Understanding sexual pain: A cognitive-motivational account

Abstract

Sexual pain 2 Introduction Sexual pain or dyspareunia is a prevalent and disabling health problem in women [21].It is generally defined as a recurrent or persistent pain during sexual activities, involving vaginal penetration or tactile stimulation of the vulva and vestibule [1]. In many patients, the pain is also elicited by nonsexual activities and is comparable to other pain syndromes in terms of severity, sensory characteristics, and neurological processes [25]. As yet, little is known about the etiology of sexual pain because current research is complicated by a number of factors. First, dyspareunia encompasses multiple pain conditions with varying etiologies, causing nosological confusion [4]. Second, evidence on causal factors is inconclusive because there are no controlled experimental studies that allow discerning cause and effect. Third, research has put more emphasis on physical markers -including neurogenic pelvic inflammation, neurochemical influences, central and peripheral sensitization, and increased vulva-vaginal innervations [35] -rather than considering psychosocial variables that may exacerbate and maintain sexual pain problems. Pain is, however, a multidimensional experience that needs to be addressed in all its dimensions, including biomedical as well as psychosocial aspects. Because much less is known about the psychological and relational determinants of sexual pain, this review focuses specifically on the role of cognitivemotivational factors in relation to pain. Such cognitive-motivational perspective is likely to inform both research and clinical practice. These physiological reactions may Sexual pain 3 then, in a self-fulfilling way, increase the pain during sexual intercourse. Hence, critical for the development of dyspareunia is the lack of genital arousal that is marked by insufficient lubrication and driven by anticipation-anxiety. In support of this model, research has shown that women react with involuntary pelvic floor muscle activity in response to threatening sexual stimuli [34] and impeded genital arousal -as measured through vaginal pulse amplitude signals -in response to appraisal (i.e., suggestion that a female actor experiences pain) and pain threat (i.e., threat of electrical pulses on the ankle) manipulations [6,7].Genital responsiveness was, however, not different in women with dyspareunia compared to healthy controls, although they did report lower subjective sexual arousal. Note that such discordance between physiological (i.e., genital) and psychological (i.e., subjective experience of) sexual arousal is commonly observed in women [26]. These results indicate the need for further study on the role of low vaginal vasocongestion and the importance of including subjective sexual arousal into research on dyspareunia. Furthermore, given that sexual arousal is not a unitary process, it is important to investigate not only the direct effect of pain on sexual arousal, but also how pain affects the cognitive and motivational processes that ultimately lead to differenti...

A Prospective 2-Year Examination of Cognitive and Behavioral Correlates of Provoked Vestibulodynia Outcomes

“…Although fear of movement and behavioral avoidance of movement are not strictly applicable to PVD, avoidance of sexual intercourse is common in these women 10 . This has previously been proposed as the circle of fear, by which fear of pain leads to avoidance of penetration 4 . Avoidance may then lead to lowered sexual arousal, vaginal dryness, and pelvic floor tension, which in turn may result in greater pain during the sexual experience.…”

“…Proposed biomedical pathways suggest that initial trauma to the genitalia may trigger inflammatory processes, pelvic floor muscle dysfunction, and other local changes, leading to increased pain sensitization and pain persistence 3 . Alternative psychosocial explanations for the development and maintenance of PVD include maladaptive pain-related cognitions and behaviors that exacerbate pain and contribute to pain-related disability and sexual dysfunction 4 . At present, no convincing evidence justifies one single biomedical or psychosocial explanation.…”

Partner Behavioral Responses to Pain Mediate the Relationship Between Partner Pain Cognitions and Pain Outcomes in Women With Provoked Vestibulodynia

“…Due to the dyadic nature of the pain experience, significant others' behavioral responses to pain may have a particularly important impact on patients' subsequent pain and depressive symptoms 13,36 . Solicitous responses, which are demonstrations of sympathy and attention, and negative responses, which are demonstrations of hostility and frustration, have garnered the most research attention.…”

“…Some theories have gone beyond simply cognitions to explore a cognitive-motivational model 1,13 , however, the present study aimed to better elucidate the cognitive factors at play. Hence, the aim of the present study was to assess whether partner cognitive variable operated though partner behavioral variables to influence patient outcomes, which would be consistent with a CBT model.…”

Genital pain in women: Beyond interference with intercourse

“…Further, the diagnosis still focuses heavily on the interference of the pain with a single type of sexual activity, intercourse. These classification challenges are reflected in our search for etiological explanations, with proponents of biomedical causes on one side [8] and those adhering to psychosexual models on the other [17]. We propose an integrated model taking into account the interdependency of biomedical -including pelvic floor muscle dysfunctions -cognitive, affective, behavioral and interpersonal factors in genital pain and associated sexual impairment.…”