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Thank you for joining me for “Tough Cases.” As you probably know, I specialize in training therapists to be highly effective working with desire discrepancy, and to that end I’ve created a series that focuses on some specific and very challenging presentations. In this series, you’ll gain serious practical skills working with issues like sex pain, pressure for sex, porn use, and more. It will culminate with a free webinar on working effectively with higher-desire partners, so don’t forget to save your seat: Friday, March 3rd, at 1 pm CST.

In this first episode, I’ll be tackling sex pain, a frequently overlooked medical issue that can create low desire and even, eventually, an aversion to sex which can be very difficult to treat. 

If you see clients with low desire, you should be asking them about sex pain. In fact, if you see clients at all, you should be asking them about sex pain.

Bold claim? Certainly. But stay with me for a minute while I explain. And then I’ll give you some nuts and bolts about working with sex pain that you can put into practice right away, even if you’ve never had any training about working with sex issues.

Why you need to ask about sex pain

Sex pain is a common issue that is very often at the root of low desire. If left untreated, sex pain usually gets worse over time, creating a complicated constellation of physical, emotional, and relational problems that gets increasingly difficult to treat. When I see couples who haven’t had intimate touch of any kind for years, I often learn that it started with untreated sex pain.

Yet most therapists don’t bring up the topic of sex in therapy, and most clients won’t bring it up either even if they are having sex pain or other significant problems.

In fact, your clients may be especially reluctant to bring up sex in therapy if they are having problems, because of the shame associated with being “broken,” unable to “perform,” or being perceived as “abnormal” or even “oversexed.”

Many of my clients have told me they assume if a therapist doesn’t bring up sex, that is an indicator that they aren’t comfortable discussing it. There is so much cultural misunderstanding, misinformation, and shame about sex issues that it is really a rich area to work therapeutically…but first, we have to open the topic. 

In my experience, untreated sex pain is one of the most common underlying contributors to low desire.

It’s hard to overstate how powerful addressing sex pain can be. Simply by opening the conversation, you’re dispelling shame about sex and correcting the tragically common misconception that painful sex is normal. And when you’re able to follow up with an effective treatment plan, you’re creating deep healing, on a physical, emotional, and relational level.

Sex pain tends to poison everything around it, making intimate interactions–which should be pleasurable, affectionate, and joyful–fraught and tense instead. It can even create problems with your clients’ internal sense of self, understanding of pleasure, and ability to enjoy being in their body.  Imagine how liberating it will be for your client to learn that pain-free sex is possible, and that you can help them get there.

How to open up the conversation

So, what’s a therapist to do, especially if you don’t have much training or knowledge about sex and sexuality? Here is my simple 3 step process:

1. Bring up sex (you can use my language: “Is there anything about sex or sexuality you think you might like to discuss in our work together?”). If they don’t want to discuss anything about sex, that’s fine, just move on.
2. If they do want to discuss a sexual concern, at some point in your conversation be sure to ask if any kind of sexual touch is physically uncomfortable or painful (again, those are my exact words; feel free to use them)
3. If your client does experience sex pain, help them find the right medical provider

Why is it that sex pain is so often ignored by clients—and so often left untreated by clients and therapists?

When you burn your hand on a hot stove, you pull your hand away. When you prick your finger, you pull your hand away from the needle. What is it about sex pain that leads people to push past that “stop it!” signal? What makes us override the body’s natural self-protection systems?

I think there are multiple factors.

Cultural myths: People with vaginas are often taught that their pleasure is not important, that sex doesn’t have to be pleasurable to be worthwhile, or even that it’s normal for sex to hurt. They may also be socialized to believe it’s their responsibility to keep their partners sexually satisfied, whether or not they actually want to have sex. Sad as this is, it is a common story. Many of my clients with sex pain have tried to hide it from their partners, or pushed through it, becoming increasingly distanced from any experience of pleasure, and reinforcing the message that their experience isn’t important.

Low differentiation of self: Saying “no” or “this doesn’t feel good” or “let’s try something else” isn’t always easy, especially if you don’t have much practice or the topic is especially sensitive. Differentiation of self is the skill that underlies both giving and withdrawing consent, and becoming increasingly differentiated is a lifelong journey, not a simple behavioral step.

Relationship dynamics: Differentiation of self becomes extra challenging if your partner is a bit pushy, or has a tendency to shut down or react dramatically when you tell them something they don’t want to hear. It might seem easier to just grit your teeth and push through the painful sex, if it feels like the alternative is a messy interaction that will ruin the whole evening.

Taboos around sex: Even people who are quite highly-differentiated in other aspects of their lives can have a lot of difficulty figuring out what is true for them and sharing that with their partner when it comes to sex! There’s just so much meaning, mythology, and shame tied to this topic that it tends to push us to the very limits of our emotional fortitude.

Transference and Countertransference: Misinformation or shame about sex, sexual pleasure, and sex pain is so rampant that most of us, clients, therapists, and health care providers alike, have been exposed to it. And, unfortunately, reparative experiences and accurate information are hard to come by. Clients are unlikely to bring up the topic themselves, and therapists are unlikely to have much training in the area. This is a large part of why I made it my mission to provide accurate information and solid clinical training about sex to care providers; I want to help you feel empowered and effective helping your clients who experience challenges related to sex.

The medical side: what you need to know

In some cases, pain with penetration can be resolved by adding lubrication. Finding out whether or not that’s the case can be an important diagnostic tool. I keep a bowl of high-quality lubricant samples on my desk so I can give them to clients to take home. If you don’t have samples in your office, suggest your client pick up some lubricant specifically made for sex, and give it a try.

If using a lubricant doesn’t resolve the issue, there could be a host of other causes. Fortunately, you don’t have to know all of them, or even be able to sort it out. You just need to know most of the time sex pain is treatable, and then help your client connect with the right medical care provider.

• If the pain is on the vulva, the ideal referral is to a vulvar pain specialist or sexual medicine specialist.
• If the pain is with vaginal penetration, the ideal referral is likely to be to a pelvic floor physical therapist.
• If the pain is in the scrotum, or associated with ejaculation, lifting, orgasm, or defecation, the ideal referral is to a pelvic floor physical therapist.
• If your client has a sex-knowledgeable Ob/Gyn (for clients with a vulva) or Urologist (for clients with a penis), those providers should be able to help sort out causes of pain. Just note, not all urologists or Ob/Gyns are very sex-knowledgeble, so if your client’s sex pain doesn’t resolve, keep looking for the right provider.

The relational side: working with the dynamics

Resolving sex pain isn’t just about medical treatment. It’s also about unraveling the emotional, social, and relational dynamics that led your client to push through the pain in the first place. Here’s how I tackle that side of things:

Counter misinformation: The first step is to make sure your clients know that sex pain is not normal. It is not an expectable part of having sex that you just need to put up with. It’s a sign of a potentially serious issue. At the same time, it is almost always treatable. Your clients should know that they should not engage in any kind of touch that causes undesirable pain, but that they can reasonably expect that, with appropriate care, the sex pain will go away. In the meantime, I encourage my clients to get creative and engage in sexual activities that do not cause pain.

Build differentiation: Helping clients develop differentiation of self is at the core of almost all the work I do in therapy, and sex pain is no exception. In fact, I find that differentiation can be especially challenging in a sexual context. Many people have no problem speaking up in other areas of life, but can’t imagine doing so when it comes to sex.

Encourage healthier relationship dynamics: This goes hand-in-hand with building differentiation of self, as differentiation is a foundational set of skills that support healthy communication in a relationship. In particular, keep an eye out for any kind of pressure for sex, including subtle pressure and internal pressure (and look for an entire article on that dynamic in this series, coming soon).

Normalize honest communication about sex: As a therapist, you’re in the perfect position to model open, non-judgemental communication about sexuality to your clients. Simply asking your clients “Is there anything about sex or sexuality you might want to discuss in our work together?” can go a very long way towards normalizing sex as a part of life, even if your clients don’t have anything in particular they want to discuss. Demonstrate that it’s possible to talk about sex with comfort and honesty, and your clients will begin to follow your lead.

Resolving pain is a necessary first step to restoring desire, because your client can’t feel desire when their body is screaming “stop!” Once the pain is gone, who knows what beautiful things might emerge in the space that’s left?