Chances are you’ve never heard of vaginismus (or, as it is now known, genito pelvic pain penetration disorder) before. Why? Because it’s the disorder nobody wants to talk about, least of all those whom it most affects – women. Vaginismus is musculature of the outer third of the vagina, which interferes with coitus and causes distress and interpersonal difficulty. This article discusses unconsummated marriage as a leading cause of infertility.

Among the male factor infertility, erectile dysfunction was found to be the top ranking cause accounting for 79.37% followed by premature ejaculation 12.01%, lack of sexual desire 3.92%, homosexual orientation 2.79%, sexual aversion disorder 1.31% and disorders of sexual preference 0.61%.

Vaginismus is believed to be a psycho-physiologic disorder due to fear from actual or imagined negative experiences with penetration and/or organic pathology. Women with vaginismus have also been noted to have a lack of sex education. Vaginismus was 63.9% , ED 11.9% , PME 8.3% , low male sexual desire 2.7%, low sexual desire in female 13.9% among the female infertility causes. The underlying unconsummated marriage which is a cause of infertility is largely treatable. Adaptation to the situation usually occurs and associated factors add to the primary cause. Treatment of the underlying dysfunction can challenge the relationship.

Sexual dysfunction is a common problem which leads to inter-personal problems and marital discord. defined as recurrent or persistent involuntary spasm of the with coitus and causes distress and interpersonal difficulty.

Treating vaginismus merits a two-front approach which includes behavioral sex therapy techniques and relational intervention. When appropriate, the behavioral intervention consists of prescribing dilators (from smallest to largest) that the wife is to use in the privacy of her own home to gradually desensitize herself to penetration (the fourth and usually largest dilator is roughly the size of a penis). While the husband may be called upon to help his wife insert the dilators (depending on his wife’s comfort level), for the most part his job is to ease off the pressure for her to perform, be supportive, and try to understand his role in the marital dynamic (usually an enabling one) and the associated symptom.
Ascribing to a psychodynamic model of treatment, is helpful for a couple to understand where their symptom came from, but I’ll admit this is not always necessary for them to achieve a positive outcome. Nevertheless, employing the psychodynamic systems approach to uncover any conflicts that might be behind or exacerbating the vaginismus. These underlying causes may include prior sexual abuse, chronic control struggles experienced in the family of origin, negative messages or beliefs about sex emanating from the family of origin, religious values that conflict with sexual pleasure, to name a few. I also pay close attention to the couple’s interactional style in order to assess whether it, too, is a contributing factor.

What causes it?

Both [primary and secondary conditions] are psychologically based. It’s a physical condition, but it’s a psychological condition as well. To treat it correctly, you need to treat both the physical and psychological aspects.

While there are many hypotheses on possible causes, its actual etiology is unknown, probably in part due to the fact sufferers are so reluctant to come forward. It’s a really complex thing, and while it is influenced by many things – there are lots of hypotheses – the big link, for primary vaginismus anyway, seems to be strong correlation between being raised in a religious environment. This may be due to several factors including lack of information, insufficient premarital education, a cultural context strongly proscribing sexual behavior, and the expectation that intercourse take place immediately after the wedding, necessitating a radical shift from sexual abstinence to sexual intercourse.

Often the anxiety resulting from repeated attempts at intercourse contributes to the sexual dysfunction. One or both partners may be anxious that penetration will be painful, that there will be bleeding, or that the woman will get pregnant. While a certain amount of anxiety surrounding sexual activity is normal, when one or both partners are overly anxious, sexual function can be affected in the following ways: The male partner may have difficulty maintaining an erection strong enough to allow penetration or he may lose his erection just prior to intercourse. Anxiety may contribute to premature ejaculation, also just prior to reaching penetration. Anxiety may prevent the woman from relaxing enough to allow penetration. She may close her legs or contract her vaginal muscles. This presentation is referred to as vaginismus, defined as the persistent or recurrent difficulty of a woman to allow vaginal entry of a penis, a finger, and/or any object, despite her expressed wish to do so. While anxiety may indeed be a factor contributing to and perpetuating many sexual problems, there are many components to sexual problems, including physiological ones. Therefore, each partner in a couple presenting with an unconsummated marriage should undergo a physical exam.

Physical presentations of the female partner that might prevent intercourse can include sexual pain disorders such as localized vulvodynia, also known as vulvar vestibulitis syndrome. This fairly common condition is characterized by pain with touch at the entry to the vagina, which can prevent intercourse. A woman’s hymen may be a barrier to intercourse. Some women have a very thick hymen, or a septate hymen, which is a thin piece of membrane running vertically which separates the vagina in to two sides. While most of these conditions can be addressed with sexual counseling and physical therapy, including use of vaginal dilators, in most cases a septate hymen needs to be repaired surgically.
Frequently, lack of knowledge about sexual anatomy and physiology may contribute to a situation whereby attempting intercourse feels awkward and un-natural. Often all that is needed is some basic anatomical information and positioning advice. For example, a couple may report that the woman’s vagina feels dry and excess friction prevents intercourse. In this case, the couple may be advised to ensure that intercourse take place when the woman is sufficiently aroused after plenty of exciting foreplay. Over the counter lubricants may be very helpful. While some people are physically active, very aware of their bodies, and comfortable with movement, other people are less so and may simply have not figured out how their bodies move in order to comfortably find a position for intercourse. One or both of the partners may have mobility problems or difficulty getting in to or maintaining a position. A woman may have difficulty keeping her legs open or a man may not be able to hold his weight up on his arms. In these cases as well, consultation with a physical therapist may be helpful in providing exercises and positioning advice.
While behavioral solutions may be found for many couples, it is important to note that couples in unconsummated relationships, particularly of long standing duration, may benefit from couples therapy directed by a competent Sexologist. A doctor working with such a couple may wish to gain understanding in how the couple presents and organizes around the problem: How is the presenting problem perceived by each partner? Is there attribution of blame? What is the significance of the dysfunction itself and how is that perceived by the couple? Who is aware of this situation and in what way is outside intervention (community, parents, and religious leader) perceived in assisting or perpetuating this condition? Identifying the various factors contributing to the condition and dealing with them with physical, psychosexual, and couples therapy, may be the key to consummation and the commencement of a satisfying intimate life.

Women don’t talk about it. They learn to live with it. I’ve seen cases where women have been married or in relationship for up to 12 years and only present themselves to the sexologist or a doctor when they want to have children. So we are talking about people who are raised in conservative faith, who may not have looked at their anatomy in the mirror. They haven’t touched themselves, they haven’t looked at themselves – they may view the entire thing as being dirty. In terms of the secondary form, this is a result of some kind of trauma or sexual issue, and can be triggered by something later on.

How to treat it

Most women who experience vaginismus choose to live with it rather than come forward and have it treated. Even those in long-term relationships may try to conceal what is happening from their partner or forgo sexual relations all together. If they don’t do that, they cut that part of intimacy out of their relationship altogether and choose to shut down any intimate feelings they might have. They end up having a very different kind of relationship. What is important to say is there is a cure and they can be helped. That’s the message that needs to get out there. Treatment for vaginismus have included systematic desensitization along with insertion of graded dilators/fingers, drugs like anxiolytics, botulinum toxin injection, and sex therapy. And in the Indian scenario where the talk about sex is taboo and limited among partners it becomes very essential to first improve their communication so as to improve the sex related issues. eclectic approach involving education, graded insertion of fingers, Kegel’s exercises and usage of anaesthesia with vaginal containment was tried.

The best approach in terms of a cure is to seek both psychological and physical treatment. For the psychological side of things, it is recommended to seek out a competent female sexologist. Physically, many women are taught how to use vaginal dilators in conjunction with relaxation techniques.

With vaginal dilators, basically how they work is you start off very very small, and then, using relaxation techniques, slowly work your way up in terms of size. It’s imperative these women have a gentle introduction and remember they are in control of the situation. There is also something called saturation therapy which is often undertaken with their partner. Using dilators, they are able to discuss their mental state and what their thoughts are at any stage. There has actually been incredible results with that. Something like 90 percent of participants report sexual success afterward. there has been some preliminary research done into the effectiveness of Botox, but states at this stage, the research is still too new to offer any kind of conclusive evidence.

Steps to take

If you think you or your partner might have vaginismus, it’s extremely important to understand treatment is available, and, better yet, comes with a high level of success rates. The first step is to see a competent female sexologist. It is one of those things that, when it presents, it is pretty obvious it is on a psychological basis. A sexologist may double-check everything is okay, but typically what they will find is anatomically they are fine and everything is in order and working – the cause stems from a psychological basis.

“The big thing about it is it’s treatable, and it is possible to lead a really fulfilled life. Don’t suffer in silence. We can definitely help. We see this, deal with it, and we have success with it.” – at our Sexual & Mental Health Clinic, Avis Hospital in Hyderabad.

Conclusion

It’s time for the unconsummated marriages to come of the the closet and treat their condition for a satisfactory married life and have healthy children subsequently.