In the show Sex Education, a character named Lily finds out she can’t have penetrative sex. Though she finds a partner and fully consents, her vagina won’t allow him entry. But she wants to do it! Her unofficial sex counselor and fellow classmate, Otis, diagnoses her with vaginismus — a sexual dysfunction condition that causes the pelvic walls to contract and let noobject in. This was pleasantly new territory for the TV space, and even critics claimed to have learned something new. However, vaginismus is one of the more common sexual dysfunctions. While stigma against female sexual dysfunction inhibits recording the real number of women suffering from it, the rate of vaginismus diagnoses for women who come to sexual dysfunction clinics ranges from 5 to 17%.

In India, where sex itself is a hush-hush topic, discourse around female sexual dysfunction is virtually unheard of. Women, especially unmarried ones, also often feel uncomfortable discussing sex-related health issues with their gynecologists. In 2018, Buzzfeed carried a powerful essay from an anonymous woman who misdiagnosed herself with vaginismus, only to find out she has a septate hymen (a band of extra tissue that creates two small vaginal openings instead of one). In it, she wrote, “Reproductive health in India, especially for young and unmarried women, is restricted to having regular periods and perhaps dealing with PCOD. Sexual activity or its lack thereof is gauged through euphemisms such as ‘Are you married?’ Ideally, my gynecologist should have done an internal examination. Was she just being lazy? I doubt it. As a society, we actively try to restrict young women from having sex. And she succeeded that day, causing me years of anguish.”

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Indian women who have pre-marital sex have no way to tackle problems like sexual dysfunction besides scouring the internet. While the above writer tells us about how she misdiagnosed a septate hymen as vaginismus, many other young women who self-diagnose find refuge in online communities, like r/vaginismus, until they have access to a non-judgemental gynecologist.

“Women who have vaginismus experience an involuntary and, at times, painful spasm or contraction of the muscles around the vagina and in the thighs, in response to attempted sexual intercourse or a gynecological examination, in the absence of any abnormalities in the genital organs,” said Dr. Sulbha Arora, clinical director at Nova IVF Fertility. According to the Diagnostic and Statistical Manual of Mental Disorders (Edition IV), vaginismus is a “recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina, which interferes with coitus and causes distress and interpersonal difficulty.” Thus, the patient’s muscles will contract due to both actual pain during penetration (sexual/non-sexual) and/or anticipated pain before penetration.

Because vaginismus is both an emotional and physiological pain response, there are a wide variety of causes for the disorder. Somatic symptoms like inflammation, atrophy, loss of epithelial integrity, and central nervous system sensitization often combine with mental factors like anxiety and phobia, genital and sexual trauma, and abuse, to cause pelvic muscular dysfunction. Thus, the vaginal walls could react to either a purely physical condition like inflammation or a psychological problem, like anxiety. They could also contract and cause pain if penetration is attempted.

Even though its psycho-somatic nature makes each treatment plan different, vaginismus remains highly treatable. Dr. Arora said, “A gentle examination should be carried out with a lot of reassurance and patience, to prove to the woman that there is no obstruction or physical abnormality, and the fear is only psychological.” She added, “It is important for the gynecologist not to rush through this and give the woman plenty of time to allow the examination. She also needs to be taught relaxation techniques and shown how to gradually begin with inserting just the tip of her finger into her own vagina, with the use of jelly if need be. Gradually, she should be able to progress to inserting one and then two fingers. Serial vaginal dilators are also available for the same purpose.” Dr. Somya Gupta, an OB/GYN resident, mentioned the use of Kegel exercises, the pelvic floor drop technique (reverse Kegel), and dilators to help affected women better control their muscle tone and relaxation. She added, “Self-insertion of dilators helps women acclimatize to penetration, but it should always be done with a topical anesthetic because the goal is to desensitize your muscles.”

Beyond physiological help, often women who develop vaginismus due to a past history of abuse can benefit quite a bit with the help of counseling and/or a sex therapist, Dr. Arora said, “It would be advisable to try and identify the cause of the problem first. For example, if it is marital discord or a case of incompatibility with the woman’s current partner, she may need to visit a counselor along with him to try and sort out the issues.” Dr. Gupta said. “These cases are called situational vaginismus, where there is an inability to tolerate certain forms of penetration, such as intercourse, yet insertion of tampons or fingers is possible. In this case, as there is no organic factor, sex therapy can definitely be useful.”

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Painful Sex Is a Real Medical Condition, But Doctors Often Miss, Dismiss It

In a conservative setting like India, talking about sexual dysfunction is taboo — especially for unmarried women. “Unmarried females complaining of dyspareunia [painful intercourse] is unheard of in the government setup where I work. Some women are bold enough to explain that they have a boyfriend and are sexually active. And sometimes they do get the proper treatment if they escape the notice of older gynecologists who are much more judgmental, as young residents are quite open-minded and do not frighten such patients,” said Dr. Gupta. “There is definitely a long way to go for society to realize that it is okay for young women to be sexually active. As doctors, our focus should be set on promoting safe sex and safe abortions. Maybe then, unmarried women with vaginismus will also feel free to consult doctors.”

However, changing mindsets and the influx of feminist-leaning providers of health care, both physical and mental, are pushing the health care system towards progress. A crowdsourced list of gynecologists, created by Twitter user Amba Azaad, collects Indian doctors who are respectful of their patients’ diverse lifestyles. iCall, a telephone- and email-based counseling service run by the Tata Institute of Social Sciences also put together a list of trustworthy Indian mental health professionals to help people make an informed choice about the care they need.

In Sex Education, when Otis discovers Lily’s vaginismus, he takes her bike riding downhill to help her ‘let go,’ only to discover she has no problem doing so. When he finally asks her why she seems so ‘desperate’ to have sex, she tells him that she simply doesn’t want to be left behind. While Lily genuinely believes she’s ready to have sex, her body refuses to relent because, deep down, she knows she’s not ready to take this big step. The scene is beautiful because it tackles unruly bodies, enthusiastic consent, and anxiety in one go — and suggests that while vaginismus may be dysfunction, dysfunction is possibly the most human trait of all.