Sex Pain and Desire: Tackling the Relational Dynamics

Source: nd3000/envato elements

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 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?