Cognitive Behavioral Therapy For Sexual Dysfunctions In Women

Drs. Moniek ter Kuile, Stephanie Both, and Jacques van Lankveld have authored a superb review of cognitive behavioral therapy for sexual dysfunctions in women that is highly recommended for providers who treat IC/BPS and its often-associated symptoms of sexual dysfunction. The review suggests to me that our literature in this regard is sorely lacking, and that our knowledge of definitions of this problem is every bit as important as definitions of IC/BPS itself if we are to make progress in treatment.


Dyspareunia is defined in DSM-IV-TR as recurrent genital pain associated with sexual intercourse that causes distress and interpersonal problems. There would seem to be a symptom of dyspareunia as well as a disorder. The disorder should not be diagnosed if it is caused exclusively by vaginismus, lack of lubrication, or a medical condition. Dyspareunia is typically described as either superficial or deep. The latter is almost always somatic. Provoked vestibulodynia disorder (PVD) was previously referred to as vulvar vestibulitis syndrome and is the most frequent type of superficial dyspareunia in premenopausal women. It is a burning or pain localized strictly to the vestibule of the vulva and provoked by pressure or friction. The presence or absence of inflammation in the vestibule is debated. Generalized vulvodynia is rare and is diagnosed when the pain is located on the whole vulva. It is a chronic pain problem rather than a sexual problem. There is a wide range of prevalence estimates for dyspareunia going up to one-third of younger women and 45% of older women.


The cognitive behavioral therapy (CBT) model is a circular one. It is assumed that pain during penetration or catastrophic memories of that pain lead to fear of pain and hypervigilance in new sexual situations. Fear of penetration results in decreased sexual arousal as well as vaginal dryness and/or increased pelvic floor muscle tone. A vicious cycle results.


CBT is often delivered in a group format with 8-10 weekly sessions encompassed by education and information about 1)vestibulodynia and dyspareunia, 2) a multifactorial view of pain, and 3) sexual anatomy. Instruction is given in progressive muscle relaxation, abdominal breathing, Kegel exercises, vaginal dilatation, distraction techniques focusing on sexual imagery, rehearsal of coping self-statements, communication skills training, and cognitive restructuring.


EMG and biofeedback training (behavioral modification), CBT, pharmacological therapy, and surgery all have similar efficacy. Effect sizes are modest. The authors conclude noting that painless intercourse may not be a realistic therapeutic goal for many women. Nevertheless, it would seem that these techniques may benefit a subset of IC/BPS women, and referral for sexual therapy is not an unreasonable approach in conjunction with treatment of the primary disorder.


ter Kuile MM, Both S, van Lankveld JJ


Psychiatr Clin North Am. 2010 Sep;33(3):595-610.


doi: 10.1016/j.psc.2010.04.010


UroToday Contributing Editor Philip M. Hanno, MD, MPH



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