Introduction
Vaginismus is defined in the DSM IV-TR as an “involuntary contraction of the musculature of the outer third of the vagina interfering with intercourse, causing distress and interpersonal difficulty” [1]. This definition has received considerable criticism recently and there is no empirical basis for the vaginal spasm taxon [2]. An international consensus committee has suggested revised criteria, recommending that vaginismus be defined as “persistent difficulties to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance and anticipation/feary’experience of pain. Structural or other physical abnormalities must be ruled out/addressed” [3]. While more in line with the clinical presentation and available research on vaginismus, these criteria still require systematic empirical support.
Definitional problems make it difficult to reliably estimate the prevalence of vaginismus [4]. and no epidemio-logically soundincidence orprevalence estimates are available [5]. Clinics and other sources [6–9] suggest referral rates ranging from 5–17%.
Vaginismus: Symptom of Dyspareunia or Diagnostic Entity?
Some researchers argue that vaginismus and dyspareunia may be impossible to differentiate because vaginal penetration problems are not specific to vaginismus but frequently present as a symptom of dyspareunia [10–12]. In particular, provoked vestibulodynia (PVD) has been consistently implicated as a cause of vaginismus or complicating treatment [13–15] and, conversely, pelvic floor pathology interfering with vaginal penetration has been reported as a key symptom in virtually all women with vulvo-vaginal pain [10, 16, 17]. It is not uncommon to receive clinical referrals for a woman with vulvar pain and “some” vaginismus or “partial” vaginismus [12]. Prevalence rates may be much higher when the term vaginismus is used clinically to indicate pelvic floor tension.
Clinical Use of the Term Vaginismus
Despite a recent increase in research attention, consensus on the definition of vaginismus and an empirical framework for research and clinical practice are lacking. The body of literature has recently been called “virginal” [18] and is considered difficult to interpret and to generalize [4, 19]. Therefore, the current state of our knowledge of vaginismus warrants the inclusion of an explicit description of the definition [14]. The following criteria may be useful for summarizing the key symptoms. (i) Vaginal penetration is impossible in all/the majority of attempts because of vaginal and/or pelvic muscle hypertonicity and/or muscle guarding at the entrance to the vagina.
(ii) Vaginal penetration is avoided for all/the majority of opportunities because of recurrent or chronic vulvar, vaginal, or pelvic pain.
(iii) Vaginal penetration is avoided for all/the majority of opportunities because of associated, significant anxiety and/or panic, and may be accompanied by feelings of disgust, dread, and/or fear.
In early writings, vaginismus was conceptualized as a defense mechanism toward unresolved psychosexual conflicts in early childhood [20]. Over the past three decades, a general consensus of vaginismus as a psychophysiological problem has emerged. Various causal hypotheses exist, but none has received systematic research attention or consistent empirical support [18, 19].
Pain and fear of pain figure prominently in past and recent reports on etiology, but it has not been established whether pain is cause or consequence of vaginismus [2, 17]. Numerous organic causes for pain have been reported in the literature, for example, hymeneal abnormalities, vaginal atrophy, PVD, endometriosis, infections, vaginal lesions, and sexually transmitted diseases [21–25]. Few of these problems have received research attention. However, PVD has consistently been reported as a cause for vaginal penetration problems for many women [11, 13, 15].
A lack of or inaccurate/incomplete sex education and education biased by conservative religious beliefs have been implicated in the development of negative expectations, fears, and sexual guilt related to sexuality, vaginal intercourse, and reproductive anatomy [26]. Clinical and research reports indicate that women with vaginismus hold negative views about sexuality, in particular premarital sexual activity [22]. report being brought up to believe that sex was wrong [27]. and hold irrational beliefs that penetration will cause pain, injury and bleeding, and fear their vagina is too small [28].
Anxiety is increasingly considered a key factor in vaginismus [4, 17]. Negative, inaccurate, or false beliefs can result in fear and anxiety and behavioral avoidance. Display of anxiety and fear during pelvic exams and avoidance of intercourse have been noted as the only differentiating symptoms in women with vaginismus and PVD [2, 11]. It has been suggested that vaginismus may be an adaptive anticopulation defense that is “overactive” in some women who otherwise desire intercourse [29]. The development of the fear and avoidance associated with vaginismus may be similar to specific phobias that occur without negative learning events but hold evolutionary relevance [30]. In addition, women with lifelong vaginismus also report an elevated number of additional fears and phobias [26, 31, 32] and indirect evidence for the role of anxiety in vaginismus is also highlighted by the fact that nearly all published accounts on the treatment of vaginismus include the use of anxiety reduction measures [7, 6, 31, 33, 34]. and anx-iolytic medication has been reported to facilitate therapy [35–37].
Sexual abuse (SA) has often been cited as a cause for vaginismus. However, in most studies with control groups, no significant differences in prevalence in SA were noted [6, 8, 22]. Only one controlled study found women with vaginismus reported a significantly higher rate of childhood SA ranging from exposure to sexual touching [38]. Although most women with SA histories do not develop vaginismus, such experiences should be assessed.
Male partner or relationship factors have historically been noted as causing and/or exacerbating vaginismus; however, little research has been conducted on this topic [39]. It has been suggested that male partners may be chosen for their passive and nonthreatening personality traits or may suffer from their own sexual dysfunction. The couple thus colludes in the avoidance of intercourse and/or the maintenance of emotional balance between partners [14]. No research exists at this point supporting Masters and Johnson’s [33] original report of male sexual dysfunction as the most frequent etiological factor. However, erectile dysfunction and premature ejaculation appear to be transient problems for some men following successful treatment of their female partners for vaginismus [6,8,9].
The current state of the literature does not point to a definite etiology for vaginismus. However, the use of the following heuristic highlighting cognitive, behavioral, and physiological factors when assessing and treating vaginal penetration problems may be helpful (see Figure 35.1). Following this model, an experience with pain, or a negative experience with or negative expectations about vaginal penetration, is associated with catastrophizing thinking. These thoughts, in turn, result in specific fears about penetration and pain associated with intercourse [40].