Navigating Conflicting Ideals of Masculinity: A Qualitative Study of the Experiences of Male Partners of Women with Vulvodynia

ABSTRACT

Vulvodynia, a long-term genital pain disorder with a high lifetime prevalence, profoundly impacts both the affected women and their partners. However, the experiences of these partners have been under-researched. Using Braun and Clarke’s thematic analysis, this qualitative study explored the experiences of male partners of women with vulvodynia. In individual interviews with seven men (20–32 years), four themes were identified: “Trying to be a good and caring partner,” “Fear of sexual and emotional rejection,” “Feelings of insecurity and being misled,” and “Keeping up the façade.” Despite efforts to support their partners, the men often faced rejection, leading to insecurities about their attractiveness, the relationship’s future, and their ability to conform to social expectations. They coped by concealing insecurities from their partners and overemphasizing traditional masculinity among peers. We discuss these results using sexual script theory, suggesting that gendered sexual scripts play a significant role in relationships with vulvodynia, with prevailing cultural assumptions regarding masculinity challenging men’s ability to be simultaneously caring and sexual. As a result, the men found themselves negotiating two contrasting ideals associated with masculine behavior: those of good caregiver and assertive, virile sexual partner. Our research suggests that male partners of women with vulvodynia tend to be left alone to deal with the resulting ambivalence and distress. Supporting these men could benefit both parties in managing vulvodynia.

Vulvodynia, an idiopathic long-term pain disorder localized to the vulva, has been estimated to affect between 7 and 28% of women during their lifetime (Ayorinde et al., 2015; Pukall et al., 2016). Those suffering from vulvodynia describe the pain as burning, itching and/or like razor blades, and many avoid various activities and clothes because they hurt (Hersh, 2018). Despite the growing literature on women with vulvodynia, little attention has yet been paid to the experiences of their partners. Given that partners are often the only witnesses to these women’s suffering (Connor et al., 2008; Myrtveit-Stensrud et al., 2023), they can play an important role in the management of vulvodynia, and their responses are known to influence both the intensity of women’s pain and their daily functioning (Prenevost & Reme, 2017; Rosen & Bergeron, 2019). Partners’ responses to the woman’s pain have also been connected to the women’s attachment style (Charbonneau-Lefebvre et al., 2021; Granot et al., 2011), underscoring the importance of focusing on interpersonal aspects of vulvodynia within relationships.

Quantitative research has shown significant negative associations between vulvodynia and quality of life, both for the women suffering from it (Arnold et al., 2006) and for their partners (Pâquet et al., 2018). Male partners of women with vulvodynia have been found to be more likely to suffer from anxiety, depression, and sexual dysfunction, as well as reporting lower emotional attachment than controls (Nygaard et al., 2019; Nylanderlundqvist & Bergdahl, 2003; K. B. Smith & Pukall, 2014), although other studies have not found any differences between partners of women with and without sexual pain (e.g., Desrosiers et al., 2008). When the women perceive their male partners to be caring, understanding and validating, the couple reports greater sexual function and satisfaction, even without changes in pain (Bergeron et al., 2021). Several studies have shown that dyadic communication within the couple may impact the women’s pain, as well as psychological distress and sexual health outcomes for both partners (Jodoin et al., 2008; Prenevost & Reme, 2017; Rancourt et al., 2016, 2022; Rosen et al., 2014). Other studies have shown that the couple’s sexual and psychological wellbeing is associated with the male partner’s pain attribution, with worse outcomes for those who perceive the pain as never-ending or impacting their whole relationship (Jodoin et al., 2008).

Rosen and Bergeron (2019) proposed an interpersonal emotion regulation model for understanding how different distal and proximal factors pertaining to a couple may influence sexual dysfunctions in women. The model suggests that distal factors, predating the sexual dysfunction (like sexual communication), influence proximal factors (such as partner responses to pain) and the couple’s emotion regulation strategies (e.g., fear-avoidance versus approach behavior). These, in turn, affect their couple outcomes (e.g., sexual function and relationship satisfaction), and women’s pain. Rosen and Bergeron (2019) emphasized the critical lack of in-depth research on relationship variables in men’s sexuality.

Qualitative research on partners of women with vulvodynia is limited. Existing studies indicate that these men often experience negative feelings such as guilt and anxiety for causing their partner pain, as well as communication issues, which can lead to feelings of failure (Sadownik et al., 2017). Some men also report positive personal growth and increased unity in their relationship due to the pain (Myrtveit-Stensrud et al., 2023). One study highlighted these men’s struggle to express their own needs while considering their partner’s pain, often feeling responsible for the pain and isolated due to it (Fardal & Grennert, 2017). Their sense of isolation has been linked to their partner’s reluctance to discuss the pain, fear of exposing their partner’s intimate issues, and societal expectations around male sexuality and ideals of masculinity (Fardal & Grennert, 2017; Myrtveit-Stensrud et al., 2023). A recent study on heterosexual couples dealing with vulvodynia highlighted their struggle with communication, especially the men’s difficulty in understanding and assisting their partners (Myrtveit-Stensrud et al., 2023). The study underscored the need to understand gendered expectations, particularly in younger couples grappling with vulvodynia amidst societal pressure on sexual experience and competence (Træen, 2008). To better comprehend how male partners perceive their specific situation and challenges related to vulvodynia, it is vital to delve into the experiences of this population using qualitative methods. Therefore, our study aimed to understand how male partners of women with vulvodynia understand and negotiate their needs in the face of cultural expectations of masculinity and sexuality in a heterosexual relationship. To address this gap in the literature, we explored the following question:

How do young men experience their role as partners of women with vulvodynia?

Theoretical Framework

The way we understand and negotiate our sexuality and our identity as sexual is socially constructed, where norms and ideals frame how our sexuality will be expressed and practiced. Within this paradigm, script theory describes how social roles and functions are learned, where scripts are cognitive representations of events that guide expectations for similar events, which in turn shape these events (Dworkin & O’Sullivan, 2005). Scripts include norms that guide behavior, individuals’ interpretations of the implications of cultural norms for interpersonal interactions, and individuals’ constructions of their desires. Scripts have been conceptualized in a number of different ways. In early versions of script theory, the focus was on general scripts regarding people’s expectations about the order in which events unfold (Schank & Abelson, 1977). Sexual script theory, developed by Gagnon & Simon (1973) postulates that sexual behavior, like other behavior, is socially scripted. Their theory explores sexual scripts at three levels: cultural, interpersonal, and intrapsychic (Gagnon, 1973, 1990; Gagnon & Simon, 1973). Cultural scripts, influenced by social institutions and media, shape perceptions of appropriate sexual choices. Interpersonal scripts are shared expectations and interpretations of cultural scripts and responses to immediate others’ cues and actions. Intrapsychic scripts combine internalized cultural and interpersonal scripts with personal desires and arousal patterns (Gagnon, 1990; Morrison et al., 2015). These desires and preferences are also shaped largely, but not entirely, by cultural scripts (Gagnon & Simon, 1973; Morrison et al., 2015). One could say that the cultural script serves as a roadmap for men’s and women’s sexual interactions with each other at the interpersonal level. It also acts as a framework through which men and women perceive and emotionally react to sexual behaviors at the intrapsychic level (Gagnon, 1990; Wiederman, 2005).

Previous research has uncovered gendered differences in sexual scripts, suggesting that while men’s scripts tend to be direct, proactive and more sex-oriented, women’s tend to favor indirect, reactive and less sex-oriented behavior (Morrison et al., 2015). In line with sexual script theory (Gagnon, 1990; Simon & Gagnon, 1986), men tend to report having more sexual partners, casual encounters, and permissive sexual values than do women (Beadnell et al., 2008; Byers, 1996; Flood & Pease, 2009; LaPlante et al., 1980; O’Sullivan & Byers, 1993; Rose & Frieze, 1993; Santana et al., 2006; Seal & Ehrhardt, 2003; L. H. Smith et al., 2005; Tolman et al., 2003). However, individuals vary in their adherence to scripts, and their preferred scripts can change over time and across situations. Notably, individuals interpret, reshape, and enact scripts differently. Despite gender-based trends, substantial variations exist between individuals, and also occur within the same individual over time (Morrison et al., 2015).

In line with our research focus, we drew on sexual script theory (Gagnon, 1973, 1990; Gagnon & Simon, 1973) to gain deeper insight into how scripts and ideals of masculinity acquired significance in participants’ efforts to support their partners. Sexual script theory (Gagnon, 1973, 1990) seeks to shed light on the ways in which cultural norms can shape and challenge individuals’ sexual expectations and behavior. The idea is that individuals learn and internalize appropriate sexual behavior in gendered ways. Consequently, there is a risk of conflict between appropriate sexual conduct and the individual’s needs and desires. While an individual might act how she or he wants in a given situation, most individuals feel pressured to behave in certain ways to avoid embarrassment and social ridicule (Ford, 2021). For young men, this can involve living up to a set of expectations where they are supposed to take advantage of any sexual opportunity, as traditional sexual scripts focus on men initiating vaginal intercourse, while women’s role is to comply with and manage men’s desire and prioritize their pleasure (Ford, 2021).

Method

In line with our research question, with its focus on gaining insight into partners’ experiences, this study utilized a qualitative approach based on in-depth, individual semi-structured interviews.

Researchers

The authors of this article comprise two clinical psychologists and two physical therapists, all with clinical experience related to chronic pain. We believe the professional background of the interviewer (a clinical psychologist) encouraged participants to give thought to psychological aspects of their situation. The interviewer was in the same age group as the participants, which we believe was a strength as it seemed to ease communication during the interview process. Participants spoke in detail and elaborated on their experiences, providing rich and nuanced data.

Participants

Our sample comprised seven men aged 20–32 years who were in romantic relationships with women diagnosed with vulvodynia (either localized, generalized, provoked, or unprovoked). The women had been suffering from vulvodynia from one year to more than ten years. Participants were recruited through their partners, who invited them to join the study. Five of the women were recruited through a physiotherapy clinic giving specialized treatment for vulvodynia (where one of the authors worked), while the last two were recruited through the Norwegian patient organization for vulvodynia. Our experience was that all women asked to participate were positive, while many of them struggled to get their partners to participate. About half of the men asked to participate declined the invitation for unknown reasons. One couple was married, while the others were in monogamous relationships that had lasted between one and ten years. None had children. Four of the men were urban-based Norwegian nationals while the other three came from other countries but were resident in Scandinavia at the time of being interviewed. Participants were either students or working full-time. The participants are presented in Table 1 with fictive names.

Inclusion criteria for our participants were that they were in a relationship with a woman aged between 18 and 30 years (there were no age restrictions for the male partners), given a diagnosis of vulvodynia by a gynecologist, as well as the current relationship having lasted at least three months. Exclusion criteria were that the woman had given birth the last year or had other infections or disorders that could account for their genital pain, as well as serious mental disorders for any of the participants.

Interviews

Individual interviews, lasting 45–120 minutes, were conducted with all participants by the first author. The first 3 interviews were conducted at a university office, while the remaining 4 interviews were conducted via video calls (with both interviewer and participant linking up from home due to the COVID-19 pandemic). The interviewer perceived that video call interviews facilitated a more relaxed environment. The glimpse into the home setting, including pets, seemed to put both parties at ease and encouraged more open conversation. One interview was conducted in English, while the rest were conducted in Norwegian. Extracts from the interviews conducted in Norwegian were later translated into English by the first author. Participants were encouraged to speak as openly as they felt comfortable with. The interviewer perceived the participants to be open and truthful to such a degree that it was decided to withhold certain statements for ethical reasons, for example when a participant spoke about possibly leaving their partner. An interview guide comprising semi-structured questions was used (see Appendix). Semi-structured interviews have the advantage of allowing the researcher to be flexible and sensitive to specific topics the participants wish to bring up (Kvale & Brinkmann, 2009), including some the researcher may not have previously considered relevant (Moen & Middelthon, 2015). Indeed, the interview guide was revised to include questions about experiences of sexual violence, as this was brought up by some of the participants. Most participants responded at length to each question. When two of the men struggled to articulate their experiences, the interviewer encouraged them by asking follow-up questions. At the end of each interview, participants were asked if they wanted to add anything. They were also invited to call the interviewer afterward if they wished to (in the event, none did).

Analysis

Our analysis was inspired by Braun and Clarke’s (2006) thematic analysis, a flexible approach in terms of theoretical standpoints, and number of participants. The thematic analysis followed six steps: (1) familiarizing ourselves with the data through interviewing, transcribing and repeated reading; (2) generating initial codes; (3) searching for themes and the relationship between codes; (4) reviewing (including combining and separating) themes to achieve internal homogeneity and external heterogeneity; (5) defining and naming themes and organizing them into a coherent and internally consistent account; and (6) producing a report that can convince the reader of the merit and validity of the study.

The analysis started inductive/data-driven, which means that tentative themes were derived directly from the data (Braun & Clarke, 2006). Analysis began during the interview process, with the first author starting the process of interpreting participants` descriptions and reactions. Interpretation continued during transcription and repeated readings of the material, seeking to identify themes perceived as particularly salient. Codes were marked with different colors and tabulated, together with the different themes, by the first author. The coding process was inductive in the sense that we focused on participants’ experiences, their interpretation of them, and what seemed to be emphasized in their replies to various questions. In these initial stages, we stayed close to participants’ experiences without determining the specific theory that would provide more insight into these experiences.

More specifically, we focused on terms and phrases explicitly stated by the men in their responses, such as in the following statement: “Another reason I’ve considered, it’s just that she’s a lesbian and not interested in men anymore.” Comparing and contrasting phrases in the transcribed interviews, the first author identified patterns across the men’s experiences, for example, patterns involving rejection. This led her to ask analytical questions during the coding process. What do the men say about rejection and how do they express this in the interviews? What do they indicate implicitly regarding rejection? Identified patterns were then systematized in terms of tentative themes and subthemes and in this process, coauthors actively participated in discussions and possible interpretations. For example, patterns involving rejection were developed into the subtheme “Explanations for being rejected” and then linked to the overarching theme of “Fear of sexual and emotional rejection.”

In line with Braun and Clarke, themes do not “emerge” from the data, but are developed through systematic identifications of patterns and analytical questions and discussions during the coding process (Braun & Clarke, 2023). Throughout the process, repeated discussions between the authors helped identify patterns and link similar patterns into subthemes and main themes. In particular, implicit statements were discussed and interpreted as to how to code them and how to understand their meaning. For instance, the statement “Another reason I’ve considered, it’s just that she’s a lesbian and not interested in men anymore,” was interpreted as implying that a man should be sexually appealing to his partner, and if he faces rejection, it could potentially be attributed to the female partner’s sexual orientation.

We focused particularly on how the men presented themselves as men in relation to cultural expectations around male sexuality, which led us to study sexual script theory (Gagnon & Simon, 1973) to gain deeper insight into how sexual scripts and ideals of masculinity acquired significance in participants’ efforts to support their partners. In other words, relevant theory was included in the final stages of analysis, to get a more abstract sense of what the men’s experiences revolved around and how to understand them in terms of sexual norms, ideals, and masculinity. Hence, in the discussion, thematic findings are interpreted in light of sexual scripts and relevant research.

Ethics

The participants signed informed consent statements and the study was approved by the Norwegian Centre for Research Data in Oslo, Norway (registration form 846535; date of approval: May 3rd, 2021).

Results

Our analysis identified four themes that seemed to encompass men’s experiences as partners of women with vulvodynia. The first theme, “Trying to be a good and caring partner,” addressed the ways in which men navigated their partner role. Next, the theme we titled “Fear of sexual and emotional rejection” encompassed participants’ encounters with, and management of, sexual and emotional rejection. The third theme, “Feelings of insecurity and being misled,” set out participants’ concerns about vulvodynia’s impact on their relationships and identities. Finally, the theme “Keeping up the façade” revealed how participants conducted role transitions in various contexts. Each of these four themes is explored below, supported by quotes from interviews (set in italics). All participants have been assigned fictional names, to preserve anonymity and facilitate a comprehensive understanding of their experiences.

Trying to Be a Good and Caring Partner

Participants spoke at length about the ideals they associated with being a good partner. These ideals included contributing to their partner`s improvement by showing empathy, offering emotional and practical support, and stepping back to give their partner space until they got better. The men were often motivated to create a better future relationship, one where the sexual relationship with partners still had positive associations. There were different opinions about how to achieve this goal. Participants varied in the degree to which they sought to be involved in partners’ treatment for vulvodynia. Some men worried that their participation in such treatment might reduce the possibility of having a positive sexual relationship later on. The introduction of physical exercises as part of the treatment process, such as breathing exercises and massage techniques from physical therapists, was a challenge for several of the men. Participants who disliked helping with physical exercises told of how such exercises seemed to remove the emotional and spontaneous component of sex they had previously enjoyed. As Matt put it: “What caused a lot of problems was that we came back to these things that one should try to do together, that the sexuality completely lost all emotion and became a clinical exercise.” Other participants felt that participating in such exercises placed them in the role of professional caregiver rather than that of loving sexual partner. There was also a sense of being made sexually redundant, as George bleakly put it: “She could just as well use a dilator. She doesn’t need me at all to do [physical exercises].”

Most participants regarded vulvodynia as a woman’s problem. This led them to withdraw sexually and wait passively for their partner’s health condition to improve. By this means they avoided putting pressure on their partners to perform sexually. Some participants described this as part of their role as partners. While some participants preferred to observe their partners` treatment from the sidelines, others wished they had been more included in the process. Chris explained how his passive and withdrawn way of coping was also related to fear of rejection:

I’m in the situation where I’m sort of waiting for a green light from her to say that she wants to try things again. (…) I find myself in a situation where, obviously if I ask and get rejected, that hurts.

Roy’s attempt to take a more proactive role in his partner`s treatment proved short-lived:

I tried to get her to do yoga. Even though I don’t do yoga myself, it’s a way to calm down. Or something like meditation before bedtime. […] But she wasn’t very keen on meditating or doing yoga, so it didn’t work out.

Paul, too, had sought to participate more in his partner’s treatment, only to find his initiatives rejected. As he ruefully put it: “I’ve offered her a couple of times to go with her to treatment. […] I really wanted to participate in that … ”

In addition to avoiding taking the sexual initiative, the men also avoided bringing up conversation topics related to sexuality in an effort to make their partners feel better about their situation. The reluctance or failure of couples to discuss their sexual relationship surfaced repeatedly during interviews. Paul explained his situation thus: “I think she’s the person I talk the least to about sexuality, in a very strange way. I talk more about it with my friends. It’s almost awkward.” Such lack of communication could form part of an effort to be a good, considerate caregiver. At the same time, it contributed to participants’ feelings of rejection and sexual redundancy.

Fear of Sexual and Emotional Rejection

For our participants, a key feature of living with a partner with vulvodynia was to have one’s sexual initiatives regularly rejected. In addition to the sexual rejection, most men talked about feeling emotionally rejected when their partner withdrew from them, giving rise to worries about the relationship. Chris coped with his fear of rejection by avoiding potentially intimate situations:

There have been times when I go to the bedroom, and she will be perhaps reading something, and then continues to read. And I feel like, you know, she might be wearing headphones or looking on her phone or something. […] If she wanted [sex] to happen, it would happen. But she’s clearly more interested in reading whatever article she’s reading at the time.

Although the men knew their partners’ painful condition was the primary reason for their avoiding intimacy, many wondered if other factors were also involved. Most participants had at some point worried that they were about to be left by their partner, whom they experienced as becoming increasingly distant. Some women rejected not only their partner’s sexual initiatives but also other forms of physical and emotional intimacy. In Paul’s case, this led him to have doubts about his partner’s sexual preference:

Another reason I’ve considered, it’s just that she’s a lesbian and not interested in men anymore. I’ve thought about that a lot. Both wondered about it and gone around thinking about it all the time. My manly hands wasn’t … She doesn’t see the appeal, in a way.

In addition to their fear of rejection, the men feared the negative consequences of initiating intimacy, especially the possibility of causing pain: As Matt explained,

I know that very often when we try, it ends up being a negative experience for us both. The fact that she might experience pain, and I have to stop and comfort her. […] It takes quite a bit of emotional energy to go through that, and it’s not necessarily a positive experience. And then it ends up with you dreading sex instead of looking forward to it.

Some participants spoke candidly of how they “turned down” their libido so as not to get sexually frustrated or disappointed by further rejection. In his account, Tom made use of metaphors drawn from the electrical field:

It has been quite a significant transition: from giving in to desires when they arise to possibly – at least periodically - having to work a little to suppress them. And when it’s once or twice, you don’t think much about it, other than that today she didn’t want to. But it’s clear that when you’re there for the hundredth time in a short period, something happens to the emotional spectrum inside the body. You become disconnected, in a way. I feel like it’s a dimmer that’s completely turned down, but it’s still possible to turn the switch back up again. It’s not a fuse that has blown for good.

Feelings of Insecurity and Being Misled

When their sexual initiatives were spurned, most participants felt insecure about themselves and their relationship. Indeed, some feared that such rejection was a sign that their partners were going to leave them. All the men described experiencing some form of insecurity, most often about the cause and prognosis of their partner’s pain and their role as partners in a changing relationship. Some of the men, particularly the younger ones, spoke of concerns about their sexual proficiency. In the absence of a better explanation for what had provoked their partner’s vulvodynia, they wondered if their lack of previous sexual experience had somehow contributed to it. In the case of Chris, a difficult first experience with his partner contributed to his growing insecurity and hopelessness:

I’d never sort of had high expectations, that the early stages of being intimate together would be amazing. I thought it would be awkward, tricky, and embarrassing. I thought we would then get better, and I thought that we would get to know each other in those areas, in those ways, better over time and improve. But what happened was instead that it started very badly and then never took off from there. […] Every time we would try it would reaffirm how bad this was.

Chris worried that his lack of sexual experience not only made him less attractive to his girlfriend but also injured her physically. It did not help that prior to developing vulvodynia his girlfriend had been in previous relationships:

I believed at the time that I was at fault, or that something I did - because I didn’t know what I was doing - had injured her… If it had always been like this, in every one of her relationships, then you feel like you’re the guy who is dating the girl who has this problem. But instead, I’m not dating this girl that has this problem. It’s “I’m dating the girl who has this problem now.” While she’s in a relationship with me is when she has got this problem.

Another source of insecurity was the fact that the women had in some cases suffered from vulvodynia for months, sometimes years, without telling the men anything about it. This gave rise to insecurity about how their partner was doing. Would she actually speak up if she was experiencing pain? Arthur found out about his partner’s pain after quite some time. At the time of being interviewed he was still unsure exactly how and when her vulvodynia had started: “In retrospect, it came as a bit of a shock. […] I think she actually mentioned it briefly, just that she’d had [vulvodynia]. So, it was a bit difficult to know when she didn’t have [pain] initially.” Tom, too, described finding out about his partner’s condition only after some time, and how this added to his sense of insecurity: “I feel that it was a bit of a performance on her part during that period. And that I didn’t understand what was really happening… Then one can easily feel a little foolish.”

Most participants described finding it easier to cope with their partner’s vulvodynia once she finally explained when and where she felt pain. On this basis the two of them could try to avoid pain without having to avoid all sexual intimacy. For Arthur, the worst aspect of vulvodynia was not knowing how to communicate with his partner. Developing this skill together proved a game-changer:

Right now, when we manage to communicate… It’s definitely the psychological part that comes later on, because we didn’t communicate about this at the start [that’s the worst thing]. […] It’s always possible to fix things, or talk about things, about how one is feeling … so that it gets a little better.

Keeping Up the Façade

The men described being conscious of how they presented themselves, their partners, and their relationships to others. Some perceived it to be much more socially accepted to talk about infertility issues than sexual problems due to vulvodynia, whether they were concerned about fertility or not in their current relationship. Perhaps not surprisingly, the older participants talked more about concerns related to fertility than the younger ones. In a situation where peers had started families, these men found themselves confronting worries about having children of their own. For Tom, the most profound consequence of his partner’s vulvodynia was the lack of biological children, and the further strain this placed on their relationship:

It could be many months between times [we had sex], and then it also becomes a little difficult to think about having children when you experience that. […] I would say that this is the most difficult experience we have had with [vulvodynia]: that it has led to us not having children today. […] If she had been diagnosed earlier, I’m quite sure that we would have had children.

There is real sadness in Tom’s wondering whether his chances of starting a family would have been different if his partner had received a speedier diagnosis and more effective treatment. Despite Tom’s deep regrets about not having children, other participants felt that this aspect of having a partner with vulvodynia was the easiest to present to other people. As Chris explained:

I think it’s more acceptable to society to try to have kids, because that’s something that we expect couples to do, sort of. And when they fail at it, we care about that journey. Whereas when it’s like a couple is not having sex …

For Chris, social norms allowed couples to talk more openly about their fertility than their sexual activity, perhaps because vulvodynia was seen primarily as a woman`s problem, unlike fertility which was considered more of a couple`s issue and less taboo. Participants spoke of how, when they were with family and friends, they could not talk about their situation as that would reveal their partner’s intimate secrets. Matt expressed it thus:

The biggest issue with this is perhaps that it’s impossible to discuss it without circling back to her problem, and I don’t want to talk about other people’s secrets in any context. […] I can’t talk about it without first knowing that they are aware of it and are somehow familiar with it. And very few people are, primarily her closest girlfriends, and I can’t talk to them.

In a similar vein, Paul emphasized how his partner would be hurt if he raised the topic with anyone: “I try not to discuss such things because I know it’s something she takes quite personally. So, I’ve never talked to anyone other than her about it. […] I think she would be hurt.” In addition to not wishing to “out” their girlfriend, some participants spoke of how cultural ideals surrounding masculinity made it difficult for them to reveal their curtailed sex lives. Chris had this to say:

I think there’s a lot of societal pressure to have an active sex life. I think that if you put your hand up to say, “I’m the guy whose girlfriend doesn’t have sex,” that’s a lot of social stigma to pick up. […] I’d rather [my friends] think that I have this perfect life: I’ve got the job, got the girl, got it all together. But if they discover that in fact we’re not having sex, it sort of shatters that illusion. […] And I think guys are very much … Their social ranking is very much a rant of how good their sex life is. I think that’s a big thing for guys.

Chris also emphasized how others’ lack of understanding made it difficult to bring up the topic, since in most cases they would react by offering him unhelpful advice:

When it comes to us, or this intimacy issue, very much of it is “Well, you’re probably not being intimate enough. You’re not approaching intimacy the right way, and if you set the mood, set the tone better, you would get better results.” And that’s not the issue. There´s a medical component to it as well, that is hard to prove exists.

Participants attempted to conceal their difficulties from friends, especially other men. They would avoid conversations where sex might be brought up, to avoid having to lie – or tell the truth. As George bluntly put it: “I wouldn’t talk about how I can’t enter [my girlfriend] unless I’m half-erect. I would never talk about that to any of my mates.” Other participants seemed to cope with the lack of sexual activity by framing sex as less important now than it used to be, or as less important than other aspects of their relationship. As Tom makes it clear: “I love her just as much today as when we began seeing each other. I’ve learned to accept the whole package, and I would never exchange her for anything in the world.”

While participants often found it difficult or impossible to talk openly about vulvodynia with other people, conversations with their partners about the situation were equally difficult. Prior to being interviewed for this study, most participants had never previously talked about living with vulvodynia. Indeed, some said at the end of an hour-long interview that they had just talked more about their sexuality with the interviewer than they had ever done with their partner. Chris described how he avoided going to the bedroom at the same time as his partner, to stave off a potential confrontation with her about their sexual issues:

Essentially, we avoid each other, in that space. Because if I go to bed the same time as she does, it then becomes very obvious, the issue in the bedroom, that nothing is happening. […] If we don’t try [to have sex], we can both pretend that maybe things will get better. But if we try, we might then discover that things are actually worse than we thought, and it will never happen.

By this means Chris seeks to maintain the façade at home. For him, it is a way of keeping the peace while at the same time upholding his self-esteem and hopes for a better future. When in the company of others, some participants compensated for their lack of sexual activity either by pretending to be more sexually active than was the case or by focusing on previous sexual experiences. Some sought to present themselves as hyper-masculine: for instance, by emphasizing how sexually dominant they were, as in the case of George:

Sexually, I’m very dominant, so I take control of the situation and steer it entirely. So, I’ve never had to - shall we say, hint? I’ve never had to hint to show that I want to have sex now. […] It’s not like you have to try and figure out “Is it okay to touch here, is it okay to touch the hair, is it okay to touch the breasts?” That has never been an option. Considering how dominant I feel I am, sexually, I should just be able to - is it okay to say this? - just help myself, in a way.

Discussion

Overall, our participants expressed a desire to support their partners and relationships. However, they often felt rebuffed in their efforts to discuss matters with their partner or offer support. These rejections led to insecurities about the future of their relationship, and about their attractiveness as sexual and romantic partners. To cope, they concealed their struggles from partners and peers, projecting a masculine image outside the relationship. Prominent in our findings are feelings of ambivalence about adhering to different, sometimes contrasting ideals and goals. The men struggled to juggle between being caring and upholding traditional norms associated with masculinity. They experienced insecurity when approaching their partner, fearing rejection while longing for intimacy. In this regard, the men seemed to negotiate two contrasting ideals associated with masculine behavior: on one hand, the good caregiver and on the other hand, the assertive, virile sexual partner. We will discuss these findings through the lens of sexual script theory (Gagnon, 1973), elaborating on how cultural norms sometimes intertwine with men’s needs and desires in an ongoing conflict.

Navigating Opposing Cultural Expectations

Script theory posits that internalized sexual scripts shape interactions between partners in romantic relationships, as well as individuals’ sexual preferences and desires. Men experience pressure to be sexually experienced and interested, in control, sexually dominant and powerful (Connell & Messerschmidt, 2005), as our participant George particularly exemplified in our study. Insufficient sexual interest may lead to their masculinity and heterosexuality being questioned, which becomes problematic for our participants when they are hindered from showing their sexual interest with their partners.

The experiences recounted by our participants suggest that their adherence to prevailing male sexual scripts was challenged by their partners’ suffering from vulvodynia, which tended to emphasize their role as caregivers rather than as sexually active, virile men. In Western culture, there are competing ideals regarding how men should behave in romantic relationships, with aspects of caring seen to conflict with more traditional notions of masculinity (Elliott, 2016).

Our findings reveal variations in the emphasis placed by participants on traditional notions of masculinity: while some gave it prominence, others placed greater weight on caregiving. Several of our participants cared for their partner by withdrawing sexually, in order to help them to recover from vulvodynia. This emphasis on care goes against traditional masculine ideals of being sexually assertive and taking the sexual initiative. As a result, the men found themselves negotiating two contrasting ideals associated with masculine behavior: those of good caregiver and assertive, virile sexual partner. Sexual initiatives were also hindered by the participants’ suspicion toward their partner’s honesty about their pain. In line with the traditional sexual script, women are expected to submit to their partner’s desires (Sanchez et al., 2012), which often entails “finishing what they have started” until the man reaches orgasm, and avoid “making a scene” by rejecting a male partner (Ford, 2021). Our participants seemed to be aware of such expectations as they were hesitant to take initiative when they were unsure about their partner’s pain level and sexual interest.

Previous research has pointed to multiple coexisting masculinities within a hierarchical structure, positioning hegemonic masculinity as the dominant form (Connell, 1987). Hegemonic masculinity is characterized by sexual prowess and appeal, with emphasis placed on high levels of sexual activity and satisfaction (Connell & Messerschmidt, 2005). Despite the powerful influence of hegemonic masculinity in contemporary, Western society, diverse expressions of masculinity offer possibilities for personal choice and change. At the same time, these choices may give rise to tension and ambivalence as men find themselves confronting different masculinity ideals. As our findings highlight, such conflicting ideals become particularly visible for men involved in their partners’ treatment for vulvodynia.

In heterosexual relationships, the caregiver role has traditionally fallen to women (Calasanti, 2010; Elliott, 2016; Swinkels et al., 2017). The concept of caring masculinities (Elliott, 2016), diverging from traditional hegemonic masculinity (Connell & Messerschmidt, 2005), offers an alternative, emphasizing relationality and positive emotions. In our study, some participants spoke of how embracing supportive approaches helped them to cope better with their situation. However, others struggled to offer support, resulting in emotional withdrawal, strained relationships, and avoidance of sexual activity.

Negotiating Intimacy

As they sought to conform to societal expectations around masculinity while also offering care – and risking the rejection of their caring initiatives – the men struggled to navigate their role as partners. Uncertainties about their desirability as sexual partners generated significant distress, as it clashed with conventional notions of men as sexually confident and assertive. In addition, they struggled with the guilt of possibly causing pain and distress to their partners. Should they be sexually assertive, or should they withdraw from sexual situations? In addition to worrying about never having sex with their partner again, some participants expressed concerns about finding themselves childless as a result of their partner’s vulvodynia. This in turn led them to grapple with existential dilemmas concerning their commitment to their partners.

While some of the men in our study wanted to take a more active role in their partner’s treatment, they grappled with concerns about how such involvement might negatively impact their sexual relationship. Despite the findings of previous research suggesting that men’s involvement in their partners’ vulvodynia treatment can both help their partners (Bergeron et al., 2018; Danielsen et al., 2018) and give the men themselves a sense of control in a challenging situation (Myrtveit-Stensrud et al., 2023), some of the men in our study felt that their active involvement in treatment would constrain them sexually and reduce them to mere caregivers.

Over recent decades, the expectation of shared sexual activity has played an increasingly prominent role in the satisfaction and happiness associated with romantic relationships (Schwartz & Young, 2009). In Western society, sexual activity and satisfaction are commonly associated with several benefits for romantic relationships, including increased relationship satisfaction, love, commitment, and pair-bonding (Birnbaum & Finkel, 2015; Meston & Buss, 2007; Sprecher, 2002). In monogamous relationships, partners rely solely on each other for sexual fulfillment, making sexual rejection particularly challenging (Sanford, 2003). As our findings highlight, participants felt discouraged by repeated rejection, whether of their sexual initiatives or their attempts at caregiving. Fearing abandonment, the men expressed hesitation about taking future initiatives. Some also felt responsible for their partners’ pain, attributing it to their behavior, whether this involved instances of excessive assertiveness or unintentional harm stemming from their limited sexual experience and lack of proficiency. Such feelings of guilt appear to contravene traditional masculine scripts and ideals around sexual prowess and competence, and heterosexual scripts positioning intercourse as the ultimate form of sexual intimacy. Such potent cultural assumptions were reflected in our participants’ experiences and helped explain their uncertainty about how to handle their situation.

While refraining from sexual initiation can be interpreted as an act of caring, it can also be understood as a way of avoiding difficult and shameful emotions following rejection. This kind of relationship dynamic has been highlighted by previous research on heterosexual couples with vulvodynia (Myrtveit-Stensrud et al., 2023), while studies of discrepancy in sexual desire suggests that couples tend to go into a demand/withdrawal dynamic (Girard, 2019). Previous research has shed light on how the way sexual advances are declined also plays an important role in relationship well-being (Day et al., 2015; J. J. Kim et al., 2020). Research suggests that, in general, men tend to experience sexual rejection more frequently than women, given that, in heterosexual relationships, the role of pursuer and initiator traditionally falls to men (O’Sullivan & Byers, 1992). Human sexual activity is typically measured in terms of quantity/frequency, not simply in the media and other purveyors of social norms but also in research. While several representative cross-sectional studies have indicated that couples have sexual intercourse on average 1–2 times per week (Badcock et al., 2014; Fugl-Meyer et al., 2000; Stabell et al., 2008; Ueda et al., 2020), other studies have found sexual advances being made 3–4 times per week (Byers & Heinlein, 1989), which suggests that about half of sexual advances do not proceed to intercourse. One study has found a correlation between sexual advances, irrespective of whether they lead to intercourse, and increased levels of sexual satisfaction (Dobson et al., 2020). This opens a way for couples dealing with vulvodynia to increase their sexual satisfaction without potentially painful intercourse: it may be that the indication of desire and interest plays a greater role in sexual satisfaction than the physical act itself.

Man of the House or Man About Town?

While some of the men were content to adhere to a caring interpersonal script within their relationships, they were aware of deviating from the traditional cultural script. Indeed, the men seemed to experience ongoing ambivalence as they sought to juggle various scripts in different contexts. These findings can be related to previous research highlighting male partners’ inclination to support their partner with vulvodynia, while at the same time presenting themselves to their peers as socially and sexually competent (Myrtveit-Stensrud et al., 2023).

Although it appears that men and women are currently transitioning toward more egalitarian scripts than before (Masterson & Messina, 2023), the traditional sexual scripts still dominate heterosexual encounters (Bowleg et al., 2004; Christensen, 2021; Dworkin & O’Sullivan, 2005; Masters et al., 2013; Morgan & Zurbriggen, 2007; Vannier & O’Sullivan, 2011). Studies of traditional sexual scripts in popular media support the notion that these scripts are normalized through gendered sexual socialization (Dillman Carpentier et al., 2017; J. L. Kim et al., 2007). The most prevalent script in the foundational work of J. L. Kim et al. (2007) is the “sex as masculinity” script, suggesting that men are expected to engage in sex, regarding it as a crucial aspect of their masculinity. Our findings support the notion that sex, and particularly intercourse, is paramount to uphold masculinity among young heterosexual men.

Individuals may conform more to gendered scripts in situations where interpersonal stakes are high, such as in romantic relationships or sexual interactions, as failure to do so may involve painful rejection (Sanchez et al., 2012). Thus, fear of romantic rejection seemingly enforces men and women to conform to gender stereotypes, even if their fears might be unfounded (Sanchez et al., 2012). This line of argument highlights why some of the men in our study felt the need to emphasize their masculine traits.

In our study, most of the men expressed feelings of shame about not living up to traditional masculine ideals. Nevertheless, when with their peers they sought to present themselves as totally in tune with traditional notions of masculinity. Such behavior would appear in line with contemporary culture’s emphasis on social and sexual competence as intertwined (Træen, 2008). Previous research has shed light on how young men may find themselves pulled between adhering to the traditional masculine scripts they recognize in the culture and their yearning for less conventional interpersonal scripts (Dworkin & O’Sullivan, 2005; Masters et al., 2013; Morrison et al., 2015). Such findings support the notion of scripts operating at multiple levels simultaneously (Gagnon, 1973), as well as the diversity of cultural scripts (Harding, 2007), providing room for individual choice and change.

Finally, the fact that some of our participants interpreted their partners’ reluctance to engage in intercourse as a possible indicator of a lesbian sexual orientation merits consideration. It seems possible that this interpretation serves as a means of preserving a man’s sense of masculinity and desirability. By attributing their lack of sexual activity to external factors unrelated to themselves, these participants were able to shield their self-esteem and uphold their adherence to traditional masculine norms.

Strengths and Limitations

The main strength of this study was the in-depth interviews conducted with our participants who we perceived to be sharing their experiences in a very open and honest manner.

The biggest limitation was the difficulty of recruiting participants, with many men declining to participate for unspecified reasons, and therefore resulting in a limited sample. It could be argued that male partners are difficult to include because they find it difficult to talk about vulvodynia as they consider it their partner’s problem and something they should keep secret. Taking into consideration the possibility of a gendered understanding, participants may have been willing to disclose more or other aspects with a male interviewer.

Their partners were likely unrepresentative of the general patient population, as most had received extensive private health care and had suffered from vulvodynia for a long time, which means that they had the knowledge and means to navigate the health care system. This means that our participants’ partners, and also our participants, likely had higher health competency and socioeconomic status than the general population. All our participants had been in their relationships for at least a year, while many couples break up before this time. Most women with vulvodynia never tell their partners about it (Elmerstig et al., 2013), and many men leave romantic relationships without sex (McPhillips et al., 2001). This means that our participants likely communicate better with their partners than many other couples, and they likely place less value on sexual activity to maintain their relationship. Our results are likely most representative for Scandinavia, as the participants in this study are situated in a cultural context of relatively high gender equality and sexual liberalism, which likely influence the adherence to gendered sexual scripts. However, our results do show many similarities with American studies, but perhaps with less clear gender expectations.

Finally, our participants’ age span can be considered a strength, as it shows similarities and differences in the men’s life situations. However, it can also be perceived as a limitation in terms of varying life stages with different previous sexual and relationship experience, as well as differing focus and goals in life. This is particularly prevalent in relation to having children, which some men considered the most important aspect of vulvodynia, while others had not thought about it at all. Rather than age alone, the duration of the relationship also shapes the impact of cultural scripts on interpersonal behavior. This impact is claimed to be more pronounced in the early stages of a relationship when partners are not so familiar with each other’s preferences (Sanchez et al., 2012).

Conclusion

The results of this study contribute to filling a knowledge gap in the literature by exploring the experiences of vulvodynia from the perspective of male partners, an area that has previously gotten scarce research attention. We have discussed how these findings add new insights to existing literature, especially relating to the conflict between adhering to sexual scripts and traditional notions of masculinity while at the same time attempting to offer care to their partners.

Gendered sexual scripts and ideals related to masculinity play a significant role in heterosexual relationships with vulvodynia. Prevailing cultural assumptions regarding masculinity challenge men’s ability to be simultaneously caring and sexual, suggesting they are left alone to deal with ambivalence and distress on these matters. Helping these men in their efforts to be good partners could benefit both themselves and their partners struggling with long-term vulvodynia.

While many studies on vulvodynia have focused on the women’s ability to perform vaginal intercourse, our findings underline that shared sexuality can be important in terms of emotional attachment, social competency, and masculine identity. Consequently, therapists can help couples with vulvodynia achieve greater sexual and relationship satisfaction, even if the woman’s vulvodynia pain is not improved and intercourse remains challenging.

Our findings suggest that partners should be involved when treating women with vulvodynia, given that relationship dynamics are important for their shared sexual lives and relationship satisfaction. Sex and couples therapists may help couples reflect on and redefine their sexual scripts, as well as extend their sexual repertoire of sexually satisfying actions while avoiding painful intercourse. Furthermore, a focus on handling sexual initiative and rejection can be helpful, as this is often found to be challenging for these couples. Therapists working with such couples can help them achieve interactions that facilitate intimacy and steer them away from stressful demand/withdrawal dynamics that result in both parties feeling alone with their distress. Finally, the issue of fertility requires more in-depth exploration in future research.

Author Contributions

The first author was responsible for the project design, data generation, analyses, and the main part of writing the manuscript. The third author contributed to the project design and data generation. The second and fourth authors contributed to the analysis and theoretical framework. All authors have read and commented on the manuscript.

Acknowledgments

We would like to thank all participants for their invaluable contribution to this study, as well as all the user representatives included in this research project. We would also like to thank the Norwegian patient organization for vulvodynia for help with recruitment. Lastly, thanks to the Norwegian Women’s Public Health Association for funding this study and helping to educate health professionals and others about vulvodynia.

Disclosure Statement

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

Data Availability Statement

The participants of this study did not consent to their data to be shared, so supporting data are not available.

Additional information

Funding

This work was funded by the Norwegian Women’s Public Health Association [project number 40017].

Appendix

Interview Guide

Part 1: About how vulvodynia affects you

I would first like to talk to you about how vulvodynia affects you.

1. How did the vulvodynia start?

   1. How was it when you first met each other?

   2. How did you notice that something was starting to change?

   3. How long did it take before your partner received a diagnosis, and how did you experience it? Have you experienced vulvodynia in previous relationships?

   4. Have you participated in her examinations and treatment? What information and treatment offers have you received?

   5. How do you think your partner experienced it?

2. How has this affected you?

   1. How does this affect your self-image?

   2. Do you think this has affected your sexuality? How?

   3. Do you think this has been different before and after she got the diagnosis?

3. How do you handle this condition?

   1. What do you think is the cause of this condition?

   2. Do you think you can influence the condition in any way?

Part 2: About how vulvodynia affects your relationship

Now I would like to talk to you about how vulvodynia has affected your relationship.

1. How do you and your partner communicate about sexuality?

   1. How did your partner tell you about her problems – if she told you about them?

   2. How is it for you to talk to your partner about this?

2. Do you think vulvodynia has affected your partner?

   1. In what ways do you think it has affected your partner?

   2. What do you think your partner thinks about this condition? How is that for you?

   3. What do you believe your partner thinks of you?

   4. How has this influenced the relationship between the two of you?

3. How do you manage your sex life after these issues started?

   1. Do you do anything differently now than you did before the issues arose?

   2. How has your sexual desire been affected by this?

   3. How is it for you to show that you are interested in having sex?

   4. How do you think she experiences it when you initiate sex?

   5. To what extent are you able to convey to your partner what you need/want during sex?

4. How is it for you that your partner talks about these difficulties with other people?