Ask Dr. Nan: What if having sex hurts?

 

Why talking about sexual pain disorders is key to promoting awareness and fighting the stigma and shame

In my book Why Good Sex Matters: Understanding the Neuroscience of Pleasure for a Smarter, Happier, and More Purpose-Filled life I explore how the ability to experience pleasure-both in and out of the bedroom- is not a luxury, but a necessity for overall wellbeing.

Having a happy, healthy sex life can greatly contribute to promoting a pleasure-positive relationship with ourselves and our partners. There are, however, some people for whom sex is a place of pain, rather than enjoyment and satisfaction.

A question I often get asked by readers is how to deal with pain related to sexual activity. Here I address some of what’s known about genital pain disorders to help women and their partners seek information and get proper treatment.  (Men also can suffer from pain related to sexual activity which will be a topic for another column).

For starters, we do know that genital pain complaints are quite prevalent. Since many women are hesitant to report pain associated with sexual activity to their health professionals due to embarrassment or shame, and their providers often don’t inquire, the prevalence of these disorders has been significantly underestimated.

End result?  Many women (and their partners) suffer in silence and simply don’t get the help they need to address the pain and improve the quality of life.

What are the various types of genital pain in women?

Dyspareunia is a term that refers to recurrent or persistent pain that happens before, during, or after having sexual intercourse.

 Superficial dyspareunia is when the discomfort is localized to the entrance of the vagina or the vulva- which includes the external parts of the genitals such as the inner and outer lips (the labia), clitoris, mons (the fleshy mound), and even the opening of the urethra.

In the case of deep dyspareunia, the discomfort or pain is felt more internally, extending deeper into the vagina and in some cases involving pain in the lower pelvis. This version can be associated with intercourse that tends to involve deep penetration.

Some women experience primary dyspareunia that occurs from the very first time they attempt intercourse, while others develop secondary dyspareunia that shows us after periods–perhaps even years-of painless sexual intercourse.

Another term, vulvodynia, can also be used to characterize painful intercourse.

Although the terms dyspareunia and vulvodynia are often used interchangeably, vulvodynia is further defined as chronic genital pain that persists for longer than three months, has no established cause, and can occur without any provocation–which means in the absence of sexual activity or touch–and is localized to the entrance of the vagina and the vulva.

In other words, dyspareunia can be thought of as a descriptive term for painful intercourse in general, whereas vulvodynia is used when the pain is chronic and localized either to the vulva or entrance of the vagina.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which is the guide that health care providers use for diagnosis of mental health and pain disorders, now uses the term, “genito-pelvic pain/penetration disorder,” which encompasses both vulvodynia and dyspareunia, as the well as “vaginismus” –a condition in which intercourse is hampered or made impossible by involuntary muscle spasms that create pain upon attempted penetration.

As mentioned previously, it is difficult due to stigma surrounding sexual health issue to get a good read at the numbers of women affected by genital pain disorders, but It has been estimated based on a comprehensive review done in 2016 that 10-28% of women of reproductive age suffer from vulvodynia. A more recent paper published in 2020 indicates that vulvodynia impacts 8-10% of women of all ages. Rates appear to differ by country and how the condition is diagnosed and studied. More specifically, studies in the USA have found that approximately 16% of women experience vulvodynia during their lives with 7–8% of women experiencing symptoms by age 40. And of note, young women before the age of 20 appear to be at even higher risk of experiencing these symptoms.

What is truly distressing is that studies suggest that only 60% of women with symptoms of vulvodynia seek help and that 40% of these women never receive the appropriate diagnosis.  This contributes to the high toll these disorders take on those afflicted.

Here’s a direct quote from Dr. Bergeron’s primer on vulvodynia:

“Although pain is the characteristic symptom of vulvodynia, the effect of the disorder is far-reaching as it is associated with reduced sexual desire, arousal, sexual frequency, and sexual satisfaction, and can adversely affect women’s and their partners’ psychological and relationship adjustment.”

The diagnosis and treatment of sexual pain disorders

As a sex therapist, I always take a comprehensive approach to this issue. There can be many causes of physical pain during sex. As sex is a biopsychosocial phenomenon involving our bodies, our minds, our experiences, and our culture’s messages, physical pain during sex can result from any number of interacting factors.

 Biological factors

Issues affecting our bodies can underlie sexual pain disorders (such as physical problems with our genitals or reproductive systems, dysfunction with muscles such as those of the pelvic floor, infections, hormone imbalances, issues with the peripheral nervous system such as damage to nerves or increased inflammatory processes, and central nervous system mechanisms such as altered pain processing involving increased sensitivity in brain regions processing sensation or pain.

Starting with a check-up with a knowledgeable ob-gyn is always a good idea. See the resources section to locate a health care provider with experience diagnosing and treating sexual pain disorders.

Psycho-Social Factors

These factors involve our experiences and learning in the context of our families and our culture. What have we been taught to believe about sexuality? Have our experiences regarding our bodies and sexuality been pleasurable or unpleasant? Have we had negative sexual experiences or traumas?  “Yucky” experiences can range from being shamed as a kid by a parent for touching ourselves– to being touched inappropriately by someone else. And as we unfold our sexuality, traumatic experiences can range from having partners not honor our boundaries or give us a chance to truly consent to sex– to the extremes of rape, sexual or relational violence, or abuse. Having a history of sexual trauma can contribute to physical pain experienced during sex. And having a painful relationship with a partner may be part of the genital pain picture.

In the biggest of pictures, culture impact our beliefs about sex and sexual pleasure. Some cultures are more permissive as to how sexuality is viewed, others more restrictive. Cultures differ in gender equality which is a big factor in how women feel about their sexuality. Religion can play a key factor in how comfortable we are taught to be about our sexuality in general and our sexual pleasure in particular. And the stigma surrounding our sexuality is the biggest obstacle we face in approaching our sexual selves.

Treatment

Effective treatment of any type of genital pain disorder should start with contacting a sexual medicine professional. For example, certified sex therapists are specially trained to help clients take the biopsychosocial approach to find answers. They can coordinate treatment with physicians who can help address the bio part of a good treatment plan, which may include ruling out medical causes for the symptoms, prescribing medication as indicated, pain management therapies, and referral for pelvic floor physical therapy. Sex therapists can provide a multilevel approach using psychotherapy to help address and manage the various symptoms to improve the quality of life.

How to get more information and find a sexual medicine provider? 

Here are links to important resources for information and referrals

The International Society for the Study of Women’s Sexual Health (ISSWSH).

Includes physicians and therapists who specialize in sexual medicine here and abroad.

 The American Association of Educators, Counselors, and Therapists (AASECT)

Has resources for referral to sexual health providers in the USA and abroad.

The National Vulvodynia Association (NVA)

Great information and also a resource for finding health care providers specializing in sexual medicine in the US.

And you can always contact me to ask questions and seek help!