How do I treat people with anxiety about vaginal penetration?

One of the most common things people come to see me for is difficulty with having anything penetrate their vagina. To give an idea of how a treatment process would work, let’s walk through a “case study,” based on a recent patient I treated in my clinic. Think of this as a peak into the detailed notes I write for each patient, and a look into how we’ll work together to treat their concerns or condition.

Age: 34 years old

Sex assigned at birth: Female

Gender: Female

Pronouns: She/her

Past medical history / general health: Excellent

Initial consultation:

Patient presents with difficulty with any penetration by object into vagina corresponding with +++central nervous upregulation and some hypertonic myofascial tissues in external hip muscles. (Translation: Their nervous system was sending out ALL the stress signals, and they’ve got muscle tightness in their hips.)

Patient goals:

In the short term:

Understand pelvic health and wellness and how this relates to sexual health

Progressively insert object such as finger or tampon into vagina at a comfortable pace for patient

In the long term:

Be able to penetrate an object into vagina for sexual intimacy and activity with another person without pain

The treatment plan: (Any why we’re going to all of these things)

Education on pelvic floor anatomy and the function and role of the pelvic floor as a unit with the inner core, breath and hip muscles:

People think that damage to the tissue or something is “wrong” with the actual tissue/vagina if you can’t penetrate. But often, if this is a persistent case, the brain is involved much more and it is upregulated or oversensitive and it needs to calm down before the tissue can be treated.

Deep breathing exercises:

When you breathe in, the diaphragm moves down and the pelvic floor moves down towards your toes in unison. It works together. So if you breathe apically or breath in just the upper shoulders and chest and not into your deep abdominals, then the diaphragm gets stuck moving very little up and down in a fast pace and so does that pelvic floor get cramped up and angry. So of course, nothing is going to penetrate. You have to breathe deeply and let the pelvic floor relax every time you breathe in and then let everything just recoil when you breathe out. Plus, the breathe is the direct line to your central nervous system/autonomic nervous system – and the only one you can control. So better get good at it!

Stretching tight muscles, likely inner thighs, hip rotators and hip flexors:

They can refer pain to the pelvic region and into your groin too, so treat from the outside an then internal eventually.

Understand if self-pleasure is a concern too:

If so, is the patient’s concern requiring collaborative work with a sex psychologist? Maybe the psychosocial aspect of the patient’s concerns needs to be addressed by a professional which is out of the scope of practice for a physiotherapist. I am psychologically influenced but definitely not trained as a psychologist or psychiatrist.

Integrate dilator work (eventually):

There are many types out there but the best is the ones that you can clean properly and that don’t trap any bacteria growth. There are usually a few sizes – about 5-6 sizes – in a dilator pack. You start with just holding size 1 dilator and getting used to it – it’s like exposure – so that you know how the object/dilator feels and holds in your hand.

Then, you start to insert the dilator size 1 – the rule of thumb is that if you can insert a dilator size fully for 10-15 mins without any pain for 2 consecutive sessions, then you can proceed to the next size up. Dilator work can be stressful so it’s important to bring in the deep breathing exercises while you do the work. It will downregulate the nervous system and allow the pelvic floor to relax and make the insertion easier. Sometimes playing a nice song while you do physio work is good too! Just calm the fuck down.

The Outcome:

In 5 months, patient was able to achieve full penetration with her partner (who has a penis) with no pain and no concerns. Now, they’re on the journey to becoming parents. Total success story!