Pleasure despite pain: Associations between experiences of vulvar pleasure, vulvar pain, and sexual function in patients with chronic vulvar pain conditions

Abstract

Background

Chronic pain can occur in the vulva, one of the primary pleasure centers of the body; however, the associations between pleasurable vulvar experiences and chronic vulvar pain have not yet been explored.

Aim

The aim of this study was to investigate associations between vulvar pleasure and pain experiences in patients with chronic vulvar pain.

Methods

This was a prospective cross-sectional study of 547 patients (aged ≥17 years) presenting over 10 months to 2 urban outpatient gynecology clinics specializing in vulvar pain. Prior to the initial evaluation, patients completed online validated questionnaires of pain-related anxiety, pain catastrophizing, and sexual functioning, as well as a researcher-developed questionnaire evaluating vulvar pleasure. Patients were divided into groups based on their pleasure and pain experiences. Between-group analyses consisting of t-tests, analyses of variance, and multivariate analyses of variance were conducted.

Outcomes

Outcomes consisted of total and subscale scores on the Pain Anxiety Symptoms Scale-20, Pain Catastrophizing Scale, Female Sexual Function Index, and a researcher-developed vulvar pleasure questionnaire.

Results

More than 70% of patients with chronic vulvar pain had experienced vulvar pleasure since the onset of their vulvar pain, with the clitoris as the most common source of pleasure. Average vulvar pleasure intensity was rated 7 (0, no pleasure; 10, extremely pleasurable). Masturbation ranked higher in pleasurable activities than vulvar stimulation by a partner or penetrative intercourse and was the most likely activity to lead to orgasm. When compared with patients who had not experienced vulvar pleasure since the onset of their vulvar pain, patients experiencing both pain and pleasure scored lower on the Pain Anxiety Symptoms Scale-20 total (P = .026) and fear subscale (P = .016), lower on the Pain Catastrophizing Scale total (P = .002) and all subscales (P = .008-.018), and higher on the Female Sexual Function Index total and all subscales (all P ≤ .001).

Clinical Implications

Incorporating strategies for cultivating vulvar pleasure in patients with chronic vulvar pain may be useful in comprehensive management approaches.

Strengths and Limitations

Strengths of this study include the novel examination of vulvar pleasure in a population with chronic vulvar pain and a large sample size. Limitations include the lack of a nonclinical comparator group and reliance on patient self-report.

Conclusion

Results suggest that greater vulvar pleasure is associated with lower pain-related anxiety, lower pain catastrophizing, and higher sexual functioning in patients with chronic vulvar pain conditions.

Introduction

Chronic vulvar pain, defined as persistent pain of at least 3 months, can be related to specific conditions (e.g., lichen sclerosus, hypertonic pelvic floor dysfunction), or it may be idiopathic (e.g., vulvodynia).¹ Many chronic vulvar pain conditions are characterized by provoked pain during sexual activity involving vaginal penetration² and are associated with reduced sexual desire, arousal, and satisfaction.³ Current treatment approaches vary by diagnosis yet focus largely on physical interventions, including topical corticosteroids for vulvar dermatoses, pelvic floor physical therapy for myofascial and muscular hypertonicity, and vestibulectomy for neuroproliferative-associated vestibulodynia.^2-4 There has also been increasing awareness of the need for multimodal treatment approaches, given the critical role of psychosocial factors in chronic vulvar pain.^2,5

Chronic pain and anxiety disorders have been tied to neural mechanisms involving pre- and postsynaptic long-term potentiation of the anterior cingulate cortex, a region of the brain that plays a key role in pain perception.⁶ The persistent features of chronic pain are highly correlated with fear-avoidant behaviors, pain-related anxiety (anxiety that occurs in response to experienced or expected pain), and pain catastrophizing (magnification of the threat value of pain coupled with feelings of helplessness).^7-12 Govind et al found that 22% of those with chronic vulvar pain associated with hypertonic pelvic floor dysfunction met criteria for clinically relevant pain-related anxiety, and an additional 27% met criteria for pain-related anxiety and depression.¹³ Additionally, data from Chisari et al support the role of psychosocial factors such as catastrophizing, depression, and distress in chronic vulvar pain conditions.^14-16

One notable feature of chronic vulvar pain is that it occurs in a region that is linked to sexual pleasure: the vulva. Although pain and pleasure are often treated dichotomously, several examples in the field of sexuality research emphasize their interplay. For example, pain may be a prerequisite or supplement to pleasure for those who engage in BDSM (bondage and discipline/dominance and submission/sadism and masochism).¹⁷ In addition, pleasurable sexual response can become painful, as in patients with conditions of painful ejaculation and orgasm.¹⁸ However, pleasure is often left out of sexual health education and health care interactions^19,20; indeed, a survey of US gynecologists found that only 28.5% asked about sexual satisfaction and just 13.8% asked about pleasure with sexual activity.²¹

Molecular imaging and animal studies have shown that the opioid and dopaminergic systems are involved in processing pain and pleasure.²² Becerra et al found that unpleasant heat stimuli triggered brain activity changes in classic pain circuitry and reward circuitry (associated with pleasure) and, in fact, that circuitry associated with pleasure occasionally reacted even faster to the heat stimuli than that associated with pain.²³ More recently, Watanabe and Narita noted that the mesolimbic dopaminergic system, which plays a central role in pleasure pathways, contributes to chronic pain modulation through the release of neurotransmitters by dopaminergic neurons in the nucleus accumbens.²⁴ These neuroscientific intersections can be supported anthropologically by people who derive pleasure from painful stimuli in sexual encounters, as in the practice of BDSM. Dunkley et al postulated that a combination of neural networks and molecules, visual stimuli, memories, environment, and emotional states allow people to merge the painful and the pleasurable in enjoyable ways.¹⁷ Whipple and Komisaruk found that pleasurable genital self-stimulation decreased pain sensitivity and increased pain tolerance thresholds.^25-27 In a study of 10 women, when vaginal stimulation was applied until orgasm, participants’ pain tolerance threshold rose by 74.6% and their pain detection threshold rose by 106.7%.²⁵ Taken together, these studies suggest that experiences of pain and pleasure in sexual contexts may have complex interactions that can enhance or inhibit each other. To our knowledge, there are no empirical investigations of sexual pleasure and vulvar pain in clinical populations. Understanding more about these enhancing and inhibiting effects may prove clinically useful in interventions targeting vulvar pain. To that end, this study investigated the relationships between vulvar pleasure, vulvar pain and sexual function in patients with chronic vulvar pain through the following questions:

• What are the characteristics of vulvar pleasure (i.e., duration, intensity, locations, and associated activities) in patients who have experienced it since the onset of their vulvar pain?

• Are there associations between vulvar pleasure experiences (including the number of years and intensity) and vulvar pain intensity, pain-related anxiety, pain catastrophizing, and sexual functioning?

On the basis of the literature cited here and our clinical experiences with patients, we expected that patients with chronic vulvar pain who had been able to experience vulvar pleasure since the onset of their vulvar pain would have lower pain intensity, pain-related anxiety, and pain catastrophizing and higher sexual functioning than those who had not. We also predicted that higher number of years with vulvar pleasure and greater vulvar pleasure intensity would be associated with lower pain intensity, pain-related anxiety, and pain catastrophizing and higher sexual functioning.

Methods

This cross-sectional study includes 547 patients (aged ≥17 years) presenting to 2 urban outpatient gynecology clinics in the United States that specialize in vulvar pain conditions. All patients were informed that their responses to survey questions would be anonymized and used for research and, by entering the survey, they provided consent. Data access and analyses received ethics approval under the Research Ethics Board of the Queen’s University Health Sciences and Affiliated Teaching Hospitals. Not all patients had chronic vulvar pain: some presented with concerns such as vulvar pruritus or abnormal discharge. From February to December 2021, new patients completed a standard clinic-based survey in addition to the measures specific to this study. Patient diagnoses were based on a complete medical history and pelvic examination (including a cotton swab test), evaluation of the pelvic floor muscles and pudendal nerves, and vulvoscopy. Those with suspected vulvar dermatoses had diagnoses confirmed via biopsy.

Measures

Prior to the initial evaluation, patients completed online validated questionnaires (SurveyMonkey) of pain-related anxiety via the Pain Anxiety Symptoms Scale–20 (PASS-20),¹⁰ pain catastrophizing via the Pain Catastrophizing Scale (PCS),²⁸ and sexual function via the Female Sexual Function Index (FSFI).²⁹ Patients who experienced vulvar pleasure since the onset of their vulvar pain also completed a researcher-developed questionnaire evaluating vulvar pleasure. Patients not currently experiencing vulvar pain, those who had never felt vulvar pleasure, and those who had not had vulvar pleasure since their vulvar pain began were excluded from the vulvar pleasure survey. All patients were first asked questions about their vulvar discomfort: “On a scale of 0 to 100, where 0 represents no discomfort at all and 100 represents the most pain you could possibly stand, what value would you assign to the following scenarios: your worst symptoms?” which was repeated for current and usual symptoms.

The PASS-20 accurately screens for pain-related anxiety in patients with chronic pain and has 20 questions based on 4 subscales: cognitive anxiety, escape/avoidance, fear, and physiologic anxiety.¹⁰ The PCS consists of 13 questions that assess pain catastrophizing along 3 subscales: rumination, magnification, and helplessness.²⁸ The FSFI, which has shown reliable psychometric validity in assessing key dimensions of female sexual function, contains 19 questions about the past 4 weeks in terms of 6 components: desire, arousal, lubrication, orgasm, satisfaction, and pain.²⁹

In the researcher-developed vulvar pleasure questionnaire (Appendix C), sexual pleasure was defined as any physical or psychological enjoyment from solitary or shared erotic experiences, including thoughts, dreams, and fantasies. Patients were then asked if they had (1) ever experienced pleasurable sensations in their vulva and (2) experienced any pleasurable sensations in their vulva since their vulvar pain began. The questionnaire included characteristics of patients’ vulvar pleasure: duration, intensity (numeric scale), location (labeled diagram), and simultaneous experience of pain and pleasure. Patients were also asked questions regarding masturbation, partner stimulation, and penetrative vaginal intercourse, including frequency, intensity of sexual pleasure, and frequency of orgasm during the behavior. Masturbation was defined as “stimulating your vulva with your hand, a pillow, a sex toy such as a vibrator, etc while alone.” Partner stimulation was defined as “when a partner stimulates your vulva, ie, through foreplay, oral sex, or manual stimulation (excluding penetrative vaginal intercourse).” Penetrative vaginal intercourse was defined as “when your partner inserts their penis, finger, a sex toy, etc in your vagina.” Finally, patients were asked whether and how vulvar pleasure affected their experiences of vulvar pain temporally and whether it was in the same or different areas of the vulva, whether they felt vulvar pain with pleasure or orgasm, whether their vulvar pleasure or orgasm ever became painful, and whether their vulvar pain ever became pleasurable.

Statistical analysis considerations

Patient survey responses were anonymized and exported into spreadsheet format. Data were examined (by visual inspection of plots and criteria including skew and kurtosis) with regard to multivariate normality, independence of observations, outliers, homogeneity of variance, and multicollinearity. No significant outliers were detected, and no variables were observed to exhibit restricted ranges. Data were determined to be multivariate normal and to exhibit independence of observations, and no violations were present regarding multicollinearity or homogeneity of variance. The data were analyzed by quantitative methods to compare between-group experiences and associations among the variables related to vulvar pleasure experiences, pain intensity, pain-related anxiety, pain catastrophizing, and sexual functioning. Between-group analyses included t-tests, analyses of variance (ANOVAs), and multivariate analyses of variance (MANOVAs). All analyses were completed with SPSS version 26 (IBM Corp) as well as R Stats (version 3.0; R Core Team).

According to the information from the survey and medical examination, patients were divided into 4 groups for the present study (Figure 1; N = 547): those who had experienced vulvar pleasure since their vulvar pain began (pain and pleasure [P&P]; n = 296), those who had not experienced vulvar pleasure since their vulvar pain began (no pleasure since pain onset [NPSP]; n = 66), those who had never experienced vulvar pleasure (never experienced pleasure [NEP]; n = 24), and those who did not have current vulvar pain but did endorse past vulvar pain (no current vulvar pain [NCVP]; n = 83). Several survey respondents (n = 78) did not fall within any of these 4 categories (mainly due to a lack of response to grouping information); these participants were included in the total sample but excluded from between-group comparisons. Therefore, the sample size for the comparisons among the 4 categories was 469: 386 of whom experienced pain and 83 of whom did not. Since participants could decline to respond to any question, sample sizes vary for each analysis.

Figure 1.

Participant recruitment flow for the present study.

Prior to conducting MANOVAs, data were examined with regard to independence of observations, outliers, multivariate normality, homogeneity of variance, and multicollinearity. No significant outliers were detected; thus, data were determined to be multivariate normal and to exhibit independence of observations, and no violations were present regarding multicollinearity or homogeneity of variance. As such, all assumptions were met regarding appropriateness of the present data for ANOVA, MANOVA, and multivariate analysis of covariance.

Results

The total sample (N = 547) consisted of patients who reported having vulvar discomfort, including chronic vulvar pain. Their average age was 41 years (range, 17-98), and 74.8% (n = 409) were currently in a relationship. An overall 92% typically engaged sexually with men, 2.2% with women, and 3.3% with men and women. In addition, 77% identified as White, 3.3% Black, 4.6% Asian, and 3.7% Hispanic/Latinx/Spanish (Table 1). The percentage of those with vulvar pain who reported having ever experienced vulvar pleasure was 92.1% (383/416), as compared with 71.9% (296/416) who had experienced vulvar pleasure since the onset of their pain. In this cohort (n = 416), 16.2% reported having experienced pleasure for 1 to 5 years, 15.2% for 5 to 10 years, and 7.4% for <1 year; at 54.7%, more than half had experienced vulvar pleasure for >10 years.

Table 1.

Selected demographic information (N = 547).^a

Characteristic	No.	%
Age, y, mean ± SD	40.78 ± 15.24
Currently pregnant or breastfeeding
Yes	8	1.5
No	523	95.6
Tampon insertion painful
Yes	87	15.9
No	157	28.7
Not using tampons	218	39.9
Speculum examinations painful
Yes	218	39.9
No	212	38.8
Never undergone examination	19	3.5
Ever used hormonal birth control medication
Yes	455	83.2
No	76	13.9
Intercourse painful
Yes	270	49.4
No	53	9.7
Not currently engaging in intercourse	203	37.1
Undergone hysterectomy
Yes	41	7.5
No	485	88.7
Marital status
Divorced	35	6.4
Married	280	51.2
Never married	209	38.2
Separated	6	1.1
Widowed	6	1.1
Declined to respond	11	2.0
Current relationship status
In a relationship	129	23.6
Not in a relationship	127	23.2
Married or declined to answer	291	53.2
Relationships/partners are typically
Men	505	92.3
Women	12	2.2
Both	18	3.3
Race/ethnicity/cultural background
African American or Black	18	3.3
Alaskan Native	1	0.2
American Indian	3	0.5
Asian	25	4.6
Caucasian	421	77
Cuban	2	0.4
Mexican, Mexican American, or Chicano	9	1.6
Puerto Rican	7	1.3
South American	1	0.2
Central American	1	0.2
Spanish	2	0.4

^aTotal sample sizes vary due to some participants not providing responses to every survey item.

For the P&P group (n = 416), the most common anatomic area of vulvar pleasure was the clitoris (n = 326, 78.4%), followed by inside the vagina (n = 240, 57.7%), the labia minora (n = 172, 41.3%), the vulvar vestibule (n = 169, 40.6%), the labia majora (n = 159, 38.2%), the perineum (n = 116, 27.9%), and the urethra (n = 87, 20.9%). The average sexual pleasure rating was approximately 7 on a 10-point scale (0 = least pleasure possible, 10 = the most; mean = 6.77, n = 326). Over a period of 1 month, 45.7% of participants with P&P reported masturbating at a frequency of 1 to 3 times per month; 17.3%, 4 to 6 times; 7.7%, 7 to 9 times; 9%, ≥10 times; and 20.3% did not engage in masturbation (see Table 2 for all masturbation and intercourse frequencies). Patients with P&P stated that for insertion into the vagina, penile vaginal insertion provided the most pleasure, followed by a sexual partner’s finger(s), the individual’s own finger(s), and, last, sex toys. Regarding orgasm experiences, 52.4% of the P&P cohort experienced orgasm from vaginal penetration alone, while 15.6% endorsed having a painful orgasm. For patients with P&P, masturbation was the method of stimulation that provided them the most pleasure (mean = 5.77, SD = 3.10, on a 0-10 scale), followed by stimulation of the vulva by a partner (mean = 5.30, SD = 3.09) and penetrative intercourse (mean = 4.43, SD = 3.07). Masturbation was the most likely method of stimulation to reach orgasm (mean = 4.32, SD = 1.30; 0 = never, 5 = always or almost always), followed by stimulation of the vulva by a partner (mean = 3.04, SD = 1.83) and last by engaging in penetrative intercourse (mean = 1.09, SD = 1.45). There were no significant differences in the method of stimulation that provided the most pleasure or the most likely method of stimulation to reach orgasm between patients in current relationships and not.

Table 2.

Frequency of masturbation and intercourse in the present sample.^a

	Participants, No. (%)
Frequency	Masturbation	Partner stimulation of vulva	Penetrative intercourse
Times per month
0	61 (20.3)	40 (15.2)	69 (26.7)
1-3	137 (45.7)	113 (42.8)	108 (41.9)
4-6	52 (17.3)	60 (22.7)	39 (15.1)
7-9	23 (7.7)	25 (9.5)	24 (9.3)
≥10	27 (9)	26 (9.8)	18 (7)
Total	300	264	258

^aTotal sample sizes vary due to some participants not providing responses to every survey item.

Among participants with P&P, 64.7% reported feeling that their vulvar pain could never be pleasurable, while 4.1% stated that their pain was pleasurable about half the time, 6% less than half of the time, 2.4% more than half of the time, and 1% almost all or all the time. The remaining participants (21.9% of the P&P sample) did not provide a response to this question (Table 3). Although 9.1% of the P&P group noted that the pain worsened upon experiencing pleasure in the vulva, 6.7% reported resolution of pain, 20.4% had pain persistence, and 23.6% indicated that the pain improved but was still present. Among patients with P&P, 55.7% did not feel pain anywhere in the vulva while experiencing vulvar pleasure, while 24.3% felt pain in a different location of the vulva during vulvar pleasure vs 20% who had pain in the same place as pleasure. Additionally, 8.0% stated that their vulvar pain had “become pleasurable” almost every time or every time, while 5.9% endorsed this more than half the time, 6.9% half the time, 13.7% less than half the time, and 24.9% never or almost never (40.6% declined response to this item).

Table 3.

Pain and pleasure experiences, pain-related anxiety and catastrophizing, and sexual functioning characteristics.^a

	Participants, No. (%)
Pleasure experiences	Vulvar pain can be pleasurable	Think about vulvar pain when experiencing pleasure	Pleasure becomes painful
Frequency
Never or almost never	269 (49.2)	56 (10.2)	136 (24.9)
Less than half of the time	25 (4.6)	60 (11.0)	75 (13.7)
About half of the time	17 (3.1)	65 (11.9)	38 (6.9)
More than half of the time	10 (1.8)	58 (10.6)	32 (5.9)
Almost every time or every time	4 (0.7)	86 (15.7)	44 (8.0)
Did not respond	222 (40.6)	222 (40.6)	222 (40.6)
Total	547	547	547
Pain experiences		Yes (experienced here)	No (not experienced here)
Physical location of pain
Pubic area		94 (17.2)	453 (82.8)
Clitoris		182 (33.3)	365 (66.7)
Labia majora		173 (31.6)	374 (68.4)
Labia minora		279 (51.0)	268 (49)
Urethra		121 (22.1)	426 (77.9)
Perineum		150 (27.4)	397 (72.6)
Rectal area		153 (28.0)	394 (72.0)
Vestibule		263 (48.1)	284 (51.9)
Vagina		303 (55.4)	244 (44.6)
Total		547	547
		Mean (SD)
Scale: subscale		P&P: endorsed vulvar pleasure	NPSP and NEP: did not endorse vulvar pleasure
FSFI
Total		15.79 (9.11)	9.33 (7.84)
Desire		2.87 (1.31)	2.33 (1.35)
Arousal		2.84 (2.02)	1.55 (1.80)
Lubrication		2.92 (2.28)	1.33 (1.96)
Orgasm		2.99 (2.31)	1.39 (2.13)
Satisfaction		2.72 (1.61)	2.12 (1.31)
Pain		1.46 (1.77)	0.622 (1.23)
PASS-20
Total		54.99 (20.58)	60.72 (23.36)
Fear		12.42 (6.04)	14.20 (6.49)
Physiologic arousal		10.32 (5.16)	11.40 (6.19)
Cognitive		17.67 (7.22)	19.26 (7.80)
Escape avoidance		14.59 (5.37)	15.87 (6.08)
PCS
Total		22.03 (13.62)	27.22 (15.21)
Rumination		7.83 (5.07)	9.49 (5.59)
Magnification		3.93 (3.18)	4.87 (3.55)
Helplessness		11.47 (5.07)	13.39 (5.41)

Abbreviations: FSFI, Female Sexual Function Index; NEP, never experienced pleasure; NPSP, no pleasure since pain; PASS-20, Pain Anxiety Symptoms Scale–20; PCS, Pain Catastrophizing Scale; P&P, pain and pleasure.

^aParticipants were able to endorse responses to multiple regions for pain experiences.

Sexual function

A 1-way ANOVA (Table 4) was conducted to evaluate differences in sexual functioning across the 4 groups (NCVP, NEP, NPSP, P&P; see Table 3 for group means on all variables). The effect of group membership was significant (F_3,465 = 14.13, P < .001). Post hoc multiple comparisons revealed significant differences between the P&P group (higher) and the NPSP group, between the NPSP group and the NCVP group (higher), and between the NEP group and the NCVP group (higher). A MANOVA (Table 5) was conducted comparing the P&P group with the NPSP and NEP groups combined (ie, all those not endorsing vulvar pleasure). A significant multivariate effect of group membership was observed for the multiple dependent variables of interest: FSFI, PASS-20, and PCS total and subscale scores (Wilks lambda [3.623] = 0.881, P < .001, ŋ_p² = 0.119). The effect of having experienced vulvar pleasure since the onset of vulvar pain on FSFI total scores was significant (F_1,387 = 36.962, P < .001, ŋ_p² = 0.087; P&P higher). All subscales differed significantly across the groups (P&P higher; Table 3). See Appendixes A (univariate) and B (multivariate) for all post hoc comparison results for all variables of interest.

Table 4.

Univariate results: ANOVA.

Total score	Sum of squares	df	Mean square	F	P value
PCS	9767.407	3	3255.802	16.501	<.001
FSFI	3488.26	3	1162.753	14.133	<.001
PASS-20	18 832.36	3	6277.453	13.782	<.001

Abbreviations: ANOVA, analysis of variance; FSFI, Female Sexual Function Index; PASS-20, Pain Anxiety Symptoms Scale–20; PCS, Pain Catastrophizing Scale.

Table 5.

Multivariate results: MANOVA (pleasure since pain).

	Tests of between-subjects effects
Pleasure since pain a : DV b	F	P value	ŋ p 2	Observed power
FSFI
Desire	11.756	<.001	0.029	0.928
Arousal	29.752	<.001	0.071	1
Lubrication	35.973	<.001	0.085	1
Orgasm	34.324	<.001	0.081	1
Satisfaction	10.36	.001	0.026	0.894
Pain	17.302	<.001	0.043	0.986
Total	36.962	<.001	0.087	1
PCS
Rumination	7.022	.008	0.018	0.753
Magnification	5.682	.018	0.014	0.662
Helplessness	9.559	.002	0.024	0.87
Total	9.496	.002	0.024	0.867
PASS-20
Cognitive	3.213	.074	0.008	0.432
Escape avoidance	3.679	.056	0.009	0.481
Fear	5.83	.016	0.015	0.673
Physiologic anxiety	2.744	.098	0.007	0.379
Total	5.027	.026	0.013	0.609

Abbreviations: DV, dependent variable; FSFI, Female Sexual Function Index; MANOVA, multivariate analysis of variance; PASS-20, Pain Anxiety Symptoms Scale–20; PCS, Pain Catastrophizing Scale.

^aPleasure since pain: Wilks lambda = 0.881, F = 3.623, P < .001, ŋ_p² = 0.119, observed power = 0.999.

^b df = 1.

Pain anxiety

A 1-way ANOVA (Table 4) was conducted to evaluate differences in pain anxiety (measured by PASS-20 total scores) across the 4 groups (NCVP, NEP, NPSP, P&P). The effect of group membership was again significant (F_3,465 = 13.78, P < .001). Post hoc multiple comparisons revealed the NCVP group to differ significantly from all other groups (lower), while the other 3 groups did not differ significantly from one another. A MANOVA (Table 5) revealed a significant effect of experiencing vulvar pleasure since the onset of vulvar pain for PASS-20 total scores (F_1,387 = 5.027, P = .026, ŋ_p² = 0.013) and the PASS-20 fear subscale (F_1,387 = 5.830, P = .016, ŋ_p² = 0.015; P&P lower). The remaining subscales did not differ significantly.

Pain catastrophizing

A 1-way ANOVA (Table 4) was conducted to evaluate differences in pain catastrophizing (PCS total scores) across the 4 groups (NCVP, NEP, NPSP, P&P). The effect of group membership was significant (F_3,465 = 16.501, P < .001). Post hoc multiple comparisons revealed significant differences between the P&P group and the NPSP group (higher). The NCVP group differed significantly (lower) from all other groups. MANOVA (Table 5) indicated that the effect of experiencing vulvar pleasure since the onset of vulvar pain on PCS total scores was significant (F_1,387 = 9.496, P = .002, ŋ_p² = 0.024; P&P lower). Regarding PCS subscales, rumination, magnification, and helplessness differed significantly across the groups (P&P lower; means in Table 3).

Length of time that participants with P&P endorsed experiencing vulvar pleasure

A multivariate analysis of covariance (Table 6) was conducted to examine pain catastrophizing, pain-related anxiety, and vulvar pleasure intensity in the P&P group endorsing various lengths of time of experiencing vulvar pleasure (>10 years, 5-10, 1-5, <1, and other), while controlling for patients’ ages. A significant multivariate effect was observed for the 3 dependent variables of interest: pleasure intensity scores, PASS-20 total scores, PCS total scores (Wilks lambda [12 762.268] = 0.903, P = .003, ŋ_p² = 0.033). The effect of length of time experiencing vulvar pleasure was significant on PCS total scores (F_4,290 = 4.667, P = .001), PASS-20 total scores (F_4,290 = 3.813, P = .005), and pleasure intensity (F_4,290 = 3.008, P = .019) such that those who endorsed having pleasure longer displayed lower pain catastrophizing and anxiety and higher pleasure intensity.

Table 6.

Multivariate results: MANCOVA (length of time experiencing vulvar pleasure).

	Tests of between-subjects effects
IV: DV a	F	P value	ŋ p 2	Observed power
Ageb
PCS total	3.138	.078	0.011	0.423
PASS-20 total	3.362	.068	0.011	0.447
Vulvar pain intensity	0.156	.694	0.001	0.068
Pleasure (how long experienced)c
PCS total	4.667	.001	0.06	0.948
PASS-20 total	3.813	.005	0.05	0.891
Vulvar pain intensity	3.008	.019	0.04	0.796

Abbreviations: DV, dependent variable; FSFI, Female Sexual Function Index; IV, independent variable; MANCOVA, multivariate analysis of covariance; PASS-20, Pain Anxiety Symptoms Scale–20; PCS, Pain Catastrophizing Scale.

^aAge, df = 1; pleasure, df = 4.

^bAge: Wilks lambda = 0.987, F = 1.236, P = .297, ŋ_p² = 0.013, observed power = 0.33.

^cPleasure since pain: Wilks lambda = 0.903, F = 2.498, P = .003, ŋ_p² = 0.033, observed power = 0.951.

For pain-related anxiety, post hoc comparisons (with Bonferroni correction) revealed a significant difference between those who experienced pleasure for <1 year (higher; mean = 67.089) and >10 years (lower, mean = 52.586; P = .002). Post hoc comparisons for pain catastrophizing indicated a significant difference between <1 year (higher, mean = 31.98) and 1 to 5 years (lower, mean = 24.405; P = .03), 5 to 10 years (lower, mean = 23.182; P = .013), and >10 years (lower, mean = 20.407; P < .001). For vulvar pleasure, post hoc comparisons revealed a significant difference between >10 years (higher, mean = 7.25) and 1 to 5 years (mean = 6.432; P = .047) as well as <1 year (mean = 5.658; P = .006). Estimated marginal means are presented for all post hoc comparisons, with the covariate (age) held at its mean of 41 years.

Discussion

This study explored the associations between vulvar pleasure and chronic vulvar pain. It is notable that most patients with chronic vulvar pain had experienced vulvar pleasure since the onset of their pain, suggesting that chronic vulvar pain does not preclude the ability to experience vulvar pleasure. Moreover, the findings indicated that vulvar pleasure was associated with better pain-related outcomes (eg, lower pain-related anxiety, lower pain catastrophizing). Perhaps unsurprising, patients who did not report current vulvar pain (NCVP) differed significantly from the other 3 patient groups on PASS-20 and PCS scores. Interestingly, although the NCVP cohort differed significantly from the NEP and NPSP groups on FSFI scores, it did not differ significantly from patients with P&P, suggesting that reports of sexual functioning do not differ between patients with P&P and those with no current vulvar pain. Additionally, the P&P group had higher sexual functioning scores, lower pain-related anxiety scores, and lower pain catastrophizing scores than patients with current vulvar pain who did not currently experience vulvar pleasure (NEP and NPSP). Finally, it is worth highlighting that experiencing vulvar pleasure for greater lengths of time was associated with lower PASS-20 and PCS scores and higher vulvar pleasure intensity scores among the P&P cohort. Together, the data indicate that experiences of vulvar pleasure are positively associated with sexual functioning and pleasure intensity and negatively associated with pain-related anxiety and pain catastrophizing in patients with chronic vulvar pain.

Of the patients with P&P, more than two-thirds listed the clitoris as the most common site of pleasure, which differed from the most common areas of vulvar pain (vagina, labia minora). These differences in anatomic location may account for the ability to experience pain and pleasure, especially as almost 65% of the P&P cohort reported feeling that its vulvar pain could never be considered pleasurable and >55% of patients with P&P did not feel pain anywhere in the vulva while experiencing pleasure. It also highlights the need to view the vulva as a multifaceted organ associated with multiple sensory experiences. The experiences of pain as pleasurable and pleasure as painful and the coexistence of pain and pleasure in the same anatomic locations suggest complex interactions of pleasure and pain in the vulva.

Almost 80% of patients with P&P masturbated each month, with about one-third engaging in masturbation at least 4 to 6 times per month or more. By comparison, a study from 2017 revealed that only 40.8% of nationally representative US women had masturbated in the past month.³⁰ Rowland et al found that higher frequency of masturbation was associated with lower satisfaction with sexual partners, greater importance of sex, and higher levels of general anxiety and depression.³¹ In a sample of 425 German women, Burri and Carvalheira noted that relaxation and stress relief were 2 of the 4 main reasons cited for masturbating (44% and 22.6%, respectively).³² It could be, then, that those who have chronic vulvar pain are more likely to engage in masturbation more frequently due to the associations between masturbation frequency and anxiety and as a tool for stress relief and relaxation. It is also possible that because penetrative vaginal intercourse is painful for most of the patients in this study, they are more likely to engage in masturbation, which likely does not involve penetration. Masturbation ranked higher on pleasure scores and ability to bring to orgasm than vulvar stimulation by a partner, which itself ranked higher than penetrative vaginal intercourse. Additionally, patients with P&P masturbated more frequently than they engaged in vulvar stimulation by a partner and penetrative vaginal intercourse. Notably, these results did not significantly differ between patients in current relationships and those not in them. As such, masturbation may be one of the most prevalent sexual activities practiced by patients with chronic vulvar pain who are still able to experience vulvar pleasure, regardless of relationship status.

Importantly, >30% of the P&P cohort stated that its pain was positively affected by vulvar pleasure. It is possible that vulvar pleasure can be analgesic to various degrees in some patients with chronic vulvar pain. This is in line with studies conducted by Whipple and Komisaruk, which revealed that vulvar pleasure and orgasm increased pain threshold and pain tolerance and decreased pain sensitivity.^25-27

Clinical implications

Vulvar pleasure should be clinically evaluated and discussed in the setting of chronic vulvar pain. Practice of mindfulness, cognitive behavioral therapy, and multidisciplinary treatment approaches in the treatment of chronic vulvar pain may benefit from the incorporation of pleasure-based strategies.^33-35 Integrating pleasure-inducing activities such as masturbation may prove beneficial in terms of pain experiences in treatment regimens for chronic vulvar pain.

Strengths and limitations

This is the first study to examine vulvar pleasure in a large sample with chronic vulvar pain. Our results have yielded several novel findings that can contribute to an even more holistic understanding of the biopsychosocial experiences of those with chronic vulvar pain conditions. Limitations of our study include the lack of a nonclinical comparator sample and the fact that we asked only patients with P&P to fill out the vulvar pleasure survey. In addition, data relied on patient self-report and did not include diagnostic or physical examination measures. Finally, the patient group sampled presented as new patients at a clinic specializing in chronic vulvar pain conditions and, as such, may not be generalizable to a broader population. Future studies can address these limitations and further our understanding of the associations between chronic vulvar pain and vulvar pleasure.

Conclusions

Vulvar pleasure is associated with lower pain-related anxiety, lower pain catastrophizing, and higher sexual functioning in patients with chronic vulvar pain conditions. Additionally, masturbation outranked vulvar stimulation by a partner and penetrative vaginal intercourse as providing the most pleasure and being the most likely sexual activity to lead to orgasm. Given these results, clinicians may want to consider incorporating pleasure-based strategies into chronic vulvar pain management.

Appendix A: univariate results (post hoc comparisons)

Table A1.

Post hoc comparisons: PCS with Bonferroni correction.

				95% CI
Group 1: Group 2	Mean difference	SE	P value	Lower bound	Upper bound
Pain and pleasure since pain
No pleasure since pain	−5.38237a	1.91209	.031	−10.4486	−0.3161
Never pleasure	−5.02252	2.98122	.556	−12.9216	2.8765
No current vulvar pain	9.47798a	1.74464	<.001	4.8554	14.1006
No pleasure since pain
Pain and pleasure since pain	5.38237a	1.91209	.031	0.3161	10.4486
Never pleasure	0.35985	3.34823	>.99	−8.5116	9.2313
No current vulvar pain	14.86035a	2.31661	<.001	8.7223	20.9984
Never pleasure
Pain and pleasure since pain	5.02252	2.98122	.556	−2.8765	12.9216
No pleasure since pain	−0.35985	3.34823	>.99	−9.2313	8.5116
No current vulvar pain	14.50050a	3.2555	<.001	5.8747	23.1263
No current vulvar pain
Pain and pleasure since pain	−9.47798a	1.74464	<.001	−14.1006	−4.8554
No pleasure since pain	−14.86035a	2.31661	<.001	−20.9984	−8.7223
Never pleasure	−14.50050a	3.2555	<.001	−23.1263	−5.8747

Abbreviation: PCS, Pain Catastrophizing Scale.

^aMean difference is significant at the .05 level.

Table A2.

Post hoc comparisons: PASS-20.

				95% CI
Group 1: Group 2	Mean difference	SE	P value	Lower bound	Upper bound
Pain and pleasure since pain
No pleasure since pain	−5.29013	2.90515	.416	−12.9876	2.4073
Never pleasure	−7.54392	4.52956	.579	−19.5454	4.4576
No current vulvar pain	14.09614a	2.65074	<.001	7.0728	21.1195
No pleasure since pain
Pain and pleasure since pain	5.29013	2.90515	.416	−2.4073	12.9876
Never pleasure	−2.25379	5.08717	>.99	−15.7327	11.2252
No current vulvar pain	19.38627a	3.51978	<.001	10.0603	28.7122
Never pleasure
Pain and pleasure since pain	7.54392	4.52956	.579	−4.4576	19.5454
No pleasure since pain	2.25379	5.08717	>.99	−11.2252	15.7327
No current vulvar pain	21.64006a	4.94629	<.001	8.5344	34.7457
No current vulvar pain
Pain and pleasure since pain	−14.09614a	2.65074	<.001	−21.1195	−7.0728
No pleasure since pain	−19.38627a	3.51978	<.001	−28.7122	−10.0603
Never pleasure	−21.64006a	4.94629	<.001	−34.7457	−8.5344

Abbreviation: PASS-20, Pain Anxiety Symptoms Scale–20.

^aMean difference is significant at the .05 level.

Table A3.

Post hoc comparisons: FSFI.

				95% CI
Group 1: Group 2	Mean difference	SE	P value	Lower bound	Upper bound
Pain and pleasure since pain
No pleasure since pain	6.92095a	1.23472	<.001	3.6494	10.1925
Never pleasure	4.92095	1.92512	.065	−0.1798	10.0217
No current vulvar pain	−1.47905	1.1266	>.99	−4.4641	1.506
No pleasure since pain
Pain and pleasure since pain	−6.92095a	1.23472	<.001	−10.1925	−3.6494
Never pleasure	−2	2.16211	>.99	−7.7287	3.7287
No current vulvar pain	−8.40000a	1.49595	<.001	−12.3636	−4.4364
Never pleasure
Pain and pleasure since pain	−4.92095	1.92512	.065	−10.0217	0.1798
No pleasure since pain	2	2.16211	>.99	−3.7287	7.7287
No current vulvar pain	−6.40000a	2.10223	.015	−11.9701	−0.8299
No current vulvar pain
Pain and pleasure since pain	1.47905	1.1266	>.99	−1.506	4.4641
No pleasure since pain	8.40000a	1.49595	<.001	4.4364	12.3636
Never pleasure	6.40000a	2.10223	.015	0.8299	11.9701

Abbreviation: FSFI, Female Sexual Function Index.

^aMean difference is significant at the .05 level.

Appendix B: multivariate results (post hoc comparisons)

Table B1.

MANOVA post hoc comparisons: “Have you experienced any pleasurable sensations in your vulva since your vulvar pain started?”

				95% CI
DV: response comparison	Mean difference	SE	P value	Lower bound	Upper bound
FSFI
Total
No vs yes	−6.461a	1.063	<.001	−8.55	−4.372
Yes vs no	6.461a	1.063	<.001	4.372	8.55
Desire
No vs yes	−0.543a	0.158	<.001	−0.854	−0.232
Yes vs no	0.543a	0.158	<.001	0.232	0.854
Arousal
No vs yes	−1.293a	0.237	<.001	−1.759	−0.827
Yes vs no	1.293a	0.237	<.001	0.827	1.759
Lubrication
No vs yes	−1.596a	0.266	<.001	−2.119	−1.073
Yes vs no	1.596a	0.266	<.001	1.073	2.119
Orgasm
No vs yes	−1.598a	0.273	<.001	−2.134	−1.061
Yes vs no	1.598a	0.273	<.001	1.061	2.134
Satisfaction
No vs yes	−0.598a	0.186	.001	−0.964	−0.233
Yes vs no	0.598a	0.186	.001	0.233	0.964
Pain
No vs yes	−0.833a	0.2	<.001	−1.227	−0.439
Yes vs no	0.833a	0.2	<.001	0.439	1.227
PCS
Total
No vs yes	5.189a	1.684	.002	1.878	8.499
Yes vs no	−5.189a	1.684	.002	−8.499	−1.878
Rumination
No vs yes	1.656a	0.625	.008	0.427	2.885
Yes vs no	−1.656a	0.625	.008	−2.885	−0.427
Magnification
No vs yes	0.937a	0.393	.018	0.164	1.71
Yes vs no	−0.937a	0.393	.018	−1.71	−0.164
Helplessness
No vs yes	1.917a	0.62	.002	0.698	3.137
Yes vs no	−1.917a	0.62	.002	−3.137	−0.698
PASS-20
Total
No vs yes	5.729a	2.555	.026	0.705	10.753
Yes vs no	−5.729a	2.555	.026	−10.753	−0.705
Cognitive
No vs yes	1.587	0.885	.074	−0.154	3.327
Yes vs no	−1.587	0.885	.074	−3.327	0.154
Escape avoidance
No vs yes	1.278	0.666	.056	−0.032	2.588
Yes vs no	−1.278	0.666	.056	−2.588	0.032
Fear
No vs yes	1.785a	0.739	.016	0.332	3.239
Yes vs no	−1.785a	0.739	.016	−3.239	−0.332
Physiologic anxiety
No vs yes	1.079	0.651	.098	−0.202	2.36
Yes vs no	−1.079	0.651	.098	−2.36	0.202

Abbreviations: DV, dependent variable; FSFI, Female Sexual Function Index; MANOVA, multivariate analysis of variance; PASS-20, Pain Anxiety Symptoms Scale–20; PCS, Pain Catastrophizing Scale.

^aMean difference is significant at the .05 level.

Table B2.

MANCOVA post hoc comparisons: “For how long have you experienced pleasure in your vulva?”

				95% CI
DV: response comparison	Mean difference	SE	P value	Lower Bound	Upper Bound
PCS
1-5 y
5-10 y	1.223	2.776	.66	−4.24	6.686
<1 y	−7.575a	3.463	.03	−14.391	−0.758
>10 y	3.998	2.199	.07	−0.33	8.326
Other (please specify)	−3.325	3.639	.362	−10.487	3.838
5-10 y
1-5 y	−1.223	2.776	.66	−6.686	4.24
<1 y	−8.798a	3.505	.013	−15.696	−1.899
>10 y	2.775	2.257	.22	−1.667	7.217
Other (please specify)	−4.548	3.678	.217	−11.787	2.691
<1 y
1-5 y	7.575a	3.463	.03	0.758	14.391
5-10 y	8.798a	3.505	.013	1.899	15.696
>10 y	11.572a	3.054	<.001	5.561	17.584
Other (please specify)	4.25	4.189	.311	−3.995	12.495
>10 y
1-5 y	−3.998	2.199	.07	−8.326	0.33
5-10 y	−2.775	2.257	.22	−7.217	1.667
<1 y	−11.572a	3.054	<.001	−17.584	−5.561
Other (please specify)	−7.322a	3.253	.025	−13.725	−0.919
Other (please specify)
1-5 y	3.325	3.639	.362	−3.838	10.487
5-10 y	4.548	3.678	.217	−2.691	11.787
<1 y	−4.25	4.189	.311	−12.495	3.995
>10 y	7.322a	3.253	.025	0.919	13.725
PASS-20
1-5 y
5-10 y	−0.404	4.224	.924	−8.717	7.909
<1 y	−9.336	5.27	.078	−19.709	1.036
>10 y	5.187	3.346	.122	−1.399	11.772
Other (please specify)	−6.836	5.537	.218	−17.734	4.063
5-10 y
1-5 y	0.404	4.224	.924	−7.909	8.717
<1 y	−8.933	5.333	.095	−19.429	1.564
>10 y	5.591	3.434	.105	−1.168	12.35
Other (please specify)	−6.432	5.597	.251	−17.447	4.583
<1 y
1-5 y	9.336	5.27	.078	−1.036	19.709
5-10 y	8.933	5.333	.095	−1.564	19.429
>10 y	14.523a	4.647	.002	5.376	23.67
Other (please specify)	2.501	6.374	.695	−10.045	15.047
>10 y
1-5 y	−5.187	3.346	.122	−11.772	1.399
5-10 y	−5.591	3.434	.105	−12.35	1.168
<1 y	−14.523a	4.647	.002	−23.67	−5.376
Other (please specify)	−12.022a	4.95	.016	−21.765	−2.28
Other (please specify)
1-5 y	6.836	5.537	.218	−4.063	17.734
5-10 y	6.432	5.597	.251	−4.583	17.447
<1 y	−2.501	6.374	.695	−15.047	10.045
>10 y	12.022a	4.95	.016	2.28	21.765
Vulvar pain intensity
1-5 y
5-10 y	−0.003	0.519	.995	−1.024	1.017
<1 y	0.774	0.647	.233	−0.499	2.047
>10 y	−0.820a	0.411	.047	−1.629	−0.012
Other (please specify)	−0.112	0.68	.869	−1.45	1.226
5-10 y
1-5 y	0.003	0.519	.995	−1.017	1.024
<1 y	0.777	0.655	.236	−0.512	2.066
>10 y	−0.817	0.422	.054	−1.647	0.012
Other (please specify)	−0.109	0.687	.874	−1.461	1.243
<1 y
1-5 y	−0.774	0.647	.233	−2.047	0.499
5-10 y	−0.777	0.655	.236	−2.066	0.512
>10 y	−1.594a	0.571	.006	−2.717	−0.471
Other (please specify)	−0.886	0.783	.258	−2.426	0.654
>10 y
1-5 y	0.820a	0.411	.047	0.012	1.629
5-10 y	0.817	0.422	.054	−0.012	1.647
<1 y	1.594a	0.571	.006	0.471	2.717
Other (please specify)	0.708	0.608	.245	−0.488	1.904
Other (please specify)
1-5 y	0.112	0.68	.869	−1.226	1.45
5-10 y	0.109	0.687	.874	−1.243	1.461
<1 y	0.886	0.783	.258	−0.654	2.426
>10 y	−0.708	0.608	.245	−1.904	0.488

Abbreviations: DV, dependent variable; MANCOVA, multivariate analysis of covariance; PASS-20, Pain Anxiety Symptoms Scale–20; PCS, Pain Catastrophizing Scale.

^aMean difference is significant at the .05 level.

Appendix C: vulvar pleasure questionnaire

Introduction: This survey focuses on feelings of sexual pleasure that you may experience in your body, specifically in your genital region. We define sexual pleasure as any physical or psychological enjoyment from solitary or shared erotic experiences, including thoughts, dreams and fantasies. Please keep this definition in mind as you complete the survey. Thank you!

• 1) Have you ever experienced pleasurable sensations in your vulva?

  1. Yes

  2. No

  3. Other (please specify):

• 2) Have you experienced any pleasurable sensations in your vulva since your vulvar pain started?

  1. Yes

  2. No

  3. Other (please specify):

The next questions are about sexual pleasure you have experienced in your vulva since your vulvar pain started.

• 1) For how long have you experienced pleasure in your vulva? (Even if you do not currently experience pleasure in your vulva, we are interested in how many years of experience you have of pleasure in your vulva).

  1. Less than 1 year

  2. 1–5 years

  3. 5–10 years

  4. More than 10 years

  5. Other (please specify):

• 2) On a scale of 0–10, please rate the average amount of sexual pleasure you feel in your vulva when you are experiencing sexual pleasure?

  1. 0 (I don’t experience sexual pleasure in my vulva)

  2. 1

  3. 2

  4. 3

  5. 4

  6. 5

  7. 6

  8. 7

  9. 8

  10. 9

  11. 10 (extremely pleasurable)

• 3) In which parts of your vulva do you feel sexual pleasure? Please rank the following areas from most pleasurable (top) to least pleasurable (bottom). If you do not feel any pleasure in a particular area, please select “N/A.” [Diagram not included due to copyright]

  1. Mons pubis

  2. Clitoris

  3. Labia Majora

  4. Labia minora

  5. Urethra

  6. Vestibule

  7. Inside the vagina

  8. Perineum

  9. Anus/Rectal Area

• 4) On average, how many times do you masturbate (stimulating your vulva with your hand, a pillow, a sex toy such as a vibrator, etc. while alone) in a period of one month?

  1. 0 times

  2. 1–3 times

  3. 4–6 times

  4. 7–9 times

  5. 10+ times

  6. N/A I have never masturbated

  7. N/A I have not masturbated since my vulvar pain began

• 5) How sexually pleasurable is masturbation for you on average?

  1. 0 (Not at all sexually pleasurable)

  2. 1

  3. 2

  4. 3

  5. 4

  6. 5

  7. 6

  8. 7

  9. 8

  10. 9

  11. 10 (Extremely sexually pleasurable)

  12. N/A I have never masturbated

  13. N/A I have not masturbated since my vulvar pain began

• 6) How often do you experience orgasm when masturbating?

  1. Every time or almost every time

  2. More than half of the time

  3. About half of the time

  4. Less than half of the time

  5. Almost never

  6. Never

  7. N/A I have never masturbated

  8. N/A I have not masturbated since my vulvar pain began

• 7) Have you had at least one sexual partner since your vulvar pain began?

  1. Yes

  2. No

• 8) On average, how many times does a partner(s) stimulate your vulva, ie, through foreplay, oral sex, or manual stimulation (excluding penetrative vaginal intercourse) in a period of one month?

  1. 0 times

  2. 1–3 times

  3. 4–6 times

  4. 7–9 times

  5. 10+ times

  6. N/A A partner has never stimulated my vulva

  7. N/A A partner has not stimulated my vulva since my vulvar pain began

• 9) How sexually pleasurable is it when your partner(s) stimulates your vulva, ie, through foreplay, oral sex, or manual stimulation (excluding penetrative vaginal intercourse)?

  1. 0 (Not at all sexually pleasurable)

  2. 1

  3. 2

  4. 3

  5. 4

  6. 5

  7. 6

  8. 7

  9. 8

  10. 9

  11. 10 (Extremely sexually pleasurable)

  12. N/A A partner has never stimulated my vulva

  13. N/A A partner has not stimulated my vulva since my vulvar pain began

• 10) How often do you experience orgasm when a partner stimulates your vulva, ie, through foreplay, oral sex, or manual stimulation (excluding penetrative vaginal intercourse)?

  1. Every time or almost every time

  2. More than half of the time

  3. About half of the time

  4. Less than half of the time

  5. Almost never

  6. Never

  7. N/A A partner has not stimulated my vulva since my vulvar pain began

  8. N/A A partner has never stimulated my vulva

• 11) On average, how many times do you have penetrative vaginal intercourse (when your partner inserts their penis, finger, a sex toy, etc. in your vagina) in a period of one month?

  1. 0 times

  2. 1–3 times

  3. 4–6 times

  4. 7–9 times

  5. 10+ times

  6. N/A I have never had penetrative vaginal intercourse

  7. N/A I have not had penetrative vaginal intercourse since my vulvar pain began

• 12) How sexually pleasurable is it when you have penetrative vaginal intercourse (when your partner inserts their penis, finger, a sex toy, etc. in your vagina)?

  1. 0 (Not at all sexually pleasurable)

  2. 1

  3. 2

  4. 3

  5. 4

  6. 5

  7. 6

  8. 7

  9. 8

  10. 9

  11. 10 (Extremely sexually pleasurable)

  12. N/A I have never had penetrative vaginal intercourse

  13. N/A I have not had penetrative vaginal intercourse since my vulvar pain began

• 13) Which object gives you the most pleasure when inserted inside your vagina? Please rank from what gives you the most pleasure (1) to the least pleasure (5).

  1. Someone else’s penis

  2. Someone else’s finger(s)

  3. My own finger(s)

  4. A sex toy

  5. Other (please specify):

  6. N/A Nothing gives me pleasure when inserted inside my vagina

• 14) How often do you experience orgasm during penetration of your vagina only (with a penis, finger, sex toy, etc.)—without simultaneous stimulation of other parts of your vulva?

  1. Every time or almost every time

  2. More than half of the time

  3. About half of the time

  4. Less than half of the time

  5. Almost never

  6. Never

  7. N/A I have never experienced penetration of my vagina

  8. N/A I have not experienced penetration of my vagina since my vulvar pain began

• 15) When you feel pleasure in your vulva, do you simultaneously feel pain anywhere else in your vulva?

  1. No

  2. Yes, in the same place where I feel pleasure

  3. Yes, in a different place from where I feel pleasure (please specify where you feel the simultaneous pain): ________

• 16) When you feel pleasure in your vulva, what happens to the pain in your vulva?

  1. I don’t ever feel pain in my vulva when I feel pleasure

  2. The pain goes away

  3. The pain gets better, but is still there

  4. The pain stays the same

  5. The pain gets worse

• 17) When you feel pleasure in your vulva, how often are you simultaneously thinking about your vulvar pain?

  1. Every time or almost every time

  2. More than half of the time

  3. About half of the time

  4. Less than half of the time

  5. Never or almost never

• 18) Does your pleasure ever become painful?

  1. Every time or almost every time

  2. More than half of the time

  3. About half of the time

  4. Less than half of the time

  5. Never or almost never

• 19) Do you feel that your vulvar pain can be pleasurable?

  1. Every time or almost every time

  2. More than half of the time

  3. About half of the time

  4. Less than half of the time

  5. Never or almost never

• 20) Have you ever experienced painful orgasm?

  1. No

  2. Yes (please describe how often orgasms are painful, where you feel the pain, and whether the pain occurs before, during, or after orgasm): ___________

Author contributions

Conceptualization: TTM, CFP, ATG, MEM, JK. Data curation: MEM, TTM. Formal analysis: MEM. Investigation: TTM, MEM, CFP, ATG, JK. Methodology: TTM, CFP, ATG, MEM, JK. Project administration: TTM. Resources: ATG, JK, CFP, MEM, TTM. Software: MEM. Supervision: CFP, ATG, JK, TTM, MEM. Validation. CFP, MEM, TTM, JK, ATG. Writing – original draft: TTM, MEM, CFP, JK, ATG. Writing – review & editing: CFP, JK, ATG, MEM, TTM.

Funding

None declared.

Conflicts of interest

A.T.G. is an employee at Daré Bioscience, a consultant at Sol-Gel, Incyte, Ipsen, Abbvie, and Board Member and President of the Gynecologic Cancers Research Foundation. No other authors have disclosures or conflicts of interest to state.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and confidentiality restrictions (i.e., containing information that could compromise the privacy of research participants).