Issue 8: When Sex Hurts: Addressing Pain, Trauma, and Hidden Struggles
Breaking the Silence Around Sexual Pain and Its Impact on Pleasure.
I. Breaking the Silence đ
Sexual pain affects up to 75% of women at some point in their lives, yet it remains one of the most under-discussed barriers to sexual satisfaction. The silence isnât just personalâitâs systemic, rooted in healthcare systems that historically dismissed womenâs pain and cultural narratives that normalize female sexual discomfort as inevitable.
Many women assume that certain discomfort during sex is just part of being female. The distinction between normal variation and actual pain conditions matters because when sex hurts, the path to orgasm becomes not just difficult but potentially traumatic.
âSexual pain is a signal worth listening to, investigating, and addressing with the same seriousness given to any other health concern.â
Pain hijacks the nervous system, triggering protective responses that shut down arousal pathways. The body canât simultaneously prepare for pleasure and defend against threat. Understanding this isnât just medical knowledgeâitâs essential information for anyone seeking to reclaim their right to sexual satisfaction.
The intersection of pain and pleasure is complex. For many, addressing sexual pain becomes the gateway to discovering what their body is truly capable of experiencing. This isnât about âpowering throughâ discomfort or accepting pain as a normal part of female sexuality.
What changes everything is learning that sexual pain often has treatable causes, and that healing doesnât require accepting diminished sexuality. Most sexual pain conditions respond well to appropriate treatment when properly diagnosed and addressed.
II. Common Pain Conditions Affecting Sexual Response đ
Dyspareunia: When Penetration Hurts
Dyspareuniaâthe medical term for painful penetrationâaffects approximately 10-20% of women regularly, with many more experiencing it occasionally. The pain can be superficial, occurring at the vaginal opening, or deep, felt during thrusting motions. Understanding the difference is crucial because they often have different causes and treatments.
Superficial dyspareunia typically stems from issues at the vaginal entrance: insufficient lubrication, hormonal changes affecting tissue elasticity, infections like yeast or bacterial vaginosis, or skin conditions like lichen sclerosus. The pain is usually sharp or burning, occurring immediately upon attempted penetration.
Deep dyspareunia occurs with deeper penetration and can indicate conditions like endometriosis, ovarian cysts, pelvic inflammatory disease, or adhesions from previous surgeries. This pain is often described as aching, cramping, or pressure deep in the pelvis.
Both types create cascading effects on sexual response. Anticipation of pain triggers muscle tension, which can worsen the pain, which further increases anxietyâa cycle that makes orgasm nearly impossible to achieve. Breaking this cycle requires addressing both the physical cause and the protective responses the body has developed.
Vaginismus: When the Body Says No
Vaginismus involves involuntary contractions of the muscles surrounding the vaginal opening, making penetration difficult or impossible. Itâs the bodyâs protective response, often occurring without conscious control.
Primary vaginismus affects people who have never been able to achieve comfortable penetration, while secondary vaginismus develops after a period of normal sexual function.
âWomen describe feeling like their vagina is âlocked shut,â despite desperately wanting to experience penetrative pleasure.â
The muscle contractions can be so strong that even inserting a tampon becomes impossible. But vaginismus affects more than just penetrationâit can impact the entire sexual response cycle. The anxiety and frustration surrounding penetrative difficulties often generalizes to all sexual activity, making it harder to relax into arousal and orgasmic response.
Understanding that vaginismus is an involuntary muscle response, not a conscious choice or relationship problem, is crucial for addressing it without shame or blame. Treatment typically involves pelvic floor physical therapy, gradual desensitization exercises using dilators of increasing sizes, and addressing any underlying anxiety or trauma. The process requires patience, but success rates are high when approached systematically with appropriate support.
Vulvodynia: The Mystery Pain
Vulvodynia presents as chronic vulvar pain without an identifiable causeâno infection, no skin condition, no obvious trigger. The pain can be constant or triggered by touch, often described as burning, stinging, or raw sensation. For many women with vulvodynia, even wearing tight clothing or sitting for extended periods becomes uncomfortable.
The unpredictable nature of vulvodynia makes sexual activity particularly challenging. Unlike conditions with clear triggers, vulvodynia pain can flare without warning, making it impossible to predict what sexual activities might be comfortable on any given day. This uncertainty often leads to sexual avoidance, which can strain relationships and contribute to secondary psychological distress.
Treatment approaches are typically multimodal, combining topical medications, oral treatments, pelvic floor physical therapy, and stress management techniques. What works varies significantly between individuals, and finding the right combination can take time.
Endometriosis: When Internal Tissue Migrates
Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, often on the ovaries, fallopian tubes, or other pelvic structures. This misplaced tissue responds to hormonal cycles just like normal endometrial tissue, causing inflammation, scarring, and often intense pain.
Sexual pain with endometriosis often follows predictable patterns related to menstrual cycles, typically worsening in the days leading up to menstruation. Deep penetration can be particularly problematic, as it may irritate endometrial implants or adhesions in the pelvis.
The chronic nature of endometriosis affects more than just sexual activityâit influences overall quality of life, energy levels, and mental health. Many people with endometriosis develop strategies for timing sexual activity around symptom cycles, communicating with partners about pain levels, and finding positions or activities that minimize discomfort.
III. Trauma and Sexual Response đ§
The Neurobiological Impact
Trauma fundamentally alters how the nervous system responds to sexual stimuli. This isnât about willpower or positive thinkingâtrauma creates neurobiological changes that affect sexual response in ways that require understanding, patience, and often professional support to address.
When the brain perceives threatâwhether real or imaginedâit activates survival systems that prioritize safety over pleasure. For trauma survivors, sexual activity can trigger these same protective responses, even in safe, consensual situations.
Dissociation during sexual activity is one common trauma response. This might involve feeling disconnected from the body, experiencing the encounter as if watching from outside oneself, or having memory gaps during sexual activity. Dissociation serves as protection, but it prevents the embodied experience necessary for orgasm.
Hypervigilance presents as inability to relax or be present during sexual activity. The nervous system remains on high alert, scanning for potential threats. This constant monitoring prevents the surrender and vulnerability required for sexual response and orgasm.
Intrusive memories or flashbacks can occur during sexual activity, even when current circumstances bear no resemblance to past trauma. These intrusions can happen suddenly, transforming a pleasurable experience into a triggering one within seconds.
Types of Sexual Trauma
Sexual trauma encompasses more than sexual assault, though that remains a significant factor. Childhood sexual abuse creates particularly complex impacts on adult sexual response, affecting the developing nervous system during critical periods of sexual development.
Medical trauma related to sexual or reproductive health procedures is often overlooked but significantly impacts sexual response. Painful gynecological procedures, traumatic childbirth experiences, or insensitive medical care can create lasting associations between medical settings and sexual anatomy with fear and pain.
Cultural and religious sexual trauma results from shame-based messages about sexuality, body autonomy, or sexual pleasure. This may not involve specific incidents but rather patterns of messaging that sexuality is dangerous, dirty, or inappropriate for women.
âIâve been pretty fortunateâI havenât had sexual trauma. I write romances, so Iâm able to approach sex pretty positively from a personal perspective and still think about it in a really romantic sense. Thatâs something I consider a blessing.â
This positive foundationâbeing able to preserve a romantic, optimistic view of sexualityâisnât universal, and recognizing this disparity is crucial for understanding why some women struggle more than others with sexual response.
The Nervous System and Trauma
Healthy sexual response requires activation of the parasympathetic nervous systemâthe branch responsible for ârest and digestâ activities. Trauma often leaves the sympathetic nervous system chronically activated, making the shift to parasympathetic dominance difficult.
The concept of âwindow of toleranceâ explains why some trauma survivors can engage in certain sexual activities but not others. Within their window of tolerance, they remain present and connected to their body. Outside this window, they may become hyperaroused (anxious, panicked, hypervigilant) or hypoaroused (numb, disconnected, dissociated).
Understanding the window of tolerance and working to gradually expand it, with appropriate support, is often key to healing sexual trauma responses.
IV. Red Flags and Medical Evaluation đ¨
When Pain Requires Immediate Attention
Certain types of sexual pain warrant prompt medical evaluation:
Sudden onset severe pain, especially if accompanied by fever, nausea, or abnormal bleeding
Progressive worsening of sexual pain over time, particularly if interfering with daily activities
Pain unresponsive to basic interventions like lubrication, position changes, or extended foreplay
Abnormal symptoms like discharge, bleeding outside normal menstruation, or systemic symptoms
Stepwise Medical Evaluation
Comprehensive sexual pain evaluation begins with detailed history taking. Healthcare providers should ask about pain characteristics (location, intensity, timing, triggers), associated symptoms, sexual history, trauma history, and impact on quality of life.
Physical examination should be conducted with sensitivity to patient comfort and trauma history. I separate out the bimanual from the speculum examâmany people find the speculum is what they donât like about a pelvic exam.âThis approach allows for modified examinations that still provide necessary clinical information while respecting patient boundaries.
Laboratory testing might include screens for sexually transmitted infections, hormone levels, or inflammatory markers, depending on clinical presentation. Imaging studies like ultrasounds or MRIs may be recommended if structural abnormalities are suspected.
Specialist referrals become necessary when primary care providers reach expertise limits. Gynecologists specializing in sexual pain, pelvic floor physical therapists, pain management specialists, or mental health professionals may all play roles in comprehensive care.
V. Trauma-Informed Care Checklist â
For Healthcare Providers
Creating physically and emotionally safe environments involves everything from waiting room atmosphere to examination room setup. Providers should explain procedures in advance, obtain explicit consent for each examination step, and check in frequently about patient comfort.
âWhen someone is giving me cues, Iâve found respectful ways of asking. If someone has a history of trauma, I acknowledge that upfront and have an honest conversation about the examâwhy I need it, what information Iâll get, what I wonât get.â
This includes giving patients the ability to decide if they want to proceed with the examination. Recognizing trauma responses during medical care allows providers to adjust their approach in real time. When patients begin dissociating, become anxious, or ask to stop, trauma-informed providers respond with understanding rather than pressure to continue.
Iâve taken people to the operating room for light sedation when theyâre so traumatized that even basic pelvic exams arenât possible. Sometimes extraordinary accommodation is necessary and appropriate.
For Individuals Seeking Care
Advocating for trauma-informed care means asking questions about provider training, requesting procedure modifications when needed, and feeling empowered to set boundaries during medical care.
When comfortable, communicating relevant trauma history to healthcare providers helps them provide better care. This doesnât require sharing details but might involve statements like âI have a sexual trauma history and may need to pause during examination.â
Setting clear boundaries during medical examinations is not only acceptable but encouraged. Patients can request support person presence, ask for breaks during procedures, or request modifications to standard positioning or examination techniques.
As long as you walk them through and they have a nurse by their side who they have good rapport with, it usually hasnât been an issue. Support during vulnerable medical moments makes a significant difference.
VI. Pain vs. Discomfort
Distinguishing Normal from Concerning
Normal discomfort might include:
Initial stretching sensations with penetration (especially after periods of sexual inactivity)
Temporary discomfort while finding comfortable positions
Mild soreness after vigorous sexual activity
Position-specific limitations during pregnancy
Concerning pain includes:
Sharp, burning, or stabbing sensations during sexual activity
Pain that worsens rather than improves as sexual activity continues
Persistent pain lasting hours or days after sexual activity
Any pain that causes you to tense up or want to stop sexual activity
Communication Tools
Developing language to describe sexual pain helps in both healthcare settings and intimate relationships. Pain rating scales can be adapted for sexual activity, describing not just intensity but quality (burning, aching, sharp) and timing (immediate, during activity, after activity).
Partner communication about pain requires honesty and ongoing dialogue. This includes discussing pain before sexual activity begins, having signals for when pain occurs during activity, and debriefing about comfort levels afterward. Partners who know each otherâs bodies well can recognize discomfort signals even before theyâre verbalized, but this takes time and intentional attention to develop.
VII. Healing and Recovery Pathways đą
Professional Treatment Options
Trauma-focused therapy modalities like EMDR (Eye Movement Desensitization and Reprocessing) and somatic experiencing address neurobiological impacts of trauma on sexual response. These therapies help process traumatic memories while building resources for present-moment awareness and safety.
Specialized sex therapy for trauma survivors combines trauma-informed care with specific attention to sexual response and intimacy. These therapists understand how trauma affects sexual function and provide targeted interventions.
Pelvic floor physical therapy addresses both physical and emotional aspects of pelvic pain. Skilled pelvic floor therapists understand connections between trauma, pain, and muscle tension, providing both manual therapy and education about mind-body connections.
Medical pain management approaches might include topical treatments, oral medications, nerve blocks, or other interventions depending on specific pain conditions. The key is finding providers who understand sexual pain as legitimate medical concern requiring comprehensive treatment.
Self-Care and Healing Practices
Mindfulness and grounding techniques help trauma survivors stay present in their bodies during sexual activity. These might include breathing exercises, progressive muscle relaxation, or sensory grounding techniques that help maintain connection to the present moment.
Gradual exposure and desensitization involve slowly rebuilding positive associations with sexual touch and activity. This process must be self-paced and should never involve pushing through significant discomfort or triggering experiences.
Building body awareness and trust requires patience and self-compassion. This might involve practices like mindful bathing, gentle self-massage, or other activities that help rebuild positive relationships with the body.
Consistent, trustworthy partner response creates safety for healing. Partner support includes education about trauma and pain, learning to recognize and respond appropriately to trauma reactions, and maintaining patience with non-linear healing processes.
VIII. Moving Forward đŞ
Sexual pain and trauma represent significant barriers to sexual satisfaction and orgasmic response, but they are not insurmountable. With appropriate support, treatment, and patience, most people can develop strategies for managing pain and trauma while reclaiming their capacity for pleasure.
The journey from pain to pleasure is rarely linear. Healing involves setbacks, breakthroughs, and everything in between. Understanding this process helps set realistic expectations and maintain hope during difficult periods.
âExperiencing sexual pain or trauma doesnât diminish your right to sexual pleasure and satisfaction.â
These experiences donât define sexuality or limit potential for healing and growth. With proper support and treatment, itâs possible to move beyond survival toward thriving sexual wellness.
The silence around sexual pain serves no one. Breaking that silenceâwith healthcare providers, partners, and trusted friendsâis often the first step toward healing. You donât have to suffer alone, and you donât have to accept pain as a permanent part of your sexual experience.
Sexual pain is a legitimate medical concern that deserves professional attention and compassionate care. Your pain matters, your pleasure matters, and your healing journey matters.
Next up: In Issue 9, weâll explore âIntimacy, Emotion & Mental Safetyâ - how emotional connection, attachment styles, and psychological safety create the foundation for satisfying sexual experiences and consistent orgasmic response.
This explains so much!! Trauma being both mental and physical, and our brain working to protect us.