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This is the last in a series about pain and discomfort during sex. Interested in starting from the beginning? Check out the first post: how to talk to health care providers about pain during sex.

For people who experience chronic pelvic pain, especially during sexual activity, there is rarely a simple and final solution. While treatments such as pelvic floor therapy can help, they don’t necessarily end pelvic pain once and for all.

One big reason for this, according to somatic psychotherapist Kayna Cassard, is that this pain is not an isolated phenomenon. It’s often connected to other aspects of your life.

This holistic perspective has its advantages, such as a new sense of empowerment and control in your work and home life. In this article, we look at ways to work with pelvic pain from this whole person perspective using Kayna’s first-hand experience with pelvic pain and her work with clients.

1. Recognize that your sexual self is tied to the rest of your identity

Folks who deal with pelvic pain often have lost or have never felt a strong connection to their sexual identity. Constructing a sexual identity is part of the process, including “being able to talk about what turns them on, what they want and need in sex.”

This is important, but the work isn’t just centered around one’s sexual identity.

Many people with vulvas come to see Kayna after doing other medical treatments, like estrogen creams or physical therapy, and, while the treatments may be helpful, they still have pain and discomfort. “A lot of [people with vulvas (PWV)] come in at the end of their rope, and I talk to them about reaching for progress and not perfection, because typically what is needed is a lifestyle change.”

That lifestyle change isn’t just in the bedroom. She explains that it’s “a shift in the way that they view everything from diet and movement to stress management to communication skills and assertiveness skills, and then, of course, sexual skills building.”

Kayna often sees parallels between what’s happening in the bedroom and what’s happening in other aspects of her clients’ lives.

Vaginismus— painful tension and spasms of the vaginal muscles, for instance, is frequently related to the need for control. Where many health care professionals tell people with vaginas to just try and relax, Kayna looks at areas in her clients’ lives where they are trying to hold onto control.

“In what ways have they felt powerless in the past or how have they been overpowered, and how are they disempowered in their everyday life? The pelvic floor muscles are expressing that. And then it’s the only way that some [PWV] can feel like they have control over a situation is by clenching their muscles. So if we start to help them identify these patterns in other areas of their lives that are more accessible for them to make change, they start to feel empowered — seeing that they can make change and that they have power in their work, with their family, and their partnership.”

When folks feel more empowered in their everyday life, they can naturally relax those muscles because that need for control is being met. “It feels like, instead of trying to force the body to do something, you’re working with the body.”

2. Work on solutions with loved ones

Chronic sexual pain often negatively impacts intimate relationships. It becomes easy for those in pain (especially for PWV) to believe that it’s “all their fault.” And they believe they’re the ones who need to do something about it. Instead, Kayna addresses it as an interpersonal dynamic in which both partners can adjust their thoughts and behaviors to improve the situation.

For instance, how do you respond when you’re alone with your partner and they offer a kiss or give you a long hug? When physical affection is often used as a lead-in to sex, a common response for chronic pain sufferers might be to pull away.

“They may get stiff or come across as uninterested in their partner,” Kayna explained. “But really it’s a pain avoidance tactic that their brain has just learned to do. It’s not that there’s anything wrong with them as a person or as a partner. Their brain has just sent that any kind of physical closeness or intimacy usually leads into sex and that pattern for them has been physically or emotionally painful.”

Kayna suggests potentially taking penetrative sex off the table for a time. “That gives them room to take that intimate moment at face value that their partner just wants to hold them because they love them and that it doesn’t mean anything else … and they learn how to rewire their nervous system to not react negatively or unpleasantly to what would otherwise be a very nice intimate moment.”

3. It’s not your fault, but you can do something about it

While much of this work is interpersonal, it’s important for the person experiencing pain to develop an understanding of their own body and thought patterns. “Just changing these really high expectations of themselves,” Kayna explains, “and giving them a lot more compassion around making mistakes or being in uncomfortable social situations or not doing everything perfectly. I work on teaching them a lot of self-acceptance and self-love.”

What does this look like? Mindfulness.

4. Use mindfulness techniques to become aware of your thought patterns and physical reactions to situations

Start to listen to your body. When clients understand their own nervous systems, Kayna explains, “they start to understand what’s going on inside of them so that they can have a better awareness and more control over their bodies.”

One such practice is noticing how anxiety arises in the body — racing thoughts, tight chest, etc. And approach the anxiety with self-compassion. “Come to a place of acceptance by saying to themselves, ‘Of course I’d be feeling this way because this pattern has been created in my body to react to that situation.’ So I’m going to shift to a place that’s neutral or pleasant in my body.”

And pay attention to thought patterns around painful experiences. “If somebody goes into an anxiety spiral, and they’re thinking about the future and worried about what’s going to happen, we might do a thought stopping technique or a mindful awareness technique where they might choose non-attachment phrases such as, ‘OK, look at that, I’m thinking,’ or ‘There’s anxiety” and then engage in shifting to a different type of thought pattern, engaging in positive affirmations (‘I can get through this’) or coping statements (‘the pain is less noticeable in this other part of my body’). It’s an active process that’s more of a cognitive behavioral therapy approach.”

5. Set realistic expectations

Much of what needs to shift is someone’s expectations. Many folks who come to see Kayna are ready for the pain to be over, but a fast and complete cure to pain isn’t always realistic.

“This work isn’t about finding the right pill and feeling better. Especially when you’re looking holistically at pain and how it fits into your life,” she explained. “Part of managing expectations is recognizing that this thing is somewhat out of their control. How can they learn to work with the challenges in a way that’s not defeating and in a way that’s compassionate? Even in that mindset shift, that’s a skill and the tool that ends up ultimately creating a healthier life and working towards pain-free or pain management.”

6. Recognize this is a journey — but it’s a hopeful one

“It’s usually a long-term process where they come out of it feeling a lot happier and healthier overall in their lifestyle,” Kayna explains. “Even if they’re still having pain, they feel more accomplished at work, and they feel more connected to passion in life. They feel like they have much more effective and an intimate conversations with their partners are able to explore more sexually.”

If major lifestyle or identity changes sound daunting, there’s hope in making small changes that have a big impact. This is Kayna’s antidote to despair. “It’s amazing how big hopelessness feels, like it’s this big tar that we get stuck in, but it’s really, really amazing how the smallest little change of this feeling that it’s going to be OK.”

For more information: check out our entire Guide to Reclaiming Pleasurable Sex for Folks with Pelvic Pain.

Jera writes about sexuality, spirituality, and social justice. They are the author of Just the Tip, a queer-friendly, sex-positive, relationship advice column and the editor of Sacred and Subversive,...