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Disordered eating and sexuality in women Dunkley, Cara R. 2015

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DISORDERED EATING AND SEXUALITY IN WOMEN by  Cara R. Dunkley  B.A., University of Victoria, 2009  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Psychology)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2015  © Cara R. Dunkley, 2015  	  ii	  Abstract Background: There has long been a proposed clinical link between sexuality and eating disorders; however, little empirical evidence exists regarding this relationship. The limited body of research on sexuality in eating disorders supports the occurrence of considerable sexual concerns. The aim of the present study was to expand on the dearth of empirical literature exploring altered sexuality in relation to disordered eating.  Study 1 examines disordered eating in relation to sexual function and sexual insecurities. Study 2 examines the association between eating disorder symptoms in relation to genital pain and sexual distress. Study 3 examines the mediational role of personality and mood on the relation between eating pathology and genital pain.  Methods: Undergraduate female UBC students completed a series of online questionnaires assessing eating habits, sexual functioning, sexual insecurities, personality, and mood. Two rounds of data collection were conducted, the first occurring from December of 2013 to April of 2014 (n = 321), the second between May of 2014 and April of 2015 (n = 854).  Results: Several domains of sexual dysfunction were associated with disordered eating symptom severity, particularly genital pain and sexual distress. Mean differences in eating disorder symptoms emerged in women with clinically significant genital pain compared to those without pain, such that women in the genital pain group reported more eating pathology. Mean differences in genital pain, sexual distress, and sexual insecurities emerged among women categorized as being at elevated, typical, or low eating disorder risk, with those at greater risk reporting greater sexual difficulties. Sexual insecurity variables, as well as personality and characteristics common to individuals with eating disorder pathology, mediated the association between disordered eating and genital pain.  	  iii	  Discussion: Sexuality is rarely considered in the context of eating disorder treatment unless a history of sexual abuse is present. The results of this study suggest that sexual functioning difficulties should be addressed during eating disorder care. Findings also indicate that women with eating disorders would benefit from treatments targeting sexual insecurities and personality gestures associated with eating pathology in addition to sexual function.                 	  iv	  Preface As the primary investigator of the current research, I formulated the original research idea and hypotheses, as well as designed the study and selected the measures used. I wrote the research proposal and submitted it to BREB for ethics approval, and completed various provisos requested by the ethics committee. In terms of data collection, I wrote the human subject pool system advertisement and trained a team of undergraduate research assistants to conduct debriefings for the online questionnaire. I was responsible for all data cleaning, statistical analysis, and results interpretation, as well as for writing all sections for the manuscripts compiling Studies 1, 2, and 3.  My primary supervisor, Dr. Lori Brotto, consulted with me on this project from its conception to completion. Dr. Brotto also advised on and provided substantive feedback throughout the statistical analysis and manuscript writing processes. Dr. Boris Gorzalka provided conceptual feedback during the initial phases of the research project, and reviewed the first draft of this research paper. Approval for carrying out these research studies was obtained by the UBC Behavioural Research Ethics Board (H13-02026).       	  v	  Table of Contents Abstract .......................................................................................................................................... ii	  Preface ........................................................................................................................................... iii	  Table of Contents ......................................................................................................................... iv	  List of Tables ............................................................................................................................... vii	  List of Figures ............................................................................................................................. viii	  List of Abbreviations ................................................................................................................... ix	  Study 1 ............................................................................................................................................ 1	  Introduction ................................................................................................................................. 1	  Methods ....................................................................................................................................... 7	  Participants .............................................................................................................................. 7	  Procedure ................................................................................................................................ 7	  Measures ................................................................................................................................. 8 Data Analysis ........................................................................................................................ 11 Results  ...................................................................................................................................... 12	  Discussion ................................................................................................................................. 18	  Study 2 .......................................................................................................................................... 24	  Introduction ............................................................................................................................... 24	  Methods ..................................................................................................................................... 28	  Participants ............................................................................................................................ 28	  Procedure .............................................................................................................................. 28	  Measures ............................................................................................................................... 28 Data Analysis ........................................................................................................................ 30 	  vi	  Results  ...................................................................................................................................... 31	  Discussion ................................................................................................................................. 36	  Study 3 .......................................................................................................................................... 40	  Introduction ............................................................................................................................... 40	  Methods ..................................................................................................................................... 47	  Participants ............................................................................................................................ 47	  Procedure .............................................................................................................................. 47	  Measures ............................................................................................................................... 48 Data Analysis ........................................................................................................................ 50 Results  ...................................................................................................................................... 50	  Discussion ................................................................................................................................. 54 General Discussion ...................................................................................................................... 58	  Tables ........................................................................................................................................... 68	  Figures .......................................................................................................................................... 82	  References .................................................................................................................................... 83	         	  vii	  List of Tables Table 1:  Means and standard deviations of disordered eating variables and genital pain variables in Study 1 and 2 samples.............................................................................71 Table 2:  Zero-order correlations between disordered eating variables and sexuality variables......................................................................................................................73  Table 3: Means and standard deviations of disordered eating variables and genital pain variables among women with clinically significant genital pain and little to no pain..............................................................................................................................76 Table 4: Means and standard deviations of sexuality variables among women with elevated, typical, and low eating disorder risk ..........................................................................73 Table 5:  Standardized canonical function coefficients and structure coefficients for Functions 1 and 2.........................................................................................................................78 Table 6:  Zero-order correlations between eating disorder variables and measures of genital pain and sexual distress among women with clinically significant genital pain........79 Table 7: Tukey	  HSD	  contrast	  coefficients	  for	  genital	  pain	  variables	  and	  sexual	  distress	  among	  elevated,	  typical,	  and	  low	  eating	  disorder	  risk	  groups....................................80 Table 8:  Tukey HSD contrast coefficients for sexual insecurity variables among elevated, typical, and low eating disorder risk groups...............................................................81 Table 9:  Means and standard deviations for personality variables analyzed in Study 3 across women in the genital pain group, little to no pain group, and whole sample.............83   	  viii	  List of Figures Figure 1: Mediation models for sexual insecurity variables on the relation between sexual pain and disordered eating..................................................................................................85  Figure 2: Mediation models for personality variables on the relation between disordered eating and sexual pain............................................................................................................85               	  ix	  List of Abbreviations AN: Anorexia Nervosa BN: Bulimia Nervosa PVD: Provoked Vestibulodynia                 	  1	  Study 1 Disordered Eating and Sexuality in Women: Sexual Function and Sexual Insecurities Clinicians have noted a significant link between sexual dysfunctions and eating disorders for a long time; however, little empirical evidence exists concerning the extent to which women with eating disorders experience sexual and intimacy issues. Though the impairment of sexual function is common in women with eating disorder psychopathology, few studies have examined the possible relationships between anorexia nervosa (AN), bulimia nervosa (BN), and the manifestation of sexual functioning difficulties. The limited body of research on sexual functioning in individuals with AN and BN demonstrates significant associations with considerable sexual concerns (Beaumont, Abraham, & Simpson, 1981; Hsu, Crisp, & Harding, 1979; Morgan, Lacey, & Reid, 1999; Raboch & Faltus, 1991), including difficulties with lubrication, orgasm, desire, and sexual arousal (Castellini et al., 2012). In line with the lack of empirical work on this subject, sexual concerns are seldom addressed during treatment of eating disorders, unless a history of sexual trauma is present. As numerous studies examining sexual functioning have found sexual health to be an integral aspect of quality of life in clinical populations (Pujols, Meston, & Seal, 2010), research connecting the occurrence of sexual difficulties in women with eating disorders is needed. This study represents the first of three investigating sexuality in the context of eating disorder pathology. The aim of the current research was to examine disordered eating symptoms in relation to the presence of sexual functioning difficulties and sexual insecurities.  Several subtypes of eating disorders have been defined in the literature, with the two primary types of disordered eating being AN and BN. Though these disorders are also observed in men, AN and BN predominantly occur in women, most often during adolescence or early 	  2	  adulthood. In this study, AN is characterized as a refusal to maintain a minimally normal body weight, an intense fear of gaining weight, and a significant disturbance in the perception of the shape and size of one’s body (DSM-5; American Psychiatric Association, 2013). According to recent census data by Statistics Canada, the prevalence of AN is 0.3-1% in Canadian women (Statistics Canada, 2013). It is estimated that 0.5-3.7% of women suffer from AN in their lifetime (The National Institute of Mental Health, 2002). BN is characterized by the presence of binge eating, accompanied by the experience of loss of control over food intake, wherein an objectively large amount of food is consumed in a discrete period of time, followed by compensatory behaviours (e.g. vomiting, laxative abuse, excessive exercise, or fasting). BN is estimated to afflict 1.1-4.2% of North American women in their lifetime (The National Institute of Mental Health, 2002). It should be noted that these two conditions commonly occur together along a spectrum of eating disorder pathology, such that a combination of AN- and BN-like symptoms manifest to varying extents. For example, AN can be further distinguished by two subtypes, namely: AN restrictive type, in which there is extreme dietary restraint and often excessive exercise, and AN binge-purge type, which is marked by binge-eating and compensatory behaviours in addition to caloric restriction (WHO, 1992).  The extant literature suggests that women with AN experience decreased sexual desire, reduced sexual activity and satisfaction, anorgasmia,1 as well as heightened sexual anxiety (Pinherio et al., 2010). These findings are thought to reflect both the physiological consequences of extreme caloric restriction as well as the negative psychological sequelae characteristic of women with eating disorders. The diminished levels of reproductive hormones common to women with AN are thought to contribute to sexual dysfunction (Copeland & Herzog, 1987). 	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  1	  Low coital orgasm ability 2 Cessation of menses	  	  3	  Difficulties with sexual desire in women with AN result from hypogonadism and emaciation (Rothschild, Fagan, Woodall, & Andersen, 1991), and endocrine changes associated with amenorrhea2 in AN may contribute to reduced vaginal lubrication and subsequent pain with vaginal penetration. Research has found menstrual abnormality to be positively associated with sexual dysfunction, as well as negatively associated with orgasm frequency, post-intercourse mood, and sexual partner harmony (Raboch & Faltus, 1991).  In support of physiological sources of sexual dysfunction in women with AN, research has found weight restoration to improve sexual drive (Morgan et al., 1999), and sexual satisfaction to be inversely related to caloric restriction (Wiederman, Pryor, & Morgan, 1996). In women with AN, greater weight loss tends to result in corresponding decreases in sexual enjoyment (Beaumont et al., 1981). Despite a reported loss of sexual interest and enjoyment following weight loss in women with AN, corresponding decreases in sexual activity were not found (Beaumont et al., 1981). Low lifetime minimum body mass index (BMI) has also been associated with the loss of libido and increased sexual anxiety (partial R2 = .12; Pinherio et al., 2010). Indeed, one study found that the majority of women who endorsed abnormal psychosexual outcomes, such as aversion to sexual contact, also reported maintaining a low body weight, further illustrating the link between low BMI and sexual health (Hsu & Crisp, 1979). Taken together, these findings suggest that BMI is related to sexual interest and function (Beaumont et al., 1981; Hsu & Crisp, 1979; Morgan et al., 1999; Pinherio et al., 2010).  Even fewer studies have examined the occurrence of sexual dysfunction in women with BN, where hypogonadism and hormonal dysregulation associated with emaciation are less prevalent. Some studies investigating sexual attitudes in women with bulimic symptoms have found such individuals to be fairly similar to healthy controls (Rathner & Rumpold, 1994), 	  4	  while other studies have found women with bulimic symptoms to report lower levels of sexual esteem and sexual satisfaction, as well as increased perceptions of performance pressure during sexual activity (Allerdissen, Florin, & Rost, 1981; Raciti & Hendrick, 1992). The existing literature points to differences in sexuality among women with AN, which is typically marked by reductions in sexual activity, versus women with BN, which is associated with increased activity. These patterns in sexual activity may result from AN being associated with more constricted/overcontrolled personality styles, and BN being more characterized by emotionally dysregulated/undercontrolled personalities (Eddy, Novotny, & Westen, 2004). Research has found women with AN to be less sexually active than women with BN and healthy controls, while women with BN report being more sexually active than women with AN or controls (Wiederman et al., 1996). There is emerging evidence to suggest that women with AN are also less likely to ever had sexual intercourse than women with BN, and are less likely to report being previously or currently involved in a romantic relationship (Beaumont et al., 1981; Morgan, Wiederman, & Pryor, 1995; Wiederman et al., 1996). Women with BN also tend to report an earlier age of sexual debut, more sexual partners, and higher levels of sexual fantasy and desire than women with AN (Morgan et al., 1995; Rothschild et al., 1991; Wiederman et al., 1996). Eddy and colleagues (2004) found that a history of AN symptoms and low body weight in eating disorder patients to be related to more prim/proper and child-like sexuality, while the history and frequency of BN symptoms were associated with destructive and seductive sexuality.   Both women with AN and women with BN are more likely to report their sexual experiences as being significantly more negative compared to healthy controls (Mangweth-Matzek, Rupp, Hausmann, Kemmler, & Biebl, 2007), and although comparisons between women with AN and BN have revealed different sexual complaints, both groups tend to 	  5	  endorse experiencing significant sexual functioning difficulties. A study using the Derogatis Sexual Functioning Inventory (DSFI), a widely used comprehensive measure of sexual function, found women with AN and women with BN to be in the lowest quartile of sexual functioning and sexual satisfaction compared to controls (Rothschild et al., 1991). Interestingly, only the sexual fantasy subscale of the DSFI revealed significant disparity between eating disorder sub-groups, such that women with restrictive anorexia fantasized less than women with bulimic anorexia, who, in turn, reported fewer fantasies than women with BN.  Although extreme caloric restriction may reduce sexual interest and desire, malnutrition in isolation does not account for the negative attitudes toward sexuality observed in many women with an eating disorder, which often persist following weight-restoration (Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950). Apart from lack of nourishment, a myriad of appearance-related cognitive distortions common to those with eating pathology, such as body dissatisfaction, poor sexual body esteem, and shame, also compromise healthy sexual function and sexual satisfaction (Eddy et al., 2004). These cognitive distortions appear to be more complex than a result of the physical toll associated with extreme caloric restriction, in that the existence of body-oriented sexual difficulties prior to eating disorder onset has been recognized by many women with AN and BN (Raboch & Faltus, 1991).  The impact of these maladaptive cognitions on sexuality have also been observed in community samples of women, wherein body image and body dissatisfaction have been linked to lower sexual satisfaction and sexual dysfunction (Pujols et al., 2010). Further, several aspects of body satisfaction, such as sexual attractiveness, thoughts about the body during sex, and weight concerns, have been found to predict sexual satisfaction in women without eating disorders (Ackard, Kearney-Cooke, & Peterson, 2000; Pujols et al., 2010). Indeed, body image 	  6	  represents an integral contributor to sexual health and sexual well-being. Research has linked poor body image to sexual dissatisfaction and sexual dysfunction in women (Pujols et al., 2010; Weaver & Byers, 2006), who tend to have higher levels of body-related concerns than men. Women with poor body esteem are more likely to be sexually inexperienced, avoid sexual activity, and perceive themselves as low in sexual skill (Faith & Schare, 1993; Holmes, Chamberlin, & Young, 1994; Trapnell, Meston, & Gorzalka, 1997). Conversely, women with positive body esteem have been found to experience higher levels of sexual esteem, sexual satisfaction, and perceived sexual desirability, as well as lower levels of sex-related anxiety and sexual dysfunction (Pujols, Meston, & Seal, 2010; Seal, Bradford, & Meston, 2009; Wiederman & Hurst, 1998).  The associations between poor body-esteem, sexual insecurities, and sexual function, all in relation to disordered eating represent the focus of this research. Despite the minute body of literature on sexuality in eating disorders, empirical evidence supporting the important connections between sexual insecurities, sexual dysfunction, and disordered eating remains relatively uninformed. Existing literature on disordered eating and sexuality is limited by a narrow focus on women with AN and inpatient samples, which may not generalize to community samples of women with less severe manifestations of disordered eating patterns (Eddy et al., 2004). The primary goal of this research was to explore the occurrence of sexual problems and poor sexual esteem in women with symptoms of disordered eating. Disordered eating variables were hypothesized to predict an array of sexual function difficulties, as well as body- and performance-based sexual concerns, and sexual self-efficacy.  As sexual insecurities contribute to poor sexual function, cognitive distractions during sex and sexual self-efficacy were predicted to mediate the associations between disordered eating and the sexual functioning variables 	  7	  most affected by disordered eating pathology.  Methods	  Participants  A total of 386 female undergraduates were recruited to participate in a study of disordered eating and sexuality, requesting completion of an online survey. Eligibility requirements included age (over 19 years) and proficiency with understanding written English. Sixty-five participants were omitted from this study because of incomplete data.  Procedure Participants were recruited by advertisements posted on the human subject pool system at the University of British Columbia. The advertisements directed interested participants to a website (www.fluidsurveys.com) to complete a web-based questionnaire. After arriving at the website, participants were presented with an online consent form which provided further information on the study topic and procedures. Upon indicating consent to participate, participants were presented with a series of online questionnaires. Students received 1 course credit in exchange for participation. The university behavioral research ethics board approved all procedures. An online survey host was chosen in place of hard copy questionnaire distribution. Web-based media have previously been shown to have a disinhibiting effect, reduces social desirability responding of its users, and create a sense of anonymity, which translates into greater honesty in responses and higher rates of self-disclosure (Gackenbach, 2011).  Measures Participants filled out a series of questionnaires assessing disordered eating, sexual function, sexual insecurities, personality, and mood. The scales measuring disordered eating and sexuality were used for Study 1 analyses, and are outlined below. Measures of personality 	  8	  and mood are discussed in Study 3.   Sexual Function Measures Female Sexual Function Index Revised (FSFI-R): The FSFI-R is a 20-item self-report scale, designed to measure several key dimensions of sexual function in women over the previous 4 weeks. The FSFI-R differs from the original 19-item version of the FSFI only with respect to an additional item that measures current sexual behaviour. A total score and scores on six subdomains of female sexuality are produced: sexual desire, arousal (both subjective and physiologic), lubrication, orgasm, satisfaction and pain. Participants rate each item on a 5-point Likert scale, in which lower scores are associated with higher levels of sexual dysfunction. Total scores range from 2 to 36 and subscale scores range from 0–5 or 1–5, with higher scores indicating better sexual functioning. Subscale scores range from 0 to 6 with the exception of sexual desire, which ranges from 1.2 to 6. The FSFI has high test-retest reliability across all domains of sexual dysfunction, as well as good construct validity (Rosen, Brown, Heiman, Leiblum, Meston, Shabsigh, Ferguson, & D’Agostino, 2000). The Chronbach’s alpha for the FSFI in this sample was good at 0.828.  Female Sexual Distress Scale - Revised (FSDS-R): The FSDS is a validated 13-item questionnaire that measures personal distress associated with sexual dysfunction in women, a domain not captured by the FSFI. Respondents indicated their degree of agreement with statements on a 5-point scale ranging from never (0) to always (4), with scores ranging from 0 to 48. Higher scores indicate more sexual distress, and a total score of 15 or higher indicates clinically significant sexual distress (Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002). The FSDS-R has shown strong psychometric properties (Derogatis, et al., 2002; Rosen, Shifren, Monz, Odom, Russo, & Johannes, 2009). Cronbach’s alpha of the FSDS-R on the current 	  9	  sample was excellent at 0.929.   Sexual Insecurity Measures Sexual Self-Efficacy Scale for Female Function (SSES-F): The SSES-F is a 37-item measure of perceived competence in the behavioural, cognitive, and effective dimensions of female sexual response. A total score, as well as eight subscales are produced, including: interpersonal orgasm, desire, sensuality, individual arousal, affection, communication, body acceptance, and refusal. For each item, the woman indicates whether or not she is able to perform the activity; if yes, she rates her confidence on a 10 (quite uncertain) to 100 (quite certain) scale. Scores for inability to perform an activity are 0. Scores are averaged over all items to yield a total score between 0 and 100, with higher scores indicating greater levels of sexual self-efficacy. The SESS-F total score has shown excellent internal consistency, and adequate internal consistency for the separate subscales, as well as high convergent validity with respect to several other comparable measures (Bailes, Creti, Fichten, Libman, Brender, & Amsel, 1998). The Chronbach’s alpha for SSES-F among women in the current sample was excellent at 0.968.  The Cognitive Distractions During Sexual Activity Scale (CDDSA). This self-report questionnaire includes 20 items measuring the experience of cognitive interference during sexual interactions. The scale provides two 10-item subscales: appearance-based concerns and performance-based concerns. On a 6-point Likert scale ranging from 1 “Always” to 6 “Never”, participants indicate the frequency with which they experience agreement with each statement. Possible total scores range from 10 to 60, with lower scores indicating that participants experience more frequent distracting body- and performance-related thoughts during sex. The CDDSA has been tested in several investigations, and displays excellent internal consistency within each subscale (Dove and Wiederman, 2000; Meana & Nunnink, 2006). The 	  10	  Chronbach’s alpha for the CDDSA on the current sample was excellent at 0.980.  Disordered Eating Measures Eating Disorders Inventory-3 (EDI-3): The EDI-3 is a 91-item self-report questionnaire designed to measure attitudes, personality features, and eating disorder symptom severity associated with Anorexia Nervosa and Bulimia Nervosa. Respondents are asked to rate each item on a 4-point scale. The EDI-3 yields 12 non-overlapping subscales: 3 of which assess eating disorder risk (drive for thinness, bulimia, and body dissatisfaction), which combined create an eating disorder risk composite score, and 9 which assess various psychological variables that have been associated with eating disorder symptomatology, including maturity fears, low self esteem, personal alienation, interpersonal insecurity, interpersonal alienation, interoceptive deficits, emotional dysregulation, perfectionism, and asceticism.  These psychological subscales can be divided into four composite scores, including ineffectiveness, interpersonal problems, affective problems, and over control, which all together produce a global psychological maladjustment score. Lower scores indicate lower eating pathology and lower levels personality factors. The EDI-3 has shown excellent internal consistency and test-retest reliability, as well as acceptable convergent validity and discriminant validity (Cumella, 2006). The Chronbach’s alpha for women in the current sample was excellent at 0.918. Revised Rigid Restraint Scale (RRRS): The 12 item RRRS assesses individuals’ tendency to avoid and feel guilty about eating foods they perceive as forbidden or unhealthy. The scale assesses two components of restrained eating: restrictive eating (desire and effort to avoid eating unhealthy, “forbidden” foods) and eating guilt (tendency to feel guilty when eating foods perceived as forbidden). Participants respond on 5-point scales ranging from 1 (never) to 5 (always). Total scores range from 12 to 60, with higher scores indicative of more disordered 	  11	  eating tendencies. The RRRS has shown adequate reliability (Ruderman, 1983). The Chronbach’s alpha for the RRRS in the current sample was excellent at 0.919.  Body Shape Questionnaire (BSQ): The BSQ is a 34-item self-report instrument developed to measure concern about body image in the development, maintenance and treatment of anorexia nervosa and bulimia nervosa. Respondents are asked to rate the frequency in which they experience various body shape preoccupations over the previous four weeks. Response categories range from 1 (Never) to 6 (Always), with higher scores indicating a higher frequency of body shape concerns. The BSQ has been shown to be a valid and reliable measure of body image, with excellent test-retest reliability and concurrent validity (Rosen, Ramirez, & Waxman, 1996). The Chronbach’s alpha for the BSQ among women in the current sample was excellent at 0.978.  Data Analysis We	  examined	  the	  relationships	  between	  disordered	  eating	  and	  sexuality	  using	  zero-­‐order	  correlations	  and	  a	  series	  of	  linear	  multiple	  regression	  analyses,	  with	  eating	  disorder	  variables	  entered	  as	  the	  independent	  variables	  and	  sexuality	  variables	  individually	  entered	  as	  the	  dependent	  variables.	  Bootstrap	  mediation	  analyses	  were	  conducted	  to	  examine	  the	  influence	  of	  sexual	  self-­‐efficacy	  and	  cognitive	  distractions	  during	  sexual	  activity	  on	  the	  relation	  between	  disordered	  eating	  and	  sexual	  pain.	  	  Results	  Sample Characteristics Of the 386 women who approached this study, only 321 completed it, thus 65 women were excluded from the analysis due to incomplete data. The mean age of the women was 20.51 	  12	  years (SD = 2.93, range = 18-51). For ethnicity, 37.2% reported being East Asian, 37.2% Euro-Caucasian, and 24.6% belonging to other ethno-cultural groups. A total of 66.5% identified as heterosexual, 18.3% heteroflexible, 10.2% bisexual, and 5.3% lesbian. Fifty-two percent of women were in a monogamous relationship, 1.1% were in an open relationship, 10.4% were in a mostly sexual relationship, and 36.1% were not in a relationship. Of those currently in a relationship, the average length was 1 year and 3 months. For sexual experience, 67.1% had engaged in mutual masturbation at least once in their life, 76.4% had engaged in oral sex, 72.1% had engaged in vaginal sex, and 25.4% had engaged in anal sex. Only women who were sexually active either alone or with a partner within the four weeks prior to participation (n = 195) were included in the sexual functioning analyses. Sexual desire was an exception, as it is applicable to women regardless of recent sexual activity, and was analyzed with the entire sample. Sexual insecurity variables were also analyzed with the whole sample. The means and standard deviations of sexuality-related measures and disordered eating measures are presented in Table 1. Generally, the sample can be characterized as being relatively healthy in terms of sexual function, and low in eating disorder risk.  Association	  between	  disordered	  eating	  and	  sexual	  functioning	  Zero-­‐order	  correlations	  between	  disordered	  eating	  variables	  and	  sexuality	  variables	  are	  presented	  in	  Table	  2.	  Of	  the	  sexual	  functioning	  variables,	  Bulimia	  was	  significantly	  correlated	  with	  the	  FSDS	  and	  all	  FSFI	  domains	  except	  Desire,	  such	  that	  more	  bulimia	  was	  associated	  with	  more	  sexual	  distress	  and	  lower	  overall	  sexual	  function.	  With	  the	  exception	  of	  FSFI-­‐Lubrication	  and	  Orgasm,	  Body	  Dissatisfaction	  was	  correlated	  with	  all	  domains	  of	  sexual	  function,	  such	  that	  greater	  body	  dissatisfaction	  was	  associated	  with	  more	  sexual	  dysfunction.	  Drive	  for	  Thinness	  was	  correlated	  with	  FSFI-­‐Total,	  FSFI-­‐Orgasm,	  FSFI-­‐Pain,	  	  13	  and	  FSDS-­‐Total,	  where	  drive	  for	  thinness	  was	  associated	  with	  poorer	  sexual	  function.	  Eating	  Guilt	  was	  correlated	  with	  FSFI-­‐Pain	  and	  FSDS-­‐Total,	  such	  that	  eating	  guilt	  was	  associated	  with	  greater	  pain	  and	  more	  sexual	  distress.	  Rigid	  Restraint	  correlated	  only	  with	  FSDS-­‐Total,	  wherein	  restrictive	  eating	  was	  associated	  with	  greater	  sexual	  distress.	  	  In	  each	  case,	  higher	  levels	  of	  reported	  eating	  pathology	  were	  associated	  with	  greater	  sexual	  dysfunction.	  Of	  the	  sexual	  insecurity	  variables,	  CDDSA-­‐Body	  and	  CDDSA-­‐Performance	  were	  significantly	  correlated	  with	  all	  domains	  of	  disordered	  eating,	  such	  that	  greater	  eating	  pathology	  was	  associated	  with	  more	  body-­‐	  and	  performance-­‐based	  sexual	  concerns.	  Bulimia	  and	  Body	  Dissatisfaction	  were	  significantly	  negatively	  correlated	  with	  all	  SSESF	  subscales,	  with	  higher	  levels	  of	  bulimia	  and	  body	  dissatisfaction	  being	  associated	  with	  lower	  sexual	  self-­‐efficacy.	  Eating	  Guilt	  and	  Drive	  for	  Thinness	  were	  negatively	  correlated	  with	  all	  SSESF	  subscales	  except	  Individual	  Arousal.	  	  Of	  the	  SSESF	  subscales,	  Restrictive	  Eating	  was	  significantly	  negatively	  correlated	  only	  with	  Interpersonal	  Interest,	  and	  Body	  Acceptance,	  such	  that	  rigid	  restraint	  was	  associated	  with	  having	  a	  lower	  interest	  in	  others	  and	  poorer	  body	  acceptance.	  The	  BSQ	  was	  similarly	  correlated	  with	  all	  SSESF	  subscales	  except	  Individual	  Arousal,	  with	  more	  body	  shape	  concerns	  being	  associated	  with	  lower	  sexual	  self-­‐efficacy	  in	  each	  case.	  In	  addition,	  the	  BSQ	  was	  significantly	  correlated	  with	  CDDSA-­‐Body	  and	  CDDSA-­‐Performance,	  as	  well	  as	  FSFI	  Pain	  and	  FSDS,	  such	  that	  greater	  body	  shape	  concerns	  were	  related	  to	  more	  body-­‐	  and	  performance-­‐based	  cognitive	  distractions,	  greater	  sexual	  distress,	  and	  higher	  levels	  of	  genital	  pain.	  	  Disordered	  Eating	  variables	  predicting	  sexual	  functioning	  variables	  In	  each	  regression	  model,	  EDI-­‐3	  Bulimia,	  Drive	  for	  Thinness,	  and	  Body	  Dissatisfaction	  subscales,	  as	  well	  as	  RRRS	  Restraint	  and	  Eating	  Guilt	  subscales	  were	  	  14	  entered	  as	  the	  Independent	  Variables.	  Sexuality	  measures	  and	  corresponding	  subscales	  were	  independently	  entered	  into	  regression	  models	  as	  the	  dependent	  variables	  (ie.,	  FSFI	  Total	  and	  FSFI	  subscales,	  FSDS,	  SSESF	  Total	  and	  SSESF	  subscales,	  CDDSA	  Body	  and	  CDDSA	  Performance).	  	  The	  overall	  model	  for	  the	  FSDS	  was	  significant	  (F(5, 180) = 9.01, p < .001), such that disordered eating explained a significant proportion of the variance (R2 = .16). FSDS was significantly predicted by Drive for Thinness (p = .029, β = .25), Bulimia (p = .000, β  = .35), Body Dissatisfaction (p = .041, β = .18), and Eating Guilt (p = .003, β = .24), such that higher levels of eating disorder pathology were associated with greater sexual distress.  The overall model for the FSFI total score was significant (F(5,180) = 7.05, p < .001), such that disordered eating accounted for a significant proportion of the variance (R2 = .16). Bulimia and Body Dissatisfaction predicted FSFI total score, such that higher levels of body dissatisfaction and bulimia were associated with higher levels of overall sexual dysfunction. FSFI total was significantly predicted by Bulimia (p < .001 β = .42) and Body Dissatisfaction (p = .037, β = .22), as well as marginally predicted by Drive for Thinness (p = .079, β = .23), such that more eating pathology was associated with poorer overall sexual function.  Of the FSFI subscales, disordered eating accounted for a significant proportion of the variance in Pain (F(5, 192) = 7.06, p < .001, R2 = .15), Desire (F(5, 230) = 3.26, p < .01, R2 = .07), Arousal (F(5, 186) = 6.40, p < .001, R2 = .15), Lubrication (F(5, 190) = 4.66, p < .001, R2 = .11), Orgasm (F(5, 195) = 3.22, p < .01, R2 = .08), and Satisfaction (F(5, 189) = 2.32, p < .05, R2 = .06). Drive for Thinness significantly predicted Arousal (p = .034, β = .27), Desire (p = .003, β = .36), and Pain (p = .028, β = .28), such that drive for thinness was associated with lower levels of arousal and desire and higher levels of sexual pain. Bulimia significantly predicted 	  15	  Lubrication (p < .001, β = .39), Arousal (p < .001, β = .42), Pain (p < .001, β = .42), and Orgasm (p < .05, β = .22), and marginally predicted Sexual Satisfaction (p = .053, β = .18), such that endorsements of bulimia were associated with lower lubrication, arousal, and orgasm, satisfaction, and greater sexual pain. Body Dissatisfaction significantly predicted Desire (p < .001, β = .36), such that greater dissatisfaction was associated with lower desire.  Disordered	  Eating	  variables	  predicting	  sexual	  insecurity	  variables	  The overall models for CDDSA-Performance (F(5, 315) = 17.21, p < .001, R2 = .22) and CDDSA-Body (F(5, 315) = 31.94, p < .001, R2 = .34) were significant, such that eating pathology explained a significant proportion of the variance in body- and performance-based sexual concerns. Bulimia (p < .001, β = .24) and Body Dissatisfaction (p < .001, β = .26) significantly predicted CDDSA-Body, while Bulimia (p < .001, β = .31) was the only significant predictor of CDDSA-Performance.  The overall model for Sexual Self-Efficacy (SSESF Total) was significant (F(5, 302) = 9.90, p < .001), such that disordered eating accounted for a significant proportion of the variance (R2 = .14). Bulimia (p < .01, β = .22) and Body Dissatisfaction (p < .001, β = .25) predicted SSESF Total, wherein greater eating pathology was associated with lower overall sexual self-efficacy. The models for all SSESF subscales were significant: Refusal (F(5, 292) = 7.09, p < .001, R2 = .11), Body Acceptance (F(5, 296) = 35.99, p < .001, R2 = .38), Communication (F(5, 295) = 8.60, p < .001, R2 = .13), Affection (F(5, 293) = 5.18, p < .001, R2 = .08), Individual Arousal (F(5, 294) = 3.40 p < .01, R2 = .06), Sensuality (F(5, 293) = 5.94, p < .001, R2 = .09), Interpersonal Interest (F(5, 297) = 8.86, p < .001, R2 = .13), Interpersonal Orgasm (F(5, 301) = 9.10, p < .001, R2 = .13). Bulimia significantly negatively predicted all SSESF subscales with the exception of Individual Arousal, with endorsements of bulimia being associated with lower 	  16	  sexual self-efficacy (Interpersonal orgasm: p <.001, β = .24; Interpersonal interest: p < .05, β = .17; Sensuality: p < .01, β = .21; Affection: p <.01, β = .21; Communication: p < .01, β = .21; Body Acceptance: p < .001, β = .20; Refusal: p <.01, β = .23). Body Dissatisfaction significantly negatively predicted all SSESF subscales except Refusal and Affection, such that greater body dissatisfaction was associated with lower sexual self-efficacy (Interpersonal orgasm: p <.01, β = .23; Interpersonal interest: p < .001, β = .30; Sensuality: p < .05, β = .18; Individual Arousal: p < .01, β = .20; Communication: p < .01, β = .25; Body Acceptance: p < .001, β = .46). Drive for Thinness failed to significantly predict any SSESF subscale, but predicted Refusal (p = .074, β = .18) with marginal significance. Restrictive Eating significantly predicted Interpersonal Orgasm, such that greater restriction was associated with lower orgasm ability, and marginally predicted Communication (p = .058, β = .15), Body Acceptance (p = .054, β = .13), and Individual Arousal (p < .001, β = .24). Eating Guilt also significantly predicted Interpersonal Orgasm (p < .05, β = .20), with more guilt associated with lower orgasm ability.  Mediating effects of sexual self-efficacy and cognitive distractions during sex A series of four mediation analyses were carried out to examine the influence of sexual self-efficacy and cognitive distractions during sexual activity on the relation between eating disorder risk and sexual pain (Figure 1). As the directionality of the association between eating disorder risk and sexual pain cannot be determined with our previous analyses, the mediation models were examined first with EDI-3 Eating Disorder Risk as the independent variable and FSFI Pain as the dependent variable, and then again with the independent and dependent variables reversed. Eating Disorder Risk represents a psychometrically normed composite score comprised of EDI-3 Bulimia, Drive for Thinness, and Body Dissatisfaction subscales.	  SSESF Total was entered as the mediating variable in the first two models. CDDSA Body and 	  17	  CDDSA Performance were simultaneously entered as the mediating variables in the second two models. 	  The overall mediation model for sexual self-efficacy on eating disorder risk predicting sexual pain was significant (F(2, 318) = 20.04, p < .001, R2 = .11), such that sexual self-efficacy partially mediated the relation between disordered eating and genital pain. The reversed mediation model for sexual self-efficacy on sexual pain predicting eating disorder risk was also significant (F(2, 318) = 10.29, p < .001, R2 = .06), with sexual self-efficacy partially mediating the association of interest. Eating disorder risk was thus found to predict sexual pain, and sexual pain was found to predict eating disorder risk, suggesting a bidirectional association. The effect size for eating disorder risk predicting genital pain was almost twice that of the R2 observed in the reversed model, indicating that the direction of this relationship favors eating disorder risk as the predictor and sexual pain as the criterion.  The overall mediation model for cognitive distractions during sexual activity on eating disorder risk predicting sexual pain was significant, F(3, 331) = 27.77, p < .001, R2 = .20. A test of indirect effects showed that CDDSA Body but not CDDSA Performance were significant contributors to the model. The loss of significance from c to c’ suggests that body-related cognitive distractions during sexual activity totally mediate the relation of eating disorder risk predicting genital pain.  The overall model was also significant when reversed, with sexual pain predicting eating disorder risk (F(3, 331) = 10.84, p < .001, R2 = .09), such that cognitive distractions during sexual activity totally mediated the relation between sexual pain and eating disorder risk. However, examination of the indirect effects suggest that neither CDDSA Body nor CDDSA Performance alone significantly contributed to the mediation model, as neither mediator was significantly associated with the dependent variable (sexual pain) in this 	  18	  instance. Thus, eating disorder risk predicting sexual pain again represented the better model fit.  Discussion  Sexual health represents an important contributor to quality of life, yet sexual difficulties are rarely addressed in the context of eating disorder care. The impetus for this study arose from the inattention to sexual concerns in women with eating disorders, and the position that sexuality represents an understudied area in the eating disorder literature. Thus, the primary aim of the current research was to examine the occurrence of sexual difficulties and insecurities in relation to disordered eating symptomatology. Although this study did not assess whether participants met diagnostic criteria for an eating disorder, we believe that these findings highlight the co-occurrence of sexual difficulties and disordered eating in a community sample of young women, a population underrepresented in existing literature of this nature. The current research highlights the occurrence of considerable sexual concerns, such as those related to sexual body esteem, sexual self-efficacy, pain, and sexual function, in women with disordered eating.  Associations between disordered eating and sexuality It was predicted that eating disorder variables would be associated with sexual function problems, higher sexual distress, a greater occurrence of cognitive distractions during sexual activity, and low sexual self-efficacy. Consistent with this hypothesis, aspects of disordered eating were found to predict lower levels of sexual function, particularly with regards to genital pain and sexual distress, as well as more cognitive distractions during sexual activity and lower sexual self-efficacy. Sexual pain and sexual distress were also correlated with eating disorder symptom severity more than any other sexual functioning variable.   Together, the eating disorder variables significantly predicted greater impairment across all aspects of sexual function measured. Again, the most impacted aspects of sexual function 	  19	  were genital pain and sexual distress, for which eating disorder pathology accounted for 15 and 16% of the variance respectively. Drive for thinness, bulimia, body dissatisfaction, and eating guilt were most predictive of sexual distress, while drive for thinness and bulimia represented the most significant predictors of genital pain. Relevant to both sexual distress and genital pain, drive for thinness represents a central feature associated with the development and maintenance of eating disorder symptoms in clinical samples, especially AN. Women scoring highly on this variable are characterized by a preoccupation with restrictive dieting and intense fears about weight gain. Sexual distress and genital pain commonly co-occur together, as the anticipation and experience of genital pain is typically associated with sexual distress. The association between genital pain and sexual distress in relation to drive for thinness provides tentative evidence suggesting that sexual pain, and potentially sexual pain conditions, might be more prevalent among extreme dieters compared to non-restrictive eaters. Drive for thinness was also found to negatively predict sexual arousal and desire, suggesting that women who endorsed a preoccupation with the desire to be thinner and a tendency to spend an inordinate amount of time thinking about dieting also reported a diminished desire for sexual activity and lower levels of arousal.  Eating guilt, or the tendency to dwell on and feel bad about food consumption, often accompanies restrictive eating and was similarly associated with sexual distress. This finding compliments the notion that restrictive eaters experience higher levels of sexual distress.   The experience of sexual distress and genital pain were similarly predicted by bulimic symptoms. Women scoring highly on bulimia in this context endorsed thoughts and behaviours that are consistent with binge eating, such as eating a large amount of food in secrecy and as a way to cope with negative emotions, as well as compensatory behaviours. In this vein, the 	  20	  experience of genital pain, and perhaps sexual pain conditions, might be more pronounced in women with binge-and-purge tendencies. Of course more research is needed to further understand these associations, as diagnoses for sexual dysfunction and eating disorders cannot be made based on the measures used. Bulimia was also significantly associated with lubrication, arousal, and orgasm, indicating that women who often engaged in thoughts about binge eating and purging also tended to report lower levels sexual arousal and lubrication, as well as difficulty achieving orgasm. Diminished sexual arousal often exacerbates anorgasmia and vaginal dryness, and a lack of lubrication is thought to account for some instances of sexual pain or at least to worsen sexual pain. It is possible that the pronounced sexual distress and genital pain observed in women endorsing bulimic symptoms can be drawn back to diminished sexual arousal. Alternatively, bulimia may impact multiple facets of the sexual response cycle independently.   With regards to sexual insecurity variables, measures of disordered eating significantly predicted body- and performance-based cognitive distractions during sexual activity, as well as global sexual self-efficacy and all efficacy subscales. Body-related cognitive distractions were most impacted by bulimia and, unsurprisingly, body dissatisfaction, while performance concerns were significantly impacted by bulimia alone. Body dissatisfaction can be described as discontentment with overall shape and with the size of those regions of the body of extraordinary concern to those with eating disorders (e.g. stomach, thighs, hips, buttocks). The more dissatisfied women were with their bodies, the greater the occurrence of body-related distractions during sexual activity. Intuitively, individuals dissatisfied with the appearance of their bodies were more likely to fixate on or be negatively distracted by body-oriented concerns while sexually engaged. The mechanism connecting bulimic symptoms with body-and performance-based cognitive distractions during sexual activity is unclear. Presumably, women endorsing 	  21	  thoughts and behaviours related to binging and purging are likely to have shape and weight concerns, which have been linked to decreased enjoyment of sexual activity (Pujols et al., 2010).   Of the six domains of sexual function assessed by the FSFI, genital pain had the strongest association with disordered eating symptomatology. To investigate this relationship further, mediation analyses were carried out with sexual insecurity variables entered as mediators on the association between genital pain and eating disorder risk. As the direction of the relationship of interest was unclear, mediation analyses were run twice with the independent and dependent variables (sexual pain and eating disorder risk) inverted. Though all mediation models were significant, the R2 was notably larger in cases where eating disorder risk predicted sexual pain, suggesting a better model fit. Both sexual self-efficacy and cognitive distractions during sexual activity were found to mediate the relation between eating disorder risk and sexual pain.  The mediational role of sexual insecurities on the relation between disordered eating and sexual pain The finding that body-related thoughts mediated the association connecting eating disorder risk and sexual pain is consistent with the literature on spectatoring (Masters & Johnson, 1970). Spectatoring refers to a cognitive self-absorption that involves fixating on and carefully monitoring or evaluating oneself within the context of sexual activity, often in a critical or judgmental light. This cognitive interference is thought to impair sexual function, as focusing on the appearance of ones body or comparing oneself to some external standard of ideal sexuality during coital activity draws attention away from enjoying pleasurable sexual thoughts and sensations. There is also research demonstrating that appearance-based cognitive distractions can impede women’s sexual responses (Dove & Wiederman, 2000) and sexual satisfaction (Pujols et al., 2010). The current research indicates that in addition to negatively effecting overall 	  22	  sexual function and sexual satisfaction, body-related concerns during sex also negatively impact genital pain, and that such cognitive distractions are at least partially responsible for the relation between genital pain and disordered eating. Indeed, that eating disorder risk was associated with the frequency of distracting thoughts about one’s body during sexual activity suggests that eating disorder risk may influence genital pain indirectly through body-related concerns.  A similar interplay of variables was observed regarding the meditational role of sexual self-efficacy on the relation between eating disorder risk and genital pain. That sexual self-efficacy was found to serve as a significant mediator indicates that the extent to which women feel competent in the behavioural, cognitive, and effective dimensions of sexual response impacts the association between eating disorder risk and genital pain. These findings suggest that the higher levels of sexual self-efficacy may diminish the impact of eating disorder symptoms on sexual pain. The meditational effect of sexual self-efficacy and cognitive distractions during sexual activity on the relation between eating disorder risk and genital pain has relevant clinical implications. Improving sexual self-efficacy and addressing irrational body- and appearance-based concerns may represent a promising avenue for attenuating the influence of eating disorder symptoms on sexuality in women with disordered eating.  Taken together, these findings emphasize the importance of considering sexuality in the context of eating difficulties. This research adds to the small but growing body of literature investigating sexual problems in relation to eating disorders. Within the limits of this study, findings provide further empirical support for lower levels of sexual function in the eating disorders, substantiating past research and decades of clinical writings connecting sexuality to disordered eating pathology. Again, genital pain and sexual distress emerged as the being the most impacted facets of sexual function by eating disorder symptoms. The relation between 	  23	  sexual function and disordered eating appears to be complex, with sexual insecurities influencing the extent to which eating disorder risk relates to genital pain. Further research is needed to tease apart these associations and gain a more catholic understanding of the link between disordered eating and sexuality.  It should be noted that these findings pertain to the whole sample of Study 1 participants, which is characterized as being relatively sexually healthy. We might predict that among the subsample of women who fall in the clinically significant range of sexual functioning that these associations would likely be stronger.               	  24	  Study 2 Disordered Eating and Sexuality in Women: Genital Pain and Sexual Distress In Study 1 I found that eating disorder pathology is significantly associated with low levels of sexual function and sexual insecurities in a university undergraduate sample of women. Among the several aspects of sexual functioning analyzed in Study 1, disordered eating symptomatology was found to have the greatest impact on genital pain and sexual distress. Although eating disorder symptoms may be relevant to many domains of women’s sexual function, disordered eating symptomatology seems to be particularly relevant when considering women with dyspareunia, which can be defined as persistent or recurrent genital pain that occurs just before, during, or after sexual intercourse.   Problems in sexual function among women with AN, including the occurrence of genital pain, has long been clinically recognized. Reports of women with AN written several decades ago refer to sexual function difficulties and decreased sexual desire (e.g. Waller, Kaufman, & Deutsch, 1940), and Garfinkel & Garner (1982) noted that some women with AN present to sexual dysfunction clinics for vaginismus—a condition defined by involuntary tightness of the pelvic floor muscles. Indeed, amenorrhea, loss of lubrication, and dyspareunia are commonly reported by women with AN (Andersen, 1985; Treasure & Szmukler, 1995). Silvia & Todd (1998) postulated that clinical presentations of vaginismus in women with AN likely results from sexual anxiety and decreased desire or sexual interest, and that dyspareunia likely arises from penetration attempts in the absence of physiological responsiveness, the latter of which is necessary for painless vaginal penetration.  In addition to clinical experience, a small number of case studies have related sexual pain 	  25	  conditions to extreme weight loss and AN (Andres et al., 2013; Arcelus & Wales, 2009; Daehyun et al, 2004). Arcelus and Wales (2009) documented a case report describing a young woman with a long history of AN, who later developed vaginismus with associated dyspareunia. The women described in this case report, given the pseudonym of ‘EP’, had a history of AN throughout her teen years and early twenties, and EP wished to document her case in hopes of helping other women with similar symptoms. When EP became involved in her first romantic relationship at age 22, she expressed a desire to become sexually intimate with her partner. However, EP’s desire to have sexual intercourse with her boyfriend proved to be difficult due to pain upon attempted penetration. She reported being unable to engage in penetrative sex, and that when she did manage to have intercourse, the experience was very painful. The authors suggested that EP’s genital pain might have manifested as an attempt to avoid romantic relationships with others. Another plausible explanation was related to the fear of losing control that is common among those with eating disorders. This fear of losing control may specifically be tied to a fear of orgasm, which is often associated with feelings of vulnerability and can entail subjective feelings of losing control for a few seconds. In addition, the authors posited that the decreased levels of circulating estrogen results in decreased physiological arousal, or a lack of the vaginal lubrication resulting in subsequent pain with penetration.  Although previous studies have explored sexual functioning more broadly, to the best of my knowledge I could find only a single study examining eating disorders and sexual pain. Castellini et al. (2012) observed that women with AN and women with BN showed lower levels of sexual arousal, lubrication, orgasm, and satisfaction, as well as higher sexual pain scores compared to controls. Further, women with AN of the extreme restricting subtype scored more highly on sexual pain and other facets of disordered eating compared to women of the 	  26	  (presumably less severe) AN binge/purging type and those with BN. This is a promising start to the investigation of sexual pain in relation to disordered eating, however, a more in depth study would be beneficial. The findings of this study also serve to highlight the severity of sexual dysfunctions experienced by women with restrictive AN over that seen in other eating disorder diagnoses. This notion is also supported by the findings of Morgan et al. (1999) who found that women with restrictive-type AN displayed a lower sex drive than women with purging-type AN, and the results of Rothschild et al. (1991) who found a dearth of sexual fantasies in women with restrictive AN at a normal weight compared to women with binge/purging AN.  Women with dyspareunia report sexual function difficulties similar to those seen in women with AN and BN. All stages of the sexual response cycle are impaired by the experience of genital pain. Reductions in sexual desire and arousal are common complaints among women with dyspareunia, as well as decreased frequency of intercourse (Gates & Galask, 2001). Women with dyspareunia also report lower levels of pleasure during sexual activity and less success in reaching orgasm (van Lankveld et al., 2010). In addition to a decrease in sexual pleasure during penetrative sex, women with genital pain often describe diminished sexual desire for an array of non-penetrative sexual activities (Payne, 2004). Like women with AN, women with provoked vestibulodynia (PVD)– a common and distressing genital pain condition – often experience discomfort with their sexual self, often reporting a general sense of detachment from their sexuality (Payne, 2004). Similarly, it has been repeatedly shown that women with genital pain experience negative feelings towards erotic stimuli, negative emotions during sexual activity, a more negative sexual self-schema, and more negative attitudes towards sexuality (van Lankveld et al., 2010).  Research investigating the role of sexual self-esteem in women with PVD has found 	  27	  genital pain to be associated with negative body image, as well as feelings of being less desirable, less sexually confident, and less feminine (Gates & Galask, 2001; Reed, Advincula, Fonde, Gorenflo, & Haefner, 2003; Sackett et al., 2001). This subjective decrease in femininity reported by women with PVD parallels patterns seen in women with AN, wherein weight loss is often associated with the desire to appear more androgynous (Leon, Lucas, Collignan, Ferdinande, & Kamp, 1985). Indeed, Leon et al. (1985) found that women with AN believed they would appear more attractive to the opposite sex at a higher weight, yet continued to pursue weight loss, suggesting that women with AN may use weight loss as a means of avoiding the sexual contact. Prior research has also found that women with a lower body weight and a history of anorexic symptoms in eating disorder patients to be related to more child-like and chaste sexual attitudes and behaviour (Eddy, 2004).  Despite the compelling clinical rationale, empirical research investigating the link between genital pain and disordered eating is lacking. Building on the results of Study 1, the current study aimed to shed light on the presence of genital pain in women reporting eating disorder pathology. This cross-sectional study included measures of genital pain to more thoroughly examine the relation between disordered eating and sexual pain. Disordered eating was hypothesized to predict genital pain intensity, such that the presence of eating disorder pathology will be associated with the presence and severity of sexual pain. It was further anticipated that women scoring above the clinical cut-off for genital pain will report more disordered eating symptoms, and that women scoring above the clinical cut-off for eating disorder risk will endorse a greater severity of sexual pain.   	  28	  Methods Participants Eight hundred and fifty-four female undergraduates were recruited from the UBC human subject pool system. Independent samples t-tests were carried out to test for mean differences between participants from Study1 and Study 2. Women in the second sample did not significantly differ from those that participated in Study 1 on any demographic variable. The mean age of women who participated in Study 2 was 20.63 years (SD = 2.93).  Procedure  The procedure for Study 2 precisely mirrored that of Study 1. The same measures of disordered eating, sexual insecurity, sexual function, personality, and mood used in Study 1 were included in the questionnaire battery distributed in Study 2. Auxiliary measures of genital pain were added to the series of online questionnaires.  Measures The McGill Pain Questionnaire (MPQ): The MPQ is a 29-item, 3 part questionnaire designed to assess multiple dimensions of pain. The scale includes the Pain Rating Index (PRI), a checklist composed of 78 adjectives assessing pain quality and intensity.  Participants are instructed to select words best describing their pain experiences. Each adjective corresponds with a score of 1-6, increasing with pain severity, for PRI total score ranging from 0-78.  An additional score counting the number of words selected is called Number of Words Chosen (NWC) and ranges from 0-20. The MPQ is highly reliable, validated, and sensitive to various types of pain. The instructions specified to the assessment of genital pain experiences. The MPQ is the most widely used pain assessment instrument. It has been demonstrated to be a reliable, 	  29	  valid, and consistent measurement tool, as well as capable of discriminating among different types of pain (Melzack & Katz, 2001). Because the MPQ pain score represents the sum of personally applicable descriptors across multiple distinct dimensions of pain, Chronbach’s alpha could not be calculated.  West Haven-Yale Multidimensional Pain Inventory (WHYMPI): This 52-item scale assesses severity of pain and its impact on daily activities.  The WHYMPI contains three sections (pain experience, significant others’ responses to communications of pain, and participation in common daily activities) and twelve subscales (Interference, Support, Pain Severity, Self-Control, Negative Mood, Punishing Responses, Solicitous Responses, Distracting Responses, Household Chores, Outdoor Work, Activities Away From Home, and Social Activities).  Items are rated on scales ranging from 0-6, with the varying anchors for each question, for a total minimum score of 0 and a maximum score of 312. For the purpose of our study, only questions A10-13 of the WHYMPI was used, each of which pertains to one’s romantic partner. These questions were also adapted to specifically address women’s partner-related experiences in the context of their genital pain (i.e. The extent to which their partner’s have been supportive, concerned, and attentive with respect to their genital pain problem). The WHYMPI has shown excellent internal consistency and test-retest reliability, as well as good construct reliability (Kerns, Turk, & Rudy, 1985; Bruckhardt & Jones, 2003). The Cronbach’s alpha for the three WHYMPI items included in this study was excellent at 0.983.  Pain Catastrophizing Scale (PCS): The PCS is 13-item self-report measure developed to assess pain catastrophizing tendencies. Respondents rate the frequency in which they experience thoughts and feelings associated with pain on a 5-point scale ranging from 0 (not at all) to 4 (all the time). The PCS instructions and questions were adapted to specifically address the 	  30	  experience of genital pain. Participants were asked to reflect on past experiences of genital pain and to indicate the degree to which they experienced each of the 13 thoughts or feelings when experiencing genital pain. The PCS yields a total score and three subscale scores, including: pain rumination, pain magnification, and feelings of helplessness. Higher scores represent higher pain catastrophizing tendencies. Cronbach’s alpha for the PCS among women in the current sample was excellent at 0.960. Additional Vulvar Pain Questions: Participants were asked a genital pain qualifier question, inquiring as to whether they have experienced any genital pain, either during sexual intercourse or other day-to-day activities (e.g. tampon insertion, urination etc.). Women who endorsed this question were then asked to fill out the genital pain measures described above. Participants were also asked to rate genital pain intensity (0= no pain at all, 10 = worst pain ever) and genital pain unpleasantness (0 = not at all unpleasant, 10 = most unpleasant ever) during intercourse on two separate 0-10 Likert scales to gauge the sensory and affective dimensions of pain (Pukall, Kandyba, Amsel, Khalife, & Binik, 2007).  Data Analysis A canonical correlation was used to evaluate the multivariate shared relationship between disordered eating pathology and genital pain, with the five measures of disordered eating entered as the independent variables set (EDI-3: Bulimia, Drive for Thinness, Body Dissatisfaction; RRRS: Eating Guilt, Restrictive Eating) and four measures of genital pain entered as the dependent variables set (FSFI-Pain, MPQ Total, Pain Unpleasantness ratings, Pain Intensity ratings). In order to make mean comparisons between women with clinically significant genital pain (n = 297) and women without pain (n = 379), participants were dichotomized based on the FSFI Pain clinical cut off score of 3 (Wiegel, Meston, & Rosen, 2005).  Due to differences in 	  31	  sample sizes between the two groups, Mann-Whitney U tests were conducted to test for significant group differences in eating disorder pathology. Zero-order correlations were carried out on the genital pain group examining disordered eating symptoms in relation to genital pain quality, intensity, and unpleasantness. The whole sample was then categorized into three groups corresponding to the EDI-3 Eating Disorder Risk clinical ranges for elevated (T score > 57; n = 177), typical (T score = 46-56; n = 270), and low (T score < 45; n = 407) levels of disordered eating pathology. A Oneway Analysis of Variance (ANOVA) was used to examine mean differences in sexuality variables between the three groups. Results Sample and Subsample Characteristics  The means and standard deviations of disordered eating variables and genital pain variables for Study 2 participants are presented in Table 1. Due to the nature of the questionnaires assessing genital pain, only women who were sexually active within the 4 weeks prior to participation and reported a history of experiencing genital pain were included in the canonical correlation analysis (n = 328). Similarly, only women who had been sexually active either with a partner or themselves within 4 weeks prior to participation (n = 676) were included in the Mann-Whitney U tests comparing women with significant genital pain (n = 297) to those with little or no pain (n = 379). Again, the genital pain versus little to no pain groups were created by dichotomizing the FSFI Pain score according to the clinical cutoff of 3 (Wiegel et al., 2005), with women falling below 3 comprising the genital pain group, and those falling above 3 comprising the little to no pain group. Means and standard deviations of disordered eating and sexuality variables amount women with clinically significant genital pain and little to no pain are shown in Table 3. The entire sample (n = 854) was included in the ANOVAs testing for 	  32	  group differences in women with elevated (n = 177), typical (n = 270), or low (n = 407) eating disorder risk. Means and standard deviations of sexuality variables among women with elevated, typical, and low eating disorder risk are presented in Table 4. The mean age group for all subsamples fell within twenty-years old.  Of the subsample of women who endorsed experiencing genital pain (n = 404), mean scores on the WHYMPI indicated that women reported their significant other as being extremely supportive of (M = 5.98, SD = 2.17) and attentive to (M = 5.26, SD = 2.14) their experience of genital pain, as well as fairly worried (M = 4.18, SD = 2.14) about their genital pain problem.  Canonical Correlation Analysis of Disordered Eating Predicting Genital Pain The canonical correlation analysis yielded four functions with squared canonical correlations (Rc2 ) of .316, .228, .121, and .014 for each successive function. Collectively, the full model across functions was statistically significant using the Wilks’s λ = .439 criterion, F(20, 1029) = 2.76, p < .001, suggesting that disordered eating pathology is associated with the experience of sexual pain. Because Wilks’s λ represents the variance unexplained by the model, 1 – λ yields the full model effect size in an r2 metric. Thus, for the set of four canonical functions, the r2 type effect size was .160, which indicates that the full model explained approximately 16% of the variance shared between variable sets.   The dimension reduction analysis was used to test the hierarchal arrangement of functions for statistical significance. As noted, the full model (Functions 1 to 4) was statistically significant. Functions 2 to 4 were also statistically significant, F(12, 823) = 1.79, p < .05. Function 3 to 4, and Function 4 (the only function that was tested in isolation) did not explain 	  33	  a statistically significant amount of shared variance between the variable sets, F(6, 624) = .78, p > .05, and F(2, 313) = .03, p > .05, respectively.   Given the Rc2 effects for each function, only the first two functions were considered noteworthy in the context of this study (16% and 7% o the shared variance, respectively). The last two functions only explained 1.5% and .1% of the remaining variance in the variable sets after the extraction of the prior functions.   Table 5 presents the standardized canonical function coefficients and structure coefficients for Functions 1 and 2. The squared structure coefficients are also given as well as the communalities (h2) across the two functions for each variable. Of the Function 1 coefficients, relevant dependent variables were MPQ Pain and FSFI Pain. This conclusion was supported by the squared structure coefficients. MPQ Pain and FSFI Pain also had larger canonical function coefficients than pain intensity and unpleasantness ratings. The structure coefficient for MPQ Pain was positive, and negative for FSFI Pain, suggesting that disordered eating was related to greater genital pain.   Regarding the independent variable set in Function 1, MPQ Pain and FSFI Pain were the primary contributors to the independent variable set. MPQ Pain and FSFI Pain were related to more eating pathology across all disordered eating variables. These results were generally supportive of the hypothesized relationships between disordered eating and genital pain.  Mean Differences in disordered eating among women with and without clinically significant genital pain To reiterate, Mann-Whitney U tests were conducted to examine mean differences in 	  34	  eating pathology between the genital pain and little to no genital pain groups. Means and standard deviations for the genital pain group and little to no genital pain group are presented in Table 3. Cohen’s d was used as a measure of effect size. The Independent Samples Mann-Whitney U tests rejected the null hypothesis for Bulimia (p < .001, d = 0.29, 95%CI = -3.33 to -1.25), Body Dissatisfaction (p < .01, d = .23, 95%CI = -3.53 to -.59), Eating Guilt (p < .01, d = .18, 95%CI = -1.66 to -.27), and Body Shape Concerns (p < .01, d = .23, 95%CI = 3.20 to 15.75), indicating significantly higher levels of bulimia, body dissatisfaction, eating guilt, and body shape concerns among women in the genital pain group versus the low- to no-pain group. Though the null hypothesis was not rejected for Drive for Thinness and Restrictive Eating, the mean group differences trended in the direction of rigid restraint being associated with a greater drive for thinness.   Zero-order correlations were conducted to examine the relationship between disordered eating and genital pain among women in the genital pain group (Table 6).  Pain Intensity ratings and MPQ Pain were significantly positively associated with all five measures of disordered eating, and Pain Unpleasantness ratings were significantly positively associated with all eating disorder variables except Restrictive Eating, which only trended towards significance. Sexual distress, as measured by the FSDS, was also significantly associated with greater eating pathology across all five measures of disordered eating. Genital Pain Unpleasantness and Intensity ratings, as well as MPQ pain score and sexual distress, were also significantly correlated with BSQ scores, such that more body shape concerns were associated with worse genital pain. PCS Rumination, Magnification, and Helplessness were not significantly associated with any disordered eating variable.  	  35	  Mean Differences in Disordered Eating among Women with and without clinically significant sexual distress  Mean differences in eating disorder symptoms between women with and without clinically significant sexual distress were examined via a series of Mann-Whitney U tests. The FSDS was dichotomized on the clinical cutoff score of 15 (Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002), such that those in the group < 15 were considered to not have sex-related distress, and those scoring ≥ 15 were in the clinically-significant distress group. The Independent Samples Mann-Whitney U tests rejected the null hypotheses for all measured facets of disordered eating, including: EDI-3 Drive for Thinness (p < .001, d = 0.43, 95%CI = 2.12 to 4.52), Bulimia (p < .001, d = 0.48, 95%CI = 2.25 to 4.27), and Body Dissatisfaction (p < .001, d = 0.34, 95%CI = 1.68 to 4.57), RRRS Eating Guilt (p < .001, d = 0.63, 95%CI = 1.84 to 3.17) and Restrictive Eating (p < .001, d = 0.38, 95%CI = 1.04 to 2.49), and Body Shape Concerns (p < .001, d = 0.55, 95%CI = 15.48 to 27.69) indicating that women in the clinically significant distress group had higher levels of body dissatisfaction,  body shape concerns, and eating guilt, as well as a greater drive for thinness and more bulimia symptoms.  Mean Differences in Sexuality among Women with Low, Medium, and High Eating Disorder Risk   A one-way Analysis of Variance (ANOVA) was carried out to examine mean group differences in sexuality variables among women scoring in the elevated, typical, and low clinical range of the EDI-3 for Eating Disorder Risk. A significant effect of eating disorder risk on sexual functioning was found for MPQ Pain (F(2,402) = 8.00, p < .001), and FSDS Total (F(2,828) = 14.06, p < .001), with FSFI Pain approaching significance (F(2,669) = 2.70, p = .06). Tukey 	  36	  HSD contrasts were used to examine paired comparisons for genital pain variables and sexual distress, and are depicted in Table 7. Planned contrasts revealed that MPQ Pain score was significantly different in women belonging to the elevated (p < .001) and typical (p < .05) eating disorder risk groups compared to those in the low risk group, such that greater eating disorder pathology was associated with greater genital pain intensity. FSDS Total score differed significantly between women in the elevated eating disorder risk group compared to the typical (p < .05) and lower (p < .001) risk groups. For FSFI Pain, women in the elevated risk group reported more pain than those in the low eating disorder risk group with marginal significance (p =.05). Significant group differences did not emerge for FSFI Total or the remaining FSFI subscales.  Among women who endorsed genital pain, a significant effect of eating disorder risk was found for genital pain intensity, F(2, 211) =9.91, p < .001; and genital pain unpleasantness, F(2, 211) = 6.30, p < .01 ratings. Planned contrasts revealed that women with elevated eating disorder risk reported more intense and unpleasant pain during sexual intercourse compared to women at typical (intensity: p < .01; unpleasantness: p < .01) or low (intensity: p < .001; unpleasantness: p < .01) eating disorder risk.  Discussion The aim of this study was to expand on the findings of Study 1 by more closely examining the associations between genital pain, sexual distress, and disordered eating symptoms. Specifically, the primary goal was to investigate the associations between disordered eating and the presence of sexual pain, as well as genital pain intensity, quality, and unpleasantness. It was hypothesized that measures of disordered eating would predict the 	  37	  genital pain intensity, and that higher levels of eating disorder pathology would be associated with more intense and unpleasant genital pain. In addition, women with clinically significant genital pain and women with clinically significant sexual distress, respectively, were anticipated to endorse more eating disorder symptoms compared to women with little to no genital pain and little to no distress, while women at significant eating disorder risk would report a more sexual pain than those falling below the clinical cut off for eating disorder risk.   As predicted, measures of disordered eating pathology were found to explain a significant proportion of the variance in genital pain. Together, eating disorder variables accounted for approximately 16% of the variance in measures of genital pain. The nature of this relationship was positive, suggesting that higher levels of eating disorder pathology were associated with a greater likelihood of experiencing genital pain. Pain quality, as measured by the MPQ, and dyspareunia, as measured by FSFI Pain, emerged as being the most affected facets of genital pain in relation to disordered eating. That is, women who reported greater severity in eating disorder pathology were more likely to endorse experiencing dyspareunia within the four weeks prior to participation, as well as to select more acute adjectives in describing the quality of their genital pain.   Women who endorsed clinically significant genital pain were also found to endorse more thoughts and behaviours consistent with binge eating and purging, greater body dissatisfaction, more concerns about body shape, and more food-related eating guilt. Within the subgroup of women reporting clinically significant dyspareunia, measures of eating disorder pathology were positively correlated with genital pain quality, as well as sexual pain intensity and unpleasantness ratings, and with sexual distress. That is, women reporting more intense and unpleasant 	  38	  experiences of clinically significant sexual pain and greater sexual distress were more likely to report a preoccupation with restrictive dieting, fears about weight gain, discontentment with their overall shape and with the size of specific body parts, more concerns about body shape, extraordinary guilt following the consumption of food, and a greater tendency to think about and engage in bouts of uncontrollable over eating and subsequent purging. In addition, group differences in eating disorder pathology emerged between women with clinically significant sexual distress compared to those with low to no sexual distress.  Women who reported high levels of sexual distress also exhibited a higher endorsement of bulimia, drive for thinness, body dissatisfaction, body shape concerns, eating guilt, and restrictive eating.    Consistent with our hypotheses, women with elevated levels of eating disorder risk reported more genital pain and sexual distress compared to women with typical levels of eating disorder risk, who in turn reported more sexual pain and distress than those at low risk. Similarly, women who endorsed experiencing genital pain reported experiencing significantly higher levels of genital pain intensity and unpleasantness during sexual intercourse among those in the elevated eating disorder risk group compared to those in the typical to low eating disorder risk groups. That is, women at high risk for an eating disorder reported a greater occurrence of genital pain compared to those at typical or low risk, and women with genital pain and elevated eating disorder risk were more likely to rate their experience of sexual pain as more intense and unpleasant compared to women with genital pain in the typical and low eating disorder risk groups.   Neither overall sexual function nor any other sexual function domain (besides pain and sexual distress) significantly differed between women characterized as being at elevated, 	  39	  typical, or low eating disorder risk based on questionnaire cut-offs. Although no decisive explanation for the lack of significant differences in these cases can be made, one possible explanation lies in the nature of the current sample, in that participants were overall quite sexually healthy. Of the FSFI subscales, sexual pain had the lowest mean value (M = 2.5), indicating more difficulty compared to the other sexual functioning domains (which had means ranging from 3.0 to 3.4). Similarly, only women who endorsed experiencing genital pain via the genital pain-qualifying question filled out the additional measures of sexual pain. Thus, women included in analyses of genital pain quality, intensity, and unpleasantness in relation to mean differences in eating disorder risk self-reported at least some sexual function difficulty compared to women who did not endorse experiencing genital pain. Perhaps normative baseline levels of sexual function mask any significant group differences in eating disorder risk that may be more apparent in a less sexually healthy sample.   The results of this study suggest that there is an association between disordered eating and genital pain. One possible explanation for this finding is that extreme caloric restriction results in endocrine changes that reduce vaginal lubrication, which in turn may lead to pain upon penetration attempts due to vaginal dryness. However, we unfortunately did not collect the information required to assess body mass index, and thus can not determine whether any participants were extremely calorie restricted or whether they are merely at risk. Another possibility is that eating disorder cognitions, such as feeling poorly about ones body shape and appearance, negatively impact one’s ability to feel like a sexual being. Perceiving oneself as lacking sexual desirability may in turn reduce the desire to be sexual with another person, as well as reduce sexual enjoyment, both of which have been linked to the experience of sexual pain (Berman, Berman, Miles, Pollets, & Powel, 2003). Alternatively, perhaps some third variable 	  40	  underlies the connection between disordered eating and sexual pain, such as negative affect or maladaptive personality traits, which tend to be more prevalent in women with eating disorders and women with sexual dysfunction.                	  41	  Study 3 Disordered Eating and Sexuality in Women: Genital Pain and the Mediational Role of Personality Studies 1 and 2 provided evidence for an association between eating disorders and sexuality, and perhaps sexual pain in particular. However, little is known about the mechanisms that might underlie the higher prevalence of sexual concerns among women with disordered eating symptoms. Although personality and mood disorders might relate to underlying mechanisms, to date research has not extensively focused on these characteristics. The goal of the current research was to examine psychological similarities commonly observed in women with eating disorders and women with genital pain. More specifically, this study aimed to investigate the influence of personality and mood variables on the association between eating and sexuality.   Personality styles typical of women with eating disorders have been identified, and may be relevant to expanding knowledge of sexuality in the eating disorders. Westen and Harnden-Fischer (2001) examined the extent to which personality patterns might account for meaningful variation among women with different eating disorder diagnoses, and derived three categories of patients: a high-functioning/perfectionistic group, a constricted/overcontrolled group, and an emotionally dysregulated/undercontrolled group. The high functioning/perfectionistic personality style is characterized by perfectionism, self-criticism, and negative affectivity, but also by healthy attributes such as empathy and conscientiousness. The constricted/overcontrolled personality style embodies more sever personality pathology across numerous domains, including the tendency to avoid intimacy and relationships, maladaptive representations of the 	  42	  self and others, and a tendency towards depressed mood and feelings of emptiness. The emotionally-dysregulated/undercontrolled personality style is characterized by impulsivity, emotional liability, and a tendency to desperately engage in self-destructive relationships in attempt to self-soothe. Women with AN are more likely to present with constricted/overcontrolled personalities, and the emotionally-dysregulated/undercontrolled personality is more characteristic of BN. In terms of sexual implications, women with the same eating disorder diagnosis but different personality styles might exhibit corresponding differences in sexuality. That is, the shared personality styles may account for some of the association between sexuality and disordered eating, as well as help explain discrepant findings in previous research.  Eddy et al. (2004) examined associations between these three personality styles and sexuality variables in women with eating disorder diagnoses and found clear links between sexuality and personality in eating disorder patients. Specifically, women characterized by the high-functioning/perfectionistic personality style displayed higher levels of healthy sexuality and lower levels of seductive and destructive sexuality. Women with constricted/overcontrolled personalities exhibited lower levels of healthy sexuality and tended to present themselves as being asexual, childlike in appearance or mannerisms, or prim and proper. Participants in this group were more likely to restrict their food intake, and displayed a congruently restrictive sexual style. The emotionally-dysregulated/undercontrolled group was typified by higher levels of seductive sexuality.  Women in this group had higher rates of binging and purging behaviours, and displayed a similar self-destructive and impulsive sexual style. These personality styles were found to predict a significant proportion of the variance in sexual attitudes and behaviour beyond that accounted for by eating disorder diagnosis. Such findings suggest that personality 	  43	  variables common to those with eating pathology may account for additional variability in sexual patterns.  Certain psychological variables that are highly associated with eating disorders are also highly associated with genital pain. Women suffering from genital pain, as well as women with AN and BN, exhibit similar comorbid pathology, such as significantly higher levels of anxiety and depression than controls (Desrochers et al., 2008; Pollice, Kaye, Greeno, Weltzin, 1997). Personality characteristics commonly associated with genital pain, AN, and BN also provide the rationale for an etiological link between these clinical groups, with perfectionism, shame, insecure attachment, poor self-esteem, and low self-efficacy being chief among them (Armstrong & Roth, 1989; Granot, Zisman-IIani, Ram, Goldstick, & Yovell, 2010; van Lankveld et al., 2010). Women with genital pain and women with AN or BN also share certain developmental risk factors, more specifically with regards to a greater likelihood of a history of sexual abuse (Harlow & Stewart, 2005; Waller, 1992a). Comparable patterns of sexual difficulties represent another bridge connecting these disorders, spanning issues from sexual dysfunction (problems with the sexual response cycle) to relationship function (Raboch & Faltus, 1991; Schmidt, Tiller, & Treasure, 1995). It is possible that these shared dispositions for personality and mood might represent risk factors for both eating disorders and genital pain conditions.  Anxiety & Depression Anxiety and depression have etiological similarities and they frequently occur as comorbid conditions with eating disorders and genital pain. Major depression is the most common psychiatric comorbidity in women with AN and BN, occurring both prior to illness onset and often persisting after recovery (Eckert et al., 1982). Women with eating disorders 	  44	  have a higher prevalence of anxiety disorders compared to controls, with obsessive compulsive disorder, social phobia, and generalized anxiety disorder being the most common (Pollice et al., 1997). Similarly, a prior history of anxiety and depression has been found to increase the odds of developing PVD by eleven and four times that of non-afflicted women respectively (Khandker, Brady, & Vitonis, 2011) and there is evidence that these psychological symptoms predated the onset of PVD. Numerous controlled studies of depression in relation to genital pain have found women with vaginal pain to report substantially more symptoms of depression than controls (de Jong, Van Lunsen, Robertson, Stam, & Lammes, 1995; Jantos & White, 1997). There is also much evidence to suggest that women with PVD report experiencing higher levels of anxiety compared to pain-free controls (Desrochers, Bergeron, Khalife, Dupuis, & Jodoin, 2009). One cross-sectional study found women with PVD to exhibit a phobic anxiety response to vaginal touch and entry compared to pain-free controls (Brotto, Basson, & Gehring, 2003).  Anxiety in particular may represent an important factor in the etiology of PVD. Specifically, anxiety and harm avoidance are thought to negatively impact sexual arousal, which correspondingly increase pain during vaginal intercourse (Granot, 2005). Greater pain sensitivity and anxiety may lead to the avoidance of intercourse by overestimating the level of potential harm; perhaps harm avoidance plays a similar role concerning sexual functioning difficulties in women with AN, where lubrication is often an issue due to amenorrhea. Indeed, there is evidence that anxiety and harm avoidance are as predictive of sexual attitudes and behaviours as eating disorder diagnoses (Pinherio et al, 2010).  Increased trait anxiety and harm avoidance in women with PVD are also thought to represent a complex stable of characteristics of avoidant, dependent, and obsessive-compulsive personality features. Corresponding difficulties with regards to sexual function in eating disorder patients have also been linked to impulsive-	  45	  compulsive spectrum symptoms and anxious thoughts (Pinherio et al., 2010; Wiederman & Pryor, 1997). Furthermore, avoidant and dependent behavioural tendencies represent prominent aspects of insecure attachment style, which characterizes women with PVD as well as women with AN and BN. Research on whether anxiety and depression represent antecedents or consequences of AN and PVD is needed, but fall outside the scope of this study.   Insecure Attachment Style Research on attachment style in relation to genital pain and disordered eating is sparse; however, extant research shows that both women with PVD and women with AN and BN have higher levels of insecure attachment than women without either condition. Armstrong and Roth (1989) found that 96% of the women in the disordered eating sample exhibited insecure attachment. Granot and colleagues (2010) found the majority of women in the genital pain sample to be characterized by insecure attachment style. Attachment style research suggests that sexual pain conditions are most commonly accompanied by avoidant attachment, which is characterized by the avoidance of intimacy and close relationships. Research concerning insecure attachment style and disordered eating is mixed, in that both avoidant and anxious attachment are prominent. However, AN is typically marked by avoidant attachment, as exhibited by lower levels of trust and partner satisfaction, as well as fear of emotional involvement, displays of affection, and intimacy (Eggert, Levendosky, & Klump, 2007). Women with BN are more likely to display anxious attachment, which is characterized by the tendency to be intrusive, needy, and overly dependent in relationships. According to a model proposed by Meredith, Ownsworth, and Kenny (2008), insecure attachment style is associated with chronic pain disorders and a diminished capacity to internally manage the distress associated with pain, as well as a higher vulnerability to depression, sexual abuse, parent-child violence, and eating disorders. As 	  46	  insecure attachment is common to women with genital pain and women with disordered eating, attachment style represents a viable etiological link between these two populations. Insecure attachment has also been found to be predict a variety of individual characteristics often found in women with PVD and women with eating disorders, including depression and anxiety (Blodgett et al., 2007), low self-esteem and poor self concept (Frederick & Grow, 1996), as well as perfectionism and maturity fears (Kiang & Harter, 2006).  Perfectionism Perfectionism is another important personality trait shared by women with AN and PVD. Women with PVD show more perfectionistic personality traits than controls, specifically with regards to high organizational standards and personal expectations, fear of negative evaluation, concern about making mistakes, and self-doubt in terms of performance (Brotto et al., 2003; Jantos & White, 1997; van Lankveld, 2010). One study on factors predictive of successful vaginal pain treatment found that elevated levels of self-oriented perfectionism obviated treatment completion (Ozdel, Yilmaz, Ceri, & Kumbasar, 2012). Much like women with PVD, women with AN are characterized as being highly perfectionistic relative to healthy controls. Perfectionism in women with AN is described as a “dimension of rigid, obsessive behaviours” that promote resistance to treatment and symptom relapse (pg. 147, Bastiani et al., 1995). Furthermore, two noteworthy studies found elevated perfectionism scores to persist subsequent to long-term weight restoration (Bastiani et al., 1995; Srinivasagam, Kaye, Plotnicov, Greeno, Weltzin, & Rao, 1995). Unfortunately, whether perfectionism persists after recovery from PVD has not yet been studied. There is also strong evidence to suggest that perfectionism represents a genotypic vulnerability to development of AN in terms of familial transmission of the illness (Strober, Freeman, Lampert, Diamond, & Kaye, 2000).  With regards to sexuality and AN, 	  47	  Eddy et al. (2004) found women who reported being emotionally constricted, perfectionistic, and over controlled with restrictive eating behaviours showed a correspondingly restrictive sexual style.  Trauma History PVD, AN, and BN also share potential developmental risk factors, such as sexual and physical abuse during childhood or adulthood (de Jong et al., 1995). Research exploring the etiology of eating disorders and sexual dysfunction, respectively, has documented an association between these disorders and sexual abuse (Palmer, Oppenheimer, Dignon, Chaloner, & Howells, 1990). As found in a qualitative study by de Jong et al. (1995), eight out of 18 interview participants with PVD reported first experiencing genital pain during unwanted sexual intercourse. Survey research has also documented that women who had a history of physical or sexual abuse in their youth were four to six times more likely to report vulvo-vaginal pain (Harlow & Stewart, 2005). From this work, a fear of future sexual abuse and a history of intrafamilial sexual abuse emerged as possible predictors of the development of PVD symptoms.  With respect to disordered eating samples, a study of women with eating disorders versus controls found substantially higher rates of childhood sexual abuse in the eating disorder samples (Bifulco, Brown, & Harris, 1994). Parallel to results from Harlow and Stewart (2005) concerning women with vulvodynia, Bushnell and colleagues (1992) found that women with a history of disordered eating reported higher levels of being sexually abused by an immediate family member compared to controls. Another study linked severity of eating disorder symptoms to characteristics of the abuse and found the severity of eating symptomatology to be markedly worse in cases where the abuse involved force, occurred prior to the age 14, or was intrafamilial (Waller, 1992a). It should be noted that there are also studies showing no link between 	  48	  history of abuse and PVD, and studies that find no particularly high incidence of a history of sexual abuse among women with eating disorders. With these similarities in mind, exploring self-reported sexual pain in relation to eating disorder symptom severity is appropriate. Investigation of the psychological and personality factors associated with both sexual pain and disordered eating is a promising avenue for expanding knowledge of these conditions. The goal of this study was to examine the mediating effects of certain personality variables in explaining the relationship between eating disorders and genital pain. This research also aimed to examine mean group differences in personality factors characteristic of women with eating disorders among women with clinically significant genital pain versus those with little to no pain. Women in the genital pain group were anticipated to have higher levels of maladaptive inter- and intrapersonal psychological problems compared to their relatively pain-free counterparts.  Methods Participants The SPSS database from Study 1 (n = 321, mean age = 20.51 years) was exported into the SPSS database from Study 2 (n = 854, mean age = 20.63 years). Participants for Study 3 represent the combined samples collected from Studies 1 and 2. Though there was a total of 1,175 participants in the Study 3 dataset, only 859 (mean age = 20.61 years) women were included in the analysis due to the nature of the scales used. Specifically, only women who had engaged in sexual activity within 4 weeks preceding study participation were included in Study 3 analyses.  	  49	  Procedure  As outlined in Studies 1 and 2, undergraduate women were recruited from the UBC human subject pool system and asked to complete a series of online questionnaires assessing disordered eating, sexual function, genital pain, sexual insecurities, personality, and mood. See in Study 1 Methods for descriptions of the FSFI and EDI-3. Measures of personality and mood that were included in Studies 1 and 2, and used in Study 3 analyses are detailed below. Measures Frost Multidimensional Perfectionism Scale (MPS-F):  This 35-item scale measures perfectionism by producing both a Total Perfectionism and scores for six subscales that focus on specific dimensions of perfectionism: Concern Over Mistakes, Personal Standards, Doubts About Actions, Parental Expectations, Parental Criticism, and Organization.  Participants respond to all items on a 5 point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).  Total perfectionism scores range from a minimum score of 35 to a maximum score of 1750. Our study utilizes two of the six subscales: Concern Over Mistakes (total score ranging from 9-45) and Personal Standards (7-35), which have been selectively singled out in previous studies examining perfectionism in women with AN. The MPS-F subscales have shown internal consistency and adequate concurrent validity (Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991). Cronbach’s alpha for the combined MPS-F subscales used in this study was excellent at 0.908.  Daily Hassles Scale (DHS): The DHS is a list of 117 hassles experienced in daily life generated from common stressors due to work, health, family, friends, the environment, practical considerations and chance occurrences.  Hassles relevant to each participant are rated on a 3-point severity scale (1 = somewhat, 2 = moderately, 3 = extremely).  The DHS also 	  50	  encourages participants to discuss their experience with additional hassles not included in the scale.  The total Daily Hassles score has a minimum of 0 and a maximum of 351. The DHS has shown adequate construct validity and internal consistency (Wright, Creed, & Zimmer-Gembeck, 2010). Cronbach’s alpha for the DHS was excellent at 0.971.  Depression Anxiety Stress Scales (DASS): The DASS is a 42-item measure designed to detect the presence of negative emotional symptoms.  Items are separated into three 14-item subscales: Depression, Anxiety and Stress.  Respondents rate the degree to which they have experienced each symptom within the past week on a four-point scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time).  The total score for each subscale ranges from 0 to 42, with a total minimum score of 0 and a total maximum score of 126. The DASS has been shown to have good internal consistency and discriminant validity (Lovibond & Lovibond, 1995). Cronbach’s alpha for the DASS among women in this sample was excellent at 0.928. Experience in Close Relationships Revised – Relationships Structures (ECR-RS): This 40-item scale is designed to assess attachment style orientation across four types of relationships (mother, father, romantic partners and best friends).  For each relationship, participants indicate the extent to which each item is representative of their feelings in this close relationships on a Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree).  Questions are divided into two subscales measuring anxious and avoidant attachment dimensions.  The score for each relationship subscale ranges from 10 to 70, with a total minimum score of 40 and a total maximum score of 280. In terms of psychometric properties, the ECR-RS has demonstrated good reliability (Fraley, Heffernan, Vicary, & Brumbaugh, 2011). The Chronbach’s alpha for the ECR-RS among women in this sample was excellent at 0.988.  	  51	  The Brief Fear of Negative Evaluations Scale (FNEB): This 12-item version of the Fear of Negative Evaluation Scale assesses individuals’ experience of distress in and resultant avoidance of social situations. The construct of fear of negative evaluation describes broad social-evaluative anxiety.  The FNEB correlates very highly with the original scale and demonstrates psychometric prosperities that are almost identical to those of the full-length scale (Leary, 1983). The FNEB has shown excellent construct validity, inter-item reliability, and test-retest reliability (Collins, Westra, Dozois, & Stewart, 2004). Cronbach’s alpha for the FNEB in this sample was very good at 0.800. Data Analysis Multiple mediation analyses were conducted as a means of investigating the influence of personality and mood variables on the associations between eating disorder pathology and sexual pain. In half of the models, FSFI Pain was entered as the dependent variable; in the other half FSFI Pain was entered as the independent variable. Where FSFI Pain was entered as the dependent variable, Either EDI-3 Eating Disorder Risk or RRRS Eating Guilt was entered as the independent variable and vice versa. The ECR-R (Anxious & Avoidant Attachment), MPQ subscales (Concern Over Mistakes & Personal Standards), DASS subscales (Depression, Anxiety, & Stress), FNE (Fear of negative evaluation), DHS subscales (Frequency & Accumulation), and EDI-3 personality factors (Interpersonal Problems, Affective Problems, Ineffectiveness, & Over Control) were individually entered as the mediating variables. Mann-Whitney U Tests were conducted to examine mean group differences in EDI-3 personality factors characteristic of eating disorders among women with clinically significant genital pain versus those with little to no pain.    	  52	  Results   Sample means and standard deviations for Study 3 variables are depicted in Table 9. Figure 2 illustrates the mediation models for personality variables on the relation between disordered eating and genital pain.  The overall mediation models for genital pain predicting eating guilt were significant for each set of mediating variables, including: insecure attachment (R2 = .05), perfectionism (R2 = .12), fear of negative evaluation (R2 = .02), negative mood (R2 = .08), daily hassles (R2 = .07), and EDI-3 personality factors (R2 = .18). The EDI-3 personality factors totally mediated the relation between sexual pain and eating guilt, with composite scores for Ineffectiveness, Affective Problems, and Over Control significantly contributing to the change in significance from c to c’ (F(5, 640) = 28.37, p < .001). ECR-R Insecure attachment similarly served as a total mediator on the association between sexual pain and eating guilt, with both Attachment Avoidance and Attachment Anxiety driving this effect (F(3, 464) = 9.43, p < .001). Fear of Negative Evaluations also emerged as a total mediator on the relationship of interest (F(2, 652) = 8.81, p < .001), as did perfectionism in the form of MPQ Concern Over Mistakes but not MPQ Personal Standards (F(3, 655) = 30.52, p < .001). Negative mood, as measured by the DASS, served as a partial mediator of the relationship between sexual pain and eating guilt, such that Depression but not Anxiety or Stress subscales contributed to the reduction in significance from c to c’ (F(4, 595) = 14.74, p < .001). Daily Hassles also partially mediated the relation between sexual pain and eating guilt, with the frequency but not accumulation of daily hassles driving this influence (F(3, 635) = 16.65, p < .001).  The overall reversed mediation model of eating guilt on sexual pain was significant 	  53	  for fear of negative evaluations (R2 = .03), perfectionism (R2 = .02), insecure attachment (R2 = .05), negative mood (R2 = .02), and EDI-3 personality factors (R2 = .04). Again, EDI-3 personality factors totally mediated the association between eating guilt and sexual pain (F(5, 640) = 5.40, p < .001); however, only Interpersonal Problems emerged as a significant contributor upon examination of the indirect effects. ECR-R Insecure attachment also worked as a total mediator on the association between eating guilt and sexual pain, with both Anxious and Avoidant attachment dimensions contributing to the observed effect, F(3, 464) = 7.40, p < .001. To a lesser extent, Fear of Negative Evaluations served as a total mediator of the relationship of interest as well, with the drop in significance of c’ falling just above alpha, (F(2, 652) = 8.81, p < .001). Negative mood partially mediated the association between eating guilt and sexual pain, with depression but not anxiety or stress driving this effect, (F(4, 595) = 3.26, p < .01). Perfectionism also served as a partial mediator, with concern over mistakes and not personal standards influencing this relationship, F(3, 653) = 3.76, p < .01. With eating guilt predicting sexual pain, Daily Hassles no longer significantly mediated the association of interest. Noteworthy drops in the value of R2 occurred for perfectionism, negative mood, daily hassles, and EDI-3 personality factors in the reversed model, suggesting that in these instances, sexual pain is a better predictor of eating guilt than eating guilt is a predictor of genital pain.  The overall mediation models for sexual pain on eating disorder risk were significant with respect to insecure attachment (R2 = .07), perfectionism (R2 = .11), negative mood (R2 = .11), and EDI-3 personality factors (R2 = .30). Insecure attachment partially mediated the association between sexual pain and eating disorder risk, with both Anxious and Avoidant attachment dimensions being significant contributors (F(3, 461) = 10.93, p < .001).  Negative mood served as a partial mediator on the relation between sexual pain and eating disorder 	  54	  risk, with DAS Depression and Anxiety subscales, but not Stress, representing significant contributing variables (F(4, 592) = 18.60, p < .001). Perfectionism also partially mediated the relationship of interest, with the MPQ subscale for Concern over Mistakes and not Personal Standards driving this effect (F(3, 653) = 26.34, p < .001). The EDI-3 personality factors totally mediated the relation between sexual pain and eating disorder risk, such that composite scores for Interpersonal Problems, Ineffectiveness, Affective Problems, and Over Control contributed to the change in significance from c to c’ (F(5, 650) = 55.18, p < .001). DHS subscales and FNE did not significantly mediate the relation between sexual pain and eating disorder risk.  The overall reversed mediation models with eating disorder risk predicting genital pain were significant for fear of negative evaluation (R2 = .03), insecure attachment style (R2 = .05), perfectionism (R2 = .02), negative mood (R2 = .03), and EDI-3 personality factors (R2 = .04). Unlike the original model, fear of negative evaluations emerged as a total mediator of the relation between eating disorder risk and genital pain (F(2, 650) = 8.57, p < .001). Insecure attachment was found to partially mediate the relation between eating disorder risk and genital pain, with both avoidant and anxious attachment contributing to the model, F(3, 461) = 7.92, p < .001. Negative mood partially mediated the relation of interest, with only depression representing a significant contributor to this effect, F(4, 653) = 3.46, p < .01. Perfectionism also served as a partial mediator on the association between eating disorder risk and sexual pain, with concern over mistakes but not personal standards acting as a significant mediator, F(3, 653) = 3.8, p < .01. Daily hassles partially mediated the association between eating disorder risk and genital pain with marginal significance (F(3, 653) = 3.30, p < .05); However, neither DHS frequency or cumulative severity were significantly associated with genital pain as the dependent variable in this model. EDI-3 personality subscales totally mediated the relation of eating disorder risk 	  55	  predicting sexual pain, but examination of the indirect effects suggest that only Interpersonal Problems significantly contributed to this mediation, (F(5, 645) = 5.45, p < .001). Marked drops in the value of R2 emerged with respect to perfectionism, negative mood, and EDI-3 personality factors, indicating that sexual pain is a better predictor of eating disorder risk than eating disorder risk is of sexual pain.   Mean Differences in sexual pain among women at elevated, typical, and low eating disorder risk To examine group differences in EDI-3 personality factors characteristic of eating disorders among women with clinically significant genital pain versus those with little to no pain, the FSFI Pain score was dichotomized on the clinical cutoff score and a series of Mann-Whitney U tests were conducted between the two groups. The Independent Samples Mann-Whitney U tests rejected the null hypothesis for Low Self-Esteem (p < .001, d = .30, 95%CI = .73 to 2.35), Personal Alienation (p < .001, d = .40, 95%CI = 1.27 to 2.90), Interpersonal Insecurity (p < .001, d = .28, 95%CI = .63 to 2.23), Interpersonal Alienation (p < .001, d = .37, 95%CI = 1.00 to 2.48), Interoceptive Deficits (p < .001, d = .32, 95%CI = 1.12 to 3.30), Emotional Dysregulation (p < .01, d = .27, 95%CI = .56 to 2.17), Asceticism (p < .001, d = 42, 95%CI = 1.21 to 2.54), Maturity Fears (p < .001, d = .35, 95%CI = 1.21 to 3.11). Although the null was retained for the EDI-3 Perfectionism subscale, a marginally significant trend was seen in the mean differences between these two groups, p = .063, d = .15, (95%CI = .02 to 1.70). In terms of EDI-3 personality composite scores, significant group differences emerged for Interpersonal Problems, (p < .001, d = .33, 95%CI = 3.45 to 9.85), Over Control (p < .001, d 	  56	  = .31, 95%CI = 3.31 to 9.64), Affective Problems (p < .001 d = .23, 95%CI = 1.87 to 9.10), and Ineffectiveness (p < .001, d = .31, 95%CI = 3.73 to 11.10) Discussion  Although women with genital pain conditions and women with eating disorders display a higher prevalence of psychological maladjustment in the form of negative mood and dysfunctional personality characteristics, research bridging the gap between genital pain and disordered eating is sparse.  To the authors’ knowledge, this is the first study to investigate the mediating effects of personality and mood on the relation between disordered eating and genital pain.  The goal of this study was to explore the pattern of psychological factors associated with PVD, AN, and BN on the relationship between disordered eating and genital pain in a sample of undergraduate women.    Personality and mood variables were hypothesized to mediate the relationship between disordered eating and genital pain. Because the directionality of the association between eating disorder pathology and sexual pain is unknown, mediation analyses were run twice with the independent and dependent variables reversed. In order of influence, EDI-3 personality factors, perfectionism, negative mood, daily hassles, insecure attachment, and feat of negative evaluation were found to mediate the association of interest with genital pain predicting eating guilt. Also in order of influence, EDI-3 personality factors, negative mood, perfectionism, and insecure attachment emerged as mediators of the relationship between genital pain predicting eating disorder risk. According to Cohen (1988), EDI-3 personality factors approached a medium size of effect (R2 = 30), while negative mood (R2 = .11), perfectionism (R2 = .11), and insecure attachment (R2 = .07) constituted small effects. In most cases, the reverse mediation models 	  57	  wherein eating guilt and eating disorder risk respectively predicted genital pain were also significant; however, the corresponding R2 values were consistently notably smaller, suggesting that these associations are likely best represented by genital pain predicting eating pathology. In both series of models, EDI-3 personality factors served as a total mediator of the relation between genital pain and disordered eating. This finding suggests that personality and mood variables characteristic of those with eating disorders, including low self-esteem, personal alienation, interpersonal insecurity, interpersonal alienation, interoceptive deficits, emotional dysregulation, asceticism, and maturity fears, may drive the association connecting genital pain with eating guilt and eating disorder risk. Global psychological maladjustment may underlie genital pain and disordered eating as separate conditions, with personality and mood variables acting as risk factors or vulnerabilities to the development of genital pain and eating difficulties. As the average women in this sample scored in the low risk clinical range for disordered eating pathology, these findings are likely relevant to women in the broader population. It is likely that these associations would be even greater in clinical samples of women with a diagnosis of an eating disorder.  In addition to examining the mediational role of personality and mood, I predicted differences in personality factors in the women with clinically significant genital pain compared to healthy women. As hypothesized, significant group differences arose for all EDI-3 variables save perfectionism, such that women with clinically significant genital pain reported lower self esteem, higher levels of personal and interpersonal alienation, more interpersonal insecurities, interoceptive deficits, emotional dysregulation, asceticism, and maturity fears compared to those with little to no genital pain.  	  58	  Women with relatively higher levels of genital pain were more likely to endorse interpersonal problems, or the tendency to experience social relationships that are tense, insecure, disappointing, unrewarding, and of poor quality. This is a relevant finding, as women with eating disorders often report experiencing social self-doubt and insecurity, as well as a general distrust of relationships and an inability to form attachments with others (EDI 3 manual; Clausen, Rosenvinge, Friborg, & Rokkedal, 2011). Women in the clinically significant genital pain group also exhibited higher levels of ineffectiveness compared to women in the little to no pain group, reflecting that women scoring highly on sexual pain reported lower self-evaluations and a sense of emotional emptiness indicative of the identity deficits often seen in women with eating disorders (EDI 3 manual; Clausen et al., 2011). Like many women with eating disorders, and particularly those with AN, women in the genital pain group reported significantly more interoceptive deficits than their little to no pain equivalents. Such interoceptive deficits reflect misperceptions related to accurately recognizing and responding to emotional states. Confusion surrounding affective and bodily functioning has been consistently described as an important characteristic of those who develop eating disorders (EDI 3 manual; Clausen et al., 2011). Finally, women in the genital pain group endorsed significantly more affective problems compared to their counterparts, representing a poor ability to correctly identify, understand, or respond to emotional states, as well as mood instability, liability, and impulsivity.  The literature has similarly documented problems in mood regulation to be a central factor contributing to the onset and maintenance of eating disorders (EDI 3 manual; Clausen et al., 2011). The findings of this study highlight potential mechanisms involved in the complex association between disordered eating and genital pain. As discussed in Studies 1 and 2, sexual pain appears to be associated with eating disorder symptoms, and this link seems to be 	  59	  markedly impacted by personality and mood variables common to those with eating disorder pathology. The mediation models carried out here suggest that personality and mood variables might account for some of the variance in sexual pain that is observed in relation to disordered eating symptoms. Indeed, the manifestation of disordered eating tendencies and genital pain alike may result as a function of broader patterns of emotional regulation and impulse control. This study makes a significant contribution to the dearth of literature linking personality to sexuality in the eating disorders.             	  60	  General Discussion  There is a dearth of empirical evidence examining the extent to which women with eating disorders experience difficulties with sexuality, and problems with sexual function are rarely addressed during treatment unless a history of sexual abuse is present. Even more sparse is the literature examining disordered eating and sexuality in women who exhibit eating disorder symptoms, but do not meet criteria for the diagnosis of an eating disorder. Even among women without an eating disorder diagnosis, a better understanding of the relationship between sexuality and eating-related symptoms is still relevant given the significant pressure to be thin in Western societies. Studies 1 and 2 demonstrated a link between disordered eating and sexuality, particularly in regards to genital pain and sexual distress. The association between eating disorder symptom severity and poorer sexual function and sexual insecurities was supported by the findings in this group of undergraduate women. Women with higher levels of disordered eating tended to report lower levels of sexual function, such as genital pain and sexual distress, as well as lower sexual self-efficacy and more body- and performance-based cognitive interference during sexual activity. As shown in Study 3, personality variables common to those with eating pathology were found to mediate the association between disordered eating and genital pain, and women in the genital pain group reported significantly more maladaptive personality features common to those with eating pathology compared to those in the little to no genital pain group.   These findings are consistent in part with the current understanding of how disordered eating interacts with female sexuality, in that eating disorder symptoms were associated with negative sexual outcomes. As in the present study, there have been several reports of eating 	  61	  disorder pathology being associated with reduced sexual function. Prior research on the association between disordered eating and sexual function has produced conflicting results. Women with AN tend to report low sexual desire, which is often attributed to hypogonadism and emaciation (Tuiten et al., 1993; Rothschild et al., 1991). In support of physiological causes of decreased sexual function, an increase in sexual desire is often observed upon weight restoration in women with AN. This improvement in sexual drive is thought to result from a corresponding rise in sex steroids, such as androgens, which have been found to facilitate sexual desire in women (Wahlin-Jacobsen et al., 2015), and accompany weight restoration in AN (Treasure, Wheeler, Safieh, & Russel, 1985). However, other sexual difficulties, and factors that negatively affect sexual function such as poor body esteem, tend to persist following weight restoration (Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950). Some research has shown women with AN to have more negative attitudes toward sexuality compared to controls (Beaumont et al., 1981), while other studies have found no such differences (Buvat-Herbaut, Hebbinckuys, Lemaire, & Buvat, 1983). The research on sexuality in women with BN is also equivocal, with several studies finding the sexual attitudes of women with BN comparable to controls (Mizes, 1988; Rathner & Rumpold, 1994) and other investigations finding women with bulimic symptoms to exhibit lower sexual satisfaction and sexual esteem (Allerdissen et al., 1981; Raciti & Hendrick, 1992). Conflicting results for altered sexual functioning have also emerged in the scant literature comparing sexuality in women with AN and women with BN (Cash & Deagle, 1996; Dykens & Gerrard, 1986; Morgan et al., 1999). The findings of the current research support the more prevalent body of evidence pointing towards considerable sexual concerns in relation to disordered eating.   The first study examined associations between disordered eating and multiple facets 	  62	  of sexuality, including sexual function in the form of sexual distress, sexual desire, arousal, orgasm, pain, and sexual satisfaction, and sexual insecurities in the form of body- and performance-based cognitive distractions during sexual activity, and sexual self-efficacy. Disordered eating variables tended to predict greater sexual dysfunction across all measured domains, as well as more sexual insecurities. These results are consistent with those of Castalini et al. (2012), who found AN and BN patients to score lower on sexual function domains of arousal, lubrication, orgasm, satisfaction, and pain compared to healthy controls.  Of the sexual functioning variables, genital pain and sexual distress were most impacted by higher levels of eating disorder symptoms. To investigate the relation between disordered eating and genital pain further, Study 1 also examined the meditational role of sexual insecurity variables on the association between disordered eating and genital pain. Sexual self-efficacy was found to partially mediate the association between eating disorder risk and genital pain, while cognitive distractions during sexual activity was found to serve as a total mediator of the relationship of interest, with body-related cognitive interference driving this effect. These findings compliment those of Pujols et al (2010), who found poor body image and weight concerns to be associated with lower levels of sexual satisfaction and function. More specifically, Pujols et al. found general body esteem to be associated with the frequency of distracting thoughts about one’s body during sex, suggesting that poorer body esteem may influence sexual satisfaction by increasing distress directly and indirectly through specific body-related cognitions. Previous research has also demonstrated body-related cognitive distractions during sexual activity to impair women’s sexual responses (Dove & Wiederman, 2000). To our knowledge, this is the first study to show that eating disorder risk may indirectly influence genital pain through sexual self-efficacy and body-related cognitive interference during 	  63	  sexual activity. In this vein, targeting sexual self-efficacy and sexual body-esteem during eating disorder treatment may have the potential to mitigate the impact of disordered eating on sexual pain.   Building on the genital pain findings of Study 1, Study 2 examined eating disorder pathology in relation to several facets of genital pain, including genital pain quality, intensity, and unpleasantness. Although the experience of sexual pain is often reported clinically by women suffering from an eating disorder, this study is one of the first to examine the association between genital pain and disordered eating empirically.  Results showed that measures of disordered eating together predicted measures of genital pain, with higher levels of eating disorder symptoms being associated with more genital pain. Again these findings parallel those of Castalini et al. (2012), the only other study that has investigated and found sexual pain to be experienced by women suffering from disordered eating. Findings were also consistent with the handful of case studies detailing the experience of genital pain in women with an eating disorder (Andres et al., 2013; Arcelus & Wales, 2009; Daehyun et al, 2004).  In further support of the link between genital pain and disordered eating, mean differences among women with clinically significant genital pain versus those with little to no pain found significant variation in bulimic symptoms, body dissatisfaction, eating guilt, and body shape concerns. Specifically, women in the genital pain group reported significantly more disordered eating than their relatively pain-free counterparts. Within the genital pain group, pain quality, intensity, and unpleasantness were found to be associated with eating disorder pathology, such that more disordered eating was related to more severe and unpleasant sexual pain. Similar results were seen in women reporting clinically significant sexual distress 	  64	  versus those with low sexual distress, whereby women with significant distress also tended to report significantly more disordered eating pathology. When the data were broken down by low, typical, and high eating disorder risk, women falling within the clinical cutoff for elevated risk also tended to report more prominent genital pain and sexual distress compared to those at typical risk, who again reported more sexual pain and distress than those in the low eating disorder risk group. These results provide evidence for the occurrence of genial pain in a university sample of women who also experience symptoms of disordered eating.  Study 3 investigated personality and mood variables common to those with eating pathology (as well as women with sexual pain conditions) in relation to genital pain and disordered eating. Authors of related studies have proposed that sexual functioning problems in eating disorder patients may be attributable to core symptoms such as high levels of anxiety and depression, and maladaptive personality traits (Pinheiro et al., 2010; Rodríguez, Mata, Lameiras, & Fernandez, 2007; Seeger, Braus, Ruf, Goldberger, & Schmidt, 2002; Wiederman & Pryor, 1997). However, very little research exists concerning the role of psychological features on the complex interplay of sexual function in the eating disorders. The results of the current research suggest that personality and mood variables associated with eating disorders influence sexual functioning and the relation between disordered eating and genital pain. Indeed, psychological variables may be the driving force connecting eating disorder symptoms and genital pain. As indicated by the total mediation of EDI-3 personality features on the relation between eating disorder risk and genital pain, personality and mood might explain a greater proportion of the variance in genital pain than eating disorder symptoms.  Mean comparisons of women with clinically significant genital pain versus those with 	  65	  low to no pain revealed group differences across an array of personality variables characteristic of those with eating pathology, including low self-esteem, personal and interpersonal alienation, interpersonal insecurity, interoceptive deficits, emotional dysregulation, asceticism, and maturity fears. Results suggest that that psychological maladjustment in personality and mood might underlie the association between genital pain and disordered eating. In this way, treatments targeting dysfunctional personality characteristics and negative mood might improve eating disorder pathology as well as comorbid genital pain.  These findings contribute to the need for improved understanding of the role of psychological variables and personality traits on sexual functioning problems in women with disordered eating pathology.    In sum, a clear link between disordered eating and sexuality emerged, where higher levels of eating pathology were associated with more sexual dysfunction and sexual insecurities. Of note, genital pain was measured with a brief validated measure of sexual function; however, we can make some speculations about how the findings might apply to a clinical group of women with the diagnosis of PVD.  Genital pain and sexual distress were found to be the most impacted facets of sexual dysfunction, both aspects of sexuality that typically manifest in women with PVD. Women with PVD share many of the psychological features commonly observed in women with AN and BN. The relation between genital pain and disordered eating, and the meditational role of several personality characteristics characteristic of women with an eating disorder hint at a link between these important women’s health conditions. Clinically, this study suggests that sexuality should be addressed in the context of eating disorder care. A clinician should assess for sexual functioning problems, such as sexual distress and genital pain, and sexual insecurities when treating clients with eating disorders. Likewise, eating disorder risk and eating guilt may be worth assessing within the treatment of sexual disorders, as eating 	  66	  pathology may have relevance for women suffering from sexual pain disorders such as PVD. In addition to addressing the sexual symptoms that were found to be associated with eating disorder pathology, clinicians should attend to the mediating variables found to impact this relationship. By targeting sexual insecurities, as well as personality and mood variables – all of which were found to influence the association between eating disorder risk and genital pain – clinicians may be able to indirectly attenuate corresponding disordered eating and sexual pain symptoms. In terms of specific treatments, mindfulness-based cognitive behavioural therapy has been found effective in treating women with PVD (Brotto, Basson, Carlson, & Zhu, 2013), perhaps similar interventions could be designed for women with eating disorders who are also afflicted by genital pain.  Future research examining the influence of disordered eating on altered sexuality will assist with developing approaches to treatment for addressing sexual concerns in women with eating disorders. The results yielded by this sample of young undergraduate women should be investigated in women with sexual pain conditions and women with a diagnosis of an eating disorder. The occurrence of genital pain and sexual distress in women with eating disorders might represent a potential target for psychological treatments. Future treatment research on women with eating disorders may benefit from including measures of sexual function and sexual esteem as outcome variables, along with personality and mood features related to altered sexuality that are common to those with eating pathology. Despite the compelling clinical rational, research directly supporting the important connections between genital pain conditions and eating disorders remains to be done. The results of this investigation has uncovered rational for exploring a possible etiological link between 	  67	  genital pain and disordered eating. Measuring the presence and severity of psychosocial factors common to women with genital pain and disordered eating could help lay the conceptual framework for a theory of shared etiology linking AN and BN with dyspareunia, and more specifically PVD. Such knowledge may encourage longitudinal work examining these psychosocial factors as shared antecedents and/or consequences connecting PVD and AN. Empirical research supporting the similarities between women with AN and PVD that have been observed clinically may facilitate the creation of therapeutic interventions and advancements in clinical assessment tools for both conditions.  The current series of studies represent the foundation for my doctoral research, which will investigate the prevalence and severity of disordered eating and genital pain symptoms in samples of women with AN, BN, and PVD. In addition, my doctoral work will explore the pattern of shared psychosocial factors archetypical of women with eating disorders and sexual pain conditions in clinical samples. Eventually, findings from this research will inform the development of a comprehensive treatment intervention for women suffering from an eating disorder. Depending on the results of these investigations, a similar intervention will be adapted for application to women with PVD. Given the low efficacy and high-side-effect profile of medications for the treatment of PVD (Basson, 2010) and the emerging evidence for psychological treatments, including both cognitive behavioural and mindfulness-based therapy (Brotto, Basson, Carlson & Zhu, 2013; Brotto, Basson, Smith, Driscoll, & Sadownik, 2013), there is strong justification for exploring the psychological characteristics of PVD, such as those also reflected in the clinical profiles of women with AN and BN. If significant comorbidities between PVD, AN, and BN are found, it may be useful to tailor existing psychological approaches for PVD to address likely eating disorder symptoms, and existing psychological 	  68	  approaches for AN to also address the possible presence of genital pain.  Though not explored in the current study, hormonal fluctuations tied to extreme caloric restriction likely influence sexual difficulties among women with eating disorders. Hormones that play a key role in sexual desire, such as androgens, tend to drop in women with AN when measured at low weights, and have been found to rise again following weight restoration (Treasure, Wheeler, Safieh, & Russel, 1985). As noted previously, women with AN report experiencing a drop in sexual desire, and a corresponding increase in sexual desire upon weight restoration. Sex steroids are required for genital tissue structure and function (Goldstein, 2006), and prior research suggests that low androgen levels may be involved in the development and maintenance of sexual pain (Harlow, Vitonis, & Stewart, 2008; Goldstein, Burrows, & Goldstein, 2010; Pessina, et al., 2006; Song et al., 2008). Sexual pain has been reduced by testosterone treatment in women with androgen insensitivity syndrome (Goldstein & Burrows, 2008), and vestibulodynia has been successfully treated with topical estradiol and testosterone (Burrows & Goldstein, 2013). Given the associations between androgens and sex steroids in relation to restrictive eating and sexual pain conditions, further exploration of common hormonal factors involved in these conditions is needed  Investigation of the psychological factors associated with both sexual pain and disordered eating is a promising avenue for expanding knowledge of these conditions. Research of this nature will further knowledge on possible personality variables and psychosexual factors that may influence the development and maintenance of genital pain conditions and eating disorders. Because there is a substantial body of research on the psychological characteristics of women with AN and BN in relation to treatment outcomes, evidence supporting a connection 	  69	  between these conditions and PVD could aid future research on PVD treatments. Similarly, research on improving sexual function in women with PVD might inform the treatment of sexual concerns in women with an eating disorder. This program of research provides an opportunity to bridge these common and distressing women’s health conditions and make a meaningful contribution that will ultimately improve the lives of Canadian women.   Limitations This study is not without its limitations. Most importantly, the data in this investigation are correlational in nature, so no causal inferences can be drawn regarding the relations between disordered eating and sexuality. As no causal inferences can be drawn, we are unable to ascertain whether differences in disordered eating directly cause changes in sexual function or vise versa. As suggested by Study 3, it is likely that other variables, such as personality and mood, play a significant role in the association between disordered eating and genital pain. Secondly, the participants in this study were a relatively homogenous group, predominantly consisting of young, Euro-Caucasian and East Asian undergraduate students. In this way, the results of this study may have limited generalizability. Additionally, our results were collected online through self-report, web-based questionnaires. However, past research has indicated that online surveys provide a high level of anonymity and are therefore fairly robust to a variety of response biases (Booth-Kewley, Larson & Miyoshi, 2007). Furthermore, advertisements for this study revealed the sexual nature of the questions participants would be asked to answer, meaning that more sexually liberal individuals would have been more likely to respond to the survey. This is an important limitation for the majority of human sexuality research (Morokoff, 1986; Saunders, Fisher, Hewitt, & Clayton, 1985). I discuss the findings of this study in terms of sexual 	  70	  difficulties, but a limitation in this study was that sexual disorders and dysfunctions, such as PVD, were not assessed, which requires a comprehensive interview and clinical exam. With this in mind, I predict that these relationships would be even stronger in a clinical sample.	  71	  Tables Table 1.  Means and standard deviations of disordered eating variables and genital pain variables in Studies 1 & 2  Study 1  Study 2  Variables M SD M SD EDI-3 Eating Disorder Risk 142.06 32.77 143.18 32.34 Drive for Thinness 10.82 7.79 10.68 7.82 Bulimia  6.74 6.73 6.76 6.63 Body Dissatisfaction 15.94 9.36 15.87 9.32 RRRS     Eating Guilt 19.44 4.42 19.34 4.51 Rigid Restraint 15.30 4.81 14.97 4.78 BSQ Total 96.62 40.17 95.55 40.97 FSFI Total 10.22 9.87 18.30 4.77 Desire 3.38 1.22 3.38 1.24 Arousal 3.2 1.18 3.16 1.24 Lubrication 3.32 1.09 3.30 1.16 Pain 2.54 1.83 2.53 1.85 Orgasm 3.00 1.35 2.96 1.43 Satisfaction 3.17 1.23 3.13 1.24 FSDS (Sexual Distress) 10.23 9.87 10.00 9.58 	  72	   Study 1 Study 2 Variables M SD M SD  CDDSA     Body 41.64 14.47 41.79 14.53 Performance 40.54 14.29 40.53 14.40 SSESF Total 50.37 33.00 49.65 32.73 Interpersonal Orgasm 43.46 34.52 43.32 34.59 Interpersonal Interest 56.80 36.08 54.92 35.83 Sensuality 59.96 39.84 58.50 39.78 Individual Arousal 49.34 37.41 48.01 37.29 Affection 59.96 36.87 59.65 37.02 Communication 46.62 36.20 45.15 36.10 Body Acceptance  47.53 36.05 47.94 35.82 MPQ Pain Score ---	   ---	   24.32 18.41 PCS     Rumination ---	   ---	   2.65 3.87 Magnification ---	   ---	   1.51 2.16 Helplessness ---	   ---	   2.64 4.32 Pain Unpleasantness Rating --- --- 3.05 1.97 Pain Intensity Rating --- --- 3.19 2.25 	  73	  Table 2. Zero-order correlations between disordered eating variables and sexuality variables  RRRS EDI-3 BSQ Sexuality Variables Eating Guilt Restrictive Eating Body Dis-satisfaction Drive 4 Thinness Bulimia Body Concerns FSFI Total --- --- -.22*** -.16* -.34*** ---    Arousal --- --- -.17*** --- -.30*** ---    Desire --- --- -.15* --- --- ---    Lubrication --- --- --- --- -.28*** ---    Orgasm --- --- --- -.14* -.20*** ---    Satisfaction --- --- -.16* --- -.19*** ---    Pain -.17** --- -.21*** -.15* -.34*** -.17** FSDS Sexual Distress .30*** .17** .23*** .22*** .32*** .35*** CDDSA-Body -.39*** -.26*** -.51*** -.48*** -.49*** -.58*** CDDSA-Performance -.34*** -.21*** -.34*** -.38*** -.43*** -.45*** SSESF Total -.16** --- -.30** -.22** -.27** -.19***    Interpersonal Orgasm -.16** --- -.27*** -.20*** -.27*** -.24***    Interpersonal Interest -.16** -.10* -.30*** -.20*** -.25*** -.27***    Individual Arousal --- --- -.21*** --- .11* ---    Affection --- --- -.21*** -.16** -.21*** -.16**    Communication -.17** --- -.30*** -.21*** -.26*** -.23***    Body Acceptance -.33*** -.19*** -.57*** -.45*** -.44*** -.54***    Refusal -.15** --- -.30*** -.22*** -.27*** -.26*** 	  74	  Table 3. Means and standard deviations of disordered eating and sexuality variables among women with clinically significant genital pain and little to no pain.  Genital Pain Group  Low to No Pain Group  (n = 297) (n = 379) Variables M SD M SD EDI-3 Eating Disorder Risk 146.12	   34.47	   139.54	   31.50	  Drive for Thinness 11.21	   9.14	   10.30	   8.13	  Bulimia  8.04	   7.54	   5.75	   5.71	  Body Dissatisfaction 16.64	   9.70	   14.58	   9.14	  RRRS 	   	   	   	  Eating Guilt 19.85	   4.68	   18.89	   4.39	  Rigid Restraint 15.11	   5.05	   14.84	   4.75	  BSQ Total 100.82	   42.74	   91.33	   38.92	  FSFI Total 15.07	   5.30	   21.72	   2.25	  Desire 3.34	   1.14	   3.88	   1.01	  Arousal 3.08	   1.64	   3.23	   0.78	  Lubrication 2.85	   1.57	   3.66	   0.39	  Pain 0.71	   1.02	   4.03	   0.43	  Orgasm 2.51	   1.64	   3.31	   1.12	  Satisfaction 2.48	   1.45	   3.63	   0.74	  FSDS (Sexual Distress) 13.59	   10.66	   8.62	   8.35	  	  75	   Genital	  Pain	  Group	   Low	  to	  No	  Pain	  Group	  Variables M	   SD	   M	   SD	   CDDSA 	   	   	   	  Body 38.43	   15.18	   44.94	   12.00	  Performance 36.77	   14.70	   43.65	   12.00	  SSESF Total 45.62	   29.85	   65.17	   28.49	  Interpersonal Orgasm 36.51	   31.44	   60.54	   31.07	  Interpersonal Interest 47.77	   32.75	   73.89	   28.58	  Sensuality 55.06	   38.22	   76.00	   32.58	  Individual Arousal 51.80	   36.05	   59.24	   35.01	  Affection 58.51	   36.03	   72.01	   32.52	  Communication 39.98	   33.77	   61.90	   32.50	  Body Acceptance  40.63	   34.85	   62.83	   32.51	  Refusal 58.13	   36.00	   58.13	   36.00	  MPQ Pain Score 27.33	   20.39	   23.05	   16.64	  PCS 	   	   	   	  Rumination 2.97	   4.11	   2.39	   3.58	  Magnification 1.73	   2.51	   1.37	   1.90	  Helplessness 3.15	   4.93	   2.32	   3.89	  Pain Unpleasantness Rating 3.38	   2.21	   2.88	   1.74	  Pain Intensity Rating 3.54	   2.49	   3.00	   2.00	  	  76	  Table 4. Means and standard deviations of sexuality variables among women with elevated, typical, and low eating disorder risk Sexuality Variables Elevated (n = 177) Typical (n = 270) Low (n = 407) M SD M SD M SD FSFI Total 18.01 4.86 18.32 4.84 18.41 4.69 Desire 3.38 1.27 3.45 1.22 3.33 1.124 Arousal 3.29 1.32 3.14 1.25 3.12 1.19 Lubrication 3.38 1.16 3.28 1.15 3.28 1.16 Orgasm 2.91 1.29 2.94 1.44 3.00 1.39 Satisfaction 2.99 1.31 3.19 1.28 3.16 1.19 Pain 2.28 1.85 2.52 1.81 2.65 1.86 FSDS Sexual Distress 13.25 10.61 10.43 9.88 8.36 8.52 MPQ Pain Quality 29.32 20.67 25.12 18.32 21.61 16.96 Pain Intensity Rating 3.56 2.25 3.15 2.06 2.76 1.71 Pain Quality Rating 3.58 2.52 3.31 2.25 2.94 2.094 CDDSA       Body 55.85 15.10 41.52 13.16 30.82 12.55 Performance 48.9 15.55 40.39 13.50 32.33 13.04 SSESF Total 40.21 30.62 46.32 32.52 55.85 32.53 Interpersonal Orgasm 34.75 32.69 40.3 34.15 48.9 34.75 Interpersonal Interest 44.11 34.47 51.93 35.27 61.47 35.46 	  77	  Sensuality 51.47 39.35 54.61 40.45 64.03 38.84 Sexuality Variables Elevated  Typical Low  M SD M SD M SD  Individual Arousal 44.66 36.84 45.18 36.26 51.31 37.97 Affection 49.33 35.98 57.35 37.36 65.55 36.19 Communication 35.73 33.06 42.06 35.31 51.19 36.82 Body Acceptance 21.67 27.93 43.71 33.12 62.02 33.44 Refusal 36.82 35.12 48.44 38.05 54.74 37.23  	  78	  Table 5. Standardized canonical function coefficients and structure coefficients for Functions 1 and 2  Function 1 Function 2 Variable Standardized Weights Structure Coefficients Standardized Weights Structure Coefficients MPQ Pain .713 .812 .020 .070 FSFI Pain -.619 -.708 -.491 -.418 Pain Intensity .256 .394 1.212 .812 Pain Unpleasantness .079 .317 .464 .406  	  79	  Table 6. Correlations between genital pain variables and disordered eating variables among women in the genital pain group. 	   RRRS	   EDI-­‐3	   BSQ	  Genital	  Pain	  	  &	  Sexual	  Distress	   Eating	  Guilt	   Restrictive	  Eating	   Body	  Dissatisfaction	   Drive	  for	  Thinness	   Bulimia	   Body	  Concerns	  Intensity	   .21**	   .14*	   .25***	   .30***	   .22***	   .23***	  Unpleasantness	   .16*	   .12^	   .19**	   .23***	   .20**	   .20**	  Quality	  (MPQ)	   .16*	   .13*	   .14*	   .15*	   .21**	   .16*	  Sexual	  Distress	   .32***	   .21***	   .21***	   .24***	   .24***	   .36***	  Note: p = .06^, p < .05*, p < .01**, p < .001*** 	  	  	  	  	  	  	  	  	  	  	  	  	  80	  Table	  7.	  Tukey	  HSD	  contrast	  coefficients	  for	  genital	  pain	  variables	  and	  sexual	  distress	  among	  elevated,	  typical,	  and	  low	  eating	  disorder	  risk	  groups	  Sexuality Variables EDI Risk (I) EDI Risk (J) Mean Difference (I-J) MPQ Pain Score 1 2 3.800 3 9.054*** 2 3 5.257* FSFI Pain 1 2 -.298 3 -.427* 2 3 -.129 Genital Pain Intensity 1 2 -.847**   3 -1.221***  2 3 -.374 Genital Pain Unpleasantness 1 2 -.882**   3 -1.052**  2 3 -.170 FSDS (Sexual Distress) 1 2 3.060**   3 4.626***  2 3 1.566 	  81	  Table	  8.	  Tukey	  HSD	  contrast	  coefficients	  for	  sexual	  insecurity	  variables	  among	  elevated,	  typical,	  and	  low	  eating	  disorder	  risk	  groups	  Sexuality Variables EDI Risk (I) EDI Risk (J) Mean Difference (I-J) CDDSA Body 1 2 -11.528***   3 -15.634***  2 3 -4.106*** CDDSA Performance 1 2 -8.737***   3 -11.668***  2 3 -2.932** SSESF Total 1 2 -8.110*   3 -16.290***  2 3 -8.18** Interpersonal Orgasm 1 2 -7.332^   3 -15.277***  2 3 -7.945** Interpersonal Interest 1 2 -9.873**   3 -17.777***  2 3 -7.904** Sensuality 1 2 -6.305   3 -13.556***  2 3 -7.251^ Individual Arousal 1 2 -1.808 	  82	  Sexuality Variables EDI Risk (I) EDI Risk (J) Mean Difference (I-J)    3  -7.401^  2 3 -5.593 Affection 1 2 -9.534*   3 -16.021***  2 3 -6.487^ Communication 1 2 -8.700*   3 -16.245***  2 3 -7.548* Body Acceptance 1 2 -24.425***   3 -40.595***  2 3 -16.169*** Refusal 1 2 -13.119***   3 -16.859***  2 3 -3.740 Note: 1 = elevated risk, 2 = typical risk, 3 = low risk Note: p < .09^, p < .05*, p < .01**, p < .001*** 	  	  	  83	  Table	  9.	  Means and standard deviations for personality variables analyzed in Study 3 across women in the genital pain group, little to no pain group, and whole sample.	  	   GP	  Group	   Non	  GP	  Group	   Whole	  Sample	  Personality	  &	  Mood	  Variables	   M	   SD	   M	   SD	   M	   SD	  MPS-­‐F	   	   	   	   	   	   	  Concern	  over	  Mistakes	   23.47	   7.05	   21.76	   7.15	   22.52	   7.06	  Personal	  Standards	   26.45	   6.40	   25.82	   6.04	   25.79	   6.31	  Fear	  of	  Negative	  Evaluations	   19.27	   7.51	   17.27	   8.28	   18.12	   7.92	  DHS	   	   	   	   	   	   	  Frequency	   48.43	   26.61	   44.05	   24.53	   45.78	   26.03	  Cumulative	  Severity	   23.92	   33.30	   19.66	   31.35	   20.78	   31.31	  Intensity	   0.43	   0.48	   0.35	   0.44	   0.38	   0.47	  DAS	   	   	   	   	   	   	  Depression	   5.65	   4.86	   4.64	   4.33	   5.08	   4.67	  Anxiety	   4.18	   4.16	   3.58	   3.54	   3.82	   3.81	  Stress	   5.91	   4.43	   5.46	   4.12	   5.53	   4.29	  ECR-­‐RS	   	   	   	   	   	   	  Attachment	  Avoidance	   4.46	   0.93	   4.74	   0.81	   4.59	   0.87	  Attachment	  Anxiety	   3.51	   1.86	   3.02	   1.73	   3.27	   1.78	  EDI-­‐3	  Global	  Psychological	  Maladjustment	   393.96	   76.11	   367.67	   72.41	   380.08	   73.18	  	  84	  	   GP	  Group	   Non	  GP	  Group	   Whole	  Sample	  Personality	  &	  Mood	  Variables	   M	   SD	   M	   SD	   M	   SD	  	  Maturity	  Fears	   	  10.95	   	  6.28	   	  8.78	   	  65.98	   	  10.23	   	  6.24	  Ineffectiveness	  	   99.03	   24.47	   91.62	   23.61	   95.88	   23.73	  Low	  Self-­‐Esteem	   6.86	   5.38	   5.32	   5.05	   6.21	   5.23	  Personal	  Alienation	  	   8.25	   5.47	   6.16	   4.97	   7.24	   5.23	  Interpersonal	  Problems	  	   100.24	   21.16	   93.59	   20.52	   97.18	   20.97	  Interpersonal	  Insecurity	   7.72	   5.30	   6.29	   4.97	   7.23	   5.18	  Interpersonal	  Alienation	   7.33	   5.01	   5.59	   4.53	   6.50	   4.75	  Affective	  Problems	  	   98.07	   24.47	   92.59	   22.67	   94.51	   23.48	  Interoceptive	  Deficits	   10.34	   7.23	   8.13	   6.70	   9.11	   6.94	  Emotional	  Dysregulation	   6.15	   5.63	   4.78	   4.65	   5.23	   4.99	  Over	  Control	  	   101.02	   21.00	   94.54	   20.42	   96.62	   20.81	  Perfectionism	   12.04	   5.36	   11.18	   5.47	   11.27	   5.43	  Asceticism	   7.19	   4.96	   5.34	   3.95	   6.10	   4.43	  	  85	  Figures Figure 1. 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