Vaginismus
is a condition in which the vaginal and
pubococcygeal muscles contract in spasms as
a result of penetration or the possibility
of it.
This is an involuntary fear response which
happens outside of the conscious awareness
of a woman.
Often it can result in
muscular pain as well as great psychological
distress. Vaginismus is a conditioned reflex
and one could also describe it as a sexual
phobia (for example, comparable to other
phobias like someone who has a panic
attack on seeing a spider/dog etc.). It
is a learned response, which can also be
unlearned with behavioral exercises and
physical and psychological self-exploration.
It is not clear how common vaginismus
is, and researchers give different
figures. One estimate puts the rate at 12-17%
of women attending sexual therapy clinics (Leiblum
2001).
How
do you know you have vaginismus?
Vaginismus may or may not be
painful when the spasms occur. However, it
normally makes penetration and genital
intercourse impossible as the man's penis
can not enter the vagina. Quite often strong
fear or an emotional aversion reaction
accompanies the idea of
penetration or any attempt to do so by the
man. Women with vaginismus sometimes
have irrational ideas about sexual anatomy
like "my vagina is too small" or that
"penetration must hurt". They will often
struggle to use tampons or attend
gynecological examinations as well as have
genital intercourse.
Causes of
vaginismus
The practical cause of
vaginismus are the involuntary muscles
spasms. Why some women develop this
response is, however, far from clear.
Vaginismus is classified as "primary" or "secondary". In
primary vaginismus a woman has never
experienced vaginal penetration, whereas in
secondary vaginismus, the problem has only
appeared later on.
There is no single
factor which causes vaginismus and it may
be caused by more than one factor.
Vaginismus may be due to
irrational fears, poor sexual health
education, sexual abuse or unsatisfactory
first sexual experiences, medical problems
such as infections, fear of pregnancy or
illness, or any other conditions which may
have caused genital pain in the past (see
dyspareunia), including child birth. Other
factors can be problems in the relationship,
religious orthodoxy, sexual inhibition,
rape, or an upbringing which taught a child
that sex was bad, dangerous or shameful.
Some women develop vaginismus out of a fear
of getting pregnant. There may also be deeper psychological
factors involved such as a general fear of
loss of control or a fear of intimacy.
As
you can see, although vaginismus
looks like a simple muscular
reflex, it's actually a complex psychological
condition which can involve irrational
cognitive beliefs, difficult childhood
memories, the state of a woman's current psychological
equilibrium and defenses, as well as the
attitude of her partner, who may or may not be sympathetic
to the problem.
Vaginismus also often
becomes a self-reinforcing negative feedback
loop similar to erectile dysfunction in men.
The physical and psychological stress
created by attempts at penetration will
result in pain and anxiety, which will then
reinforce the woman's negative beliefs about sex and
create an anticipatory anxiety about
penetration. Next time penetration is
attempted a woman may experience even more
anxiety about it, which will trigger the
spasms more quickly.
Vaginismus
and relationships
Vaginismus may or may not be
a problem in a relationship. Some women with
vaginismus have an active and exciting sex
life, which may include a broad range of
sexual experiences. Women with vaginismus
may not have difficulties getting aroused,
lubricating or having orgasms. Of course,
this raises the issue of whether women need
to be able to achieve genital intercourse
and
whether they can be happy and sexually
fulfilled
without it. Another factor in this may be
whether the couple engages in plenty of
non-sexual touching, which is important for
bonding and for giving and receiving
physical pleasure and comfort.
However, vaginismus often
occurs together with sexual inhibitions and
anxieties. Some women may avoid sexual
relationships altogether as their vaginal
spasms and fears about sexuality seem too
difficult to face. In this case a woman may
have developed vaginismus and
may not be interested in a more active sex
life; or she may wish to confront it
to be able to conceive a child naturally; or
it may her partner who pushes for a more
active sex life.
In all of these scenarios it
is important to consider the partner in
relationship with a woman with vaginismus,
if there is one. Vaginismus may not be an
issue in a lesbian relationship, but quite
often it's a difficult problem for a male
partner. Men react to vaginismus in
different ways, such as feeling rejected or
by developing erectile dysfunction
themselves to avoid the issue completely.
They are often supportive, sometimes angry,
confused and disappointed. When
treating the vaginismus of a woman who is in
a relationship it is important that the
partner is included to some extent in the
treatment. Not being able to achieve genital
intercourse will potentially have a big
impact on the relationship. Vaginismus may
also serve a function in the relationship,
such as avoiding intimacy, and that
certainly needs to be
attended to.
Treatment
of vaginismus
Success rates given for
treatment of vaginismus are very varied. Some authors
suggest a 100% success rate if women persists
with the behavioral programs, others are
less positive. However, I think it is key
for a woman to not only stick with the
behavioral exercises but also to want to
have sex for her own pleasure, and to let
herself develop sexually. Any barriers may
need to be looked at in individual
psychotherapy.
First, women with
vaginismus should consult a gynecologist to
rule out any physical complications such as
infections, STDs, etc. You may want to seek
out a doctor whom you can trust and who
you feel will be sympathetic towards any
fears about the examination you might have.
Second, quite often women
with vaginismus need to learn more about
sexual
anatomy, their
own sexual functioning, and
the mechanics
of sex, as well as about contraception
and how to protect themselves from sexually
transmitted diseases. Misinformation may
contribute to irrational beliefs like
"my
vagina is too small". In fact the vagina is
only a potential space which is collapsed
when not in use. However, when sexually
active the vagina acts as a powerful
muscular organ which stretches easily to
accommodate the penis. Sex education may
also encourage women to feel in conscious control of
their vaginas rather than "guarding" them
unconsciously with vaginismus.
Third, learning a
relaxation exercise will be useful to
control anxiety, for example autogenic
training. Anxiety is a whole body
response. It increases your heart rate,
breathing rhythm and muscle tension. The
opposite is a state of relaxation during
which your heart rate is slow and
comfortable, you are breathing deeply and
slowly and your muscles are relaxed. This is
the state we are in when we feel safe and
comfortable. For sex to work, one needs to be
relaxed so as to be able to attend to one's
bodily sensations and feelings of arousal.
Developing your ability to physically relax
and let go as well as to stay with your body
and feel comfortable with your physical
sensations will greatly aid a behavioral
program for vaginismus and help your own sexual
development.
Fourth, women
need to be
encouraged to explore their own sexual
anatomy. You may have to overcome your inhibitions to do so. However, this is an
excellent way of "owning" your own anatomy and
feeling in control of your sexuality. It's a
good idea to use a lubricant for self-exploration such as KY
Jelly or Senselle (water
based),
or alternatively an oily lube such as massage
oil. However, anything with oil in it will
quickly destroy a condom. It's important that
if you try this, you learn to enjoy self-exploration
- or at least
feel relaxed during it.
The fifth step involves a
behavioral program using vaginal trainers
of increasing sizes. A vaginal trainer is a
pen-like piece of plastic with rounded ends
and a smooth surface, like a miniature
plastic penis or dildo. Normally, they are
sold in sets of increasing sizes.
Originally, the trainers were often called
dilators, but this term is simply wrong. The vagina does not need to
be stretched or dilated when a woman
experiences vaginismus. Indeed, the vagina is always
big enough to accommodate fingers, a penis
or a vaginal trainer. However, in
vaginismus the vaginal muscles contract
involuntarily, so a woman needs to train
herself to relax and not fear an object
entering her vagina. As she inserts the
trainer into her vagina, a woman can be in complete control
of insertion and can experiment with
relaxing her body. This can be done step by
step with different sizes. The training
objects can also be her own fingers (with
short finger nails!) or tampons. Vaginal
trainers such as Amielle vaginal trainers,
Hegar or Simms can be bought via the
internet (a quick search on Google will
uncover suppliers). To repeat, it is
important that women feel in control of
their training and their vaginas! It's best
to use plenty
of lubricant.
In some women with vaginismus the reflexive
contracting of the pubococcygeal (PC)
muscles is so strong that it is not possible
for them to introduce a trainer into their
vagina, making an immediate move to step 5
impossible. If your vaginismus is so
strong that you are not able to insert a
vaginal trainer or your finger into your
vagina, we strongly recommend that you seek
help from a qualified psychosexual
psychotherapist.
Additionally,
you will need to learn how to control your
pubococcygeal muscles prior to using a
trainer through the
Kegel exercises. The Kegel exercises
teach people how to strengthen and relax
their PC muscles through conscious control.
This can help with vaginismus because strong
muscle contractions are actually very hard
for the body to keep up. Once you know how
to contract your PC muscles voluntarily, you
can then contract them on purpose really
hard when you feel an unconscious
contraction through vaginismus coming on.
Keep up your conscious contraction of the PC
muscles for as long as you can, but at some
point your muscles will relax, because they
can't keep up the pressure forever, which
means they relax at some point.
One way of using this effect is to learn the
Kegel exercises and then to try and very
gently insert a trainer or finger into the
vaginal opening, or bring it close to it.
When you feel the spasms occurring, stop,
and consciously clamp your PC muscles as
much as you can until you can feel them
begin to relax, because they have run out of
strength. You will find that you cannot
consciously clamp for too long and the
muscle spasm will ease. Keep repeating this
over and over without moving your finger or
the trainer until you feel more relaxed in
your whole body. Keep remembering to apply
what you have learned from the relaxation
exercise and watch your breathing and
overall body tension. Breathe out deeply
each time you find yourself getting tense or
holding your breath. As you begin to trust
that your PC muscles will eventually relax,
you can insert your finger a little further
each time, and each time the muscles spasm
sets in, clamp down your PC muscles
consciously, and so on. This type of slow,
graded progress needs a lot of patience and
commitment, but it should work. Please be
proud of every little bit of progress you
make, or even simply for taking the time and
making the effort to do the exercises over
and over again. Over time you will learn to
control these muscles better and better and
the spasms should ease all together.
Finally, a couple can
attempt penetration, however this should
first be attempted whilst giving the woman
full control. This is easiest through a woman
on top or side
by side sexual position. Now it also
becomes important how a couple communicates
about sex and whether the woman can say
what she would like sexually. It is a lot
easier to feel safe during sex if you can
say "no" or give clear directions about what
you would like! Finally, a woman can
experiment with giving up more and more
control to her partner, but still directing
him (as with all good sex) verbally.
The treatment of vaginismus
can be seen as a woman developing and owning
her own sexuality and feeling in conscious
control of it. This also includes the fact
that she may not wish to have genital
intercourse even if she can do so! Being able to say
"no" when you
don't feel like it is essential to being
able to say "yes" when you do.
Vaginismus may be a
difficult and trying condition for a male
partner and requires considerable patience
and understanding. It is important that you
and your partner
look at the whole of your sex life and
relationship and develop it together as much
as possible, especially focusing on your ability to talk
to each other. A great resource for men
is the following book: Bernie Zilbergeld,
1999, The New Male Sexuality, new revised
edition. The partner can contribute a
lot to the treatment of vaginismus by being
supportive and honest about the impact
of the condition on him. Partners can be
included in the dilator exercises if the
woman is ready to give up some control and
experiment.
Finally, if you or your
partner experiences vaginismus and
the description above does not sound clear,
helpful, or useful, please do consult a
qualified sex therapist in your area or
research the condition more thoroughly on
the internet. Vaginismus can be cured,
easily and quickly, but a host of other
psychological issues may be involved too and
may need your attention.
References:
Tomlinson, J. (1999) ABC of
Sexual Health. BMJ Books
Leiblum, S. (2001)
Vaginismus. A Most Perplexing Problem. In
Leiblum and Rosen (eds.) Principles and
Practice of sex therapy. 3rd edition,
Guilford Press.
