Reinhilde Melles

Therapist-aided exposure for women with lifelong vaginismus: a replicated single-case design.

Vaginismus is commonly described as a persistent difficulty in allowing vaginal entry of a penis or other object. Lifelong vaginismus occurs when a woman has never been able to have intercourse. A replicated single-case A-B-phase design was used to investigate the effectiveness of therapist-aided exposure for lifelong vaginismus. A baseline period (Phase A) was contrasted with exposure + follow-up (Phase B), using random switching between phases. The main outcome measure (intercourse ability) was assessed daily for 24 weeks. Ten women participated. The exposure consisted of a maximum of three 2-hr sessions during 1 week at a university hospital. The participant performed vaginal penetration exercises on herself, in the presence of a female therapist. Two follow-up sessions were scheduled over a 5-week period. Nine of the 10 participants reported having intercourse after treatment, and in 5 of the 9, intercourse was possible within the 1st week of treatment. The results remained at 1-year follow-up. Furthermore, exposure was successful in decreasing fear and negative penetration beliefs posttreatment and at 3-month and 1-year follow-ups. Therapist-aided exposure appears to be an effective treatment for lifelong vaginismus.

Throwing the Baby Out with the Bathwater: The Demise of Vaginismus in Favor of Genito-Pelvic Pain/Penetration Disorder

Over the past 15 years, there has been ongoing debate about whether vaginismus can be differentiated from dyspareunia categorically, dimensionally, or not at all (Reissing, Binik, & Khalifé, 1999). Despite the fact that the debate on diagnostic distinction continues, a significant change was made in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). The diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD) was introduced to replace the hitherto separate diagnosesofDyspareuniaandVaginismus,previouslyunder thesubcategory of sexual pain disorders (DSM-IV-TR; American Psychiatric Association, 2000). Binik (2005a) argued that the sexual pain disorders were the onlypainconditionsthatwereclassifiedaccordingtotheactivity they interfered with and argued for their removal from the classification of sexual dysfunctions. This was received with broad skepticism from clinicians and researchers alike (Binik, 2005b). The introduction of GPPPD may represent an apparent compromise. The diagnostic criteria for this new category have focused on symptomatology related to pain during sexual activity and/or pain with (anticipated) vaginal penetration. The multidimensional diagnosis of GPPPD is clearly more in line with the outcomes of scientific research and clinical practice than the original categorical classification in DSM-IV-TR as outlined elegantly by Binik’s (2010a, 2010b) summary of the literature. However, GPPPD fails to capture the complexity of sexual difficulties in women who have never been able to experience intercourse (for the purpose of this commentary referred tobythepreviousdiagnostic labelof lifelongvaginismus). Inour opinion, we run the risk that the baby (lifelong vaginismus) is thrown out with the bathwater (sexual pain disorders). By summarizing different aspects of lifelong vaginismus based on the results of recent studies, we will underscore this and offer a temporary solution to assist clinicians and researchers to mediate the omission of lifelong vaginismus from the DSM-5. Vaginismus was first mentioned as a sexual/reproductive problem by the Italian physician Trotula of Salerno in the eleventh century:‘‘On the tightening of the vulva so that even a woman who has been seduced may appear a virgin’’(1940; p. 37). The diagnostic term ‘‘vaginismus’’was coined by the English gynecologist, J. Marion Sims, in 1861. Even in the first description of vaginismus, the confusion between pelvic Charmaine Borg and Symon K. Spoelstra are both second authors.

Automatic and deliberate affective associations with sexual stimuli in women with lifelong vaginismus before and after therapist-aided exposure treatment

INTRODUCTION The intense fear response to vaginal penetration in women with lifelong vaginismus, who have never been able to experience coitus, may reflect negative automatic and deliberate appraisals of vaginal penetration stimuli which might be modified by exposure treatment. AIMS The aim of this study is to examine whether (i) sexual stimuli elicit relatively strong automatic and deliberate threat associations in women with vaginismus, as well as relatively negative automatic and deliberate global affective associations, compared with symptom-free women; and (ii) these automatic and more deliberate attitudes can be modified by therapist-aided exposure treatment. METHODS A single target Implicit Association Test (st-IAT) was used to index automatic threat associations, and an Affective Simon Task (AST) to index global automatic affective associations. Participants were women with lifelong vaginismus (N = 68) and women without sexual problems (N = 70). The vaginismus group was randomly allocated to treatment (n = 34) and a waiting list control condition (n = 34). MAIN OUTCOME MEASURES Indices of automatic threat were obtained by the st-IAT and automatic global affective associations by the AST, visual analogue scales (VAS) were used to assess deliberate appraisals of the sexual pictures (fear and global positive affect). RESULTS More deliberate fear and less global positive affective associations with sexual stimuli were found in women with vaginismus. Following therapist-aided exposure treatment, the strength of fear was strongly reduced, whereas global positive affective associations were strengthened. Automatic associations did not differ between women with and without vaginismus and did not change following treatment. CONCLUSIONS Relatively stronger negative (threat or global affect) associations with sexual stimuli in vaginismus appeared restricted to the deliberate level. Therapist-aided exposure treatment was effective in reducing subjective fear of sexual penetration stimuli and led to more global positive affective associations with sexual stimuli. The impact of exposure might be further improved by strengthening the association between vaginal penetration and positive affect (e.g., by using counter-conditioning techniques).

The Sexual Disgust Questionnaire; a psychometric study and a first exploration in patients with sexual dysfunctions.

INTRODUCTION Disgust may be involved in sexual problems by disrupting sexual arousal and motivating avoidance of sexual intercourse. To test whether heightened disgust for sexual contaminants is related to sexual dysfunctions, the Sexual Disgust Questionnaire (SDQ) has recently been developed. Previous research showed that particularly women with vaginismus display a generally heightened dispositional disgust propensity and heightened disgust toward stimuli depicting sexual intercourse. AIM To determine the psychometric properties of the SDQ and test whether heightened disgust toward sexual stimuli is specific to vaginismus or can be observed in other sexual dysfunctions as well. METHODS First, a large sample of undergraduates and university employees completed the SDQ (N = 762) and several trait disgust indices. Next, women with vaginismus (N = 39), dyspareunia (N = 45), and men with erectile disorder (N = 28) completed the SDQ and were compared to participants without sexual problems (N = 70). MAIN OUTCOME MEASURE SDQ to index sexual disgust. RESULTS The SDQ proved a valid and reliable index to establish disgust propensity for sexual stimuli. Supporting construct validity of the SDQ, sexual disgust correlated with established trait indices. Furthermore, sexual disgust and willingness to handle sexually contaminated stimuli were associated with sexual functioning in women, but not in men. Specifically women with vaginismus displayed heightened sexual disgust compared to women without sexual problems, while men with erectile disorders demonstrated a lower willingness to handle sexually contaminated stimuli compared to men without sexual problems. CONCLUSIONS The SDQ appears a valid and reliable measure of sexual disgust. The pattern of SDQ-scores across males and females with and without sexual dysfunctions corroborates earlier research suggesting that disgust appraisals are involved especially in vaginismus and supports the view that the difficulty with vaginal penetration experienced by women in vaginismus may partly be due to disgust-induced defensive reflexes that could disrupt sexual arousal.

Therapist‐Aided Exposure for Women with Lifelong Vaginismus: Mediators of Treatment Outcome: A Randomized Waiting List Control Trial

INTRODUCTION Therapist-aided exposure seems an effective treatment for lifelong vaginismus, but mechanisms of action have not yet been established. AIM The purpose of the present study was to investigate whether treatment outcome of a therapist-aided exposure treatment was mediated by changes in positive and negative penetration beliefs or feelings of sexual disgust. METHODS Participants with lifelong vaginismus were allocated at random to a 3-month exposure (n = 35) or a waiting list control condition (n = 35). MAIN OUTCOME MEASURE Full intercourse was assessed daily during 12 weeks. Secondary outcome measures (complaints about vaginismus and coital pain) were assessed at baseline and after 12 weeks. Possible mediators: penetration beliefs (catastrophic pain beliefs, genital incompatibility beliefs, perceived control beliefs) and feelings of sexual disgust were assessed at baseline and 6 weeks. RESULTS Treatment outcome (coital frequency, symptoms of vaginismus, and coital pain) at 12 weeks was mediated by changes in negative and positive penetration beliefs at 6 weeks, in particular by more pronounced reduction of catastrophic pain penetration beliefs. No evidence was found that changes in feelings of sexual disgust mediated treatment outcome. CONCLUSION The results strongly suggest that therapist-aided exposure affects negative penetration beliefs and that these changes in negative penetration beliefs mediate treatment outcome in women with lifelong vaginismus. Implications for treatment are discussed.

The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal

BACKGROUND Sex research lacks experimental studies in which both partners participate in a laboratory procedure. This is relevant in the context of genital pain because painful vaginal sensations often occur in the presence of the partner. AIM To examine the effects of partner presence, sexual stimulation, and vaginal pressure on the appraisal of vaginal sensations and sexual arousal, ultimately aiming to increase the ecologic validity of laboratory designs. METHODS A community sample of 42 women and their male partners watched sexual and neutral films while separated or together. We induced gradually increasing vaginal pressure in the women using an intravaginal inflatable rubber balloon. OUTCOMES Women reported on pleasant and painful vaginal pressure and perceived genital arousal. Men and women reported on subjective sexual arousal. We also examined whether these appraisals were moderated by relationship satisfaction. RESULTS The appraisal of vaginal pressure varied as a function of relationship satisfaction. Less satisfied women reported more painful pressure than women who were highly satisfied and highly satisfied women appraised the pressure as more pleasant in the context of a sex film and in the presence (vs absence) of their partner. In men and women, although partner presence had a negative effect on subjective sexual arousal, the presence of the partner did increase womens perception of genital arousal when vaginal pressure was induced during a sex film, particularly when women felt highly satisfied with their relationship. Also, the effects on subjective sexual arousal were moderated by relationship satisfaction. For couples in which the woman was less satisfied, the induction of vaginal pressure resulted in higher subjective sexual arousal when the partner was absent compared with when he was present, whereas when the man felt less satisfied, partner presence had a positive effect on sexual arousal. CLINICAL IMPLICATIONS Interventions need to focus on the importance of sexual arousal during vaginal pressure stimulation and the way this is shaped by partner and relationship variables. Our results indicate that enhancing the relationship climate is an important target of intervention. STRENGTHS AND LIMITATIONS We did not include physical indices of genital arousal and did not use a clinical sample of women with genital pain. CONCLUSIONS The appraisal of vaginal sensations and sexual arousal are context-dependent responses that vary as a function of partner presence and sexual stimulation. Including both partners in the laboratory setting is important to create more valid models on sexual responding. Dewitte M, Schepers J, Melles R. The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal. J Sex Med 2018;15:539-549.

The Vaginal Pressure Inducer: A New Device to Test the (Un)pleasurableness and Tolerance of Vaginal Pressure and the Influence of Sexual Stimuli

ABSTRACT To better understand the impact of sexual stimuli on genital pain, a new instrument was developed: the Vaginal Pressure Inducer (VPI). We administered gradually increasing vaginal pressure with the VPI to sexually functional women as they watched a neutral, erotic, or explicit sex film. Women had higher unpleasantness thresholds in a sexual context compared to a nonsexual context. Moreover, ratings of pleasurableness were higher in the sexual compared to neutral context and most so during the explicit sexual film. These results provide initial support for the suitability of the VPI to study determinants of pleasant and unpleasant appraisal of vaginal pressure.