Disgust and Vaginismus
‘…Disgust is a very strong feeling that takes over any other feeling or emotion. It brings about the feeling of dirt (personally) stretching from any crawling insects to people. For some… the two (disgust and sex) are viewed as one.’ Angie C
‘In my personal experience I describe the sex as simply disgusting. Have you ever felt a crawling insect crawling on your hands while you are sleeping on a low mattress on a breezy summer night while camping? Insects crawl in a very slow pace but they are there and when you realize they are on your body, Mr. Insect would have already toured an extensive part of your body: in this case your hand and arm… His penis stabbing my vagina was the worst. It felt like insects were let loose and they were crawling out of my vagina for hours and hours. It was horrible, the smell, the touch, the feel everything. How can a woman ever describe sex as pleasure? I don’t understand. That was the first night in a series of self-harm episodes.’ Angie C.
(This is an excerpt from a client’s description of the way in which she perceives the emotion of disgust in relation to sex.)
In this article, we will look closely at two distinct areas of interest, disgust and sexual dysfunction, and also at the interaction between them. Sexuality is currently one of the foremost among women’s health issues, as sexual dysfunction may have a serious negative impact on relationships and overall emotional well being across different life stages. Moreover, sexual dysfunction can have a negative effect on both genders (directly/indirectly). If left untreated, therefore, sexual dysfunction could cause silent suffering and significant emotional pain. Our principal emotion of interest, disgust, is also a recently growing formulation in its own right after being labelled as the ‘forgotten emotion of psychiatry’ (Phillips et al., 1998). Sexual dysfunction has been investigated from different points of view, both physiologically and within the framework of well-known psychological theories. The mechanisms underpinning these dysfunctions, however, remain far from understood and, consequently, treatment is limited. The exploration sexual dysfunction could foster a greater readiness on the part of professionals in the field to investigate and broach the topic of sex and sexuality with clients and sufferers, encouraging them to seek help immediately and to delve deeper into problems that might otherwise remain hidden.
Sexual dysfunction is a term used to define continuous impairments of sexual arousal and response (Hawton, 2003). This term can be rather ambiguous as the degree of ‘dysfunction’ is entirely determined from the subjective points of view of the individual and her partner. Sexual dysfunction is highly influenced by other factors, such as implicit and explicit memories that can generate expectations that merge with the individuals’ unique associations of the sexual experience. In this article, we are going to focus on vaginismus: for the sake of clarity, we will provide its definition below.
Vaginismus may occur in approximately 0.5 to 1% of fertile women, though accurate estimations are lacking (Graziottin, 2006). It seems to be a relatively common problem but it is underrepresented in the medical literature, which could be due to the sensitivity surrounding the problem itself as well as to the complexities involved in its definition. However, for the purpose of this study, vaginismus is defined as a ‘recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse’ (American Psychiatric Association, 2000). Vaginistic complaints are characterized by ‘persistent difficulties to allow vaginal entry of a penis/finger/object, despite the woman’s wish to do so’ (Basson, 2005). An extension of this definition includes a component of phobic avoidance and the anticipation/fear/experience of pain. As already mentioned in the introduction of this article, the treatment strategies currently available are not very effective (Van Lankveld et al., 2006) and, as a result, vaginismus often takes a chronic course (Weijmar Schultz et al., 2005).
The psychological perspective in this field seems to consider sexual dysfunction secondary to a negative reaction to erotic stimulation (Janssen and Everaerd, 1993). De Jong and colleagues identified disgust as a prominent candidate for one of these negative emotional reactions. In the latter study, findings were indicative of a connection between vaginismus and a propensity for disgust, therefore enhancing the vulnerability to vaginistic complaints in this population (De Jong et al., 2008).
However, evidence is rather limited in this area, and there is a disproportionate focus on emotional and cognitive processes related to fear and pain, with little attention paid to disgust (Kaneko, 2001). Sexual dysfunction, with a particular emphasis on vaginismus, has been often associated with a physiological, primary neurodystonia of the pelvic floor (Graziottin, 2004), and sometimes with neurological disorders. However, evidence suggests that even if this is actually presumed, a psychological reaction to the impairment may exacerbate the problem. Moreover, the disgust and fear of penetration surrounding vaginismus may impair the normal process of arousal, which can worsen the problems through processes of attention that influence the interpretation of sexual stimuli (Dorfan and Woody, 2006), thus making it more difficult for the individual to ‘merge’ with the situation. Apart from the problem low sexual arousal can create in itself, it can also trigger or act as a foundation for other, possibly more severe sexual dysfunctions.
This may interact with muscular arousal causing a defensive contraction of the perivaginal muscles (Graziottin, 2008), which can be the foundation for the vaginistic complaints expressed by these women. This posits vaginismus as a complaint susceptible to psychological sexual treatment driven by disgust-related findings. The latter can potentially refine the interventions presently available, by, perhaps, also including disgust in the interventions: for instance, by neutralizing the disgusting associations connected to body products and/or parts commonly present in sexual encounters. In focusing on the emotion of disgust, it is by no means our intention to diminish the importance of fear; instead, this approach provides a more refined lens through which look at the interaction between, and uniqueness of, these two potentially active basic emotions. For instance, fear could be elicited by an anticipation of harm or by a fear of contagion or contact with disgusting objects. This is strengthened by findings from previous studies conducted on arachnophobia, where it was found that the single best predictor of elicited fear was the enhanced sensitivity to contagion during the viewing of images of spiders (De Jong et al., 2002).
Current sexual treatments based on cognitive-behavioural principles seem to suggest that in the several stages of the treatment for vaginismus, negative attitudes may become apparent, which could reflect underlying cognitive processes and automatic associations, of which the woman may be completely or partially unaware. Automatic associations could impair the normal process of arousal (Laan and Janssen, 2007). Consequently, from the perspective of this new conceptualization of vaginismus, the impairments experienced by women with vaginismus or other sexual dysfunctions with a similar psychopathology may fundamentally reflect a disgust-induced, safety-seeking response. The minimal attention paid to disgust-related processes may be one of the possible reasons for the low efficacy of the treatments that are currently available. Moreover, targeting these automatic associations that are possibly related to a susceptibility to disgust can offer new insights into the psychopathology of such a contentious disorder.
The paucity of empirical research on disgust is very surprising, as disgust is relevant to a variety of fields (Phillips et al., 1998) and is a common and basic emotion experienced in everyday life. Disgust also has unique characteristics and manifestations: although it shares similarities with fear, disgust involves a suspension rather than an increase in activities. The opinion within existing literature is consistent about the development and function of disgust as an evolutionary defensive mechanism against the ingestion of harmful pathogens. Although disgust functions as an effective defence reaction, it has to be suspended in some situations to make normal sexual functioning possible; otherwise, it can in itself hinder the process of sexual arousal.
Theoretical accounts seem to focus on different types and constructs of disgust rather than representing it as one unitary emotion. Studies have revealed that the response to core disgust elicitors (e.g. rotten food, dirty toilets, faeces etc…) weakens overtime but intensifies for socio-moral elicitors (Simpson et al., 2006). Different psychological mechanism for animal, core and contamination disgust, may give rise to different clinical conditions and behaviour (Olatunji et al., ‘Core, animal …’). Moreover, in the context of sexual behaviour, these three seem to be the most relevant. This distinctiveness can potentially be reflected in the neural substrate when a comparison is made between the different disgust elicitors (Olatunji et al., ‘Disgust Sensitivity …’). Sexual behaviour is particularly associated with animal disgust due to its association with the ‘animalistic’ in human nature. Socio-moral disgust is also an important construct that may very well be involved in sexual behaviour due to its assumed link with the protection and internalization of cultural rules and conformity. Therefore, subjective violations of such rules can elicit disgust and interfere with sexual arousal and absorption (Rozin and Haidt, 1999) and possibly interact with the mechanism underlying a variety of sexual dysfunctions. This effect can be even more prevalent when sex is represented to individuals as dirty or inappropriate from an early age, perhaps with reference to the religious views commonly held in the social environment they grow up in.
From an evolutionary perspective, disgust is perceived as a defence from contamination present in the environment (Curtis et al., 2004). The literature suggests that specific body parts vary in their sensitivity to contamination, with mouth, vagina and penis holding the highest subjective sensitivity to contamination, while bodily products such as sweat and semen function as the strongest elicitors of disgust (Rozin and Fallon, 1987). Given the core role of these organs and products in sexual behaviour, it is difficult not to see the link between the two phenomena. However, what is most striking in this account is the lack of connections being made previously in research between the avoidance of sexual penetration and disgust, despite the fact that a connection is supported by empirical research (Carnes, 1998).
The state or experience of disgust is also generally associated with avoidant tendencies, i.e. with subjects removing themselves from situations (that elicit disgust) or withdrawing their attention. Fear of contamination would, therefore, be expected to elicit defensive reflexes aimed at self-protection and the avoidance of the perceived contaminated object (e.g. penis). This could be reflected in the involuntary contraction of the pelvic floor muscles, which was found to be associated with a general defence mechanism (Van der Velde et al., 2001). The stronger avoidance of potentially contaminated sexual stimuli found in vaginistic women when compared to women with dyspareunia or healthy controls, supports the aforementioned conceptualization (De Jong et al., 2008). The core difference that distinguished the vaginistic group from the other two groups was mainly based on differential scores on the Hygiene and Death subscales of the disgust scale (Haidt et al., 1994). Authors of this study explained this finding in the vaginistic group as evidence of an inclination towards a fearful preoccupation with contamination (De Jong et al., 2008). Therefore, given the tacit knowledge that the penis is often associated with contamination (Davey et al., 1993) and the vagina is commonly perceived as extremely sensitive to contamination, we hypothesize that this could be a contributive factor in the process that underlies vaginistic complaints.
Memory underpinning the Disgust Induced Defensive Behaviour
The retrieval of memories can possibly trigger automatic associations and a negative anticipation related to disgust that motivates the person to seek disgust-induced, defensive behaviour, possibly projected as vaginistic complaints, secondary to a relatively negative appraisal of the sexual stimulus (Brauer et al., 2008). This may contaminate the sexual encounter and encourage further avoidance. Contaminated sexual arousal can be generated by vaginal dryness and increased pelvic floor muscle tone, hence more susceptibility to pain resulting from friction (Kuile and Weijenborg, 2006). The conscious appraisal of sexual stimuli is not based exclusively on the situational experience but also on previous experiences of sexual encounters (Spiering et al,, 2004).
Evidence suggests that women who show symptoms of sexual dysfunction have a greater propensity for fear and for negative associations in connection to sexual stimuli (Brauer et al., 2008). The contradictory findings of positive rather than negative automatic associations in the dyspareunia group, despite their painful experiences, were difficult to interpret but the authors concluded that such (pain-related) experiences might influence the conscious more than the implicit and well-ingrained automatic associations (Brauer et al., 2008). This conclusion was based on the self-reported data that was incongruent with the implicit findings, suggesting a reflective (vs. reflexive) involvement in dyspareunia. It would be interesting to investigate whether this is similar for patients with primary vaginismus, using implicit measures and pictures of brain activation for both groups.
Consequently, in line with abundant literature in the area of cognitive-behavioural psychotherapy, avoidance of sexual penetration may prevent a patient from refuting her fears relating to sexual disgust, which may further increase the negative associations and disgust-induced defensive behaviour (due to repeated contaminated sexual experience and hence reinforcement of her beliefs) connected to the actual act of penetration.
From a slightly different perspective (although one that can be connected to the above account), there is a lot of literature, which shows that endogenous glucocorticoids are released in the expectancy of a subjectively abhorrent stimulation, such as the negative anticipation of penetration. Recent literature shows that this elevation of glucocorticoids is also linked to preferentialimpairment in the retrieval of emotionally arousing information (De Quervain and Margraf, 2008). Findings show that glucocorticoid treatment leads to an impairment of the ability to recall previously learned information (Wolf et al. 2001), which suggests that the ‘impaired retrieval’ of fearful memories reduces negative anticipation for the feared stimuli (Soravia et al., 2006). This finding has been applied successfully to several disorders (e.g. in Phobias and Post Traumatic Stress Disorder). It would, therefore, be interesting to investigate whether this might also be reflected in subjects with vaginismus. Positive results would be expected due to the seeming similarities in the underlying cognitive mechanism shared by specific phobias and vaginismus. This could have a groundbreaking significance for the potential treatment of patients with vaginismus, possibly in combination with other exposure interventions.
The aim of this report was to attempt to delve deeper into the realms of vaginismus, and to look at the way in which disgust is intertwined with the complexities of such complaints, focusing mainly on the concept of this basic emotion of disgust. However, we mentioned fear of pain and other concepts that we deemed were necessary and could fit in well with this revised conceptualization.
A great need exists for the enhancement of our current understanding of the role of disgust in relation to these relatively common sexual disorders, vaginismus in particular. This may contribute to the refinement of its current conceptualization, and to the development of effective psychological treatments and interventions for women suffering from these complaints as well as their partners who may also be suffering as a consequence of these problems.
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