by Brigid McCormick, The Chicago School of Professional Psychology
Vaginismus can be defined as “a conditioned response that results from associating sexual activity with pain and fear. …Women may experience not only extreme physical pain on attempted penetration but also severe psychological pain. It consists of a phobia of penetration of the vagina and involuntary spasm of the muscles surrounding the lower third of the vagina (Butcher, 1999, p. 111).” It could present in all situations, or be situational (e.g., with a certain partner, only with partners but not during a pelvic exam). According to WebMD, “Women have described the pain as feeling too small for a man’s penis. The pain has also been described as a tearing sensation or a feeling like the man is ‘hitting a wall’” (“Vaginismus Symptoms,” 2013). Vaginismus also can vary in severity among women, with some women being unable to insert anything at all to completion of vaginal intercourse, but with pain and discomfort.
Causes vary among individuals and are correlations at best. History of sexual abuse or trauma, fear or anxiety in anticipation of pain, fear of sex, pregnancy, or sexually transmitted infections, or physical causes such as medical conditions or childbirth could all be causes of the dysfunction. To define vaginismus behaviorally, contacting pain (an unconditioned aversive) leads to avoidance of the pain, and then anxiety and fear surrounding it in the future. A woman then avoids the sexual activity, which could lead to a total avoidance of sexual activity (Butcher, 1999). Also, because her behavior has likely never contacted reinforcement in the form of arousal or orgasm from intercourse, there is no establishing operation in place for that specific sexual behavior. While other sexual behaviors may still produce that primary reinforcer, as there is an unconditioned motivating operation in place for sexual arousal, the value of intercourse is likely decreased.
Brotto, Seal, & Rellini (2012) cite a national sample that suggests that 43% of American women experience some form of sexual difficulty in the form of arousal, desire, pleasure, or pain. However, research is fairly limited in identifying causes specific to vaginismus and alternative treatments to the commonly accepted cognitive behavior therapy (CBT) and physical therapy approaches. LoFrisco (2011) reviewed the current research in the field of CBT as a treatment for female sexual dysfunction, vaginismus in particular, and found mixed results across all articles supporting CBT as an effective treatment. The reasons given for this finding include a lack of follow-up data to assess long-term effectiveness and all of the studies reviewed used CBT in conjunction with other treatments. Many approaches incorporate some combination of sex education, pelvic floor exercises, oral analgesics or muscle relaxants, dilation training first without and then with a partner, sensate focus techniques, and CBT. It is difficult to verify which part of the treatment has the greatest effect. The author also notes, “Only three (Backman et al., 2008; Kabakçi & Batur, 2003; Masheb et al., 2009) out of eight studies included individual treatment” (p. 578), which is where the field could benefit from a behavioral, individualistic, data-driven approach to treatment.
The leading website on the treatment of female painful sex and penetration problems, http://www.vaginismus.com has a treatment toolkit which comprises of a book, workbook, DVD, and set of five plastic dilators. Their treatment package includes modules and exercises on: understanding vaginismus, sexual history review that guides treatment (i.e. emotion-based modules for those with a history of sexual assault), education on anatomy, pelvic floor exercises alone and with small objects (cotton swab or finger), graduated vaginal dilators to be used alone, sensate focus training, practice pelvic floor and dilation techniques with a partner, transition to intercourse modules, and finally pain-free intercourse. Use of this graduated procedure that fades into intercourse aligns with a behavioral model of treatment (“Vaginismus Treatment,” 2013).
Just as LoFrisco (2011) noted, there are not many individualized treatment programs for participants recorded in the literature. Similarly, nearly all data collected, which were most often collected at the beginning and end of treatment, were based on Likert scale measures. Weiss (2001) did ask the participant to keep the dilator in for 15-minutes, but the participant was not asked to record the duration; she only reported it anecdotally at each meeting.
Many of the treatments used for vaginismus are behavioral, but the basic principle of ABA, reinforcement, is never mentioned in any of the literature. For women who have always had vaginismus, intercourse has never contacted reinforcement. In fact, it has contacted punishment, which likely decreased attempts at intercourse, and even withdrawal in relationships. It is almost that women have to complete the treatment because they are told that maybe one day they may be successful, and may contact reinforcement. So women are expected to persevere based on a rule. Providing reinforcement for completing dilation training, for example, should be a necessary part of treatment. And, by measuring progress more precisely, the idea of “one day” being successful can be monitored and predicted, likely providing reinforcement in itself.
Brotto, L. A., Seal, B. N., & Rellini, A. (2012). Pilot study of a brief cognitive behavioral versus mindfulness-based intervention for women with sexual distress and a history of childhood sexual abuse. Journal of Sex and Marital Therapy, 38, 1-27.
Butcher, J. (1999). ABC of sexual health female sexual problems II: Sexual pain and sexual fears. BMJ, 318, 110-112.
LoFrisco, B. M. (2011). Female sexual pain disorders and cognitive behavioral therapy. Journal of Sex Research, 48(6), 573-579.
Nazario, B. (2012). Vaginismus: Causes, symptoms, and treatment. WebMD. Retrieved from http://women.webmd.com/guide/vaginismus-causes-symptoms-treatments
Weiss, J. C. (2001). Treating vaginismus: Patient without partner. Journal of Sex Education and Therapy, 26(1), 28-33.
Vaginismus.com. (2013). Vaginismus symptoms. Retrieved from http://www.vaginismus.com/vaginismus-symptoms
Vaginismus.com. (2013). Vaginismus treatment. Retrieved from http://www.vaginismus.com/vaginismus-treatment
This piece was originally published as a part of the Summer 2013 STEP SIG Newsletter.