The Complexity of Sexual Pain

By: Deborah M Wade, MA, LPC, LMFT, CST, CSAT ACTSolutions, Grapevine, TX – Founder

 

As a marriage and family therapist and certified sex therapist, one of my favorite areas of focus is working with couples who are experiencing sexual pain. My desire in therapy (and here) is to give hope to those women who have sexual pain. For couples, I want to give helpful direction. And hopefully help change anxiety into an excited anticipation of the intimacy that can be developed.

 

Sex is not supposed to hurt. If you are experiencing pain with sex, there is help and there is hope.

First and foremost, I would want to say… sex is not supposed to hurt. If you are experiencing pain with sex, there is help and there is hope. Don’t settle and think that you must live with sexual pain without treatment options or without hope. I once attended a conference for my required continuing education for my Marriage and Family Therapy License. In a breakout session, one of the presenters stated, “The problem with complexity… well, it is very complicated.” The audience seemed wowed by her statement, and I actually felt a little mad that I had paid to hear that statement… Until I became a sex therapist. Sex is very complex. The difficulty in understanding desire; the perplexity of what comes first, desire or arousal; the money spent on research regarding sex; unraveling myths and misconceptions about sex; desire discrepancy between spouses, and the conflict it causes; the differences between men and women and how they process sex; the fact that some women experience sexual pain; and then there is human anatomy! Oh my! Our bodies are fascinating. And the female anatomy is so very complex. Females have a very complex system. Because our systems are so complex, it makes addressing anything having to do with our sexual anatomy very complex. Especially when it comes to sexual pain, diagnosing the cause of pain, the impact of pain on the woman; the impact of pain on the marriage; and treatment for pain. It is all so very complex. More women experience sexual pain than what is often realized or recognized by the general public. Yet research reveals, sexual issues, and sexual pain in particular, represent a global health concern for women, and their prevalence has been shown to differ throughout various countries. Research reveals varying percentages of women who may experience sexual pain at some point in their life time. Prevalence rates of overall sexual difficulties ranged between 5.5% and 77%. For sexual pain, rates from 3% to 95.5% were found. A comparison between countries was restricted due to differences in sample size, sample type, and applied cutoffs. Representative community samples using comparable cutoffs found that 5.8–63.3% of women experience general sexual difficulty and 6–31.6% experience sexual pain (Journal of Sexual Medicine, October 13, 2018). Dyspareunia is the general term used for sexual pain. But what makes it so very complicated is, there can be many causes for the sexual pain:

  • Medical issues: This includes causes like fibroid tumors, endometriosis, interstitial cystitis, vaginal stenosis, some infections, sexually transmitted infections; physical trauma after child birth, surgeries, etc.
  • Tissues issues: Dermatological issues like the various types of Lichen Sclerosus.
  • Nerve issues: Where the pain occurs with touch or pressure to specific areas: vestibulodynia, clitoraldynia.
  • Muscle issues: Such as hypertonic pelvic floor dysfunction, formerly known as “vaginismus” (the involuntary spasming or contracting of the vaginal muscles), causing attempts at penetration to be painful or preventing penetration completely.
  • Hormonal or aging issues: Includes factors like breast feeding and genitourinary syndrome of menopause.
  • Sexual Trauma: Trauma often impacts one psychologically, emotionally, and often physiologically.

And then what can further complicate pain issues is that some of the causes for pain may be linked to certain medications (ie. oral contraceptives). As I stated, the causes of pain and “why” there is pain can be very complex.

…the causes of pain and “why” there is pain can be very complex.

 

.Several years ago I had the opportunity to speak with a pastor and staff on the various sexual issues that can cause conflict for couples and addressed sexual pain specifically. I mentioned Vaginismus and described what it is like for a wife and husband to experience pain in a sexual encounter due to her muscles contracting. There is severe pain for the wife, and for the husband, the sensation of hitting a brick wall. As I was addressing additional information on sexual pain, the pastor interrupted, asking, “can you say more about that Vaginitus problem?” I replied, “Well, we were talking about Vaginismus, but Vaginitus can also be painful. Vaginitus is an inflammation in the vagina that can result in itching and pain, but that is different from Vaginismus.” I continued with my presentation when another staff interrupted, stating, “I’m sorry to interrupt, but I do want to understand better this Vaginosis thing you are talking about.” I stated, “Well, we were talking about Vaginismus. But Bacterial vaginosis is a form of Vaginitus, it’s caused by an overgrowth of bacteria naturally found in the vagina.” The staff all looked at me like I had a third eye. The pastor finally stated, “Wow, a woman’s vagina is really complex.” And I said, “Do you know what the problem with complexity is? Well, it is very complicated.”

The Impact of Sexual Pain:

When we consider the complexity of female anatomy and all the various causes of pain, we can understand that one of the main problems with pain is getting to the right diagnosis. It is very complicated. Pain is difficult to diagnose.

The Impact of Pain on Her

Most women who have been on a sexual pain journey have seen several OBGYNs or therapists (some studies say, 4 to 9) that have not been able to be helpful regarding their pain. One study revealed that 57% of those who struggle with pain report response to therapy was unhelpful or worse for their pain (Goldstein, Pukall & Goldstein, 2011). Many women with sexual pain struggle for years thinking that something is just very wrong with them, feeling very inadequate as a woman, and feeling deep shame.

 

Many women with sexual pain struggle for years thinking that something is just very wrong with them, feeling very inadequate as a woman, and feeling deep shame.

I have heard way too many stories of hurtful and harmful things that have been said to women regarding their pain from OBGYNs, therapists, friends, and pastors.

  • “It’s all in your head.”
  • “You just need to relax more. Have a glass of wine… or three.”
  • “You know if you keep rejecting your husband this way, he will go somewhere else.”
  • “If your relationship is healthy, sex should just work.”
  • “It is your duty to serve your husband, so you need to figure this out.”
  • “If you just keep trying, it will eventually happen. Push through the pain.”

There becomes an internal conflict for the woman who feels her body has betrayed her. Many women describe that they “feel broken” or “not normal.” The pain escalates her anxiety, “I will have this pain all my life.” Or they fear, “I will never be able to please and satisfy my husband.” As a therapist, when I consider the impact of sexual pain for the woman, I have to also keep in mind that the sexual pain is also most likely impacting her sexuality in other ways… her sexual desire; possibly her ability to be aroused; and possibly her ability to orgasm. She often questions, “am I really a sexual being?”

The Impact of Pain on the Spouse

Sexual pain not only impacts the wife, it also impacts the husband. Many husbands have held on to misconceptions based on lack of understanding:

  • “If she was really attracted to me and desired me, this would not be a problem.”
  • “If she was really interested in sex, she would not experience pain.”
  • “It’s just an excuse for her to not have sex with me.”
  • “She is just not a sexual person.”
  • “It feels so rejecting to have a wife who doesn’t want you.”

As you can imagine, the experience of pain greatly impact the marital relationship.

The Impact of Pain on Marriage

Sexual pain, the lack of knowledge about the pain–and lack of empathy of course–impact the relationship. Many couples suffer in secrecy, too embarrassed to share with friends or family their struggle. The shame causes couples to feel isolated and alone. For many it causes fear, doubt, and anxiety. Unfortunately, the struggle is not limited to just the bedroom. It doesn’t just remain a sexual stressor; it feels emotionally defeating and often leads to spiritual turmoil. For Christian couples, both the wife and the husband may question God, and what they have been taught about “sex being a gift from God, designed for marriage.”

  • “Sex hasn’t been a gift for us. It’s been sexually, emotionally, spiritually painful.”
  • “Is God punishing us for crossing boundaries prior to marriage?”
  • “We thought that God would bless us with great sex because we abstained from sex before marriage! We thought we were doing it the right way.”
  • “Are we just not sexually compatible?”

Often by the time couples make it into therapy they are in an emotional and physical spiral that they cannot get out of on their own: They experience pain and have involuntary pelvic floor contractions/hypertonicity which leads to less desire/arousal which causes avoidance and then each spouse experiences catastrophizing which escalates the fear of pain and of course anxiety increases, the female experiences hypervigilance which tends to escalate relationship conflict which causes spouse to make negative attributions about one another, and the pelvic contractions/hypertonicity continue so then the cycle continues [Bergeron, 2010]. Addressing sexual pain typically requires the input of a therapist to aid in creating change in this cycle and help the husband-and-wife gain empathy for one another. Couples who are willing to be vulnerable and work in therapy together become very attuned to each other and each other’s needs. I truly find that couples that join together in this process develop a greater capacity for authentic intimacy more than other couples will ever experience. For couples coping with sexual pain, recent studies have shown an association between self-compassion and the well-being of the couple; that both for women and men when they had higher levels of self-compassion, they were more satisfied with their relationship, and both reported lower sexual distress. (The Journal of Sex Research, Bergerone, 2018)

Treatment for Sexual Pain

It has been established that sexual pain is complex. The diagnosing of sexual pain is complex. The impact of sexual pain is complex. So, we must accept that the treatment for sexual pain is complex. Women who suffer have to accept this. Spouses must accept this. We as therapists, physicians, OBGYNs, and pelvic floor therapist have to accept this. There are typically NO EASY ANSWERS… although we all wish that there were.

The ultimate goal of treatment is to reduce the pain and restore sexual health and intimacy for the couple.

Treatment requires a multidisciplinary team. I say this not to be discouraging, but to be validating and to give hope. Hope that there are answers, treatment options, and reassurance that many are working on the behalf of women and sexual health. One woman shared with me regarding her journey of vulvodynia. It took her years and several doctors just to be diagnosed correctly and gain helpful treatment. She reports that she shared, in tears, with her newest OBGYN, “It is just so FRUSTRATING to have vulvodynia.” She reports he kindly responded, “It is just so FRUSTRATING to treat vulvodynia.” It was a moment she finally felt validated that this wasn’t just her. It wasn’t that “she” was so complicated and difficult, but that the issue of pain is so complicated and difficult. The ultimate goal of treatment is to reduce the pain and restore sexual health and intimacy for the couple. There will need to be a Biopsychosocial Model of care. Each of these modalities of therapy offer something different for the women.

  • Biomedical treatment
      • Gynecologist who specializes in pain: Not all Gynecologists are trained in pain issues. So it is imperative to find one who is trained and it is an area of specialty.
      • Possibly a dermatologist: if there are “tissue issues” such as genital psoriasis that needs medication.
      • Sexual medicine doctor: there are physicians who specialize in sexual medicine.
      • Psychiatrist if medication is needed for depression or anxiety or if meds are contributing to the issue.
  • Psychosocial treatment
      • Certified Sex Therapist for the couple and/or Marital Therapist trained in sexual pain (CST/MFT). Few marital therapists are formally trained in sex therapy. It is important for the woman as well as for the spouse. Addressing sexual pain in marriage isn’t just an individual issue for the woman to figure out on her own. I highly recommend that the couple be willing to be in therapy together to address the impact on the relationship. I want couples to learn to remain sensual and intimate even if sexual intercourse must be taken off the table as an option for a while. I believe it is imperative for the couple to learn and know ways they can be sexually pleasuring and satisfying to one another even without intercourse. It is important for couples to experience encouragement together; gain knowledge together and be motivated by an outside source. Too often couples get stuck in their progress due to spiraling in the same unhelpful patterns.
      • Possibly a psychotherapist who specializes in anxiety. If the anxiety has escalated to the point that it interferes with a woman being able to relax. Working individually on the anxiety may be needed. (Sometimes this can be done in the couples work together).
      • Women’s pain group if possible: A group for women who experience sexual pain can offer educational benefits, emotional processing, encouragement, bonding in community, and much needed laughter. I have experienced that a women’s pain group greatly benefits women for their self-confidence, sexual identity, and motivation to continue to find solutions. Often when women attend a pain group it is the first time that they have sat across from another woman who has experienced and understands pain. The women have the opportunity to share of their experiences which decreases their shame. They realize that they would never say to the women sitting around them the things they so freely say to themselves, “You’re just not sexual.”…”something is wrong with you.”… “you’re just broken.”… “if your husband leaves you, who is going to want you?” Women are great encouragers of one another regarding use of dilators, exercises, and sharing what has been beneficial on their healing journey. They cry and laugh with one another. Their self-compassion is increased, the women learn to be more patient, kind and gracious to self.
      • Spousal support (group or individual therapy): During the process of therapy for the woman, I do believe it is most beneficial for the spouse to have external support from a therapist who has knowledge and training in treating sexual pain. Again, too often the spouse has been given unhealthy information, or been guided by someone ignorant of the complexities of sexual pain. The spouse has often felt rejected, misunderstood and guilty for desiring something from his wife that causes her so much pain. Support is essential for the spouse to help with his self- compassion as well.
  • Physical Therapy
      • Pelvic Floor Specialist (PFT): pelvic floor therapy is a specialty area of physical therapy that focus on the rehabilitation of muscles in the pelvic floor. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunctions in both females and males. For women, pelvic floor therapy is often needed to address issues such as dyspareunia, pelvic floor hypertonicity, vulvodynia, and weakness or tightness post childbirth. My experience is that all women who are experiencing pain with sex will benefit from and are in need of a pelvic floor specialist. Some of the treatment is done in the offices, and instruction and guidance are given regarding dilator use, stretches and exercises to be done at home.

One could feel overwhelmed by the complexity of sexual pain and the treatment for sexual pain. My desire is to give hope to anyone struggling with sexual pain. As an individual and as a couple, you do not have to do this journey alone. There is good help out there: Therapists, physicians, PFT, OBGYNs, who are invested in providing hope and solutions. There are many good books regarding sexual pain… which reminds us of that key truth: “you are not alone.” My encouragement is: seek help as soon as possible. Please don’t just keep trying to push through the pain, just praying that it goes away. The more you keep pushing through and experience more pain, the more you will become hopeless. There is hope, there is healing… it is just complicated.

Resources

Websites:

Find a Therapist Training in Sex Therapy/Certification Resource site for female sexual medicine  Resource site for vaginismus  Resource site for sexual pain Resource site for dilators and lubricants soulsource.com intimaterose.com Lubricants yesyesyes.com uberlube.com

Books:
  • When Sex Hurts Goldstein, Pukall, and Goldstein
  • Why Does Sex Hurt Nicole Eisenbrown
  • The Pleasure Prescription Dee Hartman & Elisabeth Wood
  • The V Book Elisabeth G. Stewart
  • Sex Without Pain Heather Jeffcoat

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