Tag Archives: Painful Penetration

When it comes to women talking about sexual pain, omission is a form of communication.

Vulvodynia = Women’s sexual pain.

Our society still grapples with the experience of female sexual pain. Specifically, Vulvodynia (vulvar pain) affects some 16 percent of women. “Vulvodynia is chronic vulvar pain without an identifiable cause,” reads a statement from the National Vulvodynia Association (NVA), a non-profit created in 1994 to help improve the health and quality of life of women suffering from sexual pain. “The location, constancy, and severity of the pain vary among sufferers. Some women experience pain in only one area of the vulva, while others experience pain in multiple areas.” While some sexual pain may be located on the vulva or in the vestibule (the vaginal opening), some women may feel pain internally as well. Unfortunately, millions of women experiencing pain during sex are being misdiagnosed. And so, millions suffer in silence.

Dyspareunia is an older term to describe all types of female painful sex. The most recent diagnosis of genito pelvic-penetration pain disorder (GPPPD) is the clinical diagnosis in the Diagnostic and Statistical Manual Version 5. It is the name of the conditions formally known as vaginismus and dyspareunia. Vaginismus results from involuntary contraction of the vaginal musculature. Primary vaginismus occurs in women who have never been able to have penetrative intercourse. Women with secondary vaginismus were previously able to have penetrative intercourse but are no longer able to do so.

How Women’s Sexual Pain Shows up in the Medical Realm

Epidemiological studies indicate that only 60% of women with vulvovaginal pain seek medical help and among those, 40% never receive a diagnosis. The lack of support from the health care system may contribute to feelings of invalidation and stigmatization often experienced by women with Vulvodynia. When it comes to pain specific to female anatomy, like the vulva, diagnoses frequently veer off-course. Doctors suspect menopause, PMS, depression, or anxiety. Yet surprisingly, many of the women sex therapists see are actually younger than 40 and nowhere near peri-menopause or menopause.

This gap in a detailed assessment process leaves a woman with the wrong diagnoses and still in pain, with the additional psychological pain and loneliness of being misunderstood. Women presenting with genital pain frequently experience rejection from their biopsychosocial environment. This contributes to a belief that silence is better than being misunderstood and embarrassed.

“There’s a huge problem,” Dr. Elizabeth G. Stewart, M.D., told attendees at a session on vulvovaginal disorders at Internal Medicine 2011. “There’s virtually no vulvovaginal training for clinicians.” Due to the minimal training doctors receive about women’s sexual health in medical schools, doctors may feel stymied when their female patients report having genital pain. Stewart also added that “clinicians also tend to rely on patients’ self-diagnosis and manage their problems by phone, or don’t do a physical exam before treating, which leads to incorrect therapies.”

What might cause Vulvodynia?

In a recorded webinar presented by Center for Love and Sex (CLS) created for professionals with my colleague gynecologist Dr. Chris Creatura titled “How to Help Women with Sexual Pain and Low Desire,” Creatura let therapists and gynecologists know that while examining a woman with vulvovaginal symptoms, a doctor must consider many differential diagnoses. Although we still don’t know exactly what causes all Vulvodynia symptoms, she explained that some contributing factors include:

An allergy
Atrophy
A drug reaction
Sexually transmitted infections
Infection
Low estrogen
A dermatological source
Disease elsewhere in the body
A drug
Cancer or a precancerous condition
A combination of these factors

How Women’s Sexual Pain Affects Their Partners and Relationships

Many women often keep the reality of the level of sexual pain or discomfort from their partners (whether they are new partners or longtime partners or spouses). Omission in the realms of sexuality and intimacy is a mechanism women resort to in order to feel more accepted by a partner and society out of fear of rejection, shame, and exclusion. Recent research cited in Michael Castlemen’s recent post also illustrates that it is a reaction to a patriarchal society that privileges men’s sexual pleasure over women’s desire and pleasure. Women reported that the reason they don’t tell their partners about their pain is because they felt “they should subordinate their erotic pleasure to their men’s.”

In fact, studies show that male partners of women who experience sexual pain are also deeply affected by their own shame when they are aware of the pain. In a recent study published in the Journal of Pain researching women with Vulvodynia and their partners, women experienced greater pain when they also reported pain-related shame, while their partners experienced distress when they felt shame related to the pain they were causing their partner through sexual activity. Furthermore, on days they had sexual activity both partners reported greater levels of sexual distress. The authors of the study state: “Qualitative studies have reported that many of them feel inadequate, are apprehensive to speak about their pain, and fear this condition spells the end of their romantic relationship.”

How Can Sex Therapists Help Women and Their Male Partners

As a systemic sex therapist, I consider the reach and power of a woman’s genital pain, the impact on her partner, and their relationship. It is critical for a sex therapist to first validate and empathize with the woman’s pain, since most women feel like a complainer or at times even like a hypochondriac. To uncover the source, experience, and history of the pain, the sex therapist should conduct a thorough sexual status and history assessment. (The Center for Love and Sex offers two recorded webinars on these interventions for medical professionals including therapists, sex therapists, pelvic floor physical therapists and doctors.) But then they also need to conduct assessments of her partner.

Frequently, for women in committed sexual relationships (in the cases I provide here, the partner is male), the vulvar pain also has an effect on a man’s sexual functioning. Male partners, feeling guilty for causing pain in their partner during penetrative vaginal sex, may experience erectile dysfunction, uncontrolled ejaculation, or low desire. It is important for women to seek help not only on their own but with their partner as well.

The Plan

The research cited above provides a strong argument for therapists to work with both partners in couples systemic sex therapy. Within this type of couples sex therapy, it’s critical for sex therapists to:

Provide sex education about Vulvodynia to both partners so they understand that this is a medical condition and no one’s fault.
Refer the woman suffering from pain to a well-trained sexual health medical professional able to diagnose and treat Vulvodynia and GPPPD.
Explain how the disorder impacts the entire couples’ system.
Encourage the couple to use the therapy space to address both partners’ feelings of shame, anxiety, and sense of brokenness. Give them hope that these conditions can be treated, and that their reactions are understandable.
While treatment for Vulvodynia is ongoing, outline a treatment plan to work on the pain treatment, their couple communication, and sexual alternatives.
Teach them mindfulness techniques in order for them to become more relaxed and embodied and focused on giving and receiving sexual pleasure. There is a whole body of research and a recent book written by Lori Brotto showing the benefits of MBSR (Mindfulness Based Stress Reduction) for women suffering with sexual pain.
Advocate and support women as they work with allied health care professionals.

Creating a Holistic Systems-Oriented Medical Team to Help a Woman and the Couple

In the second of CLS’s webinars on sexual pain co-presented with Pelvic Floor Physical Therapist Amy Stein titled: (“The Collaborative Clinical Care Model Between Therapists and Pelvic Floor Physical Therapists”), a case example showed a client (all identifying information was removed) experiencing severe genital pain who described feeling like a freak amongst her sexually active college peers. Another woman described a breakup with a boyfriend, suspecting the cause to be her pain during sex and the consequent lack of sex. In another example, a high-achieving professional woman worried she would lose her supportive fiancé once he started business school. In almost all cases, these women felt extremely isolated.

Therefore, silence about pain, shame, and distress creates a vicious cycle of communication and intimacy breakdowns. Excellent communication skills and having a team may ameliorate and amend communications. The system around a woman in pain–her gynecologist, therapist, physical therapist, sex therapist, and her partner(s)–must all work holistically to treat Vulvodynia and sexual pain. Sex therapists can create and coordinate care among all these providers. They can encourage women to speak authentically about the sexual pain to their sex therapist, their medical providers, and their partner.

References

Kearney-Strouse, J. (2011, June 1). Vulvovaginal disorders common but commonly misdiagnosed. ACP Internist.

Millions Of Women With This Condition Are Being Misdiagnosed: Here’s What To Know About Vulvodynia. (2018, March 14). National Coalition for Sexual Health.

Paquet, M., Rosen, N., Steben, M., & Bergeron, S. (2019, April 1). (174) Let’s Talk about it: Daily Associations between Shame and Pain and Sexual Distress in Couples Coping with Vulvodynia. The Journal of Pain. Brotto, L. (2018) Better Sex Through Mindfulness: How Women Can Cultivate Desire, Greystone Books: Vancouver

Vulvodynia Treatments. (2020). The National Vulvodynia Association.

What is Vulvodynia? (2020). The National Vulvodynia Association.

Brotto, L. (2018) Better Sex Through Mindfulness: How Women Can Cultivate Desire, Greystone Books: Vancouver

Embrace Sexual Liberty This July After the Fireworks

July 17, 2017

Sari Cooper

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We have just celebrated another July 4^th which marks this country’s liberty from the restraints of despotism. When the fireworks went off we honored the declaration of independence that promised Americans “with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” How do these rights influence your sexual life? Many in Washington seem to be challenging the meaning of these ideals in as far as sexual liberty goes, including the right for a woman to choose whether she has an abortion, the right for a transgender student to use a bathroom that aligns with their identity, and the question of whether a business owner’s claims of religious freedom override the discrimination wrought when they refuse to sell their products based on the customers’ sexual orientation.

In this July blog I wanted to focus on the theme of liberty as it relates to a couple’s sexual relationship because as an AASECT Certified Sex Therapist and Director of Center for Love and Sex, the majority of our clients come to us seeking help in identifying and/or expressing their unique erotic “pursuit of happiness”. According to Merriam Webster’s definition, liberty is alternatively described as

the quality or state of being free:

a : the power to do as one pleases

b : freedom from physical restraint

c : freedom from arbitrary or despotic control

d : the positive enjoyment of various social, political, or economic rights and privileges

e : the power of choice

When a couple first meets and they seem to click or hit it off they may feel hopeful that they finally found the ‘one’ with whom they can be totally authentic; free of restraints, or arbitrary control, and fantasizing about how they will enjoy one another to the fullest including in their sexual connection. Perhaps after that first date where they make out or the morning after they lay next to one another in the nude, the endless imagined erotic freedoms seem to pop like Independence Day firecrackers during passionate daydreams. The last definition of liberty, namely “the power of choice” is where I find many couples get stuck. What do I mean by this? Once the first couple of years have passed, many couples find that the original sexual fireworks have mellowed to the flickering of candles with an occasional pop of a sparkler or firecracker. At this point, many couples tell us that they have become so close to their partner they feel like they have literally become ‘family’, experiencing the other more like a sibling or best friend. What happened to that erotic thrill they felt when their partner was less known? Why has their erotic connection lost its sizzle?

Once partners become joined, very frequently they may unconsciously regard the other under the same category as a member of their family of origin. What can become triggered are the many restraints one felt growing up in their particular family including restrictions dictated by: religion, community, and their particular culture. Those rules, boundaries and traditions may cause them to erect walls inside their minds leaving them powerless to choose who they want to be in their sex life.

A client at CLS who was engaged to be married was working hard with her sex therapist to recover from the Genito-Pelvic Pain Penetrative Disorder so that she could honestly tell her priest that she would be ready to “perform her wifely duties” once they wed. This priest had not asked about what she looked forward to in her sex life, nor did he ask her fiancé if he was ready to give pleasure to his fiancée once they were wed. The Roman Catholic ideal of wife and husband having intercourse was focused more on procreation than bonding, pleasure and intimacy for both partners.When I use the phrase “who they want to be in their sex lives”, I mean what fantasy they want to enact, what sexual acts they may want to try with their partner(s), and/or what kind of erotic power exchange they may have dreamt of playing in the bedroom. Do they want to be consensually taken, ravaged, or overtaken by their lover? Are they hoping to play out a scene from a movie that turns them on? Do they want to dress in particular clothing that heightens their arousal?

Couples can become what David Schnarch in his respected book Passionate Marriage describes as “emotionally fused” when they fall for one another and the idea of a person making the choice to express a desire that might differ from a partner/spouse’s can lead to their partner expressing ridicule, disdain, disgust or abandonment because it is alien, kinky or frightening. The partner who is hearing the request or fantasy may not even have to say a word but the roll of the eye, or raising of an eye brow may be all it takes to indicate surprise scorn. Like a firecracker going off the partner quickly shuts down further requests of new or different sexual interests for fear of losing their partner, not to mention wanting to avoid feeling put down, rejected or just plain weird.

Recently when I asked a married het couple (I’ll call them Chloe and John to protect their identities) who were having trouble infusing their sex life with more passion and excitement, if they had seen, read or heard something recently that turned them on and kept it to themselves. The wife tentatively began telling me how she and her husband loved to watch Showtime’s series Billions together. When the scene of the lawyer Chuck Rhoades (played by Paul Giamatti) is being tied up by his wife Wendy (Maggie Siff) she quietly said that she noticed some tingling in her genitals. Her husband looked at her in surprise in the session as if seeing a new woman emerging. I asked her what happened next with this awareness and she said: I was turned on by the sensation and the scene but didn’t think I could share this with John, he would think it was weird.

So what happened in your body after you edited yourself, I asked. She looked down and said, the sensation went away and we continued to watch the show. I reflected that she had chosen to let the feeling go because she didn’t feel permitted to include what she considered transgressive turn-ons with John. Then I checked in with him and wondered what was going on in his body and mind when he heard this sitting next to her and he said: I was getting a bit turned on hearing her describe the scene, and felt surprised that she didn’t share it with me since I never knew she was into that. In fact, I was turned on watching the scene myself at the time but chose to keep it to myself to protect Chloe from my dirty mind. Each of these partners has remained behind their wall of excitement and passion for fear of how their partner might judge them negatively.

I helped them to anchor their physical experiences so that they don’t run off into analytic explanations and remain true in the session that is free of judgment and shame, so that they stay present with their authentic selves in the presence of their partner who is equally as vulnerable. In various ways with clients, I ask them these questions:

What aspects of ourselves do we choose to keep hidden or private from our partner?

What could shift in an erotic partnership if we choose to become more vulnerable, playful and curious with ourselves and one another?

These are the questions that have been continually asked by artists, scientists and creative thinkers for generations. My colleague Esther Perel asks in her latest Podcast, Where Should We Begin?, how can you want what you already have? The teacher and writer Alton Wasson offers participants of his Contemplative Dance workshops the metaphor of moving and witnessing the mover as an experience akin to a “chest of drawers”. Similar to partnered sex in which one partner is engaged in and witnessing/experiencing a partner, the choice to open a drawer to experience an aspect of ourselves and our partners happens only when there is “freedom from arbitrary or despotic control” (Declaration of Independence), meaning free of limits set by an external power. In this case it could mean external societal values, misunderstandings/myths of meaning when it comes to one’s fantasies, or limits placed on gender roles.

Myths or misunderstandings about sex, fantasy and erotic desire begins with a child’s learning from their family, religion and schooling about sexuality. Unfortunately, due to limited subjects being allowed in schools due to Abstinence Only education in the US, and heteronormative focus of sex education, people grow up with the kind of limited information that inhibits them around speaking of their sexual desires with a partner. They may have learned about STIs (formerly known as STDs), or protection like condoms, oral contraceptives and the IUD (why oh why are doctors not telling folks about the female condom, stay tuned for an upcoming blog on this topic!). Many people also believe that their partners should be able to read their mind and automatically know what turns them on. I can say from my clinical experience that it is almost impossible for people to be mind readers and know exactly what turns their partners on sexually without active and open communication.

According to relationship therapy research conducted over many years by John Gottman, open and continual communications are the building blocks of a satisfying relationship). There is often a misperception that too much communication and frankness about sexuality in a relationship may lead to the end of relationship; however, couples who are emotionally and verbally expressive (whether strongly or even in moderation) tend to have long and satisfying relationships. In other words, it is important that partners in a relationship be comfortable expressing themselves in constructive forms of communication. Since partners don’t get this training early on, nor is it modeled for them, they are lost in the woods and revert to silence and emotional shutdown on this critical aspect of their lives. After the early novelty wears off, a couple need more nuanced language to describe what they desire. Couples come to us months and sometimes years into a relationship that has been reduced to a tapering spark.

My mission in creating CLS and the Sex Esteem® model is to provide people the education, the confidence and the curiosity to become more aware of their erotic triggers, their sexual fantasies, and explore the play space of their sexuality with their consciously chosen partners. My background in modern dance and improvisation taught me from a very young age that exploration is fun, that there are no wrong movements (as long as all around you are safe and consensually there) and that you can create

from nothing an experience that is new, unique and fortifying when you are fully free.

Being able to constructively communicate sexual desires to a partner/spouse is not only freeing and gratifying for oneself and one’s partner(s), but the freeing nature of co-creating an experience serves as a bridge to a more intimate, authentic relationship. The rocket needs to be ignited again and again by each person to produce a sustaining spark of passion. And as the Declaration of Independence states “we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor.”

Be mindful of your erotic liberty and honor your intentional choices this July to enhance your sex life.

Painful Sex: Best Therapy Practices for Women and Couples

January 17, 2017

Sari Cooper

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Women who experience painful penetrative sex due to Provoked Vestibulodynia (PVD), Vulvodynia and other forms of Pelvic Pain may have suffered in silence for years. They may have thought that the pain was due to being new to intercourse and that it would subside. Or perhaps they may have mentioned it to a gynecologist, only to be told that there was no evidence of any diagnosis, or that they had a bacterial infection and prescribed a medication that didn’t help. For some women who had painful sex that was intolerable, they may have avoided going to a gynecologist for their entire adult life.

Women we see at Center for Love and Sex who are in heterosexual relationships where penetrative sex is an expected part of the sexual repertoire over time develop tremendous shame, anxiety and fear of any sexual encounter if they feel it will lead to intercourse. Their partners may gradually avoid initiating sex due to the obvious reason of not wanting to cause their partner/spouse pain but in addition, of wanting to avoid being turned down which they experience as outright rejection, lack of desirability and at times shame.

As a consequence to the painful sex, some male partners/husbands may develop their own sexual disorder like erectile dysfunction or premature/uncontrolled ejaculation due to the anxiety that develops around their penetration hurting their partner. Couples like this tend to self refer to a CLS therapists when sexual avoidance has gone on for some time and couple is in crisis or fear of losing their sex life altogether. The physical ailment causes intra-personal and interpersonal challenges that have to be addressed in therapy. Many times these women can treat and heal their pain when working with a pelvic pain physical therapist.

When I mention pelvic floor physical therapists to friends and even other therapists, they have never heard that this specialty even exists. As a systemic sex therapist, I frequently see women and couples who present with painful sex and collaborate with pelvic floor PTs to coordinate treatment in a holistic manner. I have had general therapists refer some of these cases to me after seeing clients for many months or years assuming the pain was a somatic outcome of early trauma.

It is critical for all therapists to understand the structure of the pelvis and causes of pain so that they know how to support, advocate and refer their client to the right doctors and pelvic floor PTs so that they can move ahead quickly with a treatment protocol that addresses their particular issue. It is also important for pelvic floor PTs to understand the consequences the pain has had on the client’s primary relationships, her Sex Esteem®, and shame level around discussing the specifics of her condition so that they can collaborate with the therapist. I will often assign homework assignments that will echo or support the exercises being assigned by the pelvic floor physical therapist.

In my upcoming webinar for therapists, sex therapists and physical therapists titled The Collaborative Clinical Care Model Between Therapists and Pelvic Floor Physical Therapists Involving Sexual Pain, I’ll be collaborating with Amy Stein, DPT Founder and Director of Beyond Basics, a specialty PT practice in NYC and the author of Heal Pelvic Pain, a self-help book for people dealing with painful sex, urination and other physical activities involving the pelvis. I invite you to spread the word about the webinar which will be live and take place on Monday February 6^th from 12:30-2:30 PM EST and is geared for professionals.

For those of you reading this who suffer from any sort of pain during sexual activity, I invite you to contact my practice, Center for Love and Sex via email sari@saricooper.com or coordinator@saricooper.com to discuss your situation and set up an appointment for an in person session or a coaching session if you’re outside of the NYC region.