{"paper_id":"8f7f873f-f082-4877-96e9-48cd94671ee0","body_text":"International Journal of\nPsychology and Psychoanalysis\nSilva et al. Int J Psychol Psychoanal 2023, 9:063\nVolume 9 | Issue 1\nDOI: 10.23937/2572-4037.1510063\nCitation: Silva CF, Gonçalves B, Campos RC (2023) Sexuality in Endometriosis: Preliminary Data on \nPain Malevolence and Illness Intrusiveness. Int J Psychol Psychoanal 9:063. doi.org/10.23937/2572-\n4037.1510063\nAccepted: April 14, 2023: Published: April 16, 2023\nCopyright: © 2023 Silva CF, et al. This is an open-access article distributed under the terms of the \nCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction \nin any medium, provided the original author and source are credited.\nOpen Access\nISSN: 2572-4037\n• Page 1 of 5 •\nSilva et al. Int J Psychol Psychoanal 2023, 9:063\nSexuality in Endometriosis: Preliminary Data on Pain \nMalevolence and Illness Intrusiveness\nCarolina Franco da Silva1*, Bruno Gonçalves2 and Rui C Campos3\n1Investigator at Faculty of Psychology, University of Lisbon, Lisbon, Portugal\n2Professor at the Faculty of Psychology of the University of Lisbon, Lisbon, Portugal\n3Professor at Department of Psychology, University of Évora, Évora, Portugal\n*Corresponding author:  Dr. Carolina Franco da Silva, Investigator at Faculty of Psychology, University of Lisbon, Lisbon, \nPortugal, Tell: +351-969-028-124\nAbstract\nEndometriosis has a major impact on women’s sexual \nhealth, lessening fertility and causing pain and reduced \nsexual desire in at least 50% of patients. This article \ninvestigates the relationship between infertility and sexual \nintercourse concerns and illness intrusiveness. Since both \npain and illness can be interjected as malevolent internal \nobjects, we also looked at the mediating effect of pain \nrepresentation as a malevolent object on those relationships. \nOut of 116 women, 58 met our inclusion criteria (M = 37.37 \nyears, SD = 5.10). We used the Endometriosis Health \nProfile-30, the Illness Intrusiveness Ratings Scale, and the \nPain Personification Questionnaire. Results demonstrated \nthat pain representation as a malevolent object totally \nmediated the relationship between both infertility and illness \nintrusiveness as well as sexual intercourse concerns and \nillness intrusiveness. Results highlight the importance of a \npsychodynamic approach to endometriosis, allowing for the \neffect of vulnerabilities developed in early childhood to be \nconsidered while approaching this illness.\nKeywords\nEndometriosis, Illness Intrusiveness, Sexuality, Intercourse, \nInfertility, Pain malevolence\nThe diagnosis takes between 8 and 11 years [5, 6] \nand is often only made together with that of infertility \n(the inability to get pregnant despite having frequent, \nunprotected sex for at least a year): 25 to 50% of infertile \nwomen have endometriosis, and 30 to 50% of women \nwith endometriosis are infertile [7,8].\nStudies on psychological distress in endometriosis \nare scarce, and those that do exist focus mainly \non identifying depression, anxiety, and lessened \nquality of life [9-12]. Research into sexual function in \nendometriosis has been increasing [5, 13-15], mainly \nlooking at infertility, which is significantly related to \ndepression and anxiety [16-18], and dyspareunia, which \nis present in around 50% of patients. Dyspareunia deeply \nimpacts sexuality, as the pain is felt both physically and \npsychologically: Significant negative effects on desire, \nexcitement, sexual activity, and orgasm [19-21] can take \nplace, with obviously predictable challenges for couples \n[22-26].\nIllness intrusiveness has been studied extensively \nregarding many chronic illnesses, such as cancer, \nrheumatoid arthritis and multiple sclerosis [27, 28] and \nis defined as the feeling by patients that their illness or \nassociated treatments interfere with daily activities. \nHaving no direct relationship with illness severity or pain \nintensity, illness intrusiveness is positively correlated \nwith depressive and anxious symptomatology and \nlessened quality of life [29-31]. Despite the lack of \ndata, illness intrusiveness seems likely to be present \nReview ARtiCle\nCheck for\nupdates\nIntroduction\nEndometriosis is a chronic gynecological condition \naffecting around 10% of fertile women. Key symptoms \nare dysmenorrheal, dyspareunia, dysuria, dysphasia, \ninfertility, and chronic pelvic pain [1, 2], without any \ndirect relationship between illness severity and pain \nintensity [3,4].\n\nISSN: 2572-4037\nDOI: 10.23937/2572-4037.1510063\nSilva et al. Int J Psychol Psychoanal 2023, 9:063\n• Page 2 of 5 •\nEndometriosis at the Hospital Lusíadas , Lisbon after \nreceiving the hospital’s health ethics authorization.\nParticipants ranged from 22 to 51 years of age (M \n= 37.37, SD = 5.10) and 72.5% had at least a bachelor’s \ndegree. Most were in a romantic relationship (96.6%) \nand had no children (55.2%). The average number of \nyears with pain was 17.41 years (SD = 10.22) and time \nsince diagnosis averaged 5.41 years (SD = 4.70). Other \ngynecological illnesses were present in 6.9% of our \nsample, and 24.1% had previously received a psychiatric \ndiagnosis.\nMeasures\nParticipants filled out a survey requesting socio-\ndemographic and clinical information: Age, education \nlevel, relationship status, parity, number of years \nwith pain, number of years since diagnosis, other \ngynecological illness, and previous psychiatric diagnoses.\nThe Endometriosis Health Profile-30  [ 49,50] is a \n53-item instrument measuring the condition’s impact \non women’s lives. The core instrument comprises five \nscales: Pain, control and powerlessness, emotional \nwell-being, social support, and self-image. Six \nsupplementary modules include work, relationship with \nchildren, sexual intercourse, relationship with doctors, \ntreatment, and infertility. All scales showed high \ninternal reliability (Cronbach’s α between 0.83 to 0.93 \non core questionnaire and 0.79 to 0.96 on modules) \nfor the Portuguese version. This study focused on the \nSexual Intercourse and Infertility modules, assessing \nthe presence of pain and inhibited sexual arousal and \nreduced fertility, respectively, and also the degree \nto which these issues were felt to be worrisome. \nCronbach’s alphas for the current sample were 0.93 and \n0.92, respectively.\nThe Illness Intrusiveness Ratings Scale [ 28] consists \nof 13 items assessing the extent to which disease-and \ntreatment-related factors interfere with meaningful \nlife concerns, such as family relations, sexuality, or \nwork. It generates a total score and three sub scores: \nRelationships and personal development, intimacy, and \ninstrumental. The original version has high levels of \nreliability (Cronbach’s α ranging from 0.78 to 0.97). We \nobtained the author’s permission and followed Van de \nVijver & Hambleton’s directives for translating [51] the \ntool into Portuguese. We used the total scale score, and \nCronbach’s α was 0.92 in the present sample.\nThe Pain Personification Questionnaire [ 39] is an \n11-item self-report measure investigating whether \nparticipants experienced pain as a malevolent entity \nresiding within themselves. The original instrument \ngenerates a total score with good internal consistency \n(Cronbach’s α = 0.77). We requested the authors’ \npermission and followed Van de Vijver & Hambleton’s \ndirectives [51] for translating the tool into Portuguese. \nOur Cronbach’s α was 0.86.\nin endometriosis, given the impact of the disease on \nissues central to illness intrusiveness, such as work, \ninterpersonal relationships, and sexuality [32-35].\nPain is a principal characteristic of endometriosis, \naffecting up to 80% of patients [35, 36]. However, its \nrole on psychological suffering is still not clear [3, 37]. \nUsing object relations theory, Schattner, et al. [38] \ndemonstrated that women with Systemic Lupus \nErythematosus, a chronic illness with similarities to \nendometriosis (undetermined etiology, immune system \ndysfunction, widespread impact on the body), tend to \nconstrue their illness as an internal object capable of \ninfluencing both their affective states and behaviors; \nthe same seems to happen associated to pain. These \nrepresentations, when negative or malevolent, \ncorrelate with higher levels of depression and illness \nintrusiveness [39,40]. The new relationships established \nthroughout life tend to be influenced by representations \nestablished during early interactions [41-43]. Hence, it \nmight be argued that the attribution of malevolence to \nthe interjected pain might stem from early experiences \nwith objects felt as neglecting or abusive [44-47], and \nthat this might influence the degree to which the disease \nis experienced as intrusive.\nAim and hypothesis\nGiven the tendency for endometriosis to be seen as \nintrusive and deleterious, we hypothesized that both \ninfertility and sexual intercourse concerns (including \ndyspareunia and reduced arousal) might be related \nto illness intrusiveness. We also predicted that pain \nmalevolence would mediate the relationship between \nthese two dimensions and illness intrusiveness. Given \nthe continuity between pain and illness representation \n[39], we also hypothesized that reduced fertility, even if \nunaccompanied by physical pain, would be experienced \nin a similar fashion. We expected these relationships to \nbe significant even when controlling for important co-\nvariables.\nMethods\nParticipants\nA sample of 116 Portuguese women participated \nin a larger study of endometriosis and psychological \ndistress, with only 58 women meeting the criteria for \nthis investigation. Given our focus on infertility and \nsexual intercourse disturbances, only women reporting \nsuch issues participated. The exclusion criteria were: \nAge above 51 (average age women enter menopause) \n[48], a psychiatric hospital admission within the previous \nyear, not speaking native Portuguese, and having less \nthan a 6\nth grade education. Following an online call \nfor volunteers, data was collected anonymously both \nonline, using a Google form, and in-person, both at \nsmall gatherings organized specifically for this intent \nwith the Portuguese Support Association for Women \nwith Endometriosis and at the Specialized Center for \n\nISSN: 2572-4037\nDOI: 10.23937/2572-4037.1510063\nSilva et al. Int J Psychol Psychoanal 2023, 9:063\n• Page 3 of 5 •\nto illness intrusiveness. The model explained 23% of this \nvariance. Regarding the meditational model, infertility \n(β = 0.32, SE = 0.149, p < 0.05; 95% CI [0.019, 0.608]) and \nsexual intercourse concerns (β = 0.39, SE = 0.144, 95%, p \n< 0.05; 95% CI [0.067, 0.5640) were both related to pain \nmalevolence, while this meditational variable tended to \nrelate to illness intrusiveness (β = 0.30, SE = 0.162, 95%, \np < 0.10; 95% CI [-0.003, 0.628]). No significant direct \neffects of infertility or sexual intercourse concerns were \nfound on illness intrusiveness. However, significant \nindirect effects through pain malevolence were revealed \nfor both infertility (β = 0.10, SE = 0.087, 95%, p < 0.05; \n95% CI [0.000, 0.335]) and sexual intercourse concerns \n(β = 0.12, SE = 0.077, 95%, p < 0.05; 95% CI [0.008, 0331]). \nThis reveals that pain malevolence totally mediated the \nrelationship between infertility and sexual intercourse \nconcerns and illness intrusiveness, explaining 30% of its \nvariance.\nDiscussion\nAs hypothesized, our results showed that both \ninfertility and sexual intercourse concerns are \nsignificantly related to illness intrusiveness. We also \ndemonstrated that pain representation as a malevolent \nobject has a total mediating effect on these relationships.\nBoth infertility and sexual intercourse concerns \nseem to be important to most women throughout their \nData analysis\nA preliminary analysis (Table 1) looked at the \nrelationship among our target variables and between \nthem and the socio-demographic and clinical ones (age, \neducation level, relationship status, parity, number \nof years with pain, number of years since diagnosis, \nother gynecological illness, and previous psychiatric \ndiagnoses). No significant correlations were found, thus \nno co-variables were introduced into the models. AMOS \n21 software then tested for any meditational effect of \npain malevolence on the relationship between illness \nintrusiveness and infertility and sexual intercourse \nconcerns. We tested a direct model of infertility and \nsexual intercourse concerns on illness intrusiveness and \nthen a meditational one (Figure 1). Infertility and sexual \nintercourse concerns were entered as independent \nvariables, while pain malevolence served as the \nmediator, and illness intrusivenesswas the dependent \nvariable. Bootstrapping (with 1,000 samples to build \n95% confidence intervals) assessed significance levels \nand calculated indirect effects.\nResults\nRegarding the direct model, infertility (β = 0.26, SE \n= 0.125, p < 0.05; 95% CI [0.009, 0.491]) and sexual \nintercourse concerns (β = 0.36, SE = 0.124, 95%, p < \n0.05; 95% CI [0.105, 0.586]) were both found to relate \n         \nFigure 1: Direct and indirect associations between illness intrusiveness and infertility and sexual intercourse concerns, with pain \nmalevolence as a mediational variable.\nTable 1: Correlations between study variables.\nVariables 1 2 3 M SD\n1. Infertility concerns -- 7.86 5.13\n2. Sexual intercourse concerns 0.17 -- 10.96 5.89\n3. Pain malevolence 0.38** 0.44** -- 23.64 6.77\n4. Illness intrusiveness 0.32* 0.41** 0.47*** 48.98 17.84\nNote: *p < 0.05; two-tailed **p < 0.01; two-tailed ***p < 0.001, two-tailed.\n\nISSN: 2572-4037\nDOI: 10.23937/2572-4037.1510063\nSilva et al. Int J Psychol Psychoanal 2023, 9:063\n• Page 4 of 5 •\nfertile years [17], which emphasizes how potentially \ntroublesome these concerns are for endometriosis \nsufferers. When looking at the mediating effect of pain \nmalevolence, we confirmed that the lack of physical \npain in infertility is not necessarily important. Given \nthe theoretical continuity between pain and illness \nmalevolence due to chronic illness [38], infertility may \nbe perceived as similarly malevolent.\nThese results draw attention to the importance of \nearly relationships on patients’ emotional development. \nRepresentations developed in childhood tend to persist \nthroughout life and are assumed to serve as a model \nfor new ones [42-44], including those developed in \nadulthood resulting from chronic illness. The attribution \nof malevolence to both pain and illness seems to reflect \nan inherent difficulty of some women to mobilize \ninternal resources to manage the illness’s impact. In \nfact, these women perceive the disease to be deeply \nintrusive and malignant. The attribution of malevolence \nto chronic illness pain might, therefore, result from \nearly experiences with objects felt to be unavailable, \nrejecting, or neglecting [45-47].\nWe suggest that a psychodynamic approach could \nbe used when addressing the psychological impact \nof endometriosis. This might deepen understanding \nof women’s difficulties in light of their relational \nexperiences, facilitating work on any vulnerabilities that \npotentially hinder their adaptation to this unsettling \nchronic illness.\nThe small sample size is a limitation of note in this \nstudy. Larger samples would enable future researchers \nto corroborate these findings. Dyspareunia pain intensity \nshould be controlled for, as well, when exploring its \nimpact on women’s well-being.\nDisclosure Statements\nThe authors declare they have no conflict of interest.\nThe findings reported in this manuscript have \nnot been previously published and are not being \nsimultaneously submitted elsewhere.\nOriginal research procedures were consistent with \nthe principles of research ethics, published by the \nAmerican Psychological Association.\nFunding received for this work from FCT (Foundation \nfor Science and Technology): UID/CED/04312/2016; \nUIDB/04312/2020.\nReferences\n1. Culley L, Law C, Hudson N, Denny E, Mitchell H, et al. (2013) \nThe social and psychological impact of endometriosis on \nwomen‘s lives: A critical narrative review. Hum Reprod \nUpdate 19: 625-639.\n2. 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