Of all the biological and emotional activities that humanity undertakes, the sexual side of life has the potential to afford the greatest joy and bewilderment. It may therefore also be the source of great sadness and physical or emotional pain.
In most societies sex is regarded as intensely personal and is not openly discussed. Each of us therefore may believe that any difficulties we encounter in our sex lives are unique and probably not treatable. In fact, sexuality like all other human activities has been studied and the physiology and pathology relating to our sexual lives is well documented.
Sexual development runs parallel with the development of the body, the mind and the emotional parts of our lives. There are milestones in sexual development and the problem that may occur at different times in a woman’s life can be fairly accurately predicted.
The difficulties that an 18-year-old girl encounters are different from those that a mature 26 years old has to contend with. The 46 year old woman has another set of potential problems and the 66 year old granny yet another.
Painful intercourse (Dyspareunia).
- Superficial dyspareunia
Pain at the entrance of the vagina is referred to as superficial dyspareunia. The common causes of this are infections such as thrush and herpes; skin conditions in the vulva e.g. eczema or psoriasis, or a painful scar in the tissues (such as the scar of an episiotomies which is done during the delivery of a baby).
Starting sex before one is sufficiently aroused and lubricated can also cause difficulty and pain at attempted penetration. In older women the tissues of the vulva become thinner and less elastic and this may also cause pain at penetration.
- Deep dyspareunia
Deep dyspareunia refers to pain deep inside the vagina or pain with deep thrusting by the male partner.
This type of pain can arise from anything that gets in the way or that gets ‘ bumped’ during sex. This includes chronic inflammation in the pelvis, endometriosis, a cyst or lump in the ovary, a mass in the tube (e.g. a tubal pregnancy), adhesions around the womb, a retroverted womb or an ovary that is lying low down near the womb and is being knocked about by the penis.
The bladder lies just above the front wall of the vagina, and the rectum below the back wall of the vagina. Depending on the style of sex the couple are using, the penis will either push forward and may hurt the bladder, or backward and hurt the rectum. This will be especially so if there is any condition in either of these organs that is sensitive to touch. (So, if you have deep dyspareunia it is worth noting if the pain is related to style or position of sex, as it may help your doctor work out what is causing the pain) or change the sex position.
If you persistently have pain with intercourse it really would be worthwhile to see your Gynaecologist. There is usually a cause that can be diagnosed and most of the conditions we have mentioned can be very effectively treated.
Spasm of the vaginal muscles (vaginismus)
- Primary vaginismus
Primary vaginismus is a condition in which a woman is unable to relax and allow her partner to get near, let alone enter her. The muscles of the thighs are contracted and the thighs are tightly shut.The powerful muscles around the vagina are also tight and penetration is impossible or extremely painful. These women have never been able to allow full penetration at intercourse. Very restrictive up bringing have been taught that sex is either painful or unclean or ungodly. The closing up of the body is a defense mechanism. Occasionally we see patients who have been married for months or even years and have never had complete sex for this very reason.
- Secondary vaginismus
Vaginismus may also develop as a secondary phenomenon. Some women may become nervous about sex because they have experienced pain during intercourse. Now they anticipate pain and develop vaginismus as a protective mechanism. They may desire sex and even initiate it, only to find, that at the critical moment, when the partner is ready to enter, the thigh and vaginal muscles go into spasm and sex is impossible. For this type of vaginismus the doctor needs to find the cause of the pain and if possible remove it. The problem will then rapidly disappear.
The treatment of patients with the primary type of vaginismus is more complicated. The doctor has to help the patient overcome her fear. This may require psychological help. With encouragement and gentle guidance the doctor can show the patient how to relax and how to overcome the spasm in the muscles. The husband must be a partner in this treatment program.
Failure to achieve orgasm (anorgasmia)
Many women have difficulty only with orgasm; they desire sex, they are normally aroused and they welcome their husband’s attention but they do not ‘come to climax.’
There are many possible reasons for this. Perhaps the most common is “performance anxiety’. This is the situation in which a woman wants to have a climax and wants to please her partner by having a climax. She becomes over anxious about the climax and in fact actually prevents it. A climax or orgasm is not something that you can will to happen, it is rather a case of relaxing sufficiently to allow it to happen. This is very much like trying to fall asleep; you allow it to happen.
Anatomical and physiological factors
There is a small percentage of women who cannot achieve orgasm because of a physiological or an anatomical problem. Any of the causes of dyspareunia (painful intercourse) listed earlier may prevent relaxation and prevent relaxation and enjoyment and patients with conditions such as endometriosis, infections and the likes, will be anorgasmic. Certain medicines and drugs can inhibit the climax.
For the vast majority of women who have this problem the cause is psychological rather than physical.
We are all the final products of our genetic endowment, our upbringing and our previous experiences. If the concept of sex that has been imparted by parents, siblings, teachers, religious leaders and peers, is a negative one, then sexual enjoyment may be impaired. A feeling of guilt or shame or distaste for intimacy will develop and this is certainly not conducive to a healthy joyful sexuality.
Another important aspect is self-image. People who dislike themselves may feel that the do not deserve to have total joy. Some women fear intimacy and nudity and are too anxious to enjoy sex.
The relationship with the partner is of paramount concern. Someone once said that it matters less to a woman what is being done to her, than who is doing it. A hostile relationship with lack of trust or where there is much anger precludes good sex.
Ignorance of the anatomy and physiology of female sexual response is common and this may cause sexual difficulties. In spite of everything we have said the orgasm is not the be-all and end-all of sex. For women the intimacy and togetherness are as important. There are times when there is an urgent need for a climax and other times when they are quite happy to share their husband’s pleasure and have no urgent need for orgasm.
Nature has made provision for this. Women may well have sex potential to be multi-orgasmic. Men poor devils can usually have only one orgasm at a time.
Some years ago a famous American Sexologist, Dr. Domeena Renshaw, proposed an easy to remember mnemonic for the causes of sexual problems (such as erectile failure in the man and orgasmic failure in the female, or loss of libido in male or female).
We have only to remember the 4 “A” s and the 4 “D” s.
|Aging||Dissociation of the sexual self|
The 4 “A”s
It is difficult to respond sexually to some-one if you are really angry with them. The anger may, of course, be directed against yourself for allowing yourself to be bullied or manipulated by your partner. There may also be anger against society in general and particularly to its attitude to sexual matters.
General anxiety is a sexual switch off. You cannot be worrying about your bank overdraft or your child’s school report while you are making love.
Another type of anxiety, which is probably one of the commonest causes of sexual dysfunction, is ‘performance’ anxiety. If a person is worrying before they even start with intercourse; “am I going to be able to get an erection?”, “will I come?”, “will he/she come?”; is almost certainly going to have the very problem they are anticipating.
You cannot ‘will’ an erection or a climax. You rather relax and ‘allow’ the erection or climax to happen; much the same as you allow yourself to fall asleep.
I cannot improve on Shakespeare’s famous line “alcohol increaseth the desire, but redacted the performance”. This certainly true for chronic drinkers. Also if a man has a single episode of failure to get an erection after imbibing too much alcohol at a party, he may well remember that a failure, and develop the ‘performance anxiety mentioned above.
The next he has sex he will be worrying about erectile failure and he will experience the very thing he is fearing … erectile failure.
The passage of the years does not cause sexual dysfunction, it rather brings about predictable changes in the sexual response in males and females. In the male a typical change is that it takes longer to get an erection, the erection is not as stiff at say 60 as it was at 16 and it can take much longer to climax.
In the female the vagina may be lax, lubrication may be less immediate and insufficient, and the libido may wane.
It is important to have an understanding of the changes that will come and to incorporate them into our lovemaking rather than be terrified by them.
The 4 “D”s
There are many medicines that interfere with a person’s sexual response.
Drugs that are used by addicts also affect sexuality.
People who are depressed have no enthusiasm for anything, let alone sex. One finds occasionally that patients with sexual dysfunction are given all sorts of wonderful therapies, when they really require expert treatment of clinical depression.
At times a man or woman may try to set aside their need for sex. This may be because the partner is unavailable for reasons of health, or absent for other duty. Sometimes the control may be for less obvious reasons such as to ‘punish’ the partner for some ‘crime’ either real or imagined; or even to punish oneself for all sorts of reasons.
Dissociation of the sexual self.
The development of mature adult sexuality is threatened by many pitfalls along the way. It may be impeded by factors within a person such as mental or physical ill-health. Hurtful experiences imposed by others (such as sexual, physical, or mental abuse) may prevent a healthy sexuality coming to the fore. These people may well be unaware of the cause of their dissociation and may require professional help to unravel the problem.
THE TREATMENT OF SEXUAL DYSFUNCTIONS
Painful intercourse is best treated by elucidating and treating the cause. Vaginismus is amenable to treatment and the results of treatment are usually good.
Anorgasmia, poor arousal phase and inhibited sexual desire need careful evaluation. Trained sexologists, usually family doctors, gynaecologists, psychiatrists or clinical psychologists, undertake treatment of these conditions. The treatment often involves family or couple’s therapy rather than individual. Excellent results can be obtained, depending on the commitment of the couple to solving the problem and of the ability of the therapist.
The sexual side of a woman’s life is an intriguing amalgam of desire, happiness, ecstasy and at times deep emotional hurt. If a problem arises in the area of their lives, many women will not seek help.
They are either too shy, too ashamed (!!) or too “loyal to their husbands” to involve an outsider in their personal lives. Others will be unwilling to reveal to their husbands that they actually have a problem and that they have been faking enjoyment and orgasm.
This attitude completely blocks the road to treatment and prevents resolution of the problem.
Sex is Nature’s gift to us. If you have a problem seek professional help.
SEEK HELP – DO NOT SUFFER IN SILENCE