Association between non-penetrative sexual activities and depression in women with vaginismus: a cross-sectional study

Abstract

Objective

This cross-sectional study aimed to explore the association between non-penetrative sexual activities (NPSA) and depression levels in women diagnosed with vaginismus.

Methods

A cross-sectional retrospective study was conducted between March 2016 and June 2019, after approval by the Fırat University Faculty of Medicine ethics committee. Participants comprised married women referred to our female sexual dysfunction outpatient clinic with vaginismus. Diagnosis of vaginismus was established following comprehensive evaluations, including gynecological examination and psychiatric assessment. Sociodemographic data and Beck Depression Inventory (BDI) scores were collected. We compared depression levels between women who engaged in NPSA and those who did not.

Results

Of the 75 women with primary vaginismus included in the study, 18 did not engage in any NPSA and 57 engaged in at least one NPSA. The average BDI score of those who engaged in NPSA was significantly lower than those who did not. A negative correlation was found between the number of NPSA engaged in and BDI scores (r = −0.494).

Conclusions

Women with vaginismus had high depression scores, but engaging in NPSA was associated with lower depression levels. The findings suggest that incorporating NPSA into clinical interventions may be beneficial for managing depression in women with vaginismus.

Introduction

Vaginismus is a condition that is associated with fear, pain and anxiety and that prevents the penetration of the vagina by penis, finger, tampon, vaginal dilator or gynecological examination owing to involuntary spasm of the outer third part of the vagina. ¹ The diagnosis of vaginismus is based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. The DSM has undergone several revisions, but the definition of vaginismus remained consistent until the fifth edition of the DSM (DSM-5). In DSM-5, vaginismus and dyspareunia are combined under the umbrella term “genito-pelvic pain and penetration disorder.”^2–3 This consolidation reflects a shift towards a more holistic understanding of female sexual dysfunctions that acknowledges the complex interplay of physical and psychological factors involved in these conditions. However, it is important to note that the International Classification of Diseases continues to classify vaginismus and dyspareunia as separate diagnoses, highlighting the ongoing debates and variation in diagnostic criteria across different classification systems. ² Vaginismus is a prevalent sexual dysfunction among women seeking clinical help; however, population-based studies suggest a lower prevalence, as low as 0.4%. ⁴ It has been reported that women who experience pain during sexual intercourse report general psychological distress, particularly depressive symptoms. ⁵ These include cognitive factors such as phobic avoidance and expectations of threat, as described by cognitive-behavioral models, along with other psychosocial factors such as religious prejudice, sense of sin, and strict religious or sexual upbringing. ⁶ In addition, sexual trauma, including sexual abuse, has been implicated in the etiology of vaginismus. ⁷ Sexual dysfunction is often accompanied by other psychiatric disorders. A previous study showed that depression and anxiety rates are higher in women with vaginismus than in healthy women. ⁸ Another study found that 79.9% of women diagnosed with lifelong vaginismus had at least one additional diagnosis of anxiety disorder and/or major depression. ⁹ Sexual dysfunction can result from low-quality and low frequency sexual intercourse, potentially leading to reduced physical pleasure and increased negative mood during sexual activity. ¹⁰ Vaginismus may also lead to reproductive, sexual and familial problems; these can result in depression, marital problems, feelings of loneliness and isolation from society and may lead to non-consummation of marriage or divorce.^10,11

Non-penetrative sex or outercourse is an alternative sexual activity to penile–vaginal penetration. Couples may engage in non-coital activity to preserve virginity, as a type of contraception. ¹² Non-penetrative sexual activities (NPSA) include frottage (rubbing the genitalia against the partner’s body), reciprocal masturbation, cuddling, kissing, clitoral stimulation, manual stimulation, oral–genital contact and interfemoral coitus. Most women with vaginismus prefer this kind of sexual intimacy with their partners to avoid penetration.^12,13 Outercourse offers alternative methods for satisfying sexual desire and achieving orgasm that do not involve the penis penetrating the vagina. ¹⁴ Some women with vaginismus experience arousal, lubrication and orgasm as a result of NPSA despite difficulties with vaginal penetration.^15,16

Our clinical observations suggest that depression, anxiety and marital problems are less frequently observed in women with vaginismus who, despite having difficulty with vaginal penetration, engage in NPSA and experience high levels of satisfaction as a result of these activities. Considering the above-mentioned research findings, the aim of this study was to investigate the extent of depression among patients with vaginismus, comparing those who engage in NPSA with those who do not, and to assess the association between depression and vaginismus in individuals practicing NPSA.

Methods

This cross-sectional retrospective study was approved by the ethics committee of Fırat University Faculty of Medicine (03.10.2019; approval number 15) and was conducted in accordance with the ethical standards of the 1975 Declaration of Helsinki (revised in 2000) and the National and Institutional Committee on Human Rights Watch. ¹⁷ As this was a retrospective study, signed consent from patients was not feasible or required, as no new patient data were collected. The study aimed to explore depression levels in patients with vaginismus by comparing those who engaged in NPSA with those who did not, and to examine the relationship between depression and vaginismus in individuals practicing NPSA.

Participants

Participants were married women referred to our female sexual dysfunction outpatient clinic with the complaint of vaginismus between March 2016 and June 2019. A total of 115 patients applied to the outpatient clinic during the specified period, of which 82 were diagnosed with vaginismus. All eligible patients who met the inclusion criteria were included in the study consecutively. The diagnosis of vaginismus was established following a thorough evaluation that comprised a gynecologic examination by an obstetrics and gynecology specialist and a psychiatric examination by a psychiatry specialist according to DSM-5 diagnostic criteria. A total of 82 patients were diagnosed with vaginismus and met the inclusion criteria; however, 7 of these individuals declined to participate in the study. To ensure patient confidentiality, all identifiable information was thoroughly de-identified. Patient details, including names, ages, and any other identifying information, was removed or replaced with generic descriptors. Additionally, any potentially identifying characteristics in the results were anonymized to protect patient privacy.

The inclusion criteria were as follows: Women aged between 18 and 45 years, with a partner, married, in good general health, and diagnosed with primary vaginismus.

The exclusion criteria were as follows: Patients with hymen abnormalities (structural irregularities or anomalies of the hymen, which include imperforate hymen, septate hymen, microperforate hymen or other congenital variations); congenital vaginal abnormalities; vulvodynia; secondary vaginismus owing to physical or psychological trauma; infection; menopause; history of personal psychiatric disorder prior to vaginismus (any pre-existing psychiatric condition experienced by the participant before the onset of vaginismus, including mood disorders such as depression or bipolar disorder, anxiety disorders such as generalized anxiety disorder or panic disorder, psychotic disorders, personality disorders, substance use disorders, or any other psychiatric condition); pelvic pathology; or those whose partners had sexual dysfunction that could affect sexual intercourse.

Procedure

Participants underwent a comprehensive evaluation that consisted of a gynecological examination by an obstetrics and gynecology specialist followed by a psychiatric assessment by a psychiatry specialist, according to DSM-5 criteria. Sexual trauma history was systematically assessed during the psychiatric examination using a structured questionnaire. A sociodemographic data form and the Beck Depression Inventory (BDI) were administered to all patients. Participants were asked about any NPSA they engaged in and presented with the following response options: frottage, reciprocal masturbation, clitoral stimulation, oral sex, anal sex, interfemoral coitus and watching pornography.

Sociodemographic data

Sociodemographic data collected included questions on age, educational background, marital status, physical and mental status, history of sexual trauma, non-sexual traumatic experiences, non-penetrative sexual methods and Lamont classification. According to the Lamont classification, the response to penetration in a pelvic examination indicates the severity of vaginismus, which is categorized according to four degrees. In first-degree vaginismus, the patient can relax the perineal and levator muscles for examination when advised by her physician. In second-degree vaginismus, the patient does not allow examination despite reassurance from the physician. The third degree is accompanied by spasms of the pelvic floor muscles and elevation of the hips. In fourth-degree vaginismus, severe spasm is accompanied by elevation of the hips and legs. ¹⁶

Beck Depression Inventory

The BDI is a self-report scale that measures emotional, cognitive, somatic and motivational components. ¹⁸ The BDI is the most common self-report measure of depression used by clinicians and researchers. The scale consists of 21 items with a cutoff point of 17. Studies have demonstrated that the BDI is reliable and valid for Turkish samples. ¹⁹ The reliability of the BDI was assessed using Cronbach’s alpha (alpha = 0.79).

Statistical analyses

Data were analyzed using IBM SPSS for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as mean ± standard deviation. Spearman correlation analysis was used to analyze correlations between variables, and the Mann–Whitney U test was used to compare means between groups with non-normally distributed data. A p-value <0.05 was considered statistically significant.

Results

Seventy-five women with primary vaginismus who presented to our outpatient clinic were included in the study. The mean age of the patients was 27.4 ± 5.24 years. Most participants were university graduates (60%). All patients were married and the mean marital duration was 9.4 ± 5.6 months. Only four patients had a history of sexual trauma. According to the Lamont classification, the mean vaginismus level was 3.2 ± 0.63.

Of participants, 18 (24%) did not engage in any NPSA and 57 (76%) engaged at least in one NPSA. The types of NPSA that participants engaged in are shown in Table 1.

Table 1.

Varieties of non-penetrative sexual activities in women with vaginismus.

Non-penetrative sexual activity
Frottage	29/75 (38.7%)
Reciprocal masturbation	9/75 (12%)
Clitoral stimulation	34/75 (45.3%)
Oral sex	15/75 (20%)
Anal sex	0/75 (0%)
Interfemoral coitus	35/75 (46.7%)
Watching pornography	4/75 (5.3%)

The mean BDI scores of both groups were above the cutoff score of the inventory. However, the mean BDI score of participants who engaged in NPSA was significantly lower than that of participants who did not engage in NPSA (p = 0.008). The distribution of BDI scores according to NPSA engagement is shown in Table 2.

Table 2.

Distribution of BDI scores according to non-penetrative sexual activity

Non-penetrative sexual activity	N	BDI score
		Mean	SD
None	18	25.33	10.66
Non-penetrative sexual activity	57	18.04	10.99
Frottage	29	20.00	13.11
Oral contact	15	11.00	6.60
Clitoral stimulation	34	11.41	5.37
Reciprocal masturbation	9	11.33	6.27
Interfemoral coitus	35	18.74	11.79
Watching pornography	4	11.50	7.59

BDI, Beck Depression Inventory; SD, standard deviation.

There was a negative correlation between the number of NPSA engaged in and BDI scores (the BDI scores decreased as the number of activities increased) (r = −0.494; p < 0.001).

No significant relationship was found between depression level and age, duration of marriage and Lamont classification. The correlations between depression and age, marriage duration, and Lamont classification are shown in Table 3.

Table 3.

Results of Spearman correlations between BDI scores and age, marriage duration and Lamont level in patients with vaginismus

Spearman correlation		NPSA (−) (18)		NPSA (+) (57)		All (75)
		rho	p	rho	p	rho	p
Depression	Age	0.093	0.713	−0.094	0.485	−0.016	0.889
	Duration of marriage	0.222	0.375	−0.193	0.150	−0.029	0.806
	Lamont level	−0.184	0.466	0.081	0.547	0.011	0.925

BDI, Beck Depression Inventory; NPSA, non-penetrative sexual activity.

Discussion

Sexual intercourse plays an important role in a couple’s relationship in terms of its effects on mental and physical health. Individuals who are more sexually active are happier and more emotionally and physically satisfied in their social lives.^11,19 Owing to the relatively high prevalence of sexual problems in the female population and the detrimental effects of sexual problems on overall quality of life, many clinicians have focused on this issue. ²⁰ In this study, we investigated the depression levels of women with vaginismus who engaged in NPSA and those who did not engage in NPSA. The results showed that the average BDI scores of both groups were above the BDI cutoff score, indicating that both groups had depression. However, the average BDI score of participants who engaged in NPSA was significantly lower than that of participants who did not. A recent retrospective study showed that the incidence of clinically significant depressive symptoms is twice as high in women with genital pain, dyspareunia, vulvodynia and/or other vaginal/vulvar complaints. ²¹ Stout et al. reported that feelings of loneliness and depressive symptoms increase in women who experience more severe and more frequent pain during sexual intercourse, that such women become increasingly lonely and that loneliness mediates depressive symptoms. ²² It appears that all these factors contribute to depression in these patients.^9,11

Several factors contribute to the heightened vulnerability of vaginismus patients to depression. The persistent challenges associated with sexual intimacy, including low-quality and infrequent sexual encounters, create a cycle of frustration and negative emotions.^23–24 The reduced physical pleasure experienced during intercourse, which is often a consequence of vaginismus, further compounds these feelings. Psychological distress caused by unfulfilling sexual experiences can substantially affect self-esteem and body image, exacerbating depressive symptoms. Furthermore, the societal stigma and lack of awareness surrounding vaginismus may contribute to feelings of isolation and hopelessness, thus increasing the emotional burden experienced by affected individuals.^24,25 Understanding these multifaceted factors is essential for developing comprehensive interventions and support systems for vaginismus patients. ²⁵ Addressing both the physical and psychological aspects of the condition through specialized treatments and counseling can alleviate depressive symptoms and enhance overall well-being. In this study, we investigated a specific aspect of this relationship (non-penetrative sex) and its potential effect on alleviating depressive symptoms in women diagnosed with vaginismus. Our findings suggest that engaging in NPSA may be an important factor in mitigating depressive symptoms among women with vaginismus. Focusing on alternative intimate activities to penetrative intercourse may provide individuals with vaginismus with an alternative way of experiencing physical closeness and emotional intimacy. This diversification of sexual interactions can lead to increased feelings of acceptance, comfort and satisfaction with relationships, and counteract the negative emotional experiences often associated with vaginismus.

Some women with vaginismus who cannot experience vaginal penetration and who engage in NPSA may experience arousal, lubrication and orgasm.^13,24 An early study demonstrated that women with vaginismus could have healthy sexual function. ²² These results demonstrate that sexual function in women with vaginismus is not impaired when performing NPSA. ²³ A study by Elran et al. showed no substantial differences between women with and those without vaginal penetration difficulties in the Female Sexual Function Index domains of desire, arousal, lubrication, orgasm and satisfaction. ²⁶ These findings indicate that couples who choose outercourse instead of intercourse can experience sexual satisfaction. ²⁷ Hawton and Catalan compared 30 women with vaginismus and 76 women with sexual dysfunction and found that women with vaginismus are more interested in sexuality and have higher rates of sexual arousal and pleasure compared with women with sexual dysfunction. ²⁸ In our study, 76% of women with vaginismus engaged at least in one NPSA.

Understanding the neurobiological bases of the positive effects of NPSA in reducing depression among women with vaginismus is important. By triggering the release of neurotransmitters like dopamine, and hormones such as oxytocin and endorphins, NPSA creates a neurochemical environment that is associated with pleasure, bonding and relaxation. ²⁹ This chemical response not only counters depressive symptoms but also induces neural plasticity, reconditioning neural responses to sexual intimacy. Additionally, NPSA reduces stress, regulates cortisol levels and fosters positive neurofeedback, enhancing self-efficacy and self-esteem. ³⁰ These neurobiological mechanisms collectively contribute to the alleviation of depressive symptoms, underscoring the importance of NPSA as a therapeutic and empowering approach for women with vaginismus. The neurobiological effects of engaging in NPSA provide valuable insights into the complex relationship between sexual experiences and mental well-being in women with vaginismus. Further research in this area is needed to increase understanding of these mechanisms, and to inform the development of targeted interventions and comprehensive support for individuals with this condition. Clarifying the complex effect of NPSA on the brain would help to improve the effectiveness of therapeutic strategies, which would ultimately improve the quality of life of women with vaginismus.

For woman who experience vaginal penetration difficulties, NPSA may be the best way of enjoying sex without fear of penetration and/or pain. ³¹ Shifting focus to positive NPSA sex play when intercourse between a couple is uncomfortable can help to maintain physical and emotional intimacy. ³² Breaking the vicious cycle between depression and sexual dysfunction using pleasure-oriented NPSA instead of penile penetration-oriented intercourse may improve both depression and vaginismus. Consistent with this, in the present study, women engaging in NPSA had lower depression scores than those who did not. Furthermore, there was a negative association between the number of NPSA engaged in and depression scores.

Although the present findings suggest the potential therapeutic benefits of NPSA in reducing depression among women with vaginismus, it is important to acknowledge the broad spectrum of treatments available for this condition. As vaginismus is often strongly associated with psychological and emotional factors, a multifaceted approach is needed to address both the physical and mental aspects of the disorder. One commonly used treatment modality is cognitive-behavioral therapy (CBT), which focuses on challenging and modifying negative thought patterns and beliefs associated with sexual intercourse. ³³ CBT is often used in combination with exposure therapy and it helps patients confront and manage the anxiety and fear associated with vaginal penetration. Several studies have reported favorable outcomes with CBT, indicating its effectiveness in enhancing patients’ overall sexual functioning and reducing vaginismus-related distress.^33,34 Pelvic floor physical therapy is another useful intervention, especially for cases where vaginismus is associated with muscular tension or trauma. Pelvic floor exercises, relaxation techniques and biofeedback are integral components of this therapy, and are used to alleviate muscle spasms and enhance pelvic muscle control ³⁴ Many patients have reported substantial improvements in their symptoms following pelvic floor physical therapy, indicating its potential as a non-invasive, holistic treatment approach. ³⁴ The use of dilators, which are graduated vaginal trainers that help patients to gradually accustom themselves to penetration, has shown promise in desensitizing the vaginal muscles. Dilator therapy is often combined with relaxation exercises and counseling, and allows patients to regain confidence and control over their bodies. Studies have demonstrated the efficacy of this technique, with patients reporting reduced pain, anxiety and avoidance behavior associated with penetration. ³⁵ The present study on the use of NPSA to alleviate depression in women with vaginismus adds to the diverse range of available treatments. However, although NPSA is a useful way of increasing emotional intimacy, it is essential to consider individual differences and preferences when tailoring treatment plans. The effectiveness of interventions like CBT, pelvic floor physical therapy and dilator therapy indicates the importance of personalized, patient-centered care. Continued research and comprehensive exploration of these treatments will increase understanding of vaginismus and contribute to the development of more targeted, evidence-based interventions for affected individuals.

In this study, we found that 76% of women with vaginismus engaged in at least one NPSA. Although the frequency of NPSA was not assessed in this study, this observation demonstrates that a considerable proportion of women with vaginismus may find alternative ways of achieving sexual intimacy and satisfaction beyond penetrative intercourse.

There are several implications of these findings. Engaging in NPSA has the potential to positively affect the emotional well-being and overall quality of life for women with vaginismus. By providing alternative methods of sexual expression and intimacy, NPSA may alleviate feelings of depression and anxiety commonly associated with vaginismus. Additionally, NPSA can contribute to enhanced relationship satisfaction and sexual fulfillment, fostering a sense of connection and intimacy between partners.

These findings have important implications for clinical practice. Healthcare providers should consider incorporating discussions about NPSA into treatment approaches for vaginismus. By acknowledging and validating the role of NPSA in sexual expression, clinicians can empower women with vaginismus to explore alternative forms of sexual intimacy that are comfortable and enjoyable for them. This holistic approach to treatment may help to address depression and improve overall well-being for individuals affected by vaginismus.

Although this study provides valuable insights into the potential benefits of NPSA for women with vaginismus, there are several limitations that should be acknowledged. The frequency and specific types of NPSA were not assessed, so further research is warranted to explore these aspects in more detail. Additionally, the cross-sectional nature of the study limits our ability to draw conclusions about causality or long-term effects. Additional longitudinal studies are needed to examine the relationships between NPSA, depression and sexual functioning over time.

Conclusion

This study highlights the potential therapeutic benefits of NPSA in managing depression and improving overall well-being for women with vaginismus. By recognizing the importance of alternative forms of sexual intimacy, clinicians can provide more comprehensive care for individuals affected by this condition.