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When Sex Hurts..

Q: I’ve been happily dating my boyfriend for 10 months. Initially, the sex was amazing, but a few months ago it started to hurt a lot. I’ve basically lost my sex drive and even when I am in the mood to have sex, I’m so uncomfortable that I can’t enjoy it. My boyfriend has been supportive, but I can tell he’s frustrated. My doctor diagnosed me with vulvodynia, but so far none of the treatments have worked and he said it might be psychological. How does that work?

A: First, I want to acknowledge how difficult this must be for you. I work with a lot of women with sexual-pain disorders, and I can appreciate the distress it can cause. There are many emotional layers to the condition, including relationship struggles, managing chronic pain, feelings of helplessness or failure, fear for the future of your sex life and concerns about the ability to have kids. All in all, it can be emotionally very traumatic.

Vulvodynia is a condition that causes pain in the vulva (area surrounding the vaginal opening) during sex, and it is estimated that it affects 20 percent of women in their lifetime. Most often the pain is caused by a tightening of the pelvic-floor muscles or by injury to the pudendal nerve, causing overactive nerve endings that produce a painful burning sensation. Common treatments include physiotherapy, antidepressants, anti-seizure medication and numbing creams and, less commonly, patients can undergo Botox treatments and surgical options. While it is understood that the pain is physiologically real, medical treatments are often only partially successful, which suggests a deeper root to the issue.

Our minds and bodies are deeply connected. On a neurological level, receptors in the brain are responsible for processing physical sensation, meaning that pain is actually a mental perception. Not only can our emotional experience impact our perception of pain, it can also lead to neurological changes that cause increased sensitivity to it. In essence, distress and frustration caused by sexual discomfort can actually worsen the pain. Therapy is at a minimum useful in helping to alleviate the distress and manage the perception of the discomfort.

Even on a surface level, the body is very responsive to our state of mind. For instance, when I’m concentrating, I have an unconscious tendency to clench my jaw; just like women anticipating discomfort upon penetration may find themselves unconsciously clenching their pelvic-floor muscles. It is also possible for other psychological stressors to unconsciously show up in the vagina. In some cases, working through emotional or relational issues may be sufficient to ameliorate the problem. Exploration of the relationship dynamic, feelings about intimacy, values and beliefs about sex and sexuality, previous sexual experiences and sense of confidence/self-esteem can be vital aspects of therapeutic treatment—as is developing awareness of the body’s reaction to emotional experiences, which allows for conscious relaxation of the muscles.

Certain temperament traits may also contribute to emotional somatization. Anyone that has taken an introductory psych class is probably familiar with the term “anally retentive.” Traditionally, this term reflects an anxious disposition and invites the unwanted visual of a clenched asshole. Well, I like to think that women with more anxious and internalizing natures have the capability of being “vaginally retentive.” With that said, developing new strategies for managing one’s own vigilance may help reduce the unconscious clenching that can lead to pain.

While there are often psychological underpinnings to sexual pain, therapy works best when combined with medical treatment and physiotherapy.

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