‘By the time we see couples, there is no hand-holding, let alone sex': how to treat female sexual pain
But how a person responds to sex can be complex, and female sexual pain can greatly affect a couple.
'A lot of pelvic health conditions are still taboo for many and, to be fair, most people do not discuss their sexual health with others,' says Linsey Blair, a couple and individual psychotherapist and psychosexual therapist with the
Evidence Based Therapy Centre
(EBTC) in Galway.
'It may be more difficult to discuss if one is feeling they are not functioning 'normally'. I think things are changing, but very slowly. We need to end the stigma associated with sexual health conditions and create awareness around options available for people to get solutions. Sometimes, people just don't know the help is there.'
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Female sexual pain disorders present with a variety of symptoms, including pain or discomfort with penetration or being unable to tolerate any penetration whatsoever, be that with a digit, a tampon, menstrual cup or penis. Pain is not specifically internal, but also on the vulva, the outer genitals.
'A woman who previously could have pain-free sex may start to experience pain or discomfort,' says Sylvia Farrell, a chartered physiotherapist specialising in women's and men's pelvic health. 'There are many possible reasons for this, including trauma related to childbirth if scarring is present from tearing, episiotomy or invasive medical procedures.'
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'Many women are taught they should put up with it': What to do about painful sex
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Farrell notes there are also hormonal changes that can happen at different life stages for women, namely around menopause when these variations can cause structural changes or affect the vagina's lubricant, which in turn may impact how comfortable or enjoyable sex is.
How couples deal with a pain disorder can impact marital sexual satisfaction. Most often this comes down to communication being the barrier, rather than the pain disorder itself.
'When a woman finds penetration sore or uncomfortable, instead of explaining this to her partner and seeking help, she may start to withdraw from sex,' explains Blair. 'This often means that all forms of touch get withdrawn in case they lead to sex. By the time we see couples, there is no hand-holding, hugging or light touch, let alone sex. This is not directly because of the female pelvic pain disorder.'
When couples are affected by female sexual pain, Blair and Farrell note that the first step is to seek help in identifying the pain and managing a plan on how best to treat it, which could be seeking support from a pelvic health physio or sex therapist. Ideally, both.
'A burning, friction pain during penetration may simply be lack of lubrication or using a lubricant that is causing a reaction,' says Farrell, who treats the condition from a physical point of view. 'It could also be a sign that the couple are moving to penetration too soon. If the pain is a deep pain that occurs in certain sexual positions, again it could be penetrating too soon. If the pain is a stinging, tearing pain and the penis cannot get in, this is a vaginismus-type pain.'
Equally, Blair, who would seek to treat the pain from an emotional or psychological perspective, believes that sexual pain is always trying to communicate something, and so while it is helpful to treat it physically, it is also important to explore what is happening emotionally.
'I have seen female sexual pain develop as a result of stress either in the couple's relationship or related to other external factors,' she says. 'If a couple are going too fast to penetration this might be painful for the female. After repeated sexual experiences of pain, the vagina will start to react and 'brace' itself for the pain by tightening, which unfortunately leads to more pain, and so a disorder that needs physio input might start to develop.
'I would not automatically assume that the symptomatic partner is the one with the problem and if this is fixed all will be fine. If the issue is related to stress or problems in the relationship dynamic or individual trauma then it will not be fixed by a physical treatment plan alone.'
Blair also points out that, often when sexual pain occurs, rather than the couple immediately discussing it, they keep trying the same things again and again, hoping maybe next time will be better. 'This just reinforces the pain cycle,' she says. 'If there is a lot of pelvic or genital pain, I would simply engage much more with the rest of the body and play around with the parts that often get left out like the feet, ears, stomach, backs of legs that are all very sensitive to touch.
'Just moving away from the genitals will actually help the body relax and the muscles, including the pelvic floor, will start to soften. This alone isn't a cure for sexual pain, but it is a way to keep the couple connected sexually without retriggering and thereby reinforcing the pain response.'
Farrell and Blair have developed a joint model of pelvic health physio and couples therapy at EBTC as a whole body and mind approach to female sexual pain disorders.
'The body and mind are constantly relating and impacting one and other,' says Blair. 'When a tear after birth occurs, the body's response to pain causes the mind to begin fearing penetration or physical touch and the minds solution is to get the body out of danger by withdrawing from touch. The anxiety caused by the mind then feeds back into the body and strengthens the pain response because anxiety in the body causes more muscle tension.'
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Blair also suggests that if there is a history of sexual trauma, then the mind will associate sex with negative and frightening emotions. As with traumatic birth experiences, this fear around sex will then get into the body and cause a bodily response of tightening that can then lead to pain and reinforce the idea of sex being dangerous.
'These are psychological issues that have led to a somatic response,' says Blair. 'There is no issue that is just somatic and when we work with sexual pain it is obviously not just psychological.'
Farrell and Blair have identified that the dual approach of sessions with a sex therapist and a pelvic health physio, who continually liaise and adjust treatment plans in accordance with new information, makes for a very effective form of treatment.
Additionally, the sex therapist can help the couple create more intimacy in their relationship. Overall, the intervention is a holistic approach to somatic-led pain.
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