Note: This commentary addresses a single issue in the treatment of vaginismus, which is stated in the title.. For a comprehensive review of the vaginismus, see these more complete discussions:
http://www.marriagebuilders.com/graphic/mbi5049a_qa.html
http://www.freetown.com/Uptown/WalshTarleton/1051/index.html
Introduction (Revised 3/3/01)
Prior to the development of intravaginal EMG sensors, the most common treatment for vaginismus consisted of using dilators -- plastic cylinders of varying sizes -- to "force" the muscles around the vagina to stretch or relax and allow penetration. This was traditionally done in the physician's office. In recent years there has been an improvement in the therapy, with increased emphasis on allowing the patient to self-insert the dilators at home. Typically the therapy proceeds from smaller to larger dilators, and from self-insertion to partner-assisted insertion, in a classical "hierarchy" of behavioral steps. This method is often described as extremely effective, but also as taking many weeks to accomplish.
There is a fundamental flaw in this use of dilators, which are actually intended to passively stretch pelvic (vaginal) muscles have have become shortened through years of chronic tension. The problem is that most vaginismus cases involve not actually shortened muscles but actively tense muscles.
In the past 30 years it has become clear that electromyographic biofeedback -- monitoring and displaying the muscle activity of affected muscles -- is the most effective way of teaching patients to have voluntary control over specific muscle groups. This has commonly been used in the treatment of muscle tension headaches, neck and shoulder pains, and pain in many other muscle groups.
Initially some biofeedback therapists assumed that if a patient were having difficulty with vaginal insertion it would be easier to use surface electrodes placed on the perineum instead of inserted sensors. In fact, therapeutic results show that virtually all women suffering from vaginismus have no trouble inserting vaginal sensors.
How could this be true? The fundamental difference is that when inserting a vaginal sensor, the woman has COMPLETE CONTROL over the insertion process, and can proceed at her own pace. It is also much easier to physically manipulate a 3 oz. sensor than a 185 pound husband with an erection.
With an EMG biofeedback device, the patient can quickly see and recognize the effect of her involuntary pelvic muscle contractions that prevent penetration, and learn to bring them under voluntary control. The process usually takes from a single session to a couple of weeks of home practice -- considerably less time than is claimed for dilators.
In actual therapy, the patient is usually first given a demonstration of voluntary muscle control by placing a surface patch electrode on a neutral muscle, such as the forearm. When it is clear that she understands the relationship between the sensations of voluntary contractions through proprioceptive (internal bodily) feedback and the graphic display of those contractions on the (external) biofeedback computer screen, and has practiced several contraction and relaxation sequences, training moves to the pelvic muscles themselves.
For a graphic presentation of the role of involuntary pelvic muscle activity, look at the essay on the treatment of dysmenorrhea at http://www.incontiNet.com/dysmenorrhea.htm Although the cause of the muscle spasms is different, the result is the same, and so is the treatment. Treatment consists of teaching the patient to make progressively better defined contractions and relaxations. The Zen saying "When you sit, sit; when you stand, stand!" illustrates the objective very well.
The following reply was written in response to an individual therapist's question to the sensor's manufacturer. It was distributed as a "handout" for some years before being posted on the internet for everyone to read.
Question: I've assumed that insertable EMG pelvic muscle sensors cannot be used with patients having penetration problems, so we would have to rely on surface electrodes. Is that true?
Answer: Not at all. Vaginismus was one of the very first conditions treated with the EMG perineometer when it was developed nearly 20 years ago.
Normally [in our training program] we show the class a vaginal, a rectal, and a special "pencil-size" EMG perineometer, and point out that the latter was specifically developed for vaginismus patients; however, it has never been used, because when we offer all three sizes to the patient, with the instruction to "Please insert the largest sensor that you can comfortably insert", they all managed to insert the regular vaginal sensor.
All vaginismus patients we've treated (8 or 10 women) have recovered completely after only one or two office sessions, some with a week or two of home trainer practice. It is a very easy problem to cure; the key is convincing the woman that there is no anatomical problem, it is simply a matter of learning to relax her vaginal muscles in order to accommodate the penis. The only complication is sometimes the male partner won't allow the woman to be in control, even slightly. In that case, HE needs psychotherapy by a qualified sex therapist.
Additional observations:
1. If the woman is really scared and uptight, EMG training begins in the first week with the EMG electrodes on the forearm. Only when the therapist is certain that the patient fully understands the voluntary control of muscles in general is it safe to move on to voluntary control of the threatened pelvic muscles.
2. Most women (actually, all, in our experience!) can insert just about anything into the vagina, provided only that they have complete control over the timing and positioning. [Ah, there's the rub. Some woman aren't used to having control, and some men don't want that to change.]
3. An additional strategy is to educate the forearm muscles first, then give the woman her SUP sensor (but no instrument) and tell her practice inserting and removing it at home, in privacy, on her own bed, for one week. If needed, give general relaxation training at the same time, and instruct the patient to practice general body relaxation for 20 minutes before moving to the sensor practice. Sometimes this alone is sufficient, even without the EMG biofeedback, but I think you can do a more dramatic improvement with at least a single session of biofeedback, which can be quite vivid.
4. This even works for those woman who have been professionally raped by physicians, under the guise of "dilating" the vagina (and/or urethra) as a cure. This barbaric practice is still allowed, unfortunately. It is important to explain to women who have been victims of this officially-sanctioned form of sexual abuse that this treatment is very different, because they alone have complete control over the process.
5. Patients with this history need to be told to use female-superior position for intercourse, at least for the first few weeks, until they become proficient at intercourse. (Usually they are already secretly aware of this, but afraid to or unable to confront their partners. This is what we call the "permission" level of sex therapy. "The doctor says you must let her get on top!".
6. Some vaginismus patients also suffer from chronic pelvic tension (resting level over 2.0 microvolts) and this should also be treated with EMG biofeedback.
7. With the sensor in and EMG on, have the patient close eyes, visualize past attempts at penetration, then open eyes and show high EMG; explain "This (voluntary but unconscious) contraction is what has prevented penetration in the past!"
ADDITIONAL COMPLICATIONS
The therapist should be aware that a common cause of vaginismus is childhood sexual abuse. Patients do not always have to confront that issue, but many of them will do so. If you saw Sally Jesse Raphael this morning (Tom Arnold's confrontation with his molester) you will understand that this is much more common that anyone thought even two years ago!
There is considerable evidence that persons suffering from Multiple Personality Disorder often have a problem with vaginismus. 97% of MPDs are known to have a history of repeated childhood sexual abuse (and the other 3% are suspected). However, just as MPDs have different brain-wave patterns under different "alters", (a fact long known to physiological psychologists), we have several researchers using our sensors that have discovered that different alters also have different pelvic muscle problems!
In other words, if the person in the chair doesn't show signs of vaginismus in the biofeedback office, it is most likely that is because the person(ality) in the chair is not the person(ality) that has the vaginismus! That person(ality) may only come out in the sexual situation.
MPD is a very serious mental disorder, usually requiring five to ten years of intensive psychotherapy. But the prognosis is excellent, if treated by an expert. Also, over 90% of MPDs have a mental health history that includes mis-diagnosis for a more common illness, so a history of mental hospitalization is another red flag. Anyone who suspects this condition should contact me at once to discuss the evidence and see if we can find a competent referral in their geographical area. Differential behavior of pelvic muscles is currently being used by some therapists to confront MPDs with their illness, but this needs to be done only by an MPD expert therapist!
© 1992-2001 by John D. Perry, Ph.D., Dip.ABS
(Diplomat, American Board of Sexology)
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