AUTHOR: Dr. Joshua Gonzalez
ILLUSTRATIONS BY ARI SAPERSTEIN
We typically associate sex with pleasure, connection and good feelings, but for some with vaginas, intercourse can feel exactly the opposite–painful, frustrating even isolating. This is a condition known as Vaginismus, one of the most common types of Dyspareunia, or what doctors refer to as “painful sex”.
Sex is an ongoing part of our lives and an instrumental part of our relationships, but if it hurts or feels uncomfortable, it can be very upsetting and stressful for individuals and their partners alike. Many can feel alone or abnormal and think that something’s wrong with them. Beyond this, our culture likes to push the idea that if we can’t have penetrative sex (typically the heteronormative kind), we can’t be fully intimate with a partner. However, this condition isn’t abnormal at all and intimacy can have any number of definitions! Despite what most people may believe, painful vaginal penetration is a very common issue, and one that can occur at any moment in a vagina’s lifetime. In this essay, I will provide helpful information, including the causes, symptoms, and treatments for Vaginismus.
So, what is Vaginismus?
Vaginismus affects the involuntary contractions of the pelvic floor muscles, particularly the muscles surrounding the vaginal opening. These contractions can happen out of nowhere and at any time, interfering with or preventing vaginal penetration. This condition often leads to extreme or sharp pains in the vagina and lower abdomen, intense pressure, or burning sensations—sometimes lasting for days. These types of reactions don’t necessarily always have to do with sexual intercourse, either. Vaginismus can occur with the insertion of tampons, during gynecological exams, with finger penetration during masturbation or foreplay, or with the use of sex toys or vaginal dilators.
Categorizing vaginismus can help with treatment.
Vaginismus can be either a primary or secondary condition. Primary vaginismus refers to a lifelong problem, or an individual who has never been capable of pain-free penetration. Those with primary vaginismus often present symptoms earlier, sometimes with first attempts at tampon use or masturbation. Patients sometimes report an inability to tolerate regular gynecological speculum exams or engage in penetrative sexual activity.
Secondary vaginismus refers to an acquired condition, meaning patients who were previously comfortable with vaginal penetration can no longer tolerate that same penetrative activity later in life. Often extenuating circumstances like childbirth, recurrent bacterial or yeast infections, or physical and sexual trauma can lead to secondary vaginismus.
Doctors also categorize vaginismus by the severity of a patient’s condition: complete or situational. A person with complete vaginismus is incapable of tolerating any form of penetration. Situational vaginismus is when an individual can tolerate wearing tampons or have a speculum exam, but cannot engage in other forms of penetration like sexual intercourse.
Either way, although vaginismus causes a variety of physical and emotional symptoms that every individual with a vagina will experience in their own way, pain is the main feature and the one shared by all sufferers regardless of the severity of their condition.
What causes Vaginismus?
Some patients with vaginismus and their partners describe attempted penetration like “hitting a wall.” It is important to remember that vaginismus is both a physical and psychological issue. Understanding the interplay between the physical and psychological aspects of vaginismus can provide potential causes (and treatments!) of this condition. Sometimes vaginismus occurs due to a deep emotional response (shame, fear, guilt, etc.) to cultural or religious stigmatization, or from personal beliefs about what constitutes appropriate sexual behavior. Sometimes it can occur from a response to a past trauma such as physical abuse, sexual assault or rape, or other forms of verbal, emotional and psychological trauma. Vaginismus can also occur as a physical response to specific stimuli like an infection, hormonal changes, or traumatic childbirth. Vaginismus is a bit of a mystery, as occasionally, the condition occurs out of nowhere with no identifiable cause at all.
No matter the cause, vaginismus is often associated with anxiety, fear and stress.
These psychological constructs often contribute to a cycle of pain: Anticipation of penetration causes involuntary contraction of pelvic floor muscles, which can result in pain with attempted penetration. This pain then causes the muscles to further tighten, creating even more discomfort Patients with vaginismus may start to fear sex or develop anxiety around certain penetrative activity, which only feeds the loop of anticipation of pain. It can be a vicious and challenging cycle to overcome.
How do I know if I suffer from Vaginismus?
First, I encourage anyone who may be experiencing painful sex to consult their doctor to learn more. If something doesn’t feel right, it’s probably worth getting it checked out even for the peace of mind. Here are some helpful questions to start with:
Are you able to use tampons without pain?
Have gynecological exams or pap smears ever been painful?
Is intercourse or other vaginal penetrative sexual activity physically uncomfortable?
When do you experience pain with sex? Is it with initial penetration, deeper thrusting, or both?
Are you aware of any prior personal physical, emotional/psychological, or sexual abuse?
Do you experience painful or difficult menstrual periods?
Do you have a history of recurrent yeast infections or UTIs?
Are you fearful or avoidant of sex?
Have you ever used an oral contraceptive pill or other form of systemic hormonal birth control?
Have you ever tested positive for a sexually transmitted disease or infection?
As I mentioned above, understanding vaginismus typically takes into account both physical and psychological factors. A careful history is key to figuring out if a patient is truly suffering from vaginismus or if the pain may be caused by something else. A physical exam is also important. Careful examination of the genital tissues, muscles and connective tissue of the pelvis often yields answers to what may be causing a person pain.
In addition, a hormonal evaluation may be warranted if your doctor thinks you might have vaginismus. Hormone deficiencies may predispose you to vaginismus because of their effect on the health of certain genital tissues. For example, menopause is a time where hormone changes are inevitable, sometimes leading to vaginismus. When patients have hormonally mediated changes to their genital tissues, it can cause the area to be chronically irritated or inflamed, and can develop the reactionary (and often involuntary) muscle contraction associated with vaginismus. This is especially true for individuals with secondary vaginismus.
What’s the treatment?
Once the diagnosis is made, there are a variety of therapeutic options are available to treat vaginismus.
Most options require an approach that is tailored to a patient’s specific situation as each individual experiences pain, distress, hormonal changes, etc. differently. If a problem with the muscles or connective tissue of the pelvic floor is discovered, physical therapy can be helpful. If a patient has exhibited a history of psychological, emotional, physical, or sexual trauma, then psychotherapy—both cognitive-behavioral therapy (CBT) and dedicated sex therapy—may be an effective component to treating the condition. Acupuncture and mindfulness may also play a role, as breathing exercises and learning new ways to relax can be extremely helpful for patients. Trigger point injections and dry needling, even Botox injections can be employed to relax muscle tightness. Hormone replacement therapy can be useful in those with hormonally mediated genital tissue changes that are causing involuntary muscle contraction. (A note of caution: Often people assume kegel exercises are helpful, but kegels are actually inappropriate in a person with vaginismus because they involve muscle tightening that could potentially worsen the issue.)
A few points to remember regarding vaginismus:
Painful sex is common, but can be treated.
Vaginismus is a common cause of painful sex. It can be a lifelong issue or happen to you at any age for a number of different reasons.
Vaginismus is usually a condition of the mind and body, and addressing the problem often requires recognition of both physical and psychological factors.
Vaginismus doesn’t have to be a permanent sentence! If you think you might have vaginismus, seek help. There are real solutions out there that can help you alleviate your pain and engage in pleasurable sexual activity again.
To hear more from Dr. Joshua Gonzalez, check out his recent podcast on sexual medicine and the newest research. You can also read his informative essays on erectile dysfunction and ejaculatory dysfunction.