Psychoanalytic Explanations and Treatment Approaches
Historically, psychoanalytic explanations of vaginismus conceived of the disorder as a rejection of the female role, a resistance against male sexual prerogative, a defense of the woman against real or fantasized incestual threats from her father, and a warding off of her own castration images (Fenichel 1945). Musaph (1977), a Dutch physician, suggested that the vaginismic woman unconsciously says to herself, “Now this big, dangerous instrument is going to penetrate me, there will be bleeding wounds; I will suffer unbearable pain and my revenge will be terrible” (quoted in Drenth 1988, p. 127).

Currently, traditional psychoanalytic therapists advocate an exploration of the unconscious fears and ambivalencies underlying the problem. Other psychoanalytically oriented therapists believe that a more active behavioral approach is needed in order to overcome the high anxiety accompanying the symptom. Kaplan (1974), for example, rejected the psychoanalytic view of vaginismus as a conversion symptom expressive of the woman’s hostility toward men and her unconscious wish to castrate them in revenge for her own castration. Instead, she advocated a multicausal view of vaginismus as a conditioned response to any adverse stimulus associated with intercourse or vaginal entry. The goal of treatment is the extinction of the conditioned vaginal response. The essential element in treatment is to repeatedly expose the woman, both in fantasy and in reality, to the feared situation while keeping anxiety at a minimum and providing reassurance and support. From a psychodynamic perspective, it is also important to understand the conflicts the woman may have about becoming a “genital” woman. Since many woman with primary vaginismus tend to appear somewhat immature, insecure, and dependent (i.e., “younger than their years”), an investigation of patients’ beliefs about sexuality, femininity, and mature womanhood is important.

Case Example Mrs. F had been married for 11 years prior to seeking treatment for vaginismus at age 34. She had avoided dealing with her sexual fears by literally drowning them in alcohol. It was only when her alcohol dependence could no longer be ignored and her husband threatened to leave the marriage that she consented to treatment. Following an inpatient stay at a rehabilitation center, she agreed to sex therapy.

Mrs. F presented as a youthful-looking woman with a long ponytail tied with a bow and “Mary Jane” shoes. Despite her “coed” appearance, she was articulate and thoughtful, although overly dependent on the therapist’s approval. She often looked to the therapist for confirmation of her formulations and needed much encouragement and support throughout treatment.

Mrs. F’s early history included an abusive father who regularly beat her brother and herself and a passive, insecure mother who failed to protect her and her brother from their father’s violence. She was raised as a religious Catholic and was warned that she would be disowned and disgraced if she were to become pregnant premaritally. Moreover, Mrs. F’ was admonished that if she thought menstruation was uncomfortable, she would be unable to deal with the excruciating pain of childbirth. These and similar messages were reiterated throughout her adolescence, and Mrs. F avoided even attempting tampon insertion.

At college, Mrs. F initially became involved with a physically abusive boyfriend but was rescued from this relationship by a gentle, protective classmate. She subsequently moved in with him and they dealt with their mutual sexual anxiety by heavy drinking. Attempts at intercourse were disastrous and soon were abandoned altogether in favor of oral and manual stimulation, which was mutually gratifying.

Mrs. F’s penetration phobia did not disappear after marriage, and although the couple acknowledged that they should “do something about the problem,” they avoided vaginal penetration. It was only after years of sexual avoidance and her own increasing reliance on alcohol that Mrs. F reluctantly entered treatment.

Cognitive-Behavioral Explanations and Treatment Approaches
Behavioral therapists generally view vaginismus as a conditioned fear reaction or a learned phobia. Reinforcing the conditioned fear response is the cognitive belief that penetration can be accomplished only with great difficulty, pain, and discomfort. In order to overcome the avoidance of vaginal penetration, it is necessary to challenge both the cognitive and phobic elements.

In treating vaginismus from a cognitive-behavioral perspective, the inappropriate cognitions about the size of the vagina, the size of the penis, and the likelihood of pain must be challenged. An educational approach is helpful in which the woman is encouraged to read and learn more about genital anatomy and sexuality generally, as well as about the potential size and elasticity of the vagina.

In order to reduce the conditioned fear reaction to vaginal penetration, the woman is taught relaxation exercises and is encouraged, following total body relaxation, to begin exploring her vulva in a gentle and deliberate fashion. Once she is comfortable with both visual and manual exploration of her external genitals, she is encouraged to begin exploration of her vagina. This is accomplished either through the use of finger penetration or via graduated sizes of dilators. To promote ease of insertion, the use of external lubricants, such as Astroglide or K-Y jelly, is recommended. Once the smallest finger or dilator can be inserted without discomfort and tolerated internally, insertion of a larger finger or dilator occurs. The woman is encouraged to relax for several minutes with the finger or dilator inside her vagina and even to practice moving with the inserted object. Only after one or two fingers or a dilator is easily tolerated does the woman move on to the next size, until finally, a dilator the size of a penis is inserted. When the woman is successful in these efforts, she is encouraged to show her partner how she goes about vaginal insertion and to invite him to insert his smallest fingers and then fingers or dilators of increasing size under her verbal direction. The woman is reassured that she is in total control of the situation and that penetration attempts will stop promptly whenever she wishes. Such reassurance promotes anxiety reduction and places the woman in charge of the sexual situation.

Other Explanations and Treatment Issues
Drenth (1988), a Dutch sex therapist, suggested that there are women who dislike or fear genital intercourse but who are interested in having a biological child. With these women, traditional treatment with dilators or systematic desensitization is likely to end in failure. Drenth proposed artificial insemination with the husband’s semen, performed at home by the couple themselves, as a possible treatment alternative, although he acknowledged that a successful outcome was not always achievable with this intervention. Moreover, it should be noted that following successful delivery, the sexual difficulties typically remain.

A Reconceptualization of Vaginismus
Binik and colleagues (2000) recently argued that vaginismus is not a useful diagnosis at all and that the condition may be better reconceptualized as a genital pain disorder. They note that despite the existence of many etiological theories, none have been supported by controlled empirical studies. Basson (1996) theorized that vaginismic women may suffer from chronic hypertonic muscle tension rather than a muscle spasm - the degree of interference with intercourse may vary from slight to total. It is often not certain whether the pain the woman reports is due entirely to the difficulty with penetration or whether it is secondary to some other factor such as sexual abuse or genital infection. In their proposed reconceptualization of vaginismus, Reissing and colleagues (E. Reissing, Y. Binik, and S. Khalife, “Does Vaginismus Exist? A Critical Review of the Literature,” unpublished manuscript, January 1998) recommended that vaginismus be considered a type of genital pain disorder, with the pain described in terms of quality, intensity, location, and duration. A description of the disorder should detail whether the pain is associated with imagined, attempted, or successful vaginal penetration.

Essential Components of Treatment
Almost all treatment approaches for vaginismus involve some form of muscle relaxation or desensitization, along with the gradual insertion into the vagina of objects (e.g., fingers, tampons, dilators) of increasing size under conditions of relaxation and patient control. Systematic desensitization, in which the therapist and patient construct a hierarchy of situations involving imaginal vaginal insertion (from the smallest Q-Tip to the largest penis) is sometimes used with extremely phobic patients.

Many women do well with masturbation exercises prior to vaginal insertion. Masturbation facilitates sexual lubrication and arousal with the concomitant enlarging of the vaginal outlet. Penetration is more readily accomplished if the woman is well lubricated and aroused than if she is dry and tense. For women who are uncomfortable with masturbation, deep breathing and muscle relaxation are important.

As with the treatment of dyspareunia, Kegel exercises are helpful. By having the woman squeeze and relax her pubococcygeus muscle, she becomes aware of her vaginal contractions and can achieve some control over her vaginal muscles. Moreover, many women experience pleasurable sensations in the vagina from tensing and relaxing these muscles.

Role of the Male Partner
The role of the male partner in causing or maintaining the vaginismus problem is important to assess. If he has a sexual dysfunction, such as early ejaculation or erectile failure, sexual counseling for his difficulties should parallel treatment of his partner. The therapist can explain how vaginismus and erectile unreliability go “hand in glove.” Similarly, if a man is aware that his wife is uncomfortable with or phobic about vaginal containment, it makes sense for him to ejaculate rapidly. Sometimes women “train” or encourage their partners to ejaculate quickly in order “to get it over with.” Nevertheless, months of early ejaculation can lead to the elimination of erection altogether. Moreover, when sex becomes something to be “gotten over with” rather than something to sensually enjoy and share, sexual avoidance is a likely outcome. Consequently, it is usually important to include the male partner in treatment, either from the start of therapy or after sufficient progress has been attained by the vaginismic woman so that she feels comfortable talking in front of, or with, her partner.

Both masturbation and sensate focus exercises are useful components of therapy that provide the partners an opportunity to develop confidence facilitating in their own sexual responses, in communicating their sexual preferences, and in experiencing sexual intimacy.

If the husband or partner does not have a sexual dysfunction and appears to be supportive and cooperative, much of the initial work can occur with the woman alone.