To Örebro University

Vulvodynia is a multifactorial persistent pain condition, characterized by pain in the vulva upon touch or pressure. It negatively impacts sexual function, satisfaction, and relational wellbeing. Relational factors have been indicated as integral to the understanding and outcomes of vulvodynia. The overall aim of this dissertation was to further the understanding of women’s pain-related behaviors in relation to the dyadic and normative contexts of vulvodynia.

Using a person-oriented approach, study I explored links between coping behaviors, i.e., avoidance and endurance on the one hand, and on the other, relational and pain catastrophizing, perceived partner responses, and motivational goals, in a sample of 128 women with vulvodynia. Study II explored the significance of normative context for the experience of vulvodynia by qualitatively investigating subjective experiences of five women living with dyspareunia in a queer relationship. Using behavioral observation and self-report, study III investigated patterns of sexual communication quality in heterosexual vulvodynia couples (n = 25) as compared to couples without pain (n = 37), and assessed potential associations with pain, self-disclosure, and sexual assertiveness.

The findings from the three studies together highlight the significance of the normative context and relational factors such as the emotional quality of sexual communication and women’s relational cognitions, for women’s pain-related experiences and coping behaviors. A new theoretical model, the Interpersonal Pain Coping Model of Vulvodynia, is proposed as a way of integrating contextual factors such as partner behaviors and sexual scripts into the understanding of women’s behavioral response to vulvodynia.

BACKGROUND: Sexual communication is a common target in psychological treatments for vulvodynia, and associations with sexual function and distress, as well as pain intensity, have been demonstrated. However, structured observations of the communication patterns of couples with vulvodynia are lacking, as these are needed to guide treatment efforts.

AIM: To explore (1) the sexual communication patterns in couples with vulvodynia in terms of observed communication quality (operationalized as validating and invalidating responses), self-reported sexual assertiveness, and self-disclosure and (2) associations between sexual communication quality and pain intensity.

METHODS: In a case-control design with within- and between-group comparisons, 62 couples engaged in videotaped discussions about their sexual relationship. Trained coders assessed the discussions by rating sexual communication (validation and invalidation) according to a structured behavioral coding scheme. Group differences in sexual communication quality were examined with parametric and nonparametric tests. Dyadic associations among observed communication quality, self-rated sexual assertiveness, and self-disclosure were examined within the actor-partner interdependence model. Multiple regression was used to test the predictive value of partners' validation/invalidation on the pain intensity of the women with vulvodynia.

OUTCOMES: Observed communication quality (ie, validation and invalidation), self-reported sexual assertiveness, self-disclosure, and pain intensity.

RESULTS: Partners of women with vulvodynia were more invalidating toward their partners than those of women without pain. There were no significant differences in validating/invalidating communication between women in the 2 groups or in validation between partners. Partners' validating communication were significantly associated with women's lower pain intensity. The sexual communication patterns differed between couples with and without vulvodynia, and the associations between validating/invalidating responses and sexual assertiveness were stronger in the vulvodynia group than in the group without pain. Results on validation/invalidation and self-disclosure were inconclusive.

CLINICAL IMPLICATIONS: The results indicate a need to direct treatment interventions toward couples' sexual communication quality (ie, levels of validation and invalidation).

STRENGTHS AND LIMITATIONS: Strengths include systematic behavioral coding and dyadic analyses. Limitations include the cross-sectional design and self-selection of participants.

CONCLUSION: This study demonstrated sexual communication patterns specific to couples with vulvodynia, and we conclude that validation and invalidation are important components of the sexual communication of couples with vulvodynia as they relate to sexual assertiveness, women's self-disclosure, and pain intensity.

BACKGROUND: Provoked vestibulodynia (PVD) is a common pain condition, negatively impacting the relationships and sexual lives of sufferers. Women's coping behaviour has been associated with psychosexual outcomes, yet coping patterns in clinical PVD samples are unexplored, and it is not known how women's coping relates to their relational context.

METHOD: Women (N = 128) with PVD answered questionnaires about psychosexual function, pain coping (avoidance and endurance), relational- and pain catastrophizing, sexual goals and perceived partner responses. Cluster analysis was used to explore coping patterns; clusters were validated on measures of pain and psychosexual function and compared on catastrophizing, sexual goals and partner responses using multivariate analyses of variance.

RESULTS: The analysis yielded four clusters: endurance; combined high avoidance and endurance; avoidance; and combined low. The group with high levels of both avoidance and endurance coping displayed the worst psychosexual outcomes and high levels of pain- and relational catastrophizing, approach and avoidance goals and perceived negative partner responses.

CONCLUSION: There are distinct patterns of coping among women with PVD, and these coping patterns are associated with psychosexual outcomes and relational cognitions and goals, and perceived partner responses. Women who alternate between avoidance and endurance are more distressed and report worse psychosexual functioning. This pattern needs to be identified and addressed in the treatment of PVD.

SIGNIFICANCE STATEMENT: This study extends previous findings on vulvar pain coping patterns to a clinical population of women with PVD. It is further the first study to address the relationship between relational variables, such as partner responses and relational catastrophizing and different coping patterns. Thus, the contribution of this study is the contextualizing of coping patterns among women with PVD. The results showed that a combined pattern of avoidance and endurance coping is associated with high distress, poor psychosexual outcomes, and indications of insufficient relational coping, highlighting the need for clinical assessment and intervention to target both women's individual coping patterns and their relational context.

This study explores the subjective experiences of dyspareunia among queer women in Sweden. Ten semi-structured, in-depth interviews were conducted with five participants who were all interviewed on two separate occasions. Interviews were analysed using thematic analysis. Dyspareunia was described as affecting the participants' sexual activities, intimate relationships, and identity constructs. Reported struggles involved feelings of sadness, guilt, frustration, and fear of pain. Dyspareunia was described as threatening the participants' queer identities through its effect on their ability to be sexual in idealised ways. However, queer experiences and communities were also found to be associated with advantages in pain management, such as well-developed sexual communication skills, anatomic similarity to their partner, access to non-heteronormative sexual scripts and a focus on nurturing desire. Queer related advantages in pain management are proposed to buffer to some extent against pain interference with sexual function and desire. Findings indicate that it is important to consider the unique relational and social context of queer women to understand their experiences of dyspareunia. More research is needed on the role of differences of normativities, context and communication in dyspareunia.

Vulvodynia is common and has an immense impact on affected women and their partners. Psychological factors have been found to contribute to pain maintenance and exacerbation, and treatments addressing psychological factors have yielded positive results. This study employed a replicated single-case experimental design to examine a cognitive behavioral therapy (CBT) group treatment with partner involvement in vulvodynia. Repeated measures of pain intensity related to pain-inflicting behaviors were collected weekly throughout baseline and treatment phases. Associated outcomes were measured pre-, post- and at two follow-up assessments. Participants were 18-45-year-old women, in a stable sexual relationship with a man, experiencing vulvodynia. Five women completed the treatment consisting of 10 group sessions and 3 couple sessions. Data were analyzed through visual inspection and supplementary nonparametric calculations. The study showed promising results of the CBT treatment in alleviating pain intensity in connection to specific pain-inflicting behavior since three out of five participants showed improvements. For the participants who improved, sexual function, pain catastrophizing, avoidance, and endurance behavior changed during treatment and were maintained at follow-ups. These results warrant further study of the CBT treatment, in larger, and controlled formats.