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Sexual Function and Satisfaction of Women with Vaginismus
1Psychiatrist, Bakırköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul - Turkey
2Prof. Dr, Marmara University Medical School, Department of Psychiatry, Istanbul - Turkey
Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2012; 4(25): 305-311 DOI: 10.5350/DAJPN2012250402
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Abstract

Objective: Vaginismus is one of the sexual dysfunctions that affects couples’ sexual life. There is a common opinion that women with vaginismus have a satisfied sexual life even there is no vaginal entry. But contrary to this opinion, several studies reported that sexual function and satisfaction of women with vaginismus were impaired. In our study, our purpose was to evaluate sexual function and satisfaction in women with vaginismus and to compare the findings with that of healty women’s.

Method: Forty women with vaginismus who referred to Sexual Dysfunction Therapy Outpatient Unit and fifty healthy voluntary women who had no sexual complaint participated in the study. Questionnaire regarding demographic characteristics, Symptom Check List (SCL-90 R), Cloninger’s Temperament and Character Inventory (TCI), Golombok-Rust Inventory of Sexual Satisfaction (GRISS) were evaluated.

Results: It was found that women with vaginismus avoided sexual intercourse, were more emotional and needed approval more frequently. Also, vaginismus history was more frequent in their family and among close relatives. They found inadequate their and their partners’ level of sexual knowledge. They had typical fears and they had problems in all other domains of sexual function as well as the vaginal entry. There were statistically significant differences in GRISS vaginismus, avoidance, satisfaction, frequency, lack of orgasm subscales and total GRISS score between vaginismus and control groups.

Conclusions: Unlike general opinion, women with vaginismus have problems in many domains of sexual function. We think that it would be inadequate if vaginismus is considered only a problem of vaginal entry, that all domains of sexual function, avoidance and enviromental factors should be evaluated together.

INTRODUCTION

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. 

METHODS 

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.

RESULTS

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).

DISCUSSION

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.



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Vajinusmuslu kadınlarda cinsel işlev ve doyum
1Psikiyatrist, Bakırköy Psikiyatri, Nöroloji ve Nöroşirurji Araştırma ve Uygulama Hastanesi, İstanbul - Türkiye
2Prof.Dr., Marmara Üniversitesi Tıp Fakültesi, Psikiyatri Anabilim Dalı, İstanbul - Türkiye
Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2012; 4(25): 305-311 DOI: 10.5350/DAJPN2012250402

Amaç: Vajinismus çiftlerin cinsel hayatlarını etkileyen bir cinsel bozukluktur. Vajinismuslu kadınların vajinal giriş olmaksızın da doyum aldıkları bir cinsel hayatları olduğuna dair görüşler bulunmaktadır. Ancak bu görüşlerin tersine, yapılan çalışmalarda vajinimuslu kadınların cinsel yaşamları ve doyumlarının olumsuz etkilendiği bildirilmiştir. Çalışmamızda vajinismuslu kadınların cinsel işlev ve doyum düzeyleri değerlendirilmiş ve cinsel yakınması olmayan kadınlardan elde edilen verilerle karşılaştırılmıştır.

Yöntem: Çalışmaya, cinsel işlev bozuklukları birimine başvuran 40 vajinismuslu kadın ve cinsel sorun tanımlamayan 50 sağlıklı kadın alınmıştır. Çalışmada, sıralaması randomize edilerek, tek oturumda, sosyodemografik değerlendirme formu, Belirti Tarama Listesi (SCL–90-R), Cloninger’in Mizaç ve Karakter Envanteri (Türkçe TCI) ve Golombok-Rust Cinsel Doyum Ölçeği (GRCDÖ) uygulandı.

Bulgular: Vajinismuslu kadınların cinsel birleşmeden kaçındıkları, duygusal oldukları ve onaylanma ihtiyacı duydukları belirlendi. Vajinismuslu kadınların aileleri ve yakın akrabalarında vijinismus öyküsünü daha sık olduğu görüldü. Vajinismus grubundaki kadınlar kontrol grubuna göre, hem kendilerinin hem de partnerlerinin cinsel bilgilerini anlamlı derecede yetersiz bulduklarını bildirdiler. Vajinismus grubunda GRCDÖ alt ölçeklerinden vajinismus, kaçınma, doyum, sıklık, anorgazmi alanlarında ve GRCDÖ total puanında, kontrol grubuna göre istatistiksel açıdan anlamlı farklılık saptandı.

Sonuç: Yaygın kanının aksine, vajinismuslu kadınlar cinsel işlevlerin birçok alanında sorun yaşamaktadırlar. Vajinismusun sadece vajinal giriş sorunu olarak değerlendirilmesinin eksik olabileceği, cinsel işlevlerin tüm alanlarının, kaçınma ve çevresel faktörlerle birlikte ele alınması gerektiği düşünülmüştür.