Vaginismus is considered one of the most present but unspoken disorders affecting sexual life among Egyptians. Unfortunately, the misconception of an extremely painful first intercourse after marriage is still a problem facing many Egyptian women till now. Consequently, it has been considered for a long time the main feminine cause of unconsummated marriage in Egypt [16]. Although, people are convinced with the importance of sex education, yet sex is still considered a taboo. The concept of “the culture of silence” is the unfortunately main one among the Egyptian population [17].
This study is focusing on its both psychiatric aspects of vaginismus whether psychiatric comorbidities, comorbid personality disorders, and alexithymia.
Regarding the personal and socio-demographic data, both cases and controls enrolled in the study were of nearly similar age group with mean age of 29.7 years, median 30 and 31.1 years, median 30.5 respectively. This age group lies within the age range of marriage in Egypt being between 25 and 49 (median 20.8) according to the background characteristics [18]. As regards the residence, 91.6% of both cases and controls were in urban places this could be explained by the presence of the hospital in an urban catchment area. As for the educational and economic level, the study showed that below university education and unemployment were significantly more frequent among cases (P = 0.026 and P = 0.005 respectively). In fact, efforts were made to have a matching control sample. However, in order to find a control group that would agree to participate in a study on such a culturally sensitive topic, it was easier to recruit them from people with higher education which explains why the control group had significantly higher education and employment rates. These results have been supported previously in literature being one of associations with vaginismus [19]. Meanwhile, Möller et al. supported that higher levels of education were associated with vaginismus [20]. The rationale was that education does not guarantee a proper sexual knowledge [21].
Meanwhile, having a partner of below university education (P = 0.006) was significantly more frequent among cases and it was found to be an independent risk factor for the disorder by regression model. This result is supported by Akhavan-Taghavi et al. who found that 42% of the spouses cases where having undergraduate education [19].
Regarding FGM, the current study found that 25% of the entire sample underwent FGM despite that the majority had a relatively high educational level. This was much lower than Younis et al. who found that 66.5% of the Egyptian women in the sample were exposed to FGM. It reflects the fact that FGM is still prevalent among the Egyptian culture till now [22].
The study also shows no significant relation between FGM and vaginismus. This goes with other case series in Arab-Muslim cultures [23]. Despite the theoretical explanation being conditioned painful traumatic experience to the genital area, it is considered due to being a part of the social norms of the Egyptian society which makes the condition more or less normalized within the Egyptian culture rather than being a traumatizing one.
As for alexithymia, cases were significantly showing more alexithymia than controls (P < 0.001) and it was found to be an independent risk factor for the disorder by regression model. This is supported by Ciocca et al. who found that women suffering from vaginismus have 3.8 higher probability of having alexithymia than healthy women. The association between vaginismus and alexithymia was found through difficulty in identifying and expressing feelings and also externally oriented thinking [24].
Regarding the psychiatric comorbidities, some of the disorders were subdivided into current and past disorders. This classification helped in determining whether the psychiatric disorder proceeded vaginismus (i.e., past disorder) or the disorder happened with or after the appearance of it (i.e., current disorder).
However, there was no statistically significant difference between both cases and controls in any of the tested disorders individually. But, the presence of more than one disorder was yet statistically more frequent among cases than controls (P = 0.032). Yet by regression model, the estimated presence of more than one disorder was about to be significant (yet still not) as an independent risk factor.
These results are supported by different studies that all found the commonality of anxiety and/or depressive disorders among vaginismus patients than control groups [25,26,27].
Moreover, Watts and Netle found that anxiety in vaginismus patients is not only related to penetration. However, they are generally elevated and they predicted sharing common predisposing factors between both [28]. The current study also supports this hypothesis due to the presence of both current and previous depressive and anxiety disorders. However, it was not able to explain the nature of the relationship between both.
This is because the nature of all of these studies (including the current study) is more towards case-control studies hinders the prediction of the cause-effect relationship. Further studies of different nature are still needed to prove the impact of these psychiatric disorders on the development of vaginismus and vice versa.
The current study was not able to identify different psychotic disorders (e.g., schizophrenia, bipolar mood disorder). Consequently, it was not able to find any association with vaginismus (or dispute it).
As for personality disorders, there are no sufficient studies on the relationship between vaginismus and different personality disorders [29]. Meanwhile, the current study found that borderline personality disorder/traits were significantly more common among cases (P = 0.026 and P = 0.001). In general, BPD is associated with sexual dysfunctions [30]. The main reason postulated behind that is the concomitant sexual traumatization and abuse rather than the personality disorder alone [31, 32]. The current study (unfortunately) did not assess previous sexual trauma history.
Moreover, avoidant personality traits were also significantly more common among cases (P = 0.045). Based upon the same core factor of fear and avoidance, it was expected that many of cases to be more towards the cluster C personality spectrum mainly avoidant personality traits. This is because fearfulness and avoidance are prominent characteristics of cluster C personality disorder [33].
Finally, there was a variability of associated personality disorders with vaginismus between clusters B and C supports the presence of a personality disorder generally will eventually result into poor interpersonal life due to the strict personality characteristics. This would affect their sexual life resulting into a sexual dysfunction regardless its type [34].
Another conclusion is that vaginismus may be linked to certain personality traits rather than a whole set of personality disorder. During clinical assessment of the patients in the current study it was noticed some traits being more frequently present among cases than controls. Thus, they were tested individually. These traits are rigidity, perfectionism, dramatization, mood swings, and impulsivity.
Dramatization (and specially self-dramatization) is considered a prototypical trait in histrionic personality disorder [35] which has proven to have a significant co-occurrence with vaginismus [36].
Moreover, experiential avoidance of sexual activity is considered an essential factor in sexual dysfunctions [37]. It was found to be more associated with perfectionism and rigidity in obsessive compulsive personality disorder (OCPD) [38].
Also, emotional dysregulation (represented in mood swings) and impulsivity are considered core features of BPD that are stable over time [39].
Based on the previous observations, a new term “vaginismus personality” can be introduced. Where having two or more of these personality traits is significantly present among cases and can be considered an independent risk factor for the development of vaginismus. Finally, a woman who is perfectionist, unwilling to change (rigid), emotionally unstable, impulsive, and tends to perform self-dramatization is more susceptible to develop vaginismus than others.
