Introduction
The European Association of Urology defines chronic pelvic pain (CPP) as ‘chronic or persistent pain perceived in structures related to the pelvis of either men or women’; it notes that pain must be continuous or recurrent for at least three months, although a longer period of over six months may be more appropriate for cyclical pain (Engeler et al., Reference Engeler, Baranowski, Berghmans, Birch, Cottrell, Dinis-Oliveira, Dutschler, Flink, Hughes, Messelink, Parsons, Pinto, van Poelgeest, Tidman, Vyawahare, de C Williams, Abreu-Mendes, Husein and Ali2025). The ICD-11 has divided CPP into two types: chronic secondary pelvic pain, where there is an underlying pathology (World Health Organisation, 2019/2021, MG30.4), and chronic primary pelvic pain (World Health Organisation, 2019/2021, MG30.00), where there is no obvious underlying pathology. This paper will not differentiate the two types of CPP; many women experience substantial delay in diagnosis of underlying pathology, therefore it is difficult to clearly differentiate between the two types while an individual is awaiting or undergoing further investigation (Cheong and Stones, Reference Cheong and Stones2006).
This paper focuses primarily on women’s CPP; there are several reasons for this, not least of which is that although anyone can be affected, it occurs most frequently in women; in the UK the 3-month prevalence for 12- to –75-year-old women is reported at 24% (Latthe et al., Reference Latthe, Latthe, Say, Gülmezoglu and Khan2006). There are also substantial sociological differences in the assumptions and expectations around men and women’s experience of and communication of both pain, and issues relating to gynaecological, urological, and gastrointestinal problems (Samulowitz et al., Reference Samulowitz, Gremyr, Eriksson and Hensing2018). Gendered terminology is used throughout to ensure that the specific difficulties encountered by women are highlighted; however, it is important to remember that not everyone assigned female at birth will identify as a woman or use the pronouns she/her. There are likely to be specific difficulties and needs encountered by trans and non-binary people assigned female at birth who experience chronic pelvic pain, and therefore this piece of research is likely to be most relevant to cisgender women, although the implications for trans and non-binary people will also be discussed.
Pain experiences are complex in nature, and our pain perception involves not only the signalling of tissue damage through the peripheral nerves to the central nervous system, but also our emotions, beliefs and interpretations of that pain. This is why the International Association for the Study of Pain (IASP) define pain as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ (Raja et al., Reference Raja, Carr, Cohen, Finnerup, Flor, Gibson, Keefe, Mogil, Ringkamp, Sluka, Song, Stevens, Sullivan, Tutelman, Ushida and Vader2020). Pain, therefore, is affected by a person’s beliefs, emotions, behaviours, social systems, and personal history (Keefe et al., Reference Keefe, Rumble, Scipio, Giordano and Perri2004), and as such there is often a bi-directional relationship between pain and mental health. For example, pain can cause fear of bodily harm, and fear, anxiety and attention can all increase pain perception (Chayadi and McConnell, Reference Chayadi and McConnell2019; Crombez et al., Reference Crombez, Eccleston, Baeyens, Van Houdenhove and Van Den Broeck1999). Chronic pain is even more complex, with a lengthy list of specific processes which can contribute to its generation and maintenance. One such process that demonstrates the complexity of the systems involved within chronic pain is central sensitisation, where neurons in the central nervous system have increased responsiveness to their afferent input, producing allodynia (the experience of pain from stimuli that are not normally painful), and hyperalgesia (increased sensitivity to painful stimuli) (Latremoliere and Woolf, Reference Latremoliere and Woolf2009). The phenomenon of central sensitisation is just one complicating factor which highlights why traditional methods of acute pain management are not normally effective with chronic pain syndromes; the problem is not necessarily in the presence of pathology or noxious stimuli, but is instead to do with how our perceptions, our central nervous system, and our physical bodies interact. CPP is, then, a complex condition involving both physiological and psychological processes, as well as functional processes that do not fit neatly into dualistic separations of the mind and body. CPP should, therefore, be treated with a holistic, multi-disciplinary approach that ignores neither the biomechanical, psychological, or functional aspects of the condition.
Due to the prevalence of CPP, whether a CBT therapist (henceforth referred to as therapist) is involved in the treatment of CPP directly or not, therapists will encounter women experiencing CPP in their clinical practice. There are three key reasons why CPP is relevant in CBT. Firstly, CPP has a significant impact on women’s mental health (Facchin et al., Reference Facchin, Barbara, Saita, Mosconi, Roberto, Fedele and Vercellini2015; Meltzer-Brody and Leserman, Reference Meltzer-Brody and Leserman2011) and psychiatric co-morbidity is common (Ahangari, Reference Ahangari2014; Siqueira-Campos et al., Reference Siqueira-Campos, Da Luz, de Deus, Martinez and Conde2019). Not only does chronic pain typically increase depression (e.g. it makes it harder to engage in activities which were once a source of enjoyment, and makes valued activities less enjoyable) (Till et al., Reference Till, As-Sanie and Schrepf2019), but women with CPP also report that it affects their sense of self, which can have drastic consequences for self-esteem. Secondly, psychiatric co-morbidity can worsen and make it more difficult to manage chronic pain; for example, low mood and lack of motivation from depression may prevent engagement in physical activity, which can improve symptoms and quality of life for women with CPP (Nikolis et al., Reference Nikolis, Adams, Westbay, Fitzgerald and Bennis2024), or, more directly, through lack of sleep which is a feature of many, if not most, mental health problems, and which can amplify pain perception (Till et al., Reference Till, As-Sanie and Schrepf2019). Finally, the existence of CPP in patients that are being treated with CBT can necessitate adaptations in treatment to ensure that they can make the most of CBT. As such, it is extremely relevant to CBT practice, with CBT being the psychological treatment approach recommended by the National Institute of Health and Care Excellence for most common mental health issues (National Institute of Health and Care Excellence, 2005; National Institute of Health and Care Excellence, 2013; National Institute of Health and Care Excellence, 2020; National Institute of Health and Care Excellence, 2022), whether the focus of treatment is explicitly on CPP or not.
Psychological interventions have been developed in response to findings in pain research, and CBT interventions focusing either directly on chronic pain or on associated mood and anxiety disorders have been found to be effective in supporting pain management and improving quality of life (Ólason et al., Reference Ólason, Andrason, Jónsdóttir, Kristbergsdóttir and Jensen2018; Williams et al., Reference Williams, Fisher, Hearn and Eccleston2020). In the UK, the NHS Talking Therapies service has in recent years placed increased emphasis on CBT therapists’ ability to provide treatment for people with co-morbid physical and mental health problems, with top-up training being rolled out to therapists working in these services (Mental Health Task Force, 2016). The training curriculum, however, addresses neither CPP directly, nor the mediating impact of gender on how LTCs affect mental health (NHS Talking Therapies, 2023). This study aims to investigate CBT therapists’ experiences working with CPP, and how their perceptions regarding women’s healthFootnote 1 may influence their treatment approach.
Perception of women’s pain can have significant implications for pain management. Women’s pain is often dismissed and minimised, as Zhang et al. (Reference Zhang, Losin, Ashar, Koban and Wager2021) found in their study of clinicians’ perceptions of gender and pain, which showed that women’s pain is often underestimated, while men’s is over-estimated – likely relating to stereotypes of men as stoic and women as sensitive. This can have serious treatment consequences for women’s healthcare; for example, women experiencing acute pain – especially Black women (Badreldin et al., Reference Badreldin, Grobman and Yee2019) – are less likely to be prescribed analgesic medication and have longer wait times before analgesia administration (Chen et al., Reference Chen, Shofer, Dean, Hollander, Baxt, Robey, Sease and Mills2008). These issues are endemic in the care of women with CPP, as shown, for example, by a study of general practitioners and gynaecologists’ attitudes towards women with endometriosis, an extremely common cause of CPP. They found that clinicians endorsed a discourse labelling such women as hysterical and difficult, and one in which women’s experiences of pain were questioned and viewed as less important than a clinician’s assessment of their pain (Young et al., Reference Young, Fisher and Kirkman2019). Women with CPP therefore experience great difficulty effectively communicating their pain (Drabble et al., Reference Drabble, Long, Alele and O’Cathain2021; McGowan et al., Reference McGowan, Luker, Creed and Chew-Graham2007; Pettersson and Berterö, Reference Pettersson and Berterö2020). Not being believed often also has significant psychological consequences, such as pain-related shame and self-blame for their symptoms (Brown et al., Reference Brown, James, Hunleth, Bradley, Farrar, Gupta, Lai, Lowder, Moldwin and Rodriguez2024; Pettersson and Berterö, Reference Pettersson and Berterö2020).
Method
Design
A qualitative methodology was used to investigate how differences in therapists’ perceptions regarding women’s health influence how they work with women’s CPP. I take perceptions to mean any interpretations, beliefs, or assumptions, which may be consciously or unconsciously held. In-depth, semi-structured interviews were used to gather rich data for thematic analysis (TA). The APA reporting standards for qualitative research (Levitt et al., Reference Levitt, Bamberg, Creswell, Frost, Josselson and Suárez-Orozco2018) and the APA handbook guide to TA (Braun and Clarke, Reference Braun and Clarke2012) were consulted throughout to ensure consistency and integrity in the research design and analysis.
A contextualist epistemology, which holds ‘that all knowledge is local, provisional, and situation dependent’ (Madill et al., Reference Madill, Jordan and Shirley2000) was employed. A contextualist standpoint recognises that both therapists’ perspectives and my perspective as a researcher are unavoidably subjective. In line with a contextualist standpoint, attention was paid throughout not only to the epistemic impact of participants’ backgrounds, but also to the impact of my own background and perspective.
Participants
Participants were recruited using purposive snowball sampling through my own clinical networks. Participants were located across the UK and not related to the university at which the research took place. I contacted prospective participants through email and WhatsApp and advertised on social media platforms including LinkedIn and X. Prior to recruitment, a period was set for interviews to take place in, with the aim of recruiting between 15 and 25 participants. These limits were created drawing on suggestions by Boddy (Reference Boddy2016), with consideration given to both the need for sufficient data for adequate theme development, and the requirement of a small enough sample for in-depth analysis to be conducted within a short time frame. Trainee therapists were excluded due to lack of sufficient relevant clinical experience. Qualified therapists with any level of familiarity with CPP were included, firstly to allow for a broader understanding of how therapists see working with women with CPP, and secondly because it became clear very early on in the interview process that level of training or expertise in LTCs did not correspond with level of understanding and confidence working with CPP. Some therapists with no formal training in LTCs were knowledgeable and confident in working with CPP, while other therapists with extensive training in LTCs expressed the converse. As expected, all therapists interviewed had worked with women experiencing CPP in some capacity – whether providing therapy for pain management, disability adjustment, or for a co-morbid mental health problem.
In total, 21 participants were interviewed for the study, with one non-binary/agender, five male, and 15 female participants of ages ranging from 30 to 71 years old (M=42.43, SD=11.40). All participants were trained and accredited CBT therapists. Participants’ job-roles and backgrounds were diverse, with participants working across NHS primary, secondary and tertiary care services, as well as private practice. Many participants occupied dual roles, either in multiple clinical areas, or with clinical and academic roles. Participants had also undertaken varying levels of training in working with LTCs, with some participants having had no training in the area, many having had some training, and others having specialised in CBT with LTCs; 57.14% of participants had supervisory responsibilities, and 42.86% had training responsibilities.
Materials and procedure
Participants were asked to provide their age, gender and consent prior to the interview via a survey created through Qualtrics (2024). To facilitate distance participation, interviews took place over, and were recorded with, Microsoft Teams. Interviews lasted for 25–53 minutes (M=38.48, SD=8.23). The interviews were semi-structured and split into four sections; in the first two sections I asked about the participants’ clinical background and their level of awareness of CPP. I then gave a definition of CPP and provided some examples of conditions that can cause CPP. Following information provision, I asked a range of questions about their experiences of working with women with CPP, and how they generally find out if a woman experiences CPP, including whether participants routinely ask female clients about their menstrual experiences, how relevant they think CPP is to therapy, and how they found CPP affects treatment. The interview schedule was arrived at through a process of reflection and refinement which remained ongoing throughout the first five interviews in order to develop questions which were most closely associated with the aims of the research, with questions ordered to facilitate a logical flow of conversation (Bearman, Reference Bearman2019). I also asked each participant if they had worked with any transFootnote 2 or non-binary people experiencing CPP, and if so, what their treatment experiences had been in these cases. Whether or not participants had worked with trans clients who had reported CPP, I asked participants whether they would ask such clients about their menstrual experiences, and what difficulties they could foresee in treatment with trans clients when discussing either CPP or menstrual health. I then concluded by asking if there was anything further the participant would like to add, and how they found the interview. Most questions were open-ended; where appropriate, closed questions were used and followed up with open-ended questions (for example, if a participant replied that they do not ask about menstrual health, a follow up question may have been ‘what prevents you from asking about this?’). This was to allow for targeted and concise questioning. The ordering and precise wording of questions varied. Each recording was reviewed soon after the interview and the sample questions (Appendix A in the Supplementary material) were refined based on this review; after the fifth interview, no further refinements were made. The overall interview schedule was not altered. A debrief statement was sent to each participant as a Word document following their interview. A short verbal summary of the debrief document was also given at the end of each interview.
Each interview was automatically transcribed on Microsoft Teams. The transcripts were then reviewed alongside the audio/video recording and corrected accordingly, with any potentially identifying data – including any names, locations, companies, or very specific events – being redacted. The interviews were transcribed orthographically, including false starts (denoted by a hyphen), fillers (such as mmm, uh, hmm), laughter (indicated by [laughter]), and any other sounds. Relevant visual cues such as nods were also indicated in square brackets. Once the transcripts had been corrected, the audio/visual recordings were permanently deleted.
Data analysis and reflexivity
As emphasised by Berger (Reference Berger2015), researcher characteristics and assumptions are not only impossible to eliminate from qualitative analysis, but can also be a valuable tool when the research process is carried out reflexively and data are analysed reflectively. Recognising the impact of my own background and experiences is, therefore, vital. My professional background is as a qualified and accredited CBT therapist, with social work as my core profession. I also have post-qualification training in CBT with LTCs and have clinical experience working in primary and secondary care NHS settings, and in private practice. In addition, I have lived experience of endometriosis.
Reflexive TA (Braun and Clarke, Reference Braun and Clarke2019), using a combined inductive and deductive approach, was chosen for analysis. My interviewing style was designed to aid a reflective stance, and therapists are already well positioned to reflect on how their practice is influenced by their perspectives and backgrounds due to the requirement of engaging in reflective clinical supervision (Kennerley et al., Reference Kennerley, Kirk and Westbrook2017), and the recognised benefits of self-practice/self-reflection (SP/SR) (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001). As a result, therapists were able contextualize their views and practices already; therefore, analysis at the inductive, semantic level was most appropriate. Reliance on individual reflection alone, however, presupposes an individual’s ability both to identify their own biases and belief systems and to communicate them, the barriers to which are substantial. Additionally, analysing the data through cognitive behavioural and feminist lenses allowed exploration of how therapists’ understandings were embedded in their personal and cultural contexts from an observer perspective that therapists themselves could not take, therefore some use of deductive analysis was also required (Braun and Clarke, Reference Braun and Clarke2012). A CBT lens was chosen firstly because this was likely to be closest to therapists’ own understanding of how their perspectives inform their practice, and secondly because it constitutes a clear model of how experiences lead to perceptions, and how these perceptions impact in-the-moment thoughts and behaviour. A feminist lens was chosen due to the wealth of feminist health psychology literature demonstrating the impact of gendered health inequalities on women’s healthcare.
My own knowledge and experience allowed me to interpret the data in a way which related it to CBT, feminist theory, and the impact of CPP. My understanding of the potential impacts of CPP on mental health and the therapeutic relationship also allowed me to identify fruitful areas of further questioning depending on what participants were reporting. I was also conscious, however, that it could influence the information I was collecting and the way in which I analysed it. During interviews, I attempted to manage this risk by following a semi-structured interview schedule, and by only discussing the motivations for the study during the debrief. I also kept a reflective journal (Ortlipp, Reference Ortlipp2008) throughout the interview and analysis process in order to develop my awareness of my own assumptions and how these were impacting my thoughts and responses to the data. During the interview process I used these reflections to inform subsequent interviews, and during the analysis process I used these reflections to help me identify areas in which my pre-existing assumptions were influencing which ideas I was paying attention to, and intentionally look out both for narratives that were consistent with my experiences and views, and for counter-narratives.
All transcripts were collated onto a Word document for ease of analysis. I drew on literature detailing mixed deductive and inductive styles of TA (e.g. Braun and Clarke, Reference Braun and Clarke2012; Carroll et al., Reference Carroll, Moss-Morris, Hulme and Hudson2021; Fereday and Muir-Cochrane, Reference Fereday and Muir-Cochrane2006) and followed Braun and Clarke’s (Reference Braun and Clarke2006) guidelines, taking into account that the six stages described (familiarisation, initial coding, generating themes, reviewing themes, defining and naming themes, and report writing) represent an iterative rather than a linear process. Firstly, I re-watched each recording and read the transcripts while taking annotations regarding insights that occurred. I then coded transcripts for discrete ideas which aligned with the research aims. This initial coding was primarily semantic, with ideas drawn directly from the data; however, where appropriate, I also used latent coding, such as for points that – drawing on broader context and my own understanding of CBT ideas and clinical settings – implied an underlying idea which was not directly captured in the semantic meaning. During the familiarisation and initial coding phases, I also refined the research question based on the responses from participants. Analysis was initially focused on the broad topic of what knowledge and experiences therapists have about CPP and how this affects therapy; eventually the focus became how therapists’ perceptions regarding women’s health influence their therapeutic work with female clients experiencing CPP. The development of the research question was a process grounded in my reflections on the data from the interviews, and as such it changed multiple times.
Following the initial, primarily inductive stages of coding, I reviewed and refined the codes, through first eliminating any codes not relevant to the research question and collating similar codes, then interpreting codes through CBT and feminist lenses. This was an iterative process, with both aspects of analysis influencing the other. I then used feminist theory and CBT ideas to group codes into themes, focusing, for example, on how societal norms and values shape both experience and belief, and thus influence therapist–client interactions. Next, I reviewed each theme, referring to the raw data to check their accuracy, and defined and named them, before finally weaving the themes together to form a coherent narrative about the data.
Results
I identified three broad themes, each with distinct subthemes, as shown in Fig. 1. The codes that formed each of the themes and subthemes can be found in Appendix B, and additional supporting quotes can be found in Appendix C (see Supplementary material).
Figure 1. Thematic map.
1. The gendered nature of CPP
1a. Gynaecological pain is unique
Participants had varying levels of understandings of CPP; however, among the first conditions that came to mind for all participants were gynaecological pain conditions such as endometriosis. Many also expressed surprise that conditions such as IBS and Crohn’s disease would cause CPP, even after being provided with the definition of CPP and example conditions:
‘I think there’s a point in case there isn’t that I wouldn’t necessarily associate, even though it makes perfect sense, you know, bladder issues, bowel issues, within that category. I tend to think when I’m thinking of pelvic pain, I’m thinking generally of of reproductive, menstrual health kind of issues.’ (Female, 38)
Which conditions were grouped together with gynaecological pain as being related to CPP varied among participants. Some, for example, pointed specifically to pain associated with sex, menstruation, or reproduction, whereas others grouped bladder conditions with gynaecological pain:
‘Not sure really. I guess when I think about pelvic pain. I would think more of like um the bladder kind of reproductive system rather than it being the bowels. I don’t know why that is. Like Crohn’s disease, colitis, more of the gut, bowel type of areas? I wouldn’t put under pelvic pain.’ (Female, 40)
Some participants pointed to stigma and medical misogyny which they perceived to be associated with gynaecological pain but not with other sources of CPP, and that this is why gynaecological pain seemed different:
‘This this the stigma of, I don’t know if, you’ve got pelvic, just assume it’s period pains and you know.’ (Female, 54)
Participants noted a sense of shame and a lack of understanding around women’s health issues, and that issues which affect women but don’t affect cisgender men are therefore likely to receive less attention and be taken less seriously:
‘I think that people get. I suppose. I don’t know if I’m gonna word this right, but get taken a bit more seriously when it’s a more of a- I know they’re both physical health problems, but I don’t know where a woman’s health in general, because that’s really specific to just women, isn’t it?’ (Female, 33)
1b. Women understand, men don’t
Both male and female participants reported an expectation that male therapists would be less able to understand the experiences of female clients with CPP, and therefore less able to empathise. Some participants suggested that the difference in reproductive systems would make it harder for male therapists to empathise with this client group:
‘I think women have a lot more empathy with it generally. Erm and because of probably experiences in themselves, so they might explore hormone- or the hormonal element more so’ (Female, 45)
Participants spoke of observing male therapists displaying discomfort when discussing and working with women’s health, including in supervision:
‘Not to make any generalizations, but I’m going to uh, it’s definitely something that our women therapists put on the table more than our male therapists, they’re quite often, got a couple of supervisees who were male that will quite often be um er- just thinking about the language they use. You know, like [gestured scare quotes] woman’s problems, that type of thing. So there’s less comfort having those conversations.’ (Female, 38)
Male participants spoke of a discomfort around discussing gendered painFootnote 3 such as menstrual pain or CPP, due to a worry that they wouldn’t understand:
‘Yeah, I think it’s- it does as man make me feel quite like, “God, I can’t even begin to work around this or think about this”.’ (Male, 35)
This led to a sense of caution when approaching such topics. Some participants spoke of an expectation that clients would feel less comfortable discussing CPP with male therapists, as well as an expectation that men in other healthcare professions may be more likely to be dismissive of women facing CPP; awareness of these expectations may therefore have contributed to the sense that men ought to be cautious when discussing these issues with female clients:
‘I was painfully aware, pardon the pun, that I wasn’t a woman, so I I don’t know what it’s like to have a cervix or or a uh- well and. [Interviewer: Mmm] And there’s a bunch of things I don’t know about the feeling of and there’s- so I had to be careful about questioning’ (Male, 71)
1c. It’s harder to discuss gendered pain with trans clients
Participants discussed how talking about CPP may be more difficult with trans clients, especially when pain is linked to gynaecology, such as with menstruation. Most participants had worked with trans clients, but had never discussed CPP with them. Few had discussed the impact of menstruation on these clients; those who had noted that both pelvic pain and menstruation had caused gender dysphoria-related distress. They also noted that not all their trans clients would feel comfortable discussing these issues due to concern about maintaining their gender identity:
‘There’s almost like an assumption that they can’t talk about those issues because it leans them more to like one side of the gender spectrum than the other at times as well.’ (Male, 35)
Discussion with participants who had not spoken to trans clients about CPP focused on whether and how to discuss menstruation. Only one participant reported that they currently ask trans clients about their menstrual experiences. Some participants mentioned that they associate menstruation with female-presenting people, and so would not consider the relevance of menstruation in male-presenting clients:
‘I probably would associate that very much as a woman’s issue, so I think I was working with someone who presented as a man. [Interviewer: Mmm] Erm like I’m really accepting of how people choose to present themselves. So I’d have to just remind myself that erm some of those issues would be relevant for this person.’ (Female, 40)
Participants noted that they would be less comfortable asking trans clients about CPP or menstrual experiences, due to an awareness that this could worsen gender dysphoria or could come across as misgendering the client. Some participants noted that responses to questions relating to menstruation may vary between people, and therefore it’s important to be sensitive to the needs and experiences of the individual:
‘When we’re stepping into the gender identity space, I would think about some people might be absolutely fine are answering that, and I think about some of my closest trans male friends where they wouldn’t, and they’d find it quite triggering if they were asked that and and almost along the lines of am I being misgendered.’ (Male, 37)
Some participants suggested that, although it may still be valuable to consider broaching topics typically related to women’s health, they would want to show caution in how this was approached, and they may wait longer to raise such topics with trans clients to better judge whether and how to do this:
‘Menstruation can sometimes be a source of that dysphoria. Um. So yeah, I would, yeah, just be a bit more thoughtful about how I would, yeah, bring it up with someone.’ (Agender/non-binary, 36)
2. The role of CBT
Participants demonstrated through the course of the interviews how their views on women’s health impact the role they see therapists having in relation to women’s CPP. Participants at times spoke of this explicitly, while at other times demonstrating this through the way they talked about their work with female clients experiencing CPP.
2a. The implicit assumption that CBT doesn’t deal with women’s health
Many participants discussed how their standard CBT assessments, whilst including questions around whether clients have any physical health conditions, whether they drink alcohol or use drugs, and what their living situations are like, do not include questions about clients’ menstrual experiences. They revealed that the reason for this was simple; it just hadn’t occurred to them as something that would be useful to ask:
‘I mean, without having that prompt, it wasn’t something that I was really thinking about as an area that needed to be explored.’ (Female, 34)
Those participants who reported that they do, either always or sometimes, ask about menstrual health reported that it is generally well received and can lead to clients reporting CPP that they wouldn’t otherwise have been likely to report. Participants often reported that they think that this question would be valuable and reported an intention to integrate this into future assessments with female clients:
‘It’s not that I- I I would probably now having done this interview [laughter], so it just hasn’t been on my radar.’ (Female, 40)
Some participants explicitly pointed to the training curriculum for CBT therapists to explain this, and participants consistently discussed the lack of integration of women’s health issues in CBT training and the NHS Talking Therapies LTC top-up training. Many participants discussed how this had meant that they felt at a loss on how to work with women experiencing CPP and they lacked confidence with this client group as a result:
‘I would think it’s probably because it’s not something that is, so when they’re accessing that first part of their training, I don’t feel like woman’s health reproductive health generally is on the curriculum. So I don’t think it’s something that they would be familiar with asking and assessing around and so that that would be my idea as to why perhaps it’s not standard built into any kind of semi structured interview type assessment.’ (Female, 38)
One participant suggested that the lack of integration of women’s health in the CBT training curriculum sends an implicit message that women’s health has no place in CBT, and that by extension, an ostensibly female-coded problem such as CPP is not within a CBT therapists’ remit:
‘Also, there’s something here within maybe the implicit messaging of our training curriculums that does that, topics like that don’t fit within CBT or they’re outside of the realms of CBT.’ (Male, 38)
2b. Working with CPP is like working with any other LTC
Some participants reported that the way that they would work with women with CPP would be no different to any other LTC; they would discuss it within therapy if the client indicated that this was to be the focus of therapy, and they would discuss menstrual cycles, and any pain related to them only if and when the client brought this up themselves:
‘Usually I don’t approach it at at assessment unless it seems relevant and we are talking about that sort of health condition.’ (Female, 48)
Whilst many participants felt that the standard LTC training did not sufficiently equip them for working with CPP, some participants noted that the training was still applicable to many of the aspects of CPP, especially training in working with chronic pain:
‘I think that does help with thinking about where you can go with clients with chronic pelvic pain, but mm they they do it again. It’s more chronic pain rather than chronic pelvic pain, but I do think it all applies.’ (Female, 30)
Participants also noted that they would draw on treatment styles and interventions typically recommended for working with LTCs, such as attention focused interventions or an acceptance and commitment therapy approach:
‘I don’t think now I I would work with them any differently. I think what I would do is draw on that the acceptance and commitment therapy or even sort of compassion focused therapy.’ (Female, 40)
2c. CPP should be integrated into treatment
Many participants talked about how they integrate CPP into treatment, and the impact that this has for clients. They discussed how this is first relevant at assessment, as understanding the clients’ experiences of women’s health issues and the healthcare and social experiences surrounding these can be beneficial in formulating and treatment planning:
‘If you’re including all symptoms and nothing’s off the table, you can make sure you’ve got a- a more comprehensive formulation of the problem and it would be easier to map like if there was any relationship between mood and those symptoms or anxiety and those symptoms or traum-, you know, flashbacks, and those symptoms, whatever it is, and it would be important to incorporate and make sure you’re not missing anything in the formulation. So you can target your interventions better.’ (Female, 40)
Participants spoke of numerous ways in which experiences, behaviours, and beliefs around CPP would impact on a client’s mental health problem, and on treatment. They discussed how, for example, beliefs about healthcare professionals not listening to them and missing things can contribute to health hypervigilance and anxiety, therefore integrating experiences surrounding CPP into treatment can be vital to successful therapy. Several participants also noted the importance of pain during sex, and how this can have a significant impact on relationships and self-esteem:
‘So that impacts like how they feel towards sex, how they feel about their partner, how they feel just about everything in general related to that and also maybe blaming themselves as well for not being able to have like a fulfilling sex life and yeah and, as I said self-esteem just that image that they have of themselves as well.’ (Female, 33)
Participants reported that open discussion around women’s health issues can help in targeting interventions, such as with targeted psychoeducation on the role of hormones, and the role of pain. Several participants also discussed how awareness of the clients’ menstrual cycles may impact the type of interventions that would be appropriate on a given day:
‘So an example from practice not long ago was actually a client saying to me about how awful their pain was today, er, because of their periods and actually kind of where it was quite a useful thing that they mentioned just in passing was a conversation about, well, actually, bearing in mind you’re in this much pain is today the most apt day to do the reliving?’ (Male, 38)
3. Building relationships
3a. ‘I get it’: using lived experience
Throughout the interviews, participants referred to the use of lived experience in the development of a therapeutic relationship with clients with CPP. Participants who had experienced CPP themselves discussed how their own lived experience of this pain and its sequelae improved their ability to understand the client’s experience and to empathise with the client:
‘Of course it’s helping to be empathetic because I know what it’s like to live with it and I know what it’s like to navigate the NHS health system with it, so I’ve got that level of understanding.’ (Agender/non-binary, 36)
Some participants reported disclosing their lived experience in some cases, and that this can sometimes be useful to improve trust in clients whose trust has been eroded by past healthcare encounters where their pain was minimised or inappropriately normalised:
‘I think it it my lived experience- I have in some instances self-disclosed that -------- to certain individuals but only where I felt it was was helpful particularly if they’ve had lots of barriers and they’ve not felt understood.’ (Female, 38)
Some participants who had not experienced CPP still used their lived experiences to improve their understanding and their empathy, for example, drawing on lived experience of other forms of chronic pain:
‘… because I want to be pain free and that’s something I actually, I understand. I have constant pain now, but I’m an old man and that’s the way life is.’ (Male, 71)
Additionally, some participants talked about being conscious of their lack of lived experience of CPP and highlighted this as meaning that they were less able to empathise and less able to understand than therapists with lived experience of CPP. Participants who reported a lack of lived experience also discussed the use of self-disclosure, noting that stating outright their lack of personal experience but their intention to understand as best they could, was also beneficial in developing a trusting relationship, as it demonstrated self-awareness of their positioning:
‘I would try and understand what it’s like from their perspective, but I know stop. I I obviously wouldn’t have that lived experience, obviously, which isn’t obviously necessary all the time. But erm yeah, I would understand, but maybe only to a certain point.’ (Female, 33)
3b. Validating the pain
Many participants reported that female clients with CPP have often experienced medical misogyny and have had experiences where healthcare professionals have invalidated, minimised, or dismissed their experiences of pain. Participants emphasized the need to prioritise trust building, and that validation is a key method they use. Validation is a tool that is often used in therapy, and essentially involves communicating to the client in one form or another that their emotions are justified, important, and understandable. This can involve directly telling a client that it is understandable to feel as they do, providing psychoeducation that helps to contextualise their emotions, expressing empathy, or using other creative methods:
‘And I wonder if people who’ve maybe had, you know, like I know sometimes people with e-e-e-endometriosis for ins-, for example, can have quite difficult experiences with healthcare system or might have had experiences have not been believed, or having their symptoms minimized. So I think in that context it’s then quite hard to trust new professionals.’ (Female, 40)
Many participants discussed how they would verbally validate their clients’ experiences, emphasising that they believe the experience that the client is reporting. Participants also reported giving time for clients to talk through their experiences and feel listened to:
‘So just giving them that space to talk at all through and then empathizing and normalizing and validating their experience can really do a lot, I think to build that therapeutic relationship, you know, believing them, working with it is another thing that’s gonna really help.” (Agender/non-binary, 36)
In addition to verbal validation and validation through listening, some participants mentioned advocating for their clients within the physical healthcare system. This comprises a practical demonstration to clients that they are believed and taken seriously, showing them that there is someone on their side:
‘And so I would in the past, [sigh] I’ve certainly linked in with general practitioners, wrote to them, just to kind of express me concerns about that and the impact that is having on them.’ (Female, 38)
Discussion
Therapists’ perceptions of women’s health appear to influence therapeutic practice with women experiencing CPP. Theme 1 shows therapists having an assumption that CPP is an intrinsically feminine issue, with CPP equated more with gynaecological but less so with bladder or bowel problems. This assumption is not unique to CBT therapists and is a problem endemic in the literature surrounding CPP; many studies on CPP look only at gynaecological conditions, excluding causes of CPP related to the urinary or digestive organs; for example, McGowan et al. (Reference McGowan, Escott, Luker, Creed and Chew-Graham2010) in their study of GPs’ understanding of CPP only refer to gynaecological causes of pain, while Mellado et al. (Reference Mellado, Pilger, Poli-Neto, Rosa e Silva, Nogueira and Candido dos Reis2019) only include gynaecological causes of CPP in the search criteria for their systematic review of qualitative research in female pelvic pain. McGowan et al. (Reference McGowan, Escott, Luker, Creed and Chew-Graham2010) even explicitly refer to IBS as an experience similar to but distinct from CPP, despite CPP being part of the diagnostic criteria for IBS (Lacy and Patel, Reference Lacy and Patel2017).
It is interesting to consider why therapists may associate gynaecology so strongly with CPP. Perhaps bracketing off gynaecological pelvic pain from other forms of pelvic pain is explained by a recognition of the stigma that is associated with gynaecological and feminised pain. After all, experiences related to menstruation, reproduction, and female sexuality have a unique history laced with misogyny which has not yet left medical services (Merone et al., Reference Merone, Tsey, Russell and Nagle2021; Merone et al., Reference Merone, Tsey, Russell and Nagle2022). Women with and without CPP find navigating their environments and social situations with a feminine body challenging, embarrassing, and at times terrifying (Chrisler, Reference Chrisler2011; Jones, Reference Jones2016). Although other causes of CPP may in fact confer similar experiences of stigma for women experiencing them, bladder, bowel, and musculoskeletal problems may seem less intrinsically ‘feminine’ because they are not related to the female organs. This may then reflect a view of CPP as not just a problem that is more likely to affect women, but as an intrinsically female problem. Some negative repercussions of adopting this heuristic come when its use precludes the identification of gendered healthcare inequalities in trans people experiencing CPP, as shown in Theme 1c, or where this contributes to male therapists feeling uncomfortable discussing CPP, as shown in Theme 1b.
Theme 2 suggests that while core training and LTC training can provide some of the basic skills for working with CPP, therapists must make this training fit the presentation of women with CPP. Theme 2a demonstrates that unspoken perceptions regarding women’s health and its relationship to CBT can unintentionally impact therapy through a lack of focus or awareness of the relevance of women’s health in CBT. In other areas of healthcare there has been an increasing acknowledgement of the need not only to include sex and gender in the training curricula, but to embed it within the training (Miller et al., Reference Miller, Rice, Schiebinger, Jenkins, Werbinski, Núnez, Wood, Viggiano and Shuster2013). An approach which integrated sex and gender would highlight the impact of menstrual cycles, menopause, pregnancy, and childbirth on mental health in people of different genders throughout the curriculum. The importance of such an approach has been recently noted regarding cardiovascular disease, for which the absence of consideration of sex and gender in research and training contributes to symptoms being missed and misdiagnosed disproportionately in women (Adreak et al., Reference Adreak, Srivaratharajah, Mullen, Pike, Mackay, Comber and Abramson2021).
Throughout the interviews, the therapists I spoke to emphasised the impact that social and healthcare experiences related to CPP have, as shown in Theme 3. They spoke of clients whose experiences have been denied, minimised, and dis-believed, mirroring qualitative work that has been conducted on the narratives of CPP sufferers themselves. For example, Ghai et al. (Reference Ghai, Subramanian, Jan, Thakar and Doumouchtsis2021), identify poor communication from healthcare professionals and difficulties accessing support in their meta-synthesis of qualitative research, and Pettersson and Berterö (Reference Pettersson and Berterö2020), McGowan et al. (Reference McGowan, Luker, Creed and Chew-Graham2007), and Hawkey et al. (Reference Hawkey, Chalmers, Micheal, Diezel and Armour2022), all found themes of disbelief, difficulty being heard, and stigma around CPP contributing to the difficulties women have discussing their experiences. Theme 3 shows that therapists can respond to such experiences through helping to build a trusting therapeutic relationship through demonstrating belief in their symptoms and identified implicit and explicit validation (Theme 3b) and the use of lived experience (Theme 3a) as tools that can be used to build trust with women with CPP.
Study strengths and limitations
The nature of this study meant that it was most attractive to those with an existing interest in CPP. Although it is a strength of the study that – despite the heavily gendered topic – five of the 21 participants were male, due to the nature of my clinical networks which were used for recruitment, and most participants were known to have an interest in inclusive CBT practice, even if not in CPP per se. Those who were not recruited through my clinical networks were recruited through advertisement and, as such, self-selected based on their own interests. Many of the participants interviewed disclosed that they had lived experience of CPP, and many stated explicitly that this was why they were interested in the study. Although the aims of the study necessitated talking directly to therapists rather than to clients, it is important to note that no experts by experience were consulted, and that the findings from the study are limited to the therapist’s side of the therapy dynamic; therefore, the results should be interpreted in tandem with research on the experience of patients. Further research on the experiences of CBT clients with CPP may be beneficial.
Additionally, this study, as a qualitative piece of research, was not designed to be generalisable; whilst 21 participants is sufficient for the in-depth qualitative research conducted (Boddy, Reference Boddy2016), this sample is not sufficient to make generalisations across CBT therapists. Analysis was also restricted to only one person, and the data could be open to alternative interpretations. As such, the findings of this study should be used as a starting point for reflection regarding the many ways that CBT therapists’ own perceptions relating to women’s health can influence their therapeutic practice, and to develop an awareness around how CBT with women with CPP can be improved. The fact that the participants in this study were predominantly people with a particular interest in CPP or inclusive practice and yet unspoken perceptions regarding women’s health still impacted their practice demonstrates the importance of self-reflection around how beliefs about gender and about feminised bodies may impact clinical practice.
Additionally, although this research did not focus on trans people, work with trans clients was discussed. I felt that this was of great importance, given how often trans identities are erased from research, with small sample size or a need for refined research focus often being cited as the rationale for this. This approach may contribute to high quality individual pieces of research; however, it also contributes to a conspicuous gap in research (Reisner et al., Reference Reisner, Poteat, Keatley, Cabral, Mothopeng, Dunham, Holland, Max and Baral2016) that appears strikingly similar to the female-shaped hole in medical literature that is only now starting to be filled. Researchers should be working to plug such significant gaps in the literature; the difficulty of including sufficient sample sizes to draw definitive conclusions should not lead to us excluding trans issues from our research. That being said, it is important to be aware when considering how this research applies to trans clients, that most of the participants in this study spoke of having worked with only a small number of trans clients, and very few of the participants reported any discussions with their trans and non-binary clients around CPP. Therefore, the insights regarding working with trans clients should be taken tentatively. Given some of the concerns raised in this study regarding the difficulties of discussing feminized pain with clients who do not identify as female, further research is greatly needed in how to navigate this difficult area.
Conclusion
This study suggests that CBT core training and LTC training may lack integration of women’s health issues and that this may be impacting upon clinical practice, notably through a lack of consciousness regarding the relevance of menstrual health in therapy. This is so despite therapists feeling on reflection, that menstrual experiences are highly relevant to CBT. Therapists in this study reported their female clients who have CPP facing similar difficulties to those reported in qualitative research with patients, suggesting that therapists were sensitive to the difficulties faced by this client group. They also pointed to ways that CBT can be used to support female clients experiencing CPP and highlighted the importance of relationship and trust building with this client group. This suggests that improved training provision for CBT therapists could be beneficial, especially if extended not only to the integration of CPP into LTC or chronic pain training, but also the integration of women’s health into the core CBT training curriculum.
The findings of this study also suggest that therapists should be aware when working with women experiencing CPP that they may have difficulty building trust, and they may need to spend more time on developing that relationship than they usually would. This includes taking care not to inadvertently minimise pain experiences, as well as utilising validation techniques and drawing on lived experiences where appropriate. This may be especially important for male therapists, if the assumptions of the therapists interviewed are accurate in their assessment. Additionally, therapists may wish to integrate questions about menstrual health into assessment. The results indicate that therapists thought that asking about menstrual health is helpful, beneficial for formulation, and acceptable to clients; however, there was more uncertainty regarding the acceptability of male therapists asking these questions, and of asking these questions to trans clients. Further research investigating the impact and acceptability of questioning around menstrual health with a range of demographics would be beneficial.
Key practice points
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(1) CPP is a complex experience which often has a substantial impact on women’s mental health.
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(2) Therapists may benefit from reflecting on their own perceptions relating to women’s health and how these affect their practice with female and trans clients.
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(3) Therapists may wish to consider asking about clients’ menstrual experiences in assessment.
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(4) Relationship building is a crucial part of treatment with women with CPP; this client group may show distrust of healthcare professionals as a result of prior experiences.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1754470X25100342
Data availability statement
The data that support the findings of this study are available on request from the corresponding author, A.A. The data are not publicly available due to the sensitive and detailed nature of the study.
Acknowledgements
This project was completed as part of my MSc in Psychology at the University of Nottingham. A huge thank you is owed to my project supervisor Laura Blackie, whose support and guidance was massively valuable. Thank you also to the participants who contributed their time and experience, and who I could not have done this project without, and finally to my fiancé Tadhg Ó Laoghaire, who has been a fabulous sounding board and cheerleader throughout.
Author contributions
Amber Rae Alker: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Writing - original draft (lead), Writing - review & editing (lead).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The author declares none.
Ethical standards
Ethical approval was obtained from the School of Psychology Ethics Committee, University of Nottingham (S1614). All participants provided informed consent prior to participation and the ethical principle of psychologists and the BABCP code of conduct were followed throughout. No incentives were offered for participation in the study.
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