Painful sex is common, but not normal

“My first time having sex was a nightmare, and it hasn’t gotten any better over the years. The attempts since have been pure torture. I’m desperate. Doctors always say vaginismus and throw lube at a problem I know isn’t just “not enough oil.” I have no trouble with exams, no tightening muscles, just excruciating pain. My boyfriend feels so hopeless for me. Is it even possible to experience intimacy without suffering?”

First published at feelingseen.com in February 2024

Believe it or not, pain with sex is incredibly common. Some typical causes of pain include not being adequately sexually aroused during a sexual encounter, not using enough lubricant, and infections or irritation. However, vulvar pain that lasts more than 3 months without clear identifiable cause, is consistent with the definition of vulvodynia. Between 7% and 16% of women and other individuals with vulvas will have symptoms consistent with vulvodynia in their lifetimes.

Many people with vulvodynia describe experiencing “burning”, “stabbing”, “rawness”, and “tearing” sensations at the vulva with any attempt at insertion (gynecological exams, tampon insertion, sexual activity). For some individuals, the pain is provoked (experienced only when touched) and for others, the pain is spontaneous (present all the time). Vulvodynia can sometimes be associated with pelvic floor dysfunction or increased pelvic floor tension. Some people also experience vaginismus – the fear of painful vaginal insertion.

Vulvar pain can be particularly difficult to deal with because it can impact so many aspects of an individual’s life. Many patients report a negative impact on their relationships, sex life, self-esteem, and even aspects of daily living like the clothing you wear or the types of exercise you can engage in (goodbye spin class!). In addition, vulvar pain is not the kind of pain that many people talk about openly like you might with back pain or neck pain. This can leave many people feeling isolated and alone.

Despite vulvar pain being common, it is not normal! Vaginal insertion should never be painful and should be discussed with a healthcare professional. Unfortunately, many people don’t get the help they need because they are embarrassed to bring it up with their doctor, they think that “sex is supposed to be painful” and don’t seek out help, or experience high levels of shame and just “push through” the pain to please their partners. Another unfortunate reality is that many people who bring up vulvar pain with their healthcare providers are dismissed or told “just relax and have a glass of wine” or other unhelpful advice. Often, this is because some healthcare professionals do not have adequate training in sexual health or vulvar pain and are not well equipped to help patients manage these conditions.

So, what can you do if you experience vulvar pain? First things first, remember that you are not alone. Vulvar pain is common and there are resources and professionals who are trained to help. Some things that you may want to consider:

1. Get an official diagnosis. Many people find it extremely helpful and validating to receive a diagnosis from a trained clinician. There are gynaecologists who have training in the diagnosis and management of vulvar pain conditions. Ask your healthcare provider for a referral to a vulvar pain-aware gynaecologist to ensure you get a correct diagnosis and ensure that other conditions have been ruled out.
   
   
2. Identify and remove triggers. Evaluate whether certain clothing, underwear, soaps, laundry detergents, etc. irritate the vulva and contribute to your pain. Remember, the vulvar skin is sensitive and should be washed about once per day using water only!
   
   
3. Remove what hurts. Consider discussing your vulvar pain with your partner(s) and take any painful sexual activities “off the table” for a set period of time. Many people with vulvar pain begin to avoid sexual activities and even physical touch in general because they are so worried about experiencing pain. Taking insertion-based sexual activities off the table for a while can help to reduce anxiety and tension associated with physical touch and allow you to connect with your partner again without the pressure of insertion. This can be a great opportunity to explore other sexual activities that are pleasurable for you and your partner(s).
   
   
4. There are many resources available that can help you get more informed about vulvar pain. For example, the book “When Sex Hurts” by Goldstein, Pukall, & Goldstein is a great place to start.
   
   
5. There are many evidence-based treatments available for vulvar pain including pelvic floor physiotherapy, psychotherapy, and sex therapy.
   
   
   1. Pelvic floor physiotherapy – tensing of muscles is a normal response to pain and anxiety and it is no surprise that vulvar pain is often associated with pelvic floor tension. Tension in the pelvic floor can be unconscious for many patients with pain. Working with a pelvic floor physiotherapist can be helpful for becoming more aware of the role of the pelvic floor and increase confidence to take control of your pelvic floor.
      
      
   1. Psychotherapy – for many people, psychological factors can play a contributing role to vulvar pain. Of course, this is not to say that the pain is “in your head” – it is not. However, for some patients, anxiety, trauma, and other psychological factors can play a role in pain. In addition, vulvar pain can have a negative impact on your mental health. It can be very helpful to explore these issues with a psychologist or other mental health professional who is aware of vulvar pain and sexual health issues. Cognitive behaviour therapy and mindfulness-based interventions in particular have been shown to be helpful in managing vulvar pain.
      
      
   1. Sex therapy – vulvar pain can have an impact on your sex life. It can be extremely helpful to speak to a sex therapist about this. Many patients with vulvar pain find it helpful to get support (with or without your partner) for ideas for how to explore sexual activities beyond intercourse and insertion. It can also be helpful to speak to a therapist to better understand how your sexual response works and how to create positive sexual experiences for you and your partner(s).

The B.C. Centre for Vulvar Health with the support of Doctors of B.C. and Shared Care recently launched “The Vulvodynia Toolkit” for physicians and other care providers to help patients manage the vulvodynia. The website also includes many helpful resources for patients. Check it out at www.vulvodyniatoolkit.com

About the author:

Dr. Kaitlyn Goldsmith is a Registered Psychologist in the Province of B.C. She is an Adjunct Professor in the Department of Psychology and a Clinical Instructor in the Department of Obstetrics and Gynaecology at the University of British Columbia. She sees patients at the B.C. Centre for Vulvar Health at Vancouver General Hospital and also has a private practice in Vancouver, B.C. where she sees patients with a variety of sexual health concerns. She is also a certified yoga teacher and loves to read, travel, and spend time with her husband of 15 years.

Dr. Kaitlyn Goldsmith can be reached through her website at www.kaitlyngoldsmith.com