Vaginismus: when your body says no, even though you say yes

“I really do want to. I don’t understand why it doesn’t work.”

This sentence might be said by a woman who has been with her partner for years and loves him. Or by a woman who went to the gynaecologist and had to stop the examination because her body closed before anything had even touched her. Or by a woman who has never been able to use a tampon and assumed she was simply “different”. She often says it through tears, angry with herself and convinced that something is badly wrong with her body — or with her mind.

This is called vaginismus. It is more common than people think, yet it is talked about very little — because of shame, because the subject is intimate, and because many women don’t even know their difficulty has a name. In this post I will explain what vaginismus is, why the first step is always a doctor, how body and fear become intertwined, what happens to a couple and — most importantly — that treatment is possible.

Let me say from the start where I stand. I am neither a sexologist nor a doctor. As a marriage and family therapist in training, I work with relationships, and intimacy can be one of the themes a couple brings. For treating vaginismus itself, though, the right people are a gynaecologist, a pelvic floor physiotherapist and specialists in sexual medicine. So this post is more of a map than a set of instructions.

What vaginismus is

With vaginismus, the muscles around the vaginal opening and in the pelvic floor tighten reflexively when penetration is about to happen — during sex, a gynaecological examination or when inserting a tampon. It is not a conscious decision. A woman can want sex, be aroused and trust her partner, and her body will still close. Hence the title of this post: your body says no, even though you say yes.

For a long time vaginismus was described mainly as a muscle spasm. Research has broadened that view. In 2004, Elke Reissing and her colleagues compared women with vaginismus, women with pain during intercourse and women without difficulties. It turned out that clinicians could not reliably identify muscle spasm on examination as a distinguishing feature — whereas women with vaginismus differed most clearly from the others in fear and avoidance: fear of pain and of penetration, and how strongly the body responded defensively.

That is why, in 2013, the American diagnostic manual DSM-5 merged vaginismus and pain during intercourse into a single category called genito-pelvic pain/penetration disorder. Experts concluded that in practice the two difficulties are so close that it is often impossible to separate them sharply. You can read more about pain during sex in the related post Painful sex in women: when to see a doctor and when to see a therapist.

Vaginismus can be lifelong — when penetration has never been possible — or acquired, when it appears after a period in which sex was not a problem, for instance after childbirth, an infection, surgery or a painful experience. It can be complete or partial; some women can manage a gynaecological examination but not intercourse, or the other way round.

A gynaecologist first — and why that isn’t dismissive

When there is pain or penetration is not possible, the first step is always a doctor, ideally a gynaecologist. This does not mean that it is “all in your head” or that “there’s nothing wrong”. It means that conditions which can cause pain, and so trigger or maintain tension, need to be ruled out or treated — infections, skin conditions of the vulva, vulvodynia, endometriosis or the after-effects of childbirth, for example. If there is a physical cause, that must be treated first.

For many women with vaginismus, the gynaecological examination itself is a major challenge. So it helps to know a few things:

• You may say so in advance. “Examinations are very hard for me. I feel my body closes up.” A good gynaecologist will take this seriously and adapt how they proceed.
• You may stop. You can interrupt an examination at any time. That isn’t failure; it’s information.
• You may bring someone. Some women find it helps to have their partner or a friend with them.
• You may look for another doctor if you didn’t feel safe with the first one, or if they brushed you off with “just relax”.

You can write down the questions you want to ask beforehand — the knowledge base template Questions for your doctor can help. Your gynaecologist can also refer you on, for example to a physiotherapist who specialises in the pelvic floor.

The circle of fear, tension and pain

The key to understanding vaginismus is a circle that keeps itself going. When the body expects pain, it tenses. Tense muscles make an attempt at penetration painful or impossible. The experience of pain or failure strengthens the fear. And greater fear means even more tension next time.

A fourth link joins the chain: avoidance. It is understandable to avoid something that hurts or ends in tears. A woman may start avoiding any touch because she fears it will lead to sex. Her partner may stop coming close so as not to put pressure on her. In the short term avoidance brings relief, but in the long term it keeps the fear alive, because the body never gets the experience that things can be different. How this mechanism works more generally is described in Anxiety and avoidance: why avoiding helps you today and harms you tomorrow, and in the knowledge base under Avoidance and Fear.

This circle matters because it shows why the advice “just relax” doesn’t work. You cannot order relaxation from a body that has learnt that something is dangerous. The body has to learn differently — slowly, through experiences that are not painful.

Where it can come from

There is no single cause of vaginismus. Several factors often intertwine, and for many women nothing in particular can be pointed to. This is important to say, because women often torment themselves with the question of what is “wrong” in their past.

Factors mentioned in the professional literature include:

• Messages about sex. Growing up in an environment where sex was dirty, dangerous or forbidden, where the body was not talked about, or where first intercourse was presented as something that must hurt.
• Lack of information. Women who don’t know how their body is built may imagine that the vagina is “too small” — which is almost never the case.
• Painful experiences. An unpleasant or painful gynaecological examination, a painful infection or an injury during childbirth.
• Anxiety in general. Women who are prone to anxiety in other areas of life may be more vulnerable.
• Experiences of violence. For some women, sexual abuse or other violence lies in the background. It is worth stressing, however, that the great majority of women with vaginismus have not experienced abuse, and vaginismus is not “proof” that something happened.

When trauma is in the background, treatment is different and slower. How trauma stays in the body is the subject of How trauma stays written in the body — and how the body can let it go, and the way back to your own body after abuse is explored in Sex after sexual abuse: the way back to your own body.

Almost always, though, there is something else too: shame. Women with vaginismus often describe feeling “broken”, “not a real woman”, or guilty because they “can’t give” their partner sex. Shame leads to silence, and silence leads to being alone with the problem. How shame differs from guilt, and why the difference matters, is the subject of Guilt and shame are not the same — and the difference matters; there is also a short explanation in the knowledge base under Shame.

The partner: between guilt and withdrawal

Vaginismus is not just one person’s problem. It affects the couple, and a couple can unintentionally strengthen the circle or help to break it.

Partners respond in different ways. Some become very cautious and stop touching so as not to put on pressure — which a woman may experience as rejection. Others feel rejected themselves and, sometimes without meaning to, show it through impatience. Others still look for the fault in themselves: “Maybe she isn’t attracted to me enough.” The woman, meanwhile, often carries a double burden — her own distress and the worry that she will lose her partner.

A conversation in such a couple might sound like this (a composite, not a real person):

“I know you’re disappointed. I can see it on your face.”
“I’m not disappointed in you. I’m disappointed because I don’t know how to help you.”
“Every time you touch me, I think you’re expecting it again.”
“And I don’t dare touch you any more, because I think it’ll frighten you.”
“So we’re both afraid of the same thing.”

That moment — when both realise they are afraid of the same thing, and that the silence was built by care rather than a lack of love — is often a beginning. “Your problem” becomes “our task”. If you don’t know how to start such a conversation, How to start a difficult conversation with your partner: the first three minutes decide offers concrete steps.

It also matters for a couple to know that closeness is possible without penetration. Many couples agree during treatment that intercourse is “off the table” for a while, which takes the pressure off the body and gives the couple back a kind of touch that is no longer tense with expectation.

Treatment is possible

This may be the most important sentence in this post. Vaginismus can be treated, and after treatment many women are able to have sex without pain. The path is rarely quick, but it is clear.

Treatment usually involves several professionals, depending on what lies in the background:

• A gynaecologist rules out or treats physical causes and refers you on.
• A pelvic floor physiotherapist helps a woman get to know these muscles, relax them consciously and gradually accustom the body to touch and stretching. In 2013, Elke Reissing and her colleagues reviewed the experiences of women with lifelong vaginismus who had received such physiotherapy and reported promising outcomes.
• A psychotherapist or a specialist in sexual medicine works with fear, beliefs and gradual exposure. In a randomised trial in 2013, Moniek ter Kuile and her colleagues showed that gradual, therapist-aided exposure was highly effective — women who received it were far more often able to have intercourse than those on the waiting list.
• Couples therapy comes into play when the relationship is weighed down by guilt, resentment or silence — or when the couple has become stuck in a circle of withdrawal.

What all these approaches have in common is that they proceed step by step, at the woman’s pace and without pressure. She is the one who decides when she is ready for the next step. The body does not unlearn fear through force, but through experiences of safety that slowly accumulate.

Where I fit in as a couples therapist

As I am training in relational family therapy as a therapist in training under supervision, I want to be clear about what I can offer and what I can’t.

I do not provide specific treatment for vaginismus — pelvic floor work or structured exposure. Other professionals do that. What I can be is a space where a couple talks about what has happened between them because of this difficulty: the guilt she carries, the rejection he feels, the silence that has settled between them. From a relational perspective I am also interested in the messages about the body, sex and closeness that each partner brought from their own family — because in a couple’s intimacy, two very different histories often meet.

Often this is precisely what helps treatment with other professionals go more smoothly. A woman who knows her partner isn’t angry with her, and a partner who knows he isn’t the one being rejected, can more easily walk together along a path that calls for patience.

If you would like to talk about this as a couple, I also work with English-speaking clients; sessions take place in person in Ljubljana.

Exercise: a map of your circle

This exercise is for you, not for the couple, and it involves no touch at all. The aim is to start recognising your circle, rather than being carried along by it.

1. Recall the last situation in which your body closed up or you avoided it. It needn’t have been sex — it might have been an examination, a tampon or just the thought of one.
2. Write down what you told yourself in that moment. “It’ll hurt.” “It won’t work again.” “I’ll disappoint him.” Don’t correct anything; just write it down.
3. Write down what your body did: where you felt the tension, what happened to your breath, whether you clenched your jaw, shoulders or hands.
4. Write down what you would have needed to make it even a little easier. More time? Knowing you could stop? Knowing nobody expected anything?
5. Choose one sentence from point four that you could say to your partner or your doctor. For example: “It would help me to know I can stop at any moment.”

This exercise doesn’t treat vaginismus. But it helps the difficulty take on a shape and words you can carry forward — to a doctor, a physiotherapist or a conversation with your partner.

Where this explanation falls short

Having built this whole post around the circle of fear and tension, it is only fair to say where this explanation has its limits.

It isn’t all fear. For some women there is a physical condition in the background that needs medical treatment — and no conversation will resolve it. That is why the gynaecologist comes first, not last.

It isn’t about “overcoming”. The aim of treatment is not for a woman to force herself into something she doesn’t want. Some couples decide that penetration isn’t important to them and find a fulfilling sex life in a different way. That is a legitimate choice too, as long as it is genuinely shared and not accepted out of resignation.

When sex is forced, that isn’t vaginismus — it is violence. If a partner pressures, threatens, punishes or coerces, a body that closes up is not ill; it is defending itself. In that case the first task is safety, not treatment. In Slovenia you can seek help from the SOS helpline for women and children victims of violence on 080 11 55, and in an emergency call 112 or the police on 113. If thoughts arise that you can’t go on, the Samaritans’ confidential line in Slovenia is available on 116 123, day and night.

Couples therapy is not the first step when the body is involved. Talking can help the relationship, but it does not replace an examination and specific treatment.

What to remember

• Vaginismus is a reflexive closing of the muscles when penetration is attempted — it is not a conscious decision and not a sign that you are “broken”.
• The first step is always a gynaecologist, who rules out or treats physical causes; a pelvic floor physiotherapist often helps too.
• The difficulty is maintained by a circle of fear, tension, pain and avoidance — which is why “just relax” doesn’t work.
• Treatment is possible; it proceeds step by step, at your pace and without pressure.
• A couple can strengthen the circle or break it — when “your problem” becomes “our task”, the path is easier.