Cue-specific sexual avoidance, metacognitive beliefs, and sexual functioning in women with lifelong vaginismus: a cross-sectional case–control study

Abstract Background Avoidance is a key maintaining factor in lifelong vaginismus and may extend beyond penetration attempts to broader sexual cues. Metacognitive beliefs, particularly beliefs about the usefulness of worry and the uncontrollability and danger of thoughts, may shape threat appraisal and coping responses in sexual contexts. We characterized clinician-elicited sex-related avoidance behaviors in lifelong vaginismus and examined how avoidance and metacognitive beliefs relate to sexual functioning beyond anxiety and depressive symptoms. Methods This cross-sectional case–control study was conducted in three outpatient clinics in Türkiye. Participants were 64 women evaluated for lifelong vaginismus and 30 controls. Sex-related avoidance over the past 6 months was assessed using five standardized yes/no clinician-elicited items; endorsing ≥ 1 item defined the avoidant subgroup. Participants completed ASEX (Arizona Sexual Experiences Scale), GRISS (Golombok-Rust Sexual Satisfaction Scale), MCQ-30 (Metacognitions Questionnaire-30), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Between-group comparisons examined sexual outcomes and metacognitive beliefs across groups, and hierarchical regression models examined whether MCQ-30 subscales accounted for additional variance in ASEX and GRISS scores beyond BDI and BAI. Results Thirty of 64 women with vaginismus (46.9%) were classified as avoidant. The avoidant subgroup showed poorer ASEX and GRISS scores than the non-avoidant subgroup and controls (all adjusted pairwise p < 0.05). Women with vaginismus showed greater endorsement of dysfunctional metacognitive beliefs than controls. However, the avoidant and non-avoidant vaginismus subgroups did not differ on MCQ-30 indices. In logistic regression, adding three theoretically selected MCQ-30 subscales did not significantly improve model fit beyond BDI and BAI (Δχ²(3) = 3.84, p = 0.279). Adding MCQ-30 subscales accounted for an additional 19% of variance in ASEX-total scores (R²=0.13 to 0.32) and an additional 21% of variance in GRISS-total scores (R²=0.05 to 0.26). Negative beliefs about uncontrollability and danger showed the strongest associations with higher ASEX-total (β = 0.52, p = 0.004) and GRISS-total (β = 0.58, p = 0.002) scores. Conclusions Sex-related cue avoidance beyond penetration attempts was endorsed by nearly half of women with lifelong vaginismus and marks poorer sexual functioning. Dysfunctional metacognitive beliefs—particularly beliefs about uncontrollability and danger—relate to sexual impairment beyond anxiety and depressive symptoms, supporting brief screening for avoided cues and metacognitive targets in clinical assessment.