Reviewer's report
Title:Women's experiences of using vaginal trainers (dilators) to treat
vaginismus: A qualitative interview study
Version:2Date:1 August 2014
Reviewer: ED Reissing
Reviewer's report:
Thank you for the opportunity to review this qualitative study of women whose
vaginal penetration problems are indeed much underrepresented in the research
literature. This paper presents an interesting portrait of difficulties with regard to
treatment access and process in women with an array of issues leading to
lifelong or acquired and situational or generalized penetration problems. The title
focuses on one treatment that patients accessed and had various
success/difficulties with. It may be better to change the title to reflect the
considerably larger scope of the paper (Discretionary Revision).
Major Compulsory Revisions: The lack of specificity of the group of women who
participated in this study, however, is problematic and needs to be highlighted
and specifically discussed in the limitations. The authors also need to present
more information on the actual participants for the reader to gather who the study
sample actually was. Furthermore, as an inclusion criterion, researchers can not
merely rely on "a diagnosis of vaginismus" made by a health care professionals.
There is no evidence to suggest at this point that the diagnosis of vaginismus is
valid and can be made reliably. The problems around the diagnosis are further
evidenced by the vigorous discourse and lack of agreement on the diagnostic
formulation of lifelong vaginal penetration problems characterized by fear and
avoidance and problems that are characterized by pain with sexual activity. The
authors may not be able to redress this issue but please comment in the
limitations (Major Compulsory Revision).
Some of the literature on diagnostic issues around vaginismus are outdated and
a little confusing with regard to the literature pertaining to dyspareunia and that of
vaginismus (Major Compulsory Revision). While there may be some who may
have suggested that vaginismus along with dyspareunia may be better
accounted for as a "pain disorder", to the best of this reviewer's knowledge, there
is no major discourse on the topic for vaginismus (as maybe compared to
dyspareunia) and the relevance to the current topic is unclear. The reference to
Binik et al. (2002) has been surpassed by new nomenclature and later papers
with discussions on the categorical or dimensional differences between
vaginismus and dyspareunia (not only vulvodynia; Binik, 2010; van Lankveld et
al., 2010). With the new umbrella diagnosis of GPPPD in the DSM-5 (ICD-11
notwithstanding), it becomes complicated to write about "vaginismus". A recent
paper available online (pre-publish) critiques this omission of vaginismus from
the DSM and suggests a specifier to the GPPP diagnosis of never having been
able to experience intercourse (for previous lifelong vaginismus) and may be
helpful.
Reissing, E.D., Borg, C., S.K. Spoelstra, S.K., ter Kuile, M.M., Both, S., Jong,
P.J. van Lankveld, J.J.D.M., Melles, R.J., Weijenborg, P.Th.M., Weijmar Schultz
W.C.M. (2014). "Throwing the baby out with the bathwater": The demise of
vaginismus in favor of Genito-Pelvic-Pain/Penetration Disorder. Archives of
Sexual Behavior. Online pre-publication (DOI: 10.1007/s10508-014-0322-2)
More updated information with regard to treatment of vaginismus would be
necessary (Major Compulsory Revision).
The Cochrane Review is available in an update version:
Melnik, T., Hawton, K., & McGuire, H. (2012). Interventions for vaginismus.
Cochrane Database of Systematic Reviews, 12.
Information from the (only) second RCT and rather seminal study using exposure
therapy, including vaginal trainers, therefore highly relevant to the present study
need to be included.
ter Kuile, M.M., Melles R.J., de Groot, H.E., Tuijnman-Raasveld, van Lankveld,
J.J.D.M. (2013) Therapist-aided exposure for women with lifelong vaginismus: A
randomized waiting-list control trial of efficacy. Journal of Consulting and Clinical
Psychology, 81, 1127-1136.
Also, the Ogden & Ward paper on treatment seeking in women with vaginismus
has an update in the literature, reflecting recent changes in the way in which we
approach treatment (e.g., including pelvic floor physical therapy). Information on
treatment interventions along with treatment process and outcome as well as the
use of a mixed sample make this paper highly relevant to the current paper:
Reissing, E.D. (2012). Consultation and treatment history and causal attributions
in an online sample of women with lifelong and acquired vaginismus. Journal of
Sexual Medicine, 9, 251-258.
(Major Compulsory Revision): As mentioned above, it is unclear in the
description who the women in the study are. Formal nosological caveats
notwithstanding, this appears to be a quite heterogeneous sample of women
perhaps best diagnosed with GPPPD as the overall diagnosis. Judging from the
(non-defined) descriptors is quite reasonable to assume that the researchers
present the results of a sample of women with lifelong vaginismus in the classic
sense, dyspareunia (likely PVD) and possibly pain due to lack of lubrication
and/or vulvo-vaginal atrophy (VVA) in the older women (specially the 67-year old
woman with "secondary" vaginismus). Keeping this in mind, it is important to note
that there is no evidence to suggest that vaginal trainer use would be beneficial -
in the absence of any other intervention, to the treatment of dyspareunia, VVA, or
lack of lubrication. As the authors state themselves: "It was particularly
concerning to find women had persisted with, or had been advised to persist
with, using VTs in ways that caused pain." (Discussion, 1st p.).
The examination experiences described by the patients are confirming data from
a survey study conducted from the other side of the treatment dyad, with
obstetrician/gynecologists.
Huber, J.D., Pukall, C.F., Boyer, S.C., Reissing, E.D., & Chamberlain, S.M.
(2009). "Just relax": Physicians' experiences with women who are difficult or
impossible to examine gynecologically. Journal of Sexual Medicine. 6, 791-799.
(Discretionary Revision).
The concluding paragraph of the discussion could really benefit from the latest
information on exposure in the treatment of vaginismus (ter Kuile et al., 2003)
and, albeit retrospective, treatment outcome/process results from pelvic floor
physical therapy (Reissing, Armstrong & Allen, 2013). (Discretionary Revision).
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
NO TO ALL (Elke Reissing)