Key terms for cis-gender females to learn as part of a Sex Esteem® tool-kit when it comes to penetrative sexual pain.

According to a nationally representative study of American adults, about 30% of cis-females have experienced pain during vaginal penetrative sex. When sex therapy cis-female clients come to treatment for individual or couples treatment, one of the issues they’re asked about is whether and how often they have had pain during vaginal penetrative sex. Painful sex not only impacts the cis-woman experiencing it but her partner(s) as well, especially if the pain has occurred over months or years. This is why painful sex should also be treated in couples sex therapy when a client is involved in a committed partnership or marriage.

There are several diagnostic terms that are used by medical professionals, therefore as part of developing one’s Sex Esteem® confidence it’s important to learn some key terms when discussing sexual pleasure with partners and treatment needs with medical professionals. 

Here is a primer on best principles in seeking help,  the most common terms, assessment techniques, and explanations for women to learn if they are experiencing sexual pain.  

Sex Esteem® Principles around Seeking Medical Care for Sexual Pain

Many cis-women have suffered with GPPD for years without getting a proper diagnosis from their medical professsionals. One reason may be due to the fact that of the 43% of American women aged 18 to 85 who report experiencing some form of sexual complaint, only 12% self-report to a provider.  In fact,  a woman might use understated terms like ‘discomfort’ or ‘uncomfortable’ when describing the sensations they’re experiencing during vaginal penetrative sex to their gynecologist instead of the word ‘pain’. 

Part of the Sex Esteem® Principles is to empower clients to become their own best advocates when it comes to reporting pain to medical providers. A sex therapist will coach clients to use a numbered scale system out of 10, when describing the level of pain, to discourage them from minimizing the level of pain by using mild adjectives. A sex therapist should also teach women to use the proper terminology to identify and tell their ob/gyns the location of the pain and by coaching them with these key questions that should be asked by their doctors:

• If their vestibule (vaginal opening) is a clock that their provider is facing when examining them, what o’clock is the pain usually felt upon penetration? 3 o’clock,6 o’clock, etc? 
• Is the sensation they feel more like burning, cutting or tearing and is it on the inner labia or both inner and outer labia? What level of pain is it on a scale of 10? 
• During penetration, does the sensation feel like searing pain or an aching thudding pressure against their vaginal walls? 
• Do they feel a sharp pinch when a dildo or penis bumps up against their cervix during penetration?
• Before making an appointment with a new gynecologist, we will practice asking a medical provider if they utilize a Q-tip assessment of the vestibule as part of their exams. 

The second challenge for cis-females seeking medical care for vaginal pain is that the majority of ob/gyns unfortunately have not had any or much training and clinical experience in female sexual disorders during their medical school education or their residencies. A recent survey reported that out  of 236 American medical school students, 58.5% reported receiving instruction in female sexual disorders (FSD) compared with 78.4%  who received training in male sexual disorders (MSD) in their preclinical curriculum. It’s clear that medical schools have to do more to increase the amount and depth of training around FSD. 

Pelvic Floor Muscle Dysfunction (PFMD) & Physical Therapists

The pelvic floor often refers to the muscles, tissues, nerves, and ligaments that are a bowl-like structure that supports one’s pelvic organs used for digestion, urination, and sexual activity. Research has shown that 25% of women experience one or more pelvic floor disorders in their lifetime. Pelvic floor muscle dysfunction (PFMD) is often classified into two main types:

Hypertonic: the muscles in the pelvic floor have tightened at rest and/or shortened, which causes spasms or pain.   

Hypotonic: the muscles are lengthened at rest, which weakens them. It is hard to contract your muscles with this condition.

Most cis-women who seek out sex therapy after years experiencing pain during sex require a multi-disciplinary biopsychosocial approach that includes a pelvic floor physical therapist to teach them how to strengthen hypotonic muscles and to provide pressure point massage to release hypertonic muscles.  

Most Common Sexual Pain Disorders and Proper Diagnostic Terms

1. Sexual Pain Disorder: Genito-Pelvic Pain/Penetration Disorder (GPPPD)

The Diagnostic and Statistical Manual of Mental Disorders (DSM5) categorizes Genito-Pelvic Pain/Penetration Disorder (GPPPD) is a sexual pain disorder, occurring in the vagina, the vulva, the opening and/ or inside the belly either during vaginal penetration, or spontaneously. 

1. Vulvodynia: chronic pain in the entire vulva, or in multiple areas in the vulvar region.
2. Vestibulodynia: pain in one’s vestibule, which is the tissue, at the opening of the vagina, within one’s vulva. 
3. Neuroproliferative Vestibulodynia (NPV): Women often have too many nerve endings in their vestibular tissue.
4. Vaginismus This term was removed from the DSM 5 since most women who have fear, anxiety and accompanying involuntary vaginal muscle spasms usually also have a co-occurring pain disorder so this term was incorporated into the updated GPPPD diagnosis described above.  However there are many women who have fear and spasms who have NOT experienced pain and the spasms are due to a phobic or trauma related response.  These may be women with a sexual trauma history and/or have grown up in a strict religious upbringing.  

Sex therapists conduct a thorough sexual history when working with clients to find out how long a woman has experienced Vulvodynia and Vestibulodynia or NPV, where exactly it is felt, under what conditions and how they have dealt with it when it comes to their sexual relationships. They also work with the woman with her partner or husband in order to teach them alternative techniques to increase both partners’ sexual pleasure and avoid continued painful experiences. As we know from both clinical care and research, partners exploring other types of sexual play and oral or anal penetration may experience high rates of pleasure and orgasm while a woman is getting treatment for her GPPPD. 

They’ll ask if the condition is Primary (meaning they have had pain their whole life) or

Secondary or acquired (pain developed later in life). They’ll also ask under which conditions the pain occurs; is it when the area is touched or during insertion of a tampon, finger or penis/dildo (provoked) or quite spontaneously while walking around or sitting (unprovoked)?

Sex Esteem® Steps to Advocate For Yourself if You are Experiencing Pain or Spasms:

1. Read up on how a sexual health professional conducts an exam on a recently created ISSWSH self-help handout or at Prosayla. 
2. Find an ob/gyn who is educated in diagnosing and treating sexual pain using a biopsychosocial framework through ISSWSH. 
3. Write down a highly detailed description of the pain and conditions you’re experiencing along with how long each symptom has been experienced before your scheduled ob/gyn appointment. 
4. Request a very specific exam of the pelvis, vulva, and vagina including the Q-tip test for mapping and diagnosing pain in the vulva.  (NOTE: if your provider does not offer this type of diagnostic test it may be a sign that they are not trained in sexual pain disorders). 
5. Work with an experienced sex therapist individually and/or with your partner (if in a longstanding relationship) to re-learn how to engage in pleasurable sex while re-establishing new neural pathways in your brain in approaching sex. 
6. If needed, get referrals for a pelvic floor physical therapist from your trusted ob/gyn or sex therapist or through the International Pelvic Pain Society. 
7. And remember, one shouldn’t continue to have penetrative sex if it hurts.