Samara Perez1 , Claudia Brown2, 3 and Yitzchak M. Binik1
(1)
Department of Psychology, McGill University, 1205 Dr. Penfield Avenue, Montreal, QC, Canada, H3A 1B1
(2)
Faculty of Medicine, School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
(3)
Physiotherapie Polyclinique Cabrini, UroSanté, Montreal, QC, Canada
Samara Perez
Email: samara.perez@mail.mcgill.ca
Keywords
VaginismusGenito-pelvic pain/penetration disorderSexual dysfunctionFear-avoidance modelVaginal penetrationTherapist-aided exposure
24.1 Patient Profile
My husband and I waited until we were married to have sex. To our disappointment, our wedding night was not the magical, lovemaking night we had envisioned. I had told him about my fear of intercourse, and he said we could take it slow. I enjoyed it when he touched and kissed me, and we decided to try to gradually work up to intercourse. When we did try, I became very tense and afraid and my legs would snap shut, and my arms would push him away. I went to the gynecologist who could not examine me and told me “to relax.” We have been trying to have intercourse for three years without success and are getting worried because we really want to start a family.
The above presenting description is quite typical for vaginismus. The primary motive for consultation is often the desire to start a family and/or to save the relationship. The woman has often avoided having a gynecological exam. In addition to not being able to experience intercourse, the woman may experience the following symptoms: fear and anxiety about penetration, marked tensing or tightening of the pelvic floor muscles, as well as marked vulvar pain, either in anticipation of, during, or as a result of vaginal penetration attempts (e.g., finger, tampon) [1–10]. The pain is often described as a sharp pain or a burning sensation around the opening and inside of the vagina. Women often refer to this tensing as some sort of “blockage” or “wall” that prevents penetration. Women with vaginismus may also report that their anatomy is not normal or that they feel defective, e.g., “they are too small inside” or “[that] it doesn’t fit” [10] and may experience shame and disgust regarding their genitals [11–16].
24.2 Definition and Nosology
As of 2013, the term1 vaginismus no longer appears in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) [17]. In the DSM-5, vaginismus and dyspareunia were combined into one disorder called Genito-pelvic pain/penetration disorder (GPPPD ) [17]. This change occurred for several reasons [2, 8, 18–27]. First, the defining feature required for diagnosis of vaginismus in previous DSMs [28, 29] and other classifications [30] was the presence of vaginal muscle spasm.2 Research, however, has failed to prove the presence of muscle spasm as a valid or reliable diagnostic criterion [2, 27, 31, 32]. In fact, the assessment of vaginal muscle spasm by a healthcare professional is often impossible on the first visit, due to the woman’s fear and avoidance, as she may be unable or unwilling to undergo to an internal vaginal examination [18, 33]. Second, diagnosis based solely on vaginal spasm [28, 29, 34] fails to consider the key elements of fear of penetration, anxiety, and pain, which are important components of this condition [2, 18, 35]. Third, several studies have shown that the similarities between dyspareunia/provoked vestibulodynia (PVD) and vaginismus outweigh the differences, making the diagnostic differentiation “difficult or nearly impossible” [1, 2, 6, 8, 9, 16, 27, 35, 36].
The current DSM-5 diagnostic criteria for GPPPD are persistent or recurrent difficulties with one (or more) of the following: (1) vaginal penetration during intercourse, (2) marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts, (3) marked fear or anxiety about vaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration, and (4) marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. To be diagnosed with GPPPD, at least one of the symptoms in criteria 1–4 must be present for at least 6 months and needs to cause significant clinical distress. Finally, the symptoms in criteria 1–4 cannot be better accounted for by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and are not attributable to the effects of a substance/medication or another medical condition [17]. The diagnosis requires the specifications, lifelong (woman who has never been able to have penetration) or acquired (woman who has previously been able to have penetration and currently is unable) and generalized (to all types of vaginal penetrations, e.g., vaginal intercourse, tampons, medical examinations) or situational (only to one specific situation, namely, vaginal penetration during sexual intercourse) [17]. It is important to note that the term “lifelong” GPPPD does not imply that this condition will never resolve, but that the condition has been present since the woman’s first attempt at penetration.
Some experts have argued that this new nosology may do a disservice to those women who would have previously been diagnosed with lifelong vaginismus [1, 21] because they are a distinct category. Other experts reason that women with lifelong vaginismus are better included in the new category of GPPPD, as GPPPD is based on a spectrum of symptoms which covary and include fear, anxiety, pelvic muscle tension and pain during intercourse—all of which have an impact on their inability to have vaginal penetration [37]. The nosology debate is far from over [21, 26, 37], and it will certainly take some time before consensus is reached in the research and clinical domains.
Irrespective of the nosological debate, there exists a group of women who have never been able to achieve vaginal penetration during attempted intercourse despite their expressed wish to do so. This chapter deals with these women [2, 38]. We will outline the etiology, assessment, and treatment for this group of women, who for the purpose of this chapter will be referred to as suffering from vaginismus. A case study will be used to illustrate an interdisciplinary approach to treatment using therapist-aided exposure combined with psychotherapy.
24.3 Prevalence and Etiology
There are wildly differing prevalence estimates for vaginismus, with population estimates ranging from 0.5 to 9 % [39–42] and other estimates ranging from 7 to 76 % in specialist and clinical settings [43–48]. This large variation is likely a result of different sampling methods and methods of assessment (e.g., questions about spasm, penetration, pain), the overlap in previous definitions of vaginismus and dyspareunia, and perhaps cultural perception. Irrespective of the variation in prevalence estimates, gynecologists and specialists in sexual dysfunction all receive frequent referrals of women who cannot experience vaginal penetration.
Currently, the cause(s) of vaginismus remains unknown [8, 27, 49, 50]. Although vaginismus has been linked with psychogenic etiological factors such as conservative religious upbringing, abstinence until marriage, negative sexual attitudes, ignorance, and lack of sexual education and experience [38, 51], the few available high-quality studies do not support these associations [8, 50, 52, 53]. Other hypothesized but unsubstantiated etiological factors include the occurrence of dysfunctional couple/marital relationships and sexual/physical abuse or trauma [54, 55].
One proposed theoretical explanation for the development of vaginismus follows the fear-avoidance model for phobias and pain [1]: the woman is apprehensive and fears pain during vaginal penetration. During her first attempt at penetration (often experienced with a tampon), the woman’s pelvic floor musculature contracts involuntarily, serving as a protective mechanism to occlude the vaginal entrance and prevent the feared penetration. If the woman tries to have penetration in spite of this muscle contraction or tension, she may indeed experience pain, from the compression on the vaginal entrance caused by the contraction. This pain increases her anxiety with respect to her next attempt at penetration, and a vicious cycle of pain, fear, anxiety, catastrophizing negative thoughts, and muscle tension is established. The increased fear and anxiety can lead to avoidance, as discussed by ter Kuile and Reissing in their fear-avoidance model of vaginismus [1]. This etiological mechanism has not been confirmed empirically, but is nonetheless a useful heuristic for the clinician and for future research. It remains unclear, however, whether these women avoid penetration (sex, gynecological exams, or other) in order to diminish their anxiety level similar to individuals suffering from a specific phobia or in response to their pain experience or both. However, women with dyspareunia typically do not avoid penetration to the same degree as women suffering from vaginismus [35].
24.4 Assessment and Diagnosis
The assessment of a woman with vaginismus requires sensitivity—to a woman who is experiencing pain/fear that is entrenched in emotionally charged and intimate behaviors [1, 56] and patience —to spend the time needed for the woman to be heard, which serve as a basis for a successful clinician–patient relationship. It is possible that the woman has previously consulted with other medical professionals who may have claimed that the problem could not be real or suggested that the pain was “in her head” [57, 58]. It is important to reassure the woman that she is not alone in suffering from vaginismus, that she did well to consult, and that effective treatment options do exist. For some, it is important that the disorder be named (i.e., introducing the terms vaginismus and GPPPD), as she may wish to subsequently consult online and/or with other professionals.
A detailed overview of how to successfully assess and diagnose female sexual dysfunction more broadly and the information one needs to obtain from a thorough clinical interview, physical examination, laboratory testing, and psychometric tools are outlined in Chapter 19. The relevant and specific components to consider for the assessment and diagnosis of vaginismus are outlined below.
24.4.1 Medical Screening
When a woman with vaginismus decides to seek professional help, she will likely first consult a general practitioner or gynecologist [59]. Although a medical screening may help to rule out conditions that can explain the woman’s difficulties with penetration (see Table 25.1), a physical cause for the inability to have vaginal penetration will rarely be found. Specifically, there are a few conditions such as congenital anomalies of the hymen (e.g., imperforate hymen, hymen semilunaris altus, septate hymen) or vaginal agenesis that can directly prevent vaginal penetration. In addition, it is helpful for the clinician to perform a moist cotton swab test of the vulvar vestibule to assess whether there is pain since the comorbidity of vaginismus and PVD is very high [2, 18, 27]. Almost all women can undergo at least a partial pelvic examination if treated with encouragement, patience, and instructions for relaxation through deep breathing. This may take some time, but in and of itself it can be highly therapeutic for the woman with vaginismus and can instill a sense of hope for further recovery. A suggested list of recommendations [58, 60] for the clinician to consider prior to and during the examination of a woman with vaginismus are outlined in Table 24.1. Because of the intense fear and anxiety that some women with vaginismus experience with respect to vaginal penetration, it may sometimes be advisable to delay the examination to be performed on a subsequent visit [60].
Table 24.1
Reccomendations for the pelvic/gynecological examination of a woman with vaginismus
|
Before the examination: |
|
• While she is dressed, explain to the woman step-by-step what you will do during the examination |
|
• Give her control by reassuring her that you will stop immediately at any time during the examination |
|
• Tell her she can ask questions at any point |
|
• Explain that the vaginal entrance has the potential to expand |
|
• Using a mirror, show the woman her genitals, and show areas that could be touched without pain |
|
If she agrees to be examined: |
|
• Be gentle and encourage her to breathe deeply |
|
• Begin with flat pressure on the surface of the vulva |
|
• Proceed with light pressure between the labia, and then gently move the lubricated and gloved index finger in an anteroposterior direction |
|
• Ask the woman to squeeze and let go (contract and relax her pelvic floor muscles) prior to digital insertion |
|
• Digital insertion should be done slowly with liberal use of lubricant |
|
A pediatric speculum can be used, but do not attempt a speculum examination if a manual exam is not possible |
24.4.2 Pelvic Floor Examination
An external pelvic examination may reveal the presence of protective reactions, which can range from complete refusal by the woman to assume the lithotomy position, to verbal expressions of anxiety, retraction of the pelvis, closing of the legs, facial grimacing, or crying [33]. Protective reactions may also include pelvic floor hypertonicity or an involuntary pelvic floor muscle contraction. This contraction can often be palpated externally, with compression of the soft tissue that lies inferior to the symphysis pubis and medial to the ischiopubic rami and ischial tuberosities. The hypertonic pelvic floor will demonstrate an increased resistance to palpatory compression of this tissue. If internal palpation is possible, pelvic floor hypertonicity may present as an increased resistance to passive stretch at the introitus. Assessment thus includes the degree to which the introitus may be “opened” (i.e., is it possible to fully insert the digit past the vaginal vestibule and into the vagina, to insert two digits, and to open the digits in the horizontal plane) and an evaluation of muscle tone, contractility, and post-contractile relaxation of the pelvic floor musculature. Some women who cannot tolerate vaginal palpation may be able to tolerate anal palpation, which may be done to identify the same muscular attributes and the presence of protective reactions.
24.4.3 Psychosocial and Sexual History
Understanding the woman’s psychosocial status (e.g., age, religion, and culture are particularly relevant) and sexual history can help with the evaluation and treatment [60, 61]. This includes inquiring about current and past partner relationships (e.g., duration, commitment), relevant factors in the woman’s developmental history such as physical, sexual, and/or emotional abuse (past and present), sexual self-esteem, and sexual orientation. The woman’s sexual education (e.g., formal vs. informal, family beliefs about sex, rules about sex), knowledge, and awareness of vaginal anatomy (e.g., has she discovered her own anatomy) are also important focus areas that need to be assessed [60, 61]. The assessment also creates an opportunity to begin unpacking the cognitions (e.g., “no partner wants me”), emotions (e.g., fear, anxiety, sadness, anger, frustration, disgust, inadequacy, embarrassment, guilt), and behaviors (e.g., avoidance of dating, sexual activities) underlying the presenting problem. A detailed understanding of the woman’s “self-talk” during any attempted sexual activity will provide important information which can be used during treatment to reduce anxiety and correct misinformation, e.g., “nothing will go in there that doesn’t hurt.”
24.5 Treatment
Historically, there has been much debate surrounding the of choice for vaginismus [8]. In the mid-nineteenth century, surgical interventions that included removal of the hymen, the incision of the vaginal orifice, and subsequent dilation were recommended [62, 63]. This practice was reconsidered when it became apparent that gradual vaginal dilation was effective [27, 64]. Throughout the twentieth century and until today, different variants of psychotherapy , (e.g., psychoanalysis, couple therapy) and pharmacotherapy [e.g., local anesthetics, anxiolytic medications, botulinum toxin (i.e., botox)] were often recommended [63, 65, 66]. Masters and Johnson pioneered the use of behaviorally oriented sex therapy with the couple that included sex education and practicing insertion with the use of graded dilators [67]. This became the primary treatment method after 1970 and was deemed highly successful [8, 27, 67]. Recently, there is increasing use of pelvic floor physiotherapy , which applies in vivo Masters and Johnson-type dilation, with the addition of biofeedback and manual techniques [10, 68–72]. Despite this history and the fact that many of these treatments continue to be used, there was limited empirical evidence that these interventions were efficacious [8, 73, 74].
In 2006, Masters and Johnson-type treatment for vaginismus was rigorously evaluated for the first time using a randomized controlled trial (RCT ) comparing a cognitive behavioral group therapy to a cognitive behavioral bibliotherapy and a wait-list control [53]. The treatment included vaginal dilation techniques, sex education, relaxation, and sensate focus exercises given in group therapy format or in the form of educational literature. Three months posttreatment, 18 % of women in the treatment groups (14 % group therapy; 9 % bibliotherapy) reported successful penile–vaginal intercourse, while none of the women in the wait-list control group reported successful intercourse. There was a significant treatment effect, but this effect was significantly lower than the high success rates previously reported by Masters and Johnson and others [67, 75–77].
Following the publication of new literature reconceptualizing vaginismus as a phobic disorder related to an intense fear of vaginal penetration [1, 53, 78, 79], ter Kuile et al. applied to vaginismus the highly effective in vivo gradual exposure and response prevention method used to treat phobias. In a recent RCT, they found that therapist-aided exposure for a hierarchy of fear-inducing vaginal penetration objects was highly effective in decreasing penetration fears and avoidance behaviors for women with lifelong vaginismus [1]. Impressively, 89 % (31/35) of women in the treatment group reported having had sexual intercourse post-treatment compared with 11 % of women (4/35) in the control group [78]. In 90 % of the successfully treated women, penetrative vaginal intercourse was possible within the first two weeks of treatment.
The treatment procedure used by ter Kuile et al. in this study may be outlined as follows [78, 79]: Prior to the first meeting, the woman has been physically examined by a gynecologist/physician, and physical conditions that prevent the possibility of penetration are ruled out. During an introductory hour-long session, the woman and her partner meet with the therapist (an experienced female psychologist–sexologist or gynecologist), and the treatment rationale and procedure are explained. The woman is asked to create her own, personalized hierarchical fear ladder3 consisting of all vaginal penetration situations from the least to the most fearful. She rates each of these situations on a scale of 0 = no fear at all up to 100 = maximum fear possible. The partner is asked to measure the circumference of his erect penis, so that the last dilator to be used before intercourse is of at least this circumference.
This is followed by one to three therapist-aided exposure sessions (on average 150 min each) in a room equipped with gynecological stirrups. The treatment consists of step-by-step in vivo practice as the woman works up her way up her fear ladder by gradually inserting progressively larger objects into her vagina, thereby exposing herself to more fear-inducing situations (e.g., self-insertion of one finger, a tampon, partner inserts two fingers, movement of his fingers, graduated phallic insertion devices, i.e., dilators), with the ultimate goal of successfully experiencing intercourse at home. During these sessions, the therapist encourages the woman to carry out the penetration in the office/hospital, and she is then asked to practice at home. It is important that the woman’s partner takes an active part in treatment by being present during the therapist-aided exposure sessions and by taking part during the home exercises. As this is an intensive week of treatment, it is recommended that the couple take a week off from work. It is possible that attempting penetration at home may take time or may not always be sexually exciting, and thus Viagra (sildenafil) or Cialis (tadalafil) may be prescribed to facilitate easy maintenance of her partner’s erection. Following exposure, there are 2–4 follow-up sessions (over 10 weeks). A detailed treatment manual is available [78, 79].
A recent uncontrolled study in Iran [12] successfully replicated this approach, although the mean number of in vivo therapy sessions was 5.71 (SD = 2.47, range 2–11) as compared with a mean of 1.88 therapy sessions (SD = 0.77; range 1–4 sessions) reported in ter Kuile et al.’s study from the Netherlands [78]. Overall, this treatment approach seems highly promising, and the RCT should be independently replicated. It should be noted that the sole focus of this treatment intervention is on penetration success, and it does not deal with pleasure or pain during intercourse. In fact, for about half the participants in the Netherlands, outcome measures for sexual satisfaction and pain were still not within the healthy range of sexually well-functioning women, suggesting that some women were reporting discomfort or pain during intercourse after the therapist-aided exposure therapy [78]. This is not surprising, since some of these women had previously avoided most sexual contact and pleasure in addition to penetration. If sexual satisfaction, sexual functioning, or pain remains problematic after successful treatment for penetration, then follow-up treatment with other professionals (e.g., a psychologist, sex therapist, or pelvic floor physiotherapist) may be beneficial. If dyspareunia still persists, a further evaluation for organic causes of introital allodynia must be explored. Organic etiologies may not be obvious to practitioners not experienced in the evaluation of vulvodynia and dyspareunia, and, therefore, this may warrant a referral, if possible, to a specialist in vulvar pain disorders (e.g., www.ISSVD.org, www.ISSWSH.org).
24.6 Case Study
This case study used an approach similar to ter Kuile et al.’s therapist-aided exposure [78, 79]. Although the ter Kuile et al.’s treatment approach is typically implemented by a psychologist who coaches women on how to do insertion on her own without physically assisting the woman, our case illustrates an interdisciplinary team approach including both a psychologist and physiotherapist. This format allows the physiotherapist to be “hands on” by utilizing manual techniques, physical modalities, and exercise, complemented by the psychologist who addressed the woman’s psychological needs.
Fatima4 consulted at a university hospital Sex and Couples Therapy Service, where a doctoral-level psychology intern (SP) began weekly 1-hour psychotherapy sessions. After four sessions, and with knowledge of the efficacy of therapist-aided exposure, the psychology intern consulted with a physiotherapist (CB) with over 20 years experience in pelvic floor physical therapy and who had recently been trained by the ter Kuile team in Holland. They offered Fatima the therapist-aided exposure treatment, and she agreed to this treatment course. A convenient week of treatment was scheduled during which the couple could be absent from work. Psychotherapy with Fatima alone continued for seven sessions until the scheduled week of intensive therapist-aided exposure treatment.
24.6.1 Identification
Fatima was a 39-year-old Middle Eastern French-speaking woman referred by a medical practitioner from a nearby fertility clinic. The physician told Fatima that fertility treatment would not be possible until the couple was able to have vaginal penetrative sexual intercourse.
24.6.2 Motive for Consultation
Fatima had been married for 12 years but was had never had penetrative sex despite many attempts at penetration. Motivation was high because of her approaching 40th birthday and the desire to have children.
24.6.3 History of Presenting Problem
Fatima had never been able to tolerate tampon or finger insertion or a gynecological examination. Fatima reported symptoms of panic in response to attempted penetration, described as an intense fear and “blacking out.” She said that she has improved slightly in recent months as she and her husband could now touch her labia externally without her panicking. She reported desire and pleasure when the couple was intimate during other non-penetrative sexual activities. She had never masturbated and grimaced during the interview when asked why. Fatima reported no premarital partners or attempts at vaginal intercourse. There was no history of abuse or trauma.
24.6.4 Past Psychiatric/Medical History
Fatima reported animal phobias (e.g., snakes, dogs) and a fear of dark voids, but denied being generally anxious. Fatima had never visited a mental health professional prior to her evaluation by the Sex and Couple Therapy Service nor had she been diagnosed with a psychiatric disorder. She reported no recurrent illness and had never used any contraception.
24.6.5 Mental Status
During the assessment, Fatima was quite personable, talkative, and socially appropriate.
24.6.6 DSM-5 Diagnosis
Fatima met DSM-5 criteria for GPPPD, lifelong and generalized.
24.6.7 Hypothesized Origin of Presenting Problem
Within the context of psychotherapy, Fatima explained that most women in her country of origin practice abstinence until marriage. She mentioned that she had been told that if a bride is unable to have intercourse on her wedding night, the elderly women of the town insert an oil candle in the vagina the following day. Fatima referred to her inability to have sex as a “blockage.”
24.6.8 Content of Psychotherapy Sessions
Fatima was extremely unfamiliar with her vaginal anatomy, and asked how many holes women had. The psychology intern (SP) provided psycho-education about female anatomy (e.g., pictures, diagrams) and opportunities to respond to questions about the female body/sexuality. She was also asked to purchase a women’s sexual health book. One of her first homework assignments was to look at her genitals using a mirror. Fatima was extremely reluctant at first, although was able to examine her genitals and found them to be pretty. She was often tearful in session and mad at herself for having this problem for so long. Psychotherapy provided a safe place for her to discuss her disappointment and frustrations. The psychology intern explained how her sexuality was dormant for many years and praised Fatima for opening up her sexual self. On subsequent sessions, the therapist encouraged Fatima to go home and take a cotton swab or her pinky finger and to touch the outer vaginal labia and around the vaginal opening, which she was successfully able to do. The therapist explained the interplay between emotions, thoughts, and behaviors, as Fatima had high anxiety about not being able to get pregnant. The therapist also did some deep breathing and relaxation exercises with Fatima. The psychology intern developed a strong therapeutic alliance with Fatima. The psychology intern introduced and prepared Fatima for the plan of therapist-aided exposure. Fatima’s husband attended the eleventh session to discuss the treatment plan and how the couple could work together to navigate this process.
The therapist-aided exposure was led by a physiotherapist (CB). The psychology intern, Fatima, and Fatima’s husband were all present for the following five sessions:
24.6.9 Session 1 (1 h, Day 1)
There was a team introduction, followed by a psychosocial history intake by the physiotherapist. The physiotherapist then educated and informed Fatima about the female anatomy using diagrams and a three-dimensional model of the pelvis with removable organs, which made it easy for the couple to visualize and understand the anatomy. Fatima’s husband explained that she physically blocks vaginal penetration by closing her legs. Fatima explained past symptoms of phobic reactions to penetration, such as feeling that there is a hole in her heart, having sweaty palms, and feeling “cut” at the throat. The team discussed the physical signs that she exhibits when she is beginning to have anxiety and fear-based reactions so that she could act upon them early should they present during treatment. Fatima was fully briefed on the therapist-aided exposure program and provided with an information package to take home (adapted and translated version of ter Kuile et al. treatment manual) [78, 79].
24.6.10 Session 2 (1 h, Day 6)
Fatima was taught deep breathing (20 min), followed by global stretching exercises (adductors and hamstrings, hip rotators). The physiotherapist identified genital anatomical structures as Fatima held a hand mirror. The physiotherapist applied external pressures on the surface of vulva and instructed Fatima on how to engage in pelvic floor contraction and relaxation. Fatima purchased a kit of graduated insertion devices. She was also given a fear ladder to complete at home (see Fig. 24.1) with instructions on listing items in a hierarchy of increasing fear/anxiety in relation to insertion. The ladder was to include physiotherapist’s finger, two fingers, a silicon penis, and intercourse. Glaxal Base cream was suggested for daily application because of Fatima’s dry skin and history of fissures.
Fig. 24.1
Fear ladder exercise. With permission from ter Kuile MM, Reissing ED. Lifelong Vaginismus. In: Binik YM, Hall KSK, editors. Principles and Practice of Sex Therapy, Fifth Edition 2014© Guilford Publications 2004 [1]
24.6.11 Session 3 (3 h, Day 7)
This was the first therapist-aided exposure therapy session. The physiotherapist reviewed anatomical structures and answered the couple’s questions. Next, the team reviewed, in detail, Fatima’s hierarchical fear ladder. In this session, she was able to successfully climb the 8th rung on her ladder (see Fig. 24.1). To begin the gradual exposure therapy, Fatima started by inserting a 0 fear-inducing object, a silicone tongue-shaped object. During each insertion, the psychology intern asked Fatima to rate her anxiety and pain level. Next, a tampon applicator was inserted by Fatima. The physiotherapist then inserted one finger and performed muscle identification techniques including stretching and techniques where Fatima learned to actively contract and relax her muscles. Subsequently, dilator number one was inserted by Fatima, followed by dilator number two, and then a silicone penis that Fatima had previously purchased. Next, the physiotherapist inserted two fingers and performed additional manual techniques. Fatima then partially inserted dilator number three, which was the first insertion device that produced great anxiety, recognized via her emotional and physical reactions (e.g., she mentioned that her heart was racing and that she had sweaty palms). The exposure session ended with guided mindfulness techniques by the psychology intern, who congratulated and reinforced Fatima’s progress and indicated that the team and her husband were supporting her. Fatima was emotional and tearful, but left comforted, happy with her progress, and proud of herself.
24.6.12 Session 4 (2 h, Day 9)
This was the second therapist-aided exposure therapy session. Fatima and her husband had worked on her fear ladder at home and arrived at the same point that had been reached during session 3. Session 4 began at the bottom of the ladder using device 0 on the fear ladder and progressed gradually: silicone tongue, dilator number one, dilator number two, physiotherapist’s two fingers, and manual techniques. The physiotherapist then showed Fatima’s husband how to insert his finger into her vagina. Fatima reported some discomfort, and the physiotherapist applied xylocaine cream, which helped significantly. Fatima then inserted dilator three, followed by partial insertion of dilator four. At this point, Fatima reported an anxiety level of 7/10 and a pain level of 5/10. The physiotherapist demonstrated a counterpressure technique to decrease pain during dilator removal. Fatima requested information on ideal positions for intercourse, which the physiotherapist explained.
24.6.13 Session 5 (2 h, Day 15)
The couple was happy to report that they were able to have intercourse on day 9. Fatima was able to insert devices at the top of the fear ladder on Day 10 and had intercourse again on day 11. The psychology intern and physiotherapist debriefed and received feedback from couple for the potential treatment of future women suffering from vaginismus.
24.6.14 Two Months Post-treatment
Fatima remains in psychotherapy to discuss non-related sexual issues (e.g., work-related anxieties). The couple continues to have satisfying vaginal penetrative sex 2–3 times/week and is trying to conceive naturally.
In summary, our treatment is diverged from ter Kuile et al.’s protocol [78, 79], as there were two therapists present from different disciplines working together, complementing and keeping each other on track during the therapist-aided exposure, which proved to be helpful for both therapists. A similar approach using a physiotherapist and psychotherapist is currently being carried out [10]. Moreover, the physiotherapist was able to use physical exercise instruction, physical guidance for the insertion, and manual techniques. It remains unclear whether the 11 sessions of psychotherapy were needed. However, post hoc, Fatima informed the therapists that she did not believe that she would have consulted or been prepared to begin the therapist in vivo gradual exposure immediately. She appreciated the time in psychotherapy to discuss her sexuality, her frustrations, and to feel confident enough to see the physiotherapist with her psychologist and husband present.
24.7 Conclusion
The therapist-aided exposure treatment appears to be highly effective for women with lifelong vaginismus and could also be considered for women presenting with acquired vaginismus. It remains to be seen who would be the ideal professional to deliver this treatment and act as therapist, be it a gynecologist, a pelvic floor physiotherapist, a psychologist, or perhaps all who are capable to be trained in the therapist-aided exposure approach. One practical problem with a psychologist as the therapist is whether a psychologist is ethically allowed to treat a woman who is undressed and is exposed from the waist down, although this was approved by the Dutch Society of Psychologist ethics boards in Holland [80]. Ethical professional considerations, gender of the treatment provider (e.g., thus far only female), and location of treatment (e.g., cultural context [25]) should all be evaluated in future research and clinical practice.
It is our opinion that an integrated, interdisciplinary treatment with a gynecologist, psychologist, and pelvic floor physiotherapist could provide comprehensive care for women suffering from vaginismus [10, 68, 71]. This would further address any additional symptoms of vaginismus including pain, generalized anxiety, sexual satisfaction, desire, and relationship/couple issues. Independent of the therapist’s profession and the method of delivery, there is currently a highly effective, evidence-based treatment for women with vaginismus, which makes sexual intercourse possible.
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Footnotes
1
Vaginismus is still listed in International Classification of Diseases (ICD-10). The ICD classification is currently under revision, and the ICD-11 is due to appear in 2017.
2
Vaginismus implies spasm of the vagina as ismus denotes spasm or contraction.
3
A combination of fear, anxiety, and tension, subsequently referred to as fear.
4
Name has been altered to preserve confidentiality.