Maria McEvoy, Rosaleen McElvaney, Rita Glover. Sexual and Relationship Therapy. Informa UK, 2021.
“Vaginismus […] involves recurrent or persistent involuntary spasms of the vagina’s outer muscles so that her partner cannot penetrate during intercourse” (Halgin & Krauss-Whitbourne, 2013, p. 165). As a clinical phenomenon, it is associated with high levels of distress for those affected (Crowley et al., 2009) and it can have a profound impact on how a woman feels about herself, on her partner, and on their relationship (Ward & Ogden, 1994). Vaginismus is classified as primary if the problem is lifelong, secondary or acquired if intercourse has been possible in the past and is now impossible, global if the spasm occurs whenever penetration is attempted regardless of the circumstances, and situational when it only occurs under certain conditions (Crowley et al., 2009). There is limited research available about the sexual functioning and behavior of women with vaginismus (Cherner & Reissing, 2013). For example, Binik et al. (2014) has stated that much of the literature to date has focused on primary vaginismus and women with secondary vaginismus have largely been excluded. Much of the literature has also focused on vaginismus as a physical difficulty, concentrating on the spasming of the vaginal muscles when intercourse is attempted (Halgin & Krauss-Whitbourne, 2013). This understanding fails to consider that the spasm may be secondary to other factors such as fear of actual or anticipated pain when attempting intercourse (Binik, 2010) as well as intimate relationship dynamics or cultural influences (Tiefer, 2001). Thus, the factors that contribute to vaginismus can be more helpfully thought of as a spectrum from physical to psychological, relational and cultural. Vaginismus, for the most part, occurs in the context of a couple relationship and different blends of these factors will contribute in unique ways to each couple experiencing it. This paper takes a biopsychosocial perspective to improve our understanding of this phenomenon and highlight implications for practice when working with couples where vaginismus is a concern.
Difficulties in establishing prevalence rates for vaginismus
Relatively high prevalence rates are reported in Eastern cultures when compared to Western cultures in population-based surveys. In Iran, Turkey, and Ghana, the prevalence of women reporting sexual pain was 27%, 43% and 68% respectively (Amidu et al., 2010; Oksuz & Malhan, 2006; Safarinejad, 2006) compared with 7% in America (Laumann et al., 1999) and 3% in Denmark (Ventegodt, 1998). A survey by Relate in Northern Ireland (a support services for couples) in 2002 stated that vaginismus was the second highest female sexual dysfunction reported by their clients (Roy, 2004). However, it is very difficult to establish prevalence rates for vaginismus for a number of reasons. First, most of the information comes from clinical surveys and so prevalence rates are calculated from women who attend clinics for help. It is likely that the prevalence rates in the general population are higher. Second, vaginismus tends to be a very secret hidden problem because of the shame and stigma attached to sexual difficulties and sex in general, in many cultures. Secrecy and guilt associated with vaginismus have been identified as factors that prevent the identification of reliable prevalence rates (Ogden & Ward, 1995). Most studies reporting prevalence rates have been established in settings using quantitative methods. Therefore, women who have not sought help are excluded from such statistics. More community based prevalence studies are needed as well as qualitative studies that explore the reasons that women do not go for help with vaginismus. Third, the association between sexual abuse and vaginismus may exacerbate experiences of shame, which prevents women from seeking help. Despite being often cited as a major contributing factor, few studies have actually demonstrated the link between vaginismus and sexual trauma (de Jong et al., 2009; van Lankveld et al., 2010). Nevertheless, research has identified that women have been hindered from going for counselling by a belief that such counselling would lead to the discovery of repressed childhood events (Ogden and Ward, 1995).
Understanding vaginismus as a physical spasm
Traditionally, the vaginal spasm was seen as the sole diagnostic criterion of vaginismus (Binik, 2010), indicating the presence of an underlying mental disorder (Tyrer, 2014). Classification systems of mental disorders such as the International Classifications of Diseases and Related Health Problems (ICD-10) (WHO, 1992) and the Diagnostic and Statistical Manual (DSM-IV-TR) of Mental Disorders (APA, 2000) relied on medical definitions and Masters and Johnson (1970) model of human sexuality in order to diagnose sexual dysfunctions (Shaw, 2001). The vaginal spasm was understood as dysfunctional because it causes the muscles of the perineum and outer third of the vagina to contract in an involuntary spasm, impeding the rhythmic contractions normally associated with sexual excitement (Masters & Johnson, 1970).
Later work suggested that, rather than concentrating on the muscle spasm as the defining characteristic of vaginismus, a multidimensional diagnostic framework was needed that included non-arousing influences. Additional diagnostic markers might include abnormally high muscle tone, pain, fear of pain, and behavioral avoidance (Reissing et al., 2004). Attention needed to focus on the deeper cognitive and emotional meanings behind the physical symptom (Barnes, 1986a; Basson, 2000, Jan-Mar; Shaw, 2001). As Tiefer (2001) noted, sexuality also involves “sexual motives, scripts, pleasure, power, emotionality, sensuality, communication or connectedness” (p. 90). The reasons for the vaginal spasm for each woman and couple will be unique and it is worth investigating the multifaceted nature of this difficulty.
Recent revisions of classification systems have addressed these issues to some extent. The latest version of the DSM (5th Edition; American Psychiatric Association, 2013) replaced the separate diagnoses of “vaginismus” and “dyspareunia,” under a subcategory of sexual pain disorders called genito-pelvic pain/penetration disorders (GPPD). Signs and symptoms of GPPD now include pain or fear and anxiety of anticipated pain in anticipation of, during or following vaginal pain. Similarly, ICD-11 (WHO, 2020) in its definition of sexual pain-penetration disorder includes in its list of etiological factors, psychological or behavioral factors, lack of knowledge or experience, and relationship and cultural factors. According to Reissing et al. (2014), although GPPD was an empirically based and clinically useful improvement for the diagnosis of painful sex, the inclusion of “marked tensing or tightening of the pelvic floor muscles” (APA, 2013, p. 437) in the DSM-5 diagnostic criteria is not sufficiently differentiated from the concept of “involuntary spasm of the musculature of the outer third of the vagina” (APA, 1994, p. 556) in the previous edition. Spoelstra (2017) also questions whether the reference to a “rather vague notion of pelvic muscle tension or tightening in the current DSM is an improvement” (p. 128). Reissing et al. (2014) also critique the new diagnostic criteria noting that, “GPPD does not accurately capture the symptomatology of lifelong vaginismus” (p. 1212) and suggest that “vaginal intercourse has never been possible” should be included as a specifier to the GPPD diagnostic criteria (p. 1213). Despite the recent changes to the classification systems, much of the research cited in this literature review has retained the term vaginismus as a meaningful theoretical and clinical term and the predominant therapeutic response to individuals experiencing vaginismus continues to focus on the physical spasm, rather than the range of potential etiological factors that lead to this experience.
Understanding vaginismus as a phobic response
In contrast to the medical understanding of vaginismus, behaviorists assume that disorders are functional, rather than organic (Krueger & Piasecki, 2002). Helen Singer-Kaplan (1974) recognized vaginismus as a functional muscle spasm triggered by phobic responses to, and avoidance of, penetration. Thus, the vaginismic response may be conditioned through experiences, for example, painful sexual experiences or secondary to psychological or emotional factors (Basson et al., 2000; Berman et al., 1999). In 1999, the first population-based assessment of sexual dysfunction in America since the 1950s Kinsey report highlighted that, not only were sexual dysfunctions extremely common but, in most cases, were linked to stress (Laumann et al., 1999). Feelings of threat can elicit pelvic floor reactions in all women, with or without vaginismus, indicating that the involuntary spasm of the pelvic floor may be part of the wider defense reaction of the body to stress (van der Velde & Everaerd, 2001). The pelvis and pelvic floor receive neural input from both the autonomic nervous system’s sympathetic and parasympathetic systems that mediates the sexual response cycle proposed by Masters and Johnson (1966). Thus, it was understood that pelvic contractions can be directly affected by stress or threat (van Lankveld et al., 2010). Vaginismus, therefore, may be as a phobic reflexive response to protect the individual against actual, perceived or anticipated harm from vaginal penetration (Borg et al., 2012; Fugl-Meyer et al., 2012).
Higher levels of stress and internal perceptions of stress have been identified in women with vaginismus (Bodenmann et al., 2006). Whether this involuntary spasm is the primary cause of vaginismus, or whether the spasm is a symptom of the condition, related to anticipatory anxiety, a reaction to fear of pain, or a combination of both, is unclear. Women with vaginismus have been found to score higher on tests of anxiety, and anxiety-proneness has been identified as a risk factor for vaginismus (Watts & Nettle, 2010). They also show more fear, distress, muscle tension and avoidance of vaginal intercourse than women who experience painful sex (dyspareunia) or women who have pain-free intercourse (Basson et al., 2004; Lahaie et al., 2015). Specific phobias have been reported by women with vaginismus related to bleeding, penetration, somatic injury and childbirth and an unwillingness to engage in coitus due to the possibility of pain (Crowley et al., 2009; Farnam et al., 2014; Hawton, 1985; Konkan et al., 2011). They have also been found to respond to sexual stimuli with more disgust than women with dyspareunia including increased pelvic floor tension, suggesting that one component of vaginismus may be a disgust-induced protective response (Borg et al., 2010; de Jong et al., 2009; van Overveld et al., 2013).
Fear of pain is also a significant factor and has been rated in surveys as the number one subjectively reported reason for vaginismus (Reissing, 2012; Ward & Ogden, 1994). This anticipation of pain can result in hyper-vigilance and negative appraisal of sexual cues and avoidance behaviors, which can result in lifelong vaginismus (Borg et al., 2012). These findings provide empirical support for understanding this condition as being phobic in nature and related to the anticipation of pain rather than to actual pain experiences (Klaassen & Ter Kuile, 2009; Reissing et al., 2004). Although a diagnosis of vaginismus does not require the experience of pain (Binik et al., 2001), some women who experience vaginismus also report actual pain experiences (Reissing et al., 2004) even when they have not been able to endure penetration (Kaneko, 2001). Women with primary vaginismus are also more likely than women with dyspareunia to catastrophize their pain reactions (Borg et al., 2012). Studies have made strong links between vaginismus, anxiety and phobic avoidance (Farnam et al., 2014). Therefore, these studies suggest that, rather than being a dysfunctional response, the muscle spasm may be understood as a healthy functional response to threat that protects the woman from real or perceived potential harm.
Attitudes and beliefs about sex and sexuality
Psychosocial understandings of vaginismus acknowledge the role of implicit and explicit attitudes in the vaginismus response and the sociocultural context from which these attitudes might originate. Fear-based and disgust-based attributions have been linked with lifelong vaginismus (Reissing, 2012). Studies that employ implicit and explicit measures of disgust demonstrated that women with vaginismus have unconscious automatic feelings of disgust when shown sexual stimuli but can also explicitly disclose their feelings of disgust (Borg et al., 2010; Huijding et al., 2011). Women with lifelong vaginismus report lower levels of perceived penetration control, higher levels of catastrophic and pain cognitions, negative self-image cognitions, and genital incompatibility cognitions when compared with women with dyspareunia (Klaassen & Ter Kuile, 2009). Ward and Ogden (1994) identified such cognitions in their qualitative study with women who experienced vaginismus:
sex is dangerous, pregnancy is frightening, you can be damaged, childbirth is frightening, sex is painful, sex is undignified, contraception is frightening, sex is disgusting, sex is animal-like, nice girls don’t, pleasure is not allowed, sex makes me feel guilty, sex is terrifying, I’m too small, I’ll be ripped apart. (p. 442)
The attitudes toward sex described by the women in the Ward and Ogden study also encompass their attitude toward themselves, their body and their sexuality. Persistent or recurrent vaginismus has been associated with disturbance of body image and sexual and gender roles for women (Fugl-Meyer et al., 2012; Valins, 1988b) and a more negative sexual self-schema (Reissing et al., 2003). Ward and Ogden (1994) also reported low self-esteem and poor self-worth and certain attitudes towards the self, including self-dislike, guilt and helplessness. Women in their study described feeling like an abnormal and inferior woman and being separate and distanced from other people. As a consequence, they reported not being able to confide in family and same-sex friends. Similarly, stress related to sexual dysfunction in Chinese women included loneliness and a lack of recognition or identity within the family (Ng, 2001).
It is important to consider how negative sex-related cognitions originated. Some women have reported actual painful or traumatic experiences, for example experiences of painful gynecological examinations (Dolan, 2009; Ward & Ogden, 1994). Primary vaginismus has been associated with early sexual trauma (Masters & Johnson, 1970; Reissing et al., 2003; Silverstein, 1989). Masters and Johnson (1970) described the most prevalent factor to be a partner’s sexual dysfunction, followed by the influence of religious orthodoxy, and early sexual trauma. However, few studies have actually demonstrated the link between vaginismus and sexual trauma (de Jong et al., 2009; van Lankveld et al., 2010). As some authors have pointed out, it is not always necessary to have direct experience of a phenomenon to experience disgust and phobic avoidance. This can also result from hearing about the negative sexual experiences of others (Rosenbaum, 2013) and from parental attitudes and behaviors (Dolan, 2009). Reissing (2012) found that women with lifelong vaginismus reported fears that stemmed from what they had either heard about or read regarding pain, injury, intimacy or loss of control in the context of the sexual encounter. There is evidence that sexual repression and shame has a role to play in sexual dysfunction. One survey reported that “brought up to believe sex was wrong” was the second most prevalent reason given by patients for vaginismus, after fear of pain (Ward & Ogden, 1994). A strong adherence to conservative values and strict moral related standards were found to be correlated with vaginismus and to play an active role in the defensive reflex of the pelvic floor muscles (Borg et al., 2010). Thus, there is a wide range of potential contributing factors to women’s beliefs and assumptions about sex that may impact on both her experience of vaginismus and her experience of therapy. The findings above highlight the importance of investigating the origins of negative beliefs and attitudes towards sexual functioning. It is important to consider the role of cultural attitudes, education and familial attitudes to sex and sexuality.
Social, cultural, and religious contexts
The biopsychosocial model integrates the physical, psychological and social components as contributors to sexual difficulties but the contribution of social, cultural and religious factors are the least explored (Atallah et al., 2016). Although sexuality is biological and instinctual, sexual values and the meaning of sexuality are culturally embedded (Colman, 2009; Yasan & Akdeniz, 2009). The relevance of culture is exemplified in the different prevalence rates of sexual pain disorders across different cultures. Middle Eastern countries, which report high rates of vaginismus, tend to rate high on religious conservativism, e.g. expectations that brides will be virgins, religion and social structures that restrict premarital sexual relations (Dogan & Dogan, 2008; Dogan & Varol-Saracoglu, 2009; Ozdemir et al., 2008). These cultures tend to have arranged marriages (Dogan & Varol-Saracoglu, 2009; Yasan & Akdeniz, 2009; Yasan & Gurgen, 2008) and to prioritize male sexual and marital satisfaction over female pleasure (Dogan, 2009). Despite the fact that female sexual desire problems are more common in Turkish culture than vaginismus, women are more likely to present for treatment for vaginismus due to an inability to have intercourse (Dogan, 2009). In Turkey, studies have identified vaginismus as the main cause of unconsummated marriage in just over 80% of couples. (Ozdemir et al., 2008; Yasan & Gurgen, 2008). Similarly, an Irish study by O’Sullivan (1979) found that sexual pleasure was not prioritized within the marital relationship and this influenced referrals for psychosexual problems. Women with vaginismus, as opposed to women with orgasmic difficulties, tended to come for help because the former prevented sexual intercourse and the latter did not. Thus, the differences in prevalence rates indicate that it may not be an East-West divide but a conservative-liberal divide when it comes to explaining vaginismus. These discrepancies prompt the need for a wider discussion about the impact of society and culture on the prevalence of vaginismus (Oberg et al., 2004). Societies that suppress female sexuality and place a high importance on female virginity have higher incidences of sexual dysfunction including vaginismus due to the clash between intrapersonal, interpersonal and cultural sexual scripts (Ng, 2001). It may be that women become sexually unresponsive due to the tensions between anti-sexual and pro-procreation scripts laid down by the family and culture and her own sexual desires.
Many religious traditions such as Catholicism, Judaism and Islam see an unconsummated marriage as grounds for divorce (Coppini, 1999). Traditions that link sexuality to marital duty and reproduction associate sexual dysfunction with shame and loss of social status (Atallah et al., 2016). Within the four major world religions—Christianity, Judaism, Hinduism and Islam—sexual experiences prior to marriage are expressly forbidden as sinful (Kellogg-Spadt et al., 2014). The methods of suppression used in conservative religious societies can include teaching anti-sexual morality and encouraging the passive role of the female in sexual relationships (Ng, 2001). Fear messages are also frequently used to discourage sexual behavior in females. In order to maintain the social norm of the virginal bride, families from Middle-Eastern cultures frequently request that the sheet placed under the bride on her wedding night be taken out and the blood shown to the family as proof of her virginity and to deter young women from pre-marital sex (Yasan et al., 2009). This can lead young women to believe that intercourse causes unbearable pain and excessive bleeding and transmits fear of sex, leading to vaginismus (Dogan, 2009). In traditional Muslim societies, women are taught to curb their sexual desires from an early age and are warned about the destructive effect of the penis on the vagina and uterus (Mernissi, 1985). Catholicism has been singled out as being particularly restrictive regarding sexual morality (Kellogg-Spadt et al., 2014).
Religiosity has also been linked to a lack of sexual knowledge (Kellogg-Spadt et al., 2014), which in itself has been correlated with vaginismus in countries as diverse as Singapore, India, Turkey, South Africa, Ghana, Mexico, and Canada (Amidu et al., 2011; Biswas & Ratnam, 1995; Harish et al., 2012; Konkan et al., 2012; Oniz et al., 2007; Sampson, 2007; Sanchez Bravo et al., 2010; Woo & Brotto, 2008; Yasan & Akdeniz, 2009). Religious orthodoxy, regardless of which religion, is synonymous with guilt around sexual behaviors, which frequently leads to sexual dysfunction (Barnes, 1986b). Education has been found to empower women with the knowledge and confidence to seek help for sexual problems. Studies in Nigeria, Iran and Ireland found a higher incidence of sexual dysfunction among more highly educated women. These women were much likely to seek help, were more confident in discussing sexual problems with health professionals and with their partners and more likely to utilize every facility at their disposal (Akhavan-Taghavi et al., 2015; Barnes, 1986a; Fajewonyomi et al., 2007) than women with less education. The dominance of Catholicism in Ireland has been credited with an active suppression of accurate sex education in state schools (Ferriter, 2009; Ingles, 1998), which may explain the findings that Ireland has been reported as having the highest prevalence rates of vaginismus in Europe (Barnes, 1986a; O’Sullivan, 1979).
Malesevic (2003) found that Irish values about sex and sexuality are no longer predominantly conservative and are spread across an egalitarian, open-minded to conservative spectrum. However, the only known study of vaginismus in Ireland in the last forty years suggests that the legacy of the Catholic Church in Ireland has created a culture of silence and shame regarding sexual matters that may amplify feelings of shame and isolation for those with sexual difficulties (McEvoy et al., 2018). This study found that conservative religious messages and frightening messages from the family about the negative effect of pregnancy on the reputation of the daughter and the family, designed to control the sexuality of daughters, are still prevalent in Irish society. Thus, a culture of silence prevails, resulting in some women being unable to speak to teachers, family or friends about sexual concerns.
The role of the family of origin
An important consideration in understanding the development of vaginismus is the role played by the family of origin. The family is the vehicle through which cultural norms and values are socialized. According to Masters and Johnson (1970), the extent to which religious messages affect sexuality has everything to do with upbringing, especially within the context of a rigid, inflexible adherence to religion. While religiosity has not been shown to be directly associated with vaginismus, such women often grow up in families and cultures where negative views of penetrative sex, pre-marital sex and sexuality in general predominate (Crowley et al., 2009). Modelling and polarization of gender stereotypes by parents has been linked to later sexual difficulties, including vaginismus (Sanchez Bravo et al., 2010). In Ward and Ogden’s study, one woman commented that “it is the family relationship that affects the vaginismus rather than vice versa” (Ward & Ogden, 1994, p. 443). Family factors that had contributed to vaginismus were identified as emotional distance, confused feelings, ridicule and inappropriate suggestions. Thus, family dynamics dictated by certain cultural expectations of the sexuality of women may provide the conditions from which the difficulties emerge and are maintained.
The interpersonal nature of vaginismus has not been adequately explored (Ng, 2010), in particular, the role of the mother-daughter relationship (Tuğrul & Kabakci, 1997). Psychoanalytic feminist theory has specifically highlighted the role of the mother in the transmission of cultural values and agents of sexual socialization within families (Chodorow, 1989). In terms of sex roles, this socialization is mostly indirect and non-verbal (Litton Fox, 1980). A qualitative study of women with vaginismus in Hong Kong identified negative attitudes from mothers towards pre-marital sex to have a more profound effect than religion for some women (Nga, 2004). Studies in Ireland found that mothers of women with vaginismus tended to portray sex and sexuality as unimportant or dirty (Barnes, 1986b). More recently, Rogan (2017) stated that Irish women with vaginismus tended to have mothers that either did not speak to their daughters about sex or were explicitly negative about sex, the motives and trustworthiness of men, and pre-marital pregnancy. McEvoy et al. (2018) also found that women with vaginismus in Ireland frequently reported that their mothers’ messages around sex and pregnancy had been frightening. The reputation of the family was prioritized and daughters made aware that any sexual transgressions, including extramarital pregnancy, would bring shame on the family and ruin their lives. Bernstein (1990) suggests that if familial or cultural messages create anxiety about crossing the body boundary before body integrity has been established, the girl may develop vaginismus in order to master this anxiety.
For the daughter, adolescence is a time of emotional conflict between a need to retain familial closeness and the need to establish a separate identity, including a sexual identity. For the mother, it is a time of renegotiation of her role as protector of her “daughter-as-child” to the role of a guide for her “daughter-as-woman” (Litton Fox, 1980, p. 26). The mother experiences a need to retain control over the daughter and prevent her from becoming physically and emotionally separate (Chesler, 1997). To prevent this separation, daughters are socialized to be an archetype of femaleness modelled by their own mothers: self-sacrificing, feeling guilty for their own desires and adept in the art of masking their unhappiness so as not to upset those around them (Chesler, 1997; Elmerstig et al., 2008; Klein, 2018). Barnes (1986b) noted that in Irish society, women with vaginismus were typically the “good girls” of the family: obedient, unable to express anger, and in constant need of approval (Barnes, 1986b; O’Sullivan, 1979). The heightened need for approval among women with vaginismus was also noted by Turkish and American studies (Konkan et al., 2012; Silverstein, 1989). The mother’s influence can be so powerful that, even in adulthood, an enmeshed attachment to their mother can be retained (Chodorow, 1989), “Feelings of inadequate separateness, the fear of merger are issues for women because of an ongoing sense of oneness and primary identification with mothers” (p. 108). In this context, vaginismus can be understood as a Freudian defense mechanism, a way to protect the ego, by creating a barrier to prevent merger with a controlling mother (Ward & Ogden, 1994). Vaginismus has also been linked to a fear of intimacy that stemmed from a feeling of abandonment by the mother and the protection against future separation with an intimate other by avoiding intimacy with anyone (Arcelus & Wales, 2009). Thus, vaginismus can be conceptualized as an unconscious defense mechanism, “a barrier, a way of stopping people getting inside, a way of stopping pain, a way to take control; to defend against being controlled by others; to be separate; to avoid disintegration” (Ward & Ogden, 1994, p. 441).
Fear of sexual intimacy may be rooted in an anxious/ambivalent attachment relationship in childhood and a preoccupied style of adult attachment which is underpinned by both fear of separation from and merger with another (Clulow & Boerma, 2009). The sexual encounter requires loss of control to facilitate orgasm and this involves allowing oneself to be vulnerable and the lowering of defenses (Bancroft, 2009). Fear of losing control or letting down defenses can be intensified in intimate situations. During the sexual encounter, women with vaginismus report feeling a loss of control both of their own bodies and of the sexual encounter during penetration (Cherner & Reissing, 2013). They may report fear of the disintegration of the self (Coppini, 1999), fear of physical harm, pain or even death during intercourse (Tuğrul & Kabakci, 1997). Sexual intercourse is seen as an invasion or violation of the body and the spasm represents a need to defend oneself, provide boundaries and protect against violation and the disintegration of the self (Silverstein, 1989).
The father-daughter relationship has been less explored but certain patterns have been identified. An American study found that fathers of women with vaginismus tended to be moralistic, critical, threatening, overprotective and sexually seductive and did not respect the privacy or boundaries of their daughters when they were growing up (Silverstein, 1989). Irish studies identified fathers as often peripheral figures that were frightening, threatening and aggressive, often with high rates of alcoholism (Barnes, 1986b; O’Sullivan, 1979). According to Barnes (1986b), mothers were unable to support or defend their daughters in the face of the father’s aggression; violence seen in the home was also assumed to take place in the bedroom, where sexual behavior was hidden. The participants in one Irish study chose men who were kind, gentle, passive and quite often emotionally immature and completely different from their domineering fathers (O’Sullivan, 1979), a trend that was also found in American studies (Silverstein, 1989).
The role of the partner and relationship dynamics
Barnes (1986b) study in Ireland concluded that the partner is only sometimes found to be the cause of vaginismus but always has a role in its maintenance. In contrast to the masculine stereotype that men in patriarchal cultures may strive to live up to, some men in relationships with women with vaginismus instead strive to live up to the model of the “good guy” (Sampson, 2007, p. 100), just as the woman strives to live up to the model of the “perfect little lady” (Ward & Ogden, 1994, p. 441). Both of these schemas have passivity in common, preventing women from becoming sexual adults and men from taking an active role in the sexual relationship problems. In both partners, initial experiences of guilt, shame, fear and distrust lead to frustration, anger, resentment and hostility and eventually to helplessness, hopelessness, and powerlessness (Kessler, 1988). Some theorists have suggested that the male partners’ reluctance to deal with non-consummation may be a conscious or unconscious strategy to hide their own sexual difficulties, e.g. erectile dysfunction, (Dogan & Dogan, 2008; Masters & Johnson, 1970) but other studies have not found this to be the case (Sampson, 2007; Tuğrul & Kabakci, 1997). Conversely, one study that interviewed male partners found that commitment to sex therapy and support for female partners was actually enhanced in some cases when the partners placed importance on being a “good guy” (Sampson, 2007).
The underlying fear for couples who experience difficulties in losing themselves in the sexual encounter may be that uncontained repressed feelings may be unleashed that may be threatening to the relationship (Clulow & Boerma, 2009). In order to protect against this, the couple may sublimate the sexual aspects of their relationship but to avoid separation, develop an enmeshed relationship dynamic that emphasizes similarities to an unrealistic level. Sampson (2007) highlighted the impact of collusion in the relationships that helps to maintain vaginismus. Women with vaginismus may seek out men that are less dominant, sexually inexperienced and kind, to reduce the threat of possible intercourse. Male partners may use their belief systems such as being a nice guy or family values to justify the lack of sexual intimacy and most importantly will not confront or challenge their partner’s sexually avoidant behavior. One study in Turkey found that half of the husbands were considerate and helpful and one-third showed no outward dissatisfaction with the lack of intercourse in their marriage (Tuğrul & Kabakci, 1997). Thus, with the collusion of both partners, relationships can last for decades without any sexual intimacy.
Understandings of vaginismus: implications for practice
How vaginismus is understood has implications for practice. The origins of present day sex therapy can be traced back to the Masters and Johnson publication “Human Sexual Inadequacy” in 1970 (Binik & Meana, 2009) and its emphasis on the direct treatment of the sexual dysfunction, in the case of vaginismus, the physical spasm. According to Binik and Meana (2009), this approach was in stark contrast to traditional therapies that emphasized the underlying interpersonal or intrapersonal difficulties that were seen to be at the root of sexual dysfunctions and treatments that targeted these difficulties. While describing vaginismus as “a classical example of a psychosomatic illness,” Masters and Johnson (1970, p. 250) advocated behavioral treatments designed to eliminate the spasm and viewed the ability to allow penetrative intercourse as an outcome measure of treatment success. Similarly, Singer-Kaplan (1983) noted the importance of concentrating on the current and immediate psychological antecedents of sexual dysfunction, which she referred to as the “common final pathway,” (p. 4) rather than deeper intrapsychic (psychodynamic) conflicts that may be the ultimate cause but, in her view, had little to do with current treatment.
The Masters and Johnson model of therapy as a theoretical foundation (Rosen & Leiblum, 1995; Yasan et al., 2009) for sex therapies historically led to the dominance of behavioral interventions (Basson et al., 2004; Heiman & Meston, 1997), focused on treating the spasm that prevents sexual penetration. The focus of sex therapy was to counter-condition the fear response to sexual stimuli by reducing avoidant behavior and engaging with graduated and prolonged exposure to the feared stimulus, combined with relaxation techniques (Ter Kuile et al., 2007). Systematic desensitization techniques combined with exercises for vaginal dilation, such as digital penetration and vaginal trainers, were commonly used (Jeng et al., 2006). Wijma and Wijma (1997) suggest that systematic desensitization is highly effective in reducing fear of penetration when a woman is encouraged to move through a hierarchy of anxiety provoking situations over which she has increasing control. Cognitive distortions regarding competence or spatial distortions regarding the vaginal space are also addressed, if necessary. Each successful progression can lead to increased feelings of competence that can also prevent against future relapse.
Studies of the effectiveness of cognitive-behavioral treatments generally report high success rates (Ng, 1988). However, Reissing et al. (2013) found that symptoms such as pain, anxiety, fear, sexual distress, pelvic floor tension and impaired sexual function remained despite the ability to tolerate penetration following physical therapy for women with lifelong vaginismus. A study in Sweden by Engman et al. (2010) reported that 81% of women treated with cognitive-behavioral therapy could not only achieve penetrative intercourse but also reported significantly higher self-worth as sexual partners, and as women, following treatment. The researchers noted that self-worth was as important a measure of successful outcome as the ability to have intercourse. In Turkey, Kabakci and Batur (2003) reported a 100% success rate for couples treated for vaginismus with cognitive-behavioral therapy as well as an increase in marital harmony due to a reduction in blame and acceptance that vaginismus needed to be treated in the context of the relationship.
However, Kleinplatz (1998) cautions that the use of systematic desensitization techniques may ultimately result in alienating a woman from her own body and teaching her to ignore her physical and emotional needs. Although self-dilation is advocated to encourage the gradual relinquishing of control to the partner (Jeng et al., 2006), it has been suggested that these procedures may further infantilize and disempower women who are trying to understand their sexuality (Rosenbaum, 2013). Using physical therapy to reduce tension in the pelvic floor without considering other elements such as the emotional state of the woman has been described as reductionist and potentially harmful (Rosenbaum, 2018). Given that difficulties in the emotional relationship with the partners can predict emotional distress during the sexual encounter (Bancroft et al., 2003), sensate focus exercises may exacerbate underlying anxieties for both partners. However, these anxieties can be mediated by the skills of a supportive therapist (Bancroft, 2009).
For some, the desire to have children is used as a positive indicator for successful treatment outcome (van Lankveld et al., 2010) but quite often intercourse ceases completely after the goal of pregnancy has been achieved (Binik et al., 1999; Drenth et al., 1996). Thus, even when intercourse is possible and the feelings of subjective pain can be lessened through systematic desensitization, there is no guarantee that women will be able to have pleasurable intercourse as vaginismus involves much more than just a fear of pain or intercourse (Binik et al., 1999). A Cochrane Review concluded that there was little evidence to recommend the use of systematic desensitization for vaginismus, noting that the high rates of success often come from the publication of uncontrolled or single case studies (McGuire & Hawton, 2009). Even though success rates with physical or behavioral therapies are widely reported, a recent systematic review and meta-analysis of medical and psychosocial interventions for vaginismus by Maseroli et al. (2018) concluded that there was little evidence to suggest that behavior-based sex therapies were superior to other forms of therapies. The authors also cautioned that success of any intervention for vaginismus is questionable if the successful outcome measure is vaginal penetration rather than sexual satisfaction.
There are also wider ethical implications of focusing on performance outcomes, such as the ability to tolerate penetration in the case of vaginismus, rather than emphasizing sexual health and pleasure and relationship dynamics as outcome measures of success for sex therapy (Henderson, 2014; Pereira et al., 2013). Studies have found that, even when intercourse is achieved, some women could not consummate without pain, the frequency of intercourse tended to be functional and related to childbearing (Ozdemir et al., 2008), and was not always a pleasurable experience (Binik et al., 1999). The studies by Engman et al. (2010) and Kabakci and Batur (2003), cited above, reported high success rates but also reported unsatisfactory outcomes for the women. In the Engman study, although 81% of women could have intercourse, only 6% were able to have pain-free intercourse. Kabakci and Batur (2003), while reporting 100% success rates for achieving intercourse and increases in marital harmony, found poor outcomes with regard to improving sensuality or communication between partners, due to strict cultural barriers that prohibited this form of intimacy in Turkish culture.
It has also been suggested that the emphasis on penetrative vaginal sex as an outcome measure of successful sex therapy may be a reflection of culturally based heterosexual norms (Farrell & Cacchioni, 2012). Masters and Johnson’s approach to achieving marital harmony through sexual adjustment has been criticized as traditionalist, given the emphasis placed on the woman’s ability to be able to engage in penetrative sex (Denman, 2004) and the documented ability of women with vaginismus to enjoy alternative sex acts to the point of orgasm (Kleinplatz, 1998, p. 54). Heteronormative views can also permeate the attitudes of the women themselves who seek a medicalization of a condition that is often dismissed by physicians as being “in their heads” (Cacchioni & Wolkowitz, 2011). There is a danger that such treatments encourage them to conform to heteronormative sexual stereotypes and perform what is perceived as “real” sex (Cacchioni & Wolkowitz, 2011; Farrell & Cacchioni, 2012). It has also been found that women’s concerns regarding their own sexual difficulties are often affected by traditional sexual scripts that prioritize their partner’s sexual fulfilment but not their own (Darrouzet-Nardi & Hatch, 2014).
There are also ethical implications in treating women who do not want to be treated (Kaneko, 2001). Leiblum and Wiegel (2002) suggest that some women may feel ambivalent about engaging in therapy for vaginismus. While they may wish to be able to engage in desired sexual activity, they may also experience an increased obligation to engage in sexual encounters at the request of their partner. These authors suggest that treatment of vaginismus should begin with the assessment of the woman’s feelings and fears about being perceived both by herself and by others as a sexual being. Some, however, continue to prioritize penetration as a measure of success due to a concern that changing the focus of the outcome could contribute to further avoidance behaviors (Ter Kuile et al., 2007).
Despite research into the role of emotional and cognitive factors in sexual dysfunction, it seems to have had little impact on actual clinical interventions (Rosen & Leiblum, 1995). Thus, behavior therapies or cognitive-behavioral therapies—although the emphasis is mostly on systematic desensitization and relaxation exercises (Engman et al., 2010)—continue to dominate the sex therapy practice field. One argument put forward is that sex therapy is defined not so much by the techniques it employs, but rather by the willingness of sex therapists to deal with aspects of human sexuality in therapy (Binik & Meana, 2009; Pukall, 2009). Society’s discomfort with sexuality may reinforce the specialization, and some would argue, marginalization of sex therapy from other forms of treatment (Binik & Meana, 2009). Thus, both sexual problems and sex therapy by extension, have been isolated from wider relationship issues or psychological difficulties, and the field of psychotherapy whereby a range of theoretical understandings are considered relevant to the presentation of one clinical phenomenon. Evidence for the effectiveness of behavioral interventions alone to treat female sexual disorders, especially the reduction in subjective anxiety, is lacking. As a consequence, there has been a move in recent years towards a multidisciplinary treatment model that incorporates biological and psychosocial factors (Fugl-Meyer et al., 2012; Harish et al., 2012; van Lankveld et al., 2010).
Vaginismus might be more appropriately understood as a somatic symptom disorder (Basson, 2000, Jan-Mar); a disorder with physical manifestations of psychological symptoms and may be more compatible with a psychoanalytic or psychotherapeutic approach that looks at the meanings of the symptoms for the woman (Valins, 1988a) and the meaning of penetration in terms of the sexuality of the couple (Barnes (1986a). Masters and Johnson (1970) defined vaginismus as a “classic example of psychosomatic illness” (Masters & Johnson, 1970, p. 250). Singer-Kaplan (1983) considered deeper intrapsychic (psychodynamic) conflicts to be the ultimate cause and that the symbolic nature of the closed vagina required further investigation. It may be helpful to explore, for example, the underlying erotic fantasies that trigger fear and disgust reactions within the therapeutic context (Denman, 2004). Kleinplatz (2007) advocates an experiential approach to psychotherapy that uses sexual difficulties as an entry point to understanding a client’s deeper experiences and connections with others. Rather than defining symptoms such as the closed vagina as problems to be treated, the resolution of the sexual problem occurs as a result of inner change in the person or couple. Psychosexual therapeutic approaches that embrace psychosocial, developmental and interpersonal issues as well as the physical, may be more likely to address the complexities of the female sexual response (Hiller, 2000) and have the potential to exceed what can be achieved by targeting specific physical symptoms (Kleinplatz, 2007).
Couples do not always identify non-consummation as a difficulty if sexual alternatives are mutually satisfying (Drenth, 1988). Thus, an emphasis in treatment on non-coital sexual behavior may take the emphasis from vaginal penetration to sensual pleasures (Ng, 2001) and wider issues of trust and emotional safety (Ward & Ogden, 1994). Overall, the goal of sex therapy needs to be to work out a mutually satisfactory arrangement for both partners that leads to mutual comfort, pleasure and satisfaction (Leiblum & Pervin, 1980; Leiblum & Wiegel, 2002). Sexual difficulties that are rooted in early attachment styles may be more appropriately addressed in couple therapy that focuses on the attachment that is co-created by the couple to form a secure base and good enough closeness in the relationship (Orbach, 2009). Sexual relationships can be recast as part of a complex life narrative within a specific culture in order to give meaning to the couple’s experience (Fagan, 2004). The collusive dynamic of the relationship, which is typically unconscious, could be elucidated in the experiential aspects of therapy, leading to personal and relational insights that can be catalysts for change (Butler & Joyce, 1998; Kleinplatz, 2007).
Despite its universal prevalence, vaginismus remains under-researched (Watts & Nettle, 2010). According to Ng (2010), in order to fully understand vaginismus, it must be explored at intrapersonal, interpersonal and cultural levels. This paper has explored various understandings of vaginismus, including vaginismus as a physical spasmic response, a phobic reaction, a psychosomatic defense mechanism rooted in early attachment relationships, and a manifestation of family and cultural indoctrination. While symptom focused approaches have dominated the field of sex therapy to date, these have been criticized as reductionist and objectifying (Kleinplatz, 1998). Many authors have called for a more holistic approach to both understanding vaginismus and treating this condition. One of the predictors of successful treatment for vaginismus is the attribution of the problem to psychological causes rather than physical ones (van Lankveld et al., 2010). Thus, incorporating a biopsychosocial and experiential approach into perspectives on vaginismus could be of benefit to therapists working with individuals or couples who present with vaginismus in their practice. Some guidance, informed by the literature cited above, is offered here to such practitioners.
The role of interpersonal relationships in vaginismus is the one that has been the least explored in the literature (Ng, 2010). Situational vaginismus can be a manifestation of relationship difficulties (APA, 2013). Therefore, unresolved relationship problems should be addressed in couple therapy prior to treating vaginismus (Leiblum, 2007). Nevertheless, there is evidence that the difficulties for women with vaginismus may predate the partner relationship and may be rooted in complex attachment relationships in the family of origin. In particular, the mother-daughter relationship has been highlighted as a vital component of therapy for vaginismus (Tuğrul & Kabakci, 1997). It may be necessary, therefore, to explore the role of early attachment relationships in order to understand the dynamics of vaginismus within the couple relationship. It is argued that females who, in late adolescence, can be assertive and establish an identity independently of their mothers are less fearful of sexual intimacy and non-sexual intimacy with their romantic partners (Thériault, 2003). In considering the role of the mother-daughter relationship in the development of vaginismus, therapists can be cognizant of the difficulty inherent for girls in separating psychologically from the mother when the mother is over-intrusive and lacks boundaries (Tuğrul & Kabakci, 1997).
As such, “a one-size fits all” approach to the treatment of vaginismus is inadequate to effectively respond to and resolve the complex nature of this distressing sexual difficulty for women and men in adult intimate relationships. It is incumbent on medical and psychotherapeutic professionals to provide a seamless multi-disciplinary response to women and their partners seeking help to overcome the physical and psychological pain associated with vaginismus.