Inability to Experience Penetrative Vaginal Intercourse (formerly Vaginismus/Pelvic floor dysfunction)

Introduction

Vaginismus has been a problem child for over 150 years. Gynecologist Marion Sims in 1862 spoke in an address to the Obstetrical Society of London, describing what he called vaginismus as “involuntary spasmodic closure of the mouth of the vagina, attended with such excessive supersensitiveness as to form a complete barrier to coition.”1

After Sims’ description, the medical world expended great effort to confirm the hypertonic, spasmotic muscle state of vaginismus, and to consider, without supporting evidence, this as a largely psychosomatic diagnosis. For years afterward, a struggle occurred to understand what was pain with sex (dyspareunia) or what was sexual pain (“vaginismus”). Early findings indicated that some women with dyspareunia also had pain with nonsexual types of mechanical stimulation of the vulvar region, such as tampon insertion or wearing tight clothing. In addition, these women failed to exhibit more psychosexual problems than women without dyspareunia, other than distress about their pain.2 Subsequent research confirmed that it was not vaginal spasms or pain measures which distinguished women with vaginismus from those with dyspareunia. Women with vaginismus did, however, display higher muscle tonicity, lower muscle strength, and significantly greater distress and avoidance behavior during pelvic examinations.3 And finally, long expected findings of fear and avoidance behaviors appeared to be the primary distinguishing features.4

Evolution of “Sexual Pain Disorders”

The earliest documented female sexual dysfunction is painful intercourse. Its first mention was in a set of scrolls, the Ramesseum Medical Papyrus IV,  dating approximately to the end of the eighteenth century.5  This ancient Egyptian record identified the pain in the vulva; the relationship to sexual intercourse was explicit. Approximately 4,000 years later, the emphasis on sexual interference persisted as gynecology and psychiatry/psychology evolved over the past century. Starting in the 1930s, dyspareunia was the term used to refer to painful intercourse; the term translates from ancient Greek as “difficult mating” and was first coined in 1874.6  Although Sims had used the term “vaginismus” in the 1860s, its symptoms had been described as early as the 1500s with a pointed reference to its interference with penetration.7 

Barriers to research may have included a presumed low prevalence of the condition, the challenge of performing vaginal examinations in this population, and concern that examination itself might bring further emotional injury.  Small sample sizes, varying recruitment methods, idiosyncratic methodologies, and the lack of independent replication of studies have blocked progress. Probably, the greatest barrier in nosology and classification has been the definition of what vaginismus is: how it is defined. Figuring out the role of “vaginal spasm vs pelvic floor dysfunction” unleashes myriad questions. What is muscle spasm? What is hypertonicity? Is pain experienced? What kind? How does one differentiate dyspareunia from vulvar pain? Is vaginismus sexual pain? What about abuse?  Finally, a critical element: is fear a discriminating factor?

Challenges of classification

The term dyspareunia appeared in the DSM in the second edition of the manual under “psychophysiological genitourinary disorders,” invoking causal emotional factors.8 It was the DSM-III that grouped together sexual function difficulties under “psychosexual dysfunctions.”9 Then, there were further changes in the DSM-III-R to “sexual dysfunctions,” under which were subsumed the “sexual pain disorders”—dyspareunia and vaginismus. 10

DSM-IV continued the classification11 and its later text revision (DSM-IV-TR).12 These publications initiated an ongoing dispute that questioned whether women were well or ill-served by the addition of their sexual difficulties in a manual of mental disorders. Proponents celebrated the long-awaited recognition of female sexual problems with the hope that addition of these details to the literature would lead to more effective treatments, such as those available for men (e.g., Viagra).13 Detractors warned against the medicalization of sexual difficulties likely to be based on relationships and on the societal marginalization of women’s sexuality. The extent to which desire, arousal, and orgasm problems in women should be attributed to medical, psychological, or relational/social factors promoted hot debate. The sexual pain disorders, however, were distinctive because of their involvement of a somatic experience: pain. Research efforts in the mid-1990s began to investigate the extent to which these disorders were actually connected to sexual intercourse, other than incidentally.

Given the historical focus on pain that occurred with penile-vaginal penetration, scant attention had been paid to the actual location of the pain, always the line of inquiry for other pain disorders. Research on the properties and mapping of the pain indicated that (a) it was largely located in very specific parts of the genital region, and (b) subtypes had unique pain profiles.14 These findings called into question the vague and undocumented psychogenic or psychosexual explanations of the past. This early research, as well as later findings, severed the causal connection between the sex and the pain.16

 

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