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Painful sex need not tear marriages apart. Doctors urge couples to seek help early

SINGAPORE — For most people, sexual intercourse is an intimate and pleasurable activity. Yet, there is a growing group of adults in their 20s and 30s who are finding penetrative sex painful, distressing and stressful.

  • More young people are seeking help for sexual dysfunction
  • Some have such severe forms that they cannot consummate their marriage, conceive or go through medical check-ups
  • The younger ones aside, doctors have also seen some patients in their 70s seeking help to have sex
  • Causes may be physical and psychological
  • Two patients tell how their inability to have penetrative intercourse affected their marriage and mental health

 

SINGAPORE — For most people, sexual intercourse is an intimate and pleasurable activity. Yet, there is a growing group of adults in their 20s and 30s who are finding penetrative sex painful, distressing and stressful.

Some experience such severe forms of sexual dysfunction that they cannot consummate their marriage, have trouble conceiving or even go through gynaecological check-ups.

For one 39-year-old woman, who was treated at the Sexual Health Clinic of KK Women’s and Children’s Hospital (KKH), not being able to have sex took a toll on her marriage and mental health.

The administrator, who wanted to be known as Ms Puva, was diagnosed with a female sexual dysfunction condition called vaginismus, which occurs when vaginal muscles tighten involuntarily, preventing her from having sexual intercourse.

“It was the main reason why my marriage ended,” she said.

“My former husband told me he felt cheated (by my inability to have sex). But because we did not have sexual intercourse before marriage, I did not know I had this condition. I was very hurt and our marriage fell apart.”

Another KKH patient, a 30-year-old who also works as an administrator and wishes to remain anonymous, said that she was not able to consummate her marriage for almost a year due to vaginismus.

“I felt highly stressed for not being able to have normal sexual intercourse comfortably. My husband felt self-reproach and lost, because he wasn’t sure if he did something wrong.”

However, some of her worst experiences were undergoing gynaecological procedures such as a Pap smear, before she was married. She was also offered a transvaginal scan where an ultrasound probe is placed inside the vagina during the test, but she was unable to go through it.

Before seeking help at KKH’s Sexual Health Clinic, she encountered doctors who were impatient and reacted negatively towards her fear and anxiety.

“It made me feel terrible about myself,” she said.

In hindsight, she thinks that the unpleasant experience occurred because the doctors did not understand her condition and she was also unable to clearly tell them what she was going through.

MORE PEOPLE SEEKING HELP

A check with experts here in the field revealed that despite the stigma, more people in Singapore are seeking help for sexual health concerns. They range from reduced libido to severe pain during penetrative sex.

Factors for the increase include greater awareness, the desire to conceive and life being generally more stressful in recent years.

Pandemic-related stress and fatigue aside, DTAP Clinic’s chief medical officer Jonathan Ti said that higher rates of metabolic diseases and hormonal imbalances may also contribute to the increase.

Metabolic diseases such as obesity, diabetes, and high blood pressure cause inflammation and blockages of blood vessels, which supply the nerves controlling erectile function. If the blood vessels are unhealthy, the nerves are not able to function and subsequent erectile function is affected, Dr Ti said.

Hormonal imbalances may include low testosterone levels, excessively high oestrogen levels and thyroid dysfunction.

“Even females need a certain amount of testosterone for optimal sexual health,” Dr Ti explained.

In his practice, he has seen a “moderate increase” in the last one to two years of patients seeking help for sexual dysfunction. DTAP Clinic is a general practice clinic that also caters to individuals with sexual health issues.

At the KKH’s Sexual Health Clinic, its multidisciplinary team saw 100 new cases of vaginismus last year during the pandemic — which is a 60 per cent increase compared to the cases seen in 2017. In the past few years, it has seen an increasing number of patients with female sexual dysfunction.

The most common form of female sexual dysfunction seen at the clinic is vaginismus. 

Another common condition is dyspareunia, which refers to recurring pain in the genital area or within the pelvis during sex.

Dr Christopher Chong, a uro-gynaecologist, obstetrician and gynaecologist at Gleneagles Hospital who sees around one similar case a month, has also observed an increase in patients seeking help due to a low sex drive and an inability to have penetrative sex and achieve an orgasm.

He has seen an increase of 10 to 20 per cent of such cases in recent years, but feels that there are likely more undetected cases.

“Sexual dysfunction is a taboo subject and couples may not even seek treatment, and they do not talk about it with their friends. Often, treatment is sought when they wish to conceive,” Dr Chong said.

GETTING TREATMENT EARLY

Dr Tan Tse Yeun, consultant from KKH’s department of reproductive medicine, said that the majority of the patients seen at the Sexual Health Clinic are mainly in their reproductive age, in their 30s, once they discover the problem after marriage or when they wish to conceive.

A KKH-led study involving 500 Singaporean women, where Dr Tan is the joint senior author, suggested that more than half (nearly 60 per cent) of the women who are trying to conceive have low sexual function. 

“If unresolved, the condition affects mental and physical health, relationship and quality of life for both the woman and partner. It is also a key barrier to conception and procreation,” Dr Tan said.

“Therefore, it is our wish to encourage more couples to seek help earlier to improve their treatment outcomes.”

Although most patients seen are in their child-bearing years, the doctors have also treated patients well into their 70s. The oldest patient seen at KKH for female sexual dysfunction was in her late 70s.

For Dr Chong, his oldest patient was a 73-year-old with a history of pelvic surgery, which affected her ability to have sex.

“She had a new boyfriend and could not have sex. I had to do surgery to widen the vaginal area,” he said.

MEN ARE NOT SPARED

Sexual dysfunction is not an individual problem.

Ms Cheong Xinyi, principal psychologist from KKH’s psychology service, said that some male partners of women with sexual dysfunction may also face sexual difficulties of their own.

“But often, this tends to arise in association with the distress that their partners experience from their sexual difficulties. For example, partners of women with vaginismus often report associated sexual difficulties with maintaining an erection,” she said.

Dr Ti from DTAP Clinic sees a mix of men and women who seek help to address sexual dysfunction due to its negative impact on relationships and overall mental health.

In men, they may experience various symptoms, including low sex drive, erectile dysfunction (inability to achieve and maintain an erection firm enough for sex), premature ejaculation and sexual anxiety.

“Oftentimes, they may have a combination of these problems. If left unaddressed, these issues can lead to, or at least contribute to a breakdown of relationship,” Dr Ti said.

He recently saw a married couple in their early 40s. The man had trouble getting and maintaining an erection during sex and a reduced sex drive, while his wife’s libido had become almost “non-existent” since her last pregnancy.

“They both felt that their reduced intimacy over the past few years had caused some distress and was not healthy in the long term,” Dr Ti said.

Hormonal screening revealed that both of them had lower-than-normal testosterone levels.

The husband started a regimen of testosterone replacement therapy and medications to improve his erectile function and the wife was prescribed a low-dose testosterone gel, an off-label indication that has been shown to benefit women with female hypoactive sexual desire disorder, Dr Ti said.

“Off-label indication” means that it is not an official treatment indication in Singapore for the medication — meaning it is not approved as an indication by Health Sciences Authority.

Dr Ti said the patient and doctor must discuss the potential risks and benefits and decide if the treatment is suitable to try or not for each individual patient.

Over the next six months, the couple’s sex life and energy levels improved, and the frequency of intimacy jumped from two to three times a year to one to two times a week.

PHYSICAL AND PSYCHOLOGICAL CAUSES

Sometimes, sexual dysfunction may be due to underlying medical problems. For example, diabetes, hypertension and other diseases that affect the blood vessels can hinder sexual performance.

Dr Ti pointed out that erectile dysfunction is often the first sign of metabolic disease because the small blood vessels controlling the erectile function are affected by inflammation and become blocked. It may even be a harbinger for more serious diseases such as a stroke.

Certain physical medical issues can also lead to vaginismus and dyspareunia. They include complications arising from childbirth, pelvic surgeries and premature menopause arising naturally or from cancer treatment, Dr Tan of KKH said.

Dr Ti treated a newlywed man in his 20s, whose difficulty in initiating and maintaining an erection turned out to be due to a large tumour pressing against a pituitary gland called prolactinoma.

It resulted in very low testosterone levels. His condition was treatable with medication, together with help from a neurosurgeon and endocrinologist, he said.

For others, the cause is not so straightforward and psychological support is needed.

Dr B Srilatha, a clinical Sexologist at Olive Branch Counselling Centre, Singapore, said that in the absence of medical conditions, the mind plays an important overriding role in normal sexual function.

Sexual disinterest can stem from a variety of stressors, including those related to employment or economic security during this period, Dr Srilatha said. 

“Covid-19 aside, virtual screen time has somewhat replaced the need for a real-world interpersonal relationship in the younger generation at large.”

Ms Cheong from KKH said that many patients seen at the Sexual Health Clinic blame lifestyle factors such as stress, tiredness or lack of time as barriers for sexual intimacy.

Vaginismus is often associated with a lack of sexual knowledge that can result in the formation of unhelpful sexual beliefs, she added.

“An experience of negative past sexual experiences or exposure to certain types of social upbringing, religious or cultural influences that negatively influence views about intimacy and sexuality can also predispose an individual to sexual dysfunction.

“These can give rise to anxiety and aversion to intimacy and sexuality, resulting in vaginismus.”

Ms Tammy M Fontana, a clinical sex therapist in private practice here, said that many people do not have proper education about sex, especially its emotional aspect, and focus too much on the mechanical aspect without understanding what makes sex “good”.

“For sex to happen, people need good relationship skills, self-awareness, self-reflection and the ability to communicate effectively what they like and want to have a good sexual experience, while taking responsibility for their feelings and emotions,” she said.

Ms Fontana also brought up the point that many people have unrealistic ideas about sex, and that improperly shapes their expectations. She personally does not like the term sexual “dysfunction” but added that people should see a doctor to rule out any biological causes.

“Many people think that marriage leads to sex; marriage means couples will desire each other… but that is not true. 

“Constant negative messages about one’s body or about sexuality, framing sex as ‘normal’ or ‘abnormal’, and lack of socialisation with members of the opposite sex — all of these can create fear of sex.”

Ms Fontana added that it is important for people to learn to communicate and seek help sooner than later.

Dr Srilatha advised seeking professional help if the sexual problems persist for half a year and causes distress that significantly affects their life and relationships.

Dr Chong from Gleneagles Hospital said: “Treating the most important ‘sex organ’ — that which is between the ears (meaning, the mind) — is crucial."

NO QUICK FIX

Although some sexual dysfunctions can be treated with medication, others will require psychological therapy and counselling, or pelvic floor physiotherapy, Dr Ti said.

KKH’s Sexual Health Clinic uses a multi-disciplinary approach, and patients work through their issues with a team comprising a doctor, psychologist and physiotherapist.

Dr Tan of KKH said that treatment options may involve treating contributing medical conditions, sexual education, therapy and emotion regulation work, pelvic floor muscle rehabilitation or relationship counselling.

A psychologist works with patients to explore and manage psychological factors involved in sexual dysfunction and a physiotherapist experienced in pelvic floor dysfunction may conduct a pelvic floor assessment.

Ms Caroline Chua, senior principal physiotherapist with KKH’s physiotherapy department, said that women with chronic sexual pain commonly have reduced pelvic floor function and increased tension.

One treatment involves physical therapy, which uses exercises to help the vagina muscles to relax.

Another adjunct therapy is electromyography biofeedback. For a patient with vaginismus, it involves inserting a probe into the vagina (if the patient is able to tolerate it) to help her understand whether she is relaxing or tensing her vagina muscles, Ms Chua explained.

Using a multi-disciplinary approach, Dr Tan said that treatment outcomes at KKH’s Sexual Health Clinic showed that up to 93 per cent of women achieve successful intercourse within a year  and half of the couples achieve pregnancy within a year.

Ms Cheong said that treatment duration may range from months to years and varies among individuals. However, the average duration for recovery for patients seen at the clinic is around a year.

Commitment and motivation on the patient’s part, and their partner’s support play a role in recovery. 

For the two KKH patients, overcoming their embarrassment and fear to seek professional help helped. They now consider themselves “cured”.

Both women conceived and coincidentally, had their first baby last year.

Ms Puva, who is one of them, met a supportive partner after her ex-husband left her. She said that she is sharing her experience so that more people with sexual dysfunction would seek professional help.

“In Singapore, a conservative upbringing like mine is common. It was difficult for me to even share my challenges with anyone close to me. Until now, my parents still do not understand my condition well and do not believe such a condition exists.”

She added: “After 10 long years, I finally got to hold my baby in my arms and understand how enjoyable sex can be. It need not be painful, full of fear and anxiety as what I had initially experienced.”

Related topics

sex sexual dysfunction KKH couples marriage counselling therapy

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