When Sex Always Hurts: Dealing With Vaginismus

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Slit_1Illustrated by Ly Ngo.
Diagnosis
Snoop Dogg was about to perform in the main quad at Columbia University. I was in class and could hear music pumping from the speakers outside, preparing for his arrival. The left side of my stomach had been cramping all morning. An hour into class, I couldn’t handle it anymore — I bolted for the hospital near campus.

There, a doctor applied light pressure to various areas of my abdomen; he had a hunch that it was appendicitis or ovarian cysts. He conducted a routine probing of my vagina in an ultrasound procedure, and I freaked out — not at the idea of having cysts, but at being probed. I had been diligently avoiding vaginal exams, despite being 23 (well past the recommended age for a first pap smear). I was uncomfortable with the idea of a doctor sticking something huge, plastic, and slathered with cold lubricant inside of me; the idea of something so rigid and foreign entering me made me nauseous. Despite this fear, I removed my pants and followed the doctor’s directions to scooch towards the end of the table. He came at me with the stick, and my vagina immediately clenched — closing off entry like a venus flytrap. I’m not kidding: Nothing was getting in there.

My vaginal muscles were having a spasm, similar to the way the epiglottis closes entry to the trachea when swallowing food. My vagina, I thought, was smart. It was protecting me against the evils of this doctor’s plastic stick. The doctor looked concerned. “Have you had sex before?” He asked. My eyes began to water. “Yes,” I said, beginning to cry, “But, it was always painful.” Eventually the doctor told me that, along with ovarian cysts, I had a condition known as vaginismus.

At the time of my diagnosis in 2011, vaginismus was defined in the DSM IV as “the recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted...even the anticipation of vaginal insertion may result in muscle spasm.” The technical term has since changed; in the DSM V, vaginismus was combined with dyspareunia into a new entity called “genito-pelvic pain/penetration disorder.” The condition is treated in various ways — most widely through physical-aided therapy (basically, inserting little batons inside yourself), and, in more severe cases, Botoxing the vagina.

Once diagnosed, I began questioning my past sexual experiences. As I’d told the doctor, sex had always been painful; my ex-boyfriend could never fully penetrate because my vagina muscles were so tense. Similarly, I had always been queasy about using a tampon or even touching myself. Eventually, my vaginal muscles clenched up so much that not even an inch of my boyfriend’s penis could enter me. I avoided sex in all future relationships.
Slit_2Illustrated by Ly Ngo.
Where Does Vaginismus Come From?
The vaginismus studies of Irving Binik, PhD, show that phobia — a fear of vaginal penetration and pain — is what causes the involuntary spasm. Some people are afraid of dogs, or heights, or open spaces; some are afraid of vaginal penetration, explains Monique ter Kuile, PhD, a clinical psychologist at Leiden University Medical Center in the Netherlands. Dr. ter Kuile writes in her study, Therapist-Aided Exposure for Women With Lifelong Vaginismus: A Replicated Single-Case Design, “we reformulated vaginismus from a sexual problem to a penetration phobia.”

Pick up a book on vaginismus and it will offer a myriad of possibilities for the root of this fear: a history of sexual abuse, guilt by way of religion, poor sexual education, general ignorance of female anatomy. But, I’m a liberal Jewess who has never experienced an unwanted sexual encounter. I’ve looked at plenty of vagina diagrams, and I have a clear idea of where the different holes and parts are in my body. So, where was this fear coming from? Was it a fear of STDs or — my worst fear of all time — pregnancy?

Professor Binik explains that it’s unknown how most phobias develop. Past traumatic experiences, which may seem like natural correlations, are not necessarily the cause.
Slit_3Illustrated by Ly Ngo.
Treatment
Vaginismus was first written about by James Marion Sims, MD, in 1859: “I attempted to make a vaginal examination, but failed completely. The slightest touch at the mouth of the vagina producing most intense suffering... She shrieked aloud, her eyes glaring widly, while tears rolled down her cheeks and she presented the most pitiable appearance of terror and agony.” Dr. Sims concluded that “the only rational treatment would be surgical, i.e. that of dividing the muscle and the nerves of the vulva opening… I now saw that the hymen itself was the focus of the excessive irritability, and I then proposed to cut it out entirely.”

Peter T. Pacik, MD, wrote in his book that Dr. Sims “tested ‘experimental operations’ on slave women without anesthesia, often resulting in mutilation and death.” Thankfully, in 2014, the main treatment for vaginismus is a combination of physical and psychological therapies. According to Barbara Keesling, PhD, sex therapist, sex surrogate, and author of Sexual Healing: The Complete Guide to Overcoming Common Sexual Problems, most sex therapists start women on kegel exercises to “learn to voluntarily tighten and relax that PC muscle around the vagina.” From there, the patient moves on to a set of dilators: “The largest dilator is about the size of small dildo, like a magic-marker-type thing,” explains Dr. Keesling. Women get used to inserting these, starting with the smallest and working their way to wider dilators. Carol Queen, PhD, staff sexologist at Good Vibrations in San Francisco, suggests that “A woman with vaginismus would probably do pretty well to explore herself first so that experience of insertion is under her own control.”

Those with severe cases of vaginismus (who have tried the dilator method without success) have gone the Botox route. Dr. Pacik, the plastic surgeon who developed the Botox treatment program for vaginismus, successfully treated 275 patients since 2005 and continues to have a 97% success rate. Botox injections (which calm the vagina muscles, making penetration possible) are administered when the patient is under anesthesia, and a dilator is then inserted. So, the woman wakes up with the dilator painlessly inside her and finds that penetration is indeed possible. Dr. Pacik adds that “just treating with Botox is not enough...you really have to treat some of the emotional issues,” so patients stay for about five days of counseling after the procedure.

Most of Dr. Pacik’s patients have been trying to cure their vaginismus for several years or even decades. One patient I spoke with said she realized she had vaginismus when she started dating her now-husband in her early 20s (she is now 36). She and her husband were together for 11 years before consulting Dr. Pacik. “We tried physical therapy, a bunch of other things ... Nothing seemed to help the problem at all,” she says. Mentally, this woman wanted to have sex with her husband — but the physical block would not let her. She said the procedure “worked perfectly. In seven days we were able to make love."

While I didn’t go the Botox route myself, I did invest some time in meeting with a physical therapist who guided me through breathing techniques while I inserted dilators. I then took this practice home with me; a few weeks later, I found that I was able to wear tampons for the first time. About four months later, I was able to undergo a vaginal exam. And, the following year, I was able to have sex without pain.

But, it’s still a process. Is having sex fun and enjoyable? Sometimes. It’s certainly better than it used to be (yelling in pain, curling up into the fetal position, and telling my boyfriend it just wasn’t going to work). Now, I find pleasure in the experience. I was happily surprised at my ability to not only have sex, but to enjoy it. Sometimes, I worry the spasm may start up again — but it hasn’t.

So, am I cured? Well, “cured” can mean different things for different people. For some, having penetrative sex is not the defining moment. Maybe it’s a fear-free annual gynecological exam. Maybe it’s the ability to wear tampons. Or the ability to masturbate. Or maybe it’s knowing you can leave class, go to the hospital, and get an easy ultrasound while “Gin and Juice” plays loudly in the background.