It may come as a surprise that the diagnosis of vaginismus can no longer be found in DSM-5. It may come as an even bigger surprise that until the publication of DSM-5, there had been virtually no change to the diagnostic definition of vaginismus in over 175 years. The spasm-based definition “recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse” was proposed by French physicians in the early 19th century.1 It is nearly identical to the criteria found in DSM-III and subsequent DSM editions. It is hard to find another diagnosis with such longevity. We suspect that this diagnostic longevity was not a testament to its validity but rather the result of the lack of critical attention.
In DSM-5, the spasm-based definition of vaginismus was dropped, and vaginismus was combined with dyspareunia, the other “sexual pain disorder,” which resulted in genito-pelvic pain/penetration disorder (GPPPD). A number of factors motivated these changes. The most important perhaps was that research did not support the premise that vaginal spasm was the crucial factor preventing intercourse.2,3 While such spasms can occur in some women, they account for only about a quarter of cases.3 What actually prevents intercourse appears to result from a variety of factors, including an intense fear of vaginal penetration or of pain during vaginal penetration, the experience of pain during penetration, and hypertonicity of the pelvic floor muscles.
A consideration of what typically happens during a gynecological examination to diagnose vaginismus may help to elucidate some of the historical confusion and current changes. What often happens during the examination is that the woman exhibits much distress, shuts her legs, turns away, and refuses to be examined. Not wishing to cause further distress or pain, the gynecologist reasonably does not force an examination and makes a diagnosis of vaginismus without ever verifying the presence of spasm.
When researchers systematically videotaped gynecological examinations for vaginismus and coded women’s facial expressions and behavior, it became apparent that the “vaginismic” woman was reacting phobically in the presence of the feared stimulus.4 The phobic stimulus was vaginal penetration. There was pelvic floor hypertonicity and sometimes spasm but probably as a result of the fear, just as a person with arachnophobia might tense up in the presence of a spider.
The idea that vaginismus could be conceptualized as a phobic state is not new and was proposed by Walthard in 1909.5 In fact, when a gynecologist succeeded in examining a woman with vaginismus, she was often also found to have provoked vestibulodynia (a vulvar pain syndrome). This empirical work suggested that the inability to experience intercourse was multimodal.
It became apparent that DSM-IV categorical definitions of vaginismus and dyspareunia did not reliably capture the variegated clinical presentations of women who have difficulties with vaginal penetration and/or genital pain. In fact, it was often diagnostically impossible to differentiate vaginismus from dyspareunia. Some women could have partial penetration, while others with time and relaxation could achieve penetration but experienced excruciating vulvar pain. This suggested that there was a spectrum of problems ranging from total inability to experience vaginal penetration to no apparent impairment in the ability to experience penetration despite pain and/or muscle tension. In the middle were varying degrees of comorbidity between pain, fear, pelvic floor hypertonicity, and penetration difficulties.
As a result, the new DSM-5 diagnosis of GPPPD reflects this spectrum conceptualization and allows for a diagnosis if the woman has recurrent and distressing difficulty with one (or more) of the following for at least 6 months: vaginal penetration during intercourse; marked vulvovaginal or pelvic pain during intercourse or attempted intercourse; marked fear or anxiety about the experience of vaginal or pelvic pain as related to vaginal penetration; marked tensing of the pelvic floor muscles during attempted vaginal penetration.
Ms. Perez is a Vanier Canada Graduate Scholar, and PhD Candidate in the department of psychology at McGill University, Montreal, Quebec, Canada, who has completed practica in sex therapy. She is currently completing her doctoral internship at the Couple & Family Therapy Service, Jewish General Hospital & Psychosocial Oncology Program, McGill University Health Center. Dr. Binik is Professor in the department of psychology at McGill University and founder and emeritus psychologist of the Sex and Couple Therapy Service, McGill University Health Center. The authors report no conflicts of interest concerning the subject matter of this article.
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