Millions of women have experienced pain with sex. Whether it be the first time they are having sex or an ongoing problem; it is a definite pleasure circuit breaker. Put simply, pain feels at odds with being in the moment and opening up in every way.
To be frank, pain can get a little complicated because each woman presents with her own unique set of triggers, blocks and concerns. I am always learning from my clients who experience sexual pain: just recently, a client made an astute observation. She was struggling to name and connect with her sexual anatomy – there was a block there. Medically, a common way to reference a woman’s pelvic organs is ‘the sexual and reproductive anatomy’ or, more succinctly, the vulva, pussy or yoni.
For Chelsea* the pain originating from her reproductive anatomy was completely cascading into her capacity to feel sexual so she struggled to even name this part of her body. Her pain suppressed all feeling and connection to it, especially that of arousal. This makes complete sense.
How can a woman move into sexual excitement when her anticipation isn’t exciting?
Instead, it’s terrifying. It’s daunting. When a woman’s body is anticipating something negative, it goes into a brace position. It contracts and everything tightens up.
Sexual pain is never all in a woman’s head. Sexual pain is real. Your experience is real.
One of the signs that you experience pain with sex is that you have never had a pap smear because of avoidance…or if you have had one, it was so intensely painful and uncomfortable you don’t want to go back (even though you are way overdue). You have had problems inserting tampons and tend to avoid them altogether. This has flowed on to penetrative sex – which has either been possible but completely painful or completely impossible.
It’s important to know that the female body is predominantly receptive in nature - that means that it chooses to take something into it. When the body shuts down, it is choosing to not take something in. It’s saying no for a reason. A woman’s body says no when it doesn’t trust – the surrounds, her environment, the person she is with or herself.
Your head plays a role, your body plays a role and your spirit plays a role.
Try, if you can, to reframe your sexual pain as your body protecting you. First and foremost, that is what is happening.
When you have acknowledged the way your body has been looking out for you, you can let it know that you would like to learn how it doesn’t have to be on guard all the time. You are ready for it to step out beyond the armour.
A heads up – this is not an exhaustive list but I have done my best to cover the most common complaints that I have had experience with as a woman and sexologist. I can’t answer for all the solutions to these reasons so please dig a little deeper if you suspect one is the root cause of your pain.
Here are 8 reasons why you could be experiencing pain with sex
#1 - Little to no sex education growing up
At the heart of so many women’s sexual pain is misinformation or no information. I’m talking:
+little or no information about menstruation
+little or no information about our anatomy and functioning
+little or no information about sex and pleasure
+negative cultural and/or religious beliefs about human bodies
All of this feeds into your sexuality and your capacity to open up. It’s no coincidence that women that were raised within cultures that have the most oppressive belief systems and a lack of sexual education also have the highest rates of vaginismus and dyspareunia^ (you’ll read more about these diagnoses later in the blog).
It’s also a driving force for women coming to see me – they experience numbness and pain with sex and say: I know nothing about sex. I’ve never learnt anything and I don’t know what I am doing. The start of sessions often feels like the sex education they never got. I promise, it’s never too late. I too was robbed of an adequate sex education (but I definitely feel like I have caught up now!)
#2 - An anxious mindset in anticipation
Sexual pain commonly happens when your body is unprepared mentally and physically for touch and penetration. It’s important that you know that your memory in your mind and body will work faster than your conscious thoughts. Your old primal brain that resides in the back of your head will do all that it can to protect your body and keep you safe.
Touch has a memory
- John Keats -
It’s a major cause of sexual shutdown and it happens when your body has been through an experience such as trauma, hurried or rushed intercourse, sex that you haven’t consented to/said yes to and gynaecological issues such as fibroids and endometriosis.
Anecdotally speaking, this ongoing, constant state of anticipation goes hand-in-hand with anxiety, which wants to be able to predict the future. Another part of having a predisposition to anxiety is identifying strongly with the good girl and good wife (or cool wife as I call it) persona. This can tilt us towards perfectionism, suppression of real emotions in favour of doing what is better or right for someone else and always anticipating the next move. Always wanting to know the future and what happens can be negative in that women are already thinking about (and then feeling) the pain they are expecting before they feel it on a sensory level.
There is a lot of value in learning body awareness skills and coming in to presence so that you can move slowly into sex and stay with what is happening at each moment. One client emailed me at the end of four sessions and said: I've had the first pain free period in years since I came to see you...is that because we have talked about my sexuality? Very possibly. It's not far-fetched, just expressing and normalising can do so much of the healing.
#3 - Birth trauma
The birth experience is felt by the mother well beyond desiring ‘a healthy baby’. Our memories of birth and their corresponding feelings extend well into our postpartum years. It’s a topic shrouded in silence but the after-effects of birth by both vaginal delivery and C-section can leave a woman with very real trauma through psychological and physical scaring. Recovery from organ prolapse, residual scar tissue and nerve damage can take extensive time and a lot of professional guidance to move through. Some effects can be permanent.
The emotional side of reconciliation with her changed identity alone can be the biggest hurdle to move through as women are left questioning how they can be sexual again with their bodies feeling and sometimes appearing different to pre-pregnancy. It is vital that you know you are not alone and that support is available to you during this very trying time – the Australasian Birth Trauma Association is working tirelessly to help you access the resources you need to recover and feel supported.
When it comes to moving back into sex, there isn’t one answer because each woman’s needs are so individual. What is most important is that when resuming a sexual relationship that contact and touch move very slowly and that there be no expectation of penetration or pressure on any painful sites.
#4 - Lack of preparation
Sometimes pain occurs because of the simplest of reasons. This one isn’t to be overlooked. Women can experience pain with sex because their bodies aren’t physically prepared for sexual touch and contact.
We need lubrication to ease friction, whether naturally expressed or in the form of a little help from lubricants and oils.
What lots of people don’t know is that lubrication takes place in 3 ways:
The first is vaginal sweating – facilitated by the vulvovaginal glands at the entrance to the vagina.
The second is lubrication that is released from the vaginal canal and cervix. This mucus is clear and slippery.
The third is our waters that are released with female ejaculation from the paraurethral glands (the female prostate) that reside in the urethra.
A little warning – there is a message out there that women shouldn’t need lubricant because of these inbuilt mechanisms we possess but I think that message can be a shaming one. There is nothing wrong with using lubricant to help you move into sex, especially when you are learning to relax into it in a new way. Do whatever works to break the ice in a safe and comfortable way. Those other skills and approaches can come later.
My favourite lubes are water based ones and coconut oil (but not to be used with condoms).
#5 - Vaginismus + Dyspareunia
I have worked with a number of women that have presented with the diagnoses of vaginismus and dyspareunia. What I will say straight up is that these conditions are commonly misdiagnosed in that they aren’t fully explained to the woman and can be used as blanket diagnoses that leave her a little in the dark. There are frequently exceptions to these diagnoses that she presents with and so I inform her as to what my understanding and experience is of each.
Dyspareunia is pain that can exist anywhere in the genital area before, during or after intercourse and sexual contact. It can be internal or external. Because of the breadth of possibilities, a thorough investigation with your GP and potentially your gynaecologist is needed to pinpoint the origin of the pain.
Vaginismus is an involuntary spasming of the pelvic floor that prevents the insertion of any object. It is a fear response we undertake to protect ourselves. I learnt early on that with the true, textbook definition of vaginismus, that inserting a cotton tip is impossible. Tampon use is out of the question and obviously, so is intercourse.
I’m going to go out on a limb here – I really believe that vaginismus as a diagnosis happens for a woman in all attempts at object and penile insertion. I recognise that for some women it can be situational (in that it doesn’t happen all the time and with all attempts) but I only use this term when there is impossibility with all attempts at insertion.
If a woman sits before me and can insert a tampon, a cotton tip or even a finger with some discomfort but it isn’t impossible, I ask her: do you want to use the term vaginismus? Does it help you to move on and move through your problem?
In all my years of work helping people, I have found few labels to be actually helpful in the long run usually because they have negative connotations. In helping you move away from that problem, I move away from the label as well. I don’t want women to become attached to it and say terms such as ‘because I have vaginismus’ and ‘my vaginismus’. I focus on the fact that an object can be inserted and that this is really promising for her moving this victory into penetrative sex. Never underestimate the power of this simple mindset shift from what isn’t possible to what is possible – it can be a key indicator to recovery.
I’m wondering if there is room to change the wording from vaginismus to hypertonic pelvic floor (i.e. a tight pelvic floor)? It just sounds a little less all encompassing (vaginismus might default you to believing – my vagina is wrong) and hypertonic pelvic floor is more specific to me.
#6 - Thrush/BV/recurrent UTI’s
Recurrent thrush, bacterial vaginosis and UTI’s can not only thwart your daily plans but really play with your sexual confidence. Attempting sex when you are symptomatic may well be an impossibility for multiple reasons. You are experiencing pain, discharge, frequent urination and just generally feel lethargic.
Left untreated, these vaginal and urinary infections can create further discomfort and complications. Once you have moved through the current bout, make it a priority to address the root causes of these 3 as an attempt to avoid further distress. So often, prevention can be a matter of good hygiene practices (including urinating after sex to flush your tract), avoiding perfumed products, having probiotics in your diet and not going on to antibiotics where you can avoid it (especially if you have a viral infection – they won’t change anything).
Condoms are a great form of contraception not only because they have a great success rate at preventing unwanted pregnancy but they can limit the amount of pathogens that have contact with your vagina and urinary tract.
#7 – Gynaecological Diagnoses
Approximately one in ten women around the world experience symptoms of endometriosis and adenomyosis, both of which are characterised by endometrial cells growing through the muscle wall of the uterus. The vast majority of women who are (finally) diagnosed with one or both of these conditions will tell you how much their menstrual cycle is crippled by pain. What they thought was a ‘normal’ experience for women is actually something very different in that their levels of pain, often requiring them to forgo commitments to rest and go inward. Sex can be out of the question because the pain on insertion and thrusting motion can aggravate where the uterine lining (adhesions) is attached to other organs and muscular walls of the pelvic cavity. Pair that with irregular bleeding outside of your menstrual cycle and you can feel anything but sexual most days of the year.
Thankfully, awareness of endometriosis and how to treat it outside of hormonal contraception is growing. I know a number of women who are now managing their symptoms naturally through lifestyle changes and an increased connection to their bodies, especially after they have had minor surgery (laparotomy). My favourite resource is floliving.com
#8 - A sexual trauma history
The human body releases all types of pain in myriad ways. If you are the survivor of sexual trauma, abuse, harassment and/or sex that happened without your consent, know that your body can be holding on to these painful memories on the deepest of levels.
Perhaps you experience a triggering affect whenever a partner attempts to touch you. It is then highly likely that what quickly follows you feeling triggered is flashbacks to the offence or offences. Your body goes into self-protective mode but moving into contraction and tension – all your muscles are activated to fight the threat and trying to persist or tolerate touch just doesn’t work because your body isn’t open to it. Everything that is associated with sex is traumatic, painful on all levels and unwanted.
There is no right or wrong way to process a history of trauma that is still causing a strong sense of invasion or avoidance of all things intimate for you. But, if you haven’t already, would you consider speaking to someone in private about it? To give some sense of release from that pain that is sapping you of feeling safe and comfortable? I know sexual trauma hurts so much but know that you are now worthy of feeling pleasure and you are worthy of experiencing sex for yourself as a consenting adult with the one you love.
Where to start with getting help
The first practical step is to get a really thorough health check by your GP to ensure that there isn’t a genuine medical condition that is causing pain and preventing touch and penetration. Some surgical procedures can assist the course of sexual pain, especially in the case of endometriosis and fibroids. These decisions require investigation and above all – your consent (your informed yes or no).
Sometimes women are referred to a pelvic floor specialist such as a qualified physiotherapist (I’ll put a list of Brisbane physiotherapists at the end) to assist to relieve the tension within the pelvic floor – you know how so many people promote Kegels and pelvic floor squeezes? this probably isn’t helpful for addressing your sexual pain as your pelvic floor is already too tight. The physiotherapist may advise specific exercises to assist with focussing on helping your pelvic floor to open, relax and move out of contraction. Specific vaginal dilators are frequently recommended to assist and can be used at home to gradually open up your pelvic floor.
Sex therapists and sexologists like me are the perfect compliment to this work with a pelvic floor specialist. When I work with a woman experiencing pain with sex, I help her to shed negative and limiting beliefs around her body, her primal nature, sexuality and womanhood. I teach her to adopt new ways of getting into her body and how she can honour her sexual nature, communicate with more clarity and wade into the waters of penetrative intercourse. Women need time and small (but progressive) steps to open up and trust.
And with trust, we are talking about trusting yourself most of all.
We source the words, approaches and concepts that work best for her. We highlight the triggers to closing up and use these to recalibrate her sexuality. It’s such a deep process of change and we do it at a really gentle pace.
The old metaphor of a woman’s sexuality being a flower is the most apt description for a woman who experiences pain with sex. She truly is a flower that can’t be forced open. She needs to do it on her own terms and when she is ready.
Feel like you could use some personalised attention to address your sexual pain issues? I get it, this is sensitive terrain.
I spoke at the Women’s Health and Fitness Summit in 2018 about women’s internal experience of pain with sex - it uncovers how I work with women when they are experiencing a hypertonic (overly toned) pelvic floor and how a sexologist can assist in a health care team that includes her physiotherapist and personal trainer.
Resources - Brisbane based Physiotherapists:
Sami Cattach from Body + Birth Physiotherapy
Sue Croft from Sue Croft Physiotherapist
Esme Soan from Pear Exercise + Physiology
Further recommended reading:
WomanCode by Alisa Vitti
When Sex Hurts by Andrew Goldstein
*Name changed to protect identity.
^Michetti et al. (2014) Unconsummated marriage: can it still be considered a consequence of vaginismus? Int J Impot Res.