Pain, fear, and avoidance: Why a woman’s body says no to sex

1. Pain, fear, and avoidance: Why a woman’s body says no to sex Elke D. Reissing, Ph.D. University of Ottawa, Canada Presentation given in part at the 2006 annual conference of the Canadian Psychological Association

2. Vaginismus Current listing in DSM-TR (2000): Along with dyspareunia (pain with intercourse) under the subheading: Sexual Pain Disorders “Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse” Generalized --- Acquired / Lifelong --- Surprise --- Devastating

3. Vaginismus Does Vaginismus Exist? (Reissing et al., 1999) - lack of empirical studies - clinical case studies of positive treatment outcome - recent use of “vaginismus” as an indicator of severity of dyspareunia. • No empirical evidence for validity or reliability of the singular diagnostic criterion of vaginal spasm for vaginismus. • No theoretical framework as to what interferes with intercourse (spasm, pain or anxiety).

4. Vaginismus • Pain not necessary to diagnose this sexual PAIN disorder…. • No confirmation of singular diagnostic criterion because gynecological exam can’t be tolerated or is waived. • Multiple clinical reports note that vaginismus and dyspareunia may be virtually indifferentiable (e.g., Basson, 1996; Har-Toov et al., 2001; Kaneko, 2001; de Kruiff et al., 2000; van Lankveld et al., 1996; Ng, 2001; Okawa, 2001; Pukall et al., 2000; Reissing et al., 1999, 2004; Wijma et al., 2000)

5. Vaginismus(Reissing et al., 2004, 2005) • Diagnosis • Pelvic floor pathology • Pain • Etiology

6. Vaginismus(Reissing et al., 2003, 2004, 2005) • Sample of 87 women with vaginismus, dyspareunia, and no sexual problems matched on age, relationship status and parity. • Examined by 2 - gynecologists, - pelvic floor physiotherapists, - psychologists; - underwent 2 sessions of vaginal surface EMG, - and completed questionnaire package.

7. Vaginismus(Reissing et al., 2004, 2005) • Clearly demonstrated the singular diagnostic criterion, the vaginal muscle spasm, is IRRELEVANT for diagnosis – in fact ↓ reliability • Pelvic floor hypertonicity is an important symptom of vaginismus, but does not reliably differentiate vaginismus and dyspareunia. • Hitherto neglected: Pain is an essential component to vaginismus – can not be differentiated from dyspareunia

8. Vaginismus(Reissing et al., 2004) • Does vaginismus exist? Yes! Despite similar pelvic floor tension and the same quality and intensity of reported pain • ONLY women with vaginismus demonstrated significantly ↑↑ protective/distress reactions. • ONLY women with vaginismus completely avoid intercourse. But what makes a woman (‘s body) say no to sex?

9. Vaginismus • DSM-TR associated features about etiology reflect consensus in the clinical literature: - lack of sex education/information - negative attitudes about sexuality - sexual abuse or trauma > normal sexual response if penetration is not attempted BUT: our study…

10. Vaginismus (Reissing et al., 2003) • Only 1 of the DSM IV-TR associated features could be confirmed – an increased number of reports of sexual abuse during childhood. • Contrary to the DSM, all aspects of the sexual response are compromised.

11. SUMMARY • Pain and/or fear of pain are central features in vaginismus • Pelvic floor pathology is involved – one symptom • Behavioural AVOIDANCE is key in differentiating women • All aspects of sexual response appears to be affected • Childhood sexual abuse may play a role for some women

12. Better description of women with vaginismus but no clear etiological links. Paucity of literature – traditional, reported etiological theories were not confirmed. Where to go from here? The Internet • Avoid Avoidance • Reach many • Mindful of challenges: Online research can be efficient and valid (Kraut et al., 2004; Gosling et al., 2004) • Preliminary report of 165 respondents

13. This is were I wish to thank VERY MUCH the study participants from different corners of the world! Without your participation filling out our Internet survey, we would not have this new information that highlights the importance of general fear and anxiety and significant difference between women who have always had vaginismus and those who developed it over time. We have gathered more information (for example on help-seeking and effectiveness of different types of treatments) and we will post updates as they become available. If you have not yet participated – we appreciate you considering to fill out the anonymous online survey! Thank you – Merci – Dankeschön – Gracias – Shoukran…..

14. Characteristic of the sample

15. Characteristic of the sample

16. Characteristic of the sample Vaginismus Acquired: 35% Duration: .5 – 2 years ……….. 12% 3 – 5 years ………… 27% 6 years > ………….. 61% Distress (0 – 10): 0–7 ………… 24% 8 …………… 21% 9 ………….... 21% 10 ………….. 37% Lifelong: 65%

17. Characteristic of the sample Vaginismus Lifelong: 65% Acquired: 35% Duration: .5 – 2 years ……….. 12% 3 – 5 years ………… 27% Distress (0 – 10): 0–7 ………… 22% 8 …………… 21% 9 ………….... 21% 10 ………….. 37% > 6 years …………….. 61%

18. Characteristic of the sample Vaginismus Lifelong: 65% Acquired: 35% Duration: .5 – 2 years ……….. 12% 3 – 5 years ………… 27% > 6 years ………….. 61% Distress (0 – 10): 0–7 ………… 22% 8 …………… 21% 9 ………….... 21% 10 ………….. 37% 79%

19. Results “Rank top 3 hypotheses as to why you think you have vaginal penetration difficulties”: Hyp 1: Fear of pain 42% Hyp 2: Fear of pain 27% Fear of injury, bleeding 15% Vagina is too small 11% Hyp 3: Vagina is too small 17% Fear of injury, bleeding 14% Fear of pain 11 % 80%

20. Results 53 choices of beliefs as to why participants think they have problems with vaginal penetration Asked to rate: 0 (strongly disagree) – 10 (strongly agree)

21. Results DISconfirm literature “classics”: Rating < 5 0 Lack of sex education 84% 46% Don’t enjoy sex 94% 53% Religious views 87% 56% Partner sexual dysfunction 98% 82% Physical abuse 91% 73% Sexual abuse 84% 66%

22. ResultsPerennial favorite: Childhood Sexual Abuse Incorporated parts of the Sexual and Physical Abuse History Questionnaire (Leserman et al., 1995) YES NO Forced to watch sexual act 5% 95% Had sex. parts touched 22% 78% Attempt at penetration 9% 91% Sex. acts not involving touch 11% 89% Forced to touch abuser 8% 92% Rape 5% 95%

23. ResultsPerennial favorite: Childhood Sexual Abuse Those rates are high – but sadly reflect those in the general population (North America). While some women who have been sexually abused developed vaginismus, many others did not.

24. Results The only belief endorsed highly across groups: “I believe I have problems with vag. penetration because…” “… I am afraid of pain because I experienced pain when tried to have intercourse previously” > 6 = 73%--- 10 = 42%

25. Results DIFFERENCES between lifelong and acquired vaginismus emerged in causal hypotheses: “I believe I have problems with vag. penetration because…” • … maintain control over body (p<.001) • …. remember non-sex. neg. events in childhood during sex (p<.001) • … my religious beliefs make me feel guilty + shameful about sex (p<.05)

26. Results “I believe I have problems with vag. penetration because…” • … I am afraid of getting injured through vaginal penetration (p<.01) • … I believe my vagina is too small for intercourse (p<.01) • … I don’t like male genitals (p<.001) • … I don’t like the idea of having a penis or other object in my vagina (p<.001)

27. Results Other fears and/or phobias (e.g., injections, flying, animals, open spaces): Acquired Lifelonga None 20% 11% 1 9% 13% 2 17% 6% 3 19% 13% 4 12% 16% 5 and more 24% Note: a p<.01 42%

28. Results Other fears and/or phobias (e.g., injections, flying, animals, open spaces): Acquired Lifelonga None 20% 11% 1 9% 13% 2 17% 6% 3 19% 13% 4 12% 16% 5 and more 24% Note: a p<.01 89% 42%

29. SUMMARY1 • Classic etiological hypotheses could again not be confirmed. • Fear, anxiety, and avoidance again confirmed as central to women with vaginismus. • Lifelong and acquired vaginismus may need to be explored separately – may be different disorders.

30. SUMMARY2 • Is vaginismus a specific phobia? In line with characteristics of specific phobias: - high comorbidity with other fears/anxieties - general treatment approach: progressive desensitization – but clinical evidence that more intense exposure may be more effective.

31. SUMMARY3 - central role of avoidance in maintaining fear > avoidance is negatively reinforced by reduction of fear > avoidance does not allow for disconfirmation of fear - presence of information processing biases (e.g., vagina is too small) - no clear, specific precipitating, negative event

32. SUMMARY4 • Biological value? Geoffrey Miller (2005) • Adaptive anti-copulation defense • A co-evolutionary arms race may explain both:  vaginismus in women making vaginal penetration difficult or impossible – originally there to avoid penetration that is not wanted; in the woman with vaginismus developed into generalized response.  the elongated foreskin in men as a mechanism facilitating intromission (Cold & McGrath, 1999; Taves, 2002).

33. SUMMARY5 Singular, circular, vaginal spasm focused diagnostic criterion New DSM diagnostic criteria (“International Definitions Committee”, 2005) Persistent or recurrent difficulties of the women to allow vaginal entry of a penis, finger, and/or object…..There is often (phobic) avoidance and of anticipation/fear/experience pain along with variable involuntary pelvic muscle contractions. Understanding how but understanding the WHY?