‘Sex is difficult and sometimes impossible for me’

Dear Roe,

I’ve had difficulty having penetrative sex in the past, it has always been painful and sometimes impossible – I literally can’t let someone inside me, even if I want to. After some Googling I’m beginning to think I may have vaginismus, but I’m not sure. Can you tell me a bit about it?

Vaginismus is an oft-misunderstood condition that involves the involuntary tightening of the muscles around the vagina, preventing or hindering penetration, and can lead to physical pain as well as frustration and emotional distress.

Vaginismus may be primary (ie lifelong), or secondary (occurring later in life after a period of normal sexual function or penetration.) It also may be global (occurs in all situations and with any attempt at penetration), or situational (occurs in some situations or not others – using tampons or pelvic exams may be possible, but not sexual intercourse, or vice-versa, or it may occur with one partner and not another).

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Vaginismus is considered a psychological condition with physical symptoms, as the muscle contractions don’t occur spontaneously but in anticipation of penetration.

Primary vaginismus is more common in socially conservative or religious countries and cultures where bodily autonomy and sexual pleasure are viewed negatively. South America and Ireland have some of the highest rates of vaginismus, though these numbers are based on reported cases and so don't account for the women still suffering due to their doctors' lack of awareness or understanding.

Secondary vaginismus is commonly attributed to experiencing trauma or sexual violence and this sadly can be the cause for many women. However, this connection can often be overstated, preventing doctors and psychologists from considering other factors. Stress, illness, chemotherapy and menopause can also cause secondary vaginismus. Some medical professionals speculate that in these instances, a feeling of bodily disconnect, discomfort or desexualisation can be at the root of vaginismus.

Self-fulfilment

There is also an element of self-fulfilment to this condition, in that the distress that vaginismus causes can lead to more anxiety around penetration. Vaginismus can be highly frustrating and distressing if not diagnosed and treated. While our culture is becoming more open to discourse around sex and sexuality, many women still base a huge amount of their self-worth in their ability to sexually please their partner and engage in penetrative sex, which is still unfairly valued as the only “real” form of sex, or the most important.

This value system is damaging in many ways, including the fact that it devalues sexual activities between same-sex partners, and it undervalues women’s pleasure, as only 25-30 per cent of women achieve orgasm through penetrative sex.

But it also puts pressure on women to engage in penetrative sex even when it is unpleasant or painful. Women with vaginismus can often try force themselves to endure penetration, causing immense physical pain and emotional distress.

Most doctors will thus suggest a treatment plan that tackles both the physical and psychological aspects. The good news is that for many women, a few months treatment can cure vaginismus.

One of the most common and effective treatments is a combination of sex-positive cognitive therapy to address any underlying psychological issues, and the use of medical dilators. Depending on the severity of the vaginismus, patients will start treatment by inserting a small dilator into their vagina and doing pelvic exercises. These exercises work on two levels, helping to alleviate some of the fear and stress around penetration by gaining a sense of control over penetration, while also practicing relaxing their vaginal muscles. Over a number of weeks or months, patients will increase the size of the dilators until they feel like they can attempt penetrative intercourse, or use tampons comfortably, depending on their particular difficulties.

Emotional intensity

Often, there can be challenges moving from using the dilators to having intercourse with a partner, because of the emotional intensity surrounding sex and the fact that some control is being ceded to another person, which can cause anxiety. It’s important to have a supportive partner who is willing to be patient and take time on developing trust and physical intimacy outside of penetrative sex, so that there is a foundation of trust and safety underlying all sexual encounters.

Injecting Botox into the pelvic muscles as a once-off treatment has also been found to be effective, as it breaks the cycle of anxiety and muscle contraction. This can be used in conjunction with dilation therapy, and is becoming a more common form of treatment in the UK, but as it is a relatively new treatment, be sure to ask your doctor about potential risks.

It's important to note that vaginismus is completely involuntary and is an unwanted, distressing condition. Certain people, such as Republican Todd Akin in the United States, have used vaginismus as a way of victim-blaming survivors of sexual violence, saying that women can intentionally utilise it to prevent penetration. Akin now infamously said "If it's a legitimate rape, the female body has ways to try to shut that whole thing down." This is a false and dangerous assertion that implies that women can always prevent penetration – or that if penetration isn't possible, that they must not want to have sex.

Vaginismus is a condition that prevents women from experiencing a pleasurable and fulfilling sex life, and can cause physical pain and emotional distress. The stigma around it needs to stop, so that women who are affected can seek out help without embarrassment or shame. If you do believe you are suffering, talk to your doctor immediately – and if you don’t find them supportive or knowledgeable, get a new doctor. You have a right to sexual healthcare and sexual pleasure. Don’t let anyone convince you otherwise.

Roe McDermott is a writer and Fulbright Scholar with an MA in Sexuality Studies from San Francisco State University. She’s currently undertaking a PhD in Gendered and Sexual Citizenship at the Open University and Oxford.

If you have a problem or query you would like Roe to answer, you can submit it anonymously at irishtimes.com/dearroe