Visual attention to erotic images in women reporting pain with intercourse.The last 15 years have evidenced a shift in the conceptualization of dyspareunia (painful intercourse) from somatic manifestation of inner conflict to a pain disorder in its own right (e.g., Binik, Meana, Berkeley, & Khalife, 1999; Meana, Binik, Khalife, & Cohen, 1997b; Payne et al., 2005). The research and clinical focus has moved away from the proposal of psychosexual and relational explanations toward the psychophysical properties of the pain, its measurement, and characteristics shared with other pain syndromes of unknown etiology (e.g., Pukall, Binik, & Khalife, 2003; Pukall, Binik, Khalife, Amsel, & Abbott, 2002). Sexual and relational impairments associated with dyspareunia are now generally considered consequences of the pain and have thus been relegated to secondary status in recent research attempting to understand the complex presentation of painful intercourse.
This research shift has culminated in a debate as to whether dyspareunia is better categorized as a sexual dysfunction characterized by pain--as it is now classified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychological Association, 2000)--or as a pain disorder interfering with sexual behavior, only incidentally. A special edition of the Archives of Sexual Behavior was dedicated to this issue, with compelling arguments presented by advocates of both sides. Arguing for re-classification, Binik (2005) posited that the concept of dyspareunia as a sexual dysfunction is fundamentally flawed by its implication of a special type of pain that is, by nature, sexual. This characterization is a significant departure from most descriptions of pain, which refer to the anatomical region affected rather than the activity interfered with (Binik et al., 1999). Research has also shown that the pain experienced during intercourse has similar experiential, psychophysical, and neurological properties to those of other pain syndromes, which have not been labeled psychosomatic (Bushnell, Villemure, Strigo, & Duncan, 2002; Giesecke et al., 2004; Granot, Friedman, Yarnitsky, & Zimmer, 2002; Lowenstein et al., 2004; Meana & Binik, 1994; Meana et al., 1997b; Pukall et al., 2003; Pukall et al., 2002; Pukall et al., 2005). Arguments against the re-classification of dyspareunia from a sexual dysfunction to a pain disorder have typically highlighted the dualism inherent in the suggestion that dyspareunia must be either a pain or a sexual problem. Dyspareunia clearly involves both pain and, very often, difficulties at all stages of the sexual response cycle. Exchanging one incomplete descriptor (dyspareunia as sexual dysfunction) for another equally incomplete one (dyspareunia as pain disorder) did not appear to some commentators to hold the promise of improvements in either conceptualization or treatment (Carpenter & Andersen, 2005; First, 2005; Meana, 2005; Payne, 2005). This debate has raised important questions about the experience of a pain that is unique in its association with sexual activity. Each on their own, pain and sex involve complex cognitive and emotional processes; combining pain with sex necessarily compounds this complexity.
Although both therapists and researchers have long acknowledged the important roles that attention and cognitive distraction play in sexual functioning (Abrahamson, 1985; Adams, Haynes, & Brayer, 1985; Elliott & O'Donohue, 1997; Farkas, Sine, & Evans, 1979; Geer & Manguno-Mire, 1996; Janssen, Everaerd, Spiering, & Janssen, 2000; Rupp & Wallen, 2008), very few studies have investigated the cognitive correlates of dyspareunia specifically. Payne, Binik, Amsel, and Khalife (2004) conducted an emotional Stroop test, using pain and emotional words as stimuli, with women with and without provoked vestibulodynia (PVD), the most common type of pre-menopausal dyspareunia (Bergeron, Binik, Khalife, & Pagidas, 1997). Payne et al. (2004) found a hypervigilance effect for pain-relevant information in women with PVD, such that pain words created greater interference for these women than for controls. Although there was a clear hypervigilance-to-pain effect in the women with PVD, the study did not use sexual words as comparisons, leaving us to wonder if a similar hypervigilance effect might have been found for sexual information. More recently, Thaler, Meana, and Lanti (2009) conducted a verbal memory test to examine the relative saliency of pain and sex words in women with and without sexual pain. Results indicated no group differences in recall or recognition for sex words; however, women with sexual pain had significantly more false memories (intrusions and false positives) for pain words than did no-pain controls. These findings were interpreted to suggest that women with sexual pain may have stronger semantic networks related to pain than do pain-free controls and that pain information may have greater saliency for them.
Currently, thus, we have two studies suggesting that pain information is attended to and remembered differently in women reporting pain with intercourse, with one of these studies indicating that sexual information may not be attended to in a fundamentally different manner by these women as compared to women with no sexual dysfunction. It is too early to know whether pain and sex stimuli are attended to differentially by women with sexual pain or whether sex stimuli have become akin to pain stimuli for women experiencing the repeated pairing of sex and pain. In an attempt to further investigate the potential cognitive saliency of sexual stimuli, we created a visual attention paradigm to examine attention to and distraction from sexual stimuli in women reporting pain with intercourse. In each scene of heterosexual couples engaging in sexual foreplay, a "semantically inconsistent object," such as a beach ball in an office, was digitally inserted. Research on general scene perception has shown that scene regions containing more information than others, such as those consisting of objects that are out of place (i.e., semantically inconsistent), are generally privileged in terms of the relative visual attention conferred upon them (Antes, 1974; Loftus & Mackworth, 1978; Mackworth & Morandi, 1967; for a review, see Henderson & Hollingworth, 1998).
Considering the voluminous literature linking distraction to a variety of sexual impairments (for reviews, see Barlow, 1986; Cranston-Cuebas & Barlow, 1990; see also Salemink & van Lankveld, 2006; van Lankveld & van den Hout, 2004), a sexual dysfunction conceptualization of dyspareunia would align well with the hypothesis that women reporting pain with intercourse might be more easily distracted from the sexual content in the aforementioned images than would dysfunction-free controls. Considering the equally substantial empirical support linking the attention-capture of pain information to a variety of chronic pains (e.g., Asmundson, Kuperos, & Norton, 1997; Crombez, Eccleston, Baeyens, van Houdenhove, & van den Broeck, 1999; Crombez, Eccleston, van den Broeck, van Houdenhove, & Goubert, 2002; Eccleston, 1995; Eccleston, Crombez, Aldrich, & Stannard, 1997; McCracken, 1997), a pain disorder conceptualization of dyspareunia would align well with the hypothesis that women reporting pain with intercourse would focus on the sexual content in the images more so than controls if the sexual stimuli are being processed akin to pain stimuli. A third possibility is that dyspareunia does not function as do other sexual dysfunctions or pain syndromes precisely because it combines impairments related to both sex and pain. In this case, we might evidence a pattern of visual attention that differs from that of no-sexual dysfunction controls and from that of another sexual dysfunction control group, such as women with low desire.
Our study was designed to explore these possibilities using an eye-tracking paradigm that tested visual attention to erotic stimuli in three groups of women: women reporting persistent pain with intercourse, women reporting low to no sexual desire, and a control group with no pain or other sexual dysfunction. In line with a nondualistic approach to the conceptualization of dyspareunia, we hypothesized that women with dyspareunia would exhibit a pattern of visual attention that differed significantly from both control groups in that they would exhibit more distraction from sexual stimuli than dysfunction-free controls but less than the low desire group. In other words, we expected a visual attention pattern that might indicate the uniqueness of dyspareunia in its involvement of both pain and sexual difficulties.
The primary group of interest for this study was women who experienced significant pain on at least 50% of intercourse attempts. Women with low sexual desire were recruited as a sexual problem control group, and a third group of women with no sexual complaints comprised the final group of interest. To find women who met the criteria for each of these groups, members of the research team administered the Female Sexual Function Index (FSFI; Rosen et al., 2000) to all women in the psychology subject pool who were willing to complete it.
The FSFI is a brief measure of sexual function and dysfunction composed of 19 questions pertaining to six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The items addressing sexual pain query the frequency of discomfort or pain during vaginal penetration, the frequency of discomfort or pain following vaginal penetration, and the pain intensity during or following vaginal penetration. Participants were selected if they reported experiencing pain "about half the time" during or after vaginal penetration that was of at least moderate intensity (corresponding to a weighted subscale score of 3.60 or less). In concert with Wiegel, Meston, and Rosen (2005), women who had a weighted score of 3.30 or less on the desire questions qualified for the hypoactive, or low, sexual desire (HSD) group. Women whose total FSFI score was higher than 26 qualified for the no-sexual problem control group. The FSFI has been found to have high test-retest reliability (r = .79-.86), high internal consistency (Cronbach's alpha values of .82 and higher), and acceptable discriminant validity, as demonstrated by significant differences between scores of women with sexual arousal disorder, orgasmic disorder, hypoactive sexual desire disorder (HSDD), and control groups (Meston, 2003; Rosen et al., 2000). Cronbach's alpha for our entire sample on the FSFI total score was .83.
Women from the psychology subject pool were screened over five semesters. FSFI questionnaires were completed by 941 women, 759 of whom were willing to be contacted for possible participation in this study. The vast majority of the women who were willing to be contacted either had not been sexually active during the four weeks prior to completing the FSFI or met criteria for the no-sexual problem control group. Recruitment for the no-sexual problem control group lasted only two semesters, as 176 women in this time period met criteria for this group, and we had no difficulty reaching our target sample size of 20. Of those women who were willing to be contacted and who had been sexually active during the four weeks previous to completing the FSFI, 32 met criteria for the pain group and 42 met criteria for the HSD group.
Overall, 64 women participated in the eye-tracking phase of this study; however, data for 10 participants had to be discarded and were not included in the final analyses. Due to either experimenter error or the participant moving to such a degree that no eye movements were recorded, the data for six participants were removed (one woman with pain, three women with HSD, and two no-sexual problem control women). The data for an additional four participants were removed due to classification issues (e.g., a second FSFI revealed no sexual dysfunction, self-identified lesbian).
The final sample for data analyses thus consisted of 54 women: 20 women reporting recurrent painful intercourse, 14 women with HSD, and 20 women with no sexual complaints. All participants were 18 to 29 years of age, self-identified as heterosexual or bisexual, and had normal or corrected-to-normal vision. The age, ethnic identities, and religious affiliations for the three groups are presented in Table 1. Kruskal-Wallis chi-square tests for multiple independent groups revealed that there were no overall group differences on ethnic identity, [chi square] (2, N = 54) = 0.25, p = .883; or religious affiliation, [chi square] (2, N = 54) = 5.76, p = .259. The FSFI scores for sexual desire, pain during sex, and overall functioning in the final sample are reported in Table 2. There were no differences in visual attention between the heterosexual and bisexual participants. The three groups, however, differed significantly on all three variables of interest: desire, F(2, 49) = 60.70, p < .001; pain, F(2, 49) = 37.78, p < .001; and FSFI total score, F(2, 49) = 24.78, p < .001. Participants were compensated by receiving research participation credit as part of requirements for an introductory psychology course. They were also offered short-term sex therapy for treatment of sexual dysfunction symptomatology. The women reporting pain during intercourse did not undergo a gynaecological exam, nor was their specific type of genital pain assessed, as we were interested in the generic experience of pain with intercourse and its potential impact on the cognitive processing of sex stimuli. Participants remained naive with respect to the purpose of the study until debriefing.
To ensure the equivalence of the erotic images used for the study, we recruited 40 women who reported no sexual problems (as ascertained by the FSFI) to complete stimulus ratings on a series of 12 images of heterosexual couples engaged in foreplay. These women rated these images on six dimensions using Likert scales: attractiveness, eroticism, intensity, sexiness, arousal, and appealingness. Ten inconsistent objects were presented with each scene; participants were instructed to rate each object on the likelihood that it would appear in that particular scene.
The final stimuli for the study consisted of nine erotic images that approximated one another on levels of attractiveness and eroticism, each with a semantically inconsistent object digitally inserted into it. The inconsistent objects inserted into each of the scenes were all rated as the object with the least likelihood of appearing in each of the scenes (e.g., a squirrel in a bedroom). As previously stated, these objects violated only semantic inconsistency in that they did not logically belong in that scene; there were no other types of violations (e.g., floating objects, inconsistent foreground and background). All inconsistent objects were placed a similar distance away from the models in the images so as to standardize the images as much as possible.
As a manipulation check, the women in the final sample also rated the images and inconsistent objects on the aforementioned dimensions. A multivariate analysis of variance revealed that there were no overall differences in ratings between the women in the final sample and the 40 women who had initially rated the images, F(9, 84) = 1.16, p = .332. There were also no differences found in erotic or inconsistent object stimulus ratings in the final sample as a function of ethnic identity (i.e., European American or non-European American), F(9, 42) = 1.35, p = .244; or the reporting of a religious affiliation, F(9, 42) = 1.09, p = .392.
Eye movements were recorded using an Applied Science Laboratories (ASL) Eye Track 6000 series Eye Start system (ASL, Bedford, MA). The Eye Start optics attached to this eye tracker are designed to accurately measure a person's pupil diameter and point of gaze on a stationary (room-fixed) scene space. These optical components are attached to an adjustable chinrest. This chinrest provides a very stable platform for the optics and is designed to be comfortable even with extended use. This eye tracker utilizes the corneal reflection method, which is more accurate than simply tracking the pupil alone because the computer tracks two points of reference rather than just one. The eye positions were sampled at 120 Hz. Viewing was binocular, although only the position of the left eye was tracked. The stimuli were displayed at a resolution of 1,024 x 786 Pixels x 256 Colors on a True Color monitor using a Radeon VE ATI Graphics card (ATI Technologies, Markham, Ontario, Canada) operating at a refresh rate of 85 Hz. The GazeTracker program provided by ASL presented the stimuli, synchronized and recorded the eye-movement data, and allowed for the analysis and visualization of the data collected.
Women who fulfilled selection criteria as determined by the screening process described in the Participants section were scheduled for the eye-tracking portion of the study. Both the screening and eye-tracking phases of this study were approved by the institutional review board of the University of Nevada, Las Vegas. After reading the informed consent, participants were administered the Conners' Continuous Performance Test (CPT; Conners, 1992).
The CPT is a simple test of attentional vigilance, measuring the capacity to ward off distractions to selective attention. Although there was no empirically supported reason to expect that general attentional processes to nonsexual information would vary between women with and without sexual dysfunction, we included the CPT to ensure that this was the case. During the CPT, a series of letters appear on a computer screen, and participants are instructed to press the space bar for every letter that they see, except for the letter "X." Participants respond as quickly as possible to the letters and must inhibit their response when the letter X appears. The CPT provides four measures of attention based on test performance: (a) omissions (i.e., any letter other than X appeared, and the participant did not press the space bar), considered to be a measure of inattentiveness; (b) commissions (i.e., the letter X appeared, and the participant pressed the space bar), considered to be a measure of impulsivity; (c) hit rate reaction time, which is a measure of how long it took the participant to respond; and (d) d', which is a measure of the balance between errors of omission and errors of commission. All four measures were calculated into t scores (M = 50, SD = 10) and were adjusted for age and level of education. The CPT takes approximately 14min to complete, and has proved useful in distinguishing between normal and abnormal attentional function (Lezak, Howieson, & Loring, 2004).
Upon completion of the CPT, the experimenter orally described the eye-tracking equipment as she positioned the eye-tracking apparatus and the eye tracker was calibrated. Calibration consisted of having the participant fixate on nine markers on the display area, and the calibration was checked by having the participant perform the task again. The Eye Start system was calibrated to each individual until the average error in gaze position was 0.5[degrees]. Once the eye tracker was successfully calibrated, the experimental session began and lasted approximately five minutes. Given the short nature of the experimental session, we did not anticipate fatigue effects and, thus, did not attempt to control or account for them.
In the experimental session, each participant was presented with nine erotic pictures that included an inconsistent object. Participants were instructed to look at the images presented as they normally would. They viewed each image for 10 sec; the images were presented in a randomized order for each participant. Participants were then given a test of visual acuity, the Snellen Eye Chart (similar to those found at optometrists' offices), to validate their ability to see detail at a distance. They also completed the demographic questionnaire at this time. Without the eye tracker, participants were then shown the scenes again and asked to provide ratings for the images and semantically inconsistent objects.
For the purposes of data analyses, the stimulus images were each divided into three scene regions: the bodies (i.e., the full bodies of the male and female in the images, which we conceptualized as the sexual scene region of the images), the inconsistent object, and the context (i.e., the background and everything in it). The three primary dependent measures of interest in terms of visual attention were total number of fixations, average fixation duration, and total time. These three eye-tracking measures are the most commonly reported dependent variables in the scene perception literature. Total number of fixations was a count of the times the eye landed on any given scene region; it is often theorized that total number of fixations is a measure of drawing attention, which is one indication of overall interest in that particular scene region. Average fixation duration was the mean duration (in milliseconds) of viewing time on a given scene region; it is thought to be a measure of attentional capture. Total time was a measure of the total number of milliseconds the individual attended to a particular scene region across the entire stimulus presentation time (in this case, 10sec); total time is also thought to be an indication of overall interest in a given scene region (J. Henderson, personal communication, June 2003). For each visual attention dependent variable (number of fixations, average fixation duration, and total time), results were analyzed in 3 (Participant Group: Painful Intercourse, HSD, and No Sexual Problem)x 3 (Scene Region: Bodies [including the faces of the models], Inconsistent Object, and Context) analyses of variance (ANOVAs). Because there were no significant group differences on the CPT dependent variables, thus indicating equivalent attentional capacity, these scores were not included as covariates in the final analyses.
Total Number of Fixations
Means and standard deviations of total number of fixations as a function of participant group and scene region (bodies, inconsistent object, and context) are shown in Table 3 and visually presented in Figure 1. Mauchley's Test of Sphericity was significant, so Greenhouse-Geisser results have been reported. Results of the omnibus ANOVA for total number of fixations revealed a significant main effect for scene region, F(2, 89.70) = 157.97, p<.001 ([[eta].sup.2] = .76); and a significant Participant Group x Scene Region interaction was also found, F(3.52, 89.70) = 5.17, p < .001 ([[eta].sup.2] = .17).
The Participant Group x Scene Region interaction was analyzed using simple effects analyses. A simple main effect was found for participant group, such that women with dyspareunia looked at the bodies fewer times than both the women with HSD (p = .018) and the no-sexual problem control women (p = .003). There was no significant difference between women with HSD and no-sexual problem control women for number of fixations on the bodies. No significant differences were found among the groups for number of fixations on the inconsistent object. Women with dyspareunia looked at the context significantly more times than did the no-sexual problem control women (p = .013), and the women with HSD also looked at the context more times than did the no-sexual problem control women (p = .019).
[FIGURE 1 OMITTED]
A simple main effect was also found for scene region. Women with intercourse pain looked at both the bodies and context significantly more times than at the inconsistent object (p < .001 and p < .001, respectively). Similarly, women with HSD looked at the bodies and context significantly more times than at the inconsistent object (p < .001 and p < .001, respectively). However, women with HSD were also found to have looked more times at the bodies than at the context (p = .005). The no-sexual problem control women also looked at the bodies and context significantly more times than at the inconsistent object (p < .001 and p < .001, respectively). Like the women with HSD, the no-sexual problem control women looked at the bodies more times than at the context (p < .001).
[FIGURE 2 OMITTED]
Average Fixation Duration
Means and standard deviations of the average fixation durations on each of the three scene regions are shown in Table 4 and are visually presented in Figure 2. Mauchley's Test of Sphericity was again significant, so Greenhouse-Geisser results are presented. Results of the omnibus ANOVA for average fixation duration revealed a significant main effect for scene region only, F(1.52, 77.67) = 37.69, p < .001 ([[eta].sup.2] = .43). The average fixation duration means for the scene regions, regardless of participant group, were as follows: bodies (M = 223.83), inconsistent object (M = 290.16), and context (M = 405.44). Tests of the scene region main effect revealed that participants had significantly longer average fixation durations on the context than on both the bodies (p < .001) and the inconsistent object (p < .001). Average fixation durations on the inconsistent object were also significantly longer than on the bodies (p = .007).
Total Gaze Time
Means and standard deviations for each of the three groups on total gaze time for the three scene regions are shown in Table 5 and visually represented in Figure 3. Results of the omnibus ANOVA for total gaze time revealed a significant main effect for scene region, F(2, 102) = 116.21, p < .001 ([[eta].sup.2] = .70); and a significant Participant Group x Scene Region interaction, F(4, 102) = 6.83, p < .05 ([[eta].sup.2] = .21).
[FIGURE 3 OMITTED]
The Participant Group x Scene Region interaction was analyzed using simple effects. A simple main effect was found for participant group. Women with intercourse pain looked at bodies for less time than both the women with HSD (p = .024) and the no-sexual problem control women (p < .001). No other group differences were found for the bodies scene region. No group differences were found for total gaze time at the inconsistent object. Women with dyspareunia looked for longer periods of time at the context than did the no-sexual problem control women (p = .042). Women with HSD also looked at the context longer than did the no-sexual problem control women (p = .028).
A simple main effect was also found for scene region, such that women with intercourse pain looked longer at both the bodies (p < .001) and the context (p < .001) than at the inconsistent object. Women with HSD also looked longer at both the bodies (p < .001) and the context (p < .001) than at the inconsistent object. However, women with HSD also looked for longer periods of time at the bodies than at the context (p = .028). Like the women with HSD, the no-sexual problem control women looked at both the bodies and the context for longer periods of time than at the inconsistent object (p < .001 and p < .001, respectively). The no-sexual problem control women also looked significantly longer at the bodies than at the context (p < .001).
Women with dyspareunia attended significantly less to the sexual scene regions than both women with HSD and no-sexual problem control women, and significantly more to the context or background of the scenes than did the no-sexual problem control women. Women with intercourse pain had fewer fixations on, and looked for less time at, the bodies than both control groups. In contrast, they had more fixations on, and spent greater time looking at, the context of the scenes than did the no-dysfunction control group. No group differences were found for attention conferred upon the informative objects in the scenes. Although we expected to find significant group differences in attentional capture to the various scene regions (as evidenced by group differences for average fixation durations on each of the scene regions), we did not find such differences.
The major finding of this study is that women reporting pain with intercourse attended less to the sexual aspects of the scenes than either women with low sexual desire or women with no sexual complaints. Because eye tracking is a psychophysical measure of attention and we have no self-report data about why participants attended to certain scene regions at the expense of others (which would, in any case, have been questionably reliable data at best), we can only infer the meaning of these results. We can be relatively confident that these attentional differences were specifically related to sexual information processing (i.e., not simply related to an overall pattern of attentional variation), as no group differences were found for any dependent variables from Conners' CPT (Conners, 1992). The two most likely explanations for the attention results are as follows (a) Women with intercourse pain were distracted away from the sexual scene regions, or (b) these eye-movement patterns are suggestive of an avoidance response to sexual stimuli. It is also possible that both distraction from and avoidance of sexual stimuli occur when women with intercourse pain are presented with erotic stimuli.
As previously discussed, distraction away from sexual information and stimuli (or the erotic components of a sexual situation) has long been considered to play an important role in the development and maintenance of sexual dysfunction. Cognitive distraction caused by neutral or nonsexual information often affects sexual arousal in both sexually functional and dysfunctional men and women, generally serving to reduce physiological sexual arousal (e.g., Abrahamson, 1985; Adams et al., 1985; Barlow, Sakheim, & Beck, 1983; Beck & Barlow, 1986; Elliott & O'Donohue, 1997; Farkas et al., 1979; Hale & Strassberg, 1990; Palace & Gorzalka, 1990; van den Hout & Barlow, 2000). Several, more recent, studies have also examined the effects of increasing neutral cognitive distraction tasks (i.e., numbers manipulation) on men and women with and without sexual dysfunction (Salemink & van Lankveld, 2006; van Lankveld & van den Hour, 2004). Women with dyspareunia were included in the sexual dysfunction group in the female study (Salemink & van Lankveld, 2006), although all sexual dysfunctions were collapsed in the final analyses, making it difficult to tease apart any potential differences among the different types of sexual dysfunction. However, the results indicated an increasingly negative impact on physiological arousal with added distraction in both women with and without sexual dysfunction, supporting some previous findings. Interestingly, this decrease in arousal was not noticed by the women in the Salemink and van Lankveld sample at the time of testing, as distraction did not appear to decrease subjective arousal.
Some have suggested that this shift in attention away from sexual stimuli, which in some cases appears to reduce physiological sexual arousal, sets the stage for less vaginal lubrication and, thus, painful intercourse (Brauer, ter Kuile, Janssen, & Laan, 2007). The results for physiological sexual arousal in women with dyspareunia are somewhat mixed, with some research suggesting that women with dyspareunia have greater vasocongestion to depictions of coitus compared to healthy controls (Brauer, Laan, & ter Kuile, 2006), and other data showing the opposite pattern (Wouda et al., 1998). Although physiological sexual arousal was not directly measured in this study, the relationship between cognitive distraction and sexual arousal has clear implications for our results. As one might have hypothesized, based on the aforementioned literature, the two sexual dysfunction groups attended to the sexual aspects of the stimuli less than the problem-free control women. Our results are the first to show this reduced attention (or increased distraction) with a direct measure of attention, as opposed to the more indirect measures of genital and subjective arousal. We literally can now see what women with intercourse pain are attending to compared to control women. Although we did not see differences in attention to the planted distractor, our version of a "distraction task" in this study, women with intercourse pain were significantly less interested in the couples engaged in foreplay and more interested in the components of the background settings than were the women in the two control groups. If increased cognitive distraction causes reduced physiological arousal, possibly contributing to painful intercourse, our results are a first step in determining the direction of attention in women with sexual dysfunction in a more naturalistic situation than that offered by previous experimental paradigms.
The greater distraction away from sexual stimuli evidenced in the women with intercourse pain in our sample is consistent with the sexual dysfunction conceptualization of dyspareunia. However, the pattern of results may indicate that cognitive distraction alone may not fully explain attentional differences among these groups. Cognitive distraction intuitively appears to be a better explanatory mechanism for HSD given that these women report little to no interest in sexual activity (thus, one would expect them not to attend to sexual stimuli). We originally hypothesized a greater degree of distraction in the HSD group than in either of the other two groups; this pattern generally held true for the comparison with the no-sexual problem control group (although not significantly), but it did not hold true for the comparison with the pain group. These results may suggest the presence of an additional component that influences both attention to sexual stimuli and the avoidance of sexual activity that is seen in women with sexual pain disorders. After all, lack of interest in an activity may be a very different experience than the desire for an activity that, distressingly, is consistently painful. Also important to remember is that our women with intercourse pain were specifically screened to ensure a lack of sexual desire problems (their mean sexual desire score fell well within the normal range on the FSFI). Thus, even if distraction plays a role in the development or maintenance of dyspareunia, as it appears to in low sexual desire, it does not seem to fully explain the pattern of results for this study, as the dyspareunia group showed the least amount of attention to the sexual content of the stimuli.
If the cognitive distraction hypothesis does not seem to provide the most parsimonious interpretation for our results, what might? When developing our hypotheses, we considered what we believed to be the two most prominent factors in the experience of dyspareunia: pain and interference with sexual activity. However, we did not directly consider the cognitive process of fear or anxiety about the pain and its subsequent consequences on attention. The sexual pain disorder literature supports the existence of this fear (e.g., Payne et al., 2005), and it is often targeted in treatment strategies (e.g., progressive vaginal dilatation and sensate focus as forms of systematic desensitization).
Brauer et al. (2007) theorized that in women with dyspareunia, attention is initially shifted away from sexually arousing stimuli and toward non-erotic stimuli during a sexual encounter due to the association between sex and pain (and other negative emotions) that has developed over repeated such experiences. This shift in attention from arousing stimuli toward anxious and fearful thoughts results in a lack of genital and subjective sexual arousal, creating insufficient lubrication and contributing to painful intercourse. When intercourse is attempted and pain does occur, these anxious and fearful thoughts are reinforced. This reinforcement acts to further perpetuate dysfunctional sexual responding, possibly including continued avoidance of erotic cues and a consequent focus on non-erotic cues. Although behavioral avoidance may be more prominent in vaginismus than in dyspareunia (when these can be distinguished; Reissing, Binik, Khalife, Cohen, & Amsel, 2004), the lower frequency of sexual activity in women with dyspareunia when compared to no-sexual problem control groups is consistent with a pattern of avoidance (e.g., Meana, Binik, Khalife, & Cohen, 1997a).
Studies investigating the processing of threat have overwhelmingly supported an attentional bias for, or facilitated processing of, threat-related information (Lundqvist & Ohman, 2005; Ohman, Flykt, & Esteves, 2001). From an evolutionary perspective, it is adaptive for threatening information to capture our attention, as our responses for survival are dependent upon our ability to accurately estimate threat levels and quickly choose the most appropriate response for that threat. Particularly relevant to this study is research that has shown a difficulty in the disengagement of attention from threatening information, similar to what has been found in studies investigating the cognitive processing of pain (Amir, Elias, Klumpp, & Przeworski, 2003; Cisler, Ries, & Widner, 2007). However, our women with pain were quite able to disengage from the threat-relevant stimuli presented, so overall hypervigilance to these stimuli was not observed in this study.
This study is, of course, not without limitations. First, our sample was young, and generalizability to older samples would need to be tested. Second, we relied entirely on self-report of pain and low desire, so we cannot ascertain whether the women with sexual complaints in our study would have met diagnostic criteria for dyspareunia or HSDD. Finally, the viewing of erotic images does not simulate a sexual interaction in the real world. However, visual attention to sexual stimuli is arguably a central component of most sexual interactions and, as such, we think that this experimental paradigm had sufficient real-world validity to allow for interpretation.
In summary, our results suggest that, in addition to behavioral avoidance, cognitive avoidance strategies may also be at play in the experience of dyspareunia. Further studies could utilize standardized images that are explicitly designed to elicit thoughts of pain, fear of harm, or threat to ascertain whether these attentional patterns are specifically related to sexual activity or are part of a more global pattern of harm avoidance, which could speak to additional etiological issues in dyspareunia. It may also be useful to explore whether and how eye-tracking methodology could be used in the multidisciplinary treatment of sexual dysfunctions. If women with dyspareunia are more avoidant of sexual information than healthy women, perhaps redirecting their attention to sexual content could function as a type of systematic desensitization or forced exposure (as is used in the treatment of phobias and posttraumatic stress disorder), which could serve to positively affect the sexual functioning of these women.
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Amy D. Lykins
School of Behavioural, Cognitive, and Social Sciences, University of New England, Armidale, New South Wales, Australia; and Department of Psychology, University of Nevada, Las Vegas
Marta Meana and Jillian Minimi
Department of Psychology, University of Nevada, Las Vegas
Correspondence should be addressed to Amy D. Lykins, Psychology, University of New England, Armidale, NSW 2351, Australia. E-mail: firstname.lastname@example.org
Table 1. Demographic Characteristics of Final Sample Sexual Low Control Pain Group Desire Group Group Characteristic n % n % n % Age M 19.65 19.21 18.80 SD 2.85 0.89 0.89 Ethnicity European American 11 55.0 3 21.4 10 50 Hispanic American 4 20.0 4 28.6 2 10 African American 1 5.0 0 0.0 1 5 Asian American 1 5.0 5 35.7 2 10 Pacific Islander 1 5.0 0 0.0 3 15 Other 2 10.0 2 14.3 2 10 Religious affiliation Catholic Christian 8 40.0 7 50.0 13 65 Protestant Christian 0 0.0 3 21.4 4 20 Church of Latter- 1 5.0 0 0.0 0 0 Day Saints Other 6 30.0 0 0.0 1 5 None 5 25.0 4 28.6 2 10 Note. N = 54. Table 2. FSFI Scores for Participants Sexual Pain Group Low Desire Group Control Group FSFI Score M SD M SD M SD Desire 4.20 (a) 0.78 2.36 (b) 0.44 4.89 (c) 0.68 Arousal 4.47 (a) 1.06 3.75 (b) 1.01 5.48 (c) 0.43 Lubrication 4.89 (a) 1.08 4.71 (a) 1.62 5.78 0.27 Orgasm 3.96 (a) 1.38 3.43 1.75 5.04 0.90 Satisfaction 4.24 (a) 1.23 4.43 (a) 1.18 5.80 0.30 Pain 2.92 0.91 5.14 (a) 1.55 5.56 (a) 0.55 Total 24.68 (a) 4.56 23.82 (a) 5.86 32.54 1.42 Note. Means that share a common subscript are not significantly different from each other at p < .05, as determined by a Student Newman Keuls multiple range test. FSFI = Female Sexual Function Index. Table 3. Means and Standard Deviations for Total Number of Fixations Sexual Pain Low Desire Group Group Scene Region M SD M SD Bodies [8.19.sub.x] 2.78 [10.47.sub.a,x] 2.07 Inconsistent object [2.04.sub.a] 1.26 [1.84.sub.a,y] 1.05 Context [7.41.sub.a,x] 3.25 [7.49.sub.a,z] 1.55 Control Group Scene Region M SD Bodies [10.78.sub.a,x] 2.95 Inconsistent object [1.56.sub.a,y] 1.31 Context [5.52.sub.z] 1.57 Note. Means that share a common subscript are not significantly different at p < .05, as determined by simple effects analyses. Subscripts a, b, and c denote between-group comparisons; and subscripts x, y, and z denote within-groups comparisons. Table 4. Means and Standard Deviations for Average Fixation Duration (in Milliseconds) Sexual Pain Low Desire Group Group Scene Region M SD M SD Bodies 200.44 53.67 230.46 48.82 Inconsistent object 310.56 157.58 271.03 140.25 Context 406.36 120.95 397.84 89.55 Control Group Scene Region M SD Bodies 240.59 54.50 Inconsistent object 288.88 189.93 Context 412.14 65.57 Note. There were no between-group differences for average fixation duration, so no post hoc testing was conducted. Table 5. Means and Standard Deviations for Total Gaze Time (in Milliseconds) Sexual Pain Scene Group Region M SD Bodies [2973.28.sub.x] 1015.63 Inconsistent [1010.04.sub.a] 896.71 object Context [2842.83.sub.a,x] 1132.34 Low Desire Scene Group Region M SD Bodies [3887.10.sub.a,x] 1003.03 Inconsistent [789.51.sub.a,y] 567.45 object Context [2952.58.sub.a,z] 603.28 Control Scene Group Region M SD Bodies [4511.76.sub.a,x] 1300.36 Inconsistent [778.71.sub.a,y] 698.14 object Context [2267.18.sub.z] 710.46 Note. Means that share a common subscript are not significantly different at p < .05, as determined by simple effects analyses. Subscripts a, b, and c denote between-group comparisons; and subscripts x, y, and z denote within-groups comparisons.