Vaginismus occurs when the muscles around the outer third of the vagina contract involuntarily when vaginal penetration is attempted during sexual intercourse.
Vaginismus is a sexual disorder that is characterized by the outer third of the vaginal muscles tightening, often painfully. A woman with vaginismus does not willfully or intentionally contract her vaginal muscles. However, when the vagina is going to be penetrated, the muscles tighten spontaneously due to psychological or other reasons.
Vaginismus can occur under different circumstances. It can begin the first time vaginal penetration is attempted. This is known as "lifelong vaginismus." Alternately, vaginismus can begin after a period of normal sexual functioning. This is known as "acquired-type vaginismus." For some women, vaginal tightening occurs in all situations where vaginal penetration is attempted (generalized type). For other women, it occurs in only one or a few situations, such as during a gynecological examination at the doctor's office, or with a specific sex partner (situational type). According to the professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) , in order for a condition to be diagnosed as vaginismus, the response must be due to psychological factors or a combination of psychological and medical factors, but not to medical factors alone. Because of this DSM-IV-TR criterion, this entry focuses on the psychological causes and treatments of vaginismus.
Causes and symptoms
There are many possible causes of vaginismus. One example is an upbringing in which sex was considered wrong or sinful—as in the case of some strict religious backgrounds. This is common among women with this disorder. Concern that penetration is going to be painful, such as during a first sexual experience, is another possible cause. It is also thought that women who feel threatened or powerless in their relationship may subconsciously use this tightening of the vaginal muscles as a defense or silent objection to the relationship. A traumatic childhood experience, such as sexual molestation, is thought to be a possible cause of vaginismus. Acquired-type vaginismus is often the result of sexual assault or rape.
Vaginismus can occur when any kind of penetration of the vagina is attempted. This includes attempted penetration by a penis, speculum, tampon, or other objects. The outer third of the vaginal muscles contract severely. This either prevents penetration completely, or makes it difficult and painful. The woman may truly believe that she wants to have sexual intercourse or allow the penetration. She may find that her subconscious desires or decisions do not allow her to relax the vaginal muscles.
Diagnosing sexual disorders, including vaginismus, can often be very difficult. This is mainly due to lack of comfort many people feel in discussing sexual relations, even with their physicians. Often, cultural norms and taboos deter women from seeking assistance when they are experiencing such problems. When a physician or gynecologist is consulted, involuntary spasm during pelvic examination can confirm the diagnosis of vaginismus, and the physician will rule out any physiological causes for the condition. When psychological causes are suspected, referral should be made to a psychologist or psychiatrist .
According to the DSM-IV-TR , the first criterion for the diagnosis of vaginismus is the spasm of the muscles in the outer third of the vagina that are involuntary and recurring or persistent. The symptoms must cause physical or emotional distress, or, in particular, problems with relationships. The symptoms cannot occur during the course of another mental disorder that can account for them— they must exist on their own. As mentioned, the muscle spasm cannot be the direct result of any sort of physical or medical condition for vaginismus to be diagnosed.
Although many women experience sexual disorders, it is hard to gather accurate data regarding the frequency of specific problems. Many cases go unreported. Vaginismus is thought to occur most often in women who are highly educated and of high socioeconomic status.
There are many different treatments of vaginismus, as there is a multitude of ways to treat most sexual disorders. Therapists can use behavioral, hypnotic, psychological, educational, or group therapy techniques. Multiple techniques are often used simultaneously for the same patient. Much treatment is aimed at reducing the anxiety associated with penetration.
There are three settings in which psychological treatment can occur. These are in individual, couple, or group settings. During individual therapy, the treatment focuses on identifying and resolving any underlying psychological problems that could be causing the disorder. Problems stemming from issues such as childhood trauma or rape are often resolved this way. Revealing insecurities or fears about sex resulting from such things as parents' attitudes about it, or a religious upbringing, can often be discussed successfully if the affected woman can trust her therapist.
Couples therapy has been referred to as "dual-sex therapy." The idea behind couples therapy is that any sexual problem should be treated as a problem for the couple as a whole, and not just addressed as a problem for one person. Because this view is taken, the therapist interacts with the patients both separately and as a couple. The therapist addresses both the couple's sexual history and any other problems that may be occurring in the relationship. Confronting these problems may help to resolve the cause of the vaginismus. Working with a therapist on relationship problems can be very effective— perhaps especially so if the vaginismus is caused by a subconscious use of vaginal muscle spasms as a nonverbal form of protest about one or more aspects of the relationship. The couple is educated about vaginismus disorder and given advice on the kind of activities that can be engaged in at home that may be helpful in overcoming the disorder.
Group therapy, which can be very effective, is another form of therapy for vaginismus. In this form of therapy, couples or individuals who have the same or similar sexual disorders are brought together. For people who are embarrassed or ashamed of their disorder, this setting can provide comfort and strength. It is often very beneficial to witness another person discussing sex and sexual problems in an open and honest forum. It can also help to inspire patients to become more open and honest themselves.
Another positive feature of group therapy is that it provides a certain amount of pressure. Pressure to open up can help to provide a needed "push." Also the group's expectations for each other can provide positive pressure and encouragement for the group members. For example, the therapist may recommend "homework" outside the therapy sessions, including masturbation or certain kinds of foreplay. The group members will expect each other to complete the homework, and that expectation may help individual couples overcome their aversions to completing the activities.
Hypnotherapy is also effective for some patients. In general, hypnotherapy tends to focus on overcoming the vaginismus itself, as opposed to resolving any causes or conflicts behind it. The therapist will determine if hypnotherapy is appropriate for a particular patient. There are often a number of sessions, during which the patient and therapist work to define the goals of the hypnotherapy. When the actual hypnosis occurs, the suggestions made are intended to resolve underlying fears or concerns, and to alleviate symptoms. For example, the patient may be told that she can have coitus without it being a painful experience, and that she will be able to overcome the muscle spasm.
During hypnosis, the problems causing the vaginismus may be explored, or an attempt may even be made to reverse feelings or fears that could be causing the disorder. Exploring causal relationships, as well as suggesting to the woman she can overcome her vaginal muscle spasms, can be very effective for certain patients.
Behavioral therapy is also used to treat vaginismus. When behavioral therapy is chosen, it is assumed that the vaginismus is a learned behavior that can be unlearned. Behavioral therapy generally involves desensitization. Patients are exposed to situations that they find create a mild sense of psychological discomfort or anxiety. Once these situations are conquered, the patient is exposed to sexual situations that they find more threatening, until coitus is eventually achieved without difficulty.
Another type of treatment for vaginismus involves desensitization over a period of time using systematic vaginal dilation. In the beginning of the treatment, the woman inserts a small object into her vagina. Over time, she inserts larger and larger vaginal dilators. Eventually, a dilator the size of a penis can be inserted comfortably and sexual intercourse can be achieved. There is some debate about this procedure, as it treats the symptoms and not the underlying causes of the vaginismus disorder.
Vaginismus is generally considered to be the most treatable sexual disorder. Successful treatment has been reported to be 63% or higher. For different people, the possibility of success using different treatments varies, because different cases of vaginismus disorder have varying causes. Generally, a treatment plan combining two or more therapeutic techniques is recommended.
There is no known way to successfully prevent vaginismus; however, maintaining open marital communication may help to prevent the disorder, or to encourage seeking help if it does arise.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revised. Washington DC: American Psychiatric Association, 2000.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 2000.
Kleinplatz, Peggy J. "Sex Therapy for Vaginismus: a Review, Critique, and Humanistic Alternative." The Journal of Humanistic Psychology 38 no. 2 (Spring 1998): 51- 82.
Sadovsky, Richard. "Management of Dyspareunia and Vaginismus." American Family Physician 61 no. 8 (April 15, 2000): 2511.
American Psychological Association. 750 First Street NE, Washington, D.C. 20002-4242, 800-374-2721; <www.apa.org> .
Tish Davidson, A.M.