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Engman, L., Flink, I., Ekdahl, J., Boersma, K. & Linton, S. J. (2018). Avoiding or enduring painful sex?: A prospective study of coping and psychosexual function in vulvovaginal pain. European Journal of Pain, 22(8), 1388-1398
Open this publication in new window or tab >>Avoiding or enduring painful sex?: A prospective study of coping and psychosexual function in vulvovaginal pain
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2018 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 22, no 8, p. 1388-1398Article in journal (Refereed) Published
Abstract [en]

Background: Recurring vulvovaginal pain is common, with evident effects on affected women's lives. Little is known about how affected women cope with painful sexual activities and how coping relates to pain intensity and psychosexual functioning over time. This prospective study explored the impact of avoidance and endurance on sexual function over time. Additionally, patterns of coping were studied on an individual level to increase knowledge about coping and its relation to psychosexual functioning.

Methods: One hundred and seventeen women, 18-35years old, with recurring vulvovaginal pain answered questionnaires at two measurement points, five months apart, assessing avoidance and endurance coping, pain intensity and psychosexual functioning. A multiple regression model explored the predictive value of avoidance and endurance on sexual function over time. Cluster analyses investigated patterns of coping and stability within the clusters. These subgroups were compared on psychosexual outcomes.

Results: Avoidance at baseline was the only significant predictor of sexual function five months later. Distinct and stable subgroups with different patterns of coping were identified, where avoidance and endurance coping were used both separately and combined. Women who both avoided and endured had the most unfavourable outcomes in terms of psychosexual functioning.

Conclusions: Avoidance of sexual activities was related to reduced sexual function over time, which calls for attention and clinical interventions targeting avoidance. Additionally, women who both avoid and endure sexual activities despite pain possibly need tailored interventions, as women with this coping pattern reported the lowest levels of psychosexual functioning.

Significance: In this prospective study, avoidance of sexual activities predicted sexual function over time, when controlling for pain intensity. Subgroups of women using distinct patterns of coping were identified. Those who both avoided and endured had the lowest levels of psychosexual functioning.

Place, publisher, year, edition, pages
John Wiley & Sons, 2018
National Category
Psychology Anesthesiology and Intensive Care Neurology
Identifiers
urn:nbn:se:oru:diva-66612 (URN)10.1002/ejp.1227 (DOI)000441435800002 ()29635880 (PubMedID)2-s2.0-85045933115 (Scopus ID)
Available from: 2018-04-17 Created: 2018-04-17 Last updated: 2018-08-27Bibliographically approved
Engman, L., Flink, I., Ter Kuile, M. & Linton, S. J. (2018). CBT group treatment for vulvovaginal pain with partner involvement: a single case experimental design pilot. In: : . Paper presented at IASR (International Academy of Sex Research) 44th annual meeting, Madrid, Spain, 2018.
Open this publication in new window or tab >>CBT group treatment for vulvovaginal pain with partner involvement: a single case experimental design pilot
2018 (English)Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Background: Recurring pain in the vulvovaginal regional induced by touch or pressure is thought to be the most frequent cause of superficial dyspareunia in premenopausal women. Its prevalence is 7-15% in community samples and has a serious impact on couples sexual function, sexual satisfaction, general psychological well-being and overall quality of life.

The last decade of research suggests that psychological factors, such as fear of pain, catastrophizing, and avoidance behavior may contribute to the maintenance and exacerbation of dyspareunia. Conventional cognitive behavioral therapy (CBT) interventions aim at reducing pain, restoring sexual function and improving the romantic relationship by targeting the thoughts, emotions, behaviors and couple interactions associated with the experience of dyspareunia. Furthermore, given the interpersonal sexual context in which dyspareunia is most often triggered, relationship factors is an important area to address.

Research Questions: The primary purpose is to evaluate whether a CBT group program with partner involvement improves pain during penetration in women with superficial dyspareunia. Secondary objectives are to evaluate women’s (and their partner’s) sexuality (sexual function & satisfaction), psychological adjustment (negative and positive penetration beliefs, pain coping behaviour) and relationship factors (relationship satisfaction). 

Methods: The current study consists of a CBT group treatment program of 10 group sessions and 3 individual couple sessions distributed over a period of 6 months. The study will employ a single case experimental design with multiple baselines (N=6) where each individual represents a case and is randomized to a specific length of baseline. The primary and secondary outcomes will be measured weekly through both baseline and treatment phase to enable investigation of changes in outcome between the two phases. Additionally, secondary outcomes for both women and their partners are measured pre- and post-treatment. Single case experimental designs are recommended as a first step to investigate individual responses to psychological interventions as well as testing interventions as a pilot before implementing treatments in extensive RCT studies (Morley, 2017).

Results: Data collection is in progress and will be completed early June 2018. The results of the study will be presented at the conference.

Keywords
Vulvovaginal pain, CBT group treatment, Partner participation, Single case experimental design
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-70480 (URN)
Conference
IASR (International Academy of Sex Research) 44th annual meeting, Madrid, Spain, 2018
Available from: 2018-12-04 Created: 2018-12-04 Last updated: 2018-12-04Bibliographically approved
Ekdahl, J., Flink, I., Engman, L. & Linton, S. J. (2018). Vulvovaginal pain from a fear-avoidance perspective: a prospective study among female university students in Sweden. International Journal of Sexual Health, 30(1), 49-59
Open this publication in new window or tab >>Vulvovaginal pain from a fear-avoidance perspective: a prospective study among female university students in Sweden
2018 (English)In: International Journal of Sexual Health, ISSN 1931-7611, E-ISSN 1931-762X, Vol. 30, no 1, p. 49-59Article in journal (Refereed) Published
Abstract [en]

Objectives: To examine how fear-avoidance influences vulvovaginal pain and sexual function over time.

Method: At baseline and at 10-month follow-up, self-report measures for sexual- and fear avoidance factors were obtained from 483 female university students with and without self-reported vulvovaginal pain.

Results: Individuals with pain at both times reported lower sexual function, and higher levels of fear-avoidance compared to the pain-free group. Fear-avoidance beliefs predicted the occurrence of vulvovaginal pain at follow up and the level of pain intensity.

Conclusion: The results points to the relevance of the components of the fear-avoidance model in vulvovaginal pain over time.

Place, publisher, year, edition, pages
Routledge, 2018
Keywords
Catastrophizing, fear-avoidance, sexual function, sexual satisfaction, vulvovaginal pain
National Category
Psychology (excluding Applied Psychology)
Identifiers
urn:nbn:se:oru:diva-63396 (URN)10.1080/19317611.2017.1404543 (DOI)000432548400006 ()2-s2.0-85041172070 (Scopus ID)
Available from: 2017-12-18 Created: 2017-12-18 Last updated: 2018-06-05Bibliographically approved
Engman, L., Flink, I., Thomtén, J. & Linton, S. J. (2017). Avoiding or enduring painful sex?: A longitudinal study of coping patterns and sexual function in women with vulvovaginal pain. In: SSTAR (Society for Sex Therapy and Research) 42nd annual meeting: . Paper presented at SSTAR (Society for Sex Therapy and Research) 42nd annual meeting, Montréal Canada, April 20-23, 2017.
Open this publication in new window or tab >>Avoiding or enduring painful sex?: A longitudinal study of coping patterns and sexual function in women with vulvovaginal pain
2017 (English)In: SSTAR (Society for Sex Therapy and Research) 42nd annual meeting, 2017Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Introduction: Recurring pain in the vulvar- or vaginal region induced by touch or pressure is common, affecting between 10-28% of women in reproductive age (e.g., Harlow et al., 2014). In addition to evident negative effects on sexual aspects such as frequency of sexual activity, sexual satisfaction and sexual function (for a review see Bergeron et al., 2015), vulvovaginal pain has an impact on women’s overall quality of life (Arnold et al., 2006). Despite these extensive consequences little is known about how women with vulvovaginal pain actually cope with sexual activities and the subsequent pain, and how their coping may affect the pain experience and sexual function over time. While avoidance (of pain associated activities) seem to be a commonly used strategy (for a review see Thomtén and Linton, 2013) amongst women with vulvovaginal pain, there is also evidence of endurance (of sexual activity despite pain) as a prevalent strategy (Brauer et al., 2014; Elmerstig et al., 2013).

 

Method: The study used questionnaire data from female university students between 18 and 35 years old, with two measurement points of five months apart. Women who reported experiencing recurring vulvovaginal pain during the last six months, and who responded at both measurement points constitute the sample of the study (N=117). First, multiple regression analysis was executed to test whether avoidance and endurance coping had a predictive value of sexual function beyond the pain experience in itself. Then, cluster analyses based on the respondent’s answers to the CHAMP Sexual Pain Coping Scale (CSPCS) were performed at both time points. Finally, common pathways over time was investigated to explore whether the same coping was used at baseline and follow-up.

 

Results: The multiple regression model exploring if pain, avoidance and endurance at baseline predicted sexual function at follow-up was significant, explaining 25% of the variance (F(2, 90) = 10.22, p < .001). Avoidance at baseline was the only significant predictor in the model, explaining unique variance of sexual function over time. The cluster analyses at baseline and follow up resulted in four distinct clusters respectively; Low scores, Avoidance, Endurance and High scores. The common pathways analyses, exploring typical pathways of change, revealed high stability within the clusters over time meaning that it was common for individuals in all clusters to use the same patterns of coping at both measurement points.

 

Discussion: The results of the study further manifests findings from earlier research while also making an important attribution in quantifying coping strategies in relation to vulvovaginal pain. The study reveals a strong association between vulvovaginal pain and how women cope with sexual activities, the stability of the use of coping over time, as well as the connection between coping and sexual function.

 

Utility/Limitations/Risks: Further knowledge about the relationship between coping and vulvovaginal pain will provide important theoretical and clinical implications regarding the development of the pain as well as potential clinical interventions.

 

Behavioral learning objectives:

After attending this poster presentation, the participants will be able to:

1. Recognize the importance of avoidance coping in relation to sexual function

2. Discuss the use of avoidance and endurance coping as a combined pattern

3. Identify the stability of the use of coping patterns over time

 

References:

Arnold, L. D., Bachmann, G. A., Kelly, S., Rosen, R., & Rhoads, G. G. (2006). Vulvodynia: characteristics and associations with co-morbidities and quality of life. Obstetrics and gynecology, 107(3), 617.

 

Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female sexual pain disorders: a review of the literature on etiology and treatment. Current Sexual Health Reports, 7(3), 159-169.

 

Brauer, M., Lakeman, M., Lunsen, R., & Laan, E. (2014). Predictors of task‐persistent and fear‐avoiding behaviors in women with sexual pain disorders. The journal of sexual medicine, 11(12), 3051-3063.

 

Elmerstig, E., Wijma, B., & Swahnberg, K. (2013). Prioritizing the partner’s enjoyment: a population-based study on young Swedish women with experience of pain during vaginal intercourse. Journal of Psychosomatic Obstetrics & Gynecology, 34(2), 82-89.

 

Harlow, B. L., Kunitz, C. G., Nguyen, R. H., Rydell, S. A., Turner, R. M., & MacLehose, R. F. (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions. American journal of obstetrics and gynecology, 210(1), 40-e1.

 

Thomtén, J., & Linton, S. J. (2013). A psychological view of sexual pain among women: applying the fear-avoidance model. Women’s Health, 9(3), 251-263.

 

National Category
Psychology
Identifiers
urn:nbn:se:oru:diva-62946 (URN)
Conference
SSTAR (Society for Sex Therapy and Research) 42nd annual meeting, Montréal Canada, April 20-23, 2017
Available from: 2017-12-05 Created: 2017-12-05 Last updated: 2018-08-13Bibliographically approved
Flink, I. K., Engman, L., Ter Kuile, M. M., Thomtén, J. & Linton, S. J. (2017). Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain. Scandinavian Journal of Pain, 17(October 2017), 302-308
Open this publication in new window or tab >>Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
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2017 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, no October 2017, p. 302-308Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIMS: Chronic vulvovaginal pain is strikingly common and has a serious impact on women's lives. Nevertheless, there are few longitudinal studies focusing on mechanisms involved in the pain development. One area of interest is how women cope with sexual activities and how this affects their pain. In this study, avoidance and endurance coping behaviors were explored as possible mediators of the relation between catastrophizing and pain, cross-sectionally and longitudinally.

METHODS: 251 women (18-35 years old) with vulvovaginal pain were recruited in university settings and filled out questionnaires about their pain, catastrophizing and coping behaviors at two occasions, with five months in between. Multiple mediation models were tested, exploring avoidance and endurance as mediators of the relation between catastrophizing and pain.

RESULTS: The results showed that avoidance was an influential mediator of the link between catastrophizing and pain. Using multiple mediation models we found that although the indirect effects of both avoidance and endurance were significant cross-sectionally, only avoidance was a significant mediator in the combined model exploring associations over time.

CONCLUSIONS: This study indicates that the strategies women with vulvovaginal pain use for coping with sexual activities are important for the course of pain. Avoidance and, to a lesser degree, endurance strategies were identified as important mediators of the effects of catastrophizing on pain. When exploring the links over time, only avoidance emerged as a significant mediator.

IMPLICATIONS: In this longitudinal study, catastrophizing was linked to vulvovaginal pain, via avoidance and endurance of sexual activities. Hence, targeting catastrophizing early on in treatment, as well as addressing coping, may be important in clinical interventions.

Place, publisher, year, edition, pages
Walter de Gruyter, 2017
Keywords
Vulvovaginal pain; Sexual pain; Women; Coping; Avoidance-endurance
National Category
Applied Psychology Neurology
Identifiers
urn:nbn:se:oru:diva-62464 (URN)10.1016/j.sjpain.2017.08.007 (DOI)000419851500053 ()28927649 (PubMedID)2-s2.0-85029537927 (Scopus ID)
Available from: 2017-12-04 Created: 2017-12-04 Last updated: 2018-09-17Bibliographically approved
Engman, L., Flink, I., Thomtén, J. & Linton, S. J. (2016). A longitudinal study of coping strategies in women with vulvovaginal pain. In: EABCT 2016: . Paper presented at EABCT 2016, Stockholm Sweden, August 31 - September 3, 2016. The European Association for Behaviour and Cognitive Therapies
Open this publication in new window or tab >>A longitudinal study of coping strategies in women with vulvovaginal pain
2016 (English)In: EABCT 2016, The European Association for Behaviour and Cognitive Therapies , 2016Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Introduction: Recurring vulvovaginal pain is common, affecting between 8-30 % of women in reproductive age.  In addition to evident negative effects regarding sexual function and -satisfaction, vulvovaginal pain also has an impact on sufferers overall quality of life. Despite these extensive consequences little is known about how women with vulvovaginal pain actually cope with pain-triggering sexual activities. Knowledge about coping strategies in this area would give important clinical implications in both creating and targeting effective treatment interventions.

Aims: The study aims to explore if the use of coping strategies in relation to pain-triggering sexual activities are stable over time, or if different strategies are used dependent of pain level or situation. A further aim is to explore the relationship between coping and a spectrum of psychosexual aspects over time.

Method. The study consists of a student sample of women between 18-35 years old with recurring vulvovaginal pain who responded to a questionnaire at three separate time points (Base line: N=289; 6 months: N=153; 12 months: N= 126). Based on the CHAMP Sexual Pain Coping Scale (CSPCS), which measures avoidance- and endurance coping, cluster analysis was performed to group participants into distinct subgroups of individuals who reported similar coping strategies. The same procedure was performed at each assessment point to explore whether the individuals moved between the subgroups. Lastly the subgroups were compared in regards to several psychosexual factors.

Discussion. The results will be discussed at the presentation when analyses are completed.

Place, publisher, year, edition, pages
The European Association for Behaviour and Cognitive Therapies, 2016
National Category
Psychology
Identifiers
urn:nbn:se:oru:diva-54721 (URN)
Conference
EABCT 2016, Stockholm Sweden, August 31 - September 3, 2016
Available from: 2017-01-16 Created: 2017-01-16 Last updated: 2018-07-23Bibliographically approved
Engman, L. (2016). Copingstrategier vid vulvovaginal smärta. In: : . Paper presented at Svenskt Smärtforum 2016, Jönköping, Sweden, October 20-21, 2016.
Open this publication in new window or tab >>Copingstrategier vid vulvovaginal smärta
2016 (Swedish)Conference paper, Oral presentation with published abstract (Refereed)
Abstract [sv]

Det pågående forskningsprojektet Sex och Smärta (SOS) vid Örebro universitet syftar till att undersöka psykologiska faktorer och mekanismer kring vulvovaginal smärta. Mer specifikt undersöker vi utvecklingen från akut till kronisk smärta och vidmakthållandet av smärtan, det vill säga faktorer som kan påverka om smärtan kvarstår eller ej. I förlängningen kan denna typ av kunskap öka förståelsen av problematiken, men även leda till viktiga kliniska implikationer och därmed främja utvecklingen av psykologisk behandling i den aktuella patientgruppen.

Föreläsningen ”Copingstrategier vid vulvovaginal smärta” fokuserar på hanterandet av den sexuella situationen hos kvinnor som lider av vulvovaginal smärta. Detta då copingstrategier så som undvikande och uthärdande av smärtsamma aktiviteter visats vara viktiga vid både utvecklandet och vidmakthållandet av annan typ av kronisk smärta. Copingstrategierna undersöks i relation till viktiga psykologiska mekanismer gällande smärta, men även i relation till kvinnornas generella mående både tvärsnittligt och över tid. Avslutningsvis diskuteras generella slutsatser samt möjliga kliniska implikationer av de aktuella fynden.

National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-54722 (URN)
Conference
Svenskt Smärtforum 2016, Jönköping, Sweden, October 20-21, 2016
Available from: 2017-01-16 Created: 2017-01-16 Last updated: 2017-10-18Bibliographically approved
Engman, L., Flink, I., Linton, S. J. & Thomtén, J. (2016). When sex hurts: Avoid, endure or try something different?. In: IASR 42nd annual meeting: . Paper presented at IASR 42nd annual meeting, Malmö, Sweden, June 26-29, 2016.
Open this publication in new window or tab >>When sex hurts: Avoid, endure or try something different?
2016 (English)In: IASR 42nd annual meeting, 2016Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Rationale/Background: Recurring vulvovaginal pain is a common problem among women, affecting between 8-30 % of women in reproductive age.  In addition to evident negative effects regarding sexual activities, -function and -satisfaction, vulvovaginal pain also has an impact on the individual’s daily life as well as overall quality of life. Despite these extensive consequences little is known about how women with vulvovaginal pain actually cope with sexual activities and the subsequent pain.

Research Questions: The study aims to explore how women with vulvovaginal pain cope with sexual activities that has an impact on their pain, and whether certain ways to cope are more or less adaptive in regards to a spectrum of psychosexual aspects.

Methods: The study is based on a student sample of women between 18 and 35 years old with recurring vulvovaginal pain (N=289). The CHAMP Sexual Pain Coping Scale (CSPCS) was created to measure coping behaviors among women with vulvovaginal pain. The scale was based on previous qualitative research where three apparent patterns of coping strategies has emerged; avoidance-, endurance- and alternative coping. Based on how the women responded to the avoidance- and endurance subscales of the CSPCS, cluster analysis resulted in four distinct groups of women with different profiles of coping. The coping subgroups were then compared in regards to several psychosexual factors.

Results: The results showed that women suffering from vulvovaginal pain cope with sexual activities and the subsequent pain in different ways. Women who showed a pattern of high avoidance and endurance coping strategies reported significantly higher levels of pain, lower sexual function, less sexual satisfaction and lower quality of life. In contrast, women who reported low levels of avoidance and endurance coping strategies showed significantly lower levels of pain, higher sexual function, as well as a higher satisfaction with their sex life and life in general.

Conclusions: The results of the study further manifests findings from earlier research while also making an important attribution in quantifying coping strategies in relation to vulvovaginal pain. Causal conclusions can not be drawn since the study is based on cross-sectional data. Hence, there is no knowledge to whether the coping strategy is a result of the individual’s current pain level or if the coping has an effect on the pain and associated psychosexual aspects. However, the study clearly reveals a strong association between vulvovaginal pain and how women cope with sexual activities. Future knowledge about this relationship will provide important theoretical and clinical implications regarding the development of the pain as well as potential clinical interventions.

Keywords
Vulvovaginal pain, Coping, Psychosexual factors, Quality of life
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-54718 (URN)
Conference
IASR 42nd annual meeting, Malmö, Sweden, June 26-29, 2016
Available from: 2017-01-16 Created: 2017-01-16 Last updated: 2018-07-23Bibliographically approved
Flink, I., Thomtén, J., Engman, L., Hedström, S. & Linton, S. J. (2015). Coping with painful sex: Development and initial validation of the CHAMP Sexual Pain Coping Scale. Scandinavian Journal of Pain, 9, 74-80
Open this publication in new window or tab >>Coping with painful sex: Development and initial validation of the CHAMP Sexual Pain Coping Scale
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2015 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 9, p. 74-80Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Recurrent vulvar pain is a common and debilitating condition which has received remarkably little attention in pain research. For instance, little is known about how these women cope with sexual activities, and there are no structured assessment tools. The purpose of this study was to explore coping strategies in this group, with a view to develop a measure to assess how women with vulvar pain cope with sexual activities.

Methods: The current study is based on a subsample from a longitudinal study about vulvar pain in a student sample consisting of women between 18 and 35 years old (N = 964). Only data from the ones reporting recurrent vulvar pain during the last six months (N = 289) were used in the analyses. First, the CHAMP Sexual Pain Coping Scale (CSPCS) was created, with the aim of assessing how women with vulvar pain cope with sexual activities. The scale was inspired by previous research on women with vulvar pain as well as well-known coping strategies in other pain populations. Second, the psychometric properties of the scale were explored by analyzing the factor structure and internal reliability. Third, validity features were examined in terms of criterion validity and construct validity.

Results: The analyses supported a three-factor solution, embracing the strategies endurance, avoidance and alternative coping. The internal reliability of the subscales turned out to be good, and the criterion validity was supported for all three subscales. The construct validity was clearly supported for the endurance and the avoidance subscales, but not for the alternative coping subscale.

Conclusions: The findings support the CSPCS as an instrument for assessing how women with vulvar pain cope with sexual activities. The strategies endurance, avoidance and alternative coping correspond with findings from earlier research. Endurance reflects a tendency to engage in and continue with sexual activities despite pain, while attempting to minimize or suppress thoughts of pain. Avoidance, on the other hand, involves efforts to stay away from sexual activities, in particular vaginal penetration, because of fear of pain. Alternative coping refers to endeavours to find alternative sexual activities that do not necessarily involve vaginal penetration. Even though this first study indicates that the CSPCS may be psychometrically sound, more studies are needed to confirm the psychometric properties and clinical application of this instrument. In particular, the construct validity of the alternative coping subscale needs to be further evaluated.

Implications: A valid instrument for assessing strategies for coping with sexual activities in this population has important clinical implications, since it provides a method that may enhance assessment procedures, be used in research, and stimulate the development of treatment.

Place, publisher, year, edition, pages
Elsevier, 2015
Keywords
vulvar pain, sexual pain, women, coping, assessment
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-46996 (URN)10.1016/j.sjpain.2015.05.002 (DOI)000217938500017 ()2-s2.0-84952872848 (Scopus ID)
Projects
Sex och Smärta (SOS)
Available from: 2015-12-08 Created: 2015-12-08 Last updated: 2019-03-26Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-8350-1836

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