Vaginismus treatment for professionals

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“Was vaginismus always there, or did it develop later?”

The term vaginismus was first introduced in 1861 by American gynecologist Dr. J. Marion Sims, who defined it as a clinical syndrome. He believed the cause was hypersensitivity in the genital region and recommended treatment through post-surgical use of glass dilators to expand the vaginal canal, a procedure known as dilatation.

However, the roots of this condition trace back even further in history.

In 1547, the Italian physician Trotula of Salerno, in her seminal work Diseases of Women, may have provided the first known description of what we now call vaginismus:

“The contraction of the vulva is so intense that even the most aroused woman may still remain, in effect, a virgin.”

In 1909, Walthard challenged Sims’ notion of genital hypersensitivity as the defining feature. He proposed that vaginal muscle spasms might actually reflect a phobic reaction to anticipated pain. Rather than surgical interventions or dilatation procedures, he emphasized the importance of psychotherapy and education in treatment.

In 1923, Faure and Siredey concluded that vaginismus involved involuntary, painful, and spasmodic contractions of the vulvo-vaginal canal, triggered by hypersensitivity and occurring independently of the woman’s will.

In 1989, Silverstein interpreted vaginismus as a symptom rather than a condition in itself symbolizing a defensive mechanism, a physical expression of the woman’s need to protect herself, set boundaries, or “barricade” against perceived danger.

In 1990, clinical research and observations by Hawton and Catalan revealed that couples affected by vaginismus often experienced relationship breakdowns, separation, or divorce, especially when treatment was delayed or inappropriate support was lacking.

What actually happens during vaginismus?

When penetration is attempted, involuntary, persistent muscle spasms occur in the outer third of the vagina. These spasms are often accompanied by fear of pain and intense anxiety related to vaginal entry.

In some cases, the response extends beyond the pelvic floor muscles and includes systemic symptoms such as:

• leg stiffness,
• trembling and shaking,
• palpitations,
• sweating,
• nausea or vomiting,
• heaviness in the body,
• uncontrollable crying episodes.

In most cases, these spasms make penetration physically impossible. In others, forced penetration may occur, but it is usually painful and distressing.

These spasms are not voluntary; the woman does not choose them, nor can she consciously control or stop them.

ICD-10

Vaginismus without organic cause:

Defined as the contraction of the muscles surrounding the vaginal opening, preventing penetration. If this is a secondary response to local pathology causing pain, this diagnosis should not be used.

DSM-IV Criteria

A. Recurrent or persistent involuntary contraction of the outer third of the vaginal muscles that interferes with intercourse.
B. This disturbance causes marked distress or interpersonal difficulty.
C. The disturbance is not better explained by another Axis I disorder and is not due to the direct physiological effects of a general medical condition.

Subtypes:

• Lifelong vs. Acquired
  
• Generalized vs. Situational
  
• Psychogenic vs. Mixed etiology

DSM-5 Diagnostic Criteria

Genito-Pelvic Pain/Penetration Disorder

A. Persistent or recurrent difficulties with one or more of the following:

• Vaginal penetration during intercourse
• Marked vulvovaginal or pelvic pain during penetration or attempts at penetration
• Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of penetration
• Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

B. Symptoms have persisted for at least 6 months.

C. The condition causes clinically significant distress.

D. The sexual dysfunction is not better explained by another mental disorder and is not solely attributable to the effects of a substance or general medical condition.

Etiology – Organic Factors

• Vaginal atrophy and adhesions due to atrophy
• Vaginal lesions or tumors
• Previous vaginal surgeries
• Radiation therapy involving the vaginal area
• Uterine prolapse
• Vulvar Vestibulitis Syndrome (VVS)
• Endometriosis
• Infections
• Pelvic vascular anomalies

Clues that may point to organic etiology include how pain is described:

• “Burning” instead of “pain”
• “Diffuse” rather than “localized”
• “Spontaneous irritation” rather than “triggered discomfort”

Etiology – Psychodynamic Factors

According to Freud, the development of anxiety around sexuality can stem from internalized prohibitions originating from religion, morality, tradition, and legal systems—internal voices of “this is forbidden,” “this is shameful,” “this is sinful.”

Bergeron et al. proposed that vaginismus may function as an unconscious act of disobedience in women who are not psychologically ready for intercourse, or as a veiled protest against imposed gender roles.

Helen S. Kaplan (1974) suggested that once the symptom occurs, it becomes a reflexive or phobic response to pain, resulting in a conditioned reaction to vaginal penetration.

Oktay & Tombul (2003) Study – Summary of Findings:

200 women diagnosed with vaginismus reported the following fears:

• Fear of intense pain and cramps – 57%
• Fear of excessive bleeding – 31%
• Fear of tearing or rupture – 18%
• Fear of the penis getting stuck – 17%
• Fear of fainting or dying – 11%
• Fear of disgust – 9%

Additional Contributing Factors

1. Socio-Cultural Transmission

Narratives passed to unmarried women about the “first night”:

“Sexual intercourse causes unbearable pain and long-term complications.”

2. Lack of accurate information

3. Excessive anxiety around sexuality

4. Feelings of guilt

5. Unrealistic expectations

Beliefs Surrounding Sexuality

“Sex is only for reproduction.”

“Sex is for men, not for women.”

“If I enjoy sex too much, I’ll be seen as dirty.”

“A woman’s body belongs to her husband after marriage.”

“Pain is part of a woman’s role in sex.”

“Good girls don’t like sex.”

Common Myths:

• “The penis is too large to fit.”
• “My vaginal canal is too narrow.”
• “Sex will be unbearably painful.”
• “I will bleed excessively.”
• “My genitals will tear apart.”
• “The penis will get stuck inside me.”
• “There’s a wall inside—I can’t be penetrated.”
• “The penis will suddenly come out of my mouth.”

Therapy Planning

During treatment, it is essential to discuss the identified sexual dysfunction(s), including:

• The rationale behind the therapy
• Its goals and expected outcomes
• The approximate duration of treatment

The therapist must maintain equal distance from both partners.

They are the therapist of the relationship, not of the man or the woman individually.

Initial Session Guidelines:

• It must be clearly explained that the muscle contractions are involuntary.
• No attempt at penetration will be made.
• All vaginal entry will occur only with the woman’s consent and control.
• The partner must not act without the woman’s knowledge, wish, or permission.
• No conflict or arguments will take place during the process.

Psychoeducation Topics:

• Female anatomy and physiology
• Hymen types and their role in therapy
• Pregnancy and birth control
• The logic of vaginismus and sexual therapy

Key References:

Masters, W.H. Human Sexual Inadequacy. Boston: Little, Brown Medical Division, 1970.

Faure, J.L. & Siredey, A. Traité de Gynécologie Médico-Chirurgicale, 3rd ed. Paris: Octave Doin, 1923.

Walthard, M. Die psychogene Aetiologie und die Psychotherapie des Vaginismus. Munch Med Wochenschr 1909; 1997–2000.

Silverstein, J.L. Origins of Psychogenic Vaginismus. Psychother Psychosom 1989; 52:197–204.

Hawton, K. & Catalan, J. Sex Therapy for Vaginismus: Characteristics of Couples and Treatment Outcome. Sex Mar Ther 1990: 39–48.