Treatment of primary vaginismus: a new perspective.

This paper challenges the efficacy of a cognitive-behavioral treatment model for women with primary vaginismus and proposes a conceptual shift from a focus on behavior to a focus on differentiation. Primary vaginismus is viewed as a somatic boundary, a symbolic description of an opportunity for differentiation. Four relevant themes are considered: 1) mastery versus incompetence; 2) autonomy versus dependence; 3) boundary versus fusion; and 4) the effect on the therapy of the therapist's level of differentiation. Change at this particular time in history involves shifts in clinical focus from sexual frequency to quality, from performance to experience, from compliance to mastery, and from utilization function to sexual potential. A case is made for sexual competence based on self-competence instead of on behavior. A reevaluation of what constitutes success, both behavioral and developmental, proposes an increase in differentiation in addition to symptom relief.