Cognitive behavioral therapy in the treatment of vaginismus

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Sexual dysfunction is the name given to disorders that “prevent the person from having sexual intercourse in the way they want”. Sexual intercourse consists of four stages: interest and desire, arousal, satisfaction and relaxation. The emergence of inhibition in one or more of these stages leads to sexual dysfunctions. One of these disorders is sexual pain disorder called vaginismus.

Vaginismus can be defined as the inability of a woman to enter her vagina with a penis, finger or any other object. This picture is accompanied by varying degrees of involuntary muscle contractions, phobic avoidance, and fear of pain. The absence of a history of penile penetration into the vagina is called primary vaginismus, while the presence of a previous history of vaginal entry is called secondary vaginismus.

According to DSM-IV-TR, vaginismus is a female sexual dysfunction, and it is the repetitive or persistent involuntary contraction of the muscles in the outer third of the vagina, preventing coitus (American Psychiatric Association 2000). These involuntary contractions are a physical reaction that narrows the vaginal passage, causing sexual intercourse to not take place or to be painful. In the DSM-5 (American Psychiatric Association 2013), vaginismus is included in a new diagnostic category, Genital-Pelvis Pain/Peeling Disorder, which encompasses a wide range of pain and penetration problems. While the prevalence of vaginismus worldwide is between 1-7%, it is stated that the rate increases to 5-17% in clinical conditions. In our country, it is seen that these rates are much higher (41.7%, 58.06%, 41%, respectively) in different studies.

This difference is thought to be due to the attitudes of eastern societies encouraging celibacy and prohibiting premarital sexual intercourse, and the inadequacy of sexual education given in these countries.

Vaginismus symptoms can be explained by Vlaeyen and Linton’s fear-avoidance model. According to this model, the interpretation of vaginal entry as a disaster causes increased fear during sexual intercourse. This allows attention to be focused on bodily emotions and pain, pelvic muscle contractions occur during attempts at vaginal entry. Repetitive muscle contractions cause painful and unsuccessful attempts. An increase in the number of unsuccessful attempts feeds the person’s negative thoughts. The feeling of inadequacy caused by not being able to achieve sexual intercourse, the thought or fear of pain during the trials are common problems in women with vaginismus. These problems can suppress sexual arousal and cause other sexual problems (reluctance, orgasm problems). Insufficient wetting in the vagina together with insufficient stimulation can make penile entry into the vagina more difficult and increase the symptoms of vaginismus. In this way, vaginismus and other sexual problems caused by it can affect the quality of life of both women with vaginismus and their partners.

The only treatment targeting sexual problems caused by vaginismus is sexual therapy based on cognitive behavioral methods. This treatment provides spiritual support to couples struggling with feelings of shame, inadequacy and helplessness, reduces their anxiety level and corrects their wrong beliefs. In this way, sexual therapy based on cognitive behavioral methods can be a useful method for women with vaginismus sexual problems other than vaginismus or for the sexual problems of their spouses.

From the cognitive behavioral perspective, factors that facilitate the occurrence of false sexual dysfunction are:

The family and society’s perspective on sexuality

Extremely conservative and religious upbringing

Missing or incorrect sexual information

Unrealistic expectations about sexuality

Negative relationship between parents

Early traumatic experiences

The form of communication between spouses

High arousal threshold

neurotic personality traits

Intimacy problems

separation anxiety

Exposure to sexual abuse

People are generally hesitant to reveal their sexual problems to others. In therapy, it is very important for the therapist to have a good understanding of the feelings and thoughts of the person who has a sexual problem and to help in solving the problem. Cognitive Behavioral Therapy method is very effective in the treatment of sexual dysfunctions.

We can consider the treatment process in cognitive-behavioral sexual therapies under 4 headings:

1) The first thing to do is to understand what the problem is and what is wanted to be changed about the problem, and to determine the purpose of the treatment. Many false beliefs and attitudes about sexuality pave the way for sexual dysfunctions. Couples with sexual dysfunction generally have a very low level of sexual knowledge. Correct sexual information and education, eliminating the lack of sexual information and correcting false information and beliefs constitute the first step of treatment.

2) To reveal the factors that prepare, reveal and maintain the problem. Couples with sexual dysfunction often have a severe lack of communication in both sexual and non-sexual areas. The issues that couples have difficulty in expressing to each other should definitely be discussed. The second step is to develop communication skills with homework such as telling something he/she likes to his/her spouse, expressing an aspect that he/she likes in his/her spouse, expressing a behavior that he/she dislikes in his/her spouse, reading a sexually explicit article together, viewing a sexually explicit magazine together, and telling a sexual fantasy to his/her spouse. .

3) To create the treatment plan to be applied. During the therapy process, couples will avoid doing their homework from time to time. The dynamics underlying the assignments not done in the sessions are questioned, situations arising from automatic negative thoughts in the subconscious are identified and examined. Studies are carried out to help clients acquire more functional thoughts by raising awareness of the underlying negative thoughts, experiences and images.

4) At this stage, it is ensured that correct behaviors are displayed instead of wrong behaviors. Different behavioral goals are determined in different sexual dysfunctions such as vaginismus, premature ejaculation, impotence. The prohibition of sexual intercourse, exercises to focus on extra-genital area and genital sensations, breathing and relaxation exercises, progressive vaginal expansion exercises, progressive coitus exercises, masturbation and intercourse exercises, imagination and role-playing exercises, stop and start exercises, tightening exercises. practices are taught to individuals.

A large proportion of people with sexual dysfunction, such as 70%, overcome their problems with cognitive-behavioral therapy. The relationship of trust and intimacy established with the therapist plays a very important role in progress.


“The effects of sexual therapy based on cognitive behavioral methods on the sexual problems of women with vaginismus and their spouses”, Özdel et al. p.129

“The Effect of Cognitive Behavioral Therapy on Sexual Satisfaction, Marital Adjustment, Depression and Anxiety Symptom Levels in Couples with Vaginismus”, Turkish Journal of Psychiatry, 2017;28(3):172-80

“Cognitive Behavioral Therapies”, Turkish Psychological Association Publications

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