“My Vagina Is Broken” – Debunking Myths to Improve Sexual Pain

The inspiration for this article comes from one of our favourite books, “Come As You Are”, by Dr Emily Nagoski1. In her book, Dr Nagoski pulls together years of research into women’s sexuality, relationships and wellbeing and shares an evidence based exploration of how female arousal, desire, autonomy, pleasure and orgasm works, and provides tools for women to create and sustain a fulfilling sex life.
Our patients experiencing sexual pain or dysfunction often say to us that they feel “my vagina is broken” or “my vagina isn’t normal”.  Another common observation in our practice is how little awareness and knowledge women have about their own pelvic anatomy and sexual function.  Many women have never really looked at their vulva before, nor do they understand what makes up this important part of their body.
Negative genital body image and poor knowledge about their own needs to be able experience pleasurable sex can contribute to sexual pain.  There is established evidence that fear, low self-efficacy and catastrophisation are significant drivers in people experiencing sexual pain.2  
As Pelvic Health Physiotherapists, we aim to educate women on the many myths surrounding sex that can perpetuate negative self-belief and fear and create more problems in the bedroom.   Here, we explore some of the common myths that we often find ourselves exploring and debunking to help women with sexual pain and their partners.  

MYTH #1: All vagina’s look the same

REALITY:  There is a huge degree of variation in how each vulva looks.  As Dr Nagoski says, ‘we all have the same parts, they are just organised in their own unique way’.  In relation to sexual pain, education on sexual anatomy and function can be enlightening for women to learn what is normal in relation to their own anatomy and about sex.  
For some, looking at an image or a model of a vulva can be helpful.  There are some wonderful resources such as the Labia Library, which is produced by Women’s Health Victoria that show women just how diverse the vulva is.  However, some women can find an image of someone else hard to relate to.  Using a mirror to identify the different parts of the vulva can be beneficial.  

MYTH #2: Women should be able to orgasm with penetration alone

REALITY: Dr Nagoski talks about how more than 70% of women will NOT reliably orgasm with penetrative sex, and this is healthy and normal.  We are also fortunate in our home town of Melbourne that Professor Helen O’Connell published ground breaking research into the anatomy and function of the clitoris, work that helps us explore this myth with our patients.  
Anatomically, the clitoris is a woman’s erectile tissue and is distinct from the urethra and the vagina and is highly vascularised.3   Because of the distance between the clitoris, the urethra and the vagina, most women will not be able to orgasm with penetration alone.  Dr Nagoski also acknowledges how orgasms vary for every person and also vary greatly with context.   

MYTH #3: Women should be able to become aroused spontaneously

REALITY: Both men and women can either experience spontaneous desire (a sudden or immediate desire for sex) or responsive desire (feeling desire for sex only if someone else initiates it) and both of these types of desire are normal.  Dr Nagoski references “The Dual Control Model“4, which has been proposed by Erick Janssen & John Bancroft  which describes how sexual responses involve connections between both excitatory and inhibitory processes.  She relates these processes to be like brakes and accelerators.  
The sexual excitation system (the accelerator) receives sex-related information about the environment and the context of the situation someone is in, and then sends signals from the brain to the genitals to ‘turn on’.  The sexual inhibition system (the brakes) looks out for potential threats in the environment and thoughts (eg fear) which send signals to the genitals to effectively ‘turn off’.  
Dr Nagoski talks about how the balance of how much the brakes or the accelerators are functioning influence the amount of desire and arousal.  The challenge is figuring out what turns on and turns off our brakes and accelerators.  
Sexual desire and pleasure is also highly dependent on context, and creating the right context for both partners is important to improve arousal and sexual desire.  To read more about responsive and spontaneous desire, read our blog article written by psychosexual medicine specialist, Dr Vicki Windholz.

MYTH #4: A woman is only truly aroused when they have produced enough natural lubrication

REALITY: Sexual arousal concordance is the correlation between self-reported sexual arousal and the psychophysiological sexual response.  Dr Nagoski discusses how for women, there is a 10% overlap between what a woman’s genitals will respond to as sex related and what their brains determine are sexually appealing.  For men, there is a 50% overlap.  Arousal non-concordance is perfectly normal.  How a woman’s genitals respond to sex related stimuli can vary depending on the sensitivity of her brakes and accelerator. 
We also know that Genitourinary Syndrome of Menopause (GSM) is associated with vaginal dryness and superficial dyspareunia.  Again here, it is the hormonal changes that are influencing vaginal lubrication, not arousal.  Read here our blog on GSM

MYTH #5:  Sex can be painful, and if it is, it’s because it’s all in your head

REALITY: Unfortunately, many of our patients who are experiencing sexual pain have been told that it is normal to have pain with sex (particularly if they are new to sex or if they are peri/post menopausal).  They can be told to use a lubricant, have a glass of wine and relax before sex and this should help.  They are also often told that the pain is all in their head.  
We know that pain is produced by the brain, but it is important for women to understand that the pain is real.  Explaining pain is a critical component of treatment but it needs to be done well.  Understanding the protective nature of the brain, nervous system and muscular system towards the pelvis is a crucial component of treating sexual pain and educating our patients on these concepts is something that we pride ourselves on at WMHP.   We have explored some target concepts that are essential for patients with persistent pain to understand in our blog article Explaining Pain Doesn’t Have To Be Painful
Dr Nagoski’s book Come As you Are is a fantastic and relatable read that we often recommend to women who want to learn more about their sexuality, sexual function and transform their sex life.  To learn more about the book or to purchase it, visit her website https://www.emilynagoski.com/home
1. Nagoski, E (2021) Come As you Are (2nd ed) Simon & Schuster Paperbacks
2. Descrochers G, Bergaron S, Khalife S, Dupuis M-J, Jordoin M.  Fear Avoidance and Self-efficacy in Relation to Pain and Sexual Impairment in Women With Provoked Vestibulodynia.  Clin J Pain 2009:25(6) 
3. O’Connell H and Delancey J Clitoral Anatomy in Nulliparous, Healthy, Premenopausal Volunteers Using Unenhanced Magnetic Resonance Imaging.  J Urol 2005; 173(6): 2060-2063
4. Janssen E and Bancroft J The Dual Control Model: The Role Of Sexual Inhibition & Excitation in Sexual Arousal and Behaviour. In Janssen, E. (Ed). (2006). The Psychophysiology of Sex. Bloomington, IN: Indiana University press.


March 2022


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