Sex shouldn't be a pain

Sex shouldn't be a pain McGill University

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McGill Reporter
February 21, 2002 - Volume 34 Number 11
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Sex shouldn't be a pain

It's not a topic that comes up on Sex and the City, where the lusty heroines jaw about the birds and the bees from just about every other conceivable angle. But it's a fact of life for an estimated 10 to 15 percent of women -- chronic pain during intercourse.

Photo Professor Irv Binik
PHOTO: Owen Egan

Psychology professor Irv Binik has been studying the phenomenon for 10 years. When he started, he had no idea the problem was so widespread.

Marta Meana, one of Binik's graduate students, embarked on the first controlled research study that examined women who regularly experienced pain during sex. Binik and Meana weren't quite sure how to go about finding research subjects, so they solicited the help of The Gazette and La Presse which both ran stories about the novel research project.

"We were flooded with phone calls," says Binik. "We had a sample of 110 women for the study overnight."

Going into this, Binik knew first-hand there were some women desperate for answers. As one of the psychologists affiliated with the Royal Victoria Hospital's Sex and Couples Therapy Service (he is currently the clinic's director), Binik had encountered one woman who asked him what could be done to ease the pain she regularly experienced during sex.

Binik suggested she see a gynecologist. The woman erupted. "I've already seen a million gynecologists!," Binik recalls her exclaiming. "You're a psychologist. You're supposed to know something about pain."

"She was right to be irritated," Binik warrants. Pain is part of the terrain that psychologists explore. Psychological factors tend to be very important in cases of chronic pain, for instance.

Binik started doing research on the subject and found that very little was known about what causes some women to repeatedly experience pain during sex. One thing he knew as a clinician was that the phenomenon took a toll on women and their relationships with their lovers. He decided to focus on the topic himself.

As Binik and his team began their studies on the phenomenon, they decided what the women were experiencing "wasn't a sexual problem per se. It was a pain problem. Thinking of it primarily as a sexual problem is like defining lower back pain as a work disorder." The pain itself is what needs to be understood and addressed.

With this in mind, Binik's team surveyed women who regularly experienced pain during sex to get a better idea of what the pain was like. In some cases, women only experienced mild pain during sex. But for other women, the pain was much more severe.

"It was similar to cancer pain, to labour pain, to phantom limb pain. That data alone told us we had a serious problem here."

In many cases, the pain centred around the vulvar vestibule -- the area just before the vagina. "Women described a burning, cutting pain upon penetration," says Binik. The condition was known as vulvar vestibulitis and the most popular treatment for it was surgery -- a portion of the skin inside the vestibule is cut out.

Binik and his team had their suspicions about that approach. "We didn't think it made sense to just cut something out and the pain would stop," Binik says. "Pain is more complex than that."

So Binik and graduate student Sophie Bergeron designed the first study that compared different approaches to treating vulvar vestibulitis, comparing surgery to cognitive behavioural treatments and biofeedback -- the latter treatments focusing on psychological counselling and relaxation techniques respectively.

It turns out that all the treatments helped. What caught Binik by surprise was that surgery helped the most. "Surgery helped twice as much as anything else" -- resulting in a 70 percent pain reduction.

A follow-up study examining the same women three years later confirmed the results. Also, as time progressed, cognitive behavioural therapy became a more effective treatment for the women who continued to receive it.

Another study by his group examined the pain thresholds associated with vulvar vestibulitis

Gynecologists generally use Q-tip swabs to examine women with the condition. "It's a crude test -- no two doctors come up with same results," says Binik. Invariably one will exert slightly more force than another.

One of Binik's graduate students, Caroline Pukall, used surgical filament to construct a new tool for testing thresholds -- one that works the same way regardless of who is doing the exam.

In the study, Binik and Pukall noted that both touch and pain thresholds are distorted in women with vulvar vestibulitis. "The women are exquisitely sensitive to very small stimuli," says Binik.

The researchers also examined touch thresholds in other parts of the body and noticed that this enhanced sensitivity seemed to apply to those parts as well. "There is more to this than just the vulvar vestibule," says Binik. "It reinforces the idea that this is first and foremost a pain syndrome."

Binik's team will be joining forces with physiology and anesthesia professor Catherine Bushnell to explore that notion further. Bushnell is a leading authority on brain imaging and the parts of the brain that process painful stimuli.

"All pain looks alike in the brain. It's represented in the same parts of the brain," says Binik. If his views hold water, the pain associated with vulvar vestibulitis ought to be processed in the same region of the brain that is related to other sorts of pain.

Together with graduate student Elke Reissing, Binik has studied another condition linked with pain and sex -- vaginismus. The condition is associated with spasms and a contraction of the vulvo-vaginal canal.

In doing the study, Reissing and Binik noticed something unusual about the women with the condition and how they acted during gynecological examinations.

"The women were very fearful, much more so than women with vulvar vestibulitis. Those women knew that [the exam] was going to hurt and they prepared themselves to endure it. But the women with vaginismus were fearful as soon as the gynecologist entered the room. They tensed up noticeably. They were hypervigilant to any cues associated with penetration or pain.

"I think the psychological component to [vaginismus] is dramatic. I think there is more to the story than pain. There seems to be a real fear of vaginal penetration."

He and Reissing suspect that the spasms aren't really a symptom of the condition at all but are the result of this tensing up and fear.

Binik recently received new funding from the Canadian Institutes of Health Research to continue his work. A study currently being organized revolves around new approaches to treating vulvar vestibulitis -- acupuncture and hypnosis.

A preliminary examination of hypnosis showed very hopeful results -- one woman reported being pain-free eight months after receiving the treatments. "It could be a fluke. We'll look at this in a much more formal way."

Binik says his research relies on the contributions of obstetrics and gynecology professor Samir Khalifé. "He's been a gift from heaven for us. None of this could have happened without him. Coming into this, he had no expertise [about this], but an open mind. Now, he might be the most informed gynecologist around on this topic."

Binik and his team continue to look for women who would be willing to act as research subjects for these studies. Call Talia at 398-5323 for more information.

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