Dual Jeopardy: Managing Vaginismus in a Female Having a Partner Suffering from Psychotic Disorder

Abstract

Vaginismus is a complex condition to manage, and in the presence of a partner, management becomes more complex as it involves the engagement of both partners. Besides addressing vaginismus, the management may involve addressing additional issues such as marital disharmony, situational erectile dysfunction in the partner, infertility, mental morbidity, and other associated psychosocial problems. There is a lack of data on the management of vaginismus in a woman with a partner with a psychotic disorder. In this report, we describe a couple in which the female partner had vaginismus that led to a lack of consummation of marriage for six years, and the male partner had schizophrenia. We discuss the challenges faced in the successful management of vaginismus by using an eclectic approach.

Introduction

Vaginismus is understood as a persistent or recurrent difficulty encountered by a female to permit the entry of a penis, a finger, or any other object into the vagina, despite the woman’s wish to do so. This difficulty is attributed to anticipated pain, and they experience involuntary contraction of pelvic muscles when an attempt is made for penetration into the vagina. Vaginismus is classified as primary (i.e., lifelong) or secondary (i.e., vaginismus is encountered after a period of normal sexual functioning) and, depending on the penetration difficulty, as complete (inability to tolerate penetration of any object) or partial vaginismus (can accept penetration with difficulty and pain). ¹ Vaginismus is often associated with significant distress, not only in the women suffering from it, but it can also lead to significant distress in their partner. Vaginismus is also associated with marital disharmony, depression, anxiety, low self-esteem, and infertility. ² Different treatment strategies for vaginismus include psychoeducation, relaxation exercises, systematic desensitization, counseling, and cognitive behavior therapy. ¹

Overall, vaginismus is considered a complex condition to manage, and in the presence of a partner, management becomes more complex as it involves the engagement of both partners. Management might involve addressing issues such as vaginismus, marital disharmony, situational erectile dysfunction in the partner, infertility, mental morbidity, and psychosocial problems arising due to unconsummated marriage. ³ An understanding and supportive partner can make a significant difference in the outcome.

However, there is a lack of data on the management of vaginismus in a woman with a partner with a psychotic disorder.

In this report, we describe a couple in which the female partner had vaginismus that led to a lack of consummation of marriage for six years, and the male partner had schizophrenia. We discuss the challenges faced in the successful management of vaginismus by using an eclectic approach.

Case Description

Mr. X, a 28-year-old, has had a mental illness since the age of 17 years, characterized by the delusion of reference, delusion of persecution, auditory hallucinations, and negative symptoms associated with marked psychosocial dysfunction. He also had comorbid tobacco dependence in the form of smoking cigarettes, which would increase when he experienced a relapse of symptoms. He required hospitalizations thrice before the index presentation for the management of his illness.

At the age of 22 years, while on olanzapine 20 mg/day, his symptoms were under control, he got married to a female aged 19 years, with the mutual consent of both families. As per his wife, she was not told about the patient’s illness or the medications he was on before marriage. On the first night, they tried for sexual intercourse but failed. As per the wife, during the initial few months of marriage, whenever her partner tried for vaginal penetration, she would have apprehension of experiencing severe pain, and as a result, she would not part her legs and begin to cry, stating that she was in pain. Due to this, she would shove him away. As a result, her partner would get disappointed, voicing that this was impossible (without penetration, how can someone perceive pain).

This led to significant distress in the male partner. By 4–5 months of marriage, he became irregular with medications, stating that the medications made him tired, and discontinued tab. olanzapine. Over the next 1–2 months, whenever he would attempt to have sexual intercourse, the female partner would avoid the same by giving excuses of menstruation, weakness, or tiredness. Due to this, the couple was not able to consummate the marriage. Gradually, with the worsening of symptomatology, the male partner started to ignore his partner, would talk minimally to her, spend minimal time with her, and would not even ask about her well-being. At work, he would not show any interest, and his smoking increased. Over the following months, the symptoms worsened further with the appearance of formal thought disorder, delusion of reference, delusion of grandiosity, auditory hallucinations of the commenting and commanding type, and a marked reduction in sleep. Family members tried to give him tab. olanzapine 10–20 mg/day on the pretext of medications to improve his sleep, but adherence to the same remained poor. As the psychosis worsened, he stopped taking any initiative for sexual intercourse and became distant from his wife. He would correctly identify his wife but report that she is like his sister. Hence, he should not have sexual intercourse with her.

Over the next three months, adherence to olanzapine (given up to 30 mg/day) was ensured, but his psychotic symptoms kept on worsening. Following this, the antipsychotic was changed to trifluoperazine, which was increased up to 30 mg/day. While on trifluoperazine for two years, he initially showed some improvement in psychopathology. During this period, his parents would try to explain that she was indeed his wife, and the treating team reinforced the same during the follow-ups. Following this, he again started interacting with his wife. He attempted to have sexual intercourse, but there was no sexual intercourse, as she would shove him away just before the penetration. The patient again started remaining distressed due to the same, started smoking, and previous symptoms started reappearing despite good medication adherence. Again, he started avoiding his wife and reporting that she was like his sister.

Because of the current relapse, he was admitted to the inpatient unit. A diagnosis of schizophrenia and tobacco dependence was considered. He was managed with tab. clozapine 300 mg/day and electroconvulsive therapy (ECT), with which his psychopathology improved.

Once his condition clinically improved, the family assessment revealed that the male partner’s mother was overinvolved and was not interested in involving the patient’s wife in treatment. Still, at the same time, she would ask the treating team to evaluate the sexual issues. The patient’s father was very distant and was not involved in the care of the patient except for providing financial support. The male partner’s mother had the view that the patient is not taking the initiative in sexual activity, and we need to address his poor libido and look for an assessment of other possible sexual dysfunctions. When an attempt was made to evaluate the sexual problem with the male partner, he was reluctant to discuss the sexual problem and just said that there was no problem from his side.

Accordingly, initial management involved psychoeducation of the mother about the need to involve the female partner so that the sexual issues could be understood, and then only we could address the issues. After much persuasion, the patient’s wife was called. She was very reluctant to open up about the sexual issues. After much reassurance, she revealed that she had never indulged in masturbation, had no past relationships, and was very scared about penetrative intercourse, as she had heard from her peers that penetration is very painful. She was also worried that her mother-in-law and other relatives would blame her entirely if she disclosed that she did not allow her husband to have penetrative sexual intercourse. She was not prepared for a vaginal examination either.

Based on the available information, the possibility of primary vaginismus (never experiencing non-painful penetrative sexual intercourse) was considered. She was evaluated on the Multidimensional Vaginal Penetration Disorder Questionnaire, on which she scored 72, confirming the diagnosis of vaginismus. In subsequent sessions, she disclosed that before penetration, she starts worrying as to how a big, hard penis could enter into a small vaginal opening without stretching maximally and being painful, and as a result, becomes apprehensive, stops her husband and shoves him away. She would feel frustrated and guilty about their unsuccessful sexual intercourse, spoiling the pleasurable experience between the couple. She was also worried about family members blaming her for not being able to consummate the marriage and for not having a child. Initially, supportive sessions were held with her.

Further assessment (in individual and joint sessions) revealed that the couple had poor sexual knowledge, had many myths related to masturbation and sperm production, had no knowledge about the importance of foreplay and intimacy, and there was no consummation of marriage.

Once the psychopathology in the male partner improved, joint sessions were taken with the couple to provide sex education. Further, they were given specific tasks that had to be done together to improve the emotional bonding between the couple. Initially, there was a lot of resistance from the male partner to get indulged, but gradually, with much persuasion, he became more cooperative.

After psychoeducation, using an eclectic approach, management of vaginismus was carried out. This involved the graded insertion of fingers, Kegel’s exercises, and the use of local anesthesia with vaginal containment. The partner was involved in all the stages and was informed about the female partner’s problem and how he needed to be supportive of her and should not force her into penetrative intercourse. Using the principles of the Master and Johnson technique, the couple was initially asked to indulge in non-genital sensate focus, and this was followed by genital sensate focus. The couple was sent home multiple times for sexual intimacy, and feedback was taken. Once the couple became comfortable with each other, they were asked to go ahead with the penetrative intercourse. Sessions were taken to address the problems faced by both partners individually, for example, to keep the pelvic position steady, foreplay, and stimulation of the vagina for proper lubrication before penetration. The female partner was also advised to take tab. clonazepam 0.5 mg SOS and use lignocaine gel 2% for local application. With these measures, the couple started having intercourse successfully, and interpersonal problems between them improved. However, the male partner would frequently mention that he was having sexual intercourse to have a child and not for pleasure.

In terms of the management of schizophrenia, the patient and family members were psycho-educated about the illness, with particular emphasis on adherence to medications, the need to abstain from smoking, and regular follow-up. The couple was advised to maintain sexual intimacy and discuss problems faced with the treating team regularly.

Within a few months of discharge, the mother of the male partner started pressurizing the couple to have a child. The male partner was also very keen that his wife should conceive. The male partner would expect the wife to conceive after each intercourse. If the wife had a menstrual flow, then he would get frustrated and become distressed about the lack of conception, and as a result, the relationship between the couple again started worsening. The female partner started remaining very distressed and, as a result, would have an altercation with her spouse. She would often contemplate divorce, was worried about the risk of mental illness in the child, and how she would deal with the disease of the patient throughout her life. This led to a worsening of the relationship between the couple, an increase in smoking by the male partner, and a re-emergence of psychopathology, and his functioning became poor. Gradually, he had a full-blown relapse and required another hospitalization.

During the hospitalization, besides the management of psychosis in the male partner, supportive sessions were taken with the female partner. She was also started on tab. Sertraline 50 mg/day in view of moderate depression. Once the psychopathology was controlled during the inpatient stay, joint sessions were taken with the couple and the family during the hospital stay, and the same were continued after discharge. After six months of discharge, the female partner conceived. This led to an improvement in the relationship between the couple. Supportive sessions are being continued with the couple to address the issues arising from time to time. The couple continues to have regular sexual intercourse at a frequency of once a week to once a fortnight.

Discussion

Vaginismus is an involuntary tightening of the vaginal muscles that renders sexual intercourse difficult or impossible. It is one of the most frequent female psychosexual issues. ¹ In terms of the effectiveness of various management techniques, a review of research data suggests that there is no significant difference in the effectiveness of systematic desensitization and other various control interventions, such as wait-listed control, systematic desensitization combined with group therapy, or in vitro desensitization. ² Some of the authors have used an eclectic approach to managing patients with vaginismus. ⁴ The eclectic approach involved the use of education, graded finger insertion, Kegel’s exercises, local anesthesia with vaginal containment, and the use of a selective serotonin receptor inhibitor (escitalopram). ⁴

However, none of the available literature has discussed the management of vaginismus in a female with a male partner who has a chronic psychotic disorder. The presence of psychotic disorder in the male partner initially actually acted as a shield for the female to conceal her vaginismus, and this led to the non-consummation of marriage for about six years. The lack of sexual intimacy in the couple also became part of the patient’s psychopathology (he would say that his wife is like his sister) and helped him avoid sexual intercourse. Both the partners had their own reasons to avoid intercourse. Accordingly, we first emphasized improving the marital harmony between the couple and the emotional bonding between the couple. We also provided sex education to the couple to improve their sexual knowledge and learn how to support each other while facing sexual difficulties during intercourse. The female was additionally helped by making her practice graded finger insertion, Kegel exercises, and local anesthesia for the management of vaginismus. However, the management was complex in the index case due to the presence of psychotic illness in the male partner, pressure from the mother-in-law to have children, and depression in the patient suffering from vaginismus.

The description of the index couple reveals that it is essential to evaluate both partners whenever a female presents with vaginismus. Further, whenever a male patient with psychosis is blamed for sexual dysfunction or infertility, it is essential to assess sexual problems in the female partner, too, before drawing a conclusion.