Just the Tip is a sex and relationship column from queer non-monogamous kinkster Jera Brown. Here you will find interviews with sexuality researchers and educators as well as smart and compassionate responses to anonymous questions. If you would like to be interviewed or have a sex or love question you’d like Jera to answer, email email@example.com or DM Jera on Twitter @rebellioustips.
This is the first in a series about pain during sex and other sexual dysfunction. Some general issues:
- People with vulvas (PWV) are not always believed by their health care provider.
- Significantly less research and resources exist about sexual health for PWV and queer folks.
- Health care providers are not necessarily sensitive to issues around gender identity.
- There’s still a very strong societal stigma around what sex is supposed to be like that impacts all of us.
In this first post, I spoke to two specialists about how to know when to get help for pain during sex and how to talk to health care professionals. Dr. Natalie Rosen is a clinical psychologist and principal investigator at the Couples and Sexual Health Laboratory at Dalhousie University. Dr. Jeffrey Albaugh is the director of sexual health at NorthShore Medical Group and the author of Reclaiming Sex and Intimacy After Prostate Cancer.
In the second installment, I address how to talk to intimate partners about problems during sex, and stay tuned for tips on how to break down scripts around sex that aren’t working for you, and a discussion about anorgasmia.
Jera: What are indicators that something is going on that you need external help to resolve?
Dr. Natalie Rosen: The key thing is when pain is chronic. There’s a difference between not being lubricated, like when there’s not enough lubrication and so it feels … uncomfortable and painful, and when there is definitely sufficient lubrication, and you’re using water-based lubricant and there’s really a persistent pain which is most commonly described as a burning or stinging sensation. The other thing that is a marker that there’s something going on is that the pain might not only be during sex. So often the [PWV] I see will report that they can’t use a tampon because it’s painful or they have pain during the gynecological exam or sometimes when they’re riding a bicycle because of the pressure. Those are real indicators that it’s actually a genital pain, not necessarily a sex thing.
Although typically the [PWV] report that that’s the thing that’s most distressing and the real interference in their life and in their relationships. They don’t care if they don’t use a tampon, but the fact that they have pain during sex really impacts their life. But the pain is about the location of the pain, not about the sexual activity. So persistence and generalization to other types of experiences are indicators.
Dr. Jeffrey Albaugh: If [people with penises (PWP)] have difficulty getting or keeping erections, if they notice the penis is indenting or curving with erections, or if they notice anything unusual … such as an unusual discharge or lesions or bumps or lump occur on the penis or in the scrotum or on the testicles.
I know that erectile dysfunction is the most common issue for people with penises (PWP), but are there common issues that lead to pain during sex that are not often discussed?
JA: The pain can happen due to trauma to the penis, and this can occur during sex if the penis bends unnaturally, causing corporal trauma with swelling, bruising, pain and/or scarring. In addition, a [person] could be more susceptible to this if the penis is not fully erect during intercourse, causing it to bend more easily in an unnatural way along the shaft from the base to the glans.
How do you talk to a healthcare provider about this?
NA: One of the challenges that doctors can fall into, especially with potentially sensitive topics that they might not be comfortable bringing up themselves, is that they figure if it was really a problem, the patient would bring it up, so they don’t bring it up. But then, individuals are also nervous to bring up sensitive topics around sexuality. So we end up in a situation where no one brings it up and people suffer in silence.
I would give the same message to both providers and patients that you have to figure out some space and time for bringing it up. This might look like making sure there’s enough time in the appointment; it might mean prioritizing it at the start of an appointment so that you don’t run out of time. It might mean starting from a point of, ‘I’m having a problem in my relationship,’ and then going from the relationship into the sexual functioning. There are a lot of ways to naturally segue, but thinking about how to bring it up.
What other issues arise when seeking help?
NA: Oftentimes [PWV] who experience pain during sex like this, their gynecological exam looks normal. There isn’t necessarily going to be an indicator that there’s a dermatological condition or something like that. So sometimes they get a message from a doctor who might not be that knowledgeable about this kind of thing that they don’t see anything wrong. They’ll ask whether the individual has an abuse history or whether it’s all in their head—just psychological—which is very much not the case.
The example I often give is that we don’t tell people who have chronic lower back pain that it must be in their head, but oftentimes people with lower chronic low back pain have had their MRIs or CAT scans and there’s nothing physiologically identifiable that’s causing this pain, but we still know it’s very real. And it’s the same thing going on with vulvodynia. There might not be an identifiable fissure or dermatological thing going on, but it is very much a real condition where we know that there are biological as well as silent psychological factors that are contributing to the pain.
So you can seek help, but a physician might not see your problem as an actual issue.
NA: Well, they need to keep looking. If you’re having chronic pain during sex, you need to keep going until you find a doctor who understands and says, ‘I think this might be vulvodynia’ and who would actually be knowledgeable about it and consider it as a real condition and recommend treatments.
(For some of us, it’s not just an issue of being believed. We also want to be seen and understood. Search OutCare Health for LGBTQ+ friendly health care providers in your area.)
What are some of the recommended treatments people can expect?
NA: There are several well-validated treatments, one of which is a psychological approach. There is cognitive behavioral therapy, for example, which is empirically supported for the treatment of this kind of pain, because pain is very much a multi-faceted thing. We know that pain can be affected by our thoughts and our feelings, so it doesn’t invalidate the pain by treating it in terms of how we cope with and manage the pain.
Depending on the type of pain it is, some physicians prescribe using lidocaine for twelve weeks. Lidocaine is a local anesthetic ointment that works through desensitizing the nerve endings.
The third treatment is pelvic floor physiotherapy. There’s actually great evidence behind treating the public floor muscles. A lot of [PWV] who have chronic pain during sex have a dysfunction of their pelvic floor muscles that can be directly treated through physiotherapy.
(Read Rebellious Magazine’s posts from Darling Nikki about pelvic floor dysfunction and finding sex toys that work for her.)
What are ways that PWP and their partners can address and work through the stigma around sexual dysfunction?
JA: This is probably the real challenge because although erectile dysfunction effects 1 in 5 [PWP] in their lifetime, people don’t talk about sexual dysfunction. They can talk to their healthcare provider and seek professional help. The more we get information out into the world (like this article), the more people know that they are not alone and many people suffer with sexual dysfunction especially as people get older since many medical conditions that occur later in life such as diabetes mellitus, hypercholesterolemia, heart disease, high blood pressure and chronic back issues negatively impact sexual function. Not to mention menopause.