Major Theoretical Explanations of Vaginismus

Psychoanalytic Explanations and Treatment Approaches
Historically, psychoanalytic explanations of vaginismus conceived of the disorder as a rejection of the female role, a resistance against male sexual prerogative, a defense of the woman against real or fantasized incestual threats from her father, and a warding off of her own castration images (Fenichel 1945). Musaph (1977), a Dutch physician, suggested that the vaginismic woman unconsciously says to herself, "Now this big, dangerous instrument is going to penetrate me, there will be bleeding wounds; I will suffer unbearable pain and my revenge will be terrible" (quoted in Drenth 1988, p. 127).

Currently, traditional psychoanalytic therapists advocate an exploration of the unconscious fears and ambivalencies underlying the problem. Other psychoanalytically oriented therapists believe that a more active behavioral approach is needed in order to overcome the high anxiety accompanying the symptom. Kaplan (1974), for example, rejected the psychoanalytic view of vaginismus as a conversion symptom expressive of the woman's hostility toward men and her unconscious wish to castrate them in revenge for her own castration. Instead, she advocated a multicausal view of vaginismus as a conditioned response to any adverse stimulus associated with intercourse or vaginal entry. The goal of treatment is the extinction of the conditioned vaginal response. The essential element in treatment is to repeatedly expose the woman, both in fantasy and in reality, to the feared situation while keeping anxiety at a minimum and providing reassurance and support. From a psychodynamic perspective, it is also important to understand the conflicts the woman may have about becoming a "genital" woman. Since many woman with primary vaginismus tend to appear somewhat immature, insecure, and dependent (i.e., "younger than their years"), an investigation of patients' beliefs about sexuality, femininity, and mature womanhood is important.

Case Example Mrs. F had been married for 11 years prior to seeking treatment for vaginismus at age 34. She had avoided dealing with her sexual fears by literally drowning them in alcohol. It was only when her alcohol dependence could no longer be ignored and her husband threatened to leave the marriage that she consented to treatment. Following an inpatient stay at a rehabilitation center, she agreed to sex therapy.

Mrs. F presented as a youthful-looking woman with a long ponytail tied with a bow and "Mary Jane" shoes. Despite her "coed" appearance, she was articulate and thoughtful, although overly dependent on the therapist's approval. She often looked to the therapist for confirmation of her formulations and needed much encouragement and support throughout treatment.

Mrs. F's early history included an abusive father who regularly beat her brother and herself and a passive, insecure mother who failed to protect her and her brother from their father's violence. She was raised as a religious Catholic and was warned that she would be disowned and disgraced if she were to become pregnant premaritally. Moreover, Mrs. F' was admonished that if she thought menstruation was uncomfortable, she would be unable to deal with the excruciating pain of childbirth. These and similar messages were reiterated throughout her adolescence, and Mrs. F avoided even attempting tampon insertion.