Early relationship experiences in women with sexual pain: a psychodynamic approach to the interactional function of body symptoms

Abstract

Sexual pain and difficulties with sexual intercourse in women, formerly diagnosed as dyspareunia and vaginismus and reconceptualised as genito-pelvic pain/penetration disorder (DSM-5) or sexual pain-penetration disorder (ICD-11), have caused widespread discussions in the clinical and scientific community for decades, mainly due to differential-diagnostic difficulties. Meanwhile, their developmental origin has remained under-theorised. Standard diagnostic guidelines like ICD or DSM lack psychodynamic considerations about their origins. Valuable approaches to understanding those phenomena have been commonly neglected. The aim of this study was to compare inductively obtained information from women with experiences with vaginismus (n=17) and dyspareunia (n=11) about their relationships with primary caregivers from biographic-narrative interviews. Our mixed-method analysis involved two steps: a first qualitative assessment drew on psychoanalytically informed research principles and the development of a coding frame, which was used by two independent raters to code the material; in a second step, coded experiences were statistically compared between the two groups using Fisher’s exact tests to explore similarities and differences. Integrating results with theoretical psychodynamic work, we suggest that the postulation of interactional functions of conversion and somatisation, based on early experiences with primary objects, adds significantly to the conceptualisation of dyspareunia and vaginismus. Results indicate that vaginismus might represent a conversion symptom with a triangulating function, whereas dyspareunia might be understood as a form of somatisation and serves the purpose of replacing the primary object. The results are discussed in the light of previous theoretical outlines of women’s genital pain and includes strengths and limitations of our proposition.

Keywords:

• Dyspareunia
• vaginismus
• conversion
• somatisation

Acknowledgments

We would like to thank all women who participated in our study for sharing details of their personal experiences with us. We also thank Dr. Ute Lampalzer und Samantha Schröder for conducting the second coding of data and for their input in the discussion of coding results.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset involves data from former patients of the Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Germany, and is therefore not available for public access.

Notes

1. This debate was based on the fact that pain may be experienced in consequence of muscle tension during attempts at intercourse, and muscle tension in response to pain; in these cases, a careful differential-diagnostic examination is required to establish a timeline for symptom development and identify the initial difficulty.

2. Original quotes were translated into English by the first author. To preserve the character of participants’.

direct speech and their train of thoughts, translations were kept as literal and close to the original as possible.

Quotes may therefore display disruptions in grammar or fluency of speech. Transcript explanations:

(.): short pause <1 sec.; (x): x sec. pause; ((y)): non-verbal expressions; […]: editing.

3. We acknowledge that the term ‘hysteria’ is frequently perceived as outdated or even derogatory outside the psychodynamic field; within psychoanalysis, ‘hysteria’ as conceived by Freud has received extensive criticism from feminist psychoanalysts (e.g., Cixous, 1986; Clément, 1986; Irigaray, 1985; J. Mitchell, 2000). Nonetheless, it is adopted here, given that literature using the term is presented to illustrate the usefulness of theoretical considerations around the concept for the topic under study.

4. Questions regarding the heteronormative element in and the applicability of the following considerations to non-heterosexual family arrangements cannot be addressed here in deserved detail. For the purpose of this paper, we therefore refer to the individuals involved as denominated in the original literature. Fore reflections on (hetero)normative features of psychoanalytic theory see for example Hutfless and Zach (2017).

5. Our intention is not to posit hysteria as generally underlying vaginismus and dyspareunia – although above-mentioned findings by Maseroli et al. (2017) on histrionic symptoms and traits in women with vaginismus suggest that descriptive features related to the construct could be relevant –, but to draw attention to Rupprecht-Schampera’s understanding of bodily symptoms. Considering that both conversion and somatisation are not limited to hysteria (Fenichel, 1966; Rangell, 1959), the question of whether Rupprecht-Schampera’s description of a hysteric development applies to our participants’ experiences can be treated as secondary for the aim of this paper.

Additional information

Funding

This study was part of the first author’s PhD project, which received a scholarship Evangelisches Studienwerk Villigst.

Notes on contributors

Thula U. Koops

Thula U. Koops is a psychodynamic psychotherapist in training, and a researcher at the Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry of the University Medical Centre Hamburg-Eppendorf. Her research mainly focusses on women’s sexuality and sexual difficulties, but also covers other sexuality- and body-related topics.

Peer Briken

Peer Briken is a sex researcher and psychodynamic psychotherapist, Full Professor and Director of the Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry of the University Medical Centre Hamburg-Eppendorf. He is also one of the four directors of the Institute for psychotherapy at the University Medical Centre Hamburg-Eppendorf, as well as Associate Editor of the Journal of Sexual Medicine and Editor of the German Journal of Sex Research.