Mental and Physical Solutions to Painful Sex

Painful sex (called dyspareunia in medical speak) rarely has just one etiology.  It is commonly multifactorial, meaning treating it often is a team effort (psychotherapist, sex therapist, physical therapist).


Let’s talk about some of the physical causes:



Endometriosis results when the endometrium, or the lining of the uterus, grows outside the uterus, for example, in and around the ovaries, the fallopian tubes, and the bowels. These misplaced growths can cause inflammation and scarring.

During intercourse, the endometriosis lesions and nodules can be stretched and pulled and cause pain.


Vaginal dryness and sexual pain

Another cause of pain during sex could be vaginal dryness, which can result from hormonal treatments used to treat endometriosis. Oopherectomy, or the removal of the ovaries, is sometimes performed to treat endometriosis and can also cause vaginal dryness. This occurs because the removal of the ovaries reduces circulating estrogen levels, which in turn can lead to vaginal dryness and discomfort during intercourse. Some women elect not to have hormone replacement and may try new therapies such as hyaluronic acid or lubricants.


Emotional factors

Emotions are deeply intertwined with sexual activity, so they might play a role in sexual pain. Emotional factors include:

  • Psychological issues. Anxiety, depression, concerns about your physical appearance, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain.
  • Stress. Your pelvic floor muscles tend to tighten in response to stress in your life. This can contribute to pain during intercourse.
  • History of sexual abuse. Not everyone with dyspareunia has a history of sexual abuse, but if you have been abused, it can play a role.


Treating painful sex that is heavily rooted in emotional factors is notoriously difficult to treat. Of course treatment can involve medication and/or surgery.  Some of our previous V-news articles have discussed these interventions.  However treatment very often involves coordinated efforts among providers, especially in cases with emotional factors at their root.  In these instances, a psychotherapist or sex therapist should lead the charge. The recent emergence of some very forward-thinking and exciting new treatment strategies has sparked hopeful anticipation.  We discuss a few below.


1: Mindfulness-based interventions

Sex therapists use a variety of approaches to treat sexual dysfunction. Tools such as cognitive-behavioral therapy (CBT), emotion-based therapy and couples communication techniques have been the treatment mainstays for sexual problems. Now, mindfulness-based sex therapy is increasingly recognized as an effective intervention, many sex therapists say. Mindfulness-based therapies are exciting because they are both effective and broadly applicable to many types of sexual problems.



2. Expanding inclusivity

Historically, sex therapy has been rooted in a traditional view: cisgender, heterosexual encounters between a man and a woman. Even within that already narrow definition, sex therapy has mostly been available to white, middle- and upper-middle-class married couples. Increasingly, though, researchers who study sexuality and sex therapy are taking a broader perspective. There has been a trend toward expanding inclusivity to include the full span of human sexuality and gender identity, including transgender and gender nonbinary people, those in same-sex relationships and people in nonmonogamous relationships.

The work of many therapists focuses on adapting sex therapy tools to be more relevant to transgender and gender-diverse clients. 

There’s also growing awareness that sexual- and gender-minority people who experience sexual dysfunction may have complicating factors that need to be addressed in treatment as they are often dealing with an added layer of discrimination and marginalization

Portrayals of transgender bodies are often presented in demeaning or hypersexualized ways in popular culture, which can contribute to negative feelings that transgender people have about their own bodies and sexuality. In that case, treatment might involve CBT interventions to address sexual functioning, but it might also involve challenging and countering negative messages that the individual has internalized as a result of lifelong exposure to transphobia.  

While diversity and inclusivity in sex research are gaining momentum, there’s been little yet in the way of published evidence about how best to treat these populations, This will be an important area for future research.


3: The couple’s perspective

We all know it takes two to tango, but most studies have focused on sexual problems at the individual level.  Increasingly, researchers are looking more closely at the role of partners. Sexual dysfunction is often a couple’s issue and therefore should not be addressed as an individual problem. For instance, among heterosexual women who experience pain during intercourse, sympathetic partners might be inclined to stop a sexual encounter that becomes painful. Yet research shows that women with these sympathetic partners have greater pain intensity and poorer sexual satisfaction compared with women with partners who encourage them to adapt and find ways to create sexual intimacy without engaging in the activity that is painful.

Such findings are starting to inform the way sex therapists treat patients and their partners, Moving forward, more research on the role of partners in sexual functioning and satisfaction is critical.


4: Changing attitudes toward sex

Sex is still a topic that makes people uneasy. Culturally, there tends to be a lot of anxiety around sex.  In the United States (and many other cultures), sex often involves mixed messages. You can joke about sex, but you’re not supposed to talk about how it’s really going, especially if you’re having problems. On the other hand, we are bombarded with messages suggesting we should be having amazing sex lives. We’re inundated in the popular culture with very narrow messages about what ‘good sex’ is, and those messages can create a lot of stress.

At the same time, many people still balk at the idea of seeking help for their sexual problems. That’s one reason that sex therapists are optimistic about the development of telepsychology and web-based interventions. Early studies have shown cybertherapy to be effective for treating a variety of sexual problems in men and women. Digital interventions can build a bridge to people who have reservations talking about sex in person.




5. Sex Surrogacy

Surrogate Partner Therapy is a form of therapy based on the successful methods of Masters and Johnson. In this therapy, a client, a therapist, and a surrogate partner form a three-person therapeutic team who together work to understand and resolve difficulties that a client is experiencing in their lives. The surrogate participates with the client in structured and unstructured experiences that are designed to build client self-awareness and skills in the areas of physical and emotional intimacy. These therapeutic experiences include partner work in relaxation, effective communication, sensual and sexual touching, and social skills training. Each program is designed to increase the client’s knowledge, skills, and comfort. As the days pass, clients find themselves becoming more relaxed, more open to feelings, and more comfortable with physical and emotional intimacy. 

The involvement of the team therapist, a licensed and/or certified professional with an advanced degree, is a cornerstone of this therapy process. Clients often experience apprehension as they begin therapy and when they begin to experience changes. The team therapist assists the client with these and other emotional issues. Sessions with the therapist are interwoven with the surrogate partner sessions in order to facilitate understanding and change. Open, honest, consistent communication between all team members is a fundamental ingredient of successful surrogate partner therapy.



No one form of therapy is better than another and not every form of therapy will work for an individual or a couple.  But it’s exciting that so many new forms of treatment are emerging and that we are beginning to see more and more valuable research devoted to the topic of sexual dysfunction.  The key to keeping the momentum moving in the right direction is to turn up the volume on the honest discussion around sex and intimacy.  We all deserve fulfilling sex lives, and we need to say so.



Disclaimer: This is not medical advice, does not take the place of medical advice from your physician, and is not intended to treat or cure any disease. Patients should see a qualified medical provider for assessment and treatment.

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