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reportedly they both felt "it was his problem." The whole notion of treatment format is complex, but couple cooperation is the key to good treatment, not necessarily the couples mutual attendance in the clinicians office (Perelman, 2003b). It took 10 weekly sessions for him to reach his goal of three successive coital experiences. Before reintroducing masturbation, he was weaned from sildenafil. For a couple of months, he split the sildenafil into smaller pieces, until he "forgot" to take it at all! The couple experienced a "second honeymoon," and Janice was thrilled with his increased interest in sex with her. George was advised to use the sildenafil as needed during future periods of either physical or emotional stress. With his physicians guidance he could wean himself on and off the drug as the situation warranted. He was advised about the possibility of age-associated symptoms and offered coping strategies. George began masturbating again but limited the speed and pressure to what he experienced inside his wifes vagina. Suggestions were provided to help him relax in advance of bedtime. He declined a referral to a sleep specialist. At 2-year follow-up he was still masturbating as a soporific periodically; however, the frequency was self-titrated to monthly to ensure that it would not interfere with the now again preferred coitus.

Partner issues affect males ejaculatory interest and capacity, but two require special attention: fertility and resentment. The pressure of a womans "biological clock" is often an initial treatment driver. The woman—and often the man—usually resist(s) intrusions on their plan to conceive. If the therapist suspects the patients DE is related to fear of conception, he or she should inquire about the patients ability to experience ejaculation with contraception but not during "unprotected" sex. Such a "test" serves as a powerful diagnostic indicator. If the DE occurs only during "unprotected" sex, the therapist can assume that conception is a primary concern. The therapist must then find an acceptable way to refocus the treatment temporarily on the issues responsible for the patients ambivalence. Resolving those issues typically requires individual work with the man and occasionally with the partner. Fortunately, the high levels of motivation that usually characterize fertility-related cases improve prognosis.

**Case 2**

James, a 34-year-old lawyer, was referred to his urologist for infertility treatment by his wifes gynecologist. James and Joan (32) had been married 4 years, had failed to conceive, and did not want to wait to pursue infertility treatment. James reported difficulty with ED and DE over the previous months. His urologist diagnosed a testicular transposition, noting that Jamess right testis was behind the left. Also observing Jamess severely scarred frenulum, the urologist recommended circumcision, as well as correction of the transposition. Surgery was scheduled in 3 months, during Jamess upcoming vacation. A varicocelectomy was also discussed due to a palpable varicocele. Another urologist reconfirmed the surgical recommendations. The varicocelectomy recovery period would have delayed potential conception by approximately 6 months. The urologist prescribed tadalafil and, in his referral note, suggested that couple treatment might help minimize the impact of the delays caused by 145

the surgery.

The couple was first evaluated individually, followed by a conjoint session. They were in love and eager for a child. Each feared he or she had "caused the infertility." James suggested that his ED might be related to both work stress and the performance pressure he felt when Joan was ovulating.

Although these issues exacerbated the problem, it was clear from the history that there was another reason for Jamess DE. He preferred masturbation to coitus, and he did this at high frequency and in an idiosyncratic manner (due to early injury). He had torn the frenulum of his penis (secondary to penile adhesions of his uncircumcised penis) during an adolescent coital experience. Subsequently, any time he attempted coitus, his penis would bleed, and he had pain. He developed an intense fear of hurting himself during coitus and avoided it. Unfortunately, he never discussed this with any of his physicians, nor did they ask him direct questions about his sexual response. These critical facts emerged in his first session. The challenge was helping him feel safe sharing this information with his wife, as he felt ashamed. Based on her first consultation, it was clear that she would be supportive. She was relieved to understand why this man she loved seemed to avoid sex. He was a gentle and generous lover, and she was content with their sex life but wanted a baby.

The sex therapy expanded his repertoire of orgasmic variability, and within 90 days of beginning treatment Joan became pregnant. James would have willingly suffered to impregnate her, but of course that was not necessary. General sex education, counseling, and some sex therapy exercises were provided. He first stopped masturbating and later altered his style and frequency. He was instructed to move his body during coitus in a manner as to not hurt himself and instead enhance both his own and his partners pleasure. After the pregnancy, the urologist performed a circumcision so that James would not have to be so precise in his movements and the likelihood of pain could be reduced. Finally, after the birth of their child, the urologist performed the varicocelectomy, which did benefit the quality, quantity, and motility of Jamess sperm (which were indeed subnormal despite the successful pregnancy). E-mail follow-up included thanks and the babys first-birthday photo! A recent follow-up 2 years later informed me that Joan was pregnant with their second child.

Fertility-related or not, anger toward the partner is an important causal factor and must be ameliorated through individual and/or conjoint consultation. Anger acts as a powerful anti-aphrodisiac, and although some men avoid sexual contact entirely when angry, others attempt to perform, only to find themselves modestly aroused and unable to function. The mans assertiveness should be encouraged, but the therapist should also remain sensitive and responsive to the impact of change on the partner, as well as to alterations in the couples equilibrium.

As treatment progresses, interventions may be experienced as mechanistic and insensitive to the partners needs and goals. In particular, many women respond negatively to an impression that the man is essentially masturbating himself with her body, as opposed to engaging in connected lovemaking. This perception is exacerbated when men need pornography to distract themselves from negative thoughts in order to 146

function. Indeed, because these men are sometimes disconnected emotionally from their partners, the therapist must help the partner become comfortable with the idea of postponing greater intimacy. Once the patient is functional, the therapist can encourage a man toward greater sensitivity. Alternatively, both partners may be disconnected from each other but otherwise in a valued stable relationship. The therapist must support the patients goals but not push the man (or couple) unnecessarily toward a preordained concept of success. Here, the concept of "good enough sex" provides guidance (Metz & McCarthy, 2007).

Not all cases treated resolve themselves so easily. Often, an orgasm with coitus is obtained but is not preferred in reality. These men will frequently need support from the therapist to express their preference for noncoital orgasms, especially when their coital orgasms were less satisfactory and obtained only by painstaking effort. However, therapists who readily negotiate compromises with a couple whose female partner prefers noncoital stimulation should recognize the parallel with men suffering from coital DE. Therapists must assess their own prejudices and assist couples in identifying workable sexual scripts regardless of gender. Yet for some men with DE, partner psychopathology, values regarding pornography, and relationship issues may predetermine failure.

Often the most difficult cases are men suffering sexual sequelae subsequent to prostate cancer, whether treated surgically, medically, or with radiation. In these cases vibratory devices become desirable, as greater stimulation is required secondary to the damage caused by the cancer treatments. Devices for this purpose are being evaluated by urologists (Nelson, Ahmed, Valenzuela, Parker, & Mulhall, 2007; Tajkarimi & Burnett, 2011). Sex therapists should focus on the many patients who are often disheartened by their sexual side effects secondary to prostate cancer treatments, even when the patient received proper informed consent guidance from their physician in advance of that treatment (Perelman, 2008). Yet sex therapists may find themselves humbled when rehabilitating a response that is severely anatomically limited. As one man treated for post-prostatectomy orgasmic change said, "it used to feel like a jet engine . . . it became a

paperclip after surgery. Youve got me back to a prop plane, and that is what I need to live with." Certainly, the greater the anatomical damage, the more psychotherapy facilitates adjustment to the loss rather than restoration of function. Of course, when less information has been provided to the patient regarding potential adverse side effects of treatment, the matter becomes even more complex and difficult to manage.

**CONCLUSIONS**

In summary, high-frequency idiosyncratic masturbation, combined with fantasy–

partner disparity, often predisposes men to experience problems with arousal and ejaculation. An integrated and individually nuanced sex therapy that is derived from an appreciation of multidimensional etiology and supports multidisciplinary cooperation is the optimal treatment today (see Figure 6.3). Should a safe and effective drug become 147

available, a major paradigm shift toward combining drugs and sex therapy when treating DE will occur, as happened when PDE5s became available to treat ED. Better understanding of the ejaculatory process may lead to pro-ejaculatory drugs (most likely dopaminergic), but there will always be a role for sex therapy.

**FIGURE 6.3**. DE treatment algorithm.

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**Pain**

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**CHAPTER 7**

Genital Pain in Women and Men

It Can Hurt More Than Your Sex Life

Sophie Bergeron, Natalie O. Rosen, and Caroline F. Pukall

**T** he experience of genital pain during intercourse is extremely distressing to both the sufferer and her or his partner, who may feel confused, guilty, sympathetic, and/or deprived. The consequences of this problem extend beyond sexual intercourse and affect individual psychological heath, as well as relationship satisfaction. "Our clinical experience suggests that dyspareunia is not a condition that can be treated successfully by any single health professional." This conclusion reached by Bergeron, Rosen, and Pukall is a sobering reminder that dyspareunia is a complex set of problems that requires multidisciplinary assessment and treatment. They point out that sex therapists are ideally positioned to coordinate treatment efforts. Traditionally, medically oriented treatment interventions are delivered in a linear fashion, from the least (e.g., topical creams) to the most invasive (e.g., surgery) and risk-laden options. However, in reviewing the treatment literature for dyspareunia, the authors note that when multiple interventions targeting different etiological mechanisms are delivered simultaneously rather than sequentially, treatment may be more efficient, effective, and engaging for patients, their partners, and the treating professionals. Bergeron and colleagues point out that cognitive-behavioral sex therapy/pain management is an empirically validated noninvasive therapeutic option and is likely a good starting point in the multimodal management of dyspareunia. They also point out new research concerning genital pain in men, suggesting that the idea of dyspareunia as a "womans problem" may not be accurate.

**Sophie Bergeron, PhD,** is an Associate Professor of Psychology at Université de Montréal. She is the author and coauthor of numerous articles, chapters, and conference presentations on the topics of dyspareunia and vulvodynia.

Dr. Bergerons research focuses on the treatment outcome of dyspareunia, as well as on the role of psychosocial variables in the experience of sexual pain, with an emphasis on romantic relationship factors. Her work has led to the development and empirical validation of a cognitive-behavioral group intervention for women with dyspareunia. She has served on the Executive Committee of the Society for Sex Therapy and Research and is on the editorial board of Archives of Sexual Behavior.

**Natalie O. Rosen, PhD,** is a Registered Clinical Psychologist and an Assistant Professor in the Department of Psychology and Neuroscience, Dalhousie University. She is cross-appointed at the Department of Obstetrics and Gynaecology at the IWK Health Centre in Halifax, Nova Scotia.

**Caroline F. Pukall, PhD,** is an Associate Professor in the Department of Psychology at Queens University and the Director of the Sex Therapy Service at the Psychology Clinic. Dr. Pukall received the Department of Psychology Teaching Award in 2011. Her research focuses on vulvodynia (i.e., chronic genital pain in women), sexual difficulties (e.g., sexual arousal issues, vaginismus), womens health issues, and same-sex relationships. Her work is funded by several organizations, including the Canadian Institutes of Health Research and the National Vulvodynia Association. Dr. Pukall is an Associate Editor for the Journal of Sexual Medicine and is on the editorial board of several journals, including Archives of Sexual Behavior.

"Will I ever enjoy sex?"; "Is there something physically, psychologically, and sexually wrong with me?"; "Do I still love my partner?"; "Is the pain all in my head?"; "Am I still a woman?"; "Can my relationship survive this?" Most women and men who suffer from 152

genital pain will ask themselves questions such as these as they struggle to understand and cope with this distressing problem, which negatively affects their sexuality and romantic relationship.

Nearly all health professionals have seen a woman or a couple who suffers from genital pain, whether they know it or not. Estimates of the prevalence of genital pain range from 6.5% to 45% in older women and from 14 to 34% in younger women (van Lankveld et al., 2010). Further, 20% of sexually active adolescent girls reported vulvovaginal pain during intercourse lasting more than 6 months (Landry & Bergeron, 2011).

Genital pain, often causing dyspareunia (painful intercourse), can result from underlying physical pathologies such as endometriosis, interstitial cystitis, lichen sclerosis, and other genital infections (e.g., candidiasis, herpes, bacterial vaginosis) but also from events such as childbirth and menopause. Genital pain can also fall under the general term of vulvodynia—which is characterized by a burning pain for which there are no relevant physical findings. The International Society for the Study of Vulvovaginal Disease (ISSVD) classifies vulvodynia into two symptom presentations: localized, which involves a portion of the vulva, and generalized, which involves the entire vulva (Moyal-Barracco & Lynch, 2004). The most common subtype of localized vulvodynia is provoked vestibulodynia (PVD), characterized by a burning pain that is elicited via pressure to the vulvar vestibule or attempted vaginal penetration in sexual and nonsexual contexts. Some women report suffering from pain located deeper in the vaginal canal, which often manifests as deep dyspareunia. Unfortunately, little research has been conducted with this population in order to accurately describe the condition, and the involvement of mental health professionals has been limited. The information presented in this chapter, however, is likely still pertinent for women experiencing deeper vaginal/pelvic pain.

Despite strong arguments in favor of a pain conceptualization (Binik, 2010), DSM-5

(American Psychiatric Association, 2013) has retained dyspareunia in the category of sexual dysfunction. Furthermore, dyspareunia and vaginismus have been collapsed into a single diagnostic entity called genitopelvic pain/penetration disorder, due to considerable overlap between the two conditions. The diagnostic criteria for this new disorder include difficulty with at least one of the following: (1) experiencing vaginal penetration; (2) pain with vaginal penetration; (3) fear of vaginal penetration or of pain during vaginal penetration; (4) pelvic floor muscle dysfunction. The change emphasizes the multidimensional aspects of genital pain.

**ASSESSMENT**

A study found that only 60% of women who reported chronic genital pain sought treatment, and 40% of those women never received a diagnosis (Harlow, Wise, & Stewart, 2001). This finding highlights the importance of routinely inquiring about genital pain. Direct questions are often necessary, as many women will not volunteer 153

information about sexual problems (Lindau, Anderson, & Gavrilova, 2007).

During her annual visit to her gynecologist, Sandy complained about her menopausal symptoms. She did not mention pain during intercourse, but when her physician asked about it, she began crying and said that it was what bothered her the most about the hormonal changes and how much this was taking a toll on her sex life with her husband.

Assessment and diagnosis of dyspareunia should include the organic, cognitive, affective, behavioral, and interpersonal factors that may be involved in the onset and persistence of genital pain. Creating an open, validating, and nonjudgmental context for the assessment is essential.

The psychosocial assessment should begin with a detailed evaluation of the pain, including (1) properties of the pain, such as onset, temporal pattern, pain duration, location (superficial or deep), quality, and severity; (2) factors that may ameliorate or exacerbate the pain; (3) interference of the pain and other comorbid issues (e.g., other sexual problems, relationship and/or psychological distress); (4) personal explanations for the pain; and (5) previous treatment attempts and outcomes. It is important to ask about genital pain during nonsexual activities (e.g., urination, tampon use), which will demonstrate an understanding of whether the pain influences other aspects of womens lives. Next, a sexual history should include the womans sexual activities, both partnered and unpartnered; prior sexual experiences; and the impact of the pain on sexual desire, arousal, orgasmic capacity, and frequency of intercourse, as well as sexual satisfaction.

The final component is an assessment of the cognitive, affective, behavioral, and interpersonal dimensions of the pain in both the woman and her partner, if she is in a relationship. Several important cognitive distortions may play a role in genital pain and in treatment outcomes, including catastrophizing, hypervigilance, and pain self-efficacy (i.e., the belief in ones ability to control the pain). Affective reactions, such as fear of pain and heightened anxiety or depression, are also common. These responses likely contribute to the extensive avoidance, which can go beyond vaginal intercourse, seen in many women and couples. Finally, how the pain affects relationship dynamics, as well as how relationship factors may affect the pain and sexual impairment, need to be carefully assessed. These factors may include partners responses to the pain that are solicitous ("Are you okay? Any pain?"), negative ("It doesnt hurt—its all in your head!") or facilitative ("Lets try a sexual activity that is not painful for you"), as well as the degree of emotional self-disclosure about the pain and subsequent validating and invalidating partner reactions. As the following vignette illustrates, sometimes the difficulty involves misinterpreted communication:

Nancy, a young woman in her twenties, had been experiencing dyspareunia for the last 3 years. In therapy, she and her partner explored the different ways in which they communicate about the pain. Nancy revealed that when John said, during sex, "Its been so long," it made her feel inadequate and was experienced as pressure to engage in intercourse. John was in fact trying to express how much he enjoys his intimacy 154

with her. However, John was empathic to Nancys distress and did not invalidate her take on their interaction. He subsequently was able to find other ways to convey his pleasure to Nancy.

Standardized self-report questionnaires (e.g., Female Sexual Function Index: Rosen et al., 2000; McGill Pain Questionnaire: Melzack, 1975) may complement, but should never replace, a thorough psychosocial assessment. These measures may be useful for making comparisons with clinical norms or to assist in tracking treatment progression.

A physician or gynecologist knowledgeable about genital pain should take a medical history and conduct a gynecological examination. The examination should include a cotton-swab test, which consists of palpating different areas of the vulva and asking the woman to rate the intensity of the pain (e.g., on a scale from 0–10), as well as vaginal and cervical cultures to exclude infection-related pain. If possible, careful palpation of the uterus and adnexae using a small speculum and/or a transvaginal sonographic assessment may be performed for deep genitopelvic pain (van Lankveld et al., 2010).

**ETIOLOGY OF GENITAL PAIN**

Historically, genital pain has been considered to be a consequence of either physical factors or psychological and sexual difficulties, despite recent research and theorizing suggesting that these two perspectives can and should be combined. We have proposed an integrated model taking into account the interdependency of biopsychosocial factors in genital pain and its associated impairments.


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Response:
**Biomedical Factors**

A number of biomedical risk factors have been found to be more common in women with genital pain than in controls, including: early puberty and pain with first tampon use, vulvovaginal and urinary tract infections, early and prolonged use of oral contraceptives, nociceptor proliferation and sensitization, and lower touch and pain thresholds (see van Lankveld et al., 2010). A recent study using a mouse model of PVD

showed that recurrent yeast infections can cause persistent vulvar pain by replicating important features of human PVD such as allodynia (Farmer et al., 2011). These findings suggest that both peripheral and central mechanisms play an etiological role in genital pain.

Studies investigating pelvic floor muscle (PFM) dysfunction indicate that abnormalities of the PFM while at rest, including hypertonicity and poor muscle control, hypersensitivity, and increased mucosal sensitivity, may close the vaginal hiatus and thus interfere with penetration. Women may also exhibit a defensive reaction of the PFM during attempted vaginal penetration. A vicious cycle involving the pain and further muscle dysfunction makes it difficult to identify cause and effect and is 155

complicated by the involvement of psychosocial factors.

**Cognitive, Affective, and Behavioral Factors**

A recent study found that adolescent girls suffering from genital pain reported experiencing more sexual abuse, as well as a greater fear of physical abuse, than those who did not report genital pain (Landry & Bergeron, 2011). Further, a population-based study of adult women found that sexual, physical, and psychological abuse was linked to a four- to sixfold increased risk of genital pain in adulthood (Harlow & Stewart, 2005).

Additional factors that predict greater pain intensity, sexual impairment, or both include pain catastrophizing, fear of pain, hypervigilance to pain, lower self-efficacy, negative attributions about the pain, and anxiety (Desrochers, Bergeron, Landry, & Jodoin, 2008).

Current cross-sectional study designs do not allow us to identify whether psychosocial factors precede the pain experience or whether the pain intensity heightens these factors and leads women to avoidance. A useful model, borrowed from the pain literature, is that of fear avoidance. According to this model, an initial pain experience, possibly caused by an injury, may be interpreted as threatening (catastrophizing), leading to fear of pain and to avoidant behaviors, which in turn lead to hypervigilance followed by disability (sexual dysfunction) and disuse (potential reduction of the sexual repertoire) (Vlaeyen & Linton, 2000).

**Interpersonal Factors**

There appear to be no differences in self-reported dyadic adjustment and no association between dyadic adjustment and pain in women with dyspareunia (Smith & Pukall, 2011). Nonetheless, recent studies have found that attachment orientation, attributions, and partner responses were associated with pain intensity and psychosexual functioning (see Bergeron, Rosen, & Morin, 2011; Smith & Pukall, 2011).

Expressions of pain may evoke empathic responses or assistance or may maximize proximity to the partner. Partner responses to the pain may in turn reinforce and perpetuate the pain experience. In women with PVD, more highly solicitous partner responses were associated with greater pain during intercourse, and this association was mediated by greater catastrophizing. More solicitous and less negative partner responses were also associated with more sexual satisfaction in women. Facilitative partner responses, in which the partner encourages the womans efforts at coping with the pain, were associated with decreased pain and increased sexual satisfaction. Facilitative responses may allow couples to focus on less painful activities and on the emotional benefits of sexual activity.

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**MALE DYSPAREUNIA**

In contrast to the large literature devoted to dyspareunia in women, there is relatively little coverage of male dyspareunia. What exists suggests that males can suffer from various conditions affecting their pelvic and genital organs, leading to localized or generalized pain during nonsexual and/or sexual activities, such as erection and ejaculation. The prevalence of male dyspareunia is unclear, but data suggest that it ranges from 5 to 15% (e.g., Clemens, Meenan, OKeeffe Rosetti, Gao, & Calhoun, 2005).

DSM-IV-TRs (American Psychiatric Association, 2000) definition of dyspareunia applies to males and females; however, there has been much more evolution in the term as it relates to females (see Binik, 2010). Although several research groups have made great strides in the domain of male dyspareunia recently, the diagnosis of male dyspareunia has been excluded from DSM-5 (American Psychiatric Association, 2013) because of lack of sufficient data.

Therefore one needs to look elsewhere for an empirically based definition of male dyspareunia. The most recent term, urologic or urological chronic pelvic pain syndrome (UCPPS), describes a variety of urogenital pain symptoms due to different conditions such as chronic pelvic pain syndrome (CPPS; recurrent idiopathic pelvic pain), interstitial cystitis, and other issues (Shoskes, Nickel, Rackley, & Pontari, 2009). Shoskes and colleagues have proposed that each patient with UCCPS has different etiological mechanisms, disease characteristics, symptom constellations, and progression pathways that should be described in a clinical phenotyping classification system called UPOINT.

It details the dimensions that need to be evaluated by the physician: urinary, psychosocial, organ-specific, infection, neurological/systemic, and tenderness.

Evaluating each dimension by using a thorough clinical assessment consisting of a physical examination, standard investigations, validated questionnaires, and additional testing if necessary can lead to the recommendation of specific therapies. For example, if tenderness of skeletal muscles is predominant, pelvic and/or general physiotherapy exercises would be recommended. Unfortunately, the issue of comorbid sexual difficulties—including erectile dysfunction and premature ejaculation—is not a formal part of the UPOINT system, but such concerns should be assessed thoroughly in order to provide a patient with a comprehensive treatment plan.

Interestingly, patterns of sensitivity, pelvic floor muscle function, and neural activation and structure in males with UCCPS closely mirror findings in women with PVD (e.g. Davis, Morin, Binik, Khalifé, & Carrier, 2011). This information may lead to a new understanding of the factors involved in the development and maintenance of male dyspareunia and may provide support for a novel reconceptualization of UCCPS similar to what has happened in the domain of female dyspareunia in DSM-5 (2013).

Another condition that males can experience is anodyspareunia, recurrent or persistent anal pain experienced by the receptive partner in anal intercourse. Prevalence rates range from 12 to 14% in men who have sex with men (Damon & Rosser, 2005).

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**APPROACHES TO TREATMENT**

Treatment interventions for dyspareunia are multiple and target different hypothesized etiological mechanisms. They are generally delivered in a linear fashion, beginning with purportedly less invasive, safer options followed by more risk-laden modalities such as surgery, depending on the subtype of genital pain and patient preference. This approach is based on clinical observations and, when possible, empirical evidence.

**Medical Options**

Women with dyspareunia often consult their family physicians in their initial help-seeking attempts and thus often receive a medical intervention, which includes topical applications, oral medications and, as a last resort, surgery. In recent years, the most frequently prescribed topical medication has been lidocaine, a local anesthetic. Two prospective studies in women with PVD were promising (Zolnoun, Hartmann, & Steege, 2003; Danielsson, Torstensson, Brodda-Jansen, & Bohm-Starke, 2006); however, they lacked placebo conditions. Nevertheless, lidocaine is well tolerated by patients and more studied than other topical options.

Oral medications are widely recommended by physicians and are empirically validated for the treatment of neuropathic pain, although not yet for vulvodynia. Two studies have examined prospectively the effectiveness of low-dose tricyclic antidepressants in mixed groups of women with vulvodynia. In a sample of 83 women, Reed (2006) found that 59% improved by more than 50%. Foster et al. (2010) conducted a randomized, placebo-controlled trial that showed that oral desipramine and lidocaine did not yield greater pain reductions than placebo, although all conditions resulted in significant pre- to posttreatment improvements. Given that most medical options do not provide optimal results, some physicians have traditionally turned toward surgery as the next step.

Vestibulectomy has been the most studied treatment for PVD. Recent publications continue to support the positive outcome of this surgical excision, with success rates of 65–70% or higher (Landry, Bergeron, Dupuis, & Desrochers, 2008). Because research concerning vestibulectomy has many methodological limitations, some clinicians warn that it should be recommended only after failure of more conservative options. Others claim that this cautionary statement is not justified by data. The ideal study to solve this controversy empirically would be to compare vestibulectomy with sham surgery, although this type of design is fraught with ethical issues.

We conducted a randomized treatment outcome study of PVD comparing

vestibulectomy, group cognitive-behavioral sex therapy/pain management (CBT), and electromyography (EMG) biofeedback (Bergeron, Binik, Khalifé, Pagidas, Glazer, et al., 2001; Bergeron, Khalifé, Glazer, & Binik, 2008). Although all three treatments yielded significant improvements at posttreatment and at 6-month follow-up on pain during intercourse, vestibulectomy resulted in approximately twice the pain reduction of the two other treatments. At the 2.5-year follow-up, vestibulectomy remained superior to 158

the other conditions in its impact on pain during the cotton-swab test but was equal to group CBT for pain during intercourse. Overall, these results suggest that vestibulectomy is a safe and efficacious treatment for PVD, although, at long-term follow-up, no better than CBT. Hence, within a multimodal treatment approach, nonsurgical interventions are recommended first.

**Pelvic Floor Physical Therapy**

Glazer, Rodke, Swencionis, Hertz, and Young (1995) were the first to apply EMG

biofeedback training to the treatment of dyspareunia. In a retrospective study, they found that half of 33 patients with mixed vulvodynia reported pain-free intercourse. In their randomized trials, both Bergeron, Khalifé, Glazer, and Binik (2008) and Danielsson et al. (2006) showed significant pre- to posttreatment changes in pain and sexual function in women assigned to the biofeedback condition, although they did not differ significantly from CBT or topical lidocaine.

Some have argued that pelvic floor physical therapy might be a more optimal modality, as it includes but is not limited to EMG biofeedback. Physical therapy also involves education about the role of the pelvic floor musculature in the maintenance of dyspareunia, as well as manual and insertion techniques. Bergeron et al. (2002) carried out a retrospective study of 35 women with PVD who had taken part in pelvic floor physical therapy. Self-reported pain during intercourse and gynecological examinations was significantly reduced pre- to posttreatment, and significant increases in frequency of intercourse, sexual desire, and sexual arousal were reported. Recently, in a prospective study involving 11 women with PVD, Gentilcore-Saulnier, McLean, Goldfinger, Pukall, and Chamberlain (2010) demonstrated that a physical therapy program led to a significant reduction in pain during vaginal palpation. Further, participants reported significant decreases in pain during intercourse and during a gynecological examination, as well as improved overall sexual function (Goldfinger, Pukall, Gentilcore-Saulnier, McLean, & Chamberlain, 2009).

Studies to date suggest that pelvic floor physical therapy, including biofeedback, represents a promising option for treating genital pain, although randomized controlled trials are lacking. Moreover, there is an emerging trend toward combining physical therapy and sex therapy as a first-line intervention in a multidisciplinary approach to treatment, and patients often feel more comfortable with this option than with psychotherapy alone.

**Cognitive-Behavioral Sex Therapy/Pain Management**

Despite their widespread use in the multimodal treatment of other chronic pain syndromes and their similar or superior success rates as compared with medical interventions, sex therapy and pain management are largely absent from treatment recommendations published in the medical literature. These interventions generally 159

focus on reducing pain, restoring sexual function, and improving the romantic relationship by targeting the thoughts, emotions, behaviors, and couple interactions associated with the experience of dyspareunia. The first stage of treatment typically involves psychoeducation about a multidimensional view of pain and its negative impact on sexuality, including the role of psychological factors in the maintenance and exacerbation of the pain and ensuing sexual difficulties. Self-exploration of the genitals in order to localize the pain and the use of a pain diary are generally introduced at this stage. The second stage focuses on reducing maladaptive coping strategies such as catastrophizing, hypervigilance to pain, avoidance, and excessive anxiety, while increasing such adaptive strategies as approach behaviors, self-assertiveness, reconnecting with the partner through nonsexual physical and emotional intimacy, expanding the sexual repertoire to steer the focus away from intercourse, and facilitating experiences of desire, arousal, and sexual intimacy for both partners.

Bergeron, Khalifé, Glazer, and Binik (2008) investigated the efficacy of a combination of group cognitive-behavioral sex therapy and pain management (CBT) in two different randomized studies of women with PVD. In the first study, described previously in the subsection on medical options, participants who received CBT reported significant improvements in pain at a 6-month follow-up and, at a 2.5-year follow-up, were equivalent to women having undergone a vestibulectomy with respect to pain experienced during intercourse. In another study (Bergeron, Khalifé, & Dupuis, 2008), participants were randomly assigned to either a corticosteroid cream condition or to group CBT for a 13-week treatment period. At posttreatment, women in the CBT

condition were significantly more satisfied with their treatment, displayed significantly less pain catastrophizing, and reported significantly better global improvements in pain and sexual functioning than women assigned to the topical application condition. These findings suggest that CBT may yield a positive impact on more dimensions of PVD than does a topical treatment. In a randomized clinical trial involving a mixed group of 50

women with vulvodynia, Masheb, Kerns, Lozano, Minkin, and Richman (2009) also found that CBT resulted in significantly greater reductions in pain and improvements in sexual function than supportive psychotherapy. In summary, studies focusing on CBT

show that it is an empirically validated noninvasive therapeutic option and may be a good starting point in the multimodal management of dyspareunia.

**Alternative Treatments**

Other attempts at pain relief in women with dyspareunia have been explored.

Hypnotherapy and acupuncture were the focus of two prospective pilot studies, showing that participants experienced the treatments as positive and saw improvements in pain and sexuality (Landry et al., 2008). Considering that hypnosis and acupuncture appear to be devoid of adverse effects and are successfully used in the treatment of other pain problems, more rigorous studies are warranted.

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**Summary**

In conclusion, studies focusing on the treatment of dyspareunia involve several methodological flaws, including lack of control groups, poor specification of outcome, nonstandardized treatment protocols, rudimentary or absent pain and sexual function measurement, and short follow-ups. Although there is still a pressing need for randomized controlled clinical trials, it is noteworthy that sex therapy/pain management is the most empirically validated intervention to date, which is at odds with its lack of visibility in treatment algorithms. Unfortunately, although many psychological interventions involve the significant other, no treatment outcome research has focused on couple therapy. Despite the high number of medical options, only vestibulectomy has demonstrated efficacy. Moreover, in line with a biopsychosocial model of dyspareunia, it is unlikely that any single modality will have a positive impact on all aspects of the condition, which underlines the importance of adopting a multidisciplinary, multimodal treatment approach.

**A MULTIDISCIPLINARY MODEL OF CARE FOR DYSPAREUNIA:**

**PROMISES AND PITFALLS**

In parallel with accumulating evidence suggesting the involvement of multiple etiological pathways, a multidisciplinary model of care has now been espoused by most experts in the field (Goldstein, Pukall, & Goldstein, 2009), as per the recommendations of the Third International Consultation on Sexual Medicine for womens sexual pain disorders (van Lankveld et al., 2010). Advantages of this model—especially when interventions are applied in a combined rather than sequential fashion—include a speedier treatment process, less resistance to any one single modality, more engaged patients and health professionals, increased coherence among the various physicians and therapists involved, and, last but not least, multiple dimensions of dyspareunia being targeted simultaneously. This multidisciplinary model is reflected in a recent excellent self-help book (Goldstein, Pukall, & Goldstein, 2011) and in the information provided by the National Vulvodynia Association (2013), a patient advocacy group. In particular, sex therapists are well positioned to coordinate treatment efforts and to provide education about pain and sexual function, as well as interactions therein. The broad range of interventions they offer can contribute to reduce pain, psychological distress, and relationship difficulties, in addition to improving sexual function and adherence to other treatment regimens. A key to the success of working in a multidisciplinary fashion lies in challenging patients assumptions about their pain being entirely physical or psychological. Until they adopt a multifactorial view of their problem, it remains difficult to develop a strong therapeutic alliance and to work collaboratively, irrespective of the type of treatment or health professional. One of the ways to achieve this is to provide education about the interdependency of biomedical, cognitive, affective, behavioral, and relationship factors in the onset and maintenance of 161

dyspareunia.

**CASE DISCUSSION: MULTIMODAL TARGETED GROUP**

**INTERVENTION FOR PVD**

We advocate that, where possible, women participate in an empirically supported group cognitive-behavioral pain management and sex therapy program such as the manualized treatment developed by Bergeron, Binik, and Larouche (2001). In those situations in which a group is not possible, we believe that the essential elements of the treatment program can be delivered in individual therapy. The advantage of a group is that it reduces shame and the stigma often felt by women with dyspareunia. The group also serves as a powerful motivating force for its members.

**Group Members and Assessment**

The group we are describing involved 8 women between the ages of 23 and 51 years. All had been diagnosed with dyspareunia, some lifelong, others acquired. All the women were currently in heterosexual relationships. We will follow the progress of Anita, a 34-year-old woman who lived with her husband of 8 years. She spontaneously began experiencing pain during intercourse 7 years ago. She had suffered in silence for several years until her husband confronted her about the lack of sex and intimacy in their lives.

It was then that Anita realized that she had been avoiding not only sex but any alone time with her husband, fearing that it would or could lead to sex. Anita talked to her gynecologist, who diagnosed her with PVD and referred her to the group.

**Overview of Treatment**

The treatment consisted of 10 sessions, 1.5 hours each, over 13 weeks and focused on topics such as psychoeducation; the multidimensional view of pain; impact of pain on sexuality; genital self-exploration; increasing sexual desire, arousal, and assertiveness; cognitive restructuring; role of avoidance; partners responses to the pain; and communication skills. A very important element of the group therapy experience was the opportunity that the women had to meet other women who struggled with the same issues. As Anita put it, "I always felt a bit of a freak—I mean 14-year-olds could do something I couldnt. I was a little worried about the group at first, but everyone is so, well, normal. Its a relief."

One of the first instructions given in the group was for the women to complete pain diaries, documenting their pain duration and intensity, pain-related thoughts, feelings, and behaviors, sexual response, and coping efforts in response to both sexual and nonsexual stimuli. It was explained to the women that the pain diaries would help them 162

identify patterns of responses to the pain, including how their pain is affected by events in their lives. Anita was concerned that doing the pain diary would make her focus too much on the pain, which she generally tried not to think about. When asked whether this might be a helpful strategy, she ruefully agreed that, because avoidance did not work, she would try the pain diaries. In group, the women shared their pain diaries, which helped in clarifying their triggers for varying intensity of pain. For example, Anita found that if her husband was acting "amorously" toward her during the day, she anxiously anticipated sex, and her pain was more intense than it was if her husband

"surprised" her by asking for sex. Simultaneously, group sessions focused on giving women the skills to alleviate pain. These skills were taught in the group with instructions given to practice at home. These skills included relaxation strategies (e.g., diaphragmatic breathing, progressive muscle relaxation), PFM exercises (Knight & Shelly, 2008), and vaginal dilatation. PFM exercises, such as Kegels, helped the women to increase awareness and improve relaxation of the musculature that circles the vagina and urethra and to use these skills during sexual activity to reduce pain. Vaginal dilatation involves gently and slowly inserting a finger or other dilator into the vagina, usually coupled with relaxation, in order to break the association between having something in the vagina and pain. Women also practiced cognitive restructuring, which helps reduce the impact of anxiety-provoking, maladaptive thoughts. For example, Anita noted in her pain diary the following thoughts about sex with her husband: "I cant do this" and "this [my PVD] is unfair to my husband." These thoughts resulted in anxious anticipation of pain and decreased her sexual desire and arousal. She learned to replace these thoughts with more realistic, coping thoughts, such as "intercourse may be painful, but I can do other things that are more pleasurable" and "my husband would say that this [PVD] is not my fault and he loves me." Anita happily reported to the group at the next meeting that by replacing these thoughts she had had less pain when having intercourse with her husband. She found it particularly helpful to use cognitive restructuring before intercourse because it helped focus her attention toward the more pleasurable aspects of being intimate with her husband. Anitas success encouraged other women in the group to practice cognitive restructuring.

Several members of the group who had lifelong dyspareunia were very reluctant to do the vaginal dilation exercises. Having a mixed group of women (those with lifelong and acquired dyspareunia) was helpful because many of the women who had previous experience with pain-free intercourse and genital touching were able to draw on these past experiences to help them with the dilation exercises. The group dynamic was supportive and empowering in that each womans success prompted others to push themselves a little bit more. For example, the first time it was assigned, Anita did not do the dilation exercises. She sat quietly in the subsequent group as the other women discussed their attempts. The next week Anita talked about feeling bad that she had not done the exercises and that hearing about how others dealt with their fear encouraged her to try out the dilation. Happily, Anita was able to identify ways she could insert her finger without causing pain.

Partners were invited to attend the eighth session. This session encouraged partners to express their needs, frustrations, and the impact of pain on their sex lives and 163

relationships. It also included a discussion of partner responses to the pain. For example, the difference between solicitous partner responses, which encourage avoidance (e.g., ending all sexual activity or being overly attentive to the pain), and facilitative partner responses, which encourage adaptive coping (e.g., suggesting nonpainful sexual activities, expressing enjoyment during sex), were highlighted.

Finally, some basic communication strategies, tailored to sex and PVD, were practiced in the session. Michael, Anitas husband, clearly fell in the solicitous-partner category.

He said that he could not imagine doing anything that would cause Anita pain, let alone get pleasure from something that caused her pain. He felt the same way about her anxiety, so that when he noticed Anita feeling anxious about sex, he would immediately back off and tell her it was "Okay, we dont have to do this. I can wait until this gets better." For her part, Anita thought that Michael was an incredibly supportive and understanding partner. Of course, 7 years later, Michael was feeling hopeless, and it was clear that both were colluding in a pattern of avoidance. In group, it was explained to couples that partner responses to pain and to anxiety about pain should be different. It helped Michael to know that he could be encouraging Anita not to be fearful rather than, as he previously thought, telling her to experience pain so that he could have pleasure. Michael learned to say things like "Im really happy that we are doing this

[being sexually intimate]" and "why dont we switch to a different position/activity that feels good for both of us?"

Couples were given sensate focus exercises as homework to aid in identifying their sexual needs. They involve three progressive steps in which partners take turns giving and receiving massage or touch: (1) nonerotic (nongenital) massage, (2) massage that includes genital touching but focuses on sensations and arousal rather than orgasm or performance, and (3) erotic touching for sexual pleasure. After trying the first step, Anita said that Michael was happy to be involved in the homework and that they felt it improved their intimacy. She said it was extremely helpful that intercourse was "off the table," because it reduced her anxiety and helped them focus more on the pleasurable sensations. All the women agreed that having other ways to satisfy their own and their partners sexual desires was both a relief and a bit exciting. Anita said she felt "sexy"

again for the first time in a long time.

Couple work continued, with the women bringing exercises home to do with their partners. One exercise was to do the vaginal dilation exercise using the partners finger, with the pace and angle of insertion guided by the woman. Again, Anita did not do the exercise the first time it was assigned, and again she sat quietly in group while the other women discussed their progress. Anitas avoidance was rooted in her fear that, if she put significant effort into this treatment and her pain did not improve, then she would lose hope of ever being pain free. She was confronted with the possible outcomes if she continued to avoid treatment—that is, she could be fairly certain that nothing would improve. When Anita did finally do the exercise with Michael, he was able to practice his facilitative responding. On two of the insertions Anita experienced pain, and they stopped; on one she experienced no pain; and on a fourth attempt she experienced pain, but she did some cognitive restructuring—"Its okay, Michael loves me, we can do other things if this hurts"—as well as some deep breathing, and they tried again with success.

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This same strategy was employed in graduated steps until by the end of group Anita had been able to have intercourse with discomfort but not pain. She enjoyed the sexual experience in its entirety and felt confident that one day, if she continued to use the coping skills she learned, she would be able to have pain-free intercourse.

Some, but not all, of the women fared as well as Anita. Of the 8, Anita and two other woman were able to have intercourse with no or little pain. Two women had been able to do the dilation exercises with their partners fingers and reported experiences of heightened sexual desire and arousal at various points during treatment but still had significant pain during sex. One woman dropped out because she felt the group was not helping her. One woman did not report any significant improvement in her genital pain, but she had not sufficiently practiced many of the coping tools. She felt more satisfied sexually, which she attributed to her and her partner focusing more on nonpenetrative sexual activities. The remaining woman said that she felt overwhelmed by the treatment program and frequently withdrew by not doing any homework or missing a session. Her most significant outcome was admitting that she had some control over improving her pain and sex life should she choose to do so in the future.

**CONCLUSIONS**

Our clinical experience suggests that dyspareunia is not a condition that can be treated successfully by any single health professional. Unfortunately, there is very little research evaluating a multimodal approach to the treatment of dyspareunia, although the outcome appears very positive (e.g. Spoelstra, Dijkstra, van Driel, & Weijmar Schultz, 2011). These promising findings point toward the need for more empirical work aimed at validating an integrated approach to care for this highly prevalent womens sexual health issue.

Groups may be particularly beneficial for women who have been recently diagnosed and for those who are not dealing with serious additional psychological (e.g., depression) or relationship (e.g., separation or divorce) difficulties. For some women, the group treatment may be sufficient to provide them with the tools to continue progressing on their own. However, many women will require additional treatment following the group, such as couple therapy to deal with relational components of the pain and/or individual therapy to address deeper psychological issues (e.g., history of sexual abuse).

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**CHAPTER 8**

Lifelong Vaginismus

Moniek M. ter Kuile and Elke D. Reissing

**T** er Kuile and Reissing reject the DSM-IV definition of vaginismus with its central criterion of vaginal muscle spasm. Instead, they present a conceptualization of lifelong vaginismus as a vaginal penetration phobia. This reconceptualization is based on the fear-avoidance model of chronic pain: "The basic tenet of the model is that catastrophic thinking about vaginal penetration and/or a catastrophic interpretation of a negative experience with penetration will give rise to vaginal penetration-related fear. To cope with fear, a woman may avoid all activities related to vaginal penetration. . . . " The treatment implications of this reconceptualization are dramatic. They imply that the traditional Masters and Johnson vaginal dilatation therapy may be inadequate, as it does not sufficiently expose the woman to the phobic stimulus (vaginal penetration) while preventing avoidance. Instead, ter Kuile and Reissing adapt for vaginismus the highly effective paradigm for phobias of prolonged exposure. The result is therapist-aided prolonged in vivo exposure. The therapist encourages, guides, and reduces avoidance while the woman performs all insertions. Given professional caveats for psychologists directing such in vivo genital exposure, this intervention should occur in a medical setting and include the partner. If the strikingly effective initial results for this intervention are confirmed, then in vivo exposure may become a treatment breakthrough for vaginismus.

**Moniek M. ter Kuile, PhD,** is an associate professor in the Department of Gynaecology of Leiden University Medical Center in the Netherlands. She is registered as a health care psychologist and clinical psychologist by the Dutch Ministry of Health. She is a supervisor of clinical trainees for the Dutch Association for Behavioral and Cognitive Therapy (VGCT) and the Dutch Society of Sexology (NVVS).

**Elke D. Reissing, PhD, CPsych,** is professor at the School of Psychology and director of the Human Sexuality Research Laboratory at the University of Ottawa in Canada. She is the supervisor for sex therapy training at the Centre for Psychological Services and Research and has a private practice serving mostly women with vulvo-vaginal pain and vaginismus.

Eva, 27 years old, 3 years married to Rob, was referred by her general practitioner with the complaint that sexual intercourse had never been possible; attempts resulted in pain and significant fear and were typically avoided.

**DESCRIPTION OF THE PROBLEM**

In line with current nosology, Eva would be diagnosed with lifelong vaginismus, which is defined in DSM-IV-TR (American Psychiatric Association, 2000) as an involuntary contraction of the vaginal musculature that interferes with coitus. However, the focus on vaginal spasm as the key diagnostic criterion has not been supported empirically (Reissing, Binik, Khalifé, Cohen, & Amsel, 2004). An international consensus committee 168

had suggested revised criteria that are more reflective of the clinical presentation of vaginismus: "persistent difficulties to allow vaginal entry of a penis, a finger, and/or any object, despite the womans expressed wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance and anticipation/fear/experience of pain"

(Basson et al., 2003). In response to the lack of empirical support for the DSM diagnostic criteria and the persistent difficulties in clearly differentiating vaginismus from dyspareunia, the two sexual pain disorders in DSM-IV-TR have been merged into a new DSM-5 (American Psychiatric Association, 2013) disorder called "genito-pelvic pain/penetration disorder" (GPPPD; Binik, 2010).

Vaginismus can be either lifelong or acquired. In acquired vaginismus, a woman who was able to experience intercourse is no longer able to do so. She may be unable or unwilling to continue experiencing pain associated with intercourse. In acquired vaginismus, the interference with intercourse may be the result of pain (e.g., due to vulvodynia). Shared etiology makes it difficult to differentiate acquired vaginismus from dyspareunia, and treatment described for dyspareunia may be more effective (see Bergeron, Rosen, & Pukall, Chapter 7,  this volume). The treatment approach described here can be helpful for women with acquired vaginismus in which fear and avoidance of penetration have become central and interfere with treatment approaches used for dyspareunia. In this chapter, however, we focus on women with lifelong vaginismus who have never been able to experience complete vaginal intercourse and who demonstrate marked fear and avoidance of vaginal penetration. Hence, unless otherwise specified, in this chapter we refer to lifelong vaginismus as "vaginismus."

**PREVALENCE AND INCIDENCE**

Epidemiological studies often subsume vaginismus in more generalized questions about pain with intercourse, resulting in few accurate prevalence estimates. The best estimates of reported rates vary between 0.4 and 6.0% (e.g., Christensen et al., 2011). In more sexually conservative cultures, significantly higher prevalence rates have been observed (e.g., Yasan & Gurgen, 2009).

**ETIOLOGY**

Research on the etiology of vaginismus is lacking, and no definite cause has been identified. Conservative and religious attitudes, lack of sex education, sexual abuse, and relationship factors have all been reported as potential causal variables; however, none have been confirmed empirically (e.g., van Lankveld, et al., 2010). A somatic explanation for lifelong vaginismus is found very infrequently (0–5%) and can include hymeneal or vaginal abnormalities. Research shows that many women diagnosed with vaginismus also experience vulvar pain. This vulvar pain is typically diagnosed as provoked 169

vestibulodynia but may also be the result of pelvic muscle tension and/or lack of sexual arousal and lubrication.

Three lines of inquiry into the etiology of vaginismus have emerged as promising in the past decade.

**Pelvic Floor Muscle Involvement**