Individual Counseling, Couples Counseling and Sex Therapy

Female Sexual Pain and CBT

Female Sexual Pain is a prevalent, yet commonly misunderstood and misdiagnosed group of disorders.  Let’s begin with some definitions.  Sexual pain disorders are defined in the DSM-IV TR as either dyspareunia or vaginismus.  Dyspareunia is pain associated with intercourse that is troublesome to the individual and not caused exclusively by medical conditions.  Vaginismus is an involuntary spasm of the outer third of the vagina that prevents sexual intercourse, causes the individual distress, and is not due exclusively to a medical condition.  Vulvodynia, pain in the vulvar, and its subtype, provoked vestibulodynia (also referred to as vulvar vestibulitis), pain in the vulvar vestibule area, are both types of dyspareunia.  Clinically, it is difficult to separate dyspareunia and vaginismus, as they often occur together.

Female sexual pain disorders are prevalent and can have devastating effects on women’s health and happiness.  Statistics vary, but most researchers estimate that the rate of dyspareunia is 20% in the general population.  Vaginismus rates seem to be lower, with the National Institutes of Health reporting rates of 30% in a primary care setting and 1 – 5 % in the community.  Because many researchers have found healthy, positive and satisfying sexual behavior to be important for women’s health and happiness, these statistics point to the importance of accurate diagnosis and effective treatment to women’s well-being.  Yet, according to one research study, only 60% of pain sufferers seek treatment, and only 40% receive a diagnosis.

If these disorders are prevalent and can have such a negative effect on women’s health and happiness, why don’t clinicians have a better understanding of these disorders?  One reason is that the research and clinical community can’t seem to agree on how to conceptualize these disorders.  The main disagreement seems to center around whether or not these disorders should be classified, and therefore treated, simply as pain disorders; or if there is something “different” about them that warrants inclusion into their own unique category.  Another reason could be the lack of research.  Although recently there is renewed interest, historically there has been a dearth of information on the topic.  Finally, there is confusion and misunderstanding about the etiology of the disorder.

Because it is thought that there are psychological elements to pain, many practitioners include psychological and behavioral elements when treating female sexual pain disorders.  Researchers have reported that women with a sexual pain disorder can benefit from sexual education, improving sexual skills, improving communication, physical therapy (such as vaginal dilation or Kegel exercises), addressing cognitive disorders; and using behavioral interventions like sensate focus, visualization and relaxation exercises.

Because Cognitive Behavioral Therapy addresses the connection between thoughts, feelings and behaviors, many researchers think CBT may be a viable alternative in treating female sexual pain.   The main idea behind using CBT is that by changing the thoughts around the pain we can actually change the pain experience.

Several research studies have shown that CBT (whether in group, individual, or bibliotherapy format) is initially somewhat effective in treating female sexual pain disorders.  However, a few studies indicated that biofeedback, Supportive Psychotherapy and medication were equally or more effective.  In fact, one study showed that vestibulectomy (excising a portion of the vulvar) was significantly more effective.  However, both vestibulectomy and medication are considered more invasive treatment than CBT, making them less desirable.

CBT is not completely benign. One study showed that it decreased marital satisfaction.  A possible reason for this is the lack of any type of couples’ therapy.  And, not all studies showed lasting effects.  Interestingly, non-randomized studies showed lasting effects, but randomized studies did not.

More research needs to be done with regard to the effectiveness of CBT for female sexual pain.  In particular, there was a lack of information on individual treatment, and how the inclusion of couples’ therapy might affect the results.

It is my experience and opinion that many interpersonal and relationship factors are present in most sexual experiences for women.  Sex does not occur in a vacuum.  For most women, factors such as how the woman feels about herself, how she feels about her partner, her past experiences, how she perceives her partner feels about her, etc., are relevant in a woman’s sexual expression.  Because female sexual pain is associated with the genitals, and is usually experienced during some form of sexual expression, it is my opinion that female sexual pain is tied to the sexual experience.  Because sexual experiences are tied to relationship factors, therefore so is female sexual pain.  Thus I disagree with the opinion that female sexual pain should be treated as any other pain disorder.  Rather, it needs to be addressed both in a sexual and a relational context.

It is these unique features of female sexual pain that indicate the need for more comprehensive interventions.  Treatment should include some form of assessing how the woman feels about herself as a sexual being, her body image, how desirable she feels she is, how she views sexual expression, her past sexual experiences and what her parents may have taught her about sex.  There is a possibility that a woman’s negative view of herself as a sexual being could block good and positive sexual feeling and create tension, thus making the pain worse.  This could create a vicious cycle: as the pain gets worse she thinks more negatively about her sexuality, which worsens the pain, and so on.

Relationship factors are also important to consider.  Most women present because they cannot have sexual intercourse with their partners, which is negatively affecting their relationship because it is inhibiting intimacy.  Some women present with not wanting their partner to touch them in a sexual way due to the fear of pain.  Either way, it is inarguable that the couples’ intimacy is adversely affected.  Once intimacy is reduced, it is much easier for the couple to begin building misunderstandings, hostility, and eventually, resentments.  For the woman, once this happens it is likely she will blame herself, which will worsen the negative thoughts she has about her pain and her genitalia, thus worsening the condition.  For the man, he may feel frustration but not communicate his feelings to his wife because he is afraid of making the situation worse.  All of these negative dynamics are appropriately fodder for couples’ therapy.

In conclusion, female sexual pain is difficult to understand and treat due to differing clinical conceptualizations and the lack of research.  Unfortunately, this condition is prevalent and can have deleterious effects on a woman’s well-being.  Although initial results from CBT treatment appears to be positive, future research and study is necessary, particularly in the areas of individual CBT treatment and the inclusion of couples’ therapy.

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