As mentioned in Part 1 of this article, the causes of unconsummated marriages and relationships may be varied. A problem with the sexual functioning in one or both of the partners in a couple can prevent intercourse. Often the anxiety resulting from repeated attempts at intercourse contributes to the sexual dysfunction. One or both partners may be anxious that penetration will be painful, that there will be bleeding, or that the woman will get pregnant.  While a certain amount of anxiety surrounding sexual activity is normal, when one or both partners are overly anxious, sexual function can be affected in the following ways: The male partner may have difficulty maintaining an erection strong enough to allow penetration or he may lose his erection just prior to intercourse. Anxiety may contribute to premature ejaculation, also just prior to reaching penetration. Anxiety may prevent the woman from relaxing enough to allow penetration. She may close her legs or contract her vaginal muscles. This presentation is referred to as vaginismus, defined as the persistent or recurrent difficulty of a woman to allow vaginal entry of a penis, a finger, and/or any object, despite her expressed wish to do so. While anxiety may indeed be a factor contributing to and perpetuating many sexual problems, there are many components to sexual problems, including physiological ones. Therefore, each partner in a couple presenting with an unconsummated marriage should undergo a physical exam.

Physical presentations of the female partner that might prevent intercourse can include sexual pain disorders such as localized vulvodynia, also known as vulvar vestibulitis syndrome. This fairly common condition is characterized by pain with touch at the entry to the vagina, which can prevent intercourse. A woman’s hymen may be a barrier to intercourse. Some women have a very thick hymen, or a septate hymen, which is a thin piece of membrane running vertically which separates the vagina in to two sides. While most of these conditions can be addressed with counseling and  physical therapy, including use of vaginal dilators, in most cases a septate hymen needs to be repaired surgically.

Physiological components contributing to male sexual dysfunction should be ruled out as well. As mentioned, premature ejaculation and erectile dysfunction can prevent intercourse. While in most cases the etiology of premature ejaculation is anxiety, erectile dysfunction may have a physiological basis which may be treated medically. Another physiological problem that can prevent intercourse may be a curvature of the penis. In mild cases, this can be dealt with through creative positioning. In more severe cases, medical or surgical treatment may be warranted.

 Frequently, lack of knowledge about sexual anatomy and physiology may contribute to a situation whereby attempting intercourse feels awkward and un-natural. Often all that  is needed is some basic anatomical information  and positioning advice. For example, a couple may report that the woman’s vagina feels dry and excess friction prevents intercourse. In this case, the couple may  be  advised to ensure that intercourse take place when the woman is sufficiently aroused after plenty of exciting foreplay. Over the counter lubricants or oils may be very helpful.  While some people are physically active, very aware of their bodies, and comfortable with movement, other people are less so and may simply have not figured out how their bodies move in order to comfortably find a position for intercourse. One or both of the partners may have mobility problems or difficulty getting in to or maintaining a position. A woman may have difficulty keeping her legs open or a man may not be able to hold his weight up on his arms.  In these cases as well, consultation with a physical therapist may be helpful in providing exercises and positioning advice.

While behavioral solutions may be found for many couples, it is important to note that couples in unconsummated relationships, particularly of long standing duration, may benefit from couples therapy. A therapist working with such a couple may wish to gain understanding in how the couple presents and organizes around the problem: How is the presenting problem perceived by each partner? Is there attribution of blame?  What is the significance of the dysfunction itself and how is that perceived by the couple? Who is aware of this situation and in what way is outside intervention (community, parents, and religious leader) perceived in assisting or perpetuating this condition?  Identifying the various factors contributing to the condition and dealing with them with physical, psychosexual, and couples therapy, may be the key to consummation and the commencement of a satisfying intimate life.