Ayden Ferstenberg, Psy.D.
Let's talk about vaginismus
People talk about sex—maybe not always publicly and in loud voices, sometimes just in whispers or in private chats between friends—but people talk about sex. And people hold sex up to be a pinnacle of pleasure, something so mind blowing, explosively satisfying that obviously everyone wants it all the time. Right? Wrong. Sometimes sex isn’t amazing (which actually isn’t a bad thing, see more about this here). And sometimes, not only is it not amazing, but it hurts.
Painful sex can be caused by a number of things, but today we’re going to talk about one of the common causes of painful sex: vaginismus.
Vaginismus (sometimes called hypertonic pelvic floor disorder) is when the large muscles around the vaginal opening involuntarily spasm or tighten when something is inserted, making intercourse difficult or impossible. Vaginismus can be primary, or lifelong, where it has been present your entire life, or it can be secondary, or acquired, where you develop vaginismus after a period of time of normal functioning. For people with lifelong vaginismus, these muscle spasms often interfere with using a tampon or receiving an annual gynecological exam, in addition to making vaginal intercourse painful. For people with acquired vaginismus, it’s possible you had typical functioning and a healthy sex life at some point, but then something changed and made all forms of vaginal insertion very difficult and painful.
Various factors can exacerbate the distress associated with vaginismus. Some examples include:
Many people experience a lot of shame associated with vaginismus. Some people believe there is something fundamentally wrong with them if they struggle with intercourse, which is often (wrongly!) portrayed in pop-culture as something intuitive, spontaneous, and easy. Because of this, many people struggle with this issue for a long time before they decide to seek help.
Sex is supposed to hurt.
This may sometimes be seen as a truth some women have to accept. But the truth is, sex isn’t supposed to hurt. In fact, sex can, and should be, something quite pleasurable! If believe that sex hurts, you may expect pain during intercourse and might even notice your body tense up as you think about this prospect. This is a natural physiological reaction to pain—when we expect pain, we tense our bodies to prepare for it. Think about getting a shot—it’s normal to feel yourself tense as you prepare for the momentary pain, even if you’re not actually anxious about the injection. Buying into the myth that sex is supposed to hurt can create or exacerbate pain in a situation where it doesn’t need to exist.
Another consequence of the belief that sex is supposed to hurt is it makes it much less likely that you’ll seek help for this very treatable problem, instead, believing that this is normal or that everyone deals with this.
Limited or inaccurate knowledge
It is not uncommon for people to have partial or inaccurate information about sex. One example relates to the hymen. Many women have been taught to think about the hymen as something that “breaks” during a woman’s first intercourse. The image of the hymen as a physical barrier that must be “broken” often elicits scary images and fear of tearing, blood, and pain. While it is possible to bleed with your first intercourse, the hymen is actually a thin, flexible piece of tissue by the opening of the vagina that stretches during penetration. Think of it as widening, rather than tearing. Sometimes, inaccurate ways of thinking about vaginal penetration contribute to anticipated fears about what to expect. Similarly, a lack of information about what to expect allows for the possibility of your mind to run wild—and since our minds are story-machines, they love to fill in our gaps of knowledge and areas of uncertainty with narratives that might not actually be true and can even be quite scary or horrifying. Correcting these misconceptions through appropriate education is an important part of treating vaginismus.
If penetration is painful due to these involuntary muscle spasms, it is natural that you would start feeling anxious at the prospect of intercourse. This anxiety then makes you hypervigilant to signs of pain, further tenses your body, and makes it more likely that you’ll notice any discomfort and label it as "pain". Much of this cycle is further influenced by the narratives you then tell about yourself, even in your own mind. For example, it is not uncommon to have thoughts such as: “This is going to really hurt me, I won’t be able to handle it”, “There’s something wrong with me”, or “This will never get better". These types of thoughts make it more likely that you’ll pay attention to discomfort, keep your focus on the pain, and may impact your expectations. In such a way, any pain produces many fears and cognitions about pain and your ability to handle it, which often makes the pain worse. This often leads to people avoiding intercourse (or any other forms of sex that feel too similar to intercourse) altogether. While avoiding intercourse might make you feel better in the moment—after all, you’re avoiding the pain—you’re also denying yourself the possibility of finding the pleasure in sex.
Painful sex is not a personal problem or a personal fault. Relationship dynamics significantly contribute to the effects of vaginismus in a few meaningful ways. First, partners can be solicitous, negative, or facilitative in their reactions to your pain. If they are solicitous, or that are concerned, they may completely halt sexual contact and avoid engagement due to fear or causing pain for their partner. Perhaps, similar to your own avoidance of sex, this type of partner avoidance prevents sexual creativity and opportunities for sexual connection. A negative reaction is when a partner shames, criticizes, blames, or reacts with other types of hostility in response to the difficult penetration. This type of reaction is often associated with increased pain and reduced satisfaction with the relationship. A facilitative partner is someone who is sensitive, validating, and respectful of the pain, while simultaneously encouraging and reinforcing efforts to have sex. This type of response is the most helpful and important in managing vaginismus.
A second way relationship dynamics can exacerbate distress associated with vaginismus is when the pain associated with vaginal intercourse becomes associated with all forms of sexual contact. When this happens, often all forms of physical touch or indications of intimacy are then avoided for fear of it leading to intercourse. For example, if when your partner starts to rub your back, you start thinking, “Oh no, he's rubbing my back. That means he’s going to expect sex, but that hurts too much. I better stop him before this gets out of control,” you may pull away or get irritated at your partner for expecting something of you that they know is painful. This type of story that your mind tells you may become the narrative that plays out in much of the relationship, which prevents other forms of intimacy and sensuality that aren’t painful. This can then significantly effect the relationship.
What do I do now?
If you struggle with difficulty or pain around penetration, it’s possible you have vaginismus. The good news is vaginismus is easily treated, usually in collaboration between a few different expert providers. The diagnosis of vaginismus requires a pelvic exam where a medical provider can assess the muscles surrounding the vaginal opening. Once diagnosed, vaginismus can be treated through the use of dilators (cylinder rods of varying sizes that you systematically insert in your vagina to progressively stretch out the vaginal muscles; with time, this allows for comfortable vaginal penetration) and psychotherapy. Psychotherapy will provide you with education and discrete skills to help you manage the pain, as well as help you process and navigate personal and interpersonal feelings of distress associated with this problem. Whether you’re partnered or not, treating vaginismus gives your greater autonomy over your body and opens the door for the possibility of personal sexual pleasure, as well as opportunities for greater intimacy and connection in relationships.
If you’re struggling with vaginismus, reach out today to schedule a consultation.