When Sex Feels Scary: Confronting Vaginismus as a Phobia Response

Have you had to prolong foreplay, linger in bed, and snap out of a hot moment simply due to the fear of painful sex? When what could have been an ‘oo-lala’ moment soon turned into a compensatory make-out session? It may have affected your partner, too. What if we told you that you are not alone? Many struggle with fear and avoidance of penetrative sex due to pain. Science calls it vaginismus, and this article talks about vaginismus as a phobia response.

Vaginismus is of two types:

• Primary vaginismus is when you discover pain and tension in your vagina when inserting a tampon/menstrual cup for the first time or on the first attempt of having sex.  
• Secondary vaginismus happens with time in an otherwise healthy vagina due to reasons such as pathology (endometriosis, vaginal inflammation, childbirth trauma, etc.), sexual trauma (abuse, rape, etc.), severe stress (marital conflicts, lack of intimacy, etc.) and more.

Recent research explores many aspects of vaginismus that allow the inclusion of other causative factors. It was renamed ‘genito-pelvic pain/penetration disorder’ by The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association.

We can now add other mental responses that precipitate vaginismus and have a purely psychological set of causes.

A phobia is an excessive fear of something that’s usually irrational. We now describe primary genital pain, vaginismus, with secondary behavioural features — vaginismus as a phobia or fear response. 

It usually affects a smaller section of women who may have had a gynaecological examination once in their lifetime, who desire sexual intimacy and vaginal childbirth but are scarred by the thought of vaginal penetration. 

They are in a state of ‘anticipatory anxiety’ with the thought of penetrative sex. 

The key symptoms of fear of vaginismus as a phobia response include fear of pain or penetration as well as involuntary tension in the pelvic floor muscles. Phobic anxiety defines the state resulting in avoidance behaviours during penetration attempts. Thus, avoidance behaviour, aimed at preventing pain, plays a central role in perpetuating the condition. 

However, vaginismus (here, vaginismus as a phobia response) and penetration phobia are different. In vaginismus, avoiding penetration helps prevent expected pain, while in penetration phobia, avoiding penetration prevents the upcoming intense panic or anxiety. Vaginismus is within the extended scope of clinical gynaecology — a psychosomatic (related to the body and mind) condition. Penetration phobia, on the other hand, is purely related to psychiatry. 

Understanding the mental and emotional aspects behind physical symptoms is crucial. Vaginismus results from a mix of physical and psychological factors influenced by relationships and cultural context. Each case is unique.

Possible causes of fear of vaginismus as a phobia response are:

1. Longstanding ideas of sex being painful, unpleasant, and terrifying through distorted sex education, misinformation from peers/family, or through inaccurate videography.
2. Restrictive, orthodox upbringing in the family, through religious scriptures or social taboos on sex. 
3. Beliefs about hymen damage and tissue tearing with sex
4. Conservative and primitive thoughts about masturbation, penetrative sex, fingering, or sexual toys being inappropriate
5. Fear of pregnancy, contraction of sexually transmitted diseases, etc.
6. Traumatic first sexual encounter, experiencing or witnessing sexual abuse, poor intimacy, unhealthy and abusive relationships.
7. General stress and anxiety due to work, personal life, or something more overwhelming happening in life can also lead to vaginismus as a response.

The steps to treating fear of vaginismus as a phobia response are slow, steady, and gentle. The idea is to diagnose the root cause first, identify the triggers, and smartly approach them. Diagnosis is challenging, often relying on patient history due to examination difficulties. With that as the core, studies divide the treatment plan into two parts — for those with a clear diagnosis and those without. A gynaecological examination is crucial but often deferred due to patient discomfort, which relies on history and observed behaviour.

Treatment starts with deliberate attempts to overcome the ‘avoidance behaviour’. How does that work?

Science terms it as ‘gradual desensitisation’ through at-home exercises with a dilator or at your gynaecologist’s clinic. It is a good idea to involve your sexual partner in treatment for fun learning and comfort. But there is a downside to this. Some partners accommodate avoidance behaviours, hindering treatment progress. 

If the diagnosis is unclear, it is considered a good idea to work your way outside in. As regular treatment regimens continue, the cause may be established. A comprehensive approach at a clinic can help with proper diagnosis and treatment planning. Cognitive behavioural therapy (CBT), vaginal exercises, mind-body relaxation exercises/yoga, and medication are traditionally used.

Fear of vaginismus as a phobia response is much more common than we realise. It is unspoken — hence goes undiagnosed and untreated. The unique complaint in this case includes the fear and anxiety involved with the thought of an upcoming painful sexual encounter. Once identified and diagnosed, cognitive and behavioural therapy (especially with your partner) is super effective. You might just get back in bed with a bang sooner than you’d ever imagined! 

The fear of painful sex is normal and now treatable. You first need to speak out. Discuss with your partner and your gynaecologist. Through mild medicines, behavioural therapies,  vaginal exercises, and stress management, it may be resolvable.

Yes, studies show that anxiety at work and in your personal life can make your vaginal muscles tense and reduce the feeling of arousal and intimacy, resulting in painful penetrative sex.  

Sexual encounters can be relaxing with your partner. Sex allows your hormones to flow, arouses you, and boosts emotional health — thereby reducing anxiety.

The biggest psychological effect of painful sex is the avoidance behaviour for the next encounter. You may also feel scared, anxious, and stressed by thoughts of having sex. 

Panic attacks during sex can be multifactorial — painful penetration, past sexual trauma, sexual abuse, inaccurate and distorted ideas of sex, and more.