For about 15% of women in North America, sex isn’t just uncomfortable — it’s downright painful. We’re talking intense, burning, stinging, or shooting pain that happens regularly.
Unfortunately, our society has normalized this experience. If you’re a woman, you may remember being told to expect pain the first time you had sex, or had your issues minimized when you sought support.
Researchers are starting to dig deeper into the causes, symptoms, and treatments of painful sex in women. There’s still a lot we don’t know, but evidence is growing that painful sex in women may be linked with anxiety.
Quick note: Whenever we use the term “women” here, it can be swapped out for “people with vulvas.”
Types of pain
There are different terms to describe the types of painful sex:
- Dyspareunia: A catch-all term for persistent genital pain during sex. Sex is achievable but penetration is painful.
- Vulvodynia: Refers to unexplained pain around the vulva that isn’t necessarily tied to sex.
- Provoked vestibulodynia (PVD): Severe pain in the vulva’s vestibule (the area around the vaginal and urethral openings) triggered by touch. Doctors rule this out if it’s caused by menopause, STIs, skin conditions, or other factors.
- Vaginismus: When the vagina closes involuntarily during penetration attempts of any kind — like with a penis, fingers, tampon, or a speculum during a Pap test. Insertion may not be achievable at all.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) used to treat dyspareunia and vaginismus as separate diagnoses but now combines them under “Genito-Pelvic Pain or Penetration Disorder.”
Since the causes of these conditions are still unclear, we’ll use the terms “sexual pain disorders,” “painful intercourse,” or “painful sex” in this article.
What causes painful sex?
As with other chronic pain conditions, like fibromyalgia, finding a cause for painful sex can be frustrating.
Doctors used to think it was primarily due to surface issues like inflammation, infection, or trauma to the vulva. But newer research highlights other potential causes, including:
- Over-sensitive pain receptors in the brain (called central sensitization)
- Genetic factors
- High stress levels
- Negative sexual attitudes, such as negativity about sex before marriage
- Cultural norms and expectations
- Lack of sexual education
- Relationship factors
- Sexual or physical abuse
The anxiety-pain link
Anxiety, depression, stress, and trauma are closely tied to painful sex, according to the book So Tell Me About the Last Time You Had Sex: Laying Bare and Learning to Repair Our Love Lives.
For example, women with anxiety disorders are 11 times more likely to also experience painful intercourse.
And personality traits like perfectionism, fear of judgment, and self-criticism are linked to PVD.
Many women that have “Type A” personality traits are more likely to have increased muscle tone which can lead to pelvic floor pain, tightness, and dysfunction, adds Jenna Aiuto, MScPT, a pelvic floor physiotherapist based in Calgary, Canada.
Catastrophizing, which happens when you anticipate terrible outcomes, can also impact your body’s experience of pain.
The emotional processing part of your brain may perceive a trigger (like, your partner asks if you want to have sex) which then sends a signal to your body to prepare for pain that is not currently physically happening.
For women with vaginismus, this might show up as involuntary muscle tightening or leg clenching.
Triggers may be a result of past painful sex, but can also come from emotionally scary or painful experiences, such as being taught sex is shameful.
The anticipation of pain can create a feedback loop that makes the pain feel more intense. Simply put: fear of pain can make real pain.
Medical treatments
If painful sex is due to physical issues, like low arousal or lubrication, solutions can include using lubricants and making sure to do more sexual activity before having penetrative sex, according to the book So Tell Me About the Last Time You Had Sex: Laying Bare and Learning to Repair Our Love Lives.
For hormonal issues, treatments might involve estrogen creams, laser therapy, Botox, or surgery, though surgery rarely helps.
Topical creams work for some, but many women find they don’t help — or even make things worse.
Mind-body approaches
Some researchers believe sexual pain disorders have more to do with mental health than physical causes. That’s why more and more treatments take a mind-body approach to pain.
Pelvic floor physiotherapy
This type of specialized physio will help you reconnect and understand your pelvic floor.
The therapist may use manual therapy techniques to improve blood flow and circulation to your pelvic floor, which can help relax the muscles. They’ll also guide you through relaxation exercises to relieve tension and improve pelvic floor range of motion.
They may recommend a dilator set or vaginal wand to help with tissue relaxation, or may recommend desensitization strategies if you have PVD.
Dilator therapy
This technique involves using a set of stretching instruments in varying sizes to gradually stretch your vaginal opening.
Combining mindfulness with this therapy can help women manage the discomfort and better understand their pain, according to the book Better sex through mindfulness: How women can cultivate desire.
This type of therapy is often done with the support of a pelvic floor physiotherapist. There are also psychological aspects that can be helpful to talk through with a sex therapist.
Sex therapy
Therapists working with issues of painful sex typically try to get a holistic picture of your experience — not just the physical pain.
They often explore factors related to mental health, stress levels, relationships, and sexual satisfaction.
Since many people don’t receive proper sex education, sex therapists are also trained to provide information on the connection between psychological factors and pain, the benefits of using lubricants, and ways to prioritize pleasure over “pushing through” discomfort.
A sex therapist can also typically refer you to a pelvic floor physio to collaborate with.
Mindfulness
Mindfulness — a practice of staying present and nonjudgmental — can be super effective, according to the research of Dr. Lori Brotto, a professor and director of the Sexual Health Laboratory at the University of British Columbia.
It helps calm the overactive nervous system that’s common in both anxiety and sexual pain disorders.
Cognitive behavioral therapy (CBT)
CBT helps address anxiety, depression, and catastrophic thinking. Strategies include challenging negative thoughts, reducing avoidance of sex, and making sexual experiences more enjoyable.
My go-to books as a sex therapist
Better Sex Through Mindfulness by Lori Brotto is a great guide to incorporating mindfulness techniques to strengthen your mind and body connection.
This book is for you if you struggle to stay present in your body during sex, find yourself avoiding any type of physical contact with your partner out of the fear that sex might happen, or if you rarely, if ever, feel “in the mood.”
There is also an entire chapter specifically focused on working with sexual pain.
My Broken Vagina by Fran Bushe.
As a sex therapist, when I recommend this book to clients, I always like to give a huge caveat that the message here is NOT that your vagina is broken. The title is a glimpse at the author’s humour and vulnerability that permeate this memoir.
When I first read this book, I was so excited that it gave words to a theme that I often see where people who struggle with sexual pain also often are working on recovering from people-pleasing and prioritizing their own needs and boundaries.
It is a story of the author’s personal experience with painful sex and her pursuit of trying various therapies to learn more about what she and her vulva need to heal.
If you are longing to feel less alone in your pain, I can’t recommend this book enough.
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The final word
Painful sex is not “normal,” and it is not something anyone should just have to put up with.
While there’s still a lot we don’t know, research is helping us understand how anxiety and mental health are tied to sexual pain.
Medical professionals need to validate these experiences with their patients, and more work is needed to find effective treatments.
Experts like Dr. Lori Brotto are leading the charge, offering evidence-based strategies that combine mindfulness and therapy to make a real difference.
Erin Davidson, MA, RCC, CST
Erin Davidson (she/her) is a Registered Clinical Counsellor and Certified Sex Therapist working in private practice in Vancouver, British Columbia. She is a firm believer in the healing power of pleasure and being kinder to ourselves. Erin is the author of two booksBreak Through the BreakupandThriving in Non-Monogamy. She is most proud of her new fluffball Marv who recently graduated top of his class in puppy preschool.