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Limitations of official diagnostic criteria
We find that vaginismus is often misdiagnosed by gynaecologists and General Practitioners. Although things seem to be improving (maybe thanks to the work each one of us is doing too, educating each other AND our doctors!), way too many women are not told what they have and are given counterproductive advice.
One of the reasons this may still happen is because of the limitations in the definition and criteria used in the official DMS IV (The Diagnostic and Statistical Manual of Mental Disorders). Some of these limitations have finally been addressed and challenged by an international multi-disciplinary group (Basson R, Leiblum S, Brotto L et al. 2003. Read more below), but the fact that vaginismus is described and categorized as a mental illness tells us more about the mysoginy of the people who included it there, than about our sanity..
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) primary vaginismus is
"a female sexual dysfunction, specifically a genital pain disorder, consisting of lifelong involuntary spasms of the vaginal muscles, not caused by a general medical condition, which interfere with intercourse causing distress and interpersonal difficulty"
(APA 2000).These are the official, disputed diagnostic criteria for Vaginismus:
Women with this sexual dysfunction disorder experience otherwise unexplained recurrent or persistent involuntary contraction of the perineal muscles around the outer third of the vagina associated with penetration with any object
A. Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.
B. The disturbance causes marked distress or interpersonal difficulty.
C. The disturbance is not better accounted for by another Axis I disorder (e.g., Somatization Disorder) and is not due exclusively to the direct physiological effects of a general medical condition.
This definition has not been challenged for more than a century despite the fact that the diagnostic criteria of spasm has never been empirically evaluated until recently, and when they have, the presence of pain and fear/phobia has been found to be much more relevant than the actual presence of spasms.
See also:
• Van der Velde J. And Everaerd W. (2001) The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus Behaviour Research and Therapy 39: 395-408
• Van der Velde J. et al. (2001) Vaginismus, a component of a general defense mechanism: An investigation of pelvic floor muscle activity during exposure to emotion-inducing film excerpts in women with or without vaginismus. Urogynecology Journal and Pelvic Floor Dysfunction 12: 328-331
In addition, classifying vaginismus as a sexual dysfunction implies a disruption in the phases of the sexual act (desire, arousal, orgasm etc.), again this is not validated by scientific data and does not take into account how this disruption may be a natural result of experiencing or anticipating pain, the effect of sexual abuse or an acceptable defence mechanism rather than a stigmatizing sexual disorder (Kleinplatz 2005; Yitzchak et al. 2002; Shaw 1994; Silverstein 1989; Ohkawa 2001; Butcher 1999; Valins 1992; Van der Velde et al. 2001).
Finally, the focus of the definition is on its interference with intercourse, which led to largely ignoring sufferers’ problems in non-sexual situations such as insertion of tampons, specula, medications and dilators.
This focus has also led research to measure the success of treatments by the occurrence of pain free heterosexual penetration, which besides being a questionable outcome, has pathologised those women who may wish not to engage in penetrative sex (Ussher 1993; Tiefer 1999) but who may nevertheless want to solve their experience of pain at inserting a tampon, speculum etc.
Recently, an international multi-disciplinary group has finally reviewed the evidence for traditional assumptions about vaginismus. (Basson R, Leiblum S, Brotto L et al. 2003). The group concluded that:
"The anticipation and fear of pain characteristic of vaginismus has to be noted while the assumed muscular spasm is omitted given the lack of evidence."
Finally, a recommendation was made that all diagnoses be accompanied by descriptors relating to associated contextual factors.
See
• Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision (Basson R, Leiblum S, Brotto L et al. (2003) in J Psychosom Obstet Gynaecol. 24(4):221-9.
Views partly extracted from the Literature Review submitted by the webmaster at the University of Melbourne for her postgraduate degree in Women's Health, 2006.
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