Virtual reality exposure for vaginismus : a mixed-methods proof-of-concept study

Background: Vaginismus involves fear of painful vaginal insertion and involuntary tightening of pelvic floor muscles that interfere with vaginal intercourse. It has been conceptualized as a specific phobia of vaginal insertion. Treatment-as-usual involves self-insertion of vaginal accommodators at home, but avoidance limits effectiveness. Virtual Reality exposure (VRE) is as effective as real-life exposure for specific phobias and involves immersing individuals in 3D simulations of their feared situation. This proof-of-concept, mixed methods study was the first in a series to evaluate whether VRE for vaginismus could prove an innovative solution to this gap in care. Aims: I explored 1) whether individuals with vaginismus experienced greater negative affect in response to VR erotic stimuli than controls without any vaginismus symptoms, 2) erotic stimuli characteristics that evoked negative affect for the vaginismus sample (quantitative objectives), 3) perceived acceptability of VRE for vaginismus, 4) preferences for accompanying psychoeducation (qualitative objectives), and 5) the optimal design of a future VRE program for vaginismus (mixed methods). Methods: Forty individuals with vaginismus and 40 without symptoms of vaginismus used a VR headset to view five erotic videos: non-insertive sex from 3rd person point of view (POV), insertive sex from 3rd person POV, masturbation from 1st person POV, non-insertive sex from 1st person POV, and insertive sex from 1st person POV. After each film participants completed measures of distress, anxiety, fear, and disgust (quantitative measures). Participants completed semi-structured interviews assessing the acceptability of VRE (qualitative measure). Analyses: I used mixed-model ANOVAs to evaluate quantitative objectives, and inductive thematic analysis to assess qualitative objectives. Results: Individuals with vaginismus reported greater distress, anxiety, fear, and disgust during the VR session compared to controls, and groups responded differently to video elements. I identified five themes relating to VRE’s acceptability: offering validation to reduce shame and isolation, supporting autonomy to facilitate integration, acknowledging beliefs and traumas to increase suitability, calibrating emotional responses to improve acceptability, and personalizing erotica to enhance presence. Conclusion: Quantitative and qualitative data were integrated to describe the optimal design for a future VRE program for vaginismus, which has the potential to improve care for this underserved population.