Vaginismus – An Anxiety and Sexual Pain Disorder

A girlfriend called me yesterday saying that two of her friends were unable to achieve intercourse. Full penetration was impossible six months into their marriages. Too much pain was the complaint. While virginity on the wedding day may be rarer these days, some couples do enter marriage with little sexual experience or without having complete sexual intercourse.

For all women, regardless of prior experience, becoming fully sexual is a process rather than an event. Although often a sign of strong religious belief, sometimes a lack of consummating the union indicates other problems. For instance, vaginismus could mean a hesitancy to make a complete commitment or a mask for more serious sexual dysfunctions. One specific sexual problem such a situation could indicate is vaginismus. Vaginismus is a sexual pain disorder which shows as recurrent and persistent involuntary spasms of the outer third of the vagina.  It makes intercourse painful or impossible.

At Awakenings, women with vaginismus have most often been referred by gynecologists after impossible pelvic exams.  Alternatively, if an exam was possible, the patient has told her gynecologist that her marriage is unconsummated even after many months or years. The etiology of vaginismus is often caused by a combination of historical, physical, and emotional problems. It is always caused by anxiety. Culture also appears to play a role. Sometimes, vaginismus has to be differentiated from the natural discomfort of being sexual with someone unknown.  Frequently cultural issues are implicated in vaginismus.  For instance, we see many Middle eastern couples in arranged marriage and fundamental Christians with little sexual education and vaginismus.  Sometimes the cause can be a secondary conditioned response to vestibulitis or dyspareuria and a woman has grit her teeth to “play through the pain”.

Types of Vaginismus

1. Religious prohibition.  Here’s  a fairly benign and straightforward case. A young religious woman came to the center after 6 months of unconsummated marriage accompanied by her disappointed but patient husband. He relayed that there had been one instance prior to marriage of full intercourse.  She had neglected to mention in her initial intake interview. In response to her husband’s revelation, she expressed some doubt and inability to clearly remember the instance.
2. Childhood prohibition. Same case. The young woman could also not remember masturbating as a child but could obtain satisfactory orgasms currently. For several weeks she resisted treatment suggestions by saying there hadn’t been enough time in her week to complete them. As we worked through her resistance, a memory emerged. She had been caught masturbating by an older sister and exposed to her mother who had been very upset. Her religious guilt over the sexual involvement with her husband prior to their wedding seemed to be relieved by her unconscious punishment of herself and her husband by denying intercourse. Within 6 months she had come to a gentle respect for her body and could masturbate. She was able to see her God as wishing her to enjoy her sexual union with her husband regardless of her past.  Returning the next week they had successfully had full penetration three times that week.

1. Sometimes the vagina is wiser than the woman. One wife of an alcoholic husband who had premature ejaculations developed secondary vaginismus. With premature ejaculation and impotence problems, there can be such anxiety that intercourse is rushed and women experience pain due to inadequate lubrication and vasocongestion. While the sexual issues could be resolved, this woman’s vagina seemed to be screaming that her husband was a poor match. Listening to her vagina, the young woman confronted the difficult truth of who she had married. Her vagina had something very important to tell her about her interpersonal relationship.
2. Vaginismus can also represent trauma. Issues which can be analyzed through therapy by understanding dreams and associations. Sometimes repressed memories of sexual trauma, molestation or rape emerge and must be worked through before the following treatment can proceed

Treatment of Vaginismus

1. We take an extensive sexual and family history when treating vaginismus. We listen for the unconscious conflicts and reasons not to have intercourse.
2. We almost always include the spouse in treatment. It’s okay if she comes alone to the early sessions. But vaginismus is  a shared sexual problem.  Successful treatment can often be followed by male impotence as the husband faces his own fears of sexual aggression or entrapment.
3. We address issues of body dissociation by beginning to have women take ownership of their genitals in a number of ways: washing in the shower with their own hands, using a mirror to examine themselves, smelling their underwear to become aware of their changing fragrance throughout their cycle and to counter messages of “dirty” or “stinky”.
4. Vaginal insertion. When the woman feels really ready and safe we, we have her begin to insert her own finger into her vagina in a relaxed bath or after masturbating to orgasm. Sometimes we have the woman buy graduated candles to use as dilators. We nearly always work in tandem with women’s health physical therapists!
5. Relaxing. If acceptable we recommend wine or a prescription of Xanex (a short acting anti-anxiety medication.) Often we send them back to their OB/Gyn for a prescription to insure relaxation.
6. Partner involvement. Gradually, we help them proceed to partner involvement, penetration with partner fingers and penetration with multiple fingers of their partner. We tell them how to identify their G-spot so they can start to enjoy different vaginal sensations before full penile penetration. At each stage we help work through psychological issues as they emerge until intercourse is possible.

Vaginismus absolutely needs the help of sex therapy to be overcome.