Genito-Pelvic Pain/Penetration Disorder · Clinical Exercise

Already Dismissed Four Times

When a client with this presentation arrives, they have most likely already been dismissed, told the pain is in their head, or advised to use more lubricant and relax. That is the starting condition, and it changes what the first session is for.

What this exercise practises

Sorting by subtype in order to decide who else needs to be involved and how soon, choosing the one opening that does not repeat what the client has already been told four times, and holding the boundary in a presentation where you are the first clinician to take her seriously.

All four options in the first-session question are things a thoughtful clinician would say. One of them is accurate, and the other three are versions of what she has already heard.

Estimated time to complete this exercise: 25 minutes

1Four subtypes
2You are the fifth
3The boundary
4Close

Before you begin

How this one works

When a client with this presentation arrives in your office, they have most likely already been dismissed, told the pain is in their head, or advised to use more lubricant and relax. That is the starting condition, and it changes what the first session is for.
Part 1 sorts six presentations by subtype, because the subtype determines which other professional needs to be involved and how soon.
Part 2 is the first session. All four options are things a reasonable clinician would say, and one of them is the only one that does not repeat what she has already been told.
Part 3 is the boundary. Three of the eight items are outside scope or actively harmful, and one of them will feel like the thing she has been waiting three years for.
Nothing is graded and nothing is recorded. Reloading starts it again.

This presentation is not primarily psychological. Framing it as such repeats the history of dismissal the client has already experienced, and it is the single most consequential error available in this domain.

References

  1. Bornstein, J., Goldstein, A. T., Stockdale, C. K., Bergeron, S., Pukall, C., Zolnoun, D., & Coady, D. (2016). 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstetrics & Gynecology, 127(4), 745–751. https://doi.org/10.1097/AOG.0000000000001359
  2. Harlow, B. L., Kunitz, C. G., Nguyen, R. H., Rydell, S. A., Turner, R. M., & MacLehose, R. F. (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: Population-based estimates from 2 geographic regions. American Journal of Obstetrics and Gynecology, 210(1), 40.e1–40.e8. https://doi.org/10.1016/j.ajog.2013.09.033
  3. Morin, M., Carroll, M. S., & Bergeron, S. (2017). Systematic review of the effectiveness of physical therapy modalities in women with provoked vestibulodynia. Sexual Medicine Reviews, 5(3), 295–322. https://doi.org/10.1016/j.sxmr.2017.02.003
  4. Nguyen, R. H., Mathur, C., Wynings, E. M., Williams, D. A., & Harlow, B. L. (2015). Remission of vulvar pain among women with primary vulvodynia. Journal of Lower Genital Tract Disease, 19(1), 62–67. https://doi.org/10.1097/LGT.0000000000000041
  5. Portman, D. J., & Gass, M. L. S. (2014). Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy. Menopause, 21(10), 1063–1068. https://doi.org/10.1097/GME.0000000000000329
  6. Pukall, C. F., Goldstein, A. T., Bergeron, S., Foster, D., Stein, A., Khera, M., & Bachmann, G. (2016). Vulvodynia: Definition, prevalence, impact, and pathophysiological factors. Journal of Sexual Medicine, 13(3), 291–304. https://doi.org/10.1016/j.jsxm.2016.01.021