A number of assumptions about the treatment of vaginismus occur in the clinical literature. These must be challenged, especially when working with long-standing, treatment-refractory cases.

Assumption l: Husbands Are Only Peripherally Important in Treatment

Both women and their partners are quick to identify vaginismus as a woman’s problem. Even some therapists believe that because the problem preceded marriage and would probably occur with any partner, the female patient must be the exclusive focus of treatment.

In fact, partners are critically important in determining treatment outcome. If the partner sabotages treatment by placing continual pressure on the woman to attempt coitus before she is ready, the woman often reacts in a passive-aggressive manner, avoiding the assigned sexual exercises. Some partners avoid sexual encounters at times when their participation is crucial if the treatment is to move forward. They may go to sleep early, start quarrels, or express sexual disinterest at times when their participation is needed. It is not uncommon for a husband to become uncooperative when the wife has made significant progress and is close to attempting penile penetration. At such times, the partner may feel insecure about his ability to either achieve or maintain an erection or may become so fearful about inflicting pain that he avoids sex altogether. It is essential that the therapist be empathic to the frustration the male partner has experienced in living with a vaginismic woman and understanding of the anxiety he may feel once progress has been made. Not including the male partner throughout treatment can compromise the success of the therapy.

Assumption 2: Treatment Is Straightforward and Usually Successful

This view was expressed more than 100 years ago by J. Marion Sims, an American gynecologist in an address to the Obstetrical Society of London in l862:

From personal observation I can confidently assert that I know of no disease capable of producing so much unhappiness to both parties of the marriage contract and I am happy to state that I know of no serious trouble that can be cured so easily, so safely, and so certainly. (Quoted in Drenth 1988, p. 126)

Sims recommended complete excision of the hymen and the use of a glass bougie to be worn for 2 hours twice daily for a few weeks.

While it is true that vaginismus is often resolved relatively rapidly with well-motivated patients, it is not true that hymenectomy is usually helpful or that medical intervention eliminates the problem, since psychological factors are always implicated and must be confronted. Moreover, although most therapists attain some measure of success with relaxation training and exercises involving vaginal insertion and dilation, treatment can be quite protracted, with rapid progress followed by lengthy periods of sexual avoidance.

Assumption 3: Once Successful Penetration Is Achieved, the Problem Is Resolved

Although women and their partners are generally elated when they can successfully accomplish penile penetration and ejaculation, a single occasion (or even several occasions) of successful intercourse does not necessarily indicate that treatment is over. In fact, for some couples, consummating the marriage only heralds the revelation of other fears and conflicts. Concerns about pregnancy, conflicts about parenthood, and fears of vaginal delivery may now be expressed. Furthermore, some women fear that overcoming the vaginismus represents a form of sexual capitulation, since they now have no “legitimate” excuse for avoiding coitus. They must “submit” to their husband’s sexual demands and wishes.

Case Example Mrs. G was a 28-year-old Iranian woman who had been married for 5 years to a successful Iranian engineer. Her vaginismic difficulties began at age l8 when she was unable to tolerate a gynecological examination. Following three unsuccessful attempts, she finally had an examination under anesthesia. She justified her avoidance of premarital intercourse on the basis of her religious beliefs. Following marriage, all attempts at intercourse were unsuccessful, and her husband (and his mother) placed increasingly insistent demands on her to “overcome the problem” so that she could start to have children. Mr. G was quite authoritarian, and Mrs. G behaved in a passive-aggressive fashion with him. She reported ambivalent feelings about overcoming the vaginismic problem, since success would signify a loss of independence and a sense that she would be constantly “invaded.” Although ultimately successful in accomplishing penetration and ejaculation, Mrs. G continued to avoid sexual encounters.