Sexual self-concept and intimacy in context of vaginismus: A case–control study

Abstract

Background

As sexuality and its related issues are significantly associated with sociocultural settings, addressing the sexual health status of individuals in different societies is of the utmost importance. Women with vaginismus have more stress, anxiety, depression, and they also feel hopeless and have low self-esteem. And this problem can disturb intimacy between couples and women's sexual self-concept. Therefore, the present study was to determine and compare sexual self-concept and intimacy in women presenting with and without vaginismus.

Methods

This case–control study was conducted in 2021–2022 on 240 women with and without vaginismus, referring to selected sexual health clinics based in Iran. The data collection tools recruited were the demographic characteristics’ information, the Multidimensional Sexual Self-Concept Questionnaire, and the Sexual Intimacy Scale. To calculate the odds ratio of the studied variables, the logistic regression analysis using the SPSS Statistics software (ver. 25) was also employed.

Results

The mean age of women with and without vaginismus was 27.85 ± 4.62 and 28.51 ± 4.34, respectively. According to the regression results, the variables of sexual intimacy (odds ratio (OR) = 0.864, P < 0.001), sexual awareness (OR = 6.090, P = 0.003), sexual-anxiety (OR = 1.613, P < 0.001), fear of sex (OR = 1.338, P = 0.021) and sexual problem prevention (OR = 0.765, P = 0.016) were significantly associated with vaginismus.

Conclusions

According to these results, sexual intimacy, sexual awareness, sexual-anxiety, fear of sex and sexual problem prevention were significantly associated with vaginismus. Therefore, it is suggested that for the treatment of women with vaginismus, interventions can be designed to improve sexual intimacy, sexual knowledge and positive sexual self-concept and reduce sexual anxiety.

Resumen

Antecedentes

Como la sexualidad y sus cuestiones relacionadas están significativamente asociadas con entornos socioculturales, es de suma importancia abordar el estado de salud sexual de las personas en diferentes sociedades. Las mujeres con vaginismo tienen más estrés, ansiedad, depresión, y también se sienten desesperanzadas y tienen baja autoestima. Y este problema puede perturbar la intimidad entre las parejas y el autoconcepto sexual de las mujeres. Por lo tanto, el presente estudio fue para determinar y comparar el autoconcepto sexual y la intimidad en mujeres con y sin vaginismo.

Métodos

Este estudio de casos y controles se llevó a cabo en 2021-2022 en 240 mujeres con y sin vaginismo, refiriéndose a clínicas de salud sexual seleccionadas con sede en Irán. Las herramientas de recolección de datos fueron la información de características demográficas, el Cuestionario multidimensional de autoconcepto sexual y la Escala de intimidad sexual. Para calcular la proporción de probabilidades de las variables estudiadas se empleó el análisis de regresión logística utilizando el software SPSS Statistics.

Resultados

La edad media de las mujeres con y sin vaginismo fue de 27,85 ± 4,62 y 28,51 ± 4,34 años, respectivamente. Según los resultados de regresión, las variables de intimidad sexual (odds ratio [OR] = 0,864, p < 0,001), conciencia sexual (OR = 6,090, p = 0,003), ansiedad sexual (OR = 1,613, p < 0,001), miedo al sexo (OR = 1,338, p = 0,021) y prevención de problemas sexuales (OR = 0,765, p = 0,016) se asociaron significativamente con el vaginismo.

Conclusiones

Según estos resultados, la intimidad sexual, la conciencia sexual, la ansiedad sexual, el miedo al sexo y la prevención de problemas sexuales se asociaron significativamente con el vaginismo. Por lo tanto, se sugiere que para el tratamiento de mujeres con vaginismo se puedan diseñar intervenciones para mejorar la intimidad sexual, el conocimiento sexual y el autoconcepto sexual positivo y reducir el autoconcepto sexual negativo.

Background

Vaginismus refers to the involuntary contraction of the muscles surrounding the vagina during sexual intercourse, which is considered as a barrier to intimate sexuality and thus leading to a sense of acute pain in women.¹ Based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, genito-pelvic pain/penetration disorders are defined as persistent or recurrent problems with one or more cases, such as difficulty with vaginal penetration, pelvic pain or vulvodynia, manifest fear or anxiety, and pelvic floor muscle spasms during sex or sexual intercourse relationship.² The existence of diverse definitions of vaginismus is one of the main reasons for various reports of the prevalence of this disorder.³ According to a study, this rate varies from 1% in Australia to approximately 61.8% in Ghana.⁴ In one study, the prevalence of this sexual pain disorder in Iran was reported to be 8%.⁵

Several factors are involved in the development of vaginismus. Psychological factors shaping this condition consist of sexual or physical abuse, negative attitudes toward sex, and communication problems. In some surveys, environmental factors such as congenital anomalies, typical birth defects and traumas, genital surgery, as well as vaginal lesions and tumors have also been suggested, but such assumptions have not been thus far endorsed in large-scale and high-quality research.^3,6

The most significant consequences in women with vaginismus are stress, anxiety, and depression, reduced quality of life, as well as feelings of hopelessness and low self-esteem.⁷ Sexual functioning is further impaired in these women and the levels of sexual desire, vaginal lubrication, sexual arousal, and orgasm may decrease.⁸ This sexual disorder consequently affects all aspects of marital life in a way that frustration, despair, tension, coldness, distrust, and conflicts in family/couple relationships have been so far reported in this respect. Too much anxiety and emotional distress can also be observed in women.⁹ On the other hand, sexual pain disorders disturb intimacy between couples and women's sexual self-concept.¹⁰ According to some studies, couples reporting less-intimate sexual relationships show lower marital satisfaction.¹¹ Sexual intimacy predicts the couple's relationship, passion, sex drive, frequency of sexual intercourse, and sexual satisfaction.¹²

Sexual self-concept is a multi-dimensional and dynamic construct formed based on individuals’ perceptions in the domain of sexuality and its related issues. Perceptions of sexual needs are thus shaped with regard to social expectations accompanied by a growth in social, psychological, and sexual schemas.¹³ Women having more negative sexual self-concepts accordingly suffer from higher levels of impaired sexual functioning, because a negative self-concept can undesirably affect their sexual behaviors and practices.¹⁴ Genital pain along with loss of social roles also influence sexual identity and then intimidates a person's sense of self. In view of this, more research is required to reflect on the role and the relationship between pain and sexual self-concept.¹⁵

So, according to what has been said, sexual dysfunctions such as vaginismus are one of the factors contributing to the decline in the quality of life. Failure to establish a sexual relationship can further lead to social, physical, and mental health consequences.² The awareness of extensive dimensions and related factors shaping vaginismus can thus result in more effective and faster treatment. However, there is little research in this area in Iran. Considering that sexuality and its relevant issues can significantly improve sociocultural conditions and addressing sexual health status in individuals and different societies has been of the utmostimportance at all times, this study was to determine and compare sexual self-concept and intimacy in women with and without vaginismus.

Methods

Participants

This case–control study was fulfilled from December 2021 to May 2022 on a total number of 240 women with and without vaginismus. The sampling technique in this study was of the convenience type practiced among women referring to selected health care centers and sexual health clinics based in the city of Tehran, Iran. The sample size in this study was thus estimated by 110 women in each group with reference to the statistical formula of n=P(1−P)Z2/d2 (type-I error of 0.05 and test power of 0.9) as well as the study by Fadul et al. (2019) in which the sample size was considered 120 women in each group with 10% attrition of samples. The cases fulfilled the criteria of patients with lifelong vaginismus according to the criteria from the DSM-IV-TR (2000) and confirmed by a specialist. The controls were patients from the health care centers and sexual health clinics of the same institution. Each case was matched with one control admitted on the same date in which the case was admitted to the institute. Control had the same age, such as: levels of education, and no previous history of sexual dysfunction.

The inclusion criteria were age range of 18–45, heterosexual women, Iranian nationality, literacy (viz. reading and writing), monogamy, lack of pregnancy, breastfeeding, and menopause, lack of chronic diseases, lack of psychological problems confirmed by a psychologist, lack of experience of a traumatic incident within last three months, no drug abuse, no use of psychotropic drugs affecting sexual desire, not having serious conflicts in family/couple relationships over the last month, experience of at least six months of sexual activities or relationship, and definite diagnosis of primary vaginismus in the case group confirmed by a specialist. The controls consisted of an educationally and age-matched group of women with normal sexual function. The exclusion criteria were answering not more than 5% of the questionnaire items.

After obtaining permission from the Ethics Committee of Shahid Beheshti University of Medical Sciences, Iran, the members of the case group were examined by a gynecologist in the selected centers and clinics. The pelvic exam encompassed the appearance of the vulva and its sensitivity (using a cotton swab to apply gentle pressure to the vulvar lips) and hymeneal ring anatomy. At the end, the individuals in the case group were diagnosed with primary vaginismus by the specialist and then included in the study. Of note, the control group was selected out of patients, meeting the inclusion criteria, referring to the selected centers and clinics for annual checkups. First, a complete description of the genitourinary, digestive, and musculoskeletal systems as well as sexual functioning was taken in the exam room. Then, a pelvic exam was performed using the lithotomy position, which involved evaluation of the exterior genitalia, touch of the inside of the uterus, along with examination of the vagina and the cervix with a speculum. The exterior genitalia and the vagina were also evaluated in terms of lesions, scratches, scars, erythema, swelling, and discharge. During pelvic exams, women with dyspareunia or vulvodynia were excluded. Afterward, both groups were examined by a psychologist in the health care centers or sexual health clinics in terms of psychiatric illnesses and those without any severe disorders showing willingness to participate in this study completed a written consent form. The participants were further assured with regard to the confidentiality of their information.

Main outcome measures

The data collection tools recruited in this study were the demographic/obstetric characteristic's information questionnaire, the Snell's Multidimensional Sexual Self-Concept Questionnaire (MSSCQ), and the Sexual Intimacy Scale developed by Botlani et al.

Socio-demographic and sexual information form

The researcher-made socio-demographic and sexual characteristic's information questionnaire accordingly included information such as age, husband's age, level of education and husband's level of education (namely, academic and non-academic), occupation (i.e., employed and homemaker), duration of marriage (duration of relationship), type of marriage (traditional and modern), having a separate bedroom, frequency of sexual intercourse per month, and level of sexual awareness (using a Likert-type scale of low, moderate, high), that face and content validity were confirmed through 10 participants and 15 faculty members working at Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Multidimensional Sexual Self-concept Questionnaire (MSSCQ)

The Persian version of this questionnaire contained 78 items within 18 subscales, whose psychometric properties had been assessed by Ziaei et al. (2013). This questionnaire was also classified into three larger scales called negative, positive, and situational sexual self-concept. The sub-scale of the positive sexual self-concept (minimum-maximum score) accordingly included sexual self-efficacy (0–16), sexual consciousness (0–20), motivation to avoid high-risk sexual behaviors (0–20), self-blame with sexual problems (0–16), management of sexual problems (0–12), sexual self-esteem (0–16), sexual satisfaction (0–20), prevention of sexual problems (0–20), and inner control of sexuality (0–20). As well, the sub-scales of the negative sexual self-concept (minimum-maximum score) were sexual anxiety (0–20), sexual optimism (0–16), sexual supervision and monitoring (0–12), fear of sex (0–20), and sexually depressed symptoms (0–12), and the sub-scales of situational sexual self-concept (minimum–maximum score) encompassed sex motivation (0–20), sexual arousal (0–16), sexual intent (0–16), and individual sex patterns (0–20). The questionnaire items were also scored on a Likert-type scale from 0 to 4 (total score between 0 and 312). Accordingly, scores higher than the mean value in each sub-scale indicated that the individual has more of that feature.¹⁶ To assess the reliability in the present study, Cronbach's alpha coefficient of sexual intimacy was equal to 0.723.

Sexual intimacy

Botlani et al. also designed the Sexual Intimacy Scale according to valid scientific references, the Marital Intimacy Needs Questionnaire (MINQ), and related studies in this domain.¹⁷ The questionnaire contained 30 items, examining the intimacy needs of couples as well as emotional, psychological, intellectual, sexual, physical, spiritual, esthetic, social, and recreational dimensions. Each item also had four Likert-type scale, wherein the maximum and minimum scores were 120 and 30, respectively. Higher scores in this regard denoted a higher level of sexual intimacy.¹⁷ In the present study, the Cronbach's alpha coefficient of sexual intimacy was calculated to measure its reliability, which was equal to 0.846.

Procedure

Since it was not possible to match the individuals (individual matching) recruited in this study, both groups were matched in terms of important variables such as age, husband's age, and level of education from the beginning, and there were attempts to maintain the balance between the two groups. Three items of selection, comparability, and exposure underlined in case–control studies were also controlled. With regard to the scale of comparability in this study, the researchers matched the groups from the onset to reduce bias and then practiced between-group comparisons and regression analysis in order to minimize bias in the results. The main objective of the study was also verbally explained to the participants, and they were asked to read and sign the informed consent form. The participants were further assured of the confidentiality of their information. Then, they were asked to complete the research questionnaires in an isolated environment. After completing the questionnaires, the contact information of the researchers was provided to them if they desired to receive the results of the present study.

Statistical analysis

The data extracted was subsequently analyzed using the SPSS Statistics software (ver. 25) along with descriptive and inferential statistics. Firstly, the distribution of the quantitative variables was examined using the Kolmogorov-Smirnov test. In the event of a normal distribution, parametric tests, and in the other cases, non-parametric ones were exercised. Logistic regression analysis was also employed to determine the odds ratios (ORs) and the confidence intervals (CIs) of 95% to evaluate sexual intimacy status and sexual self-concept with regard to vaginismus development. If there was a correlation between both confounding factors of the given disorder, it could be included in the logistic regression and its effect could be adjusted. To prevent the residual confounding effect, some potential variables with noteworthy confounding effects, which had no significant relationships, were imported into the model. The significance level was considered by 0.05.

Results

A total number of 240 women placed in two groups, including 120 women with primary vaginismus (case group) and 120 controls without any history of this condition (control group) were entered into the study. In the case group, involuntary contraction of some or all of the pelvic floor muscles during a physical exam was also observed by a gynecologist and the majority of the cases refused the exam and showed extreme resistance. In the present study, there was no attrition and the response rate was 100%. Table 1 depicts the demographic/sexual characteristics of the participants. The mean age of the women with and without vaginismus was 27.85 ± 4.62 and 28.51 ± 4.34 years old, respectively. Both populations are comparable, there are not significantly different between groups in terms of age, level of education, husband's level of education, occupation, type of marriage, duration of marriage, having a separate bedroom, and marital satisfaction.

Table 1.

Socio-demographic and sexual information of women with and without vaginismus (controls).

Socio-demographics variables	Vaginismus (n = 120)		Control (n = 120)		P-value
	M ± SD	Med	M ± SD	Med
Age (year)	27.85 ± 4.62	28	28.51 ± 4.34	29	.257*
Age of partner (year)	31.60 ± 4.94	31	31.95 ± 3.49	32	.527*
Duration of relationship (year)	3.86 ± 3.34	3	4.29 ± 2.44	4	.259^**

Socio-demographics variables	n (%)	n (%)	p value
Education
Academic	99 (82.5%)	99 (82.5%)	1.00^***
Non-academic	21 (17.5%)	21 (17.5%)
Education of partner
Academic	85 (70.8%)	88 (73.3%)	.666^***
Non-academic	35 (29.2%)	32 (26.7%)
Employment
Housewife	68 (56.7%)	57 (47.5%)	.155^***
Employee	52 (43.3%)	63 (52.5%)
Marriage pattern
Traditional	56 (46.7%)	67 (55.8%)	.060^***
Modern	64 (53.3%)	53 (44.2%)
Having separate bed room
Yes	118 (98.3%)	114 (95.0%)	.308^***
No	2 (1.7%)	6 (5.0%)
Sexual awareness
Low	32 (26.7%)	7 (5.8%)	<.001^**
Medium	54 (45%)	22 (18.3%)
High	34 (28.3%)	91 (75.8%)

m = Mann–Whitney U test; M = mean; Med = median; n = number of participants; SD = standard deviation; t = Student t test; X² = Chi-square test.

Bold value indicates statistically significant.

*

Student t test.

**

Mann–Whitney U test.

***

Chi-square (X²).

The mean frequency of sexual intercourse per month in women affected with vaginismus was also significantly lower compared with that in the control group (P = 0.002). In a way, this average was 5.70 ± 4.46 times a month in vaginismus women and 7.57 ± 3.89 times a month in the control group women. In terms of satisfaction with marital relationships, there was no significant difference between the two groups of women under study (0.073). In addition, the level of sexual awareness in the group suffering from vaginismus was significantly lower than in the controls (P < 0.001).

The mean scores for sexual intimacy in the study groups with and without vaginismus were respectively 55.49 ± 12.26 and 59.35 ± 11.75, and the difference between both groups was statistically significant (P < 0.013). In Table 2, the sub-scales of sexual self-concept in the study groups are compared. The study results demonstrated that the mean scores between the two groups were statistically significant in all sub-scales of sexual self-concept except for sex motivation.

Table 2.

Comparison subscale of sexual self-concept and sexual intimacy between groups.

Subscale of MSSCQ/sexual intimacy	Vaginismus (n = 120)		Control (n = 120)		P*
	M ± SD	Med	M ± SD	Med
Sexual-anxiety	9.97 ± 4.47	9	17.65 ± 4.93	17	<.001
Sexual self-efficacy	19.60 ± 3.35	20	16.69 ± 3.0	16	<.001
Sexual-consciousness	20.30 ± 3.45	21	17.75 ± 3.69	17	<.001
Motivation to avoid risky sex	22.51 ± 2.69	23	20.38 ± 4.25	21	<.001
Sexual-preoccupation	12.14 ± 4.52	11	13.62 ± 4.53	14	.003
Sexual-assertiveness	15.46 ± 2.15	15	14.66 ± 2.58	15	.013
Sexual-optimism	15.51 ± 2.28	16	16.41 ± 3.11	17	.019
Sexual problem self-blame	12.89 ± 4.15	13	16.40 ± 4.57	16	<.001
Sexual-monitoring	11.05 ± 3.24	11	12.92 ± 4.84	13	.030
Sexual-motivation	19.28 ± 3.86	19.50	18.80 ± 3.43	19	.273
Sexual problem management	19.10 ± 3.24	19	16.56 ± 3.63	16	<.001
Sexual-esteem	19.46 ± 3.44	19	15.66 ± 3.72	15	<.001
Sexual-satisfaction	20.09 ± 4.04	21	14.81 ± 4.57	15	<.001
Sexual self-schemata	22.58 ± 2.81	23	21.11 ± 3.87	22.50	.002
Fear-of-sex	14.76 ± 2.16	14	16.95 ± 2.95	17	<.001
Sexual problem prevention	21.39 ± 3.38	22	18.17 ± 3.42	18	<.001
Sexual-depression	9.40 ± 5.42	8	16.17 ± 5.13	15	<.001
Internal-sexual-control	19.15 ± 3.34	20	18.25 ± 3.46	18	.027

MSSCQ = Multidimensional Sexual Self-concept Questionnaire; M = mean; Med = median; SD = standard deviation.

Bold value indicates statistically significant.

*

Mann–Whitney U test.

To measure the factors associated with vaginismus, the logistic multivariate regression analysis was performed, and the significant variables were imported into the statistical model. In this model, the Hosmer and Lemeshow Test results were not significant (P = 0.948), suggesting that the test was appropriate for the data.

Based on the regression analysis results, the variables of sexual intimacy (OR = 0.864, P < 0.001), sexual awareness (OR = 6.090, P = 0.003), sexual-anxiety (OR = 1.613, P < 0.001), fear of sex (OR = 1.338, P = 0.021) and sexual problem prevention (OR = 0.765, P = 0.016) were significantly associated with vaginismus. It meant that the OR of developing vaginismus dropped by 14% for each one-unit increase in the sexual intimacy score. In women with low levels of awareness of vaginismus, the OR of this condition was 6.09 times higher, compared with those with high levels of sexual awareness. For each one-unit rise in the sexual-anxiety and fear of sex scores, the OR of developing vaginismus was compounded respectively by 61% and 33%. Nevertheless, for each unit growth in the sexual problem prevention score, the OR of developing vaginismus declined by 24% (Table 3).

Table 3.

Regression analysis of sexual self-concept, and sexual relationship information in the differentiation of patients with vaginismus from healthy control subjects.

Variables	Logistic regression analysis
	B	S.E.	OR	P	95% CI
Number of sexual activity (per month)	−.064	.058	.938	.269	.837, 1.051
Sexual intimacy	−.146	.035	.864	<.001	.807, .925
Sexual awareness
Low	1.807	.601	6.090	.003	1.877, 19.761
Medium	1.271	.719	3.564	.077	.872, 14.574
High	RC	RC	RC	RC	RC
Sexual-anxiety	.478	.103	1.613	<.001	1.317, 1.976
Sexual self-efficacy	−.068	.129	.935	.602	.725, 1.205
Sexual-consciousness	−.093	.105	.911	.375	.741, 1.120
Motivation to avoid risky sex	−.113	.093	.893	.223	.744, 1.071
Sexual-preoccupation	−.120	.072	.887	.093	.771, 1.020
Sexual-assertiveness	.036	.130	1.037	.779	.805, 1.337
Sexual-optimism	.132	.105	1.141	.211	.928, 1.401
Sexual problem self-blame	−.122	.087	.885	.161	.747, 1.050
Sexual-monitoring	−.028	.078	.973	.723	.834, 1.134
Sexual problem management	−.162	.093	.850	.081	.709, 1.020
Sexual-esteem	.005	.103	1.005	.965	.820, 1.230
Sexual-satisfaction	−.148	.113	.863	.190	.692, 1.076
Sexual self-schemata	−.032	.098	.968	.742	.799, 1.174
Fear-of-sex	.291	.126	1.338	.021	1.044, 1.714
Sexual problem prevention	−.268	.112	.765	.016	.615, .952
Sexual-depression	−.062	.102	.940	.546	.769, 1.149
Internal-sexual-control	.156	.136	1.169	.252	.895, 1.527

RC = reference.

r = Pearson correlation coefficient, OR = odds ratio.

Logistic regression analysis.

Bold values indicate statistically significant.

Discussion

This study aimed to compare sexual self-concept and sexual intimacy in women with and without vaginismus. The study results showed that the OR of occurring vaginismus decreased in respect of each unit upturn in the score of sexual intimacy. Of note, intimacy has been recognized as one of the most important aspects of marital relationships.¹⁸ In line with the results of the present study, Alizadeh et al. (2019) found that lower intimacy with one's husband was correlated with genito-pelvic disorders (GPPPD) in women.⁵ In another survey, more empathy and intimacy in couples was significantly correlated with higher levels of sexual satisfaction and lower sexual distress.¹⁹ In a study, empathy and intimacy were pointed out as key factors in women's positive compatibility with vaginismus.²⁰ On the other hand, not talking about sexuality and its related issues between couples can lead to little experience of sexual pleasure.²¹ Therefore, intimacy in women suffering from persistent sexual pains or other disorders is deemed as a protective factor, so that sexual intimacy between couples in such situations is associated with higher levels of sexual satisfaction.²²

Based on the results of the present study, the OR of developing vaginismus in women with low levels of sexual awareness was 6.09 times more than that in their counterparts with higher levels of sexual awareness and the incidence of vaginismus is 3.5 times higher in women with a medium level of sexual awareness. Sexual education can affect health-related behaviors, healthy sexual behaviors, mental health status, prevention of sexual disorders, and family health.²⁰ In this respect, Karagüzel et al. (2016) reported that women with vaginismus had significantly lower levels of sexual awareness.²³ In another survey by Yeganeh et al. (2018) in Iran, most participants had mentioned lack of information related to issues of sexuality as one of the effective factors in the development of vaginismus, so that the majority of them had reiterated that they had started their marital life without any awareness.²⁴ Sexual education programs for individuals who have not yet established their sexual activities such as children, adolescents, and young people and even for individuals having sexual intercourse are thus necessary²⁵ and not responding properly to these needs can contribute to the development of vaginismus as a sexual pain disorder.²⁴

In this study, for each one-unit increase in sexual-anxiety, the OR of developing vaginismus augmented. Anxiety is typically one of the most important causes of vaginismus.² In the study by Watts, the prevalence of anxiety disorders in women with vaginismus was higher compared with that in controls, and in general, the levels of anxiety in women with vaginismus, especially when they had felt no support from their sexual partner or at much pressure to improve their situation, were higher.²⁶ As reported in another survey, women with vaginismus had higher levels of depression and anxiety.²³ Moreover, Ziaei et al., in a study of reproductive age women's they concluded that the variable of sexual anxiety has a direct and significant relationship with sexual fear.¹⁴ As well, Rellini et al. (2011) stated that negative sexual self-concepts could be a sign of negative emotional damage in the past.²⁷ In this study, for every unit increment in the score of fear of sex, the risk of vaginismus increased. Reissing et al. (2012) in their study also demonstrated that in women with vaginismus, there was fear of pain and harm, loss of control during sex, negative body image (including negative images of one's genitals and male sex organs) and disgust of sexual intercourse.²⁸ Fear and fear of sex have thus recently emerged as one of the significant causes of vaginismus. According to the fear avoidance model, if the pelvic floor muscles contract during the first relationship at vaginal penetration, pelvic genital pain is experienced. This pain then increases the expectation of fear and anxiety in the next attempts and causes attempt behaviors and sexual abstinence.²

In the present study, the odds ratio of developing vaginismus was reduced for each one-unit increase in the score of sexual problem prevention. The variable of sexual problem prevention was also considered as the sub-scale of positive sexual self-concept.¹⁶ Reissing et al.²⁹ indicated that improving and changing sexual self-concept is immensely effective in improving natural sexual function and preventing sexual dysfunction. Hucker et al.³⁰ observed that, sexual self-concept possibly increments women's sexual function. Another study appeared that, strengthen sexual self-concept in women improves their sexual wellbeing.³¹ Women with improved sexual self-concept have a better and are more successful sexual function.³² Sexual self-concept can thus play a fundamental role in sexual relationships and individual performance. Women with a negative sexual self-concept are more likely to have sexual dysfunctions because a negative sexual self-concept has a negative effect on their sexual behaviors and practices.¹⁴ One study had reported that sexual dysfunctions were correlated with lower levels of positive sexual self-concept.³³ Mueller et al. (2016) had correspondingly shown that the perception of a positive sexual self-concept at the ages of 21–65 could significantly contribute to predicting interpersonal relationships, leading to better sexual consequences and higher levels of satisfaction.³⁴

One of the limitations of the present study was the lack of generalization of the study to different populations, because our study was conducted in a limited population and even in a specific city and cannot be generalized to other societies. Another limitation of our study was that discussing sexual issues is a sensitive matter and can be subject to report bias. Case–control study (transversal design) has a risk of design bias, and no information is provided regarding the previous sexuality of the participants. Others that could be considered as limitations would be the criteria used in the study to categorize and, therefore, include cases (provided some cases do not have exploration, which could lead to a misdiagnosis, provided the diagnosis of vaginismus requires a physical examination) and the sample collection according to the sample convenience type, which could lead to a selection bias.

Among the strengths of this study was the use of the MSSCQ for women with vaginismus, which was used for the first time along with other potential and significant variables in the regression model. The future research is hoped to design counseling and treatment interventions for women suffering from vaginismus with an emphasis on developing sexual intimacy, boosting positive sexual self-concept, and minimizing negative sexual self-concept in couples.

Conclusion

Based on the regression analysis results, the variables of sexual intimacy, sexual awareness, sexual-anxiety, fear of sex and sexual problem prevention were significantly correlated with vaginismus. The present study also showed that sexual intimacy and negative sexual self-concept could well explain the vaginismus status of women. Therefore, for the treatment of women with vaginismus, interventions may well continue to be designed to improve sexual intimacy and self-concept should continue to be taken into account when developing counseling and treatment interventions for women with vaginismus.

Ethical disclosures

Protection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of data

The authors declare that they have followed their workplace's protocols regarding the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appears in this article.

Ethics approval

This study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences with the ethics code IR.SBMU.RETECH.REC.1398.659.

Patient consent

All research was performed in accordance with the Declaration of Helsinki and the methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants and/or their legal guardian in the study. Identifiable data of the participants were anonymized through attributing unique identification numbers or pseudonyms to guarantee anonymity. Confidentiality and voluntary participation were assured and participants had all rights to withdraw at any time.

Availability of data and materials

All data generated or analyzed during this study are available upon request from the corresponding author. Any additional data/files may be obtained from the corresponding author.

Funding

None of the funders had any role in the study design and the collection, analysis and interpretation of data or in the writing of the article and the decision to submit it for publication.

Conflict of interests

The authors declare that they have no competing interests.

Acknowledgements

The authors would like to express their gratitude to all sites and participants involved in this work. Hereby, we would like to thank the Research Administration of Shahid Beheshti University of Medical Sciences and Health Services, Tehran, Iran.