When Sex Really Hurts: The Pain Behind Closed Doors
When Sex Really Hurts: The Pain Behind Closed Doors
My work in psychiatry exposes me to a wide array of disorders and personalities. But I’ve occasionally encountered women with similar struggles around the same problem: SEX. The fear and anxiety in their eyes, and the way they carry themselves, are clear signs of how deeply they’ve been affected. Many of these women are terrified of sex and have faced serious relationship problems especially due to difficulties with penetration, which has sometimes led to difficult consequences like divorce once or more. As a result, many of these women live with a lack of confidence and a shaken sense of femininity. These cases made me realize that this issue is more common than I initially thought, and I started to wonder, is there a disorder that explains the pain and emotional distress related to penetrative sex in women? Surprisingly, yes. But are there enough studies on this topic, especially among Arab women? Sadly, no
Why is it not spoken about?
Studies report that genito-pelvic pain during sexual intercourse affects up to 28% of women, meaning as many as 1 in 3 may endure this pain.1 Unfortunately, many of these women suffer in silence. Sexual pleasure in some societies is viewed as a luxury that is often overlooked. However, neglecting this aspect can lead to separation and family dysfunction.
At the partner’s level, communication is utterly important, but it is not always achieved. The reason why couples usually avoid discussions about sexual issues is that they may be perceived as a threat to the relationship or to their partner’s satisfaction. Furthermore, talking about sexual matters can be seen as a threat to self-image.2 As a result, silence often becomes the default, and some women may grow up believing that pain during sex is normal, only seeking help when the pain becomes unbearable.3
In some communities like the Arab world, sex education and discussions are often considered a cultural taboo, with most information coming from unreliable sources like peers. In such communities, discussions about sexuality are usually off the table. This situation can be attributed to several barriers, including feelings of embarrassment, a lack of same-gender doctors, limited knowledge, and insufficient access to specialized help.4
What is Genito-pelvic pain/penetration disorder?
The latest edition of the Diagnostic and Statistical Manual (DSM-5), published by the American Psychiatric Association1, defines penetration disorder (or genito-pelvic pain) as the persistent experience of one or more of the following symptoms for around six months:
- Significant tightening of the pelvic floor muscles during penetration (vaginismus)
- Significant pain during vaginal intercourse or any attempts at penetration (dyspareunia)
- Significant difficulty with penetration during sex, vaginal examination, or even tampon use
- Severe fear or anxiety before, during, or after vaginal penetration
The onset of symptoms may occur during the first sexual experience or later in life. It’s also noted that this distress is not attributed to relationship issues, other life problems, or due to other mental, medical, or substance use conditions. These symptoms cause clinically significant distress for the individual. Moreover, couples in some Arabic communities frequently face social pressure to conceive early, which intensifies the stress associated with difficulties in penetration.5
Causes and Risk Factors
Sex is a bio-psycho-social phenomenon, and therefore, the potential causes of this disorder could be generally categorized as either organic or psychosocial.6
Organic factors: Multiple factors can cause or exacerbate this disorder, such as genital infections, skin conditions, hormonal imbalances, oral contraceptive use (OCP), and congenital abnormalities like an imperforate hymen, vaginal agenesis, or a vaginal septum.
Psychosocial factors: It’s essential to understand that the pelvic floor operates as an emotional organ that interacts with the stressors. Studies show that penetration disorder is more common in women with history of abuse, whether sexual, physical or emotional. Depression and anxiety are associated with penetration disorder
Some researchers consider penetration disorder to be a vicious cycle in which biological and psychological factors influence one another. An initial painful experience leads to catastrophizing the pain which increases bodily alertness and intensifies the negative emotions such as fear, resulting in the avoidance of sexual activity. This cycle, further exacerbated by pelvic floor increased tension, which impairs genital arousal and reduces lubrication, and ultimately reinforces pain and avoidance behaviors.7
Management of Penetration Disorder
Managing penetration disorder involves a combination of treatments tailored to the individual’s needs. The treatment may include medical therapy, surgery, or other psychological approaches.6 The first step we recommend is to visit a gynecologist to exclude or address any organic causes.
Treatment of the Cause of the Pain, If Possible
When a specific cause is identified, treatment targets that issue. Lubricants, topical anesthetics and corticosteroids may reduce pain. Surgery might play a role in some severe cases.
Pelvic Floor Physical Therapy
The doctors also may guide you to pelvic floor physical therapy which helps reduce muscle tension and improve control over pelvic floor muscles. Some relaxation exercises can make penetration more comfortable, especially for those with anxiety related to penetration.
Psychotherapy
Cognitive-behavioral therapy (CBT) is crucial, especially when psychological or relational issues contribute to the disorder. CBT helps reframe negative thoughts and behaviors, and can be done individually, or as a couple.
In conclusion, while penetration disorder can be a challenging and distressing experience, it is essential to remember that help is available. Seeking support from healthcare professionals can lead to effective treatment options tailored to individual needs. With the right approach, many women can overcome these difficulties, reclaim their sexual health, and restore intimacy in their relationships.
References
1. APA – DSM – Diagnostic and Statistical Manual of Mental Disorders. https://www.appi.org/products/dsm.
2. Rehman, U. S., Balan, D., Sutherland, S. & McNeil, J. Understanding barriers to sexual communication. https://doi.org/10.1177/0265407518794900 36, 2605–2623 (2018).
3. Carter, A. et al. ‘Fulfilling His Needs, Not Mine’: Reasons for Not Talking About Painful Sex and Associations with Lack of Pleasure in a Nationally Representative Sample of Women in the United States. J Sex Med 16, 1953–1965 (2019).
4. Alselaiti, M., Saleh, M. A., Muhammed, H., Attallah, E. & Dayoub, N. Prevalence of Female Sexual Dysfunction and Barriers to Seeking Primary Health Care Treatment in an Arab Male-Centered Regime. Open Access Maced J Med Sci 10, 493–497 (2022).
5. Muammar, T. et al. Management of vaginal penetration phobia in Arab women: a retrospective study. Ann Saudi Med 35, 120 (2015).
6. Dias-Amaral, A. & Marques-Pinto, A. Female Genito-Pelvic Pain/Penetration Disorder: Review of the Related Factors and Overall Approach. RBGO Gynecology & Obstetrics 40, 787 (2018).
7. Basson, R. The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle. J Sex Med 9, 2077–2092 (2012).
