When we think of vulva anatomy most of us think about the obvious parts, the clitoris, labia, and vagina, the things we have seen on our own bodies, on others, or have learned about when we learned about the “birds and the bees”. What many of us don’t think about is the muscles that live under these parts. These muscles, known as the pelvic floor are integral to our sexual function.
Oftentimes, I have seen individuals who have been gaslit into thinking something is inherently wrong with them when they experience pain with sexual function.
As a pelvic floor physical therapist, I have spent my career treating issues of the pelvic floor. Oftentimes, I have seen individuals who have been gaslit into thinking something is inherently wrong with them when they experience pain with sexual function. I have seen people of all genders who have been to every doctor imaginable and who have been tested negative for disease or infection, left to feel that somehow, they were the source of their sexual pain. That somehow, their action or inaction had been the cause of their issues in bed. Many had gone for years without knowing that the source of their pain was spasms and tightness in their pelvic muscles and more importantly, they did not know that their pain could be treated. It is my hope that if you feel this way, this piece can provide you some clarity on what may be causing your sexual pain and empower you to heal it and live your best sexual life.
For the purposes of this piece, I will be writing about folks with vulvas, however, I want to take time to note that people with penises experience pelvic floor dysfunction too, and can experience many of the same symptoms I will describe later on.
To understand pain with sex, you must first understand the pelvic floor. The pelvic floor is the group of muscles that lay in between your tailbone in the back and your pubic bone in the front. These muscles perform four basic functions along with sexual function. In addition to sexual function, the pelvic floor helps to stabilize the spine, return blood and lymphatic flow to the body, support our pelvic organs, and maintain continence. As interesting as all that stuff is, I’m guessing you are not here to learn about these four functions, you want to learn about how the pelvic floor helps with having awesome pain-free sex.
When we get horny, we experience erection regardless of whether we are working with a penis or a clitoris. Both share the same embryologic origin and share many features, believe it or not. The muscles of the pelvic floor can help in the process of erection, making the clitoris more responsive to stimulation. The deeper muscles of the pelvic floor should also be able to lengthen and relax to allow a penis, fingers, or toy to enter without pain. When the muscles of the pelvic floor are too tight or too loose (this is the less common presentation where I practice, even with postpartum people), they can become weak and even painful. Weak and tight pelvic floor muscles can cause pain with arousal, deep pain with penetration, and even prevent penetration all together (vaginismus).
Usually, pelvic floor dysfunction occurs gradually over time and may not be noticed until it really starts to impair your ability to have sex.
The reasons for pelvic floor dysfunction are many. Most of the time there isn’t the “oh crap” moment when you realize you’ve injured your pelvic floor. It’s not like spraining an ankle or tearing your hamstring. Usually, pelvic floor dysfunction occurs gradually over time and may not be noticed until it really starts to impair your ability to have sex. One obvious exception to this statement is childbirth, spinal cord injury, or neurodegenerative disease, amongst others.
For most of my patients, I see people with pelvic floors that have been held in tension for a really long time. Almost to a person, there is no definitive singular cause we can put our fingers on for their pelvic tension. It usually boils down to a “little of this and a little of that”. Poor habitual posture can put the pelvic floor in a position where it must over tighten to support your pelvic organs. Additionally, having poor deep core stabilizers (think the abs under your abs) can lead the pelvic floor to overwork.
Individuals who have had chronic infections or even just one really gnarly one in the genital or bladder area can develop pelvic floor issues because of a crazy reflex known as the viscerosomatic reflex. Basically in the viscerosomatic reflex, muscles innervated by the same nerve root as the affected organ will experience pain and spasm. For example, someone who has had a bladder infection may experience spasms in their pelvic floor, long after the infection has been cleared. A more known example would be the arm and or jaw pain experienced by people suffering a heart attack.
Importantly for almost all of us, stress is a major contributor to pelvic floor tension and pain. In a landmark study in 2001, van der Velde and colleagues attached sensors to the external pelvic floors of individuals with vulvas, both with pelvic floor dysfunction and those without it. They showed the study subjects four film excerpts, erotic, neutral, sexually threatening, and threatening. For both groups, regardless of their pelvic floor dysfunction status, the threatening films caused increases in the muscle activation of the pelvic floor. Individuals experiencing high levels of stress can be especially vulnerable to pelvic floor dysfunction.
Pelvic floor dysfunction can show up in a multitude of ways. With sex, we may see individuals having trouble getting aroused, experiencing pain with arousal and orgasm, deep and superficial pain with penetration, and in the case of vaginismus, the muscles surrounding the vagina involuntarily contract to make penetration of a penis, toy, speculum, or tampon, excruciating, or downright impossible.
Vaginismus can be terribly distressing as the person experiencing it may deeply wish for the penetration but lack the control over their pelvic floors to achieve it.
Vaginismus can be terribly distressing as the person experiencing it may deeply wish for the penetration but lack the control over their pelvic floors to achieve it. To put it bluntly, it really sucks. Vaginismus can be classified in two ways. It can either be considered primary or secondary. Primary occurs from the very first time one attempts penetration. I have seen it clinically as early on as in adolescents who have had to sit out beach vacations because they could not insert a tampon despite having a great desire to do so, so they can be with their friends and do normal teenage beach activities.
Secondary occurs later on after having once achieved successful penetration. It can be brought about usually from some type of painful experience. Trauma, both capital T and lowercase t trauma is often a culprit, but I want to make it abundantly clear that one need not experience a trauma of any kind to have primary or secondary vaginismus. Vaginismus can be brought on from previous painful sex experiences, think those caused by muscle tension, infection, or the vulvar tissue changes brought on by menopause and estrogen deficiency. It can also be worsened by stress, think back to the van Der Velde article we discussed earlier.
TLDR: You are not crazy or broken, you are not alone, and there is hope.
There are a few things I want to make clear about vaginismus. Although psychological interventions are tremendously helpful in treating vaginismus, as well as helping to deal with the emotional burden of the condition, it is not all in your head. Powering through the pain, not only is not helpful but may backfire by causing the muscles of your pelvic floor to become even more sensitive and contract more readily to protect your body from the perceived threat of pain with penetration. Vaginismus is not all that uncommon and can indeed get better with the right treatment. TLDR: You are not crazy or broken, you are not alone, and there is hope.
I have worked for the better part of a decade with people with vaginismus and have seen amazing things. I recognize access to pelvic PT is a privilege not all of us have, but there are places we can all start from, right now to help with your vaginismus symptoms. Here are my tips:
- If you haven’t already done so, get yourself to a doctor or clinic who can rule out infection. All the pelvic PT in the world, won’t really have a solid chance if you have a raging UTI. This is honestly where I would put my money first.
- Please don’t do kegels. There is a time and place for them, I have yet to see it with vaginismus, tightening an already tight muscle will usually make the problem worse.
- To the best of your ability, start working on stress. I am a huge advocate of mindfulness meditation, however, even just cutting out 5 minutes a day to have a relaxing cup of tea, or stretch is a great start. Do you as long it relaxes you.
- Consider dilators. Dilators are cylindrical rods (sometimes described as dildo-like), that gently stretch the muscles around the vagina. I would highly advise you to start a dilator program under the guidance of a medical professional, even if it is a one-off visit, just to make sure you are doing them correctly and safely. The most important thing to keep in mind with dilators is to keep your pain level low with them. Too much pain will backfire.
- Take penetration off the table for a period of time. Whether it’s with a penis or toy, give penetration a break. Instead, explore the world of outercourse, which can be tremendously fun. Take this time to give your vulva a break as well as to teach the muscles of the pelvic floor that your genitals can be a source of pleasure and not pain.
- If it is possible, consider pelvic floor physical therapy. A highly trained pelvic floor physical therapist can guide you through your dilator program as well as catch any other factors that may be affecting your pelvic floor.
- Don’t lose hope. You are not alone and you can get better.
Fiona is a Physical Therapist working in NYC. She has devoted her entire career as a physical therapist to the treatment and awareness of pelvic floor dysfunction. In addition to helping her patients of all genders and orientations achieve awesome sex, Fiona takes time for her many hobbies such as distance running, hiking, and camping.
van der Velde J, Everaerd W. The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther. 2001 Apr;39(4):395-408. doi: 10.1016/s0005-7967(00)00007-3. PMID: 11280339.