What to Do When Sex Is Painful

It didn’t hurt the first time I had penetrative sex. Though my first time was upsetting for other reasons (the fact that it was coercive being chief among them), the sex itself didn’t hurt. Not yet. My body had not yet constricted in on itself, gained that rigidity that felt like a suit of armor. That came later.

That first sexual relationship was likely at the root of it all, because the next time I let myself get that close to someone that’s when it happened. I winced my way through penetrative intercourse. My insides seized up with every thrust, jagged pain corkscrewed through my entire pelvic region.

When I tried to find out what was wrong with me—why I was so broken—there were no real answers. My gynecologist told me she couldn’t see or feel anything wrong inside of me. She suggested it might be a psychological problem. A transabdominal ultrasound tech couldn’t find anything either.

Was it all in my head?

The Complex Source(s) of Painful Sex

For the longest time, medical practitioners believed that—depending upon the patient—issues of painful sex were either purely physical or purely psychological.

Reflective of this, in earlier versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), there were separate diagnoses for vaginismus (the “painful spasmodic contraction of the vagina in response to physical contact or pressure”) and dyspareunia (“difficult or painful sexual intercourse”). These days, the official DSM diagnosis for this type of sexual pain is known simply as Genito-Pelvic Pain/Penetration Disorders (GPPPD), a term that erases the strict binary between physical and psychological pain. Instead, it acknowledges that the source of such pain can exist on a spectrum.

Similarly, in 2015, the International Society for the Study of Vulvovaginal Disease (ISSVD) also updated the terminology for diagnosing vulvar pain. Initial guidelines already distinguished between vulvar pain caused by vulvodynia (vulvar pain without any known cause) and vulvar pain caused by specific disorders (which could include anything from herpes to yeast infections to vulvovaginal atrophy). The new guidelines dug even deeper into the various types of vulvar pain that might be experienced from person to person (localized, provoked, etc.). It also acknowledged that a woman’s pain might be caused by a combination of factors, both known and unknown.

Talli Rosenbaum, M.Sc. calls it “biopsychosocial.” It’s a theoretical model that acknowledges the ways in which biological, psychological, and socio-environmental factors can intersect. An expert in the treatment of genital pain disorders, Rosenbaum once explained to me that all genital pain disorders can be triggered by a confluence of physical pain, anxiety, and a woman’s reactive behavior around penetration (in other words, how much a woman tenses up in anticipation of penetration).

Which means that telling women to use more lube or to “just relax” doesn’t really cut it.

How Do You Know If Your Pain Is Problematic?

There is a mythology that women learn and internalize around penetrative sex. It is the one that teaches us that painful sex is normal… especially the first time.

This is a lie—one that has proven harmful to many.

Part of this lie is wrapped up in the fallacy of broken hymens and lost virginity. The thing is, virginity is a social (not a biological) construct. The folds of tissue near the vaginal opening (and their status at any given time) have nothing to do with whether or not you’ve ever engaged in penetrative sex.

The other part of the lie is the fact that female pleasure has often been sidelined in favor of male pleasure. When penis-in-vagina penetrative sex is overwhelmingly seen as the end goal of sexual activity, it’s no surprise that the vulva and the clitoris are given short shrift.

Sadly, many instances of uncomfortable or all-out painful sex could have been avoided if only a personal lubricant were incorporated into sex play. It could also be avoided if more attention were paid to making one’s partner sufficiently aroused and prepared for penetrative sex. Another solution is taking penetrative sex off the table completely in favor of other sources of pleasure.

In some instances, even these things may not work. Which could mean that something else (or somethings else) are at play.

If you’ve experienced pain during sex play, you may have noticed something was off in your body even before attempting penetrative sex. According to the National Vulvodynia Association, those with vulvar pain might also experience discomfort when inserting a tampon, undergoing a gynecologic examination, sitting for a prolonged period of time, or wearing too-tight pants.

If any of these things have caused you pain and if this pain has persisted for three months or more, it may be time to seek out professional help.

Leave It to the Professionals

Since sexual pain is biopsychosocial, it can often require a multidisciplinary approach, which means your gynecologist may only be your first stop on an entire tour of medical specialists.

Your regular gynecologist may send you along to a urogynecologist. This is a subspecialist who goes beyond those annual pap smears and IUD insertions and instead diagnoses, manages, and treats pelvic health conditions in women.

From there, you might schedule an appointment with a vulvovaginal specialist who treats vulvar pain. This type of specialist typically conducts vulval and vaginal exams to rule out various skin disorders and infections and pinpoint where, exactly, your pain lies.

You might go straight to the vulval dermatologist, who has the ability to pinpoint any number of skin conditions that affect the vulva.

Neurologists, pain management specialists, and even pelvic floor-focused physical therapists have all been known to treat genital pain conditions.

The point is: You may have to see a few different doctors before you get your answer. Don’t get discouraged if the first doctor you see isn’t able to give you a clear diagnosis.

Various Treatments for Painful Sex

Once you’ve received your diagnosis (or diagnoses), your doctor may recommend a combination of treatments. The most common treatments include pain-blocking medications, antidepressants, topical medications, and pelvic floor therapy (which often incorporates the use of dilators).

These treatments are not always enough and sometimes that’s because of the way we approach sex on a mental and emotional level.

The first time I spoke to Rosenbaum about genital pain, she told me about a client of hers who needed an additional year of psychodynamic therapy on top of physical treatments. During this therapy, the woman worked to develop a sense of self and autonomy. She also developed the ability to more effectively set boundaries.

“Unless your voice can say no,” says Rosenbaum, “your muscles are going to continue to say no for you.”
That was the crux of it for me. Because I had such an unhealthy sexual relationship my first time out of the gate, I had no sense of sexual autonomy. In fact, I faced penetrative sex with something akin to dread. This made me tense my pelvic floor muscles which, in turn, made me experience penetrative sex as painful.

After that, the expectation of painful sex only begat more painful sex. Instead of communicating with my partner about what I was experiencing and why, I approached sex as something to endure. Thus, it became a self-fulfilling prophecy.

I could have benefited from a therapist who specialized in sexuality or from any number of other therapeutic modalities. In fact, in addition to psychodynamic therapy, Rosenbaum also recommends such treatments as cognitive behavioral therapy (CBT), sensate focus exercises, and mindfulness techniques.

Luckily, I became more adept at communication. I’m now a pro at telling my husband when something doesn’t feel right and setting boundaries about how, where, and whether I’d like to be touched.
And why.

It’s now been a long time since I’ve experienced the shooting pain I once experienced during penetrative intercourse.

The first step in getting to this point was acknowledging that sex was painful—and then acknowledging that it shouldn’t be.

I deserve sex that feels good. You do too.