Vaginismus and sexual pain: in conversation with a gynaecologist

Interview conducted by Claire Vasseur, Slow Sex & Love Life. This interview is part of our series on female sexuality and mindful intimacy.

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Understanding vaginismus: the basics

Dr. Lefebvre, vaginismus is a term many women have heard but few fully understand. How do you explain it to a patient arriving in your office for the first time?

The first thing I do is normalise. Vaginismus is an involuntary reflex — a protective muscular contraction of the pelvic floor that happens without the person’s conscious intention or desire. It is not a rejection of the partner. It is not a sign that something is “wrong” with the person. It is the body doing what it has learned to do, for reasons that made sense at some point and now no longer serve.

The analogy I use is the eye blink reflex. If someone waves a hand near your face, you blink involuntarily — you cannot prevent it by willpower alone. Vaginismus works similarly: the pelvic floor muscles have learned to contract in anticipation of penetration, and that learning can be unlearned.

Who does vaginismus affect? Are there risk factors you commonly see in clinical practice?

It cuts across age, background, and relationship history in ways that still surprise clinicians. I see it in women who have never had any sexual contact and in women who have been sexually active for years. I see it in women with no history of trauma and in women with complex histories.

That said, there are patterns. Women who received strongly negative or shame-laden messages about sexuality in childhood or adolescence appear at higher frequency. First penetration experiences that were painful — whether sexual or medical — can set the reflex in motion. A very common trigger I see is the routine speculum examination: performed too quickly, on a patient who is not relaxed, it can be profoundly aversive and create anticipatory anxiety that generalises to all penetration.

This is why the clinical environment itself matters. Gynaecological examinations should never be rushed. They should be explained, offered alternatives when possible, and paced by the patient.

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Dyspareunia and vaginismus: distinguishing the conditions

What is the difference between vaginismus and dyspareunia? Are they related?

They overlap clinically but are distinct conditions. Dyspareunia means painful intercourse, and it has multiple possible causes — including but not limited to vaginismus. Endometriosis can cause deep dyspareunia. Vulvodynia (chronic vulvar pain without an identifiable cause) causes superficial dyspareunia. Hormonal changes — particularly oestrogen decline in perimenopause and menopause — cause vaginal dryness that makes penetration painful.

Vaginismus, specifically, is the musculoskeletal reflex component. A woman can have dyspareunia from endometriosis without vaginismus. She can develop secondary vaginismus because repeated painful penetration has trained the pelvic floor to contract protectively.

Clinically, distinguishing between them requires proper examination — ideally including input from a pelvic floor physiotherapist, because the examination itself needs to be performed carefully and with the patient’s active collaboration.

What does diagnosis look like in practice? How do you approach the physical examination for a patient who is anxious or in pain?

Very differently from a standard gynaecological examination. When a patient comes to me with suspected vaginismus or pelvic pain, the first appointment is almost entirely verbal. We talk. I take a detailed history — not just medical, but relational, emotional, contextual. How does the pain or contraction present? In what situations? With what thoughts? What has she already tried?

The physical examination, if it happens at all in the first session, is proposed — never assumed — and entirely controlled by the patient. I use the smallest instruments. I explain each step before I perform it. I stop the moment she signals discomfort, without pressure to “push through.”

The goal of the first examination is not diagnosis. It is building trust — between the patient and her own body, and between her and the clinical space. Without that trust, examination is counter-therapeutic.

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Treatment pathways

What does the treatment pathway look like for vaginismus? What can a patient expect?

Current best practice is a multimodal approach. No single intervention works alone for most women.

Pelvic floor physiotherapy is the cornerstone for the physical dimension. A specialised physiotherapist works progressively — first through breathwork and relaxation techniques, then through manual therapy on the pelvic floor muscles, and eventually through graduated dilation exercises using vaginal trainers. This is not painful: the patient sets the pace entirely.

Sex therapy or cognitive-behavioural therapy addresses the anticipatory anxiety component — the mental loop of “it will hurt” that reinforces the muscular contraction. Thought patterns around penetration, pain catastrophising, and sexual expectations are worked through explicitly.

Couple therapy is often beneficial when vaginismus has created distress or distance in the relationship. Partners need guidance too: how to support without pressure, how to maintain intimacy during treatment, how to understand that vaginismus is not about them.

Medical interventions — topical oestrogen for hormonal dryness, treatment of co-existing vulvodynia or dermatological conditions — are addressed where relevant.

Where does [mindfulness](/en/mindful-sexuality/) fit in this picture?

Increasingly centrally. Lori Brotto’s work in Vancouver has shown that mindfulness-based approaches reduce the anticipatory anxiety that drives the reflex. When a woman can be present with sensation — observing it without immediately interpreting it as threat — the amygdala’s alarm response begins to decrease.

For women with vaginismus, I often recommend body-focused mindfulness practices before any dilation work begins: learning to be present in the body in non-sexual contexts, developing interoceptive awareness, practising the tolerance of sensation without automatic flight. Yoga, somatic movement, conscious breathing — all of these create useful neural ground. When the underlying cause involves trauma, the work of body-oriented therapy for sexual trauma provides a complementary path toward reclaiming embodied safety.

The ISSWSH provides clinician guidelines that now formally recognise mindfulness-based interventions as adjunctive treatments for female sexual dysfunction, including vaginismus-adjacent conditions.

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The partner’s role and relational dimension

What advice do you give to the partners of women with vaginismus?

First: understand that this condition has nothing to do with attraction, desire, or love for you. The reflex is not personal. Partners who internalise vaginismus as rejection are suffering unnecessarily and, in many cases, inadvertently adding pressure that worsens the situation.

Second: your role is to reduce pressure, not to accelerate progress. Progress happens on the woman’s timeline, in her body. Patience is not passive — it is an active contribution to healing. Maintaining intimacy in non-penetrative forms — touch, presence, shared sensory experiences — is both practically useful and emotionally important.

Third: come to a session with the therapist if you can. Hearing from a professional what is happening neurologically and physiologically often helps partners understand in a way that conversations at home cannot.

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Prognosis and what practitioners rarely say

What is the typical prognosis? And what do you think practitioners don't say often enough to women with vaginismus?

The emotional and relational dimension of this healing process connects directly with what we explore in our guide to couple intimacy rituals.

The prognosis is genuinely very good. Studies consistently report resolution rates of 80–95% with appropriate multimodal treatment. Vaginismus is one of the most treatable sexual dysfunctions we know. The difficulty is not the condition itself — it is access to qualified care and the courage to seek it.

What practitioners rarely say, I think, is this: you are not broken. The reflex is protective intelligence that got applied in the wrong context. Your body is working correctly — it is trying to protect you. Treatment is not fixing something defective; it is teaching the body that the situation has changed, that it is safe.

The second thing that isn’t said enough: penetration is not the only or even the primary measure of sexual fulfilment. Treatment should aim at wellbeing, not at a specific act. Some women in treatment discover that what they wanted was not penetration per se, but intimacy without fear. That is a valid destination, and reaching it counts as full success.

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