Dyspareunia is painful sexual intercourse. The same term is used whether the pain results from a medical or a psychosocial problem. Dyspareunia may be diagnosed in men and women, although the diagnosis is rare in men; when it does occur in men, it is almost always caused by a medical problem.
This discussion focuses only on pain with intercourse caused by psychosocial problems; therefore, only women's experiences are emphasized in this entry.
The professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders , Fourth edition, text revised (known as the DSM-IV-TR ) classifies this condition as a sexual dysfunction.
Dyspareunia is any pain experienced any time before, during, or following sexual intercourse. The pain may be located in the genitals or within the pelvis. It is not unusual for women occasionally to experience pain during intercourse. This is not true dyspareunia.
A woman who has dyspareunia often also has vaginismus . This is an involuntary tightening of the vaginal muscles in response to penetration. It can make intercourse painful, or impossible.
Causes and symptoms
Psychosocial causes of dyspareunia include:
- Prior sexual trauma. Many women who have been raped or sexually abused as children have dyspareunia. Even when a woman wishes to have sex with someone later, the act of intercourse may trigger memories of the trauma and interfere with her enjoyment of the act. Vaginismus also often occurs in such women.
- Guilt, anxiety, or tension about sex. Any of these can cause tense vaginal muscles and also prevent arousal from occurring. People who were raised with the idea that sex is bad may be more prone to have this problem. Fear of pregnancy may make arousal difficult.
- Prior physical trauma to the vaginal area. Women who have had an accidental injury or surgery in the vaginal area may become sensitive to penetration. Vaginismus is common in these cases, as well.
- Depression or anxiety in general. Either of these can lead to loss of interest in sex. This can be experienced by either sex.
- Problems in a relationship. Dyspareunia may occur when a woman feels her sexual partner is abusive or emotionally distant, she is no longer attracted to her partner, or she fears her partner is no longer attracted to her. Men, too, can lose interest in sex because of prior emotional trauma in a relationship; however, the result is usually impotence, rather than dyspareunia.
- Vasocongestion. Vasocongestion can occur when either partner frequently becomes aroused but does not reach orgasm. Vasocongestion is a pooling of blood in dilated blood vessels. Normally, the pelvic area becomes congested with blood when a person becomes sexually aroused. This congestion goes away quickly after orgasm. If there is no orgasm, the congestion takes much longer to resolve.
Any of these factors may cause painful sex. The affected person may then associate pain with sex and find it even harder to relax and become aroused in future.
The DSM-IV-TR diagnostic criteria for dyspareunia are as follows:
- Recurrent or persistent genital pain related to sexual intercourse that may occur before, during, or after intercourse.
- The affected person is distressed by the pain, or experiences relationship problems as a result of the pain.
- The pain is not caused exclusively by vaginismus or lack of lubrication, is not better accounted for by another disorder, and is not due exclusively to the direct effects of a drug, medication, or a general medical condition. Dyspareunia can occur with other sexual dysfunctions.
The most common symptom of dyspareunia from psychosocial causes is pain at the vaginal opening as the penis enters the vagina. Entry may be difficult, and the pain may be burning, or sharp. The woman may have a sense of being "dry." Pain may continue or ease as thrusting continues.
Vasocongestion can cause an aching pain in the pelvic area that persists for hours after intercourse. Pain with orgasm, or pain deep in the pelvis with thrusting, is more likely to be a sign of a medical problem, but can result from lack of arousal and tension.
A person who experiences pain during sex may feel embarrassed or ashamed. Dyspareunia can cause problems in relationships or lead to the affected person avoiding relationships altogether.
About 15% of women may have pain with intercourse at some point in their lives. About 1–2% have true dyspareunia. The incidence is much higher in women who have been raped or otherwise sexually abused. As stated, dyspareunia in men is rare and is almost always caused by a medical problem.
About 30% to 40% of all women who seek help from a sexual counselor for dyspareunia turn out to have a medical problem that is causing their pain. A full medical examination is necessary to rule out a possible medical cause. This includes a pelvic exam and may also include an ultrasound, as well as other diagnostic tests. Examples of possible physical causes are infections, sexually transmitted diseases (STDs), estrogen deficiencies, and vulvar vestibulitis.
Once a medical cause is ruled out, a full family and sexual history can help pinpoint possible psychosocial causes. A psychological evaluation can determine the cause of the problem. Women who have been raped or abused may also suffer from post-traumatic stress disorder (PTSD) or generalized anxiety disorder .
There are two types of dyspareunia. Lifelong or primary dyspareunia means that the condition has been present for the entire sexual life of the affected person. This type is usually associated with being raised to believe that sex is bad, sexual abuse, fear of sex, or a painful first sexual experience. Acquired or secondary dyspareunia begins after a period of normal sexual function. It often has a medical cause, but may be a result of some sort of trauma, such as rape.
Counseling is often helpful to identify and reframe negative feelings about sex. Couples therapy can help improve communication between partners and resolve problems that may be a factor in the sexual relationship. Women who have been abused or raped may benefit from counseling techniques designed to help overcome fears and issues caused by traumatic experiences.
Sex therapy may be offered to provide information about the physical aspects of arousal and orgasm. A sex therapist will also offer suggestions for how to improve sexual technique. For example, increasing time for foreplay and allowing the woman to control when and how penetration occurs can help her to relax and become aroused more easily.
Women who also have vaginismus may be given a set of devices they can use at home to dilate the opening of the vagina. Affected women start with a very small device and gradually work up to a penis-sized device, proceeding to a larger size only when they can use the smaller one without pain or fear. This retrains the vaginal muscles and helps the involuntary muscle tightening of vaginismus.
Use of a vaginal lubricant, at least temporarily, may be helpful in some women to reduce anxiety about possible pain.
There are no specific medications that treat dyspareunia. Medications that increase blood flow or relax muscles may be helpful in some cases.
With treatment, the chance of overcoming dyspareunia and having an enjoyable sexual life is good. Treatment can take several months, particularly in the case of survivors of a violent trauma such as rape.
Hales Robert E., Stuart C. Yudofsky, and John A. Talbott, eds. The American Psychiatric Press Textbook of Psychiatry. 3rd ed. Washington DC: American Psychiatric Press, 1999.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 2000.
Jody Bower, M.S.W.