Critical literature Review on Vaginismus
COPYRIGHT: University of Melbourne - Australia - Faculty of Medicine - Paper submitted by the webmaster for an exam in a Postgraduate Course in Women's Health - 2005/2006
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 in 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).
This definition has not been challenged for more than a century despite the fact that the diagnostic criteria of spasm and pain have never been empirically evaluated until recently (Reissing et al. 2004, 2003, 1999; Yitzchak et al. 2002: Van der Velde and Everaerd 2001). 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 the interference with intercourse, which led to largely ignore sufferers’ problems in non-sexual situations such as insertion of tampons, specula, medications or objects. 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. In the light of these and other identified limitations, such as the lack of epidemiological estimates on prevalence or aetiology, vaginismus has been described as “an interesting illustration of scientific neglect” (Beck 1993 p. 381 in Reissing 1999) and only recently a number of academics have challenged some aspects of vaginismus and begun more rigorous scientific research on it (Reissing et al. 1999, 2004 ; Yitzchak et al. 2002; Van der Velde and Everaerd 2001, 1999).
Although such quantitative clinical studies are needed and praiseworthy, it is perplexing to notice how the voices of the actual sufferers have been rarely taken into consideration and their concerns ignored. In fact, apart from isolated case-studies from sex/psychotherapy reports (see for instance Kaplan and Leiblum in Leiblum1995) and few researches with small samples, focused on establishing aetiology ( Ward and Odgen 1994) or sufferers’ family patterns (Silverstein 1989), no other qualitative methodological study has widely addressed vaginismic women’s experience of this condition, the impact of its visibility (or invisibility) in society and their barriers to receive help. Secondary evidence shows that openly using the term vaginismus and disclosing one’s symptoms and origins (pelvic muscle tension, spasms, phobia, pain at intercourse or at insertion of tampon, speculum; sexual abuse etc.) may prove extremely difficult and distressing, therefore preventing many women from accessing available information and treatments (Valins 1992; Kessler 1988; Leiblum 1995).
As the term vaginismus is still not part of people’s everyday vocabulary and seems absent from the media and from most material published on sexuality, some sufferers feel that it is “an invisible handicap” (Valins 1992, p. 54); this silence may also contribute to the false impression that this is a rare condition (Valins 1992; Leiblum 1989). Although a prevalence rate has not been assessed scientifically, estimates of vaginismus range from 5% to 47% of people presenting for sex therapy or complaining of sexual problems, with significant differences across cultures (see Reissing et al. 1999; Nusbaum 2000; Oktay 2003). Despite the lack of consensus on prevalence, what is agreed upon is that large numbers of women possibly do not ever come to clinical attention, yet reasons for this low presence have not been explored. Unlike other sexual dysfunctions or genital problems, vaginismus prevents both intercourse and the ability to conceive, it seems likely that society’s expectations of women’s sexuality may particularly impact on these sufferers.
For instance, the term “unconsummated marriage”, possibly used to describe cases of vaginismus, suggests society’s expectation that a ‘normal’ wife will be willing or able to engage in sexual penetrative intercourse; this unchallenged assumption, in many countries endorsed by law, may lead to extreme pressures to “perform”, interpersonal problems, divorce, sense of abnormality, humiliation, pain and even marital rape for some vaginismic women or ‘virgin brides’ (Renshaw 1995; Bramley 1983; Kaplan 1995; Zargooshi 2000; Valins 1992). Evidence therefore suggests that society attitudes and knowledge of this condition may have a major impact on the mental and physical health of sufferers involved in heterosexual relationships/marriages, yet no research has yet established this impact nor the knowledge of vaginismus and its symptoms and attitudes among the public. Tampon use and gynaecological exams are two other aspects which have not been researched qualitatively in their relation to vaginismus.
Although a recent study has shown that 72% of vaginimsmic patients had never had a gynaecological examination and up to 83% had never experienced inserting a tampon (Reissing 2003), no study has yet assessed vaginismic women’s experiences with tampon use and gynaecological exams or the relation between inability to insert tampons and specula and ability to have sexual intercourse or be diagnosed. Furthermore, although there is evidence that many vaginismic women find those tests painful or extremely distressing and may often avoid or delay them (Ashurst 1989; Valins 1992, in worldwide studies assessing women’s obstacles to pap smear tests, even when pain is recognized as one of the barriers, the term vaginismus rarely, if ever, is mentioned (Matin 2004; Steven et al. 2004; Eaker 2001; Glasgow 2000; Holroyd et al. 2001; Hoyo (2005); Smith et al. 2003).
Considering that vaginismus can stem from sexual or physical abuse, the risk of potential retraumatization is an issue during intimate examinations of these patients (Silverstein 1989; Maltz 2001; Kaplan 1995: Coldicott et al. 2003). However, no study has determined gynaecologists’ practices when examining vaginismic patients nor has it been determined what practices could make those exams less difficult, painful, traumatic or simply easier to access for sufferers. For example, a recent study researched the feasibility of offering patients the chance to self-insert the speculum (Wright et al. 2005); although not aimed at vaginismic women, it seems evident that the development of cost-effective policies or practices, such as this self-insertion method, more qualitative studies aimed at removing barriers to treatment and to diagnoses together with an increased public awareness could reduce suffering for many vaginismic women and improve access to help for the ones still suffering in silence.
Please click on REFERENCES to see all references for studies mentioned in this section.
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