The above-described views and treatment models show that there is wide variation in the causal attributes of vaginismus and that this "diagnostic" variety leads to an even wider variety of therapeutic interventions. In itself this is not particularly surprising when we consider that in order to have sexual intercourse in a satisfactory manner, obviously apart from the physical conditions that have to be met, there must also be special knowledge, expertise, attitudes and, last but not least, emotional moods. All this is overruled by motivation: Do I really want to?
A thorough diagnostic procedure in which an inventory is made of somatic, psychological, and social aspects, therefore seems vital in order to choose the best approach. During such a procedure, it is often difficult to say when the diagnostics end and the therapy begins.
The literature shows that it is impossible to make a direct comparison of the effectiveness of the different treatment methods (5,11 -13). It is also striking that no studies have appeared that used a pre-post design or a between-groups design, in which for example, a treatment was compared to a waiting list condition (50).
Prediction of treatment by means of psychological variables has thus far been investigated in noncontrolled studies only (51-53). Irrespective of the type of treatment and the specific therapeutic aims, an average success rate of 60-80% is reported. However, if we only look at the examinations that more or less pass the methodological criticism test then the success rate would be about 60% or less (54,55).
These rates suggest that all treatment forms achieve results and as far as this aspect is concerned, they vary very little. This indicates a nonspecific treatment effect. In terms of attention, validation of her complaint, and the patient's feeling of control and competence, the active constituents seem to be effective on a meta level than on a content level. Cost/effectiveness ratios of the diverse treatment forms then become interesting. Behavioral therapy, in comparison with other psychotherapeutic approaches, can be regarded as relatively efficient (56). This finding in combination with the fact that behavioral therapeutic techniques can also be transferred to non-psychotherapists, make the behavioral therapeutic treatment of vaginismus interesting in more than one respect. Each care provider will choose a therapeutic strategy for vaginistic couples on the basis of his or her training. For example, for gynecologists and urologists, in most cases without any specific sexological training, the behavioral therapeutic approach will be the most obvious choice. It works and it is efficient too! However, its application requires more intense effort than just the acquisition of a set of vaginal rods. It is a treatment that is very time-consuming, requires great patience, great empathy, sensitivity to nonverbal signals, and insight into relational interactions. A care provider who intends to treat vaginismus has to be able to take a good sexual history. He or she must be able to signal or interweave ambivalent feelings regarding coitus, sex, the partner, their own body, the desire to have children. He or she must be able to bring to light serious relational problems or severe traumatic experiences (sexual violence!) and he or she has to realize that being able to have sex does not automatically mean that the coitus is enjoyed. Thus in brief, the same applies to every care provider who intends to treat vaginismus as it applies to the patient: Do I really want to?
If the answer is no, then it is better to refer the patient elsewhere. If the answer is yes, then it is highly recommended to follow a suitable training course first.
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