In virtually all cases of dyspareunia, psychological factors are implicated either directly (as the cause) or indirectly (as a concomitant of the sexual discomfort). Psychological assessment must include a complete developmental history, with particular attention to the sexual values and messages of the client’s immediate family and their religious persuasion and beliefs, as well as a careful psychosexual history. It is not uncommon to find that sexuality is associated with sin and immorality and that feelings of guilt and fear accompanied early sexual exploration and experimentation. Often, poor self-esteem and body image are implicated, and the dyspareunic patient may have a history of overt or subtle sexual abuse (Walker et al. 1988).
Ms. E, a 28-year-old married woman, was referred to the sex therapy clinic after having consulted 11 gynecologists in 10 years complaining of disabling and distressing dyspareunia. Although various diagnoses were made, ranging from chronic yeast infections to endometriosis, no definitive reason for her sexual complaints could be established, and all physical treatments proved ineffective.
Ms. E acknowledged that sex had always been a source of conflict for her, both because of her negative feelings about the female genitalia and because of her negative associations about sex generally. “Sex is like Alaska,” she said. “It’s cold, dark, barren.”
As a child, Ms. E felt inadequate, fat, and unattractive. “Eating was my only friend as a child. I felt safe fat,” she said. Her mother was an obese, “lazy and unclean” woman who had Ms. E “keep her company” during all of her toileting functions. Ms. E was “grossed out” by this too-intimate association with her mother and found both the sight and odor of her mother’s genitals “disgusting.” Her father was a quiet but extremely fastidious man who spoke disparagingly of his wife and was overly involved with his only daughter, Ms. E. Although there were no memories of actual sexual abuse, Ms. E recalled that she felt uncomfortable with her father’s rubbing her back by placing his hand under her blouse and his “kissing me too hard.”
Ms. E reported that throughout high school, she was fat and sloppy, as a way of warding off social involvement. She said that her first boyfriend “forced me into sex” and that although she enjoyed having orgasms, she found sex uncomfortable. Now, 3 years into marriage, she describes intercourse as akin to being “ripped apart.” She refrains from using tampons (although she is able to insert them) and avoids all sexual encounters with her husband. Nevertheless, Ms. E feels very guilty and depressed, because she loves her husband, wants to have a child, and yearns for a “normal sex life” without pain or discomfort.
Revision date: July 4, 2011
Last revised: by Jorge P. Ribeiro, MD