Vaginismus is an often under-discussed and misunderstood condition. Quite simply, the condition causes pain in women and other people with vaginal tissue whenever vaginal penetration is attempted. Though the numbers are far from precise, globally, the condition is estimated to affect 1% to 7% of people with vaginal tissue.
Beyond physical pain, vaginismus can cause shame, anxiety, and relationship challenges for those who deal with it. One reason why is that they often lack a clear understanding of its origins or how to resolve it. Unfortunately, the condition is just as poorly understood even among medical professionals, which has resulted in many challenges for people who seek treatment—or even being physically and emotionally traumatized by their providers.
Fortunately, there are options for those struggling with this condition, as well as cultural shifts that point toward better treatment.
With an eye on present-day progress and solutions, TheBodyPro spoke to researcher Maria McEvoy, Ph.D., of Ireland’s Waterford Institute of Technology, about the causes of vaginismus, how some patients have been affected by the condition, and available treatment options.
Rosen Pitman-Wallace: Can you tell me a bit about your background?
Maria McEvoy, Ph.D.: I am a psychology lecturer. About seven years ago I started studying vaginismus for a Ph.D., and it was the first time it had been studied in Ireland in 40 years, so I thought it was about time we got some new information. I’m interested primarily in the sociocultural elements of vaginismus.
Diagnosing Vaginismus
Pitman-Wallace: How do you define vaginismus?
McEvoy: Vaginismus, I say, is the experience of not being able to have penetrative sex. In textbooks, it will often be defined as a physical spasm, but I’m trying to push us away from that. In my view, that’s a symptom, but that’s not actually what it is. Some writers have talked about vaginismus as being a phobia of penetrative sex, for example.
There are two types of vaginismus, a primary type and a secondary type. If you have the secondary type, you have been able to have penetrative sex and, possibly, very pleasurable penetrative sex previously, but then something has happened. For example, a traumatic [Pap] smear test or a traumatic childbirth, which then starts a vicious cycle of pain and tightness, which makes sex increasingly difficult. On the other hand, the primary type of vaginismus is where the person has never been able to tolerate any type of penetration, so not just sex, but things like using tampons or getting a smear test are also impossible. So while, as I said, some writers have described it as a phobia of penetrative sex, it’s often wider than that as well.
Pitman-Wallace: What are some of the problems with classifying or diagnosing vaginismus?
McEvoy: I think the emphasis on the physical aspects is the wrong emphasis. When women go to doctors, they’re usually told it’s something physically wrong with you, and [the doctors] will insist on making a diagnosis using an internal exam. For a woman with vaginismus, that is very anxiety-provoking. It may even be impossible and will often make the problem worse. So one needs to ask, why is the person having this difficulty? If we look at the physical spasm associated with vaginismus, it’s not something a person can do consciously―it’s totally unconscious.
In the last study [on vaginismus] in Ireland, 40 years ago, the psychiatrist doing the research highlighted the very strict Catholic culture in Ireland at that time, which was very sex-negative. I looked internationally when I was doing my research, and it turns out it doesn’t matter much what the particular religion is, but across the world it is more prevalent in countries with very strict, sex-negative interpretations of religion. Then there’s how it’s reinforced in the family, because of course everyone in a given society is growing up with those same wider cultural messages, but not all develop vaginismus.
It seems to be particularly common in families where it’s strongly reinforced that a sexual relationship, and especially an extramarital sexual relationship, will bring shame on the family, and you’ll get pregnant and ruin your life. On the individual level, it’s often associated with overall high anxiety. I often think of vaginismus as a protective wall that the person has unconsciously set up, so we need to examine why that wall has been put up.
Pitman-Wallace: Are there any myths about vaginismus you’d like to debunk?
McEvoy: There is a myth that vaginismus is always caused by sexual abuse, and doctors often say this to patients. That can be really damaging and disturbing for patients, especially because they may start to question whether there’s something they’ve repressed in their past. I looked at 50 years of research for my Ph.D., and I found that sexual abuse is very far down the list of causes for vaginismus. There really isn’t a definite link, so professionals shouldn’t suggest that at first―they should listen to the patient and hear their story.
There’s also a common idea that it’s to do with a problem with a specific partner or relationship. People whose partners have vaginismus often blame themselves and wonder if their partner isn’t attracted to them, or if they’re doing something wrong. But usually the person with vaginismus had those issues around sex and intimacy [before] the relationship, so it’s not about the specific partner at all. The partner can actually be very helpful in navigating treatment.
There’s another myth about vaginismus―that if a woman can’t have penetrative sex, she can’t have any kind of sex life. But actually, a lot of the couples I spoke to had very fulfilling and intimate sex lives, just without penetrative sex.
Treating Vaginismus―With Compassion
Pitman-Wallace: So, are there treatment options for people who have vaginismus?
McEvoy: In my research, I interviewed a lot of different professionals that work with vaginismus and talked to them about treatments and causes, and I also talked to couples. There hadn’t actually been a study before which had included couples together, so that was new. I was very interested in asking couples what had worked for them and what hadn’t worked for them.
What’s offered primarily is the physical treatment, so you get a diagnosis where providers try to do a physical exam, and then when a physical exam isn’t possible, patients will be referred to a gynecologist. And a lot of these people have had quite traumatic experiences with gynecology, where for example they were put under anesthetic and artificially stretched―which was very painful and very traumatic. [Artificially stretching the vagina under anesthetic means pushing the walls open when they are not relaxed, in order to perform the internal exam.]
And then patients are told, “There’s nothing physically wrong with you, so just go home and have sex,” basically. [So patients leave with] very little aftercare, very little advice at all, and then they go home and feel like failures and feel ashamed. And, often, the problem gets worse. So that kind of treatment, if you can call it [treatment], seems to actually make vaginismus worse. It actually traumatizes the person more. And there [hasn’t been] a lot of treatment other than that. Some people I've spoken to also reported that medical professionals have been unsympathetic, even unkind, and view [their patients] as difficult or obstructive when they couldn’t perform a physical exam.
On the other hand, many of the people I spoke to had very positive experiences with physiotherapists. While this is a kind of physical therapy, those appointments usually lasted half an hour or longer, and patients would often be allowed to bring their partner along. So there would be a lot more listening and time taken to understand their experiences. And usually physiotherapists would have a more holistic, multidisciplinary approach than gynecologists or primary care providers and [would also] refer on to psychotherapists if they felt there was a need for that.
Now, some of the women I spoke to had good experiences with psychotherapists, and some were not so good. The ones that had not-so-good experiences were usually with general therapists, who weren’t trained in sex therapy or couples therapy specifically, so they didn’t have the skills to discuss these issues appropriately. They would often refuse to include the partners in therapy, because they didn’t see why the partner had any role to play in the therapy. A specialized therapist will look at vaginismus differently, in terms of, yes, it has a physical aspect, but it also has a psychological aspect.
Some people found things like dilators very helpful, and some didn’t, but if you get dilators, I think it’s really important to have support. A lot of women are advised by their primary care provider to order one from the internet. But if you order them from the internet, people sometimes try to force them in and go too quickly and can physically and emotionally traumatize themselves further. Whereas if you have a therapist who can talk it through with you—and talk about ways to alleviate anxiety, or talk to them if you have trouble—and give you emotional support, then you can progress with dilators. I've met some couples who overcame vaginismus themselves, without a professional, but they were couples who usually had very good levels of communication and a very high level of intimacy, so those resources were there in the relationship.
Not everyone has to go to therapy. Some couples can resolve it themselves if they have a certain level of insight and communication, but there’s really no one size fits all.
Pitman-Wallace: Do you have any advice for someone who is seeking treatment for vaginismus and is hoping to avoid some of the more negative or traumatic treatment experiences?
McEvoy: Find someone who is properly qualified, ideally in psychosexual therapy and in couples therapy. During the therapy process, good communication with the partner is very important, and, usually, properly qualified therapists will include the partner in the therapy. The other thing is to look for a therapist who you have a good relationship with, that you have a rapport with, because not everyone will click with every therapist. You need to be really comfortable with them, because these are very intimate things to explore, and often it will include painful things about the family of origin and messages which can be really tough to unpack.
When Possible, It's Important to Process the Root of Vaginismus
Pitman-Wallace: What about physical treatment options, such as Botox?
McEvoy: There are some people that say this worked for them, and I’m delighted to hear that. But I spoke to physiotherapists and therapists about this, and one of the issues with Botox is you can’t localize it, so you can end up with incontinence and things like that as it spreads to that whole area. The other issue is that you’re breaking down that unconscious protective wall artificially, but you’re not asking why the person needed that wall in the first place, and if you take that away from them, [it ignores whether] they are putting up with unpleasurable penetrative sex just to please a partner?
If a person has vaginismus, there is a reason for it, and I think [using Botox] misses an opportunity to find that reason so they can resolve it forever. If you use something like Botox, I think you’re not dealing with the problem, you’re just navigating around it. Having said that, though, therapy is difficult, and not everyone can access it, so I understand wanting to find other solutions and other options. If you can find the right therapy, I think it is very worthwhile. For example, I spoke to a couple who had resolved vaginismus with a therapist, and after childbirth, some of the problems came back. But using the skills they learned in therapy, they were able to resolve it again. So it gives you life skills and relationship skills to have a happy and pleasurable sex life.
Pitman-Wallace: Why do you think there is so much shame and anxiety around not being able to have penetrative sex?
McEvoy: Well, it’s to do with a pressure to have children, because historically a woman’s value has always been tied to her ability to have children and give her husband an heir. In many sexually conservative cultures, there’s very high rates of anorgasmia―the persistent difficulty or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress―and women not enjoying sex. But they’re not going to sexual clinics for those problems. They’re going for vaginismus because vaginismus prevents them from having children. So it’s not culturally prioritized whether a woman feels pleasure from having sex, whether she enjoys it, but it is very culturally concerning if she cannot procreate.
Pitman-Wallace: Do you think that more sex-positive sex education can help reduce vaginismus in future generations?
McEvoy: Yes. I think if you’re not getting those sex-positive messages at home, it would be great if you at least got them in school, to at least have a different perspective. But, obviously, in many more conservative places, sex education is banned outright, or people are trying to ban it. Information is a right for everybody, and everyone deserves access to accurate, non-stigmatizing information about sex. It would be great if sexual dysfunctions like vaginismus could be included in sex education. I think that would help a lot of people.