Treating Vaginismus as an OT: Why the Nervous System Comes First

OTs in Pelvic Health Podcast · 23 min listen

If you're an OT who isn't sure how comfortable you are working with vaginismus — or you're wondering where OT fits into treating it at all — this is for you.

I'm Lindsey Vestal, an OT in pelvic health, and I founded The Functional Pelvis in New York City. What follows is why I think vaginismus is one of the most misunderstood diagnoses in all of pelvic health, why dilators so often stall, and what a nervous-system-first approach actually looks like in a session.

"Vaginismus is not just a pelvic floor problem. It's not a dilator problem. It's not even primarily a pain problem. It's a nervous system problem — and that is 100% in the OT lane."

By the end of this, I think you'll see vaginismus in a completely new light. And more than that, I think you'll see your own OT skill set in a completely new light.

Start with the definition

Vaginismus, at its most basic level, is the involuntary contraction of the vaginal muscles that makes penetration painful or impossible.

That could be penetration during sex, during a gynecological exam, tampon insertion, toy insertion. The range is wide. Some people experience discomfort. Others experience severe pain. Some are completely unable to achieve penetration at all.

And here's where most of the conversation stops. We identify the involuntary muscular contraction, people reach for a dilator, and that becomes the most public-facing solution. It's what most clinicians are trained to do.

To be fair, dilators have a role. I'm not throwing them out the window.

But sit with this instead.

You can't out-exercise it. You can't out-stretch it. You can't cognitively talk your way out of it. And you absolutely cannot dilate your way through it — at least not sustainably, and not without risking retraumatization.

Think about how we approach other involuntary responses in the body. We don't tell someone with CRPS to just move through the pain. We don't tell someone with fibromyalgia to try harder. We recognize that the nervous system is running the show, and we meet it there.

Vaginismus is the same.

What the body has learned

At its core this is a nervous system response. The body has learned, for any number of reasons, that penetration is not safe.

Trauma. Cultural messaging. Painful past experiences. Religious purity teaching. Medical procedures. Anxiety.

Whatever that person's experience was, the message the body took from it was the same. And the body is doing exactly what it's designed to do. It's protecting itself.

This is not a flaw. It's a feature.

When we start seeing it that way, everything about how we treat it changes. And everything about how our clients interpret their own diagnosis changes.

When we reduce vaginismus to a dilator problem, we minimize a deeply complex, deeply biopsychosocial experience into something purely physical. And for the women living with it — who have been dismissed, misdiagnosed, or handed a dilator kit with very little support — that minimization is one more wound on top of many.

We can do better. And as occupational therapists, we are uniquely positioned to.

The standard trajectory, and where it breaks

It usually goes something like this.

A woman finally musters the courage to raise her symptoms with a provider. Let me pause there, because that alone is an act of real bravery. She has likely been sitting with shame, confusion, frustration and grief for months, or years, or decades before she says a word out loud.

And when she does, she might be told to relax. To have a glass of wine. To try harder. She might be handed a dilator kit and told to practice. She might get a referral to pelvic floor therapy.

Pelvic floor therapy can absolutely be part of healing. But even in the best settings, the primary framework is often biomechanical. We assess tone, coordination, strength, flexibility. We give home programs. We progress dilator sizes.

Sometimes that works.

But for many people with vaginismus — especially those with trauma histories or deeply rooted nervous system dysregulation — it doesn't. Or it works temporarily and then stalls. Or it produces progress with dilators that never translates to real intimacy, real life, real function.

And here's what that feels like on the receiving end. Demoralizing. Profoundly demoralizing. Because she has done the work. She has done the exercises. She has done her dilating. She has shown up to every appointment.

And she still feels broken.

I can't tell you how many times a client has looked me in the eye and told me she feels like her body is betraying her.

"When the standard approach isn't working, it's not the client failing. It's a signal that we're treating the wrong thing."

If you've ever worked with someone who progressed to the largest dilator size and still couldn't transition to penetrative sex with her partner — that gap tells you everything. The problem was never the dilator size. It was the involuntary response that no amount of voluntary practice can override.

Let me say it plainly. If a client's nervous system is dysregulated when she attempts dilation or any penetrative activity, you aren't going to get lasting results. You might get temporary compliance. You might get short-term progress. But the nervous system will call it back every single time, because it believes it's keeping her safe.

Until you help her body learn that it actually is safe — not just tell her, but help her nervous system learn and feel and experience genuine safety — you're working against yourself.

This isn't a criticism of pelvic floor therapy. It's an invitation to go deeper.

Why OT specifically

Our seat at this table isn't the same seat. It's different, and it's deeply essential.

So if you've ever felt like you don't have enough tools, like you're not medical enough, like you're not sure where you fit in pelvic health — hear this.

Vaginismus may be the diagnosis that shows you most clearly why we were made for this work.

What a nervous-system-first approach looks like

The order here is not negotiable. Each step depends on the one before it.

How I explain this to clients

One of the challenges in pelvic health is finding language that's accessible, relatable and empowering — language that doesn't pathologize.

Here's the framework I use. I find it beautiful because of its simplicity.

When clients understand this — when they stop seeing their pain as malfunction and start seeing it as communication — everything shifts.

Because now the question becomes what does my body need? rather than what's wrong with me?

That shift, from victim of the body to partner with the body, is where healing begins.

Your job as the clinician is to help her develop strategies to intercept that energy before it lands in the pelvic floor. And to help her hear what her body is saying, and respond with care instead of fear.

What I'd want you to take away

Vaginismus is not primarily a pelvic floor problem. It's a nervous system concern. Until we treat it as one, we'll keep getting partial results.

The word involuntary is your North Star with this diagnosis. Involuntary responses require nervous-system-level intervention, not more voluntary effort.

The curiosity mindset is magic. Teach it early, return to it often, and watch what opens up.

And the healing always spills over. When you help a client understand her nervous system in the context of intimacy, she gets better at understanding it in every context. That's the OT ripple effect, and it's the most beautiful part of this work.