Good Sex with Emily Jamea: Pleasure and Pain

Emily Jamea, Ph.D., is a sex therapist, author and podcast host. You can find her here each month to share her latest thoughts about sex.

Good sex only happens when there’s mutual consent and mutual pleasure. But unfortunately, women often struggle to experience pleasure during sex and many actually experience significant discomfort and even pain. Sometimes, the pain can be so bad that intercourse isn’t even possible. (What about people who enjoy the kinky mix of pleasure and pain? Sex shouldn’t hurt unless you want it to. Period. Full stop.)

It’s hard to say for sure how many women experience sexual pain, but the American College of Obstetrics and Gynecology estimates that three out of four women have pain during sex at some point during their lives. Sometimes the pain is temporary and sometimes, it’s long-term.

Why do so many women experience pain with intercourse, and what can we do about it?

There are many reasons women experience pain during sex. Genito/pelvic pain/penetration disorder is an umbrella term for several conditions that cause sexual pain. The two main conditions that cause sexual pain for women are vulvodynia and vaginismus. For some, the pain is mild, but for others, it can be severe. For instance, some women may be able to insert a tampon or tolerate a pelvic exam, but experience pain with sexual intercourse. For others, the pain may be so severe that they can’t sit for long periods of time or even wear tight-fitting pants. Let’s break it down.

Vulvodynia translates to pain in the vulva. (As a reminder, that’s what you see if you’re looking at the external genitalia.) When an area of the vulva becomes inflamed, it causes pain. Most of the time, there’s a physiological reason for this kind of pain.

Vaginismus happens when there’s an involuntary spasm of the pelvic floor muscles. The pelvic muscles are the ones you contract when you do a kegel exercise or when you’re holding in gas. In most cases, vaginismus has a psychological component. Women are more likely to experience vaginismus when they were raised in a sex-negative home, within a rigid religious or spiritual environment, or when they have a history of sexual trauma. The spasm is the body’s way of saying no to something that is consciously or unconsciously scary.

There are, of course, other causes of sexual pain. Women who are not adequately lubricated, which commonly happens among post-menopausal women or during breastfeeding when estrogen is low, may experience too much friction, causing pain with intercourse. Women may also experience pain as they recover from giving birth (whether they had a vaginal birth or a C-section), especially if they tore or had an episiotomy.

Is pain during sex normal?

Pain during sex isn’t normal, but women are often given the message that pain is just part of the female condition. We’re taught to expect pain the first time we have intercourse, and many women think that’s just the way it always will be for them.

When I first started working as a sex and relationship therapist, my clients had seen an average of six medical professionals before landing in my office. Six! And those doctors weren’t equipped with the knowledge to accurately diagnose, let alone treat, these conditions. Startling, right? If I had a dollar for every time a patient sobbed in my office, saying that her doctor had told her to “just relax,” “have a glass of wine” or “try reading Cosmo to learn how to get more turned on,” I’d be rich. It was incredibly distressing for them.

Many of my clients came in complaining of low sexual desire, and it wasn’t until I conducted a thorough assessment that I learned that the root of their concern was often that sex hurt. If something’s painful, you’re not going to want to do it. Women who experience sexual pain often also have reduced feelings of arousal, low sexual desire and conflict in their relationships. Partners are usually more lost than they are.

Fortunately, there’s been a radical transformation in the accurate assessment and treatment of sexual pain. In most cases, a combination of pelvic floor physical therapy and psychotherapy works best.

Psychotherapy is particularly effective for women whose pain is caused by emotional or psychological issues. Sex therapists have specific techniques such as CBT, mindfulness and EMDR that can help alleviate the fear, anxiety and — in some cases — trauma surrounding your history of sexual pain. We’re also trained to help clients actively participate in treatment so everyone’s on the same page. Treatment is more effective when women feel like they’re working as a team with their partners.

Hallelujah for pelvic floor physical therapists. These experts (who are finally growing in number) are trained to treat the physiological underpinnings of sexual pain. Interventions like biofeedback, electrical stimulation (e-stim) and manual manipulation work together to help women learn to relax and control the pelvic floor muscles. PSA: If you experience sexual pain, don’t assume that simply doing kegel exercises is the answer. Strengthening a muscle that is already spastic can actually make your pain worse. Your PT may work with you to focus on learning to relax the muscle before transitioning to strengthening exercises.

In some cases, more aggressive treatments, conducted only by a healthcare provider (HCP), are needed. These include Botox injections to the pelvic floor muscles and in some cases, vestibulectomy, which is removal of the tissue that is inflamed.

If you experience pain with intercourse, don’t be afraid to talk to your HCP. Pain is not something you should learn to tolerate. And if you’re not satisfied with what your HCP suggests, reach out to a sex therapist. They can guide you to the right professionals for care. Don’t forget that sexual pleasure is your birthright. Don’t lose hope — options are available.