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The integration of pelvi-perineal re-education and cognitive-behavioural therapy in the multidisciplinary treatment of the sexual pain disorders

Painful genital sexual activity in women is a neglected, poorly understood, and costly sexual health issue. Often misdiagnosed or ignored, it entails great personal cost to patients and significant financial outlay for society. A recent study showed that only 60% of women who reported suffering from chronic genital pain sought treatment for this symptom, and 40% of those never received a formal diagnosis (Harlow et al., 2001). Painful genital sexual activity has traditionally been diagnosed as either dyspareunia and/or vaginismus, two disorders classified under the category of sexual pain in the DSM-IV (American Psychiatric Association, 1994). Based on these definitions, current epidemiological estimates suggest that dyspareunia has a prevalence of 8 – 21% in community samples (Laumann et al., 1999). Vaginismus— a presumed recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina—accounts for 12 – 17% of women presenting to sex therapy clinics (Spector & Carey, 1990). Despite high prevalence rates and associated impairments in reproductive and sexual functioning (Meana et al., 1997; Reissing et al., 2003), there is only one randomized trial evaluating treatments for dyspareunia (Bergeron et al., 2001), and no published studies examining the efficacy of treatments for vaginismus (Heiman & Meston, 1997). Moreover, typical interventions are still largely based on a unidimensional view of painful intercourse and fail to address all of its biopsychosocial components (Bergeron et al., 1997). One of the main problems with the DSM classification is that there is considerable overlap between dyspareunia and vaginismus. In fact, recent studies show that the vast majority of women diagnosed with vaginismus experience pain during a gynecological examination and during attempted intercourse (Reissing et al., 2002). Moreover, avoidance of penetration appears to be the only factor that differentiates between dyspareunia and vaginismus (de Kruiff et al., 2000; Reissing et al., 2002). We have thus suggested that these two disorders are but one and the same, i.e., a chronic, recurrent pain syndrome, albeit with multiple aetiologic pathways (Meana & Binik, Sexual and Relationship Therapy, Vol 18, No. 2, 2003