Making sex less painful, via couples therapy

One in five women experiences pain during sex. In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the bible of American psychiatrists, the condition is called genito-pelvic pain, or penetration pain.

Such pain is not only psychological, however.

Indeed, about eight percent of women in North America are affected by a condition called  provoked vestibulodynia, characterized either by a burning pain at the entrance to the vagina during penetration or the insertion of tampons, or any other form of contact with the area.

To reduce these burning sensations, women can often apply lidocaine, an anesthetic cream.

Now a study in Canada of 108 couples has found that cognitive-behavioral couple therapy works better than the cream at getting the pain under control. Published today in the Journal of Consulting and Clinical Psychology, the study was led by researchers at Université de Montréal and Dalhousie University.

A disorder with unknown causes

To date, doctors have not been able to determine what causes provoked vestibulodynia.

 There are many risk factors: biomedical ones such as repeated infections causing inflammation in the vulvar region (cystitis and vaginal infection, for instance) and the use of certain oral contraceptives, as well as genetic predispositions, relationship factors or even depression and anxiety.

Abnormalities in the pelvic floor muscles have also been identified. It is not known whether these abnormalities are consequences of the pain or whether they are one of its causes. Population-based studies have shown that anxiety is both a risk factor for the development of genito-pelvic pain and one of its consequences.

“Psychological interventions are therefore advised, because once pain is established, it has such a negative impact on sexuality and on the couple that it becomes essential to break the vicious circle of fear and avoidance,” said UdeM psychology professor Sophie Bergeron, the study’s lead author.

“For women, pain often leads to a loss of desire and both partners are frustrated – this is a real problem, not an imaginary one," said Bergeron, director of UdeM’s Sexual Health Laboratory and holder of the Canada Research Chair on Intimate Relationships and Sexual Well-Being.

She conducted the study with her UdeM colleagues Marc Steben and Marie-Hélène Mayrand, as well as with Marie-Pier Vaillancourt-Morel of Université du Québec à Trois-Rivières, Serena Corsini-Munt of the University of Ottawa, and Isabelle Delisle and Natalie O. Rosen of Dalhousie University, the latter as co-principal investigator.

Partner plays a major role

It is a common practice among psychologists and sexologists to offer couples therapy. In the case of provoked vestibulodynia, the partner plays a major role, since this person can either aggravate the problem or help reduce it, and so couples therapy is key.

The efficacy of first-line medical treatments has not been supported by reliable scientific evidence, but group therapy has. So for her new randomized clinical trial, Bergeron evaluated the benefits of cognitive-behavioural couple therapy versus lidocaine to treat provoked vestibulodynia.

The result: couples therapy was found to be more effective than lidocaine in reducing women's pain sensations; lessening their fear, anxiety and helplessness vis-à-vis the pain; diminishing their sexual distress; and in improving their sex life overall. After a six-month follow-up, the women randomized to couples therapy were twice as satisfied with their sex life – and their partners, three times as much.

The intervention – based on acceptance and commitment therapies – was spread over 12 weeks.

“Acceptance therapy means that instead of getting a person to change their thoughts, we try to get them to accept them – we proceed with cognitive de-fusion, that is, we introduce a psychological distance between the person and their thoughts,” said Bergeron.

“At the beginning of the therapy, women tend to define themselves by their genito-pelvic pain. The therapy allows them to make these thoughts have less influence over them,” she continued.

“We also try to break the association they have made that sexuality equals pain. We want to replace it with new associations such as ‘sexuality equals pleasure with my partner,’ and “sexuality equals intimacy with my partner,’” she said.

The therapy also takes sexual motivations and values into account. What is important to couples in their sexuality?

Exploring pleasure in sex

“We try to explore other aspects of sexuality that are pleasurable," Bergeron said. “Behaviourally, we can help couples expand their repertoire of sexual activities that don't involve pain. Generally, it's vaginal penetration that causes pain, so we try to steer the focus away from that.”

Finally, therapy helps the couples work on regulating their emotions. “When one partner reacts with anger or frustration during a pain experience, it only makes the problem worse,” said Bergeron.

“We help the couple to better manage their emotional relationship. We get the partner to be more empathic to the woman's experience of pain and the woman to be more empathic to her partner's frustration.

“We help them to see that they are a united team.”

Having a partner in therapy “helps the woman reduce her pain because she’s no longer alone to face it,” she explained. The study partners reported they now have a better understanding of each other's problems and experiences and are happy to work together to improve things.

At the end of their therapy, couples say they are particularly satisfied with having reclaimed their sexuality in a non-threatening way by putting the emphasis back on pleasant experiences rather than letting the pain take over, Bergeron said.

And there is every reason to believe, she added, that with other types of genito-pelvic pain this treatment could work, as well.