Vaginismus is a multifaceted sexual pain disorder that must be studied from a personal, interpersonal, and cultural standpoint. Several theoretical models can be used to describe vaginismus. The biopsychosocial model, first introduced to the field of sexuality in 1994, holds that sexual problems are influenced by a combination of physical, psychological, interpersonal, and social factors. This study aimed to examine the determinants of sexual function in women with vaginismus using a biopsychosocial model.

From May 2021 to January 2022, a cross-sectional study with convenience and purposive sampling was conducted among married women with primary vaginismus referred to sexual health-related clinics in Tehran, Iran. Married women between 18 and 45 years old with primary vaginismus and at least six months of unsuccessful vaginal penetration attempts were eligible. DSM-IV-TR and the diagnostic questionnaire for vaginismus designed by Reisy et al. were used to diagnose vaginismus, which a gynecologist and a sex therapist confirmed. In this study all biopsychosocial determinants were measured using reliable and valid questionnaires. The determinants of vaginismus' sexual function were evaluated using structural equation modeling with LISREL 9.2 software (Scientific Software International). Through structural equation modeling, the direct and indirect effects of  biological domain of sexual health (age), psychological domain of sexual health (depression, anxiety, stress, sexual knowledge and attitude, and sexual efficacy), interpersonal domain of sexual health (sexual quality of life, sexual intimacy, marital satisfaction, sexual satisfaction, sexual violance, and finance), penetration cognition, and fear of sex on the sexual function of women with vaginismus were investigated. Of note, the effect of each independent variable's on the dependent variable was rerported with standardized path coefficient, i.e.,  "β" that a greater β value indicates a stronger effect

210 women aged 27.67 +/- 5.54 were included in the study. Most women (70.45%, and 70.50%, respectively) were academically educated and housewives. Approximately 52.90% of women reported that their husbands usually initiate sex. Most women (58.60%) stated that "man on top" was the most frequent sex position. Anal sex with their husbands was reported in 21% of women. Sexual knowledge and attitude (r = 0.437, P =.001), sexual efficacy (r = 0.226, P =.001), and sexual intimacy (r = 0.482, P =.001) were in a significantly positive relationship with sexual function. Depression, anxiety, and stress (r = 0.313, P.001), sexual quality of life (r = 0.284, P.001), sexual violence (r = 0.252, P.001), vaginal penetration cognition (r = 0.133, P =.05), and fear of sex (r = 0.318, P.001), on the other hand, were negatively correlated with sexual function. Additionally, depression, anxity, and stress (r = 0.532, P.001), sexual quality of life (r = 0.447, P.001), sexual violence (r = 0.355, P.001), vaginal penetration cognition (r = 0.373, P.001), and fear of sex (r = 0.464, P.001) all had a significant positive relationship with vaginismus. While, sexual knowledge and attitude (r = 0.345, P =.001), sexual efficacy (r = 0.225, P =.001), sexual intimacy (r = 0.462, P =.001), financial status (r = 0.182, P =.008), and sexual function (r = 0.352, P =.001) were negatively correlated with the diagnostic score of vaginismus.
The direct, indirect, and total effects (β values) of sexual health on sexual function and diagnostic score of vaginismus were β =0.57, β =0.02, β =0.59, and β = -0.55, β = -0.26, β = -0.81 respectively (all P<0.001). The results also showed that the direct, indirect, and total effects of vaginal penetration cognition (β =0.31, β =0, and β = -0.31) and fear of sex (β =0.20, β =0.14 and β =0.34) on the diagnostic score of vaginismus were significant (P=0.016; P=0.005).

The model fit well because the Root Mean Squared Error of Approximation (RMSEA), standardized RMR, and Comparative Fit Index (CFI) were all less than 0.08, and the Incremental Fit Index (IFI) was greater than 0.90. In the current study, given being less than 3, the Minimum Discrepancy Function divided by Degrees of Freedom (CMIN / DF=2.42 ) ratio was acceptable that indicated the model's good fit.

The current study corroborates that the majority of sexual health dimensions exert signigicant direct, indirect, and overall effects on sexual function and vaginismus. Incorporating these findings into knowledge translation can prompt sexual health-related stakeholders at all levels (from patients to policymakers) to take an overarching and trans-disciplinary approach to complex sexual problems like vaginismus.

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Continence 7S1 (2023) 100907
DOI: 10.1016/j.cont.2023.100907