This is a loaded question and there are a lot of factors that can contribute to why it hurts to have sex. There may be hormonal, mental and musculoskeletal components, and many times there's a combination of all three. But the most important thing to remember if it does hurt to have sex is that you’re not alone and there is absolutely something you can do to change this.  

Who can have pain with sex? 

It can hurt to have sex no matter who you are and what genitalia you have. Anyone who has sex can be at risk for painful intercourse (medically know as dyspareunia). That being said, there are some groups of people who may have a higher risk of experiencing pain than others. People at higher risk for pain with sex are: 

• Women or those assigned female at birth (AFAB)

• Those who are recovering from or have recovered from pelvic illness, surgery or injury (ex: pelvic inflammatory disease, sexually transmitted infections, hysterectomy, gender affirming procedures, pelvic cancers, pelvic fractures, hip replacements, etc.) 

• Perimenopausal or menopausal people 

• People who have birthed a child (specifically those who experienced an episiotomy or tear) 

• People taking anti-androgenic birth control (See Dr. Andrew Goldstein’s work on this) 

• Those with a background in purity culture/ideology

How can pelvic floor muscles hurt during sex? 

The pelvic floor is a huge contributor to both sexual wellness and sexual dysfunction. When the pelvic floor muscles are doing their job, sex can feel amazing! And when they’re not, it’s quite a different story. 

Briefly, the pelvic floor muscles are a group of muscles that support the pelvic organs, control sphincter opening and closing (control your pee and poop), stabilize the pelvis and hips, control posture and impact lymphatic function. 

They are also integral in sexual function by supporting the clitoris for improved sensation, controlling the blood flow to and from the genitals for erection of the clitoris and penis, and they are responsible for rhythmically contracting every 0.8 seconds during orgasm.  

That’s what they do in a well-functioning, relaxed environment. But in those who experience pain with sex, this is not always the case.  

Sometimes the pelvic floor can get overactive or tight as a result of many things, but oftentimes we don’t know this is happening until we try to receive penetration or try to have an orgasm and all of a sudden things really hurt! 

Sometimes there can be compounding factors here such as perineal scarring from childbirth, trauma from a pelvic injury like a fracture, or tightness in the pelvic floor as a result of changes in the hip like a hip replacement or severe arthritis due to the interconnectedness of the pelvic floor and hip.  

Pelvic floor physical therapists and occupational therapists are specially trained to assess and treat these muscles, improve scar tissue mobility, increase hip mobility and teach people how to relax their muscles so that they can leave the pain in the past and start enjoying sex again!

How could my mental wellbeing make it hurt to have sex?

Our mind and body are immensely interconnected. In fact, when our brain perceives a threat, our pelvic floor will tighten up for protection. It doesn’t even need to be an actual threat for our body to respond, the brain just has to think it’s being threatened for the pelvic floor to respond.  

When I work with my patients on managing pelvic pain, there is almost always a psychological background that needs to be addressed. Sometimes this is an actual threat of a previous sexual assault or other form of abuse. Sometimes it’s more of a perceived threat like financial stressors, a work deadline or a sick child. Again, your brain doesn’t know if it’s a perceived or actual threat, it’s going to respond the exact same way. The problem with perceived threats is that they are all around us, can seem never ending and can often lead our bodies to respond in the hallmark signs of anxiety, part of which is a tightening of the pelvic floor, jaw, neck and abdominal muscles. 

Sometimes the stressor comes from an upbringing where one was given little to no sexual education and the education they did receive was shame based. People are taught “don’t look at it, don’t touch it, don’t let anyone else touch it” when it comes to their genitals and then the night they get married they are supposed to forget everything they’ve been told and suddenly relax into sexual activity with their new spouse for the purposes of procreation. This is not only present in people with conservative religious upbringing but can affect people across many different cultures and societies.  

If you find that you’re experiencing pain with sex and think you might have some fears and stressors to work through, I highly recommend working with a mental health professional who is experienced in this area so that they can help you discover safety and pleasure in your body instead of fear and stress.

How hormones might be making sex hurt? 

Hormone based dyspareunia is much more common in women and AFAB people due to the nature of the vaginal tissues origination from its embryological state and the effects hormones have on tissue quality and health in the vagina. 

From a developmental standpoint, the tissue in the vulvar vestibule (the area on the inside of the labia minora that contains the vaginal opening and urethra) is the same type of tissue as the male urethra. This tissue needs androgen hormones like testosterone to function well. Anti-androgen birth controls suppress the testosterone production from the ovaries meaning the vulvar tissues don’t get what they need to feel healthy. This can contribute to reduction in size of the clitoris, labia and vaginal opening as well as vaginal dryness. All of which can contribute to pelvic pain with sex.

Another important consideration for hormonal health of the pelvic tissues is estrogen, specifically estrodiol. Estrogen is a water loving molecule, it pulls moisture into the tissues. And what do the vulva and vagina hate? Dryness. As we age, estrogen begins to drop and this can increase dryness, tissue irritation and pain to touch. For many women/AFAB people, specifically those who are perimenopausal or menopausal, a topical estrogen product can work wonders in balancing out the hormones and improving tissue health. 

If you think you might be experiencing hormone induced pain with sex, follow up with your medical provider to see if medication shift would be right for you.

Who treats pain with sex? 

I find that the majority of my patients with dyspareunia get better much faster when taking a team approach between pelvic floor physical therapy, mental health support and physician support when needed. When looking for a practitioner, ensure they have a background in working with pain with sex, not all practitioners are created equal. And if you try working with someone and it’s not the right fit, don’t give up! You might just need another practitioner in the same field. 

If looking for a pelvic floor physical therapist, be sure to ask about their background and experience to ensure they will be a good fit for you. If you’re in the Columbus, Ohio area, reach out and we’d be happy to help you! If not, check out an online directory to help you find a great pelvic PT or OT in your area.

When looking into a mental health professional, The American Association of Educators, Counselors and Therapists Directory is a good place to start your search. 

When looking for a physician, again, ask questions. Sometimes an OB/GYN or urologist has experience in treating and supporting your with dyspareunia, but you may need someone more specialized like a urogynecologist or a physician specializing in sexual medicine.

Most importantly, though, if sex hurts for you, know that you have options and that a team approach will most likely be the most effective way to get the fastest results!