On the right an illustration of a phallic-shaped dilator, and on the right a set of different sized vaginal dilators and a carrying case

What Happens Under the Ether: Vaginismus and the Question of Consent in the Nineteenth Century

Content Warning: sexual violence; gynecological and obstetric violence.

Vaginismus is having a moment. A sexual disability that is medically classified as the involuntary spasming of vaginal walls, vaginismus might not seem like an obvious choice for pop culture representation. But the last decade has seen a marked uptick in its visibility: the Netflix miniseries Unorthodox shows the protagonist Esty Shapiro (Shira Haas) struggling with the condition, including suffering in visible agony during sexual intercourse with her husband. The same ultra-orthodox kallah (bride) teacher who had explained the mechanics of sex to Esty the night before her wedding later diagnoses her with vaginismus, pressing a silicone dilator kit into her hands as Esty regards the phallic pink objects in stunned silence. In Sex Education, another Netflix series, high school student Lily Iglehart (Tanya Reynolds) tells her girlfriend that she has vaginismus and is working through dilator treatment (“If I’m patient, I’ll eventually be able to get the big one in,” she says, displaying her box of dilators arranged by size). Buoyed by twenty-first century sexual discourse, people with vaginismus have stepped into the pages of the New Yorker, The New York Times, the feminist blog Jezebel, and other public online forums like Tiktok in the 2010s and into the 2020s.

This recognition, more than 150 years since infamous physician James Marion Sims named the condition in 1862, is overdue. But it masks a long history. While what contemporary gynecologists call vaginismus has a history far beyond the clinic, I begin with its formal medical recognition in the mid-nineteenth century because it is then that we encounter one of the most startling treatments for women with vaginismus. Physicians like Sims advocated for anesthetizing these women so their husbands (and it was almost always women with husbands) could “cohabit” with them. As I read through the case files, the question of consent gnawed at me. But what did consent even mean in this context? What these women knew about the extent of this arrangement is ambiguous in the historical record, raising critical questions about how physicians communicated with patients and what characterized the experience of people with this and other sexual disabilities in the past.

Half-nude woman lying on operating table and being attended by 2 doctors. Breasts exposed
Woman lying on an operating table attended by two doctors.
(© Wm. Wood & Co. /Reproduced at Picaryl)

American physicians incorporated vaginismus into their diagnostic frames shortly after Sims gave it its moniker, defining it loosely as “a spasm of the vagina.”[1] Their chief concern regarding vaginismus was not the painful symptoms experienced by women who suffered from this condition, but rather that it made penile penetration impossible. Women described blinding pain on attempting penetrative intercourse, which physicians chronicled in dozens of harrowing case studies in the mid to late-nineteenth century. “In the case of vaginismus,” Sims wrote, “the gentlest touch with the finger, a probe, even with a feather, produces the most excruciating agony.”[2] Recorded cases were nearly all white women, with only a few cases documented among black women, which reflects the limitations and priorities of the American medical record in the nineteenth century. One Black woman saw a white physician who compared her “vaginal convulsions” from vaginismus to the sexual copulation of dogs.[3] Obstetric violence appears in words as well as in bodies.

The stories of these women are distorted, mediated through the physicians’ gaze. Pain cuts across the patient experience of vaginismus and so does fear: fear of sex, fear of pain during sex, fear of pain during doctors’ visits. One woman told her doctor that she regarded the approach of her husband with “the greatest terror.”[4] Most experienced pain during penetration, whether penile or digital, as well as during pelvic exams: Sims wrote that one woman he treated for vaginismus “shrieked and sobbed aloud; her eyes glared wildly; tears rolled down her cheeks” during his diagnostic examination.[5] But, despite personifying, as he characterized it, “terror and agony,” he continued, “she had the moral fortitude to hold herself on the couch, and implored me not to desist from my efforts.”[6] For women with marriages and livelihoods on the line, many had their own reasons for pursuing a remedy by any means necessary.

A 19th century advertisement for the Electric Belt
London Advert for Harness’ “Electropathic Belts” which helps weak backs, cures debilities, hysteria, nervousness, sleeplessness, rheumatism, sciatica, lumbago, torpid liver and kindred ailments. (Wellcome Library)

Physicians largely understood vaginismus to be a “neurotic” condition like hysteria. The medical literature described case after case of women and their husbands desperately seeking help for their inability to consummate their unions, sometimes after years of marriage. In the United States, the most common medical treatments were surgical operations on the hymen and the introduction of dilators, the latter of which is the prevailing treatment for vaginismus today.

But in addition to prescribing ether for surgery, physicians would also anesthetize women for cervical dilation. One surgeon described a woman who was experiencing what he called “exquisite pain and sensitivity of the vaginal surface” and had sex only “very rarely, and with extreme suffering.”[7] Her physician had previously given her “chloroform to insensibility, and used great mechanical force to dilate the vagina” to treat her.[8] While informed consent only entered the medical lexicon in the 1950s, these sources raise questions about how much women knew about what was happening to them, how they understood it, and what they felt when they regarded the nature of treatment for their condition.

Treatment could also include vaginal penetration while the woman was unconscious. One New York physician anesthetized his patient “and then left her to her husband, who cohabitated with her with the greatest ease.”[9] Another “advised sexual intercourse while the wife was etherized. This was soon done and the wife knew nothing of it.”[10] She must have had some idea of what had happened, though how she was told (before? after?) remains a mystery. The same woman returned, again and again for over a year, until she conceived and delivered two children through this method.[11] The physician Edwin Hale affirmed a decade later that “several cases are on record where coition was performed while the wife was under the influence of chloroform or ether, and that conception resulted from such intercourse.”[12] Physicians often hoped that enduring childbirth would “cure” the affliction.

The silences in these narratives are thunderous. We do not read the moment of waking, bleary-eyed through the thick haze of ether, perhaps quickly, quietly mapping bodily sensation for lingering pinpricks of pain. We do not see white-knuckled grips of fabric, nails cutting into palms. We do not know how these women regarded the pain and deadly risk of childbirth after a ‘successful’ procedure—was this cure? We do not know what coercion, manipulation, or threats preceded a visit to the physician, nor do these sources reveal how personal desire for intimacy, sex, or the conception of a child factored into decision-making. But distortions can be revealing, fractured though they are. We know that women returned, sometimes with their husbands, sometimes alone. We know that some of these women were deeply invested in the ability to have penetrative sex, often, but not always, to have children. We know they were afraid.

Still, the question of consent looms large. Would a woman who underwent anesthesia to have penetrative sex and so avoid the agony it entailed, have regarded such penetration as violence? What would she have been told in advance? In the aftermath? How did husband and wife discuss the act, if they discussed it at all?

These questions, and their accompanying silences, linger into the present. The clinical definition of vaginismus hasn’t really changed, though healthcare providers have expanded its causes to include rape, sexual assault, and other trauma. The dilators that Sims designed remain a core component of treatment, although today’s are medical grade plastic or silicone, rather than glass or rubber, and sold directly to consumers. In a departure from the past, most cases of vaginismus in the United States are not treated by a physician; patients are generally referred to a pelvic floor physical therapist for treatment and perhaps a psychologist. Then as now, many people are simply never treated at all or self-manage in their own ways.

Nearly every publication about vaginismus today notes that there have been very few clinical trials and little sustained research, in stark contrast to the billions of dollars in funds and research devoted to erectile dysfunction. Estimates on rates of vaginismus vary, but most suggest somewhere between one and seven percent of people assigned female at birth in the United States experience the condition. But vaginismus is so underreported and understudied that many medical practitioners haven’t even heard of it, and so even those who present with symptoms today are often left untreated for years or decades.

The ambiguity—or simply violation—of consent under anesthesia also continues today. In 2020, the New York Times reported that a standard part of medical education included medical students practicing pelvic exams on unconscious women who had been anesthetized for other, often unrelated procedures. Patients interviewed for the 2020 story reported how upon waking they felt violated, confused, and sometimes terrified, as one woman experienced when she woke up while the speculum was still inside her (“Is it a nightmare?” she wondered at the time.)[13] Others weren’t sure, suspecting but never knowing with certainty whether a pelvic exam had been performed. Legislation prohibiting non-consenting pelvic exams has passed in several states (bipartisan legislation, no less: forced pelvic exams cross a line among right-wing legislators that forced birth appears to elide.) Today’s unconscious pelvic exams are unethical because they violate informed consent, a norm that since the 1950s has become a cornerstone of modern medicine. In the nineteenth century though, patients with vaginismus endured similar violations, never completely knowing what was happening to them under anesthesia. In both contexts, people are transformed into bodies, and then silently into objects, but at the moment of waking, what remains?

Notes

  1. Matthew Duncan, “Clinical Lecture on Vaginismus,” Medical Times & Gazette 2 (October 1878): 453-455.
  2. James Marion Sims, Clinical Notes on Uterine Surgery: with Special Reference to the Management of the Sterile Condition (New York: William Wood & Co., 1866), 340.
  3. Andrew Jackson Howe, Operative Gynaecology (Cincinnati: Robert Clarke & Co., 1890), 73.
  4. James Marion Sims, “On Vaginismus,” Transactions of the Obstetrical Society of London 3 (London: Longman, Green, Longman, and Roberts, 1862), 361.
  5. Sims, Clinical Notes, 330.
  6. Sims, Clinical Notes, 330.
  7. John Hilton, with W.H.A. Jacobson, Rest and Pain: A Course of Lectures on the Influence of Mechanical and Physiological Rest in the Treatment of Accidents and Surgical Diseases, and the Diagnostic Value of Pain (Cincinnati: P.W. Garfield, 1891), 276.
  8. Hilton and Jacobson, Rest and Pain, 276.
  9. Sims, Clinical Notes, 340.
  10. Sims, Clinical Notes, 340.
  11. Sims, Clinical Notes, 331
  12. Edwin M. Hale, The Medical, Surgical, and Hygienic Treatment of Diseases of Women, Especially Those Causes Sterility (New York: Boericke & Tafel, 1878), 10.
  13. Emma Goldberg, “She Didn’t Want a Pelvic Exam. She Received One Anyway.” The New York Times, 17 February 2020.

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