Sexual Pain Disorder: When Sex Really Hurts

I am a clinical psychologist specializing in women’s health as well as sex and couples therapy. Having completed my Ph.D. at Laboratory of the Biopsychosocial Study of Sexuality at McGill University, I have done extensive research on female sexuality, genital, pelvic, and other pain problems. I am an instructor in Behavioral Medicine, Cambridge Health Alliance, Harvard Medical School. In my clinical work I focus on health psychology, problem-focused therapy, and medical hypnosis. Many of the women I see in my private practice consult for the following areas:

  • Sexuality & Relationships
  • Reproduction, Labor, & Delivery
  • Acute & Chronic Pain
  • Stress, Depression & Anxiety
  • Medical Problems

Women’s Sexual, Perinatal, & Pelvic Health

My work on women’s health issues includes sexual and reproductive concerns such pelvic pain, pregnancy, labor and delivery, and post-partum adjustment. Pelvic pain in women can often be related to uterine fibroids, endometriosis, or labor and delivery. Genital pain in women can be related to Vulvodynia, Vestibulodynia, or Vulvar Vestibulitis Syndrome (VVS). Both pelvic and genital pain often result in pain during sexual intercourse (Dyspareunia). Dyspareunia is a severely neglected health problem and can cause devastating effects for millions of women and their partners. Women with sexual pain often experience adverse consequences such as relationship difficulties, psychological distress, anxiety, depression, or poor self-esteem. Many of my clients have suffered for several years without receiving a proper diagnosis or appropriate treatment.

Dyspareunia and Vaginismus

Health care professionals usually define sexual pain disorders as sexual dysfunctions and divide them into two broad categories: Dyspareunia and Vaginismus. Dyspareunia is defined as “recurrent or persistent genital pain associated with sexual intercourse”, where sexual intercourse includes any penetrative sex act for any partner. Vaginismus is defined as “recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse” (Diagnostic and Statistical Manual; American Psychiatric Association). Sexual pain disorders, whether involving sexual intercourse or any other sexual activity, cause significant personal distress for women and their partners; these feelings may include low sexual desire, lack of sexual enjoyment, anger, sadness, hopelessness, or decreased body image.

Psychological symptoms resulting from a chronic pain condition can become as crippling as the physical pain itself and do warrant treatment. In my experience, reliance on purely medical interventions such as oral and topical drugs are not sufficient to break the vicious cycle of sexual pain. Comprehensive approaches that address both mind and body, and both the physical and psychological effects of pain are most promising. Women tend to recover best from sexual pain when profiting from medical interventions plus physical therapy, psychotherapy, sex and couples therapy, or alternative treatments.

Signs and symptoms of sexual pain disorders

Women may experience some discomfort or tension during their first sexual encounters; this does not constitute a sexual pain disorder. Dyspareunia is defined as a consistent pain before, during, and/or after intercourse. Women often describe this sensation as a sharp and burning pain at the entrance to the vagina during penile insertion or other penetrative activities. Women can also experience pain in the vagina with thrusting during sexual intercourse. In contrast, the main symptom of Vaginismus is an involuntary contraction of pelvic muscles, whenever vaginal penetration is attempted. Symptoms can range from mild to severe contractions, the later preventing penetration of any object such as tampon, finger, penis, or speculum. Some of my clients were never able to complete a standard annual check-up with gynecological examination; this represents a potential threat to their health.

The Vicious Cycle of Pain

In my clinical practice, I have not met a single woman who likes to experience pain during sexual activity. I have also not met a single partner who likes to cause their female partner to be in pain. When sexuality - which is supposed to be a pleasurable experience - becomes a major source of suffering one’s quality of life gets more and more impaired. Sexual libido, arousal, and orgasm are often dramatically diminished by both Dyspareunia and Vaginismus. Sexual pain disorders can interfere with one’s marital happiness. When left untreated, these disorders may even result in marriages without any physical bond and unfulfilled yearnings for parenthood.

Help is available!

The good news is that help to battle the impact of sexual pain disorders is available through a variety of treatments. Treatment options range from sex and couples therapy, psychological pain management, physical therapy, pharmacological treatments, surgery, hypnosis, to other alternative approaches. That being said, I do admit that sexual pain disorders can be difficult to treat because of the complex cycle involving not only pain, but also failure to achieve adequate lubrication, lack of desire, relational distress, anxiety, depressed mood, hopelessness, and relationship conflict.

If not a mindfully addressed and worked through, sexual and relationship difficulties will persist. Comprehensive treatments crossing boundaries between medical, psychological, and sex therapy interventions work best. A sensible approach often starts with the least invasive treatment first and then moves up in terms of severity and possible side effects.

Final personal note

If my one of my friends would ask me what to do when experiencing pain during intercourse, I would recommend to take a proactive stance while starting out with the least aggressive treatment. I would suggest being cautious about the latest treatments often promoted through unnamed online sources.

A good starting point for any woman experiencing dyspareunia often is to contact a health care professional that she already knows and feels comfortable with, such as a family physician. Physical symptoms (e.g., infections, fissures, hormonal changes) need to investigated. If my friend did not have a supportive primary care physician, I would urge her to find one. If my friend is not reporting any reduction in symptoms after this first consultation, the next step could be seek out the help of physician specializing in genital /pelvic pain to rule out / address any physical abnormality. If my friend then is still experiencing pain, I would strongly suggest seeking out treatment with a psychologist or therapist trained in sex therapy and pain management. In addition, pursuing physical therapy with a pelvic floor specialist will be beneficial.

The vicious cycle of pain is best addressed as early as possible: pain creates more pain, fear, and muscular tension; fear creates more fear, pain, and muscular tension; muscular tension creates more pain and fear. Both the physiological and psychological aspects of sexual pain disorders are best addressed with timely and appropriate care and there is no need for them to become chronic problems.

Nicole Flory, Ph.D.