The Integrated Guide to Treating Penetration Disorders in Women

Transforming Sexual Relationships from Fear to Confidence

Maha Nasrallah-Babenko

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9780367653767
• eBook ISBN: 9781000481686
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

Maha Nasrallah-Babenko presents a culturally sensitive and uniquely accessible guide that equips clinicians, student sex therapists, and female clients with the tools to confidently treat genito-pelvic pain and penetration disorders (GPPPD).

Addressing the issue from an integrated approach, the book provides evidence-based information and sensate, solo and partner practical exercises derived from the author's experience to help clinicians support women in redefining their relationship with sex, their bodies, and their partners. With a special focus on those from conservative and religious backgrounds, this beautifully illustrated text emphasizes the psychological, emotional, and relational factors that may increase shame and fear surrounding sex. The book defines GPPPD before outlining the author's ABCs approach, awareness, body, control, and safety, where she examines topics such as sexual abuse, how to communicate with you partner, sexual beliefs and messages, the importance of arousal, vulnerability and assertiveness, and shifting the significance of penetration for an enjoyable sex life.

This book is essential reading for training and established sex therapists, family therapists, and couple therapists looking to support those struggling with sexual intimacy, as well as the couples seeking their help.

1General Overview of Genito-Pelvic Pain/Penetration Disorders

DOI: 10.4324/9781003129172-1

What Is Vaginismus/GPPPD?

According to the DSM-IV (American Psychiatric Association, 2000), which is the diagnostic manual that psychologists and other mental health professionals follow in their assessment and diagnosis of psychological disorders, vaginismus is defined as:

Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with coitus and causes marked distress or interpersonal difficulty. The condition cannot be better accounted for by another Axis I disorder and is not caused exclusively by a physical disorder.

In other words, vaginismus is a condition where the woman consistently experiences involuntary contractions of her vaginal muscles which causes difficulties with penetration and leads to significant personal or relationship distress.

Often vaginismus makes penis-in-vagina (PIV) sex impossible and can be the cause of an unconsummated marriage. Although the muscular spasms that occur in vaginismus can help the condition be diagnosed (by a qualified gynecologist, pelvic physical therapist, or family doctor), diagnostic agreement between different clinicians has been shown to be poor; vaginal pain and spasms did not differentiate between women with vaginismus and dyspareunia (a genital pain disorder; i.e. painful sex) resulting from vulvar vestibulitis (Reissing et al., 2004) In addition, many of the health professionals usually involved in the assessment of vaginismus have insufficient expertise in diagnosing the muscular spasm, not to mention there being a lack of consensus around which muscles are involved in the spasms. Furthermore, it is difficult to discern whether the vaginal spasms have developed as a defense to painful attempts, or whether the spasms are what cause the pain. Some women with vaginismus display similar characteristics as people with specific phobias (hence why I sometimes use the term vaginal penetration phobia) (Lahaie et al., 2010). Fear of pain is the primary reason for some women with vaginismus abstaining from and avoiding sex, and so the previous classification of vaginismus does not take enough into account how fear plays into its development.

These are some of the reasons why the new version of the DSM (fifth edition) combined vaginismus, dyspareunia, and other penetration disorders into one main and broader diagnosis: genito-pelvic pain/penetration disorders (GPPPD) (American Psychiatric Association, 2013). The new DSM-V guidelines specify that if the woman has recurrent and distressing difficulty with one (or more) of the following for at least six months, then a GPPPD diagnosis is warranted:

• vaginal penetration during intercourse
• marked vulvovaginal or pelvic pain during intercourse or attempted intercourse
• marked fear or anxiety about the experience of vaginal or pelvic pain as related to vaginal penetration
• marked tensing of the pelvic floor muscles during attempted vaginal penetration

(Perez & Binik, 2016)

I should note that, though the diagnoses of vaginismus, dyspareunia, and other penetration difficulties have been merged into GPPPD, the treatment guideline I describe in this book is mostly based on my work with women who suffered from either vaginismus or vaginal penetration phobia (which, together, I will refer to as “penetration disorders” throughout the book), and not dyspareunia. And so though many of the suggestions in this book could also be beneficial in treating painful sex, it must be noted that they may not be appropriate or sufficient for some of these cases. I may use the terms GPPPD, vaginismus, or penetration disorders interchangeably throughout the book to refer to the condition. If PIV sex or attempted vaginal penetrative sex is painful, it may be useful for the client to consult a pelvic physical therapist (if they are available where the client resides) for a complete evaluation to assess whether there may be organic or physical causes for the pain. If the client has no access to a physical therapist specializing in pelvic issues, then they may consult a qualified gynecologist instead.

Prior to the development of the GPPPD diagnosis in the DSM-V, I personally did not rely solely on identifying muscular spasms for the diagnosis of vaginismus. Whenever a client presented to me with a self-report of either not being able to have PIV sex, complete a gynecological exam, or insert a tampon, I would treat the condition in a similar manner. My preferred definition has thus been inspired by Basson et al. (2004) who recommend the following guidelines:

The persistent or recurrent difficulties of a woman to allow vaginal entry of a penis, a finger, and or any object, despite a woman’s expressed wish to do so. There is often (phobic) avoidance and anticipation/fear/experience of pain, along with variable involuntary pelvic muscle contraction. Structural or other physical abnormalities must be ruled out/addressed.

So to put it simply, if a woman is unable to have vaginal penetrative sex or insert a tampon or have a gynecological exam due to either fear or uncontrollable muscle contractions, despite her desire to do so, and this difficulty is causing her distress, then I would approach it similarly to treating vaginismus, with a great focus on her fears and discomfort. Even if she is not experiencing muscle contractions and is merely experiencing an uncontrollable phobic response or avoidance (specific phobia linked to sex or vaginal penetration), I would follow the same guidelines. In other words, one way in which GPPPD may show up is that the couple may be attempting vaginal penetrative sex and the penis might not be able to enter the vagina because there is a tightening/tensing of her vaginal and pelvic muscles, or because of pain. Alternatively, the couple may not actually be having any penile-vaginal contact and they are unable to have PIV sex because of the woman’s avoidance behaviors such as tightening and closing of the legs, pushing the partner away, or moving away from the partner. In both situations there is an experience or anticipation of pain and/or vaginal penetration, and in my opinion, it is that experience or fear that is underlying vaginismus or dyspareunia in many women (Leiblum, 2007, p. 125). Though the treatment plans in both cases generally look the same in my approach, they will and should, of course, be tailored to each individual according to her needs, circumstances, and severity. Therefore, this book offers a general guide to overcoming this difficulty, which I encourage the reader to modify according to what they deem would be best for their client or situation.

Vaginismus may arise as part of a conditioning response that is acquired secondarily to negative physical and/or psychological stimuli. This means that a woman can associate sex or any other penetrative activity with physical pain, fear, or trauma, if she experienced one (or more) incident(s) where the physical or psychological stimuli were present at the same time as a sexual or genital experience. It is one of the most common female sexual dysfunctions – prevalence rate is not accurately known and varies in different parts of the world (figures range from 5 percent to 43 percent depending on where the data was collected and how it has been classified, and tends to be higher in Muslim-populated countries) (Oksuz & Malhan, 2006; Perez, Brown, & Binik, 2016; Nobre, Pinto-Gouveia, & Gomez, 2006; Laumann, Paik, & Rosen, 1999; Lau, Kim, & Tsui, 2005; Leiblum, 2007, p. 130). I can confidently say that it was the most common presenting issue Arab and South-Asian women would bring to me in therapy during my years practicing in the UAE, which supports some of the evidence that it tends to be more common in more conservative and religious parts of the world.

What Is Dyspareunia?

Though this book is not about dyspareunia specifically, I am going to briefly describe it, as some women suffer from it in addition to vaginismus and separating the two can get confusing. As vaginismus and dyspareunia can be a common comorbidity (co-occurring diagnoses), it is likely that this is one of the reasons they have been merged into one main category. Put simply, dyspareunia is recurrent genital pain associated with sexual activity (could be superficial/external, vaginal, or deep). It is usually used to describe pain on penetration but can occur during genital stimulation. In situations where dyspareunia is an issue, I highly recommend stopping any activity that is painful, and consulting a gynecologist or pelvic physical therapist to check for any potential physical abnormality, or medical/organic cause such as infection, inflammation, endometriosis, or cysts.

If no medical cause is found, it is often a result of insufficient lubrication and/or low arousal, which generally happens if the woman is not relaxed (such as if she has vaginismus or is anxious/fearful), and/or is not excited enough (for example, if she has low desire, or is not attracted to the partner, or is anxious, or not stimulated in the appropriate manner). At times paying more attention to sensual touch and appropriate sexual stimulation helps, if it is mainly a matter of creating more arousal. And sometimes couples therapy may be advised if problems in the relationship are leading to a lack of interest in or aversion to sex. Though this book discusses the integrated treatment of penetration disorders, which are part of GPPPD, I cannot claim that it can also treat painful sex, as there could be other potential factors involved in pain. What I can say, however, is that incorporating some of the themes or exercises provided in this book could potentially be helpful in addressing the pain, depending on the specific case and causes.

How Vaginismus Develops

Like many other psychological or medical issues, it can be very difficult to find a cause for vaginismus. Generally speaking, however, a combination of contributing factors can be associated with vaginismus. Some of these factors, such as traumatic events, can act as triggering factors, while other predisposing factors, such as one’s upbringing, make the woman susceptible to potentially developing a sexual dysfunction. There are also maintaining factors, such as some of the partner’s behaviors or relationship dynamics that may be either exacerbating or maintaining the issue.

Contributing Factors

• Fear of pain or fear of tearing during penetration (Fadul et al., 2019): may be due to stories they have heard about sex being painful, scary, traumatic, or involving a lot of blood.
• Fear of losing control over the body or situation (Fadul et al., 2019), fear of the unknown: not being able to predict or know what sex is going to feel like, how they may react or behave during (for example, if they are going to have a panic attack or do things that may be embarrassing), and whether or not they will enjoy it. This fear may also involve the fear of not knowing how their partner is going to act during sex (for example, if they are going to be rough or lose control).
• Childhood sexual trauma: molestation, sexual assault, and sexual abuse experienced during childhood. Sexual abuse is discussed further in Chapter 2.
• Sexual assault: sexual harassment, sexual assault, or rape during adulthood.
• Religious/conservative background: recent studies from Turkey and other predominantly Muslim countries suggest a very high prevalence of vaginismus. These reports are consistent with older clinical reports from other highly religious groups (Perez & Binik, 2016).
• Familial, religious, and cultural taboos, shame and guilt associated with sex, and high emphasis on virginity: this is related to the previous point but also different in that it is specifically about being exposed to negative messages and information around sex in one’s environment due to cultural, religious, or familial taboos.
• Authoritarian/abusive parenting style: more women with vaginismus reported being educated under authoritarian/abusive environments than controls (Fadul et al., 2019).
• Lack of sexual education: many countries and cultures lack any sex education at school or in the household, which can lead to inaccurate and unrealistic beliefs about sex.
• Inadequate sexual information: even when sex education is provided in some schools and countries, it often covers the main biological and anatomical information about sex, thus lacking useful insights around some of the important psychological, social, and relational aspects involved in sex. When education or information about sex is inadequate, that could also contribute to the development of unrealistic and harmful beliefs and behaviors around sex.
• Unrealistic sexual beliefs/fantasies (e.g. the vagina is too small to accommodate a penis): when sex education is inadequate or lacking, or children and adults gather incorrect information about sex from peers or unreliable sources, one can then develop unrealistic expectations about sex, which could lead to shame, anxiety, fear, and guilt around sex.
• Painful or traumatic first attempt: when a woman experiences a painful or traumatic first attempt, this could condition her to associate pain or fear with sex. As a result, she could then anticipate pain in future attempts, and ultimately experience fear and/or pain during sex. This will be discussed further throughout the book.
• Physical pain caused by some medical issues such as genital tract infections, vestibulitis, postmenopausal estrogen deficiency, trauma associated with genital surgery and radiotherapy, problems with arousal that result in poor lubrication and consequently painful vaginal penetrative sex (arousal dysfunction is more common in women with diabetes, multiple sclerosis, or spinal cord injury).
• Traumatic gynecological examinations by unsympathetic health professionals: similar to the painful or traumatic first attempt, if the woman experiences a painful or traumatic medical exam, she could then associate pain with objects penetrating or even approaching her genital area.
• Relationship problems (may lead to or maintain vaginismus or other sexual difficulties): relationship factors could contribute to the development or maintenance of penetration difficulties by creating a lack of emotional (or even physical) safety in the relationship.
• Fear of pregnancy: though this fear is often subconscious or minimized, it could contribute to the woman finding penetrative sex difficult. At times even if sex is protected and safe, fears around pregnancy can sometimes be irrational due to underlying anxiety and guilt around sex.
• Anxious personality traits: having anxiety or finding it difficult to have a flexible and relaxed mindset could contribute to the woman needing to control situations that are unknown or that she is not fully in control of. Sex could be one of those situations. This is again elaborated further later in the book. Women with vaginismus tend to experience higher levels of pain catastrophizing cognitions and harm avoidance (Borg et al., 2012).
• Being with an inexperienced partner: this is mostly related to the woman feeling confident and safe during sex. Having an inexperienced partner who does not exhibit confidence during sex could contribute to the woman feeling less safe and more anxious, especially when attempting something that is new to her that she does not feel confident in either.
• Failure to communicate: the inability of the couple to openly communicate about sex specifically can perpetuate the sexual negative cycle or exacerbate the issue.

There is suggestion of a cycle that evolves where fear and anticipation of pain, leading to some muscular tension/contraction, increases the likelihood of future penetration attempts resulting in a sensation of pain – this then leads to avoidance of future penetration attempts, thus reinforcing the avoidance due to relief of the fear (as shown in Figure 1.1). As briefly described above, the fear and anticipation of pain could develop from several of the contributing factors, such as painful/traumatic first attempts, experiences, or gynecological exams, insufficient or inadequate sexual information, unrealistic beliefs about sex, and anxiety or lack of safety.

Figure 1.1Vaginismus pain cycle.

Case Example

Zaynab, who is from the UAE, shares the story of many young women from the Arab and South-Asian worlds. She got married in her early twenties to a young man she met through her family who is part of her community, grew up in a religious family, did not receive much sex education, and heard some women in her extended family and circle of friends talk about traumatic first sexual experiences that were very painful and bloody. On their wedding night, they were both tired but still attempted vaginal penetrative sex as it was the “normal” and expected thing to do. She could not forget the scary stories she had heard about sex and was very nervous during. They did not engage in much touch or other forms of sexual intimacy and went straight to attempting vaginal intercourse. Her legs were tense and contracted but she tried really hard to keep them open and allow him to penetrate her. She was also not very lubricated due to her anxiety and lack of erotic build-up which did not help create sufficient arousal. As soon as the tip of his penis pushed into the entry of her vagina she felt a sharp intense pain. That pain created even more fear, more muscular tightness, and less arousal, which continued to lead to pain with each thrust or attempt. They decided to stop because she was clearly very distressed, and he did not want to see her in so much pain. Each time they attempted vaginal penetrative sex after that was just as, if not more, difficult, scary, and painful for her,...

Table of contents

• Cover
• Half-Title Page
• Endoresement Page
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Foreword
• Preface
• Acknowledgments
• Introduction
• 1 General Overview of Genito-Pelvic Pain/Penetration Disorders
• 2 Psychological and Emotional Factors
• 3 Between Control and Vulnerability
• 4 Relational Factors
• 5 Mastering Her Body
• 6 Incorporating the Partner
• Conclusion: Closing Words and Beyond
• Index