Definition of vaginismus which had been done by Sims (1) in 1861 as vaginal spasm hindering sexual intercourse has virtually not been changed up-to-date. Medical knowledge about vaginismus has been formed according to opinions of experienced clinicians focused on this area rather than being evidence-based. Difficulties of studying with human sexuality contributed to higher importance of opinions of experienced clinicians. Although there is limited number of studies, prevalence of vaginismus was reported 1-6% in general population and 5-17% among admissions to sexual dysfunction outpatient clinics (2-10). Vaginismus has been reported to be the most prevalent reason of admissions to women’s sexual dysfunction units by 43–75.9% rates (11-16).
Vaginismus was related to several factors. Examples to these factors are as follows: Characteristics of women with vaginismus and their families (2), sexual and physical abuse (17-19), finding sexuality and sexual organs disgusting and negative attitude towards sexuality (20,21), lack of sexual knowledge and training (22-24), having various disturbing thoughts and images about sexuality (25,26), religious conservatism (26), marital problems (27,28) and miscommunication between couples (29), fear of being pregnant (20), guilt feelings about sexuality (30), negative feelings towards body such as incapacity of vagina to meet requirements of sexual intercourse (20,31), a version of general defensive response to a threatening situation (32), a response or fear reflex to pain, low self-esteem and inadequacy feelings of women towards themselves (33) and intense anxiety (34). Vaginismus was also related to personality characteristics (24). Friedman proposed that defense mechanisms which women having impaired marital relations used to cope with contradictory emotions about sexuality eventually become part of their personality traits (35). Although there is expert consensus, these factors should be confirmed by objective assessments by validated tests.
Another generally accepted expert opinion about vaginismus is that sexual capacity and satisfaction of these women are generally adequate (3). Results of studies to confirm this impression are contradictory. Sexual relationship of women with vaginismus were reported to be satisfactory although without penile penetrance in some studies (36,37). In some other studies, it was proposed that other sexual functional disorders seen in women with vaginismus evolve secondary to chronic vaginal penetrance difficulties (38). Tugrul and Kabakcı (16) reported that women with vaginismus avoid sexual intercourse and their frequency of sexual intercourse and sexual satisfaction is reduced contrary to general agreement. In our study, we aimed to evaluate other domains of sexual function other than vaginal penetrance difficulty, evaluate sexual satisfaction and compare to other healthy volunteers who have not sexual complaints in women with vaginismus who were admitted to sexual dysfunction unit for treatment in order to test the hypothesis that they do not have problems in other areas of sexuality other than vaginal penetrance difficulty.
As part of a wider study examining various aspects of vaginismus, 40 women who were admitted to Sexual Function Disorders Outpatient Unit of Bakırköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery between March 2005 and September 2005 and diagnosed as lifelong vaginismus according to DSM-IV-TR criteria by experienced sexual therapists and 50 women who were admitted to Mother and Child Health and Family Planning Outpatient Clinic, having similar socio-demographic characteristics with the study group but do not describe difficulty and pain related with penile penetrance during sexual intercourse. Participants were informed about the study and their consent was taken. Tests were administered in a single session, after obtaining socio-demographic data and by randomized sequencing. Conditions related to development and maintenance of vaginismus such as socio-demographic characteristics, symptoms, medical and sexual development history, sexual and physical abuse till 15 years old, negative comments about sexuality from family and warnings about importance of protecting hymen, marriage style, confidence to sexual knowledge of her husband and herself, negative perception towards sexual organs, body and sexual identity were examined by a form developed by investigators during assessments.
Psychiatric symptoms, stress experienced or negative stress response were assessed by Symptom Check List developed by Derogatis and validated in Turkish (39,40). Temperament and character characteristics were evaluated by Cloninger’s Temperament and Character Inventory which was developed by Cloninger based on his personality theory and validity and reliability in Turkish was done (41,42).
Sexual function and disorders were examined in 7 domains of sexual function (frequency, communication, satisfaction, avoidance, touching, vaginismus and anorgasmia) by GRISS women’s form which was developed by Rust and Golombok and validity and reliability study was done by Tuğrul et al. (43,44). Scores between 1 and 9 at the scale give information about severity of sexual dysfunction. Choices selected between 0 and 4 are calculated as “0” and scores 5 or over are calculated as “1”. “0” point suggest no sexual dysfunction at the domain examined and “1” point suggest a sexual dysfunction. Also, converted and total scores obtained by sum of crude scores suggest a sexual dysfunction in any domain.
Data were analyzed by SPSS for Windows 10.0 statistics package software. Independent Sample t test and Mann-Whitney U test were used for comparisons. P<0.05 level was accepted as significant.
Mean age was 24.92 in vaginismus group and 25.35 in control group. Mean duration of education was 10.6 years in vaginismus group and 11.2 years in control group. Majority of both groups were housewives. There was a positive family history in 5 patients (12.5%) from vaginismus group but no history of vaginismus was present in control group (p<0.05). No statistically significant difference was found between patient and control groups for urban character of the province grown up, duration of marriage and marriage style.
In vaginismus group, 38.5% of cases told that they quit trying vaginal penetrance in the previous month and vaginal penetrance trial was reported in 25.6% occasionally, 15.4% frequently and 20.5% at all intercourses.
No statistically significant difference was found between vaginismus and control groups for “giving messages about importance of sexuality and hymen by parents during development period”, “physical and sexual abuse under 15 years old” and “negative body and sexual organ perception”. Women in vaginismus group reported statistically significantly inadequate level of sexual knowledge at both themselves and their partners compared to control group (Table 1).
Significant differences were found in vaginismus group compared to control group in particularly depression, obsessive-compulsive symptoms, interpersonal sensitivity, anxiety symptoms and sub-symptom clusters such as additional symptoms (EKB), total positive symptoms (PST) and total general symptoms (GST) (Table 2).
When evaluating temperament and character by Turkish TCI, statistically significant higher scores were found in vaginismus group compared to control group only at emotionality item scores of reward dependence sub-scale.
Statistically significant difference was found in vaginismus group compared to control group at “vaginismus”, “avoidance”, “dissatisfaction”, “infrequency” and “anorgasmia” sub-scales and total score of GIRSS. Difference in non-sensuality and non-communication sub-scales between vaginismus and control groups were not found statistically significant (Table 3).
Age of admission and disease duration at admission were found similar to another studies done in Turkey in vaginismus group (12-16,45). It was reported that number of penetrance trials of patients with vaginismus decreases or vanishes in time and main reason of admission is desire to have child (16). No difference was found between vaginismus and control groups for involuntary marriages which may contribute to development of vaginismus. Presence of a family history of vaginismus was found significantly higher in the vaginismus group than the control group in our study. Reason for this higher prevalence may be due to a learned behavior according to cognitive theories but a genetic predisposition is also possible. This finding should be confirmed by family and genetic studies with wider sample sizes.
It has been reported in the literature that majority of women with vaginismus have negative thoughts about sexuality in general and pre-marital sexual relations in particular and negative messages from family about sexuality is important in development of these thoughts (21,35). Kayır and Sahin (46) reported that women with vaginismus generally have families having conservative sexual thoughts. We did not find statistically significant difference between vaginismus and control groups regarding negative sexual messages from family and warnings about importance of hymen.
It has been proposed that exposure to or witnessing sexual trauma before 15 years old may be a factor for development of vaginismus as well as several other psychiatric disorders (17,18,47,48). There are also studies reporting a negative correlation between vaginismus and sexual trauma (21). No significant difference was found between vaginismus and control groups regarding physical abuse before 15 years old in our sample (2,3,38,49,50). However, this finding should be confirmed by studies having wider and structured interviews due to difficulty to determine sexual abuse and need to make subjective interviews.
Women with vaginismus were reported to have negative emotions such as shame, disgust and unlike about their sexual organs (24,34,50). Tugrul and Kabakcı (16) reported a weak relation between body perception and vaginismus. No significant difference was found between groups regarding sexual, personal and negative perception level according to subjective reporting in our study. Body perception assessment was not done by validated tests in our study so this finding should be confirmed by validated objective tests.
One of the possible causes contributing etiology of vaginismus was inadequate sexual knowledge and training of both women and their partners (23,24,48). In a recent study, no significant difference was found between vaginismus, vulvar vestibulitis and control groups regarding having basic sexual knowledge (50). Vaginismus group reported statistically significantly inadequate sexual knowledge of both themselves and their partners in our study. Women with vaginismus think that they at least have inadequate sexual knowledge and information although not been taken as an objective evidence of sexual knowledge and information. It is generally been thought that increasing sexual information sources and considering this need during therapy process will contribute to therapy process.
Kaplan (33) reported high frequency of anxious symptoms as well as phobic avoidance in women phobically avoiding or disgusting from sexual relationship. In our study, significantly higher scores were found in depression, interpersonal sensitivity and general symptom index sub-scales in symptom check done by SCL-90-R in the vaginismus group compared to control group. In conclusion, an integrated psychiatric evaluation and treatment is required in cases with vaginismus in addition to problem-oriented approach.
Various personality organizations and characteristics were reported to be related with development of vaginismus (14). Friedman (35) reported that most of the cases with vaginismus are infantile women living like brother and sisters with their husbands, dependent on their families and in position of eternal students. Silverstein reported that women with vaginismus find it difficult to express their angers and have personalities requiring excessive approval (24). Kayır et al. (30) reported that women with vaginismus have infantile personality, being frustrated, strong emotional dilemmas, low self-esteem and feelings of incapacity, avoidance from problems, inadequacy to comprehend reality and repression of guilt feelings by superego. In our study, no significant difference was found between vaginismus and control groups except the item assessing emotionality of reward dependence sub-scale of Turkish version of TCI. When evaluated by standardized and objective assessment methods, no characteristic specific to vaginismus was found in our sample and we thought that specific character differences reported in the literature might have been due to assessment methods.
There is a general agreement among researchers and clinicians that sexual conduct repertory of of women with vaginismus is normal unlike other sexual function disorders and they experience satisfactory sexual relations in spite of absence of penile penetrance (3,6,37,51). Other sexual functional disorders which women with vaginismus complain of are usually considered secondary to chronic vaginal penetrance difficulties (38). Tugrul and Kabakcı (16) reported that frequency of sexual intercourse decrease in women with vaginismus and their satisfaction from sexual relation is low. In our study, differences for scores of “vaginismus”, “avoidance”, “satisfaction”, “frequency” and “anorgasmia” sub-scales and total scores of GRISS were found statistically significant. All sexual function domains assessed by GRISS were found statistically significantly impaired in women with vaginismus compared to control group except communication sub-scale. Contrary to general agreement, there is impairment at all areas of sexual function besides penile penetrance in women with vaginismus. This issue should be considered in evaluation and treatment.
By these results, general agreement of vaginismus affects only penile penetrance but does not affect sexuality in general was thought to be incorrect. Vaginismus was determined as a multifactorial disorder which describing with only one characteristic is inadequate. Treating vaginismus only by treating the penetrance difficulty will be inadequate and an integral evaluation is required. Vaginismus negatively affects nearly all domains of sexuality and satisfaction from sexuality. All domains of sexuality and satisfaction should be asked when evaluating women with vaginismus and these should be utilized when formulating vaginismus therapy.
Examining factors accompanying vaginismus based on self-reporting and small sample size were thought to be limitations of the study. In order to establish a causal relationship of these factors, examining in a wider sample by objective standardized assessment tools is required.
1. Sims MJ. On vaginismus. Transactions of the Obstetrics Society of London 1861; 3:356-367.
2. Barnes J. Primary vaginismus (part 1): social and clinical features. (part 2): aetiological features. Ir Med J 1986; 79:59-62.
3. Hawton K, Catalan J. Sex therapy for vaginismus: characteristics of couples and treatment outcome. J Sex Marital Ther 1990; 5:39-48.
4. Kilmann PR, Boland JP, Norton SP, Davidson E, Caid C. Perspectives of sex therapy outcome: a survey of AASECT providers. J Sex Marital Ther 1986; 12:116-138.
5. Lamont JA. Vaginismus. Am J Obstet Gynecol 1978; 131:632-636.
6. Lamont JA. Vaginismus: a reflex response out of control. Contemporary Obstetrics and Gynecology 1994; 3:30-32.
7. Lewis RW, Fugl-Meyer KS, Bosch R, Fugl-Meyer AR, Laumann EO, Lizza E Martin-Morales A. Definitions, Classification, and Eidemiology of Sexual Dysfunction: In Lue TF, Basson R, Rosen R, Giuliano F, Khoury S, Montorsi F (editors). Sexual Medicine: Sexual Pain and Its Management. Paris: Health Publications, 2004, 48.
8. Reissing ED, Binik YM, Khalifé S. Does vaginismus exist? A critical review of the literature. J Nerv Ment Dis 1999; 187:261-274.
9. Schmidt G, Arentewicz G. Symptoms: In Arentewicz G, Schmidt G (editors). The Treatment of Sexual Disorders: Concepts and Techniques of Couple Therapy. New York: Basics Boks Inc., 1982, 123-146.
10. Spector IP, Carey MP. Incidence and prevalence of the sexual dysfunctions: a critical review of the empirical literature. Arch Sex Behav 1990; 19:389-408.
11. Dogan S. Vaginismus and accompanying sexual dysfunctions in a Turkish clinical sample. J Sex Med 2009; 6:184-192.
12. İncesu C, Yetkin N. Assesment of 200 Subjects referred to a sexual dysfunction outpatient clinic in Turkey. Proceedings of the XIIIth. World Congress of Sexology, 1997, 285-290.
13. Kayır A, Geyran P, Tükel MR, Kızıltuğ A. Cinsel sorunlarda başvuru özellikleri ve tedavi seçimi. XXVI. Ulusal Psikiyatri ve Nörolojik Bilimler Kongresi Özet Kitabı, 1990, 451-458 (Article in Turkish).
14. Oktay M, Tombul K. 200 cases of Vaginismus: The patients and their husbands’ psychological evaluation. Yeni Symposium Dergisi 2003; 41:115-119.
15. Sungur M. Evaluation of couples referred to a sexual dysfunction unit and prognostic factors in sexual and marital therapy. J Sex Marital Ther 1994; 9:251-265.
16. Tuğrul C, Kabakçı E. Vaginismus and its correlates. J Sex Marital Ther 1997; 12:23-34.
17. Biswas A, Ratnam SS. Vaginismus and outcome of treatment. Ann Acad Med Singapore 1995; 24:755-758.
18. Jones KD, Lehr ST, Hewell SW. Dyspareunia: Three case reports. J Obstet Gynecol Neonatal Nurs 1997; 26:19-23.
19. Fritz GS, Stoll K, Wagner N. A comparison of males and females who were sexually molested as children. J Sex Marital Ther 1981; 7:54-59.
20. Blazer JA. Married virgins: a study of unconsummated marriage. J Marriage Fam 1964; 26:213-214.
21. Ward E, Ogden E. Experiencing vaginismus-sufferers’ beliefs about causes and effects. J Sex Marital Ther 1994; 9:33-45.
22. Audibert C, Kahn-Nathan J. Le vaginisme. Contracept Fertil Sex 1980; 8:257-263.
23. Ellison C. Psychosomatic factors in the unconsummated marriage. J Psychosom Res 1968; 12:61-65.
24. Silverstein JL. Origins of psychogenic vaginismus. Psychother Psychosom 1989; 52:197-204.
25. Hawton K: Sexual Dysfunction: In Hawton K, Salkovskis PM, Kirk J, Clark M (editors). Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford: Oxford University Press, 1989, 370-405.
26. Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: Little Brown, 1970.
27. Grafeille N. Profil comportemental des partenaires des femmes vaginiques. Psychol Med 1986; 18:411-414.
28. Weiner MF. Wives who refuse their husbands. Psychosomatics 1973; 14:277-282.
29. Bancroft J. Human Sexuality and Its Problems. Edinburgh: Churchill Livingstone, 1980.
30. Kayır A, Salman B, Arı D. 100 vajinismus olgusunun TAT verileri. 7. Ulusal Psikoloji Kongre Kitabı, 1992 (Article in Turkish).
31. Derogatis LR, Melisaratos N. The DSFI: a multidimensional measure of sexual functioning. J Sex Marital Ther 1979; 5:244-281.
32. Van der Velde J, Laan E, Everaerd W. Vaginismus, a component of a general defensive reaction. Int Urogynecol J Pelvic Flor Dysfunct 2001; 12:328-331.
33. Kaplan HS. The New Sex Therapy: Active Treatment of Sexual Dysfunctions. New York: Brunner-Mazel, 1974, 413-429.
34. Kennedy P, Doherty N, Barnes J. Primary vaginismus: a psychometric study of both partners. J Sex Marital Ther 1995; 10:9-22.
35. Friedman IJ. Virgin wives. London: Tavistock, 1962.
36. Beck JG. Vaginismus: In O’Donohue W, Greer JH (editors). Handbook of sexual dysfunctions: assessment and treatment. Boston: Allyn and Bacon Inc., 1993, 381-397.
37. Leiblum SR, Pervin LA, Campbell EG. The Treatment Of Vaginismus: Success and Failure: In Leiblum Sr, Rosen Rc (editors). Principles and Practice Of Sex Therapy. New York: Guilford, 1989, 113-118.
38. Van Lankveld JJ, Brewaeys AM, Ter Kuile MM, Weijenborg PT. Difficulties in the differential diagnosis of vaginismus, dyspareunia and mixed sexual pain disorder. J Psychosom Obstet Gynaecol 1995; 16:201-209.
39. Derogatis LR. SCL-90. Administration, Scoring and Procedures Manual-I for the Revised Version. Baltimore: John Hopkins University School of Medicine, Clinical Psychometrics Research Unit, 1977.
40. Sercan M, Yüksel Ş. Depresif bozukluklarda bedensel belirtilerin baskınlığı. Turk Psikiyatri Derg 1990; 1:2-7 (Article in Turkish).
41. Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD. The Temperament and Character Inventory (TCI): A Guide to Its Development and Use. St. Louis: Washington University Center for Psychobiology of Personality, 1994.
42. Köse S, Sayar K, Kalelioğlu Ü, Aydın N, Ak İ, Kırpınar İ, Reeves RA, Przybeck TR, Cloninger CR. Mizaç ve karakter envanteri (Türkçe TCI): Geçerlilik, güvenilirliği ve faktör yapısı. Klinik Psikofarmakoloji Bülteni 2004; 14:107-131 (Article in Turkish).
43. Rust J, Golombok S. The Golombok-Rust inventory of sexual satisfaction (GRISS). Br J Clin Psychol 1985; 24:63-64.
44. Tuğrul C, Öztan N, Kabakçı E. Golombok Rust Cinsel Doyum Ölçeği’nin Standardizasyon Çalışması. Turk Psikiyatri Derg 1993; 4:83-88 (Article in Turkish).
45. Yargıç İ, Kayır A. Vajinismus: Bir grup psikoterapisi sunumu. Düşünen Adam: Psikiyatri ve Nörolojik Bilimler Dergisi 1996; 9:31-34 (Article in Turkish).
46. Kayır A, Şahin D. Kadın cinselliği ve cinsel işlev bozukluğu. Ege Psikiyatri Sürekli Yayınları 1998; 3:19-58 (Article in Turkish)..
47. Amerikan Psikiyatri Birliği. Psikiyatride Hastalıkların Tanımlanması Mental Bozuklukların Tanısal Ve Sayımsal El Kitabı. 4. Baskı, yeniden gözden geçirilmiş tam metin (DSM-IV-TR). Köroğlu E (Çeviri Ed.), Ankara: Hekimler Yayın Birliği, 2007 (Book chapter in Turkish).
48. Malleson J. Vaginismus: Its management and psychogenesis. Br Med J 1942; 2:213-216.
49. O’Sullivan K. Observations on vaginismus in Irish women. Arch Gen Psychiatry 1979; 36:824-826.
50. Reissing ED, Binik YM, Khalifé S, Cohen D, Amsel R. Etiological correlates of vaginismus: Sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther 2003; 29:47-59.
51. Duddle M. Etiological factors in the unconsummated marriage. J Psychosom Res 1977; 21:157-160.