Genito-Pelvic Pain or Penetration Disorder (Sexual Pain Disorder)
Extreme discomfort or pain experienced by women while attempting or engaging in sexual intercourse can be deeply distressing, reduce sexual desire, and disrupt relationships. Genito-pelvic pain/penetration disorder may involve a number of causes and symptoms, both physical and psychological, and a clinician can help an individual or couple take steps toward restoring a healthy sex life.
The disorder involves difficulty having intercourse and feeling significant pain upon penetration. The severity can range from a total inability to experience vaginal penetration to the ability to experience penetration in one situation but not another. For example, a woman might not feel discomfort when inserting a tampon but might experience intense pain when attempting to have vaginal intercourse.
Genito-pelvic pain/penetration disorder was previously referred to as a sexual pain disorder consisting of dyspareunia (pain in the pelvic area during or after sexual intercourse) or vaginismus (an involuntary spasm of the musculature surrounding the vagina causing it to close, resulting in penetration being difficult, painful, or impossible).
The number of women with genito-pelvic pain/penetration disorder is not known, but it is estimated that 15 percent of women in North America experience recurrent pain during intercourse, according to the DSM-5. The disorder is associated with other challenges, including reduced sexual desire and avoidance of any genital contact that might cause pain. As a result, many women living with the disorder may have problems in their romantic relationships, and many report that their symptoms make them feel less feminine.
Signs and symptoms of genito-pelvic pain/penetration disorder, as cataloged by the DSM-5, include persistent or recurrent difficulties with one (or more) of the following:
- Vaginal penetration during intercourse.
- Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
- Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
- Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
To be diagnosed with genito-pelvic pain/penetration disorder, a patient's symptoms must be present for at least six months and cause clinically significant distress. Also, the sexual dysfunction should not be better explained by a nonsexual psychiatric condition or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors, nor be attributable to the effects of a substance, medication, or another medical condition.
Genito-pelvic pain is most commonly reported during early adulthood and in the peri- and postmenopausal periods.
Many individuals avoid communicating about sexual problems because they fear it would harm the relationship, hurt their partner’s feelings, or lead to personal vulnerability and shame. But open communication can help couples solve their problems and enjoy a healthy sex life. Sexual pain is no exception; women should tell their partner how they feel during sex so that their partner can better understand their experience and support them in working with a professional to treat the condition.
The disorder can be characterized as being lifelong or acquired. The specifics of the disorder's development are not known, but factors relevant to its cause and treatment may include:
- A partner's health status or challenges with sexual intercourse.
- Relationship factors, such as differences in sexual desire or a lack of communication.
- Individual vulnerability, such as a history of abuse or poor body image.
- Cultural and religious attitudes toward sexuality.
- Medical concerns such as infections or conditions that cause pain in the genito-pelvic region.
An important risk factor for the development of genito-pelvic pain/penetration disorder is pain during tampon insertion. Many women may also experience an increase in genito-pelvic pain-related symptoms during the postpartum period or after a history of vaginal infections.
Research indicates that many women who experience pain during sex do not tell their partner about their pain or seek professional help to alleviate it. The reasons for this include feelings of embarrassment or shame, stigma around female pleasure, outdated cultural scripts about prioritizing male pleasure, and the fact that many clinicians don’t ask about sexual pain.
Treatment and outcome of genito-pelvic pain/penetration disorder depends on the cause of the pain. A clinician can help to determine a diagnosis and consult on appropriate treatment.
- For painful intercourse after pregnancy, gentleness and patience should be exercised.
- For painful intercourse in menopausal women, lubricants and estrogen-containing creams or medications may be used as prescribed.
- For painful intercourse caused by endometriosis, medications can be obtained. Surgery may also be an option and might provide total relief.
- For painful intercourse due to other complications, disease, or psychological factors, a healthcare provider can offer the best means of intervention tailored to the specific reason for the pain.
At a clinical visit, a patient's medical history will be obtained and a physical examination performed. Detailed medical history questions documenting difficulty with intercourse could include:
- When did the pain first develop?
- Is intercourse painful every time that it is attempted, or only some of the time?
- Has it always been painful?
- Is intercourse painful for your partner as well?
- Is the pain in the labia, the vagina, or the entire pelvic area?
- Does the pain occur during entry?
- Have you experienced a significant traumatic event in your past, such as rape or child abuse?
- Are you currently being treated for any illnesses, diseases, or disorders?
- Are you currently taking any medications?
- Has there recently been a significant emotional event in your life?
- What steps have you taken to try to make intercourse less painful? How well have they worked?
- What other symptoms are you experiencing?
Unless the problem is clearly caused by one person's physical issues, a couple should see the doctor together. If a physical problem is suspected, tests will be ordered.
Good hygiene and routine medical care may help to some extent. Adequate foreplay and stimulation will aid in ensuring proper lubrication of the vagina. The use of a water-soluble lubricant like K-Y Jelly may also help. (Vaseline should not be used as a sexual lubricant. It is not water-soluble and may lead to vaginal infections.)
Treatment of Vaginismus
Dyspareunia (painful intercourse) inhibits sexual interest as well as responsiveness. In some situations vaginismus may occur, causing the vaginal muscles to involuntarily contract and clamp down as a self-protective way of avoiding the anticipated discomfort. The treatment of choice for vaginismus is an extensive therapy program combining education and counseling about sexual anatomy, physiology, the sexual response cycle, and common myths about sex, as well as exercises including Kegel exercises (pelvic floor muscle contraction and relaxation) to improve voluntary control. Vaginal dilation exercises using plastic dilators may also be recommended, but should be done under the direction of a therapist or other health care provider. Treatment should involve the partner as much as possible; this should include gradually more intimate contact culminating in intercourse.
Sex therapists often work with both members of a couple to treat sexual pain. In this context, sex therapists may educate the couple about genito-pelvic pain or penetration disorder, refer the woman suffering from pain to a medical professional, discuss how sexual pain may have impacted the relationship, address feelings of shame, anxiety, or distress, teach communication skills, develop a treatment plan, and discuss sexual alternatives that may be feasible.