Majority of couples with problems in physical intimacy initially consult a gynecologist or sex specialist rather than a mental health specialist. This is because physical intimacy or sexual intercourse is considered a physical act by many rather than a combination of physical and psychological effects. For some, sex is considered necessary only to produce children and is a responsibility or duty towards the same without psychological considerations. Many consider the problem to be that of a woman and hence initially consult the gynecologist.
When the gynecologist examines the woman, it is possible that they may find medical reasons that can explain the discomfort or lack of physical intimacy. These can be reasons related to the reproductive system or other medical disorders or conditions. Some of these might require medication, some might require surgical interventions. However, it is also possible that the problems with physical intimacy exist even in the absence of any obvious physical problems. These may related to non-physical problems like phobias related to pain or a fear of pain, misconceptions regarding masturbation and the sexual experience, low self esteem, feelings of inadequacy or inferiority, cultural stigma and taboos related to sexual intimacy and possibly childhood sexual abuse/assault/molestation. The discomfort with physical intimacy can also occur if the partner is considered physically or emotionally unattractive or if the environment is not amenable to relax. Needless to say, stress related to finances, work or other areas is an important factor to consider. Irrespective of the primary cause, it is important to work with the mind as much as with the body to improve comfort levels in persons/couples who face problems in physical intimacy.
Psychosexual counseling starts with the assessment of possible factors that may contribute (currently active factors or factors maintained from the past) to the problem. This stress includes a detailed interview of couple (separate interviews initially) exploring possible factors, both common and rare. Once an understanding of the issues that face the couple and the possible reasons for it are obtained, the next step is to initiate the process of addressing and overcoming these issues.
The initial step is to clarify thoughts regarding various aspects of intimacy such as the need for emotional bonding with partner, open communication of likes and dislikes regarding each others preferences related to intimacy including sensitization that it is acceptable for the female to have preferences and sorting out issues/stressors related to other significant family members or family or work environment that contributes to stress.
The fear of pain and the feeling of intrusion may be a factor for discomfort in female partners. In such instances, there is a need to initiate to relaxation exercises through a schedule for a week or 10 days. The relaxation exercises will cover the whole body from the head to toe and training to relax will be provided using Jacobson’s Progressive Muscular Relaxation. The logic of these sessions is that a relaxed body will lead to a relaxed mind and the process of relaxing the body relaxes the mind. The relxaed body and muscles will reduce friction and tension and help to reduce or overcome pain.
Masturbation has often been considered as a cause for problems especially in males. Masturbation is worngly considered as contributing to erectile dysfunction or premature ejaculation. Specific techniques and training on the mind will be taught to overcome these causes in the males (in the absence of any physical cause) to overcome these dysfunctions.
Cultural and stigma related causes remain a major cause for discomfort with physical intimacy. Appropriate sex and health education is given to the partners with specific focus on identified issues. When childhood abuse orr incest is a contributing factor, emotional or thought related (cognitive therapy) is recommended to settle deep seated trauma that can very actively interfere in couple relations- both emotional and intimacy related.
Where factors related to stress with significant family members such as over involvement or lack of privacy for the couple are involved, the couple has to be helped to find out practical solutions to create healthy boundaries between the couple and the other family members, or the space for the couple and other family members. The couple has to be helped to reduce the impact of other stressors on the quality of the time they spend together. The couple has to be educated that physical intimacy or sex is an aspect that is more influenced by the couple’s emotional relationship rather than feelings of equality or control or determination of who contributes more to the relationship.
In summary, problems with sexual intimacy can be physical, psychological or a combination of both. Psychological issues can be worked on and resolved as much as possible if the mind is open and willing to acknowledge the presence and depth of the problem. Willingness to work towards resolution also necessitates a willingness to change one’s view and improving acceptance of the partner.