A Controversial Question: Is the Pain Sexual or is the Sex Painful?
In this account, the pain was seen as mediated by physiological mechanisms, namely muscular reactivity of unknown etiology. There is no insinuation that the pain had a psychological origin, nor is there any allusion to it being a “sexual pain” even though the pain was regional and affected the vaginal introitus.
The “sexualizing” of urogenital pain appears to be a post Freudian phenomenon (Binik et al., 1999: Binik, 2005). It reflects a past theoretical perspective which dates back to: “a less enlightened era of medicine in which women’s reports of pain were much more likely than men’s to be met with some form of the ‘it must be in your head’ explanation from their doctors, including gynaecologists…Genital pain was thus vulnerable to being read as a manifestation of disturbances of women’s minds and social relationships, rather than an organic ailment” (Kaler, 2005, p. 35).
The literature from the mid 1900’s manifests a trend by which dyspareunia is included under the general rubric of frigidity, hysteria and manipulative sexual avoidance behaviour (Fenichel, 1945). On the basis of this perspective it was suggested that: “The dyspareunic patient must be helped to see for herself that the hyperesthesia is a fiction and that the pain is of her own making” (Malleson, 1954, p. 390). The statement fully attributes the cause of vulvar pain to psychological factors.
In more recent publications, Dodson and Friedrich, in a 1978 paper entitled Psychosomatic Vulvovaginitis argued that vulvar pain is a psychosomatic disorder (Dodson & Friedrich, 1978). They stated that “Psychosomatic vulvovaginatis is a real clinical entity that should be suspected in any patient whose vaginal complaints do not correlate with the physical findings.” The authors were of the view that chronic pain must be accompanied by visible pathology; otherwise, its absence is evidence of psychogenic aetiology. The evidence cited to support their view is as follows:
- the pain was characterized by persistent symptoms of longstanding duration,
- it lacked any demonstrable pathology,
- was typified by sexual inactivity arising from symptoms,
- resulted in unsuccessful consultation with multiple physicians,
- showed reluctance to accept a psychophysiological explanation of its cause,
- showed allergy to many common vaginal preparations and,
- many of the patients exhibited psychological difficulties including emotional lability and dependence.
The authors went on to comment that “The patient often pleads for help but is absolutely resistant to any suggestion that her symptoms might be psychologic in origin” (Dodson & Friedrich, 1978, p. 23s). Furthermore, claims that patients would enjoy sex and would resume normal relations if they were cured of their disease were seen as inconsistent.
Published accounts consistently document a refusal by women to accept the psychogenic origin of their pain and evidence shows that the primary motivation for seeking a diagnosis and treatment is a desire to resume and increase the level of sexual activity (Jantos & Burns, 2007). However, Dodson and Friedrich concluded that patients: “…manifested signs of neurosis, dependant personality, guilt feelings, emotional lability, while denying psychologic difficulties…these patients receive secondary gain from their symptom complex, i.e., a reason not to engage in sexual activity. As a consequence, they are understandably reluctant to accept any treatment that might destroy the defence mechanism that they have unconsciously constructed…Patients with persistent or incapacitating symptoms however, should be promptly referred to psychiatric care” (Dodson & Friedrich, 1978, pp. 24s-25s).
The statement implies that vulvodynia patients engage in “pain games” and “psychosomatization for secondary gain.”
The specific presentation features of vulvar pain reported by Dodson and Friedrick (1978) are consistent with current accounts of vulvodynia, but their conclusions about the psychological origins of the disorder continue to be unsupported.
In less than ten years, Friedrich’s perspective on vulvar pain changed significantly, as was evident from his landmark paper Vulvar vestibulitis syndrome and his subsequent publications(Friedrich, 1987, 1988). Friedrich’s published criteria for the diagnosis of vulvar vestibulitis syndrome focused solely on physiological changes in the vulva and made no allusions to psychological factors in its etiology. His published criteria have aided the development of a more systematic study of vulvodynia.
However, patients still continue to be told that they are “frigid, sexually dysfunctional, repressed, or otherwise sexually abnormal because they experienced pain,” and based on their encounters with medical practitioners, the pain appears to be generalized into diagnoses that imply that their entire sexual being is somehow sick (Kaler, 2005, p. 35). Recent publications continue to argue that a lack of demonstrable pathology is the basis for assuming a psychogenic etiology (Schrover et al., 1992; Mascherpa et al., 2007; Lynch 2008). A dualistic perspective of chronic pain appears to lead to the common sexualizing and psychologizing of lower urogenital tract pain.
