Making these changes may be less difficult than you think. Many problems with orgasm are not caused by deep-seated psychological conflicts but rather by simply not knowing how your body works and not doing activities that are stimulating enough. Many women do not explore their own bodies until after they have been with sexual partners. If you do not know how your own body works, you may be unable to withstand real or imagined sexual pressure from a partner. You may believe that you are incapable of having an orgasm, or just feel uncomfortable with the sexual interaction in general. Remember that biological or physical causes for the inability to reach orgasm are very rare.
How long should it take to reach orgasm during intercourse? This is for you to decide. I will teach you techniques in Chapter 27 that are so effective that you can reach orgasm right at penetration if you want to.
Carol
Here’s a case that illustrates a situational problem with orgasm that was due to deep-seated psychological problems. Carol, age forty-two, the client of a male surrogate partner who was a colleague of mine, experienced problems in becoming aroused to orgasm. She had experienced orgasms in the past and could reach orgasm through masturbation. Carol’s problem was that as she approached orgasm during intercourse she felt herself shutting down and becoming distracted. In working with a surrogate partner she revealed that she had severe psychological conflicts related to a recent incestuous episode. Every episode of intercourse brought back the anxieties associated with that relationship. When she approached orgasm, she literally had flashbacks of being with her relative. For Carol, successfully dealing with her orgasm problem required a combination of talk therapy to deal with the incest and working with a surrogate partner on the distractions and anxiety as they occurred in sexual situations.
Carol also began to understand that she had spent so much time worrying about other people’s enjoyment and doing what other people wanted that she had forgotten it was all right to accept her own sexual desires and enjoy herself. Today, Carol regularly experiences orgasms during intercourse.
An Alternative View of Female Sexual Problems
It’s very common for a woman to have more than one sexual problem. For example, if a woman has arousal problems, it’s obvious that she also has orgasm problems. Low sexual desire often accompanies the other female sexual problems. Because of this, there was a movement several years ago to combine three of the female sexual problems into one diagnosis called female sexual disorder (FSD). FSD includes a constellation of low sexual desire, female sexual arousal disorder, and female orgasm disorder. As of the writing of the most recent DSM, however, it was decided to keep these disorders separate.
A composite diagnosis of female sexual disorder is a good idea in the sense that it reflects the reality that it’s fairly common to have more than one sexual problem. Also, female sexual functioning is more psychologically oriented and diffuse than male sexual functioning, as well as more dependent on the interpersonal context of a sexual relationship. I believe that the reason why a diagnosis of female sexual disorder was unacceptable to the compilers of the DSM is that it was being pushed by pharmaceutical companies for their own interests and did not reflect the specific symptom presentations that sex therapists, psychologists, and psychiatrists treat every day. One diagnosis would have made it easier for pharmaceutical companies to put a large amount of money behind one drug rather than behind three or four.
chapter 12
Vaginismus
This chapter and the next are about sexual pain and are organized a little differently from the chapters on the other sexual dysfunctions. Not much is known about sexual pain, especially dyspareunia (psychological pain during intercourse), even though sexual pain may affect as many as 10 percent of women in some demographic groups.
Vaginismus is currently defined in the DSM-IV as a “recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.” The PC muscle that surrounds the vaginal opening goes into a spasm and prevents penetration because the vagina is so tight.
What’s Normal?
The majority of women in the world are able to experience sexual intercourse without their PC muscle going into an uncontrollable spasm. The majority of women are also able to have sexual intercourse without pain. Therefore, I would say that having those two abilities is the norm.
Types of Vaginismus
In lifelong vaginismus, a woman has never experienced sexual intercourse. In acquired vaginismus, a woman has successfully experienced sexual intercourse in the past but is unable to do so now. In generalized vaginismus, a woman cannot experience any type of penetration, including by a penis. In situational vaginismus, a woman can experience vaginal penetration with some objects but not with others, or with some partners but not with others.
The two most common forms of vaginismus are lifelong generalized vaginismus and situational acquired vaginismus. In lifelong generalized vaginismus, a woman has never experienced successful vaginal penetration with any object. This usually occurs in young women, although there have been cases of lifelong generalized vaginismus in women in their fifties and sixties. Common causes of this form of vaginismus are a lack of sexual education, and a childhood and adolescent climate of sexual guilt and fear. This type of vaginismus usually includes a history of unsuccessful experimentation with finger penetration or tampon use.
In acquired situational vaginismus, a woman develops the condition as a reaction to a sexual trauma such as rape. The vaginal spasms are usually restricted to attempts at intercourse.
Sometimes it’s difficult to make the distinction between vaginismus, dyspareunia, and sexual aversion disorder. If you are dealing with sexual pain, you may find that elements of all of these conditions apply to you. To heal your problems, you may decide to do the sensate-focus programs for all three disorders, beginning with the easiest one first, which is the treatment for sexual aversion disorder.
I know of only one book on vaginismus. It’s entitled Private Pain: It’s about Life, Not Just Sex: Understanding Vaginismus and Dyspareunia, by Ditza Katz and Ross Lynn Tabisel (see Recommended Reading). The authors run a clinic in New York that specializes in treating vaginismus. The book was privately published by their clinic. Private Pain is not a self-help book. That is, it does not include exercises to help women and their partners deal with vaginismus. The authors believe that the majority of cases of vaginismus can only be dealt with using professional help. Obviously, I disagree. I mention Private Pain because its value lies in the many case histories quoted throughout the book. I think the book would be valuable to women who want to convince themselves that they are not alone with this problem.
Here are some observations I made after reading Private Pain. The authors believe that women need to experience what they call the “five penetrations of life” to be able to maintain their vaginal and reproductive health and hygiene, and to enjoy sexual intimacy. These five penetrations include: penetration by a speculum, so a woman can receive a yearly pelvic exam; penetration by an applicator, to administer medicine in the case of a vaginal infection; penetration by a tampon, for feminine hygiene; penetration by a finger, for solitary sexual pleasure; and penetration by a penis, for sexual intimacy with a partner.
Based on these five types of penetration, let me revisit the most common forms of vaginismus and place them in a slightly different framework. Some women are unable to experience any of the five types of penetration. Some women are able to experience some of the five but not others. Finally, some women are able to insert a tampon, a speculum, a medicine applicator, and a finger, but are unable to have sexual intercourse.
Symptoms and Causes of Vaginismus
The authors of Private Pain describe vaginismus as a panic attack in the PC muscle. The woman with vaginismus typically has a history of bad experiences with tampons, fear of her own genitals, lack of masturbation, and no knowledge of the PC muscle.
Women with vaginismus often rep
ort a ticklish sensation in the inner thighs and vaginal area. In some extreme cases, women have needed to be sedated in order to receive a pelvic examination. Women with long-term cases of vaginismus often become accepting of the idea that they may never have children because of their inability to have sexual intercourse. In some cases, women can have oral sex or even anal intercourse, but not vaginal sex. Having vaginismus can make you feel like a freak. Some women have even gone so far as to undergo painful and unnecessary surgery (a hymenectomy or a procedure to supposedly widen the vaginal opening). Vaginismus is one of the most common reasons for unconsummated marriages. (Erection problems are another.)
Immediate symptoms that occur when penetration is attempted are symptoms of anxiety or extreme arousal of the sympathetic nervous system (the part of the nervous system responsible for the fight-or-flight reaction). These include sweating, shaking, urinary urgency, nervousness, nausea, stomachache, closing the legs tight, general body tension, holding one’s breath, grasping onto the bed or a wall, closing one’s fists, and scooting up on the bed or examination table to get away from a penis or speculum.
Vaginismus is often accompanied by an inability to look at one’s own genitals, touch one’s own genitals, masturbate, receive manual or oral sex from a partner, or have an orgasm. It is also sometimes accompanied by weird beliefs about the vagina: misconceptions about its length, structure, and what it looks like inside.
If you have vaginismus, you may have experienced it in various ways. You may think that your partner has an exceptionally large penis or that you are very tight. You may think, “I just can’t do it,” or, “It just won’t go in, no matter how hard I try,” or even, “I want to do it, but I’m just not big enough.” In fact, vaginismus is unrelated to the actual size of the vagina. It is rare for a vagina to be so small that it will not accommodate a penis of any size. An exception would be in cases of congenital problems with the vagina. For example, there are girls who are born with a vaginal opening but no vaginal canal. Their vagina is only an inch or so deep. But this is very rare.
Obviously, the cause of vaginismus in a sexual situation is fear—fear of one’s own genitals and fear of penetration. Causes from the past could include a restrictive religious upbringing, an upbringing in which sexual intercourse was consistently described as painful, failed penetration attempts, actual painful intercourse, sexual inexperience, and not feeling that one has the power to say no to an unwanted sexual situation. Vaginismus is also likely to develop in response to sexual trauma, for example, rape or molestation. It is common for women who develop vaginismus to do so as a defense against pain, especially pain that was never properly diagnosed or treated.
Vaginismus may also develop in response to a partner who thrusts too hard or for too long, causing discomfort or pain. Women sometimes develop vaginismus in response to a partner’s sexual problem—for example, problems with erections or ejaculation. Vaginismus can also lead to sexual problems in the partner; for example, a man may develop premature ejaculation in response to a partner whose vagina is always tightly shut.
Treatment Outlook
The authors of Private Pain believe that only what they call “marginal” cases of vaginismus can be treated with self-help strategies. I would describe what they call marginal cases as short-term, acquired cases of vaginismus (cases in which the woman was able to have successful penetration in the past), or cases in which a woman can accept all of the types of penetration except the type that occurs during intercourse.
If you have an overwhelming, incapacitating fear that prevents you from looking at or touching your own genitals, or that prevents you from receiving a pelvic exam, you will probably need professional help to deal with your problem. Although vaginismus can be extremely frustrating and scary, it is the sexual dysfunction that has the highest cure rate. I encourage you to give the program in this book a try. The sensate-focus exercises can’t hurt you, and if you’re still afraid after trying them, you can always decide to see a sex therapist.
With vaginismus, it may be more important than with other sexual problems to determine the underlying psychological causes of the condition. If your vaginismus was caused by a sexual trauma, you will need to deal with that trauma, and you may need to seek a qualified therapist. Let me assure you: Your fear and anxiety stemming from past trauma and pain can be overcome, and the sexual exercises in Chapter 30 can help with the vaginal muscle spasms.
To overcome vaginismus, you can learn to exercise and control the muscles around your vagina, to relax your stomach and thigh muscles, to focus on the sensations in your genitals, to touch your own genitals, and to masturbate to orgasm with or without objects in your vagina. You and your partner can learn to communicate honestly with each other about the fear and frustration you have both been experiencing, and you can develop trust in each other.
Sally
Here’s a case history that illustrates generalized lifelong vaginismus. Sally, age forty-eight, developed a typical case of vaginismus in response to molestation as a child, and she had never received any help or treatment. Before marriage she feigned a number of illnesses in order to avoid intercourse with her future spouse. In twenty-five years of marriage, she had fewer than ten successful episodes of sexual intercourse. (I define successful here as including penetration; she found no enjoyment in any of these instances and in fact felt them to be quite painful.) Her husband developed a severe case of premature ejaculation and sought extramarital relationships in which he eventually had successful and satisfying intercourse.
Unlike most of the other case histories in this book, Sally’s case does not have a happy ending. Her husband begged her to accompany him to therapy, but she refused to admit there was anything wrong with her. Her life continued to be frustrating and depressing. Unfortunately there are many women like Sally. But many other women in Sally’s situation have obtained help and have overcome vaginismus, and they now enjoy pain-free and satisfying sexual expression. In fact, of all of the sexual dysfunctions that I talk about in Sexual Healing, vaginismus has the highest treatment success rate. In most cases, all it takes is one episode of being able to relax the PC muscle and engage in pain-free intercourse to set the stage for further enjoyment.
Chapter 13
Dyspareunia
Dyspareunia is currently defined in the DSM-IV as “recurrent or persistent genital pain associated with sexual intercourse in either a male or a female.” In reality, most cases of dyspareunia involve women. More specifically, dyspareunia is psychological pain with sexual intercourse. This means that in order to diagnose dyspareunia, you have to rule out all potential physical causes for the pain. When men experience pain during intercourse, it is usually much easier to rule out physical causes than it is for a woman, because with men there are fewer medical conditions that are known to cause pain during intercourse.
Patterns of Dyspareunia
In lifelong dyspareunia, a person has had pain with intercourse ever since she or he started having intercourse. In acquired dyspareunia, a person experienced pain-free intercourse in the past but has pain now. In generalized dyspareunia, a person has pain during intercourse with any person or upon penetration with any object. In situational dyspareunia, a person has pain with some partners but not others or upon penetration with some objects but not others.
I have never heard of a case of situational dyspareunia. The most common forms of the disorder are lifelong, in which a person has never been able to experience pain-free intercourse, and acquired, in which a person develops psychological pain during intercourse secondary to a traumatic event.
What’s Normal?
It’s normal to be able to have sexual intercourse without pain. The majority of people report that they feel pleasure from sexual intercourse rather than pain. However, I recently read some research suggesting that about 15 percent of women in their late teens and early twenties expect sexual intercourse to be painful, and for them it is.
It’s also normal to e
xperience occasional pain in the vagina or penis. Most likely this is temporary and is caused by one of the physical problems I describe in the next few pages. I have tried to provide an exhaustive list of all the conditions that might cause sexual pain, but it’s certainly possible that I have overlooked something.
Physical Causes of Sexual Pain in Men
When men have pain during sexual intercourse, it usually results from a medical cause that’s not too difficult to identify. The following sections identify some of the categories of medical problems that need to be ruled out. These are all common causes of pain during erection, intercourse, or ejaculation.
Sexually Transmitted Diseases
The following is not intended as a comprehensive look at sexually transmitted diseases or safe sex. I discuss these medical conditions only in the sense in which they are related to sexual pain.
Bacterial sexually transmitted diseases like gonorrhea and chlamydia can cause sexual pain, including intense itching and burning during both urination and intercourse. Gonorrhea and chlamydia are diagnosed by analyzing the discharge from the penis under a microscope. Another bacterial sexually transmitted disease, syphilis, usually does not cause genital pain. A syphilitic sore, or chancre, looks nasty but is usually painless. Bacterial STDs respond to antibiotics.
Herpes, which is a viral sexually transmitted disease, can definitely cause genital pain. Herpes sores develop into groups of blisters that are extremely painful when they burst. When a person has a herpes outbreak, it is very obvious due to the existence of the blisters. When herpes is dormant and blisters are not present, there is no pain. Another viral sexually transmitted disease, human papilloma virus, or HPV, is the virus that is thought to cause genital warts. Although the warts may be unsightly, they usually are not painful. Removing them, however, either through cauterization, cryosurgery, medication, or surgery, can be painful. As you probably know, viral STDs cannot be cured, although many people who have them go for years between painful outbreaks.
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