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Your husband is going to leave you, yeh mai app ko likh ke deti hoon [mark my words], is what 29-year-old Laiba* was told when she went to an experienced and well-reputed gynaecologist in Karachi. Laiba, now 34, still remembers those words. “It wasn’t the choice of words that cut deep; it was the tone, the absolute lack of empathy this woman showed me, the shame she meant for me to feel.” Laiba recalls how she sat there frozen, unable to voice her concerns.

“Jo aurat apna basic kam nah ker paye [A woman who isn’t able to fulfil her basic responsibilities]…I suggest you grow up and stop being a silly schoolgirl.”

It took Laiba almost another two years to mentally prepare herself to see another gynaecologist. She recalls going home from the clinic in tears, “My mother kept reassuring me that my husband would do no such thing as I sobbed in the waiting room and then in the car on the way home. Of course, I knew my husband wouldn’t leave me, but what I couldn’t explain to my mother was that my husband wasn’t the issue. The truth was, it had taken me an entire year to muster the courage to talk about something that had so much shame attached to it.” She waited another two years before visiting another gynaecologist. “I remember asking the friend who had been to her if she was kind. Can you imagine? That is the bare minimum I was expecting.”

The second doctor listened to Laiba’s journey since her marriage and, after examination, diagnosed her with vaginismus. “I was so relieved. I mean, it’s strange to hear someone being relieved upon hearing that they have a serious medical condition, but I felt so alone and I finally received validation that there was a term for what I had and I wasn’t alone in it,” Laiba recalls, with a flood of happy tears.

So what exactly was Laiba diagnosed with? According to the NHS, vaginismus is when the vagina suddenly tightens up when you try to insert something into it. It can be painful and upsetting, but it can be treated. Vaginismus is most common in women in their late teens to early 30s but anyone with a vagina can get it.

Dr Mala Jitendra Shahani, a consultant obstetrician and gynaecologist based out of Altamash General Hospital in, Karachi, offers a detailed explanation of this condition. According to Dr Shahani, vaginismus manifests as an automatic and uncontrollable response when penetration is attempted. The muscles around the vagina tighten or go into spasm without any conscious control from the woman. This reaction is entirely involuntary and occurs specifically when something is being inserted during intercourse.

Dr Shahani notes that in her practice, she frequently encounters women who use various methods to manage this condition. They may use menstrual cups, tampons, or other devices without problems. However, when it comes to sexual intercourse or other forms of penetration, the involuntary muscle contractions persist. This condition, known as vaginismus, is thus characterised by an unintentional and reflexive muscle spasm, which complicates the experience of penetration.

Why does it happen?

According to Dr Shahani, vaginismus is a psychosomatic response — an interaction between mind and body. The body anticipates pain with penetration, leading the vaginal muscles to contract and go into spasm. This can occur due to various psychological and physical reasons, but it is primarily psychological, often rooted in societal stigma surrounding sex.

In many cultures, sex and intercourse are considered taboo subjects. Dr Shahani explains that the first impression many girls have of sex is something painful and unpleasant. “Our mothers, grandmothers, sisters, and relatives often discuss this topic in a very negative light, which psychologically embeds discomfort and pain in many young girls’ first impressions of intercourse.”

Dr Omema Akhtar, a consultant gynaecologist at the Jinnah Postgraduate Medical Centre in Karachi, says, “Almost every woman, to some extent, experiences this, but some overcome it while [for] others [it] persists.” She explains that although there is no statistical data available, “roughly speaking, in every two clinics, one patient presents with a history of vaginismus.” The doctor emphasises that it is not a particularly challenging condition to treat effectively.

She compares vaginismus to erectile dysfunction — neither of these conditions are in the control of the person suffering from it. Dr Akhtar adds that there is nothing to be ashamed of if someone struggles to overcome this problem. “There is no fault of the woman in this, because it is involuntary and not in her control at that time.”

According to a study published in the Journal of South Asian Federation of Obstetrics and Gynaecology, the worldwide prevalence of vaginismus is reported to be in the range of one and seven per cent. In clinical settings in the US, the prevalence of vaginismus in contemporary population ranges from five to 17pc. Studies conducted in Egypt report vaginismus as 20pc. The study noted that no previous research had been conducted on vaginismus in India. It surveyed 160 married women in India’s Karnataka and found 28pc had primary vaginismus while 30pc had secondary vaginismus.

Apart from a few limited studies, there is no official data on how many women suffer from the condition in Pakistan, but based on her own experience, Dr Akhtar estimates that approximately one in 20 women has vaginismus.

Discussions about sex and pleasure are rarely healthy in Pakistan. Sex is often portrayed as something dirty and unmentionable, associated with pain, tearing, and bleeding. This negative portrayal can lead to fear and apprehension about sexual experiences.

According to Samia Khan, a licensed professional counsellor, licensed marriage and family therapist, and certified sex therapist with her own practice in Wisconsin, USA called the Whole Hearted Wellness, “Cultural and religious backgrounds contribute to the development of vaginismus. Essentially, the idea is that our mind and body are deeply connected, especially regarding emotions and physical experiences. When society sends messages that make intimacy taboo, we internalise the belief that it is something we should avoid or not engage in. Consequently, when we are married and ready to be intimate with our partner, we might struggle due to these ingrained perceptions”.

She adds how our body says “no” because our mind has been conditioned to view intimacy as bad, dirty, or inappropriate for girls. As a result, our body reacts to these internalised beliefs by physically resisting, leading to pain and muscle spasms that prevent penetration. In her opinion, these factors can definitely worsen vaginismus.

Meanwhile, Dr Shahani notes that previous trauma from sexual assault or rape can significantly contribute to this fear.

Misha*, 36, reflects on her childhood sexual abuse, noting, “I grew up in an environment where the burden of sexual abuse was placed on the victim. Although I knew deep down it wasn’t my fault, I chose to suppress the trauma. After marriage, I struggled with intimacy; my husband felt like there was a wall he couldn’t get past anytime penetration would take place between us. I initially thought I had a physical deformity, but after a consultation with a surgeon, I was told I had vaginismus.” Misha’s diagnosis was pronounced in the US, and she is thankful for the opportunity to move there after her marriage. She recognises that had she remained in her hometown of Gujranwala, she likely would have received little to no support.

But while sexual assault or abuse can contribute to the condition, it isn’t the only reason for it.

Anum*, 27, recalls how her gynaecologist did diagnose her with vaginismus but dismissed it. “She insisted I was sexually abused as a child but I was not admitting to it or had repressed it. I didn’t, but she wouldn’t buy it, so I changed doctors until I found someone who understood this was beyond my control and it wasn’t a condition that was an outcome of abuse.”

But how does one find out they have a condition that no one wants to speak about? “We Google everything, don’t we? From how to make a pancake to fixing the geyser —everything. So this was very natural,” recalls Ayesha* an A-level math teacher. “All I had to type in was ‘fear of penetration’ and lo and behold, I was introduced to not just the term vaginismus but a whole community very willing to help. However, I found it a little difficult to connect culturally with these white people who were surprised I lost my virginity at 25 and had never explored my body per se.”

That is when Ayesha realised she needed people who would understand her issues in a language and culture where she did not have to struggle as much. “I Google everything and it’s an instant problem solver — things I am ashamed of, things I wouldn’t even say aloud to my husband, but that is a privilege I have. I sympathise with our mothers who navigated life without this very useful tool.”

The road to recovery

Anxiety surrounding penetration can worsen the condition. Treatment options for vaginismus often involve a combination of physical therapy to relax the pelvic floor muscles and psychotherapy to address any underlying anxiety or fear.

Counsellor Khan believes a physical therapist specialising in pelvic floor therapy can help address vaginismus by working to relax and exercise the pelvic muscles. This can be particularly beneficial when psychological impacts or past traumas, such as childhood sexual abuse, contribute to muscle spasms and physical blockages. By normalising these treatments and making such resources more available, we can better manage the guilt and shame prevalent in our culture.

When considering whether vaginismus is physical or psychological, Dr Shahani clarifies, “In medical terms, when physical factors are involved, we refer to it as dyspareunia, not vaginismus. Vaginismus primarily involves the contraction of the muscles. Dyspareunia is used to describe pain during intercourse when physical factors are present. Vaginismus, on the other hand, is mainly psychological, with the underlying cause often being psychological.”

Physical factors like previous childbirth or conditions such as vaginal lesions, tumours, atrophy, or narrowing can contribute to discomfort and pain, but these are often secondary to the primary psychological causes. Vaginismus may involve muscle spasms during attempted penetration, and sometimes hymen abnormalities can also play a role.

To treat vaginismus, Dr Shahani employs a multidisciplinary approach involving a psychologist, physiotherapist, sex therapist, and sometimes a neurosurgeon for pain management. Medications can also help — topical gels can numb pain, while muscle relaxants in ointment form or Botox injections can relax the muscles. Anti-anxiety medications prescribed by a psychiatrist may also be beneficial, depending on the patient’s history and condition.

Khan also believes that there no one way approach for curing the condition. Talk therapy or psychotherapy alone may not be sufficient. Combining it with pelvic floor physical therapy can address both the psychological and physical aspects of these conditions.

While talk therapy helps with the mind-body connection, pelvic floor therapy targets muscle relaxation and pain management. Research indicates that vaginismus is not solely psychological; it involves real physical pain and muscle spasms that need to be treated both mentally and physically.

Dr Shahani’s treatment physical protocol includes the use of vaginal dilators, starting with the smallest size. She often instructs the patient’s partner to assist with dilation in the clinic, as some patients feel more comfortable with their partner’s support.

Dr Shahani suggests using candle sticks as an alternative to expensive silicone dilators, noting that candles come in various sizes and the wax is generally gentle on the skin.

She emphasises that a supportive partner is crucial to overcoming vaginismus. The doctor has observed that some couples may separate or divorce if the condition is not managed effectively. Patience is key, as it can take up to three years for some couples to successfully manage penetration.

Dr Akhtar agrees: “As long as there is no supportive partner, the treatment of vaginismus can be challenging. I have seen patients whose partners were not understanding at all. These women came to us for the treatment of vaginismus and were able to insert dilators on their own. However, when their partners approached them, they were unable to allow it.

“How can they, when there is no mental or emotional understanding? When there is no spark in their relationship, how can a woman feel ready to allow her partner to be intimate? That’s why vaginismus treatment often involves both partners — it’s a couple’s treatment. Doctors recommend that once we treat vaginismus, couple’s counselling and participation become very important.”

Hamnah*, now 33, got divorced when she was 21. “I got divorced fairly young. I was married to a friend of the family who was 11 years my senior. Before my wedding night, I had no concept of physical intimacy, let alone ever having spoken to a boy. The opposite gender was alien to me and I didn’t know what to expect.

“On the wedding night he forced himself on me. I broke my hymen in the most painful way possible, and after that, I wouldn’t let him touch me — I was so traumatised. Every time he would initiate intimacy, I would start shivering and crying to the point where my in-laws got involved. After six months of this ordeal, he dropped me off at my parents’ place and sent divorce papers before I turned 22.” Hamnah has not remarried.

Much to learn

The truth is that women’s bodies are not studied enough, especially in the realms of reproductive health and female genitalia. Symptoms associated with menopause and menstruation have long been dismissed by doctors. Let’s not forget about the 19th and 20th century medical fascination with female hysteria, leading to women experiencing what was likely mental health issues being locked away from society. For far too long, research has been tainted by gender bias, with studies predominantly based on male participants and then applied onto women.

There is still much to learn about vaginismus and its physical and psychological impacts on women. In a country where mental health is considered a privilege reserved for a select few, many suffer in silence and shame.

Vaginismus is a lonely and terrifying condition. It isolates those who experience it, and when they seek help, they are often met with shame and silence. In a culture that confines women’s bodies to roles of enduring pain and delivering pleasure, it’s no surprise that we find ourselves burdened with trauma and unspoken emotions. These feelings accumulate in the hidden spaces between our hips, places shrouded in silence and misunderstanding, leaving us unsure of how to release them

“I have been in clinical and physical therapy both,” says 31-year-old Qurat*. “Just a month ago, I managed to get a pap smear and felt invincible. But a week later, I couldn’t manage to get an internal ultrasound. I have seen people ‘cure’ themselves of vaginismus, but I guess everyone is on their own journey. Mine has had lots of ups and downs, but I just need to keep reminding myself that this doesn’t make me less of a woman or partner. If I am not kind to myself, no one else will be either.”

*Names have been changed to protect interviewees’ privacy