Journal of Sex & Marital Therapy

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Treatment of primary vaginismus: A new

perspective

Jeanne Shaw

To cite this article: Jeanne Shaw (1994) Treatment of primary vaginismus: A new perspective,
Journal of Sex & Marital Therapy, 20:1, 46-55, DOI: 10.1080/00926239408403416

To link to this article: http://dx.doi.org/10.1080/00926239408403416

Published online: 14 Jan 2008.

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 Treatment of Primary Vaginismus:
A New Perspective
JEANNE SHAW

This paper challenges the efficacy of a cognitive-behavioral treatment

model for women with primary vaginismus and proposes a conceptual
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shft from a focus o n behavior to a focus on differentiation. Primary

vaginismus is viewed as a somatic boundary, a symbolic description of
a n opportunity f o r differentiation. Four relevant themes are considered:
I ) mastery versus incompetence; 2) autonomy versus dependence; 3 )
boundary versus fusion; and 4) the effect on the therapy of the therapist’s
level of differentiation. Change at this particular time in history in-
volves shifb in clinical focus from sexual frequency to quality, from
performance to experience, from compliance to mastery, and from utili-
zationfunction to sexual potential. A case is made f o r sexual competence
based on selfcompetence instead of on behavior. A reevaluation of what
constitutes success, both behavioral and developmental, proposes a n
increase in dfferentiation in addition to symptom relief.

For over two decades the treatment of vaginismus has emphasized a

cognitive-behavioral approach. A shift from psychoanalytic to behavioral
treatment in the late 1960s and early 1970s gave relief to many women
who had developed either primary or secondary vaginismus. For the
purposes of this paper, primary vaginismus is defined as vaginismus that
is congenital or that develops before the first occasion of penis-in-vagina
sexual activity. Secondary vaginismus is defined as vaginismus that is
acquired through conditioning or experience after a woman has become
sexually active. Women with primary vaginismus sometimes have bene-
fited from cognitive-behavioral treatment and sometimes have not.
The purpose of this paper is to challenge the efficacy of a cognitive-
behavioral treatment model for many women with primary vaginismus
and to propose a conceptual shift from a focus on behavior to a focus on
differentiation. This proposal is based on Murray Bowen’s indication that
the ability to mate successfully increases in direct proportion to one’s
level of differentiation. ’,*
Address correspondence to Jeanne Shaw, Ph.D., 145 Inland Drive, NE, Atlanta, GA 30342-2059.

Journalof Sex 8c Marital Therapy, Vol. 20, No. 1, Spring 1994 0 Brunner/Mazel, Inc.
46
 Treatment of Primary Vaginismus 47

a
Differentiation, functionin autonomously with emotional and physical
maturity, is vital to women w o consciously want, and yet physically can-
not allow, vaginal penetration. The differentiation process allows these
individuals to explore their symptom, make conscious the somatic symbol,
e
begin to be themselves in relationshi and learn to function in the service
of personal growth. Maturation he ps individuals to look at and handle
fear, dread, and anxiety, and to behave sexually as an expression of self
rather than as a perceived responsibility for a partner’s need for sex.
Schnarch’ elaborates on the process: “At the highest level of differenti-
ation, the individual is sure of hidher beliefs, convictions, and self-assess-
ment-but capable of hearing others’ viewpoints and discarding old be-
liefs in favor of new ones. He/she can listen without reacting, tolerate
intense feelings, and not act automatically to alleviate them. Individu-
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als . . . can respect the identity of others without becoming critical or

involved in tryin to modify others’ life course. He/she is realistically
aware of hidher c fependence on others and is free to enjoy relationships”
(p. 201).
Schnarch3 further elaborates on abilities the differentiating person
achieves, such as: maintaining one’s own identity in close proximity to
a partner; soothing oneself in the face of deprivation or anxiety; self-
regulating emotions instead of surrendering to limbic (automatic) re-
sponses; maintaining self-presence in the face of one’s partner’s anxiety;
tolerating ambivalence and the inherent paradoxes in living; being resil-
ient to the contagion of anxiety; tolerating emotional pain and anxiety
in the service of personal experience and growth; and being able to stand
apart, separate and different, in the service of intimacy with self and
intimacy with partner.
Normative biases of some therapists, however, do not support intimacy
or maturation, they obligate therapists to help people have sex, even
obligatory sex, to relieve the pressure for sexual intercourse. The idea
of normative bias is a core issue about sex thera y standards raised first
g
~ * ~largely ignored y clinicians. Therapist
in 197’7 by A p f e l b a ~ m and
a
expectations for partners to behave sexually is a demand strate y. This
is illustrated in present vaginismus treatment by the use of be avioral
techniques that manipulate a woman’s genitals open in the name of nor-
mality. Technique and expectation, coupled with inattention to differen-
tiation needs, contributes to the intrusiveness of behavioral intervention.
Behavioral techniques are powerful; they can change behavior without
allowing for the ersonal emotional development that could accompany
F
or follow such a iteral opening of the body to a partner. Success can be
based first on differentiation and autonomy, then on sexual behavior.
Cognitive-behavioral approaches such as in vivo desensitization, self-
control, Kegel exercises, progressive relaxation training, fantas , in-
serting fingers and/or dilators, audiovisual education, use of the l efen-
sive or systemic nature of the symptom, and gynecological exam have
uided many couples in achieving penis-in-vagina intercourse. There-
fore, when treatment appears successful, why change it?
Perhaps the treatment need not be altered for women with secondar
vaginismus, a conditioned response needing simply to be deconditione d
 48 Journal of Sex &-? Marital Therapy, Vol. 20, No. I , Spring I994

A close look at standard treatment of primary vaginismus, however, re-

veals a relentless assault on a symptom that carries a symbolic message
we are apparent1 not getting, at least not in published accounts of sex
therapy fai1uresJ7 The mesa e of the symptom is about lack of self-
defined boundaries, not lack o sex.'i:
An alternative treatment approach advances the individual's sense of
self, allows rather than forces openness, and reco nizes each partner's
i
personal responsibility to grow, heal, and self-vali ate i n relationshz A
trend increasingly noted in clinical resentations and the literature is 8-9
P
that techniques alone can adverse y affect people, especially women,
whose sexual development lags behind their sexual competence. The cost
to the individual can be autonomy or individual rowth. The cost to
the couple can be their lack of awareness of inert, fused, codependent,
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transferential, or stagnant relationship patterns. This lack of self and

relational awareness is a trade-off for utilitarian sex, passionless yet func-
tional, a monotonous completion of the sexual response cycle.
The usual treatment for primary vaginismus consists essentially of
shaping a woman's behavior to fit her partner's (and society's) expectation
that she perform.10." Current treatment enables her to tolerate penetra-
tion, please her partner, and feel like a woman. These achievements help
her feel functional and competent. Feelin functional, she now behaves
x P
on behalf of her artner to express herse f through sexual intercourse.
In actuality, she oes not feel self-contained enough to express herself
to hemelf, let alone to her partner-although after treatment she may be
physically able to behave, but not experience, this expression.
The past captures her in an unnecessary survival mode until she inten-
tionally claims the right to be in charge of herself and her body, including
its use, misuse, and disuse. All of which raises the question: Does she
want to sewice her partner or does she want to want him?3A problem can
develop when she matures enough to feel used. After learning how to
tolerate and enjoy sexual intercourse for him, what she wants is to be
wanted, yet she is afraid to want him. Why is she afraid to want him
physically?
Vaginismus lets us know that the subconscious drive to avoid an ego
boundary violation is in high gear. The therapist's task is to create a
milieu in which a couple can transform their res ective historical survival
K
energies into closeness and intimac , where fig t, flight, compliance or
dissociation are no longer requirecr coping strategies. Therapists have
both an opportunity and responsibility to pose uestions that can shift
P
people from a position of normative bias to one o growth and differenti-
ation.
Instead of engaging each other in somatic, security-seeking ways,12
they could gain awareness, for example, of how pressure for reassurance
burdens the partner who does the reassuring and demeans the partner
who ets it. They can consider how a somatic boundary such as va inis-
f
mus orfeits her obligation to herself to self-define boundaries ver ally. %
Both partners deceive themselves when they tolerate a sexual relationship
without appropriate sychological separateness-the alternative to oblig-
P
atory sex is being ab e to define effectively one's own boundaries.
 Treatment of Primary Vaginismw 49

The couple, not the therapist, should be in charge of directing how

they use her body or his. The therapist can be in charge of the process,
illuminating the meaning to their behavior, anxiety, and suffering. A
person’s right to be in charge of hidher own body is sometimes dimin-
ished by standard sex therapy techniques. Encouraging one person via a
demand interventive strategy to sexually service the other in the name
of normality, for example with vaginismic women and nonejaculating
men, diminishes both partners in a relationship.
Apfelbaum5 elaborates on the detrimental results of demand strategy
treatment for men with retarded ejaculation; this also applies to vaginis-
mic women. Both disorders are treated with standard sex therapy tech-
niques which demand a normative response from the patient. The follow-
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ing paragraph is quoted with “vaginismus” substituted for “retarded

ejaculation” [in brackets] to illustrate the pressure of behavioral norms
and demand strategies of therapy:

The [vaginismic woman] is the object of what is by far the most

aggressive attack on a symptom to be found in the field of sex
therapy. The use of a coercive strategy with [vaginismus] has
even gone so far as to include such an unceremonious proce-
dure as [gradients of dilators coupled with required relaxation]
used to force [the PC muscle open]. The standard procedure
for treating [vaginismus] is to use a demand strategy . . . The
idea behind this strategy is that [the PC muscles are in spasm]
and that [relaxation and dilation] will break the ‘spell’ . . . This
approach to patient care reveals a normative bias and a poten-
tial for coercion inherent in standard sex therapy practice^.^
(pp. 174-175)

Thus, it is not surprising that standard sex therapy for the vaginismic
woman has a not-so-subtle coercive component. Almost every published
report of successful vaginismus treatment in the last 20 years is based on
methods to induce the woman to perform sexually and to ignore the
message of her PC muscle spasm. The bind we create as clinicians is
trying to reduce performance anxiety with an inherently coercive de-
mand approach. The misfortune is that the focus is on performance and
compliance, not on self and self-expression.

INVITATION T O CHANGE PERSPECTIVES

T o move the treatment of vaginismus from a focus on behavior to a focus

on differentiation, we need to consider at least four relevant themes:
1) mastery versus incompetence; 2) autonomy versus dependence; 3)
boundary versus fusion; and 4) the effect of the therup.st’s level of differ-
entiation.
 50 Journal of Sex [j, Marital Therapy, Vol. 20,No. I , Spring 1994

Mastery versus Incompetence

The antidote to feelings of incompetence is mastery of self. Do therapists,
knowing this, support mastery? Do they continue teaching vaginismic
women to sexually service a partner just because both partners respect-
fully request such inherently disrespectful behavior? A problem conspic-
uous to the vaginismic woman is her conscious desire to please her part-
ner and her unconscious desire to protect her integrity. She can resolve
the paradox with a shift in belief; her conscious desire to please herself
paradoxically can also please him and bring pleasure to both.
While subconsciously withholding herself from her partner emotion-
ally and physically, the real issue is that she is withholding her Self (her
reality, identity, and autonomy)from herself. When she claims the right to
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herself and can maintain her own identity in close proximity to her part-
ner, connecting deeply with herself, she can invite her partner in both
emotionally and physically. Shifting to self-competence and mastery, em-
phasis on self, results in each partner actually being sexually competent
(as opposed to behaving it).
Partners can learn the difference between wanting the other and want-
ing the other to give them sex, as a commodity instead of an expression
of self. They can explore and evaluate their abilities to self-soothe when
one or both distances, applies pressure, or experiences anxiety. They can
risk being sexually competent, individually and relationally, by being real
instead of being compliant or helpful. This does not give them license to
intimidate each other; rather, it frees them up to be who they reaZZy are
in the presence of the other. A partner’s love can force our growth or
confront us to see ourselves in ways we have spent years avoiding.’*
Sexual competence can be both extraordinary and utilitarian. Extraor-
dinary competence means reaching for one’s sexual p ~ t e n t i a la, ~lifelong
aspect of actualization that usually happens best, if at all, in a long-term
committed relationship between differentiating partners, or sometimes,
simply after midlife passes and old age begins.
Utilitarian competence is another term for functional or obligatory sex.
Utilitarian sex is what many people in long-term relationships complain
about-boring, monotonous physical release. The result of measuring
one’s normality by the ability to provide obligatory, utilitarian sex is to
defeat the purpose of being in a loving, growing relationship where each
partner is willing to inspire the relationship to deeper, more intense levels
of contact and intimacy.
Sex therapists working without a differentiation lens rarely caution
against obligatory or negotiated sex; quite the opposite, we teach it. This
is most notable with vaginismic and other couples where negotiating for
sex is the norm. When partners want each other, negotiation is not an
issue. Self and intimacy are intensely personal, not interpersonal; they
are experience, not behavior. While relationships and behavior may be
negotiable, experience is not. This is the crux of the problem with behav-
ioral treatment for people with unseen, unmet growth potential.
In the face of emotional fusion, florid transferences, abandonment
 Treatment of Primary Vaginismus 51

issues, and engulfment fears, behavioral techniques and negotiation for

sex can compromise integrity and experience for couple and therapist.
When a therapist requires a couple to have a penis-in-vagina outcome in
order to pronounce the therapy successful (and, perhaps, diminish the
therapist’s own performance anxiety), integrity and experience are com-
promised. No matter how diligently we teach patients and ourselves to
relax, anxiety remains necessary for emotional growth. The ability to
tolerate increasing levels of anxiety and continue to function is one aspect
of this growth process.
Autonomy versus Dependence

The antidote for dependence is autonomy, with special emphasis on

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ownership: To whom does the woman’s vagina belong? This seemingly

simple question can subtly pit the vaginismic woman against therapist
and partner in a covert power struggle. The therapist and partner be-
come allied through their normative bias (e.g., “To be normal she must
have penis-in-vagina”),a bias which often leads to impasses and treatment
failures.
With current practice standards, a couple and therapist treat a woman’s
vagina as though it were owned conjointly. A nonresistant, compliant
woman, thus takes the stance, “My vagina belongs to you, too. I relinquish
sole ownership in order to feel like a normal woman to have normal sex
for my normal partner.” Thus, a functional vagina can service a utilitar-
ian illusion of shared genitals.’
On the other hand, a resistant, noncompliant woman, protecting her
integrity against the onslaught of societal, partner, and therapist norma-
tive biases, holds onto her boundaries unconsciously via PC spasms until
she can learn to do it verbally, in relationship to herseZf. If she is to hold on
to herself with conscious intent, somebody in the treatment room must
support her claim to sole proprietary rights to her genitals. Who defines
her rights?
With a therapy standard that promotes normality (fusion) more than
integrity (differentiation), and behavior (penis-in-vagina) more than ex-
perience (self-encounter), therapists and partners define and, unfortu-
nately, disempower the vaginismic woman. The choice between her integ-
rity and her self-imposed obligation to satisfy her partner’s sexual needs
jeopardizes her decision. Under present standards either he has rights
or she does. This is an unconscionable dilemma for therapists. “Your
vagina belongs to him. Let’s help you do penis-in-vagina intercourse.
When you behave in the normal way we will consider the case successful”
(as though “normal” equals ability to contain something in the vagina).
With a differentiation stance, we separate her right to integrity from
his n e e d - o r her belief in his need-to be fulfilled by her. We validate
her right not to want sex and give her enough consideration and support
to decide whether or not she wants him. If she decides she wants him,
she can want him sexually on her own terms and behalf, not to comply but
 52 J o u m l of Sex & Marital Therapy, Vol. 20, No. 1, Spring 1994

to connect. Wanting one’s partner is antithetical to negotiated, utilitarian,

coercive, boring, or obligatory sexual behavior.
We Ban encourage him to use the opportunity to decide whether he
wants her to service him or to want him, recognize what he wants and
learn to retain his self-worth if he doesn’t get it from her. This is not
encouragement for sex outside of the relationship; it is an opportunity
to learn self-soothing, self-respect, self-mastery, and self-identity in rela-
tionship.

Boundary versus Fusion

One element in the overall issue of boundaries is who gets to do what to

whom. This equation includes the therapist. Therapists can unravel fu-
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sion patterns and help patients define clearer personal boundaries by

including a differentiation perspective in their work. Or, they can inad-
vertently and unknowingly support static patterns inherent in a fused
relationship. This implies that each partner and therapist has or is willing
to acquire ego boundaries such that each experiences herself/himself as
separate and different from the other, especially in the face of pressure
for togetherness and similarity,’p2reciprocity and mutuality.’
Boundary issues belong to both partners, not just to the person carrying
the observable symptom, and to the therapist. The major purpose of
boundaries is for each person in the therapy room to develop and use
an increasingly solid sense of self, each structuring and strengthening
their own ego boundary in order to experience self as separate and
different from others. The couple does this in relation to each other and
the therapist does this in relation to each partner. The therapist who can
be self-responsible, aware, congruent, and present models these and
other desirable qualities. Couples may then subliminally acquire the en-
acted qualities.
Therapist’sLevel of Dqferentiation

The effect on the therapy of the therapist’s level of differentiation (a.k.a.,

level of autonomy, authenticity, congruence, development, awareness,
etc.) is represented by the works of Bowen,’p2 Schnarch,’ and many oth-
ers, beginning with Freud. Functioning autonomously with emotional
and physical maturity is prerequisite to the therapist’s tasks as well as the
couple’s. All issues with patients’ boundaries also apply to the therapist’s.
Nothing in the literature argues against the therapist’s need for continu-
ing growth and development. Volumes are written about therapist self-
awareness, countertransference, and the motivation of therapists for
their own reparative work.
It is, thus, the person of the therapist who sits with patients. The mature
therapist can, for example, sit with a visibly anxious couple without need-
ing to alleviate the patient’s or their own anxiety; instead, they know how
to use anxiety in the service of growth-the patient’s and their own.
Learning to tolerate and use high levels of anxiety, one’s own and the
 Treatment of Primary Vaganismus 53

patients’, can increase the therapist’s differentiation level. Ample oppor-

tunity occurs for increasing the level of differentiation regardless of
whether one is therapist or patient. One of the more well-known sayings
of Carl Whitaker is that the therapist should be the most experienced
patient in the room. Thus, the professional growth of a mature therapist
depends on growth as a person.
Each time an impasse is recognized and attended, the therapist, the
individual, and the couple increase their level of differentiation and the
impasse usually dissolves. Differentiation, by definition, depends on de-
velopment. As therapists we must handle ourselves in the face of anxiety,
resistances and impasses. Anxiety, resistances, and impasses stretch us
and are, therefore, a key to functioning at higher levels both personally
and professionally.
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Therapists encountering failure with the vaginismic couple might ben-

efit by examining their own values, needs, resistances, and normative
biases. (An unaddressed issue: whose responsibility is it to define thera-
peutic success and failure?) Many an impasse can be prevented, averted,
or resolved simply through therapists’ ability and willingness to explore
their own subconsciousissues, especially issues of control, intrusion, viola-
tion, neglect, and reje~tion.’~Behaviorists also affect the subconscious of
patients, regardless of their intent to do so. Recalcitrant patients give us
and themselves opportunities for differentiation.
On the other side, has any therapist not met with a couple having
better, more erotic or satisfying sex than the therapist? Are we mature
enough to have healthy envy and respect, push our own personal rela-
tionships forward, and take neither credit nor blame for how the couple
uses therapy? The challenge to our growing edge is continuous.
Couples and individuals have a capacity not only to push therapists to
their greatest strength, but to illuminate their vulnerabilities. The thera-
pist who can tolerate this much opportunity for growth can meet patients
at their highest level of functioning instead of their lowest. Therapeutic
impasses seem to occur most often when the therapist operates from
inadequacy, remaining unaware of growth opportunities.
Carl Whitaker and Thomas MaloneI5express clearly the growth poten-
tial of therapy for both patients and therapists: “The continued challenge
of the patient’s demands for greater integration on the part of the thera-
pist, for hidher deeper participation in their own suffering, and for help
in their struggle with their world and with themselves inevitably produce
personal growth in the therapist’’ (p. 149). It seems clear that, being
human, therapists suffer and grow, too.

CONCLUSION

Primary vaginismus may be an unspoken, somatic boundary, a nonverbal

limit, a way to respect oneself. Vaginismus is not a bad symptom, it is a
solution, a symbolic description of what needs to happen. Our task as
clinicians is to look, listen, question, and give meaning to the symptom.
 54 Journal of Sex k?Marital Therapy, Vol. 20, No. 1 , Sprang 1994

Developing and maintaining boundaries is a vital component of deepen-

ing sexual contact, intimacy, and differentiation. As Schnarch’ writes,
“Although reproductive sex is a natural function, intimate sex is not.
Intimacy during sexuality is an acquired skill and a developed taste” (p.
474). The idea of mastery, autonomy, boundaries, and differentiation is
as valid a challenge to the thera ist as it is to the couple.
Pathfinders such as Ka lan,g Lieblum,” LoPiccolo,18 Masters and
Johnson,’’ and the growtR of feminismz0 have moved us consistently
forward since the Kinsey reports and Master’s and Johnson research of
the 1960s. A new paradigm spearheaded before its time by A p f e l b a ~ m ~ ? ~
and more recently by Schnarch3 can move the field ahead another step
as we attend to intrinsic, continuous needs for paradigm changes.
Change at this particular time in history involves shifts in clinical focus
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from sexual frequency to quality, from performance to experience, from

compliance to mastery and differentiation, and from utilitarian function
to sexual potential. A reevaluation of what constitutes successful outcome,
behavioral and developmental, should include an increase in differentia-
tion in addition to symptom relief.
We often miss the therapeutic boat by doing effective sex therapy.
When the focus of sex therapy standards shifts toward differentiation
and mastery, not ignoring the import of behavior, but rather, viewing it
as one aspect of self-mastery, sex and couples’ therapy will be able to
support multilevel therapeutic interventions and, consequently, sexual
competence based on self-competence. Differentiation concepts are vital
because they define the tasks prerequisite to adults functioning intimately
with self and partner, in relationship.
REFERENCES
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2. Kerr ME, Bowen, M: Family evaluation. New York, Norton, 1978.
3. Schnarch D: Constructing the sexual crucible: An integration of sexual and maribl therapy.
New York, Norton, 1991.
4. Apfelbaum B: A contribution to the development of the behavioral-analytic sex
therapy model. J Sex Marital Ther 3 :128-138, 1977.
5 . Apfelbaum B: Retarded ejaculation: A much misunderstood syndrome. In SR
Lieblum, RC Rosen (eds), Principles and practice of sex therapy: Up&& for the 1990’s.
New York, Guilford, 1989.
6. Kope SA: Vaginismus: If treatment is so simple, why is the symptom so persistent?
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7. Shaw J: The treatment of vaginismus: What is wrong with this picture? Paper pre-
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8. Valins L: When a woman5 body says no to sex: Understanding and overcoming vaginismus.
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11. Lieblum S, Pervin L, Campbell E: T h e treatment of vaginismus: Success and failure.

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19. Masters WH, Johnson VE: Human sexwrl inadeqmcy. Boston, Little, Brown, 1970.
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