This article first appeared in the National Vulvodynia Association newsletter (NVA News), Volume V Issue III, published Fall, 1999 and is reprinted in the Interstial Cystitis Association newsletter (ICA Update), Volume 14, Number 4, published April 2000.
Vulvovaginal Pain Disorders and Sexual Functioning
By Howard I. Glazer Ph.D.
I have always been amazed at the lack of interdisciplinary approaches to vulvovaginal pain disorders. These conditions overlap a number of specialties including pain management, gynecology, dermatology, urology, gastroenterology, rheumatology, pathology, neurophysiology and not least of all, sex therapy. Each of these fields takes their own perspective on treating these disorders without much multidisciplinary integration. Gynecologists look for infections, dermatologists look for dermatoses, pain physicians look for neuropathic pain, urologists, gastroenterologists and rheumatologists look for related conditions such as interstitial cystitis, irritable bowel and fibromyalgia, pathologists look for vulvar tissue pathology, neurophysiologists look for pelvic floor muscle dysfunction. With all these specialists looking at the parts they specialize in the patient may well ask "does anybody care if I am having sex?" While pain relief is a major goal for vulvovaginal sufferers, the major functional consequences of these conditions is to limit and often preclude sexual intercourse. This is particularly so with vulvar vestibulitis syndrome where there is only pain on pressure, such as that associated with attempted penile-vaginal intercourse. Otherwise these sufferers have no pain. Often for essential vulvodynia sufferers sexual intercourse raises the level of their chronic pain substantially and also leads to sexual abstinence as with vestibulitis sufferers. It is my experience that patients do not want to only reduce or eliminate their pain; they want to do so in order to get back to having penatrative sex with their partner. I dont think too many patients would ingest medicines, put creams on their vulvas and in their vaginas, do hours and months of muscle exercises, or even undergo surgery so that when their vulvas are poked with a q-tip it does not hurt. No, my patients want to be able to have good, loving, intimate, physically and emotionally fulfilling sex with their partner.
The medical specialists are rightfully concerned with identifying and treating the pathology within their field of specialty. Like most people they are not that knowledgeable or comfortable discussing issues of sexuality. Although this may sound strange for doctors who specialize in treating vulvovaginal pain, many of my patients tell me that when they ask their gynecologist about details of sexual activity the doctor becomes visibly uncomfortable. Now on the other side of the coin we have the sex therapists. I must admit that before starting my work in pelvic floor muscle rehabilitation in the treatment of vulvovaginal pain I had many years of training and experience as a sex therapist. But sex therapists are from the ranks of mental health professionals. No matter how much they try or know better they are trained to look for unresolved or unconscious sexual conflicts or repressed memories of child or adult sexual abuse, etc. So many of my patients tell me how frustrating it is to go to couples or sex therapy because the therapist may give lipservice to the fact that these are medical conditions, but they cant help but delve into your psyche looking for psychological reasons for why you have unexplained pain in your vulva and vagina. So once again the sufferer is left in the middle with doctors inspecting your anatomy and therapists inspecting your psyche but nobody helping you to get back to having sex.
I confess that when I first started working with vulvovginal pain patients using pelvic floor muscle rehabilitation techniques, I specifically stayed away from dealing with the sexual aspects of these problems because I too had been clincally trained to assume there must be some psychological underpinnings to these vulvovaginal pain conditions. Since then I have changed my practice dramatically due to two factors. First, a considerable database has now been published demonstrating that vulvovaginal pain patients do not show any psychopathology or abuse history that differentiates them from non pain control groups. Second I saw more and more patients who were "cured" or substantially relieved of their pain and were considered successful outcomes because their vulvar tissue, flora, nerve endings, etc were normalized. But when I asked many of these patients about sex I discovered that many, perhaps even the majority, had not resumed sexual activity.
So a number of years ago I started to integrate my knowledge of sex therapy techniques into my work with vulvovaginal pain patients. I began to see all my patients with their sexual partners when possible. I began to spend considerable time reviewing sexual history information, discussing with my patients issues such as clitoril stimulation, masturbation, orgasms, oral sex, intercourse and nonintercourse sexual positions, thrusting duration, physiology of female arousal, anticipatory anxiety related to sexual pain, libido, vulvovaginal self examination, and a host of related topics. I would have all my patients start reexperiencing orgasms, or for some learning how to have them for the first time, conducting non penatrative sexual activities with their partners, or with masturbation; becoming friendly with their genitals, their appearance, sensations, anatomy, etc. I continue to be amazed at how otherwise very well educated people have such little knowledge about matters of sexuality. Many of my patients at first resisted this approach saying "just fix my tissue and I will get back to having sex, I used to have great sex". As it turns out this is simply not the way it works for most vulvovaginal pain sufferers; they do not get back to sex spontaneously after their pain is gone because they have developed powerful habits of sexual avoidance and fear and often have little remaining libido. I have found that resexualizing my patients immediately upon initiating treatment makes a marked difference in the final outcome of treatment. Getting my patients to truly love their genitals, understand how they work, how to maximize pleasurable sensations etc. is now an integrated part of my work. I explain to my patients that it is normal to cut off awareness from areas of pain in your body. When this area is your genitals your not only lose sensory awareness of pain but also of pleasure. Reconnecting to your genitals, exploring them as a source of pleasure, and the extended psychological benefits of self acceptance and self respect are critical aspects in the rehabilitation of all vulvovaginal pain patients. I believe strongly that pain relief alone does not constitute adequate treatment of vulvovaginal pain syndromes. We must restore sufferers to their full potential as partners, as lovers, as intimates, in short, as complete women and as complete people.
It is my hope that treating professionals and reading this have a little more awareness
that we are really not dealing with just the restoration of tissue health to vulvas and
vaginas. Our true goals must be to restore full sexual functioning, full gender identity,
full capacity to express love, in short, full humanity, to our patients, to have a truly
successful therapeutic outcome.