1. No category

Sexual function and behaviour of
women with lifelong vaginismus
Elke D. Reissing, Ph.D., C.Psych. &
Rebecca A. Cherner, Ph.D.
What is vaginismus?
• DSM IV-TR (APA, 2000); ICD-10 (WHO, 1994):
o Sexual dysfunction
o Sexual pain disorder
o Defined by one diagnostic criterion: vaginal spasm interfering with
vaginal penetration
o Lifelong / Acquired
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What is vaginismus?
•
DSM IV-TR (APA, 2000); ICD-10 (WHO, 1994):
o Sexual dysfunction
o Sexual pain disorder
o One diagnostic criterion: vaginal spasm
What is vaginismus?
•
DSM IV-TR (APA, 2000); ICD-10 (WHO, 1994):
o Sexual dysfunction
o Sexual pain disorder
o One diagnostic criterion: vaginal spasm
Reissing et al., (1999, 2004)
Not reliable nor valid
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What is vaginismus?
•
DSM IV-TR (APA, 2000); ICD-10 (WHO, 1994):
o Sexual dysfunction
o Sexual pain disorder
o One diagnostic criterion: vaginal spasm
Reissing et al., (1999, 2004)
Not reliable nor valid
Int. Consensus Committee (2003)
Clinical diagnosis: inability to exp. vaginal
penetration despite expressed wish–phobic anxiety
What is vaginismus?
•
DSM IV-TR (APA, 2000); ICD-10 (WHO, 1994):
o Sexual dysfunction
Sexual pain disorder
o One diagnostic criterion: vaginal spasm
o Lifelong / Acquired
3
What is vaginismus?
•
DSM-5 (forthcoming)
Genito-pelvic pain / penetration disorder (GPPPD; Binik, 2010)
No empirical evidence for differences between vaginismus & dyspareunia
HOWEVER, no empirical evidence for a combined diagnosis either....
Short-circuiting research investigating (lifelong) vaginismus
What is vaginismus?
•
DSM IV-TR (APA, 2000); ICD-10 (WHO, 1994):
Sexual dysfunction
o Sexual pain disorder
o One diagnostic criterion: vaginal spasm
o Lifelong / Acquired
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Vaginismus = sexual dysfunction?
Sexual Function
o DSM-IV-TR: Sexual function not affected (desire, pleasure, orgasm)
unless penetration attempted / anticipated (APA, 2000)
o DSM–5: only mentioned with regard to the absence of vaginal
penetration (Binik, 2010)
o However, most studies suggest that sexual function is compromised
(Reissing et al., 2003, 2013; ter Kuile et al., 2009; van Lankveld et al., 2006)
Sexual Behaviour
o Reports of non-penetrative sexual activity (Lamont, 1994)
o Lack of studies on frequency and range of sexual repertoire
compared to controls.
Vaginismus = maladaptive cognitions about sexuality?
Negative, maladaptive cognitions about sexuality
(e.g., Borg et al., 2012; Klaassen & ter Kuile, 2009; Reissing, 2012)
o
o
o
o
o
Perception of genital incompatibility
Fear of losing control
Catastrophizing physical sensations (pain)
Negative body – genital image
Fewer positive thoughts
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Sexual response in ♀ with vaginismus
Emotional response to erotic films and slides depicting
intercourse (Borg et al., 2010)
o ↓ pleasant feelings
o ↑ disgust specific to sexual stimuli
o ↑ disgust, threat and annoyance
Physiological sexual response in ♀ with vaginismus
o No information about vaginismus and physiological arousal
o Past challenges with assessing genital response
o The solution:
Thermography (Kukkonen et al., 2007; Kukkonen et al., 2010)
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Bring on the heat: Investigating physiological sexual response
Vaginismus (n = 15)
o
Intercourse never possible (lifelong), OR
o
Attempted intercourse – but could not tolerate insertion, thrusting or moving
Dyspareunia (n = 15)
o
Pain during minimum 50% of intercourse experiences
o
Pain at entrance of vagina
o
Pain provoked by pressure/touch
o
Quality of pain is burning, raw, sharp, knife-like
o
Lifelong
No-pain control (n = 15)
o
No history of difficulties or pain with intercourse
Cherner & Reissing (2013)
Testing Protocol
Session 1
Session 2
Demographics interview and
questionnaires
Other neutral film (15 min)
Neutral Film (15 min)
Film Scale
Film Scale (Heiman & Rowland1983)
Neutral Film (1 min)
Neutral Film (1 min)
Erotic film (15 min.; penetration / no penetration)
Erotic film (15 min.; penetration / no penetration)
Film Scale
Limited debriefing
Film Scale
Final, full debriefing
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Human Sexuality Research Laboratory set-up
Genital Arousal to Film Stimuli
OC
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Subjective Responses: No-penetration Film
***
*
***
***
**
* p < .05
** p < .01
*** p < .001
Subjective Responses: Penetration film
***
*
* p < .05
*** p < .001
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Negative Emotional Responses: No-penetration film
***
***
**
**
**
* p < .05
** p < .01
*** p < .001
Negative Responses: Penetration film
***
**
***
***
*
*
***
*
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Physiological sexual response in women with vaginismus?
• Intact physiological sexual response
o Regardless of stimuli (pen/no pen)
o Despite significant negative emotional response
Negative subjective response significantly different from women
with dyspareunia: ↑ anxiety, worry, disgust and threat.
Sexual response ok…what about sexual function – and pesky negative thinking?
•
Online survey (n=174)
o Vaginismus (n=68)
o Dyspareunia (n=59)
o No-pain control (n=47)
Sexual function (Female Sexual Function Index; Rosen et al., 2000)
Sexual behaviour (Sexual Activity Questionnaire; adapted from Ochs & Binik, 1999)
Sexual arousability and anxiety (Sexual Arousability Inventory-Expanded; Hoon, 1978)
Penetration-related cognitions (Vaginal Penetration Cognition Questionnaire; Klaassen
& ter Kuile, 2009)
Cherner & Reissing, 2013 (in press)
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Sexual Function (FSFI)
*
**
***
Sexual Behaviour: Range of Activities
***
**
**
*
* p < .05
** p < .01
*** p < .001
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Sexual Arousability and Anxiety (SAI-E)
***
**
***
* p<.05
** p=.01
*** p<.001
Penetration-Related Cognitions (VPCQ)
***
***
***
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Sexuality of women with vaginismus
•
Intact physiological sexual response
o despite negative emotional response
•
Sexual function
o Function problems across the board
↓ desire, arousal, lubrication, orgasm, satisfaction, arousability, ↑anx
•
Sexual Behaviour
o ↓ decreased range of sexual behaviour
•
Cognitions
o ↑ concerns about control, catastrophic/pain, self-image, genital
incompatibility, ↓ positive
Implications
•
Is vaginismus a sexual dysfunction?
o Sexuality affected beyond episodes were “penetration is attempted +/or
anticipated”.
o Range of sexual behaviours is limited.
o Physiological sexual response not impeded.
Tx of vaginismus focusing on vaginal penetration alone does not result in sexual
rehabilitation (e.g., Reissing et al., 2013; ter Kuile & Reissing, in press)
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Implications
•
Is (lifelong) vaginismus a pain disorder?
o Highly questionable... Cognitive processing of sexual situations and behaviours
different from women whose main concern is the experience of pain with sexual
activity.
o Disgust, worry, maladaptive beliefs (e.g., genital incompatibility)
Implications for conceptualisation of lifelong vaginismus
Increased Muscular Guarding/Reactivity
Avoidance ∞
Disconfirmation
Confrontation
Hypervigilance
Cognitive processing of:
Negative Experience (pain)
Negative Expectations/beliefs
Catastrophizing Thoughts
Fear (worry) of and disgust with
penetration / aspects of sexuality
(Cherner & Reissing, in press; Reissing, 2009; ter Kuile & Reissing, in press)
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