For the fourth session in our Sex Plus Symposium, we had the opportunity to learn about sexual pain disorders from an AASECT certified sex therapist and a former pelvic floor physical therapist, Talli Rosenbaum.

Talli Yehuda Rosenbaum is an individual and couples therapist and is certified as a sex therapist by The American Association for Sex Educators, Counselors and Therapists (AASECT), as well as the Israeli Society for Sex Therapy (ISST). 

She is also an AASECT certified sex therapy supervisor. She co-hosts the Intimate Judaism podcast and is co-author of the book I am For My Beloved: A Guide to Enhanced Intimacy for Married Couples and co-edited the Springer textbook entitled The Overactive Pelvic Floor. 

Talli has authored more than 40 journal articles and several book chapters on sexual pain disorders, sexual health, unconsummated marriage, sexuality and Judaism and is an associate editor of the Sexual Medicine Reviews. 

Talli earned a Masters in Clinical Sociology and Counseling and a certificate in Mental Health Studies from the University of North Texas in Neve Yerushalayim. She holds a bachelor's degree in Physical Therapy from Northwestern University and before training in psychotherapy, treated patients as a physical therapist for 25 years. 

In addition to maintaining an active private practice, Talli is the academic advisor for Yahel: The Center for Jewish Intimacy. Talli frequently lectures both in Israel and abroad, to lay as well as professional audiences. 

You can learn more about Talli from her website. Read on to learn more about her teachings on female sexual pain disorders.

Female Sexual Pain Disorders

It is estimated that 12 to 21% of women are affected by sexual pain disorders.

In the past, disorders were broken out into dyspareunia — the experience of pain with sexual intercourse — and vaginismus — the inability to allow any vaginal penetration due to anxiety or fear of pain. So, physical pains were treated with physical medicine and pains “in the mind” were treated with sex therapy.

Today, we know there are many aspects to each sexual pain disorder and each requires a more comprehensive treatment. There are psychosocial, relational, sexual, medical and physiological complexities. 

Overactive Pelvic Floor

At the root of each sexual pain disorder, there is an overactive pelvic floor. The pelvic floor controls the muscles within the vagina. It is a muscle that needs to be able to support the organs, but also needs to provide the right amount of support rather than only being reactive or overactive.  

It contributes to things such as injury or inflammation, recurrent thoughts of pain, fears about activity, avoidance or hyper-vigilance, emotional factors, relationship factors, sexuality and sense of self.

The top causes of female sexual pain disorders include:

• Overactive pelvic floor

• Vulvodynia

• Vaginismus

• Chronic pelvic pain

• Vulvar disease

• Infectious

• Musculoskeletal

• Mechanical

The hyperactivity of the pelvic floor is not simply an isolated dysfunction, but it’s also a physical manifestation of the patient’s emotional state. The Overactive Pelvic Floor textbook Talli co-edited goes into greater detail about the overactive pelvic floor and the different issues that stem from it.

Typically, there is a sense of shame surrounding genital pain and a woman may have visited many medical doctors seeking treatment without receiving a diagnosis or validation for her symptoms. Treating an individual's pelvic pain means meeting them in their most intimate and vulnerable space.

Sexuality and Sexual Partners

Aside from the physical and psychological factors that contribute to sexual pain, another important component of sexual pain disorders are the social factors.

Social factors such as culture, race, ethnicity and religion determine our attitude and value to sexuality and when we do or do not choose to engage in sexual intercourse. 

Often, women will feel guilty during intercourse and have sex without pleasure because they feel vaginal intercourse must be allowed to satisfy their partner. Women with dyspareunia will continue to have intercourse despite feeling pain in order to feel “normal” or do their duty and avoid their partner cheating or a negative response.

Other psychosocial factors have to do with the relationship itself. The types of questions that can and should be asked between a couple or within couples therapy can include: 

• What is the mood of each partner?

• Can you discuss the cognitive and emotional responses to pain?

• How does each partner deal with the difficulty of intercourse?

• What are the relationship dynamics?

Sexual Psychoeducation

First and foremost, it’s important to feel comfortable talking about sex.

Within sex therapy, it is also important to educate on the importance of arousal. Sexual pain disorders may stem from repetitive, painful intercourse without adequate arousal and a tense pelvic floor.

Encouraging couples to explore other, non-painful sexual alternatives and acknowledge culture and religion is vital for understanding the sexual disorders one partner may be experiencing. 

There is a cultural sensitivity and ethical challenges that come with the territory of diagnosing and treating sexual pain disorders. Healthcare professionals must provide a culturally informed approach to care within an ethical framework that imbues respect, understanding and tolerance.

Sociocultural Factors

Sexuality and sexual behavior vary widely across differing sociocultural spheres.

Sociocultural factors are important for how sexual information is obtained. It informs decisions for appropriate sexual behaviors for things such as age of first intercourse, attitudes about gender and sexual orientation. It also impacts the development of intimate relationships and concepts and expectations regarding desire. 

Religion, and more specifically purity-based religions, cause a conflict when it comes time for sexual intercourse and can cause root fears contributing to a sexual disorder compounded with shame. 

In part two of our sexual pain disorders session, we’ll explore the contributing factors for sexual pain disorders and different treatment options.

To learn more about sexual pain disorders and sex therapy, or if you’re experiencing a sexual pain disorder, contact us or learn more about sex therapy.