‘I don’t live in my body somehow’: metaphorical talk in women’s accounts of vaginismus and dyspareunia

Abstract

Vaginismus and dyspareunia are common sexual difficulties; they often take a long time to be appropriately diagnosed, and their origins remain unclear. This paper examines the metaphors used by women to describe bodily experiences associated with vaginismus and dyspareunia, and highlights the contribution this form of analysis can make to the study of sexuality and sexual difficulties. A secondary analysis was conducted on primary data from biographic interviews exploring women’s experiences of sexual pain and difficulties with sexual intercourse. Metaphor analysis was used to analyse a data subset of 28 interviews translated from German into English. Metaphorical concepts lying at the basis of the metaphors used were identified and grouped into three themes: characterisation of sexual difficulties; split body and ‘self’; and sexual agency and objectification. Results are discussed with in the context of literature regarding the function of metaphors and the utility of metaphor analysis for research, and healthcare research and interventions more generally.

Keywords:

• Sexual pain
• vaginismus
• dyspareunia
• metaphor analysis
• healthcare communication

Introduction

Sexual pain, or the experience of genital pain during sexual activities involving vaginal circlusion¹ or other forms of stimulation of the vulva, is a sexual difficulty affecting a considerable number of women worldwide (Koops and Briken 2018; McCool et al. 2016). Since the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013) recurrent/persistent and distressing sexual difficulties involving genital pain are clinically conceptualised as genito-pelvic pain/penetration disorder. Previously they used to be covered by two diagnoses: vaginismus (difficulties with vaginal circlusion) and dyspareunia (genital pain during or after sexual activities). Despite their common occurrence, their origins are still poorly understood; accordingly, knowledge concerning the psychological risk factors for sexual pain disorders has been deemed ‘limited’ (Bergeron et al. 2015, 161). As with other conditions lacking a direct physical/medical ‘cause’, there are a range of body-related factors associated with experiences of sexual pain, for example Candida infections, endometriosis or painful outcomes of childbirth (Graziottin and Gambini 2017), but vaginismus and dyspareunia specifically refer to difficulties without a clear physical/medical origin. There is no ‘objective test’ for difficulties with sexual pain; women who experience such difficulties thus rely on language to communicate their pain experience. Metaphor is one strategy used for communicating these experiences.

Metaphors

Metaphors are figures of speech which can transform abstract phenomena into something concrete and familiar. Although researchers interested in language use (e.g. discourse analysts and poststructuralist researchers) or lived experience (e.g. phenomenologists) have often drawn attention to metaphors, in this paper, we focus specifically on Metaphor Analysis (MA) as an approach dedicated to exploring the utility of metaphorical communication. Metaphors are words or phrases whose meaning is extended beyond the literal in the respective context. The literal meaning is rooted in an area of sensory or cultural experience which is transferred to a second (abstract) area (cited from Schmitt 2005). Developing their Conceptual Metaphor Theory (CMT) based on cognitive linguistics, Lakoff and Johnson (1980) argued that ‘metaphor is pervasive in everyday life, not just in language but in thought and action’ (1980, 3). In other words, metaphors go beyond being a tool for communication; they are conceptual tools for thinking, understanding and shaping reality. Importantly, several metaphors can represent a single phenomenon which may even contradict each other (Schmitt 2005). Using Lakoff and Johnson’s theory as a springboard, interest in the systematic study of metaphors has grown over the last decade as specific analytic methods to support metaphor identification and interpretation have been developed (see Materials and Methods).

The emergence of Metaphor Analysis has sparked a growing body of work looking at metaphors in health and healthcare, most notably experiences of pain and cancer (Semino et al. 2017). Initially, this research focused on developing taxonomies to capture the different types of metaphors used to describe pain (e.g. Munday, Newton‐John, and Kneebone 2020; Semino 2010). Research has examined the metaphors used by patients to describe experiences of pain across a range of medical contexts including chronic pain (Munday, Kneebone, and Newton-John 2021), pain arising from spinal cord injury (Hearn et al. Fine 2016), or endometriosis (Bullo 2020), and has powerfully demonstrated the ability of metaphors to vividly conceptualise and communicate embodied experience.

Like pain, sex and sexual difficulties can be difficult to talk about directly. Competing social conventions position sexual communication as both socially taboo and as necessary to maintaining healthy sexual relationships. Consequently, much talk about sex is metaphorical. People use metaphors to describe specific sexual practices (e.g. metaphors of chasing and gifting in bareback sex among gay men, Hammond, Holmes, and Mercier 2016), experiences of sexual aggression and violence (e.g. describing sexual re-victimisation in terms of imprisonment, homelessness, contamination and disability, Ben-Amitay, Buchbinder, and Toren 2015), understandings of sexual health (e.g. Ugandan students describing unprotected sex as like eating an unwrapped sweet, Mutonyi 2007); or genitalia (e.g. using animal metaphors like ‘beaver, pussy, snake, worm’ or edibility metaphors like ‘beef burger, bean, pie, sausage’, Braun and Kitzinger 2001).

However, we could find only two empirical studies using Metaphor Analysis to systematically explore sexual metaphors. The first examined the metaphors used by speakers of 27 different languages to describe sexual orgasm, in which orgasm was variously conceptualised as a peak, a death, a destination, a release of force, as fire/heat or as a feeling of satisfaction/pleasure (Yen Chiang and Chiang 2016). The second identified three different metaphors young people in Malawi used to conceptualise sex in focus group discussions: sex as utilitarian (as routine and mundane like brushing teeth), sex as pleasurable (like eating sweets or hitting water), and sex as passion (totally and vigorously expending energy ‘breaking’ or ‘finishing’ each other) (Undie, Crichton, and Zulu 2007).

To our knowledge, the metaphors used by women who have been diagnosed with vaginismus or dyspareunia to describe their bodily experiences have not previously been examined. In this paper, we draw on empirical data from a study of women’s experiences of vaginismus and dyspareunia (conducted by the first author, TUK) to explore the role of metaphors in conceptualising and communicating bodily experience. Our aim is not to provide a comprehensive taxonomy of metaphors relating to sexual pain; rather by examining a small number of metaphors in the context of existing research, we aim to illustrate the value of metaphor analysis for researchers working at the interface of health and sexuality.

Materials and methods

Metaphor analysis rests on the systematic identification and interpretation of metaphors. An interdisciplinary collective, The Pragglejaz Group (2007), developed the Metaphor Identification Procedure (MIP) as a way of systematically identifying metaphors in text. Their goal was to ‘provide a research tool that is relatively simple to use and flexible for adaptation by scholars interested in the metaphorical content of natural discourse’ (2007, 2). In short, their approach involves structuring the text into individual lexical (meaning) units which typically consist of a word or small number of words which convey one meaning (e.g. traffic light, take care of, basket). Next the contextual meaning of an expression (e.g. describing orgasm as a ‘little death’) is compared with the basic meaning of this word (e.g. death: noun, the end of life, Cambridge Dictionary Online 2021). Where a mismatch or contrast exists between the contextual and basic meaning, metaphorical meaning is derived – e.g. orgasm is an end of sex. They provide an extensive worked example, propose a structure for recording and reporting the results which documents the decisions made at each point of the process, and suggest ways of testing the reliability of the identification process. This is sometimes referred to as Systematic Metaphor Analysis and has been used by a number of researchers in the health field (e.g. Beck 2017; Bullo and Hearn 2021). A similar approach is suggested by Schmitt (2005) which is targeted specifically towards qualitative researchers. Importantly, Schmitt’s approach pays attention to the process of interpreting, as well as identifying, metaphors. He places particular importance on the idea of the ‘metaphorical concept’ – for example, helping can be contextualised as helping people with a heavy burden or helping as putting people on the right track.

Data set

Metaphor Analysis can be used as part of quantitative, qualitative (Beck 2017; Isobel, McCloughen, and Foster 2020) or mixed methods studies (Bullo and Hearn 2021; Hearn, Finlay, and Fine 2016). Metaphors can be specifically elicited (e.g. by asking participants what metaphors they use to describe their pain Munday, Newton‐John, and Kneebone 2020), or identified from interview data, naturalistic talk/text, or other qualitative data (e.g. Bullo and Hearn 2021). In this paper, secondary metaphor analysis was applied to existing interview data (see also Beck 2017; Magaña 2019). The primary data set was an interview study of 28 women’s experiences of vaginismus and dyspareunia (see Koops and Briken 2021 for details). These women were over 18 years of age, fluent in the German language, and had been diagnosed with either vaginismus or dyspareunia. Former patients from an outpatient clinic in Hamburg were invited to participate, and health practitioners from psychotherapy, gynaecology, and physiotherapy practices were asked to distribute study information among patients/clients.

Participants chose whether to be interviewed either at the clinic (n = 19) or in their homes (n = 9). Two women decided against participating for personal reasons at the beginning of the interview; no data of either of them was included in the data set. Interview duration ranged between 25 and 128 min (mean = 47 min). Sample characteristics are summarised in Table 1 above.

Table 1. Sample characteristics (n = 28; cf. Koops and Briken 2021).

Age [Mean, range]	32.4, 24–58
Nationality of parents [n (%)]
German	23 (82)
German-Croatian	1 (4)
German-Polish	1 (4)
Turkish	3 (11)
Children [n (%)]
No children	20 (71)
Pregnant (eight months)	1 (4)
One child	6 (21)
Three children	1 (4)
Relationships [n (%)]
Previously in a relationship with a man	28 (100)
Previously in a relationship with a woman	1 (4)
Currently in a relationship with a man	20 (71)
Currently single	8 (29)
Experience of psychotherapy [n (%)]
Yes	24 (86)
No	4 (14)
Sexual complaints (fulfilling diagnostic criteria) [n (%)]
Currently	20 (71)
In the past	8 (29)
Primary	16 (57)
Secondary	12 (43)
Fulfilled diagnostic criteria for … (when complaints were present) [n (%)]
Vaginismus (DSM-IV)	17 (61)
Dyspareunia (DSM-IV)	11 (39)
Genito-pelvic pain/ penetration disorder (DSM-5)	28 (100)

Note. Percentages rounded.

In semi-structured interviews based on biographic-narrative method (e.g. Bohnsack 2014), participants were asked to recount their life story in as much time as they needed, and to include all aspects they considered important. After finishing they were asked further questions for clarification and with regard to a pre-defined list of topics if those had not been mentioned before. Interviews were audio-recorded and transcribed verbatim using the conventions described by Bohnsack (2014) which capture the intonation and delivery of speech, as well as the words spoken.

All participants provided written informed consent; the study was approved by the ethical review board of the Hamburg Chamber of Psychotherapists.

Analysis

Previous primary data analysis involved line-by-line coding of all interview transcripts and included coding for metaphors. This subset of data originally coded as metaphorical formed the data corpus for the secondary analysis presented here. For this study, the data subset was translated from German into English by the first author. Magaña (2019) illustrates the interpretative difficulties arising from the translation of metaphors. With the authors being German (TUK) and English (HF) native speakers, nuances in the original and translated interview material were thoroughly discussed in the analysis process; differences in meaning are indicated in the discussion.

Our analysis draws on principles from systematic metaphor analysis (Schmitt 2005, 2017). This qualitative method aims at elucidating patterns through which individuals both perceive and produce their surroundings. These patterns are assumed to be culturally disseminated and socially situated, meaning that although they are adopted individually to different degrees, they refer to experiences which are culturally collected and processed. Based on the approach outlined by Schmitt (2017), our analysis comprised the following steps:

• Choice of topic of analysis: metaphors describing bodily experience

• Collection of background metaphors: review of available literature on metaphors regarding pain and sexuality; reflection on the authors’ own metaphors

• Compilation of data set: reduction of dataset to text passages involving metaphors which describe bodily experience

• Systematic analysis: coding of metaphors with respect to underlying themes; formulation of metaphorical concepts

• Heuristics-based interpretation: interpretation of themes, metaphorical concepts, and associated metaphors regarding their function of drawing attention to certain kinds of experience and away from others; comparison and identification of conflicts between metaphorical concepts

According to Schmitt (2017), the next step involving triangulation of results through interrater reliability and other quality criteria is dependent upon the research question. Due to our exploratory approach and the relatively small data set, this step was not pursued. Nevertheless, to enhance ‘trustworthiness’ (Schmitt 2005), analysis and interpretation were conducted by both authors and kept close to the original material.

Results and discussion

We identified a number of different metaphorical concepts used to describe bodily experience (e.g. pain as injury, pain as fire, Stage 4). Resulting from the heuristic-based interpretation (Stage 5), these metaphors were grouped into three thematic areas as follows: Characterisation of sexual difficulties; Split body and ‘self’; and Sexual agency and objectification (see Table 2). We describe each of these themes, drawing on existing literature to examine their meaning. Metaphors are illustrated below with extracts from the interviews. To aid comprehension, we offer this brief guide to the transcription symbols used:

two words merge into one: but = I

short pause: (.)

editing: […]

non-verbal expressions: ((…))

laughingly spoken: @…@

stretching of sound: pain::

pause of a specified length in seconds: (2)

quietly spoken: °I can°.

Table 2. Overview of the metaphors clustered into three themes.

Themes	Characterisation of sexual difficulties	Split body and ‘self’	The sexual body, sexual agency and objectification
Metaphors	Pain as fire	The body as a machine	Sexual arousal as a creature inside one’s body
	Pain as injury	The head as a set of wires	Genitals as access to one’s ‘self’
	Genitals as a barrier	The body as residence of the ‘self’	Giving access to one’s genitals as sexual permissiveness
	Genitals as a tight space		The body as an inanimate and rigid object

Our analysis aims to provide answers to the question ‘what metaphorical concepts do women use?' and our initial exploration of the question ‘what do metaphors do?’ or ‘what is the function of this metaphor within this context?’

Characterisation of sexual difficulties

Metaphors relating to the sexual difficulties participants experienced focused either on descriptions of pain (pain as fire; pain as injury) or other genital sensation genitals as a barrier; genitals as a tight space). In descriptions of pain, the vulva and/or vagina became a site of (potential) harm, injury or damage.

Pain was described a ‘burning’ sensation by women who had experienced either vaginismus or dyspareunia, sometimes emphasised by a comparison with ‘fire’ or ‘hell’. This reflects other pain research in which metaphors which imply physical damage or utilise physical properties (such as temperature or weight) are common (see, for example, Bullo and Hearn 2021; Munday, Newton‐John, and Kneebone 2020; Semino 2010), and research in which genital pain specifically is described as ‘burning’ (see, for example, Svedhem, Eckert, and Wijma 2013, 341 on genito-pelvic pain; Groven et al. 2016, 823–4 on vestibulodynia). One function of these metaphors is to make experience intersubjectively knowable, and to communicate the intensity of the experience by taking it beyond the literal. By describing an experience as like ‘hell’ or ‘fire’, participants can evoke extreme, intolerable experiences in the absence of observable physical injury. This may, as Semino (2010) suggests, elicit an internal embodied simulation of pain experiences for the listener, providing the basis for empathy and understanding from partners and/or healthcare professionals.

Women sometimes described pain as ‘stabbing’, implying physical injury but also, evoking intercourse and/or the bodily intimacy involved as the source of this injury. Whilst both fire and injury metaphors imply some form of physical damage, they have different implications regarding causality or agency. Whereas ‘burning’ and ‘fire’ do not imply their cause, ‘stabbing’ suggests that harm is being done by something (a sharp object or weapon) or someone (a person wielding a weapon) and is an act of violence – although the second meaning is less explicit in the German language original. We do not know whether women who describe their pain as ‘burning’ and those who describe it as ‘stabbing’ have different ways of conceptualising the origin of their pain (e.g. is the ‘cause’ external or internal, and is it an individual or an inter-individual issue?) or the impact of these metaphors on experience of pain or distress (e.g. do women who use more violent metaphors like ‘stabbing’ experience greater distress about their sexual difficulties?). However, there are good reasons to believe this would be a fruitful area to explore. Demjén et al. (2019, 21–22) found that people with psychosis who used violence metaphors to describe their experience of hearing voices (‘I feel like lying down, ‘cause I get tired of fighting him’), compared to support metaphors (‘they try and support me’) and in-group metaphors (‘I treat her like a sister’), experienced more intense distress. Further research could illuminate what specifically might be perceived as threatening or harming about the sexual/intimate situation by these women (e.g. does it evoke fear about intimacy, bodily intrusion, loss of agency etc?).

Similarly, while scholars researching chronic pain have also noted implicit references to an embodied or disembodied other (e.g. Munday, Newton‐John, and Kneebone 2020), in the context of sexual activity the other who is brought to mind is the sexual/intimate partner(s). Surprisingly, sexual partners are not often included in research on women’s sexual pain despite the difficulty impacting on them personally, relationally, and sexually (Boswell 2021). Examining whether metaphors which imply violence and/or an agentic other (such as stabbing) impact more negatively on partners, or indeed, whether metaphors are shared between partners, could further illuminate the relational dynamics surrounding sexual distress.

Finally, it is worth noting the multiplicity and ambiguity of meanings associated with metaphors. Whilst ‘heat’ and ‘fire’ metaphors are used to describe pain, with regard to sexuality more generally they are also frequently used to describe sexual arousal and/or desire. Although the latter meaning was not intended by participants, this parallel raises the question of whether similar bodily sensations might be interpreted very differently depending on context and emotional state, or whether cultural discourses sanctioning women’s sexual desires and active engagement in sexual activities affect women’s interpretations of their own genital sensations.

Participants also drew on metaphors to describe genital sensations other than pain, often in connection with their experiences of (attempted) vaginal circlusion. One metaphor referred to the feeling of vaginal tightness as something is attempted to be ‘pushed through’. One participant described this as feeling ‘like a piece of rubber band ehm which you eh, which you try to pull through = over the finger and that is just like very tight’. Others referred to some sort of barrier – the most common expression being having ‘a wall down there’, a barrier which was located in the genitals specifically. Women spoke of a ‘blockade’ or ‘resistance’, sometimes located in the body but sometimes located in the ‘head’. In previous studies, women’s genitals have sometimes been metaphorically referred to as ‘doors’ which can be ‘opened or closed’ (Undie, Crichton, and Zulu 2007) reflecting the problematic ‘gatekeeper’ role women are culturally assigned in relation to sex. The slipperiness of metaphors points both to ambivalence or confusion about whether the difficulty is physiological or psychological in origin or remedy, and to issues of agency. ‘Blockades’ or ‘walls’ are actively erected, although their purpose is ambiguous – walls simultaneously enclose, protect and give privacy, as well as divide, exclude and obscure. A blockade is deliberately designed to prevent people from entering or leaving, while ‘resistance’ usually refers to a physical quality or refusing to accept or comply with use of force or violence. These metaphors imply a shutting out of someone or something – which perhaps partners may interpret as a sexual rejection (Boswell 2021). The fact that participants also used the metaphor of the ‘wall’ in nonsexual contexts to refer to another person who they perceived as unresponsive to their attempts to communicate adds to this focus on relational dynamics.

Split body and ‘self’

Participants used a range of metaphors which created an image of the body as a kind of machine. Mostly referring to attempts at sexual intercourse, the sexual body was described something which ‘just doesn’t function in the way that it should’, or which ‘doesn’t work’. Participants described difficulties engaging in intercourse as being like a switch which shifts between on and off quickly and without volition: ‘it is just a short moment there is such a switch that flips (.) and (.) from that moment on it then hurts for me’. There was also the expectation that the body (and intercourse) should ‘function frictionlessly’ and exasperation when it is ‘just not frictionless’. In contrast to this image of a well-oiled machine, one participant perceived sexual encounters with her partner as ‘very mechanical’ – implying something impersonal, automatic or stilted, something without thought or spontaneity. Imagining the body as a machine offers the possibility that identifying and fixing faulty part might solve the difficulty. Describing the experience of a ‘stabbing pain’ as if there were a ‘resistance’ one participant wistfully observed that she had, at one time, thought she had ‘an adhesion there [in her genitals]’ something ‘physically not all right’ and that she ‘wished’ this was the case because this could have been ‘cut away’.

The metaphorical concept of the head as a set of wires represented another way to describe experience as based on physical and functional entities. This is remarkable considering that references to the ‘head’ usually involve a person’s psyche as opposed to their physical body. Participants’ ideas about how their sexual difficulties were resolved contained the image of ‘knots in [their] head’ which ‘got untied’. Similarly, the image of an independent switch which was sometimes in the head (when my ‘head switche[d] on’) suggests a lack of agency, something surprising and instantaneous and outwith the individual’s control. This was also reflected in the way that some participants talked about the resolution of sexual difficulties:

Ehm (.) I don’t = know = and = at = some = point it also just clicked for me as if everything was OKk and then, it was working [literally: running] again ((inhales)) (.)there was no kind of trigger or something like that, but it was like ((claps)) and then it worked [literally: moved] again

Although a parallel could be drawn between participants’ representation of their sexual difficulties as ‘knots in the head’ and the expression of being ‘messed up’ as in having emotional or mental problems (Hornby, Ashby, and Wehmeier 2000), the metaphor still involves a detachment from emotions or motivations which might be connected to the sexual difficulties, and thus denotes another variation of a ‘physical’ issue.

In both metaphorical concepts of the body as a machine and the head as a set of wires the body is assigned the status of an object which in some way serves the ‘self’, in this sense a metaphor of the body as a residence of the ‘self’ is apparent. Elsewhere, women experiencing sexual difficulties have described their frustration with bodies which they perceive to be ‘faulty’ (Ayling and Ussher 2008, 294), and how this extends to feeling like a ‘broken woman’ (Kaler 2006, 61). As we see in our analysis, this framing of bodily experiences leaves little space for appreciating the co-construction of mental and bodily processes and perceiving the body as belonging to the ‘self’. Referring to the body more generally, one participant described her relationship with her body while talking about her aversion towards going dancing as ‘well @I don’t live in my body somehow@, like properly’. However, describing this discomfort as ‘not living in’ her body still indicates a connection between body and ‘self’. Her description evokes a degree of dissociation and a disruption of the subjective integration of certain aspects of psychological functioning which, in its more severe forms, is thought to be related to traumatic or overwhelming experiences (Spiegel et al. 2011). Given that women with vaginismus and dyspareunia exhibit greater difficulties with perception and experience of their bodily self in a comparison with controls (Koops et al. 2021) and that associations have been found between somatoform dissociation – dissociative phenomena involving body processes – and vaginismus, dyspareunia, and orgasmic disorders in women (Farina et al. 2011), it would be interesting to further explore how the metaphor of ‘not living in one’s body’ also characterises these women’s sexual experiences.

The sexual body, sexual agency and objectification

Overall, metaphorical descriptions of positive sexual sensations were rare in participants’ accounts. One participant described arousal as something animal-like within her body: ‘those are the things which (.) where it still scu-scu-scurries in my tummy right like phew (.) […] Woah something is stirring there in the tummy’. This image suggests that it was not ‘herself’ who was sexually aroused but a creature inside of her which was ‘woken up’ by an arousing film and could be read as an example of dealing with such sensations when active desire for sex is perceived as prohibited for women who, according to the stereotype, ‘should’ be sexually passive and receptive.

In other examples, expressions were used which conflated a woman’s openness to sexual activity with literal physical acts in non-sexual contexts. One participant said that ‘I cannot spread my legs either, that is somehow, too, a mo:ve, ((inhales)) which, I can only do that under my own duvet, when I want to lie comfortably somehow or somehow, or change the position’. Another participant recounted from her experience of childbirth how ‘during the contractions they [hospital staff] come in between again and again and look how many centimetres and (.) at some point you really were fed up with it and it (2) and you are in such (.) great pain:: you (.) really put out for anyone’. Not only did these women equate allowing access to their vulva/vagina in a nonsexual context with sexual permissiveness; they also expressed an expectation of harsh judgement of such permissiveness by their choice of derogatory expressions (‘put out’ and ‘spread my legs’).

Participants also drew a parallel between gynaecological examinations and the act of ‘open[ing] up to someone’ – ‘And e::hm (.) I think, I never saw a reason [to go see a gynaecologist], I was fine, I didn’t see a reason and then thought, I also didn’t, but I do think that a little bit, now in hindsight fear played its part, having to be examined down there […] to open up to someone, but I wasn’t aware of that in that moment’. Whereas in this context the expression oscillated between its literal and metaphorical meaning, the image of ‘closing up’ was also used in other contexts in a more clearly metaphorical sense to speak about openness to a relationship: ‘I didn’t go partying that much anymore probably, well, and I never, met someone, who interested me somehow:: and I also believe, that I closed up a bit’. ‘Closing up’ could also be seen as a variation of the ‘barrier’ metaphors mentioned above. The metaphorical concept of the genital as access to one’s ‘self’, which was also present in participants’ accounts, is in line with constructions of women as ‘saints’ and ‘sluts’ by conflating sexual practices involving vaginal circlusion – usually interpreted through a heteronormative lens as sexual intercourse with a man – and the act of ‘giving access’ to something ‘hidden’ inside themselves. It further resonates with the value placed on ‘virginity’ and cultural rules around how it ‘should’ be ‘lost’ without ‘losing’ dignity.

Finally, one participant made use of the image of a ‘plank’ to illustrate how her body felt during intercourse attempts with a partner, referring both to the stiffness of her body and the object-like image she had of herself in those moments: ‘For me as well [sexual intercourse] is just all, really uncomfortable, and ehm, not great at all, I feel like, °I can = once describe exactly° what I feel like, like a, ehm, I feel humiliated, I feel like a use-, like a plank which is used’. This ‘plank’ feeling was also related to feeling inanimate, or as she put it, ‘dead’. Such a strong image possibly related to a feeling of objectification during sexual intercourse alludes to several aspects: a complete lack of agency and mobility, the rawness and violence of the act considering that planks are oftentimes treated with hammer and nails, and an even stronger state of dissociation than that mentioned in the previous example above. Her body not being pictured as of flesh, but as a hard piece of wood, or even sometimes felt to be ‘dead’, defines an absence of lively bodily perception and experience. Further research could shed light on the role of body-mind dissociation in sexual pain and difficulties with vaginal circlusion. As may be apparent from the discussion so far, there was often ambiguity in whether participants were using words metaphorically or literally, or a blurring between abstract thinking about the body and concrete physical experiences. This collapsing of abstract and literal meanings of metaphors corresponds with research on the ‘concretised metaphors’ used by women with anorexia nervosa in which psychic and physical reality are treated as equivalent (Skårderud 2007). Although this fuzziness is sometimes seen as a methodological problem (Semino, Heywood, and Short 2004), examining the messiness of this data (as above) can sometimes bring the most productive insights.

Discussion

The aims of this study were to explore the metaphors used by women diagnosed with vaginismus or dyspareunia, and to exemplify the advantages of metaphor analysis for health and sexuality research. Given our secondary analysis of a relatively small dataset, we did not set out to generate an exhaustive taxonomy of metaphors used to describe sexual pain difficulties. Rather, by examining a number of metaphors regarding sexual pain and difficulties with vaginal circlusion, we hoped to illustrate the value of attending to metaphorical talk and the functions that metaphors might serve.

Firstly, metaphors can offer a way for people to express difficult experiences. In her study of endometrial pain, Bullo (2020) found that women used metaphor because they did not feel that they had adequate words to express their experiences and experienced emotional relief from discovering a way to talk about pain. Not all of the 28 women in this study used metaphors to describe their bodily experience, although a substantial proportion did; three (out of eleven) women with experiences with dyspareunia, and thirteen (out of seventeen) women with experiences with vaginismus used body-related metaphors. Further investigation is required to determine whether there are consistent differences in the use of metaphor and in symbolic capacities between women experiencing vaginismus and women experiencing dyspareunia. Moreover, qualitative differences in the type of metaphors used (e.g. violence metaphors, journey metaphors, etc.) and the impact of these on providing relief from, or exacerbating, sexual distress is a promising area of research.

Secondly, metaphors can function as useful tools for communication – both between people experiencing difficulties and their partners, families or carers, and with healthcare professionals. Being able to share a distressing experience with loved ones and professionals may being a sense of connection from communicating and sharing experiences (Stewart and Ryan 2019). As well as evoking empathy, metaphorical expression can enable health professionals to gain greater insight into the ways in which individuals are experiencing and managing specific difficulties. For example, mothers using metaphors to describe their experiences of caring for their children with obstetric injuries found this enabled them to capture elements which medical jargon did not and provided clinicians with valuable insights (Beck 2017). However, metaphors can be problematic when they are not shared, are imperfectly understood, or conflict with dominant metaphors or models. Exploring the difficulties women face in attempting to describe their pain in medical consultations, Bullo (2020) found that a mismatch in assumptions could lead to miscommunication and potentially a delayed diagnosis. This may be exacerbated when metaphors are not shared across cultural or other social divisions, or where communication extends across different languages (Magaña 2019).

Thirdly, with regard to support and intervention, metaphors might be used purposely and therapeutically to alleviate people’s experience of distress. There is a small, but developing, body of health-related research which attempts to use knowledge about metaphors to positively influence people’s illness experience. In one study, images based on pain metaphors were made available for people to use in medical consultations (Padfield et al. 2018). The use of these images was associated with greater amount of talk and emotional disclosure by patients, and greater non-verbal affiliative behaviour by doctors.

Finally, metaphors are thought to express unconscious content given their frequently unconscious use and their ambiguity (Arlow 1979; Colman 2005; Schmitt 2005). For example, an issue which was rarely explicitly addressed in the interviews but became visible in several metaphorical concepts was the question of agency. Oftentimes, participants suggested with their use of metaphor that the sexual difficulties they had experienced, or other bodily processes, were not under their control, which could be understood as a way to obscure potential motivations for ‘disturbing’ the seemingly desired ‘frictionless’ sexual intercourse. However, it could also be read as an expression of not feeling in control in sexual interactions. Considering negative reactions to the idea of being an active sexual ‘agent’, equated with being seen as a woman who ‘spreads her legs’ or ‘puts out’, it is understandable if sexual agency represents a conflict-laden issue, as it may be wished for and feared simultaneously. Whilst a tentative hypothesis at this point, the analysis of metaphors is nevertheless a source of inspiration for approaches to the understanding of sexual pain.

Limitations

There are several limitations to this study. First, data were not collected with the intention of analysing metaphors. Future research might actively elicit metaphors in the interview process, for example by prompting reflections on bodily perceptions. Second, the original data were translated for this analysis. Efforts to counter a potential loss of information through this procedure were made by constant dialogue between the authors who were German and English native speakers. Third, like most research using this method, our analysis focused on the semantic content of metaphors, future research would benefit from also attending to details of speech delivery (i.e. intonation, pace, etc.). Finally, Metaphor Analysis is an interpretive approach and can, from a clinical perspective, only give ideas about relevant issues for the sexual difficulties discussed here. More research is necessary to determine how and to what extent the aspects raised by our analysis – the framing of the sexual difficulty as an experience of harm or a prevention of an unwanted experience, the splitting of body and ‘self’, or difficulties in reconciling individual experience and cultural discourses on women’s sexuality – shape women’s experiences of sexual pain and difficulties with vaginal circlusion. Nonetheless, the identification of these aspects not only provides direction for future investigations, but also demonstrates the strength of metaphor analysis for health and sexuality research.

Acknowledgements

We thank all the women who participated in our study for sharing their personal stories and experiences.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The first author held an Evangelisches Studienwerk Villigst doctoral scholarship at the time of data collection.

Notes

1 Given the heteronormative and misleading connotations of the term penetration in this context, we use the word circlusion as suggested by Adamczak (2016) (for a version in English language see Lewis (2016), meaning the active intake or surrounding of an inanimate object or body part by someone/something (“pushing something – a ring or a tube – onto something else – a nipple or a shaft”).