Sexual Pain Disorders
By Talli Rosenbaum PT
Sexual pain disorders are classically divided into dyspareunia, which means “painful intercourse,” and vaginismus, which refers to the inability to allow vaginal penetration. In the past, sexual pain disorders were considered to be either physical or psychological, such that dyspareunia was perceived as “real” pain, and vaginismus was “all in the head.” Today, it is understood that various factors combine to create painful intercourse. For example, if a woman is not aroused or lubricated, intercourse can be uncomfortable. If she is anxious and afraid of the pain, her muscles may contract as a guarding mechanism to prevent this pain, even when she really wants the penetration to occur.
A couple can have difficulty allowing penetration in the beginning of marriage for many reasons. Some difficulties be may be related to the male partner as well. The experience of female sexual pain could be due to a tight or inflexible hymen, tight muscles, or vaginal dryness. The most common cause of ongoing sexual pain in women in the childbearing years is a condition known as provoked vestibulodynia (PVD). It is known by other names including localized vulvodynia and vulvar vestibulitis, syndrome. PVD is characterized by pain at the entry to the vagina with touch and /or attempted intercourse and is associated with overactive muscles of the pelvic floor.
Some women suffer with pain after childbirth. This can be due to a combination of factors including painful stitches from an episiotomy or tears, and vaginal dryness due to the nursing and hormonal birth control. These symptoms can be heightened by fatigue and an overall drop in interest in sex which is not uncommon in the postpartum period.
Treatment for sexual pain disorders should be multidisciplinary. Women who experience painful sex, should see a gynecologist to determine the physical causes. Pelvic floor physical therapy can be very helpful in teaching women how to relax the pelvic floor muscles in order to allow painless penetration.
It is also important to consider the context of sexual relations within the couple’s relationship. Is sexual activity being experienced in a relaxed, comfortable, and pleasurable way, or is it perceived as a task that is difficult to accomplish? Frequently, sexual counseling or therapy can also be helpful in providing direction in helping couples enjoy a comfortable and meaningful sexual life together.
For more information:
Click here for a Hebrew directory of pelvic floor physical therapists in Israel.
Talli Rosenbaum, M.Sc., PT, CST, IF is the only AASECT certified sex therapist who is also a pelvic floor physical therapist and is an internationally recognized expert on the role of combined physiotherapy and sex therapy in the treatment of sexual pain disorders. She has authored over 20 peer reviewed journal articles and several book chapters on sexual health, unconsummated marriage, and sexuality and Judaism. She is an associate editor of the Journal of Sexual Medicine. In addition to maintaining an active private practice, Talli lectures in the sex therapy program at Bar Ilan University, the Puah Institute, and the Israeli Institute for Marriage and Family Studies. She is also co-director of the bi-yearly training program for pelvic floor physiotherapists in Israel.
Halacha and the Treatment of Sexual Pain Disorders
Sometimes, in order to strengthen a couple’s sexual relationship in the long term, it is necessary to rely on some halachic leniencies in the short term.
Hotza’at zera levatalah, the prohibition of wasting seed, generally prohibits ejaculation outside of the vagina. However, ejaculation in the vagina might not be possible or advisable for some couples struggling with sexual pain disorders.
When a disorder has been diagnosed and a couple is in treatment (or awaits treatment) and attempts at vaginal intercourse are contra-indicated, it may be permissible for the couple to modify relations, in consultation with their treatment team and a halachic authority. The precise recommendation would depend on the situation and might change over the course of treatment.
A couple can continue to strive to create an atmosphere of sanctity during treatment by adhering to the individual halachic guidelines that they are given, knowing that they are working toward healing and enhancing shalom bayit, with a goal of enabling a fuller sexual relationship in the future.
When contraceptive use is indicated for a couple working through a sexual pain disorder, hormonal contraception may be contraindicated, since it can contribute to dryness and affect libido. In these cases, inserting an IUD under anesthesia is often preferred halachically. In cases in which neither hormonal contraception nor an IUD is feasible, a couple should consult with a halachic authority to review their options.