The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal.

BACKGROUND: Sex research lacks experimental studies in which both partners participate in a laboratory procedure. This is relevant in the context of genital pain because painful vaginal sensations often occur in the presence of the partner. AIM: To examine the effects of partner presence, sexual stimulation, and vaginal pressure on the appraisal of vaginal sensations and sexual arousal, ultimately aiming to increase the ecologic validity of laboratory designs. METHODS: A community sample of 42 women and their male partners watched sexual and neutral films while separated or together. We induced gradually increasing vaginal pressure in the women using an intravaginal inflatable rubber balloon. OUTCOMES: Women reported on pleasant and painful vaginal pressure and perceived genital arousal. Men and women reported on subjective sexual arousal. We also examined whether these appraisals were moderated by relationship satisfaction. RESULTS: The appraisal of vaginal pressure varied as a function of relationship satisfaction. Less satisfied women reported more painful pressure than women who were highly satisfied and highly satisfied women appraised the pressure as more pleasant in the context of a sex film and in the presence (vs absence) of their partner. In men and women, although partner presence had a negative effect on subjective sexual arousal, the presence of the partner did increase women's perception of genital arousal when vaginal pressure was induced during a sex film, particularly when women felt highly satisfied with their relationship. Also, the effects on subjective sexual arousal were moderated by relationship satisfaction. For couples in which the woman was less satisfied, the induction of vaginal pressure resulted in higher subjective sexual arousal when the partner was absent compared with when he was present, whereas when the man felt less satisfied, partner presence had a positive effect on sexual arousal. CLINICAL IMPLICATIONS: Interventions need to focus on the importance of sexual arousal during vaginal pressure stimulation and the way this is shaped by partner and relationship variables. Our results indicate that enhancing the relationship climate is an important target of intervention. STRENGTHS AND LIMITATIONS: We did not include physical indices of genital arousal and did not use a clinical sample of women with genital pain. CONCLUSIONS: The appraisal of vaginal sensations and sexual arousal are context-dependent responses that vary as a function of partner presence and sexual stimulation. Including both partners in the laboratory setting is important to create more valid models on sexual responding. Dewitte M, Schepers J, Melles R. The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal. J Sex Med 2018;15:539-549.

The Vaginal Pressure Inducer: A New Device to Test the (Un)pleasurableness and Tolerance of Vaginal Pressure and the Influence of Sexual Stimuli.

To better understand the impact of sexual stimuli on genital pain, a new instrument was developed: the Vaginal Pressure Inducer (VPI). We administered gradually increasing vaginal pressure with the VPI to sexually functional women as they watched a neutral, erotic, or explicit sex film. Women had higher unpleasantness thresholds in a sexual context compared to a nonsexual context. Moreover, ratings of pleasurableness were higher in the sexual compared to neutral context and most so during the explicit sexual film. These results provide initial support for the suitability of the VPI to study determinants of pleasant and unpleasant appraisal of vaginal pressure.

Attentional Bias for Pain and Sex, and Automatic Appraisals of Sexual Penetration: Differential Patterns in Dyspareunia vs Vaginismus?

INTRODUCTION: Current information processing models propose that heightened attention bias for sex-related threats (eg, pain) and lowered automatic incentive processes ("wanting") may play an important role in the impairment of sexual arousal and the development of sexual dysfunctions such as genitopelvic pain/penetration disorder (GPPPD). Differential threat and incentive processing may also help explain the stronger persistence of coital avoidance in women with vaginismus compared to women with dyspareunia. AIMS: As the first aim, we tested if women with GPPPD show (1) heightened attention for pain and sex, and (2) heightened threat and lower incentive associations with sexual penetration. Second, we examined whether the stronger persistence of coital avoidance in vaginismus vs dyspareunia might be explained by a stronger attentional bias or more dysfunctional automatic threat/incentive associations. METHODS: Women with lifelong vaginismus (n = 37), dyspareunia (n = 29), and a no-symptoms comparison group (n = 51) completed a visual search task to assess attentional bias, and single target implicit-association tests to measure automatic sex-threat and sex-wanting associations. RESULTS: There were no group differences in attentional bias or automatic associations. Correlational analysis showed that slowed detection of sex stimuli and stronger automatic threat associations were related to lowered sexual arousal. CONCLUSION: The findings do not corroborate the view that attentional bias for pain or sex contributes to coital pain, or that differences in coital avoidance may be explained by differences in attentional bias or automatic threat/incentive associations. However, the correlational findings are consistent with the view that automatic threat associations and impaired attention for sex stimuli may interfere with the generation of sexual arousal.

Therapist-Aided Exposure for Women with Lifelong Vaginismus: Mediators of Treatment Outcome: A Randomized Waiting List Control Trial.

INTRODUCTION: Therapist-aided exposure seems an effective treatment for lifelong vaginismus, but mechanisms of action have not yet been established. AIM: The purpose of the present study was to investigate whether treatment outcome of a therapist-aided exposure treatment was mediated by changes in positive and negative penetration beliefs or feelings of sexual disgust. METHODS: Participants with lifelong vaginismus were allocated at random to a 3-month exposure (n = 35) or a waiting list control condition (n = 35). MAIN OUTCOME MEASURE: Full intercourse was assessed daily during 12 weeks. Secondary outcome measures (complaints about vaginismus and coital pain) were assessed at baseline and after 12 weeks. Possible mediators: penetration beliefs (catastrophic pain beliefs, genital incompatibility beliefs, perceived control beliefs) and feelings of sexual disgust were assessed at baseline and 6 weeks. RESULTS: Treatment outcome (coital frequency, symptoms of vaginismus, and coital pain) at 12 weeks was mediated by changes in negative and positive penetration beliefs at 6 weeks, in particular by more pronounced reduction of catastrophic pain penetration beliefs. No evidence was found that changes in feelings of sexual disgust mediated treatment outcome. CONCLUSION: The results strongly suggest that therapist-aided exposure affects negative penetration beliefs and that these changes in negative penetration beliefs mediate treatment outcome in women with lifelong vaginismus. Implications for treatment are discussed.

Automatic and deliberate affective associations with sexual stimuli in women with lifelong vaginismus before and after therapist-aided exposure treatment.

INTRODUCTION: The intense fear response to vaginal penetration in women with lifelong vaginismus, who have never been able to experience coitus, may reflect negative automatic and deliberate appraisals of vaginal penetration stimuli which might be modified by exposure treatment. AIMS: The aim of this study is to examine whether (i) sexual stimuli elicit relatively strong automatic and deliberate threat associations in women with vaginismus, as well as relatively negative automatic and deliberate global affective associations, compared with symptom-free women; and (ii) these automatic and more deliberate attitudes can be modified by therapist-aided exposure treatment. METHODS: A single target Implicit Association Test (st-IAT) was used to index automatic threat associations, and an Affective Simon Task (AST) to index global automatic affective associations. Participants were women with lifelong vaginismus (N = 68) and women without sexual problems (N = 70). The vaginismus group was randomly allocated to treatment (n = 34) and a waiting list control condition (n = 34). MAIN OUTCOME MEASURES: Indices of automatic threat were obtained by the st-IAT and automatic global affective associations by the AST, visual analogue scales (VAS) were used to assess deliberate appraisals of the sexual pictures (fear and global positive affect). RESULTS: More deliberate fear and less global positive affective associations with sexual stimuli were found in women with vaginismus. Following therapist-aided exposure treatment, the strength of fear was strongly reduced, whereas global positive affective associations were strengthened. Automatic associations did not differ between women with and without vaginismus and did not change following treatment. CONCLUSIONS: Relatively stronger negative (threat or global affect) associations with sexual stimuli in vaginismus appeared restricted to the deliberate level. Therapist-aided exposure treatment was effective in reducing subjective fear of sexual penetration stimuli and led to more global positive affective associations with sexual stimuli. The impact of exposure might be further improved by strengthening the association between vaginal penetration and positive affect (e.g., by using counter-conditioning techniques).

The Sexual Disgust Questionnaire; a psychometric study and a first exploration in patients with sexual dysfunctions.

INTRODUCTION: Disgust may be involved in sexual problems by disrupting sexual arousal and motivating avoidance of sexual intercourse. To test whether heightened disgust for sexual contaminants is related to sexual dysfunctions, the Sexual Disgust Questionnaire (SDQ) has recently been developed. Previous research showed that particularly women with vaginismus display a generally heightened dispositional disgust propensity and heightened disgust toward stimuli depicting sexual intercourse. AIM: To determine the psychometric properties of the SDQ and test whether heightened disgust toward sexual stimuli is specific to vaginismus or can be observed in other sexual dysfunctions as well. METHODS: First, a large sample of undergraduates and university employees completed the SDQ (N = 762) and several trait disgust indices. Next, women with vaginismus (N = 39), dyspareunia (N = 45), and men with erectile disorder (N = 28) completed the SDQ and were compared to participants without sexual problems (N = 70). MAIN OUTCOME MEASURE: SDQ to index sexual disgust. RESULTS: The SDQ proved a valid and reliable index to establish disgust propensity for sexual stimuli. Supporting construct validity of the SDQ, sexual disgust correlated with established trait indices. Furthermore, sexual disgust and willingness to handle sexually contaminated stimuli were associated with sexual functioning in women, but not in men. Specifically women with vaginismus displayed heightened sexual disgust compared to women without sexual problems, while men with erectile disorders demonstrated a lower willingness to handle sexually contaminated stimuli compared to men without sexual problems. CONCLUSIONS: The SDQ appears a valid and reliable measure of sexual disgust. The pattern of SDQ-scores across males and females with and without sexual dysfunctions corroborates earlier research suggesting that disgust appraisals are involved especially in vaginismus and supports the view that the difficulty with vaginal penetration experienced by women in vaginismus may partly be due to disgust-induced defensive reflexes that could disrupt sexual arousal.

Cognitive-behavioral therapy for women with lifelong vaginismus: process and prognostic factors.

Cognitive-behavioral therapy (CBT) seems an effective treatment of lifelong vaginismus, but mechanisms of action have not yet been established. The present study explored whether the effect of CBT for lifelong vaginismus is mediated by changes in fear of penetration and avoidance behavior, which CBT explicitly aims to alter. A second aim of this study was to predict treatment outcome on the basis of pre-treatment variables. Participants with lifelong vaginismus were allocated at random to a 3-months CBT (n=81) or a waiting-list control condition (n=36). Full vaginal penetration with the penis of the partner constituted the primary outcome measure. Change scores in successful 'non-coital penetrative-behavior' and 'fear of coitus' were used to measure the mediating variables. Treatment resulted in an increase of intercourse (outcome), a decrease in fear of coitus, and an enhancement of successful non-coital penetration behavior, compared with no treatment. Outcome (intercourse) was partly mediated by changes in fear of coitus and changes in avoidance behavior. No treatment predictors could be detected in this study sample. It is concluded that techniques such as gradual exposure, aimed at decreasing avoidance behavior and penetration fear, constitute an important avenue of change in the treatment of lifelong vaginismus.

Cognitive-behavioral therapy for women with lifelong vaginismus: a randomized waiting-list controlled trial of efficacy.

Women with lifelong vaginismus (N=117) were randomly assigned to cognitive-behavioral group therapy, cognitive-behavioral bibliotherapy, or a waiting list. Manualized treatment comprised sexual education, relaxation exercises, gradual exposure, cognitive therapy, and sensate focus therapy. Group therapy consisted of ten 2-hr sessions with 6 to 9 participants per group. Assistance with minimal-contact bibliotherapy consisted of 6 biweekly, 15-min telephone contacts. Twenty-one percent of the participants left the study before posttreatment assessment. Intent-to-treat analysis revealed that successful intercourse at posttreatment was reported by 14% of the treated participants compared with none of the participants in the control condition. At the 12-month follow-up 21% of the group therapy participants and 15% of the bibliotherapy participants, respectively, reported successful intercourse. Cognitive-behavioral treatment of lifelong vaginismus was thus found to be efficacious, but the small effect size of the treatment warrants future efforts to improve the treatment.

Therapist-aided exposure for women with lifelong vaginismus: a randomized waiting-list control trial of efficacy.

OBJECTIVE: Vaginismus is commonly described as a persistent difficulty in allowing vaginal entry of a penis or other "objects" (e.g., tampons, fingers, speculum). Lifelong vaginismus is diagnosed when a woman has never been able to have intercourse. The aim of this study was to investigate the efficacy of therapist-aided exposure for lifelong vaginismus. METHOD: Seventy women and their partners were randomly allocated to exposure or a waiting-list control period of 3 months. The main outcome measure (intercourse ability) was assessed daily during 12 weeks. Secondary outcome measures were complaints about vaginismus, coital pain, coital fear, sexual distress, and sexual functioning. The exposure treatment consisted of a maximum of three 2-hr sessions during 1 week at a university hospital. Each participant performed vaginal penetration exercises herself, in the presence of her partner and a female therapist. Two follow-up sessions were scheduled over a 5-week period. RESULTS: Thirty-one out of 35 (89%; 95% CI [72%, 96%]) participants reported having had sexual intercourse at posttreatment compared with 4 out of 35 (11%; 95% CI [4%, 28%]) participants in the control condition. In most of the successfully treated women (90%), intercourse was possible within the first 2 weeks of treatment. Moreover, treatment resulted in clinical improvement regarding other symptoms related to vaginismus, coital fear, coital pain, and sexual distress. No treatment effects were found regarding other aspects of sexual functioning in women or their partners. CONCLUSIONS: This study provides evidence of the efficacy of therapist-aided exposure therapy for women with lifelong vaginismus.

Therapist-aided exposure for women with lifelong vaginismus: a replicated single-case design.

Vaginismus is commonly described as a persistent difficulty in allowing vaginal entry of a penis or other object. Lifelong vaginismus occurs when a woman has never been able to have intercourse. A replicated single-case A-B-phase design was used to investigate the effectiveness of therapist-aided exposure for lifelong vaginismus. A baseline period (Phase A) was contrasted with exposure + follow-up (Phase B), using random switching between phases. The main outcome measure (intercourse ability) was assessed daily for 24 weeks. Ten women participated. The exposure consisted of a maximum of three 2-hr sessions during 1 week at a university hospital. The participant performed vaginal penetration exercises on herself, in the presence of a female therapist. Two follow-up sessions were scheduled over a 5-week period. Nine of the 10 participants reported having intercourse after treatment, and in 5 of the 9, intercourse was possible within the 1st week of treatment. The results remained at 1-year follow-up. Furthermore, exposure was successful in decreasing fear and negative penetration beliefs posttreatment and at 3-month and 1-year follow-ups. Therapist-aided exposure appears to be an effective treatment for lifelong vaginismus.