The Behavioristic View

Another view on the origination of vaginistic reaction comes from the behavior-istic angle. Although the majority of authors with this point of view agree that vaginismus is a conditioned anxiety reaction that results in spasm of the entrance to the vagina (23-26), only a small minority give an explanation for the origination of this behavior. Brinkman, for instance, gave an explanation model (27). He assumed that vaginismus is the end result of a classic conditioning process in which painful sexual intercourse took place. As a consequence of this process, the penis is conditioned into an aversion stimulus that when an approach is made, gives rise to tension and avoidance behavior, which once again leads to painful spasm of, in particular, the vaginal and anal sphincter muscles. Brinkman assumed that conditioning of the vaginistic reaction can occur in various ways. Sometimes one negative experience is enough, particularly in the case of incest or rape. Often, conditioning takes place over several experiences and such influences are far more difficult to establish.

Treatment according to the behavioristic view, which has been gaining popularity over the past 20 years, is based on the learning principle. In other words, a reaction that has been learned can also be unlearned. To resolve vaginis-tic complaints, various therapy forms have been developed within behavioral therapy: systematic desensitization, muscle exercises, and counter-conditioning. These therapy forms are not mutually exclusive and are often used in combination.

Systematic desensitization was originally developed by Wolpe and it appears to be effective in reducing various forms of tension (28). Wolpe made two basic assumptions:

1. A certain stimulus (e.g., an approaching penis) causes anxiety (response).

2. When a response can be generated that is antagonistic to anxiety (e.g., relaxation in the presence of an anxiety-invoking stimulus), then the relationship between the stimulus (the approaching penis) and the anxiety response will diminish.

There are two forms of systematic desensitization: in vitro and in vivo. In vitro means that the desensitization takes place in a fantasy situation, whereas in vivo means that it takes place in the real situation. Systematic desensitization in vivo is the more commonly used method for the treatment of women with vaginistic complaints. First, the woman learns to relax. Then she learns to gradually accept objects of increasing diameter in her vagina, such as fingers or vaginal rods. She starts with the smallest size and finishes with the largest size that matches the size of the partner's penis in erection. Many therapists employ systematic desensitization (23,25,27,29-33). It is often combined with other techniques, such as muscle exercises (23,34-36), stroking exercises (29,34-37), discussing difficult relational aspects (34), and cognitive therapy (33). Some therapists exchange the relaxation exercises for tranquillizers or hypnosis. The aim of muscle exercises is to teach women to become conscious of their vaginal muscles and to practice contracting and relaxing them. Consciousness is important, because vaginistic women contract their pelvic floor muscles convulsively, without being aware of doing so.

An often used method to gain control of the vaginal muscles was described by Luyens (34). According to this author, a woman can become conscious of her vaginal muscles by looking at her genitals using a hand-mirror and then making squeezing and bearing-down motions with the vagina. Often, first attempts are unsuccessful, because many women are unable to localize these muscle groups and pull in their stomach instead. However, this can be learned by means of pelvic floor muscle exercises. An additional advantage of pelvic floor muscle exercises is that these exercises have a positive effect on the intensity with which genital sensations are experienced during sexual arousal.

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