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When sex is painful

March 13th, 2014

Dr Petra

Many years ago I was asked to review a small qualitative study for a healthcare journal. It focused on women talking about painful sex. They had various phrases to describe the pain that occurred during and after intimacy. Sometimes they knew what the pain was caused by (infections, particular positions, post birth recovery) other times they did not. But what struck me most about the study was while pain upset the women, most did not tell their partner about it nor seek further help. Most continued to have sex regularly even though it hurt them.

While I thought the paper was worthy of publication with revisions, I don’t believe it was ever published. Which is a shame as painful sex continues to be an issue in relationships and yet the focus tends to be on the biomedical and physical rather than the psychological and practical reasons why people experience pain, whether or not they seek adequate help for this, and why they continue to have sex when it hurts.

In my experience of being an Agony Aunt (writing advice columns) painful sex is one of the most common questions I’m asked about. And why I picked it to answer in my first column at The Telegraph around eighteen months ago. At the time friends and colleagues were critical of the approach I took in my answer, saying it focused too much on medical issues and less on psychological and personal ones. They also pointed out that many of the problems that can be linked to painful sex aren’t always sex specific. So you can experience pain whether or not you have sex if you’ve got something like cystitis. While a focus only on pain can also distract from problems like chlamydia that may be symptom free (at least in the early stages of infection).

This got me thinking why in media advice giving do we recommend medical solutions as a first port of call? There are several reasons. To cover ourselves in case there really is a serious cause of the pain, to acknowledge sometimes physical problems can be the reason for pain, and because it’s easier to focus on the medical and physical symptoms than explore and unpack the more complex issues around intimate relationships that may lead to sex being painful or unsatisfactory.

One colleague also explained this medical narrative as “it may be safer to go straight to the medical response because the idea that a someone isn’t becoming aroused to order, in the ‘correct’ way, is just too complex to contemplate. I think people put up with a lot of sex that they’re just not really into, just because ‘you’re supposed to like it because all the magazines said so’ and they would feel inadequate otherwise. I think people put up with all sorts of pain to avoid that shame and keep the relationship, and then blame themselves”.

The same question keeps on coming
It’s assumed with media advice giving that if you answer a question in a generic way with clear links and sources of support then others who’re facing similar problems can also get help.

Not so. What usually happens is people who are experiencing problems are triggered by a reply to ask for advice for themselves – even if the advice you’d give would be pretty much the same as what’s already published. In the past when problems went out in print media or on air asking for the same issue to be covered was understandable for those who’d previously missed the information. With advice available online you might think this no longer is the case. Instead what I’m seeing is people find your reply while seeking an answer to their problem that prompts them to write in and ask the same question.

Unsurprisingly over the eighteen months since the first reply went live the most common question I’m sent on a weekly basis continues to be about painful sex. This echoes experiences at other advice columns I’ve worked on. And is mirrored by other’s who’ve worked as Agony Aunts including my colleague Leonore Tiefer “This is the same question most popular when I was a columnist at Playgirl magazine in 1976. You tell me times have changed!”

Because of the volume of questions on this topic I decided to return to it again – this time exploring more about the psychological, social and personal issues that might contribute to genital pain during and after sex.

Feedback this time was more positive, although colleague Bruce Maybloom reminded me “It may be helpful to expand on the STI section to really spell it out eg safe sex and dodgy looking dicks. Also need to put a bit in about odour, secretions and pain when not playing around. Are pap smears up to date. Other things to consider: previous or recent pelvic trauma or operations. Blood in the urine as well”

There are more questions than answers
Reflecting on my replies to questions about painful sex made me realize, however, there were still more limitations with talking about this issue in media advice giving.

I’ll start unpacking them here but I imagine this will be a blog post that I continue to update with new resources and information. If you have further links to advice or comments about thinking critically around painful sex please email me info@drpetra.co.uk and I can update accordingly.

I’m hoping this will be useful to you if you’re worried about painful sex, if you write about this topic in the media, or if you’re a therapist or healthcare provider.

Men and pain
As mentioned, while pain and sex is probably the most often asked question I get from women world wide, I also hear from men about this topic too (albeit in smaller numbers). Within the media painful sex, when it is talked about, tends to be in women’s media and talking about women’s bodies.

The replies linked to above about pain and sex to a degree addresses men’s needs but there are other issues that can contribute to sex being painful for men.

This can include feeling anxious or afraid about sex, a past history of sexual abuse, recovery following surgery (either to the genitals or nearby parts of the body). Being unsure what is arousing or feeling unable to express what is enjoyable – including not feeling able to tell a partner when something is not pleasurable can also play a part in men experiencing painful sex. Stereotypically we may expect men to either not have sexual problems or to not have any difficulty talking about their sexual needs which overlooks the difficulties men may have in discussing pain and ways to avoid it. Shame, embarrassment, fear or bravado may all play a part in preventing such conversations.

Because research in this area, where it exists, focuses more on clinical problems it may be we know far less about the psychological and personal reasons why men of all sexualities experience painful sex. Assumptions about gender and intimacy may mean media coverage fails to acknowledge men’s painful sexual experiences, brushes aside concerns they may have or turn such issues into a joke. While some studies exist around issues of painful sex for gay men this is mostly located in the literature around sexually transmitted infections – the needs of all men who experience pain that are not related to infection, and particularly men who are bi are not adequately addressed.

Men can experience pain in their penis, urethra, testicles, bum, stomach or thighs. Pain may occur during arousal (and can hamper ability to get/stay hard), and/or during or after sex. This may be caused by the factors highlighted above or:

Sexually Transmitted Infections (STIs)
Penile and testicular cancers, or bowel, anal, bladder or rectal cancers (symptoms of pain aren’t automatically a sign of cancer, if in doubt speak to your doctor. More information on sex and cancer here and about prostate cancer and sex here)
Urinary Tract Infections
Peyronies – often noticed due to a bend/curve in the penis (explained more in this piece with additional information on preparing to talk to a doctor about genital pain and problems).
Prostatis
Penis fracture
Lack of lubrication during masturbation, or vaginal or anal sex
Bruising to penis, testicles or bum
Thrush

The most common causes of pain for men I hear about relate to Foreskin problems – when the foreskin’s too tight to pull over the head of the penis (phimosis) or where the foreskin gets stuck behind the head of the penis (paraphimosis) (information on both available here) or tears/cuts to the foreskin. Even here the focus in media advice giving tends to be on what causes the physical problems and clinical cures rather than looking at how this impacts on pleasure, sex and may contribute to other psychosexual problems (particularly erectile difficulties).

The way we write about men and sex, either in sex features or problem pages tends to either reinforce ideals of masculine sex – deep/fast penetration over as long a period of time as possible and delaying ejaculation. There is seemingly no thought these might ever be problematic or painful (or even not what men want). Sex tips for men tend to focus on positions and performance and lube is not a main focus. When it is discussed it tends to be in relation to women not being aroused rather than men needing or liking lube.

How painful sex affects Trans* or Intersex people
If we only talk about painful sex in terms of women and men we may overlook the questions and concerns of Trans* people. In writing about this topic I’ve come to realize I have rarely expanded questions to think about the needs of those who’re genitally diverse.

Inviting colleagues to reflect on this with me led to some useful insights about what information may be needed to improve media and self help discussions on sex and pain for Trans people.

Christine Burns “Firstly, trans women (like all women) is a wide demographic. It includes people whose vaginoplasty may have taken place 50 years ago and those who underwent such treatment yesterday. Techniques have evolved considerably but competence always tends to have lagged, with the result that some outcomes may fall very short of ‘state of the art’. In particular there was an age when many surgeons thought that any old hole would do, without any consideration of either cosmetics or function.

Neovaginas can also be fashioned in different ways. One technique involves using former penile (and possibly scrotal tissue). None of this has the capacity for natural lubrication and it is only relatively recent that surgeons have sought to do much about the hair follicles in that tissue, with the result that there are many trans women with hair growing within their vagina … hair that is then impossible to remove and which can result in huge pain during penetration. The other kind of tissue sometimes used for vaginoplasty is a section of sigmoid colon. This has the capacity to lurbricate (embarrassingly when the owner smells a fresh meal) but the tissue is more fragile than the former variety.

Both kinds of surgery are susceptible to stenosis … a narrowing at the suture lines which are inevitably required in the patchwork of finding enough donor tissue to line a vagina. Surgeons vary in how careful they are to remove enough of the erectile tissue in what was the root of the penis … as this surrounds the urethra and can lead to incontinence if too much is removed. On the other hand, leaving too much spongy tissue behind can mean painful erectile sensation near the mouth of the vagina, where the blood no longer has anywhere to go. Finally, depending on the patient’s build and the size of their partner, there could also be discomfort if the neovagina is not deep enough or if penetration results in pressure on internal organs such as the bladder (above) or the colon (behind). So, there are a multitude of reasons why penetration could be painful for a trans woman … not exclusively down to the competence of the surgeon and the time when the surgery was performed … but largely influenced by those factors plus the type of donor tissue involved. And I’ve not even got on to the topic of sensation and pleasure”

Anon “I agree with Christine that the variation between different techniques and surgical skill is a major factor. I could tell you my own experiences but they will probably not apply to others…Depending on the technique I think the time healing takes can vary wildly. I suspect there’s a correlation between the time it takes for discomfort to cease to be an issue after surgery and the eventual amount of sensation ie. more successful rearranging and consequent neural remapping may take longer to settle down … even up to two years or more … but end with a better result. There can be a degree of lubrication from the bulbourethral gland though again I’m sure this varies between individuals and surgical technique. Regular maintenance is important and I suspect that inadequate HRT may also often be an issue.

What I really do like is your reference to problems arising as a result of “numerous issues from relationships issues to partner problems and lack of confidence”. I think a lot of trans women tend not to anticipate the importance of these issues. I don’t know how to put this without sounding sexist but to me there are major differences between having sex influenced by testosterone or oestrogen and between male or female genitals .. to a degree a difference between action and reaction … and actually ‘getting in the mood’ which can take time to fully adjust to.

I think sex for trans women is somewhere in the pre- Masters and Johnson era and it’s a real shame there’s not more objective data on outcomes. I often wonder about the number of trans women who say sex doesn’t really matter to them. If your experiences are negative, there’s no support I know of out there except to talk to other trans women. It’s easy to give up and that seems a real shame.

I think it would be a wonderful resource to collect the sexual experience of trans people, young and old, early and late transitioners, different orientations and put them online. From my own limited knowledge there’s so much variety of experience. What tends to happen is that an individual will take it upon themselves to generalise from their own subjective experience, their surgeon, their particular sex drive and decide that that’s the way everyone should be.

Some may exaggerate the upside because of the emotional investment and because trans people feel themselves so beleagured by cisgenderist expectations of doom. But just as likely some may minimise good outcomes or not speak about them because it’s clear that some outcomes are very much better than others. Perhaps anonymising responses might overcome this. To be able to access a collection of honest different accounts, different experiences might be very comforting to those looking for answers”

Christine Burns “Incidentally, another point worth keeping in mind is that pain during intercourse for a trans woman may be a reminder of the need to think about protection. As the tissue in a neo vagina may be (a) more fragile and (b) less well lubricated, the possibility of bleeding exacerbates the risk of infection. This is a reason (I’m told) why trans women prostitutes run a higher than average risk of acquiring STIs. Also trans women in general may feel pressured into unprotected sex as lack of confidence and the desire for validation may combine to leave them less assertive about demanding protection. Hard on the heels of making sex more enjoyable for trans women is the need to ensure they can negotiate these issues with partners

Well one of the problems immediately faced by trans people is the historical experience that any questions or issues with sex after surgery were (still are) likely to be met with “well, what do you expect?”. We hear of trans women with quite routine urological problems being referred to gender clinics (because mainstream clinicians want the right to throw up their hands and have nothing to do with all that) so it is routine for any issues to become over pathologised from the outset. Thrush? Ooh, you’ll need to see a gender specialist about that!”

Meg Barker “For me an important point is to say ‘for those who have had such surgery’ re trans women given that not all have, and remembering that some trans men an non binary folk have penetration as well as trans and cis women. ‘People with vaginas’ can be good language”

B “Don’t forget some trans guys don’t get lower surgery but do stay sexually active”

In general discussions around pain and sex tend to focus on primarily cis women, overlooking Trans women and cis men, Trans men and those who’re intersex or gender queer are talked about still less. These guides on sexual health for Transmen and women are useful but still don’t address in full some of the more complex psychosexual issues around painful sex. Nor the more common ones of thrush, UTIs etc that may contribute to difficulties in sex but are seen as a more acute problem in Trans* or Intersex people than cis (see comments above). There are good reasons for focusing on sexual health information for Trans* people but we also need to be mindful of what issues (and genders) we focus on and who may be being excluded or sidelined.

We need more understanding of diverse experiences across genders around what we mean by ‘pain’ and ‘sex’ along with thoughtful training for practitioners to ensure care is given when needed but we don’t medicalise or pathologise commonplace problems. Or dismiss physical concerns because they are related to sex. This applies to those giving media advice and the practitioners who they’ll be referring their readers to. It’s not unusual for health practitioners to view sexual worries as frivolous or secondary to physical issues – or to find talking about pleasure difficult or embarrassing. Finding ways to overcome this in both healthcare and media is important, as is ensuring we focus on a range or reasons why pain might be experienced, acknowledge genital diversity, and present a variety of solutions.

Western solutions to worldwide problems
Painful sex is not limited to the UK or US where most media advice givers are located and where most mainstream media features on this topic reside. In fact I would say in this digital era a significant proportion of the questions I get about painful sex come from people in the global south.

If we consider the standard advice to pain and sex – as illustrated by the two replies of mine at the start of this blog post – then the focus tends to be on highlighting what could be the cause of pain, giving ideas about how people might overcome this for themselves, and signposting them to support services if they require further help.

This works well in countries where healthcare services are easily available and free, or for people who can afford healthcare in countries where accessibility is limited. If we consider much media advice in this area states ‘see a doctor’ as the first response to any mention of genital pain during/after sex this only works if you have a doctor you can afford and access. If taboos exist around seeking help for genital problems or if you require permission from family or spouse before you can see a doctor your ability to get help when sex is painful is less likely. And even if you can get help in many countries psychosexual services or secondary care for serious illnesses are limited. Practitioners may not consider painful sex to be much of a problem if they are facing more complex and widespread health issues and/or poverty. Products like lubricant that may assist in avoiding painful sex may not be considered a priority and may be expensive and difficult to obtain. Stigma relating to sexual health – particularly HIV may lead to people avoiding seeking help. Or they may feel there’s nothing that can be done so simply don’t ask for help.

Alternatively in media coverage we may suggest that people who experience pain due to a lack of pleasure might consider masturbation alone or with a partner to find out what feels good, to use a lubricant, or to identify what arouses them and to share that with a partner. We might suggest they buy and try sex toys. Together we encourage them to explore pleasure that they both enjoy.

This works in interpersonal relationships where such communication is possible, and where sex toys and lube (if desired) are available and affordable. And in cultures where talking about sex in terms of pleasure and enjoyment is commonplace. In cultures or communities that find this alien, disturbing, immoral or threatening, talking about pleasure as an antidote to pain may be difficult or dangerous.

Aside from putting the person providing such advice at risk it also puts those considering acting on said advice in potential danger of partner or family violence, or judgement from spouses, healthcare providers and other advice givers.

Even if we want to explore options around communication, exploration and desire in media this can be difficult or impossible if sex is associated with fear, shame or suspicion. Telling your partner you want to try something new is always interpreted in Western media as a healthy treat nobody could pass up on. Whereas in other cultures (or even in problematic relationships in the West) it might be taken as a sign of infidelity or a criticism of a partner and have adverse consequences.

Simplistic approaches of suggesting sex positive models of Western mediated sexuality transfer to all of us, but particularly those in the global south need challenging. Alongside this, media and self help examples of how we might talk about pleasure for those experiencing painful sex in resource limited or gender unequal communities would be of use. Again if you know of such approaches that are community driven and not just Western inspired bolt-ons I’d appreciate hearing about them and can add them here.

BDSM
When we respond to questions about pain and sex the immediate reaction is that pain is bad and requires urgent assistance. Clearly when people are in distress and require help thinking about pain and how to solve or avoid it is important. However in pairing pain and sex in a consistently negative way we can reinforce the sense that the two do not belong together. Colleagues have questioned whether this in turn pathologises those who enjoy consensual BDSM.

That question is worth exploring, but perhaps misses an additional question for those who enjoy BDSM but still experience sex as painful. In such cases seeking help from the media, therapists or clinicians can be difficult if pain is assumed to be solely related to BDSM rather than other causes (all of which are listed/linked to above). Equally problematic would be media coverage or health/therapy professionals who are so keen to welcome alternative sexualities they don’t question whether the way someone’s engaging in BDSM may be contributing to unwanted pain. A lack of awareness of BDSM within media, therapy and healthcare providers can result in inappropriate advice or care being given. Wider training to address sexual diversity could go some way to address this and has had some success in therapy but remains unusual in healthcare and almost unheard of in media.

What is ‘sex’?
Where painful sex is discussed in media it’s usually assumed, but often not stated, that pain is caused by penis in vagina sex. In gay men’s media occasional discussions around penetration focus on anal sex but usually within the context of STIs rather than other issues that might contribute to pain. Features in mainstream media and advice about anal sex for straight couples tend to operate from the position that anal sex will automatically be painful (for the woman) with suggestions about how she may learn to like it. Advice on penetration of men by their girlfriends remain limited in mainstream media. Where features on anal sex exist the focus is on technique, toys and positions rather than communication about what people would like to try and what feels good or painful.

Because we take this approach it means if someone writes to us describing painful sex we usually assume they’re heterosexual and they’re a woman finding penis in vagina sex painful. We don’t think about pain that happens during arousal, masturbation or getting oral sex regardless of a person’s gender or sexuality.

Moreover we assume when someone says to us that sex hurts that they must mean their genitals, whereas they might be talking about other physical problems, mobility issues or disabilities that cause sex to be painful in other parts of the body.

It might equally be that painful sex is not about a physical pain but related to emotional distress – perhaps due to past or current sexual abuse or relationship violence, a traumatic birth or dealing with bereavement. To make things more complicated these issues may in turn aggravate physical symptoms.

In radio or online advice giving where conversation is possible clarifying what ‘sex’ and ‘pain’ means would be useful – as it would in therapy and healthcare. However for print or broadcast media where you’re working from a problem with limited details there will be many more unknowns. Broadening out answers to include what pain and sex may mean might ensure a wider audience of people with problems are reached.

Focus on couples
When we give advice the reply is usually aimed at the person with the problem, and good media advice usually includes ideas for better communication with a partner and suggestions for both of them to try to ensure sex becomes more pleasurable.

We assume therefore the person experiencing pain is in a long-term monogamous relationship – which they may be. But if their relationship status isn’t stated and they simply tell us that sex is painful they could also be single, or have recently met someone, or is in a non-monogamous relationship. We may also miss that many people avoid relationships because of a fear of pain.

It may help in writing about this to not assume this is only a problem affecting people in relationships and widen our discussions to those who’re in different situations and who may or may not be sexually active at the time of seeking help.

Allergies
Many media features on sex routinely recommend condoms and lubricant as part of contraception and/or sexual health advice. This may ignore how allergies to latex or some ingredients in lubricant can make problems with pain worse. It is rare to see advice and media features pausing to ask readers if they need to check for allergies to condoms and lube. This can be particularly an issue in cases of vaginal dryness causing pain (for example during breastfeeding) where an additional irritation from lubricant can worsen the problem. Because the media and medics recommend lube and condoms without always clarifying the potential for irritation this may mean people continue to think the pain is related to other factors and keep on using the very thing that’s causing the problem. (You’ll notice in the replies I’ve recently written about pain this is something I neglected to mention and a colleague had to point this omission out to me).

Healthcare referrals
When someone tells you they’re in pain during/after sex, particularly if they have other symptoms like bleeding, even if you outline many possible causes and self help solutions it does make sense to recommend seeing a doctor (although not necessarily as the first action needed). But this assumes that healthcare is available and healthcare providers have the time, skills and confidence to talk about pain and sex.

It’s not unusual for medics to find such topics embarrassing or difficult to discuss. Or that they prefer to focus on the clinical but not wider lifestyle issues. For example women with recurrent cystitis or thrush may well find this contributes to painful sex. Yet practitioners may never ask if the condition impacts on someone’s personal life. If pain is reported as getting in way of sex the solution often offered by practitioners is to give up sex completely or avoid penetration. Practitioners can also be unwilling to refer cases of genital pain to specialists if the patient is expressing concerns over their sexual lives, seeing this as a less valid reason to try and fix an issue.

Because we don’t address this adequately within healthcare training it means practitioners may not be aware of possible treatment options and often ignores how important sex may be to people. The flip side of this of course remains the pressure to have sex when you do not want to means people get help to address physical symptoms but perhaps there is no effort made to explore the reasons why someone may not want sex – something that is difficult if consultations are time limited and practitioners have few referral services to use. This is another reason why focusing on the medical in media replies can mean we don’t actually ask people if they want sex or not.

And so…
The issue of painful sex is one that’s commonplace and concerning to many people of all genders and sexualities worldwide. Currently in media advice giving we only go so far in answering their questions. We leave out more people than we include and many of our proposed solutions are out of reach to those who need help. The challenge remains of how we can be as inclusive and thoughtful as possible in our answers in often time/space limited contexts while ensuring we fulfill editor’s briefs and the needs of our wider audience.

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