Men's experiences of their partner's vaginismus (A phenomenological study)

Introduction: Vaginismus is one of the sexual dysfunctions in women which is associated with pain during sexual intercourse and affects the sexual relation of couples. The purpose of this study was to explain the experience of men whose wives are suffering from vaginismus. Methodology: This study is a phenomenological research, with the Van Manen’s approach. The participants consisted of seven men, whose wives was suffering from vaginismus, selected through the purposive sampling method and questioned in semi-structured interviews. The acquired data awas analyzed by Van Manen’s approach. Results: Two main themes extracted from data analysis: "the shadow of the disorder in couple's life." and "the encountering approach with the disorder". Each theme is included in several subthemes. Conclusion: The findings indicated that men who living with wives with vaginismus are faced with serious challenges in various dimensions of life. The process of following-up and treatment are repeatedly disrupted by faulty diagnosis and lack of specialized therapists. This makes to be challenged encounterance approach, with this disorder, and the duration of the conflict with vaginismus takes a long time. The main reason for these challenges is the lack of information and knowledge about the vaginismus. This can be due to the taboo of sexual education to the children, especially for girls in Iran.


Introduction
Strong marital relationships depends on satisfactory of sexual relation (1) and sexual satisfaction is an influential factor in a happy marital life (2). Sexual dysfunction affects the couples' quality of life (3,4). Vaginismus is one of the sexual dysfunctions of women, which is associated with pain during sexual intercourse (5). It is also classified as the sexual pain disorders (6). Vaginismus defined as a difficulty inserting an examiner's finger, speculum or penis into the vagina, despite the tendency of women towards sex. Vaginismus is associated with the severe and uncontrolled contractions of muscles in pelvic floor and outer third of the vaginal muscles (7). Evidence suggests that bitter and unpleasant sexual experiences, (8) Psychological problems and inaccurate information are the causes of vaginismus (9). Also, the prevalence of vaginismus can be related to psychogenic issues, the impact of childhood psychosocial development, and the effect of fear and anxiety on sexual relationships during marriage (10). The prevalence of vaginismus is unclear. Probably due to the presence of Shame, cultural factors, lack of attention to the problem and hide it behind a physical or psychological disorders (11). In the literature, the prevalence of this disorder in the world is about 1 to 7% (12) and has been reported 17% among the referrals to clinical setting (13). The prevalence of this disorder is much higher in societies in which, talking about sexuality for girls is embarrassing, and the virginity of girls at wedding night has a strong cultural value (14). In Iran, there are no definite statistics of vaginismus, but according to Ghavam and Tasbihsazan, vaginismus is the second most commonly reported sexual dysfunction in Iranian women (15).
In couples, the sexual dysfunction is always accompanied by psychological reactions. These reactions are more severe in men than women, which attributes it to definition of society from the role of man as the responsible for creating sexual satisfaction (16). For men, ensuring the sexual satisfaction of their wives, is more important than themselves (3), also, for men, the best predictor of sexual behavior is their estimate of the level of spouse's sexual satisfaction (4). For this reason, in the process of treating female sexual dysfunction, the role of men is essential for achieving positive therapeutic outcomes. Particularly in Vaginismus, if a man turns away himself from sexual intercourse because of worrying about hurting his wife, not only his wife will not have enough motivation to continue the treatment, but he will also suffer from a variety of sexual dysfunction, including erectile dysfunction, over time (16). These problems has a significant effect on the man's self-esteem, quality of life, emotional distress and marital challenge (16). In studies about female sexual dysfunction, little attention has been paid to their partner (17). However, based on evidence, men are affected by their spouse's sexual dysfunction and are physically and emotionally affected by unwanted changes (18). In Iran, scientific attention has been given to sexual disorders for a short time, and many families still consider sex education, especially for girls, as a taboo (15). The taboo of sexual issues in Iranian culture and also the few studies about sexual field, has led to the lack of appropriate services in terms of counseling and education. Therefore, we need more extensive studies, especially with qualitative methods, in order to gain a deep understanding of the live experience of couples with sexual dysfunction. So, the phenomenological method can be helpful for describing and interpreting the meaning of this experience (19). Results of this study can provide a clear picture of vaginismus, and help couples to develop effective coping strategies by correcting their existing misconceptions. In addition, the findings of this research can be a basis for holistic nursing care in this regard and also familiarize nurses with different aspects of this phenomenon, so they can be more effective in taking care of people with this disorder.

Materials and Method
The present study is a qualitative study with Van Manen's phenomenology approach, which was conducted during 2017-18. This study was conducted in health clinic affiliated to Shahed University and the participants were selected from that clinic. The participants included seven men whose wives was suffering from vaginismus. The data were collected by face-to-face, semi-structured and in-depth interviews with the participants, after obtaining written informed consent to record their voices. The main question of the research included: What is the lived experience of men whose wives was suffering from vaginismus? Data analysis was initiated based on the Van Manen's phenomenology approach, after the first interview. Data management was done by MAXQDA software.
The Van Manen's phenomenology approach has six steps (20). In this study, the first step was the main question of the study: "What is the live experience of men whose wives was suffering from vaginismus?" The second step involved actions that led to the production of data, including the use of personal experience as a starting point, hearing live narratives, interviews, empirical descriptions in texts, etc. In the third step, the goal was to draw the essential meaning of the experiences by "reflecting the intrinsic themes". At this step, for each interview, the sentences and thematic phrases were extracted from the text of the interviews and transformed into conceptual sentences. In the fourth step, the statements of participants were rewritten and the results were extracted according to the notes and some quotations of the participants. In the fifth step, the researcher's engagement with the phenomenon, its meaning, the data, and the phenomenon was taken into consideration by the research team in all steps. Finally, in the sixth step, the researcher focused on the whole process and matched each component with previous components as well as the whole process to maintain integrity in the research process.
Rigor: The trustworthiness of this study is evaluated through Guba and Lincoln Criterion (21). Credibility was established in this study through prolonged engagement with participants and the data, member check, peer check, external check and constant comparison. The research members had regular meetings and reviewed the process of analysis in various sessions. We also used observation and field note (21,22) to achieve a better understanding of the context. To ensure confirmability of the findings, the analysis and the primary conclusions were presented, reviewed and revised in a seminar with a research team and a number of nursing faculties who were knowledgeable in the given field of research and were familiar with qualitative approaches. Transferability was enhanced by rich and deep description of the context and characteristics of the participants.

Results
The average age of the participants was 31.1 (SD = 3.42) years. They were all employed and had higher levels of education than middle school degree. Data analysis led to the extraction of two main themes; "the shadow of the disorder in couple's life." and "the encounterance approach with the disorder". The theme "the shadow of the disorder in couple's life" consisted of four subthemes of "Amateurish", "Perplexity", "Apprehension", and "Acrimony and Desperation", and the theme of "encounterance approach with the disorder" had two subthemes of "confronting with the disorder" and "Seeking the solution".
A: The Shadow of the disorder in couple's life: Vaginismus significantly affects the couple's life, so that's shadow can be seen in different aspects of couple's life. In the following, the subthemes of this main theme are explained.
A.1) Amateurish: Amateurish behaviors refer to factors like cultural and social context, poor information and less experience about sexual relationship. Clumsy behaviors, disregard for the disorder and do not taking the disorder serious, are the types of amateurish behaviors. One of the participants' stated: "We were amateurish and stressed, in the first times that we have sex, and when it was not successful, I was saying to myself that, it is perhaps due to my lack of knowledge and inexperience.
A.2) Perplexity: Perplexity refers to the excessive anxiety of couples who are at the position between accepting and denying the disorder. Perplexity makes the person to have any effort to find a way out of the disorder, but often their efforts comes to a dead end. One of the participants' stated: "I started to watch porn movies, but it did not work..., we got somewhere that we were masturbating, it did not work too, Sometimes I would say that they prayed for us, so I went to the priest..." A.3) Apprehension: After the acceptance of the disorder by the couples, they feel losing control of their own behavior, and then experiencing some kind of tension, tensions between couples, family tensions, distrust between couples, fear and concern about disorder. One of the participants' stated: "The lack of sex pushed me and made me to become aggressive and nervous, sometimes I was losing my self-control and Shokoh Varaei et.al., Men's experiences of their partner's vaginismus (A phenomenological study) ISSN: 0976-5921 started to swear, and beat." A.4) Acrimony and Desperation: Experiencing vaginismus by men leads to mental-emotional distress, attenuation of physical and emotional power and personality changes. This subtheme refers to disappointment, depression, frustration, coldness, reduced self-esteem, personality crisis, etc. One of the participants' stated: "In my life, I feel that there is nothing left in me. My manhood and everything else is taken from me. I've just become another man, I'm disillusioned and feel humiliated, and my self-esteem and self-confidence is gone..... I feel some kind of inner hate about myself. " B: Encounterance approach: The couples after various conflicts with disorder, were taking different approaches, including ignoring the disorder, accepting and following it up. This theme had two subthemes; "confronting the disorder" and "seeking the solution". In the following, the subthemes of this main theme are explained.
B.1) Confronting the disorder: this subtheme represents the psychological approach adopted by couples in the long-term exposure to vaginismus. These approaches ranged from love and hope to ignoring the disorder. One participant stated: "This disorder has made me pay more attention to my wife and I love her more than before." Another participant stated: "My wife did not like follow the treatment, because of without getting any positive outcome. So she said I did not want to continue the treatment... That's why we ignored the problem for a while." B.2) Seeking the solution: Refers to the various actions taken by couples to find replacement and peace. These actions were sometimes rational, such as communicating with God, increasing awareness about the disorder to reduce concerns, following up the treatment of the disorder properly and sometimes their actions were irrational, such as replacing another sexual partner and tendency towards tobacco, etc.... one of the participants' stated: "I smoke cigarette to get calmer in such situation, and when I was more upset, I smoke more." Another participant said, "I would like to talk to my god, I'm getting calmed down."

Discussion
The results explained the answer to this question, what is the lived experience of men whose wives were suffering from vaginismus?
Vaginismus affects all aspects of couple's life, their performance in different situations of life is disrupted and they undertake amateurish behaviors, followed by a kind of perplexity that disrupting the couples' ability to make decisions, leads to apprehension, disappointment and frustration from not being able to solve the problem.
Lack of awareness about vaginismus confused the couples and leads to amateurish behaviors such as making extra effort to perform sex, the use of force and pressure for penetration, and in some cases disregarding and ignoring the disorder. In Sampson (2008) study, due to inability to have successful sexual relationship, unawareness and amateurish behaviors caused the couples avoid sex and sometimes they think it would be solved automatically after a while (23). Oktay (2003) in a study entitled: "Evaluation of women with vaginismus and their husbands" indicated that among the pivotal and known problems, couples who are affected by the vaginismus having false and traditional beliefs about sexual issues (24). These findings are consistent with the findings of our study. In another study, Munasinghe (2004) also refers to the use of force and pressure for penetration and states that, in romantic marriages, men would use minimum amount of force and pressure in order to prevent pain in their wives and this exacerbates the vaginismus (25). In our study, the use of extra pressure for penetration has been referred to as a negative point, which is somewhat contradictory with the findings of Munasinghe's study.
After repeatedly failing to have successful sexual relation, couples will become confused and anxiously take actions that are often wrong and will come to a dead end. Among these actions, they tried to watch porn movies, masturbating and satisfying each other without sexual intercourse, using sedative medications to reduce muscle spasm, etc. Similar findings are seen in the Elden's study (2014), which refers to an inability to understand the status and could not make a wright decision about the problem (26). Sampson (2008) also states that, in his study some participants used porn movies, to check whether their sexual relation is correct, or not, some others pushed their wives to have sex, and in other participants, they found other ways to reach orgasm without sexual intercourse (23).
Fears and worries of couples become worse after their decisions come to a dead end, and they experience many psychological stresses, including insecurity, impatience and lack of faith in each other. The root of most of these fears and concerns is in the unawareness and disappointment caused by the treatment. Jodoin (2008) in a study declared that, the men experience anxiety and apprehension due to wives pain with vestibulodynia (17). These findings are also consistent with the Sampson's (2008) findings that men expressed fear and concern about the persistence of their wives' disorder, the fear of being painful for their spouse, and eventually the level of their anxiety. Indeed they mentioned that men avoid sex because of the fear of being rejected by their wives and the occurrence of violence between them (23).
Consequences of vaginismus, most of participants complained about the decrease in selfesteem, depression, coldness or loss of sexual desire, and personality changes as men. Feeling humiliated, frustrated, and losing the sense of masculinity were the most frequent highlighted concepts. In this regard, Sampson (2008) refers to the "impact of disorders on men", which describes the feeling of loneliness, helplessness, tiredness, and insecurity in men. The lack of sexual security and marital relationships causes men to worry about leaving their wives, or separating from them (23). Culley (2017), in a study entitled: "The effect of endometriosis on the sexual relationship", states that men are emotionally affected by the disorder and suffer from hopelessness, disappointment, anxiety and anger (27). Eserdag (2011) also mentioned that: Medicine, 2019, 10(3), 252-256 ISSN: 0976-5921 decreased libido, with more than 22% prevalence, is an outcome of sexual dysfunction in men whose wives are suffering from vaginismus (7). These results are compatible with our study. About the impact of emotional distress because of vaginismus in the Malleson's study (1954) they mentioned that they may develop excessive anxiety or ignorance that can worsen their wives' vaginismus significantly (28).

International Journal of Ayurvedic
2. Encounterance approach: The participants' performance in encountering with this disorder was seen in various forms: Confrontation with the disorder varies from love and hope to disappointment and disregard. Some of the participants were following their wife's treatment with hope and were talking about love. They said, in such circumstances, they cannot leave their wives alone, because they love their life and their wives. Some others had become disappointment from the follow-up process, because of the length of the treatment process and the lack of result, and even were thinking about separating from their wives. In this regard, Kaplan (1974) stated that, the experiences of men and their attitudes toward sexual dysfunction of their wives may be very different (29). The findings of Sampson's (2008) study pointed out that some participants emphasized that, vaginismus had no effect on their relationship with their spouses, and they not only do not think about separation, but also they feel more responsible for their spouse and increasingly think about them. On the other hand, some participants stated that, they were tired of pursuing treatment and not having sex, and were thinking about separating from their spouse (23). Pacik states that men are affected by this disorder as much as their wives, and refers to isolation, tiredness, low self-esteem, distress, feelings of guilt and anger, as well as concepts, such as divorce, separation, changes in marital relationships, and even suicide attempts as a ugly aspects of vaginismus (30). These are consistent with our findings.
In encountering with vaginismus, as a solution, some of the couples was replacing sexual partner, accepting existing conditions, pursuing ways to obtain peace, etc. Replacing the sexual partner was used to compensate for the lack of sex, and also turning to alcohol and smoking, spending time with friends, working excessively, sympathizing with spouse, and talking to spouse were mentioned as ways to obtain peace. In this regard, Basson (2005) refers to creating greater intimacy between couples as one of the ways to achieve relaxation and peace in couples affected by sexual dysfunction, because it can reduce the anxiety caused by the sexual dysfunction (31). Pacik (2012) mentioned that, one of the ways to achieve peace in couples affected by vaginismus, are to becoming a member of related groups, that they have similar problems. By doing so, they can improve their relationships with their spouses by learning communication skills. Pacik identified effective communication as the key factor in overcoming this disorder (30). Sampson (2008) stated that some participants were thinking about separating from their spouse or having another sexual partner as they were tired of the treatment process that had not been successful, and they regretted their marriage. In contrast, some participants were feeling more responsible for their wives and became more intimate with them as a result of vaginismus. They were doing so to achieve calm and peace for themselves and for their wives and reduce their anxiety (23). These results are consistent with our findings.

Conclusion
The findings of this study indicate the different aspects of lived experience of men whose wives were suffering from vaginismus. These results provided a clear description of this phenomenon. Unawareness and inexperience at the very beginning of the disorder are the cause of amateurish behaviors that occasionally prevent couples from pursuing treatment for several years. On the other hand, apprehension, anxiety and stress lead couples to often undertake irrational actions. Being affected by this disorder could be seen by couples in a variety of ways, such as fear and anxiety about the future, depression, decreased self-esteem and sexual desire, etc. All of these, describe and interpret the lived experience of men whose wives suffer from vaginismus. This study is considered as a unique study, due to the traditional atmosphere of Iran and the taboo of sexual issues in Iranian culture, because Iranian culture has a significant impact on the study of sexual issues, especially issues related to men and has caused very few scholars to address these issues. Findings of this study can clarify the different aspects of a factor that leads to divorce in couples and also can be used as the reminder of comprehensive approach to treatment for therapists, especially nurses. Paying attention to the spouses of patients with sexual dysfunction is the essence of everything that is emphasized on by this study. Finally, researcher suggests further researches and a more serious look at the categories of men's health, especially in countries with traditional cultures.