The complaint of dyspareunia is most typically regarded as a problem unique to women, and in fact, dyspareunia is relatively rare in men (Sandberg and Quevillon 1987). Bancroft (1989) indicated that only 1% of the men attending his Edinburgh clinic complained of dyspareunia, and Diokno et al. (1990) in the United States found that 1.4% of men 60 years or older reported pain during intercourse. In women, however, dyspareunia has been identified as the most common sexual complaint spontaneously reported to gynecologists (Steege 1984). Although incidence figures vary considerably depending on the age of respondents and the method and location of data collection, they range from 3% (Hawton 1982) to 34% (Glatt et al. 1990). Because dyspareunia is probably experienced more often than it is reported, incidence figures vary widely. Physicians and therapists who do not routinely question women about pain or discomfort during coitus generally report lower incidence figures than do those who consistently include such questions in the initial evaluation.

Patients typically seek sex therapy for dyspareunia only after seeking medical consultation and/or receiving unsuccessful medical treatment. In fact, the complaint of dyspareunia is often due to organic factors, although psychological factors typically exist as well. Not surprisingly, it is not always easy to determine whether psychological difficulties are the result or the cause of a sexual pain disorder.

Although dyspareunia is seen less frequently by mental health clinicians than by gynecologists, it is far from rare and is sometimes associated with a prior history of sexual or gynecological insult or trauma. Usually by the time the woman consults a specialist, marital problems accompany the sexual ones, and there may be a significant history of developmental and relational conflicts or difficulties.

According to DSM-IV (American Psychiatric Association 1994), the diagnosis of dyspareunia is made when the patient complains of recurrent or persistent genital pain before, during, or after sexual intercourse that is not caused exclusively by lack of lubrication or by vaginismus. Clinically, it is often difficult to separate dyspareunia from vaginismus, since vaginismus may occur secondary to a history of dyspareunia and even mild vaginismus is often accompanied by dyspareunia. It is important to establish whether the dyspareunia is acquired or lifelong and whether it is generalized (complete) or situational. Further inquiry should determine whether the pain is superficial or deep - whether it occurs primarily at the vaginal outlet or vaginal barrel or upon deep thrusting against the cervix. Even when the pain can be reproduced during a physical examination, the possible role of psychological factors in either causing or maintaining the pain must be acknowledged and dealt with in treatment.

Binik and colleagues (2000) argued that dyspareunia should be viewed as a pain disorder rather than a sexual dysfunction. These authors note that most clinicians tend to regard dyspareunia either as attributable to a particular physical pathology or, if a discernible physical cause is undetectable, as reflecting psychosexual conflict. Binik et al. suggest that this model is both unacceptable and disrespectful to the patient. Rather, they suggest, dyspareunia should be assessed and treated like any other pain disorder (e.g., lower back pain). The important issue is the central phenomenon of the problem - namely, the pain - rather than its location. Using a pain model, one would carefully evaluate the pain complaint and assess the degree of interference with everyday life, including sexual relations. One would also anticipate that a single intervention, whether medical or psychological, would be unlikely to resolve the problem.

In cases of dyspareunia, therefore, it is important that assessment be performed by a multidisciplinary team working together to consider the different aspects of the pain - the possible neurological, muscular, affective, and interpersonal contributors. Treatment should be similarly coordinated. Understanding the parameters (location, intensity, quality, elicitors, time course) of the pain and the circumstances of its occurrence is crucial, since a careful, comprehensive biopsychosocial assessment legitimates the pain complaint and helps guide intervention. Gynecologists should be involved in the assessment process along with clinicians. Determining which subtype of dyspareunia (e.g., vulvar vestibulitis, vaginal atrophy, mixed pain disorder) the woman is experiencing is important as well.

Binik and colleagues believe that all reports of dyspareunia involve both psychogenic and organogenic elements and that both must be taken seriously. Interestingly, these researchers have found that women who attribute their pain to psychosocial causes tend to report higher pain scores, higher levels of distress, lower marital adjustment, and more sexual problems than do women who ascribe their pain to physical causes (Meana et al. 1997).

In addition to determining the exact site of the pain, the therapist should ask about when the pain began, the severity of the discomfort, and whether any specific events or experiences preceded the symptom’s onset. For example, nonspecific pain that occurs subsequent to date rape would be treated differently from dyspareunia occurring during the postpartum period following episiotomy.

One especially puzzling aspect of dyspareunia is the observation that some women are able to function sexually despite the report of great pain, whereas others are not. Similarly, the rated intensity of pain does not usually correlate with physical findings. Behavioral disruption cannot be reliably predicted from the gynecological examination or even from past history.