Vaginismus means you have persistent or recurrent difficulties in allowing your partner’s penis, a finger, or any object into your vagina – despite your expressed wish for penetration to happen. This is not something that you are choosing to do, so it can be an extremely distressing sexual difficulty for you and your partner. Some women with vaginismus will never have had penetrative sex, and may have found tampons and/or smear tests difficult or impossible.

Vaginismus occurs when the internal muscles around the vaginal wall clench so hard that penetration is difficult or impossible. The vagina is the internal canal. The external genital anatomy, is referred to as the vulva.

The clenching or spasm is an involuntary reaction, not a conscious response, and applies to attempted penetration with anything, from a tampon to a penis, speculum or sex toy. Attempted penetration can feel painful, burning, uncomfortable or impossible to achieve. This can affect women’s sex lives and medical examinations, such as Pap tests.

Some women respond so severely that they physically withdraw, convulse, and feel lightheaded and panicky. Four levels of vaginismus severity have been described with women visiting a gynaecologist. First degree reaction is when the spasm that is relieved with reassurance from a specialist. Second-degree reaction is when the spasm of the pelvic floor remains even when the woman is provided with reassurance. Third-degree reaction is when the woman elevates the buttocks when clenching the pelvic floor muscles. At level four, also known as Grade 4 vaginismus, is the most severe form with the elevation of buttocks, tightly closed thighs, and retreat. A fifth degree has been added which is described at having visceral reactions including sweating, trembling, palpitations, nausea, and hyperventilation.

Many women experience ‘partial vaginismus’ which means that sometimes penetration is possible, and sometimes it is not, and it is usually always painful. The pain often feels like a burning, itching sensation, and the whole vulval area can be sore when it is touched.

It is not clear the number of women affected by vaginismus. It is estimated from 1 to 7 percent of all women. It is thought that vaginismus is a reason for the non-consummation of marriage. The condition is not well known and some women are ashamed to admit it is a problem or ask for help, not realising that treatment is available and that they are not the only one with the problem.

Sometimes vaginismus is misdiagnosed as vulvodynia, or vulval pain.

Having vaginismus does not necessarily mean the woman does not desire her partner; some women can be aroused and desiring penetration and be frustrated by their own vaginismus.

Sex therapy helps you understand vaginismus, and teaches you and your partner techniques to overcome it. Sex therapy can also be very helpful alongside medical treatments for vestibulodynia.

VAGINISMUS AND THE PHYSIOLOGY OF THE VAGINA AND PELVIC REGION

There are three main muscles that can be involved in vaginismus 2. If any entry to the vagina seems impossible, it is probably the bulbocavernosus muscle which rings the opening to the vagina which has tightly clenched shut. This is the muscle most commonly implicated in vaginismus. Above this muscle, a little further in, is the pubococcygeus muscle, which is the one women are taught to exercise when they do pelvic floor exercises, sometimes called Kegel exercises. This muscle is less likely to be the problem in vaginismus. Higher again in the vagina, about half way, is the puborectalis muscle which has to be relaxed to allow full penetration. Some women with vaginismus can achieve partial penetration up to this muscle and no further.

WHY DOES VAGINISMUS HAPPEN?

Some women have always had vaginismus when they attempt penetration (Primary vaginismus), and other women experience it after previously being able to have penetration without problems (Secondary Vaginismus).

Vaginismus can be a result of stress, fear, and anxiety or after surgery or a trauma. Fear can come from not having had good sex education which can lead some women to worry about touching their own bodies, or being touched by a partner where sex is presented as a positive experience, and with clear information about what to expect. Some women grow up with stories about the pain of first sexual intercourse and subconsciously fear their own first experience. Some doctors have observed a family history of vaginismus, especially on the maternal side. Fear or anxiety can come from when a woman has experienced a trauma, such as sexual assault, and vaginismus is a reaction to that.

Some women can develop vaginismus after repeated pain with penetration from a range of reasons such as dryness or inflammation, and the body’s response to stop this pain is to prevent access to the vagina, hence vaginismus 3. The pain may be from an infection; if you have burning, soreness, an unusual discharge, itching, pain or unusual swelling of the vulva, see a doctor.

Some women worry that that their vagina is too small 4. This is not usually the problem. The vagina is elastic and can stretch to accommodate a tampon, penis or baby, then return to its previous size.

PRIMARY VAGINISMUS

Primary vaginismus is the term sued to describe when a woman cannot achieve vaginal penetration at all – whether a penis or tampon, or speculum. Primary vaginismus is often diagnosed in during adolescents or early adulthood when a young woman is unable to insert a tampon, or unable to have a Pap smear.

Primary vaginismus may be the result of any number of factors or experiences. These include:

• urinary tract infections;
• vaginal yeast infections;
• experiences of abuse whether sexual abuse, rape, sexual assault, domestic violence/intimate partner violence, attempted abuse or assault;
• knowledge of (or witnessing) sexual or physical abuse of others;
• chronic pain conditions (e.g., endometriosis);
• generalized anxiety;
• stress;
• fear, especially of sex; breaking the hymen and potential associated pain; or
• strict, limited, or poor sexual and moral education. This experience can influence perceptions of self and sexuality, include disgust of sex.

SECONDARY VAGINISMUS

Secondary vaginismus is diagnosed when a woman has previously been able to achieve (pain-free) penetration and now is not able to achieve penetration. Secondary vaginismus is often the result of psychological causes and may also include physiological causes.

Secondary vaginismus (and in some cases primary vaginismus) may be the result of:

A fear of losing control, or a sense of powerlessness;

Primary vaginismus may be the result of any number of factors or experiences. These include:

• lack of trust of one’s partner;
• Self-consciousness as a result of body image, or genital image issues;
• Exaggerated expectations or misconceptions of a “normal” sex due to social messages like pornography;
• Denied or unrealised sexuality (being lesbian or asexual) or gender identity (being trans/transman/genderqueer); or
• Fear one’s vagina will be too small (or not long or wide enough) / fear of partner’s penis being too big

WHAT DOES THERAPY FOR VAGINISMUS INVOLVE?

Treatment for vaginismus may include a multi-disciplinary approach incorporating gynecologists and pelvic floor physiotherapists. It is important you have a medical check up with your GP or gynecologist to rule any other possible diagnoses. Pelvic floor physiotherapists are specialist physiotherapist who can assist us in teaching you to manage your pelvic floor muscles.

Therapy for vaginismus will include:

• A comprehensive psychosexual history for you and your relationship;
• Psycho-education and sexual education;
• Development of an understanding of pain;
• Anxiety management;
• Pelvic floor training;
• Relationship therapy;
• Sensate focus and pain free intimacy; and
• Relaxation and sexual mindfulness training.

As part of your therapy you will be given homework exercises to complete in the privacy of your home.

WHAT ARE THE THERAPEUTIC OUTCOMES FOR VAGINISMUS THERAPY?

Through therapy you can expect to achieve:

• Vaginal penetration;
• Pain-free sex play;
• Improved relationship;
• A healthy understanding of your sexuality;
• Anxiety management skills and techniques; and
• Relaxation skills.

VAGINISMUS TREATMENT IN MELBOURNE AND THE MORNINGTON PENINSULA

Sex Life Therapy has two clinics in East Melbourne and Frankston. The team at Sex Life Therapy are all trained and experienced in treating vaginismus. Female and male therapists are available.

References

1. Lamont, J.A., Vaginismus. American Journal of Obstetrics and Gynecology, 1978. 131: p. 633-6.
2. Pacik, P. and J. Cole, When sex seems impossible: Stories of vaginismus & how you can achieve intimacy. 2010, Manchester, New Hampshire: Odyne Publishing.
3. Carrellas, B., Ecstasy is Necessary. 2012, London: Hay House.
4. Braun, V. and C. Kitzinger, The perfectible vagina: Size matters. Culture, Health & Sexuality, 2001. 3(3): p. 263-277.