The importance of clinical counseling in holistic vaginismus treatment

Women with vaginismus not only suffer pain but experience many side effects. Few vaginismus patients have been diagnosed correctly, if at all, from the start of their seeking help. Many tell of a long journey involving several kinds of physicians, alternative practitioners, and therapists, most of whom have misdiagnosed the problem often telling the woman in effect that it’s all in her head. Stories told by patients include feeling “not being a whole woman” and therefore unable to be a “real wife”. Others tell of dating men who abuse them because they don’t deserve better: “No good guy would want someone who can’t have real sex.”

Because understanding of vaginismus is recent, clinicians and physicians often lack training in the diagnostic criteria. They “see” nothing wrong and conclude that the pain stems from psychological issues of the individual or her relationship. Other types of practitioners focus treatment on emotional and physiological awareness and pain control, or on manual relaxation of the pelvic region.

Vaginismis myths


Several myths exist regarding the causes of vaginismus. One of the most prominent is that sufferers were raped or sexually abused and, in response, developed resistance and pain. Another is that negative background, including attitudes of shame or fear of sex, caused the problem. These sound like reasonable causations based on symptoms, but recent research suggests no more prevalence in backgrounds of abuse or negativity than in women with no vaginismus. Nor does sexual pain appear to be a consistent response in women who do have abusive or negative backgrounds. Many vaginismus sufferers report no exceptionally negative backgrounds with regard to sexuality; their female siblings, raised in the same family, do not have vaginismus. The condition of vaginismus has also been confirmed cross-culturally, suggesting that background is not a causative factor.

Vaginismus realities


The most telling support for the diagnosis that vaginismus is NOT “all in your head” is the experience of women who receive appropriate medical treatment. During treatment, under anesthesia, spasms still occur when muscles are touched. Since the woman’s “head” is not involved at the time, one conclusion is that spasms are local and physical as well as involuntary. When such spasms occur in another part of the body, such as facial tics, [botox] is effective in eliminating the spasms. The same treatment works on vaginal muscles. Even after the patient wakes up and her thinking head is again involved in her physiological functioning, the spasms and pain are gone.

Elements of treatment


As in many medical treatments, ending the physical cause is not the total healing process. As we know from other types of bodily injury and rehabilitation, the body may have to learn new muscular responses to the brain’s new signals. Women with vaginismus have tight, short muscles that need stretching over time. Since painful spasms have now been stopped, other forms of therapy can begin. Successful vaginismus patients have daily contact with the physician or nurse for many days or weeks during the dilation therapy that follows Botox treatment. If this supportive, coaching style follow-up is not provided by the physician or her/his well-trained staff, a sex therapist trained in vaginismus treatment and follow-up is necessary.

This process has been reported as 95% successful, success being defined as ability to have painless intercourse within weeks or months of treatment. This success, however, also involves clinical counseling. Although the cause of vaginismus is not in the head, many side effects of suffering from the condition become lodged in the mind and manifest in the woman’s relationships.

Sexuality is central to one’s personal identity; pain of any kind experienced during sexuality affects self-identity. After physical pain has stopped and normal physiological function can begin, lack of positive sexual experience, self -esteem issues, and awkward or scary feelings inhibiting sexuality do not necessarily disappear along with the pain.

What is called “low desire” refers in part to experiencing less automatic desire for sexual relations than one wants to have. Not only the woman, but also her male partner, may have low desire for sex even when her pain is stopped and her muscles have stretched. In her, a lack of sexual desire may result from years of associating pain with sex. Her relationships have also been negatively affected: Women with vaginismus and their partners often experience anxiety, depression, deep feelings of rejection, doubt in themselves and in the relationship, guilt, and lack of trust.

A man in relationship with a woman who has vaginismus may have low desire stemming not only from lack of positive experience, but from feeling he’s caused pain for his partner. This results in no confidence and poor sexual functioning. Not wanting to hurt their partner may lead to erectile or orgasm problems. Both partners are afraid of pain and emotional disappointment, and sexual encounters have often been fraught with apologies and attempts to convince each other that failure of “normal” sex is not due to a lack of loving one another.

Who could have an automatic desire for sex after all that?

Instead, what is now automatic for many couples are negative and anxious emotions and thoughts, recovering from which is not an instant or given result of the medical treatment that stops her spasms. Such issues and experiences are also not exclusive to vaginismus sufferers, fortunately, because this means that qualified sex therapists can help with these non-medical aspects of healing.

Misdirected therapies


Many women and couples who, prior to medical treatment, undertook counseling that did not help are leery of seeing another therapist during or after treatment. Many a woman has been told that she may have repressed memories of abuse, or that some other deep-seated psychological problem is causing vaginal spasms, or that her vagina is closing up because somewhere in her psyche she wants to “keep out” the man’s penis or “avoid emotional as well as physical penetration” (quotes from therapists on e-list discussion).

Objections have been raised by some therapists about the use of botox and dilators to correct vaginismus, claiming that inserting the dilators while the patient is under anesthesia is a violation of the woman, even though she stated wanting (and consented in writing) to the treatment. This is a specious argument unless one assumes that women with vaginismus, despite what they say, don’t really know what they want, whereas the therapist does: that the therapist knows more about the woman than she does about herself – the therapist cannot trust what the patient says and has the right to override what the patient says.

Such assumptions presume that vaginismus IS a psychological problem based on “not wanting to be penetrated.” Such a perspective may be seated in political views. If those views are meant to support women, then it is imperative to understand that women with vaginismus are not psychotic; they have a physical, medically treatable condition.

All women so far treated (Pacik, 2011, 2015) report resulting positive experience, including being happily surprised, even healed from their disbelief, when they wake up with a dilator inserted without pain. Healing does not result from violation. If we adopt the “violated” view, we must also conclude that every woman is lying post-treatment.

Design of successful, non-physiological treatment


A comprehensive and holistic treatment plan for vaginismus includes counseling with a relationship and sex therapist as part of pre-medical treatment preparation. The woman and couple will almost certainly need post-medical relationship and sex counseling. Having a rapport with such a therapist already in place is arguably imperative so that the couple is comfortable with the counselor when pain has stopped, rehabilitation is happening, and intercourse becomes possible. Connection with an appropriately trained counselor prior to treatment combats mistrust caused by any experiences with therapists who may have compounded personal and relationship problems with incorrect diagnosis and treatment.

If the physician is providing much of the vaginal rehabilitation follow-up counseling, part of post-treatment counseling need is being met, but issues beyond the scope of any physician ought to be assessed and addressed by a qualified clinician. Often physicians understandably don’t know what questions to ask, nor how to address the answers; women and their partners themselves often have not sorted out the details and depths of the negative side-effects caused by struggling with vaginismus for months or years. A qualified sexuality counselor with additional current information on vaginismus treatment is integral to helping the woman, her partner, and their relationship heal from the effects of this painful and damaging condition.

Rhea Orion, PhD, CST

Dixon and 

Napa, CA



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