When Sex is Scary

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 demonstrated. What better defines vaginismus is the fear and anxiety that occurs upon attempting vaginal penetration. Much of the fear is that it will hurt, and in fact, vaginismus often accompanies a common pain disorder known as PVD (provoked vestibulodynia). PVD is characterized by pain at the entry to the vagina with touch and /or attempted intercourse and is often associated with overactive muscles of the pelvic floor. Rather than an isolated muscle spasm, however, the reaction to penetration in women with vaginismus often 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. 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.

The conflict between the cognitive desire to have intercourse, and the experience of aversion and anxiety when attempting to do so, is very common. Many women express a great deal of motivation to "fix" the problem, and in doing so, attempt to ignore their fear as they try again and again to allow intercourse. Often these women, as well as thir partners, express feelings of "failure". They become steeped in self judgment and criticism, blaming themselves and sometimes, one another.

I treated Staci and Bill  with a unique program combining mindfulness, cognitive behavioral therapy and physical therapy. The mindfulness program allowed Staci to become aware of when she was feeling her anxiety, and to learn to accept and contain her feelings, and slowly, with breathing and other techniques designed to allow her to maintain control of her body, she was able to learn to relax enough to begin the physical aspects of the program. This involved the use of psychoeducation to learn about her body and to slowly be able to connect to and look at her genitals in the mirror, touch herself, learn to relax the muscles of her pelvic floor, and allow self insertion of gradual vaginal dilators. The cognitive  aspect of the therapy program allowed Staci to recognize when she was expressing unhelpful, negative, or catastrophic thoughts and replace them with more positive ones. Finally, Staci and Bill were instructed in ways to enjoy intimacy and slowly work in to intercourse, in ways that Staci would feel safe. Staci was concerned about disappointing Bill, and Bill was worried about pushing Staci. Couples work allowed them to express each others concerns as well as learn to accept and contain each others reactions.

Often women with vaginismus feel as though they are the sexually handicapped ones in the relationship. In therapy, Staci learned to value her ability to enjoy non penetrative sexual activities and to view the ability to enjoy penetrative sex as an additional journey, rather than a goal that had to be acheived at all costs. Eventually, Bill and Staci were able to enjoy painless and enjoyable sexual intercourse.