Overview of sex therapy and what it can offer to vaginismus

Sex therapy involves the therapeutic treatment of sexual disorders such as impotence, premature ejaculation, retarded ejaculation, concerns with sexual arousal or sexual interest, compulsive sexual behaviour, concerns about sexual interests and sexual orientation, trouble reaching orgasm, painful intercourse, problems with penetration, hypoactive sexual desire, painful coitus, and orgasmic disorders. It can resolve a wide range of concerns about sexual function, feelings that affect the sex life, or the way the individual relate to his or her partner. These problems have been found to be sources of considerable emotional distress and interpersonal conflict in relationships. A sex therapist [1] will be focusing on the couple’s physical relationship after identifying the couple’s attitudes about sex and the sexual problem and it will recommends specific exercises to re-focus the couple’s attention and expectations. Specific objectives may include any of the following:

• Learning to relax and eliminate distractions.

• Learning to communicate in a positive way.

• Learning nonsexual touching techniques.

• Increasing or enhancing sexual stimulation.

• Minimizing pain during intercourse [2].

The sex therapist can teach about the sexual response cycle and the elements of sexual stimulation and it can help the patient identify problems in his life that may be expressed as sexual problems [3]. For some patients these problems are fairly clear, including past sexual or other abuse or traumatic sexual encounters. For others, the problems may involve unresolved emotional issues or dissatisfaction with other areas of life. The therapist usually focuses on resetting the patient’s attitudes toward sex and the goal is to get rid of old attitudes that got in the way of enjoyable sex, establishing new attitudes that increase sexual responsiveness. The therapist will try helping couples recognize, understand and solve their problems. First, the counselor explores the relationship to find the issue spots. Some sexual problems are purely physical (example like side-effect of medication), some are purely psychological, originating in negative childhood messages or sexual trauma, or maybe coming from relationship difficulties.

A therapist will help the individual to identify if the cause is physical, psychological or a combination of the two. If the patient is in a relationship, he will explore if there are any unresolved tensions or anxieties that are significant. Also personalized plan of exercises for the patient to do at home will be prepared. These exercises will help the patient grow in self-awareness, sexual knowledge and sexual skills. At the same time, they will help to persuade the patient’s body to respond to sexual stimulation and overcome a specific problem [1]

The counselor will recommend exercises and activities that will improve the couple’s communication and trust. Sex therapists often use the “sensate focus” [1] exercises to treat sexual issues. The exercises start with nonsexual touching and encourage both partners to express how they like to be touched. The goal is to help both partners understand how to recognize and communicate their preferences. Sex therapists can also recommend exercises to help ‘overcome’ vaginismus. One successful technique is the use of Kegel exercises which involves voluntary contraction and relaxation of the muscles around the opening of the vagina [1]. Some patients have been helped by using dilators to relax the vaginal spasms. Kegel exercises may improve the chance of success with this technique.

Leiblum [1] pioneers in the sex therapy field have stated that at one time or another half of all marriages have significant sexual problems. Sex therapy should begin with a thorough history of the patient’s problem. Masters and Johnson approach on sexuality is about the focusing on the emotionally painful thought patterns that have become associated with sex and building new sexual skills. They classified sexual issues of women into three types: orgasmic dysfunction, vaginismus and dyspareunia. Beside the types, the onset of a problem and the situation plays an important role. There can be either a primary or secondary dysfunction. The primary is experienced continuously (vaginismus enters this type and it must be the initial focus of therapy) and the secondary is experienced only after a certain satisfaction in the sexual interaction.

The existential approach

The phenomenon of Vaginismus: The existential perspective: One existential belief is that a lot of people’s problems are because we get stuck in certain ways of seeing things; one way to help patients is to challenge them and explore their options available [4]. The existential approach to human sexuality. For patients with sexual problems, a therapist who has a positive attitude towards sex and the human body may be beneficial; encouraged to do so in a nonjudgmental and safe place. The sexual intimacy issues can have a negatively impact one’s body image and sexual self-esteem. Some patients can lose faith in her ability to be a ‘real girlfriend’ or a ‘real women’ and also having low self-esteem.

From an existential perspective, how can we approach vaginismus from an existential point of view? Sex therapy is basically concern with the ontic, rather than the ontological; it is preoccupied with the genitals and the sexual dysfunctions. On the other hand, from an existential perspective we can have a broader approach to vaginismus. Sex therapy lacks the ontological aspect, it is not a complete or comprehensive approach, it is a CBT based approach and one of its basic components is about eliminating the symptom. An existential therapist might see vaginismus as something that has meaning to the patient; there must be something around this symptom. What does this symptom has to say about my patient? Even the term ‘sexual dysfunction’ is being medicalized; and as an existential therapist this term is labeling people.

By exploring and clarifying my patients sexual being-in-theworld and their relatedness to others can bring paramount steps in the therapy programme. The existential approach will look upon the individuals experience with others around them and later on explored and analyzed by various statements in regard their own sexual being. The next step will be the analysis of how their perception of their own body looks like. If their sexuality was not clearly acknowledged and understood, then this can be analysed bringing further explorations. Another aspect is how the patients can engage in this world as an embodied sexual being. The body-subject topic can encapsulate further sessions and in bringing Sartre’s [4] formulations of the human body into discussion can be useful in further explorations (the body-foritself, the body-for-others and my body as it is known by others). Stating Sartre’s ideas about the body can help patients in understanding that they can not separate their body from their inner existence and their sexual issue and intimacies from her world. Sexuality is part of the individual’s world, is about relating to others and towards being with others as sexual beings. Denying relatedness to others means denying the sexual embodied individuals. If patients deny their own sexuality and after exploring their sexual dilemmas, only then they could grasp the thoughts about relating or how to authentically relate to the other individuals (e.g.: one of my patients was focused on the ontic part of the sexuality; the ontology was not kept in mind. Her main focus was how to engage in a sexual relationship; not what it is to be understood by all her symptoms, attitudes and why vaginismus was present in her life. Her growing awareness of why was this happening to her was developed later; her attitude towards sexuality was changed and so she changed her boyfriend and her symptoms of vaginismus gradually faded away. Her relationship with her new boyfriend was making my patient to become a sexual being-in-this-world and sexually relating to others. Engaging more fully and authentically to her new boyfriend made the link between her bodies to the other bodies in the world).

I found it extremely useful the 4 dimensions Umwelt, Mitwelt, Eigenwelt, Uberwelt and after really getting there with my patients, only then I could really understand their worldview and their sexual dilemmas [4]. Sex therapy focuses exclusively on the functions and dysfunctions of the genitals; it does not explore the meaning of the symptoms. Working existentially means to clarify and understand the patient’s material in a meaningful way. What is meaningful for the patient and how can we help the patient to become a sexual being? My personal view as an existential therapist is that we must not label, categorize and pathologize our patients. Together with my patients we can explore their life and their own way of living. The 4 dimensions used in the existential approach can explore the patient’s background, values, morals, cultural issues and their own perspectives about themselves and others around them. In the case of sexual dysfunctions it is mandatory to listen to our patients how and when they first heard, learned and were taught about sex and sexuality in general. It is about the exploration of their own experience as beings in the world and how do they see a healthy or a normal sexual behavior or a sexual relationship. How do they relate to others? How do they relate to their own bodies? How do they experience themselves as sexual beings in the world?

What sex therapy is missing is the fact that it does not explore the individual as a whole. It lacks and fails to relate the individual worldview. My existential work did not include the perspective of vaginismus as a disease or as a particular dysfunction treatment. My patient’s relatedness to their inner world, to their self and to their symptoms of vaginismus was the highlight of my sessions. From my point of view, sexuality involves emotions, feelings and intimacy. The need for intimacy or the lack of it (in some of my patient’s case) is a crucial part in sexual issues. Without being intimate we can chose to stay in a sort of isolation and withholding from the others. Not relating or not fully being with others can sometimes not be acknowledged by some patients in the beginning of our therapy. The awareness of that isolation can be explored and clarified later on. Sometimes the vaginismus experience can be only a temporary symptom present in a patient’s life. This can have much to do with choosing or finding the right partner. Also, it can only be present with a certain partner and not with another person in a patient’s life (e.g.: a patient experienced the vaginismus symptoms only with her ex-boyfriend and it gradually disappeared after the break-up with him. Her description of her life included many self-analysis, selfdiscovery of what it means to have vaginismus. My main focus was on her relationship with her ex-boyfriend and how she related to him. It seems that she had intimacy issues and in a way vaginismus was an expression of her relationship dissatisfaction). Some patients fear that they never will relate sexually towards another individual in their life.

Another focus on my existential work is the examination of the inner world and the own experience that the patient owns. How they reflected how they experiences their own body and others around and how they relate to the males/females around them. The examination of patient’s inner world and how they feel about sexuality in general is another way of working with sexual dysfunctions. It can be a challenge to engage authentically in finding words for vaginismus or to describe in an open and clear manner how patients feel. The emotions are playing a big role in my therapy and in this way the focus on my patient’s emotions was underlined. Fear, anxiety, rage, hostility, shame and guilt were marking the path to facing all those, instead of avoiding them. Facing anxiety and fears about vaginismus and exploring what does those mean to patients and to their body was another step forward in my sessions.

Nevertheless, by exploring our patient’s attitudes, values and views about their sexuality must not be neglected. In this manner we can understand from where our patient is coming from (the cultural factor must also be included if the therapist and the patient are coming from different cultural background and at the beginning of the therapy programme it should be addressed to each parts their own cultural point of views, perspectives in order to grasp each one’s personal learning about sexuality in general).

So far, I presented the application of sex therapy and the existential therapy to sexual dysfunctions and vaginismus. I presented the effects of both approaches and as a summary of this paper it will include the major key aspects to sexual difficulties and basically to vaginismus as following:

Sex therapy is an effective tool for people of different ages, genders and sexual orientation and it can be helpful. It incorporates ways to resolve concerns and help patients to learn skills and techniques to improve communication and intimacy issues. The sensate focus exercises concentrate on the pleasure of touch between partners without engaging in intercourse. On the other hand, Thomas Szasz [5] stated that sex therapists or ‘sex experts’ advises individuals to stay on the so- called safe side in regard to sex, but Szasz stated that behaving sexually towards another individual implies a certain amount of risk; sex can be seen as something personal and it is self-revealing [5].

The terms ‘sexual dysfunction, sexual disorder’ are labeling people and the terms are informing an individual that there might be a problem, a medicalized problem and a dysfunction or a disorder that we might have. Basically, this is the perception we get from the sex therapists. Refusing sex means we got a sexual problem and all people are being labeled. Our entire sexual habits, moods and views are being medicalized. As a critic to the sex therapy will be that it focuses mainly on couples with sexual ‘dysfunctions’, rather than with an individual, is missing any attempt to describe the person. The focus of this therapy became the couple; the individuals with sexual issues were relatively overlooked and neglected.

However, sexuality cannot be separated from the self of an individual. The behavioral framework of sex therapy includes the homework assignments designed also for the couples, not the individual alone. The homework assignments can be insufficient for a positive outcome of the therapy, because they can’t overcome the sexual problem totally. Patients can fail to carry out or cease those assignments. Another critic to sex therapy is regarding the Kegel exercises, and Keith Hawton describes in his book [3] that sometimes ‘a women is unable to begin this exercise unaided, the therapist must intervene more actively; the therapist should carry out a gentle vaginal examination.’ Mostly it explores the symptoms of a client, rather than understanding and exploring the symptoms or the meaning of it, emotions and feelings are being slightly neglected. From the positive outcome of the sex therapy, basically it is about short-term and it is not focus on a long term success. It came from the brief psychotherapeutic and behaviorally strategies oriented.

Other critics to sex therapy are: the focus is on marital or couple therapy and without including a partner ‘crucial info is lost and therapeutic outcome is compromised’ [1]. In regard to the therapy outcome of vaginismus, sex therapists suggested a combination of sex therapy and medical/pharmacology interventions (for example anxiolytic medications), physical therapy, bibliotherapy and waiting list control. Working with a team like that, including a gynecologist brings out an issue, like for example a patient might not want to work with that team, or female patients will feel intrusive. Nevertheless, treating the genitals alone is unlikely to lead to long-term success. One approach is to end therapy if only a partial success is available, brief counsellinglimitations of sex therapy and only problem-focused approach, critic short term result, [3]. The short term outcome where Masters and Johnson stated that vaginismus had nil failures, but at that time Masters and Johnson did not ‘distinguish problems concerning sexual interest or desire.’ Failure rate was based on the treatment of 500 couples only. They recommended sessions on a daily basis, seven days per week, in three weeks with the main focus on anxiety reduction and eliminating the symptoms or relapse prevention.

Sex therapists neglected the fact that by introducing the sensate focus might not be beneficial for everyone. They ignored the fact that sensate focus might have a negative impact on an individual. This one can feel the exercise intrusive and too personal to approach it. Sex therapy has a limited and fragmented perspective on vaginismus and other sexual problems, while the existential perspective has a broader framework.

The existential approach integrates all the symptoms and it explores the entire being of the patient: being-in-the-world, beingtowards- others and being a sexual being in this world [4]. By clarifying the patient’s emotions, thoughts and by understanding the patient worldview, the sexual dysfunctions can be understood and so the patient will make sense of his own sexual world. Someone that rejects sexual intercourse, must not be viewed as a patient with sexual dysfunctions or disorders; instead we must understand what the symptoms are telling to our patient and explore together not by eliminating the symptom, but exploring it. Nevertheless, the existential therapy will explore also the emotional effects on the individual (reduced self-esteem, anxiety and guilt feelings).

Sexuality was a topic often treated with evasion, viewed as taboos, the word related to sex was considered as a dirty word. Nowadays, there are various techniques of sex therapy, analyzing the female sexual arousal disorder, lack of desire, anorgasma, dyspareunia and vaginismus, open discussions about the hymen and virginity, the therapy plan for it and the in-depth exploration of human sexuality in XXI century.

I can say that my patients generally benefitted from the therapy sessions, living a healthy relationship. Both the sex therapy and the existential approach to the sexual dysfunctions were compared and contrasted here and both of them showed positive outcomes in working with sexual dysfunctions. However, even if I presented some critics to the sex therapy and how it approaches the patients, combined with the existential approach it had been very useful in my own private practice.

As a concluding remark, I can state that what I learned from seeing patients with sexual dysfunctions is the fact that we must approach human sexuality with open minds. A therapist who has a positive attitude towards sex and the human body may be beneficial for patients with sexual issues and the patient will feel encouraged to do so in a non-judgemental and safe place. However, paramount value also holds a validating, empathic, respectful, and nonjudgmental and an open attitude are optimal for patients that are bringing a sexual issue in the therapy.

As Thomas Szasz stated in his book ‘when it comes to sex, however, such common sense vanishes. Everyone now knows that physicians, especially gynecologists and psychiatrists, are experts on sex’ [5].

-The sexual dysfunction is characterized by a disturbance in the processes that characterize the sexual response cycle or by pain associated with sexual intercourse [6].

-Vaginismus is ‘the inability to experience coitus due to vaginal pain, without an organic cause, possibly accompanied by muscle spasm.’ The inability can be a cause of the pain or fear of pain. Involuntary vaginal spasms interfere with penetration [3]