Helping Couples With Unconsummated Marriage

by Bruce Jancin

DURBAN, SOUTH AFRICA -- Sexual excess, teen pregnancy and divorce tend to grab the headlines, but at the other end of the sexual behavior spectrum are couples who have never had intercourse, Dr. Domeena C. Renshaw said at WONCA 2001, the conference of the World Organization of Family Doctors.

Unconsummated marriage is a real and difficult problem, yet it's not even listed in the International Classification of Diseases. Acceptance of an unconsummated marriage by both parties is rare, Dr. Renshaw explained. The problem is that unconsummated marriage often causes shame, frustration, and despair. Dr. Renshaw reported on 155 such couples who presented to the Loyola University Chicago sexual dysfunction training clinic in Maywood, Ill., during 1972-2000. They comprised 7% of all couples undergoing sex therapy at the clinic, said Dr. Renshaw, director of the clinic and professor of psychiatry at the university.

The causes of a sexless marriage are legion. People of all socioeconomic groups and education levels are affected. Dr. Renshaw has even treated American physicians for the condition--most of them are originally from other countries where arranged marriages are common and there is no formal sex education.

The first question that couples typically ask a physician when they decide to seek help is: Is it treatable?

The answer depends on the underlying diagnosis and the motivation of both partners. At the Loyola sex therapy clinic, a course of treatment is 7 weeks long, with 5 hours of therapy per week. The success rate--defined as achievement of penile / vaginal intercourse--was 49% among the 155 couples. Another 40% reported symptomatic improvement, while 11% reported no change.

The waiting list at the Loyola clinic is lengthy. "There aren't many sex clinics left," she said. "It's because there's no big money in it. It's very time-intensive work."

As a result, many affected couples will eventually seek help from their family physician. Family physicians have a relationship with the patient that is long and is generally based on trust. "That's a huge factor," Dr. Renshaw observed, adding that working with these couples is "extremely gratifying."

Among the 155 couples with unconsummated marriages, physical findings among the men included five previously undiagnosed primary adenomas and an equal number of previously undiagnosed cases of phimosis, along with one case of Klinefelter's syndrome and one case of hypogonadism.

Physical findings among the women included 68 cases of vaginismus, 1 case of vaginal agenesis, and 6 cases of atrophic vaginitis. Of the 42 women who had an intact hymen, 5 had-surprisingly--been to infertility clinics.

"How can you run an infertility clinic and not do a physical exam?" asked an incredulous Dr. Renshaw.

She characterized 54 of the men as symptom free and having a symptomatic partner. Among the remaining men, sexual inexperience, ignorance, or inhibition was a possible causal factor in about 70%; the others had commitment phobia, global sexual anxiety, or fear of impregnation.

Sexual anxiety and commitment phobia were about as common in the women as in the men. Sexual ignorance, inhibition, and inexperience were even more common possible causal factors in the women, compared with their male partners.

And fear of coital pain was a contributing factor in 64 women.

In addition to providing explicit sex education and behavioral counseling, physicians often find prescription medications useful.

Dr. Renshaw has found particularly helpful topical Xylocaine for helping women overcome their fear of coital pain during the first few attempts at intercourse, and alprazolam for patients with a high level of sexual anxiety.