The Frequency of Sexual Dysfunctions in Male Partners of Women with Vaginismus in a Turkish Sample

ORIGINAL ARTICLE The frequency of sexual dysfunctions in male partners of women with vaginismus in a Turkish sample

S Dogan1 and M Dogan2

1Department of Psychiatry, GOP Hospital and Bogazici University Mediko-Sosyal Center, Istanbul, Turkey and 2Department of Psychiatry, Esenler Hayat Hospital, Istanbul, Turkey

The aim of this investigation is to determine the sexual history traits, sexual satisfaction level and frequency of sexual dysfunctions in men whose partners have vaginismus. The study included 32 male partners of vaginismic patients, who presented at a psychiatry department. Subjects were evaluated by a semi-structured questionnaire. The questionnaire was developed by researchers for assessing sexually dysfunctional patients and included detailed questions with regard to socio- demographic variables, general medical and sexual history. All participants also received the Golombok Rust Inventory of Sexual Satisfaction (GRISS). According to DSM-IV-TR criteria, 65.6% of the investigated males were diagnosed with one or more sexual dysfunctions. The most common problem was premature ejaculation (50%) and the second one was erectile dysfunction (28%). The transformed GRISS subscale scores provided similar data. It is concluded that the assessment of sexual functions of males who have vaginismic partners should be an integral part of the management procedure of vaginismus for optimal outcome. International Journal of Impotence Research (2008) 20, 218–221; doi:10.1038/sj.ijir.3901615; published online 20 September 2007

Keywords: male sexual dysfunction; vaginismus; sexual satisfaction; GRISS

Introduction logical and sexual vulnerability. He might simply be frustrated by his inability to penetrate his wife, Although research on vaginismus in female patients or he might interpret her dysfunction as a rejec- has been carried out for a number of years, the focus tion. Kaplan also stated that the husband’s ability of investigation has remained relatively narrow. to function sexually might remain intact, but Many researchers have studied prevalence,1 psy- husbands of vaginismic patients frequently deve- chopathology2 and pathophysiology3 in females loped secondary impotence as a reaction to their with vaginismus. Others have inquired into the wives’ disorder.11 Leiblum, however, emphasized effectivity of cognitive behavioral therapy,4,5 physio- the importance of treating both partners by way of therapy6 and combined treatment options to treat giving a case example in which both a vaginismic vaginismus.7–9 For instance, Masters and Johnson female and her husband concurred in attributing the have discussed a variety of etiological factors ‘cause’ of their difficulty to the husband’s inability causing vaginismus including a response to male to sustain erections.12 Vaginismus is a frequently sexual dysfunction.10 On the other hand, Kaplan has observed sexual dysfunction in Turkey and there are reported that the man’s reaction to his wife’s some studies related with the role of a male partner dysfunction would vary depending on his psycho- in treating a vaginismic woman.5,13–15 It is anti- cipated that vaginismus may affect the quality of life and sexual satisfaction level of both the female and her male partner. Unfortunately, there are no reliable data at the moment concerning the incidence of Correspondence: Dr S Dogan, Department of Psychiatry, sexual dysfunctions in male partners of vaginismic GOP Hospital and Bogazici University Mediko-Sosyal Center, Atakoy 5.Kisim E-2-5-D Blok Daire:76, Bakirkoy, women. Istanbul 34184, Turkey. Hence, our descriptive study was primarily E-mail: [email protected] designed to assess the sexual history traits, sexual Received 17 July 2007; revised 18 August 2007; accepted satisfaction level and frequency of sexual dysfunc- 20 August 2007; published online 20 September 2007 tions in men who have partners with vaginismus. Frequency of sexual dysfunction S Dogan and M Dogan 219 Materials and methods The Golombok Rust Inventory of Sexual Satisfaction The GRISS is a short measure of sexual dysfunction Participants that may be administered to heterosexual couples Between 2004 and 2006, 32 consecutive new female or individuals who have a current heterosexual patients with a diagnosis of lifelong vaginismus relationship. It provides overall scores, for men and their husbands participated in our study. The and women separately, of the quality of sexual func- 32 couples were from the outpatient population tioning within a relationship. In addition, subscale of psychiatry clinic of the GOP Hospital, Turkey. scores of impotence, premature ejaculation, anor- Written informed consent was received from each gasmia, vaginismus, infrequency, noncommunica- participant, and the study was approved by the tion, male dissatisfaction, female dissatisfaction, Local Ethics Committee. male nonsensuality, female nonsensuality, male Eligibility criteria for male participants were as avoidance and female avoidance can be obtained follows: heterosexual male, age 18 or older, being and represented as a profile. The GRISS can be used the husband of a woman with lifelong vaginismus, to assess improvement as a result of sexual or being in good general health and the absence of marital therapy and to compare the efficacy of diagnosis of affective and psychotic disorder, and different treatment methods. It can also be used marriage duration of not less than 1 month. General to investigate the relationship between sexual health condition was determined by history taking. dysfunction and extraneous variables. The subscales The diagnosis of lifelong vaginismus was assessed are particularly helpful in providing a profile for after full sexual history taking. The criteria for the diagnosis of the pattern of sexual functioning diagnosis confirmed DSM-IV-TR.16 within the couple, which can be of great benefit The average age of the 32 men involved was in designing a treatment program. 26.672.87 and ranged between 21 and 33, whereas The GRISS, in separate forms for men and women, the average age of 32 vaginismic women was 23.47 appears on a single sheet and has a standard format. 3.82, ranging between 18 and 33. Average marriage There are 28 items in each form, and the items are all duration was 13.28725.84 months and ranged Likert type (5-point) with response options labeled between 1 and 120 months. For 13 men (40.6%), as follows: never, hardly ever, occasionally, usually marriage style was voluntarily arranged. Nineteen and always. A combination of norm referencing and men (59.4%) married after a dating period. Sixteen criterion referencing yielded transformed scales, men (50%) graduated from primary school (1–5 years) giving a good indication of the existence and and were born in a town or a village. The number of severity of any problems. Transformations are to a immigrants from small birthplaces to metropolises pseudo-stanine scale (from 1 to 9) with a score of was 19 (59.4%). Twenty-seven men (84.4%) belonged 5 being borderline and a score of above 5 indicating to a nuclear family and five of them (15.6%) to a large a problem. one. Thirty of them (93.8%) were employed and 26 of Respondents circle the number indicating the them (81.3%) reported medium income levels. frequency with which each statement applies. The GRISS normally takes between 4 and 10 min to complete.17,18 For Turkish samples, the validity and Procedure reliability tests of the GRISS were made by Tugrul All husbands and wives were evaluated by using et al.,19 in 1993. In internal consistency studies, semi-structured questionnaire and the Golombok from the point of view of total scores Cronbach-a for Rust Inventory of Sexual Satisfaction (GRISS). men was 0.92 and Cronbach-a for women was 0.91. Cronbach’s a-values for subscales were also satisfactory. In reliability studies, the total and subscale Questionnaire scores of sexual dysfunction and non-dysfunction The questionnaire was developed by researchers and groups were compared with t-test (for total scores, contained 56 items. The first 16 questions of the t ¼À14.52, s.d. ¼ 123.33, Po0.001). For subscales, questionnaire were used to determine the socio- t-values were also satisfactory. In men, discrimi- demographic variables such as age, gender, marriage nation analysis results for dysfunction and non- style, education level, employment status, family dysfunction groups showed the items’ discrimination type, income level, birthplace and migration. Ques- ratio of the groups as 98%. For subscales, the same tions from 17 to 25 were used for medical history ratio was 94%. In women, the same ratios were 98 taking. The remaining 31 questions were used and 95%, respectively. for sexual history taking and included the sexual knowledge level, masturbation habits, age at first sexual experience, first sexual partner, occurrence of any sexual problems during first sexual encounter, Results marital harmony, sexual attractiveness of the partner, fidelity, using pornographic materials, sexual orien- Fourteen men (43.8%) reported having adequate tation and presence of current sexual problems. sexual knowledge and the rest of the group (56.2%)

International Journal of Impotence Research Frequency of sexual dysfunction S Dogan and M Dogan 220 reported having inadequate sexual knowledge. All GRISS transformed subscale scores confirmed the of them (100%) had masturbated until marriage. clinical diagnoses. Thirteen of them (40.6%) reported that they quit masturbation after marriage, and 19 men (59.4%) were still going on masturbation. The mean masturbation frequency for 32 men was 4.1 per week before Discussion marriage. The mean masturbation frequency for 19 men who were still going on masturbation after The results of this study point out that in the marriage was 2.4 per week. The mean first sex age partners of women who are treated with the diag- of 32 men was 2074.13 (range 14–31). The majority nosis of vaginismus, the sexual satisfaction level is of the male partners reported having had sexual inadequate. Furthermore, the partners have a high problems during their first sexual experience incidence of sexual dysfunction. Relying upon these (n ¼ 19, 59.4%), and for 15 men (46.9%) the problem findings, we might argue that it is significant to was premature ejaculation and for 4 men (12.5%) it incorporate them in the process of diagnosis and was erectile dysfunction (ED). A summary of sexual treatment. The sexual dysfunctions of the partners history traits of the group is shown in Table 1. of the women with vaginismus can be either a result Of the 32 men participating in the study, 11 of of or a reaction to vaginismus. Nevertheless, it them (34.3%) did not report any sexual dysfunction. should be kept in mind that the sexual disorder The remaining 21 (65.6%) reported one or more in the man can be a primary factor, that is it may sexual dysfunctions. According to DSM-IV-TR be simultaneously and equally responsible for the criteria, in 16 men (50%) we found premature ejacu- absence of sexual intercourse. As in men with ED, lation, in 9 men (28.1%) ED and in 9 men (28.1%) evaluation of the sexual function of the partner is hypoactive sexual desire disorder. In 10 men also important in the diagnosis and prognosis of (31.3%) there was only one sexual dysfunction. women with vaginismus.20,21 In 11 men (34.3%) we found more than one sexual The rate of men having a sexual problem was dysfunction. In four men we diagnosed ED and found to be 65.6% with DSM-IV-TR criteria and premature ejaculation, in one man ED and hypoac- GRISS transformed subscale scores. Taking into tive sexual desire disorder, in four men premature account the fact that 56.2% of men had inadequate ejaculation and hypoactive sexual desire disorder, sexual knowledge and 50% had only an education and in two men ED, premature ejaculation and level of elementary school, it can be inferred that the hypoactive sexual desire disorder together. The unawareness of having a sexual dysfunction in oneself can be associated with an inadequate education level. The findings of two different Turkish Table 1 Sexual history traits of the sample studies have implied that there is no high prevalence of sexual problems in male partners of vaginis- Statement n (%) tic women.13,15 Our study could not replicate the finding of the previous studies. The discrepancies Sexual knowledge level between previous studies and our results may be Adequate 14 (43.8) related to the methodological differences. Inadequate 18 (56.2) Although the most frequent sexual dysfunction in First sexual partner our sample group was premature ejaculation, ED, Spouse 9 (28.1) which is as important as vaginismus concerning the Girlfriend 5 (15.6) inability to carry out sexual intercourse, was also Fiancee — rather frequent (n ¼ 9, 28.1%). Taking into consi- Prostitute 18 (56.3) deration the fact that the rate of ED during the first Attractiveness of the partner sexual experience was 12.5% (n ¼ 4), it can be noted Attractive 21 (65.6) that the increased rate in ED is related to the Moderate 11 (34.4) interaction with the vaginismic wife.10–12,22 Repulsive — It should be considered that psychosocial factors Marital harmony rather than organic factors are effective in the Well 26 (81.3) occurrence of sexual problems in this group of parti- Moderate 5 (15.6) cipants with an average age of 26.6, good general Bad 1 (3.1) health status, absence of prescribed drugs or alcohol Infidelity or substance abuse or addiction. The first sexual Yes 1 (3.1) partners of 56.3% of men being prostitutes are No 31 (96.9) related with the fact that premarital sex is still not very well tolerated in our country. In the traditional Using porn Yes 23 (71.9) societal structure where women are expected to No 9 (28.1) preserve their virginity until marriage, men do not have other chances than prostitutes to have their

International Journal of Impotence Research Frequency of sexual dysfunction S Dogan and M Dogan 221 first sexual experience. Nineteen (59.4%) men 5 Kabakci E, Batur S. Who benefits from cognitive behavioral taking part in our study reported having sexual therapy for vaginisnus? J Sex Marital Ther 2003; 29: 277–288. problems during their first sexual experience. This 6 Rosenbaum TY. Physiotherapy treatment of sexual pain disorder. J Sex Marital Ther 2005; 31: 329–340. result is compatible with the view that failure 7 Praharaj SK, Verma P, Arora M. Topical lignocaine for during the first sexual experience can be a pre- vaginismus: a case report. Int J Impot Res 2006; 18: 568–569. cipitating factor in the current sexual dysfunction.1 8 Schultz WW, Basson R, Binik Y, Eschenbach D, Wesselmann Although 65.6% of the 32 men involved in our U, van Lankveld J et al. Women’s sexual pain and its management. J Sex Med 2005; 2: 301–316. study found their wives sexually attractive, the fact 9 Jeng CJ, Wang LR, Chou CS, Shen J, Tzeng CR. Management that 40.6% got married through arranged marriages and outcome of primary vaginismus. J Sex Marital Ther 2006; can be considered to be a cultural factor in the 32: 379–387. occurrence of sexual problems.1 10 Masters WH, Johnson VE. Human Sexual Inadequacy. Little In conclusion, we might say that although our Brown: Boston, 1970, pp 252. 11 Kaplan HS. The New Sex Therapy: Active Treatment of Sexual study was carried out with a limited number of Dysfunctions. Brunner/Mazel: New York, 1974, pp 412–428. participants, it should be deemed important in that 12 Leiblum SR. Vaginismus: a most perplexing problem. In: it designates the high rate of sexual dysfunction Leiblum SR, Rosen R (eds). Principles and Practice of Sex and sexual dissatisfaction in men with vaginismic Therapy. The Guilforf Press: New York, 2000, pp 181–202. 13 Oktay M, Tombul K. 200 cases of vaginismus: their and their wives. This finding emphasizes that the inclusion of husbands’ psychological evaluation [200 Vajinismus vak’ası the partner in the treatment process is not enough, ve es¸lerinin psikolojik yo¨nden incelenmesi]. New Symp 2003; and sexual functions should be definitely evaluated 41: 115–119. in exposing the problem, maintenance and positive 14 Kayir A, Sahin D. The roles of the partners in delaying the response to treatment in women with vaginismus. treatment of vaginismus [Vaginismus Tedavisinin Uzamasında Es¸lerin Rolu¨ ]. No¨roPsikiyatri Ars¸ivi 1997; 34: 178–185. We believe that future studies with larger samples 15 Tugrul C, Kabakci E. Predictor variables of vaginismus and cross-cultural methods will contribute to the [Vaginismus Olgularında Yordayıcı Deqis¸kenler]. Tu¨rk Psikiyatri information database in this field. Dergisi 1996; 7: 201–207. 16 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text revised. American Psychiatric Association: Washington, DC, 2000. 17 Rust J, Golombok S. The Golombok–Rust inventory of sexual References satisfaction (GRISS). Br J Clin Psychol 1985; 24: 63–64. 18 Rust J, Golombok S. The GRISS—a psychometric instrument 1 Badran W, Moamen N, Fahmy I, El-Karaksy A, Ghanem H. for the assessment of sexual dysfunction. Arch Sex Behav Etiological factors of unconsummated marriage. Int J Impot 1986; 15: 157–165. Res 2006; 18: 458–463. 19 Tugrul C, Oztan N, Kabakci E. Golombok rust cinsel doyum 2 ter Kuile MM, van Lankveld JJDM, Vlieland CV, Willekes C, olceginin standardizasyon calismasi. Tu¨rk Psikiyatri Dergisi Weijenborg PTHM. Vulvar vestibulitis syndrome: an important 1993; 4: 83–88. factor in the evaluation of lifelong vaginismus. J Psychosom 20 Greenstein A, Abramow L, Matzkin H, Chen J. Sexual Obstet Gynecol 2005; 26: 245–249. dysfunction in women partners of men with erectile dysfunc- 3 Engman M, Wijma K, Wijma B. Itch and burning pain in tion. Int J Impot Res 2006; 18: 44–46. women with partial vaginismus with or without vulvar 21 Ghanem H, Zaazaa A, Kamel I, Anis T, Salem A, El Guindi A, vestibulitis. J Sex Marital Ther 2005; 26: 245–249. et al. Short-term use of sildenafil in the treatment of 4 van Lankveld JJDM, ter Kuile MM, Melles R, Nefs J, unconsummated marriage. Int J Impot Res 2006; 18: 52–54. Zandbergen M. Cognitive-behavioral therapy for women with 22 Rust J, Golombok S, Collier J. Marital problems and sexual lifelong vaginismus. A randomized waiting-list controlled trial dysfunction: how are they related. Br J Psychiatry 1988; 152: of efficacy. J Consult Clin Psychol 2006; 1: 168–178. 629–631.

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