1. THE PSYCHOSOCIAL CAUSES OF VAJINISMUS IN TURKISH SOCIETY May 2010

2. 2 Sexuality has many aspects such as biological, anatomical, psychological, sociological and cultural and they all affect the sexual life. Particularly society's wrong beliefs about sexuality, culture, the concept of sexuality in the society, local customs, traditions, sexual education affect the sexual life and have an active part of the emergence of the sexual problems.

3. 3 Vaginismus is a sexual pain disorder, where spasm of musculature of the outer third of the vagina interferes with intercourse. During the sexual intercourse not only the vagina muscles but whole body contracts and there happens something like panic atac. Vaginismus is seen quite often in Turkey. According to the recent surveys it is found that the prevelance of vaginismus is 1 in 10 women in Turkey. %73 of the women apply to sex therapy clinics because of vaginismus. Vaginismus is not a common problem in the outher countries. According to the Western sources, it is estimated that the prevelance of vaginismus is % 1- 6.

4. 4 Vaginismus is experienced in 2 types such as primary and secondary vaginismus. Primary means the experience of vaginismus in the ‘first-time’ intercourse attempts. Secondary occurs after a traumatic sexual relationship, child birth or a vaginal infection. Primary vaginismus is commonly seen in Turkish society. Nearly all of the vaginismus patients have primary vaginismus. In a research which is conducted in 50 women who have vaginismus, it is found that % 70 of them have primary vaginismus. This result shows us that Turkish men have a lack of sexual knowledge and they don't know how to treat their partners in the first sexual relationship.

5. 5 The possible causes of vaginismus are: · The fear of the first night (the first intercourse) · The hyperbolic importence of hymen in the society (having been taught that sex is bad, harmful, sin, etc.) · The belief that vagina is so tight and small and penis can never penetrate · Negative thoughts about sexuality · To be a witness of parent's sexual relationship · Traumatic childhood experiences ( to be a victim or witness of sexual abuse) · High- level anxiety · To raise in a religiously or morally rigid family · Fear of getting pregnant · Fear of intimacy · Electra complex · The desire to be countinue being the daddy's good girl · Issues about the partner · To live in the same house with the parent in law.

6. 66 The possible causes of vaginismus are: In a study which is conducted on 200 women have vaginismus, it is found that the most common reason of vaginismus is the fear of first intercourse caused by inadequate sexual information. According to this study, causes of vaginismus are: · The fear of first intercourse (%61) · To be forced by the partner during the firts intercourse and feel pain (%18) · Sexual abuse during childhood (%10.5) · To have negative thougts about sexuality (%4.5) · To be a witness of parent's sexual relationship (%2.5) · To be a witness of child birth · To have a pelvic or vaginal trauma ( %1.5) In a study Sexual Health Institute conducted on 30 women who have vaginismus, it is seen that the most common reason of vaginismus is the conversion of the expectance of ''bleeding'' to the fear of first intercourse.

7. 77 The First Night Sexuality is still a taboo in Turkish society and the first intercourse has a great importance. There is a concept called ''the first night'' in Turkish society. This means the first intercourse which has to happen in the first night of the marriage. Just because of sex before marriage is not allowable in Turkish society, both bride and groom are sexually inexperienced. The obligation of having intercourse at the first night makes the couple feel under pressure and it usually ends up with failure. Woman usually thinks that it will hurt and bleeed too much during the first intercourse and she doesn’t let the intercourse happen and it becomes a habit in the length of time.

8. 8 Most common expressions of women who have vaginismus are: ''I am afraid of feeling an awful pain during sexual intercourse'' ''I feel like dying at that moment'' ''I become so rigid when my husband touches me and I start shaking'' ''I don't have a vaginal opening, it is impossible for me to have intercourse'' ''In the childhood it is told me that having intercourse is like to undergo a lemon into the eye of the needle.'' ''If I bleed to much and if it doesn't stop'' ''A close friend of mine told me that there something happens like bomb explosure during the penetration of penis to the vagina.'' ''I feel pain even when I touch my vagina.'' ''I am afraid if my vaginal muscles clamp down on the penis and if penis can't get out from the vagina. How can we go to the hospital?''

9. 9 These expressions are the proof of why vaginismus is seen in 1 of the 10 women in Turkey. To be raised with the negative feelings and thoughts since the childhood, to see sex as a painful and fearful action intead of seeing it as a sharing of love and pleasure with the one you love makes our women have vaginismus. When the woman expects to have pain, the pain arises as a ''self fulfilling prophecy.'' Hymen has a great importance in Turkish society and it has to ''bleed'' at the first night. It is believed that bleeding is the proof of virginity. Hymen must surely bleed and this blood must be too much. And also there has been a common tradition in some regions of Turkey which is lessened but not got lost yet. It is called '' bed sheet tradition.'' The couple has to show their bloody bed shit in the morning aftter the wedding night. If the couple couldn't achieve the first intercourse, they has to finf f another solutions to show the bloody bed sheet, usuallt the groom cuts his hand or arm and drains some blood. Now this tradition is not common in big cities but it is often seen in the hinterland. Most common expressions of women who have vaginismus are:

10. 10 There isn't sexual education in our country and most of our women don't have any informtion about their sexual organs. Women who have vaginismus have negative feelings about their vaginas, they see their vaginas as a dirty part of their body, they are aimed to think that vagina is to small to take the penis in. There are women who think that they don't have vaginal openings. It's just because they don't have accurate information about their body and sexual organs.

11. 11 Another cultural reason of vaginismus in our country is to have the first intercourse in a crowded house full with parents, relatives. Usually in the hinterland it is common to live with the parent in law. This a traditional stituation and also the couple may not have enough materiality to have a seperate home. That's why they have to live in a crowded house with their parents. To have a healthy sexual life, the couple has to have a private place to be with eachother. But in these conditions the couple doesn't have a privacy and the feel under pressure during the sexual relationship, can't feel comfortable, can abstain to their voice to be heard by the others. Because women who have vaginismus usually think that they will shout aloud during the intercourse and have a fear of people to hear their voices.

12. 12 Arranged marriage is still common in Turkish society too. That means men and the women see each other several times before marriage, sometimes they don't have a opportunity to have a date and then they get married without knowing each other well. This type of marriage can be a reason of sexual problems too.

13. 13 A Cultural Model of Vaginismus Treatment Vaginismus is may be the only sexual dysfunction which can be treated completely. It can be treated successfully in 10 sessions ( this 10 sessions may last 7-10 days). Teratment should be authentic. They should reflect the society's points of view, thougts, traditions. Our vaginismus therapy model is based on ''the expentancy of bleeding'' in the first intercourse because the most common reason of vaginismus in Turkey is the fear of bleeding and pain. This therapy model is particularly avaliable for Muslim patients, but it also can be adopted to other religions.

14. 14 As Sexual Health Instıtute we claim that hymen doesn't bleed if all the conditions are normal. And sometimes we argue with the gynecologists about this subject. But until now none of 1354 women who got the vaginismus treatment in Sexual Health Institute bleed. We think that this is a proof of our claim. To give accurate information is so important in the treatment and in some cases it is just enough to tell the couple that the hymen won't bleed can be the %50 of the treatment. Of course it is not enough to tell it just to woman, all the sexual information must be given to the couple together. Because men are so obsessed about bleeding too and if it doesnt bleed they can blame their wives with infidelity. A Cultural Model of Vaginismus Treatment

15. 15 ''First believe, then make believe'' Sex therapist must believe that he/she will treat the patient herself/himself first, then can make the patient to believe that she will overcome vaginismus. A Cultural Model of Vaginismus Treatment

16. 16 ''The importance of using fingers instead of dilators'' Finger dilatation exercises are one of the most important part of the treatment. In treatment we prefer to use fingers instead of dilators. Because dilators are unnatural, but fingers are a part of our body and they are more natural. Most of the woman who have vaginismus has a great fear about the finger dilatation exercises and they th,ink that they can never achieve that. But when they believe themselves and try again and again they can achieve the exercises.

17. 17 It must be called ‘’brainismus’’, not vaginismus The vagina muscles do not contract on their own, the reasons of their contraction are the negative thoughts and beliefs about sexuality and sexual intercourse. Brain is responsible of vaginismus,not vagina. That’s why we believe that the name of this sexual dysfunction must be brainismus, not vaginismus.

18. 18 Vaginismus is ‘’a postponement and avoidance illness’’ Women who have vaginismus postpone applying to the therapy consistently because of their fears about sexual intercourse and because of this reason vaginismus may last for years. Until now we had patients who are married for 5, 10 or 15 years. There was a case that they were married for 22 years but they didn’t come to the therapy. Because after sometime living without sexual intercourse becomes as a habit and the couple gets used to live like that. In the first years of the marriage they believe that vaginismus will go on their own, then years go by and they start to think that there’s no cure for vaginismus and there is no hope for them. They go on living with vaginismus.

19. 19 The Stages of the Vaginismus Treatment  Determining the problem  Taking the sexual history  Giving detailed sexual information  Eleminating the fear and expectation of bleeding with the congnitive reconstructive techniques  Teaching relaxation exercises  Self knowledge and body knowledge exercises and sensate focus  Fantasizing  Personal and couple finger dilatation exercises  Limited penis insertation and sexual intercourse  Exercises for increase pleasure

20. 20 Bad Treatments for Vaginismus  To accept having a sexual problem and apply to a sex therapist may be so embarrassing for the couple. That’s why they always postpone the therapy. In Turkish culture having a child is an important part of the marriage and people start to ask why they don’t have child. That’s why couple comes to the therapy usually when they want to have a child.  Patients always want ‘’a miracle’’. But there isn’t a miracle treatment. The couple tries many different ways before sex therapy.

21. 21  In Turkey first of all they go the hodjas. Then they try short and fast ways to get rid of vaginismus. One session treatments, hymenectomy (removal of the hymenal tissue with an operation), having the sexual intercourse under anaesthesia in the therapist’s office, sometimes in front of the therapist, applying anesthetic creams to the vagina, applying botox to the vagina, applying vapour bath to the vagina to relax the vaginal muscles, sitting in the hot water, using tranquillizers and muscle relaxants, etc. Bad Treatments for Vaginismus

22. 22  In an University Hospital in Ankara it s determined that %50 of the woman who applied there for vaginismus treatment had hymenectomy. But vaginismus is a psychological condition and hymenectemy doesn’t solve the problem but only makes it worse If it is considered that women who have vaginismus have difficulty to have gynecological examination, having hymenoctomy may cause avoidance of sex and malke the situation worse than before. Bad Treatments for Vaginismus

23. 23 Usually in vaginismus treatment it is aimed that to insert penis to the vagina. But we believe that the treatment doesn’t end up when penis enters the vagina. The treatment finishes when the couple has a healthy and satisfying sexual relationship and woman starts to get pleasure from the intercourse.

24. 24 What can be done to prevent Vaginismus in Turkey? The only way to prevent sexual problems is to heighten sexual awareness by giving sexual education. As Sexual Health Instıtute we offer that Sexual Education should be made legally compulsory starting from kindergarten and civil governments must provide Pre-marriage Sexual Counseling and Guidance Services to the couples who are about to marry.

25. 25 Aslo we have many Turkish patients who live in Germany. Particularly young girls get married and go to Germany for living, they can’t speak German, they can’t Express themselves and also they usually have sexual problems cause by living wth parents in law. And they can’t know where to go when they have a sexual problem. We believe we can do something do something for Turkish people who live in Germany, we can organize seminars and educations for giving right sexual information to them. What can be done to prevent Vaginismus in Turkey?

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