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. Author manuscript; available in PMC: 2021 May 28.
Published in final edited form as: J Sex Marital Ther. 2020 May 28;46(6):589–598. doi: 10.1080/0092623X.2020.1766611

Psychosocial factors influence sexual satisfaction among women with vulvodynia

Jennifer Jo Connor 1, Miriam Haviland 2, Sonya S Brady 3, Beatrice “Bean” E Robinson 4, Bernard L Harlow 5
PMCID: PMC7413302  NIHMSID: NIHMS1607827  PMID: 32460678

Abstract

Vulvodynia affects about 8% of women, many of whom report a negative impact on their ability to have sexually satisfying relationships. In this study, we examined predictors of sexual satisfaction in 207 women with clinically confirmed vulvodynia. We adapted a model examining resilience in chronic pain patients originally developed by Sturgeon and Zautra (2010) to include resilience factors (communication with partner about sexual health, coping strategies) and vulnerable factors (abuse history, pain intensity, rumination). These variables were regressed onto sexual satisfaction. In the full model, only emotion-based rumination was predictive of sexual satisfaction. Thus, focusing on emotion-based rumination in clinical intervention may improve sexual satisfaction.

Keywords: vulvodynia, sexual satisfaction, rumination, genito-pelvic pain penetration disorder, sexual pain

Vulvodynia is a pain condition of the vulva that affects approximately 8% of women by the age of 40 (Harlow et al., 2014; Reed et al., 2012). Women with vulvodynia experience vulvar pain without any “clear, identifiable cause” (Bornstein et al., 2016, p. 1) and often report lower quality of life (Arnold, Bachmann, Kelly, Rosen, & Rhoads, 2006), including lower sexual arousal, desire, and satisfaction, as well as less frequent orgasm than women in comparison groups (Gates & Galask, 2001; Meana, Binik, Khalifé, & Cohen, 1997; Smith, Pukall, & Chamberlain, 2013).

Conceptual models have been used to determine how psychological processes can contribute to experiences of pain intensity, impact on activities of daily living, and distress in chronic pain patients. In the field of sexual pain, researchers have applied the Fear Avoidance Model (Vlaeyen & Linton, 2000) and the Endurance Model (Hasenbring, Hallner, & Rusu, 2009) to examine how behaviors (e.g., avoidance, endurance), affective processes (e.g., anxiety and mood), and cognitive processes (e.g., catastrophizing, minimizing) are associated with pain (Chisari & Chilcot, 2017; Davis et al., 2015; Flink, Engmana, Ter Kuile, Thomtén, & Linton, 2017). Studies have found some evidence that catastrophizing is associated with greater pain intensity and pain interference (Chisari & Chilcot, 2017; Flink et al., 2017). However, Davis et al. (2015) found that changes in catastrophizing, fear, or anxiety (Fear Avoidance Model constructs) were not associated with changes in pain or sexual functioning over a one year period. In this study, changes in sexual self-efficacy resulted in reduced pain intensity and improved sexual functioning. The authors suggested that protective factors are an important area of focus for future research and clinical care.

In contrast to the fear avoidance and endurance models, Sturgeon and Zautra (2010) identified factors that can reduce distress and promote well-being in those suffering from chronic pain. They proposed that resilience to pain involves recovery, sustainability and growth. Sturgeon, Zautra, and Arewisikporn (2014) defined resilience to pain as “the preservation of existing positive functioning or protection against subsequent negative emotional states” (pp. 292). Sturgeon and Zautra (2010) posited that coping responses moderate relationships between resilience or vulnerability characteristics and pain outcomes. We note that positive forms of coping, when implemented on a regular basis, also may be viewed as a resilience characteristic. The model presented in Sturgeon and Zautra’s work has not been examined in the context of chronic sexual pain, such as vulvodynia.

In our research, we apply Sturgeon and Zautra’s (2010) model to sexual satisfaction in the context of vulvodynia. Higher levels of sexual satisfaction could be considered resilience in the face of sexual pain. Based on sexual pain and vulvodynia research, we conceptualize that positive communication with a partner about sexual health is a resilience resource that will have a positive association with sexual satisfaction (Rancourt, Flynn, Bergeron, & Rosen, 2017; Rosen & Bergeron, 2019). Childhood abuse, higher pain intensity, and rumination are vulnerability characteristics that will have negative associations with sexual satisfaction (Corsini-Munt, Bergeron, Rosen, Beaulieu, & Steben, 2017; Harlow & Stewart, 2005; Khandker et al., 2019). Our measure of rumination was specific to women’s thoughts and feelings about vulvodynia during the last time they experienced symptoms. Emotion-focused rumination is consistent with descriptions of catastrophic worry, characterized by a perseverative iterative style of thinking (i.e., rumination), helplessness, and magnification (Davey & Levy, 1998; Flink, Boersma, & Linton, 2013). Flink and colleagues note that a focus on negative repetitive thinking while engaging in activities may eliminate positive reinforcement. Applied to intimacy, women who engage in emotion-focused rumination about vulvodynia (i.e., catastrophic worry) may be less likely to focus on positive aspects of intimacy with a partner and experience lower levels of sexual satisfaction.

Finally, we hypothesize that coping responses will act as moderators of associations of resilience and vulnerability characteristics to sexual satisfaction. We examined these associations in a sample of women with clinically-confirmed vulvodynia.

Methods

Participants

Recruitment for this study has been described in previous manuscripts (Harlow et al., 2017; Khandker et al., 2019). Women between the ages of 18–40 who had visited a healthcare provider within a Minneapolis/St. Paul major medical system, for any reason, between March, 2010 – October 2013, received an invitation letter to complete a brief questionnaire to determine eligibility. Almost half (45.9%) of the 66,857 women who received invitations completed a questionnaire, and those who indicated a history of vulvar pain were invited to participate in a clinical examination (1,398 women). A study physician examined 350 women, of whom 234 met the criteria of vulvodynia set by the ISSVD, ISSWSH, and IPPS (Bornstein et al., 2016); a history of vulvovaginal pain, spontaneous or elicited by touch, and skin findings that are limited to erythema of the vulva or vagina; women with secondary, primary, generalized, and localized vulvodynia were all included. Of these women, 27 with missing information on key variables were excluded. The present analysis included 207 participants with clinically confirmed history of vulvodynia (i.e., included those whose pain fluctuated or remitted) who answered all items.

Procedures

The study was approved by the University of Minnesota Institutional Review Board. Women who consented to participate completed self-administered medical and sexual history and lifestyle surveys at home, and a telephone-administered structured clinical interview for the assessment of current and past psychiatric morbidity (SCID-IV). In addition, a clinical examination assessed gynecological conditions that would explain the vulvar pain and thus exclude the participant from the study, and other gynecological co-morbid conditions present but not an explanation for the vulvar pain. Upon clinical confirmation of a vulvodynia diagnosis, an assessment of pain levels due to vulvar pain were assessed (see below). Additional eligibility criteria included having no active genitourinary infections at the time of the clinical visit, and if parous, being at least 1-year postpartum. Participants received $25 for completion of self-administered assessments, and $75 for participation in clinical assessments. Participants were reimbursed for all ancillary costs, such as transportation costs and parking, associated with participation.

Measures

Sexual Satisfaction

Participants were asked to (1) “check the category that best describes how much emotional satisfaction you have felt from engaging in sexual activities, including masturbation,” and (2) “check the category that best describes how much physical satisfaction you have felt from engaging in sexual activities, including masturbation.” These items were developed by the research team. Item responses ranged from 0 (none) to 5 (a lot). These two items were summed and averaged.

Sexual communication with partner

To assess communication about sexual health, participants were asked “do you discuss your sexual health (e.g., difficulty reaching orgasm, how to use sexual aids) with your spouse/partner?” This item was developed by the research team. Item responses ranged from 0 (never discuss) to 5 (always).

Childhood Abuse

History of childhood abuse was assessed using a 73-item questionnaire developed by researchers from Brown University, the Harvard School of Public Health, and Brigham and Women’s Hospital (Wise, Zierler, Krieger, & Harlow 2001). Items were derived from the Conflict Tactics Scale and the Pregnancy Abuse Assessment Screen, widely recognized as representing a broad spectrum of abuse (McFarlane, Parker, Soeken, & Bullock, 1992; Straus, Gelles, & Steinmetz, 1980). Women selected the category that best described the frequency of physical and sexual abuse during childhood (defined as younger than 12 years), using the responses “0,” “1–4 times,” “5–9 times,” or “10+ times.” Women were classified as having had “severe” physical abuse if they (a) were ever choked, burned, or physically threatened with a knife or gun, or (b) responded to any other item as 5 or more times. All other physical abuse was considered “moderate.” Women were classified as having had “severe” sexual abuse if they responded to being sexually assaulted or forced to have sex one or more times or were coerced or pressured to be sexual 5 or more times. All other sexual abuse was considered “moderate.” The levels of reported physical and sexual childhood abuse were used to create a composite categorical variable: no childhood abuse, moderate abuse, severe childhood abuse; if the physical or sexual abuse variable was categorized as “severe,” the childhood abuse variable was then categorized as severe.

Pain Intensity

Pain threshold was assessed during the clinical examination by a physician who used a vulvalgesiometer, a mechanical device that allows for measurement of pain threshold via a cotton swab and a set of cylindrical, hand-held, syringe-like devices, with a cotton swab on the end, that contain springs with standardized rates of compression (Pukall, Binik, & Khalifé, 2004, p. 72). The clinician started with the lowest compression vulvalgesiometer. When applied to the vulva, if it did not elicit a pain response, then the next compresson level vulvalgesiometer was used. This continued until there was enough compression to elicit a response from the participant. The entire set of vulvalgesiometers exerted a range of compression between 1 and 3 grams. In the current study, the cotton swab tip of the vulvalgesiometer was placed at the 5 o’clock and 7 o’clock points of the vulvar vestibule. The participant rated her level of intensity, pain, and unpleasantness at 5 and 7 o’clock on a scale from 0 – 3, with 3 being the highest level. The clinician recorded the vulvalgesiometer pressure at each participant rating of intensity, pain, and unpleasantness. This form of assessment has been validated in a previous study (Pukall, Young, Roberts, Sutton, & Smith, 2007).

Based on the average pressure at which women reported experiencing level 3 intensity, pain, or unpleasantness at 5 and 7 o’clock, we created a pain intensity variable. We scaled the pressure variable such that each sequential pressure increase on the vulvalgesiometer corresponded to a one-unit increase on a scale ranging from 1–23. If a woman reported level 3 intensity, pain, or unpleasantness at different pressures, we used the pressure associated with intensity. If a woman did not report a score of 3 for intensity, we used the pressure associated with pain. If she did not report a score of 3 for either intensity or pain, we used the pressure associated with unpleasantness. All women had a score of 3 for at least one sub-scale at either 5 or 7 o/clock. If a woman reported at least one score of 3 at 5 o’clock but not at 7 o/clock, we used only the 5 o’clock associated pressure. If she reported at least one score of 3 at 7 o’clock but not at 5 o’clock, we used only the 7 o’clock associated pressure. If she reported scores of 3 at both positions, we used the average associated pressure.

Rumination

Three rumination subscales (emotion-focused, instrumental, searching for meaning) were assessed through the Multidimensional Rumination Questionnaire (MRQ), a standardized 28-item, self-report questionnaire (Fritz, 1999; Siegle, Moore, & Thase, 2004). Participants were asked to report how often they ruminated about vulvodynia on a 5-point Likert scale. Items within each subscale were averaged, with higher scores indicating higher levels of rumination. The emotion-focused subscale consisted of 15 items (α=.95; e.g., “how much did you wonder when you would stop being in a depressed mood about vulvodynia?”). The instrumental subscale consisted of 7 items (α=.90; e.g., “how much did you think of the best things to do for yourself to deal vulvodynia?”). The searching for meaning subscale consisted of 6 items (α=.86; e.g., “how much did you find yourself thinking about what it was that you might have done that caused vulvodynia?”).

Coping

Four coping subscales (positive reinterpretation, use of instrumental social support, use of emotional social support, acceptance) were assessed through the COPE scale, a standardized scale (Carver, Scheier, & Weintraub, 1989). These four subscales were chosen from the 14 available COPE subscales because they are likely to be adaptive when responding to relatively uncontrollable stressors (Lazarus & Folkman, 1984). Participants were asked to think about how they usually handled stress and answered on a 4-point Likert scale, with higher scores indicating a greater tendency towards using that particular coping response. The positive reinterpretation subscale consisted of 4 items (α=.82; e.g., “I try to grow as a person as a result of the experience”). The instrumental social support subscale consisted of 4 items (α=.78; e.g., “I try to get advice from someone about what to do”). The emotional social support subscale consisted of 4 items (α=.88; e.g., “I discuss my feelings with someone”). The acceptance subscale consisted of 4 items (α=.75; e.g., “I accept that this has happened and that it can’t be changed”). Items within each scale were summed.

Analysis Plan

In preliminary analysis, we assessed distributions of all potential predictors of sexual satisfaction and calculated Pearson correlation coefficients to examine correlations between all predictors and the outcome, sexual satisfaction. We created a base linear regression model that included three covariates that were potential confounders of associations (age, education, marital status). We then ran a linear regression model to assess how psychosocial predictors impacted sexual satisfaction while adjusting for covariates. As we hypothesized that coping would modify associations between other psychosocial predictors (resilience and vulnerability characteristics) and sexual satisfaction, we fit a series of linear regression models that included a single interaction term for each combination of a coping variable with a resilience characteristic (sexual communication with partner) or vulnerability characteristic (childhood abuse, pain intensity, rumination). All analyses were conducted using SAS 9.4.

Results

As shown in Table 1, the majority of participants identified as white, had at least some college experience, and were married or partnered. Table 2 presents distributions of and correlations between study variables. Several variables were correlated positively with sexual satisfaction, including communication with partner about sexual health, the absence of childhood abuse, lower levels of emotion-focused and meaning-focused rumination, and greater use of emotional support as a coping strategy. Notably, most coping strategies were not associated with reported sexual satisfaction, nor was level of pain intensity.

Table 1.

Participant characteristics at time of enrollment

n %
Race
 Non-Hispanic white 180 87.0
 Non-Hispanic black 8 3.1
 Asian 6 2.9
 Hispanic 9 4.4
 Other 4 1.9
Age
 16- ≤18 2 1.0
 19- ≤22 21 10.1
 22- ≤29 91 44.0
 30- ≤40 93 44.9
Education
 High school diploma or less 10 4.8
 Some college 41 19.8
 Undergraduate degree 115 55.6
 Graduate degree 41 19.8
Marital status
 Single 54 26.1
 Married or partnered 142 68.6
 Separated 3 1.5
 Divorced 6 2.9
 Unknown 2 1.0
Parity
 0 107 51.7
 1 29 14.0
 2 35 16.9
 ≥3 36 17.4
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Table 2.

Distributions of study variables and Pearson correlation coefficients

Mean Range 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
1. Sexual satisfaction average 2.1 0.0, 4.0 1.0
2. Communication about sexual health 1.0 1.0, 5.0 .16* 1.0
3. Any childhood abuse 3.5 0.0, 2.0 −15* −13 1.0
4. Pain Intensity 16.0 2.0, 23.0 .11 .05 <.01 1.0
5. Emotion focused rumination 2.2 1.0, 5.0 −31*** .03 .12 −10 1.0
6. Instrumental rumination 2.8 1.0, 5.0 −03 .28*** .10 .04 .49*** 1.0
7. Meaning rumination 2.1 1.0, 5.0 −17** .01 .19** −12 .66*** .50*** 1.0
8. Positive reinterpretation 11.7 4.0, 16.0 −02 .09 −08 −03 −23*** .03 −07 1.0
9. Use of instrumental social support 12.5 5.0, 16.0 .05 .23*** −04 .01 −05 .20** .11 .28*** 1.0
10. Use of emotional social support 12.6 4.0, 16.0 .15* .30*** −14* .05 −06 .12 .02 .17** .73*** 1.0
11. Acceptance 10.6 4.0, 16.0 .03 −15* −04 −04 −19** −03 −12 .36*** .08 .09 1.0
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*

p<0.05

**

p<0.01

***

p<0.001

Table 3 depicts the base model of sexual satisfaction regressed on all covariates, followed by the full model. In the base model, those with a high school education had lower sexual satisfaction than those with a college education. The R2 for the base model was .14. In the full model, education continued to be a significant predictor of sexual satisfaction. The only other significant predictor, adjusting for covariates and all other psychosocial variables, was emotion-focused rumination. The R2 for the full model was .30, indicating that 30% of the variance in sexual satisfaction for women diagnosed with vulvodynia can be attributed to the demographic and psychosocial variables in the model. No interaction terms were significant (data not shown).

Table 3.

Sexual satisfaction regressed on psychosocial predictors

Model for covariates only B ß St Error t p
Intercept 2.23 .0 .25 9.00 <.001
Age (23–29)a .38 .17 .26 1.46 .15
Age (30–40)a −.23 −.10 .26 −.91 .37
Not married −.28 −.12 .16 −1.79 .07
High school education −1.30 −.24*** .37 −3.48 <.001
College −.04 −.02 .20 −.18 .86
Graduate degree .02 .01 .24 .07 .94
All Predictors
Intercept 2.44 0 .77 3.17 <.001
Age (23–29)a .31 .14 .27 1.16 .25
Age (30–40)a −.17 −.08 .27 −.64 .52
Not married −.22 −.09 .17 −1.33 .18
High school education −1.41 −.28*** .38 −3.74 <.001
College −.22 −.10 .21 −1.04 .30
Graduate degree −.23 −.08 .25 −.92 .36
Discussed sexual health with partner .13 .12 .08 1.58 .12
Moderate abused −.18 −.07 .22 −.85 .40
Severe abused −.19 −.08 .17 −1.10 .27
Pain Intensity .01 .04 .02 .63 .53
Emotion focused rumination −.41 −.39*** .10 −4.01 <.001
Instrumental rumination .14 .12 .10 1.40 .16
Meaning rumination .06 .05 .12 .47 .64
Positive reinterpretation coping −.05 −.12 .03 −1.56 .12
Use of instrumental social support coping −.03 −.07 .05 −.67 .50
Use of emotional social support coping .05 .13 .04 1.30 .20
Acceptance coping .02 .04 .04 .58 .56
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a

reference group 18–22 years of age

b

reference group married

c

reference group some college

d

reference group no abuse

***

p<0.001

Base model R2 = .14

Full model R2 = .30

Discussion

We proposed and tested a conceptual model of sexual satisfaction in vulvodynia patients, based on a resilience to chronic pain model developed by Sturgeon and Zautra (2010) to include resilience factors (communication with partner about sexual health), vulnerability factors (abuse history, pain intensity, rumination), and coping strategies. Sexual satisfaction was regressed on resilience and vulnerability factors. In the full model, only emotion-based rumination was predictive of lower sexual satisfaction. Thus, focusing on emotion-based rumination in psychotherapy or sex therapy may be helpful when treating sexual dissatisfaction in women with vulvodynia.

Although several variables were significant in bivariate analyses, in the full model, emotion-focused rumination was the only psychosocial variable that was a significant predictor of sexual satisfaction. Women who engaged in lower levels of emotion-focused rumination had higher levels of sexual satisfaction. Communication with partner and coping through emotional support were no longer associated with sexual satisfaction in the full model. Vulnerability factors besides emotion-focused rumination, such as childhood abuse, also were not significant in the full model. In fact, pain intensity was not a significant predictor in either bivariate or regression analyses, suggesting that for those who experience pain, it is the psychological approach to pain rather than the intensity of pain that most contributes to sexual satisfaction. This finding is in line with research done by Aerts, Bergeron, Pukall, and Khalifé (2016), who found that pain intensity was not related to sexual function or sexual satisfaction in a sample of women diagnosed with provoked vestibulodynia.

Previous research has found an association between childhood abuse and the development of vulvodynia (Harlow & Stewart, 2005). Our findings provide some hope for women who have experienced childhood abuse and developed vulvodynia, in that reducing emotion-focused rumination, independent of childhood abuse history, may be an effective strategy in improving sexual satisfaction. Among women who had a diagnosis of vulvodynia, the overall model (i.e., hypothesized interactions between coping and other psychosocial characteristics) was not supported; interaction terms were non-significant, and most of the variance was accounted for by the emotion-focused rumination variable, a vulnerability factor.

Psychological interventions for women diagnosed with vulvodynia have primarily focused on cognitive behavioral interventions, with particular focus on catastrophizing (Bergeron, Khalifé, Dupuis, & McDuff, 2016; Brotto, Yong, Smith, & Sadownik, 2015). In the context of vulvodynia, catastrophizing may focus on how vulvar pain interferes with a variety of activities, as well as interfering with sexual intimacy with a partner. The present study suggests that emotion-focused rumination about stressors that precede vulvodynia can be important. Khandker et al. (2019) posited that emotion-focused rumination may trigger inflammatory processes that make the development of vulvodynia more likely; inflammatory processes may make sexual intimacy more difficult and lower sexual satisfaction. It is also possible that women who ruminate about past stressors are more likely to ruminate about current stressors, which may interfere with sexual intimacy and pleasure. Therapists and other health professionals can aid women in recognizing when they are ruminating about vulvodynia – particularly, the negative emotions that are attached to vulvodynia. Being mindful of rumination is arguably a necessary precursor to the intentional adoption of a present-focus while engaging in different activities (e.g., enjoyment of emotional and physical intimacy).”

There are several limitations to the current study. In particular, no partner data was collected. Rosen, Bois, Mayrand, Vannier, and Bergeron (2016) found that in a sample of women with genito-pelvic pain, women’s sexual satisfaction was associated with how their partner approached sex. Future research should include partner data to develop a more holistic understanding of sexual satisfaction for women in partnerships. A second limitation concerns measurement. Sexual satisfaction was assessed through two items rather than a validated scale, and some constructs reviewed in our literature (e.g., pain catastrophizing, sexual self-efficacy) were not examined in the present study. Further research utilizing more comprehensive measures are needed. The present study examined communication with a partner about sexual health as a resource for resilience, and sexual satisfaction as a resilience outcome. Childhood abuse, rumination about a past stressor or trauma, and current pain intensity were examined as vulnerability characteristics. We acknowledge that these constructs may not adequately assess the concept of resilience to pain, as originally proposed by Sturgeon and Zautra. Further research is needed to more fully assess Sturgeon and Zautra’s concepts of recovery, sustainability, and growth. Finally, the data was collected between 2010 – 2013; it is unknown if recent developments in treatment of vulvodynia would alter the findings – though this is unexpected. However, several methodological strengths provide confidence in the findings. In particular, the sample was derived using community based recruitment, and the vulvodynia diagnosis was confirmed through a clinical examination. During the clinical examination, pain was assessed through vulvalgesiometer, which assessed women’s responses to a standardized amount of pressure applied to the vulva. While this was a strength of the present study, the pain stimuli may not have been strong enough to elicit differences in perceptions that had relevance to sexual pain and satisfaction.

Conclusion

Our findings add to a growing body of literature that suggests psychological processes can influence outcomes in women with vulvodynia --- namely that emotion-focused rumination may be related to sexual satisfaction in women with vulvodynia. This cross-sectional study cannot determine the direction of this relationship; did increased emotional rumination about vulvodynia decrease women’s sexual satisfaction or did increased sexual satisfaction (due to other unknown factors) decrease women’s emotional rumination about their vulvodynia? Future research should replicate and further explore our initial findings about the relationship between emotion-focused rumination and sexual satisfaction in women with vulvodynia.

Acknowledgments

The writing of this article was partially supported by the National Institute of Child Health and Human Development (NIH-NICHD-058608). We also thank Heidi Fall for meticulous editorial and administrative support and Dr. Jill Dreyfus for statistical consultation.

Contributor Information

Jennifer Jo Connor, Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School.

Miriam Haviland, Department of Epidemiology, Boston University School of Public Health.

Sonya S. Brady, Division of Epidemiology & Community Health, University of Minnesota School of Public Health.

Beatrice “Bean” E. Robinson, Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School.

Bernard L. Harlow, Department of Epidemiology, Boston University School of Public Health.

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