Psychological connections between women and sexual dysfunctions

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The purpose of this paper is to explore the topic of female sexual dysfunctions and the psychological connections between women and their sexual dysfunctions. Sexual dysfunctions refers to a problem during any phase of the sexual cycle preventing women to encounter sexual satisfaction. Female sexual dysfunction can affect any women, age or race. Vaginismus sufferers were found to have cognitive and emotional responses which are essential factors of vaginismus symptoms as they expressed fear, anxiety, depression, avoidance behavior including sexual abuse victims. Vaginismus is a pain disorder that is described to be an involuntary pelvic muscle spasm that affects vaginal penetration. Treatments for vaginismus have been successful and effective through assessments, cognitive behavioral therapy, group counseling, and physical therapy and dilation programs.

"Female sexual dysfunction affects a significant number of women of all ages, but the prevalence tends to increase with age" (Merkatz, 2002, p.331). Sexual dysfunction includes many problems with desire, arousal, orgasmic, and pain within sex. Physiological changes as well as psychological issues are associated with female sexual dysfunctions. Many women that are diagnosed with this problem can relate with traumatic events and experiences a very negative emotional well being. The influence of cognitive and emotional factors is associated with specific sexual dysfunctions (Nobre, Pinto-Gouvela, 2008). Psychological assessments have indicated that emotional variables such as anxiety, depression, fear, and avoidance due to sexual traumatic events are linked to sexual dysfunction in women (Kaya, Unal, Ozenli, Gursoy, Tekiner, & Kafkasli, 2006). Sexual pain disorders can be a personal distress in a woman, not being able to experience sexual satisfaction, but her feeling of incompetence. Vaginismus although is the most common female sexual dysfunction the general population is unknown of this sexual pain disorder, and most of the time is misdiagnosed. "Vaginismus is understood as an involuntary muscle spasm that tightens the outer muscles of the vagina making penetration painful or impossible" (Hiller, 2000, p.87). Some women have negative view and strong feelings of carrying into intercourse as their experience have been painful. "Fear is the best predictors of vaginismus (Nobre, et al., 2008). Many women who suffer from the vaginismus are not able to receive a simple gynecological exam, or not able to insert foreign objects such as tampons or suppositories because of the extreme pain (Kullie, Weijenborg, Beekman, Bulte, Melles, & Onghena, 2009). Vaginismus is a treatable dysfunction and through many interventions programs as cognitive behavioral therapy, group therapy, physical therapy exercises and dilator programs it has been found to be effective. Education is also provided as a form of knowing about the dysfunction and the correlation with fear and avoidance behavior, it is a great way of recognizing the etiology of the dysfunction.

A women's lack of sexual activity can be a contribution to a number of things, but emotional problems and traumatic events are major issues that can interfere with her sexual functioning. The main factors related to all types of women's sexual dysfunction are their attitudes toward sex, quality in their relationships, and anxiety (Mcnabe, 2005). Women that are diagnosed with vaginismus have a higher level of anxiety as they are not supported by their partners or pressured to cure their condition. "Chronic pain may lead to anxiety and depression as inevitable stress" (Kaya, et al., 2006). Anxiety have a psychological contribution to vaginismus dysfunction as it brings out the fear of pain and creates an avoidance behavior to sex to avoid encountering pain. Anxiety and depression come together increasing the unpleasant feeling of despair, making them feel worse through the condition. Psychological and psychosexual distress due to muscle tightness may lead to physical signs of anxiety and depression and an increased severity in pain (Kaya et al., 2006). Fear is the centrality, and pain should not be presented as the core symptom, rather it is manifested as a genetical dysfunction representing anxiety in a much deeper level (Hiller, 2000). The women that suffer from vaginismus are to receive encouragement, love, and patience from their partners as that will help them to have a positive outlook to overcoming the condition. "Fear and avoidance behavior are increasingly considered to be key factors in vaginismus" (Kuile, et al., 2009, p. 149). Women share many feeling, experience especially hopelessness, but the biggest issue to them are beating down the walls of avoidance and fear. These women have a subset of fear perforation of their vaginal walls and are diagnosed with general anxiety disorder (Koeler, 2002). Women witness the response to pain and fear, just by getting a routine pelvic check. Investigated diagnostic criteria found that vaginismus and dyspareunia were significantly different, except that women with vaginismus display anxiety and fear during pelvic floor examination resulting in a complete avoidance of any form of vaginal penetration (Kuile, et al, 2009).

The decrease of sexual activity, the fear of penetration, and the inability to enjoy sex can all be initial responses from early child sexual abuse. "Women who have had a history of molestation in childhood, or adolescence are likely to present with vaginismus as part of their sexual dysfunction" (LoPiccolo & Stock, 1986, p. 161). Many women stated during interviews and completed questionnaires that being sexually abused have shaped this avoidance aversion and the fear of intimacy. A number of negative outcomes are associate with child sexual abuse including anxiety, depression, suicide attempts, low self-esteem, substance abuse, and problem with trust and intimacy (Merill, Guimond, Thomsen, & Milner, 2003). Moral disgust is another feeling that many women exhibit towards sexual intercourse as it see it as a disgusting activity. Sexual related behaviors that are uncommon women relatively feel a strong feeling of disgust just to imaging getting involved (Jong & Peters, 2009). Vaginismus can be found to be a sexual dysfunction in women that have been sexually abused because it gives them negative sexual outlook and they see sex with disgust. Disgust and fear are probable candidates for it proposes potential contamination to the involuntary contraction of the pelvic floor muscles in women with vaginismus, as they see the penis as contamination (Jong & Peters, 2009). Sexually abused women are presented with severe emotional and relationship difficulties (Gehring & Chan, 2001).

Despite a woman's expressed wish to do so, vaginismus is commonly described as persistent difficulties to allow vaginal entry of the penis, finger, or foreign object (Kuile, et al., 2009). A woman that suffers from vaginismus does not deliberately do this unfortunately they have no control over the muscle spam and this occurs as a reaction of their fear. By definition, in vaginismus, there is no physical lesion causing pain, is the psychosomatic contractions of the vaginal musculature caused by fear of penetration that is the problem (LoPiccolo & Stock, 1986). Psychological factors and sexual abuse and trauma can be a link to possible cause of vaginismus to many women. Women experience extreme pain during intercourse, and sometimes penetration is impossible creating for them great distress and an avoidance response to sex. Avoidance of penetration seems to be the only factor that differentiates between vaginismus and dyspareunia, because there is considerable overlap (Burgeron & Lord, 2003). There are two different classification of vaginismus there is the primary and secondary vaginismus. Primary (lifelong) vaginismus, is referred as the unconsummated marriage, were a women has never been able to have intercourse with penetration because of the involuntary muscle spasm (Hiller, 2000). Secondary vaginismus is referring to a woman that has experienced intercourse at one time, but no longer is able to be penetrated because of the contractions of the muscles spasm (Hiller, 2000). The psychological and emotional issues are what most of these women experience and they are very much related to the symptoms of the sexual dysfunction of vaginismus.

There is not a universal treatment for women that suffer from vaginismus. Clinicians use various methods such as self report to evaluate and review the psychological and physiological aspect of the female. The self report consists of interviews, questionnaires, and behavioral records that identify information and history of the patient. The interview process is one of the most earliest and common procedure for clinical assessments of sexual dysfunction (Conte, 1986). The interview is a tool that provides a description of the problem, and gives a closer look at the emotional feelings that are exposed through the use of specific questions. The counselor through these questions then is able to make diagnoses of the sexual dysfunction and recommendation for treatment is organized. Female deficiency can derive from many factors, and psychological patterns are best to recognize this dysfunction as they are connected to a patient's past. Self reports are essentials for assessment of sexual behavior (Conte, 1986). Counselors evaluate very critical the psychological, behavioral, and physiological context of the patients and through the formal interview it makes it easier to get know the patients personality. This form of assessment is an excellent way of having an accurate diagnose and is a better respondents to the patients.

Sexual activity is neglected by women, and vaginismus is one of that sexual dysfunction that is not very well understood. Psychological disorders are best treated through psychotherapy as it helps to find the source of the problem. The recurrent and persistent muscle spasm of the outer vagina interferes with penetration impairing intercourse from performing (Bergeron & Lord, 2003). Women that exhibit these symptoms to the condition of vaginismus are presented to sex therapy clinics.

The therapeutic goals and strategies used in cognitive behavioral therapy for pain and sexual dysfunction are to enable patients to: (1) Reconceptualize genital pain as a multidimensional pain problem influenced by a variety of factors including thoughts, emotions, behaviors, and couple interactions; (2) modify those factors associated with pain during intercourse with a view to increasing adaptive coping and decreasing pain intensity; (3) improve the quality of their sexual functioning and (4) consolidate skills (Bergeron & Lord, 2003, p. 137).

The aim of a therapist is to decrease the fear of pain and penetration and for to have patient take control over the involuntary muscle spasm. An approach through therapeutic addresses psychosocial, interpersonal, and developmental issues as well as dealing with physical reactions is more likely to encompass the full complexity of the female sexual response (Hiller, 2000). Cognitive therapy is use for restructuring of these pain irrational beliefs. The initial session clients are clarified in any area of sexual confusion, the necessity of foreplay and couples are to freely engage on arousing sex play (Sotile & Kilmann, 1977). Patients are to self explore their genitals and the area that they experience the pain. Vaginismus sufferers are willing to follow exposure therapy as it can reduce the avoidance behaviors, and be exposed to their fear, relieving a traumatic experience. Fear of penetration maintains avoidance behavior denies or precludes the opportunity to challenge any erroneous beliefs from cognitive perspective (Kuile, et al., 2009). The purpose of the exposure therapy is to enable the women to penetrate themselves, confronting fears of object penetration while relaxing, using fingers or dilators for vaginal penetration. The main factor in cognitive behavioral therapy is to explore the psychological distortions, help women to overcome the fear, achievement of penetration, couple reeducation, information on genital pains, and self-exploration.

The lack of education put many women at risk for painful encounters, not being educated of their normal functioning sex organs give them to be open to myths, fears, and inadequate communication with their sexual partners and health care providers. (Koehler, 2002).

The use of masturbation exercises adds relaxation and arousal as penetration can be accomplished. "Investigations of the effects of combining masturbatory training with other treatment techniques should also be undertaken" (Sotile & Kilmann, 1977, p. 627). Masturbating can alleviate the fear, as well as the psychological pressure with their partners; it will help them to identify these areas as pleasurable and not painful. The goal for 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 (Burgeron & Lord, 2003). Treatment steps can usually be completed at home using a self- help approach, allowing a woman to observe the illustrations and she can do this at the comfort of her own privacy, or in cooperation with her specialist. These approaches are very helpful strategies, to make the process a positive and successful experience.

Group therapy is evidence that is very efficient, conducting psychotherapy group for women diagnosed with primary and secondary vaginismus are very successful. The group treatment consisted of 15 sessions of complementary and alternative healing methods, cognitive-behavioral techniques, desensitization, and psychoeducational materials (Gehring, & Chan, 2001). Women that suffer from vaginismus, also have their partners suffering as well, feeling frustration, helpless, rejected so treatment for them is also important. Women manifesting sexual disorders, faulty sexual attitudes are sexually reeducated through group interactions as it diminishes their feelings of inadequacy and peculiarity (Sotile & Kilmann, 1977). The therapeutic group process emphasize that women and partners have the willingness to disclose repressed feelings, perception of sex, and the effects on their relationships (Gebring & Chan, 2001). Women that participated in the group reveal their excruciating pains of penile intercourse, and their concern about losing their partners to another sexual partner. "The first seven sessions focused on building rapport, individual belonging, and group cohesiveness (Gehring, & Chan, 2001, p.62). The group therapy consisted of various topics dealing with unpleasant memories, using visualization as technique. Each session promote relaxation, and desensitization to the thoughts relating to sexual contact also providing assertiveness and confidence training (Sotile & Kilmann, 1977). The group becomes a source of support and involves a trust within the group alleviating anxiety. Participants who develop relaxation methods began to reduce their fear, anxiety, pain, and would begin use of dilators (Gehring & Chan, 2001). The use of group therapy is recommended in treating women with sexual dysfunction as it serves as a healing method to improve a women's emotional functioning, and to give them the ability to have trust and security in a loving relationship.

Physical therapy and dilation programs are very effective as they help women that suffer from vaginismus. Patient can use this program and overcome fear and anxiety. Physical therapy use relaxation and vaginal exercises known as Kegel's exercises. The Kegel's exercises consist of pelvic floor exercises for strengthening and increasing control of vaginal muscles (Sotile & Kilmann, 1977). Many women that have found with vaginismus disorder have a high rate of muscle tensions. Physical therapy gives them a supportive atmosphere to experienced insertion by an experienced clinician reducing fears of physically harmed to women too phobic to try their own dilation (Koehler, 2002).

The main goal for physical therapy is to rehabilitate the pelvic floor: (1)increasing awareness and proprioception of the musculature; (2) improving muscle discrimination and muscle relaxation; (3) normalizing muscle tone; (4) increasing elasticity of the tissues at the vaginal opening, as well as desensitizing the painful area, (5) decreasing fear of vaginal penetration (Bergeron & Lord, 2003).

Painful genital sexual activity is probably contributing to the chronic pelvic floor hypertonicity that indicates based on findings that is should be dealt directly in treatment via physical therapy (Bergeron & Lord, 2003). Physical therapy shares the same therapeutic goals as cognitive behavioral therapy as they both want to decrease the fear of pain and penetration. The therapist performs the physical therapy techniques first in the office atmosphere so that the patients can learn and partners get involved. The convenience of physical therapy is that it can be done at home, and the specific techniques help a woman to relax the pelvic muscles. Initiated by moving a biofeedback vaginal sensor in and in and out motion, help patients to learn how to relax when there is movement in the vagina (Bergeron & Lord, 2003). Physical therapy and the use of vaginal exercises can be a great treatment vaginismus.

Dilation programs are also a great contribution to woman that has vaginismus. Vaginal dilators are referred to objects inserted into the vagina in an attempt to gradually condition the pelvic muscles to remain relaxed during penetration (LoPiccolo & Stock, 1986, p.160). "Early models for the treatment of vaginismus, such as perineotomy followed by daily insertions of glass dilators, hymenectomy, and psychoanalysis, all proved effective (Koehler, 2002, p.5). Dilators come in various sizes and some are plastic and flexible to help make insertion much easier and a more comfortable feeling. The penetration process should be controlled by the woman, sometime the partners can engage, making it more intimate, but should be administered by clinician. Dilation performed by gynecologist or by client herself at home research does not indicate differential effectiveness (LoPiccolo & Stock, 1986). A woman who is treated with these methods, voluntarily and seized to obtain control of her muscle spasm can allow the insertion of a resistant object such as a finger (Sotile & Kilmann, 1977). The dilation program is extremely effective and is clear if the couple can be convinced to follow the procedures without rushing to larger dilators, finger insertion, and entry of penis (LoPiccolo & Stock, 1986).

Cognitive behavioral therapy based on report and findings is the most suitable and effective treatment for women that suffer from vaginismus. Cognitive therapy is a valuable form of therapy because it works through the unhealthy emotions and aims to decrease in the reduction of fear and anxiety of penetration. In cognitive therapy there is the restructuring process and special attention given to the psychological disorders that are repressed feeling of anxiety and avoidance behavior which are main reasons for impairments of sexual intercourse. The use of exposure therapy confronts the patterns of fear and avoidance helping to break down the pattern and expose a stronger more confident attitude towards sexual activity. Self exploration is a great method to be combined with therapy as it helps women to explore with their bodies and work toward a positive outlook towards sex. Cognitive behavioral therapy does not provide a form of relaxation technique to their vaginismus patients, but as well as their partners. They involve the partners as they know that it is a difficult matter for them to accept as they feel unworthy and incompetence in their sexual activity. Treatment using cognitive therapy is extremely excellent and providing coping techniques to overcome the condition of vaginismus.

In conclusion, sexual dysfunction disorder of vaginismus is known to be an involuntary uncontrollable muscle spasm that makes penetration impossible. Psychological disorders are a clear connection to the vaginismus dysfunction. Emotional factors are very essential to the symptoms of vaginismus as it affects anxiety, depression, and the avoidance behavior of sexual activity. Women that suffer from this condition are in fear of any object of penetration, as they have had past experience of intercourse involving pain. The various treatments available are effective and reliable to the women that are diagnosed with vaginismus, it brings them to be able to increase their sexual attitudes and to understand their bodies through the self exploration techniques. Group therapy is a great interaction that provides to every woman and their partners a release of repressed feeling, and is able to provide them a supportive system of trust. The use of physical therapy through exercises is able to help giving the pelvic muscles to loosen up by the relaxation techniques, making a more comfortable penetration. The use of dilators is able to make the process more intimate as the partners are able to share the experience and see a change in their relationship. Effective treatments are a resourceful intervention that addresses psychological issues and brings a helpful hand to these women that suffer from vaginismus.