Cognitive-behavioural therapy can reduce pain during intercourse

One in five women experience pain during intercourse. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the bible of American psychiatrists, lists it under "genito-pelvic pain or penetration disorder." However, this type of pain is not purely psychological.

Provoked vestibulodynia is a condition experienced by approximately 8% of women in North America. It is characterized by severe pain at the vaginal opening during sexual intercourse or when inserting tampons. To reduce the burning sensation, many women apply lidocaine, an anesthetic cream.

A new study of 108 couples found cognitive-behaviural therapy (CBT) for couples to be more effective than lidocaine. The study was conducted by Sophie Bergeron, professor in the Psychology Department in the Faculty of Arts and Science at Université de Montréal, director of the UdeM Sexual Health Laboratory and holder of the Canada Research Chair in Intimate Relationships and Sexual Wellbeing, and Natalie O. Rosen of Dalhousie University.

Marc Steben and Marie-Hélène Mayrand of Université de Montréal, Marie-Pier Vaillancourt-Morel of Université du Québec à Trois-Rivières, Serena Corsini-Munt of the University of Ottawa, and Isabelle Delisle also contributed to the study, which has just been published in the Journal of Consulting and Clinical Psychology.

Unclear causation

The causes of provoked vestibulodynia have yet to be determined. There is a lengthy list of risk factors, including biomedical factors such as repeated infections causing inflammation in the vulvar area (cystitis, vaginal infections), the use of certain oral contraceptives, genetic predisposition, marital factors, and depression and anxiety.

Abnormalities in the pelvic floor muscles are also associated with provoked vestibulodynia, but it is not known whether they are a consequence of the pain or its cause. Similarly, it is unclear whether anxiety is a cause or a result, but it has been found that the higher the level of anxiety, the greater the pain.

Psychological intervention is recommended because once pain sets in, it has such a negative impact on sexuality and on the relationship that it becomes very important to break the vicious cycle of fear and avoidance," says Sophie Bergeron. "The pain often leads to loss of desire in women and frustration in both partners. This is a real problem; it's not imaginary."

Sophie Bergeron, Professor in Psychology Department, Faculty of Arts and Science, Université de Montréal

Few validated treatments

Couple therapy is commonly offered by psychologists and sexologists. In the case of provoked vestibulodynia, the partner plays a critical role and can help alleviate the problem or aggravate it. It is therefore every important to include the partner in the intervention. However, some interventions were not previously supported by evidence.

Now for the first time, a randomized clinical trial has compared the efficacy of couple CBT and lidocaine.

Therapy was found to be more effective than lidocaine application in reducing women's fear of pain, sexual distress and alarm, and in improving their sexual experience. After six months, the women were twice as satisfied with their sex lives and their partners three times as satisfied.

Nature of the sessions

The couples attended acceptance and commitment therapy (ACT) sessions for 12 weeks.

"Acceptance means that instead of trying to get a person to change their thinking, we encourage them to accept it," Bergeron explains. "We practice cognitive defusion, a technique that creates a psychological distance between the person and his or her thoughts. At the beginning of the therapy, the women define themselves by their genito-pelvic pain. The therapy helps them reduce the hold those thoughts have over them. We also try to break the sexuality = pain association and replace it with new associations, such as sexuality = pleasure with my partner, intimacy with my partner."

The therapy also looks at sexual motivations. What is it about sexuality that is important to the couple? "We try to explore other aspects of sexuality that are pleasurable," she says. "In terms of behaviour, we can help them expand their repertoire of sexual activities that don't cause pain. Generally, it's vaginal penetration that's painful, so we try not to always focus on that."

Finally, the therapy works on the couple's emotional regulation. "When one partner reacts to a painful experience with anger or frustration, it only makes the problem worse. We help the couple manage their emotional relationship. We get the partner to be more empathetic to the woman's experience of pain and the woman to be more empathetic to her partner's frustration. We help them see themselves as a united team."

The importance of the partner in therapy

According to Sophie Bergeron, the partner's involvement "helps alleviate the woman's pain because she is no longer alone with her pain." Both partners report they understand the problem and the other's experience better, and they are relieved to be able to work together to improve the situation.

At the end of the therapy, couples report satisfaction with having reclaimed their sexuality in a non-threatening way by refocusing on pleasurable experiences rather than allowing the pain to take control. This treatment could well be effective for other types of genito-pelvic pain as well.