It may come as a surprise that the diagnosis of vaginismus can no longer be found in DSM-5. It may come as an even bigger surprise that until the publication of DSM-5, there had been virtually no change to the diagnostic definition of vaginismus in over 175 years. The spasm-based definition “recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse” was proposed by French physicians in the early 19th century.1 It is nearly identical to the criteria found in DSM-III and subsequent DSM editions. It is hard to find another diagnosis with such longevity. We suspect that this diagnostic longevity was not a testament to its validity but rather the result of the lack of critical attention.

Definition

In DSM-5, the spasm-based definition of vaginismus was dropped, and vaginismus was combined with dyspareunia, the other “sexual pain disorder,” which resulted in genito-pelvic pain/penetration disorder (GPPPD). A number of factors motivated these changes. The most important perhaps was that research did not support the premise that vaginal spasm was the crucial factor preventing intercourse.2,3 While such spasms can occur in some women, they account for only about a quarter of cases.3 What actually prevents intercourse appears to result from a variety of factors, including an intense fear of vaginal penetration or of pain during vaginal penetration, the experience of pain during penetration, and hypertonicity of the pelvic floor muscles.

A consideration of what typically happens during a gynecological examination to diagnose vaginismus may help to elucidate some of the historical confusion and current changes. What often happens during the examination is that the woman exhibits much distress, shuts her legs, turns away, and refuses to be examined. Not wishing to cause further distress or pain, the gynecologist reasonably does not force an examination and makes a diagnosis of vaginismus without ever verifying the presence of spasm.

When researchers systematically videotaped gynecological examinations for vaginismus and coded women’s facial expressions and behavior, it became apparent that the “vaginismic” woman was reacting phobically in the presence of the feared stimulus.4 The phobic stimulus was vaginal penetration. There was pelvic floor hypertonicity and sometimes spasm but probably as a result of the fear, just as a person with arachnophobia might tense up in the presence of a spider.

The idea that vaginismus could be conceptualized as a phobic state is not new and was proposed by Walthard in 1909.5 In fact, when a gynecologist succeeded in examining a woman with vaginismus, she was often also found to have provoked vestibulodynia (a vulvar pain syndrome). This empirical work suggested that the inability to experience intercourse was multimodal.

It became apparent that DSM-IV categorical definitions of vaginismus and dyspareunia did not reliably capture the variegated clinical presentations of women who have difficulties with vaginal penetration and/or genital pain. In fact, it was often diagnostically impossible to differentiate vaginismus from dyspareunia. Some women could have partial penetration, while others with time and relaxation could achieve penetration but experienced excruciating vulvar pain. This suggested that there was a spectrum of problems ranging from total inability to experience vaginal penetration to no apparent impairment in the ability to experience penetration despite pain and/or muscle tension. In the middle were varying degrees of comorbidity between pain, fear, pelvic floor hypertonicity, and penetration difficulties.

As a result, the new DSM-5 diagnosis of GPPPD reflects this spectrum conceptualization and allows for a diagnosis if the woman has recurrent and distressing difficulty with one (or more) of the following for at least 6 months: vaginal penetration during intercourse; marked vulvovaginal or pelvic pain during intercourse or attempted intercourse; marked fear or anxiety about the experience of vaginal or pelvic pain as related to vaginal penetration; marked tensing of the pelvic floor muscles during attempted vaginal penetration.

Prevalence

The prevalence of GPPPD is, of course, unknown but likely to be high, since pain during intercourse (dyspareunia) is now included in this spectrum of problems. Cross-sectional prevalence estimates available for dyspareunia have often been close to 15%, but there are no reliable estimates for the prevalence of vaginismus.6 Considering the high prevalence of pain during intercourse, clinicians who assess sexual function are advised to ask about pain even if it is not a presenting complaint. Since dyspareunia is highly comorbid with lack of desire/arousal, it is also suggested that clinicians differentiate dryness, discomfort, and pain that may result from lack of lubrication from vulvovaginal pain syndromes that typically do not respond to lubricants.

Etiology

Traditionally, vaginismus has been attributed to a variety of factors, including strict religious orthodoxy, poor sexual education, negative attitudes toward sex, and sexual or physical abuse.7 Although there is no systematic evidence to support these etiological factors, recent studies from Turkey and other predominantly Muslim countries suggest a very high prevalence of vaginismus.8 These reports are consistent with older clinical reports from ultraorthodox Jewish communities and other highly religious groups.7 It remains to be seen whether such reports can be verified.

A recently proposed model may be a useful heuristic for the clinician to consider when diagnosing and treating GPPPD.9 It hypothesizes that a cycle of pain, fear (of pain), anxiety, and muscle tension is established during a woman’s first attempt at penetration or perhaps first tampon insertion. If the woman’s pelvic floor muscles are contracted during this attempted penetration, she likely experiences genital pain. This pain then increases her anxiety/fear in anticipation of the next attempt, which often leads to the avoidance of future penetration attempts. This is the fear-avoidance model of vaginismus, which is borrowed from the fear-avoidance model of chronic pain.

Similar models were applied during discussion of early behavioral treatments for phobias. While this model may be a useful heuristic, there is no empirical evidence to support the idea that difficulties with penetration actually start this way. The model does, however, accord with early clinical reports that emphasize the fear element in vaginismus.

Treatment

In 1970, Masters and Johnson10 reported that 100% of their patients with vaginismus were successfully treated using an intensive, couple-focused treatment consisting of sex education and behavioral exercises that focused on the use of graded vaginal dilatation. This treatment was adapted by sex therapists for weekly outpatient treatment, but neither the original Masters and Johnson treatment protocol nor the adaptations were ever rigorously evaluated until some 35 years later.11

In 2006, van Lankveld and colleagues12 randomized 117 participants to 1 of 3 groups:

1. Cognitive-behavioral therapy (CBT) group: a modified Masters and Johnson treatment (eg, vaginal dilation techniques, sex education, relaxation, sensate focus exercises) delivered in a group format

2. CBT bibliotherapy group: the identical CBT group treatment delivered in written format

3. A waitlist control group

Twelve months after treatment, 21% of women in the CBT group and 15% in the bibliotherapy group reported successful penile-vaginal intercourse. While the approximately 20% improvement was clinically and statistically significant, the outcome was nowhere near the 100% success rate reported by Masters and Johnson or by subsequent uncontrolled reports.

Dissatisfaction with these outcomes led ter Kuile and colleagues13,14 to pursue a somewhat different approach. They re- conceptualized vaginismus according to the fear-avoidance model and developed a treatment based on the exposure model used for the management of phobias. This treatment returned to many of the original Masters and Johnson10 principles, including an intensive couple- focused, graded in-vivo insertion protocol.

Women who participated in the study had several 2- to 3-hour exposure sessions in 1 week, during which they were encouraged by a therapist to insert graduated dilators, tampons, or fingers in the presence of and with the help of their partners. The behavioral insertion exercises were based on a personalized graded fear hierarchy that the woman had constructed with her therapist. The couple was instructed to practice at home before returning for the next session. The findings from ter Kuile and colleagues indicate that it took only an average of 150 minutes of such exposure treatment over 2 or 3 sessions before 89% of couples were able to successfully have intercourse. At 3-month follow-up, 83% were still having sexual intercourse.13

This outcome confirmed the initial 90% success rate that they reported using a rigorously controlled and replicated single-case A-B–phase design (N = 10 women with lifelong vaginismus), in which results were maintained at 1-year follow-up, and 5 of the 10 women became pregnant.14 (A detailed treatment manual is available by contacting Dr. ter Kuile at the Leiden University Medical Center, m.m.ter_kuile@lumc.nl.)

These results, albeit with a different rationale, confirm the original approach of Masters and Johnson. It is important to note that these results raise a number of practical questions. First, how should the intensity and duration of the in-vivo sessions be set up? ter Kuile and her group recommend that couples take 1 week off from work so that they can have long exposure sessions and practice intensively by themselves (approximately 2 or 3 times per day). Second, who are the ideal clinicians to provide this treatment? The ter Kuile group selected clinical psychologists, but they may be limited by professional standards that do not allow them to touch patients (eg, in intimate areas) or demonstrate pelvic exercises or insertions. We have attempted to modify the treatment by using both a clinical psychologist/sexologist comfortable with exposure treatments for phobias and a pelvic floor physical therapist to help with the hands-on physical modalities, manual techniques, and pelvic floor exercises. Our initial experience with one patient was very gratifying.

CASE VIGNETTE

M, a married 38-year-old Turkish woman was referred to a sex and couples therapy service by a fertility clinic after being told that fertility treatments would not be tried until she attempted sexual intercourse. Her chief complaint was that she had been married for 10 years and was still a virgin, despite many attempts at penetration.

M could not tolerate tampon/finger insertion, gynecological examinations, or sexual intercourse. She reported sexual desire, arousal, and dreams of enjoying sex. She received 11 sessions of individual psychotherapy, including behavioral homework exercises (eg, examining the genitals with a mirror, visiting a sex store), psychoeducation about sexuality, mindfulness exercises, and an opportunity to discuss her emotions and thoughts surrounding her presenting problem.

With her husband present, she attended 2 introductory sessions guided by a physiotherapist, with her psychologist present. During these sessions, information about anatomy, function, and position of the pelvic floor as well as the establishment of an individualized fear hierarchy ladder (ie, what she feared least to most).

The couple attended 2 sessions (240 minutes) of in-vivo gradual exposure, during which M inserted “objects” (eg, fingers, dilators) of increasing diameter into the vagina guided by the physiotherapist. She successfully completed all tasks on her fear hierarchy during the exposure and was able to have sexual intercourse at home with her husband for the first time. Three months after treatment, the couple reported having sexual intercourse 3 or 4 times per week and were trying to conceive.

After treatment, M wrote the following about her treatment experience: “Sexuality is a culture that has nothing to do with religion. It is true that I never dared to speak of my problem with others . . . I needed someone who understood my fear, and someone who could explain why I had these ideas in my head. That is the role that the psychologist played. She answered all my questions and helped me manage my fear and my pain with tools that did not frighten me. Then, the physiotherapist and I discussed what was frightening to me internally. Once I understood . . . [about] the wall of muscle that we could pass with the famous movement, ‘pulling and releasing,’ I managed to successfully overcome to the top of my ladder.”

Conclusion

There has been much progress in both the conceptualization and the treatment of vaginismus in the past 15 years. It remains to be seen whether the GPPPD spectrum diagnosis is both clinically and scientifically useful. Some have argued that women who have lifelong vaginismus form a distinct category rather than an endpoint in the continuum.15 Hopefully, there will be new data to resolve this issue. While there are multiple possibilities as to why some women are unable to experience vaginal penetration, it appears that couple-based, in-vivo, therapist-aided, exposure-type treatments are highly effective. It will be particularly important to replicate the results from ter Kuile and colleagues. Further research is needed to understand the crucial therapeutic mechanisms as well as to better understand the most feasible and cost-effective treatments.

Disclosures:

Ms. Perez is a Vanier Canada Graduate Scholar, and PhD Candidate in the department of psychology at McGill University, Montreal, Quebec, Canada, who has completed practica in sex therapy. She is currently completing her doctoral internship at the Couple & Family Therapy Service, Jewish General Hospital & Psychosocial Oncology Program, McGill University Health Center. Dr. Binik is Professor in the department of psychology at McGill University and founder and emeritus psychologist of the Sex and Couple Therapy Service, McGill University Health Center. The authors report no conflicts of interest concerning the subject matter of this article.

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