Understanding chronic pelvic pain in women survivors of sexual violence: a qualitative study

Background: Chronic pelvic pain (CPP) affects an estimated 14.8% of UK women. Survivors of sexual violence are more likely to experience CPP, but the relationship is complex and underexplored. Shame and stigma from both experiences may interact and influence help-seeking. Aims: To broaden understanding of how women survivors of sexual violence make personal meaning of CPP, and to consider clinical implications of findings. Design & setting: A qualitative study of UK community-recruited women who have survived sexual violence and who experience chronic pelvic pain (CPP).

Ten participants were recruited via social media and engaged in individual, semi-structured online interviews about their experiences and understandings of sexual violence and CPP. Interviews were transcribed verbatim and analysed using reflexive Thematic Analysis.

Three main themes were developed: (1) Healthcare professionals’ attempts to silence women, who felt ignored, disbelieved or dismissed; (2) Treating the whole woman, describing the need for integrated, biopsychosocial approaches; and (3) A woman’s place is in the resistance, highlighting women’s active efforts to reclaim their narratives and pursue care. Shame was compounded across experiences, and women expressed frustration with fragmented care and assumptions about the psychological origins of pain.

These results give insights into the complex meanings women survivors of sexual violence hold about their CPP, and how healthcare systems could better support them to explore and respond to those meanings. The aim should be compassionate care that recognises the complex biopsychosocial impact of sexual violence and CPP, while keeping women in control of their own care.

Chronic pelvic pain, sexual violence, qualitative, primary care, trauma-informed care, women's health How this fits in Chronic pelvic pain (CPP) is common and can be difficult to treat. Some women with CPP are survivors of sexual violence. How such women understood their pain was strongly influenced by feeling ignored by doctors and shamed by both CPP and sexual violence. According to women in our study, a ‘good enough’ response from GPs involved being seen as a whole person, being asked about sexual violence, pain being adequately investigated, and the GP acknowledging what is not understood about CPP and sexual violence. This allowed the negotiation of a pain explanation that validated the woman’s experience and integrated her social context with medical results, delivered with empathy and understanding. Women with chronic pelvic pain who have also survived sexual violence struggle for integrated, accepting medical assessment and treatment. Competing interests: The authors declare no competing interests. Ethical approval: UCL Research Ethics Committee [19447/001]. Understanding chronic pelvic pain in women survivors of sexual violence: a qualitative study

Chronic pelvic pain (CPP) is defined as pain perceived in structures related to the pelvis persisting for more than three months (1). UK prevalence estimates range from 3.8% (2) to 14.8% (3). CPP is frequently complex in origin, with biological, psychological, and social contributors (4; 5; 6). Despite its prevalence, women with CPP often experience delayed diagnosis, their symptoms dismissed or misattributed to psychological causes (7; 8; 9; 10; 11). Rates of sexual violence experienced by women and girls are notoriously hard to estimate (12; 13) but 1 in 5 English/Welsh women are thought to have experienced sexual assault (14). CPP following sexual violence is common (15;16; 17; 18), though the mechanism is unclear; genital injury, emotional trauma, and alterations in pain processing may all contribute but a causal link between CPP and sexual violence is hard to establish, and many women struggle to find language or support to articulate their experiences. The meanings of pain affect daily experience and responses to treatment (19); after traumatic events in particular (20). Survivors of sexual violence frequently encounter stigma, disbelief, and silencing within healthcare and more widely (21; 22); these experiences intersect with the poorly understood nature of CPP, creating additional barriers to care, and shame is often internalised and compounded by dismissive responses from health professionals (23). Little research elicits women’s own accounts of the meanings of chronic pelvic pain after sexual violence. This study explores how UK-based women survivors of sexual violence make personal meaning of their chronic pelvic pain. By using qualitative interviews and reflexive thematic analysis, the research seeks to foreground women’s voices and provide insights that can inform trauma-informed, compassionate care in general practice.

Design and ethics: Semi-structured interviews with reflexive Thematic Analysis explored the understandings that women survivors of sexual violence brought to their CPP. The study had ethical approval (UCL Research Ethics Committee 19447/001); all participants provided informed consent. Recruitment: A research advertisement produced in consultation with an expert by experience was shared on Twitter and disseminated by supportive organisations and individuals via email and online forums. The advertisement linked to a website where potential participants found information necessary for informed consent. Inclusion criteria were: being a woman, 18 or over, living in the UK, speaking English, currently experiencing chronic pelvic pain, and having survived sexual violence or abuse of any kind as a child or adult. The participant information webpage encouraged women to contact the study only if they were safe and the abuse was in the past. Data collection: All participants, having read and electronically signed a consent form, were interviewed and audio-recorded using MS Teams. The semi-structured interview (Box 1) was developed with help from colleagues with extensive experience of supporting women survivors of sexual violence. As interviewer, the main researcher [CMcC] had experience supporting survivors of domestic and sexual violence and training in clinical psychology, both mentioned in participant information. Before beginning interviews, CMcC asked women if they were in a private space where they would not be overheard. Women were signposted to support after the interview and sent a £15 voucher. Audio recordings were immediately transcribed, anonymised and deleted; transcripts were stored securely. Box 1. Areas of questioning Areas of questioning 1. Can you tell me about your pain? 2. How do you understand your pain? 3. Can you tell me about what you’ve done to get help or support for the pain? 4. What advice would you give pain clinicians and support workers (or any other professionals already mentioned by participant), about helping women with pain related to sexual violence? 5. Can you tell me about something you do to look after yourself? How does it help you? 6.Is there anything you feel that we did not talk about or that you would like to add? Researcher position CMcC is a white British woman in her 30s, recently qualified as a clinical psychologist. Prior to training in clinical psychology, she worked in the social care sector for 10 years, supporting survivors of domestic and sexual violence. CMcC's epistemological position is that psychological research should contribute by design towards liberating and transforming the experience of excluded or ‘othered’ groups by centering issues of power and epistemic violence. This study sought to use the critical lens of liberation and feminist psychologies to address a neglected space within psychological research. AW is an academic and clinical psychologist with over 35 years’ experience working in chronic pain, including in survivors of sexual and other violence. She supervised CMcC and endorsed her epistemological stance. Data analysis Reflexive Thematic Analysis (TA) (24, 25) was used to analyse transcripts, aiming to identify, analyse and report patterns within women’s narratives of pain and sexual violence (24) whilst owning the main researcher’s role in the creation and interpretation of data (26). The researcher (CMcC) transcribed the audio recordings by hand to maximise data immersion; she then read and re-read the transcripts, making notes before systematically generating codes that she attached to chunks of data and grouped on a spreadsheet. Groupings were mapped and re-mapped into themes, allowing reflection on assumptions made in data interpretation (27). Discussion with the second author (AW) and colleagues helped with this process. Since subjectivity is central to reflexive TA, double coding was not conducted. The final version had three themes and eight subthemes acting as interpretive stories about the data (26). Sampling and saturation Resource constraints were a significant factor in sampling limitations, alongside the difficulties in reaching this population. Reflexive thematic analysis critically engages with the idea of achieving data saturation, arguing that this position suggests that themes are there to be discovered in the data (25) rather than generated by the researcher. Braun and Clarke suggest the request for data saturation represents a positivist quality standard applied in qualitative research.

Participants Twelve women responded to the advertisement, but one did not respond further and another did not attend the arranged interview or reconnect. One woman did not complete the demographic information, but information that she shared during the interview has been added. Interviews took between 40 and 100 minutes. The ten women who completed interviews were from 23 to 43 years old (mean age 32). Six were white British, one each white/Asian, white/Latin American, and black African, with one unknown. Three described themselves as heterosexual, two each as lesbian and as bisexual, one as queer, and two did not answer. Five classified themselves as working class, three as middle class, and one as emerging service worker; five had postgraduate degrees, three undergraduate degrees, one had not attended university and one is unknown. Six had children under 18 living with them, and three had significant unpaid caring responsibilities; seven did paid or voluntary work and three did not. Five felt that they had just enough money after paying bills, three not enough, and one more than enough. They described their spiritual beliefs in varied ways, only two (one Sikh, one Catholic) in organised religion. Initially, 26 codes were generated before searching for patterns across data that became three themes, presented alongside subthemes and illustrative quotations in Table 1. Individual participants are referred to by interviewee number, for example 1. Brief pauses in conversation are indicated by (.) and – indicates self-interruption. Table 1. Themes, subthemes and illustrative quotations Theme & summary Sub-themes Examples 1.1 Healthcare professionals’ failure to ask about sexual violence and inadequate responses to disclosure P4: I wonder if I could have … got support a lot earlier on if just those things were kind of brought to my attention and sort of asked from me. 1.2 Disbelieving women P6 It would be so great to have to know that I was going to a GP that was going to believe me (.) and take me seriously. P2: stop seeing women as liars like when they come to you and tell you [about] their pain Theme 1: (Attempts at) Silencing women Multi-level, systemic attempts to deny, minimise, normalise or ignore women’s experiences both of sexual violence and of chronic pelvic pain; disclosure of one compounded the (poor) treatment of the other. 1.3 Shameful, broken bodies P8: it kind of feels like it’s too, too damaged … it just feels like everything's just rotten 2.1 False dichotomy of mental and physical health P1: As soon as a doctor hears you’ve got mental health problems, they’ll automatically discount all of your physical health issues and say it’s all down to your mental health 2.2 Fragmented care and dead ends P5: It's like snakes and ladders (.) just like always end up right back at the beginning P9: I think I just kind of thought it's not really going anywhere (.) umm and I'm just trying to manage it myself (.) so yeah I haven't (.) I haven't gone back [to the GP to discuss CPP] for a long time. Theme 2: Treating the whole woman The importance of integrating a biopsychosocial explanation of pain in medical treatment. 2.3 Being seen in ‘my complexity’ P10: Treat the whole person and not just the symptoms to understand everything that's going on in that person's life and to take it all as one kind of big picture rather than separating things out into this person has anxiety depression and pelvic pain (.) look at it altogether Theme 1: (Attempts at) Silencing women The women interviewed described experiencing multi-level, systemic attempts at denying, minimising, normalising or ignoring their experiences both of sexual violence and of CPP, with disclosure of one compounding (poor) treatment of the other. Subtheme 1.1: Healthcare professionals’ failure to ask about sexual violence and inadequate responses to disclosure Most participants in this study had not been asked about sexual violence despite presenting with indications of trauma. Women struggled to understand the silence of healthcare staff, especially given that sexual violence is “such a big problem and it's happening so much” (I4). Not asking 3.1 Women taking control of their own narrative. P7: On the days that I could run it just felt really good to feel my body (.) my body's power basically if that makes sense because I think one of the things about constant pain is that you can feel weak and incapable (.) and seeing the difference …in my body it gave me like a strength a feeling of strength and like self-control like I have power and authority over my body (.) which after everything that's happened and the experiences I've had (.) I often feel like I don't (.) so it gave me that sense of it back which was quite powerful. P3: I'm the patient (.) I know exactly where my pain is (.) I know exactly what I'm talking about you know P8: I am not a tree (.) I'm not a bridge (.) you know and I shouldn't have to carry a load Theme 3: A woman’s place is in the resistance The multiple ways of resisting the cancellation and denial of women’s voices and experiences, and resisting shame’s edict to hide. 3.2 Persistence in efforts to access adequate support P5: if I hadn't managed to fight so much and if I hadn't managed to find the right support I would- and they told me like you know basically I'd still be in a wheelchair colludes with the myth that rape is uncommon or inconsequential, whilst also communicating that GPs are not equipped to deal with sexual violence disclosures: “Some people just need to know that your doctor knows what they're doing and not going to say stupid shit [in response to sexual violence disclosure] … believe me (.) and take me seriously about my pain.” (I6) I2 understood how trivialisation of rape informed the lack of empathy and poor care she received, including from her GP: “with the pain that I'm in and that (.) they [GPs] don’t even take it seriously because they don’t really understand that it’s not sex (.) it’s rape (.) there’s a massive difference” By contrast, being given sufficient time and being believed created a positive context for disclosure: “That doctor who I told (.) was just like look (.) we could take as much time as you want (.) anything else you want to talk about? She was like I- supposed to be ten minutes (.) but I don't do that (.) yeah she was great.” (I6) Failure to ask about sexual violence, in the context of widespread recognition of social factors in physical and mental health, effectively deny women power through silencing (28) both of their pain and the sexual violence; this moves beyond the finding that women in pain are routinely ignored (29; 30). Similarly, dismissing a woman’s disclosure of rape as ‘bad sex’ denies women’s experience and alienates them from healthcare. Given that shame is common after sexual violence (28; 31) and serves to isolate survivors from support, sensitive questioning is often necessary to elicit disclosure, and where women had experienced it, they trusted and confided in the doctor. Subtheme 1.2: Disbelieving women The impact of systems and individuals denying women’s subjective experiences of both pain and sexual violence was described by many participants in this study. I1 stressed the importance of pain reports being believed: “even if they’re gonna use the wording of it [pain] being created in your brain (.) they don’t try and put it across like you’re making it up.” Being believed about sexual violence was also important: “It's actually astonishing…how similar that [taking pain seriously] is to [taking] sexual violence [seriously] like it’s the same (.) because you know (.) just being believed is all.” (I6) Doctors who approached their patients with curiosity and sensitivity to power dynamics after trauma were appreciated: “what do I need to know about that to help me care for you now.’ And how do I keep you in control? I think recognising the lack of power and control is really important and people don't do that at all.” (I8) Explanation of pain and of the mechanisms by which it persists, with care about the language used, can be helpful and validating. It starts with statements of belief in a woman’s disclosure, distancing the discussion from rape myths, culpability and shame, and involving the woman in her care and treatment planning. Subtheme 1.3: Broken bodies The altered ways women viewed their bodies following sexual violence intersected with how women understood their CPP. Humiliating thoughts of being defective elicited a desire to hide and to silence part of the self; rape myths affected the meaning women made of their pain. I5 developed pain during pregnancy and linked her inability to disclose (unlike ‘true victims’ of rape myths) and thus ‘deal with’ being raped during childhood with fears about her body: “[I was] worried that I wouldn’t be able to give birth like that, that something would block and I just wouldn’t be able to open up or something and it was almost literally because I hadn’t been able to open up about what I had experienced” I8 felt that her body was irreparably damaged by sexual violence, and no longer functioned in the same way as other women’s bodies: “it kind of feels like it’s too, too damaged … it just feels like everything's just rotten” For some women, pain served as an unwelcome reminder of rape, worsened where their GPs did not offer belief or support. For others, meanings of rape made pain harder to deal with: “[when] I think to myself (.) I should have had stronger boundaries (.) I should have respected myself more or cared for myself more to remove myself from that situation … that's what I really (.) really have a difficult time [with the pain].” (I7) In contrast, I9 conceptualised her pain as a witness to how much she has survived and uses this knowledge to validate its intensity: “I think it [therapy] kind of helped me to see that [pain is] kind of my body's reaction to something that's happened to me and almost how my body is processing things that I've experienced… And I think seeing it that way helped me (.) yeah (.) see it not so much as a problem or that there's something that I'm doing wrong or I'm not strong enough” Women engaged with rape myths and explicit or implicit rules dictating women’s behaviour in understanding themselves and their bodies in pain. They felt that CPP and sexual violence were linked, causally or through similar responses elicited from individuals and systems. Theme 2. Treating the whole woman This theme explored how women experienced the segregation of mental and physical health care, particularly after disclosing sexual violence. Wanting to be understood in an integrated way contrasted with silencing, explored in theme 1. Subtheme 2.1. False dichotomy of mental and physical health Women reported their GPs’ failure to apply a biopsychosocial model of care to sexual violence and chronic pelvic pain. Some described ways their mental and physical health were interconnected: “When I then notice my pain (.) it always comes with kind of (.) thinking back to things that happened (.) or even if it can happen the other way around (.) where I've had a flashback and then I feel the pain umm more noticeably than maybe before I'd had that flashback.” (I9) Yet following a disclosure of sexual violence, physical health complaints were minimised as psychosomatic and left unexplored; some women did not trust their GP to respond well to emotional aspects of their pain so withheld them for fear of being labelled “a bit mad” (I8). The division of mental and physical health left women with a feeling that no one in the system fully understood their pain: “The thing is with secondary mental health services is that you speak to your psychiatrist and they write this report about you and I don’t know (.) it’s not really addressed at dealing with the pain (.) [They agree with the GP that] it’s all in your head but well that’s not really helpful because it’s the physical pain that’s causing you know flashbacks and everything.” [12] Subtheme 2.2: Fragmented care and dead ends Women experienced fragmented care, with implicit and explicit messages that expecting relief from CPP was unrealistic, or referral for physical investigation that was disjointed and physically focussed. I5 expressed exasperation at the fragmented care she received, how disempowering the process was, and how it extended the time she spent being “bounced around” the NHS like a game of “snakes and ladders” where she “always end[ed] up right back at the beginning.” Care could reach a dead end despite continued CPP; some women expressed anger at their GP’s apparent indifference and lack of creative thinking beyond normal test results. Subtheme 2.3: Being seen in ‘my complexity’ Women desired clinicians to understand and treat the whole person and show willingness to engage with complexity. Women understood their difficulties and potential solutions to be complex and integrated: “everything kind of like is like interwoven with each other (.) so I kind of need someone who gets like the whole of me” (I4) I7 described her relief at encountering a GP who seemed curious about her healthcare journey beyond their immediate clinical encounter: “She was amazing... it was the first time that I was like (.) I feel like someone cares and they don't just care about this one thing that I've come for this 10 minute appointment (.) but about my whole entire journey (.) and that was very special.” For some, the unwanted reminder of sexual violence formed an additional burden accompanying pain. As crucial to a woman’s pain experience, any such connections in meaning need to be understood by any treating clinician. For I1, an integrated explanation of CPP would have broken the silence and secrecy surrounding CPP and encouraged help-seeking. Some women described how talking about the experience of abuse brought about a reduction in their CPP; others were unsure whether their experiences of sexual violence and pain were linked. Women would have liked their GPs to collaboratively explore their complex presentations. As in subtheme 2.1, women reflected on their desire for integrated mental and physical health treatment. For them, holistic treatment made sense given their own intertwined understandings of physical and psychological elements of pain. Theme 3: A woman’s place is in the resistance Women resisted the cancellation and denial of their voices, narratives and experiences by reclaiming choice and control and resisting shame and secrecy. Normalising women’s pain removed the impetus to treat it, and women actively resisted this through continuing to seek healthcare. Subtheme 3.1: Taking control of their own narrative Talking about taboo topics resists their shaming impact, and women responded to my invitation to do this. I2 firmly rejected thin narratives about the vulnerability of rape victims: “I have a massive problem with people calling me vulnerable as a result of going through rape and that because I think that they just kind of situate you relative to the offender’s motives like they don’t really see you.” She described how the label “vulnerable” was used to justify controlling and disempowering care decisions, including the police talking to her parents rather than her, safeguarding meetings being held about her without her, and her GP refusing to allow her to book appointments for CPP. Yet I2 resisted being defined by what happened to her. Similarly, I8 described her objection to being described as ‘strong’, an outwardly benign adjective but one that denied her space for various emotions: “Being told that you're really strong makes it really hard when you're having a crap time of it to say, actually things don't feel OK…I am not a tree (.) I'm not a bridge (.) you know and I shouldn't have to carry a load and you know and how it's kind of saying ‘oh it's okay because we can keep loading things on you because you can cope with that’.” Women acted to regain control of the narratives surrounding their experiences of sexual violence and of CPP. Describing survivors as strong and able to cope relieves society of collective responsibility to change rape culture, obscuring the reality of abuse and demanding women find positive meaning from situations of utter despair. For some women, resistance had developed through talking with others or community organising, breaking the silence of normalisation and individualisation surrounding sexual violence and chronic pain. Subtheme 3.2: Persistence in efforts to access adequate support Reflecting on years of battling with the NHS for adequate care, I1 described the gradual realisation that ‘expert’ knowledge did not obscure and discount her own: “I've been told a million and one different things by various different specialists …So for me I just keep thinking ‘you don’t know that you’re right. How do you know I'm not right?” I10 described having the courage to reject the advice of her first GP to stay silent about sexual assault and accessing the specialist support she needed whilst also reducing her experience of pain. With considerable effort and determination, I5 drew on her pelvic pain specialist’s information that CPP was poorly understood to firmly reject the physiotherapist’s advice to abandon rehabilitation: “I was like (.) so you're telling me just to give up because (.) not because I can't get better (.) but because you don't have enough training or knowledge or support or funding to help me … it's not that I can't (.) it's that you can't” Women courageously persisted in their efforts to access pain care, and spoke of their healthcare journeys as one of increasing resistance to their pain being normalised as part of womanhood, since this removes the motivation to treat it. They spoke about the transformational process of learning to privilege their own self-knowledge. Gillberg and Jones suggest dead ends in CPP care reflect knowledge gaps about women’s health, resulting from minimal research into conditions that lack ‘medical prestige’ (Gillberg & Jones, 2019).

Summary Women’s narratives described an interaction between the meanings of CPP and of sexual violence, both of which were negotiated in healthcare encounters, often unsatisfactorily. Participants brought highly personal meanings to their pain, influenced by their experiences of sexual violence and by responses to disclosure, and for some the meaning included shame associated with chronic pain and with an altered body image following sexual violence. All women referenced rape myths, with narratives of victim culpability and (for some) of shame for failing to prevent sexual violence; these narratives discouraged seeking support. Pain for some women was described as directly caused by sexual violence, with intense pain triggering flashbacks or vice versa; others conceptualised it as a physical manifestation of psychological trauma, with psychotherapy helping to build pain understanding and coping. For both, reactions of others, including healthcare professionals, to disclosure were distressing and affected meaning-making: women who were disbelieved, told to ‘get on’ with pain, or to keep sexual violence secret described the burden of carrying pain and trauma alone, or the difficulty of repeatedly requesting support after being dismissed. Both gender bias in healthcare and segregated services for mental and physical health contributed to women’s experiences of poor pain care. Women described both over- and under-application of psychological concepts to their pain, neither leading to constructive discussion and treatment. Assumptions about the psychological aetiology of pain meant that physical investigations were denied; a focus on physical factors neglected pain meanings that required integration into treatment. Most women found that their pain care ended without resolution, in stark contrast to the few descriptions of a multidisciplinary approach encompassing medical and psychosocial aspects of pain in which women felt listened to and believed, and clinicians worked collaboratively to find a pain explanation and treatment. Women found ways to resist the thin stories told about them in relation to pain or as survivors of sexual violence, using integrated understandings of their own health. They persisted in their efforts to access adequate healthcare, requesting referrals and trusting their self-knowledge, resisting the silence about CPP and sexual violence by reconnection with their bodies, organising and advocacy. Strengths and limitations Sampling women from unseen populations with distressing experiences made recruitment difficult. Recruitment via social media risks excluding women in digital poverty or non-users, and the lack of older women in our sample could reflect that (33). It could be that women who had already made connections between sexual violence and CPP were more likely to opt into this research, potentially influencing the perspectives captured. Participating women were better educated (34) and declared more diverse sexuality than the UK population (35; 36). Limiting participation to English-speaking women likely excluded many migrant women, a group known to be at increased risk of sexual violence and barriers to care. Recently elaborated principles for evaluating adequacy of sample size suggest good information power [37] despite small sample size . Our study had a fairly narrow/focused question, addressed specific experiences, drew on existing theory, and the interviewer was experienced enough to provide rich data. The only principle that would require a larger population was if sampled experiences had been heterogeneous, and although we did not anticipate it, women’s accounts were remarkably consistent. Interviewing online enabled participation, despite the modest sample size. The flexible interview schedule allowed exploration of meaning, so that despite the highly sensitive topic, interviews articulated and valued women’s experiences (38), countering dominant, thin narratives (39) with rich data. Comparison with existing literature This study adds support to a care model in which pain is an embodied experience within a specific historical, cultural and social context (9, 40). Psychological aetiology cannot be determined by absence of physical pathology in chronic pain (41; 42), yet this was the experience of some participants. Trauma following sexual violence is well documented (43) and should inform care and treatment. An embodied model of pain care disrupts dualism in the biomedical model (44) and brings contextual meanings of pain to treatment experience and outcome (19). Embedding psychological treatment is best practice when working with CPP (45; 46), while fragmented care, as described in this study, undermines treatment (47; 48). Women in this study specified clearly how clinicians could build trust with them: take time, ask, listen, and believe. In healthcare, the dynamics of sexual violence can be replicated in a power-over model. A trusting doctor-patient relationship can challenge stigma, described widely in chronic pain (9; 10; 11; 32; 49; 50), and a collaborative relationship enables joint exploration of aetiology and treatment options. Other studies have identified shame about chronic pain in women (51; 52; 53; 54; 55; 56), and pressure to hide it (9). Shame prevented or delayed some participants in this study from accessing support, and sexual relationships were particularly fraught, as in findings of previous studies into heterosexual sexual activity and CPP (57; 58), but adding insight into the compounding of shame where CPP arises in trauma. Sexual desire and activity can be addressed alongside pain treatment, rather than by separate treatment for sexual trauma (59). It is common for women to be treated differently after disclosing sexual violence (31) and in an attempt to avoid over-attribution of pain to psychological causes, women may choose not to describe emotional aspects of their pain experience (60; 61), leaving important components unexplored. A clear preference for being asked by healthcare providers about interpersonal violence (62; 63; 64) emerged, facilitating disclosure (65). In this study, some women had never been asked, and those who disclosed it received varied responses, from belief to silencing; negative experiences of disclosure discourage subsequent attempts (28). Healthcare is embedded in political and cultural structures (32), including rape culture and the prevalence of rape myths (66; 67), and this contextualises the repeated denial and silencing of women’s pain after sexual violence and punishes disclosure (68). Primary healthcare staff can feel undertrained and under-resourced to investigate signs of trauma (69; 70) and ill-equipped to adequately discuss the interaction between physical and emotional health (71). Lower socioeconomic status is also associated both with risk of experiencing sexual violence (72) and of developing chronic pain (73); this applied to half our participants. An embodied model of pain as a function of the whole person in her or his environment (74) validates the experience regardless of clinical findings, since pain meaning is created in social context (75). Implications for research and/or practice Women described some exceptional clinicians and clinical care. A trauma-informed approach to physical health presentations is best practice in primary care (70), recognising and responding to how psychological trauma affects individuals and communities and their sense of safety and trust in clinicians and others. Integration of mental and physical (including sexual) health can be achieved in general practice and in specialist, particularly multidisciplinary, pain clinics with a trauma-informed approach to health care (76; 77). More specifically, participants in this study reported wanting clinicians to ask about abuse, rather than having to initiate disclosure; to respond without judgement, and to appreciate the complexity of interpersonal violence (66; 77). A supportive, validating response to disclosure can counteract societal normalisation and minimisation of sexual violence (78) and reduce the health impact of trauma (79). Clinicians need to reflect on rape myths and how they ask about sexual violence, using guidance (80) or intervention to challenge rape myth acceptance, as for jurors (81). According to women in our study, a ‘good enough’ response from GPs involved being seen as a whole person, pain being adequately investigated (82), and the GP acknowledging what is not understood about CPP and sexual violence. This allowed the negotiation of a pain explanation that validated the woman’s experience and integrated her social context with medical results, delivered with empathy and understanding. Women and GPs could collaborate on writing and reviewing guidelines for GPs. More accurate estimates of the number of women living with CPP could justify funding for better treatment. Research into CPP mechanisms and interventions should sample from diverse populations and intentionally include multiple social identities and characteristics (83; 84) and a wide range of psychological and social variables (85), to improve generalisability of findings and intended benefit for underrepresented groups (83). Funding None Ethical approval UCL Research Ethics Committee [19447/001] Competing interests None

Thank you to Maria who helped design the advertisement and develop the interview schedule, to former colleagues within the women’s sector who further supported the development of the interview schedule and to Lara who read my thesis and provided a GP’s perspective. Thank you to the women whose courage to speak inspired and enabled this research.

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