Intimacy, we view it as a form of love, a deep act of affection towards another human being, often characterized by mutual respect and care. It can go from a simple act of touch, to sharing your most inner fears, hopes and dreams. It is viewed, for many, as a very positive notion, and is sought after to increase a special bond. 

Yet for many women, intimacy is a frightening concept, one which goes as far as paralyzing them from being physically intimate with their partner. Intercourse is a deeply traumatic experience which they fear going through. Unfortunately, many of these women feel abnormal, resulting in low self esteem, and a poor sexual life. 

As a midwife, throughout my career I have encountered several women struggling with these symptoms. A desire for intimacy with their spouse, but a physical inability to attain it. While discussing with them, the same pattern came up – they suffered a severe contraction of their pelvic muscles, preventing anything from entering the vaginal canal. 

These symptoms define the very misunderstood disorder, known as Vaginismus (1).

What is Vaginismus? 

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) (2), vaginismus is a female sexual dysfunction, defined as a recurrent or persistent involuntary spasm of the muscles of the outer third of the vagina (American Psychiatric Association, 2000) (3). It results in a difficulty which prevents entry of a penis, a finger or any object, despite the woman’s expressed wish to do so.

Vaginismus can be partial, allowing a very painful but possible form of intercourse, or complete. It could be primary, where the woman discovers her difficulty to have sex during her first attempt, secondary due to a physical and/or mental trauma (4), or caused by a serious infection or anatomical abnormalities. Vaginismus could be also the result of external pressure coming from the relatives, and the growing desire for a quick pregnancy (5). 

 The severity of the symptoms could also vary with different partners. The women affected by this are very likely to adopt avoidant behaviors with their significant others. Mariah Mcavoy and al pointed out in their study “Understanding Vaginismus: a biopsychosocial perspective” (2021) (6), that the partners of women who suffered from vaginismus were usually nice and amenable men, who were unlikely to be sexually aggressive or pressure their female partners into engaging in intimate relations (1).

  

A Challenge for Women 

The female reproductive system is a complicated entity. It is capable of growing a watermelon-sized human being, going through massive highs of pain, and stretching out to an extreme extent.

But what happens during intercourse?

In the 60’s, Ms Virginia E Johnson and Dr William Masters, conducted the first ever study surrounding sex, and wrote their groundbreaking book ‘Human Sexual Response’, first published in 1966 (7). To this day, many scholars and doctors quote their research. They effectively described each stage of the sexual response, from excitation to resolution.

When aroused, the vaginal canal secretes lubrication fluid through the Skene and Bartholin glands, located near the vulva, allowing an easier penetration. The first third of the vaginal canal expands and lengthens, as blood flow increases in the vaginal walls, making them congested, and therefore a lot more sensitive to touch. The female body is getting ready and signaling that it’s fully prepared. The excitation stage preceding the arousal, is mostly enhanced through increased desire for your partner, by using physical and mental stimulation. 

So why do some women have this inability to have sex with their significant other?

The Cultural Stigma of Vaginismus

Throughout my research, and experiences, I observed that vaginismus was most prevalent amongst young women who had either suffered from sexual abuse or had a negative attitude towards sex. This condition is known to be detrimental to sexual, mental and general health (1).

As I started to gather data with each patient, I was able to single out a common denominator; they all had a cultural upbringing with values that came from warped religious beliefs. Every woman I had examined and taken care of, whether for a delivery or a simple vaginal sonogram, had the same deep rooted fear of experiencing acute levels of pain during sex. This extremely distorted perception of what could happen, led to a vicious cycle where they imagined and were certain they would experience discomfort or pain, resulting in the involuntary contractions and spasms of their pelvic muscles. Thus the penetration becomes a painful experience, thereby confirming their initial fears.

My patients came from different cultural backgrounds and ethnicities, ranging from Morocco to Pakistan. Taking the time to allow them to open up at their own pace during our interactions, whether a consultation or before/after delivery, allowed me to point out the underlying misconceptions and patterns that they held and which led to their experiences. 

Carice Ellison, wrote in her scientific article ‘Psychosomatic factors of the unconsummated marriage’, published in 1968 (8), that the prominent issue among women who suffered from vaginismus was, their lack of sexual knowledge and a sense of guilt about sex, resulting in a general fear of the sexual act itself. These were the precise reasons I identified in most of my patients.  

They were all raised with strong religious values that promoted virginity until marriage, while also having been brought up believing that intercourse was supposed to be “painful” and would involve “a lot of blood”. They mostly, had secondhand experience when it came to sex, from female figures in their entourage, about how a woman should experience intimacy with her spouse. 

“My cousin said that it was normal and that I should feel pain.”

“The second I know that he’s about to go in, I can’t help but be scared and it’s like my muscles cannot stop contracting.”

“We tried a lot of things but I still can’t relax and fully enjoy the moment, it’s really taken a toll on my overall relationship with my husband.”

The cultural distortions of islamic religious beliefs have unfortunately vilified the sexual act, to the point where women feel an extreme amount shame, and therefore cannot allow anyone near them. In addition, the general stigma in certain cultures regarding the impurity of a woman who has had premarital sex, also resulted in a fear of the act itself. Women I have encountered felt ashamed, dirty and disgusting, even if they were married and therefore had the right to enjoy intimacy with their spouse. They generally wanted to enjoy it, but failed when the opportunity presented itself. 

Contrary to these beliefs, Allah says in the Qur’an:

“And of His signs is that He created for you from yourselves mates that you may find tranquility in them; and He placed between you affection and mercy. Indeed in that are signs for a people who give thought.”  (Qur’an 30:21) 

“They (your wives) are a clothing for you, and you are a clothing for them.” (Qur’an 2:187)

What Does the Scientific World Say About Vaginismus?

There is unfortunately a general lack of epidemiologically substantial data on the prevalence of vaginismus, but Mojedeh Banaei and al in “Bio-psychosocial factor of vaginismus in Iranian women” (10), highlighted the importance of sexual knowledge. 

Many muslim women, including the highly educated, have a severe lack of knowledge about their own bodies (11). The female outer genitalia is often perceived as mysterious and a ‘no-go’ zone. General notions on how the human body works, especially the female body, could deconstruct a lot of misconceptions and help a lot of women in smashing their fears. 

It is difficult to assess the prevalence of vaginismus worldwide. Most women that have been surveyed were participants in clinical studies. This indicates that the numbers may be a lot higher than what has been initially described. In many cultures, the shame and stigma that surrounds sex in general, keeps women from speaking up about possible struggles that they might be going through within their marriage. The guilt that comes with it has also been a detrimental factor to the difficulty of properly evaluating the severity of this condition across the world (12).

Most studies have identified a higher prevalence of vaginismus, in Muslim countries. Mhuri and al (2013) have estimated the number of women affected by it to go up to 40% in Tunisia (8), while Lahaie and al (2010) (13),  have noted a prevalence that could increase to 17% worldwide in clinical settings. 

With mystery comes interrogation, and the human brain is wired to be afraid of the unknown. Deconstructing the general stigma and teaching young women about sex in a safe and balanced way could help desacralize sex, and make it a more pleasurable experience for them. 

Cognitive Behavioral Therapy (CBT) (14), has had massive positive outcomes in tackling vaginismus, as it completely modifies specific cultural beliefs and allows women to learn more about themselves. The treatment process is slow paced and beneficial for the couples dynamics (15). Patience and empathy are both key components, as it cannot be resolved overnight, and will require the partner’s sympathy, as well as the surrounding family’s.

Although the treatment available is mostly psychological, some clinical studies have experimented with the injection of botulinum toxin (16) into the pelvic muscles of women who had refractory vaginismus that was unresponsive to conventional therapies. 

Pelvic floor physical therapy (1)  is also another approach which doesn’t involve any pharmaceuticals. Different sessions conducted by a therapist or sexologist are required, with exercises to perform at home with your partner. These sessions help women become more aware of the different parts of their body, and feel different sensations as they explore (17).

Husna*, for example, who is currently working on healing from vaginismus, started her journey from therapy with a licensed midwife and sexologist. Positive thinking via CBT helped her overcome the fear of losing control, and instead focus on fully enjoying the moment. Communication with her partner, particularly explaining to him how she feels and taking each step one day at a time, played a huge role in her healing process. Dhikr and relying on her relationship with Allah aided her in letting go of her deepest fears. 

Vaginismus is a spectrum and cannot be resolved overnight, but it also isn’t an incurable disease. Fear and misunderstanding of one’s body is often the root of it. Therefore, education, therapy and patience are essential in helping women overcome it. 

Sex is an important part of life and can have a very positive impact on the overall human health. Our beautiful religion has taught us that knowledge is of extreme importance, and proximity with our spouse is a form of ibadah. Unfortunately, the different cultures across the globe have had a negative impact on how we view sex, on the alleged claim from surrounding families that it protects and prevents from harm. It is our duty to educate young girls in a safe way and guide them through one of the most significant moments they will face throughout their lives. 

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References

1. Clinical review by Tessa Crowley, ‘Diagnosing and managing vaginismus’, 2009 BMJ
2. The DSM diagnostic criteria for vaginismus, 2010 
3. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).
4. Tamara Melnik and al, ‘Interventions for vaginismus’, December 2012
5.  M Ramli and al, ‘Vaginismus and subfertility: case reports on the association observed in clinical practice’, April 2012
6. Mariah McAvoy and al, ‘Understanding Vaginismus: a biopsychosocial perspective’, 2021
7. W Masters and V Johnson, ‘In Human Sexual Response’, 1966
8. M Nabil Mhiri and al, ‘Unconsummated marriage in the Arab Islamic World: Tunisian experience’, 2013
9. Yosra Zgueb and al, ‘Cultural aspects of vaginismus therapy: a case series of Arab Muslim patients’, January 2019
10. Mojedeh Banaei and al in ‘Bio-psychosocial factor of vaginismus in Iranian women’, October 2021
11. Konkan and al, ‘Sexual fonction and satisfaction of Women with vaginismus’, 2012
12.  Ogden & Ward, ‘Help seeking behaviour in sufferers of vaginismus’, 1995
13. Lahaie and al, ‘Vaginismus: A Review of the Literature on the Classification/Diagnosis, Etiology and Treatment’, 2010
14. Wijma, B., & Wijma, K. ‘A cognitive behavioral treatment model of vaginismus’, 1997
15. Moniek M. ter Kuile and al, ‘Cognitive Behavioral Therapy for women with lifelong vaginismus : Process and prognostic factors’, March 2007
16. Shirin Ghazizadeh and al, ‘Botulinum toxin in the treatment of refractory vaginismus’, November 2004
17. Elke D. Reissing, ‘Pelvic floor physical therapy for lifelong vaginismus: A Retrospective Chart review and interview study’, March 2013