{"paper_id":"70e46a88-2118-4cd5-b361-6f6247115a56","body_text":"Accepted Manuscript\nBritish Journal of General Practice\nUnderstanding chronic pelvic pain in women survivors of \nsexual violence: a qualitative study\nMccarter, Catherine; Williams, Amanda\nDOI: https://doi.org/10.3399/BJGP.2026.0057\nTo access the most recent version of this article, please click the DOI URL in the line above.\nReceived 24 January 2026\nRevised 27 July 2026\nAccepted 31 July 2026\n© 2026 The Author(s). This is an Open Access article distributed under the terms of the Creative \nCommons Attribution 4.0 License (http://creativecommons.org/licenses/by/4.0/). Published by  \nBritish Journal of General Practice. For editorial process and policies, see:  \nhttps://bjgp.org/authors/bjgp-editorial-process-and-policies\nWhen citing this article please include the DOI provided above.\nAuthor Accepted Manuscript\nThis is an ‘author accepted manuscript’: a manuscript that has been accepted for publication in British Journal of  \nGeneral Practice, but which has not yet undergone subediting, typesetting, or correction. Errors discovered and  \ncorrected during this process may materially alter the content of this manuscript, and the latest published version (the  \nVersion of Record) should be used in preference to any preceding versions\n\nTitle\nUnderstanding chronic pelvic pain in women survivors of sexual violence: a \nqualitative study\nAuthors\nCatherine McCarter, BSc, DClinPsy, Clinical Psychologist, Fromeside Medium Secure Unit, Blackberry \nHill Hospital Site, Bristol BS16 2JR. catherine.mccarter.19@ucl.ac.uk. ORCID iD:  0009-0009-4797-\n3719\nAmanda C de C Williams, MSc, PhD, Emeritus Professor of Clinical Health Psychology, University \nCollege London. ORCID iD: 0000-0003-3761-8704. amanda.williams@ucl.ac.uk\n\n\nAbstract \nBackground: Chronic pelvic pain (CPP) affects an estimated 14.8% of UK women. Survivors of sexual \nviolence are more likely to experience CPP, but the relationship is complex and underexplored. \nShame and stigma from both experiences may interact and influence help-seeking.\nAims: To broaden understanding of how women survivors of sexual violence make personal meaning \nof CPP, and to consider clinical implications of findings. \nDesign & setting: A qualitative study of UK community-recruited women who have survived sexual \nviolence and who experience chronic pelvic pain (CPP).\nMethod: Ten participants were recruited via social media and engaged in individual, semi-structured \nonline interviews about their experiences and understandings of sexual violence and CPP. Interviews \nwere transcribed verbatim and analysed using reflexive Thematic Analysis.\nResults: Three main themes were developed: (1) Healthcare professionals’ attempts to silence \nwomen, who felt ignored, disbelieved or dismissed; (2) Treating the whole woman, describing the \nneed for integrated, biopsychosocial approaches; and (3) A woman’s place is in the resistance, \nhighlighting women’s active efforts to reclaim their narratives and pursue care. Shame was \ncompounded across experiences, and women expressed frustration with fragmented care and \nassumptions about the psychological origins of pain.\nConclusions: These results give insights into the complex meanings women survivors of sexual \nviolence hold about their CPP, and how healthcare systems could better support them to explore \nand respond to those meanings. The aim should be compassionate care that recognises the complex \nbiopsychosocial impact of sexual violence and CPP, while keeping women in control of their own \ncare.\nKeywords\nChronic pelvic pain, sexual violence, qualitative, primary care, trauma-informed care, women's \nhealth\nHow this fits in\nChronic pelvic pain (CPP) is common and can be difficult to treat. Some women with CPP are \nsurvivors of sexual violence. How such women understood their pain was strongly influenced by \n\n\nfeeling ignored by doctors and shamed by both CPP and sexual violence.  According to women in our \nstudy, a ‘good enough’ response from GPs involved being seen as a whole person, being asked about \nsexual violence, pain being adequately investigated, and the GP acknowledging what is not \nunderstood about CPP and sexual violence. This allowed the negotiation of a pain explanation that \nvalidated the woman’s experience and integrated her social context with medical results, delivered \nwith empathy and understanding. \nWomen with chronic pelvic pain who have also survived sexual violence struggle for integrated, \naccepting medical assessment and treatment.\nCompeting interests: The authors declare no competing interests. Ethical approval: UCL Research \nEthics Committee [19447/001].\n\n\nUnderstanding chronic pelvic pain in women survivors of sexual violence: a qualitative study\nIntroduction\nChronic pelvic pain (CPP) is defined as pain perceived in structures related to the pelvis persisting for \nmore than three months (1). UK prevalence estimates range from 3.8% (2) to 14.8% (3). CPP is \nfrequently complex in origin, with biological, psychological, and social contributors (4; 5; 6). Despite \nits prevalence, women with CPP often experience delayed diagnosis, their symptoms dismissed or \nmisattributed to psychological causes (7; 8; 9; 10; 11).\nRates of sexual violence experienced by women and girls are notoriously hard to estimate (12; 13) \nbut 1 in 5 English/Welsh women are thought to have experienced sexual assault (14). CPP following \nsexual violence is common (15;16; 17; 18), though the mechanism is unclear; genital injury, \nemotional trauma, and alterations in pain processing may all contribute but a causal link between \nCPP and sexual violence is hard to establish, and many women struggle to find language or support \nto articulate their experiences.\nThe meanings of pain affect daily experience and responses to treatment (19); after traumatic \nevents in particular (20). Survivors of sexual violence frequently encounter stigma, disbelief, and \nsilencing within healthcare and more widely (21; 22); these experiences intersect with the poorly \nunderstood nature of CPP, creating additional barriers to care, and shame is often internalised and \ncompounded by dismissive responses from health professionals (23). Little research elicits women’s \nown accounts of the meanings of chronic pelvic pain after sexual violence.\nThis study explores how UK-based women survivors of sexual violence make personal meaning of \ntheir chronic pelvic pain. By using qualitative interviews and reflexive thematic analysis, the research \nseeks to foreground women’s voices and provide insights that can inform trauma-informed, \ncompassionate care in general practice.\n\n\nMethod\nDesign and ethics: Semi-structured interviews with reflexive Thematic Analysis explored the \nunderstandings that women survivors of sexual violence brought to their CPP. The study had ethical \napproval (UCL Research Ethics Committee 19447/001); all participants provided informed consent.\nRecruitment: A research advertisement produced in consultation with an expert by experience was \nshared on Twitter and disseminated by supportive organisations and individuals via email and online \nforums. The advertisement linked to a website where potential participants found information \nnecessary for informed consent. Inclusion criteria were: being a woman, 18 or over, living in the UK, \nspeaking English, currently experiencing chronic pelvic pain, and having survived sexual violence or \nabuse of any kind as a child or adult. The participant information webpage encouraged women to \ncontact the study only if they were safe and the abuse was in the past. \nData collection: All participants, having read and electronically signed a consent form, were \ninterviewed and audio-recorded using MS Teams. The semi-structured interview (Box 1) was \ndeveloped with help from colleagues with extensive experience of supporting women survivors of \nsexual violence. As interviewer, the main researcher [CMcC] had experience supporting survivors of \ndomestic and sexual violence and training in clinical psychology, both mentioned in participant \ninformation. Before beginning interviews, CMcC asked women if they were in a private space where \nthey would not be overheard. Women were signposted to support after the interview and sent a £15 \nvoucher. Audio recordings were immediately transcribed, anonymised and deleted; transcripts were \nstored securely.\nBox 1. Areas of questioning\nAreas of questioning\n1. Can you tell me about your pain? \n2. How do you understand your pain?  \n3. Can you tell me about what you’ve done to get help or support for the pain?\n4. What advice would you give pain clinicians and support workers (or any other \nprofessionals already mentioned by participant), about helping women with pain \nrelated to sexual violence?\n5. Can you tell me about something you do to look after yourself? How does it help \nyou?\n6.Is there anything you feel that we did not talk about or that you would like to \nadd?\n\n\nResearcher position\nCMcC is a white British woman in her 30s, recently qualified as a clinical psychologist. Prior to \ntraining in clinical psychology, she worked in the social care sector for 10 years, supporting survivors \nof domestic and sexual violence.\nCMcC's epistemological position is that psychological research should contribute by design towards \nliberating and transforming the experience of excluded or ‘othered’ groups by centering issues of \npower and epistemic violence. This study sought to use the critical lens of liberation and feminist \npsychologies to address a neglected space within psychological research. AW is an academic and \nclinical psychologist with over 35 years’ experience working in chronic pain, including in survivors of \nsexual and other violence. She supervised CMcC and endorsed her epistemological stance.\nData analysis\nReflexive Thematic Analysis (TA) (24, 25) was used to analyse transcripts, aiming to identify, analyse \nand report patterns within women’s narratives of pain and sexual violence (24) whilst owning the \nmain researcher’s role in the creation and interpretation of data (26). The researcher (CMcC) \ntranscribed the audio recordings by hand to maximise data immersion; she then read and re-read \nthe transcripts, making notes before systematically generating codes that she attached to chunks of \ndata and grouped on a spreadsheet. Groupings were mapped and re-mapped into themes, allowing \nreflection on assumptions made in data interpretation (27). Discussion with the second author (AW) \nand colleagues helped with this process. Since subjectivity is central to reflexive TA, double coding \nwas not conducted. The final version had three themes and eight subthemes acting as interpretive \nstories about the data (26). \nSampling and saturation\nResource constraints were a significant factor in sampling limitations, alongside the difficulties in \nreaching this population. Reflexive thematic analysis critically engages with the idea of achieving \ndata saturation, arguing that this position suggests that themes are there to be discovered in the \ndata (25) rather than generated by the researcher. Braun and Clarke suggest the request for data \nsaturation represents a positivist quality standard applied in qualitative research. \nResults\nParticipants\nTwelve women responded to the advertisement, but one did not respond further and another did \nnot attend the arranged interview or reconnect. One woman did not complete the demographic \n\n\ninformation, but information that she shared during the interview has been added. Interviews took \nbetween 40 and 100 minutes.\nThe ten women who completed interviews were from 23 to 43 years old (mean age 32). Six were \nwhite British, one each white/Asian, white/Latin American, and black African, with one unknown. \nThree described themselves as heterosexual, two each as lesbian and as bisexual, one as queer, and \ntwo did not answer. Five classified themselves as working class, three as middle class, and one as \nemerging service worker; five had postgraduate degrees, three undergraduate degrees, one had not \nattended university and one is unknown. Six had children under 18 living with them, and three had \nsignificant unpaid caring responsibilities; seven did paid or voluntary work and three did not. Five \nfelt that they had just enough money after paying bills, three not enough, and one more than \nenough. They described their spiritual beliefs in varied ways, only two (one Sikh, one Catholic) in \norganised religion. \nInitially, 26 codes were generated before searching for patterns across data that became three \nthemes, presented alongside subthemes and illustrative quotations in Table 1. Individual \nparticipants are referred to by interviewee number, for example 1. Brief pauses in conversation are \nindicated by (.) and – indicates self-interruption. \nTable 1. Themes, subthemes and illustrative quotations\n\n\nTheme & summary Sub-themes Examples\n1.1 Healthcare \nprofessionals’ failure \nto ask about sexual \nviolence and \ninadequate \nresponses to \ndisclosure\nP4: I wonder if I could have … got \nsupport a lot earlier on if just those \nthings were kind of brought to my \nattention and sort of asked from me.\n1.2 Disbelieving \nwomen \nP6 It would be so great to have to know \nthat I was going to a GP that was going \nto believe me (.) and take me seriously.\nP2: stop seeing women as liars like when \nthey come to you and tell you [about] \ntheir pain\nTheme 1: (Attempts at) \nSilencing women \nMulti-level, systemic attempts \nto deny, minimise, normalise \nor ignore women’s experiences \nboth of sexual violence and of \nchronic pelvic pain; disclosure \nof one compounded the (poor) \ntreatment of the other.\n1.3 Shameful, \nbroken bodies\nP8: it kind of feels like it’s too, too \ndamaged … it just feels like everything's \njust rotten\n2.1 False dichotomy \nof mental and \nphysical health\nP1: As soon as a doctor hears you’ve got \nmental health problems, they’ll \nautomatically discount all of your \nphysical health issues and say it’s all \ndown to your mental health\n2.2 Fragmented care \nand dead ends\nP5: It's like snakes and ladders (.) just like \nalways end up right back at the \nbeginning\nP9: I think I just kind of thought it's not \nreally going anywhere (.) umm and I'm \njust trying to manage it myself (.) so \nyeah I haven't (.) I haven't gone back [to \nthe GP to discuss CPP] for a long time.\nTheme 2: Treating the whole \nwoman \nThe importance of integrating \na biopsychosocial explanation \nof pain in medical treatment.\n2.3 Being seen in ‘my \ncomplexity’\nP10: Treat the whole person and not just \nthe symptoms to understand everything \nthat's going on in that person's life and \nto take it all as one kind of big picture \nrather than separating things out into \nthis person has anxiety depression and \npelvic pain (.) look at it altogether\n\n\nTheme 1: (Attempts at) Silencing women\nThe women interviewed described experiencing multi-level, systemic attempts at denying, \nminimising, normalising or ignoring their experiences both of sexual violence and of CPP, with \ndisclosure of one compounding (poor) treatment of the other. \nSubtheme 1.1: Healthcare professionals’ failure to ask about sexual violence and inadequate \nresponses to disclosure\nMost participants in this study had not been asked about sexual violence despite presenting with \nindications of trauma. Women struggled to understand the silence of healthcare staff, especially \ngiven that sexual violence is “such a big problem and it's happening so much” (I4). Not asking \n3.1 Women taking \ncontrol of their own \nnarrative. \nP7: On the days that I could run it just \nfelt really good to feel my body (.) my \nbody's power basically if that makes \nsense because I think one of the things \nabout constant pain is that you can feel \nweak and incapable (.) and seeing the \ndifference …in my body it gave me like a \nstrength a feeling of strength and like \nself-control like I have power and \nauthority over my body (.) which after \neverything that's happened and the \nexperiences I've had (.) I often feel like I \ndon't (.) so it gave me that sense of it \nback which was quite powerful.\nP3: I'm the patient (.) I know exactly \nwhere my pain is (.) I know exactly what \nI'm talking about you know\nP8:  I am not a tree (.) I'm not a bridge (.) \nyou know and I shouldn't have to carry a \nload\nTheme 3: A woman’s place is in \nthe resistance\nThe multiple ways of resisting \nthe cancellation and denial of \nwomen’s voices and \nexperiences, and resisting \nshame’s edict to hide.\n3.2 Persistence in \nefforts to access \nadequate support\nP5: if I hadn't managed to fight so much \nand if I hadn't managed to find the right \nsupport I would- and they told me like \nyou know basically I'd still be in a \nwheelchair\n\n\ncolludes with the myth that rape is uncommon or inconsequential, whilst also communicating that \nGPs are not equipped to deal with sexual violence disclosures: \n“Some people just need to know that your doctor knows what they're doing and not going \nto say stupid shit [in response to sexual violence disclosure] … believe me (.) and take me \nseriously about my pain.” (I6)\nI2 understood how trivialisation of rape informed the lack of empathy and poor care she received, \nincluding from her GP:\n“with the pain that I'm in and that (.) they [GPs] don’t even take it seriously because they \ndon’t really understand that it’s not sex (.) it’s rape (.) there’s a massive difference” \nBy contrast, being given sufficient time and being believed created a positive context for disclosure:\n“That doctor who I told (.) was just like look (.) we could take as much time as you want (.) \nanything else you want to talk about? She was like I- supposed to be ten minutes (.) but I \ndon't do that (.) yeah she was great.” (I6)\nFailure to ask about sexual violence, in the context of widespread recognition of social factors in \nphysical and mental health, effectively deny women power through silencing (28) both of their pain \nand the sexual violence; this moves beyond the finding that women in pain are routinely ignored \n(29; 30). Similarly, dismissing a woman’s disclosure of rape as ‘bad sex’ denies women’s experience \nand alienates them from healthcare. Given that shame is common after sexual violence (28; 31) and \nserves to isolate survivors from support, sensitive questioning is often necessary to elicit disclosure, \nand where women had experienced it, they trusted and confided in the doctor.\nSubtheme 1.2: Disbelieving women\nThe impact of systems and individuals denying women’s subjective experiences of both pain and \nsexual violence was described by many participants in this study. \n I1 stressed the importance of pain reports being believed:\n“even if they’re gonna use the wording of it [pain] being created in your brain (.) they don’t \ntry and put it across like you’re making it up.”\nBeing believed about sexual violence was also important:\n“It's actually astonishing…how similar that [taking pain seriously] is to [taking] sexual \nviolence [seriously] like it’s the same (.) because you know (.) just being believed is all.” (I6)\nDoctors who approached their patients with curiosity and sensitivity to power dynamics after \ntrauma were appreciated:\n\n\n“what do I need to know about that to help me care for you now.’ And how do I keep you in \ncontrol? I think recognising the lack of power and control is really important and people \ndon't do that at all.” (I8)\nExplanation of pain and of the mechanisms by which it persists, with care about the language used, \ncan be helpful and validating. It starts with statements of belief in a woman’s disclosure, distancing \nthe discussion from rape myths, culpability and shame, and involving the woman in her care and \ntreatment planning.\nSubtheme 1.3: Broken bodies\nThe altered ways women viewed their bodies following sexual violence intersected with how women \nunderstood their CPP. Humiliating thoughts of being defective elicited a desire to hide and to silence \npart of the self; rape myths affected the meaning women made of their pain. \nI5 developed pain during pregnancy and linked her inability to disclose (unlike ‘true victims’ of rape \nmyths) and thus ‘deal with’ being raped during childhood with fears about her body:\n“[I was] worried that I wouldn’t be able to give birth like that, that something would block \nand I just wouldn’t be able to open up or something and it was almost literally because I \nhadn’t been able to open up about what I had experienced” \nI8 felt that her body was irreparably damaged by sexual violence, and no longer functioned in the \nsame way as other women’s bodies:\n“it kind of feels like it’s too, too damaged … it just feels like everything's just rotten”\nFor some women, pain served as an unwelcome reminder of rape, worsened where their GPs did not \noffer belief or support. For others, meanings of rape made pain harder to deal with:\n“[when] I think to myself (.) I should have had stronger boundaries (.) I should have \nrespected myself more or cared for myself more to remove myself from that situation … \nthat's what I really (.) really have a difficult time [with the pain].” (I7)\nIn contrast, I9 conceptualised her pain as a witness to how much she has survived and uses this \nknowledge to validate its intensity:\n“I think it [therapy] kind of helped me to see that [pain is] kind of my body's reaction to \nsomething that's happened to me and almost how my body is processing things that I've \nexperienced…  And I think seeing it that way helped me (.) yeah (.) see it not so much as a \nproblem or that there's something that I'm doing wrong or I'm not strong enough”\n\n\nWomen engaged with rape myths and explicit or implicit rules dictating women’s behaviour in \nunderstanding themselves and their bodies in pain. They felt that CPP and sexual violence were \nlinked, causally or through similar responses elicited from individuals and systems. \nTheme 2. Treating the whole woman \nThis theme explored how women experienced the segregation of mental and physical health care, \nparticularly after disclosing sexual violence. Wanting to be understood in an integrated way \ncontrasted with silencing, explored in theme 1. \nSubtheme 2.1. False dichotomy of mental and physical health\nWomen reported their GPs’ failure to apply a biopsychosocial model of care to sexual violence and \nchronic pelvic pain. Some described ways their mental and physical health were interconnected:\n“When I then notice my pain (.) it always comes with kind of (.) thinking back to things that \nhappened (.) or even if it can happen the other way around (.) where I've had a flashback \nand then I feel the pain umm more noticeably than maybe before I'd had that flashback.” \n(I9)\nYet following a disclosure of sexual violence,  physical health complaints were minimised as \npsychosomatic and left unexplored; some women did not trust their GP to respond well to \nemotional aspects of their pain so withheld them for fear of being labelled “a bit mad” (I8). The \ndivision of mental and physical health left women with a feeling that no one in the system fully \nunderstood their pain:\n“The thing is with secondary mental health services is that you speak to your psychiatrist and \nthey write this report about you and I don’t know (.) it’s not really addressed at dealing with the pain \n(.) [They agree with the GP that] it’s all in your head but well that’s not really helpful because it’s the \nphysical pain that’s causing you know flashbacks and everything.” [12]\nSubtheme 2.2: Fragmented care and dead ends\nWomen experienced fragmented care, with implicit and explicit messages that expecting relief from \nCPP was unrealistic, or referral for physical investigation that was disjointed and physically focussed. \nI5 expressed exasperation at the fragmented care she received, how disempowering the process \nwas, and how it extended the time she spent being “bounced around” the NHS like a game of \n“snakes and ladders” where she “always end[ed] up right back at the beginning.” Care could reach a \n\n\ndead end despite continued CPP; some women expressed anger at their GP’s apparent indifference \nand lack of creative thinking beyond normal test results. \nSubtheme 2.3: Being seen in ‘my complexity’\nWomen desired clinicians to understand and treat the whole person and show willingness to engage \nwith complexity. Women understood their difficulties and potential solutions to be complex and \nintegrated:\n“everything kind of like is like interwoven with each other (.) so I kind of need someone who \ngets like the whole of me” (I4)\nI7 described her relief at encountering a GP who seemed curious about her healthcare journey \nbeyond their immediate clinical encounter:\n“She was amazing... it was the first time that I was like (.) I feel like someone cares and they \ndon't just care about this one thing that I've come for this 10 minute appointment (.) but \nabout my whole entire journey (.) and that was very special.” \nFor some, the unwanted reminder of sexual violence formed an additional burden accompanying \npain. As crucial to a woman’s pain experience, any such connections in meaning need to be \nunderstood by any treating clinician. For I1, an integrated explanation of CPP would have broken the \nsilence and secrecy surrounding CPP and encouraged help-seeking. Some women described how \ntalking about the experience of abuse brought about a reduction in their CPP; others were unsure \nwhether their experiences of sexual violence and pain were linked. Women would have liked their \nGPs to collaboratively explore their complex presentations. \nAs in subtheme 2.1, women reflected on their desire for integrated mental and physical health \ntreatment. For them, holistic treatment made sense given their own intertwined understandings of \nphysical and psychological elements of pain.\nTheme 3: A woman’s place is in the resistance\nWomen resisted the cancellation and denial of their voices, narratives and experiences by reclaiming \nchoice and control and resisting shame and secrecy. Normalising women’s pain removed the \nimpetus to treat it, and women actively resisted this through continuing to seek healthcare.\nSubtheme 3.1: Taking control of their own narrative\nTalking about taboo topics resists their shaming impact, and women responded to my invitation to \ndo this. I2 firmly rejected thin narratives about the vulnerability of rape victims:\n\n\n“I have a massive problem with people calling me vulnerable as a result of going through \nrape and that because I think that they just kind of situate you relative to the offender’s \nmotives like they don’t really see you.”\nShe described how the label “vulnerable” was used to justify controlling and disempowering care \ndecisions, including the police talking to her parents rather than her, safeguarding meetings being \nheld about her without her, and her GP refusing to allow her to book appointments for CPP. Yet I2 \nresisted being defined by what happened to her. \nSimilarly, I8 described her objection to being described as ‘strong’, an outwardly benign adjective \nbut one that denied her space for various emotions:\n“Being told that you're really strong makes it really hard when you're having a crap time of it \nto say, actually things don't feel OK…I am not a tree (.) I'm not a bridge (.) you know and I \nshouldn't have to carry a load and you know and how it's kind of saying ‘oh it's okay because \nwe can keep loading things on you because you can cope with that’.” \nWomen acted to regain control of the narratives surrounding their experiences of sexual violence \nand of CPP. Describing survivors as strong and able to cope relieves society of collective \nresponsibility to change rape culture, obscuring the reality of abuse and demanding women find \npositive meaning from situations of utter despair.\n For some women, resistance had developed through talking with others or community organising, \nbreaking the silence of normalisation and individualisation surrounding sexual violence and chronic \npain. \nSubtheme 3.2: Persistence in efforts to access adequate support\nReflecting on years of battling with the NHS for adequate care, I1 described the gradual realisation \nthat ‘expert’ knowledge did not obscure and discount her own:\n“I've been told a million and one different things by various different specialists …So for me I \njust keep thinking ‘you don’t know that you’re right. How do you know I'm not right?”\nI10 described having the courage to reject the advice of her first GP to stay silent about sexual \nassault and accessing the specialist support she needed whilst also reducing her experience of pain. \nWith considerable effort and determination, I5 drew on her pelvic pain specialist’s information that \nCPP was poorly understood to firmly reject the physiotherapist’s advice to abandon rehabilitation:\n“I was like (.) so you're telling me just to give up because (.) not because I can't get better (.) \nbut because you don't have enough training or knowledge or support or funding to help me \n… it's not that I can't (.) it's that you can't”\n\n\nWomen courageously persisted in their efforts to access pain care, and spoke of their healthcare \njourneys as one of increasing resistance to their pain being normalised as part of womanhood, since \nthis removes the motivation to treat it. They spoke about the transformational process of learning to \nprivilege their own self-knowledge. Gillberg and Jones suggest dead ends in CPP care reflect \nknowledge gaps about women’s health, resulting from minimal research into conditions that lack \n‘medical prestige’ (Gillberg & Jones, 2019). \nDiscussion\nSummary\nWomen’s narratives described an interaction between the meanings of CPP and of sexual violence, \nboth of which were negotiated in healthcare encounters, often unsatisfactorily. Participants brought \nhighly personal meanings to their pain, influenced by their experiences of sexual violence and by \nresponses to disclosure, and for some the meaning included shame associated with chronic pain and \nwith an altered body image following sexual violence. All women referenced rape myths, with \nnarratives of victim culpability and (for some) of shame for failing to prevent sexual violence; these \nnarratives discouraged seeking support. \nPain for some women was described as directly caused by sexual violence, with intense pain \ntriggering flashbacks or vice versa; others conceptualised it as a physical manifestation of \npsychological trauma, with psychotherapy helping to build pain understanding and coping. For both, \nreactions of others, including healthcare professionals, to disclosure were distressing and affected \nmeaning-making: women who were disbelieved, told to ‘get on’ with pain, or to keep sexual violence \nsecret described the burden of carrying pain and trauma alone, or the difficulty of repeatedly \nrequesting support after being dismissed. \nBoth gender bias in healthcare and segregated services for mental and physical health contributed \nto women’s experiences of poor pain care. Women described both over- and under-application of \npsychological concepts to their pain, neither leading to constructive discussion and treatment. \nAssumptions about the psychological aetiology of pain meant that physical investigations were \ndenied; a focus on physical factors neglected pain meanings that required integration into \ntreatment. Most women found that their pain care ended without resolution, in stark contrast to the \nfew descriptions of a multidisciplinary approach encompassing medical and psychosocial aspects of \npain in which women felt listened to and believed, and clinicians worked collaboratively to find a \npain explanation and treatment. \n\n\nWomen found ways to resist the thin stories told about them in relation to pain or as survivors of \nsexual violence, using integrated understandings of their own health. They persisted in their efforts \nto access adequate healthcare, requesting referrals and trusting their self-knowledge, resisting the \nsilence about CPP and sexual violence by reconnection with their bodies, organising and advocacy.\nStrengths and limitations\nSampling women from unseen populations with distressing experiences made recruitment difficult. \nRecruitment via social media risks excluding women in digital poverty or non-users, and the lack of \nolder women in our sample could reflect that (33).  It could be that women who had already made \nconnections between sexual violence and CPP were more likely to opt into this research, potentially \ninfluencing the perspectives captured. Participating women were better educated (34) and declared \nmore diverse sexuality than the UK population (35; 36). Limiting participation to English-speaking \nwomen likely excluded many migrant women, a group known to be at increased risk of sexual \nviolence and barriers to care. Recently elaborated principles for evaluating adequacy of sample size \nsuggest good information power [37] despite small sample size . Our study had a fairly \nnarrow/focused question, addressed specific experiences, drew on existing theory, and the \ninterviewer was experienced enough to provide rich data. The only principle that would require a \nlarger population was if sampled experiences had been heterogeneous, and although we did not \nanticipate it, women’s accounts were remarkably consistent. \nInterviewing online enabled participation, despite the modest sample size. The flexible interview \nschedule allowed exploration of meaning, so that despite the highly sensitive topic, interviews \narticulated and valued women’s experiences (38), countering dominant, thin narratives (39) with \nrich data. \nComparison with existing literature\nThis study adds support to a care model in which pain is an embodied experience within a specific \nhistorical, cultural and social context (9, 40). Psychological aetiology cannot be determined by \nabsence of physical pathology in chronic pain (41; 42), yet this was the experience of some \nparticipants. Trauma following sexual violence is well documented (43) and should inform care and \ntreatment. An embodied model of pain care disrupts dualism in the biomedical model (44) and \nbrings contextual meanings of pain to treatment experience and outcome (19). Embedding \npsychological treatment is best practice when working with CPP (45; 46), while fragmented care, as \ndescribed in this study, undermines treatment (47; 48). \nWomen in this study specified clearly how clinicians could build trust with them: take time, ask, \nlisten, and believe. In healthcare, the dynamics of sexual violence can be replicated in a power-over \n\n\nmodel. A trusting doctor-patient relationship can challenge stigma, described widely in chronic pain \n(9; 10; 11; 32; 49; 50), and a collaborative relationship enables joint exploration of aetiology and \ntreatment options. \nOther studies have identified shame about chronic pain in women (51; 52; 53; 54; 55; 56), and \npressure to hide it (9). Shame prevented or delayed some participants in this study from accessing \nsupport, and sexual relationships were particularly fraught, as in findings of previous studies into \nheterosexual sexual activity and CPP (57; 58), but adding insight into the compounding of shame \nwhere CPP arises in trauma. Sexual desire and activity can be addressed alongside pain treatment, \nrather than by separate treatment for sexual trauma (59).\nIt is common for women to be treated differently after disclosing sexual violence (31) and in an \nattempt to avoid over-attribution of pain to psychological causes, women may choose not to \ndescribe emotional aspects of their pain experience (60; 61), leaving important components \nunexplored. A clear preference for being asked by healthcare providers about interpersonal violence \n(62; 63; 64) emerged, facilitating disclosure (65). In this study, some women had never been asked, \nand those who disclosed it received varied responses, from belief to silencing; negative experiences \nof disclosure discourage subsequent attempts (28). \nHealthcare is embedded in political and cultural structures (32), including rape culture and the \nprevalence of rape myths (66; 67), and this contextualises the repeated denial and silencing of \nwomen’s pain after sexual violence and punishes disclosure (68). Primary healthcare staff can feel \nundertrained and under-resourced to investigate signs of trauma (69; 70) and ill-equipped to \nadequately discuss the interaction between physical and emotional health (71). Lower \nsocioeconomic status is also associated both with risk of experiencing sexual violence (72) and of \ndeveloping chronic pain (73); this applied to half our participants. An embodied model of pain as a \nfunction of the whole person in her or his environment (74) validates the experience regardless of \nclinical findings, since pain meaning is created in social context (75). \nImplications for research and/or practice\nWomen described some exceptional clinicians and clinical care. A trauma-informed approach to \nphysical health presentations is best practice in primary care (70), recognising and responding to \nhow psychological trauma affects individuals and communities and their sense of safety and trust in \nclinicians and others. Integration of mental and physical (including sexual) health can be achieved in \ngeneral practice and in specialist, particularly multidisciplinary, pain clinics with a trauma-informed \napproach to health care (76; 77). \n\n\nMore specifically, participants in this study reported wanting clinicians to ask about abuse, rather \nthan having to initiate disclosure; to respond without judgement, and to appreciate the complexity \nof interpersonal violence (66; 77). A supportive, validating response to disclosure can counteract \nsocietal normalisation and minimisation of sexual violence (78) and reduce the health impact of \ntrauma (79). Clinicians need to reflect on rape myths and how they ask about sexual violence, using \nguidance (80) or intervention to challenge rape myth acceptance, as for jurors (81). According to \nwomen in our study, a ‘good enough’ response from GPs involved being seen as a whole person, \npain being adequately investigated (82), and the GP acknowledging what is not understood about \nCPP and sexual violence. This allowed the negotiation of a pain explanation that validated the \nwoman’s experience and integrated her social context with medical results, delivered with empathy \nand understanding. Women and GPs could collaborate on writing and reviewing guidelines for GPs. \nMore accurate estimates of the number of women living with CPP could justify funding for better \ntreatment. Research into CPP mechanisms and interventions should sample from diverse \npopulations and intentionally include multiple social identities and characteristics (83; 84) and a \nwide range of psychological and social variables (85), to improve generalisability of findings and \nintended benefit for underrepresented groups (83).\nFunding\nNone\nEthical approval\nUCL Research Ethics Committee [19447/001]\nCompeting interests\nNone\nAcknowledgements\nThank you to Maria who helped design the advertisement and develop the interview schedule, to \nformer colleagues within the women’s sector who further supported the development of the \ninterview schedule and to Lara who read my thesis and provided a GP’s perspective. Thank you to \nthe women whose courage to speak inspired and enabled this research.\n\n\nReferences\n1.Parsons B, Baranowski A, Berghmans B, Borovicka J, Cottrell A, Dinis-Oliveira P, et al. \nManagement of chronic primary pelvic pain syndromes. 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