Vaginismus is a sexual dysfunction that has received insufficient empirical attention. The first chapter of this thesis consists of a critical review of the literature and demonstrates the overall paucity of research studies and their poor methodological quality. The second and third chapter are based on the results of an experimental study comparing 87 women, matched on age, relationship status, and parity and assigned to 3 groups, vaginismus, dyspareunia/vulvar vestibulitis syndrome (VVS), and no pain. A structured interview evaluating pain with intercourse and history of gynecological problems as well as psychometric measures; evaluating sexual and physical abuse, sexual knowledge and schema, sexual functioning, relationship adjustment and psychological distress were administered. The reliability of vaginal muscle spasm as the main diagnostic criterion, differential diagnosis, and the role of pain were assessed via by 2 separate gynecological and, 2 separate physical therapist examination, 2 EMG evaluations, and a review of the interview data by 2 separate psychologists. Findings suggest that the spasm-based definition and resulting diagnostic reliability of vaginismus are not adequate. Both, women in the vaginismus and VVS groups exhibited higher levels of pelvic floor hypertonicity compared to women with no pain; however, women in the vaginismus group demonstrated the highest levels. Measures of pain did not distinguish between women with vaginismus and VVS. The only dependent measure clearly differentiating women with vaginismus was defensive and avoidant reactions during the physical exams. A re-conceptualization based on a multidimensional diagnostic framework including pelvic floor hypertonicity, avoidance and defensive reactions to vaginal penetration, and genital pain was suggested. The third paper was based on the results of questionnaires investigating etiological correlates of vaginismus, sexual and physical abuse, sexual self-schema, sexual knowled

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There is extensive debate on how the condition of vaginismus is understood, classified and diagnosed. A significant amount of literature argues that no school of thought has adequately explained the condition, and no terminology sufficiently describes the experience of sufferers and their partners. This study explores the experiences and perceptions of male partners to contribute towards a more meaningful understanding of the condition. The participants were volunteers who, together with their partners had sought treatment at a sexual and reproductive health clinic. Each participant consented to a semi-structured interview which explored themes around their relationship and sexual interaction, and understanding of and response to vaginismus. The interview data was analysed using content analysis and themes were drawn from the patterns identified. These themes provide a rich description of the experience of men in relationships with women diagnosed with vaginismus. There is also some support for the literature findings on the characteristics of the male partners. The participants appear to have particular personality characteristics, which are sustained in the context created by the sexual and relationship difficulties associated with vaginismus. It is aspects of the participants’ personalities and their social and cultural identities which mediate their experience in the context of the relationship. In addition, the participants’ understanding of sexual identity is strongly influenced by culturally defined norms. Although the problem may be conceptualised as a sexual difficulty, it can become pervasive and affect other aspects of the relationship. However, the condition also has the potential to amplify the importance of the relationship and lead to increased commitment. The time periods before seeking treatment varied considerably, though all the participants reported finding ways in which to manage the sexual difficulties. The couples’ main objective for seeking treatment was to have penetrative intercourse and/or conceive children. The experience of seeking treatment was hampered by inconsistent diagnoses and a lack of specialized knowledge. It is recommended that future research focuses on improving assessment and diagnosis of vaginismus

Student Number : 9809910J - MA research report - School of Human and Community Development - Faculty of Humanities / This study explores the perceptions of women suffering from vaginismus regarding their condition, themselves and their significant relationships. The subjective world of women suffering from vaginismus was therefore focused upon, within the context of a qualitative paradigm. Four volunteers who were diagnosed with the condition by a sexologist at the DISA health clinic, and were at the time seeking treatment for the condition, participated in the research. The research was conducted in the form of a semi-structured interview. Various psychological, emotional and social themes were explored. The participants’ responses were recorded and then analysed utilising content analysis. Within the analysis, a lack of constancy was noted amongst the participants. Differences with regard to etiological themes, personality profiles, emotions as well as relationships with intimate partners and parents were found. This is coherent with findings in the literature, which are also inconsistent. However, it should be noted that that whilst few aspects were found to be universal, most shared some commonality. Thus, various trends were established. The experience of vaginismus appears to be stressful, impacting on one’s emotions, selfesteem and intimate relationships. Trends were identified with regard to choice of partner. However, different relationship dynamics were found suggesting that couples react differently to the experience of vaginismus. All of the participants gave vague descriptions of their parental figures and relationships. Thus, it is difficult to make assertions regarding these relationships. Patterns of interaction and behaviour were experienced during the interviews. Avoidance of emotion was prevalent. The tendency to idealise relationships was found with all of the participants. The participants also appeared to make contradictory statements throughout the interviews.

Vaginismus is defined as a persistent difficulty with vaginal entry, despite a woman’s expressed wish, due to muscle tension, avoidance, and/or pain (Basson et al., 2003). The disorder is classified as a sexual dysfunction; however, there is a paucity of literature on the sexual response, sexual function, and sexual behaviour of women with vaginismus. This thesis research was designed to investigate the differential aspects of sexual health in women with lifelong vaginismus, compared to women with lifelong dyspareunia (pain with intercourse) and women with pain-free intercourse. In the first study, 45 women viewed erotic films, of which one set depicted penetration and the other did not. Physiological sexual arousal was assessed via thermography. Subjective responses to films were assessed with questionnaires. Despite significantly greater negative emotions and lower mental sexual arousal in response to erotic stimuli, women with vaginismus showed genital arousal comparable to the comparison groups. In the second study, 174 women completed an online survey. Women with vaginismus reported more sexual difficulties than the no-pain group and a restricted range of lifetime sexual behaviours and lower frequency of intercourse attempts/experiences than the comparison groups. Women with vaginismus and dyspareunia reported more anxiety during sexual activity and a restricted sexual behaviour repertoire in the previous year and month compared to the no-pain group. Women with vaginismus endorsed more negative cognitions related to penetration, specifically concerns about losing control of their body and the situation. The findings suggest that sexual function difficulties and restricted behavioural repertoire may be associated with negative emotions and maladaptive cognitions. Women with vaginismus may avoid encounters that could lead to intercourse. Alternatively, the negative response to sexual stimuli may be indicative of a more global negative response to sexuality beyond intercourse. The negative penetration-related cognitions, negative responses to sexual stimuli, anxiety during sexual activity, and reduced range and frequency of sexual behaviours of women with vaginismus provide support for the Fear-Avoidance Model of Vaginismus. The impairment in sexual functioning supports the need to move beyond the singular treatment focus of making intercourse possible to an approach that addresses overall sexual rehabilitation.

Female sexual pain is a common problem affecting women worldwide yet remains a poorly researched area of women’s sexual health. Dyspareunia and vaginismus are two types of sexual pain disorder each having psychological and physical health consequences for women and their partners. Part 1: A literature review of the qualitative research literature exploring women’s experiences of sexual pain disorders and their treatment was conducted adopting a narrative synthesis approach. Searches of psychological and medical electronic databases highlighted the paucity of research exploring women’s experiences of sexual pain disorders. Ten studies met the inclusion criteria for the review. The type of qualitative method and quality varied. Findings highlighted the complexity of women’s experiences of sexual pain. Positive experiences of treatment identified alternative benefits of treatment in addition to the traditional outcome of vaginal penetration and penetration without pain. Existing literature has focussed on dyspareunia, and further research is needed on vaginismus. Part 2: The research study used an Interpretative Phenomenological Analysis (IPA) of women’s experiences of vaginismus. Three women were interviewed about their experiences of vaginismus and the treatment they received. Interview transcripts were analysed using IPA. The findings identified the complexity of experiencing vaginismus, the struggle the women faced when trying to make sense of their vaginismus and the wider impact of these experiences on their identity. The findings highlight the value of psychological therapy with this client group and of the need to raise awareness amongst primary care professionals whom women with vaginismus are likely to consult in the first instance. Part 3: A critical appraisal of the research process is presented with focus on the experience of conducting qualitative research as a trainee clinical psychologist. A discussion of the findings is presented in the context of critical reflections on both the strengths and limitations of the study.

INTRODUÇÃO: A dor coital é definida pelo Manual Diagnóstico e Estatístico dos Transtornos Mentais (DSM-IV), como transtorno de dor sexual, fazendo referência ao vaginismo e a dispareunia. OBJETIVOS: Avaliar o efeito da intervenção fisioterapêutica na dor coital, avaliar a função sexual das mulheres portadoras de dor coital, verificar presença risco para depressão e ansiedade, avaliar o impacto do tratamento fisioterapêutico na função sexual destas mulheres e identificar o número de sessões necessárias para redução da dor coital. MÉTODOS: Trata-se de um ensaio clinico controlado não randomizado que incluiu onze mulheres com diagnóstico de dispareunia e cinco com vaginismo, referenciadas para atendimento no Ambulatório de Estudos em Sexualidade Humana (AESH) do Departamento de Ginecologia e Obstetrícia da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. A avaliação prévia da dor foi realizada através da escala visual analógica (EVA) e Índice de dor de Mc Gill, para avaliação da função sexual foi utilizado o Índice de Função Sexual Feminina (IFSF). A Escala Hospitalar de Ansiedade e Depressão (HAD) foi utilizada para rastrear sinais de ansiedade e depressão, em seguida foi realizada a avaliação funcional e do tônus dos músculos do assoalho pélvico, pelo Sistema de Graduação Modificada de Oxford. Os recursos utilizados para o tratamento das mulheres foram orientações gerais (visualização dos músculos do assoalho pélvico e percepção corporal e importância das preliminares), auto- relaxamento, alongamento passivo dos músculos adutores do quadril, propriocepção e a massagem intravaginal. RESULTADOS: 81,25% das mulheres apresentavam risco para disfunção sexual e 43,75% para ansiedade, verificou se uma diferença significativa (p<0,05) de todas as medidas de desfecho entre: avaliação inicial e avaliação pós tratamento imediato e entre avaliação inicial e avaliação após seis meses de tratamento. Houve forte correlação positiva entre IFSF e Oxford; forte correlação negativa entre IFSF e Mc Gill, e entre as medidas HAD depressão e Oxford. CONCLUSÃO: O tratamento fisioterapêutico foi eficaz para o tratamento da dor coital. Contribuindo para melhora da função sexual, redução do risco para disfunção sexual ansiedade e depressão de mulheres com dispareunia e vaginismo. / INTRODUCTION: Coital pain is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as a disorder of sexual pain, referring to vaginismus and dyspareunia. OBJECTIVES: To evaluate the effect of physiotherapeutic intervention on coital pain, to evaluate the sexual function of women with coital pain, to verify the presence of risk for depression and anxiety, to evaluate the impact of physiotherapeutic treatment on the sexual function of these women and to identify the number of sessions required to reduce Coital pain. METHODS: This was a randomized non- controlled clinical trial that included eleven women diagnosed with dyspareunia and Five with vaginismus, referenced for care at the Ambulatory of Studies on Human Sexuality (AESH) of the Department of Gynecology and Obstetrics of the Medical School of Ribeirão Preto, University of São Paulo. Pre-assessment of pain was performed using the Visual Analogue Scale (EVA) and Mc Gill Pain Index. The Female Sexual Function Index (IFSF) was used to assess sexual function. The Hospital Anxiety and Depression Scale (HAD) was used to track signs of anxiety and depression, and functional and pelvic floor muscle tone assessment was performed by the Oxford Modified Graduation System. The resources used to treat women were general guidelines (visualization of the pelvic floor muscles and body perception and importance of the preliminaries), selfrelaxation, passive stretching of the adductor muscles, proprioception of the hip and intravaginal massage. RESULTS: 81.25% of the women had a risk for sexual dysfunction and 43.75% for anxiety, and a significant difference (p <0.05) was found between all the outcome measures between: initial assessment and immediate post-treatment evaluation and between Assessment and evaluation after six months of treatment. There was a strong positive correlation between IFSF and Oxford; Strong negative correlation between IFSF and Mc Gill, and between HAD depression and Oxford measures. CONCLUSION: Physiotherapy treatment was effective for the treatment of coital pain. Contributing to improved sexual function, reduced risk for sexual dysfunction anxiety and depression of women with dyspareunia and vaginismus.

Vaginismus is defined as a persistent difficulty with vaginal entry, despite a woman’s expressed wish, due to muscle tension, avoidance, and/or pain (Basson et al., 2003). The disorder is classified as a sexual dysfunction; however, there is a paucity of literature on the sexual response, sexual function, and sexual behaviour of women with vaginismus. This thesis research was designed to investigate the differential aspects of sexual health in women with lifelong vaginismus, compared to women with lifelong dyspareunia (pain with intercourse) and women with pain-free intercourse. In the first study, 45 women viewed erotic films, of which one set depicted penetration and the other did not. Physiological sexual arousal was assessed via thermography. Subjective responses to films were assessed with questionnaires. Despite significantly greater negative emotions and lower mental sexual arousal in response to erotic stimuli, women with vaginismus showed genital arousal comparable to the comparison groups. In the second study, 174 women completed an online survey. Women with vaginismus reported more sexual difficulties than the no-pain group and a restricted range of lifetime sexual behaviours and lower frequency of intercourse attempts/experiences than the comparison groups. Women with vaginismus and dyspareunia reported more anxiety during sexual activity and a restricted sexual behaviour repertoire in the previous year and month compared to the no-pain group. Women with vaginismus endorsed more negative cognitions related to penetration, specifically concerns about losing control of their body and the situation. The findings suggest that sexual function difficulties and restricted behavioural repertoire may be associated with negative emotions and maladaptive cognitions. Women with vaginismus may avoid encounters that could lead to intercourse. Alternatively, the negative response to sexual stimuli may be indicative of a more global negative response to sexuality beyond intercourse. The negative penetration-related cognitions, negative responses to sexual stimuli, anxiety during sexual activity, and reduced range and frequency of sexual behaviours of women with vaginismus provide support for the Fear-Avoidance Model of Vaginismus. The impairment in sexual functioning supports the need to move beyond the singular treatment focus of making intercourse possible to an approach that addresses overall sexual rehabilitation.

INTRODUÇÃO: A dor coital é definida pelo Manual Diagnóstico e Estatístico dos Transtornos Mentais (DSM-IV), como transtorno de dor sexual, fazendo referência ao vaginismo e a dispareunia. OBJETIVOS: Avaliar o efeito da intervenção fisioterapêutica na dor coital, avaliar a função sexual das mulheres portadoras de dor coital, verificar presença risco para depressão e ansiedade, avaliar o impacto do tratamento fisioterapêutico na função sexual destas mulheres e identificar o número de sessões necessárias para redução da dor coital. MÉTODOS: Trata-se de um ensaio clinico controlado não randomizado que incluiu onze mulheres com diagnóstico de dispareunia e cinco com vaginismo, referenciadas para atendimento no Ambulatório de Estudos em Sexualidade Humana (AESH) do Departamento de Ginecologia e Obstetrícia da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. A avaliação prévia da dor foi realizada através da escala visual analógica (EVA) e Índice de dor de Mc Gill, para avaliação da função sexual foi utilizado o Índice de Função Sexual Feminina (IFSF). A Escala Hospitalar de Ansiedade e Depressão (HAD) foi utilizada para rastrear sinais de ansiedade e depressão, em seguida foi realizada a avaliação funcional e do tônus dos músculos do assoalho pélvico, pelo Sistema de Graduação Modificada de Oxford. Os recursos utilizados para o tratamento das mulheres foram orientações gerais (visualização dos músculos do assoalho pélvico e percepção corporal e importância das preliminares), auto- relaxamento, alongamento passivo dos músculos adutores do quadril, propriocepção e a massagem intravaginal. RESULTADOS: 81,25% das mulheres apresentavam risco para disfunção sexual e 43,75% para ansiedade, verificou se uma diferença significativa (p<0,05) de todas as medidas de desfecho entre: avaliação inicial e avaliação pós tratamento imediato e entre avaliação inicial e avaliação após seis meses de tratamento. Houve forte correlação positiva entre IFSF e Oxford; forte correlação negativa entre IFSF e Mc Gill, e entre as medidas HAD depressão e Oxford. CONCLUSÃO: O tratamento fisioterapêutico foi eficaz para o tratamento da dor coital. Contribuindo para melhora da função sexual, redução do risco para disfunção sexual ansiedade e depressão de mulheres com dispareunia e vaginismo. / INTRODUCTION: Coital pain is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as a disorder of sexual pain, referring to vaginismus and dyspareunia. OBJECTIVES: To evaluate the effect of physiotherapeutic intervention on coital pain, to evaluate the sexual function of women with coital pain, to verify the presence of risk for depression and anxiety, to evaluate the impact of physiotherapeutic treatment on the sexual function of these women and to identify the number of sessions required to reduce Coital pain. METHODS: This was a randomized non- controlled clinical trial that included eleven women diagnosed with dyspareunia and Five with vaginismus, referenced for care at the Ambulatory of Studies on Human Sexuality (AESH) of the Department of Gynecology and Obstetrics of the Medical School of Ribeirão Preto, University of São Paulo. Pre-assessment of pain was performed using the Visual Analogue Scale (EVA) and Mc Gill Pain Index. The Female Sexual Function Index (IFSF) was used to assess sexual function. The Hospital Anxiety and Depression Scale (HAD) was used to track signs of anxiety and depression, and functional and pelvic floor muscle tone assessment was performed by the Oxford Modified Graduation System. The resources used to treat women were general guidelines (visualization of the pelvic floor muscles and body perception and importance of the preliminaries), selfrelaxation, passive stretching of the adductor muscles, proprioception of the hip and intravaginal massage. RESULTS: 81.25% of the women had a risk for sexual dysfunction and 43.75% for anxiety, and a significant difference (p <0.05) was found between all the outcome measures between: initial assessment and immediate post-treatment evaluation and between Assessment and evaluation after six months of treatment. There was a strong positive correlation between IFSF and Oxford; Strong negative correlation between IFSF and Mc Gill, and between HAD depression and Oxford measures. CONCLUSION: Physiotherapy treatment was effective for the treatment of coital pain. Contributing to improved sexual function, reduced risk for sexual dysfunction anxiety and depression of women with dyspareunia and vaginismus.

Vaginismus is defined as a persistent difficulty with vaginal entry, despite a woman’s expressed wish, due to muscle tension, avoidance, and/or pain (Basson et al., 2003). The disorder is classified as a sexual dysfunction; however, there is a paucity of literature on the sexual response, sexual function, and sexual behaviour of women with vaginismus. This thesis research was designed to investigate the differential aspects of sexual health in women with lifelong vaginismus, compared to women with lifelong dyspareunia (pain with intercourse) and women with pain-free intercourse. In the first study, 45 women viewed erotic films, of which one set depicted penetration and the other did not. Physiological sexual arousal was assessed via thermography. Subjective responses to films were assessed with questionnaires. Despite significantly greater negative emotions and lower mental sexual arousal in response to erotic stimuli, women with vaginismus showed genital arousal comparable to the comparison groups. In the second study, 174 women completed an online survey. Women with vaginismus reported more sexual difficulties than the no-pain group and a restricted range of lifetime sexual behaviours and lower frequency of intercourse attempts/experiences than the comparison groups. Women with vaginismus and dyspareunia reported more anxiety during sexual activity and a restricted sexual behaviour repertoire in the previous year and month compared to the no-pain group. Women with vaginismus endorsed more negative cognitions related to penetration, specifically concerns about losing control of their body and the situation. The findings suggest that sexual function difficulties and restricted behavioural repertoire may be associated with negative emotions and maladaptive cognitions. Women with vaginismus may avoid encounters that could lead to intercourse. Alternatively, the negative response to sexual stimuli may be indicative of a more global negative response to sexuality beyond intercourse. The negative penetration-related cognitions, negative responses to sexual stimuli, anxiety during sexual activity, and reduced range and frequency of sexual behaviours of women with vaginismus provide support for the Fear-Avoidance Model of Vaginismus. The impairment in sexual functioning supports the need to move beyond the singular treatment focus of making intercourse possible to an approach that addresses overall sexual rehabilitation.