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Keywords:

  • chronic pelvic pain;
  • sexual dysfunction;
  • sexuality counseling;
  • sexuality education;
  • gynecology nursing;
  • PLISSIT model;
  • interstitial cystitis;
  • vulvodynia;
  • dyspareunia;
  • endometriosis;
  • sexual adjustment

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Sexual concerns are common in women with chronic pelvic pain and often remain unresolved when pain improves. Therefore, to restore pelvic function, treatment should address sexuality in addition to pain. In this article, I describe sexual challenges experienced by women with chronic pelvic pain, introduce a modified sexuality counseling model, and suggest sexuality resources and training for gynecologic nurses and other health care providers who are ideally positioned to offer sexuality counseling to this population.

Case: Hana and Collin had been a couple for 3 years when urinary urgency began to interrupt Hana's regular activities, including sleeping and sex. Arousal, vestibular stimulation, and vaginal penetration that came in contact with her anterior introitus, urethra, and bladder increased the urgency. Frequent urination attempts rarely provided relief. Orgasm also exacerbated her symptoms, and the couple stopped engaging in sexual touch.

Over the next 4 years Hana's irritation and pain continued to worsen, and with numerous medical visits she was finally diagnosed with interstitial cystitis/painful bladder syndrome (IC/PBS). She and Collin were relieved to finally have a name for her pain and hoped that when they found a cure, their lives would return to normal and sexual activity would be pain free and fun again.

During 9 months of pain treatment, they continued to put off sexual touching and became more distant while waiting for a cure. Hana's pain improved markedly, but her sexual activity remained painful and awkward. As a couple they felt disappointed and stuck. In spite of her improvement, Hana was afraid sexual activity would provoke a new pain flare, so she withdrew from Collin's touch. She felt defensive, nervous, frustrated, guilty, victimized by her own body, and a failure as a woman; Collin was afraid to touch her and felt rejected, anxious, and concerned about his ability to please Hana. He was frustrated and felt guilty for feeling frustrated.

Couples often reach this point of isolation, hopelessness, fear, and rejection before finding a sexuality counselor, assuming they ever find one. If health care providers routinely screened for sexual distress and offered support for sexual concerns during the course of a patient encounter, they could ease suffering and assist with sexual adjustment. Sexual adjustment refers to self-perceived sexual health, which is a state of biological and psychosocial well-being in relation to sexuality that goes beyond the absence of disease (World Health Organization [WHO], 2006). Sexual adjustment counseling helps patients to develop, recover, or maintain a state of self-perceived sexual health. Gynecologic nurses are ideally positioned to provide sexual adjustment support to women with chronic pelvic pain.

In this article, I illustrate the need for sexuality counseling in the management of chronic pelvic pain; describe common sexual challenges experienced by women and couples with chronic pelvic pain; introduce a modified Permission, Limited Information, Specific Suggestion, and Intensive Therapy (PLISSIT) sexuality counseling model called ImPLISSIT; and suggest resources and training for gynecologic nurses and other health care providers ideally positioned to offer confident and competent sexuality counseling in a clinical setting.

Defining Chronic Pelvic Pain

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Chronic pelvic pain (CPP) is a syndrome lacking standard definitions or research parameters (Latthe, Latthe, Say, Gülmezoglu, & Khan, 2006; Williams, Hartmann, & Steege, 2004). Often defined as persistent pain in the pelvic region for a minimum duration of several months, this syndrome has diverse symptoms including dysmenorrhea, dyspareunia, vulvar pain, and nonspecific complaints that are related to the lower abdomen, pelvic floor, or uterus (Leserman, Zolnoun, Meltzer-Brody, Lamvu, & Steege, 2006). Commonly, CPP is associated with endometriosis, IC/PBS, vulvodynia, vulvar vestibulitis syndrome (VVS), and irritable bowel syndrome (IBS) (Rosenbaum & Owens, 2008). Therefore, evaluation and treatment of CPP occurs within several different subspecialties of medicine (Wesselmann & Czakanski, 2001). In addition, pain is classified differently by various professional organizations in accordance with the descriptive symptoms that reflect the specialty (Rosenbaum & Owens, 2008).

Sexual adjustment counseling can conceivably have a greater impact on a woman's pain experience than the treatment of pain.

Chronic pelvic pain affects an estimated 12% to 39% of women in the United States (Harlow, Wise, & Stewart, 2001; Jamieson & Steege, 1996; Mathias, Kuppermann, Liberman, Lipschutz, & Steege, 1996), 24 to 25% of women in the United Kingdom and New Zealand (Grace & Zondervan, 2004; Zondervan et al., 2001), and is the most common cause of referral to women's health services (Latthe et al., 2006). Due to the variety of specialties where women seek care for their symptoms of CPP, diagnosis is complicated, and ultimately this condition goes undiagnosed for 61% of women with CPP (Zondervan et al., 1999). In addition, pain often remains unresolved even when diagnosis is made (Grace & MacBride-Stewart, 2007).

Chronic pelvic pain entails progressive sensitization by the peripheral and central nervous system (CNS), which affects normal sensory processes (Jantos, 2007) and results in a pain experience that is disproportionate to the degree of tissue damage (Steege, 1998). Chronic pelvic pain requires fundamentally different management strategies from those used for acute pain (Jantos; Steege) due to the multiple organ involvement, and emotional, behavioral, and CNS interactions (Steege).

Chronic Pelvic Pain and Sexuality

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Chronic pelvic pain affects a woman's general health (Zondervan et al., 2001) and sexual function (Florido, Perez-Lucas, & Navarrete, 2008; Lee et al., 2008; Tripoli et al., 2011) to such an extent that patients with CPP report more sexual problems than patients with any other type of chronic pain (Collett, Cordle, Stewart, & Jagger, 1998). Even effective pain treatment for CPP is usually insufficient to resolve sexual concerns (Bergeron et al., 2001; Goldfinger, Pukall, Gentilcore-Saulnier, McLean, & Chamberlain, 2009). Therefore, sexuality issues need to be addressed directly in addition to the pain.

Sexuality is expressed in attitudes, behaviors, and relationships and is influenced by biology, psychology, sociology, and culture (WHO, 2006). When health suffers, the sexual health of the individual and partner may also suffer (Clayton & Ramamurthy, 2008) as well as the relationship (Butt & Chesla, 2007; Hawkins et al., 2009). Because the suffering integral to pain drives women to seek health care (Loeser, 2005), addressing suffering should be the goal of care. This may be accomplished by maximizing quality of life (Sullivan, 2001), which includes sexuality (Tripoli et al., 2011). When sexual adjustment counseling effectively relieves suffering, it could conceivably have a greater impact on a woman's pain experience than the treatment of pain.

For some women, CPP is experienced independently of sexual arousal, stimulation, and orgasm; for others, it is exacerbated by sexual response or behavior; and for the rest, it is only present during or triggered by sexual response or behavior. The way a woman experiences pain is critical to sexual adjustment. For the many women who associate pain with sex and attempt to avoid pain by avoiding sexual behavior, sexual adjustment may not occur without counseling to address that association.

Physiological Components of CPP

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Physiologically, the epicenter of pelvic pain is the pelvis, and the pain typically affects structures involved in sexual pleasure, such as the clitoris, vulva, vestibule, vagina, perineum, anus, urethra, bladder, uterus, abdomen, buttocks, and inner thighs. In addition to local pain, women with CPP typically have lowered pain thresholds in their entire bodies (Davis, Maykut, Binik, Amsel, & Carrier, 2011; Giesecke et al., 2004) and can experience widespread myofascial pain, or pain that extends to other pleasure sites such as the nipples. Pain rather than pleasure may be felt during the phases of sexual response, such as arousal and orgasm. Women may describe muscle cramps, shooting pains, or electric shock during orgasm in areas like the lower abdomen, genitals, or anus. Often the resolution phase is incomplete for a woman with a tight or spastic pelvic floor and limited pelvic circulation.

Other physiological challenges experienced by women with CPP include vaginal dryness and susceptibility to vaginal irritation, infections, and tears, all of which can feel punishing during and after sexual activity. Tight pelvic muscles and bladder or bowel irritation can prevent complete voiding or evacuation, which can be distracting and frustrating during sexual stimulation. Pelvic floor and body tension and spasms can exacerbate pain and limit exercise and flexibility, which ultimately make it difficult to achieve and maintain sexual positions and movement.

Common sexual pain patterns are associated with the various gynecologic syndromes that constitute CPP. Examples include deep dyspareunia at the cervix and uterus associated with endometriosis, urethral and bladder irritation associated with IC/PBS, vestibular irritation and shallow dyspareunia at the introitus associated with VVS, shallow dyspareunia at the introitus associated with referred trigger point pain, and orgasmdynia associated with pelvic floor myalgia. Women often present with symptoms of more than one syndrome resulting in complex sexual complaints and limitations.

The amount of time, number of procedures, and medications involved in managing CPP can have direct or indirect sexual side effects. These side effects may include exhaustion, drowsiness, anxiety, insomnia, inability to obtain restful sleep, weight gain, memory loss, speech difficulty, reduced libido, and difficulty achieving orgasm. These side effects can lead women to completely avoid sexual activity and can affect or be affected by psychological or sociological factors.

Psychosocial Components of CPP

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Pain during activities that are expected to be pleasurable, or fear that pleasure will cause a pain flare, can amplify suffering, be demoralizing, and interfere with self-identity, relationships, and treatment progress. Many women with CPP describe developing a fear of touch, as it may be painful or lead to sexual activity that is painful (Howard, 2008). The level of volatility and unpredictability of the condition and resulting capabilities can make women feel unstable. Loss of control or the unknown can produce anxiety about pain, which can lower pain thresholds and exacerbate pain perception (Sullivan, 2001). Women experiencing CPP may require more control over and become protective of their bodies, circumstances, and surroundings. Some women remain braced for pain to the point that the expectation of pain becomes more debilitating than the pain itself.

These women may experience loss of independence, grief, self-doubt, loss of confidence, confusion, anger, resentment, depression, embarrassment, and shame. They may search for something or someone to blame for their baffling pain, such as sex, a partner, a procedure, medical professional, or themselves; some view their pain as punishment; some blame themselves for ensuing relationship difficulties. Women experiencing CPP often feel victimized by their own bodies and may dissociate or separate from their bodies and bodily sensations. They describe feeling abnormal, disadvantaged, damaged, and isolated (Howard, 2008).

These beliefs can all lead to a diminished body image, reduced self-worth, or loss of identity as a person, a sexual being, and a partner. Women experiencing CPP may describe sexuality as something that “improves the conditions of my life,” “helps with thinking I'm more normal,” and “more of a woman”; problems with sexuality can result in feeling defeated and hopeless and ultimately avoiding dating or beginning new relationships due to feeling unworthy, damaged, or embarrassed (Howard, 2008).

Psychological factors become intertwined with sociological factors. Fear of embarrassment, pity, and rejection can pervade all social interactions, leading many women to become progressively isolated. Women describe concerns associated with being regarded “as crazy” or “as complainers” by family, friends, and health care providers. Because pain is not objectively measurable or visible, women with CPP are susceptible to invalidation and judgment regarding their reports of pain and their management of it.

Relationship dynamics often change, and fears for one's future become compounded by fear of relationship failure. Many women can't perform their perceived gender roles in terms of sex, household chores, or work. Some become dependent and feel like burdens, especially with partners in caregiver roles. Partners can feel helpless, frustrated, afraid, confused, and rejected. The sexual challenges that often accompany CPP can profoundly influence intimate relationships. Women have described feeling like “freaks of nature” and “damaged goods” when they are unable to perform sexually as they believe they should, and many wonder, “why would anyone want to put up with me?” Sexual communication can be even more difficult than usual, as “pain isn't sexy” (Howard, 2008).

Just as changed sexual function can alter a woman's self-image and sense of identity, so too can it alter the self-image of a partner. A woman's inability to experience pleasure or reach orgasm may affect a partner's ego. Many partners develop sexual difficulties, such as loss of confidence, diminished self-image, and erectile difficulty. In addition, health problems of partners can compound the sexual challenges in the relationship. For example, if the only comfortable intercourse position for a woman with CPP is missionary and her partner is incapable of maintaining missionary position, both partners could feel frustrated and inadequate. For this reason, addressing sexuality at the relationship level and learning about the sexual health and attitudes of both partners can improve sexual adjustment.

Role of Health Care Providers

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

In spite of known sexual side effects of many chronic diseases and treatments, the sexual aspects of chronic disease remain largely unaddressed by researchers and clinicians (Bitzer, Platano, Tschudin, & Alder, 2007; Verschuren, Enzlin, Dijkstra, Geertzen, & Dekker, 2010). Physicians do not consistently ask women about sexuality (Bekker et al., 2009; Pauls et al., 2005; Roos, Thakar, Sultan, & Scheer, 2009), nor do the majority of nurses, despite understanding how disease and treatment can affect sexuality and considering sexuality counseling within the domain of holistic nursing care (Bekker, Van Driel, Pelger, Lycklama à Nijeholt, & Elzevier, 2011; Saunamaki, Andersson, & Engstrom, 2010).

Reasons nurses may skip the topic of sexuality in clinical practice include the following: (a) lack of time; (b) lack of privacy; (c) lack of knowledge about how to ask appropriate questions, address sexual problems or therapeutic options; (e) lack of comfort or embarrassment with the topic; (f) strongly held attitudes about sexuality and about patient conservatism; (g) concern about causing patient anxiety or a negative response; (h) the assumption that other healthcare providers are responsible for addressing sexual issues; and (i) the belief that patients do not expect nurses to ask about sexual concerns (Bekker et al., 2011; Kautz, Dickey, & Stevens, 1990; Lewis & Bor, 1994; Magnan, Reynolds, & Galvin, 2005; Saunamaki et al., 2010; Schnarch, 1981). Patients do believe discussing sexual concerns with nurses and caregivers is appropriate (Nusbaum, Singh, & Pyles, 2004; Waterhouse, 1993), but they unfortunately will not seek medical treatment for their concerns (Moreira et al., 2005). These findings indicate that caregivers must initiate the conversation.

Multimodal, multidisciplinary treatment is the optimal approach in caring for women experiencing CPP (Jantos, 2007; Pearce & Curtis, 2007) and should include experts in sexuality counseling. Treatment teams rarely include a sexuality counselor, a doctor in the developing field of sexual medicine, or even an explicit protocol to ensure that any member of the team addresses sexuality. At a minimum, health care providers working in integrated teams should agree on who is responsible for addressing sexual health so that women's sexuality is not left unsupported (Bekker et al., 2011). Future integration of sexuality specialists into multidisciplinary teams caring for women experiencing CPP may improve patient outcomes.

Even when health care providers do address sexuality, the needs and expectations of women with chronic illness are often not met due to stereotypical assumptions about female sexuality and the expertise of the provider being limited to reproductive function and pathology (Hordern & Street, 2007). Health care providers have an important role in establishing a therapeutic relationship so women can share their experiences related to CPP. Researchers found the predominant barrier for pain relief was difficulty communicating with a health care provider (Shi, Langer, Cohen, & Cleeland, 2007; Sullivan, 2001).

The ImPLISSIT Sexuality Counseling Framework

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

The identified barriers for nurses to provide sexuality counseling may be overcome with training and preparation. Annon (1974) found that many women with sexual concerns responded better to a targeted, brief approach than to intensive psychotherapy. He designed the Permission, Limited Information, Specific Suggestion, and Intensive Therapy (PLISSIT or P-LI-SS-IT) model of sexuality counseling as a way for all health care providers to offer counsel based on their time, training, and level of expertise. Annon (1974) theorized that each successive level would require increased time, knowledge, training, experience, and skill and suggested that P, LI, and SS together constituted “brief therapy,” whereas IT, “intensive therapy,” remained the domain of qualified psychotherapists. This framework allows practitioners to offer more support of all types described in the model as they obtain additional training.

The PLISSIT model and its various modifications have been used in conjunction with chronic pain conditions (Albaugh & Kellogg-Spadt, 2003; Mercer, 2008; Stilos, Doyle, & Daines, 2008; Taylor & Davis, 2006, 2007). I suggest a modified version called ImPLISSIT, to highlight the Implied assumptions that should be examined and preparations that should be made prior to beginning the PLISSIT intervention. The clinical reference guide in Table 1 provides examples of how this model might be used to offer sexuality adjustment counseling. It includes corresponding decision processes, resources, and training available.

Table 1. ImPLISSIT Sex Counseling: Framework and Protocols
ImPLISSIT STAGE, ACTIONS & TRAININGEXAMPLES & RESOURCES
Note
  1. ImPLISSIT = Permission, Limited Information, Specific Suggestion, and Intensive Therapy sexuality counseling model; SAR = Sexual Attitudes Reassessment (or Restructuring).

Implied PreparationActions Personal Examination: examine personal attitudes about sexuality; Practice: practice rapport building dialogue;  Environment: create time and privacyTraining  SAR training: http://www.AASECT.org, http://www.IASHS.org;  Sexual interviewing techniques with role play: http://www.HermanWallace.com;  Review cases with supervisorPractice interviews & speaking explicit sex words; Practice admitting to not knowing and providing referral
PermissionAction Inquire to build rapport, gather informationTraining  Notice when personal buttons pushedSay: “People with chronic pelvic pain often experience sexual difficulties. What changes or difficulties have you noticed since your symptoms began?” Learn about pain: nature, intensity, duration, location, sexual activities that make it better and worse (position, pacing, timing, arousal, orgasm, method of stimulation, treatments).
Limited InformationAction Offer relevant education and resourcesTraining  Sexuality science: http://www.sex-science.org, http://www.ISSWSH.orgHandouts  Sexual Pain Guides http://www.SexualRehab.com;  IC Fact Sheets http://www.ichelp.org/page.aspx?pid=351;  Sexuality & Pain http://96.10.7.92/pdfs/patient_edu/sexuality_20090416.pdf;  Sexual Devices http://www.dhrn.ca/files/sexualhealthmanual_lowres_2010_0208.pdfBooks Goldstein, Pukall, & Goldstein: When Sex Hurts  Herrera: Ending Female Pain Joannides: The Guide to Getting it On  Kaufman, Silverberg, & Odette: The Ultimate Guide to Sex and Disability  Stewart & Spencer: The V BookWebsites  Sex ergonomics: http://www.Ergoerotics.com;  Sex health: http://www.ashastd.org;  Sex education: http://www.SexSmartFilms.com Referrals Sexologist for brief therapy http://www.AmericanCollegeofSexologists.org, http://www.AmericanBoardofSexology.com;  Sex therapist for intensive therapy http://www.AASECT.org,  Sexual medicine http://www.ISSWSH.org
Specific SuggestionAction Suggest behavioral techniques to meet goalsTraining  Sex counseling skills: http://www.AASECT.org, http://www.HermanWallace.orgActivities, positions, products, medication or skills to enhance pleasure and/or reduce sexual pain Exercises to improve sexual comfort, body image, body knowledge communication Mindfulness-based exercises to reduce anxiety, relieve pain and foster embodied consciousness, etc.
Intensive TherapyAction  Offer referral to sex therapistTraining Therapy degree & supervision from http://www.AASECT.orgProvide sex therapist referral: www.AASECT.org

Implied Preparations: Role of the Provider, Dialogue, and Environment

Prior to beginning a dialogue about sexuality according to the PLISSIT model, the role of the provider and purpose of dialogue must be considered. Barratt and Rand (2009) described the professional's role as engaging clients in protecting their own sexual health and offering sex-positive guidance. The primary purpose of dialogue is to build a partnership to serve as a basis for ongoing discussions related to their sexual advocacy. Gathering factual information is of secondary importance. This interactive process is referred to as “sexual health assessment” rather than “sexual history taking” to emphasize sexual health promotion versus historical information collection that may be irrelevant to current sexual health and could inhibit relationship building needed to promote ongoing sexual health.

Questions should be designed to provide permission and support to explore sexuality and elicit awareness. The best way a practitioner can prepare for patient dialogue is to practice interviewing skills and to examine personal attitudes in order to develop comfort with sexuality. Knowledge is secondary. A permissive and private environment must also be created in preparation for commencing dialogue. This entails consideration of documentation and reporting and time commensurate with the content.

Permission

Permission is acceptance and validation of the patient's individual concept of sexuality, even if she is not interested in sexuality. It most often involves normalizing or encouraging a woman's sexual goals, thoughts, feelings, attractions, responses, or risk-aware and consensual behaviors. The best way to begin a dialogue about sexuality is with a normalizing statement and a simple, open-ended question such as, “Chronic pelvic pain often has an impact on sexuality. How does your pain relate to your sexuality?” If problems, concerns, or questions are reported, some follow-up questions could be “What goals would you like to accomplish in terms of your pain levels and sexuality” and “Would you like some resources to help you meet those goals?”

Nurses need not become sexuality experts; they can provide triage by beginning a dialogue and assessing sexual health to direct women to appropriate resources.

In the example of Hana and Collin, permission could consist of taking the time to listen and showing interest as one or both share their stories, thoughts, feelings, frustrations, hopes, and goals. If they choose to share, it could improve their awareness, understanding, communication and reduce isolation. Validation of their experience by listening with interest can be therapeutic. After the initial normalizing question, a series of particular exploratory questions could be asked such as, “At this point, what are your sexual goals? You said you are concerned that sexual activity might cause a pain flare. Why do you think that might happen? Which activities seem to make your pain worse? Which activities seem to be pleasurable? What, exactly, does the pain feel like? How does clitoral stimulation affect you? What is the most comfortable way to do that? How about vaginal

penetration? Nipple stimulation? Anal stimulation? Arousal? Orgasm?” Encouraging patients to reflect on their own experiences acknowledges and encourages their expertise.

When time and privacy are limited, permission to continue the discussion can be negotiated. For instance, one option is to say, “I'd really like to have enough time to discuss this in depth. Let's make another appointment for you to come back and discuss your sexual concerns.” Another option is direct referral to a sexuality counselor, a session in which time and space are designated for sharing personal information with an expert who regularly discusses sexuality can provide safety and comfort to the patient.

A permission-giving practitioner is comfortable with sexual discussion and diversity and remains free of judgment or is value neutral. Annon (1974) suggested that clinicians be aware of their personal value systems and try not to impose them on clients. The separation of personal beliefs from professional values is best achieved through process-oriented education designed to increase provider awareness of one's own attitudes (Lewis & Bor, 1994; Hayter, 1996). One such educational process, called Sexual Attitudes Reassessment (or Restructuring), known as SAR, was developed in the 1960s (National Sex Forum, 1975; Vandervoort & McIlvenna, 1976) and remains a staple of contemporary sexological training (Barratt, 2008).

A provider who perceives that a more skilled counselor is needed may say, “Thank you for sharing this information with me. I can find some answers for you or give you the contact information for a sexuality counselor who is better qualified to help you.” This communicates that sexuality is valued while providing a resource. According to Annon (1974), a clinician should permit himself or herself to not be an expert and to disclose lack of knowledge to a patient. Demonstrating comfort with not having an answer and with collaborative learning that elicits the expertise of the patient, research or other experts provides an empowering model for the woman experiencing CPP to participate in her own care.

Limited Information

Limited Information is relevant education or information about common concerns, ways to connect or to cope sexually. Offering limited information can be accomplished by explaining biological or psychosocial processes or providing resources. These resources may include relevant research, books, articles, websites, and referrals to support groups or relevant practitioners. This information can often provide normalization and permission.

In the example of Hana and Collin, the provider could state that at least 60% of people with IC/PBS experience sexual difficulties (Ottem, Carr, Perks, Lee, & Teichman, 2007), which would be educational and normalizing. Other limited information may include handouts for reducing sexual pain or for IC and intimacy, referral to another practitioner, or resources such as a website that offers a community for individuals with health conditions in which they discuss sexual coping (see Table 1).

For the health care provider, identifying a sexuality counselor who is willing to offer guidance and collaboration is often the best first step. Such an expert can help build a resource list and assist patients and partners directly when the provider reaches the limits of her time, knowledge, skills, or comfort. Pain and sexuality exist within a social context; by supporting intimate partners and relationships, sexuality counselors can help improve the environment in which pain and sexual difficulties occur, which may have a profound impact on adjustment and pain levels.

Any solutions offered must be relevant to the woman's goals and experience of her own sexuality and should not reflect the provider's agenda or meaning. Clinicians should be aware of their own levels of knowledge and should only offer suggestions when they are reasonably competent to assess relevant risks (in general and for that particular patient).

Specific Suggestion

Specific suggestions are targeted recommendations designed to help women meet their self-identified sexual goals. They often consist of activities like new sexual positions or trying pleasure-enhancing or pain-reducing products, or progressive skills–building exercises based on a cognitive-behavioral approach to build confidence and expand the sexual comfort zone until the goal is met.

In the example of Hana and Collin, this suggestion could consist of helping them to find a pleasurable activity that is unlikely to be painful. It might be nonsexual, like enjoying a meal together that doesn't cause a pain flare. Suggestions would incorporate the provider's understanding of pain mechanisms, sexual options, Hana and Collin's particular goals, sexual comfort level, and pleasure and pain mappings. Ideally, all necessary information would be obtained from Hana and Collin, and focused elicitation questions might be, “What type of pleasurable activity might you be comfortable trying if you could avoid vaginal penetration, which you described as triggering your worst pain? Perhaps taking a walk together or trading foot massages? How about sexual pleasure? Clitoral stimulation? With a finger, tongue, vibrator?” Notice that the specific suggestions can also be permission-giving and educational.

Intensive Therapy

Intensive therapy, if required, is best administered by a sex therapist, a licensed therapist with experience addressing sexual issues. If seeking a sexuality counselor for resources or referral during the brief therapy (P-LI-SS) stages of the PLISSIT model, clinical sexologists are ideal due to their extensive training in sexology (the science of human sexuality) and their sexual attitude awareness.

Additional Considerations

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Language

Sensitivity to terms used and messages implied is especially important in working with people with chronic pain; in their case, the pathologizing of sexuality can have a more detrimental impact than with other populations. Many women with chronic pain have seen a number of specialists in their quest for understanding and healing and have been labeled dysfunctional and disabled in numerous ways, which can be devastating and demoralizing. The practice of pathologizing locks women into identifying themselves as dysfunctional, when their responses could be functional responses to circumstances, instead reframing the problem and focusing on what is desired and possible can change self-perception from inadequate to functional instantaneously.

Consider using terms that describe behavior and avoid historically value-laden associations, such as self-stimulation instead of masturbation. Also use terms that reflect a woman's perspective rather than external assessment, which are often based on preconceptions of normality. Consider sexual difficulty, concern, or problem rather than sexual dysfunction. Also, consider traumatic experience rather than abuse.

Every conversation and questionnaire about sexuality serves to educate patients about sexuality from the perspective of a perceived expert. Nonverbal messages such as body language and tone can betray emotions like surprise, discomfort, and disgust. Simply being interviewed by a provider who is nonjudgmental and sex positive can give women a sense of permission, acceptance, validation, confirmation that there is no objective normal, and access to a role model who embodies sexual comfort and a healthy approach to sexuality.

Screening for Sexual Abuse

Many pain management protocols, such as that of the American College of Obstetricians and Gynecologists (2011), suggest screening for sexual abuse. Inquiries must be conducted with sensitivity and information put to the best use. If current abuse is identified, the provider can advocate for patient safety. Historical abuse, however, may not be relevant to a woman's current condition, and an insensitive exploration is potentially damaging to her progress.

Training

Additional training is available to help providers offer competent, comfortable, and compassionate sexual health assessments. Sexuality education is suggested at all stages of nursing education in the domains of knowledge, sexual communication and counseling skills, and assessment of sexual attitudes and biases (Bekker et al., 2011; Lewis & Bor, 1994). For improved knowledge, courses are available in areas such as sexual anatomy and physiology, sexual function, sexual side effects of medications commonly prescribed for pelvic pain, protocols for treating sexual concerns, risk reduction, sexual rehabilitation and ergonomics, the sexual spectrum, and diversity. For attitude self-assessment, SAR-type experiential processes are available to learn about and reduce biases and judgments in a clinical context. For development of sexuality communication and counseling skills, courses are available in sexual interviewing and rapport building that include practice and supervised role play (see Table 1 for courses).

Conclusion

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography

Women must be helped in their struggles to find new identities and new levels of normalcy that incorporate pleasure into their lives, despite experiencing CPP. Given the importance of sexuality to relationships, self-image, and quality of life, helping a woman to adjust sexually could be a concrete way to affect change, even if the pain itself is resistant to treatment. Turning the focus to sexual adjustment can provide women with a welcome diversion in their lives that previously may have been singularly focused on pain and the quest to eradicate it.

To address the great unmet need for sexual adjustment counseling in women experiencing CPP, it is imperative that providers who treat CPP prioritize sexuality and ensure that at least one person on the team is conducting sexual health assessments with all patients. Health care providers such as nurses need not become sexuality experts to make a difference; they can provide triage by beginning a dialogue and assessing sexual health to direct patients to appropriate resources. According to the ImPLISSIT framework, dialogue, assessment and referral are elements of sexuality counseling that provide a smooth transition to care with expert sexuality counselors within or outside of the team who have extensive training in the bio-psycho-social components of human sexuality.

The Permission, Limited Information, Specific Suggestion, and Intensive Therapy (PLISSIT) model allows providers to offer sexual counseling based on time, training and level of expertise.

Trained sexuality counselors consist of clinical sexologists who are board certified through either the American College of Sexologists (ACS) or the American Board of Sexology (ABS), sexuality counselors and therapists who are certified through the American Association of Sexuality Educators, Counselors and Therapists (AASECT), or clinical nurse specialists or other health care providers who have sought specialized training in human sexuality. Because pelvic pain and sexuality are inextricably linked for many women, pelvic pain treatment programs provide a logical locus for collaboration between gynecologic nurses and qualified sexuality counselors.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography
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Biography

  1. Top of page
  2. ABSTRACT
  3. Defining Chronic Pelvic Pain
  4. Chronic Pelvic Pain and Sexuality
  5. Physiological Components of CPP
  6. Psychosocial Components of CPP
  7. Role of Health Care Providers
  8. The ImPLISSIT Sexuality Counseling Framework
  9. Additional Considerations
  10. Conclusion
  11. REFERENCES
  12. Biography
  • Heather S. Howard, PhD, is a board certified sexologist practicing sex counseling, education, and mindfulness-based health management, Center for Sexual Health and Rehabilitation, San Francisco, CA.