Sex Pain and Desire

What Therapists Need to Know

Teaser: Sex pain causes a host of problems, physical, relational, and emotional, which only get worse the longer the pain goes untreated. How can therapists help? 

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. 

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.

This is part one of a two-part series. In the next part, I’ll delve into the relational dynamics that prevent our clients from resolving sex pain, and what you can do to help. 

Originally posted on Psychology Today.