research on relationship variables and vulvovaginal pain has focused on attachment, emotion regulation, and intimacy. Attachment theory can provide a useful framework for understanding how couple dynamics may influence the experience of vulvovaginal pain and associated psychosexual difficulties. Attachment patterns are constructed within early interactions with primary caregivers . Recent studies indicate that romantic attachment patterns are closely linked to sexual thoughts, emotions, and behaviours . In a study involving 116 couples in which the women presented with provoked vestibulodynia, both anxious (anxiety about rejection) and avoidant (avoidance of intimacy) attachment styles were associated with women’s lower sexual satisfaction. Attachment avoidance was associated with women’s lower sexual function. Interestingly, women’s sexual assertiveness was found to be a significant mediator of the relationship between their attachment styles, sexual function, and satisfaction. This suggests that anxious and avoidant attachment may limit women’s ability to be assertive in their sexuality, and that this lack of assertiveness may in turn lead to less satisfying sexual activities for these couples .

Indeed, how couples communicate about the vulvovaginal pain problem and its resulting negative consequences on their sex life could have an impact on their degree of adaptation to this challenge. A study conducted among 254 couples in which the woman suffered from vulvovaginal pain showed that those who had low ambivalence concerning the expression of their emotions, that is, couples who were the most comfortable with their level of expressiveness, had higher sexual satisfaction and sexual function, less depressive symptoms, and better dyadic adjustment . This suggests that an emotional regulation that is low in ambivalence for both members of the couple may promote better psychological, sexual, and relational outcomes for women and their partners, possibly by facilitating their sharing about intimate aspects of the vulvovaginal pain problem and its impact on their sexuality.

Intimacy is another relationship variable that could help couples navigate the challenge of vulvovaginal pain. In a sample of 91 women diagnosed with provoked vestibulodynia and their partners, women’s reported greater sexual intimacy was associated with women’s increased sexual satisfaction and higher pain self-efficacy, beyond the effects of partners’ sexual intimacy. In addition, women’s reported greater sexual intimacy and women’s greater relationship intimacy were associated with their increased sexual function, beyond the effects of partners’ sexual and relationship intimacy .

Taken together, findings concerning the psychosocial correlates of vulvovaginal pain suggest that the context within which this pain is experienced does matter. How women and their partners think, feel, and communicate about this pain influences the extent to which they can adapt to it, reduce its intensity, and maintain a healthy sex life and relationship despite it.

Psychosocial precursors/maintenance factors

To date, controlled research has shown that compared to asymptomatic controls, women with vulvovaginal pain report more anxiety , depression , and pain catastrophizing. Higher levels of hypervigilance to pain, fear of pain, and catastrophizing have been found to be significant predictors of increased pain in this population, whereas greater anxiety and avoidance are associated with poorer sexual function. In addition, lower levels of pain self-efficacy, or the belief in one’s capacity to meet the challenges of managing pain, are related to both worse pain and sexual function .

Three studies provide some evidence suggesting that psychosocial factors may contribute to the development of persistent vulvovaginal pain. A population-based survey of adult women found that sexual, physical, and psychological abuse was linked to a four- to sixfold increased risk of reporting vulvodynia in adulthood . Another large-scale cross-sectional study focusing on adolescent girls with pain during intercourse showed that they reported significantly more sexual abuse and fear of physical abuse than controls . Further, a community-based study showed that the odds of vulvodynia were four times more likely among women with antecedent depression or anxiety compared to women without . However, because this area of research is still in its infancy, most works to date have been cross-sectional. Nonetheless, taken together, findings highlight the importance of environmental variables in the development of idiopathic vulvovaginal pain and indicate that psychosocial factors may contribute to the persistence of the pain and its associated negative sequelae.

Pain during intercourse is not limited to the woman’s experience, but occurs in a relational context. In a first study on the dyadic aspects of provoked vestibulodynia conducted with 43 couples, greater partner solicitousness, that is, demonstrations of sympathy, but also greater partner hostility, that is demonstrations of anger, were significantly associated with higher levels of pain during intercourse, suggesting that partner responses, both positive and negative, may play a role in the experience of vulvovaginal pain . Results from a larger cross-sectional study of 191 couples indicated that higher solicitous partner responses – assessed from the perspective of both the woman and partner – were associated with higher levels of women’s pain intensity. Furthermore, the associations were mediated by greater patient and partner pain catastrophizing and self-efficacy . In fact, partner pain catastrophizing and self-efficacy directly predicted patient pain, suggesting that the partner’s view of the pain may modulate patient symptomatology . Lower negative partner responses were also associated with more sexual satisfaction in women, and this association was mediated by greater dyadic adjustment . Another study with a sample of 121 couples showed that facilitative partner responses – defined as partner responses that encourage a patient’s efforts at adaptive coping with the pain (e.g., decreased avoidance) – were associated with lower vulvovaginal pain and higher sexual satisfaction . Facilitative responses may be fostered in a targeted couple intervention by helping couples to focus on less painful activities, on the emotional benefits of sexual activity, and on expressing affection and pleasure during or after sexual activity.

Rosen et al. (in press) recently completed a 2-month daily diary study involving 69 heterosexual couples coping with vulvodynia . They found that a woman’s pain during intercourse increased on days when she perceived greater solicitous and negative partner responses, and when her male partner reported greater solicitous and lower facilitative partner responses. A woman’s sexual functioning and satisfaction increased on days when she perceived greater facilitative and lower solicitous and negative partner responses, and when her male partner reported lower solicitous responses. Further, a man’s sexual functioning and satisfaction decreased on days when he reported greater solicitous and negative responses. These findings highlight the influence of partner-perceived variables on women’s pain and sexual experience, as well as the impact of PVD on male partners’ sexuality. To summarize, research findings have consistently shown that facilitative responses yield positive couple outcomes and should be fostered in an intervention, whereas solicitous and negative partner responses lead to negative outcomes and should be reduced.

Other recent research on relationship variables and vulvovaginal pain has focused on attachment, emotion regulation, and intimacy. Attachment theory can provide a useful framework for understanding how couple dynamics may influence the experience of vulvovaginal pain and associated psychosexual difficulties. Attachment patterns are constructed within early interactions with primary caregivers . Recent studies indicate that romantic attachment patterns are closely linked to sexual thoughts, emotions, and behaviours . In a study involving 116 couples in which the women presented with provoked vestibulodynia, both anxious (anxiety about rejection) and avoidant (avoidance of intimacy) attachment styles were associated with women’s lower sexual satisfaction. Attachment avoidance was associated with women’s lower sexual function. Interestingly, women’s sexual assertiveness was found to be a significant mediator of the relationship between their attachment styles, sexual function, and satisfaction. This suggests that anxious and avoidant attachment may limit women’s ability to be assertive in their sexuality, and that this lack of assertiveness may in turn lead to less satisfying sexual activities for these couples .

Indeed, how couples communicate about the vulvovaginal pain problem and its resulting negative consequences on their sex life could have an impact on their degree of adaptation to this challenge. A study conducted among 254 couples in which the woman suffered from vulvovaginal pain showed that those who had low ambivalence concerning the expression of their emotions, that is, couples who were the most comfortable with their level of expressiveness, had higher sexual satisfaction and sexual function, less depressive symptoms, and better dyadic adjustment . This suggests that an emotional regulation that is low in ambivalence for both members of the couple may promote better psychological, sexual, and relational outcomes for women and their partners, possibly by facilitating their sharing about intimate aspects of the vulvovaginal pain problem and its impact on their sexuality.

Intimacy is another relationship variable that could help couples navigate the challenge of vulvovaginal pain. In a sample of 91 women diagnosed with provoked vestibulodynia and their partners, women’s reported greater sexual intimacy was associated with women’s increased sexual satisfaction and higher pain self-efficacy, beyond the effects of partners’ sexual intimacy. In addition, women’s reported greater sexual intimacy and women’s greater relationship intimacy were associated with their increased sexual function, beyond the effects of partners’ sexual and relationship intimacy .

Taken together, findings concerning the psychosocial correlates of vulvovaginal pain suggest that the context within which this pain is experienced does matter. How women and their partners think, feel, and communicate about this pain influences the extent to which they can adapt to it, reduce its intensity, and maintain a healthy sex life and relationship despite it.