A Controversial Question: Is the Pain Sexual or is the Sex Painful?
Furthermore, it is not uncommon for views on female dyspareunia to frequently reflect a gender bias. Even though dyspareunia is a disorder that affects both men and women, there appears to be an implicit assumption that it does not exist in men, and if men do experience pain, it is “real” and therefore should not to be diagnosed as dyspareunia (Townsend, 2005). It has been claimed that in women, dyspareunia is more likely to involve psychological factors than in male dyspareunia (Abarbanel, 1978). Why the same chronic pain condition should have a greater psychological content in its etiology for women than for men, is not clear. Such gender bias has not helped advance the understanding of vulvodynia.
Literature reveals a continued polarization of views on the potential links between “organic” and “psychogenic” contributors to the etiology of vulvodynia symptoms. There is an ongoing failure to see the experience of pain as consisting of both somatic and psychological aspects and to treat it accordingly (Merksley & Bogduk, 1994). Instead, proponents of physiological causes of vulvar pain argue that the prevalence of psychological variables in the etiology of pain is low or negligible (Bohm-Starke et al., 1998; Lowenstein et al., 2004), whereas proponents for psychological causes minimize the physiological links, asserting a prevalence of psychological variables (Schrover et al., 1992; Lynch, 2008). It appears that the attribution of pain to psychological causes, when pathology is not evident, may arise, in part, on account of a poor understanding of the nature of chronic pain (Steege, 1998; Jantos, 2007); or the physician’s inability to make a specific diagnosis, inability to relieve the pain and unwillingness to listen (Lynch, 1986); or the patients visibly depressed and tearful state (Edwards, 1997). However, none of these reasons justify classifying pain as a psychiatric disorder or sexualizing its etiology (Binik, 2005). Pain needs to be classified according to the guidelines applicable to chronic pain nosology and managed according to the primary presenting symptom – which is pain.
The answer to the question of whether the pain is sexual or the sex is painful, appears to depend on the theoretical presuppositions about the nature of pain. In relation to chronic vulvar pain, assumptions about the nature of pain can lead to incorrect classification and ultimately inappropriate treatments. The discussion in the section that follows will review literature which identifies potential organic and psychogenic factors related to the etiology of vulvodynia and will seek to identify any emerging trends in the understanding of the condition.
