21-year-old Staci and 23-year-old Bill arrived together for a consultation. They had been dating for six months and had been intimate together in many ways but still had not had sexual intercourse. Staci enjoys kissing, cuddling, and petting, and enjoys giving and receiving oral sex. When Bill approached her about having intercourse, she simply said she wasn’t ready. Bill was very understanding and didn’t push things. Recently, on one particularly romantic evening, things heated up between Bill and Staci. Staci told Bill she felt ready and they proceeded to have intercourse. But as soon as Bill attempted to insert his penis in her vagina, Staci panicked. She closed her legs and pushed Bill away. Bill was confused and Staci spent the rest of the night in tears.

Staci explained she was a virgin by circumstance rather than by design. She wasn’t raised in a particularly religious household and in fact, first attempted intercourse several years ago with her ex-boyfriend. However, she panicked then too, and would not allow her boyfriend to enter her. Staci then admitted, "The truth is, I have never even been able to put in a tampon. I don’t even think I could find the opening. It just doesn’t seem like anything could really get in there and I am afraid of the pain."

Staci’s story is not all that unusual. She suffers from a disorder known as vaginismus. Vaginismus has been traditionally defined as a reflexive spasm of the vaginal muscles, which prevents intercourse. However, researchers have recently begun to question this definition, as the presence of vaginal muscle spasms has never really been proven. What better defines vaginismus is the fear and anxiety that occurs upon attempting vaginal penetration. Rather than an isolated muscle spasm, the reaction to penetration involves the whole body, which enters into a heightened state of anxiety. This reaction can include lifting the buttocks, closing the legs, mouth dryness, rapid breathing and increased heart rate. What is particularly interesting is that this reaction often occurs despite the woman’s expressed willingness and desire to allow penetration. The reaction of fear and anxiety is often surprising to her, and leaves her feeling powerless and out of control.

What causes the fear of penetration? This is unclear and there is probably not one simple answer. In many cases, vaginismus has been found to occur together with actual pain disorders, such as vulvar vestibulitis syndrome (VVS). You can read more about this in my article A Woman’s Guide to Alleviating Painful Intercourse. While a heightened state of anxiety may be a hyper vigilant reaction to pain, nonetheless, the aversion is due to pain-avoidant behavior. This may turn into a conditioned response even after the source of pain is no longer relevant. Early studies on vaginismus have attributed this phenomenon to psychological, psychosocial and relational causes. These include the inability to trust others; a cultural background that is sex-negative or which highly values virginity, or the need to maintain control in a relationship, amongst a host of other theories. However, while it is certainly valuable to explore personal and relationship issues in therapy, talk therapy alone may not be sufficient to actually effect behavioral changes.

While more studies need to be done to demonstrate the efficacy of this approach, the best way to treat vaginismus appears to be a combination of cognitive and psychodynamic therapy, together with physical therapy consisting of education, desensitization, manual therapy, pelvic floor biofeedback and behavioral therapy including the use of gradual vaginal dilators. Education and desensitization can include teaching the woman about her vulva, having her look in the mirror and begin to touch herself, eventually finding the vaginal opening and even inserting a finger inside. Manual therapy techniques include stretching and massaging the vulva to help it become more flexible and ready to accept penetration. Pelvic floor biofeedback is a method of treatment whereby a sensor placed in the vagina reads the muscle activity inside the vagina and displays it on a computer screen. The woman is then able to learn how to relax, strengthen and control her vaginal muscles in order to facilitate easier vaginal penetrationp>

Staci and Bill were seen in physical therapy for eight sessions. Staci learned how to insert vaginal dilators, which are "sticks" designed for the purpose of allowing gradual vaginal penetration. The first dilator was about the size of a tampon, and the sixth in the set was about the standard size of a penis. She and Bill also received instruction in working with the dilators together. She learned to relax her muscles using biofeedback and by the end of the treatment, she and Bill were able to have intercourse, which eventually became pleasurable as well as pain and fear free.