The third publication of the Journal of Sexual Medicine’s methodology update series will be Dr. Natalie Rosen’s “Recommendations for the Study of Vulvar Pain in Women, Part 1: Review of Assessment Tools," which was published in JSM’s February 2020 issue.

The second part of her methodology update, “Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges,” will be published in another JSM issue this year (https://doi.org/10.1016/j.jsxm.2019.12.018).

Natalie O. Rosen, PhD, is an Associate Professor in the Department of Psychology and Neuroscience and Department of Obstetrics and Gynaecology at Dalhousie University in Nova Scotia, with a research focus on sexual dysfunction, desire and pain.

To get a more in-depth understanding of the thoughts behind her paper, we conducted a text interview with Dr. Rosen:

1. How do we best define sexual and genital pain in women?

“In our paper we focus on chronic vulvar pain, as defined by the 2015 Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. The terminology differentiates between: (1) vulvar pain caused by a specific disorder including infectious, inflammatory, neoplastic, neurologic, trauma, iatrogenic, or hormonal deficiencies, and, (2) vulvodynia, defined as vulvar pain lasting at least three months and without a clear identifiable cause. Sexual pain may be defined as pain that occurs during sexual activities, including but not exclusive to vaginal intercourse.”

2. What are the challenges when performing research on genital pain in women?

“A key research challenge involves the inconsistent use of measurement tools across studies, making comparisons difficult.  Additional challenges to the field include selection and sample biases, heterogeneity of vulvar pain, (lack of) inclusion of the partner, and neglect of the multidimensional aspects of vulvar pain.”

3. What endpoints should we choose in research?

“Endpoints should acknowledge the multidimensional nature of this condition. Multiple self-report measures of the pain itself (e.g., intensity, unpleasantness) as well as important associated impairments (e.g., sexuality, mood, relationship satisfaction) should be considered.  When feasible and consistent with study goals, pain assessed in “real-time” such as during a cotton-swab test or using a vulvalgesiometer will reduce recall bias and should be used in conjunction with self-report measures.”

4. What endpoints should we choose in the clinical setting?

“Endpoints in a clinical setting may be more restricted by the need for brevity. However, the goal should still be for the endpoints to tap into the multidimensional aspects of vulvar pain. Numerical ratings scales for self-reporting pain during intercourse, pain unpleasantness, and pain during a cotton-swab test may be especially useful for this purpose. Clinicians should select other validated endpoints based on their study goals but ensuring that they capture the core impairments associated with vulvar pain, including sexuality, relationship and psychological function.”

5. What would you like for the future in the assessment of genital pain in women?

“Two of our key recommendations for moving the field forward include a more careful and detailed tracking and characterization of research samples and greater multidisciplinary collaboration to better capture the complexity of chronic vulvar pain.”

The fourth publication of the Journal of Sexual Medicine’s methodology update series will be Dr. William Fisher’s “Reading Pornography: Methodological Considerations in Evaluating Pornography Research," which was published in JSM’s February 2020 issue.

William Fisher, PhD, is a Distinguished Professor in the Department of Psychology and the Department of Obstetrics and Gynaecology at the University of Western Ontario, with research focusing on various areas including the impact of pornography on behavior.

To get a more in-depth understanding of the thoughts behind their paper, we conducted a text interview with Dr. Fisher and his co-author, Taylor Kohut, PhD. These responses represent the combined input of Dr. Fisher and Dr. Kohut:

1. Do you believe pornography studies have been biased by some form of political standards?

“This seems clearly to be the case. The radical left and conservative right see only harms of pornography while sexual liberals tend to minimize the potential harms and point to benefits. More interesting, and far less discussed, is the causal bias that permeates research in this area. Regardless of their value system, researchers (and reporters) generally interpret observational evidence as implying a singular causal direction. It is almost always pornography use that is seen to ‘drive’ changes in an ‘outcome’ of interest, possible reverse causation is mentioned infrequently, and serious consideration of alternative plausible causal models is almost entirely absent. Political and personal values seem consistently to trump the careful scientific interpretation of evidence.”

2. What would be the optimal methodology approach to deal with the strong inconsistencies and controversial evidence that we see in pornography studies?

“Perfect studies are impossible, but a gold standard approach might involve transparent pre-registered adversarial collaborations (collaborations of researchers with competing perspectives and predictions) that seek to test a specific hypothesis across a range of methodologies (qualitative / quantitative) and designs (cross-sectional, longitudinal, and experimental), using standardized conceptual and operational definitions of the constructs of interest. Such efforts would also need to be followed by independent replications by non-invested labs. Should anyone wish to contribute to such a collaboration, please seek us out!”

3. Can you comment on future research targets within this field of research?

“At least one scholar is suggesting that porn is contributing to global warming. More seriously, there seems to be a growing acknowledgment of potential positive effects of pornography but the research foundation supporting such claims is even more limited than that supporting most asserted harms. We anticipate some growth in the area of ‘positive effects’, provided that the political climate does not make research in this direction even more difficult to pursue.”

4. What are the major challenges a young researcher may face in this specific area of research?

“As in more fields of scholarly endeavor than most realize, social and professional backlash can occur, regardless of what ‘side’ you're on. Potential stigma can be suffered by early career researchers looking for work in parent disciplines, again depending upon what ‘side’ you’re on.  Research challenges can include difficulty securing funding, yet again depending upon what ‘side’ you’re on, specific research design difficulties can be encountered (e.g. recruiting men with no experience with pornography) and ethical dilemmas must be considered (i.e., if pornography use is assumed to be pathogenic, how can we conduct carefully controlled laboratory research?). There is also the potential for internal challenges too, as when researchers’ personal values conflict with evidence.”

5. How far can we go in pornography studies, in terms of ethics or ethical implications?

“The ethical considerations in pornography research are no different than those in other scientific work with human subjects. Informed individuals who are capable of freely consenting to participation in studies that pose no clear direct and unacceptable harms are required in this and all other fields. Given the controversy concerning pornography related effects, researchers might be well advised to proceed cautiously.”

6. Is there solid evidence on the positive versus negative effects of pornography consumption?

“There are reliable ‘indications’ in both directions, but strong unambiguous evidence is lacking for most effects outside of pornography-induced general increases in sexual desire and arousal; anyone that tells you differently is selling something.”

7. How do you anticipate pornography science, sexual health and politics will articulate in the future?  

“Pornography research will continue elicit the concern, polarization, and engagement of those who are uncomfortable with sexuality and seek to control it, the concern, polarization, and engagement of those who are comfortable with sexuality and seek to liberate it, and the dedicated efforts of scientists who try their best to accumulate fair, convergent, and replicable findings in accord with established principles of empirical science, for public debate and consideration.”

8. Can you comment on the panorama regarding public funding of pornography studies?

“There is political oversight on public funding of research in all fields. In the contemporary setting, there seems to be a priority on research funding for work focused on potential harms of pornography.”