What causes pain during sex? It’s not just psychological
There are many answers to the question of what causes pain during sex.
Pain during sexual penetration or intercourse, also called dyspareunia, is actually pretty common. Chronically affecting 15% of women and people with vulvas, according to the Journal of Sexual Medicine. Dyspareunia is defined as pain that occurs before, during, or after intercourse or sexual penetration. Dyspareunia can affect anyone with a vagina, including non-binary and trans people.
For this article, “sex pain” will include dyspareunia and be defined as unintended pain in the vulva (including the vagina, labia, or clitoris) during sexual activity, usually from penetration or erotic touch.
Sex pain can begin at any stage of life. Some can enjoy years of pain-free sexual activity before it begins. For others, it’s there from the start.
While the severity of pain varies, vulvovaginal pain can impact a person's mental health, sexual health, and their relationship. Therapy can lessen this impact.
It’s important to note that dyspareunia or vulvovaginal pain and pelvic pain are different types of pain with different causes, and different effects on the person and their relationships. We’ll cover pelvic pain in more detail at the end of this article.
Physical pain during sex: It’s not all in your head
One of the most difficult parts about having vulvovaginal pain (sometimes called vulvodynia, and defined as pain in the vulva or genitals, including the vagina, vestibule, labia, or clitoris) is how long it can take to get a diagnosis. It can take years for doctors to listen and figure out what is going on.
Many women are told that the pain is just a part of sex.
That this is how it’s going to be from now on. That they should just take a Tylenol or have a glass of wine. Or they should “just relax.”
The truth is, any unintended pain during sex is a concern. Vaginal penetration or touch during sex should never hurt, so long as the sex is consensual and your body is sufficiently aroused and lubricated (whether on your own or with a lubricant). Temporary discomfort is normal, but unwanted pain is not. If you are wincing or white-knuckling through sex pain in the vulva or vaginal canal, then it’s time to see a doctor.
There are dozens of possible reasons for sex pain. Here are some of the most common:
Hormonal and tissue changes
Hormonal changes that come with typical life stages like pregnancy, perimenopause, and menopause can cause changes in the levels of hormones like estrogen and progesterone. These changes can cause an increase in vaginal dryness, vaginal atrophy, or vestibulodynia, also called vulvar vestibulitis.
Infections and similar conditions
Vaginal infections like vaginitis, sexually transmitted diseases, or infections related to urinary tract infections like cystitis can all cause pain during sex.
Muscular tension
Involuntary tensing of the pelvic muscles during penetration can lead to vaginismus, which is often treated through pelvic physical therapy and psychotherapy. While vaginismus can happen on its own, it is not the correct diagnosis for all sexual pain. It can also happen as a side effect of one of the physical causes.
As you can see, there are quite a few possible reasons for the pain, and these are just the start of what might be going on.
The good news is that there are many possible treatments once you get an accurate diagnosis. It’s important to see a doctor who has special training in sexual health or sex pain, because most OB/GYN’s do not receive training on how to diagnose or treat vulvovaginal pain. Here are some specialists we recommend in the DC metro area.
Emotional and psychological factors do make a difference
While the pain is definitely not in your head and not solely emotional, some emotional factors can contribute to making the pain worse. A lot of this depends on the diagnosis and underlying cause of the pain.
The first part of this is the cycle of anxiety and pain. When you experience pain, the first thing your body does is tense up. This is to protect yourself from more pain. Of course, in a lot of ways, this can be counterproductive as muscle tension can then cause muscle soreness, which in turn causes more pain.
When it comes to sex, tensing the pelvic floor muscles and other muscles in the area can cause pain and discomfort during sex. So if you are already experiencing pain or even just thinking about the pain that occurred last time you tried to have sex, your muscles tighten, which causes more pain.
So once you start associating sex with unintended pain, sex can become more and more painful. Psychotherapy and pelvic physical therapy can help break the cycle.
Sexual arousal is also important for optimal levels of vaginal lubrication. If you are experiencing stress around penetration because of the pain you have experienced in the past, your body’s arousal response may be inhibited (and lubrication may also be inhibited), and sex may continue to be painful.
Beliefs, attitudes, and personal history can also impact pain during sex
A second set of factors that can contribute to pain is your attitudes and beliefs about your body and sexual activity overall. If you have a negative relationship with your body and its sexual functions or sex overall, this can increase stress during sexual activity, which in turn increases pain.
Some examples of what this can look like might be:
If you dislike your body and don't feel comfortable in it, clothed or naked, you may have difficulty being present during sexual activity. This discomfort can then increase stress, which increases pain.
Growing up in a family that had strict religious beliefs can also exacerbate sexual pain. One study found that women who experience guilt about sexual activity are more likely to experience pain during sex.
These factors may also reduce the likelihood of discussing the pain with your doctor. Impacting your ability to receive an accurate diagnosis, treatment, and find relief.
Mental health impact of sex pain
Many women experience some mental health impacts from the pain that they experience during penetration. It isn’t just the actual pain during sex, but feeling invalidated and gaslit by the medical system.
Some women see up to a dozen different doctors before they get an accurate diagnosis. This can increase the depression and anxiety they may already be experiencing around how this pain is impacting their relationship and sex life.
The pain itself and the resulting avoidance of sexual activity then contributes to lower confidence and self-esteem. You may feel as though there is something wrong with you because your body doesn’t work the way you want it to.
For some women, the pain results in avoiding sexual activity and/or experiencing emotional paralysis around sex. This can extend to avoiding a relationship completely, impacting your sex life in the long-term.
Relationship impacts
This type of pain can have an impact on intimate relationships.
Even with a supportive partner, you might still experience guilt or shame around the pain. In a less supportive relationship, it can cause a lot of fighting and problems in that relationship that end up extending beyond the sexual part of the relationship. In some cases, one or both partners may believe that the sexual dysfunction or pain is a personal fault.
No matter if the relationship is supportive or not, you may struggle to figure out how to navigate a sexual relationship when there is sex pain. You may struggle with how to talk to your partner about this, so you both feel heard and understood. This is where couples therapy can help.
Pain during sex vs pelvic pain: what’s the difference?
Often, when pain during sex is discussed in our culture, pelvic pain becomes the main part of the conversation.
Let’s talk about the difference between vulvovaginal pain and pelvic pain.
Vulvovaginal pain occurs in the vulva, vagina, vaginal canal, clitoris, or vestibule (the opening of the vagina), and is often penetration-specific, leading to painful intercourse and other sexual activities.
It can also be so severe that inserting anything into the vagina, like a speculum or tampon, is impossible.
Pelvic pain is any pain in the abdomen or uterus and is not necessarily related to penetration. It can, at times, make sex painful, but it isn’t necessarily caused by it. It can impact other sexual organs like the fallopian tubes or even the bladder.
Some causes of pelvic pain are conditions like adenomyosis, pelvic inflammatory disease, a retroverted uterus, and uterine fibroids.
Some conditions can cause both sexual pain and pelvic pain. For example, endometriosis and pelvic nerve irritation. But because they might be cyclical or painful without insertion, the impact on the person's life is quite different. Pelvic floor dysfunction is another condition that can cause pain in both areas.
With sex pain or vulvovaginal pain, the pain is directly tied to sexual function and intimacy and they take longer to get an accurate diagnosis, both of which affect your emotional, mental, and relationship functioning. It’s common to develop negative feelings about sexual touch specifically or sexual body parts.
While pelvic pain conditions can also be chronic and painful, they have a different impact on the person’s life and functioning. Some people with chronic pain have trouble participating in day to day activities, which can be debilitating all around. However, often with pelvic pain, sexual touch or vaginal penetration does not hurt, and sexual activity is still possible.
When to see a doctor
Sexual intercourse, touch or penetration should be pleasurable and enjoyed by all parties involved. Unintentional sexual pain is a sign that something is not going as it should.
If you have experienced pain with penetration on more than one occasion, it’s time to see a doctor.
There are many possible treatments for pelvic pain and vulvovaginal pain, like pelvic floor physical therapy, lubricants, vaginal estrogen cream, other hormones, onabotulinumtoxinA injections, and other types of pelvic rehabilitation.
But you need an accurate diagnosis for the treatment to work.
Unfortunately, not all doctors are fully educated on female and trans sexual health issues, so if you feel blown off or like your pain isn’t being taken seriously, it is important to advocate for yourself and ask for a second opinion.
It’s important to be prepared to talk about your sexual history with the doctor, as they will ask for this information.
When diagnosing sexual pain conditions, the doctor will often do what is called a Q-tip test to identify where the pain is actually coming from. They may also do a hormone test to get a clearer picture of what is going on.
Unfortunately, for many people, it can take quite a few doctor visits with different doctors to get an accurate diagnosis, so don’t give up.
What you can do
Experiencing pain during sex can be quite stressful, and it’s important to get both medical and mental health support as you’re navigating this. You might need support individually as well as with your partner.
Individual sex therapy, as well as couples therapy, can help you to process the feelings that you’re having around the pain you are experiencing.
Sex therapy can help you and your partner communicate how you feel about the pain, and what to do about it. With the support of a trained mental health professional, you can progress more quickly and even improve your relationship along the way.
The most important thing is to advocate for yourself with your medical professionals. Keep pushing until you find the right team to get an answer to why you are experiencing this pain with sexual penetration.
Can sex therapy in Washington, D.C. help with pain during sex?
If you are still wondering what causes pain during sex in females, sex therapy can help. We can help you navigate the medical system by helping you find the right professional and supporting you emotionally.
We can also help you and your partner to figure out what the next steps are in your sexual relationship and help both of you understand what is going on.
Schedule a consultation if you would like to get started.
Do you want to hear more from me (Camille Espinoza, LICSW) on this subject?
Check out my appearance on 1A podcast “In good health: Chronic pelvic pain in women.” with Dr. Sarah Cigna and Dr. Maria Uloko.
Part 2 will be airing on July 6, 2026, at 11 am ET on your local NPR station or the1a.org
