Vaginismus, which has now been renamed in the DSM-5 as genito-pelvic pain/penetration disorder (GPPPD), is the fear of penetration due to a number of contributing factors. I am increasingly finding clients presenting with this problem, with their first memory of discovering a difficulty occurring when they attempted, aged 12 or 13, to insert a tampon.
What I am realising is the tampon is seen amongst some teenage girls as representative of status and adult femininity, and girls are actually being bullied if they can’t use them. This is easily discovered at school swimming lessons, when the ones who are menstruating at the time of the lesson can’t use tampons and have to sit at the side and not enter the pool.
In some schools, communal showers are still occurring where girls might be seen to bleed, exposing them to ridicule. In order to ensure against this, girls will attempt to insert tampons before they start menstruating. This involves attempting to insert a tampon into a dry vagina, which would be very difficult and painful.
Discovering this, some girls continue to try, and the trauma of failure sets them up for fear of penetration of any kind. There seems to be little education around this in schools. I remember myself a teacher demonstrating to us how a tampon works by dipping one into a glass of water, so that we could see how absorbent it was. I don’t remember any discussion about at what angle it was best inserted, what physical positions made it easier, and there was no advice regarding only using them if bleeding enough to warrant use. There was certainly no discussion about inserting a finger first to explore and get to know one’s vagina.
The fact that GPPPD - which can affect approximately two in every 1000 women - can start with a tampon is shocking, and surely easily prevented with more education in schools and a discussion about it around swimming lessons or amongst family members, where the same problems may occur on a holiday beach or private pool.
Understanding GPPPD in the therapy room
Sometimes, clients will present initially with a goal of wanting to have a cervical smear, or insert a tampon. I don’t believe, as a therapist, this is a very positive therapeutic goal for the work, so I will explore with them further their thoughts on penetration and what this might mean for them. They will say things like 'I am not a real woman', so we might explore what it means to them to be a 'real woman'.
Responsibilities come with adulthood, and sometimes it is these that are frightening. They are alarmed at what they see as the expectations and demands that might be made of them should they be able to be penetrated, including sexual intercourse, intimacy, and pregnancy. They may have worries about their sexuality, or fear of abandonment if they allow penetration to occur. In some circles, the size of tampon being used, if discovered, can serve as an indicator of the level of the users' sexual experience, which in truth has absolutely no relevance.
Many women depending on cultural and religious backgrounds, may not be permitted to self-touch, so tampon use is not allowed. Other women may have never seen a penis close up, so the idea of this unfamiliar body part, much larger than a tampon, entering them is terrifying, resulting in huge difficulties in heterosexual relationships and many very tragic wedding nights and honeymoons. I have worked with women who have been married for a number of years before seeking help with this problem. Grown women worry about having enough room in the vagina, or knowing where it actually is because they have not looked in a mirror or been able to explore.
I would urge women and young girls to seek help from their GP, from a psychosexual therapist, or from their sisters or mothers if from a family where this issue could be comfortably brought up. I would hope modern teachers could also address this issue if asked. Menstruation and puberty is challenging enough in the modern world of Instagram and mass body image issues without girls ridiculing other girls for not being able to use a tampon, leading to the self-infliction of private 'tampon trauma'.
An increasing number of clients are suffering from GPPPD, which is highly treatable with the right support. It is often viewed from a strictly medical perspective, and it is very important to consider all contributing factors, starting with why the woman wants sexual intercourse in the first place. I never come from the stance that sexual intercourse is 'natural' or something women 'should' be able to engage in.
By exploring her feelings and emotions around penetration, by looking at any myths and false beliefs, or possible previous experience of trauma including tampon use, her sense of self and sexuality, and her understanding of anatomy and physiology, supportive therapy can help take women’s vagina from a closed and terrified stance to an open and welcoming one, if that is what she truly wants.
That said, it is important to acknowledge that, in some circumstances, women can be in unhappily arranged or even forced marriages, and violent or otherwise abusive relationships where vaginismus might be serving them by protecting them from an unwelcome invasion.