Sexual functioning in women with chronic pelvic pain: the impact of depression, support, and abuse.

Chronic pain is known to affect sexual functioning and sexual relationships. Both pain and sexual functioning are multidimensional constructs. Different aspects of the experience of chronic pain are related to psychological, physical, and social health and to overall well-being (Penny, Purves, Smith, Chambers, & Smith, 1999), as well as to various dimensions of sexual functioning, such as arousal, drive, sexual behavior, and satisfaction with sexual relationships (Flor, Turk, & Scholz, 1987; Monga, Tan, Ostermann, Monga, & Grabois, 1998).

In studying these effects, much of the research on chronic pain and sexuality has focused on patients involved in chronic pain treatment programs or other types of medical care and, in particular, on the sexual functioning of men with various disabilities. In the broader research literature, the experience of chronic pain, depression, the quality of intimate relationships, and child sexual abuse have all been shown to be related to sexual function; however, no study has looked at these factors in combination.

This study contributes to research in this area by examining sexual functioning in a nonclinical sample of women with chronic pain who may or may not have been involved in treatment and thus are more diverse than patient samples. The aim of the study was to clarify and extend the results of previous studies with primarily male participants who were receiving medical care (Coates & Ferroni, 1991; Flor et al., 1987; Monga et al., 1998; Tan, Monga, Thornby, & Monga, 1998). This study focused on women who suffer from chronic pelvic pain, as research has shown them to have difficulty with sexual functioning due to the pain (Fry, Crisp, & Beard, 1991; Collett, Cordle, Stewart, & Jagger, 1998) and a higher probability of having experienced childhood abuse (Collett et al., 1998; Walling et al., 1994). The main objective of the study was to develop a model of sexual functioning in women with chronic pelvic pain, incorporating key predictor variables such as pain experience, depression, relationship mutual support (i.e., support in intimate relationships), and childhood sexual abuse.

Chronic Pain

Chronic pain has a deleterious effect on sexual functioning. Factors that have been addressed in the area of chronic pain and sexuality include pain-related variables such as pain severity and frequency of pain (Ambler, Williams, Hill, Gunary, & Cratchley, 2001), as well as appraisal of control over life, the extent of interference caused by chronic pain (Monga et al., 1998), depression (Averill, Novy, Nelson, & Berry, 1996; Tan et al., 1998), and marital satisfaction (Flor et al., 1987). Work-related and demographic factors also affect sexual functioning in people with chronic pain, specifically unemployment, disability status (Monga et al., 1998), and age, with older age having a negative correlation with sexual frequency, drive/interest, and satisfaction (Monga et al., 1998; Tan et al., 1998).

Being a gynecological condition, chronic pelvic pain is, to some degree, more directly associated with sexual dysfunction than chronic pain at other sites. In one study of chronic pelvic pain patients' feelings and beliefs about their pain or illness, 40 out of 64 participants cited sexual dysfunction as one of the chief problems the illness had caused, making it the most frequent complaint (Fry et al., 1991).

Relationship Mutual Support

The quality of intimate relationships is closely connected with sexual function (McCabe, 1999; Metz & Epstein, 2002; Trudel, 2002). Satisfaction with the sexual relationship appears to be associated with higher marital functioning (Flor et al., 1987; Trudel). In addition to its relationship with marital dissatisfaction, sexual dissatisfaction is related to sexual dysfunction (Flor et al., 1987). In cases in which one partner suffers from chronic pain, the ability of both partners to cope with the pain and the extent to which partners are supportive of the chronic pain sufferer have been found to be a predictor of sexual functioning (Flor et al., 1987; Jenson, 1985).

Depression

Depression is one of the most frequently-studied aspects of chronic pain's impact on psychological health. Rates for probable depression in pain patients range from 38% to 87% (Flor et al., 1987; Holzberg, Robinson, & Geisser, 1993; Monga et al., 1998; Tan et al., 1998). Independently, pain-related factors such as pain duration and pain intensity do not appear to account for significant variation in depression scores (Averill et al., 1996; Turner, Jensen, & Romano, 2000), though Heinberg, Fisher, Wesselmann, Reed, and Haythornthwaite (2004) found that pain severity independently predicted depression. Other factors may mediate the effects of pain on depression, such as work status, education, and marital status (Averill et al.).

Apart from its link with chronic pain, depression also independently has a powerful influence on sexual relationships. A problematic issue in addressing the relationship between depression and sexual function is that while depression is closely associated with decreased sexual function (Basson, 2001; Philipp et al., 1999), sexual function is also often negatively impacted by medication taken for depression (see Ferguson, 2001 for a review). However, Michelson, Schmidt, Lee, and Tepner (2001) evaluated the effects of the drug fluoxetine in treating depression and found the sexual function improved for the majority of patients. Deterioration in sexual function appeared to be related to increases in depressive symptoms rather than to side effects of the drug.

Tan et al. (1998) found the effects of depression to be primarily focused on satisfaction with sexual functioning and not on sexual drive or frequency of sexual activities, though in Monga et al. (1998), depression was correlated with sexual behavior/experiences, orgasm, and sexual drive/relationship. Both findings demonstrate the importance of treating sexuality as a multidimensional construct. It is not clear how much of the disruption that chronic pain causes in sexual relationships is due to depression and how much is due to factors involved in the experience of pain itself. This distinction is a key issue in developing effective treatments for overcoming, or for coping with, chronic pain.

Sexual Abuse

Chronic pelvic pain appears to be particularly associated with sexual abuse (Collett et al., 1998; Fry, Crisp, & Beard, 1997; Lampe et al., 2000; Walling et al., 1994), or with having experienced both sexual and physical abuse (Green, Flowe, Rosenblum, & Tait, 1999). Studies by Walker and colleagues found high rates of child sexual abuse among chronic pelvic pain patients: 64% for chronic pelvic pain patients and 23% for a comparison group (Walker et al., 1988), 82% versus 43% (Walker, Katon, Neraas, Jemelka, & Massoth, 1992), and 58% versus 30% (Walker et al., 1995). The differences were much larger when considering only severe child or adult sexual abuse.

The evidence for a direct connection between child sexual abuse and difficulties in adult sexual functioning is mixed, particularly in nonclinical samples. Studies generally find either evidence of negative attitudes toward sexuality, including sexual aversion and avoidance (see review by Wyatt, 1991), fewer positive responses to sexual invitations (Gold, 1986), less satisfaction with present sexual relationships (Bartoi & Kinder, 1998; Gold), dissatisfaction with orgasm, physical discomfort during intercourse, and reported need for sex therapy (Feinauer, 1989), and low body esteem regarding sexual attractiveness (Wenninger & Heiman, 1998), or they find that survivors of child sexual abuse have more frequent and diverse sexual experiences and are more likely to engage in unsafe and irresponsible sexual behavior (Meston, Heiman, & Trapnell, 1999). At least two studies using university student or community samples have not found a relationship between child sexual abuse and sexual function (Bartoi, Kinder, & Tomianovic, 2000; Greenwald, Leitenberg, Cado, & Tarran, 1990).

The differences in these findings are probably due in part to different definitions of abuse and varying measures of sexual functioning. However, it is also likely that there are mediating factors that determine which survivors are more likely to experience sexual problems. Depression, in addition to its relationship to chronic pain, is also related to experiences of sexual abuse, particularly childhood sexual abuse (see reviews by Browne & Finkelhor, 1986; Putnam, 2003). Depression is the most common symptom reported by survivors of sexual abuse in the clinical literature, a finding supported by empirical research literature as well (Browne & Finkelhor). The prevalence of sexual problems in adults with a history of child sexual abuse may possibly be explained through the relationship of depression with sexual function.

This Study

One aim of this study was to clarify and extend previous research by identifying which areas of women's sexual relationships are most affected by chronic pain and in what ways they are affected. However, the primary objective was to develop a model predicting sexual functioning for women with chronic pelvic pain, integrating the factors of chronic pain experience, child sexual abuse, and mutual support in intimate relationships and the criterion measure of sexual function. An important goal in developing this model was to test whether depression was a mediating factor between the predictors of chronic pain experience, child sexual abuse, and mutual support in intimate relationships, and the criterion measure of sexual function.

In developing this model, we hypothesized that child sexual abuse, relationship mutual support, and pain experience (severity of pain and interference of pain with life) would indirectly predict sexual function through their relationship with depression. Relationship mutual support (mutuality in intimate relationships), as it is specifically related to the sexual relationship, was hypothesized to predict sexual function directly as well. Because of the lack of evidence strongly linking chronic pain factors to sexual functioning as measured by the Derogatis Interview for Sexual Function (Derogatis, 1997), we did not expect chronic pain severity or interference with life to predict sexual functioning directly (Monga et al., 1998). No hypothesis was proposed as to whether child sexual abuse would directly predict sexual functioning because of the mixed evidence connecting sexual abuse with comprehensive sexual function measures in nonclinical samples (Bartoi et al., 2000; Greenwald et al., 1990).

Method

Participants

Sixty-three women with chronic pelvic pain participated in this study. Three hundred survey packets were mailed to members of the Endometriosis Association, an organization for women with a gynecologic condition commonly causing pelvic pain; 48 were returned, a return rate of 16%. As surveys were mailed by the Endometriosis Association and they are not able to distinguish between members with a diagnosis of endometriosis and members who treat or have an interest in endometriosis, it was likely that some recipients of the surveys did not have endometriosis. Additionally, not all women with endometriosis suffer from chronic pelvic pain. Those members who did not have endometriosis or did not suffer from chronic pelvic pain were thus ineligible for the study and did not respond. Only women who were eligible for the study completed and returned the questionnaires. Announcements also were made in psychology undergraduate classes and posted on internet support groups for women with chronic pelvic pain, asking women to voluntarily request a survey packet (n = 15).

Participants' ages ranged from 19 to 50, with a mean of 33.27 (SD = 7.70). The majority of participants were married (58.7%). Approximately one fourth (25.4%) of participants were single, 9.5% were divorced or separated, and 6.3% were living with a partner. One participant identified herself as a lesbian. The racial identity of the sample was 87.3% White/European American, 4.8% African American, and 7.9% Other. The mean education level attained was 15.19 years (SD = 2.30, Range = 11-21 years).

Materials

The survey packet consisted of the Derogatis Interview for Sexual Function--Self Report (Derogatis, 1997), the West Haven-Yale Multidimensional Pain Inventory (Kerns, Turk, & Rudy, 1985), the Center for Epidemiological Studies Depression Scale (Radloff & Locke, 1986), the Mutual Psychological Development Questionnaire (Genero, Miller, & Surrey, 1990), and the Sexual/Physical Abuse History Questionnaire (Leserman, Drossman, & Zhiming, 1995). Questions on demographic factors and medication use were also included.

Instruments

The Derogatis Interview for Sexual Function--Self Report (DISF--SR) assesses five domains of sexual functioning: sexual cognition/fantasy, sexual arousal, sexual behavior/experiences, orgasm, and sexual drive/relationship (Derogatis, 1997). Each scale contains 4 to 5 items, and participants respond to each on a scale from 0 (not at all) to 8 (4 or more per day) or from 0 (not at all) to 4 (extremely) or (never) to (always). For example, in the drive/relationship scale, one question asks, "With the partner of your choice, what would be your ideal frequency of sexual intercourse?" Scores are calculated for each domain, and these domains are also combined into an overall score. Total scores can be converted to standardized T-scores to compare with the community population norm of T= 50 (SD = 10; Derogatis, 1997). The DISF-SR has demonstrated good reliability in community samples, with internal consistency coefficients for the five scales ranging from .74 to .80 and test-retest coefficients falling between .80 and .90. For the purposes of this study, total scores were calculated by summing scores from the sexual behavior/experiences, orgasm, and sexual drive/relationship subscales (possible range = 0-88). The sexual cognition/fantasy and sexual arousal subscales were not included because of the lack of evidence linking them to depression or pain variables in chronic pain populations (Monga et al., 1998; Tan et al., 1998).

The Multidimensional Pain inventory (MPI) measures the impact of pain on the sufferer's life. It consists of three sections: Pain Experience, Daily Activities, and Pain-Relevant Significant Other Responses. The first section, Pain Experience, includes five scales: pain severity, interference with life, self-control (perceived control over life), negative mood (affective distress), and support. Reliability estimates for the scales range from .70 to .90 (Kerns et al., 1985). In this study, pain experience scores were calculated by combining the scale interference with life and pain severity to address specific pain variables (r [62] = .75, p < .001). Two of the other subscales (support and negative mood) were addressed by the measures of relationship mutual support (r [58] = .41, p = .001) and depression (r [61] = .54, p < .001), and the self-control subscale did not specifically address pain. The interference and severity scales were both 6-point scales, so the combined chronic pain experience scores were on a 12-point scale, with higher scores indicating more interference from and severity of pain. The Daily Activities section of the MPI consists of four scales: household chores, outdoor work, activities away from home, and social activities; reliability estimates range from .70 to .86. In the third section, there are three scales measuring Pain-Relevant Significant Other Responses: negative responses, solicitous responses, and distracting responses, with reliability coefficients ranging from .75 to .80 (Kerns & Rosenberg, 1995). Scale ratings range from 0 to 6, with anchors such as never to very often or no change to extreme change, depending on the scale. A mean score is calculated for each subscale.

The Center for Epidemiological Studies Depression Scale (CES-D) is a frequently used, validated measure that was developed to measure depressive symptomatology in nonclinicial populations (Radloff, 1977). Initial reliability estimates were .84 and .85 in samples from the general population and .90 in a psychiatric patient sample (Radloff). Responses are scored from 1 to 4 on a scale based on the frequency of each symptom's occurrence. Total scores can range from 0 to 60, with higher scores indicating higher levels of depressive symptomatology. A score of 17 or above is suggested as a designated range for possible depression, and a score of 23 or more is generally considered probable depression (Radloff & Locke, 1986).

The Mutual Psychological Development Questionnaire addresses the quality of individuals' relationships with their partners (the extent of mutuality in the relationship) and is highly correlated with other measures of support, relationship satisfaction, and cohesion, particularly with significant others (Genero, Miller, Surrey, & Baldwin, 1992). Inter-item reliability coefficients range from .89 to .92. One section addresses the respondent's behaviors in discussions with a partner, and the second section addresses the spouse/partner's behaviors. A mean mutuality score is calculated by dividing the total score on the two sections by the number of questions. The range of mutuality scores is from 1 to 6, with higher scores indicating higher levels of relationship mutual support.

The Sexual/Physical Abuse History Questionnaire assesses physical abuse and sexual abuse in both childhood (13 and younger) and adulthood (defined as 14 and older; Leserman et al., 1995). For the purposes of this study, only responses to questions about sexual abuse were analyzed. Respondents answer yes or no to questions such as "Has anyone ever touched the sex organs of your body when you did not want this?" and "Has anyone ever made you touch the sex organs of their body when you did not want this?" In tests of reliability and validity, the test-retest reliability of the sexual abuse scale was .81, and there was 81% overall agreement between the questionnaire and an interview asking about any sexual abuse (Leserman et al.).

Women were considered to have experienced sexual abuse if they answered yes to any question other than "Has anyone ever exposed the sex organs of their body to you when you did not want it?" This question was not used to classify women as sexually abused because experiencing someone exposing their sex organs is not generally used in definitions of sexual abuse as it is not as invasive and traumatic as sexual abuse involving touch or force. Responses to the questions were summed to create an index of sexual abuse for both childhood and adolescent/adulthood, which was then recoded as 0 for no sexual abuse and 1, 2, and 3 for answering yes to having experienced 1, 2, or 3 types of sexual abuse, respectively. "Yes" responses to the question on forced intercourse were weighted as a 2 because of its greater severity. Higher scores on the index thus reflected more experiences of childhood sexual abuse or adolescent/adulthood sexual abuse (abuse at age 14 or older).

Procedure

The instructions informed participants that the study concerned chronic pelvic pain and its effects on intimate relationships. The survey required between 45 and 90 minutes to complete. Participants brought the packets to a designated drop-off location or returned them by postage-paid return mail. There was no reimbursement, but students were offered extra credit for participating.

Data Analysis

Path analysis was used to develop and test models predicting sexual functioning for women with chronic pelvic pain, including chronic pain experience, child sexual abuse, mutual support in intimate relationships, and depression as predictors. We tested the models using path analysis with generalized least squares estimation in Lisrel 8.71 (Joreskog & Sorbom, 2004). After eliminating cases with missing data, 56 cases were included in the analysis. Sample size, although small, was adequate for testing the simple models we used (Bentler & Chou, 1987). We first tested a saturated model, one which included all paths from predictor variables to sexual function and paths from pain experience, child sexual abuse, and mutual support to depression. Nonsignificant paths were then removed one by one to test a partially-mediated model.

Results

Table 1 presents descriptive results for the sexual function, pain, depression, and mutual support measures. Participants' mean standardized total score on the Derogatis Interview for Sexual Function-Self Report was smaller than the standardized community norm for this scale (T = 42 vs. T = 50; Derogatis, 1997), showing evidence of some sexual dysfunction, though participants' scores differed from the community norm by less than one standard deviation (SD = 10). Participants also reported less severe pain than a normative patient sample (Kerns et al., 1985).

The mean score on the Center for Epidemiological Studies Depression Scale (Radloff, 1977) was 20.16 (SD = 13.17), which exceeds the suggested cutoff for possible depression (17). Seventeen percent of the women met this criteria for possible depression and 37% met the criteria for probable depression (a score of 23 or above). Fully 54% of the women, then, scored as possibly or probably suffering from depression.

Forty participants (64.5%) reported experiencing sexual abuse. Of these, 5 (8.1%) reported sexual abuse in childhood only, 23 (36.5%) in adulthood only, and 12 (19%) in both childhood and adulthood.

The correlation matrix between the variables included in the path analysis--sexual function, child sexual abuse, pain experience, depression, and mutual support--is presented in Table 2. Sexual function was significantly related to depression and relationship support, while depression was significantly correlated with all variables.

Model 1 was a saturated path model (see Figure 1). As hypothesized, pain experience did not directly predict sexual function. This path was removed, and since the path from child sexual abuse to sexual function was now non-significant in this model, it was also removed to create a more parsimonious model (Model 2; see Figure 2), which could be assessed for model fit. By convention, satisfactory model fit is indicated by a non-significant Z2 statistic, a [chi square]: df ratio less than 3, CFI values greater than .90, and a SRMR of .10 or less (Kline, 1998; Joreskog & Sorbom, 1988). Model 2 demonstrated good fit according to these criteria (chi square [1, N = 56] = .53, p =.45, [chi square]: df = 1.50, CFI = .95, SRMR = .06).

[FIGURES 1-2 OMITTED]

In Model 2, child sexual abuse, pain experience, and relationship mutual support predicted depression, and depression and relationship mutual support predicted sexual function. Pain experience, child sexual abuse, and relationship mutual support had significant indirect effects on sexual function through depression (partial regression coefficients or beta weights were -.15 for chronic pain, -. 10 for child sexual abuse, and 0.12 for support, ps < .05). Therefore, the hypothesis that depression would mediate the effects of relationship mutual support on sexual function was partially supported, as mutual support both directly and indirectly predicted sexual function. Depression fully mediated the effect of child sexual abuse on sexual function. Although pain experience had a significant indirect effect on sexual function, the hypothesis that depression would mediate the effects of pain experience on sexual function was not supported. The correlation between pain experience and sexual function was not significant and thus did not meet the criteria for mediation (Baron & Kenny, 1986). Correlations between predictor variables were not significant, with the exception of the correlation between child sexual abuse and pain experience, r = .41, p < .01. Model 2 accounted for 31% of the variance in sexual function scores and 48% of the variance in depression scores.

Since both pain and sexual function are multidimensional constructs, further correlational analyses were conducted on individual dimensions of the Pain Experience scale from the Multidimensional Pain Inventory and the Derogatis Interview for Sexual Function-Self Report. Table 3 shows the correlation matrix between the sexual function and pain scales, age, and education. Perceived life control was related to all other Pain Experience subscales except support (not included in Table 3), as well as to the orgasm subscale. Women who rated themselves as having more control over their lives reported less interference from their pain, less severe pain, less negative mood, and greater satisfaction with orgasm. Age was negatively related to fantasy, arousal, and drive/relationship, whereas education was positively associated with behavior/experiences, orgasm, and drive/relationship. Education was also positively correlated with perceived life control and negatively related to pain severity, pain interference, and negative mood. Although education was related to all variables in the path analysis except child sexual abuse (pain experience, r [62] = -.40, p < .01 ; mutual support, r [60] = .33, p < .01; depression, r [63] = .45, p < .001; and total sexual function, r [60] = .40, p < .01), regression analysis showed that education was no longer significantly associated with depression or sexual function when pain experience and mutual support were included in the model. Age was not correlated with pain experience, mutual support, child sexual abuse, depression, or total sexual function.

Discussion

This study combined the factors of chronic pelvic pain experience, depression, relationship mutual support, and child sexual abuse together in a model predicting sexual function in women with chronic pelvic pain. The primary finding was that depression mediated the effects of child sexual abuse and partially mediated the effects of relationship mutual support on sexual behavior, sexual drive, and satisfaction with sexual relationship. Mutual support was the only factor, apart from depression, to predict sexual function independently. Mutual support, along with pain experience, also indirectly predicted sexual function though depression. Contrary to studies using community or student samples (e.g., Bartoi et al., 2000; Greenwald et al., 1990), child sexual abuse directly predicted sexual function when the path from pain experience to sexual function was included in the model, and indirectly predicted sexual function through depression when this path was removed. This sample differed substantially from Bartoi et al. and Greenwald et al. in consisting of women with chronic pelvic pain, who most likely had much higher levels of depression.

Thus, in this nonclinical sample, the effects of child sexual abuse on sexual function depended on the extent of depressive symptomatology, while the effects of relationship mutual support depended in part on depressive symptomatology. In women with chronic pelvic pain, supportive intimate relationships provide a buffer against depression and problems with sexual functioning, as they do in individuals not experiencing chronic pelvic pain (McCabe, 1999; Trudel, 2002).

In the multidimensional analysis, only one of the chronic pain variables was related to sexual function: life control appraisal was significantly correlated with orgasm. This contrasts with Monga et al. (1998), who found life control to be correlated with all sexual function variables and interference from pain to be related to all sexual function variables except fantasy and arousal. The participants in Monga et al. were primarily male patients in a chronic pain treatment program who suffered from pain at various sites. They most likely had more severe pain that interfered with their lives to a greater extent than did the pain of the participants in this study. Male patients tend to report a greater decline in frequency of sexual activity and are less likely to report sexual dysfunction before the onset of chronic pain, though male and female patients report a comparable decline in sexual adjustment after pain onset (Maruta & Osborne, 1978; Maruta, Osborne, Swanson, & Halling, 1981). Monga et al. also had older participants, with a mean age of 49.90, as opposed to 33.27 in the present study. The difference in sexual function in the present study and the Monga et al. study (beside the disparity in pain severity and interference) may be due in part to this age difference, since in the present study, as in Tan et al. (1998), age was related to decreased sexual function. Older women reported lower levels of fantasy, arousal, and drive/satisfaction with relationship.

Age was not related to chronic pain variables. However, life control appraisal was related to specific chronic pain variables, in that more perceived control over life was linked with diminished interference from and less severity of pain and lower incidence of negative mood. Additionally, a higher level of education was associated with less interference from pain, lower incidence of negative mood and depression, and more feelings of life control, along with higher scores on the behavior/experience, orgasm, and drive/relationship scales. This accords with the findings of Roth, Punch, and Bachman (2001), who reported inverse associations between education level and impairment from chronic pelvic pain, such as severity of pain, lower levels of functioning, somatic preoccupation, and emotional suffering. However, education was not predictive of depression or sexual function when pain experience and mutual support were included as predictors.

Rates of depression were substantial, with more than half of the participants meeting the criteria for possible or probable depression. This rate was much lower than rates in general chronic pain patient samples using the same measure (Monga et al., 1998; Tan et al., 1998), but similar to other patient samples using a comparable measure (Flor

et al., 1987; Holzberg et al., 1993), and higher than the rate of psychiatric diagnoses of current depression in chronic pelvic pain patients (Walker et al., 1995).

Limitations

The method used to recruit participants resulted in a low return rate. Not all women with endometriosis suffer from chronic pelvic pain and not all members of the Endometriosis Association have endometriosis. Thus, many members who received the survey may not have been eligible to participate and accordingly did not respond. Without data on nonresponders with chronic pelvic pain, it is difficult to know how representative the sample is of women with chronic pelvic pain in general. The small sample size limited the number of variables that could be included in the model and may have affected findings regarding child sexual abuse, as only 17 participants reported experiencing sexual abuse in childhood. Thus, the study is best regarded as a preliminary or exploratory study. Nonetheless, the model was able to show the direct and indirect impact of chronic pain, mutual support, and depression on sexual function.

The instruments used to measure sexual function and sexual abuse could be improved. The Derogatis Interview for Sexual Function--Self-Report focuses on physiological, behavioral, and cognitive (fantasy, satisfaction) aspects of sexual function. Since women's sexuality has been found to focus more on intimacy and emotional relating (Mansfield, Koch, & Voda, 1998), this inventory may not address some aspects of sexual function that are especially important to women. Body image is another issue that may be particularly relevant to women with chronic pain and histories of sexual abuse (Wenniger & Heiman, 1998).

Because this was a nonclinical sample, it was more likely to be variable in regard to whether the women had received psychotherapy or had been involved in medical treatment. Some women reported in their comments that their chronic pelvic pain had improved and that they were functioning better than they had in the past. The effects of chronic pelvic pain in these cases would be weaker. Nonclinical samples are beneficial in obtaining information on the wider range of individuals suffering from chronic pain who are not currently in treatment or who have never sought treatment. This nonclinical sample also included younger women, who have not been well-represented in previous studies which used patient samples with higher average ages (Flor et al., 1987; Maruta & Osborne, 1978; Maruta et al., 1981; Monga et al., 1998;. Tan et al., 1998). However, this sample was not diverse in terms of ethnicity, gender, or pain site, as it was primarily made up of White women with pelvic pain. The experience of chronic pain may be different for various cultural groups and for men. Normal sexual function possibly is defined differently as well.

Directions for Future Research

The final model should be validated in additional, larger nonclinical or community samples and in patient samples, as well as compared to pain-free community samples. In larger samples, gender and perceived life control could be included to increase the amount of variance in sexual function the model explains. Further research could demonstrate whether this model holds for various ethnic groups, for men, and for individuals with chronic pain in other sites. There may be other variables that are important in these populations that are not addressed in the current model. Additionally, the model could be tested in clinical samples of survivors of child sexual abuse as well as in clinical samples of chronic pain patients.

Practical Implications

This research provides a look at the quality of sexual functioning for women with chronic pain in a nonclinical sample, and at the factors that influence sexual function in individuals living with chronic pain. Although the women in the sample did not experience the same severity and amount of interference caused by pain as reported in some patient samples, they were clearly affected by chronic pain, amount of support in intimate relationships, depression, and quality of sexual function. The results of the study show that women with chronic pelvic pain who are more depressed or who do not have a supportive intimate relationship are more at risk for problems in sexual functioning. Depression appears to be a crucial factor in improving sexual function in chronic pain patients. Treatment for depression has shown promise in treating problems with sexual function (Michelson et al., 2001) and is likely to improve the overall functioning of individuals with chronic pain. Thus, chronic pain patients should be consistently screened for depression.

Comprehensive treatment plans for chronic pain that address sexual functioning could also benefit from an awareness of the effects of age and education on sexual functioning and by focusing on increasing individuals' feelings of control over their lives. The fact that many individuals cope successfully with chronic pain and are able to limit its impact on their lives, including their sexual relationships, provides hope that others can learn successful coping as well.

References

Averill, P. M., Novy, D. M., Nelson, D. V., & Berry, L. A. (1996). Correlates of depression in chronic pain patients: A comprehensive examination. Pain, 65, 93-100.

Ambler, N., Williams, A. C., Hill, R, Gunary, R., & Cratchley, G. (2001). Sexual difficulties of chronic pain patients. Clinical Journal of Pain, 17, 138-145.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1,173-1,182.

Bartoi, M. B., & Kinder, B. N. (1998). Effects of child and adult sexual abuse on adult sexuality. Journal of Sex & Marital Therapy, 24, 75-90.

Bartoi, M. G., Kinder, B. N., & Tomianovic, D. (2000). Interaction effects of emotional status and sexual abuse on adult sexuality. Journal of Sex & Marital Therapy, 26, 1-23.

Basson, R. (2001). Using a different model for female sexual response to address women's problematic low sexual desire. Journal of Sex and Marital Therapy, 27, 395-403.

Bentler, E M., & Chou, C. P. (1987). Practical issues in structural equation modeling. Sociological Methods & Research, 16, 78-117.

Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66-77.

Coates, R., & Ferroni, E A. (1991). Sexual dysfunction and marital disharmony as a consequence of chronic lumbar spinal pain. Sex and Marital Therapy, 6, 65-69.

Collett, B. J., Cordle, C. J., Stewart, C. R., & Jagger, C. (1998). A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners. British Journal of Obstetrics and Gynaecology, 105, 87 92.

Derogatis, L. R. (1997). The Derogatis Interview for Sexual Functioning (DISF/DISF-SR): An introductory report. Journal of Sex & Marital Therapy, 23, 291-304.

Feinauer, L. L. (1989). Sexual dysfunction in women sexually abused as children. Contemporary Family Therapy, 11, 299-309.

Ferguson, J. M. (2001). The effects of antidepressants on sexual functioning in depressed patients: A review. Journal of Clinical Psychiatry, 62, 22-34.

Flor, H., Turk, D. C., & Scholz, O. B. (1987). Impact of chronic pain on the spouse: Marital, emotional and physical consequences. Journal of Psychosomatic Research, 31, 63-71.

Fry, R. P. W., Crisp, A. H., & Beard, R. W. (1991). Patients' illness models in chronic pelvic pain. Psychotherapy Psychosomatics, 55, 158-163.

Fry, R. P. W., Crisp, A. H., & Beard, R. W. (1997). Sociopsychological factors in chronic pelvic pain: A review. Journal of Psychosomatic Research, 42, 1-15.

Genero, N. P., Miller, J. B., & Surrey, J. (1990). Research project report: The mutual psychological development questionnaire. Wellesley, MA: Stone Center for Developmental Service and Studies.

Genero, N. P., Miller, J. B., Surrey, J., & Baldwin, L. M. (1992). Measuring perceived mutuality in close relationships: Validation of the Mutual Psychological Development Questionnaire. Journal of Family Psychology, 6, 36-8.

Gold, E. R. (1986). Long-term effects of sexual victimization in childhood: An attributional approach. Journal of Consulting and Clinical Psychology, 54, 471-475.

Goldberg, R. T. (1994). Childhood abuse, depression, and chronic pain. Clinical Journal of Pain, 10, 277-281.

Green, C. R., Flowe, V. H., Rosenblum, L., & Tait, A. R. (1999). Do physical and sexual abuse differentially affect chronic pain states in women? Journal of Pain and Symptom Management, 18, 42-426.

Greenwald, E., Leitenberg, H., Cado, S., & Tan-an, M. J. (1990). Childhood sexual abuse: Long-term effects on psychological and sexual functioning in a nonclinical and nonstudent sample of adult women. Child Abuse & Neglect, 14, 503-513.

Heinberg, L. J., Fisher, B. J., Wesselmann, U., Reed, J., & Haythornthwaite, J. A. (2004). Psychological factors in pelvic/urogenital pain: The influence of site of pain versus sex. Pain, 108, 88-94.

Holzberg, A. D., Robinson, M. E., & Geisser, M. E. (1993). The relationship of cognitive distortion to depression in chronic pain: The role of ambiguity and desirability in self-ratings. The Clinical Journal of Pain, 9, 202-206.

Jenson, S. B. (1985). Sexual relationships in couples with a diabetic partner. Journal of Sex and Marital Therapy, 11, 259-270.

Joreskog, K. G., & Sorbom, D. (Eds.) (1988). LISREL 7: A guide to the program and applications. Chicago: SPSS.

Joreskog, K. G., & Sorbom, D. (2004). LISREL 8.71. Chicago: Scientific Software International.

Kerns, R. D., & Rosenberg, R. (1995). Pain-relevant responses from significant others: Development of a significant-other version of the WHYMPI scales. Pain, 61, 245-249.

Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale Multidimensional Pain Inventory. Pain, 23, 345-356.

Kline, R. B. (1998). Principles and practice of structural equation modeling. New York: Guilford Press.

Lampe, A., Solder, E., Ennemoser, A., Schubert C., Rumpold, G., & Sollner, W. (2000). Chronic pelvic pain and previous sexual abuse. Obstetrics & Gynecology, 96, 929-933.

Leserman, J., Drossman, D. A., & Zhiming, L. (1995). The reliability and validity of a sexual and physical abuse history questionnaire in female patients with gastrointestinal disorders. Behavioral Medicine, 21, 141-150.

Mansfield, P. K., Koch, E B., & Voda, A. M. (1998). Qualities midlife women desire in their sexual relationships and their changing sexual response. Psychology of Women Quarterly, 22, 285-303.

Maruta, T., & Osborne, D. (1978). Sexual activity in chronic pain patients. Psychosomatics, 19, 531-537.

Maruta, T., Osborne, D., Swanson, D. W., & Halling, J. M. (1981). Chronic pain patients and spouses: Marital and sexual adjustment. Mayo Clinical Proceedings, 56, 307-310.

McCabe, M. P. (1999). The interrelationship between intimacy, relationship functioning, and sexuality among men and women in committed relationships. Canadian Journal of Human Sexuality, 8, 31-38.

Meston, C. M., Heiman, J. R., & Trapnell, P. D. (1999). The relation between early abuse and adult sexuality. The Journal of Sex Research, 36, 385-395.

Metz, M. E., & Epstein, N. (2002). Assessing the role of relationship conflict in sexual dysfunction. Journal of Sex and Marital Therapy, 28, 139-164.

Michelson, D., Schmidt, M., Lee, J., & Tepner, R. (2001). Changes in sexual function during acute and six-month fluoxetine therapy: A prospective assessment. Journal of Sex and Marital Therapy, 27, 289-302.

Monga, T. N., Tan, G., Ostermann, H. J., Monga, U., & Grabois, M. (1998). Sexuality and sexual adjustment of patients with chronic pain. Disability and Rehabilitation, 20, 317-329.

Penny, K. I., Pures, A. M., Smith, B. H., Chambers, W. A., & Smith, W. C. (1999). Relationship between the chronic pain grade and measures of physical, social and psychological well-being. Pain, 79, 275-279.

Philipp, M., Delini-Stula, A., Baier, D., Kohnen, R., Scholz, H. J., & Laux, G. (1999). Assessment of sexual dysfunction in depressed patients and reporting attitudes in routine daily practice: Results of the postmarketing observational studies with moclobemide, a reversible MAO-A inhibitor. International Journal of Psychiatry in Clinical Practice, 3, 257-264.

Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of American Academy of Child Adolescent Psychiatry, 42, 269-278.

Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-01.

Radloff, L. S., & Locke, B. Z. (1986). The community mental health assessment survey and the CES-D Scale. In M. Weissman, J. Myers, & C. Ross (Eds.), Community Survey (pp.177-189). New Jersey: Rutgers University Press.

Roth, R. S., Punch, M. R., & Bachman, J. E. (2001). Educational achievement and pain disability among women with chronic pelvic pain. Journal of Psychosomatic Research, 51, 563-569.

Tan, G., Monga, U., Thornby, J., & Monga, T. (1998). Sexual functioning, age, and depression revisited. Sexuality and Disability, 16, 77-86.

Trudel, G. (2002). Sexuality and marital life: Results of a survey. Journal of Sex and Marital Therapy, 28, 229-249.

Turner, J. A., Jensen, M. P., & Romano, J. M. (2000). Do beliefs, coping, and catastrophizing independently predict functioning in patients with chronic pain? Pain, 85, 115-125.

Walker, E. A., Katon, W. J., Hansom, J., Harrop-Griffiths, J., Holm, L., Jones, M. L., et al. (1995). Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics, 36, 531-540.

Walker, E., Katon, W., Harrop-Griffiths, J., Holm, L., Russo, J, & Hickok, L. R. (1988). Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. American Journal of Psychiatry, 145, 75-80.

Walker, E. A., Katon, W. J., Neraas, K., Jemelka, R. E, & Massoth, D. (1992). Dissociation in women with chronic pelvic pain. American Journal of Psychiatry, 149, 534-537.

Walling, M. K., Reiter, R. C., O'Hara, M. W., Milburn, A. K., Lilly, G., & Vincent, S. D. (1994). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics & Gynecology, 84, 193-199.

Wenninger, K. & Heiman, J. R. (1998). Relating body image to psychological and sexual functioning in child sexual abuse survivors. Journal of Traumatic Stress, 11,543-562.

Wyatt, G. E. (1991). Child sexual abuse and its effects on sexual functioning. Annual Review of Sex Research, 2, 249-266.

Manuscript accepted August 30, 2005

We wish to thank Steven Pinkerton, Ph.D., for his assistance in the preparation of this manuscript. This research was supported in part by center grant P30MH52776 from the National Institute of Mental Health and by NRSA postdoctoral training grant T32-MH19985. This study is based on the doctoral dissertation of Mary E. Randolph. Portions of the study were presented at the annual meeting of the American Psychological Association in 2003.

Address correspondence to Mary E. Randolph, Postdoctoral Fellow at the Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 2071 N. Summit Avenue, Milwaukee, WI, 53202; e-mail: [e-mail].

Mary E. Randolph and Diane M. Reddy

University of Wisconsin-Milwaukee

Table 1. Descriptive Data for Sexual Function, Pain, Child
Sexual Abuse, Depression, and Support Measures

                           M      SD       Range

Sexual functiona         33.70   15.38     4-63
Pain experience (MPI)     5.85    2.97    0-11.67
Depression (CES-D)       20.16   13.17     0-49
Support                   4.31     .63   2.95-5.27
Child sexual abuse         .54     .97      0-3

(a) Calculated by combining the behavior/experiences, orgasm, and
drive/relationship subscales of the DISF-SR.

Table 2. Correlation Matrix for Variables Included in the
Path Analysis

                       1.    2.      3.       4.        5.

1. Sexual function     --  -.31 *  -.20     -.46 ***   .43 ***
2. Child sexual abuse        --     .38 **   .43 ***   .02
3. Chronic pain                      --      .57 ***  -.15
4. Depression                                 --      -.38 ***
5. Support                                             --

* p < .05 ** p < .01 *** p < .001

Table 3. Correlations Between Sexual Function Variables,
Depression, Relationship Support, Age, and
Education

                      Age        Education    Life Control

Age                     --
Education              .03          --
Life Control          -.17         .32 *          --
Pain Severity          .10        -.38**        -.40***
Pain Interference      .03        -.37**        -.45***
Negative Mood          .04        -.33**        -.50***
Fantasy               -.27 *       .06           .07
Arousal               -.26 *       .06          -.04
Behavior              -.24         .27 *         .19
Orgasm                -.09         .37 **        .33 **
Drive                 -.33 **      .28 *         .22

* p < .05 ** p < .01 *** p < .001