Decoding vaginismus

You’ve seen a million ads—and spam emails—about how to treat erectile dysfunction. But when was the last time you saw an ad about vaginismus? If you’re like me, never. And what a shame.

Vaginismus is a condition that makes inserting anything—a tampon, a finger, a toy, a penis—into a vagina excruciatingly painful. It’s difficult to estimate its prevalence because it is understudied, underreported and underdiagnosed. But anyone with a vagina can experience vaginismus—trans women, trans men, non-binary people and cis women included.

For folks who grew up being told that sex is bad, sex is shameful and sex hurts, it can be a challenge to recognize vaginal pain as abnormal. It’s also difficult to talk to a doctor about this kind of pain when medical practitioners may dismiss complaints, suggesting instead to  just “relax a little.”

But if you’re experiencing intense vaginal pain, you deserve appropriate medical care.

Dr. Pavan Ananth is an assistant professor of obstetrics and gynecology at Columbia University Medical Center in New York and a gynecologist at New York-Presbyterian Hudson Valley Hospital. Xtra interviewed Ananth about working with LGBTQ2S+ patients experiencing vaginismus.

What’s the technical definition of vaginismus?

Understanding vaginismus requires more nuance than a textbook definition can offer.

With that caveat, the traditional definition of vaginismus is a persistent discomfort with allowing anything into the vaginal canal. The underlying etiology is considered to be an involuntary contraction of the pelvic floor muscles, making it difficult, painful or impossible to insert anything into the vagina. This traditional definition is rooted in societally heteronormative ideals of sex and vaginal penetration, which is problematic.

I’d frame it as pain with any kind of insertion in the vagina. The pain is caused by a muscular reaction of the vulva or vagina in response to a trigger. It can even be anticipatory—meaning the pain can start even before any touch happens. This broader definition allows for the complexity of psychological, interpersonal and physical reasons someone may experience pain.

Other than to address pain, why do patients see you?

Some people come in because they need an annual exam. Others have a specific problem they would like to address, such as abnormal bleeding or hormonal imbalance. Oftentimes, patients have seen many different providers and they just don’t feel like they’re being heard appropriately, or being understood in terms of their issues and goals.

It’s unfortunate, and I think part of it has to do with our poorly structured health care system. If a provider only has 15 minutes with each patient, it’s difficult to investigate complex topics like vaginismus, pelvic pain and painful intercourse—those require more than just a 15 minute conversation. Not everyone has that luxury.

In my office, we have 30 minute new patient appointments and 15 minute follow-up visits. To make sure we have enough time to delve into diagnosis, etiology and management without rushing the process, I schedule multiple visits at the outset.

What happens at a typical appointment?

There’s no standard formula. What people need or want generally guides the visit. Patients who suffer from vaginismus sometimes just come in for a general checkup or for a different concern. I have to create a space where people feel comfortable talking about their sex life, their feelings towards their bodies.

A lot of people don’t come in expecting to have an honest dialogue about intimate, personal issues. Keeping the conversation open-ended allows people to explore topics that otherwise might be uncomfortable, triggering or never previously shared with a provider.

How do you usually open those conversations?

I start with: “Do you have any questions, concerns or anything in particular you want to talk about?” If I’m meeting somebody for the first time, they may just say, “No, I’m here for an annual exam.” As we go through the appointment, I’ll ask more specific questions. For example: “Are there any areas where you feel uncomfortable? Do you have any issues, pain or bleeding with sex? Is there anything else you have questions about?” This allows people to hone in on what’s important to them.

How does pain come up?

Before I ask the patient to undress, I ask if they have any concerns about the pelvic exam. If someone says “I’m really nervous about it,” or “pelvic exams are really difficult for me” then we’ll pause and explore. I’ll ask what in particular makes them nervous and, if they experience pain, whether it only occurs during a speculum exam, or at other times too. We’ll also try to localize the pain: Is the whole vulva sensitive, or is it the vagina? Discussing which sexual positions or activities cause the most pain allows me to understand which anatomical areas are most affected.

Some people dread coming to the gynecologist—exams can be uncomfortable and emotionally distressing, especially for LGBTQ2S+ patients whose discomfort and sexuality have often been invalidated. Before the exam starts, I’ll walk patients through all of the steps, and ask them to let me know if at any point anything is painful or uncomfortable. If they experience physical pain even before touch, that’s another place to pause and unpack what’s going on. A lot of times I’ll say, “I know you came here for an exam, but if you don’t feel comfortable proceeding at this point, we don’t have to cram everything into this visit. We can start with just a conversation.” Frequently, people have a lot to say but don’t feel comfortable saying it. Building a therapeutic relationship can change that.

What do patients typically ask you?

They’ll often say, “I don’t understand why this is happening—is there something wrong with me?” It’s vital to provide validation. You are not broken and it’s not your fault. It’s about shifting the self-blame away and figuring out what happened in the past to cause your body to respond in this way. This allows us to delve into the mind-body relationship and recognize that we’re not just made up of parts. Psychological, emotional or physical trauma can cause an involuntary vaginal muscle contraction. There’s a lot more to it.

The next biggest question is, “Okay, well, how do I fix it?” We have to figure out the root cause to design the appropriate management plan.

Do people bring their partners with them to appointments?

During the pandemic, no, and before, not very often. It’s beneficial to have the initial conversation without a partner present. There’s frequently a lot of guilt and shame associated with vaginismus, so it’s important to have a really frank conversation in a one-on-one setting. A lot of patients come in and say, “This is affecting my relationship, and that’s why I want to address it.” Sometimes it’s not even for their own benefit. They’re concerned about their partner. And sometimes vaginismus is a symptom of issues in a relationship. For example, if someone is in an emotionally unfulfilling or abusive relationship, they may have negative feelings around sex, which can lead to a physical response like vaginismus.

What causes vaginismus?

It’s typically multifactorial. One of the most common causes is trauma, which may be sexual, physical and/or emotional. Any negative feelings around the vagina and vulva can be a factor. Patients will sometimes have a history of sexual abuse, maybe one that they’ve never spoken about or thought they had already processed. After being violated, any act in or around the vagina can be a reminder of powerlessness. Other people may share that they associated their earliest sexual experiences, either alone or with others, with guilt or shame. Some are in toxic relationships or just don’t feel comfortable with their partner. Still more people (including trans men) feel a profound sense of disconnect between their vagina and the rest of their body that causes physical pain.

Underlying medical conditions, including interstitial cystitis, fibromyalgia, endometriosis and vaginal atrophy can contribute to vaginismus. There’s a lot of research that shows any kind of pelvic organ irritation, pain or inflammation can upregulate your nervous system to respond with this kind of vaginal muscular contraction. In other words, as your nervous system gets more sensitive to pain, even things that used to feel like mild touch become painful. We call that pain cycle “central sensitization of pain.”

Sometimes there is no identifiable underlying cause and that can be extremely frustrating  for patients. Usually, though, it’s a pretty complex interplay between all of the factors I just mentioned.

It sounds like this takes a multidisciplinary team—providers to care for both the physical and psychological parts.

Yes. Ideally there’s a multidisciplinary team. An OB/GYN, a counselor and a physical therapist can address vaginismus in a well-rounded way. The OB/GYN typically evaluates for underlying causes and initiates multimodal treatment. We then reach out to other specialists for a holistic approach. There should definitely be a therapist—a psychotherapist, clinical psychologist or sex therapist—to address the psychological aspect. Pelvic floor physical therapy is amazing, too, and is important for long term recovery. Interventions to relax contracted or shortened pelvic floor muscles can help alleviate pain, and can help people learn about and become more comfortable with their anatomy.

Who experiences vaginismus?

Previously, in the scientific community, there was a misperception that only cis women experience vaginismus. Anyone with a vagina can experience it; it’s not about gender, orientation, genitalia at birth or the kind of sex someone has. People across the gender spectrum with vaginas can have vaginismus. Unfortunately, vaginismus is very underreported, so it’s difficult to know how common it is. It’s not studied adequately. Providers or partners often simplify the trauma, conclude that it’s all in people’s heads, or say that vaginal pain is normal. But it is a very real medical problem and should be addressed. Doing that means talking to the patient about their goals.

What kinds of goals do patients have?

Commonly they’ll say, “I want to be able to have sex without having pain.” Part of the conversation should include talking about the definition of sex. There are a lot of different ways to have fulfilling sexual partnerships without vaginal intercourse. If vaginal intercourse is someone’s goal, we’ll work on that, but there are many routes to sexual satisfaction and pleasure without that. Some people just want to understand: “Why do I have this?” That’s where learning more about the person’s history matters.

Others simply want to be able to put in a tampon without feeling so much discomfort.

What specific concerns do queer patients talk about?

Many queer people have experienced shame around sexual pleasure or have suffered sexual violence that is connected to their identity. The idea of even having a vagina can be distressing for some trans, transitioning or gender nonconforming patients. A lot of LGBTQ2S+ people also come in with the expectation that their provider is going to have a heteronormative ideal about what sex is and what vaginal penetration looks like. Sometimes they rephrase their concerns in a way they think will be better understood by a straight audience.

Are there any special considerations for treating vaginismus in a person who’s had vaginoplasty?

It depends on whether we’re talking about experiencing vaginismus during the postoperative healing period, or much later. The dilation associated with post-op care after vaginoplasty is meant to create and maintain the anatomy that the patient wants to have. It can be associated with vaginismus due to the physical trauma during surgery. When vaginismus develops in the postoperative period, it may resolve with healing of the tissue, but sometimes it persists because that physical surgical trauma may have triggered a pain cycle. In a patient who has already gone through the healing process, felt fine with inserting something vaginally, but developed pain later, there should be a conversation about what has changed.

How does hormone replacement therapy (HRT) affect vaginismus?

It depends on the underlying physical causes and the hormone being administered. Taking estrogen can help ameliorate vaginal atrophy. On the other hand, testosterone frequently causes vaginal atrophy, which can be very painful.

If a person taking testosterone wants to maintain the ability to insert something into their vagina, vaginal estrogen can help without causing systemic feminization effects. I typically prescribe estrogen cream—there are different formulations in the U.S. and Canada, but it helps maintain the vaginal tissue in a way that makes penetrative intercourse less painful. 

What are the treatment options for vaginismus?

All treatment should involve education about the body and any underlying causes—physical, emotional, prior trauma, those kinds of things. Pelvic floor physical therapy and psychotherapy can help here. Problems like endometriosis can often be treated with medications and/or surgery.

Generally speaking, vaginal dilators are helpful. Use of a local anesthetic with the dilators breaks the cycle of anticipating and feeling pain. While this can be seen as masking discomfort, it can be really freeing for patients to experience vaginal penetration without physical pain. It can lessen their overall anxiety and provide hope for improvement. 

Usually patients benefit from learning what is pleasurable, understanding what is painful and discovering what kind of feelings they want to have. Experiencing those sensations alone and then teaching a partner how to reproduce them can really change a person’s relationship with their vagina.

What about cases that aren’t tied to a specific root cause?

With primary vaginismus—when there are no underlying physical conditions, there are no emotional challenges, there is no trauma history—neuromodulators like Botox may be helpful. Research is still ongoing, but there are several case reports demonstrating patient satisfaction. The premise of this treatment is that when vaginismus is caused by a prolonged muscle contraction, making that muscle relax relieves the pain. That’s what neuromodulators like Botox do: They are injectable muscle relaxers. Botox only lasts three to four months. But sometimes, having those months of vaginal penetration without pain is enough to break the pain cycle, just like a topical anesthetic breaks the pain cycle with dilators.

But again, the most effective treatment is individualized. If you simply anesthetize the vaginal muscles for someone who’s been a victim of sexual abuse, it’s not going to result in improvement without other concurrent therapies.

At what point during treatment should patients expect to notice improvements?

It’s detrimental for people to think, “I’m going to get an injection and it’ll be better,” or “I’m going to get through this set of dilators and it’s going to be fine.” Vaginismus doesn’t develop overnight, and it’s not going to be managed overnight. But I also offer patients reassurance: Maybe it’s going to take several months or several years, but their goals aren’t unreachable. I assure them we’re going to provide enough support so that they’re not struggling through this alone. That’s also where the partner comes in. If the person is concerned about their sexual relationship with someone else, that partner needs to be on the same page in understanding that there’s no quick fix.

What additional resources do patients find helpful?

There are patient education websites. For example, the American College of Obstetricians and Gynecologists has a patient FAQ about sexual pain. Unfortunately, resources for vaginismus in the medical field are scarce, but finding a support group or connecting with online communities and discovering people with similar stories or experiences can also be really reassuring. Vaginismus is a common problem. It’s just not spoken about very widely, and it’s not researched enough, especially in queer and trans populations. It’s most important for people to see that they’re not totally alone. 

What would you tell folks who are diagnosed with vaginismus and feeling alone?

I hope that people don’t see the standard cisgender, heterosexual representation of vaginismus and feel isolated because that’s not their story. A lot of people have this diagnosis and it can manifest in many different ways. 

What advice do you have for people who aren’t sure how to talk to their doctor about pelvic pain?

Starting a conversation is often hard for people. It’s helpful to be as open and honest as you can going into your exam; share your story and clarify what you hope to achieve from treatment.

Unfortunately, not every health care provider is going to feel comfortable talking about or managing pelvic pain. It does sometimes take a few tries. If one provider isn’t receptive, don’t be discouraged. Try someone else. Sometimes patients tell me they’ve seen three gynecologists already who just told them to relax or go see a therapist. That kind of approach isn’t effective, because treating vaginismus requires a long term commitment from a multidisciplinary team.

If you do find a community where people are having similar experiences and they’ve had positive experiences with a particular provider, seek that person out. You’ll have a better chance of feeling heard and understood, and getting appropriate treatment.

There are people who will be helpful. It sometimes takes a little bit of a journey to find them.

This interview has been edited for length and clarity.