Causes of Vaginismus: Primary vs. secondary vaginismus
The causes of vaginismus differ between primary vaginismus and secondary vaginismus. Though both conditions present with sexual pain, the causes (etiology) are different. Take some time to learn about what causes vaginismus, and begin the journey to healing.
Primary vaginismus refers to a condition in women who have never had pain free intercourse, or worse, a condition wherein intercourse is impossible. Often these women compare attempted penile penetration to “hitting a wall,” and this history is usually related to the physical finding of spasm of the entry muscle of the vagina (bulbospongiosum). I have found this spasm of the entry muscle to be the most important cause of vaginismus and the major reason why women are unable to consummate their marriages or participate in sexual relationships. While we do not know the “cause” of the spasm, this finding is of major significance in the treatment of vaginismus, as it brings to light some clarification to the question, “What is vaginismus?” It is for this reason that Botox and progressive dilation under anesthesia is used as vaginismus treatment. The Botox calms the spastic muscle, while the dilators stretch this tight muscle. Since there is a very high level of anxiety in most women with vaginismus, especially those with severe vaginismus, the treatment needs to be done under anesthesia. The high rate of success of treatment with Botox injections and dilation speaks to the importance of this program to treat vaginismus.
Other causes of primary vaginismus may be related to strict sexual upbringing, strong family religious overtones, fears of first-time sex, exposure to sexually transmitted diseases and pregnancy.
Other Causes of Primary Vaginismus
Though spasm of the vaginal entry muscle is the most important physical cause of vaginismus, other psychological causes have been considered. The actual causes (etiology) of primary vaginismus are unknown.
Sexual Abuse in Vaginismus
A 2003 Canadian research article investigated whether childhood sexual abuse played a role in the later development of vaginismus (inability to have intercourse, and often any form of penetration). The goal was to look more deeply into the causes of vaginismus. The study found that women with vaginismus were twice as likely to have been sexually abused as children as compared to women who did not have vaginismus. This finding was in contrast to physical abuse during childhood in which no correlation could be found to vaginismus.
Though this study has received considerable press, my own findings do not support these vaginismus causes. In an evaluation of over 200 patients with vaginismus, I found that an average of about 20-25% of women with primary vaginismus have been sexually molested, which is about average for most women whether they have vaginismus or not. Sexual abuse during childhood is a concept that has been picked up by psychologists and sex therapists. My patients tell me that too much is made of this, and often their counseling sessions dwell on sexual abuse even though they do not have a history of sexual molestation, so it is not something that causes vaginismus for them. Some of these patients have been referred to hypnotists to delve further into their history. This too does not help, and much time, effort and money is wasted, especially since these women do not get better with their vaginismus.
Other findings of the Canadian study found that women with vaginismus and those who experience painful intercourse (dyspareunia) had less sexual desire, less sexual arousal, less sexual pleasure, and less self-stimulation than women in the no-pain group. Further, women with vaginismus had significantly less self-perception of their own sexuality compared to women who did not have vaginismus.
I too have found this to be true. Women who have vaginismus tend to lose interest in sex because of the associated pain with intercourse. For many, intercourse is impossible. Each attempt reminds them of their inability to function as a woman. Each unsuccessful attempt further undermines their relationship. This can be one of the most discouraging vaginismus symptoms.
Fear of intercourse
Vaginismus may be related to a fear of sexual involvement. Whether or not this fear actually causes vaginismus is unknown.
Fear of sexual involvement may start with a strict religious upbringing sometimes coupled with a sex negative atmosphere. Invoking all sorts of “punishment” for straying into the corrupt world of sexuality, and, worse, getting pregnant out of wedlock, and bringing shame and embarrassment to the family, is enough to scare even the most stoic young women. Whether this actually causes vaginismus is unknown, because women who do not have vaginismus are often exposed to a similar upbringing.
Strict sexual upbringing
Apart from a strict religious upbringing, a girl may be influenced by the parent’s belief that “sex is dirty” and that any sexual involvement, or worse intercourse, must be delayed until after marriage (when suddenly it becomes OK). I have read through countless histories describing the agony to this exposure and the uncertainty that it creates in allowing a woman to experience sexual feelings that are entirely normal. Once again, is this a cause of vaginismus? Many women who do not have vaginismus experience the same type of psychological trauma.
First time intercourse
Girls talk. When the discussion centers around the pain and trauma of first time intercourse, this can be scary for most young women. They may be told of pain, ripping of the vagina, and bleeding.
Pain with first-time intercourse can be common. Virginal vaginal musculature is normally tight. Like any tight muscle, the vagina needs to be stretched slowly to avoid the “burning” sensation that accompanies any muscle that is stretched too quickly. Combine this with the inexperience of young men, and the stage is set for an unpleasant first experience. Is this one of the causes of vaginismus? It is hard to know because, once again, many “normal” women experience similar conversations, become sexually involved with inexperienced men, yet go on to have a normal and healthy sex life.
Fear of sexually transmitted diseases (STDs), pregnancy and childbirth.
These factors may also be implicated in the cause of vaginismus, yet most women are exposed to this information. 1-7% of the world population suffers from vaginismus, yet the majority of women exposed to the same information do not struggle with painful intercourse. In the end, we do not know which factors influence the development of primary vaginismus.
Secondary vaginismus refers to women who initially had normal pain-free intercourse but something happens that causes pain with penetration. The actual cause triggering this pain is often unknown, but may be related to birth control pills, yeast infections, childbirth, trauma to the pelvic area, hysterectomy, radiation, or menopause. Pain with intercourse appears to initiate an avoidance reflex. It is my opinion that in an effort for the body to protect itself against pain, a reflex is established that causes spasm of the vaginal muscles. This is the body’s attempt to say “no” to vaginal penetration to protect itself from pain. When women with secondary vaginismus are examined, I often find the same spasm of the entry muscle as I do in primary vaginismus. This is why both primary and secondary vaginismus patients respond to Botox injections and dilation under anesthesia as vaginismus treatment.
Any condition that causes pain with intercourse may result in secondary vaginismus. Initial discomfort with intercourse may advance to more intense pain and this is often the beginning of vaginismus and the inability to have intercourse. When a patient with established secondary vaginismus is examined, especially the more severe cases, the same spasm of the vaginal entry muscle is often noted as in the primary vaginismus cases. Therefore, the vaginismus treatment is essentially the same, namely Botox injections and progressive dilation under anesthesia with post procedure counseling. Peri-menopausal and menopausal vaginismus is helped by estrogen replacement and topical estrogen creams. Milder cases of menopausal vaginismus may respond to dilation therapy. Physical therapy has also been shown to be effective.
Secondary menopausal vaginismus appears to start with “microtears,” small tears near the opening of the vagina, especially in the part of the vagina closest to the anus (posterior vaginal fourchette). Once this area suffers a tear, repeated trauma opens the area, causing pain. Here, as in primary vaginismus, I believe that this pain sets up a protective reflex where the vagina is saying “no entry” as a result of spasm of the entry muscle.
Though the causes of primary vaginismus are unknown, there is little question that spasm of the entry muscle is related to the more severe cases of vaginismus. Patients with secondary vaginismus are more likely to demonstrate a cause related to some condition that preceded the onset of vaginismus. Treatment with Botox injections and dilation under anesthesia can be very effective for both primary and secondary vaginismus regardless of the cause.