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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2021 Aug 4;34(1):81–89. doi: 10.1080/19317611.2021.1954576

Psychological Predictors of Sexual Quality of Life Among Iranian Women With Vaginismus: A Cross-Sectional Study

Psychological predictors of sexual quality of life among women with vaginismus, Atefeh Velayati a, Shahideh Jahanian Sadatmahalleh a, Saeideh Ziaei a,✉, Anoshirvan Kazemnejad b
PMCID: PMC10903621  PMID: 38595678

Abstract

Background

Vaginismus is an involuntary contraction of muscles around the vaginal and one of the most common sexual disorders among women. It is often associated with psychological problems, leading to poor sexual quality of life (SQOL). This study aimed to determine SQOL predictors in women with vaginismus.

Methods

In this cross-sectional study, convenience sampling was used to enroll 236 individuals with vaginismus among all women visiting sexual health clinics of Tehran, Iran in 2018. The data were collected using the Sexual Quality of Life-Female (SQOL-F) Questionnaire, Hospital Anxiety and Depression Scale (HADS), and Rosenberg Self-Esteem Scale. The data were analyzed using the General Linear Model (GLM).

Results

The mean (SD) SQOL score of the participants was 56.82 (20.18). There was a significant direct correlation between the participants’ self-esteem and their SQOL (r = 0.54, p < 0.001). However, the participants’ SQOL had significant inverse correlations with the variables of anxiety (r = − 0.48, p < 0.001) and depression (r = −0.47, p < 0.001). Based on the GLM results, the variables of anxiety, depression, self-esteem, and duration of disorder predicted SQOL, and explained 42.3% of the variance of SQOL in the participants.

Conclusion

The results indicated that psychological factors such as anxiety, depression, and self-esteem are predictors of SQOL in women with vaginismus.

Keywords: Vaginismus, anxiety, depression, self-esteem, sexual quality of life

Introduction

Vaginismus is a sexual disorder that can adversely affect marital relationships and quality of lives (Molaeinezhad et al., 2014). It was classified as a genito-pelvic pain/penetration disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There is a great overlap between vaginismus and other sexual disorders such as vulvodynia and dyspareunia making them difficult to distinguish (Dick et al., 2021). Vulvodynia, particularly as a chronic pain condition of unknown causation, is affecting between 7% and 15% of women, is a frequently missed pathology and often confused with vaginismus (Barnabei, 2020). As a result, in the most cases, it is more likely not to be diagnosed properly (Vieira-Baptista et al., 2017). Vaginismus is diagnosed based on a woman’s history of involuntary, persistent or recurrent pelvic floor muscle spasms while inserting any external object such as finger, tampon, penis and gynecologic examination (Aslan et al., 2020). Of course, this condition may depend on the situation and some women would experience this more with penile penetration, but not gynecological exams or tampon insertion (Goldfarb et al., 2013).

There are two types of this disorder, namely the primary and secondary vaginismus. In the primary type, the person has no history of penetration, while in the secondary vaginismus, the woman has experienced successful penetration in the past (American Psychiatric Association, 2013). The prevalence rate of vaginismus is 15.5% in the UK and up to 17% in Saudi Arabia; however, few studies have been carried out in Iran (Tadayon et al., 2017). According to studies, sexual dysfunctions are highly prevalence in Iran, and vaginismus is among the main causes of marital disputes and divorce in this country (Yeganeh et al., 2020).

Sexual dysfunction is defined by the DSM-5 as any dysfunction in the sexual response cycle phases (including desire, arousal, orgasm, and resolution) due to emotional or physical causes and/or other medical conditions. It can cause severe discomfort and may affect the quality of life of people and their interpersonal relationships (Sabeti et al., 2018; Velayati et al., 2019). In vaginismus, spasms mainly occur due to mental health problems such as depression, anxiety and worries about physical appearance (Rajaee & Eshghi, 2018). However, sexual dysfunctions can result in separation, divorce, depression, anxiety, and low self-esteem (Dehnavi et al., 2016; Rajaee & Eshghi, 2018; Ranjbaran et al., 2016).

Self-esteem is a psychological concept that is formed during personal development (Krauss et al., 2020; Kupcewicz & Jóźwik, 2020). Healthy self-esteem stems from one’s ability to accurately assess himself/herself, and is associated with personality traits, abilities, weaknesses, and other psychological characteristics (Fadda et al., 2021). Self-esteem is a reflection of external evaluations, and self-esteem development requires long-term specialized planning (Cvencek & Greenwald, 2020; Fereshteh et al., 1970).

Anxiety is a feeling of fear and distress that can cause insecurity (Soelton et al., 2020), helplessness, and exhaustion to the point that one cannot control himself/herself (Berenskoetter, 2020). Anxiety has many destructive effects on the body (Kalin, 2020; Nahidi et al., 2015). According to the World Health Organization (WHO), depression is one of the most important mood disorders that is characterized by depressed mood, loss of interest, feelings of guilt and worthlessness, disturbed sleep and appetite, low energy, and poor concentration (Giuntini et al., 2020). Sexual dissatisfaction has devastating consequences such as depression and low self-esteem and may also reduce the sexual quality of life (SQOL) (Rostami et al., 2016). SQOL is an important part of life, as well as a critical topic in the discussion of sexual health and fertility (Lamyian et al., 2016). According to the WHO, sexual health refers to the compatibility and harmony of body, mind, intellect, and social relationships that promotes personality, relationships, and marital love (Sabeti et al., 2018).

Any kind of stress, emotional disorder, or sexual ignorance may lead to primary vaginismus disorder (Yeganeh et al., 2020); thus, any improvement in the above factors can enhance sexual functioning and SQOL (Rajaee & Eshghi, 2018). However, no study was found to identify predictors of SQOL in women with vaginismus in Iran. Indeed vaginismus has been largely ignored in Iranian research and literature. This is mainly because of cultural taboos around sexuality matters; therefore, considering the key role of sexual quality of life in improving marital relationships and family stability, and considering little information in this field in Iran, it is important to show how psychological factors adversely affect the sexual quality of life among Iranian women with this problem. This study aimed to determine the psychological predictors of SQOL in Iranian women with vaginismus.

Methods

Study design and participants

In this cross-sectional study, the authors enrolled 236 women with vaginismus admitted to sexual health clinics in Tehran, Iran in 2018.

The participants included Iranian, literate, and married women between the age of 18 and 49 years (who lived with a male husband/partner) who have had vaginismus for at least 6 months, with no history of acute or chronic physical illness, no history of psychiatric treatment, no use of anti-depression drugs or hormonal contraceptives which could interfere with sexual function in the past three months. Women who were unwilling to participate in the study and those who did not complete the questionnaires were excluded.

Reliability of the questionnaire was determined by using test–retest method after conducting a pilot study on 20 women with vaginismus. Both of the reproducibility (ICC = Intraclass Correlation Coefficient) and internal consistency (Cronbach's alpha coefficient) were determined for all questionnaires. ICC (confidence interval) and Cronbach's alpha coefficient for SQOL-F, HADS and RSES were 0.90 (0.84–0.98) and 0.8, 0.89 (0.87–0.91) and 0.86, 0.87 (0.85–0.91) and 0.85, respectively.

Sampling

The participants were selected from four sexual health clinics located in the north, south, west, and east of Tehran using convenience sampling. All women with vaginismus who met the inclusion criteria and were willing to participate in the study completed the questionnaires. In these centers, all specialists consisted of a team of gynecologists, psychologists and urologists, all were sex therapists by training and had an experience of working with various sexual disorders.

After the referrals’ of women with sexual disorders (difficulties with vaginal penetration during intercourse due to pain, fear, anxiety and tightening of the pelvic floor muscles during attempted vaginal) to the Sex Clinics, they are initially examined by experienced gynecologists, who had trained in sex-therapy. The diagnosis of vaginismus was initially identified through Pelvic examination, which included assessment of the external appearance of the vulva, vulvar sensitivity (QT test: using a cotton swab). Also, external genital examination included the evaluation of scratch, erosion, wound, erythema, edema and unusual vaginal discharge. Through an external examination any cases of itchiness, odor, pain was noticed. Moreover, self-report of cases such as unusual color of vaginal discharge, burning during urinating or vaginal bleeding and spotting were also taken into account during the examination. Sometimes women were also referred to urologist to make sure they did not have any urinary infection/or diseases. In the absence of any physical and structural abnormalities, disease or any active vaginal infection, women then were referred to psychologists. Phycologists by using DSM5 indicators and going through the sexual history of women confirmed diagnose. 300 women who had been referred to Sex clinics were screened. Out of 300 women, 44 women who had been referred to the clinics were excluded from our sample due to other conditions such as endometriosis, pelvic inflammatory disease, active genitourinary infection and vulvodynia. A total number of 256 women identified with vaginismus condition. 240 of them met our inclusion criteria, and finally 236 individuals signed the informed consent forms and completed the questionnaires (Figure 1).

Figure 1.

Figure 1.

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Information on the selection of study’s participants.

It may be useful to state that all women had gynecological examination externally. Internal pelvic examinations were almost impossible for the participants because of the presence of an involuntary contraction some or all of the pelvic floor muscles. They all had not vaginal intercourse, for which they were seeking treatment.

Tools

The data were collected using the socio-demographic characteristics questionnaire, Sexual Quality of Life-Female (SQOL-F) Questionnaire, Hospital Anxiety and Depression Scale (HADS), and Rosenberg Self-Esteem Scale (RSES).

Socio-demographic characteristics questionnaire

This researcher-made questionnaire included questions about the participants’ age, educational qualifications, and job, spouse’s age and educational qualifications, number of children, duration of disorder, and housing status.

Sexual Quality of Life-Female (SQOL-F)

The Persian version of the SQOL-F Questionnaire was used to measure the participants’ sexual quality of life. SQOL-F is an18-item questionnaire in which the items are scored on a six-point Likert scale (Total score range: 18–108). Higher scores indicate higher quality of sexual life. Items 1, 5, 9, and 13 are scored inversely. The validity and reliability of this questionnaire was confirmed by Masoumi et al. Reliability evaluation had high internal consistency and good test–retest reliability. The Cronbach’s alpha coefficient was 0.73 and intra class correlation coefficient (ICC) was 0.88. (Maasoumi et al., 2013).

Hospital Anxiety and Depression Scale (HADS)

This 14-item self-report questionnaire was used to measure the participants’ anxiety and depression levels. It assesses the intensity of depression and anxiety symptoms in patients over the past week. This questionnaire can be completed in less than five minutes and its target population ranges from 16-year-old adolescents to the elderly. HADS has two 7-item subscales of anxiety and depression. Each item is scored on a scale from 0 to 3 (Total score range of each subscale: 0–21). Items 1, 3, 5, 6, 8, 11, and 13 are scored inversely. For the anxiety (depression) subscale, participants with scores of “0–7” are considered as healthy, while those with scores of “8–10,” “11–14,” and “15–21” are considered to have low, mild, moderate, and severe anxiety (depression), respectively. Montazeri et al. confirmed the reliability and validity of this questionnaire in Iran. Cronbach's alpha coefficient (to test reliability) has been found to be 0.78 for the HADS anxiety sub-scale (HADS-a) and 0.86 for the HADS depression sub-scale (HADS-d). Validity as performed using known groups comparison analysis showed satisfactory results (Montazeri et al., 2003).

Rosenberg Self-Esteem Scale (RSES)

This10-item scale measures self-steam and self-worth. The items are scored on a four-point Likert scale from “strongly agree” to “strongly disagree” (Total score range: 0–30). Items 1, 3, 4, 7, and 10 are scored inversely. The validity and reliability of the Persian version of this questionnaire was confirmed by Shapurian et al.The alpha reliabilities for the scale were .83 (Shapurian et al., 1987).

Sample size

The sample size was estimated as 202 based on the study of Shahraki et al. (Shahraki et al., 2018). By considering absolute precision (d) = 0.04; mean SQOL score = 83.4, SD = 17.0, and α = 0.05, the final sample sized was calculated as 236.

Statistical analysis

The data were analyzed in SPSS 19. The normality of the variables was assessed using skewness and kurtosis. Descriptive statistics including frequency (percentage) and mean (SD) were used to describe the research variables. Pearson correlation coefficient test was used to assess correlations of SQOL with the variables of anxiety, depression, and self-esteem. In addition, Pearson correlation coefficient test, one-way ANOVA, and independent t-test were used to examine the relationships of socio-demographic variables with SQOL. To determine SQOL predictors, the socio-demographic variables that had significant relationships with SQOL along with the variables of anxiety, depression, and self-esteem were inserted into a General Linear Model (GLM) (p-value < 0.05).

Results

The means (SD) age of the participants and their spouses was 27.9 (5.7) and 31.5 (5.5) years, respectively. Most of the participants (82.2%) and their spouses (75%) had bachelor’s degrees.

The majority of the participants (89%) had no children. Despite the fact that some of the participants were able to conceive using infertility treatment, they all had not vaginal intercourse, almost, all women suffered from primary of vaginismus for which they were seeking treatment, with the exception of one woman with a 10 year-old child. She suffered from secondary vaginismus after she found out about her husband’s affair. More than half of the women (58.9%) had read about vaginismus in the Internet. About two thirds of the participants (65.7%) were housewives. As the table demonstrates, about one third of the women (29.2%) had been experiencing vaginismus for 2–5 years. As the table indicates more than half of women (52.5%) had suffered for a period of less than 2 years. Despite, women’s effort to solve their problems earlier, still 18% of participants had an experience of vaginismus more than 5 years (Table 1).

Table 1.

Relationship of socio-demographic characteristics with sexual quality of life in women with vaginismus (n = 236).

Variable Number Mean (SD) p
Age (Year) 236 27.9 (5.7) *0.475
Education     0.019‡
Under diploma 12 62.5 (21.6)  
Diploma 13 40.8 (10.9)  
Bachelor 194 57.2 (20.0)  
Masters and PhD 17 60.7 (21.9)  
Job     †0.068
Housekeeper 155 55.1 (20.5)  
Employed 81 60.1 (19.2)  
Duration of disorder     0.005‡
<1 59 57.0 (18.5)  
1–2 65 58.5 (21.3)  
2–5 69 57.3 (19.6)  
5–10 33 47.1 (15.0)  
>10 10 73.2 (28.6)  
House status     †0.508
Retired 154 56.2 (20.3)  
Private 82 58.0 (20.0)  
Husband age (Year)   31.5 (5.5) 0.198*
Husband’s education   <0.001‡  
Under diploma 28 41.9 (13.8)  
Diploma 15 52.9 (20.4)  
Bachelor 177 60.0 (20.1)  
Masters and PhD 16 51.1 (17.8)  
Information source   0.061‡  
Friends 18 60.5 (19.6)  
Books 11 18.5 (5.6)  
Internet 164 20.2 (1.7)  
Friends, books, internet 19 21.7 (5.0)  
Friends, books 20 18.9 (2.7)  
Having child     †0.217
Yes 27 61.3 (22.7)  
No 209 56.2 (19.8)  
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†Independent t-test.* Pearson correlation test. ‡One-Way ANOVA.

The mean (SD) total SQOL score of the participants was 56.8 (20.2). The mean (SD) total depression, anxiety, and self-esteem score was 11.0 (4.5), 7.4 (4.3), and 17.4 (5.5), respectively (Table 2). Pearson correlation test results showed a significant direct correlation between the participants’ self-esteem and their SQOL (r = 0.54, p < 0.001). The participants’ SQOL had significant inverse correlations with the variables of anxiety (r = −0.48, p < 0.001) and depression (r = −0.47, p < 0.001) (Table 2).

Table 2.

The status of the sexual quality of life, anxiety, depression, self-esteem and their relationship (n = 236).

Variable Mean (SD*) Obtainable score range obtained score range Relationship with sexual quality of lifer (p)
Sexual quality of life 56.8 (20.2) 18–108 18–108 –
Anxiety 11.0 (4.5) 0–21 0–21 −0.48 (<0.001)
Depression 7.4 (4.3) 0–21 0–21 −0.47 (<0.001)
Self-esteem 17.4 (5.5) 0–30 2–29 0.54 (<0.001)
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*Standard deviation.

Based on the bivariate test results, SQOL had significant relationships with the variables of educational qualifications (p = 0.019), spouse’s educational qualifications (p < 0.001), and duration of disorder (p = 0.005) (Table 1). The adjusted GLM results showed significant relationships of SQOL with variables of depression, anxiety, self-esteem, and duration of disorder (p < 0.05). These variables predicted 42.3% of the variance of SQOL in women with vaginismus (Table 3).

Table 3:

The relationship of anxiety, depression, self-esteem with sexual quality of life based on a general linear model (n = 236).

Variable B (95% confidence interval) p
Anxiety −0.78 (−1.35 to −0.06) 0.030
Depression −0.71 (−1.35 to −0.06) 0.031
Self-esteem 1.04 (0.55 to 1.53) <0.001
Education (Reference: Masters and PhD)    
 Under diploma 8.50 (−5.98 to 22.98) 0.249
 Diploma −7.54 (−22.61 to 7.53) 0.325
 Bachelor −5.00 (−14.91 to 4.91) 0.321
Husband’s education (Reference: Masters and PhD)
 Under diploma −2.08 (−14.68 to 10.52) 0.745
 Diploma 5.81 (−8.21 to 19.82) 0.415
 Bachlor 9.49 (−0.63 to 19.62) 0.066
Duration of disorder (Month) (Reference:>10)  
 <1 −15.00 (−25.86 to −4.13) 0.007
 1–2 −11.86 (−22.56 to −1.16) 0.030
 2–5 −14.37 (−25.19 to −3.56) 0.009
 5–10 −17.29 (−28.90 to −5.67) 0.004
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*Confidence interval.

Discussion

This was the first study to investigate the relationships of SQOL with psychological factors of anxiety, depression, and self-esteem in Iranian women with vaginismus. SQOL had significant inverse correlations with anxiety and depression, and a direct correlation with the variable of self-esteem. In addition, the variables of depression, anxiety, self-esteem, and duration of disorder were predictors of SQOL. Although depression was one of indicators of our study, we excluded anti-depression drug users or those who were using hormonal contraceptives three months before the study. The reason for this exclusion was the potential interference of drugs with women's sexual functions. Moreover, it would also affect the HADS results in terms of participants’ answers to the intensity of depression and anxiety symptoms. (Lorenz et al., 2016; Yanartas et al., 2016). Furthermore, women with evidence of any active genitourinary infection and other conditions such as endometriosis, pelvic inflammatory disease and vulvodynia were excluded from the study.

In this study, depression predicted SQOL in women with vaginismus. Karaguzel found higher levels of depression and anxiety in women with vaginismus than in healthy women. After the treatment, the participants’ sexuality, orgasm, sexual satisfaction, and quality of life improved; however, anxiety scores decreased following the intervention (Karaguzel et al., 2016). In the study of Nimbi et al. (2020), women with vaginismus had lower sexual performance and lower quality of life in comparison with healthy women, and those with genital pain had more psychological problems (Nimbi et al., 2020). Consistent with the present results, Shahraki et al. (2018) concluded that depression is a predictor of SQOL (Shahraki et al., 2018). Frohlich et al. reported that depressed women experience more sexual pain problems than non-depressed women. Moreover, women with vaginismus received significantly higher depression scores (Frohlich & Meston, 2002).

Anxiety predicted SQOL in women with vaginismus. Accordingly, Cooper (1969) found higher levels of anxiety in patients with vaginismus (Cooper, 1969). Kennedy et al. (1995) also observed relatively high levels of anxiety in women with vaginismus (Kennedy et al., 1995). Hudd et al. argued that higher anxiety scores are associated with lower confidence levels (Hudd, 2000). Yildirim et al. showed at least one comorbid anxiety disorder and/or depression was found in 79.86% of the cases (Yildirim et al., 2019). These variables also reduce the quality of life and sexual quality of life of women with vaginismus (Bokaie et al., 2017).

Self-esteem had a significant direct relationship with SQOL (Mizrahi, 2018; SadatiKiadehi et al., 2020). Similar findings were reported by Muehrer (Muehrer et al., 2006), Morley (Morley & Kaiser, 2003), Anastasiadis and Abarbanel (Anastasiadis et al., 2002) who observed a negative association between self-esteem and sexual dysfunction indicating that lower self-esteem levels increase the risk of sexual dysfunction (Abarbanel & Rabinerson, 2004). In another study, a positive correlation was found between self-esteem and SQOL of obese women (Polat & Serin, 2020; Türkben Polat & Kaplan Serin, 2020), which is in line with the present results.

The present findings indicated a significant impact of psychological factors (e.g., anxiety, depression, and self-esteem) on sexual quality of life in women with vaginismus and should be more focused in clinical care. Effective counseling and treatment programs must be organized to improve psychological factors associated with the SQOL of women with vaginismus. However, due to the correlational nature of the discussed relationships; one cannot definitely conclude that poor sexual quality of life (caused by vaginismus) provokes low self-esteem and depression, or that high depression and low self-esteem levels lead to poor sexual quality. A prospective study may better reveal the direction of this relationship.

Strengths and limitations of the study

The use of standardized tools was among the strengths of the present study. However, due to the cross-sectional nature of the study, the aforementioned relationships are not exactly causal relationships. Furthermore, most of the participants had high educational qualifications, therefore, they do not properly represent the general population of women with vaginismus. There are other limitations to this study that we would like to highlight them. For instance, we did not have any other control group to compare and contrast the results of our study. Moreover, although we identified that in our study some women had pain, we did not make an analytical comparision for the responses given by women who had to pain and those without pain. This is mainly because the aim of the study was to investigate the correlation between the Psychological factors with sexual quality of life among woman with vaginismus problem. However, such separated alanysis and comparision could have enriched the outcome of the study. Although we trust that the diagnosis of vaginismus by experienced gynocologists was correct and adequate, there is a possibility that other sexual disorders such as vulvodynia, due to the overlapping symptoms, has been overlooked. We recommend that the future studies and trainings pay more attention to the overlapping symptoms of vaginismus and other sexual disorders, especially vulvodynia . This will help to avoid any further suffering to vulvodynia patients by wrongly referring them to psychological investigation.

Conclusion

Based on the results, psychological factors such as anxiety, depression, and self-esteem are the main determinants of SQOL in women with vaginismus. The results can help health providers adopt effective strategies in order to better recognize psychological problems and provide appropriate treatments for women with vaginismus to enhance their sexual life.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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