A Controversial Question: Is the Pain Sexual or is the Sex Painful?
By Marek Jantos Ph.D.
Characteristically, clinicians and medical specialists are guided in their approach to chronic pain disorders by certain assumptions about the nature of chronic pain. This is well illustrated in the case of gynecology and psychiatry when it comes to lower tract urogenital pain. Traditionally, the strategy in gynaecology was to look for organic causes of pain and in their absence to assume psychogenic etiology (Binik, 2003). In psychiatry, pain was seen as psychogenic unless there was evidence of medical causes. But the gynaecological and psychiatric views of sexual pain differ in one other important way. In gynaecology, the focus is on the anatomical structures affected, whereas in psychiatry it shifts away from the location of the pain and focuses on the activity with which the pain is associated, thus labelling urogenital pain conditions such as vulvodynia as “sexual pain” (Binik, 2003).
The listing of so called “sexual pain” disorders in the DSM classification system, raises the important question of whether a special type of pain exists, that is sexual in nature and that warrants inclusion in psychiatric nosology. The psychiatric classification assumes that such a unique form of pain exists. In questioning this assumption, some have argued that if there is a pain that is indeed sexual in nature, it should be possible to induce the pain not only by sexual activity but also by sexual thoughts and sexually related feelings (Binik et al., 1999). Furthermore, if sexual pain exists, then by implication, other categories of pain may also exist that can be defined by the activity that triggers the pain, including, eating pain, work pain, or sports pain. Yet, sexual pain disorders are the only forms of chronic pain noted in the psychiatric classification system (Binik, 2003). What determines the sexual nature of this pain condition or why it should be considered a sexual dysfunction is not clear, but its inclusion in the DSM classification system creates much ambiguity and confusion (Moser, 2005).
In relation to dyspareunia, the DSM lists pain as the primary diagnostic feature of the disorder but provides no suggestion as to its causes, or underlying mechanisms. The psychiatric classification system makes no reference to the fact that genital pain can exist in the absence of sexual activity, and can be triggered by other activities that are non sexual, such as the use of tampons, wearing of tight clothing, sitting for prolonged periods, undergoing medical examinations, and other general day-to-day activities (Sandownik, 2000). All of these non-sexual activities are known triggers of vulvar pain and are known to exacerbate the severity of symptoms.
From an historical perspective, it is interesting to note that while medical accounts of chronic vulvar pain from the 18th to early 19th century attributed the pain to such physiological causes as “hyperesthesia” and “abnormal sensitiveness,” none of the reports attributed its etiology to psychological factors (Thomas, 1874; Skene, 1898). This is well illustrated in a case study presented by Sims in 1861 and cited in a recent discussion paper (Binik et al., 1999). The case is that of a patient who though married for a quarter of a century, remained a virgin because of her vulvar pain symptoms. In his account, Sims states;
“Amongst other investigations of her, I attempted to make a vaginal investigation but failed completely. The slightest touch at the mouth of the vagina producing most intense suffering. Her nervous system was thrown into great commotion: there was a general muscular agitation; her whole frame was shivering…She shrieked aloud, her eyes glaring wildly, while tears rolled down her cheeks and she presented the most pitiable appearance of terror and agony. Notwithstanding all these outward involuntary evidences of physical suffering, she had the moral fortitude to hold herself on the couch, and implored me not to desist from any efforts if there was the least hope of finding out anything about her inexplicable condition. After pressing with all my strength for some minutes, I succeeded in introducing the index finger into the vagina up to the second point, but no further. The resistance to its passage was great, and the vaginal contraction so firm, as to deaden the sensation of the finger, and thus the examination revealed only an insuperable spasm of the sphincter vaginae.” (In Binik, 1999, p. 212).
