ORIGINAL ARTICLE

Development and validation of the

multidimensional vaginal penetration disorder
questionnaire (MVPDQ) for assessment of
lifelong vaginismus in a sample of Iranian women
Mitra Molaeinezhad1, Robab Latifnejad Roudsari2, Alireza Yousefy3, Mehrdad Salehi4, Effat Merghati Khoei5
Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran, 2Research Center for
1

Patient Safety, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran 3Medical
Education Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran 4Department of Psychiatry, School of Medicine, Isfahan
University of Medical Sciences, Isfahan, Iran 5Family & Sexual Health Unit in the Brain and Spinal Injury Research Center (BASIR), Iranian
National Center of Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran

Background: Vaginismus is considered as one of the most common female psychosexual dysfunctions. Although the importance
of using a multidisciplinary approach for assessment of vaginal penetration disorder is emphasized, the paucity of instruments
for this purpose is clear. We designed a study to develop and investigate the psychometric properties of a multidimensional
vaginal penetration disorder questionnaire (MVPDQ), thereby assisting specialists for clinical assessment of women with lifelong
vaginismus (LLV). Materials and Methods: MVPDQ was developed using the findings from a thematic qualitative research
conducted with 20 unconsummated couples from a former study, which was followed by an extensive literature review. Then,
during a cross-sectional design, a consecutive sample of 214 women, who were diagnosed as LLV based on Diagnostic and
Statistical Manual of Mental Disorders (DSM)-IV-TR criteria completed MVPDQ and additional questions regarding their
demographic and sexual history. Validation measures and reliability were tested by exploratory factor analysis and Cronbach’s
alpha coefficient via Statistical Package for the Social Sciences (SPSS) version 16. Results: After conducting exploratory factor
analysis, MVPDQ emerged with 72 items and 9 dimensions: Catastrophic cognitions and tightening, helplessness, marital
adjustment, hypervigilance, avoidance, penetration motivation, sexual information, genital incompatibility, and optimism.
Subscales of MVPDQ showed a significant reliability that varied between 0.70 and 0.87 and results of test–retest were satisfactory.
Conclusion: The present study shows that MVPDQ is a valid and reliable self-report questionnaire for clinical assessment
of women complaining of LLV. This instrument may assist specialists to make a clinical judgment and plan appropriately for
clinical management.

Key words: Clinical assessment, Clinical psychology, Cognitions, Reliability, Self-report measure, Vaginismus,
Validation, Women

How to cite this article: Molaeinezhad M, Roudsari RL, Yousefy A, Salehi M, Khoei EM. Development and validation of the multidimensional vaginal
penetration disorder questionnaire (MVPDQ) for assessment of lifelong vaginismus in a sample of Iranian women. J Res Med Sci 2014;19:336-48.

variations of penetration disorders under the umbrella

INTRODUCTION of the genito-pelvic penetration/pain disorders
(GPPPD), the following dimensions have been defined
Vaginismus has been defined in the Diagnostic and for its diagnosis: 1. inability to have vaginal intercourse/
Statistical Manual of Mental Disorders (DSM) IV-
penetration; 2. marked vulvovaginal or pelvic pain
TR as “recurrent or persistent involuntary spasm of
during vaginal intercourse/penetration attempts;
the musculature of the outer third of vagina, which
3. marked fear or anxiety either about vulvovaginal
interferes with intercourse.” [1] An international
or pelvic pain or vaginal penetration; and 4. marked
consensus committee has recommended that
“persistent difficulties to allow vaginal entry of a tensing or tightening of the pelvic floor muscles during
penis, a finger, and/or any other object, despite the a empted vaginal penetration.[3,4] Despite the recent
woman’s expressed wish to do so, should be considered thorough investigations, li le progress has been made
as revised criteria.” Obviously, any structural or other in consensus on the definition of vaginismus and an
physical abnormalities must be ruled out.[2] In the empirical framework for research and clinical practice
current version of the DSM-V it is combined with other is lacking.[2,5]

Address for correspondence: Dr. Effat Merghati Khoei, Family & Sexual Health Unit in the Brain and Spinal Injury Research Center (BASIR),
Neurological Research Center Building, Imam Khomeini Hospital Complex, Keshavarz Blvd, PO 61-14185, Tehran, Iran. E-mail: [email protected]
Received: 17-08-2013; Revised: 28-08-2013; Accepted: 21-10-2013

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

According to Masters and Johnson (1970), a reliable Like other conservative societies, in Iran also, vaginismus is
diagnosis of vaginismus can be made by a specialist considered as a woman’s failure in the sexual encounters.[19,20]
who would carry out a pelvic examination, such as This contextual mindset is associated with a couple’s
gynecologists. However, mental health professionals help-seeking behavior or their compliance with therapy.[7,15]
can identify vaginismus based on client’s self-report.[3,6] Couples experiencing unconsummated marriage face
Meanwhile, many psychiatrists and gynecologists are many problems due to social and family pressures, e.g.
reluctant to carry out a diagnostic pelvic exam because consummation of their relationship, having children, threat
of the fear in women; many vaginismus patients are of divorce and separation, and to seek a remedy for their
diagnosed based on their self-report in achieving vaginal penetration problem.[7,15-17] Too o en, diagnostic assessment
penetration.[3] and therapeutic interventions designed to manage this
sexual dysfunction rely on multiple invasive gynecological
Still, health professionals tolerate some level of tension examinations, self-reports, and traditional unidirectional
while facing an unconsummated marriage case.[7] Lack of and surgical approaches such as hymenectomy, which fail
a sensitive or specific instrument to evaluate the case can to place contextual factors at the center of both diagnostic
be a reason for their pressure. This lack has been claimed assessment and therapeutic interventions.[15,20] There is a
by Binik (2010) that there is no a published instrument gap in the literature regarding an instrument which directly
or algorithms that translate self-report into DSM-IV-TR takes into account the societal and cultural norms related
definition and GPPPD diagnostic criteria for diagnosis of to sexual intercourse. Furthermore, a multidimensional
vaginismus.[3] questionnaire for clinical assessment of women’s cognition,
sexual behaviors, and relational pattern which may
Despite the wide-ranging list of factors (e.g. somatic/ maintain vaginal penetration problem is also lacking, to
biological factors, psychological as well as interpersonal the best of our knowledge.[3,10,17]
issues) that have been proposed to explain the etiology
In a large mixed-methods design, we explored both the
of vaginismus, and its underlying mechanism, they are
nature of couples’ views associated with their efforts for
still largely unknown.[8[ Few questionnaires have been
first intercourse and the self-identified determinants of
introduced for the diagnosis of vaginismus,[3] such as the
experiencing difficulties in the first intercourse. Based
Golombok Rust Inventory of Sexual Satisfaction (GRISS)
on the findings from our formative research, the present
and a 5-item vaginismus scale, which are not sufficient
paper reports the processes used to develop and validate a
to make a DSM-IV-TR and GPPPD diagnosis since they
questionnaire that focuses on the assessment of cognitions,
do not confirm pelvic muscle dysfunction during vaginal
emotions, and sexual and marital relations, to be used for
penetration a empts.[3,9]
women with LLV, on which clinicians could base their
judgments and plan for appropriate management in women
In a recent study, Klaassen and ter Kuile (2010) developed
with LLV.
and validated a well-established instrument that assesses
vaginal penetration cognitions in a sample of women with For this purpose, we investigated the psychometric
vaginismus and dyspareunia.[10] However, this instrument properties of multidimensional vaginal penetration
only investigates catastrophic cognitions that are related disorder questionnaire (MVPDQ) within a group of Iranian
to vaginal penetration, and like GRISS, cannot interpret women. So, the factor structure, internal consistency and
self-report of spasm by vaginismic women to a clinical stability, and the association between the MVPDQ total
diagnosis. So, yet there is no empirically based algorithm and subscale scores and demographic data of participants
available on which to base one’s clinical judgment about were investigated.
vaginal penetration problem.[3]
MATERIALS AND METHODS
Although many studies have been conducted in other
countries about lifelong vaginismus (LLV),[6,8,9,11-13] there A mixed-methods study was addressed to develop and
are few studies that have been conducted in this field in investigate the psychometric properties of the MVPDQ.
Iran.[14,15] In Iran, like other Middle Eastern countries, young The mixed-methods sequential exploratory design consists
people, particularly women, face strong pressure to marry of two distinct phases: qualitative followed by quantitative.
and to have children a er marriage as the main outcome of In the exploratory design with the intent of developing
a successful marriage. Furthermore, a marriage ceremony is and testing an instrument, the issues arise as to what
expected to include consummation.[7,16,17] In Iran, premarital information is most useful in designing and developing
and extramarital sexual relations are seriously banned due an instrument and what procedures should be used in
to religious sanctions.[18,19] this process.[21]

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

During the first phase which was a qualitative study, partners had completed the questionnaire. The partner
data were collected from 20 unconsummated couples version of MVPDQ was also completed by the partners and
at Isfahan Medical University Psychosexual Clinic validated through another study, which will be published
a er obtaining their informed consent and using in- elsewhere.
depth interviews, each lasting for 2-3 h. Permission
was obtained from the Ethical Commi ee of Mashhad Ethical aspects
University of Medical Sciences to conduct the research The ethical permission was approved by the Ethical
(Code: 900983). The findings from the first phase and Commi ee of Mashhad University of Medical Sciences
an extensive literature review were used to develop the (le er no.: 511/1313).
MVPDQ. The second phase was a quantitative research
and MVPDQ was completed by 214 consecutive women Questionnaire development
with LLV. Qualitative thematic analysis of interviews with 20
unconsummated couples from the first phase of the
Selection of the participants study, which was followed by an extensive literature
The study sample consisted of women who were unable review, resulted in a pool of 208 candidate items. Clarity
to have vaginal intercourse despite several a empts, and and relevance of generated items were assessed by the
diagnosed as LLV based on their sexual history taken by research team and two sequential expert panels, and 119
an experienced psychiatrist or sexologist. Consecutive items that were considered as unrelated and repeated
participants were selected if it was the first time permanent items were eliminated. Then, psychometric characteristics
marriage,1 and they were never being diagnosed with a of the questionnaire (e.g. content and face validity, factor
psychological problem, never being diagnosed with an structure, internal consistency and stability, and construct
abnormal hymen which was revealed during the initial validity) were assessed in the second phase [Figure 1]. The
assisted self-examination of the external genitalia, and never compiled data were analyzed using Statistical Package for
reported the history of pregnancy. the Social Sciences (SPSS) 16 so ware, a general statistical
so ware tailored to the needs of social scientists and the
Participants were recruited through general physician general public. First, preliminary item-by item analysis was
and gynecologist referrals and web-based advertisement conducted for missing data, normality, and linearity on the
to Isfahan Medical University Psychosexual Clinic and items of the MVPQD. Then, internal structure of the study
three private sex therapy clinics (two in Isfahan and one measures was determined using exploratory factor analysis
in Tehran). The advertisement invited women who were (EFA). Principal component analysis (PCA) was conducted
“unable to have vaginal intercourse.” Website users who on the items to increase the utility of the instruments in
complained of unconsummated marriage were interviewed evaluation, and ultimately increase the creditability and
over the telephone by the first author (MM) to be enrolled efficacy of assessment. Scree test criterion, along with
for the study. Then, after obtaining informed consent consideration of the degree of clinical interpretability was
from the participants and informing them about the used to determine the number of factors most suitable for
objectives of the study and their rights as participants, the the questionnaire. Cronbach’s alpha coefficient was used
subjects were asked to come to Isfahan Medical University for examination of inter-item correlation, and Pearson
Psychosexual Clinic to sign the consent form and complete correlations between subscales and the total score were
the questionnaire. calculated as an internal criterion for validity of the
subscales.
All participants were screened by one of the two
psychiatrists and diagnosed based on DSM-IV-TR The validation of the tools and pilot test
vaginismus diagnostic criteria. After full evaluation Face and content validity
for eligibility, participants and partners were asked to The face and content validity was assessed by presenting
complete the questionnaires, without mutual discussion the preliminary 89-item scale to 10 experts in psychology,
in the research center. Totally 216 couples [108 couples sexology, reproductive health, urology, and psychiatry.
from Isfahan and 108 couples from other parts of Iran
They assessed the content validity ratio (CVR) and
(e.g. Tehran, Mashhad, Gheshm, Sari, Larestan, Khansar,
content validity index (CVI) calculated for each item.
Mahshahr, Gorgan, Zahedan)] entered the study. Two
When the CVR was greater than Lawshe’s (1975) table
of the couples were excluded because only the woman
for each item, the item was considered as necessary,
otherwise it was eliminated. The CVI for each item scale
1
In Iran, permanent marriage is compared with temporary marriage. This form of was the proportion of experts who rated the item as
marriage is a campaign for single men who cannot afford permanent marriage.
These men are officially registered their marriage for a short period of time. Both
a 3 or 4 on a 4-point scale.[22,23] Respondents indicated
man and woman give official consent for this form of marriage.[21,30] their agreement with each item as CVI through three

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

items (clarity, relevance, and importance), and items visual fear/contraction 10-point self-report scales and a
with total scores less than 0.7 were considered as not diagram of genital/pelvic area based on Binik’s (2010)
suitable and eliminated. CVI was calculated based on the suggestion, so that the participants could point to where
formula given below and seven items were eliminated they experienced pain during penetration attempts.[3]
in this phase: Respondents were also asked to choose the intensity of
pain they experienced based on a 4-point scale (0 = no
pain, 1 = some pain, 2 = moderate pain 3 = severe pain).
Other questions were scored based on Likert scale ranging
Then 82-item version of the MVPDQ was presented to from 1 to 5 (1 = never, 2 = sometimes, 3 = half of the
15 participants. Six items were eliminated a er this phase time, 4 = most of the time, 5 = always), except for marital
because of disagreement of participants and low inter-item intimacy which was ranged on a 10-point self-report scale.
correlation. The reliability was obtained through Cronbach’s The measurement was based on the total scores of every
alpha coefficient.[24] The Cronbach’s alpha coefficient for the dimension. Two questions regarding the last attempt
questionnaire at this stage was 0.78. for vaginal penetration and the frequency of a empts
during the last 6 months were included, as the diagnostic
The MVPDQ threshold for vaginal penetration disorder based on
The final 76-item version of the MVPQ was presented Diagnostic Guidelines for the Assessment of Genito-pelvic
as a self-reporting questionnaire which consisted of 20 Pain/Penetration Disorder.[3] These questions were not
included in the factor analysis, but their correlation with
the MVPDQ total score was calculated. The MVPDQ is
available upon request from the first author.

Construct validity
Exploratory factor analysis (EFA)
Construct validity is the degree to which an instrument
measures the construct it is intended to measure. [25] Initially,
we conducted a PCA (eigenvalues > 1) considering the
remaining 76 questions. PCA describes the degree to which
the items in the instrument relate to the relevant theoretical
construct. [23] Four items which showed a minimum value of
communalities, smaller than 0.3, were excluded for factor
analysis. These items were: “I’m afraid when penetration
fails, my husband will get angry” (0.255), “I’m afraid that
penis enters my urethral orifice or anus” (0.170), “when
penetration fails, I can’t experience orgasm during non-
penetrative relations” (0.289), and “there is an abstraction
in my vagina” (0.230).

EFA was conducted on the 72-item version of the

MVPDQ for reduction of items. After recording of
10-point items as 5-point scales, items with a loading on
one factor exceeding 0.3 were considered to belong to
a subscale. Kaiser-Meyer-Olkin (KMO) index (0.887) and
Bartle ’s test of sphericity with X2 of 14097.358 (df = 2556),
which were applied for evaluation of adequacy of samples
for factor analysis, were significant (P < 0.0.1).

RESULTS

Participants
Figure 1: A model for validation of MVPDQ Detailed demographic and diagnostic characteristics of the
participants are reported in Table 1 and 2. All women with
2
Some of the Iranian families strongly believe in superstitious power which “locks
vaginismus reported a history of previous treatment and
the groom’s sexual ability” and disables him to erect or penetrate.[26] referral for treatment to midwives/gynecologists, urologists,

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

psychiatrists, consultants, or magicians.1 The most reported score indicated high level of fear and marked tightening of
phobias by the participants were blood phobia (50.5%) and the pelvic floor muscles.
injection phobia (43.9%).
The second subscale was interpreted as “helplessness”
Exploratory factor analysis which contained items (items 33–51) about negative
The final MVPDQ included nine subscales which explained emotional and interpersonal reaction on failed a empts at
a total of 52.52% of the amount of variances [Table 3]. The vaginal penetration, and the mean score and SD were 56.91
Scree plot graph also showed inflexion on the curve (>1) and 15.72, respectively. This subscale accounted for 9.62%
a er nine-factor solution for the MVPDQ [Figure 2]. of the total variance of MVPDQ.

Mean values and standard deviations for subscale scores Items regarding marital satisfaction, sexual adjustment, and
of the MVPDQ are summarized in Table 4. marital intimacy were loaded in the third subscale which
accounted for 6.98% of the total variance of MVPDQ. The item
Subscale one was “catastrophic cognitions and tightening,” “My husband feels hopeful about treatment” was also loaded
which accounted for 12.19% of the total variance, included in this subscale, which was interpreted as “marital adjustment.”
32 items, and reflected the fear cognitions and pelvic muscle
dysfunction that women experienced during a empts for The avoidance behaviour and postponing attempts for
vaginal penetration [mean (SD) = 104.53 (24.38)]. A high vaginal penetration were interpreted as “avoidance”
subscale and accounted for 5.19% of the total variance of the
Table 1: Subjects’ characteristics for women with questionnaire. The fi h subscale accounted for 4.65% of the
vaginismus (N = 214) total variance of MVPDQ and was interpreted as “penetration
Mean (SD) motivation.” This subscale consisted of the items which
Age of the woman (years) 27.98 (4.26) postulated positive cognitions about vaginal penetration, and
Age of the partner (years) 31.27 (4.34) two items regarding fear of pregnancy and relatives’ pressure
Duration of relationship (months) 50.20 (32.82) for pregnancy were also loaded in this subscale. The last four
Duration of treatment (months) 20.49 (28.11) subscales of MVPDQ accounted for 3.93%, 3.52%, 3.26%, and
Duration of dating (months) 13.73 (10.29) 3.03% of the total variance, respectively.
Duration of marriage (months) 36.36 (36.759)
Duration of complaint (months) 31.31 (31.79)
The sixth subscale was interpreted as “sexual information”
Education n (%)
which included three items regarding information about
Secondary 5 (2.3)
penetration mechanism and female and male genitalia. Two
Higher 58 (27.1)
items regarding “switch off,” which means vagina ge ing dry
University 151 (70.6)
Marriage type n (%)
during penetration a empts and failed penetration despite
Traditional 113 (52.8) vaginal lubrication, were interpreted as “hypervigilance.”
Traditional familial 55 (25.7)
Dating and premarital relationship 46 (21.5) Positive a itudes about future and hope for treatment were
Previous treatment n (%) loaded in a subscale, which was named as “optimism.” Also,
Midwife/gynecologist negative beliefs about genitalia, e.g. too narrow vagina,
Yes 185 (86.4)
No 29 (13.6)
Psychiatrist
Yes 85 (39.7)
No 129 (60.3)
General practitioner
Yes 33 (15.4)
No 181 (85.1)
Urologist
Yes 56 (26.2)
No 158 (73.80)
Consultant/sexologist
Yes 94 (43.9)
No 120 (56.1)
Magician/augur
Yes 38 (17.7)
No 176 (82.3) Figure 2: Scree plot

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

Table 2: Diagnostic characteristics of women with vaginismus (N = 214)

Pain site during (attempts at) vaginal penetration
(point on diagram — participants could choose more than one site)
Vulva as a whole n (%)
No 188 (87.8)
Some pain 9 (4.2)
Moderate pain 12 (5.6)
Severe 5 (2.4)
Fourchette and vVaginal introitus n (%)
Moderate pain 99 (46.3)
Severe 115 (53.8)
Clitoris n (%)
No 171 (79.5)
Some pain 14 (6.5)
Moderate pain 26 (12.1)
Severe 3 (1.4)
Urethral orifice n (%)
No 170 (79.4)
Some pain 3 (1.4)
Moderate pain 32 (15.0)
Severe 9 (4.2)
I heard dreadful stories about the first sexual intercourse n (%)
Yes 173 (80.8)
No 41 (19.2)
I heard that sexual intercourse will be painful a long time after the first experience n (%)
Yes 173 (80.8)
No 41 (19.2)
When did you and your partner attempt for vaginal penetration for the last time?
Mean (SD) 21.36 (15.00) days
How many times you and your partner tried for vaginal penetration in the last 6 months? n (%)
Never 0 (0)
Less than 5 times 44 (20.6)
5-10 times 41 (19.2)
More than 10 times 129 (60.2)
Penetration problem as the greatest problem in life n (%)
Yes 193 (90.2)
No 21 (9.8)
Phobias
Blood phobia n (%)
Yes 108 (50.5)
No 106 (49.5)
Dentistry phobia n (%)
Yes 56 (26.2)
No 158 (73.8)
Acrophobia n (%)
Yes 79 (36.9)
No 135 (63.1)
Insects’ phobia n (%)
Yes 68 (31.85)
No 146 (68.2)
Claustrophobia n (%)
Yes 24 (11.3)
No 190 (88.7)
Agoraphobia n (%)
Yes 12 (5.6)
No 202 (94.4)
Injection phobia n (%)
Yes 94 (43.9)
No 120 (56.1)
Other types of phobia(s) (e.g. zoophobia, hydrophobia, etc.) n (%)
Yes 79 (36.9)
No 135 (63.1)

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

Table 3: Validated 72 items of the multidimensional vaginal penetration disorder questionnaire, with factor loadings
(≥ 0.3), Mean (SD)
Component
Mean (SD) 1 2 3 4 5 6 7 8 9
Factor 1: Catastrophic cognitions and pelvic floor tightening
How much you are afraid when 9.42 (1.21) 0.449
your partner attempts to have a
full penile penetration?*
How much you are afraid when 8.86 (1.72) 0.399
your partner attempts to have
partial penile penetration?*
How much you are afraid when you 3.13 (3.44) 0.412
watch films/pictures about vaginal
penetration/intercourse?*
How much you are afraid when you 5.04 (4.30) 0.414
attempt to insert your own finger
in vagina?*
How much you are afraid when 6.12 (4.13) 0.385
your partner attempts to insert his
finger in your vagina?*
How much you are afraid when you 3.31 (3.77) 0.465
attempt to watch your genitalia in
a mirror?*
How much you are afraid when your 3.98 (3.64) 0.486
husband watches your genitalia?*
How much you are afraid when you 4.57 (4.56) 0.522
attempt to insert an applicator/
vaginal pad in your vagina?*
How much you are afraid when a 7.41 (3.58) 0.538
gynecologist attempts to conduct
vaginal examination on you?*
How much you are afraid when 6.38 (3.71) 0.563
your husband touches your vaginal
entrance/introitus?*
How much do you experience cramp 9.42 (1.21) 0.373
up when your partner attempts to
have a full penile penetration?*
How much do you experience cramp 8.86 (1.72) 0.311
up when your partner attempts to
have partial penile penetration?*
How much do you experience 3.01 (3.44) 0.442
cramp up when you watch films/
pictures about vaginal penetration/
intercourse?*
How much do you experience 5.32 (4.34) 0.431
cramp up when you attempt to
insert your finger in vagina?*
How much do you experience 6.32 (4.00) 0.348
cramp up your partner attempts to
insert his finger in your vagina?*
How much do you experience 3.41 (3.87) 0.493
cramp up when you attempt to
watch your genitalia in a mirror?*
How much do you experience 3.98 (3.64) 0.564
cramp up when your husband
watches your genitalia?*
How much do you experience 4.56 (4.54) 0.523
cramp up when you attempt to
insert an applicator/vaginal pad in
your vagina?*
How much you do experience 7.61 (3.53) 0.525
cramp up when a gynecologist
attempts to conduct vaginal
examination on you?*

Contd...
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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

Table 3: Contd...
Component
Mean (SD) 1 2 3 4 5 6 7 8 9
How much do you experience cramp up 6.56 (3.48) 0.584
when your husband touches your vaginal
entrance/introitus?*
I’m afraid the penis is locked up in my 2.59 (1.62) 0.374
vagina
I’m afraid that penetration causes a 3.65 (1.39) 0.522
severe tearing/damage in vagina
I’m afraid that my hymen is too thick 3.57 (1.50) 0.425
I’m afraid that penetration causes severe 4.46 (0.88) 0.598
and unbearable pain in vagina
I’m afraid that penetration causes severe 3.66 (1.38) 0.474
bleeding
I’m afraid that pain caused by penetration 3.45 (1.42) 0.449
will get worse increasingly
I’m afraid if I give control of situation 3.57 (1.48) 0.483
during penetration attempts to my
husband
I’m afraid even my hymen is opened 3.31 (1.46) 0.318
I feel defecation/urination sensation 2.52 (1.52) 0.318
during attempts for penetration
I feel nausea during attempts for 1.93 (1.39) 0.345
penetration
My legs are cramping up during attempts 4.55 (0.97) 0.493
for penetration
I push out my husband during attempts 3.94 (1.35) 0.414
for penetration
Factor 2: Helplessness
When penetration fails, I’d like to suicide/ 2.04 (1.41) 0.376
do self-mutilation
When penetration fails, I cry 3.62 (1.38) 0.484
I don’t like to meet anyone who knows 2.76 (1.58) 0.418
about my penetration failure
I feel aggression when penetration is not 3.47 (1.32) 0.610
possible
I experience sleep disturbances when 3.02 (1.41) 0.609
penetration fails
When penetration fails, I have no desire 3.29 (1.32) 0.602
to work
I feel no pleasure in my life when 3.61 (1.21) 0.711
penetration is not possible
I lose my concentration when I think 3.46 (1.32) 0.635
about penetration failure
I blame myself when penetration fails 4.15 (1.17) 0.427
When penetration fails, I/my partner 2.45 (1.49) 0.542
quarrel
When penetration fails, I/my partner 2.14 (1.54) 0.494
reproach and blame each other
When penetration fails, I/my partner use 1.68 (1.35) 0.538
force/violent behavior
When penetration fails, I/my partner 1.79 (1.58) 0.456
threaten each other to disclose to others
When penetration fails, I/my partner 1.73 (1.39) 0.402
consider/threaten each other to divorce/
separation
I am afraid when penetration is not 4.03 (1.60) 0.458
successful, our relationship is getting cold
I am afraid when penetration is not 2.09 (1.40) 0.480
successful, my partner starts a new
relationship with a new partner
Contd...
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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

Table 3: Contd...
Component
Mean (SD) 1 2 3 4 5 6 7 8 9
I am afraid when penetration is 1.94 (1.40) 0.474
not successful, we should consider
divorce/separation
I am afraid anyone knows that we’ve 4.03 (1.34) 0.354
failed in penetration
My relatives threaten me to divorce 1.35 (0.91) 0.311
because of penetration failure
Factor 3: Marital adjustment
I feel happy in my marital life 4.62 (0.85) −0.493
My husband considers my sexual needs 4.06 (1.31) −0.489
Our relationship is intimate* 7.46 (2.46) −0.452
My husband feels hopeful about 1.78 (0.97) −0.404
treatment
Factor 4: Avoidance
I postpone the penetration attempt 3.31 (1.45) 0.493
when my husband proposes
I and my partner give up penetration 3.18 (0.47) 0.407
attempt when it fails
Factor 5: Penetration motivation
It will be my most pleasant moment of 4.28 (1.11) 0.303
life, when penetration will be successful
Penetration will result in the climax 3.40 (1.54) 0.350
I’m afraid that I get pregnant during 2.12 (1.47) −0.429
penetration
My relatives remind us to have a child 3.54 (1.57) 0.488
Factor 6: Sexual information
I know what happens in my body 2.86 (1.26) 0.607
during penetration
I know about anatomy of female 2.93 (1.07) 0.701
genitalia
I know about anatomy of male genitalia 2.89 (1.21) 0.695
Factor 7: Hypervigilance
When I attempt for penetration, my 3.50 (1.46) 0.360
vagina gets dry
Penetration fails, even if my vagina 3.50 (1.60) −0.332
gets wet
Factor 8: Optimism
I will be successful for penetration 3.46 (1.39) 0.426
I feel hopeful about treatment 2.54 (1.39) −0.334
I and my partner become sexually 3.98 (1.32) 0.306
pleased with non-penetrative sexual
intercourse
Factor 9: Genital incompatibility
My vagina is too narrow for penetration 3.54 (1.48) 0.349
My vagina is different from others 2.78 (1.54) 0.397
My husband’s penis is too big for my 3.07 (1.56) 0.394
vagina
*
Mean and SD were calculated before recoding to 5 points; SD = Standard deviation; N = 214

too big penis, and a different vagina, were loaded in the subscale yielded the lowest and a negative correlation with
last subscale named as “genital incompatibility.” Pearson the rest of the dimensions (−0.138) [Table 5].
correlations between the MVPDQ subscales were calculated
as an internal criterion for the validity of subscales. The Reliability analysis
results indicated that there existed a correlation among items The Cronbach’s alpha coefficient for the questionnaire as
and the total score of that dimension. The highest correlation a whole was 0.79 and for the dimensions varied between
was found between “catastrophic cognitions and tightening” 0.70 and 0.87. The least Cronbach’s alpha coefficient was
subscale and the total MVPDQ scores. The marital adjustment related to “penetration motivation” (0.70) and the highest

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

Table 4: Mean and SD of the of the multidimensional dysfunction and pain during penetration a empts, 3)
vaginal penetration disorder questionnaire total score psychological and relational problems experienced
and subscales by women when vaginal penetration fails, 4) sexual
Subscales Mean (SD) Min. Max. information about penetration and female and male
Catastrophic cognitions* 104.53 (24.38) 42.00 156.00 genital anatomy, 5) hypervigilance and avoidance during
Helplessness 56.91 (15.72) 24 100.00 vaginal penetration a empts, 6) marital adjustment, 7)
Marital adjustment* 12.78 (1.68) 9.00 18.00 optimism and positive cognitions regarding future and
Avoidance 6.12 (2.59) 2.00 10.00 treatment, 8) penetration motivation, and 9) negative
Penetration motivation 14.24 (2.56) 6.00 20.00
thoughts about genitals’ compatibility.
Sexual information 8.70 (3.07) 3.00 15.00
Hypervigilance 7.01 (2.02) 2.00 10.00
Statistical analysis showed the psychometric properties of
Optimism 9.67 (2.22) 3.00 15.00
Genital incompatibility 9.37 (3.44) 3.00 15.00
the MVPDQ are in an acceptable range and include the four
Total score 218.30 (33.40) 124.00 307.00 dimensions of the proposed Guidelines for the Assessment
*Calculated after recoding 10-point items as 5-points Likert scale; SD = Standard of Genito-pelvic Pain/Penetration Disorder, i.e. percent
deviation; N = 214 of success of vaginal penetration, pain , fear with vaginal
penetration, and pelvic floor muscle dysfunction, except for
Table 5: Inter-correlation coefficient of the medical co-morbidities with vaginismus.[3]
multidimensional vaginal penetration disorder
questionnaire subscales with total score and reliability As Reissing et al. (2004) have stated in their report, “a
coefficient for each subscale woman may be able to tolerate a pelvic examination,
Subscale Pearson Cronbach’s but not penile penetration.”[3,12] On the other hand, the
correlation alpha health professionals usually involved in assessment of
Catastrophic cognitions and spasm 0.846** 0.87 vaginismus rarely have sufficient expertise to diagnose
Helplessness 0.573** 0.86
pelvic floor tightening. Also, gynecological confirmation
Marital adjustment −0.138* 0.78
of spasm is waived to avoid causing unnecessary pain
Avoidance 0.291** 0.79
or discomfort. So, we need an instrument that translates
Penetration motivation 0.284** 0.70
Sexual information 0.255** 0.81
self-report of pelvic muscle dysfunction during
penetration a empts to DSM-IV-TR and then to GPPPD
Hyper vigilance 0.366** 0.74
criteria for diagnosis of vaginismus.[3,4] In this study, the
Optimism 0.188** 0.74
participants reported high levels of fear and pelvic floor
Genital incompatibility 0.268** 0.84
muscle dysfunction when penile/finger and other object
Total score 0.79
**
P < 0.01 (two-tailed); *P < 0.05 (two-tailed) penetration was tried. They also reported a high level of
fear and spasm while they themselves or their husbands
was related to “catastrophic cognitions and tightening” watched their own genital in a mirror; they also reported
(0.87). The test–retest correlates also indicated that MVPDQ high level of catastrophic cognitions regarding genital
subscales have appropriate levels of stability over a period incompatibility. These findings are in accordance with
of 2 weeks for 15 participants (ranged from 0.78 to 0.87). Basson et al.’s (2004) definition of vaginismus [29] and
indicated that MVPDQS could be used for assessing
DISCUSSION cognitions and physical muscle dysfunction related to
vaginal penetration in women with LLV. Although we
Using accurate measures warranties the dependability had no control group and could not decide if the MVPDQ
and trustworthiness of any research,[27] especially when was able to detect differences between women with and
exploring complex phenomena and sensitive topics without LLV, a high mean of the reported scores and
such as sexuality. The results of developing and testing internal consistency in this subscale are in line with
the MVPDQ revealed that it is an accurate instrument abundant literature in behavioral psychotherapy. It is
to assess LLV in the Iranian population. While LLV has assumed that “maladaptive catastrophic beliefs regarding
been recognized as an important sexual dysfunction in vaginal penetration increase a propensity for the fear
women, health professionals find it difficult to manage response and avoidance behavior in women with LLV.”[10]
assessing and treating couples with unconsummated
marriage, largely because sexuality is highly subjective In Islamic societies like Iran, successful sexual intercourse
and o en confused with cultural scenarios and religious is the only condition in which marriage is accepted as
codes.[28] This paper reported the psychometric validation consummated. [30] Beyond a couple’s own instinctive
of the MVPDQ to assess: 1) catastrophic cognitions and desire for sexual contact, the community’s interest is to
fears regarding vaginal penetration, 2) pelvic muscle reassure a union characterized by the capacity for sexual

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 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

satisfaction combined with the potential for producing intensity of stress that is experienced by women with LLV.
a new generation.[31] In this context, traditions focus on These findings are supported by the idea of Strzempko
confirmation of virginity of a bride and engaging in sexual Bu and Chesla (2007) that “when issues of sexuality and
intercourse at the wedding night may increase the anxiety relationship are addressed within the medical environment,
of women during the first sexual intercourse.[19,32] Many women with chronic pelvic pain and their partners would
couples tend to be secretive about their unconsummation. be relieved and feel supported.”[38] So, we suggest the
So, following the disclosure of failure in consummating overall relational concerns of unconsummated couples
a relationship, the social pressure would be intensive.[33] should be addressed during the assessment and planning
As a result, in this study, some of the women with LLV for management of LLV.
were afraid of disclosure of their unconsummation and
possible breakdown of their families following repeated The finding of high levels of avoidance and hypervigilance
failed penetration attempts. [14,15,34] The high levels of behavior, e.g. postponing, withdrawal, and dryness of
distress reported by women with LLV regarding this issue vagina during a empts for vaginal penetration, which were
support the idea that societal and cultural norms for sexual reported by women with LLV in this study, is in accordance
encounters should be considered during planning for with the findings of both Borg et al. (2012) and Rissing (2008)
management of LLV.[31] It is also noteworthy for helping which indicated that specific fears about penetration and
the couples who are silently embarrassed about what they anticipated pain associated with intercourse and penetration
consider a shameful inadequacy,[33,35] to come out with their of any object may impact women with vaginismus in a
penetration problems in early years, during general medical way to keep them stuck in a self-perpetuating spiral of
history taking by physicians, so that they benefit from the increasing avoidance of anticipated pain.[2,11] So, our results
appropriate treatment referrals. are in accordance with the findings of Klaassen and ter
Kuile (2009) which suggested that vaginismus needs re-
As indicated in our results, manifestation of depressed conceptualizing as either an aversion or a phobia of vaginal
mood, isolation, low concentration, suicidal and self- penetration.[10]
mutilation thoughts, and self-blame were the most
self-reported psychological problems by participants. In this study, lower scores of sexual information regarding
These findings are in accordance with Robinson’s (2004) penetration mechanism and female and male genital
findings that indicated manifestation of depression and anatomy showed a negative correlation with penetration
apathetic a itudes, personal distress and psychological motivation, and a significant correlation with MVPDQ
problems, self-blame, self-destructive behavior, and total score and catastrophic thoughts score. This indicated
mutilation were more common in unconsummated that high level of sexual information might increase
couples. [34] In our study, participants’ helplessness positive a itudes about penetration and could moderate
scores showed a significant correlation with duration of catastrophizing cognitions related to vaginal penetration.
marriage and complaints, which indicated that women’s There were suggestions that lack of or inaccurate/
emotional adjustment tends to deteriorate when the LLV incomplete sex education have been implicated in the
is continuing. These findings are also consistent with development of negative expectations and fears and
those of Reissing et al. (2003) who found that vaginismus sexual guilt related to sexuality, vaginal intercourse, and
patients showed less positive self-schema compared reproductive anatomy.[2,39,40]
to the women in no-pain group,[36] and are in line with
Klaassen and ter Kuile’s (2009) findings which indicated Finally, as these findings indicated, MVPDQ is a valid
that women with LLV reported higher levels of negative and reliable measure for assessment of cognitions and
self-image and cognitions about future.[10] psychological and relational problems of women with LLV,
and can be implicated in a multidisciplinary management
Although experiencing pain during vaginal penetration of LLV. But a number of important limitations need to
is an intimate sexual problem which directly involves the be considered here. First, because we aimed primarily
partner, few studies have focused on the investigation of to provide the best treatment to all participants at the
dyadic factors and relationship adjustment in couples with appropriate time, some of our participants had already
a sexual pain disorder.[37] As indicated in this study, marital received treatment during the first phase of the study and
adjustment is a factor which may play a role in planning their answers might have been influenced by the cognitive–
for management of LLV. This subscale showed a negative behavioral therapy that they had received.
correlation with the total score of MVPDQ and helplessness,
which may indicate that increase in sexual coherency, Second, we had no control group including no-pain
marital intimacy, and satisfaction and a positive a itude group and women with dyspareunia, so it cannot be
of husband about treatment might lead to a decline in the claimed that all nine subscales of MVPDQ were able to

| April 2014 | Journal of Research in Medical Sciences 346

 Molaeinezhad, et al.: Psychometric properties of the of the multidimensional vaginal penetration disorder questionnaire

differentiate between women with and without genito- 3. Binik YM. The DSM diagnostic criteria for vaginismus. Arch Sex
pelvic penetration pain disorders.[3] Future studies are Behav 2010;39:278-91.
4. Bro o L. Sexual Pain Disorders. [Internet]. Brithish Colombia:
needed to investigate the divergent and convergent
UBC Sexual Health Lab., Inc: 2006. Available from: h p://www.
construct validity of MVPQD. Third, the sample size obgyn.ubc.ca/SexualHealth/sexual_dysfunctions/pain_disorders.
of our study did not meet the rule of thumb of at least php [Last cited on 2013 Aug 30].
five cases for each observed variable,[41] but indicators of 5. Crowley TD, Goldmeier HJ. Diagnosing and managing
samples’ adequacy for factor analysis were found to be vaginismus. BMJ 2009;3:225-9.
satisfactory. 6. Masters WH, Johnson WE. Human sexual inadequecy. Boston:
Li le, Brown & Company; 1970. p. 92-115.
7. Zargooshi J. Unconsummated marriage: Clarification of aetiology;
We hope that MVPDQ can balance the need for multiple treatment with intracorporeal injection. BJU Int 2000;86:75-9.
invasive gynecological examinations and clinical judgments 8. Weijmar Schultz W, Basson R, Binik Y, Eschenbach D, Wesselmann
based on self-report of women with LLV. Findings of this U, Van Lankveld J. Women’s sexual pain and its management. J Sex
study also may assist specialists for implication of an Med 2005;2:301-16.
9. Van Lankveld JJ, ter Kuile MM, de Groot HE, Melles R, Nefs J,
individualized approach at assessment and goal se ing
Zandbergen M. Cognitive-behavioral therapy for women with
for treatment, identifying the personal factors which lifelong vaginismus: A randomized waiting-list controlled trial
“interfere” with vaginal penetration or taking action toward of efficacy. J Consult Clin Psychol 2006;74:168-78.
“maintaining factors” for the penetration problem.[2] It is 10. Klaassen M, TerKuile MM. Development and Initial Validation
also important to suggest future studies for determination of the Vaginal Penetration Cognition Questionnaire (VPCQ) in
of diagnostic threshold of MVPDQ using larger samples in a sample of women with Vagnismus and dyspareunia. Int J Sex
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different subcultures with conservative and liberal sexual
11. Borg C, Peters ML, Schultz WW, de Jong PJ. Vaginismus:
norms. Heightened harm avoidance and pain catastrophizing cognitions.
J Sex Med 2012;9:558-67.
Authors’ contributions 12. Reissing ED, Binik YM, Khalifé S, Cohen D, Amsel R. Vaginal
MM, EMK, MS, and RLR carried out the design and spasm, pain, and behavior: An empirical investigation of the
coordinated the study, participated in most of the diagnosis of vaginismus. Arch Sex Behav 2004;3:5-17.
13. Reissing ED, Armstrong HL, Allen C. Pelvic floor physical therapy
experiments, and prepared the manuscript. AY provide
for lifelong vaginismus: A retrospective chart review and interview
assistance in the design of the study, and acquisition, study. J Sex Marital Ther 2013;39:306-20.
analysis, and interpretation of data. MS coordinated and 14. Mirzaie N, Saremi AT. A fourteen year unconsummated marriage
carried out all the psychological interviews and participated and its successful treatment (a case report). J Reprod Infertil
in manuscript preparation. All authors have read and finally 2002;3:59-63.
approved the content of the article. 15. Ghorbani B, Arefi S, Modabberi Saber Y, Sadri AH. Successful
infertility treatment and spontaneous pregnancy in an
unconsummated marriage after 7 years. J Reprod Infertil
ACKNOWLEDGMENTS 2006;7:284-9.
16. Zargooshi J. Male sexual dysfunction in unconsummated marriage:
This article is part of a PhD thesis in Reproductive Health Long-term outcome in 417 patients. J Sex Med 2008;5:2895-903.
focused on the sexual behavior patterns of the couples with 17. Merghati KE, Merghati KT. Effect of vaginismus in demolishing
“unconsummated marriage,” which has been approved by of a marriage contract (Faskh-e –Nekah) Q Med Figh 2010;2:25-37.
Mashhad University of Medical Sciences, Mashhad, Iran (Code: 18. DeJong J, Jawad R, Mortagy I, Shepard B. The sexual and
900983). The financial support provided by the university is highly reproductive health of young people in the Arab Countries and
appreciated. We gratefully acknowledge Mohammad Soltani, Msc, Iran. Reprod Health Ma ers 2005;13:49-59.
Azita Shahriari, BSc, and Peyman Salehi, MD for patient referrals 19. Aghajanian A. Family and Family Change in Iran. Diversity in
and their generous input on earlier version of the MVPDQ. We Families: A Global Perspective. In: Hennon CB, Brubaker TH,
also gratefully acknowledge Charmaine Borg,PhD for her grateful Belmont, editors. 1st ed. Canada: Wadsworth Publishing Company;
2001. p. 45-54.
comments on an earlier version of the manuscript.Our sincerest
20. Gheshlaghi F. History, Ethics and laws for midwifery. Tehran: Zia
thanks also go to the couples who participated in the study. We
Publication; 2005. p. 63.
also appreciate the support received from Isfahan Psychosexual
21. The act of support of family. [Internet]. 2011. Available from: h p://
Clinic staff during the study.
www.dadiran.ir/LinkClick.aspx?fileticket=8vEhLFR1lZw%3d&ta
bid=1039&mid=1669. [Last cited on 2013 Oct 01].
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