Female Sexual Pain Disorders and Cognitive Behavioral Therapy

LoFrisco, Barbara M., The Journal of Sex Research

Female sexual pain disorders are important to study because they can negatively affect both a woman's well-being and her romantic relationships. Despite the consequences of the disorders, there is a dearth of research on the topic. Of what is available, cognitive-behavioral therapy (CBT) interventions appear to be the most frequently studied, possibly because CBT addresses the psychological elements of pain. The purpose of this article is to provide a rationale for the use of CBT, provide a critical analysis of these research studies by evaluating each study in detail, and identify gaps in the research base.

Sexual pain disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]; American Psychiatric Association [APA], 2000) as either dyspareunia or vaginismus. Dyspareunia is defined by the DSM-IV-TR as "(A) Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female; (B) The disturbance causes marked distress or interpersonal difficulty; (C) The disturbance is not caused exclusively by Vaginismus or lack of lubrication, is not better accounted for by another Axis I disorder (except another Sexual Dysfunction), and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition" (p. 556). Vulvodynia, pain in the vulva, and its subtype, provoked vestibulodynia (also referred to as vulvar vestibulitis), pain in the vulvar vestibule area, are both types of dyspareunia. Although the definition of dyspareunia includes males, this article only addresses research with females.

Vaginismus is defined by the DSM-IV-TR as "(A) Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse; (B) The disturbance causes marked distress or interpersonal difficulty; (C) The disturbance is not better accounted for by another Axis I disorder (e.g., Somatization Disorder) and is not due exclusively to the direct physiological effects of a general medical condition" (APA, 2000, p. 558).

Although they are separately defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; APA, 1994), because many researchers think that vaginismus and dyspareunia are related and because they contain many of the same features, they are discussed as one condition. Specifically, the involuntary contracture of the pelvic floor, the distinguishing feature of vaginismus, could be a reaction to a pain condition (Backman, Widenbrant, Bohm-Starke, & Dahlof, 2008) and may also play a role in maintaining the pain (Bergeron & Lord, 2003). Thus, vaginismus can be a reaction to dyspareunia and can interfere with the treatment of dyspareunia. In fact, Bergeron and Lord (2003) reported that they are so closely related they really mean the same thing.

Importance and Prevalence

Female sexual pain disorders are both important for women's well-being and prevalent. Researchers have found that sexual satisfaction can have a significant, positive effect on women's overall happiness (Blanchflower & Oswald, 2004; Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004; Laumann et al., 2006). Sexual frequency can also have a significant, positive effect on happiness (Blanchflower & Oswald, 2004). Thus, it follows that a reduction in sexual satisfaction may lead to a reduction in overall well-being and general happiness (Laumann et al., 2006). In addition, Kahneman et al. (2004) found that out of the common activities that women perform, sex was rated as providing the most pleasure. Because female sexual pain disorders can prevent or reduce frequency of sexual activity or negatively impact satisfaction, they can have a deleterious effect on women's overall happiness and well-being.

Dyspareunia appears to be prevalent, although estimates vary according to study. One study found 60% of women have experienced dyspareunia at some point in their lives, with 33% experiencing persistent pain (Glatt, Zinner, & McCormack, 1990). Yet, other studies report lower numbers (i.e., 14.4%; Anastasiadis, Davis, Ghafar, Burchardt, & Shabsigh, 2002) and ranges (from 3% to 18%; Simons & Carey, 2001). One possible explanation for these divergent numbers is that prevalence rates vary by age group and culture (Anastasiadis et al., 2002). Vaginismus also appears to be prevalent, with 15% to 17% of patients presenting at sex therapy clinics having this disorder (Anastasiadis et al., 2002).

Rationale for CBT Treatment

Because the combination of physical therapy to address physical aspects and CBT to address psychological aspects has been effective in other pain disorders, it is likely to be beneficial in the treatment of dyspareunia (Bergeron & Lord, 2003). Furthermore, McCabe (2001) commented that, according to the literature, cognitive strategies to reduce anxiety are an important ingredient for treatment.

This leads to the following questions:

Q1: How effective is CBT in treating female sexual pain disorder?

Q2: Is CBT equally effective as more invasive treatments such as vestibulectomy?

Q3: Are some modalities of CBT more effective than others?

Method

Studies that addressed the utilization of CBT in treating female sexual pain disorders were identified through a literature search. Two electronic databases, MEDLINE and PsychINFO, were used. Search terms used were the following: dyspareunia, vaginismus, vulvodynia, vulvar vestibulitis, or female sexual pain; and CBT, cognitive …

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Publication information: Article title: Female Sexual Pain Disorders and Cognitive Behavioral Therapy. Contributors: LoFrisco, Barbara M. - Author. Journal title: The Journal of Sex Research. Volume: 48. Issue: 6 Publication date: November-December 2011. Page number: 573+. © 2007 Taylor & Francis Group, LLC. COPYRIGHT 2011 Gale Group.

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