Towards improved sexual health among women with provoked vestibulodynia: experiences from a somatocognitive therapy approach

Abstract

Purpose

Provoked vestibulodynia (PVD) is a common reason for sexual pain in young women. Furthermore, this persistent vulvar pain condition can have a significant negative impact on an individual’s sexual health and well-being. As knowledge about effective treatments is limited, the aim of this study was to gain insight into meaningful processes towards improved sexual health, supported by a multimodal physiotherapy intervention.

Methods

Through individual semi-structured interviews, this longitudinal, qualitative study explored the experiences of ten young women with PVD who took part in a somatocognitive therapy program. Participants were interviewed towards the end of their therapy period, and again one year later, to develop insight into therapeutic processes unfolding over time.

Results

Through analysis we identified the following themes: (1) Developing positive feelings of embodiment, (2) Developing a greater awareness of internal feelings and bodily states, and (3) Developing sex-positive beliefs and behaviours.

Conclusion

The findings show how individually tailored physiotherapy emphasising embodiment and sexual health can promote meaningful processes towards improved sexual health for women living with PVD.

Keywords:

• Provoked vestibulodynia
• vulvodynia
• physiotherapy
• somatocognitive therapy
• embodiment
• sexual health
• sexual agency

Introduction

Longstanding vulvar pain, or vulvodynia, is an unexplained and distressing condition that can have a detrimental impact on the sexual health¹ of young women. Multifactorial in nature, the maintenance and severity of vulvodynia has been associated with various biological, social, and psychosexual factors [1–5]. With an estimated lifetime prevalence of 7–16% vulvodynia represents a significant personal, clinical, and societal challenge today [6–8].

Provoked vestibulodynia (PVD) is the largest subgroup of vulvodynia [9] and considered the most common cause of pain during sexual intercourse among premenopausal women [9,10]. The condition is characterised by burning or stinging pain, provoked by touch or pressure to the vulvar vestibule or attempted vaginal penetration. Although there are currently no evidence-based treatment guidelines available, a biopsychosocial treatment approach is generally recommended [11]. As knowledge about the condition and what constitutes effective treatment is limited, women with PVD are often misdiagnosed, misunderstood, or even dismissed by health care professionals [12]. Their road to recovery can be long, lonely, and costly, and many women explore different treatment options before experiencing any improvement of their symptoms [12]. This article explores women’s experiences of addressing sexual health in a physiotherapy context and how experiences of sexual health might intersect with experiences of embodiment.

Sexual health is a key part of a person’s overall health and well-being. When sex becomes a source of pain, the negative consequences for a woman’s sexual health can be profound. Previous research has provided valuable insights into the subjective experiences of living with vulvar pain and of negotiating painful sex in the context of romantic relationships. In a study exploring women’s experiences of vulvar pain, Katz [13] found that feelings of shame, guilt, social isolation and sexual inadequacy were very common. The women’s narratives also revealed experiences of a loss of self and loss of femininity, as well as diminished self-confidence. Women with vulvar pain often discount their own needs to accommodate the sexual desires of their partners [14–17], indicating that the physical, emotional, sexual, and social dimensions of longstanding vulvar pain are tightly interwoven.

The limited existing literature exploring connections between the quality of one’s embodiment and the quality of one’s sexual health, suggests that embodiment can be linked to feeling more comfortable with one’s sexual desire and feeling entitled to sexual pleasure, as well as a stronger sexual agency [18]. A recent study found that engaging in regular embodied practice encouraged a shift from experiencing sexuality from an objectified perspective to sexuality as a lived experience, connected to internal bodily states [19].

Physiotherapy is commonly recommended as a first line of treatment for women with PVD [20], although the optimal physiotherapy intervention in terms of pain reduction and improvement of sexual function remains unclear [21]. However, few studies have investigated the experiences of women with PVD interacting with physiotherapy, and we know little of their experiences addressing sexual health in a physiotherapy context. Insight into such experiences is paramount in developing targeted physiotherapy interventions in line with the women’s preferences and perspectives on what constitutes meaningful processes of change. Hence, the purpose of our qualitative study was to gain insight into meaningful processes towards improved sexual health among women receiving somatocognitive therapy, a multimodal physiotherapy intervention, for PVD. More specifically, we address the following research question:

What, from the perspective of the participants, are meaningful processes toward improved sexual health supported by somatocognitive therapy?

Theoretical perspective

A feminist embodiment framework informs this study and allows us to understand the women’s body-anchored experiences within broader sociocultural contexts [22]. We draw on Piran’s [22] Developmental Theory of Embodiment (DTE), a research-based social theory that aims to explain the development and experience of embodiment among girls and women. The DTE builds on Merleau-Ponty’s understanding of embodiment as lived experience and of the mind and body as an inseparable whole, existing in a reciprocal relationship with culture. Referring to critical and feminist theorists such as Foucault [23], Bartky [24], and de Beauvoir [25], the DTE directs our attention to how a woman’s body is a site of social control, where social discourses socialise women to inhabit ‘compliant’ and ‘docile’ feminine bodies.

The DTE outlines five dimensions that shape the quality of one’s Experience of Embodiment, each representing a scale from positive to disrupted:

Dimension 1 Body Connection and Comfort vs Body Disconnection and Discomfort.

Dimension 2 Agency and Functionality vs Restricted Agency and Restraint.

Dimension 3 Experience and Expression of Desire vs Disrupted Connection to Desire.

Dimension 4 Attuned Self-care vs Disrupted Attunement, Self-harm, and Neglect.

Dimension 5 Inhabiting the Body as a Subjective Site vs as an Objectified Site.

According to these dimensions, positive embodiment is defined as ‘positive body connection and comfort, embodied agency and passion, and attuned self-care’ [22]. The opposite is disrupted embodiment, defined as ‘disrupted body connection and discomfort, restricted agency and passion, and self-neglect or harm’ [22]. By collating these five dimensions previously understood and studied as distinct phenomena, under the wider concept of embodiment, the DTE provides an integrative framework from which to explore the women’s embodied therapeutic journeys.

Context: somatocognitive therapy

The women who participated in this study had all taken part in a Somatocognitive therapy (SCT) intervention for PVD. SCT is a multimodal physiotherapy intervention originally developed to treat persistent pain disorders [26]. In later years SCT has been further adapted to treat women with persistent vulvar pain [27]. The participants had received a median of 12 SCT sessions over the course of 13–22 weeks, at an outpatient clinic at Oslo Metropolitan University, Norway.

SCT is based on therapeutic principles from the Mensendieck physiotherapy tradition [28] – a tradition emphasising body awareness and functional movements. In addition, SCT is inspired by Cognitive therapy in the sense that unhelpful pain-related cognitions and behavioural schemata are identified and addressed [29]. SCT as a therapy form is not connected with the DTE-framework used in this study. However, the DTE may provide a useful framework for how SCT can influence specific aspects of PVD. When SCT is applied to treat other types of conditions (e.g. chronic musculoskeletal pain), other theoretical frameworks may be applied.

Central components of SCT include therapeutic alliance, bodily exploration, pain education, coping with thoughts and emotions, and homework to be practiced between sessions.

Bodily exploration is at the core of the SCT approach, with the aim of promoting whole-body awareness and facilitating new bodily experiences and insights. Women are also encouraged to begin relating to their vulvas and sexuality in a more positive, embodied way. As a key part of their home assignments, women are encouraged to begin approaching their vulvas with more curiosity and compassion. When introducing home exercises that explicitly involve the genitals, the goal of SCT is not to stretch or release the pelvic floor muscles (PFMs), but rather to support a shift from fear, avoidance, and shame, towards a more comfortable and positive bodily connection. This direct approach to their vulvas is continuously integrated with and related to working with the whole body, to support a reintegration of the vulva into the whole-body experience.

Conversations about sexual health are integrated into the treatment sessions related to the women’s own experiences and concerns, where topics such as setting boundaries, communicating openly about one’s pain and sexuality, and focussing on own pleasure are typically addressed.

An important goal of SCT is to empower women to take ownership of their own recovery process, through gaining bodily awareness, -insight, and -agency, and through developing individually adapted strategies to reduce pain and improve sexual function and health. To support these processes, SCT places a strong emphasis on developing a sound therapeutic alliance through empathy and a patient-centered approach. Table 1 provides a descriptive overview of the SCT treatment context relevant to this study. For more details on the SCT intervention as it is tailored to women with PVD, see Kaarbø et al. [27].

Table 1. Overview of Somatocognitive therapy as it was conducted in the context of this study (table adapted and used with permission from Kaarbø et al. [30]).

Overview	Description
Brief name	Somatocognitive therapy (SCT)
What	SCT is a multimodal physiotherapy intervention designed to target the multiple dimensions of vulvar pain, utilising a biopsychosocial approach. A bodily approach is combined with a cognitive restructuring of negative thoughts. Overall, the aim is to improve body awareness to reduce vulvar pain and psychological distress and improve sexual function.
Materials: Participants	Resources: vulva.no
Materials: Physiotherapist	Equipment included a treatment bench, mat, pillows, massage balls, mirror, Pilates ball, and educational material.
Procedures	Initial appointment: Assess participant – take a thorough history (including previous experiences, beliefs, and expectations) and clinical examination (quality of movement, breathing pattern). The main areas of SCT include the following: Therapeutic alliance is an essential component of SCT; patient and therapist are in a close working relationship, agreeing on treatment goals and home assignments. Participants take an active part in the decision-making process about their own treatment and progression. The bodily approach: breathing patterns, maladaptive movement, and postural patterns are addressed in various positions (sitting, standing, walking, and in supine). Through manual techniques and touch, participants are taught various techniques to increase body awareness, improve relaxation, and reduce muscle tension. Education about PVD, chronic pain, stress, and healthy vulvo-vaginal and sexual behaviours. Coping with emotions and thoughts related to bodily experiences. Participants learn to become aware of negative/catastrophizing thoughts and learn how to restructure or accept these thoughts as well as how to overcome fear avoidance behaviour. An important aspect is the women’s ability to adapt and to self-manage their condition such as coping with pain and flare-ups. Structured homework promoting the application of learned techniques in daily situations. Gradual exposure to activities associated with pain, desensitisation exercises, and exercises to increase the pelvic floor and vulva awareness. Relaxation and breathing exercises. Last session – create a self-management toolbox with participant.
Who provided the treatment	Experienced female physiotherapist trained in SCT, the second author of the article.
How	Each session has a three-phased structure: (1) The conversation, (2) the bodily intervention/exploration, and (3) the home assignment.
Where	In a closed room with access to the gym, outpatient physiotherapy clinic, Oslo Metropolitan University, Norway. Home assignments performed by the participants integrated into ADL.
When and how much	The median number of sessions: 12 (min 7; max 15) face to face with a physiotherapist. Treatment period: minimum of 13 weeks and maximum of 22 weeks. Each session (including the initial session) lasted up to 60 min. The number of sessions required was personalised.
Tailoring	The treatment is personalised and tailored to the individual. The patient’s participation and collaboration are important. The treatment principles are the same for all but are adapted to suit the individual’s needs.

Methods

In line with our research question exploring meaningful processes towards improved sexual health supported by somatocognitive therapy, a longitudinal, qualitative study design was emphasised. This design entailed conducting two rounds of interviews in order to explore participants’ experiences with somatocognitive therapy over time: the first author conducted semi-structured interviews of women with PVD towards the end of their treatment period, and follow-up interviews one year later. Semi-structured interviews enabled us to explore the women’s experiences, allowing us insights into potentials and pitfalls with promoting sexual health as part of a physiotherapy treatment journey [31].

Participants and recruitment

The interviews were a part of the ProLoVe feasibility study in preparation for a randomised clinical trial. The feasibility study [30] took place at an outpatient physiotherapy clinic in Oslo. Participants were recruited from the Vulva Clinic at Oslo University Hospital and were included in the study if they were diagnosed with PVD and aged between 18 and 35 years. Women with an ongoing infection or a dermatological disease in the vulvar area were excluded from participation.

A total of ten women were included in the feasibility study and the participants received a median number of twelve treatment sessions. The same ten women also signed informed consent to take part in individual qualitative interviews towards the end of the treatment period, and seven participants accepted to take part in follow-up interviews one year later. During interviews nine and ten from the first interview round, no new major themes were identified analysing the women’s experiences. However, the second round of interviews enriched themes from the first round of interviewing in the sense that the women’s experiences entailed more nuances and insights into the unfolding of long-term therapeutic processes. Given that no new major themes were identified during these interviews, the sample was considered adequate to ensure saturation on the topic.

The participants were nulliparous Norwegian women aged between 18 and 33 years. They had suffered with vulvar pain between three and fifteen years, with a median duration of seven years. Four were in stable relationships while six were single at the time the study started. Nine described themselves as heterosexual, while one discovered her bisexuality after the end of treatment. All had or were in the process of receiving higher education, and many had part-time jobs alongside full time studies.

Data collection

In line with our longitudinal, study design, the first round of interviews was conducted when the women were near the end of their treatment program. In this way, their experiences of participating in SCT were fresh in their memories. The first author conducted face-to face interviews in a private room at Oslo Metropolitan University based on a semi-structured interview guide. The second round of interviews took place approximately one year after the SCT treatment was ended, allowing insights into how the women’s experiences of therapeutic processes changed over time. Due to Covid-19 restrictions, the second round took place on zoom, a digital communication platform that enables secure sound and video transfer [32]. Each interview lasted between 60 and 90 min and was carried out by the first author, a female physiotherapist experienced with qualitative research. The researcher was familiar with the SCT approach, but not involved in the treatment of the women. Furthermore, she had no previous contact with the participants.

Following a semi-structured interview guide, participants were invited to share their experiences with the SCT approach including meaningful changes (or lack thereof) related to the treatment process. Open-ended questions encouraged the women to talk about aspects of their therapeutic journeys that felt important to themselves. Homing in on their experiences related to sexual health, the women were further asked to share their experiences with and attitudes towards sexuality and sexual health growing up, their experiences with how PVD impacted on different aspects of their sexual health, and their experiences negotiating these aspects in the context of SCT. In the second round of interviews, central themes from the first round were followed-up, and the women were asked to share their experiences of the period following end of treatment. To encourage rich narratives, the women were asked to elaborate and exemplify where appropriate.

The interviews were recorded with a Dictaphone app, with direct and encrypted transfer to a secured research server. The interviews were transcribed verbatim, and immediate impressions and interpretations were noted down after every interview to complement the transcripts.

Data analysis

Following the thematic analysis approach described by Braun and Clarke [33], data were analysed inductively. This involved coding the women’s embodied experiences related to processes towards improved sexual health with the SCT approach. The first author came across the Developmental Theory of Embodiment (DTE) during the course of analysis, and this theory functioned as a sensitising lens during the final stages of the analytical process.

The data processing software NVivo12 was used to organise transcripts, codes, and themes through the analytical process. The first author read through the transcribed texts several times to gain a good overview of each woman’s account. During this process, preliminary themes both within and across the participants started to form, related to the research question and aim. Corresponding pieces of text were coded and collated, and different ways of organising the codes into themes and subthemes were explored until a tentative thematic map was in place. The second author independently read through the original transcripts and noted down her own immediate thoughts and impressions, before comparing her own interpretations with the preliminary thematic map. She then reviewed the map for validity against the original transcripts, considering alternative or contrasting excerpts, angles, interpretations, and missing or overrepresented statements. Alternative interpretations and themes were discussed among the authors until agreement was reached. The analytical development from initial codes to subthemes and themes is outlined in Table 2.

Table 2. Overview of the analytical process from codes to sub-themes and main themes.

Codes	Sub-themes	Main themes
Performing the body Negative feelings towards own body Using food and exercise to control the body vs. moving because it feels good Beginning to experience the body from the inside Beginning to inhabit the body with more comfort and confidence From self-critical to a more friendly and patient internal dialogue Avoidance and alienation of the vulva Developing more positive feelings towards the vulva Would have preferred a more hands-on treatment of the pelvic floor muscles	Beginning to shift from performing the body, towards inhabiting the body with comfort and confidence Beginning to relate to the body in more accepting and self-compassionate ways Outcast vulva: from avoidance to curiosity and acceptance	Developing positive feelings of embodiment
High-paced, high-stress lifestyles Not paying attention to or ignoring bodily and emotional needs Body as a fearful site Daring to be present with bodily feelings and sensations A movement from meeting internal cues with fearfulness, to more curiosity and calmness Contact is important to start a healing process Discovering and addressing unhelpful bodily habits Beginning to pay more attention to and prioritise own needs and wants A holistic approach feels meaningful, but can also be demanding/overwhelming	From bodily distance to purposely directing attention inwards From vague and intimidating, to understandable bodily signals Learning to trust, learn from, and be guided by internal cues	Developing a greater awareness of internal feelings and bodily states
Sex as duty, performance, and self-sacrificing care-work Difficulties with intimacy Beginning to assert personal boundaries (guided by internal cues) Disrupted connection to sexual desire and pleasure A new mindset around sexuality Exploring and reclaiming own sexual desire and pleasure A greater interest in own needs and wants	From sex as duty and performance, to mutual satisfaction and intimacy Developing a healthy curiosity towards own body and sexuality Taking ownership of own body and sexual health	Developing sex-positive beliefs and behaviours

Ethical considerations

The study was approved by the Norwegian Committee for Medical and Health Research Ethics (2018/1036) and adhered to the Helsinki declaration. The participants received both verbal and written information about the nature and purpose of the study. Information included the right to refuse or withdraw participation. Any personal information was deidentified, and data were stored confidentially.

Sexuality can be a sensitive subject. Painful sex and topics related to disrupted sexual health is tied up with shame and taboo and can be embarrassing and even painful to talk about. Each interview therefore started with an informal chat about non-sensitive topics to establish an atmosphere of trust and comfort. As the interviews touched on sensitive and private experiences, the researcher was on the lookout for signs that the participants were uncomfortable sharing their stories and did not press for further elaboration if she felt a limit was being reached.

Results

Our findings will be organised through the three themes identified through our analysis: (1) Developing positive feelings of embodiment, (2) Developing a greater awareness of internal feelings and bodily states, and (3) Developing sex-positive beliefs and behaviours.

Developing positive feelings of embodiment

For most of the women, the SCT process supported a shift from relating to the body as an object, towards experiencing the body as a subject. Several reflected on how they for a large part of their lives had adjusted and ‘performed’ their bodies to meet cultural expectations. Sophia linked her vulvar pain to early adolescence, when she was very conscious of how other people were perceiving her body:

I was very concerned with being skinny and all those things. I would walk around and… because I knew that if I tightened my thighs like this then they looked right. And when I walked, I would tense my arms and legs. And after a while I just started doing it without even being aware of it.

Being guided to experience her body from the inside was a valuable shift for Sophia and an important part of her recovery process. Beginning to feel more comfortable and confident within her own body was a new experience for her:

I feel in contact with and in control over my whole body. And that feels really nice. Not pushing it [the body] away. I have noticed that I have started to sweat more (laughs). And that is actually very good. And I can feel that I am breathing more, that I am more alive in a way. That my whole body is more connected.

For all ten participants the vulva had been a particularly difficult and alienated part of their body. The women described how they would ignore, avoid, and even push this painful area out of their awareness. They would rather not touch it, talk about it, or even think about it. For several of the women, the vulva did not even feel like a part of their body, but rather like something separate from themselves. Most of the women associated the vulva with painful experiences and disappointment, further giving them a feeling of powerlessness. Being encouraged to approach the vulva in a more curious and self-compassionate way helped several of the women break some of the patterns of fear and avoidance tendencies and develop a closer relationship with the vulva. Adele described how her relationship with her vulva had changed during the course of SCT. Where she had previously felt anxiety, she now experienced the vulva as a more integrated part of her body:

I feel more comfortable with my vulva now. I have gradually developed a different relationship to it. Ím not so afraid of it. And maybe it is a little easier to place it, in a way. Because when it has been painful in the past, I have stayed away from it, I would avoid touching it, expecting pain. Whereas now it is not so scary anymore. I have started to become more aware of my contact with the pelvic floor, relaxing the tensions in these muscles. I think this practice has contributed to it. And to think about the vulva as part of the body. That it is not simply a problem area, being more kind to it.

Lily and Fiona, however, who had experienced little improvement following the SCT approach, felt it would have been more helpful if the therapy also included a more hands-on approach to the PFMs. From previous treatment interventions, such as physiotherapy or osteopathy, they had both experienced how manual techniques could help reduce tensions in their PFMs. Fiona also felt it would have been useful if the therapist could give her feedback on the state of tension in her PFMs and any progress, as she felt unable to assess this herself:

It [SCT] is great for the mental aspect and for relaxation and those things, but I miss a more physical approach. The therapist doesn’t do that here, it is me who is supposed to do things, if that makes sense? I particularly miss having the therapist being able to tell me if I am making progress.

Some of the other participants also had experiences with manual techniques for stretching and relaxing the PFMs from previous treatments but emphasised that being encouraged to familiarise themselves with their own vulvas and taking ownership of their own process was gentler and made more sense in a long-term perspective. As Tessa explained:

I have appreciated both approaches, but I feel that I have benefited more from this approach in a long-term perspective. The previous treatment was more short-term. Maybe you felt better the next day, but the following week it was just as tight again. Whereas here we are working more holistically. I have more confidence in this approach because everything is connected; the tensions and the pain and the breath, the physical and the psychological…

Developing a greater awareness of internal feelings and bodily states

All ten women described having a distant relationship with their bodies at the start of treatment. Some described a lack of awareness of bodily signals and needs. Others described a more purposeful strategy to live from the neck and up, avoiding checking in with the sensations of the body. To some of the participants, this disconnection from the body was tied to a busy lifestyle. Adele explained how she sometimes would forget to meet her basic bodily needs such as eating and sleeping, because she was cramming too many activities into her daily schedule. Jenna experienced high levels of stress, responsibility, and a pressure to perform at work, and stopping to acknowledge her internal states felt like an inconvenience. For others, the bodily disconnection was due to fear. Some of the women described how bodily signals could feel threatening and could give rise to anxiety or even panic. For Emily, living disconnected from the sensations of her body was a conscious coping strategy. To her, the body felt unreliable and unpredictable, and bodily signals and sensations felt intimidating. These were often met with catastrophic interpretation:

Before I had a fear that if I paid close enough attention, I might discover that there was pain, or that I might trigger pain in a way. Everything from the neck down was just gone. That part of me would have to manage on its own. I wouldn’t think about it or talk about it or anything. And that is not good, because then when something actually happens, when you react to something, you think: Oh my God! This is very unusual or really painful, or this is something I haven’t felt in a long time, this is really weird!

The explorative treatment approach encouraged the women to actively turn their attention inward, to become aware of and dare to be present with the different bodily sensations as they moved, breathed, and relaxed. Gradually, this inquisitive approach started a process moving towards listening to the body with greater calmness and curiosity, and with less fear. As bodily reactions and sensations became increasingly normalised and comprehensible, the body felt less threatening and unpredictable. Daring to be in contact with both pleasant and unpleasant feelings and sensations was viewed as an important part of the therapeutic process for most of the women. They increasingly felt better equipped to notice, understand, and address bodily reactions. To Isabelle, this process provided a greater confidence in being able to understand and regulate her bodily and emotional reactions:

I feel that I am better able to control the reactions in my body and to be present in my body. At least compared to how it was before. Before when I felt an emotion, I would just shut it out. Because that was my best way of getting through it, or to deal with it. But now I have gained some tools to handle things better, and to be aware of how I am feeling. I feel that is very useful.

As well as developing a greater awareness of bodily feelings and states, several of the women also described an important shift towards starting to value, trust, and let themselves be guided by their internal bodily cues. Accessing bodily cues as an internal guide helped Olivia to sense how her body and PFMs would tense up, and how her breathing became restricted, at the prospect of painful intercourse. It also enabled her to notice unhelpful thoughts that would typically arise in anticipation of painful sex:

In the beginning I could actually be really afraid, and then I would notice that I tensed up my entire body, I held my breath. And that is how it was before too, when I would think about having sex. So, I notice that there are a lot of negative thoughts associated with it, and then you want to protect yourself. When you expect that it will be painful, then you just sort of want to get it over with, you don’t really want to.

Gaining more insight into these connections made it easier to start letting go of unhelpful muscular defense mechanisms, for example through various relaxation and breathing techniques.

Although the process of developing a greater awareness of internal feelings and bodily states was valued as meaningful by most women, it was found to be a challenging process. As guided explorative exercises could involve encountering intimidating sensations, thoughts, and feelings previously avoided, this was sometimes a process that required both courage and persistence. Having to uncover and address painful issues at the initial stages of treatment felt hard to some of the participants. This process caused Lily to experience a surge of difficult thoughts and feelings about her past and future. In a similar vein, Jenna explained how it brought up painful memories from her childhood that she had not processed:

I guess I have tried to cover things up. That I have thought to myself that I am okay and that things are fine. And through filling out the questionnaires and talking with the therapist, I have become more aware of things…. That I actually carry with me some things that are quite difficult. So that has probably been very useful, but also hard.

Becoming aware of the complexity of different factors involved in their experiences of sexual pain could also feel overwhelming. Some found being confronted with the magnitude of different physical, mental, and behavioural habits to address at one time daunting. Although attributing a lot of her improvements to this process, Mary remembered feeling overwhelmed and even a little disheartened at first, becoming aware of her maladaptive habits and discovering how much she had to work on:

It can feel like a lot. Like everything is wrong with me. The way I stand and walk and breathe… I am doing everything wrong (laughs). It can feel like a lot. But the therapist is very good at helping me address one thing at the time.

Developing sex-positive beliefs and behaviours

Almost all the participants recounted enduring painful intercourse with their current partners, or a history of doing so if not currently in a relationship. Several tied this to a sense of duty or expectation to be sexually available in an intimate relationship and expressed a sense of guilt or shame at not being able to offer their partner sex. Most of the women’s accounts demonstrated self-effacing tendencies; down prioritising their own needs and not wanting to burden their partners with their problems. As Isabelle put it:

I guess it [enduring painful sex] is motivated by a desire to perform, in a way. And you don’t want to disappoint your partner either. Sort of trouble your partner with your own problems.

Thematizing sexual health and pleasure with the therapist, combined with an inquisitive approach to the body and its sensations, started a process of developing a new way of viewing sex. This process involved building confidence to safeguard bodily boundaries, as well as developing a healthy curiosity towards their own sexuality. Adele described how she had become inspired to be more tuned into her own needs and desires when it came to sex. She wanted sex to be ‘for my own sake, to get more pleasure and enjoyment out of it myself. That this is about me now’.

Becoming more curious about their own sexual needs and desires, several of the women expressed a stronger wish to safeguard their own boundaries concerning sex and pain, and to access sexual pleasure and joy. Feeling more empowered in sexual situations, they now felt ready to explore their own sexuality further, to try different ways of having sex, and to discover what could feel enjoyable for them. Already midway through the SCT course Olivia felt more confident in setting limits for her own body:

I have always felt very strongly that I have to perform. Even if it [sex] is only barely achievable, I do it. But then there is no longer any joy associated with it. (…) So now I have learnt to say – ‘No, this is my body, why should you…’. Just put my foot down, no matter if they don’t want me. And the more you say no, the more empowered you feel (laughs). (…) I am very positive to having sex now. I can even understand the enjoyment part better.

Rediscovering their potential for experiencing sexual desire and pleasure however, felt challenging to some of the participants. Particularly the women who had never experienced positive feelings or sensations in relation to sex found it difficult to know where to start this process of familiarising themselves with their sexuality. To Lily, being encouraged to approach her own sexuality with curiosity and patience felt frustrating as she felt at a loss as to what to look for. To her sex had only ever been associated with pain, anxiety, and shame:

I don’t really know what I am supposed to look for, because I don’t know what feels good. The only thing I think of when I think about my vulva and my self is pain. Either I feel nothing, or it really hurts.

Although challenging, most of the women found this process of connecting with their positive sexuality meaningful. Through exploring her body and sexuality, Tessa had started to learn more about ways she could experience pleasure and what she needed to ‘get in the right mood’ for sex. She had realised how important it was for her to be both mentally and physically prepared for sex. She reflected on how getting in the mood for sex was not just like turning a switch. She needed time and ample stimulation to feel ready. She also described how she used these insights in intimate situations with her husband, explaining to him what she needed him to do and making sure that sex was something that they could enjoy and take pleasure in together.

Discussion

Our findings depict three central processes towards improved sexual health. The first process, developing positive feelings of embodiment, involves a shift from self-objectification and bodily shame towards experiencing the body as a subject, inhabiting the body with more comfort and confidence, and beginning to relate to the body in more accepting and self-compassionate ways. The second process, developing a greater awareness of internal feelings and bodily states, involves a shift from bodily distance to turning attention inward and learning to trust and value bodily cues. The third process, developing sex-positive beliefs and behaviours, involves developing a healthy curiosity towards one’s own body and sexuality, developing a sense of comfort with and entitlement to sexual feelings of desire and pleasure, and developing agency to know and assert sexual boundaries and needs.

Developing positive feelings of embodiment

A major finding in our study was participants’ feelings of disembodiment at the start of the SCT program. This involved being preoccupied with meeting objectified expectations, rather than experiencing enjoyment. Resonating with these findings, a recent study reported that women with PVD often score high on measures for body-exposure anxiety [4]. As women who objectify their bodies tend to be more preoccupied with looking good rather than feeling good, sex can transform into a performance act rather than a subjective and joyful embodied experience. Shifting from self-objectification towards experiencing the body as a subjective site, on the other hand, can allow women more freedom to immerse themselves in joyful activities; to engage in the world with agency, comfort, and well-being [22].

Central to this shift, the women described how they were guided and encouraged to focus their attention inward, experiencing how the body felt rather than looked as they explored different ways of breathing and moving their bodies. Consistent with previous findings [19,34], this shift towards a more subjective experience of the body empowered the women to begin resisting the objectifying gaze of their culture and enabled a greater attunement to bodily feelings of pleasure.

The narratives of all ten women included descriptions of body disconnection and discomfort at the beginning of the SCT treatment course, describing how they mostly engaged with the world from the neck-up and harboured negative feelings about their bodies. The vulva was emphasised as an especially alienated part of the women’s bodies. Consistent with previous research, the vulva was for many associated with pain and shame, and experienced as a disconnected, ‘useless’, or ‘dead’ part of the body [35,36].

Developing more positive feelings of body connection and comfort can promote sexual comfort and agency [37]. Several of the women described how their relationship with their bodies (and vulvas) had started to change through the SCT course. They gradually began relating to their bodies in more friendly ways, where the vulva felt more connected to the whole-body experience. Home assignments aimed at approaching the vulva with curiosity, kindness, and compassion, while at the same time paying mindful attention to the whole-body, played a key role in this process for several of the women. The integrative impact of moving between part and whole in this way has previously been found to promote an experience of the body as a cohesive, interconnected unit [35]. The current findings further illuminate how daring to explore intimidating bodily sensations and emotions was also valuable to support a coherent experience of the body.

Developing a greater awareness of internal feelings and bodily states

Most of the women described either being unaware of, or actively suppressing, information from their bodies pertaining to their physical, emotional, and sexual needs. These needs could include the need for food, rest, or sleep, the need for emotional support, or the need to set limits for themselves in sexual interactions as well as in everyday life. Attunement to internal needs, and responding to these needs in self-caring ways, is fundamental to an individual’s overall health and well-being [22], of which sexual health is part.

The degree of attunement to bodily cues can also impact women’s sexual health in more direct ways. Women with disrupted attunement to internal needs and cues are more vulnerable to engage in sexual activities that they are not ready for or may not enjoy [34], feeling compelled to put other people’s needs before their own [22]. It is also likely that living disconnected from bodily signals and sensations will impede positive experiences of sexual pleasure, comfort, and well-being [18]. Supporting a shift towards greater attuned self-care could therefore be essential in improving the sexual health and well-being of women with PVD.

Several of the women in our study began developing a greater attunement to their internal feelings and needs through the SCT treatment sessions. Several also began to act on these internal cues in more self-caring ways. This involved tuning into what was going on in their bodies, and interpreting what their bodies were telling them. Some of the women described how this contributed to a greater sense of bodily comfort and agency. Coming into contact with internal feelings and cues empowered the women to make necessary adjustments to feel better in everyday situations, as well as in sexual contexts.

As our findings demonstrate, however, the process of developing a greater awareness of internal feelings and bodily states could feel both intimidating and overwhelming. It has been suggested that women with vulvodynia might find comfort in a mind-body split as a way of distancing themselves from the troublesome body [17,36]. In support of this, our findings illuminate how fear and avoidance of potential physical and emotional pain caused several of the women to distance themselves from listening inwards. By suppressing uncomfortable signals from their bodies, the women were to a certain extent able to ‘escape’ their condition and its painful implications in daily, non-sexual contexts. Avoiding attending to these internal messages however, left them out of tune with their own internal states and needs, making it difficult to accurately interpret and respond to their bodily signals in self-caring ways.

Combined with a troublesome relationship with the vulva and/or sexuality, relating to bodily feelings and internal states with anxiety and avoidance could sustain a cycle of anxiety, bodily tension, and pain in sexual contexts [38,39]. Beginning to approach and explore rather than avoid their internal feelings and sensations required both effort and courage. At the same time, counteracting these fear-avoidance tendencies was emphasised as an important part of their therapeutic process towards improved sexual health.

Developing sex-positive beliefs and behaviours

Sexual agency is an essential component of a woman’s sexual health and can be conceptualised as her ‘ability to act on her own behalf sexually, express her needs and desires, and advocate for herself’ [40]. When a woman is able to act with agency, she can navigate her sexual life and make active choices to ensure her own sexual health and well-being [41,42]. Women with PVD, however, often feel compelled to engage in sexual intercourse despite pain, to down-prioritise their own sexual needs and wants in favour of their partner’s desires, and to keep their sexual and emotional problems secret [14,15,36,43,44]. In line with these previous findings, the sexual experiences of the women in our study seemed oriented towards meeting the needs of and pleasing the other, rather than engaging with their own internal subjective needs and desires. There was little talk of their own pleasure in the interviews, and some experienced difficulties envisioning what pleasurable sex could even feel like. Our findings also illuminate how several of the women found it difficult to (re)connect with their own feelings of sexual desire and pleasure, and that some felt shameful about exploring their sexual bodies.

Developing a healthy curiosity towards their own body and sexuality was emphasised as a meaningful path towards improved sexual health for several of the participants. Being encouraged to explore pleasurable sensations in their bodies, not limited to the genital area, but rather familiarising themselves with their bodies overall, was helpful in this regard. Several also began exploring their bodily feelings of sexual pleasure, and to notice contexts that either facilitated or disrupted their ability to experience sexual desire. Beginning to develop a greater confidence in and comfort with their own sexual bodies in this way helped several of the women start to (re)connect to subjective feelings of desire and pleasure.

Developing more comfort with, and a healthy sense of entitlement to, sexual desire and pleasure has previously been found to empower women to act with more agency in relation to sexuality [18]. An increased sense of sexual agency was also expressed by several of the participants in our study. Several felt that (re)connecting with their body and sexuality in more positive ways further empowered them to communicate more openly about their pain and sexuality with their partner and to engage their partner in mutual intimacy and pleasure.

Strengths and limitations

By combining an explorative, semi-structured interview design with a feminist embodiment perspective, this qualitative study has enabled novel insights into possible interactions between the sexual health and quality of embodiment among women with PVD. The chosen theoretical framework contributes to illuminate how disrupted embodiment plays an important role in the sexual narratives of these ten women, and why experiencing embodiment and engaging with the world in an embodied way, can be challenging for them.

Another strength of this study lies in its choice of a longitudinal design. Follow-up interviews after one year allowed insight into processes of change that developed over time and helped us see how embodiment was a state the women moved in and out of, a continuous back-and-forth process. Follow-up interviews also enabled informal member checking, where preliminary interpretations from the first interviews could be validated or clarified by the participants.

This study also has some limitations that need to be addressed. Our study sample represents women who have sought out and received relevant care for their pain, and who were willing to participate in a research study and be interviewed about their experiences related to sexuality. It is possible that the sample is therefore made up of particularly resourceful women well suited for the potentially demanding SCT approach. Moreover, all ten women received treatment at the same out-patient clinic and were treated by the same physiotherapist – a female therapist with long clinical experience working with persistent pain patients. Nevertheless, the therapeutic processes narrated by these ten women might be transferable to other women in similar contexts. To allow the reader to consider the transferability of our findings in their own contexts of use, we have provided thorough descriptions of settings and participants.

Another limitation is that three of the women from the first round of interviews (Lily, Olivia, and Sophia) did not, for various reasons, take part in a follow-up interview.

Conclusion

This exploration of women’s experiences with meaningful processes towards improved sexual health has provided novel insights into disrupted embodiment as an important dimension of the reduced sexual health seen among women with PVD. Interpreted through the lens of a feminist embodiment framework, our findings identify experiences of disembodiment among all ten participants at the start of the SCT program. Our findings further suggest that through supporting subjective experiences of bodily comfort, pleasure, and agency, a bodily explorative physiotherapy approach such as SCT can initiate and support several beneficial processes that promote embodiment and sexual health among women with PVD.

Clinical implications

Exploring and considering the individual patient’s attunement to her internal states and comfort in inhabiting her body and her sexuality can be relevant when tailoring a treatment plan for women with PVD. Physiotherapeutic modalities aimed at promoting subjective experiences of body connection and comfort and attuned self-care may enhance the sexual health and well-being for those women who tend to live disconnected from their bodily needs and wants. By encouraging the patient’s active engagement in her own recovery process, the physiotherapist can help strengthen her agency to access her own feelings of desire and pleasure, to engage in (sexual) activities aligned with her own needs and wants, and to assert herself and act on her own behalf when engaging with the world.

At the same time, the women’s experiences reveal that therapeutic processes involving exploring and allowing difficult sensations and emotions can be demanding and require significant effort and courage from the patient. A flexible and patient-centered approach that enables the patient to influence the pace, intensity, and progress of her therapeutic processes is therefore important. Developing a sound therapeutic alliance with the patient, built on empathy, trust, and shared decision-making, is crucial when approaching challenges with sexual health in this context.

As highlighted in our discussion, women’s experiences of embodiment and sexual health are strongly influenced by compelling social discourses that encourage them to act demure, to objectify their bodies, and to subvert their own needs to meet the needs of others. If unaddressed in therapy, these contextual factors can hamper the therapeutic progress by limiting the woman’s agency to know, feel comfortable with, and assert her needs and desires. Supporting a shift towards an experience of the body as the self, can help these women resist the objectifying norms of their culture and to pursue pleasure and well-being on their own terms.

Disclosure statement

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

Note

Additional information

Funding

This work was funded by Oslo Metropolitan University under grant number 201127; and the Norwegian Fund for Post-graduate Training in Physiotherapy under grant number 112220. The funding bodies had no role in the design of the study and collection, analysis, or interpretations of data or the writing of the manuscript.

Notes

1 Sexual health is defined by the World Health Organization (WHO) as “a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility to having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence” (WHO, 2006).