CONTENT WARNING: contains mention of sexual trauma
Vaginismus, in its most simple term, is being unable to participate in penetration without experiencing pain. The DSM-5 classification stresses that vaginismus is a penetration disorder in that any form of vaginal penetration such as tampons, finger, vaginal dilators, gynecological examinations, and intercourse is often painful or impossible. The pain is due to the muscles of the vagina squeezing or having a spasm when something is attempting to penetrate it; this tightening of the vagina means any attempt of penetration is met with pain. Broken down further, there are two types of vaginismus, with treatment varying for each. Primary Vaginismus is where pain is experienced every time they try to insert something into their vagina, or they may have never been able to insert anything into the vagina without pain. Secondary Vaginismus is where penetration may have been previously possible, but is then difficult or impossible—this can be caused by sexual trauma, menopause, childbirth or yeast infections. With either primary or secondary vaginismus, it is important to know that this tightening is completely subconscious, it is an involuntary spasm of the pelvic muscles. This lack of control is what makes vaginismus a challenge to overcome, but as you will see throughout this article, there are multiple solutions to vaginismus. This article will be exploring multiple research papers looking at vaginismus, which we will see even these academic articles can be fooled by common misconceptions, as well as possible solutions and treatments of Vaginismus.
A paper published several months ago revealed that “despite its universal prevalence, vaginismus remains under-researched.” There has been a growth in discussion and representation of it. Netflix series Sex Education has been praised for its discussion of vaginismus in the show. In the finale of Season 2, Lily reveals to her partner that she has vaginismus, and has been struggling with the treatment of it because of the pressure she puts on herself. The show does not stop here, Lily explains that she just “keeps to the outside” which encourages the couple to engage in mutual masturbation. Both members are satisfied without the pressure to engage in penetration. This shows that vaginismus does not have to mean the end of sexual pleasure, as well as reinforce that penetrative sex is not the only act of sex one can participate in.
The pain issue in discourse on vaginismus is arguments between what the condition is itself. Some argue that it is a psychological condition, others attribute it to being a physical condition. Vaginismus was first written about in 1859, with the conclusion that the only possible treatment would be “that of dividing the muscle and the nerves of the vulva opening…I now saw that the hymen itself was the focus of the excessive irritability, and I then proposed to cut it out entirely.” This practice is no longer welcome, and it is now a combination of physical and psychological therapy used to overcome vaginismus. These treatments for vaginismus will be discussed later on in the article.
As much as we would like to think treatment and thoughts about vaginismus have changed since 1859, it appears there are still many false ideas. A 2004 paper discusses that the etiology (causes) of vaginismus remain controversial, and man are some of these ideas wrong! This research explains that vaginismus was originally “considered to constitute a hysterical or conversion symptom, being conceptualized as a symbolic expression of a specific unconscious intrapsychic conflict.” The paper explained how many doctors listened to Freud instead of those experiencing vaginismus, concluding that vaginismus is a result of penis envy and an unconscious desire to castrate men:“If the girl does not resolve her penis envy, she is likely to develop vaginismus later in life.” Others (the paper does not specify who) have taken Freudian theory a further step, claiming that the husband has come to represent the father and in the mind of the woman, sex would be incest, hence the vaginal walls tense up to prevent this happening. It becomes apparent that many of these theorists see vaginismus as a result of a poor relationship with the father, and the choice of partner being based on the father. Not all theories mentioned in the paper were completely invalid. Elison concludes that vaginismus can be a result of sexual guilt and conflict, especially in a religious setting. They are so fearful of punishment from having sex, that this manifests physically and their body will not allow them to experience penetration.
At this point, I was hopeful that the paper would have a turning point, and whilst there was mentionings of a fear of pain and sexual violation as causes of vaginismus, it quickly turned back around to being a byproduct of a poor father-daughter relationship. The paper concluded that “there appears to be an agreement that vaginismus is a psychophysiological disorder with phobic elements resulting from actual or imagined negative experiences with penetration attempts.” At first I was glad that the paper concluded on something that wasn’t focused on the relationship to the father, but the final sentence explaining what the solution to vaginismus is quickly threw away any positive thoughts I had about this paper. The author concluded that “the sexual secure husband can usually overcome mild degrees of vaginismus by persistent but firm penile insertion.” Not only does this seem to conclude that marriage is part of the solution to vaginismus, but puts the solution in the hands of the male (or penis owner) rather than the person experiencing vaginismus.
DIAGNOSIS
If you feel you may have vaginismus, the best thing to do is see your doctor. Many will allow you to bring a trusted friend or companion with you, and you have every right to request a female doctor. Your doctor will likely ask you:
When you noticed the problem
How often it occurs
What seems to trigger it
Your doctor will also ask you about your sexual history, which may include questions about sexual trauma or abuse. Possibly the most difficult part of a vaginismus diagnosis is the necessary pelvic exam, which is done in order to rule out possibilities of infection. It is very normal for people with vaginismus to be fearful about pelvic exams, but there are many ways it can be made more comfortable. Some people may prefer not to use stirrups and instead try a different position for the exam. Others like to use a mirror to see what the doctor is doing. The doctor may further suggest that you help guide their hand or medical instrument into the vagina to make penetration easier and at your own pace. The important thing to remember is that vaginismus is a treatable disorder.
TREATMENTS
There are multiple treatments that are effective in helping vaginismus. “Treatment is a team effort and post-treatment counseling is usually needed regardless of the type of treatment utilized, because of the interplay of the physical and emotional aspects of vaginismus”
Dilator Therapy
Dilators are used to overcome the physical aspect of vaginismus, as well as the psychological fear or anxiety of penetration. Dilator therapy involves the use of progressively larger dilators to help stretch out the vagina and, in turn, allow vaginal penetration to become more comfortable. Education should be used in conjunction with dilators. The paper discussing treatments notes that “asking a woman to simply purchase a set of dilators is a setup for failure in that most women do not know how to use their dilators and no support is given to overcome the emotional aspects of penetration.”
The article goes on to mention what should be included in counseling sessions. On the day after treatment these sessions should include explaining how dilators should be used, overcoming the anxiety associated with the use of dilators, transitioning from dilators to intercourse and coital positions that relax the pelvic floor. They further note their patients find the use of a vibrator helps them relax during the dilator process.
Patients are encouraged to use a dilator for two hours a day for the first month. This schedule should be reduced as the larger dilators become more comfortable for a longer period of time. Finger penetration, whether it is the patient's own or their partners', has also been found helpful with initiating dilation. Patients may be asked to keep daily logs of their dilation progress in order to encourage accountability and motivation.
Physical Therapy
There are physical therapists who have specialized training in the evaluation and treatment of pelvic floor disorders. It has been observed that isolated stretching and use of dilators can be effective in treating vaginismus. Physical therapy can help the patient to understand how to lessen tension in the pelvic floor.
Sex Counseling
For those struggling in a relationship, sex counseling can help improve communication skills and can help reduce anxiety and depression. Sex counseling can further educate the patient on progressing with dilators, and is helpful in supporting less severe cases of vaginismus.
Psychotherapy and hypnotherapy
Both of these are aimed at reducing the anxiety associated with vaginismus. Cognitive behavioral therapy (CBT) can further help the patient understand their thoughts and feelings that influence their behaviors. This can help shift the focus away from fear of penetration and avoidance behavior.
Botulinum Toxin
This is a fancy word for Botox. These injections seem to be a promising treatment for vaginismus in the way botox can relax the muscles that are obstructing penetration
Post-procedure Counseling
The article revealed that although patients may feel they are doing well with the physical element of dilation or penetration, they “need to catch up emotionally to where they are physically.” Though they may be able to insert dilators with ease, they struggle with the emotional comfort of penetration. This follow up procedure is essential for a successful treatment.
There are many options for treatment of vaginismus, with most involving a combination of emotional and physical therapy. No matter the severity of vaginismus, it can be overcome. Some people may simply take more time than others, and that is okay. You are the one who can decide what your end goal is. Being “cured” can mean different things for different people. Some may base this on penetrative sex. For others, being free from vaginismus means being able to wear tampons or no longer fearing a gynecological exam.
By Stephanie McCartney