"Anger, embarrassment, less than a woman": the emotional impact of Black women's sexual pain.

Data were derived from phase one of a larger, IRB-approved, exploratory mixed methods study examining premenopausal Black women’s sexual pain, sexual anxiety, sexual pleasure, and how culture and social identities impact their communication with sexual partners and providers. In November 2020, we recruited participants using snowball sampling and word-of-mouth through social media platforms. Phase one collected data from November 2020 to January 2021 through a 10 to 15-minute online Qualtrics survey. Eligibility criteria included (1) identifying as a Black cisgender woman, (2) being between the ages of 18 and 50, (3) living in the southern United States, (4) having one or more experiences with sexual intercourse, and (5) identifying as premenopausal. After completing an online consent form, eligible participants responded to Likert scale and open-ended questions about sexual pain, sexual anxiety, and sexual pleasure. At the end of the survey, participants received an invitation for a random selection raffle to win one of three $25 gift cards. The initial sample included responses from 284 Black women. Sexual pain was not required for study participation. However, respondents who indicated “yes” to experiencing sexual pain at some point during their lifetime ( n = 176) had the option to answer follow-up questions about their pain. This study’s data analysis was restricted to participants who answered one open-ended follow up question. The final sample consisted of 126 Black women. Secondary data analysis consisted of Robinson’s (2021) structural tabular thematic analysis (ST-TA) to examine participants’ open-ended responses to the following question: what feelings emerge when you think about sexual pain (e.g., anger, shame, guilt, embarrassment, etc.?) . ST-TA is a modified approach to Braun and Clarke’s (2006) thematic analysis designed for brief texts. Seven phases are detailed below for an abductive ST-TA. Participants’ responses were exported from the Qualtrics survey to Dedoose, a qualitative and mixed-methods data analysis software. Next, we consulted informational power guidelines by Malterud, Siersma, and Guassora (2016) and created an audit trail. A sample size of 126 was sufficient based on this study’s aim, specificity, theory, dialogue, and type of analysis. The first author updated the audit trail throughout coding. The audit trail ensured the dependability and confirmability of the results ( Nowell et al. 2017 ). Phase one of data analysis was a priori theme development. Plutchik’s model informed the a priori themes: emotion types and emotion components. During phase two, “deep immersion,” we reviewed participants’ open-ended responses and completed memos detailing our reflections on the data. Phase three consisted of coding and allowed for revising codes and themes “in context of and influenced by” a priori themes ( Robinson 2021 , 6). This phase provided context for the abductive nature of this study’s data analysis process. The first and second authors led coding using the a priori themes identified in phase one and the revised codes. Only the a priori emotion type codes were changed to fit the data better. The final emotion type codes are presented in the results. Next, we independently tabulated the frequency of each code (phase four). The fifth phase consisted of reviewing codes and establishing inter-analyst agreement. The final two phases concluded the ST-TA by examining theme frequencies and producing this report. Throughout the coding process, we engaged in peer debriefing and data triangulation using open-ended responses and memos to ensure reliability. The research team included Black, cisgender, pre-menopausal women with queer and heterosexual sexual orientations. All members were highly educated with sexual health research experience. Two Black women associate professors provided mentorship to the primary investigator throughout the study.

Table 1 provides the socio-demographic characteristics of the study sample. Participants were between 21 to 45 years old ( M = 29.6, SD = 5.85), predominantly heterosexual ( n = 100, 79.4 percent), and of African American ethnic origin ( n = 116, 92.1 percent). Sixty-two participants had a graduate or professional degree (49.2 percent). Most participants reported experiencing unwanted genital pain sometimes during sexual intercourse ( n = 101, 80.2 percent). Four participants (3.2 percent) reported being medically diagnosed with a sexual pain disorder. Their diagnoses were vaginismus ( n = 1) and endometriosis ( n = 3). Although endometriosis is not classified as a type of GPPPD, we recognize its impact on sexual intercourse, including heightened sexual pain and long-lasting pelvic pain. Last, 69 (54.8 percent) participants reported a history of sexual abuse or trauma. Types of emotions, emotion components, and frequencies are reported in Table 2 . Participants reported 45 emotions. The top five emotions were embarrassment ( n = 40), shame ( n = 25), frustration ( n = 22), anger ( n = 17), and guilt ( n = 14). Broadly, the emerging emotions participants reported when thinking about sexual pain informed five emotion categories or families: self-judgment ( n = 96), anger/distrust ( n = 56), sadness ( n = 20), anxiety ( n = 16), and emotions felt somatically ( n = 9). Nine participants reported indifference emotions or lack thereof. Participants’ emotions when thinking about sexual pain often overlapped (e.g., “embarrassment, weakness, shame, longing for painless sex”); however, some participants reported one salient emotion. Most participant reports fell within the feeling state ( n = 170) or cognitive appraisal ( n = 17) emotion components. Feeling state components described feeling based on monitoring one’s inner emotional state. Cognitive appraisal emotions were indicative of a meaning-making process. The least common emotion component was physiological changes ( n = 8), which emerged when participants reported bodily functions. It is worth noting that one participant enjoyed sexual pain and found it pleasurable: “somewhat pleasure because I like the pleasure/pain play.” Additionally, nine participants reported no emotions: “I don’t have feelings,” “nothing.” One participant reported “just how to get over it,” which may imply some emotion. However, those reporting no emotions and feelings of pleasure were not included in the emotion categories detailed in Table 2 . Self-judgment emotions were most commonly a mixture of feeling states and cognitive appraisals. There were three sub-categories of self-judgment: embarrassment, shame , and guilt . While many participants used guilt and shame as combined feelings of self-judgment, we separated them to understand potential nuanced differences in the intensity of these emotions since emotions exist on a continuum ( Plutchik 1958 ). Forty participants reported feeling embarrassed when thinking about sexual pain. One participant said “a little bit of embarrassment but mainly because I have to tell my partner to stop.” Most participants indicated their embarrassment was accompanied by another negative emotion like shame or inadequacy. For example, one participant stated “embarrassment, shame, longing for painless sex.” Twenty-five participants reported shame . Three examples of shame were: “[feeling like] less than a woman,” “weak, inadequate, and [like] a failure,” and “a little shame because I felt unhealthy.” Lastly, participants reported guilt ( n = 14) when thinking about their experiences of sexual pain. One participant shared “guilt, deflated, and disappointed,” and another participant shared “guilt and limited.” Anger ( n = 56) emotions were best captured by the feeling state component of emotion. For example, participants said, “mostly anger, annoyance, and frustration” and “it makes me mad.” One participant reported “pissed that it happened to me.” Another participant said “annoyance.” Some participants thought sexual pain was unfair to experience. Two participants captured indignation stating “the feeling of why is this happening” and “feeling that it is unfair for others to get pleasure from sex.” Using a mixture of feeling state and cognitive appraisal emotion components, participants reported feelings of sadness ( n = 20) when thinking about sexual pain. Sadness manifested as “unhappiness,” “hopelessness,” “defeat,” and feeling “unfortunate.” For some participants, thinking about sexual pain was a trigger for sexually traumatic experiences that they experienced. Sexual pain occurring during consensual sex often made them think back to a time when they were sexually assaulted. For instance, one participant said “sadness and regret – I often think about my abuser.” Sixteen participants reported feelings of anxiety when thinking about sexual pain. These participants used words such as “anxiousness,” “distressed,” and “scared.” Participants also reported concerns about their sexual pain indicating a sexual health issue. For example, one participant said “worried that it might be something serious.” All anxiety emotions were categorized as feeling states except for “vulnerable,” which was coded as a cognitive appraisal. Some participants discussed emotions about sexual pain using physiological descriptions ( n = 9), except for “limited” which was interpreted as a cognitive appraisal informed by the limitations sexual pain put on one participant. Participants used words such as “exhausted” or “discomfort.” One participant elaborated on her discomfort sharing “it’s like angles or certain touch that causes pain or tenseness inside” and “inability to relax from penetration.” Another participant described the circumstances that made penetration painful: “It definitely depends on my partner and their girth and length.”

Despite research suggesting Black women are likely to minimize their emotions, our results show that Black women are willing to disclose emotions connected with thoughts of sexual pain. Without integrating a thorough inquiry and examination from professionals that considers Black women’s sociocultural context, this group’s negative emotional experiences with sexual pain will remain highly prevalent. Conversely, acknowledging Black women’s negative emotions may reduce their frequency and intensity and lead to improvements in Black women’s sexual functioning and wellness.

Findings supported our hypothesis, which predicted that Black women would report unpleasant emotions when thinking about sexual pain. Feelings of self-judgment (e.g., embarrassment, shame, guilt) were most reported by women, followed by anger, sadness, and anxiety. These emotions, particularly self-judgment, are consistent with findings from research with and without Black women included in study samples ( Elmerstig, Wijma, and Berterö 2008 ; Maillé et al. 2015 ). Often Black women receive cultural messaging of silence and stigma around their sexuality ( Crooks et al. 2019 ). These cultural messages have roots in politics of silence – a political strategy among Black women emerging during the late nineteenth century to counter negative stereotypes about Black female sexuality (e.g., immoral, impure, hypersexual; Hammonds 1996 ). Not only does society continue to view Black women’s sexuality through the lense of sexual stereotypes, but because of politics of silence, some Black women may hesitate to define their sexuality for themselves or express their sexual needs ( Hammonds 1996 ). This may explain why our participants experienced negative emotions when asked to think about sexual pain and outwardly report how it made them feel. Black women may also contend with cultural messages that they should persist through pain or not experience pain at all ( Rose 2004 ). For these participants, an inability to endure pain during sex might have indicated that they were not fulfilling one of their roles as Black women ( Rose 2004 ), resulting in distressing emotions. Results obtained in studies excluding Black women have found that women may strive toward being their impression of an ideal woman during sex, which may include meeting their partner’s sexual needs or being sexually satisfying ( Elmerstig, Wijma, and Berterö 2008 ). However, whether these findings are based on gendered or gendered racial expectations is unclear. A closer examination of women’s reasons behind experiencing these emotions may yield more insight into possible racial/ethnic differences in women’s emotion reports. Black women may endorse the belief that they should not ask for help. This belief stems from the Strong Black Woman stereotype ( Beauboeuf-Lafontant 2007 ) and Superwoman Schema ( Woods-Giscombé 2010 ) and may inform participants’ reports of hopelessness, lack of fairness, and a longing for painless sex. The Strong Black Woman stereotype and the Superwoman Schema have roots in Black women’s enslavement in the U.S. and promote the idea that Black women should overcome challenges without assistance from others and with limited resources ( Woods-Giscombé 2010 ). Within the context of sex, the manifestation of these stereotypic roles could look like Black women’s discomfort or an unwillingness to communicate about their sexual pain due to shame, guilt, or anger ( Dogan et al. 2022 ). Alternatively, it is possible Black women are doing everything they can to feel pleasure during sex, but instead encounter barriers that cause painful sex such as poor partner communication, a sexual or reproductive health diagnosis, or lack of awareness to coping resources (e.g., using lubricant or building arousal). Providing this counter explanation is important considering not all Black women endorse components of the Strong Black Woman stereotype or Superwoman Schema. Women’s reports of anxiety were consistent with literature linking sexual pain and anxiety ( Basson and Gilks 2018 ). There are a few possible explanations for why participants reported anxiety emotions when thinking about sexual pain. Sexual anxiety may be one of the few or only emotions some Black women experience when thinking about sex if they have a history of mostly sexually painful experiences ( Rosenbaum 2013 ). Of note, over half of our sample reported a history of sexual abuseor trauma. For these women, sex may be anxiety-provoking and painful. Second, thinking about sexual pain could have caused women to ruminate on various factors associated with their pain, such as its intensity and duration. Sexual pain is likely distressing to think about; thus, influencing participants’ anxiety reports. It is also possible that Black women are unsure how to navigate sexual pain because they have not identified coping skills. A lack of proactive coping skills for sexual pain may influence women’s perceived ability to manage their pain and result in anxiety. Alternatively, women may have coping skills but not use them effectively (i.e., passive coping; Malone et al. 2021 ). Notably, none of the results reflected positive emotional responses such as self-compassion or care. Some Black women’s sociocultural orientation toward pain may complicate their ability to be sensitive to their discomfort - particularly if they are socialized to demonstrate strength and suppress their emotions ( Woods-Giscombé 2010 ). Encouraging self-compassion when thinking about sexual pain could be a useful step in resolving Black women’s negative emotions. We determined the frequency of emotion components present in participants’ reports based on Plutchik’s (2001) assertion that emotions consist of a group of phenomena occurring through a cognitive process. Women’s reports were primarily feeling states, followed by cognitive appraisals and physiological changes. Additionally, few women reported more than one emotional component in their responses. The connection between race and emotion may elucidate this finding. Smith and colleagues (2009) described racialized emotions as socially informed emotions that emerge when people think about racialized interactions with others, objects, or an experience. Sexual pain is an experience possibly invoking racialized emotion among our participants. Black women experiencing sexual pain may navigate environments that minimize or erase their emotions ( Dogan et al. 2022 ; Thorpe et al. 2022 ). This speaks to what Bonilla-Silva (2019 , 6) called the racialized “hierarchical ‘structure of feelings,’” which assumes that society values the emotions (as an experience featuring feeling states, cognitive appraisals, and physiological changes) of those with social privilege and devalues the emotions of the marginalized. It could be that naming emotion via a feeling state was most accessible to our participants because they experience a disconnect from the totality of their emotions (i.e., as a mind-body process) due to how society invalidates their emotions. Physiological changes were the least common emotion component present in the results. Interestingly, except for indifference emotions or lack thereof, emotions felt somatically were the least common emotion reported by participants. For these women, descriptors within the physiological component of emotion (e.g., “tense”) were synonymous with their physical response to sexual pain. Research shows that emotions resonate in the mind and body ( Oosterwijk et al. 2012 ). Some individuals can better identify emotions in their bodies but may not believe these somatic experiences relate to emotion as a group of phenomena (e.g., having a bodily experience but reporting no emotion). Some women in our sample may not have had access to emotion words (i.e., feeling state component of emotion) to label how thinkning about sexual pain made them feel. Their lack of access could be informed by psychological conditions like a lack of awareness or insight, desensitization, and avoidance behavior ( Thomtén and Linton 2013 ). This study used a convenience sample of predominantly middle-class Black women living in the South. Findings may not be generalizable to Black women who have a lower socioeconomic status or reside in other US regions. Most participants were heterosexual, had male partners, and primarily referenced penile-vaginal sex. Sexual pain may be experienced during other forms of sex that were not wholly addressed. These data did not allow for the nuanced investigation of sexual pain based on factors such as origin, duration, diagnosis, treatment, or medication use. Future studies on Black women’s sexual pain and emotions may control for these factors. Fourth, the examples of emotions in the open-ended question could have influenced participants’ responses. Our results may present a concern related to construct validity. It is unclear whether these results were the emotions participants experienced during painful sexual encounters. Future qualitative studies may employ a narrative approach to explore Black women’s emotions when asked to recall a sexually painful experience. Through narrative inquiry, researchers can elicit rich narratives from Black women about their sexual pain that can be interpreted inductively to understand Black women’s emotional sense-making process better. Last, since we did not conduct member checking, participants did not directly confirm these results or address any questions we had about their responses. Future qualitative inquiry on Black women’s sexual pain should incorporate member checking to enhance data trustworthiness and validity ( Birt et al. 2016 ). Results have implications for health providers and therapists serving Black women. Improving Black womens interactions with professionals treating their sexual pain and associated conerns like negative emotions begins with removing oppressive values and practices from healthcare environments and training. Black women should enter healthcare spaces and feel heard and held. An anti-oppression stance should also be valued among providers and therapists. Professionals are responsible for addressing their biases and stereotypes toward Black women to ensure they create an environment for Black women’s symptom reporting and effective communication ( Thorpe et al. 2022 ). Strikingly, less than 4 percent of our sample reported a medically diagnosed sexual pain disorder, yet all participants reported experiencing sexual pain during their lifetime. Health providers and therapists should recognize that Black women have a variety of emotions related to their pain and may use different terms to describe symptoms ( Brown et al. 2015 ). This reiterates the importance of asking Black women about their sexual pain. Therapists’ use of client-centered therapeutic interventions informed by Black women’s sociocultural context may help normalize and reduce some of the negative emotions that Black women feel when thinking about sexual pain ( Hargons, Malone, and Montique 2022 ). A therapist’s empathy toward these emotions could facilitate rapport and encourage help-seeking. Moreover, a therapist’s empathy may encourage Black women to have care and compassion toward their pain. Last, research shows that Black women have rich sexual pleasure maps ( Thorpe et al. 2021a ) and definitions for pleasure ( Thorpe et al. 2021b ). Promoting sexual pleasure to Black women while also addressing their sexual pain could shift traditional approaches taken with this population from deficit-based to sex-positive ( Thorpe et al. 2021b ).

In addition to amplifying pleasure, desire, and agency, ensuring women’s sexual wellness requires discussing barriers to good sex like sexual pain. Three out of every four women experience unwanted genital pain during sexual intercourse over their lifetime ( American College of Obstetricians and Gynecologists 2017 ). Sexual pain can negatively impact women’s sexual wellness, physical and mental health, and interpersonal relationships ( Rancourt et al. 2016 ). These outcomes are important to healthcare providers and therapists who may assist women in navigating emotions that arise when thinking about sexual pain and related outcomes. There are varying definitions of sexual pain ranging from unwanted and recurring genital pain during sexual intercourse ( Townes et al. 2019 ) to sexual pain conditions like Genito-Pelvic Pain/Penetration Disorder (GPPPD) ( Brauer et al. 2014 ). In this study, sexual pain referred to unwanted and recurring genital pain, including penetrative and vulvar pain, during sexual intercourse. This definition is not limited to a sexual pain diagnosis since many Black women may forgo symptom reporting or go undiagnosed ( Townes et al. 2019 ). Apart from recent work by Black sexuality scholars ( Dogan et al. 2022 ; Malone et al. 2021 ; Thorpe et al. 2022 ; Townes et al. 2019 ), little research exists about Black women’s sexual pain. Extant sexual pain research typically uses mixed-race samples and fails to highlight potential nuanced differences in how pain may be interpreted based on racial/ethnic identity. Moreover, few studies focus on Black women’s emotional experiences with sexual pain. For example, Malone et al. (2021) provided helpful insight into Black women’s emotional reactions to sexual pain and how they cope. Yet, their study only provided a quantitative measure of emotional response rather than a context for the types of emotions Black women may contend with when they have sexual pain. Investigating the emotional states Black women report when thinking about sexual pain within their sociocultural context matters, considering their context differs from that of White and non-Black women of Color. This study provides data that will give insight into Black women’s emotional states connected to sexual pain. The sociocultural contexts in which Black women’s emotions are situated may impact them and others’ perceptions of them ( Hargons, Malone, and Montique 2022 ). When Black women endorse gendered racial stereotypes and schemas (e.g., Strong Black Woman or Superwoman Schema), they may persist through adverse experiences like sexual pain to appear strong, suppress their emotions, and put their partners’ needs before their own ( Beauboeuf-Lafontant 2007 ; Collins 2002 ; Woods-Giscombé 2010 ). In a sexual context, these roles may manifest as refraining from sharing sexual pain and emotions with partners in an effort not to appear sensitive, ruin the experience, or decrease a partner’s pleasure. Indeed, ample research shows that Black women are often perceived as too emotional by others, like partners and providers ( Dogan et al. 2022 ; Thorpe et al. 2022 ), who may view them through gendered racial stereotypes or roles; thus, preventing them from considering Black women’s reports of pain or taking their emotions seriously. This reiterates the importance of this study, which is the first to the authors’ knowledge to explore the types of emotions Black women report when thinking about sexual pain. Emotions are complex and best captured by a “group of phenomena” rather than a single element ( Plutchik 2001 , 344). Plutchik’s circumplex model advanced previous work by scholars studying the nature of emotions. Plutchik (2001 , 345) describes emotions as “feeling states” informed by human cognition and action. Communication is informed by a feedback process beginning with a stimulus like sexual pain. First, an event happens from which humans receive sensory input. Next is a cognitive, evaluative process during which humans interpret painful experiences based on their memory and social context. Intersectionality provides an understanding of how systems of oppression inform the previously mentioned stereotypes and roles Black women may encounter when dealing with sexual pain. The interpretive process of pain features feeling states, cognitive appraisal, physiological changes, and action-impulses (i.e., group of phenomena) that may or may not lead to behaviors informed by Black women’s social context ( Plutchik 2001 ), like telling one’s partner that they are experiencing pain. This study aims to determine how these emotional phenomena, described as emotion components, emerge in Black women’s reports of sexual pain. Women’s emotions are grouped into larger categories, or families of emotions. Outside of the context of consensual pain (i.e., sadomasochism) or kink, it may seem evident that painful sex adversely impacts emotions. We hypothesized that Black women report distressing emotions when thinking about emergent feelings. In doing so, this study provides a necessary assertion to existing sexual pain literature that humanizes Black women.