Vaginismus: When Sex Hurts

Vaginismus remains shrouded in misguided beliefs and shame that cause delays in dealing with the problem, and aggravate psychological distress amongst those concerned (Pacik & Geletta, 2017 ; Melnik et al., 2022). What’s more, those affected are less likely to consult a professional for sexual health matters due to negative experiences during previous gynaecological examinations (Chalmers, 2024).

Vaginismus is defined by an automatic, persistent contraction of the muscles surrounding the entrance to the vagina (the pubococcygeus muscles). It occurs during any attempt at penetration, whether that be during a sexual encounter, the insertion of a tampon, or the insertion of a speculum during gynaecological examinations (Pacik, 2014 ; Lamont, 1978). This involuntary, unconscious contraction, can be primary (present during one’s first penetrative encounters), or secondary (appearing after a period of normal functioning sexuality) (MedG, 2019). For vaginismus to be diagnosed, it must be present for at least six months and have an impact on the quality of life of the affected.

Recently, the name ‘vaginismus’ has been replaced by ‘genito-pelvic pain’ or ‘penetration disorder’ (DSM-5-TR, APA, 2022). It encompasses the fear of penetration, pain during penetration, and pelvic floor troubles (Lahaie et al., 2015). That being said, the term ‘vaginismus’ remains in common usage, and is a useful term for patients to describe their lived experiences (Chalmers, 2024).

The main symptoms of vaginismus include:

• The impossibility of penetration, despite sexual arousal and the desire to be penetrated (Basson et al., 2004).
• Intense pain (also called dyspareunia) at the vaginal entrance, often described as a burning sensation, blockage or tearing.
• Anticipatory anxiety (the fear of being in pain), causing one to avoid penetration. This is often associated with psychological distress (Pacik & Geletta, 2017 ; Melnik et al., 2022).

It must be noted that vaginismus must be differentiated from dyspareunia (pain during sexual encounters, unrelated to muscular contractions) and vulvodynia (persistent pain around the vulva), although it’s possible that these issues arise around the same time.

There are multiple possible causes that often combine psychological, physiological and contextual dimensions.

• Education and beliefs: restrictive sex education, religious or cultural taboos, and a lack of understanding surrounding the female anatomy may make this trouble more likely to appear (MedG, 2019).
• Trauma: previous history of sexual abuse, painful gynaecological examinations or traumatic birthing experiences may contribute in provoking vaginismus (Pacik & Geletta, 2017).
• Fear and anxiety: fear of being in pain, of fertilisation, pregnancy or a misguided perception around the size of the vagina also proves problematic.
• Relational conflicts: difficulties within a relationship, insistence or lack of understanding from the partner, and a lack of communication can provoke or aggravate vaginismus (MedG, 2019).

• Pelvic floor hypertonia: chronic muscular tension, often linked to stress or postural habits, contribute towards vaginismus (Melnik et al., 2022). For example, amongst those who suffer from vaginismus are horse riders or gymnasts who have practiced high-intensity sports since childhood.
• Infection and inflammation: repeated vaginitis, endometriosis or the after-effects of pelvic surgery can provoke chronic pain (Vidal, 2025), causing the vaginal muscles to contract.
• Vaginal dryness: due to menopause, breast feeding, lack of arousal… all of these increase the chance of pain associated with vaginismus (Pacik, 2014).

• Lack of information: sexuality remains a delicate subject for most people, thus a lot of women aren’t aware that the vagina is a stretchy, self-lubricating organ. Some believe that the vagina can tear easily, and that the entrance and internal canal are too small to house a finger, penis, sex toy, tampon…
• Social pressure surrounding sexuality: problems with sexual performance, penetration and pleasure are numerous. Those suffering from vaginismus often experience guilt due to feeling useless, feeling different or experiencing a lack of pleasure (MedG, 2019)
  

A clinical examination is envisaged in order to assess the symptoms, one’s medical and psychosexual background and the impact of the problem on one’s way of life (Melnik et al., 2022). A gynaecological examination is necessary, but only if the patient is in agreement and can tolerate it, as no gynaecological examination should be imposed upon them. The patient can, for example, choose the right time for them, ask for step-by-step explanations of the process, and stop the examination the moment pain becomes too intense. What’s more, the patient can undergo examination in an alternative position (such as on their side), with a small, lubricated speculum, to limit contraction of the pelvic and gluteal muscles (Chalmers, 2024).

When done gently, clinical examination will allow a medical professional to evaluate muscle tone and rule out other possible causes (inflammation, scarring, dermatose…) (Pacik, 2014). Verified evaluation forms, such as the Index of Feminine Sexual Function (Trudel et al., 2012), or the Lamont scale (Lamont, 1978) can confirm the presence and the severity of vaginismus.

Managing vaginismus demands a combined approach to care that’s adapted to the individual. The most effective approaches are detailed below (Melnik et al., 2022). Let’s not forget that it’s equally as possible and pleasurable for some patients and their partners to simply practice non penetrative forms of sex.

Cognitive behavioural therapy aims to desensitise the patient to the fear of penetration via exposure (roleplay exercises), first imaginative, then real. This pattern of gradual confrontation is discussed in advance with the patient, so that the exercises are as manageable as possible. Care is always adapted to the patient’s journey, problems and abilities. In parallel, the patient puts into question and modifies their misguided beliefs about sexuality and anatomy (for example: “my vagina is too small”, “penetration is going to tear the skin of my vagina since it’s so delicate”).

Learning relaxation techniques (breathing, mindfulness, body scan…) is important to help reduce anxiety and favour muscle relaxation. The goal is to break the vicious cycle of “pain- fear- muscular tension” that sustains vaginismus (Vlaeyen & Linton, 2000 ; McEvoy et al., 2021). Indeed, painful experiences during penetration feed anxious thoughts (“It’s going to hurt too much”, “I can’t”), that cause hypervigilance and hypertonia in the pelvic floor region. Avoiding sexual relations over short term periods reduces anxiety, but causes fear and long term dysfunction (Vlaeyen & Linton, 2000).

According to Pacik (2014), CBT provides significant improvements in 70 to 80% of cases, these improvements have also been proved by other studies (Ter Kuile, 2013 ; Maseroli et al., 2018).

This begins with sexual education, providing the patient with information on their anatomy, lubrication, and the feminine sexual response. Couples exercises can be proposed, such as, communicating positive feelings, non genital touching, and gradual exploration of penetration, starting with a finger. The Sensate Focus is perfectly suited to allowing partners to start over with sex, ensuring it’s pleasurable, sensual and penetration free.

Next, and only if this is wanted by both partners, the body is to become reaccustomed to penetration and pain free feelings, thanks to the use of vaginal dilators that gradually increase in size (Pacik, 2014). This step can be guided by a specialised physiotherapist, gynaecologist, or midwife. In parallel, perineal rehabilitation will help the patient to identify and relax the pelvic floor muscles.

Vaginismus has a major impact on sexual, emotional and relational dynamics. Conjugal care is often necessary in order to improve communication and the level of support received, as well as to reduce the pressure of penetration. What’s more, explaining the mechanisms of the vagina to the partner is useful in helping them to understand the involuntary causes of such a problem, and thus limit feelings of guilt or rejection. They can also participate in desensitisation exercises by helping to slowly introduce a finger or dilators into their partner.

Sophrology and hypnosis can additionally be proposed as a way to work on relaxing the body and having better mental representation of the vagina.

Localised treatments such as lubes and anaesthetics can provide immediate pain reduction during sexual encounters. In the case of any underlying infection, antifungals or antibiotics are necessary (Vidal, 2025). What’s more, hormone therapy can be prescribed for atrophic vaginitis due to menopause (Pacik, 2014). If you have any doubts, don’t hesitate to consult a urologist, gynaecologist, midwife or sexologist.

In the case of severe, consistent vaginismus, following the advice of a doctor further interventions may be envisaged, such as botox injections in the hypertonic muscles (Pacik, 2014), however their effectiveness remains disputed.

Through comprehensive, adapted care, a large majority of women manage to rediscover a fulfilling sex life (Ter Kuile, 2013 ; Pacik, 2014 ; Maseroli et al., 2018). Improvement is generally evaluated by the absence of instinctive contraction of the muscles, or the absence of pain during sexual activities. The length of treatment can vary from a few months to a few years, depending on the severity of the problem and how long the patient has been suffering for.

Those who suffer from vaginismus aren’t alone, solutions do exist, and pain free sex is possible! This problem is without a doubt, a complex one, but it can be treated thanks to a multidisciplinary approach combining psychotherapy, perineal rehabilitation and, if necessary, couples therapy. The key to improvement resides in communication, sexual education and personalised care that’s adapted to the causes and lived experiences of each patient. To finish, two things are extremely essential: patience and benevolence, towards oneself (for the patients), and towards their partner (for the partner of the affected). Despite the length of suffering, and the desire to have a quick solution, one must accept that progress will be gradual.

If you’re looking for in depth information on a range of topics related to vaginismus, take a look at https://www.vaginismusawareness.com/.