Vaginismus is defined as an involuntary tensing of pelvic floor muscles, which can make penetrative sex painful or even impossible, while dyspareunia essentially describes painful sexual intercourse. The International Classification of Diseases, a tool for framing and understanding diseases and health conditions, now classifies vaginismus and dyspareunia together as sexual pain-penetration disorder.

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While many studies have explored the nature and characteristics of this disorder, the ways in which it develops and evolves over time remains unclear. In addition, very little research has investigated the disorder from a psychodynamic standpoint, or in other words, looking at its links to childhood experiences and unconscious thoughts and feelings.

Psychodynamic Theory, first introduced by Sigmund Freud, is considered to be valuable for the diagnosis and treatment of numerous sexual difficulties. A team of researchers in Germany, led by Dr Thula Koops and Professor Peer Briken, thus set out to examine women’s sexual pain from a psychodynamic standpoint, while also considering the personality functioning – so-called structure – of affected women.

To do so, the research team surveyed 24 women diagnosed with dyspareunia and vaginismus. The anonymous online survey completed by the women touched on a series of psychodynamic and psychological aspects defined by the Operationalized Psychodynamic Diagnosis system, while also collecting general information about the women’s backgrounds.

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Participants were asked questions about their quality of life, physical and psychological health, social relations, environment, and sexual difficulties. They were also asked how often they experienced different psychological symptoms, such as anxiety, deep sadness, feelings of hopelessness, and so on.

The questionnaire then explored different dimensions of personality functioning rooted in psychodynamic theory. One of these dimensions was self-perception, which includes the ability to reflect about oneself, one’s sense of identity, and the ability to distinguish between different emotions. Another was object perception, which describes how one perceives others and oneself in relation to others.

The survey assessed how well the women regulated their own emotions, including their ability to control impulses, tolerate negative emotions, and regulate their own feelings of self-worth. It also looked at how they balanced their interests, how they communicated with themselves internally and with others around them, their attachment styles, and the presence of any psychodynamic conflicts.

Psychodynamic conflicts are different inner and relational conflicts that people can experience throughout their lives. These include the conflict between doing things alone or being dependent on others, being submissive or in control, and needing the care of others or being self-sufficient. They also include conflicts related to self-worth, guilt, and the ‘Oedipal’ conflict, which describes unconscious conflicts around the need for attention, admiration, and recognition.

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Dr Koops and the team then analysed the responses given by women diagnosed with vaginismus and dyspareunia, and compared them with a matched sample of healthy women from previous studies on psychodynamic conflicts and personality functioning. This allowed them to gain insight into the possible psychological and psychodynamic aspects of sexual pain, as well as other possible influencing factors.

Interestingly, they found significant differences between the groups of women, highlighting some of the potential underpinnings of sexual pain. Overall, women diagnosed with vaginismus and dyspareunia reported some psychological symptoms with greater frequency than the women from the control groups, including over-worrying, and feelings of interpersonal sensitivity.

On average, participants also reported having moderate, but not great, psychological health and social relationships, as well as high satisfaction with their living environment. In terms of sexual difficulties, more than half of respondents with the disorder said that, additionally, they felt distressed by a lack of sexual interest, while approximately half also mentioned that they could not reach orgasm.

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When looking at the parts of their survey that explored psychodynamic dimensions according to the Operationalized Psychodynamic Diagnosis system, the researchers found that women with sexual pain seemed to struggle more in relation to themselves rather than to others.

Compared to the healthy control group, they appeared to have an impaired self-perception and internal dialogue. They also reported difficulties in regulating their emotions and impulses, as well as in realistically interpreting and experiencing emotions.

The women who experienced sexual pain also viewed their body in unrealistic ways, found it harder to have lively bodily experiences, and found it difficult to regulate their feelings of self-worth. These results are aligned with previous research, which found that women with vaginismus have lower self-esteem, which could lead to depression and anxiety.

Finally, the researchers found that women in the sexual pain group were more prone to experience conflicts around guilt, self-worth, the desire for admiration and recognition, and often pondered their level of dependency or independence.

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The results gathered by this team of researchers offer unique insights into the complex psychological and psychodynamic aspects that can contribute to vaginismus and dyspareunia. While the study design does not confirm that these psychodynamic variables are risk-factors for the development of vaginismus and dyspareunia, the results indicate that the women from the study seem to struggle more with these issues.

Aside from the question of causality, this study could guide the work of psychodynamic therapists, as it highlights several key areas that they could explore during therapy sessions with women whose lives are affected by sexual pain.