Articles on Relationships and Sex

Pain During Sex

Pain during sexual intercourse can affect men and women and often the GP or a sexual health clinic is the first place they present. Pain during sex is often the result of physical problems. Pain for women can be caused by physiological problems such as fibroids, endometriosis and vulvodynia. It can also be caused by infections like pelvic inflammatory disease, or other sexual transmitted infections. 

It can follow chemotherapy, surgery, menopause or insufficient sexual arousal. This is because there is a lack of sufficient lubrication and or the skin of the vagina has become thin (atrophied). This can be helped with artificial lubrication, HRT if applicable, or longer and better directed foreplay to encourage arousal. It can also be caused by skin conditions like lichens sclerosis. Pain can follow a difficult birth where scar tissue has developed after an episiotomy. Infections can also affect men as can other conditions such as phimosis, where the foreskin of uncircumcised men is too tight and doesn’t retract sufficiently. They can also develop problems like Peyronie's disease which causes a bend in the penis. Most of these conditions are highly treatable and a GP should be able to treat or refer on to a consultant for assessment.

Chronic long term conditions such as rheumatoid arthritis may indirectly cause sex to be painful. I don’t regard these as sexual dysfunctions but conditions which impede function. Adaptations can be made including pain medication and supports such as pillows and hoists to help manage these difficulties. Sex and disability is for another article.

What if the problem isn't physiological?

Once a physiological problem has been ruled out we are left with psychological influences. I have never seen a man presenting with pain for psychological reasons. They are more lightly to present with erectile difficulties, premature or delayed ejaculation. Complaints of pain in women are most often caused by vaginismus. A diagnosis of this kind is not always helpful but it is as well to understand what it means. It is when the vaginal muscles go into an involuntary spasm as become so tight that intercourse is either very painful or actually impossible. This can be ‘primary’ (i.e.: in woman who have never had intercourse) or 'secondary' (in women who have previously managed sexual intercourse without a problem and life circumstances or a single incident such as a sexual assault has occurred to alter her experience). 

Pain can also occur when a partner is angry with their sexual partner or is having sex out of duty or obligation. I am not suggesting sexual intercourse is the only sexual activity but it is the one most commonly presented with complaints of pain. This could also occur with women having sex with women if wanting penetration using fingers or strap ons.

What are the causes of vaginismus?

Vaginismus is usually as a result of fear of penetration. This could due to many and multiple reasons. The first attempt at intercourse may have hurt due to the lack of experience for both partners. The situation may not have been ideal or it may have been non-consensual. As a result the woman tenses and penetration is painful. The next time she attempts intercourse she is on the alert for pain and the vaginal muscles tense in anticipation and a vicious circle then develops. These women then tend to develop a negative relationship with what they see as their ‘broken vagina”. They disengage from it and avoid penetration. These women may or may not be sexually active and orgasmic when engaging in alternative sexual activity. Muscle tightness can also be due to fear of pregnancy so it is important as a therapist not just to ask if they are using contraception but whether they trust it. I worked with a woman for a year before she revealed that she did not trust the progesterone-only pill she was using due to break through bleeding. On my advice she changed method and had a implant inserted and managed sexual intercourse within a few weeks.

Sometimes friends or the family of origin set the woman up to expect pain. I had a client who was told by her Aunt to “expect a blood bath” on her wedding night. Who could possibly be relaxed if this is what they are anticipating? If sex has been forbidden before marriage it is not automatically smoother sailing just because a marriage ceremony has taken place. I have seen a number of couples who may have been very sexually active before marriage but avoiding intercourse and after marriage the vaginal muscles remember the ‘rules’ and are not able to respond instantly to the new situation.

Getting support with vaginismus

If a clinician diagnoses vaginismus they might suggest a graded exposure program with vaginal trainers but this is a very intrusive approach and although it can give women confidence and work well, it requires ongoing support from a clinician or psychosexual therapist and some discussion about why the muscles might be so tight before trying to relax them. 

I think it is important to first explore why a women wants penetrative sex in the first place. Is it for the right reason, her reasons or to please others or fit into media and cultural expectations? Specialist physiotherapists can also work with this problem using biofeedback and massaging the trigger points within the vagina to help them relax. However the woman needs to be relaxed enough to tolerate this treatment and practice in between treatment sessions.

I have had a client who associated menstrual blood with ‘wounding’ and somehow her genital area had become all about ‘wounding'. The vagina is unseen and a ‘potential space’. It is hard for some women to imagine that an erect penis is going to fit in there. Where is it going? I will get woman to look in a mirror to identify their vagina. I might also show them my hand going into a flat paper bag to help them imagine this potential space that expands and accommodates. Pain with sexual intercourse is complex and can take a lot of empathetic exploration to overcome. It is treatable and I have had many clients who took the journey from pain and anxiety to a new and positive relationship with their vagina and with their penetrating partner. 

First published on welldoing.org  April 24th 2019.