Psychosexual ImpactThe Essentials

Psychological, Emotional, and Sexual Well-Being

It is important to acknowledge and explore the impact of vulvodynia on a patient’s psychological, emotional, and sexual well-being. Asking open-ended, non-judgmental questions in these areas can improve a patient's understanding of the relationships between psychological well being, sexuality, and pain. Exploring these areas with patients can be very reassuring, making it clear that all aspects of their health will be a priority as a treatment plan is developed.

Action Steps

1.  Assessing the Psychological and Sexual Impact
2. How to Respond to Patient Experiencing Distress

1. Assessing the Psychological and Sexual Impact

Get permission: ask the patient if it is ok to ask questions about their sexual health.

Example: “Many patients find that vulvodynia impacts their sexual life and well-being. Is it ok if I ask you some questions about that?”
Normalize the discussion of this topic.

Example: “It can feel uncomfortable or awkward to discuss some of these things, but it is an important area of your health. Let me know, as we are talking, if there are questions you want to skip or if you need clarification.”
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‍Educate the patient as you take their history.

Example: “Many patients find that their sexual activities with their partner have been impacted by the pain. Some patients adjust their sexual repertoire and engage in fewer insertion-based sexual activities, while others find changing their sexual routine challenging. What impact has the pain had on your sexual activities?"

2.  How to Respond to Patient Experiencing Distress

Click the dropdown menus for questions to ask about important aspects of the patient's psychosexual functioning:
Sexual Self-Image


Q1: “Vulvodynia can affect the way people feel about their sexual expression and confidence, is that something you have experienced?”

Sexual Response Cycle


Q1. “Often when people have vulvar pain, it affects their sexual response due to changes in the way the brain and body process sexual information. Is it ok if I ask you some questions about how vulvar pain has affected your sexual experience?”

Q2. “It is common for people with vulvar pain to experience changes in the way their body responds to intimacy. Is this something you have experienced?”

More than likely, the patient’s sexual response cycle (desire, arousal, and orgasm) has been affected. Let them know that this is common and expected when someone is experiencing sexual pain and will be addressed in more detail in their subsequent care.

Q3: “What percent of your sexual encounters result in sexual pain?"

Follow Up Question: "Some people find that there is an emphasis on insertion-based sexual activities during sexual activity and some people feel pressured to engage in these activities. Do you feel pressured to have certain types of sex that cause pain?" 

Q4: “Sexual encounters can include many different activities and techniques. Considering your pain as it is today, what activities and techniques would your ideal sexual encounters include (if any at all)?"
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Follow Up Question: "Many people find the following activities to be positive and pleasurable in their sexual lives. Would any of the following be true for you?"

Prompts might include:
- sexting, sharing sexy photos or selfies, video or phone sex
- conversation, flirting, cuddling, massage, solo sex (i.e., masturbation), mutual masturbation (i.e., side by side masturbation with partner(s)
- oral sex, anal sex, manual stimulation with fingers or toys that does not involve penetration (i.e., external genital stimulation only)
- insertional vaginal sex (i.e., penetration with a penis, fingers, toys)
-other activities

Q5: “Do you worry you have lost (or never had) a desire for sexual intimacy?"

Follow Up Question: If the answer is ‘yes’, "does sexual pain play in your sexual desire?"

Q6: “Do you find you desire sexual intimacy, but do not pursue it because of sexual pain?"

Q7: “Do you think you are somehow “less than” or "unworthy" because of your sexual pain?"

Relationships & Dating


Q1. “Vulvodynia can affect partnered sexual relationships. Is it ok if I ask you some questions about your experience with this?”

For patients who are in a partnered sexual relationship:

Q1. “People in relationships often notice that vulvodynia can impact their relationship in many ways including avoidance, conflict, physical touch in general, family planning, etc. In what ways has your relationship(s) been impacted by vulvodynia?”

Q2. “Many people notice barriers to physical and emotional intimacy caused by vulvodynia such as lack of communication, confusion, and avoidance. Are there factors that get in the way of physical and emotional intimacy for you?”

For patients who are not in a partnered sexual relationship:

Q1. If the patient has had previous relationships: “People often notice that vulvodynia can impact their relationship in many ways including avoidance, conflict, physical touch in general, family planning, etc. How has the pain impacted previous relationships?”

Q2. “Many people with vulvodynia notice that it impacts the desire desire to date or pursue sexual relationships. Is this something you have noticed?"

Follow Up Question: "Many people with vulvodynia experience anxiety, avoidance, confusion, and uncertainty. Many people do not know how to bring up vulvodynia with potential partners which can get in the way of pursuing relationships in the first place. Do any of these factors get in the way of pursuing romantic or sexual relationships for you?” 

‍Q3: "It is common for people with vulvodynia to have difficulties experiencing pleasure during masturbation or solo sex activities. Do you notice any difficulties experiencing pleasure or orgasm on your own?"


To explore other important aspects of life impacted by Vulvodynia:

Q1: "Many people with vulvodynia experience difficulties outside of sex and relationships, what aspects of your life are impacted by your pain?"

Prompts might include:

-  Ability to ride a bike, sit for long periods of time
- Using tampons or menstrual cups
-  Wearing certain clothing
-  Concerns regarding carrying a pregnancy or giving birth vaginally
-  Pain distracting from work or other important activities
-  Participation in certain forms of exercise
-  Avoidance of important physical examinations required for routine or specialized health care (e.g., PAP smears, colposcopy)
- Frustration around the invisible nature of the condition – difficulty telling friends, family, and coworkers about chronic pain and the associated burden due to the intimate nature  of vulvodynia

3. Provide Key Information

Even if you have limited time, providing the following key pieces of information can be extremely helpful to patients:
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4. Watch for Red Flags

🚩Assess level of distress in the relationship - if there is significant conflict/discord in the relationship, these issues are best addressed with therapy first before undergoing treatment for vulvodynia. Typically, these individuals are too distressed to experience maximal benefit from treatment.

Examples of relationship conflict: partner dismissing pain claims, frequent arguments about the sexual relationship, and poor conflict resolution.    

🚩Erotophobia (fear of sex or sexual intimacy). It is recommended to address erotophobia through psychotherapy first before pursuing treatment for vulvodynia.

5. Sexual Response

Have your patient watch this video to help them understand how their sexual response can be impacted by vulvodynia.

6. Handouts and More Readings

More handouts, videos and recommended readings for patients can be found in the 🔗Resources section.
📄 Handout: How partners can support individuals with vulvodynia ⬇

End of Psychosexual Impact. Visit the 🔗 Going Beyond section
or proceed to Treatment below.

Proceed to Treatment

Going beyond

This section is for physicians who want to explore sexual response cycle and associated exercises with their patients

Given that vulvar pain can have an impact on sexual response, it can be helpful to understand sexual response in more detail and to understand how pain can affect many aspects of sexuality.

You can explore the impact of vulvodynia on sexual response with your patient in several ways

  • Discuss the sexual response cycle with the patient
  • Provide your patient with the link to the whiteboard animation video explaining the sexual response cycle
  • Give your patient the handout explaining the sexual response cycle (you can also provide the blank sexual response cycle handout for them to fill out and review at a follow-up visit with you)

The Sexual Response Cycle

In the 1960s, sex researchers Masters and Johnson published their book “Human Sexual Response”, which outlined sexual responsiveness in three distinct phases:

PHASE 1

SEXUAL DESIRE

the motivation or feeling of wanting to engage in sexual activity.

PHASE 2

SEXUAL Arousal

physiological changes (e.g., increased heart rate, breathing rate, erections, and vaginal lubrication) along with the subjective feeling of being “turned on” or excited sexually.

PHASE 3

Orgasm

a series of muscular contractions that many people experience as pleasurable.

However, research since has suggested that many people do not move through all the phases sequentially, there may be additional phases, and that not all sexual events begin with sexual desire.

Most significantly, Dr. Rosemary Basson at the University of British Columbia  suggested that sexual desire is not necessary to begin a sexual encounter and that someone may begin at a place of sexual neutrality and experience desire in response to various cues (e.g., touch, conversation) 🔗 Basson, 2000.

You can give the following handout to your patient as a guide while watching the video. They can then fill out the blank handout to help them see how their sexual response is currently affected by vulvodynia.

📄 Sexual Response Cycle Diagram & Blank Handout⬇


Have your patient watch the linked video to help them understand how their sexual response can be impacted by vulvodynia 🎥


Below are the components of the Basson Sexual Response Cycle as explained in the video:

Reasons For Sex


It may be difficult for an individual with pain (sexual and non sexual) to consider positive reasons for sexual activity. See handout below for more information.
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📄 Reasons for Sex⬇
Sexual Stimuli


People with sexual pain often forego activities that would trigger their sexual arousal (e,g,. touch to other parts of their body, kissing) in favour of “just getting intercourse over with” – this is especially common when one or both individuals in a sexual encounter favour penetrative vaginal sex

The Brain


The brain processes sexual information and it can be hampered by biological factors (e.g., medications, fatigue) or psychological factors (mood, anxiety, distractions, fear, low body image, etc.). There can be also be shame and guilt associated with vulvodynia. For example, penile vaginal sex is often considered the ‘normal’ way to have sex, resulting in those who have pain with vaginal sex feeling ‘abnormal’ and sexually ‘substandard’ further contributing to anxiety and stress. Every unsatisfying or painful encounter serves to reinforce individual’s negative associations with sexual activity and internalize beliefs about being “sexually substandard”.

Sexual Arousal


If a person becomes sexually aroused, and is able to maintain their arousal (while avoiding pain), their desire for ongoing sexual activity in the future will emerge.

Responsive Desire


Desire can emerge if the other factors in the model occur. It is not the necessary that desire be the start point of sexual activity or arousal –  which is especially important with those who have sexual pain or other complex relationships to sexuality, that diminish or inhibit desire. The intentional choice to enter into sexual activity whereby arousal, pleasure, and enjoyment become a byproduct, is often a reparative experience and can help challenge the idea of the self as damaged or sub standard sexually.

Positive Outcomes


Benefits of sexual activity include emotional closeness, sexual satisfaction that may or may not include orgasms, freedom from pain, and challenging negative thoughts about ones’ self or relationship. All of these reinforce the motivation for sexual activity in the future. Thus, if an individual with pain prioritizes a sexual encounter with pain free sexual activities that elicit arousal for them personally, and not pain, they are more likely to move past the barriers to sexual pleasure and sexual relationships for those with sexual pain.


Important Considerations

It is important to remember that not everyone wishes to engage in sexual activity. Relationships and sexual partners with goals at odds with those of the person with sexual pain should be examined and aligned to prioritize pain free interactions:

★ People with sexual pain should not feel pressured to engage in sexual activity;
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★ Sexual activity of all kinds should be explored if it is a stated goal;
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★ Everyone is different - vaginal penetration might be very important to some patients, and less important to others; and
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★ Partnered sex may be important to some, where solo sex may be better for others

The Dual Control Model of Sexual Response

Another useful model of sexual response to understand is the Dual Control Model of Sexual Response. This model was developed in the 1990s by Dr. John Bancroft and Dr. Erick Janssen 🔗 Bancroft and Janssen, 2006.

This model is based on the idea that sexual response is the product of a balance between excitatory and inhibitory processes.

These excitatory and inhibitory processes are thought to work somewhat independently of one another, much like a brake pedal and a gas pedal. People have high levels of sexual inhibition and low levels of sexual excitation, or vice versa, or another combination.  

Everyone’s accelerator is uniquely sensitive. Some common factors that can increase excitation include:

  • Love/bonding
  • Erotic cues
  • Visual sexual cues
  • Romantic behaviours

Sexual inhibition can play an important protective role in reducing sexual response incases of danger or potential danger. Some common factors that increase inhibition are:  

  • Body image concerns
  • Unwanted pregnancy
  • Inappropriate timing of a sexual encounter
  • Past negative sexual encounters
  • Feeling tired or  stressed
  • Having low mood, or experiencing anxiety

‍Pain is another factor that can have a powerful inhibitory effect on sexual response.

Helping patients to understand their own “accelerator” and “brakes” can be helpful for helping them to understand their own sexual response as well as the role of pain in their sexual life.

★ Option to assign journaling exercise: some patients find it helpful to journal about their own accelerators and brakes to gain more insight into their sexual response

Action
steps
1. assess
impact
2. respond to
patient
3. provide key
information
4. watch for
red flags
5. Sexual response
video
6. handouts and
readings