ORIGINAL RESEARCH & REVIEWS

Genital Pain and Sexual Functioning: Effects on Sexual Experience,

Psychological Health, and Quality of Life
Filippo Maria Nimbi, PhD, PsyD,1,2 Valentina Rossi, PsyD,2 Francesca Tripodi, PsyD,2 Mijal Luria, MD,3
Matthew Flinchum, MS,4 Renata Tambelli, FP, PsyD,1 and Chiara Simonelli, AP, PsyD1,2

ABSTRACT

Background: Genital pain (GP) is a common symptom in women of reproductive age. The prevalence of GP is
difficult to gauge as it has been underreported by both patients and clinicians and neglected in clinical studies
despite wide recognition of the adverse effects to women's health.
Aim: The purpose of the present study was 3-fold: (i) to explore the self-reported presence and perception of GP
and its association with sexual functioning, sexual distress, emotions, psychopathology, and quality of life (QoL);
(ii) to explore if, controlling for the pain effect, women with Female Sexual Function Index (FSFI) scores
indicating sexual dysfunction also reported worse outcomes regarding sexual distress, emotions, psychological
health, and QoL than GP women with higher FSFI scores; and (iii) to evaluate the effects of GP duration,
comparing women with GP with shorter (<6 months) duration of symptoms with women with longer
(
6 months) duration of symptom of GP on sexual functioning, distress, emotions, psychopathology and QoL.
Methods: A total of 1,034 women (age ranges between 18 and 40 years) from the Italian general population
completed a web survey on sexual health.
Outcomes: 6 self-report questionnaires exploring different biopsychosocial factors were assessed: the FSFI, the
Female Sexual Distress Scale, the Positive and Negative Affect Schedule, the Short Form McGill Pain Ques-
tionnaire adapted for GP, the Short Form 36, and the Symptom Check List-90-Revised.
Results: Women who reported GP (n ¼ 319) indicated generally lower sexual function than women without
GP (n ¼ 648; P ¼ .036). They reported a higher level of sexual distress (P < .001), more negative emotions
related to sexual experiences (P ¼ .001), lower scores in all QoL domains (P < .001), and higher levels of
psychopathological symptoms (P < .001). Controlling for pain effects, women whose FSFI scores indicated
sexual dysfunction (n ¼ 150) reported higher rates of sexual distress than women whose FSFI scores indicated
normal sexual function (n ¼ 169; P < .001). The scores also indicated fewer positive (P < .001) and more
negative emotions (P < .001) related to sexuality, lower QoL (P < .001) and significantly higher psychological
burden (P < .001). Moreover, women experiencing GP for
6 months reported significantly lower means on the
FSFI total score (P < .05; especially in the desire, satisfaction, and pain domains), distress (P < .001), and
emotions (P < .05) than women experiencing GP duration <6 months. No significant differences were found on
the QoL and the psychopathological symptoms.
Clinical Implications: GP is significantly pervasive, but a high percentage of sexual problems and related
emotional suffering is overlooked. Raising awareness about this issue is critical, both among clinicians and the
general public.
Strengths & Limitations: The present study highlighted important characteristics of GP from a community
sample; the results indicate problems related to pain experiences and their repercussions on sexual, psychological,
affective health, and QoL. Major limitations are related to the use of self-report measures via a web-based study.
Conclusion: The results provide evidence of a lack of awareness regarding pain experiences as they relate to
sexual functioning in women; clinicians would be advised to more fully investigate sexual functioning and
psychosocial variables associated with GP during routine consultation beginning with the first onset of the

4
Received April 13, 2019. Accepted January 17, 2020. Department of Counseling & Psychology, Texas A&M University Central
1
Department of Dynamic and Clinical Psychology, Sapienza University of Texas, Killeen, TX, USA
Rome, Rome, Italy; Copyright ª 2020, International Society for Sexual Medicine. Published by
2
Institute of Clinical Sexology, Rome, Italy; Elsevier Inc. All rights reserved.
3 https://doi.org/10.1016/j.jsxm.2020.01.014
Center for Sexual Health, Obstetrics and Gynecology, Hadassah University
Hospital, Mt Scopus, Jerusalem, Israel;

J Sex Med 2020;-:1e13 1

2 Nimbi et al
symptoms. Nimbi FM, Rossi V, Tripodi F, et al. Genital Pain and Sexual Functioning: Effects on Sexual
Experience, Psychological Health, and Quality of Life. J Sex Med 2020; XX:XXXeXXX.
Copyright  2020, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Pain; GPP/PD; Biopsychosocial Model; Pelvic Pain; Women Health
INTRODUCTION
Genital pain (GP) is a complex experience involving biolog-
ical, psychological, relational, and cultural meanings.1 Consid-
erable evidence indicates GP is a common concern in women of
reproductive age (12e60%) despite evidence suggesting as much
as 40% of women between the ages of 20 and 40 years did not
seek help for their condition.2e5 Evidence also indicates that
health-care providers (HCPs) poorly understand and often
misdiagnose GP.3 The broad range of prevalence estimates and
poor understanding stem from differences between the pop-
ulations involved study design and the inconsistent use of
definitions.6
Instead of a broad definition of GP, various terms are used in
the literature to refer to pain in the genito-pelvic area (eg, dys-
pareunia, sexual pain, pelvic pain, vaginismus, vulvodynia and
vestibulitis), depicting the complex nature of these complaints.
Despite the disparate nature of the conditions, the current clas-
sification system for GP is based on those diverse components
and imposes a broad definition for GP. In the latest edition of
the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5),7 genito-pelvic pain/penetration disorder ([GPP/PD],
which encompasses what were previously termed as “dyspar-
eunia” and “vaginismus”) refers to 4 symptom dimensions: (i)
difficulty having intercourse, (ii) genito-pelvic pain, (iii) fear of
pain or vaginal penetration, and (iv) tension of the pelvic floor
muscles. Each of these criteria represents distinct phenomeno-
logical experiences, yet a diagnosis can be made based on only
one dimension. Symptoms must be present for at least 6 months,
cause clinically significant distress in the individual, and not be
better explained by another problem, such as relationship distress
or other stressors.
Suggestions for the International Classification of Diseases
(ICD-11) also include “sexual pain-penetration disorder” for
recurrent symptoms during sexual interactions involving or
potentially involving penetration, which are not entirely attrib-
utable to a medical condition.8 This system allows for adding
associated factors, such as biological, psychological, behavioral,
relational, and cultural variables. The ICD-11 has a separate
category (dyspareuniaeGA12) for pain or discomfort that occurs
before, during, or after sexual intercourse that is related to an
identifiable physical cause such as infection, inflammation, and
neoplastic or neurologic etiology.
In addition, the International Society for the Study of Vul-
vovaginal Disease suggested yet another nomenclature for vulvar
pain based on the presence of a specific etiological basis.9 They
suggest assessing the location (localized vs generalized) and
whether the pain is provoked by a stimulus or it is spontaneous.
Furthermore, they also acknowledge the role of psychosocial
factors as part of the suggested criteria for diagnosing vulvodynia
and comorbidities with other pain-related issues.
Despite evidence in favor of a conceptualization of the prob-
lem as a “pain disorder,” GP remains within the category of
sexual dysfunction.3 Several studies report that the DSM-5
definition seems to underestimate the peculiarities of the con-
ditions characterized by GP and that the GPP/PD umbrella is
too strictly focused on pain interference with sexual intercourse
(regardless of the pain location) rather than with the whole sexual
experience and quality of life (QoL).10e14 Furthermore, the
6-month criteria for the GPP/PD diagnosis might exclude a
significant number of women suffering with GP, without
considering their distress and the possible effects of pain on the
psychological status and QoL in the early period. These elements
may impede direct access to care and enable a crystallization of
the painful symptomatology.
In addition, past GP studies performed on the general pop-
ulation relied on self-reported data and have many methodo-
logical issues which may have substantially affected the
interpretation of results. In these cases, no uniform conclusions
can be drawn on the etiology, prevalence, coping strategies, and
treatment of GP as one entity.15 However, they are useful to
deepen understanding of the phenomenology of women
expressing painful symptomatology. They also provide a foun-
dation for awareness and prevention programs, as well as for
clinical studies based on specific criteria and specialist diagnosis
on national and international basis.
A broader definition of GP based on the symptom as a
complaint rather than a specific diagnosis is critical for cross-
sectional studies on the general population.16,17 In such
studies, women are self-selected based on questionnaire scores
(eg, Female Sexual Function Index [FSFI]) or by self-declaration
of having a symptom. These studies should be able to differen-
tiate the experience of sexual and GP. For example, some
studies18,19 have highlighted that it could be easier for women to
report experiencing pain during sexual intercourses as a problem
rather than pelvic pain not associated with penetration. Thus, it
could be useful to comprehend both definitions in self-reported
measure-based studies.
These diverse definitions led the studies on GP to be equally
disparate. However, some commonalities emerged. Women re-
ported an average symptom duration of 15e24 months14
localized in the external genitalia, the introitus, or the deep
part of the vagina. GP has been found to be related to provoked
J Sex Med 2020;-:1e13
Genital Pain and Sexual Functioning
vestibulodynia, endometriosis, pelvic inflammatory diseases,
urological infections, cystitis, sexually transmitted infections
(STIs), bowel syndrome, adhesions, and vaginismus; however,
most cases remain without a clear organic etiopathogenesis.5,14,20
In the community setting, around 60% of women have not
received a diagnosis for their pain, and up to 20% have not
undergone any investigation.14 Less than half of women coping
with pelvic pain get referred to a gynecological specialist.20 When
referred, women often have high expectations of the gynecolo-
gist. Furthermore, the gynecologist may be looking for organic
pathologies which may not exist.5
As sexual medicine has slowly moved away from a biomedical
model, the biopsychosocial (BPS) model is now widely accepted
as the most valuable and comprehensive approach able to un-
derstand, assess, and treat GP.15,21 A lack of knowledge regarding
pathways and interactions rather than the relative influence of
biological and psychosocial variables in predicting pain and its
consequences has been reported.15 Research has historically
underscored the role of psychological factors (eg, emotions,
anxiety, and depression) in GP, and most studies have high-
lighted a negative impact of GP on sexual functioning and
satisfaction.22,23 The sexual experience might be the most
impacted area for women with GP and their partners. Simulta-
neously, it is an element which can improve coping with pain
and QoL. In fact, sexual dysfunction is strongly related to low
physical and emotional satisfaction and has been associated with
poor QoL, depression, and nonadherence to medication.24e27
Hence, the complex role of sexual functioning in GP should
be better investigated, not only in relation to the quantity and
duration of the painful experience but also in its complex rela-
tionship with affection, psychological burden, and QoL, putting
an emphasis on models of empirical and clinical relevance.
The present study is part of a wider project on GP in women's
sexual health, aiming to test if an interaction between sexual
function and satisfaction play a protective role regarding a
woman's ability to cope with GP, its associated psychological
burden, and QoL. To better understand these relationships and
to propose a path diagram for future studies, the main aim of this
work was to explore the self-reported presence and perception of
GP in a group of women from the general population together
with some validated measures on psychosocial and sexual health.
Specifically, our aims were (i) to investigate the presence and the
characteristics of GP in a group of women from the general
population, testing if women with GP have worse scores on
sexual functioning, distress, emotions, psychopathology, and
QoL than women without GP; (ii) to explore if, controlling for
the pain effect, there is a significant difference in the level of
distress, emotions, psychopathology, and QoL between women
with GP and sexual dysfunction versus women with GP who are
sexually functional as identified by the FSFI; and (iii) to test if
women who have experienced GP for
6 months have signifi-
cantly different levels of sexual functioning, distress, emotions,
J Sex Med 2020;-:1e13
3
psychopathology, and QoL measures than women whose GP
symptoms have occurred for <6 months.
Our hypotheses were that women with GP compared with
women without GP would present generally worse sexual func-
tioning, higher levels of sexual distress, more negative affection
related to sexual experiences, worse scores regarding QoL, and
higher levels of psychopathology symptoms. We also expected
better reported sexual function (higher FSFI scores) in women
with GP would be associated with better psychological, affective,
and QoL outcomes regardless of the intensity of the pain than
women with GP and FSFI scores indicating sexual dysfunction.
Moreover, we expected to find, controlling for the intensity of
the pain, higher scores in all the sexual, affect, psychological, and
QoL dimensions assessed in the group of women with a duration
of symptoms of <6 months compared with women with longer
GP conditions (
6 months).
PARTICIPANTS AND PROCEDURES
A total of 1,034 female participants from the Italian general
population were enrolled in a cross-sectional study using snow-
ball recruitment on websites and social networks (eg, www.
sessuologiaclinicaroma.it, https://web.uniroma1.it/dip42/, Face-
book, and LinkedIn). A general study on women's sexual health
was advertised to prevent major selection biases (eg, having
“genital/pelvic pain” or references to sexual complaints in the
title of the study may have favored the self-selection of people
reporting sexual problems). Participants answered an anonymous
web survey assessing psychosocial domains related to female
sexuality using the Google.docs platform. All participants pro-
vided informed consent and did not receive any remuneration for
taking part in the study. The questionnaire took approximately
30 minutes to complete.
Data were collected in an encrypted electronic database form
and were kept in the Institute of Clinical Sexology of Rome. The
institutional ethics committee of the Department of Dynamic
and Clinical Psychology (Sapienza University of Rome) provided
the approval to carry out the research on September 20, 2017.
Data were collected from November 2017 to September 2018.
The inclusion criteria were self-declaring as a woman, between
18 and 40 years old, and being a fluent Italian speaker. The
exclusion criteria were being in menopause (n ¼ 39; early or
pharmacologically induced) or never being sexually active
(n ¼ 28). Following these criteria, 967 women (93% of the
whole sample) were eligible for the study.
MEASURES
For the present study, 6 self-report questionnaires exploring
different BPS factors were assessed. The following questionnaires
were chosen for their validity, ease of use, and diffusion in
research and clinical fields.
4 Nimbi et al
A sociodemographic questionnaire collected information
about age, relationship and marital status, sexual orientation
(based on a 7-point Kinsey scale), work status, educational level,
children, smoking habits, alcohol and substance use/abuse,
presence and duration of sexual difficulties (“During the past
6 months, have you had any sexual problem?” and “How long
have you had this sexual problem?), help-seeking behavior, and
treatments.
The FSFI 28,29 evaluated sexual functioning with a 19-item
Likert type scale (from 0 to 5) encompassing 6 sexual do-
mains: desire, arousal, lubrication, orgasm, satisfaction, and pain.
Psychometric studies reported good reliability, validity, and the
ability to discriminate between women with or without sexual
dysfunctions. A total score <26.55 indicates sexual dysfunc-
tion.29,30 In this study, the Cronbach's alpha values for this
measure ranged from 0.83 (desire) to 0.91 (pain).
The Female Sexual Distress Scale31 assessed personal distress
related to sexuality with a 12-item questionnaire. The items
converged in a single factor structure (distress total). The test-retest
reliability and internal consistency coefficients were acceptable.
The scale showed a discriminant ability distinguishing between
sexually functional and dysfunctional subjects. The Cronbach's
alpha value for this measure in the present study was 0.94.
The Positive and Negative Affect Schedule (PANAS)32,33 is a
20-item self-report measure of positive and negative emotions.
Respondents are asked to rate their experience of each emotion
presented within a specified period or situation (in this study,
they were “related to sexuality”). Higher scores indicate higher
emotional endorsement. The Cronbach's alpha values for this
measure in the present study ranged from 0.86 (negative affects)
to 0.89 (positive affects).
The Short Form McGill Pain Questionnaire (SF-MPQ)34,35
consists of 15 descriptors (11 sensory and 4 affective) which
are rated on an intensity scale from “none” to “severe.” This
questionnaire collects both quantitative and qualitative infor-
mation about the subjective experience of pain. A total score can
be calculated as an indicator of pain intensity. For this study, the
SF-MPQ was adapted for genito-pelvic pain, specifying the
location of the pain in the genital area and adding the Marinoff
scale36 for dyspareunia (1 item). The SF-MPQ was assessed only
in women answering “yes” to the question “In the last 6 months,
have you experienced any kind of pain/discomfort located in the
genital area (in general or associated to sexual activity)?”The
Cronbach's alpha value for the adapted measure in the present
study was 0.86.
The Short Form 36 (SF-36) for quality of life37,38 is a 36-item
generic, coherent, and easily administered QoL measure. The
SF-36 is composed of 9 scales: physical functioning, role func-
tioning/physical, role functioning/emotional, energy/fatigue,
emotional well-being, social functioning, pain, general health,
and health change. Higher scores indicate better QoL. The
Cronbach's alpha values for this measure in the present study
ranged from 0.81 (social functioning) to 0.92 (physical
functioning).
The Symptom Check List-90-Revised (SCL-90-R)39,40 is a
commonly used checklist measuring the severity of self-reported
psychopathological symptoms on a 5-point Likert scale ranging
from “not at all” to “extremely.” The SCL-90-R includes 9
subscales exploring the previous 7-day condition: somatization,
obsessive-compulsive (O-C), interpersonal sensitivity (I-S),
depression, anxiety, hostility, phobic anxiety, paranoid ideation,
and psychoticism. It is used in clinical practice as a general
screening of the psychological state of the patient and has also
been adopted in psychotherapy as an outcome measure. The
validity of the 9-symptom subscales of the SCL-90-R demon-
strated good internal consistency. The Cronbach's alpha values
for this measure in the present study ranged from 0.83 (phobic
anxiety) to 0.91 (depression).
DATA ANALYSIS
First, sociodemographic descriptive data were discussed, high-
lighting the qualitative and quantitative characteristics of women
reporting GP in the last 6 months. To analyze the differences in
sexuality, psychological functioning, and QoL between women
reporting GP and women without GP symptoms, factorial one-
way analysis of covariances (ANCOVAs) and multivariate anal-
ysis of covariances (MANCOVAs) were conducted. Age and
relationship status (coded as 0 ¼ single and 1 ¼ partnered) were
defined as covariates for each questionnaire subscale as suggested
by Aerts et al.41 To better explore the role of sexuality, further
divisions were conducted inside the GP group: women were
divided into FSFI sexually dysfunctional (FSFI total
score < 26.55) and FSFI sexually functional women (FSFI total
score
26.55). Once again, factorial one-way ANCOVAs and
MANCOVAs were conducted having age and relationship
status and pain scores as covariates to analyze differences in
sexuality, psychological function, and QoL. Data were analyzed
using the Statistical Package for Social Sciences, version 23.0
(SPSS, Chicago, IL).
RESULTS
The sociodemographic characteristics of the sample are pre-
sented in Table 1. The mean age of the participants was
26.7 ± 5.3 (median ¼ 26; interquartile range ¼ 23e29). Most
participants reported being unmarried and being in a romantic
relationship. (Almost half of the women were living together with
their partner.) As per the 7-point Kinsey scale, most women
declared themselves as predominantly heterosexual (1e2 points),
followed by bisexual (3e5 points) and predominantly homo-
sexual (6e7 points). Most of the participants reported having no
children, and almost one quarter of the sample expressed having
a desire to be a mother at the time of the survey. Most of the
J Sex Med 2020;-:1e13
Genital Pain and Sexual Functioning 5

Table 1. Sociodemographic characteristics of the sample (n ¼ 967) Table 1. Continued

Variable M ± SD (range) Variable M ± SD (range)
Age 26.7 ± 5.3 (18e40) Masturbation frequency (in the
n (%) last 6 months)
Marital status 1 ¼ Never 333 (34.5)
Unmarried 867 (89.7) 2 ¼ 1e2 times a month 203 (21)
Married 84 (8.7) 3 ¼ Once a week 139 (14.4)
Separated 16 (1.7) 4 ¼ 2e3 times a week 102 (10.5)
Relationship 5 ¼ 4e5 times a week 114 (11.8)
Single 292 (30.2) 6 ¼ Daily 55 (5.7)
In a relationship (not 446 (46.1) 7 ¼ Many times a day 21 (2.2)
cohabitant) Porn consumption frequency (in
In a relationship (cohabitant) 229 (23.7) the last 6 months)
Sexual orientation (7-point Kinsey 1 ¼ Never 541 (55.9)
Scale) 2 ¼ 1e2 times a month 207 (21.4)
Exclusively heterosexual 633 (65.5) 3 ¼ Once a week 72 (7.4)
Predominantly heterosexual, 195 (20.2) 4 ¼ 2e3 times a week 80 (8.3)
only incidentally homosexual 5 ¼ 4e5 times a week 46 (4.8)
Predominantly heterosexual, 41 (4.2) 6 ¼ Daily 13 (1.3)
but more than incidentally
7 ¼ Many times a day 8 (0.9)
homosexual
Sexual problems (self-reporting at
Equally heterosexual and 33 (3.4)
least a sexual problem in the
homosexual
last 6 months)
Predominantly homosexual, 14 (1.5)
No 688 (71.2)
but more than incidentally
Yes 279 (28.8)
heterosexual
Genital pain in the last 6 months
Predominantly homosexual, 26 (2.7)
only incidentally heterosexual No 648 (67)
Exclusively homosexual 25 (2.6) Yes 319 (33)
Children
No 893 (92.4)
Yes 74 (7.7) participants had a medium-high educational level and were
Desire of having a baby now students (more than half of the sample) or employed.
No 744 (77) In regard to risky behaviors, 39% declared that they smoke,
Yes 223 (23) 86% consumed alcohol (from “a few times a month” to
Education level “everyday”), and 20% used recreational substances (in addition
Primary school 24 (2.5) to 19% who had used them in the past). The most reported
Secondary school 276 (28.5) substance consumed was tetrahydrocannabinol (93%). In addi-
Degree or higher 667 (69) tion, regarding sexual behavior, women reported having sexual
Employment intercourse approximately 2 to 3 times a week (median ¼ 4;
Unemployed 100 (10.3)
interquartile range ¼ 3e5), masturbating once to twice a month
Employed 317 (32.8)
(median ¼ 2; interquartile range ¼ 1e4), and rarely consuming
Student 549 (56.8)
pornography (median ¼ 1; interquartile range ¼ 1e2).
Retired 1 (0.1)
Sexual intercourse frequency (in In the present study, 3 of 10 women reported experiencing at
the last 6 months) least one sexual difficulty in the last 6 months (mean
1 ¼ Never 110 (11.4) duration ¼ 38.03 ± 49.65 months, median ¼ 15; interquartile
2 ¼ 1e2 times a month 127 (13.1) range ¼ 5.5e60), primarily in the areas of desire, orgasm, and
3 ¼ Once a week 144 (14.8) pain. In these cases, the sexual problems had occurred at a certain
4 ¼ 2e3 times a week 194 (20.1) point of the sexual activity (70%) and were predominantly
5 ¼ 4e5 times a week 181 (18.8) situational (65%). Among women reporting a sexual difficulty
6 ¼ Daily 110 (11.4) (n ¼ 279), only 53% sought help and 35% were currently under
7 ¼ Many times a day 101 (10.5)
treatment (medical or psychological therapy) for their sexual
(continued) complaints.

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6 Nimbi et al

Table 2. Qualitative and quantitative characteristics of genital pain Table 2. Continued

([GP]; n ¼ 319)
Variable n (%)
Variable n (%)
FSFI sexually dysfunctional
Localization of the pain*
No 169 (53)
Vaginal introitus (opening, 153 (48)
Yes 150 (47)
entrance)
(Total score < 26.55)
Initial part of the vagina 105 (33)
Deep part of the vagina 95 (30) FSFI ¼ Female Sexual Function Index.
External genitalia (vulva, labium 85 (26.7) *More than one answer possible for every woman.
majora and minora)
Ovary 66 (20.7)
All women were asked if they had experienced any sort of GP
Uterus 55 (17.2) in the last 6 months. Pain-related characteristics are provided in
Clitoris 41 (13) Table 2. 33% of the sample reported GP with a mean duration
Anal area (perineum and anus) 35 (11) of 29.5 ± 51.8 months (median ¼ 9.5; interquartile
Urethra 25 (7.8) range ¼ 3e36) based on the question “How long has your pain
M ± SD (range) been occurring in the genital area (please indicate the pain
Genital pain duration duration in months)?” More than half of these women (56%)
Months 29.5 ± 51.8 (1e420) reported that the pain was “brief, momentary and/or transient”,
Genital pain intensity rather than rhythmic or continuous; 66% did not have a diag-
McGill total 26 ± 15 (4e78) nosis for their GP.
n (%)
In addition, the pain localization was quite variable, with
Pain changes with time
almost half of the GP sample reporting the vaginal introitus,
Brief momentary transient 179 (56.1)
followed by the initial and deep parts of the vagina. The mean
Rhythmic periodic intermittent 98 (30.7)
Continuous steady constant 42 (13.2)
score from the McGill Pain Questionnaire adjusted for GP was
Diagnosis 26 ± 15 (median ¼ 21; interquartile range ¼ 15e34) (the
Unknown 211 (66.1) higher the score, the greater the pain). Vulvovaginal infections
Vulvovaginal infections 37 (11.6) and cystitis were the most reported causes associated with pain.
Cystitis 31 (9.7) Referring to the Marinoff scale for painful sexual intercourse,
Endometriosis 16 (5) 52% of the sample reported having “pain with intercourse that
Vulvodynia 15 (4.7) doesn't prevent completion” and 32% reported “pain with in-
Vaginismus 4 (1.3) tercourse requiring interruption or discontinuance.” Of the 319
Others (eg, cancer, 5 (1.6) women with GP, only 45% (145 women) declared having a
malformations, and so on)
related sexual problem, recognizing their GP as a problem
M ± SD (range)
affecting their sexual health. Among these, 107 women (74%)
Marinoff scale
reported FSFI sexually dysfunctional scores. Interestingly, 43
Mean score 1.5 ± 0.8 (0e3)
n (%)
women (25%) who did not associate their GP with a sexual
Pain with intercourse that doesn't 166 (52) problem reported an FSFI sexually dysfunctional score (chi-
prevent the completion squared ¼ 76.48; df ¼ 1; P < .001). In this cohort, 35% of
Pain with intercourse requiring 102 (32) women with GP sought the help of an HCP (physician, psy-
interruption or discontinuance chologist, and so on) for it, and only 17% underwent treatment
Pain with intercourse preventing 36 (11.3) (medical or psychological) for their gynecological condition.
any intercourse
To explore the differences between women with (n ¼ 319) and
No pain with intercourse 15 (4.7)
without GP (n ¼ 648) in some specific domains of sexuality, psy-
GP as a sexual problem
chological function, and QoL, one-way ANCOVAs and MAN-
No 174 (54.6)
Yes 145 (45.4) COVAs were run having age and relationship status as covariates;
Help seeking for GP the results are shown in Table 3. The GP group reported a signif-
No 208 (65.2) icantly lower mean score than the no-GP group in the FSFI total
Yes 111 (34.8) score, in the pain FSFI subscale and in all SF-36 domains except for
Under treatment for GP “Health Change.” Moreover, the GP group had higher significant
No 264 (82.8) mean scores in sexual distress, in the negative emotions related to
Yes 55 (17.2) sexuality (PANAS negative affects), in the SCL-90-R Global
(continued) Severity Index and in all the related symptomatologic subscales.

J Sex Med 2020;-:1e13

Genital Pain and Sexual Functioning 7

Table 3. Differences between women with and without genital pain: One-way ANCOVAs and MANCOVAs
95% CI
No-GP group GP group
(n ¼ 648) (n ¼ 319) Lower Upper Partial
Variable M ± SD M ± SD D F(1,964) p bound bound Eta2
FSFI total score 27.07 ± 8.11 24.95 ± 10.2 2.12 4.41 .036 0.046 1.361 0.008
(sexual function)
Desire 3.99 ± 1.16 3.97 ± 1.17 0.02 - .81 0.136 0.176 -
Arousal 4.1 ± 1.69 3.93 ± 2.02 0.17 - .83 0.278 0.224 -
Lubrication 4.54 ± 1.92 4.41 ± 2.22 0.13 - .76 0.233 0.317 -
Orgasm 3.99 ± 1.97 3.78 ± 2.23 0.21 - .78 0.316 0.239 -
Satisfaction 4.21 ± 1.56 4.03 ± 1.68 0.18 - .87 0.223 0.19 -
Pain 4.17 ± 2.44 3.12 ± 2.03 1.05 13.92 <.001 0.266 0.857 0.014
FSDS total score 9.53 ± 10.66 13.53 ± 12.84 4 29.92 <.001 5.819 2.746 0.030
(sexual distress)
PANAS (sexuality-related
emotions)
Positive affects 35.98 ± 8.54 35.07 ± 8.5 0.91 - .186 0.487 2.501 -
Negative affects 15.95 ± 7.12 18.28 ± 9.09 2.33 11.34 .001 3.756 0.989 0.020
SF-36 (quality of life)
Physical functioning 93.83 ± 13.37 87.59 ± 19.15 6.24 23.40 <.001 3.081 7.286 0.024
Role functioning e physical 85.71 ± 27.11 71.98 ± 35.95 13.73 38.85 <.001 8.952 17.18 0.039
Emotional well-being 59.96 ± 19.03 54.68 ± 19.02 5.28 18.84 <.001 3.138 8.315 0.020
Role functioning e emotional 58.9 ± 41.35 50.05 ± 41.84 8.85 12.38 <.001 4.461 15.708 0.013
Energy/fatigue 54.58 ± 17.38 48.34 ± 17.63 6.24 24.45 <.001 3.62 8.384 0.025
Social functioning 67.93 ± 22.06 60.48 ± 24.1 7.45 23.57 <.001 4.576 10.785 0.024
Bodily pain 81.46 ± 20.07 70.7 ± 22.9 10.76 50.98 <.001 7.545 13.264 0.051
General health 68.71 ± 17.99 58.76 ± 21.1 9.95 53.95 <.001 7.133 12.333 0.054
Health change 52.99 ± 27.63 51.75 ± 27.66 1.24 - .497 2.465 5.078 -
SCL-90-R Global Severity Index 0.72 ± 0.57 0.89 ± 57 0.17 21.45 <.001 0.26 0.105 0.022
(psychological problems)
Somatization 0.72 ± 0.66 0.94 ± 0.67 0.22 21.57 <.001 0.306 0.124 0.022
Obsessive-compulsive 0.93 ± 0.76 1.14 ± 0.79 0.21 19.22 <.001 0.338 0.129 0.020
Interpersonal sensitivity 0.75 ± 0.72 0.88 ± 0.73 0.13 9.37 .002 0.25 0.055 0.010
Depression 0.96 ± 0.79 1.18 ± 0.81 0.22 19.37 <.001 0.352 0.135 0.020
Anxiety 0.72 ± 0.69 0.90 ± 0.74 0.18 14.28 <.001 0.282 0.089 0.015
Hostility 0.60 ± 0.64 0.73 ± 0.67 0.13 8.98 .003 0.224 0.047 0.009
Phobic anxiety 0.27 ± 0.48 0.36 ± 0.57 0.9 7.50 0.006 0.166 0.027 0.008
Paranoid ideation 0.69 ± 0.7 0.85 ± 0.75 0.16 13.02 <.001 0.278 0.082 0.014
Psychoticism 0.45 ± 0.52 0.58 ± 0.55 0.13 16.57 <.001 0.221 0.077 0.017
ANCOVA ¼ analysis of covariance; FSDS ¼ Female Sexual Distress Scale; FSFI ¼ Female Sexual Function Index; GP ¼ genital pain; MANCOVA ¼ multivariate
analysis of covariance; PANAS ¼ Positive and Negative Affect Schedule; SCL-90-R ¼ Symptom Check List-90-Revised; SF-36 ¼ Short Form 36.
Age and relational status were put as covariates.

Focusing on women with GP (n ¼ 319), the difference be-
tween women with FSFI sexually dysfunctional (n ¼ 150) and
FSFI sexually functional (n ¼ 169) scores in some domains of
sexual experience, psychological function, and QoL were explored
by running one-way ANCOVAs and MANCOVAs having age
and relationship status as covariates. The FSFI sexually dysfunc-
tional group reported a significantly higher mean score (P < .001)
than the FSFI sexually functional group on the McGill total score.
To better highlight the role of sexual functioning on the assessed
variables (distress, emotions, psychopathology, and QoL), the
McGill total score was added as a covariate; the results are pre-
sented in Table 4. The FSFI sexually dysfunctional group reported
a significantly lower mean score than the FSFI sexually functional
group in the PANAS positive affect and in all the SF-36 domains,
except for “Physical Functioning” and “Health Change”. In
addition, the FSFI sexually dysfunctional group had significantly
higher mean scores for Sexual Distress, for the negative emotions
related to sexuality, on the SCL-90-R Global Severity Index, and
for all the related symptomatologic subscales (except for somati-
zation and phobic anxiety).
Exploring the role of symptom duration in GP women
(n ¼ 319), the differences between women with GP duration
<6 months (n ¼ 111) and GP duration
6 months (n ¼ 208)
in some domains of sexual experience, psychological function,

J Sex Med 2020;-:1e13

8 Nimbi et al

Table 4. Differences between women reporting genital pain (GP) with FSFI sexually dysfunctional versus functional scores: One-way
ANCOVAs and MANCOVAs
FSFI sexually FSFI sexually 95% CI
functional dysfunctional
group (n ¼ 169) group (n ¼ 150) Lower Upper Partial
Variable M ± SD M ± SD D F(1,316) p bound bound Eta2

FSDS Total Score (Sexual 6.52 ± 7.58 21.38 ± 13.01 14.86 160.78 <.001 16.172 11.336 0.339
Distress)
PANAS (sexuality-related
emotions)
Positive affects 38.77 ± 7.09 31.17 ± 8.13 7.6 48.21 <.001 5.43 9.74 0.205
Negative affects 14.4 ± 5.62 22.38 ± 10.22 7.98 45.26 <.001 10.327 5.644 0.195
SF-36 (quality of life)
Physical functioning 88.93 ± 19.88 86.05 ± 18.22 2.88 - .25 1.753 6.704
Role functioning e physical 77.53 ± 31.86 65.65 ± 39.28 11.88 8.69 .003 3.887 19.499 0.027
Emotional well-being 57.93 ± 18.54 50.97 ± 18.95 6.96 10.29 .001 2.657 11.083 0.032
Role functioning e 54.96 ± 41.45 44.44 ± 41.72 10.52 4.72 .031 0.967 19.612 0.015
emotional
Energy/fatigue 51.76 ± 17.48 44.42 ± 17.03 7.34 14.87 <.001 3.695 11.393 0.046
Social functioning 64.44 ± 23.81 55.95 ± 23.7 8.49 40.12 .002 3.26 13.835 0.032
Bodily pain 75.25 ± 20.54 65.49 ± 24.37 9.76 15.58 <.001 4.893 14.622 0.048
General health 63.19 ± 18.42 53.71 ± 22.83 9.48 15.84 <.001 4.66 13.774 0.048
Health change 53.72 ± 27.99 49.49 ± 27.21 4.23 - .123 1.327 11.051 -
SCL90 R Global Severity Index 0.78 ± 0.52 1.01 ± 0.6 0.23 14.49 <.001 0.296 0.039 0.045
(psychological problems)
Somatization 0.88 ± 0.59 1.01 ± 0.74 0.13 - .077 0.284 0.015 -
Obsessive-compulsive 1.01 ± .75 1.27 ± .81 0.26 8.36 .004 0.436 0.083 0.026
Interpersonal sensitivity 0.75 ± 0.65 1.01 ± 0.79 0.26 13.23 <.001 0.458 0.136 0.041
Depression 1.01 ± .79 1.37 ± .8 0.36 17.49 <.001 0.557 0.2 0.053
Anxiety 0.79 ± 0.66 1.01 ± 0.8 0.22 8.74 .003 0.41 0.082 0.028
Hostility 0.64 ± 0.59 0.85 ± 0.73 0.21 9.09 .003 0.377 0.079 0.029
Phobic anxiety 0.31 ± 0.5 0.42 ± 0.63 0.11 - .060 0.249 0.005 -
Paranoid ideation 0.73 ± 0.67 0.99 ± 0.8 0.26 9.88 .002 0.117 0.156 0.031
Psychoticism 0.44 ± 0.49 0.74 ± 0.56 0.3 28.73 <.001 0.44 0.204 0.085
ANCOVA ¼ analysis of covariance; FSDS ¼ Female Sexual Distress Scale; FSFI ¼ Female Sexual Function Index; MANCOVA ¼ multivariate analysis of
covariance; PANAS ¼ Positive and Negative Affect Schedule; SF-36 ¼ Short Form 36.
Age, relational status, and McGill total score were put as covariates.

and QoL were tested by running one-way ANCOVAs and
MANCOVAs having age, relationship status, and the McGill
total score as covariates. The results are presented in Table 5.
Women with GP duration
6 months reported significantly
lower mean scores in the FSFI total score and in the desire,
satisfaction, and pain domains than women with GP duration
<6 months. Differences were also significant in the distress scale
(women with GP duration
6 months showed higher rates of
sexual distress than women with less GP duration) and in the
PANAS subscale (showing lower positive and higher negative
emotions in women with GP duration
6 months than in the
other group). No significant differences were found on the QoL
and psychopathological measures.
DISCUSSION
This study represents an attempt to explore the presence and
self-perception of GP in a group of Italian women from the
general population. It deepens the understanding of the rela-
tionship between pain, sexual functioning, sexual distress, emo-
tions, psychological health, and QoL. Despite the
nonrepresentability of the sample owing to the recruitment
method (a snowball internet survey), some interesting data
highlighting the considerable presence of GP in the Italian female
population were found.
A large group of young women, in line with the young Italian
female population,42 was reached. The sample consisted primarily
of unmarried heterosexual women in a romantic relationship, with
a medium-high level of education and who were students or
employed. Possibly because of their young age, most of the women
in the sample had no children and only a quarter of the group
expressed a desire to be a mother at the time of the survey.
Regarding sexual behavior, women reported having an active
sexual life, occasionally masturbating and rarely consuming porn.
In terms of sexual health, in accordance with the literature,43e48

J Sex Med 2020;-:1e13

Genital Pain and Sexual Functioning 9

Table 5. Differences between women with genital pain with shorter (<6 months) and longer (
6 months) duration of symptoms:
One-way ANCOVAs and MANCOVAs
95% CI
GP duration <6 GP duration
6
months (n ¼ 111) months (n ¼ 208) Lower Upper Partial
Variable M ± SD M ± SD F(1,316) p bound bound Eta2
FSFI total score (sexual function) 26.50 ± 8.52 22.59 ± 8.64 5.74 .017 0.469 4.787 0.021
Desire 4.29 ± 1.06 3.68 ± 1.21 8.31 .004 0.141 0.746 0.031
Arousal 4.37 ± 1.69 3.76 ± 1.69 - .069 0.032 0.844 -
Lubrication 4.78 ± 1.84 4.21 ± 2.01 - .306 0.237 0.751 -
Orgasm 4.21 ± 1.98 3.69 ± 1.99 - .176 0.159 0.861 -
Satisfaction 4.47 ± 1.58 3.89 ± 1.54 4.65 .032 0.037 0.823 0.017
Pain 4.36 ± 1.93 3.34 ± 1.99 9.07 .003 0.256 1.223 0.033
FSDS total score (sexual distress) 8.57 ± 8.98 17.79 ± 13.78 17.02 <.001 9.419 3.333 0.061
PANAS (sexuality-related emotions)
Positive affects 38.58 ± 6.95 32.61 ± 8.83 10.18 .002 0.487 2.501 0.066
Negative affects 14.77 ± 5.04 21.27 ± 10.35 5.51 .02 3.756 0.989 0.037
SF-36 (quality of life)
Physical functioning 90.88 ± 16.91 85.76 ± 19.07 - .696 3.695 5.53 -
Role functioning e physical 80.77 ± 28.64 64.12 ± 39.05 - .116 1.722 15.663 -
Emotional well-being 58.11 ± 18.48 52.48 ± 19.01 - .149 1.296 8.513 -
Role functioning e emotional 52.38 ± 43.07 47.08 ± 40.27 - .693 8.583 12.887 -
Energy/fatigue 52.69 ± 17 46.02 ± 17.45 - .206 1.539 7.101 -
Social functioning 65.39 ± 23.2 55.51 ± 23.98 - .084 0.723 11.299 -
Bodily pain 75.35 ± 19.72 66.29 ± 24.55 - .763 4.285 5.835 -
General health 63.57 ± 19.01 54.74 ± 22.78 - .192 1.788 8.881 -
Health change 52.75 ± 30.38 50.99 ± 28.12 - .779 6.584 8.778 -
SCL-90-R Global Severity 0.77 ± 0.55 0.96 ± 57 - .143 -0.253 0.037 -
Index (psychological problems)
Somatization 0.8 ± 0.61 1.04 ± 0.717 - .287 0.265 0.079 -
Obsessive-compulsive 0.98 ± 0.77 1.23 ± 0.79 - .098 0.383 0.033 -
Interpersonal sensitivity 0.75 ± 0.69 0.93 ± 0.72 - .099 0.346 0.03 -
Depression 1 ± 0.79 1.3 ± 0.8 - .098 0.381 0.033 -
Anxiety 0.79 ± 0.69 0.95 ± 0.75 - .538 0.247 0.129 -
Hostility 0.66 ± 0.63 0.78 ± 0.69 - .573 0.228 0.127 -
Phobic anxiety 0.28 ± 0.49 0.38 ± 0.54 - .635 0.171 0.105 -
Paranoid ideation 0.75 ± 0.68 0.91 ± 0.77 - .188 0.332 0.066 -
Psychoticism 0.52 ± 0.55 0.63 ± 0.55 - .492 0.191 0.092 -
ANCOVA ¼ analysis of covariance; FSDS ¼ Female Sexual Distress Scale; FSFI ¼ Female Sexual Function Index; GP ¼ genital pain; MANCOVA ¼ multivariate
analysis of covariance; PANAS ¼ Positive and Negative Affect Schedule; SCL-90-R ¼ Symptom Check List-90-Revised; SF-36 ¼ Short Form 36.
Age, relational status, and the McGill total score were put as covariates.

around 30% of women (n ¼ 279) self-reported at least one
sexual difficulty in the last 6 months, mainly in the desire,
orgasm, and pain areas. In these cases, the sexual problems were
predominantly secondary and situational. Of these women, only
half (n ¼ 138) sought help from a physician or sexologist, and
only a few (n ¼ 99) were currently under treatment for their
sexual complaints.
These results are not surprising; studies49e52 have indicated
that female sexual problems are very common at all ages. Most
women do not seek help for their pain. Reported reasons for this
behavior include time constraints, considering sex to be unim-
portant, thinking “their sexual problems cannot be solved,” or
because “it is normal for women to experience pain during sexual
intercourse and to have an unsatisfying sexual life.” The same
studies highlighted that women are usually more motivated to
seek help if they have a partner, if their physician (general
practitioner, gynecologist) routinely screens for sexual problems,
and when symptoms become more bothersome.53
The present study also explored the self-perception of pain in
the last 6 months and how it is related to sexual life. Interest-
ingly, 319 women reported having GP which was primarily
localized between the external genitalia and the deep part of the
vagina. This result is in line with literature reporting high rates of
GP in young adult women.2e5 The percentage of women
complaining of GP (33%) was slightly higher than the per-
centage that reported sexual problems (29%). The average

J Sex Med 2020;-:1e13

10
McGill scores were moderate, and the duration of pain was
widely variable (median ¼ 9.5; interquartile range ¼ 3e36)
probably because of the differences between the women assessed:
most of them had suffered from pain for a few months (<1 year),
whereas others declared having GP for very long periods (eg, 32
participants reported a duration of more than 10 years).
Furthermore, most women did not seek for any professional
help for their GP, did not receive a diagnosis for their symptoms,
or did not undergo treatment for their pain. In accordance with
the literature,5,14,20 the most reported diagnosis was vulvovaginal
infections and cystitis, followed by endometriosis, vulvodynia,
and vaginismus. Reported painful sensations were brief and
momentary, and they could interfere with sexual intercourse.
When asked directly, only 45% of women with GP declared a
related sexual problem (painful penetration during sexual inter-
course). Although women reported that their pain could interfere
with sexuality and scored sexually dysfunctional on the FSFI
(mainly in the pain domain), most women with GP did not seem
to associate their pain with sexual problems when directly asked.
Future studies should better investigate this association in
awareness and prevention programs to understand if there is a
difference between the self-perception of having a sexual problem
related to GP and the FSFI score (which is a pluri-validated
measure to screen for sexual dysfunction) and if it may affect
professional help-seeking behavior.18,19 Are women with GP who
recognize a negatively impacted sexuality more able to seek help?
Or do sexual taboos restrain women from asking for specialist
assistance? The cognitive aspects related to GP such as negation or
normalization of pain during the menstrual cycle and sexual
experience in women may play a role in this association.50,54e56
Following the first specific aim of this study, the differences in
the FSFI, Female Sexual Distress Scale, PANAS, SF-36, and SCL-
90-R scores between women with and without GP were explored.
As expected, women with GP reported having generally worse
sexual function (not only in the pain area), a higher level of sexual
distress, more negative emotions related to sexual experiences,
worse scores for QoL in all the domains (except for “health change
during the last year”), and higher levels of psychopathology
symptoms. This is consistent with literature on the BPS under-
standing of GP.15,22e27 Referring to the Basson model,57 when
pain enters the circle of the sexual response, it may negatively affect
the whole sexual experience as well as psychological, relational, and
social areas. GP could be significantly pervasive and a holistic BPS
approach, able to account for all the effects that pain might have,
may be the best treatment option for these women.2,10,15
Focusing on women with GP (n ¼ 319), the difference between
the group with FSFI sexually dysfunctional (n ¼ 150) and func-
tional scores (n ¼ 169) were explored to deepen our understanding
of the role of sexual functioning in GP and its effects on psycho-
logical, emotional, and QoL correlates. The FSFI sexually
dysfunctional group consistently reported higher scores on pain
than the functional group. Controlling for pain effects, FSFI
Nimbi et al
sexually dysfunctional women showed higher sexual distress, less
positive and more negative emotions related to sexuality, worse
QoL, and a significantly higher psychological burden. Distress and
emotions explained a large amount of the variance, confirming the
importance of considering these variables in sexual functioning. A
linear association between higher perceived pain ratings and lower
sexual functioning was also confirmed.58
Moreover, the data show that FSFI sexually dysfunctional
women reported significant negative scores on the psychological,
emotional, and QoL dimensions even when the effect of pain
was controlled. This may suggest a fundamental role of sexual
functioning in affecting psychosocial variables, above the role of
pain itself. The profile of women experiencing GP with sexual
problems is highly characterized by isolation and depressive
symptoms (eg, feeling without energy), negative emotional
memories of sexual experience, and poor general health.59 The
general picture of GP is characterized by pervasive negative im-
plications on the BPS context of these women.
When controlling for the pain effects, some differences be-
tween women with GP duration <6 months (n ¼ 111) and

6 months (n ¼ 208) were highlighted on psychological,
emotional, and QoL scores. The 6 months criterion was chosen
following the DSM-5 criteria for GPP/PD. The group with GP
duration
6 months reported lower scores on pain, desire,
satisfaction, FSFI total score, and PANAS positive affects and
higher scores on distress and PANAS negative affects than the
group with GP duration <6 months. These data seem to show a
decrease of the sexual functioning and the related subjective
experience as the duration of symptoms increases.
As suggested earlier, the Basson model57 may give a realistic
explanation of deterioration of sexual experience after GP, occur-
ring soon after the first painful episode. More interestingly, no
differences were found in the psychopathological and QoL domains
between the 2 groups, both reporting low psychological and QoL
scores than no-GP group. These results may suggest that psycho-
logical status and QoL may be affected even before 6 months from
the GP onset and thus challenge the accuracy of the 6-month time
inclusion criterion used in the DSM-5 for the GPP/PD.
In the clinical practice, it should be strongly suggested to every
woman complaining about GP to seek help soon after the first
onset of the painful symptomatology. This may help to foster the
access to care for these women, before the effects of pain cause
clinically significant outcomes to their mental health and QoL.
Duration is an important variable that should be better identified
in future clinical studies. Considerable evidence differentiates the
consequences of acute and chronic pain,1,45 but a deep assessment
of the effects of time on GP and their sexual, psychological, and
QoL effects is still lacking in the literature and very important for
future editions of diagnostic classifications.
A general GP conceptual model (path diagram) based on the
literature and on the current findings may be useful to address
future research lines in this area with a more clinical
J Sex Med 2020;-:1e13
Genital Pain and Sexual Functioning
perspective.60 For example, it could be interesting to explore if
sexual functioning could mediate the role of GP on QoL and
psychological burden. A leading role of sexuality in deter-
mining the GP experience may support the implementation of
a positive approach to sexuality 61e63 in this cohort of women,
focusing primarily on pleasure and motivating them to find
ways to reach a more satisfying sexual life and, consequently, a
higher QoL.
These results add value to the need for further studies focusing
on the peculiarities of GP conditions and related BPS factors. It
is our firm belief that the DSM-57 underestimates the role of GP
etiology in the different groups of women falling under the GPP/
PD umbrella. From a clinical point of view, vaginismus is
extremely different from dyspareunia, vulvodynia, endometriosis,
and other conditions, with specific treatment algorithms and
suggestions. The ICD-11 proposal seems to make a small step
forward, with the possibility of specifying associated BPS factors
and recognizing the differences between organic and psychogenic
pain in the genital area.
However, given the current state of the literature, it is hard to
establish whether the psychosocial dimensions investigated in
this study were influenced by, or had an influence on, sexual
functioning and the pain experience. Based only on these data, it
is not possible to determine a precise direction (causality) of the
effects because the tested associations are linear and bidirec-
tional. Nevertheless, referring to the BPS model, the factors
raised could have a key role in clinical practice, that is, indi-
cating areas in which the HCPs should focus their attention
when dealing with women with GP. Having a general theoret-
ical model for GP may be a guideline to better identify the
differences and experiences of women with different diagnoses,
thereby confirming, expanding on, or disconfirming general
assumptions about GP.
The findings from this study should be interpreted with
caution because of some limitations.
(i) Questionnaire administration was based online and the
snowball sampling was used for ease of dissemination of the
survey. However, this leads to concerns regarding the
generalization of the results. The cohort of women reached,
although demonstrating good variability, was not repre-
sentative of the female population and may better describe
young Italian adults. To limit this bias, some sociodemo-
graphic variables (eg, age and relationship status) were
considered as covariates in all the analyses. Moreover, the
choice of having a web-based survey could have limited the
participation of women who are less familiar and confident
with technology.
(ii) The protocol was only composed by self-report question-
naires, of which the SF-MPQ was adapted by the authors
for GP and has not yet been validated. Nevertheless, to
control the possible lack of validity, it was administered in
J Sex Med 2020;-:1e13
11
association with validated measures (such as the FSFI), and
the results were highly concordant. Deepening the analysis
of GP with specific tools may be of significant help. Future
studies should implement these measures with direct
physical measures (such as the tampon test, pelvic floor
examination, and so on), in-person interviews, focus groups,
and including the partner to contemplate the relational as-
pects of GP.64
(iii) In addition, in this study, the etiopathogenesis of GP was
not verified by diagnostic examinations, but only self-
reported by women. This confirmation is fundamental to
studies that aim to explore the BPS characteristics of the
different conditions that currently fall under the GPP/PD
umbrella. In other words, self-report data have been valu-
able to create a baseline understanding of GP, but future
research may need to exert more experimental control to
isolate specific etiologies.
CONCLUSIONS
The present study shows a high presence of GP in the
general Italian female population, which is strongly associated
with impairment in sexual functioning, emotional correlates,
psychological well-being, and QoL. Moreover, the results
draw attention to a lack of awareness about pain experiences
and sexual health in women. Even if women with GP cope
with sexual problems, most of them do not seek specialists'
help. Clinicians should better investigate sexual functioning
and its direct effects on improving general health and QoL.
Women may be more willing to discuss their sexual issues if
HCPs ask about it during routine checkups. Interaction
models based on a BPS approach, that is, simultaneously
considering physical, psychological, sociocultural, and inter-
personal factors in GP, are necessary to improve the knowl-
edge on this field and the clinical care of this cohort of
women.
Corresponding Author: Filippo Maria Nimbi, PhD, PsyD, c/o
Institute of Clinical Sexology, Via Savoia 78, 00198, Rome,
Italy. Tel: þ393405006643; E-mail: filipponimbi@hotmail.it
Conflict of Interest: The authors report no conflicts of interest.
Funding: This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Filippo Maria Nimbi; Valentina Rossi; Francesca Tripodi
12
(b) Acquisition of Data
Filippo Maria Nimbi; Valentina Rossi; Francesca Tripodi; Mijal
Luria; Matthew Flinchum
(c) Analysis and Interpretation of Data
Filippo Maria Nimbi; Valentina Rossi; Francesca Tripodi; Mijal
Luria; Matthew Flinchum; Renata Tambelli; Chiara Simonelli
Category 2
(a) Drafting the Article
Filippo Maria Nimbi
(b) Revising It for Intellectual Content
Filippo Maria Nimbi; Valentina Rossi; Francesca Tripodi; Mijal
Luria; Matthew Flinchum; Renata Tambelli; Chiara Simonelli
Category 3
(a) Final Approval of the Completed Article
Francesca Tripodi; Mijal Luria; Matthew Flinchum; Renata
Tambelli; Chiara Simonelli
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