A pretty lady appeared on my television screen, talking about "your honey." I was momentarily confused. Was this some sort of new ad for organic honey? Was it about beekeeping?
Nope. It was just another ad for Viagra, which is advertised widely—during the Super Bowl, on a coffee mug on a boss's desk. Former senator and U.S. presidential candidate Bob Dole endorses the erectile dysfunction drug. It's a medication that has entered the mainstream consciousness, and although the conversation isn't totally transparent—as the linked article states, the references to erectile dysfunction in commercials for Viagra aren't always direct—the conversation is there.
So, what do we talk about when we talk about erectile dysfunction's female equivalent, vaginismus?
Connie Lappa, M.S.W., L.C.S.W., has been working as a sex therapist since 1990, and although she's seen many cases of vaginismus, she reports that the condition is not brought up frequently among her patients, or even studied very much by professionals—even though vaginismus has a serious physical and emotional impact on women, much like the effect erectile dysfunction has on men.
"I have rarely read any mainstream articles about it," she said. "I think it is a reflection of our culture's shame over sexuality despite sex being all over the media, and in particular, women's sexuality. We can have ads for Viagra, but when the makers of Zestra—a female arousal oil—tried to put a commercial on TV, they were met with resistance in being explicit about its function."
Vaginismus is a specific kind of sexual dysfunction: it's a condition that makes the muscles of the pelvic floor tighten, preventing a woman from having vaginal intercourse, or having other objects placed inside her vagina, such as a tampon or a speculum during a pelvic exam. Many people describe the condition as being similar to when you reflexively close your eyelids when an object gets too close to your eyes.
The muscles that tighten are the pubococcygeus (PC) muscles, and in some cases the levator ani muscles (the group of muscles that includes the PC muscles), and even thigh and stomach muscles connected to the pelvic floor. Lappa said that a physical therapist can conduct an exam, and from that exam may be able to tell which muscles are involved in each case.
According to the Society of Obstetricians and Gynaecologists of Canada, vaginismus can occur in a few different scenarios:
Vaginismus may be primary (i.e. lifelong), or secondary (occurring after a period of normal sexual function). It may also be global (occurs in all situations and with any object) or situational (may only occur in certain situations, such as with one partner but not others, or with sexual intercourse but not with tampons or pelvic exams or vice versa).
Because a woman needs a pelvic exam to be diagnosed, it is not easy to calculate how common vaginismus is. Lappa said that she "lean[s] toward a prevalence rate quoted as 5-17% in clinical settings."
The causes of vaginismus remain vague: there's not one specific reason behind it, and it's not caused by the vagina being "too small" for intercourse, as women with the condition sometimes believe. According to Lappa, it's often a bodily response to fear or anxiety: women experiencing vaginismus may have recently undergone treatment for a painful yeast infection, or had a particularly painful pelvic exam, for example.
Talli Y. Rosenbaum, a physical therapist and sex therapist, writes in a 2013 article that "pain and anxiety are understood to be salient and interactive components of…vaginismus […] Pelvic floor dysfunction is not simply an isolated mechanical condition, but may be a physical expression of an emotional state." (The article also cites conditions like endometriosis or irritable bowel syndrome, which may also lead to a tightening of the pelvic floor muscles.)
Abuse is also a common complicating factor: A 2009 study conducted by Leclerc et al. looked at the prevalence of abuse in women who were diagnosed with dyspareunia, a term that refers to painful intercourse (it doesn't always overlap with vaginismus, but can lead to the condition). The study concluded that about 60 percent of women experiencing dyspareunia had a history of sexual abuse. Any negative association with penetration may contribute to the condition; for example, a woman who is told that having vaginal intercourse for the first time is painful may tighten her muscles during sex, and it "becomes a self-fulfilling prophecy."
"There is an association for some women with any type of penetration," Lappa said. "Insertion of contacts, dental work, blood draws, etc. In that case it may have something to do with fear of [losing] their body integrity. For religious women who have been taught that they are the gatekeepers of their virginity, and that they are sinful to allow penetration, they may have been unconsciously guarding for awhile and have developed high muscle tone as a result. It can be difficult to flip the switch after they marry and let their body open up."
Christine had never heard of vaginismus before she was diagnosed with it.
"I found out that I had vaginismus on my wedding night, the first time I had ever tried to have sex—but I first began to suspect that something was up the first time that I tried to use a tampon, several years earlier," she said.
"I did eventually figure it out, but putting [the tampon] in and taking it out was such an ordeal that I rarely used them—we're talking maybe one every two years. When I was diagnosed, suddenly I felt so much relief. I wasn't broken, and this experience that I was having was a legitimate problem for other women, too. And finding out that there was a high rate of successful treatment really helped to motivate me to move forward."
The types and lengths of treatment are different for every woman. Components of treatment can include vaginal dilators (also known as vaginal trainers) to help the woman "gain control of the pelvic floor"—not, as is sometimes assumed, to stretch the vaginal opening or the tissues within the vagina.
Other kinds of treatment include physical therapy and/or meeting with a sex therapist.
"I address beliefs about sexuality, what it means to them personally, and help them with understanding and expressing their sexual needs," Lappa said. "I also [give the client] psychoeducation about vaginismus and sexual anatomy and response. I structure a plan for treatment with the client. That includes relaxation, mindfulness, [and] often physical therapy—I coordinate care with [the physical therapists];—non-penetrative sexual touching and pleasure exercises, gradual use of dilators, [and] integration of their partner. Once intercourse is occurring, I continue to meet [with the client] and assess progress and work out any issues until the client feels ready to terminate."
For women who have been sexually abused, Lappa said that she works on treating the trauma that the women experienced before she works on treating vaginismus. "I educate them about the psychological effects of abuse, including PTSD, [and] help them process their fear, anger, shame, grief, etc. We examine how they coped, their strengths, and move through the healing process. Once we have progressed through that, then we start to address how it affected them sexually."
"I usually suggest that they stop being sexual during the process as it can be more traumatizing," Lappa said. "Then we work on creating a new meaning for sex, learn about setting boundaries, and very gradually introduce non-sexual touch and then progress to more sexual experiences."
After this step, Lappa said, clients with a history of sexual abuse are also taught mindfulness and relaxation techniques. "[The clients] work on positive associations with touch and sexual activity. I have them use dilators with them being completely in control and at their own pace, and eventually integrate their partner."
When a client is diagnosed with vaginismus because of other painful experiences, like having a catheter inserted or sustaining pelvic injuries—which she sees "fairly often" amongst her clients—Lappa said that "treatment is similar except for not needing to process the sexual abuse."
Vaginismus is highly treatable. Christine underwent treatment for four months and said that "because my treatment process was relatively short and the dilators worked for me, I can't really think of anything [about treatment] that was unhelpful. But besides the physical retraining, I think the most helpful part was being able to talk about it, to know that I wasn't some sort of physical freak."
Because of the complicated and heightened importance placed on female sexuality within today's culture, women with vaginismus often say they feel alienated or inadequate.
"Woman often say they feel that sex is easy for everyone else and feel less of a woman," says Lappa. "It affects their self-esteem. The message that women are to be sexually pleasing to men first and that their needs are secondary is still promoted in the media and in our culture in general. Therapy always includes women assessing and asserting their own needs and promoting their self-esteem." For clients struggling with this, she recommends some reading: the book Sex Matters for Women.
But the diagnosis of vaginismus may help a woman's view of sex shift—for example, the realization that sex is not the summation of romantic relationships, or that understanding their sexual needs is vital.
"Many women come out of treatment with a more holistic view of sex and a much better understanding of their sexuality and how to express their sexual desires," Lappa said.
As for Christine, she offered women who have vaginismus these words of encouragement: "I would advise women with this condition to seek the help of a sex therapist or some other medical professional," she said. "Don't get discouraged. Stay the course with your treatment; improvement comes slowly."
Faith Cotter is an award-winning writer and editor based in Pittsburgh, PA. Her background includes working as an investigative reporter for The Innocence Institute of Point Park University, and an internship with the Pittsburgh Post-Gazette. She is currently working toward a Master of Arts in Professional Writing from Chatham University. As an author, she published Paper Dragons and Clara: A Short Story this past summer, and writes about reproductive health for her blog series, Miss Informed. She can be reached by email at email@example.com, or via her website.
Illustration by Jim Cooke.