Who treats dyspareunia?

In Poland, two professional groups treat sexual disorders. Both of them call themselves sexologists, so it is usually up to the patient to verify their qualifications and assess the possibility of competent help. Dyspareunia can be treated by a doctor with a specialisation in sexology. Such doctors are scarce in Poland and, moreover, a visit to a sexologist is rarely reimbursed by the National Health Fund. In some voivodeships there is no such possibility at all. A doctor of this specialisation will certainly want to order a gynaecological consultation, if he is not also a gynaecologist himself, in order to exclude other medical conditions which may give similar symptoms. Besides, an accurate diagnosis depends on a thorough history taking. There are no pills registered for the treatment of dyspareunia or vaginismus, so psychotherapeutic methods are rather used for this diagnosis.

The second professional group called sexologists are psychologists. A psychology graduate has the opportunity to complete postgraduate studies in sexology, but only after passing an exam (similar to a medical specialisation exam) does he/she receive a sexologist certificate and, according to the Polish Society of Sexology, has the right to call himself/herself a sexologist. Unfortunately, in practice, this rule is often not respected, and there is no possibility of drawing consequences because psychologists do not associate in Poland in the equivalent of medical chambers, which would take care of the honest presentation of their qualifications. Regardless of his or her original training, if a sexologist has postgraduate training in psychotherapy, he or she is the most suitable person to treat dyspareunia.

Use of psychotherapy in the treatment of dyspareunia

Psychotherapy is the preferred and much more effective method of treating dyspareunia than otherwise used topical anaesthetics or surgical interventions, e.g. in the form of excision of the vaginal vestibule. At the same time, it should be emphasised that there is no single universally recognised therapeutic protocol for the treatment of this disorder. The programmes that have been developed in this area are the subject of publications in the form of articles and have not appeared in a larger book edition. The most common treatment for dyspareunia is cognitive-behavioural psychotherapy, sometimes mindfulness or mindfulness practice, focusing on current sensations. Behavioural interventions are used to treat vaginismus, which involves learning to gradually insert dilators (a type of dildo) of increasing size into the vagina. This exposure ends when the woman is able to insert a dilator into the vagina that is about the size of a male penis. Cognitive elaboration, i.e. discussing such an experience, helps to get rid of the fear of intercourse combined with vaginal penetration.

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The model of understanding this disorder used in psychotherapy assumes that central to vaginismus is the belief that penetration will hurt and the perception of it in terms of threat rather than pleasure. This belief leads to avoidance of sex, anxiety, decreased levels of arousal and, consequently, decreased vaginal lubrication and increased pelvic muscle tone. These symptoms lead to a genuine obstruction of the sexual act and secondarily exacerbate the fears. Psychotherapy lasting 3-4 months brings lasting symptomatic improvement.

A few words of commentary

The cursory description of psychotherapy presented above focuses interventions on enabling vaginal penetration. This is, of course, not the only sexual practice that can give satisfaction to partners, and treatment is not provided by force without the consent of the person with the diagnosis. However, for many, dyspareunia is associated with discomfort, a diminished sense of femininity, and is an impediment to pregnancy, although it does not prevent it. The psychotherapy described above is addressed to such people.