Dyspareunia, by definition, is pain that occurs during sexual intercourse, and, by its very nature, occurs in an intimate context. Women with dyspareunia often experience psychological distress and sexual difficulties, and partners may also be negatively impacted by the pain. This chapter examines sexual, relationship, and psychological factors associated with dyspareunia resulting from a variety of conditions, including provoked vestibulodynia (PVD), vulvodynia, vaginismus, interstitial cystitis (IC), endometriosis, and chronic pelvic pain (CPP). Although still preliminary, research in this area has increased substantially over the past decade and has provided some understanding of the links between dyspareunia and psychosocial functioning.

One of the most investigated psychosocial aspects of dyspareunia is that of sexual functioning. Sexual intercourse is explicitly linked to the experience of pain among women with dyspareunia, and other sexual difficulties may develop as intercourse becomes associated with negative, rather than pleasurable, outcomes. In addition, women may anticipate the pain in intimate contexts, thereby reducing their ability to become aroused or experience enjoyment. Accordingly, several studies have indicated that all components of the sexual response cycle are negatively affected by the pain. Women with dys-pareunia experience lower levels of sexual desire, arousal, and satisfaction, less vaginal lubrication, and lower frequencies of sexual intercourse, orgasm, and masturbation in comparison to nonaffected women [1–4]. Also, recent surveys report that 80% of vulvodynia sufferers and 49% of women with IC indicate that the pain significantly and negatively affects their sexual functioning [5, 6].

Although prospective studies are lacking, the onset of pain during intercourse appears to be highly associated with altered sexual functioning. For example, 78% of women with PVD reported negative changes in sexual activity and satisfaction after pain onset, with most stating that they felt less able to participate in sexual activity [7]. In addition, compared to premorbid functioning, women with IC reported significant declines in level of sexual desire and frequency of orgasm [8]. The experience of pain may even lead some women to avoid or discontinue sexual activity [5, 9, 10]: in one sample, 90% of women with vulvodynia reported having to stop sexual activity at least once because of the pain, and 56% ceased penetrative activities altogether [5]. However, some women with dyspareunia continue to engage in intercourse for reasons that include feeling obligated to please their partners or experiencing emotional and physical pleasure from intimacy that outweighs the pain [11].

Women with dyspareunia also experience higher levels of erotophobia (feelings of guilt and fear related to sex) and more negative feelings toward sex as compared to women without such pain [1, 3, 7, 12]. Heightened fear of pain during sexual intercourse has also been documented in dyspareunia sufferers [8, 13]. Consistent with these findings, studies have found that women with dyspareunia are less likely to make sexual advances, more likely to refuse their partner’s advances, and more likely to participate in sexual activity without wanting to do so [3, 7, 14, 15]. Affected women also are more likely to report feeling guilty or inadequate as a result of not being able to perform sexually and are less likely to feel relaxed or fulfilled after sexual activity [3, 7, 9, 14]. Not surprisingly, women with dyspareunia report less sexual satisfaction [15, 16] and perceive their partners to be more sexually dissatisfied in comparison to nonaffected women [15].

Clinical reports make reference to the devastating impact that dyspareunia has on intimate relationships [17–20]. Despite having theoretical and intuitive draw, surprisingly little research has systematically examined the sexual relationships of women with dyspareunia. Of the existing research, evidence regarding decreased relationship adjustment is mixed: several studies have found no differences in relationship functioning between women with dyspareunia and control women [1, 12, 21–24], whereas others report less relationship satisfaction among affected women [15, 25].

Most women with PVD report that their intimate relationships have been impacted by the pain [26, 27]. Specifically, 40% reported severe and negative changes in their intimate relationships [7], and 77% reported fears that the pain would ruin their relationship [11]. These findings may be related to feelings, on the part of the women with dyspareunia, that their partners are less sexually satisfied [15, 28] and that they themselves are less sexually desirable to their partners [7]. In addition, pain severity and relationship adjustment appear to be differentially associated: Meana et al. [29] found that affected women who reported better relationship adjustment also reported less pain. The link between dyspareunia and relationship functioning is likely complex and moderated by several factors, many of which have yet to be investigated empirically.

Very little is known about the sexual and psychological characteristics of partners of women with dyspare-unia. A recent study found no deficits with regards to self-reported erectile function or relationship satisfaction in male partners of women with vaginismus; this same study indicated that male partners also reported more sexual and overall satisfaction in comparison to normative data [30]. Other research, however, has reported increased depression among partners of women with PVD, and feelings of helplessness, anger, and low mood among partners of women with endometriosis [26, 31]. To date, it is not known how partner-specific factors influence dyspareunia-affected couples, nor is it well understood how partner responses to the pain contribute to women’s experiences with dyspareunia, or vice versa. However, recent evidence suggests that women who perceive their male partners to be more solicitous (i.e., more supportive or attentive) in response to the dyspareunia experience more intense pain during intercourse [32]; although seemingly paradoxical, this is consistent with findings from the general chronic pain literature.