By: Rivki Chudnoff, PT
I had been treating a young woman, married for eight months, who was referred to my practice because all attempts at intercourse were painful, and their marriage was still unconsummated. After a few months of physical therapy, she was making excellent progress. One day, her husband called me to discuss his wife’s treatment. After attaining consent from my patient to discuss our sessions with her husband, I spoke with him on the phone one afternoon. I described his wife’s course of treatment and progress toward her goals. I reassured him that she was doing well, and that she was on track to meet all of her goals for treatment. Sensing our conversation was drawing to a close, he pleaded,”Please, just one more question…”
“I need to know for my shalom bayit, is my wife’s pain real? Or is it in her head?”
I focused my thoughts on the face of my patient during our treatment sessions, on the perseverance, courage, and determination she brought to each session, and answered, “100%, your wife’s pain is real”
As a physical therapist specializing in women’s health and pelvic floor dysfunction, I have found that kallah teachers are in a unique position to act as a trusted resource for new kallot. A well-informed kallah teacher often has the opportunity to help prevent or help identify difficulties that women may experience as they grow into a physically intimate relationship with their husbands.
By creating an open and trusting relationship with her students while instructing them in the intricacies of the halachot of taharat hamishpacha, the kallah teacher is in the position to continue the conversation with the new kallah even afterthe wedding. When the kallah experiences her teacher as open and non-judgmental in regard to her most sensitive questions before the wedding, she will be more likely to turn to her kallah teacher with the new questions that will surely arise after the wedding. Likewise, when the conversation about sexuality is included in the kallah teacher’s curriculum before the wedding, it becomes more comfortable for the new bride to approach her kallah teacher to ask related questions after the wedding.
While new brides may be reluctant to discuss these issues with their mothers, family members, friends, or even their new chattan, the kallah teacher can serve as an important resource for providing these brides with helpful and accurate information. The kallah teacher does not need to have all the answers, but she can be an excellent “point person” to direct the kallah to the appropriate professional resources. For these reasons, it is essential that the kallah teacher assure her kallah that she will be following up with her after the wedding and sheva brachot. At that time, the kallah teacher needs to ask, ”How’s it going? Do you have questions? Is there something I can help you out with?”
In my practice, I often work with women who experience difficulty or pain upon attempting sexual intercourse, which results in what is commonly known as an “unconsummated marriage”. In my practice, I have seen how a relatively small issue can evolve into a much bigger issue when the couple waits too long to seek out guidance because they are too embarrassed or don’t know where to turn to for help.
When is it appropriate to refer a bride for a consultation with a pelvic floor physical therapist?
It depends on the couple. If they seem to be relaxed and satisfied with moving slowly at their own pace, follow up again with them in a few weeks. However, if after two mikvah cycles there is a tension developing between the otherwise happy couple, it may be time to seek out the guidance of a pelvic floor physical therapist.
The most common question I hear in my practice is: “Well, how long is this going to take to fix?”
I don’t have an easy answer to this question, as each case is different. What I have found to be generally true over the years, is that the longer the issue has been going on, the longer it takes to resolve. For this reason, I generally encourage people to not wait too long before seeking out professional consultation. The couple’s attitude and ownership of the responsibilities that are expected of them during treatment also play important roles in their progress. Attending all appointments as scheduled, following up with the exercises that are prescribed, and supporting each other during the treatment process are all important ingredients for an effective treatment program. Over the years, I have found that the end of treatment is sometimes more challenging for couples than the beginning. Even the most supportive of spouses become impatient over time wondering, “Why isn’t it fixed yet?” and “How much longer is this going to take?”
The patient herself becomes fatigued from having to “deal” with this issue, and tired of coming to therapy sessions and the “homework” assigned.
Ironically, it is often when the couples are closest to the end of treatment, and their goals are in sight, that they become the most impatient and begin to wonder if their issue will ever resolve.
How does pelvic floor therapy help?
For women who are not familiar with their own pelvic anatomy, a physical therapy consultation is an excellent opportunity to educate them by using both an anatomy illustration and hand mirror to help them identify the basic structures of their own pelvic floor anatomy. Often, dilator therapy is employed to both decrease sensitivity in the area and improve tissue mobility. This process could best be described by comparing it to childbirth, but, just in reverse. During a vaginal delivery, a woman needs to know how to breathe, relax, and ultimately push her baby through the birth canal out into the world. Likewise, to allow for penetration to occur comfortably, a woman must learn to breathe and release the tension in her muscles. However, instead of pushing something out, she must be comfortable allowing something to enter inside her.
Another analogy that I have found effective is to that of wearing contact lenses for the first time. Just as a new contact lens wearer must learn to override the reflex to blink in order to allow herself to successfully place a foreign object into her eye (ie the contact lens) so too, during pelvic floor physical therapy, a woman learns techniques to override the (sometimes strong) protective reflexes of her pelvis that occurs for some women during physical intimacy.
A new contact lens wearer is acutely aware of the lens in her eye for the first few times she wears her lenses, but after a few days of wearing contacts, she become desensitized to the novel sensation of the contact lens resting on the back of her eyelid. The integration of this sensation has allowed her to tolerate the wearing of contact lenses without difficulty. Pelvic floor physical therapy provides the desensitization and sensory integration of the pelvis necessary for sexual intercourse to be tolerated in women experiencing difficulties.
I have developed a list of “Red flags” for the kallah teacher to keep in mind when working with kallah class students indicating that they may benefit from a pelvic floor physical therapy evaluation:
While these indicators are commonly found in women who subsequently have difficulty with intercourse, it is by no means extensive nor predictive of future difficulties. A woman may present with any or all of these indicators and subsequently have no problem with intercourse.
- Difficulty performing b’dikahs
- Not sure where to insert b’dika cloth
- Demonstrates discomfort with the idea of inserting her own finger vaginally
- Seem excessively preoccupied with things being “Germ-y”, “Sicky”, “Icky” and “Gross”
- Uncomfortable with her own body
- Have never successfully used tampons, or finds even the smallest tampon uncomfortable
While many women have never worn tampons and have never had any problems with intercourse, the overwhelming majority of the women I have treated for difficulties with intercourse reported a common history of never having been able to comfortably wear tampons.
“Lo alecha hamlacha l’gmor, v’lo atah ben chorin l’hivatel mimena”
Kallah teachers have the opportunity to greatly impact a couple ’s transition into married life. Seeking out the support of healthcare and mental health providers to partner with when necessary, can make all the difference in the shalom bayit of a couple.