The Effectiveness of Emotion-Focused Psychotherapy and Counseling in Married Women with Vaginismus

Introduction

Vaginismus is recognized as one of the most complex and distressing female sexual dysfunctions, characterized by involuntary contraction of the pelvic floor muscles that interferes with vaginal penetration and is often accompanied by intense fear, anxiety, and avoidance of sexual intercourse. Beyond its physiological manifestations, vaginismus is increasingly understood as a multidimensional condition rooted in emotional, cognitive, relational, and sociocultural processes. Contemporary clinical perspectives emphasize that vaginismus cannot be adequately explained by anatomical or purely medical factors alone, but rather emerges from an interaction between maladaptive emotional responses, dysfunctional beliefs about sexuality, interpersonal dynamics within the marital relationship, and broader cultural narratives surrounding female sexuality (Abdenijad & Simber, 2021; Fitria, 2025). As such, effective intervention requires an integrative psychotherapeutic approach that addresses not only behavioral avoidance but also the underlying emotional and relational patterns that sustain the disorder.

In many cultural contexts, particularly within traditional or collectivist societies, sexual concerns such as vaginismus are associated with stigma, silence, and feelings of shame. Women experiencing vaginismus often report profound emotional distress, including guilt, inadequacy, fear of marital failure, and anxiety related to sexual performance and intimacy. These emotional experiences can be intensified by societal expectations regarding marital roles and sexual availability, leading to chronic relational tension and psychological burden (Omidvar et al., 2021; Sahoo & Biswas, 2024). Research has consistently shown that untreated vaginismus not only affects sexual functioning but also undermines marital satisfaction, emotional intimacy, and overall quality of life, highlighting the necessity of timely and psychologically informed interventions (Ozturk & Arkar, 2017; ter Kuile et al., 2007).

Traditional therapeutic approaches to vaginismus have largely focused on behavioral and cognitive-behavioral frameworks, emphasizing gradual exposure, relaxation techniques, pelvic floor training, and cognitive restructuring. Cognitive-behavioral therapy has demonstrated efficacy in reducing penetration-related fear and avoidance, as well as improving sexual satisfaction and marital adjustment (Ozturk & Arkar, 2017; ter Kuile et al., 2007). However, despite these positive outcomes, a growing body of literature suggests that exclusively cognitive-behavioral or technique-driven approaches may not sufficiently address the deep-seated emotional conflicts and attachment-related insecurities that characterize many cases of vaginismus. This limitation has prompted increasing scholarly attention toward emotion-centered and relationally oriented models of psychotherapy (Akhlaghi & Rasouli, 2022; Hashemi & Ghahramani, 2021).

Emotion-focused psychotherapy and counseling are grounded in the premise that emotional experiences play a central role in shaping psychological distress and interpersonal functioning. From this perspective, maladaptive emotional processing, unresolved emotional pain, and ineffective regulation of core emotions such as fear, shame, anger, and sadness are viewed as key mechanisms underlying psychological symptoms. In the context of vaginismus, emotional processes such as fear of penetration, disgust, anticipatory anxiety, and emotional disconnection from one’s partner are not merely secondary reactions but primary drivers of symptom persistence (Hashemi & Ghahramani, 2021; Kakavand et al., 2025). Emotion-focused approaches aim to help individuals identify, experience, regulate, and transform these maladaptive emotional states, thereby facilitating more adaptive emotional responses and healthier relational interactions.

Recent empirical studies have increasingly supported the relevance of emotion-focused interventions in the treatment of vaginismus. For instance, research comparing emotion-focused schema therapy with other therapeutic modalities has demonstrated significant reductions in vaginismus symptoms alongside improvements in sexual satisfaction, self-esteem, and sexual self-assertiveness (Akhlaghi & Rasouli, 2022; Kakavand et al., 2025). These findings suggest that targeting emotional schemas and attachment-related patterns may yield therapeutic benefits beyond symptom reduction, contributing to more sustainable relational and sexual well-being. Moreover, emotion-focused couple-based interventions have been shown to enhance emotional intimacy, reduce anxiety during sexual intercourse, and improve dyadic coping among couples affected by vaginismus (Hashemi & Ghahramani, 2021).

Another important consideration in the treatment of vaginismus is the relational context in which the disorder develops and is maintained. Vaginismus rarely exists in isolation from the marital relationship; rather, it is deeply embedded within patterns of interaction between partners. Male partners may experience confusion, frustration, rejection, or feelings of inadequacy, which in turn can exacerbate relational tension and reinforce avoidance cycles (Eserdag et al., 2021). Emotion-focused couple therapy explicitly addresses these dyadic processes by fostering secure attachment bonds, facilitating empathic communication, and restructuring negative interactional cycles. By helping couples access and express vulnerable emotions in a safe therapeutic environment, this approach aims to transform rigid patterns of fear and avoidance into experiences of emotional safety and mutual support.

Comparative studies examining various psychotherapeutic modalities further underscore the importance of addressing emotional regulation and relational dynamics in vaginismus treatment. While mindfulness-based cognitive therapy and cognitive-behavioral therapy have demonstrated effectiveness in improving sexual satisfaction and cognitive emotion regulation, evidence suggests that interventions integrating emotional processing may produce deeper and more enduring changes (Ahmadi et al., 2022; Omidvar et al., 2021). Similarly, hypnotherapy and integrative approaches that incorporate emotional and experiential components have shown promise, particularly for individuals who do not fully respond to traditional behavioral techniques (Karav et al., 2025; Taştan et al., 2021).

Despite the growing body of international research, there remains a relative scarcity of methodologically rigorous studies examining the effectiveness of emotion-focused psychotherapy and counseling for vaginismus within specific cultural contexts. In Iran, where sociocultural norms surrounding sexuality may intensify emotional inhibition and communication barriers, understanding the applicability and effectiveness of emotion-focused interventions is particularly important (Nekoolal Tak et al., 2021; Soleimani et al., 2021). Furthermore, recent systematic reviews and meta-analyses emphasize the need for well-designed quasi-experimental and controlled studies to clarify the comparative effectiveness of contemporary therapeutic approaches for vaginismus (Zulfikaroglu, 2025).

Taken together, the existing literature highlights vaginismus as a multifaceted condition requiring interventions that extend beyond symptom-focused techniques to encompass emotional awareness, regulation, and relational transformation. Emotion-focused psychotherapy and counseling, with their emphasis on core emotions and attachment needs, appear theoretically and empirically well-suited to address the complex emotional and interpersonal dimensions of vaginismus. However, further empirical evidence is needed to substantiate their effectiveness and to inform culturally sensitive clinical practice.

Accordingly, the aim of the present study was to investigate the effectiveness of emotion-focused psychotherapy and counseling in reducing vaginismus symptoms among married women.

Methods and Materials

Study Design and Participants

This study employed a quasi-experimental design with a pretest–posttest structure and a control group to examine the effectiveness of emotion-focused psychotherapy and counseling in married women diagnosed with vaginismus. The statistical population consisted of all married women presenting with sexual dysfunctions who referred to counseling centers located in District 2 of Tehran during the second half of 2024 and the first half of 2025. Participants were recruited through purposive and convenience sampling procedures, whereby eligible women were identified and introduced by counseling centers and subsequently enrolled after providing written informed consent. Inclusion criteria comprised an age range of 30 to 45 years, a minimum of two years of marital life, at least a lower secondary level of education, self-reported difficulties in sexual functioning, and willingness to participate in group-based therapeutic sessions. Exclusion criteria included pregnancy, the presence of severe psychiatric disorders, use of psychotropic medications, chronic physical illnesses, absence from more than one intervention session, or voluntary withdrawal from the study at any stage. Based on prior empirical studies and power analysis with an assumed statistical power of 80 percent and a significance level of 0.05, a total sample size of 30 participants was determined. The participants were randomly assigned to either the emotion-focused intervention group or the control group, with 15 individuals allocated to each group.

Measures

Data were collected using a demographic information form and the Vaginismus Questionnaire developed by Raeisi et al. in 2015. The demographic questionnaire gathered information related to age, duration of marriage, educational level, and other relevant background characteristics. The Vaginismus Questionnaire is a self-report instrument consisting of 15 items designed to assess the severity and multidimensional aspects of vaginismus symptoms. Items are rated on a five-point Likert scale ranging from “not at all” to “very much,” with response options tailored linguistically to the content of each item. The questionnaire encompasses four dimensions, including sexual pain and inability to engage in sexual intercourse, negative emotional experiences during sexual relations, inappropriate contextual and situational conditions surrounding sexual activity, and fear and avoidance of sexual intercourse. Items 1 to 5 assess sexual pain and intercourse inability, items 6 to 8 evaluate negative emotional experiences, items 9 and 10 address contextual and situational factors, and items 11 to 15 measure fear and unwillingness toward sexual relations. Psychometric evaluations conducted by the developers indicated satisfactory validity and reliability of the instrument within the Iranian population. Exploratory factor analysis yielded a Kaiser–Meyer–Olkin index of 0.81, confirming sampling adequacy, and Bartlett’s test of sphericity was statistically significant at a level below 0.05, supporting factorability of the data. Internal consistency reliability assessed via Cronbach’s alpha was reported as 0.91, indicating excellent reliability. Additional evidence from subsequent research reported a Cronbach’s alpha coefficient of 0.83, further confirming acceptable reliability of the questionnaire for use in clinical and research settings.

Intervention

The intervention protocol consisted of emotion-focused psychotherapy and counseling delivered in a structured group format over eight weekly sessions, each lasting approximately 90 minutes. The protocol was grounded in the core principles of emotion-focused therapy and tailored to address the emotional and relational dimensions of vaginismus. Initial sessions focused on establishing therapeutic alliance, creating a safe and nonjudgmental environment, and providing psychoeducation about vaginismus with an emphasis on the role of emotions, fear responses, and attachment needs. Subsequent sessions guided participants in identifying and accessing primary maladaptive emotions related to sexual intimacy, such as fear, shame, anxiety, and emotional disconnection, while facilitating emotional awareness and validation. Therapeutic techniques included emotion labeling, experiential exercises, guided imagery, and empathic reflection to help participants process unresolved emotional experiences associated with sexual relations. Later sessions emphasized emotional regulation, transformation of maladaptive emotional responses, and development of more adaptive emotional experiences, alongside fostering self-compassion and emotional security within the marital relationship. The final sessions focused on integrating emotional insights into daily life, strengthening emotional expression and communication, and consolidating therapeutic gains to support sustained improvement in sexual functioning and relational intimacy.

Data analysis

Data analysis was conducted using SPSS version 26. Descriptive statistics were used to summarize demographic characteristics and baseline scores. Prior to inferential analysis, assumptions of normality and homogeneity of variances were examined. Inferential analyses were performed using repeated measures analysis of variance to assess the effects of time, group, and their interaction on vaginismus components and the total score, followed by Bonferroni post-hoc tests to identify pairwise differences between measurement stages. The significance level was set at 0.05 for all statistical tests.

Findings and Results

The demographic characteristics of the participants indicated that the two groups were broadly comparable in terms of marital duration and educational attainment. In the emotion-focused couple therapy group, which consisted of 15 participants, the mean duration of marriage was 8.15 years with a standard deviation of 4.33 years, ranging from a minimum of 4 years to a maximum of 15 years. In the control group, also comprising 15 participants, the mean duration of marriage was 9.75 years with a standard deviation of 3.55 years, with marital duration ranging from 3 to 15 years. Regarding educational level, in the intervention group, 30% of participants had completed middle school education, 45% held a high school diploma, 15% had an associate degree, 5% held a bachelor’s degree, and 5% possessed a master’s or doctoral degree. In the control group, 35% of participants had middle school education, 30% held a high school diploma, 10% had an associate degree, 20% held a bachelor’s degree, and 5% had completed master’s or doctoral studies. Overall, the distribution of marital duration and educational levels suggests reasonable homogeneity between the two groups prior to the intervention.

As shown in Table 1, the experimental group receiving emotion-focused couple therapy demonstrated a clear and consistent reduction in mean scores across all components of vaginismus from the pretest to the posttest, with these improvements largely maintained at the follow-up stage. Specifically, notable decreases were observed in sexual pain and inability to engage in intercourse, negative emotional experiences during sexual relations, inappropriate contextual conditions, and fear and avoidance of sexual intercourse. The largest mean reductions in the experimental group were evident in the dimensions of sexual pain and fear and avoidance, suggesting substantial clinical improvement following the intervention. In contrast, the control group exhibited relatively stable mean scores across the three measurement stages, with only minor fluctuations that did not indicate meaningful change over time. Overall, the descriptive results indicate a divergent pattern between groups, with the experimental group showing progressive improvement across time, while the control group maintained relatively unchanged levels of vaginismus-related symptoms.

As shown in Table 2, the repeated measures ANOVA revealed statistically significant main effects of time on all components of vaginismus, including sexual pain and intercourse inability (F = 24.87, p < .001, η² = .47), negative emotional experience (F = 21.56, p < .001, η² = .43), inappropriate contextual conditions (F = 18.37, p < .001, η² = .40), fear and avoidance of sexual intercourse (F = 31.62, p < .001, η² = .53), and the total vaginismus score (F = 35.74, p < .001, η² = .56). Significant main effects of group were also observed across all variables, with effect sizes ranging from moderate to large. Importantly, the interaction effects between time and group were statistically significant for all components and the total score, indicating that changes over time differed significantly between the experimental and control groups. The largest interaction effect was observed for the total vaginismus score (F = 32.61, p < .001, η² = .55), suggesting a substantial differential impact of emotion-focused couple therapy across measurement stages.

The Bonferroni post-hoc comparisons presented in Table 3 indicated significant reductions from pretest to posttest and from pretest to follow-up for all components of vaginismus and the total score in the experimental group. For example, sexual pain and intercourse inability decreased significantly from pretest to posttest (mean difference = 2.21, p = .004) and from pretest to follow-up (mean difference = 2.65, p = .002). Similar significant patterns were observed for negative emotional experience, inappropriate contextual conditions, fear and avoidance of sexual intercourse, and the total vaginismus score, with all corresponding p-values below .01. In contrast, comparisons between posttest and follow-up measurements were not statistically significant across any component or the total score, indicating stability of treatment gains over time. These findings suggest that emotion-focused couple therapy produced significant and sustained improvements in vaginismus symptoms among the participants in the experimental group.

Discussion

The findings of the present study demonstrated that emotion-focused psychotherapy and counseling produced significant and sustained reductions in vaginismus symptoms among married women, as evidenced by improvements across all assessed components, including sexual pain and inability to engage in intercourse, negative emotional experiences during sexual relations, inappropriate contextual conditions, and fear and avoidance of sexual intercourse. The significant time × group interaction effects observed for all subcomponents and the total vaginismus score indicate that the changes over time were not attributable to spontaneous remission or passage of time alone, but rather to the specific therapeutic effects of the emotion-focused intervention. The maintenance of treatment gains at the follow-up stage further suggests that the intervention facilitated relatively stable psychological and relational changes rather than short-term symptom suppression. These results align with contemporary conceptualizations of vaginismus as a disorder sustained by maladaptive emotional processing and relational dynamics, rather than by physiological factors alone (Abdenijad & Simber, 2021; Fitria, 2025).

One of the most notable findings of this study was the substantial reduction in sexual pain and fear-related components among participants in the intervention group. Emotion-focused psychotherapy emphasizes the identification and transformation of primary maladaptive emotions, such as fear, shame, and anticipatory anxiety, which are central to the experience of vaginismus. The observed reductions in fear and avoidance of sexual intercourse are consistent with the theoretical premise that emotional avoidance and defensive responses perpetuate involuntary muscular contractions and sexual distress. By facilitating emotional awareness, validation, and regulation within a supportive therapeutic context, emotion-focused interventions may disrupt the cycle of fear–tension–avoidance that characterizes vaginismus. Similar findings have been reported in studies demonstrating that therapies targeting emotional processes can effectively reduce vaginismus symptoms and enhance sexual functioning (Akhlaghi & Rasouli, 2022; Hashemi & Ghahramani, 2021).

The improvement observed in the dimension of negative emotional experiences during sexual relations further underscores the relevance of emotion-focused approaches. Women with vaginismus often report persistent feelings of inadequacy, guilt, and emotional disconnection during sexual encounters, which may intensify symptom severity and undermine intimacy. The present findings suggest that emotion-focused psychotherapy may help participants reprocess these emotional experiences and develop more adaptive emotional responses to sexual intimacy. This interpretation is consistent with previous research indicating that interventions addressing emotional schemas and attachment-related beliefs lead to improvements in sexual satisfaction and emotional well-being in women with vaginismus (Kakavand et al., 2025; Omidvar et al., 2021). Compared to approaches that primarily target cognitive distortions or behavioral avoidance, emotion-focused therapy may offer a deeper level of emotional restructuring that contributes to enduring change.

Another important outcome of the present study was the reduction in inappropriate contextual and situational conditions surrounding sexual activity. This component reflects the broader interpersonal and environmental factors that influence sexual functioning, including communication patterns, emotional safety, and relational expectations. Emotion-focused psychotherapy, particularly when delivered within a couple-based or relational framework, emphasizes the creation of secure emotional bonds and the transformation of maladaptive interactional cycles. Improvements in this domain suggest that participants may have experienced enhanced emotional safety and relational attunement, which are critical for facilitating sexual intimacy. These findings align with evidence indicating that relationally oriented therapies can improve marital adjustment and reduce sexual dysfunction by addressing dyadic emotional processes (Eserdag et al., 2021; Ozturk & Arkar, 2017).

The present results also corroborate and extend prior findings from comparative studies of different therapeutic modalities for vaginismus. While cognitive-behavioral therapy has been shown to be effective in reducing avoidance behaviors and improving sexual satisfaction, its primary focus on symptom management may limit its impact on deeper emotional conflicts. Studies comparing cognitive-behavioral therapy with mindfulness-based or emotion-oriented approaches suggest that interventions incorporating emotional awareness and regulation may yield broader psychological benefits (Ahmadi et al., 2022; Omidvar et al., 2021). Similarly, research on hypnotherapy and integrative models highlights the importance of experiential and emotional components in facilitating therapeutic change for vaginismus (Karav et al., 2025; Taştan et al., 2021). The present study adds to this literature by providing empirical support for emotion-focused psychotherapy as an effective intervention capable of producing multidimensional improvements.

Cultural considerations further contextualize the significance of these findings. In sociocultural settings where open discussion of sexual concerns is constrained by stigma and traditional norms, emotional suppression and avoidance may be particularly pronounced. Emotion-focused psychotherapy offers a culturally adaptable framework that does not require explicit sexual techniques in early stages, but instead prioritizes emotional safety, validation, and gradual exploration of vulnerable experiences. This may enhance acceptability and engagement among women who experience shame or anxiety related to sexual topics. Prior Iranian studies have emphasized the need for culturally sensitive interventions that address emotional and relational dimensions of vaginismus, and the present findings provide empirical support for such approaches (Nekoolal Tak et al., 2021; Soleimani et al., 2021).

The stability of treatment effects at follow-up is another important contribution of this study. The absence of significant differences between posttest and follow-up scores suggests that participants were able to maintain therapeutic gains over time, which may reflect internalization of emotional regulation skills and changes in relational patterns. This finding is consistent with meta-analytic evidence indicating that therapies targeting core emotional processes tend to produce more durable outcomes compared to interventions focused solely on behavioral symptom reduction (Zulfikaroglu, 2025). By fostering adaptive emotional responses and secure attachment experiences, emotion-focused psychotherapy may equip individuals with enduring capacities to manage sexual anxiety and relational challenges beyond the therapeutic context.

Despite these strengths, the interpretation of the findings should be situated within the broader literature acknowledging the multifactorial nature of vaginismus. While the present study supports the effectiveness of emotion-focused psychotherapy, it does not negate the potential utility of other therapeutic modalities. Rather, the findings suggest that emotion-focused approaches may serve as a valuable component within an integrative treatment framework tailored to individual needs. Previous reviews emphasize that optimal outcomes in vaginismus treatment often result from flexible, multimodal interventions that address emotional, cognitive, behavioral, and relational factors (Abdenijad & Simber, 2021; Fitria, 2025). The present study contributes to this integrative perspective by highlighting the central role of emotional processing in symptom reduction.

Conclusion

Overall, the findings of this study support the growing body of evidence positioning emotion-focused psychotherapy and counseling as effective interventions for vaginismus. By addressing core emotional experiences, enhancing emotional regulation, and improving relational dynamics, this approach appears well-suited to the complex psychological and interpersonal features of vaginismus. The consistency of the present results with prior empirical and theoretical work underscores the clinical relevance of emotion-focused models and their potential contribution to advancing evidence-based practice in sexual health interventions.

The first limitation of the present study relates to the relatively small sample size, which may limit the generalizability of the findings to broader populations of women with vaginismus. In addition, the use of a quasi-experimental design and convenience sampling may introduce selection bias and reduce external validity. The reliance on self-report measures also raises the possibility of response bias, particularly given the sensitive nature of sexual functioning and emotional experiences.

Future research should employ larger and more diverse samples to enhance the generalizability of findings and examine the effectiveness of emotion-focused psychotherapy across different cultural and socioeconomic contexts. Longitudinal studies with extended follow-up periods are also recommended to assess the durability of treatment effects over time. Additionally, comparative studies directly contrasting emotion-focused psychotherapy with other established interventions could further clarify relative efficacy and mechanisms of change.

From a practical perspective, the findings suggest that clinicians working with women experiencing vaginismus should consider incorporating emotion-focused principles into assessment and intervention processes. Training programs for therapists may benefit from emphasizing emotional awareness, regulation, and relational attunement as core competencies in sexual health counseling. Integrating emotion-focused psychotherapy within multidisciplinary treatment settings may also enhance treatment accessibility and effectiveness for women affected by vaginismus.

Authors’ Contributions

L.B. was responsible for the conceptualization of the study, formulation of the research objectives, and coordination of the intervention protocol. A.S. supervised the methodological design, provided theoretical and clinical guidance on emotion-focused psychotherapy, and critically reviewed the study framework. R.K. contributed to participant recruitment, data collection, administration of assessment instruments, and statistical analysis. All authors collaborated in interpreting the findings, drafting and revising the manuscript, and approved the final version of the article. All authors agree to be accountable for the accuracy and integrity of the work.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.

Transparency Statement

Data are available for research purposes upon reasonable request to the corresponding author.

Acknowledgments

We would like to express our gratitude to all individuals helped us to do the project.

Declaration of Interest

The authors report no conflict of interest.

Funding

According to the authors, this article has no financial support.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.