A medical evaluation by a specialist in gynaecological pain is always necessary. This evaluation must include a careful examination for subtle anatomical, pathological, or iatrogenic factors. Then the mental health clinician should review the locus of the pain, its onset, the average duration of a pain episode, and the degree of interference of the symptom with sexual life. (83) With vaginismus it is important to assess the conditions under which any penetration of the vagina can occur: tampon insertion, speculum examination, physician's finger, woman's finger(s) during masturbation, and partner's finger(s). The couple's sexual style is investigated in terms both of the amount of time devoted to psychological and physical preparation for lovemaking and of the degree of physical aggressiveness used during intercourse. Childhood and adult histories of sexual coercion/abuse are relevant, as are negative cultural/religious attitudes toward sexuality. The consequences of the pain disorder require assessment in terms of the development of secondary avoidance symptoms. Finally, the overall quality of the couple's non-sexual relationship is explored with specific questions about the partner's response to the symptom.
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