Sometimes when she is sexually aroused, Nidhi thinks about making love with her husband of three years. Yet, she cannot. To this 33-year-old HR executive, sex means pain — so much so that she has never been able to have intercourse with her partner. He is empathetic and had known of her discomfort with any sort of penetration from the time they were dating, but Nidhi feels insecure about her marriage. She is wracked with guilt over ‘depriving’ her husband of penetrative sex, and it has taken a serious toll on her mental health and overall wellbeing. For her, the anxiety is often worse than the physical pain.
When Nidhi consulted a gynaecologist she was diagnosed with vaginismus — a painful condition caused by the involuntary spasming or contraction of the vaginal muscles at the time of penetration. Even gynaecological examinations were physically painful for Nidhi, as is the case with most women suffering from this condition.
According to clinical psychologist Ruchika Kanwal, pain due to vaginismus can range from mild to severe, and is often accompanied by emotional distress. “Vaginismus does not mean that a person cannot experience sexual arousal. But the idea of having penetrative sex often leads to panic attacks and anxiety symptoms leading to an extreme aversion to sex,” she said.
Despite the misery brought on by the condition, many Indian women hesitate to seek treatment for it or even discuss it with their intimate partners due to the social taboo on talking about sex.
We spoke to medical experts and therapists to understand more about vaginismus, how it affects a woman’s physical and mental wellbeing, and what the path to healing looks like.
Symptoms and causes
A woman may not be aware she has vaginismus unless she has tried penetration of some sort, whether it is sex or inserting a tampon or undergoing a medical examination. If a woman suffers from this condition, she usually experiences a tightening in her vaginal/pelvic floor muscles during penetration, leading to painful and burning sensations.
According to Dr Ranjana Sharma, Senior Consultant, Gynaecology, Indraprastha Apollo Hospitals, vaginismus can manifest in the following ways:
Fear of vaginal penetration and decreased sexual desire
A burning sensation with tightness during intercourse
Difficulty in penetration (it may be impossible for some)
Trouble breathing during attempted intercourse
Muscle spasms during attempted intercourse
Pain during tampon insertion
Pain during examination by gynaecologist.
Vaginismus can be related to a number of factors. Physical triggers include infections (such as a UTI), surgery in the perineal area following childbirth or after attaining menopause, skin disease, and improper vaginal lubrication.
The condition may also have a psychological genesis. Traumatic experiences such as child sexual abuse, sexual assault, or unhealthy relationships can be the root cause of vaginismus, as can issues with anxiety (such as performance anxiety) or fear of pain and childbirth.
Vaginismus can also develop at any time in a woman’s life. According to Dr Madhu Goel, Associate Director, Obstetrics and Gynaecology, Fortis Hospitals, vaginismus can be primary or secondary. “Primary vaginismus is when penetration has not happened before, and secondary is when it happened in the past but is not possible now. This can happen after surgeries or infections. Therapy and counselling play a big role in treating cases of both primary and secondary vaginismus,” Goel said.
Because of their condition, some women believe that celibacy is their only option. However, while vaginismus can make a woman anxious about penetrative sex, it does not prevent her from being sexually aroused. “Since there is a lack of discussion on the topic, most women or their partners don’t realise that the woman is capable of craving sexual pleasures and even having multiple orgasms. Activities that don’t involve penetration, such as massages or masturbation, work really well,” Sharma said.
The first step for a woman experiencing symptoms is to consult a gynaecologist and get a medical diagnosis done. If there is no physical cause (such as an infection), it is important to explore psychological factors with the help of a therapist. Understanding the root cause of vaginismus is integral to recovery.
Unfortunately, social strictures can prevent Indian women from seeking help for sexual conditions such as vaginismus. They try to bear the pain alone, which increases their anxiety levels and leads to more painful experiences during penetration. They may also think that there is something wrong or ‘defective’ about them when in fact vaginismus is very treatable, especially once the source of the problem is identified.
Sexual abuse: a common trigger
Sexual abuse in childhood is often the root cause of vaginismus in Indian women, according to medical experts and therapists. “I’ve treated many women who are dealing with vaginismus and most of them have experienced sexual abuse in their early childhood. Women who have experienced significant assault, such as rape, may also develop vaginismus,” Kanwal said.
Yet, thanks to our culture of silence and shaming, many women do not associate their history of sexual abuse with the painful condition. Fearing judgement and questioning, they try to hide both realities, leading to immense mental trauma. This is where therapy can help them draw the connection and initiate the healing process.
Clinical psychologist Anindita Chowdhury grades her vaginismus patients based on their level of discomfort, with Grade 3 being the most severe of all. “All my Grade 3 clients, who experience intense pain, have had a history of sexual abuse as adolescents. They build a ‘body coping mechanism’ over time and are avoidant of sex,” she said.
Chowdhury told us of a couple in their mid-30s who consulted her for the man’s erectile dysfunction. However, even after he was treated, he complained that he couldn’t complete penetration. This is when she decided to check the wife. “She wouldn’t allow me to examine her. Her muscles would flinch and her thighs would tighten. She didn’t allow me to insert even a finger, and this is when I realised she had vaginismus,” Chowdhury said. It turned out that this woman, like many others, had internalised the pain, shame, and guilt that came with being abused as a child.
Chowdhury, who has worked with many such clients over the past 13 years, said that it frequently requires extensive therapeutic work to make women acknowledge the continuing impact of abuse. “Sadly, most of these women fail to associate the abuse with the trauma and physical pain. They block all sexual advances by partners and resist seeking treatment. They open up gradually after a few sessions, but never in front of their partners.”
Insecurity and relationship anxiety
Neha, a 23-year-old assistant director, once enjoyed a healthy sex life. But three years ago, that changed when she first experienced excruciating pain during sex. She decided to visit a gynaecologist who diagnosed her with a vaginal infection and prescribed medicines. When that didn’t help, Neha went on to consult two more doctors. The pain continued for nearly three years, until she visited a third gynaecologist. “That doctor was the first to enquire about my mental health. I was taken aback, because I had not linked the physical discomfort to my anxiety,” she said.
Neha realised that she had become stuck in a vicious cycle. Her physical pain stemmed from her anxiety and insecurity about her relationship, and her resultant inability to have sex reinforced those feelings. “Even the thought of sex became traumatic for me and I didn’t know how to articulate my condition to my partner. I realise how understanding he has been but I have told him he is free to walk out of the relationship,” Neha said.
It is unsurprising then that vaginismus can result in feelings of inadequacy, shame, and low self-esteem in women because they internalise the guilt of not being able to ‘provide’ sex. “The condition often interferes with relationships and may cause dysfunction in family life,” Goel said.
In some cases, women may even externalise their frustration by blaming their partner. “Different women project their insecurities in different ways. In order to stall sex, they may complain of their partner’s body or mouth odour. Some even shame the partner for wanting ‘too much sex’ or for not being able to arouse her,” Chowdhury said. Since most of these mechanisms happen subconsciously, it takes time, therapy, and teamwork to make treatment succeed.
The role of the partner
Therapists believe that it is helpful to include partners in counselling sessions in order to address the relationship and emotional issues stemming from vaginismus. “Building empathy is essential and teamwork makes the prognosis better,” Kanwal said.
Another issue that needs to be addressed is that many Indian women view sex as an act of ‘giving’ pleasure rather than receiving it, and they tend to neglect their own needs. These notions contribute to women being at odds with their own body. One way to address this is to re-educate couples about intimacy. “Through couples sex therapy, we help them open up and explore their own bodies as well as their partners’. The exercise helps them discover pleasure points and understand that intimacy is more than intercourse, especially for women with vaginismus,” Kanwal said.
A reduced emphasis on penetrative sex can be liberating for women with vaginismus, but it requires the cooperation of a supportive partner. According to Dr Nupur Gupta, Director, Obstetrics and Gynaecology, Fortis Memorial Research Institute, Gurugram, the healing process can progress better when the partner does not blame the woman, refrains from repeatedly asking for vaginal intercourse, and supports her in her sexual journey. “Respecting her decisions, being patient, supportive and compassionate helps in the early resolution of the problem,” Gupta explained.
Men at times may lack basic knowledge about sex and women’s bodies, with many believing incorrectly that vaginal pain during sex is normal or even pleasurable for the woman. “What we need is more awareness around vaginismus as a medical condition rather than it being misinterpreted as women having ‘tight’ vaginas or being virgins. For most Indian women, not only is the condition traumatic but so is the partner’s response to it,” said sex educator Pallavi Barnwal.
Some women too have similar misconceptions about pain and sex. “Women continue to tolerate the pain as they have not been taught better. They are either made to feel ashamed or they start believing they are gifted with ‘tight’ vaginas,” Barnwal said.
Male partners to acknowledge that vaginismus is not a rejection of sex by the woman, but a cue that she is unable to enjoy it. “Why not cuddle, kiss, or stimulate the clitoris instead? Also, take her to the doctor or visit a therapist together. There’s a lot that a male partner can do to help begin her healing process,” Barnwal added.
How psychosexual therapy helps
Her impending wedding galvanised 30-year-old Tarini to attend psychosexual therapy sessions. She had never had sex, but feared that she may have vaginismus, as the very idea of intercourse was horrifying to her — which was not something she was comfortable discussing with her conservative family. Her sessions started with the therapist helping her to relax and explore her body and to understand the kinds of touch she found pleasurable. The therapist also used vaginal dilators in a graded fashion to help Tarini relax her muscles and become more accustomed to the sensation of penetration.
Thus, treatment for vaginismus may involve a number of physical and psychological interventions.
Building body and pain awareness: Gupta, who has treated many women with vaginismus, emphasised the importance of counselling in helping women understand their own body and the pain process. “When the cause of vaginismus is psychological, the resolution of emotional factors helps the woman to relax her vaginal muscles. Pelvic floor or Kegel exercises also help to a certain extent,” she said. “Anti-anxiety drugs and anaesthetic creams are also prescribed, but only when necessary.”
Vaginal dilation: A common physical intervention is the graded use of vaginal dilators. The aim here is for women to gradually learn to accept the pressure as normal. Of course, the insertion of dilators can be anxiety-provoking for women with vaginismus, but therapists are sensitive to this. “The use of dilators is always a step-by-step process, where we start with the minimum thickness and ask the woman to experience how it feels to insert something in the vagina. As she gets used to that size, we slowly move on to thicker dilators,” Kanwal explained.
Tools to fight anxiety: Psychological techniques such as relaxation and breathing exercises to ease anxiety can be extremely useful. Neha, who developed vaginismus despite a normal sex life earlier, says that a key component of her recovery is dealing with her fears. “I suffer from anxiety… I can’t control what my body does and my stomach involuntarily feels like stone during acts of physical intimacy and I end up crying,” she said.
According to Chowdhury such cases are usually connected to dyspareunia or painful sex due to infections or surgeries. The act of sex later triggers traumatic memories of the pain. “These are women with Grade 1 or 2 of vaginismus. Their brain tells them penetration will hurt, but are often okay with other forms of intimacy. They need progressive relaxation techniques to overcome their concerns,” she said. Neha says that with regular therapy, meditation, and breathing exercises, she is learning how to be in control yet let go.
Clearing harmful misconceptions: Therapists must often work on changing women’s mindsets about sex and help them approach it as something that holds the potential for pleasure. Sex is a forbidden topic in most Indian households and some women start believing that it is painful based on inauthentic versions from friends or movies. In therapy, these women are guided to understand their condition better and take charge of their sex lives. It is also important for women to realise that vaginismus can develop even in those who had no problems with sex before.
Turning partners into allies: For women who are in a relationship, it is beneficial to involve their partner in the therapy process. One major reason is to make the partner trust the therapy process and not sabotage it. The healing journey can suffer if women are pressured for sex mid-therapy. “Men insist on sex with, ‘How would you know therapy is working until you give it a try?’ or ‘I will be gentle, let’s try’. This further traumatises women already suffering from vaginismus, Kanwal said. “This is why we keep harping on couples therapy — we need to educate the man as much as the woman.”
This article originally appeared on HuffPost India and has been updated.