Janine Farrell & Thea Cacchioni. The Journal of Sex Research. Volume 49, Issue 4. 2012.
The medicalization of women’s sexual problems under the overall rubric of female sexual dysfunction (FSD) has been thoroughly critiqued by academics, health practitioners, and sex therapists (Kaschak & Tiefer, 2001; Moynihan, 2003; Tiefer, 2008). However, there has been much less commentary on the medicalization of sexual pain—currently a subset of an official FSD diagnosis (American Psychiatric Association [APA], 2000). Practitioners and critics alike recognize that sexual pain is a unique case among a multitude of sexual problems (Boyer, Goldfinger, Thibault-Gagnon, & Pukall, 2011). Whereas a concept such as (dys)functional sexual desire lends itself to debate as to whether it is an objectively measurable phenomenon relevant to the domain of health (Meana, 2010), sexual pain has a more obvious relationship to biomedicine’s expertise in pain pathways and pain reduction. Yet, as sexual pain is understood through an increasingly biomedical lens and dealt with using an array of expert-led treatments, it is important for scholars to unpack the meanings, benefits, and losses of medicalizing a phenomenon with such clear (and unclear) biological, psychological, and social components.
This article critically examines interdisciplinary understandings and ways of addressing women’s sexual pain problems, including biomedical, cognitive behavioral, psychosocial, and physical therapy, as well as alternative (often) demedicalized approaches. We focused on literature examining ongoing acute or chronic pain in or around the genitals and connected musculature (e.g., pelvic floor muscles) generally experienced during sexual contact, but also outside of sexual and non-sexual contact. We did not review literature on occasional sexual pain, as it is primarily the former that has been medicalized. We reviewed the aforementioned paradigms through an extensive search of electronic journal databases featuring publications on sexual pain from the biomedical and social sciences and by collecting educational, self-help information available to women through books, Web sites, and the popular press.
We analyzed these sources by drawing on Conrad’s (1992) medicalization thesis and feminist critiques of heteronormativity (Jackson, 1999), with attention to the reciprocal relationship between these social processes. Medicalization is an evolving conceptual framework that scholars and activists have developed to chart the increasing power of medical concepts, institutions, and individual figures of authority (Conrad, 1992). The term has traditionally referred to “a process whereby non-medical problems become defined and treated as medical problems, usually in terms of illnesses or disorders” (Conrad & Potter, 2000, p. 210) or a process wherein “more and more areas of everyday life have come under medical dominion, influence, and supervision” (Zola, 1983, p. 295). Heteronormativity is defined by Jackson (1999) as “the normative status of heterosexuality which renders any alternative sexualities ‘other’ and marginal” (p. 163). This concept is used to describe the dominance of heterosexuality above all other expressions of sexuality, but also the dominance of certain normative practices within sexual relationships—namely, the equation of penile penetration as the only “real” sex. Feminist medicalization theorists have long argued that the social construction of normative heterosex drives the overall medicalization of sex, and that certain modes of heterosex are lent expert legitimacy through the medicalization process (Irvine, 1990; Potts, 2002; Tiefer, 1995). Individuals who do not or cannot conform to heteronormative sexual standards due to their sexual pain may seek justification for their failure and exemption from the standards through medical diagnosis and treatment.
In this article, we argue that women’s sexual pain has been medicalized. Many women who experience sexual pain have been eager for medicalization as a path to minimizing pain during sexual activity and reinstating normative heterosexual practices and identities—goals lobbied for by patient advocacy groups and pursued by professionals in the field. Guided by a growing body of feminist theoretical and qualitative, empirical research on women’s sexual pain (Ayling & Ussher, 2008; Cacchioni & Wolkowitz, 2011; Elmerstig, Wijma, & Bertero, 2008; Grace, 2003; Kaler, 2006; Marriott & Thompson, 2008) and a case example from the first author on embracing, challenging, and reinterpreting medicalized and heteronormative frameworks for sexual pain, we note that, although there are some clear benefits to this case of medicalization, there are also theoretical, personal, and political costs.
Most contemporary research and treatment efforts still reduce women’s sexual pain to (dys)functional parts of the body. Yet, as qualitative studies on sexual pain demonstrate, women’s distress over their pain is often exacerbated by their perceived inability to have “normal sex” with a male partner—that is, women’s distress may not be entirely due to the pain itself, but also due to the fact that their pain prevents them from living up to socially constructed (hetero)sexual norms (Ayling & Ussher, 2008; Grace & MacBride-Stewart, 2007; Marriott & Thompson, 2008). The demand for sexual normalcy fosters market demand and a captive base of consumers of new products, procedures, and drugs that will improve sex and cure pain (Conrad & Leiter, 2004; Tiefer, 2008). Although health professionals have made great strides in finding non-invasive methods to manage sexual pain, market competition may well produce new commercial and invasive options, with significant health and financial liabilities. Because such nuances are rarely seen in current biomedical theory, research, and praxis on women’s sexual pain, we conclude by offering some practical and theoretical strategies and frameworks for understanding and addressing women’s sexual pain as a lived, embodied, biological, and physiological experience that is simultaneously shaped by social norms.
Understanding Sexual Pain
We begin by examining the paradigms employed by researchers to understand and classify sexual pain. The theoretical frameworks underpinning this body of research and the organization of clinical diagnostic systems shape the ways that sexual pain is understood and how it is valued within and beyond the research domain. Our review reveals that most contemporary approaches to understanding sexual pain, even popular and self-help, privilege biomedical paradigms.
Historically, disorders that have unknown origins (including sexual pain) were often labeled as psychosomatic (McKay, 1989); during the 18th and 19th centuries, many “diseases of women” were understood and diagnosed as hysterias. Often, the absence of a detectable organic cause meant no diagnosis, and it was assumed the pain was “in a woman’s head” (Grace, 2000). More specific to sexual pain, unexplained itching in the vulva has been documented for over 100 years (Friedrich, 1987), but the medical profession did not study this area in earnest until the 1980s, following the 1975 establishment of the International Society for the Study of Vulvar Disease (ISSVD) and the growth of patient advocacy groups such as the National Vulvodynia Association (NVA), founded by five women with sexual pain in 1994.
In the last few decades, the medical domain has turned its attention to the problem of sexual pain, as evidenced by the explosion of technical language and diagnostic criteria developed to describe and define it. However, there is division among biomedical experts as to how to understand these complex phenomena. The source generally granted the most legitimacy in this area is the APA’s (2000) Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]). The DSM-IV-TR classifies sexual pain disorders as sexual dysfunctions under the overall rubric of mental disorders. Sexual pain disorders are divided into dyspareunia and vaginismus (APA, 2000). Dyspareunia is defined as “recurrent or persistent genital pain associated with sexual intercourse” that causes significant “distress and/or interpersonal difficulty,“ and is not exclusively caused by vaginismus or lack of lubrication (p. 554). If dyspareunia is seen as resulting from medical or iatrogenic factors, then “sexual dysfunction due to a general medical condition” or “substance induced sexual dysfunction” are the recommended classifications (APA, 2000, p. 554). Vaginismus is defined as “a recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse” (APA, 2000, p. 556). The upcoming fifth edition of the DSM may revise these definitions to reflect a single diagnostic category of sexual pain disorder called “genito-pelvic pain/penetration disorder” (Donaldson & Meana, 2011, p. 814).
Ongoing commentary over the classification of dyspareunia is exemplary of the inter- and intra-disciplinary debate over these classification systems. A number of researchers and clinicians have called for dyspareunia to be reclassified as a chronic pain syndrome (Binik, 2005), as the ISSVD already does. Many argue there is insufficient clinical evidence for distinguishing between dyspareunia and vaginismus due to their frequent overlap and that dyspareunia is typically (rather than exceptionally) related to chronic genital pain conditions without sexual activity (“Peer Commentaries on Binik,” 2005). Diagnoses not specified in the DSM-IV-TR, which refer to ongoing genital pain outside of sexual activity, include chronic pelvic pain, generalized vulvodynia, and provoked vestibulodynia. These labels are used depending on the location and duration of pain, but there is also debate over whether there is sufficient evidence for these distinctions. When an article published by Binik in a 2005 issue of the Archives of Sexual Behavior made the case to classify dyspareunia as a chronic pain disorder, it elicited at least 20 lively responses, reflecting the extent of the debate around sexual pain, its origins, and treatment (“Peer Commentaries on Binik,” 2005). Interdisciplinary commentators from health and social sciences with expertise in sexual pain widely differed in their opinion of Binik’s thesis, but generally agreed the medicalization of sexual and genital pain was a positive development for “clinical inquiry and treatment, professional education, health insurance coverage, and research attention” (Tiefer, 2005, p. 50). Leonore Tiefer (2005). well-known critic of FSD classification, argued that “as long as there are expert-based listings of sexual dysfunctions, we do women a disservice by failing to include pain as one of them,” but she was the only contributor to add the caveat that she would be “happy to dispense with such norms entirely” (p. 51).
Like the diagnostic classification literature, most biomedical research on women’s sexual pain aims to illuminate the complex and unclear mechanisms through which sexual pain arises and persists in women. Research generally operationalizes physiological and subjective aspects of sexual pain along strict biomedical lines, and seeks to understand causes via complex interactions down to the cellular level. Problems with immune system response, dermal hypersensitivity, allergies, chronic nerve pain and congestion, genetic markers and risk factors, and imbalanced hormones and neurotransmitters are commonly investigated potential “causes” of sexual pain (Basson, 2008; Graziottin & Brotto, 2004; Landry, Bergeron, Dupuis, & Derochers, 2008).
Most recently, biopsychosocial frameworks have been favored in lieu of or in addition to strictly biomedical factors, with the intention of moving beyond reductionist perspectives (Boyer et al., 2011). Yet, research aimed to illuminate social, relational, and psychological aspects of women’s sexual pain experience is often framed in a reductive way, resulting in the presentation of sexual pain and related phenomena as fractured statistical constructs. Rosen, Bergeron, Leclerc, Lambert, and Steven (2010) provided a poignant example:
The overall model for woman-perceived partner responses predicting sexual satisfaction was significant, F(5, 185) = 15.66, p < .001, and accounted for 30% of the variance in sexual satisfaction, with 5% of variance accounted for by partner responses. (pp. 3720-3721)
This literature bears striking resemblance to biomedical accounts of bodily processes; here, even the emotions and relational experiences are quantified.
Historically, most research on sexual pain has focused on either physiological or psychological origins of sexual pain. As Boyer et al. (2011) pointed out, this pervasive mind/body split is a vestige of using strictly biomedical and positivist frameworks in health-related research. This is often assumed to be eliminated by researchers employing a biospychosocial framework. Unfortunately, this split is still implicit to the majority of contemporary scientific frameworks wherein the biological, psychological, and social determinants of sexual pain are considered as related, but not interacting or mutually reinforcing phenomena. Here, the bio usually takes precedence over the psycho and social (Grace, 2003, 2007). We further argue that contemporary biopsychosocial frameworks typically reduce broader social and structural forces that directly influence women’s experiences of sexual pain to individual, psychological, or interpersonal “abnormalities,” rather than framing them as influenced by social determinants (e.g., shaped by constructions of gender and sexuality).
On the opposite end of the spectrum, a growing body of feminist qualitative research explicitly centers the voices and lived experiences of women with chronic sexual pain and emphasizes the role of social factors in women’s experiences of sexual pain. For example, Ayling and Ussher (2008), Cacchioni and Wolkowitz (2011), Grace and MacBride-Stewart (2007), Kaler (2006), and Marriott and Thompson (2008) used empirical qualitative methods (primarily interviews) to uncover a deeper understanding of sexual pain from the perspectives of the women experiencing it. Although certain conditions involve genital pain outside of sexual contact, the overwhelming majority of women in these studies reported that the pain during sexual activity caused them the most distress. Sexual pain was constituted and reinforced by women’s experiences of their gender, particularly as it overlapped with the pressure to adhere to heterosexual norms and bodily practices that become imperative due to compulsory notions of heterosexuality (Rich, 1980). This was most commonly experienced by these women as an imperative to have penetrative penile-vaginal sex with a male partner. Many women felt this kind of sex was essential to the longevity of their relationships. Women in these studies frequently perceived their pain as excluding them from all forms of sex they considered legitimate or “real,” which often led to powerful experiences of guilt, failure, and inadequacy in relation to being a “real woman” or a “good partner” in a heterosexual relationship. Thus, the social construction of gender and sexuality directly shape the fear and distress of women with sexual pain. Although relatively unaddressed in the research, feminist qualitative research also points out that social factors such as race, class, education, ethnicity, sexual orientation, and ability influence women’s experiences of sexual pain (Cacchioni, 2007; Grace & Zondervan, 2004; Roth, Punch, & Bachman, 2001).
To move past the constraints of medicalized approaches to chronic sexual pain, Grace (2003) studied frameworks employed by chronic pain researchers, and called for the adoption of new epistemic lenses and understandings of pain that extend beyond medicine’s focus on the physical and psychology’s focus on the psychological. She advocated frameworks that forge unconventional alliances between a broader array of disciplines, including neuroscience, neuropsychology, consciousness research, and, importantly, the integration of theories of embodiment and neurophenomenology (Grace, 2003, p. 45). The integration of feminist embodiment frameworks into scientific research allows a single research project to simultaneously examine biological and psychological processes at the individual level while still considering the influence of broad social forces, like gender and heteronormativity, on the pain process. Rather than focusing on goal-oriented, linear processes (which often reinforce normative notions of sexuality and gender), embodiment frameworks allow for messier models of understanding and also healing.
Treating Sexual Pain
The reinstatement of normative sexual activity is a common goal of treatment. However, genital pain occurs for many women outside of sexual contact, often chronically. Hence, there are also many non-sexual reasons women seek treatment to minimize genital pain (e.g., conceiving and giving birth to a child, wearing a tampon, or riding a bike). Professionals who specialize in treating sexual pain tend to agree that multifactorial, multidisciplinary approaches to treatment are necessary for this extremely complex, heterogeneous problem (Boyer et al., 2011; Graziottin & Brotto, 2004; Landry et al., 2008). Some argue that, historically, this has taken the form of medical, followed by mental health, interventions when and if medical intervention fails (Payne, Bergeron, Khalifé, & Binik, 2006). Whichever approach is taken, the goal of most treatments is pain reduction, most often measured by the restoration of penetrative sex (although many women wish to restore other pain-free sexual activities, like manual and oral stimulation).
A chapter on sexual pain in a definitive textbook on “sexual dysfunctions” explains that medical interventions for dyspareunia “lie on a continuum from relatively minor to invasive methods, operating largely on a trial and error basis” and with little empirical support (Payne et al., 2006, p. 474). Depending on the type of sexual pain, medical treatment may begin with the following:
Local topical treatments (such as sitz baths), progressing to topical medical treatments involving corticosterioid, estrogen, or lidocaine cream, to oral medications such as calcium citrate, corticosteroids, or fluconazole. Should such methods fail, progressively more invasive approaches are recommended, such as interferon injections, neurophysiologic treatments, and finally surgical excision via vestibuloplasty, or partial to total vestibulectomy. (p. 474)
Vestibulectomy is described as a “minor surgical process, which consists of the excision of the hymen and sensitive areas of the vestibule” (p. 474). Healing takes up to eight weeks, and the “success” rate has been estimated to be between 43% and 100%. It is important to note here that success is defined as the minimizing or complete reduction of pain during intercourse.
Invasive treatments for symptoms associated with vaginismus are also being developed. For the past 10 years, intravaginal injection of Botox—the trade name for the highly poisonous substance Botulinum Toxin—has been under consideration as a treatment for vaginismus. Each study conducted so far has involved a sample of 60 women or less (Ghazizadeh & Nikzad, 2004; Pacik, 2009; Shafik & Eli-Sibai, 2000). On August 11, 2010, the Food and Drug Administration (FDA) approved clinical trials for the use of Botox to treat vaginismus in the United States. Peter P. Pacik, the principal investigator of the study, was given permission to inject 150 units of Botox intravaginally in 30 patients. Pacik claims to have treated 20 patients in his practice with off-label Botox at a 90% success rate. Of these 20 patients, Pacik (2009) reported that 16 were able to achieve intercourse in two to three weeks; three patients advanced to the fifth or sixth of six dilators, whereas another patient was “unable to advance beyond the smallest dilator” and was, therefore, “considered a failure” (pp. 455-456). Although Pacik has yet to present the results of his data to the FDA, he has already published a self-help book entirely dedicated to promoting the use of Botox as a treatment for vaginismus (Pacik & Cole, 2010).
Still, many sexual pain experts advocate for the least invasive approaches with fewer side effects, claiming that desensitization techniques involving a cognitive behavioral element are the most proven strategies for treatment of dyspareunia and vaginismus (Payne et al., 2006). Some techniques are so demedicalized that Cacchioni and Wolkowitz (2011) noted their similarities (and differences) to 1970s feminist consciousness-raising practices. However, typically, practitioners report managing sexual pain by advising patients to gradually get used to the sensation of having physical (and, eventually, sexual) contact. To this end, vaginal dilation is often prescribed for managing sexual pain and restoring intercourse (Backman, Widebrant, Bohm-Starke, & Dahlof, 2008; Graziottin & Brotto, 2004). Pelvic physiotherapy with biofeedback is another treatment for sexual pain involving cognitive behavioral elements and little risk (Boyer et al., 2011; Landry et al., 2008). Physiotherapists have adapted common physiotherapy techniques to reduce involuntary muscle tension and target pain pathophysiology for women with sexual pain. Patients are led through pelvic floor exercises and sometimes internal and external pelvic massage and trigger-point work, which is meant to desensitize painful areas (Stein, 2009). Successful outcomes in this domain are measured as reduced or absent pain during vaginal penetration, most commonly measured as penile-vaginal intercourse, followed by other measures relevant to non-coital and non-sexual pain, including painless insertion of finger or tampon (Boyer et al., 2011; Spoelstra, Dijkstra, van Driel, & Weijmar Schultz, 2011).
Yet, many women opt to educate themselves in desensitization and cognitive behavioral techniques, taking charge of their own healing process. In some cases, a self-help approach is even endorsed by health professionals. For example, Canadian physiotherapists and gynecologists partnered with Come As You Are (2011), a Canadian cooperative sex store, to develop high-quality, “user-friendly” dilators available online and in person. Amy Stein, a well-known pelvic physiotherapist and author of the self-published book Heal Pelvic Pain (2009) and the Web site www.healpelvicpain.com, is a self-help guru who has appeared on numerous medical segments on popular news programs. Stein’s self-help materials, exemplary of a more commercialized approach, offer a step-by-step guide for exercises and techniques women can practice at home and promise “success” while also serving as an advertisement for her private New York clinic for those who want to go “beyond the basics” (see Beyond Basics Physical Therapy, LLC at http://www.beyondbasicsphysicaltherapy.com/pfd.shtml).
A notably less medicalized and less commercial forum for the do-it-yourself approach to dealing with sexual pain is the Vaginismus Awareness Network Web site (see http://www.vaginismus-awareness-network.org/). Because vaginismus is commonly linked to dyspareunia, the Web site appeals to a wide range of women’s sexual pain issues. Although the anonymous author of the explicitly not-for-profit Web site acknowledges that “some women may really benefit from the help of a professional,” she laments the perceived need for expert guidance and the “invisibility in the literature of the women who have actually self-treated … on their own despite clear evidence they exist and in great numbers.” She highlights the explosion of “medical authority so that only doctors are allowed to talk about vaginismus.” She offers support and suggestions for alternative modes of intimacy for women who do not wish to work toward pain-free penetrative sex with step-by-step guidance on desensitization and dilation techniques for those who do. In her view, learning these techniques at home, with (or without) a partner, can be the most affordable, self-empowering approach to healing. She admits this takes skill, but “professional, not necessarily.”
Finally, some women eschew education or guidance on how to alter their sexual pain altogether, choosing to change their approach to sexuality. The second author’s (Cacchioni, 2007) in-depth, qualitative interviews with women who identified as having a range of sexual pain experiences revealed that some women preferred to change their definitions of real or successful sex within their heterosexual relationships (also called “queering” sex). In this context, queering sex does not necessarily mean engaging in same-sex sexual activity (although it may), but more widely undertakes the spirit of “queer” to reflect the disruption of normative heterosexual practices and engagement in any sexual practice that provides pleasure and does not privilege, require, or culminate in penile-vaginal intercourse. In this qualitative study, only one physician recommended this strategy to only one woman, although, by contrast, it was the strategy of choice for women who did not seek expert advice.
A Case Example
Feminist qualitative health studies embrace the personal narrative as a legitimate form of evidence to capture nuanced individual experiences, often invisible amid proliferating medical technology, language, and research (Blaxter, 2009). In the spirit of encouraging greater inclusion of women’s voices and experiences of sexual pain in this body of research, I (the first author) offer my own account.
My “illness experience” has spanned well over one decade. Today, I think of myself as a sexually healthy person, free of illness, but my pain has not completely subsided. In the beginning, and after six months of unsuccessfully managed pain, I was diagnosed with vestibulodynia. I then gained access to care at a medical clinic specializing in sexual pain, which I regularly attended over the course of many years. My treatments began with biomedical attention (from sexual medicine and chronic pain specialists), physiotherapy and massage, yoga classes and relaxation exercises, psychological/talk therapies, and other home remedies (recommended by a medical doctor) in place of pharmaceutical treatments. I consider the relatively successful management of my pain as a marker of my tremendous privilege to which all women are not assumed to be privy. As a Canadian, my universal health coverage paid for the medical appointments. However, the bulk of my treatment would have been inaccessible or financially debilitating had I not been young enough to justify my parents paying and extending their own health coverage to help.
The onset and persistence of my pain also marked the end of my heterosexual relationship. Without a partner to measure my pain experience with (i.e., during intercourse), I felt as if my pain could no longer be recorded or quantified by the available diagnostic tools. Although my pain was significantly reduced in all other domains of my life, I thought it was too soon to quit treatment because we did not know yet that I would be able to have painless intercourse with a man. Still, my medical treatment at the clinic ended to make space for other women waiting for care.
Without the clinic to depend on, I adopted a critical feminist perspective toward sexuality and health, which helped me to adapt and manage what pain I had left. This process was similar to that described by Cacchioni (2007) as “queering” one’s sexuality to cope with difficulties in adhering to sexual norms. Along with biomedical and other therapeutic approaches, questioning and rejecting heteronormative, goal-oriented scripts of sexuality helped reduce my fear that I would suffer from this ailment (beyond the physical level) for my entire life. This approach holds the potential for agency within, and even freedom from, predetermined scripts of gender, sexuality, disease experience, rehabilitation, and cure.
Medicalization, Heteronormativity, and the Embodied Experience of Sexual Pain
Sexual pain has been medicalized at each of the three levels referred to by Conrad (1992). At the conceptual level, it is largely understood in individualized, biomedical terms to discover pathways of causation and etiological origins for each type of sexual pain (Graziottin & Brotto, 2004; Landry et al., 2008). At the institutional level, as patient advocacy groups such as the NVA had hoped, sexual pain is now an issue that receives medical recognition, funding, and resources. At the interactive level, practitioners from a number of expert disciplines help women minimize pain and reorient toward sexual activity and intercourse. These levels do not operate independently of one another; pressures from biomedical funding bodies encourage the legitimacy of the biomedical lens, whereas patient demand sets the tone for the focus on the restoration of heterosexual intercourse (Landry et al., 2008).
Indeed, this particular case of medicalization has been very much consumer led. For many women with sexual pain, their greatest distress is related to months, and even years, of having no medical diagnosis or helpful advice (Feldhause-Dahir, 2011). Similar to the case of other chronic pain conditions, women with sexual pain have understandably been “eager for medicalization,” as it lends medical and social legitimacy to their experience and paves the way for direct solutions (Becker & Nachtigall, 1992). Without the legitimizing voice of medicine and scientific research behind sexual pain, it is fair to say many women would still feel (or be told that) their pain is unreal, and there would likely be little demand or support for research. Qualitative research suggests the medicalization of sexual pain may demonstrate what Conrad and Schneider (1980) referred to as the “light” side of medicalization. For example, Cacchioni and Wolkowitz (2011) found that women who are able to successfully get help with pain management feel elated, particularly after having have had their pain dismissed as “in their heads” by physicians and other professionals.
However, physiological experiences are interpreted through a socially constructed lens. Thus, the overall demand for the medicalization of sexual pain must be understood in the context of the reciprocal relationship between heteronormativity and medicalization (Cacchioni, 2007). This connection is exemplified by the value afforded to penetrative vaginal sex in measurement, diagnostic, and treatment tools. Although women’s reasons to seek treatment and reduce pain range significantly and may not involve sexual contact at all, medical and sociological literature confirms that women with sexual pain often feel most distressed due to their inability to perform what is seen as “real” sex. The vast majority of treatment for sexual pain addresses these anxieties by helping women conform to heteronormative sexual norms (Cacchioni, 2007; Cacchioni & Wolkowitz, 2011; Elmerstig et al., 2008; Grace & Macbride-Stewart, 2007). Even in those instances where solo measures of lessened pain are considered (e.g., tampon insertion, masturbation, wearing underwear, and urinating), hierarchical models of rehabilitation consistently privilege heteronormative intercourse with a monogamous partner as the ultimate sign of successful treatment. Women’s willingness to use intravaginal Botox as an off-label treatment for vaginismus is testimony of the desperation women feel due to their combined pain and inability to practice normative heterosexual behavior. Further, it demonstrates how far some medical practitioners will go to ensure their patients can achieve normative heterosex.
To overcome this limitation in contemporary research and practice, it may be helpful to borrow languages and concepts from the sociology of health, which is similarly challenged to bridge this gap. Some scholars have attempted to balance the discipline’s tendency to focus on the “subjective” by emphasizing the need to reconsider the significance of “the biological body” (Birke, 1999), albeit “cautiously” (Benton, 1991). Birke (1999) warned: “[B]y emphasizing social constructionism, in opposing it to biological determinism, we have perpetuated the [mind/body] dualism; and have played down the importance of the biological body itself” (p. 22). Birke suggested that, rather than ignoring the roles and possibilities of the biological components of health, we should take up study on “the complex ways in which they could themselves be influenced by, or act in concert with, our environment” (p. 22). This strategy corresponds with Grace’s (2003, 2007) call for embodiment frameworks for understanding sexual pain, which thoroughly dismissed dualistic traditions of research and praxis:
[P]ain, as perception, is so entangled with meanings associated with our emotional, psychological and cultural experience that an adequate model must enable an understanding of pain, not just in terms of how pain is created in the nervous system, but … at the complex point where biology and culture intersect [where] meanings of gendered subjectivity in the history of the individual’s life become viscerally integral to their embodied experience. (Grace, 2003, pp. 48-49)
Current analyses of medicalization stress the growth of market-driven technologies. The sexual pain industry takes advantage of a public need, but, as with all industries, the need for “newer” and “better” interventions moves toward more technological and more invasive methods. The sexual pain industry is part of the new sexual medicine driven, in part, by careerist and financial motives. Although some countries offer some biomedical services for sexual pain as part of universal health care coverage, the comprehensive treatment plan advocated for by practitioners is never entirely covered. Treatments range from $100 to $200 for a single visit to a pelvic physiotherapist and up to $10,000 for treatment at a private clinic. It is estimated that the price of Botox treatments for vaginismus will be $800 or more per treatment (http://www.vaginismus-awareness-network.org/). As pharmaceutical solutions such as Botox gain popularity, the desire for profit may further blur understandings and approaches to treatment, downplaying the social context in which women’s sexual experiences take place.
Suggestions for the Future
In light of the previous discussion, we present recommendations to researchers, practitioners, patients, and advocates working in the domain of women’s sexual pain, along with our hope that there can be new dialogues and discoveries in future understandings and treatments of women’s sexual pain:
- We believe that more qualitative and mixed-methods approaches to this domain of research are critical to ensure that the voices and experiences of women with sexual pain are represented and the multiple social factors that influence women’s identity and experiences are recognized.
- We recommend researchers, advocates, and clinicians adopt embodiment approaches to their understanding and treatment of illness processes and chronic pain instead of or in addition to biopsychosocial approaches. Embodiment approaches will begin to address the multiple co-occurring factors integral to chronic pain and the tendency of biopsychosocial approaches to frame social issues as individual, psychological factors.
- We also encourage researchers and practitioners to take advantage of opportunities to make information about sexual pain (and relieving it) as accessible as possible. We believe this kind of knowledge translation is essential, for not all women have access to specialized health professionals. This dissemination of knowledge must occur not only to the public, but across scientific and medical specialties to ensure that practicing physicians and other health care practitioners have a clearer understanding of women’s sexual pain so that it does not continue to go unacknowledged and untreated.
- We support the revision of pain scales, measurements, and treatments that assume pain-free intercourse is the ultimate goal or primary sign of recovery from sexual pain.
- Finally, we recommend the growth of patient empowerment through education aimed at healing and not for profit treatments with as few side effects or health risks as possible. These techniques should encourage the recovery of less or pain-free penetrative vaginal sex when women feel this is what they would like to pursue, but they should also emphasize the notion that there are other options.
We believe that these recommendations will help position women with sexual pain as active agents who are aware of their choices, even within the medical system, as they consciously interact with competing sexual pain discourses, resist them, or use them as resources to overcome their pain.