The disorders that were previously discussed above were classified according to the three phases of the Sexual Response Cycle. However, this next set of disorders is not easily categorized in that way.
Sexual Pain Disorders: The O in OUCH! I thought Sex was supposed to feel good!
The DSM-IV-TR lists two sexual pain disorders: dyspareunia and vaginismus. While they both share the component of pain, vaginismus only applies to women as it involves painful spasming of the outer third of the vagina that interferes with sexual intercourse. Sexual pain disorders rarely affect men. But when men are affected by sexual pain, it most often has a bio-medical cause. Such is not the case for women. Interestingly, researchers have had difficulty pinpointing an exact cause of the sexual pain disorders for women. It appears that in women the cause can be medical, psychological, or include a combination of medical and psychological factors (Wincze, Bach, & Barlow, 2008). Factors such as religious orthodoxy, low self-esteem and poor body image, traumatic sexual experiences, conditional anxiety, and fear responses have been thought to play a role in the development of sexual pain disorders (Masters & Johnson, 1970). While a history of sexual abuse comes to the mind of many when they hear sexual pain, some researchers have found that women who have dyspauerunia are not any more likely to have a history of sexual abuse than women who do not have dyspauerunia.
The DSM-IV-TR defines vaginismus as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. Some researchers have suggested perhaps sexual pain disorders represent a continuum of pain and that vaginismus might simply be the severe phobic end of the dyspareunia spectrum (Meana & Binik, 1994). Biological causes of vaginismus are similar to those hypothesized for dyspauerunia. For example, one well identified cause of sexual pain is vulvar vestibulitis which is a condition whose cause is multifactorial and is thought to be related to the nervous system, musculoskeletal system, immune system, and vascular system. It essentially involves pain and vaginal redness at the entry of the vagina when penetration is attempted or when the area is touched.
From a psychological perspective, vaginismus is thought to be a learned response that developed from a paired association of pain and sexual intercourse. A paired association is another principle of Behaviorism. It refers to how two or more unrelated events can become linked together, and incorrectly learned as one event causing (or associated with) the other. In this case, a paired association occurred when the woman experienced painful intercourse: intercourse equals pain. Avoiding intercourse relieves the anxiety that results from fearing the pain associated with intercourse. This ultimately reinforces the avoidance of sexual activity (Meana, Binik, & Thaler, 2008). More can be learned about this reinforcing effect of avoidance and its relationship to anxiety by reading the article on anxiety (coming soon). Vaginismus mostly occurs when intercourse is attempted and women describe it as "hitting a wall" when penetration is attempted. This may also occur when penetration is attempted using a finger, a tampon, or a speculum (Wincze, Bach, & Barlow, 2008).
The DSM-IV-TR defines dyspareunia as recurrent or persistent genital pain associated with sexual intercourse. Dyspareunia is thought to occur in 3-18% of women (Simons & Carey, 2001) and for most women the pain is located at the entrance of the vagina. The nature, duration, and intensity of pain can be different for different individuals but often occurs during sexual intercourse (Wincze & Carey, 2001).
Dyspareunia can interfere with sexuality and may result in disruptions in individual and relational well-being (Bauer, Moniek, Laan, & Trimbos, 2009). Clearly, if sex is painful your sexual relationship with your partner is likely to be impacted. However, dyspareunia as a sexual pain disorder has been questioned and criticized by researchers and theorists arguing that dyspareunia may be better classified as a sexual pain disorder rather than a sexual dysfunction because the pain associated with dyspareunia is not always limited to sexual activity (Binik, Reissing, Pukall, Flory, Payne, & Khalife, 2002). For example some women also report pain during any activity that requires penetration (i.e., tampon use, gynecological exams). In fact, some women experience pain with any type of genital contact (i.e., merely wearing panties). Furthermore, the sexual pain disorders appear to be disorders than impact sexuality but are not inherently sexuality-based. Simply put, the main feature of these disorders is pain and painful sex is an unfortunate outcome of that pain.
When it comes to dyspareunia, other sexual dysfunctions seem to go hand-in-hand. For example, women who have dyspareunia are more likely to have difficulty with arousal and lubrication, are less satisfied with their sex life, and experience more negative feelings during sexual activity than women who do not have dyspauerunia. Furthermore, research has indicated that women with dyspareunia report impaired sexual functioning, higher levels of sexually-related personal distress, more negative sexual attitudes, and a more negative appraisal of their latest sexual experience than controls (Brauer, Ter Kuile, Laan, & Trimbos, 2009).
In addition to other sexual dysfunctions going hand-in-hand with dyspareunia, it seems that other mental health conditions are often present as well. For example, both depression symptoms (e.g., Brotto, Basson, Gehring, 2003), somatization disorder (Schover, Youngs, & Cannata, 1992), and anxiety (e.g., Granot & Lavee, 2005) have been found in women who experience pain with intercourse. In fact, recent research has suggested that anxiety sensitivity, and anxiety related to physical health concerns, are more common among women who report pain during intercourse than among women who do not (Meana, & Lykins, A. 2009). This in no way implies that depression, somatization, or anxiety cause dyspauerunia or vice versa; they merely seem to co-occur with unusual frequency.
Sexual Pain Disorders-Treatment Options
In terms of treatment of the sexual pain disorders, women may wish to see a pelvic floor therapist. The pelvic floor is a group of muscles, tissue, and ligaments that connect from the pubis bone in front to the tailbone in back. They act as a sling and support the internal organs and promote bowel and bladder continence. The pelvic floor plays a very important role in sexual function, especially when pain is involved. Thus, individuals suffering from a sexual pain disorder may need to undergo a thorough evaluation of the pelvic floor and may be encouraged to engage in pelvic floor exercises. Pelvic floor therapists can also provide education regarding the physical and anatomical characteristics of the genitals. Additionally, the may instruct women to use vaginal dilators, engage in pelvic floor muscle strengthening exercises, and relaxation exercises. Individuals experiencing pain may be instructed to avoid irritants such as synthetic garments, detergents, and feminine products (Rosenbaum, 2007). In cases where vulvar vestibulitis (a.k.a. vulvodynia) is the cause, treatment may include surgery where the tissue that is causing the pain is removed.
It is important to keep in mind that relationship factors may play a role in the development, maintenance, and/or worsening of dyspareunia. Therefore if it is important that relationship factors be addressed. While many women report their partners are understanding and supportive, they also report feeling as though their partners may become impatient or unhappy because of the decreased frequency of intercourse and the chronic complaints about the sexual pain (Davis & Reissing, 2006). For more information see here.
Our next category of disorders, called Paraphilias, increases the complexity of the distinction between normal or healthy, and abnormal or unhealthy.