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Painful sex and mental health have a surprising relationship

Painful sex and mental health have a surprising relationship

Image: IAN Moore / Mashable

Sealed Lips is Mashable’s series on pelvic pain, an experience rarely discussed but shockingly common.


No one ever told me painful sex was a problem. 

While consistently experiencing vaginal pain with practically every new partner that’d leave me sore for days — before usually going away over time if we did it more often — I never said anything. Not to those partners, not to my friends, and certainly not to any doctor. One day though, after mentioning it to a group of girlfriends in college, everyone shared their own similar yet varied experiences of pain during sex. As we swapped horror stories (more than once the pain led me to cry silently while partners rarely noticed and carried on), we laughed it off. I went as far as admitting to taking a little pride in it, some twisted pleasure in the pain because I thought it meant I was “tight.”

It took years of therapy, growing up, and writing about sex professionally for me to realize what was likely happening: I didn’t feel very comfortable or relaxed around new partners. Then, after enough times of having pain with new partners, my body just started expecting it, tensing up to brace for impact.

Painful penetrative sex is one of the most common, widespread sexual problems.

“Pain during sex is never just in someone’s head. But oftentimes, it can be related to anxiety or stress,” said Dr. Sonia Bahlani, dubbed the pelvic pain guru. Dr. Bahlani, who has expertise in urology, obstetrics, and gynecology, related it to how some people clench their jaws while stressed or anxious. The same thing can happen to the pelvic floor. “Emotional states can be a cause of painful intercourse. And more often, there’s a multitude of sources.”

Painful penetrative sex is one of the most common, widespread sexual problems. About three out of four women will experience it, according to the American College of Obstetricians and Gynecologists. Chronic vulvar pain from unknown origins (also called vulvodynia), which often causes pain with sex, impacts up to an estimated 28 percent of women of reproductive age. That percentage can’t fully account for underreporting due to misdiagnoses or women not recognizing pain as a problem at all. 

“I have so many women come into my office and say, ‘Well, I’ve always had painful sex, but that’s just normal, right? Everyone has painful sex,'” said Dr. Bahlani. “And the answer is no. But it’s absolutely ingrained in our culture that painful sex is just the way it goes for women.”

From longstanding myths around virginity and vaginal tightness, to other gender norms and social pressures, and the taboos around discussing any of it, our psychological relationship to sex is often inextricably linked to our experiences of pain during the act.

“You can be the wokest, dopest hardcore feminist and still, patriarchal concepts of being sexual are hardwired in you… There is still this component of being expected to please the partner, placating the partner, making sure they’re happy,” said Dr. Uchenna Ossai, a University of Texas Medical School professor with a doctorate in physical therapy who also founded sex ed platform You See Logic

In the growing body of research around the psychological components of painful sex, multiple studies found women with chronic pelvic disorders had higher rates of anxiety and depression, while another suggests a connection to low body image. Other studies link it to trauma from sexual or physical abuse, with one finding women who suffered from painful sex were three times more likely to have experienced abuse in childhood. 

“Pain is not just a physical experience. It’s not just a sensation, but an emotional experience as well. And if we’re not addressing the emotional factors associated with pain, particularly chronic pain, we’re doing a disservice to our patients,” said Meryl Alappattu, a research assistant in the physical therapy department at the University of Florida who published a 2011 paper on the topic.

The psychology of painful sex is physical

At the same time, the tendency for practitioners to blame unexplained chronic pain with sex exclusively on a patient’s emotions, distress, or trauma do a serious disservice too. It can feel invalidating, like suggesting that their severe physical symptoms are imagined. 

A surprisingly common piece of medical advice exemplifying this problem is the suggestion that patients simply drink a glass of wine before sex to relax. A mentor of Alappattu’s uses a simple demonstration in lectures to dispel clinicians of such unhelpful advice: She puts a bolt that’s too small next to a big screw on the table, then asks if they think it’ll fit in the bolt after it’s had a glass of wine. The obvious answer is no. So why, then, do many providers still instruct patients to do that like it’ll miraculously make intercourse not painful?

“Aside from just perpetuating the mentality that it’s all in your head, it’s harmful for patients because — if you do have a glass of wine, have sex, and it’s still painful, what’s gonna happen? You’re not going to want to have sex again,” said Dr. Bahlani.

Finding the right dream team of providers to help is often key.

Finding the right dream team of providers to help is often key.

Image: vicky leta / mashable

Sure enough, studies show that people with chronic unexplained pain during sex can often develop sexual dysfunctions like lower drive, arousal, satisfaction, and ability to orgasm. Pain with intercourse can build a fear-based aversion to sex that feeds into itself, which in turn, can cause lower quality of life, issues around intimacy, and romantic relationships. All of it is made worse by a medical system that’s ill-equipped to find holistic, multi-faceted solutions to such complex yet misunderstood dysfunctions.

“Your nervous system becomes hyperactivated if, every time you attempt to have sex, it hurts. The psychological component is a systemic piece, informing your nervous system, your hormones, which essentially trains the brain to respond a certain way,” said Ossai. So what’s going on in your head does have physiological effects. “That’s why you need a multidisciplinary approach to treating pelvic pain. You have the circle of biology, psychology, socio-cultural components, interpersonal components, and trauma. That’s how you get a full picture of your sexual health. Which means there’s not just one person that’s going to be able to fix you.”

Treating chronic pain with sex requires clinicians who ask the right questions to determine which medical professionals can best address these combined factors likely at play. Gynecologists, urologists, and pelvic floor physical therapists help with the biomedical and physiological, while sex counselors and therapists not only help address the disorder itself but the emotional fall out of dealing with what’s often a maddeningly arduous journey of chronic pain with few certain answers.

Notably, the studies that found a correlation between mental health issues and unexplained chronic painful sex or pelvic pain can’t explain the exact nature of that relationship.

“What came first, the chicken or the egg? Was it that patients had depression and anxiety, so it fed into their pain with sex? Or is it that they had pain with sex, have been misdiagnosed, feel stigmatized, and so now it’s created this cycle of increased rumination, hyper-vigilance, and stress around it?” asked Dr. Bahlani. “You have to peel that onion back to figure out the primary pain generator and secondary issues so patients can not just have painless sex, but pleasurable sex.”

“You don’t have to just have bad sex for the rest of your life.”

Even patients with known physical sources, like being prone to infection, can develop this anxious, self-perpetuating aversion to penetrative sex. They get nervous about causing another infection, can’t relax the pelvic floor fully, which can leave urine in the bladder — thus making infection more likely.  

More often, Dr. Bahlani sees patients who’ve reached a level of debilitating distress because they’ve been punted to different medical professionals who fail to treat the whole picture of a person, instead making assumptions that don’t solve the issue.

“Patients are kind of gaslit a little because there’s so few people who can actually diagnose and treat these disorders,” she said. Often, imaging and lab tests can appear perfectly normal even when the pain generator is more physiological than psychological. “We need to show patients that both these components go hand-in-hand and are treatable. You don’t have to just have bad sex for the rest of your life.”

The cultural influences of painful sex

You can’t just address the physical disease and expect everything to be OK though, Ossai said. Healing the psychological and socio-cultural factors connected to chronic pain with sex requires as much validation of an individual’s specific circumstances and environment.

“Social and cultural narratives do play into it. But it also depends on what culture you’re coming from,” said Ossai. For example, both she and Dr. Bahlani serve various religious groups in their communities, with patients who are from Catholic Latinx, Jewish Orthodox, and South and East Asian religious backgrounds. While it’s important to never generalize or stereotype, often, “if you grew up in an environment where there’s a lot of cultural shame surrounding sex, it can be a little bit of a steeper climb.”

“Social and cultural narratives do play into it. But it also depends on what culture you’re coming from.” 

On the whole, everyone struggling with these chronic pelvic penetrative pain disorders can benefit from expanding definitions of what constitutes as sex.

Medical research and patriarchal society, Ossai noted, put penetrative sex on a pedestal as the ideal of sexual functioning. As one recent paper on women with endometriosis (another source of chronic painful sex) pointed out that “no data on orgasm rates in different sexual activities are available.” Treatment that encouraged couples to try noncoital sex did, in fact, raise rates of satisfaction. 

Societal pressures around penetrative sex can make patients feel like they’re not “normal” or “fixed” until they can have it, which might exacerbate stress and anxiety-induced reflexive pelvic floor clenching that often worsens pain.

“We are all educated culturally, in school, at home, in heterosexual society, that sexy time is just penis in vagina, that’s always in the back of a person’s mind,” said Ossai. “If we just started by saying: Sex is an activity that you engage in where you explore your pleasure, that gives you joy, happiness, fulfillment — and you can experience sex with nipple play, vaginal play, anal play, mouth play, whatever.”

But also, practitioners must be respectful of a patient’s unique socio-cultural expectations of sex and what successful recovery means to them. For example, certain religious beliefs view sex as being only for procreation, not pleasure. So some women seeking treatment won’t feel fully healed until they’re able to get pregnant from penetrative sex.

Some studies do suggest that women of Hispanic origin are more likely to develop vulvar pain symptoms than white women, though again, the exact reason for this higher prevalence is unknown. Regardless of whether it’s from biological, environmental, or cultural factors (or any combination), the more important data point is that they were also less likely to seek treatment even with access to healthcare.

As a first-generation American born to Nigerian parents, Ossai comes from a family that practiced female genital mutilation for generations. She worries clinicians (particularly white ones) can impose their biases and assumptions on patients with different cultural backgrounds, creating a judgmental environment that doesn’t treat them on their own terms.

“We should focus on the patient’s distress as a measure. You might have a patient with pain with sex, but it doesn’t impact their pleasure or sexual functioning. Or a patient who has a very mild pain with sex that is incredibly distressing to them. That should inform how we address the pain,” Ossai said.

Spreading education on pelvic pain can be key to working through socio-cultural obstacles.

Spreading education on pelvic pain can be key to working through socio-cultural obstacles.

Image: vicky leta / mashable

Biases in medicine can have serious impacts on how effectively certain demographics and communities are treated for conditions, especially Black women. In her experience, Ossai has seen the cost of that when Black women come to her with chronic pelvic pain. “They’re just ready. They’re like, ‘I’m tired of this.'”

While some studies found evidence that Black women report less chronic pelvic pain than white women, like Hispanic women, they were also less likely to have access to knowledge about these disorders or seek treatment if given the opportunity 

There’s little to no data on whether discrimination impacts someone reporting pelvic pain and sexual dysfunction, though Ossai is soon launching a pilot study on it. But it can’t hurt to consider how various forms of bigotry can be legitimate barriers to treating chronic pain with sex.

Recovering from the emotional journey of painful sex

Since individual factors run the gamut in chronic pain with sex, it’s hard to give blanket advice for folks who are dealing with it. But there are some general best practices to consider.

First and foremost, people who start experiencing severe, distressing pain with sex should listen to their own bodies over any external pressures, whether social or from a partner.

“Don’t try to push through it and say, ‘I’m just going to suck it up,'” said Alappattu. That’s especially true for people who’ve been experiencing pain for longer than three to six months, or post-partum women having pain after being cleared by an OB-GYN to have sex. “Talk to your provider, let them know… You don’t have to wait weeks or months of suffering through painful intercourse.”

But many providers aren’t well trained in the nuances of chronic pelvic pain or pain with sex, said Alappattu. Not all gynecologists or physical therapists or sex therapists or counselors will specialize in managing these disorders. Some helpful directories for finding ones that do are on the International Pelvic Pain Society and Academy of Pelvic Health Physical Therapy.

Unfortunately, getting the proper care for these issues often takes a lot of self-advocacy on the part of patients, which can be really intimidating.

“It’s completely valid and fair to ask a potential provider, you know: Do you often treat other women with pelvic pain? What percentage of your practice is people with pelvic pain? What kinds of treatments do you typically prescribe? What are your outcomes? What percentage of your patients show significant improvement in three months, six months — whatever your desired outcome is,” she said. “Find providers willing to listen to you and take care of you.”

For people with more mild symptoms or who, for whatever reason, are not ready or able to seek provider care yet, Ossai’s free online workbook on sexual health can be a great place to start for a variety of issues.

Dr. Bahlani also suggested experimenting with dilators like Intimate Rose, which come with an online platform for pelvic floor therapy. Exploring different lubes (some even help with pH balance, which may help those prone to infection), pelvic floor wands, and vibrators — first alone then (if desired) with a partner when you feel ready. In partnered sex, foreplay is key. 

“We oftentimes want to increase blood flow to the clitoris because stimulating it prior to penetrative intercourse can be helpful in the beginning to regain that pleasure cycle,” she said.

In general, it’s good to take note of some telling differences that can help determine a physiological source for the pain.

“Are you having pain with initial penetration, or deep penetration? Have you always had pain with sex, or did you have pain-free intervals of intercourse?” said Dr. Bahlani. “Are there certain positions that present more pain than others?”

Above all, the most important step to unraveling the emotional and physical complexities of pain with sex is open dialogue. That goes for communication between individuals — like honest conversations with your partner, friends, and providers about it — and on a larger cultural scale.

“We need to educate the masses early on that pain with intercourse is not normal, excessive, debilitating pain with your menstrual cycle is not normal,” said Alappattu. “We need to be having those conversations with girls in their late teens or early 20s, not letting them go five to 10 years before they even know they can get help… Because that really weighs down on someone’s emotional state and hope that they can eventually solve it.”

Simply talking about painful sex and normalizing pelvic pain is at the heart of tackling the psychological toll of living with it.

“That’s why this conversation we’re having right now is so important,” said Dr. Bahlani. “People need to know they’re not suffering alone, that it’s a human thing, and that people get better.”

Read more about pelvic pain

Source: Painful sex and mental health have a surprising relationship

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