Sexual Pain Part II: A Look at the Emotional Side of Things

In Female Pelvic Pain, Male Pelvic Pain by Stephanie PrendergastLeave a Comment

In part one of our blog on sexual pain, we covered many of the physiological issues surrounding sexual pain, in this follow up post, we’re taking a closer look at the emotional side of the things.

So what are some of the emotional issues that those with sexual pain face?

To answer this question we turned to two experts in the field of sex therapy: Rose Hartzell, Ph.D., a certified sex educator and therapist at San Diego Sexual Medicine and Erica Marchand, Ph.D., a licensed psychologist specializing in couples and sex therapy in Los Angeles.

Q. What emotional issues can crop up with sexual pain, in both men and women? 

A. Dr. Marchand: Our usual response to pain is to escape it, and when we can’t escape it, we understandably feel trapped and anxious. Living with pain that feels inescapable can also lead to feelings of sadness, depression, or despair.

Add sex to that—not only are you experiencing pain, but you’re having pain that keeps you from enjoying one of life’s built-in sources of enjoyment, and you’re having pain that keeps you from connecting with other people in an important way. It’s a double blow.

There can also be shame and embarrassment, since sexual functioning is so personal and for some people so integral to identity, attractiveness, and connection.

A. Dr. Hartzell: With sexual pain, avoidance of sex or any intimacy at all is often an issue. For many of my patients, there is a fear that any type of physical touch will lead to intimacy or sexual intercourse; therefore, they will close off all physical touch with their partner. Ultimately, the physical distance will lead to emotional distance, and this can be disastrous for a relationship.

And this can work both ways. I had a patient with vulvar pain who had a high sex drive and on the days when she felt good enough to have sex, her partner was not interested because he had developed low sexual desire as a result of how complicated their intimacy issues had become. His worry was always: “What if we are intimate, but she has pain, and there is a failed encounter.”

Q. So how do you council patients who are having avoidance issues around sex?

A. Dr. Hartzell: Because every patient/couple is unique there is no standard. Having said that, I will say that I always want to instill in my patients that there is no such thing as failed sex. And that they are not broken! Sex is not a performance, it’s about having a connection, it’s about fun, and it’s about being intimate with your partner. And you can do that a lot of different ways.

Often when I begin working with a couple I will try to take whatever activity is the most painful–and more often than not it’s penetration–off the table. The goal is to get them to a place where instead of associating sex with pain, they begin to once again associate it with pleasure.

The next step is to get them to be intimate again even if they can’t have penetration or engage in other activities that are too painful. You would be surprised at how many people, especially women, are hung up on the idea that to have sex you must have penetration. The bottom line is sex does not equal penetration. There are so many other activities on the menu! For example, using a vibrator on the clitoris, oral sex, and clitoral stimulation without touching the vulva or the vagina, to name a few.

I would like to add that this is also true for gay and lesbian couples dealing with sexual pain issues. Penetration does not equal sex.

I’ll often give my patients assignments to help them reestablish intimacy. One of my favorite assignments is for them to go to the Dollar Store to purchase $10 worth of items. Then each time they are intimate, they’ll use one of the items. You would be surprised how much fun you can have with whipped cream or a spatula!

Q. Now I’m intrigued. What are some other assignments?

A. Dr. Hartzell: I’m a big advocate of vibrators, so I have them go to a sex shop together and pick out one that they like, and begin experimenting with it.

Also I ask them to participate in what is called “Sensate Focus”. Here’s how it works: The couple will set up their bedroom for intimacy. For example, lighting candles, putting on soft music, and then they’ll get undressed and each will spend 15 minutes or so giving the other pleasure, not orgasm, but exploring their partner’s body. The partner on the receiving end is to give feedback as to what he or she likes/doesn’t like.

The communication is the key to this exercise. Oftentimes, when you’re caught up in the heat of sex you’re not going to “spoil the moment” by telling your partner what’s working or what’s not working. But this way you’re given the opportunity to really communicate what you like or don’t like.

Also, since the end goal is not about achieving orgasm, the pressure is off.

Q. Are there emotional issues that are specific to men and women? If so, can you explain?  

A. Dr. Marchand: There are some cultural pressures around gender and sexuality that impact how men and women feel about their sexual problems. For women, we’re told to use our sexuality to please others, to be “sexy” and available to our partners, and that’s what it means to be a woman. For men, the cultural script is that they’re supposed to want sex and be able to “perform sexually” at all times, no matter how they’re feeling. So sexual problems leave men and women feeling like they’re not measuring up, in slightly different but parallel ways.

That said, I think men and women tend to experience similar emotions but might respond to them differently. With sexual pain, anyone—male or female—could feel sad, anxious, worried, frustrated, and/or embarrassed.

But how they respond to their emotions is influenced by a lot of things, including gender. Whether it’s more a biological difference or a learned difference is up for debate, and in reality it’s probably a bit of both. Some of the classic differences I see are men tending to cope with emotions by keeping them inside and distracting themselves, while women tend to be more inclined to get relief by talking about their feelings.

Q. When pain with sex is driven by a physical issue, and that issue resolves, can emotional issues continue to linger?

A. Dr. Marchand: You bet. In some ways there’s a habitual nature to emotions. If your experience with sex has been “try sex -> feel pain -> feel anxiety” then you learn to associate sex with anxiety. There’s a saying that “neurons that fire together, wire together.” That means that our brains are very good at building connections between events and emotions that seem important together.

Therefore, if sex and anxiety or sadness co-occur often enough, our brains will “help us out” by strengthening that connection so it’s more automatic. Next time we encounter sex, our brain says, “Nope! Remember, that’s terrifying.” So even when the pain is gone those emotional associations with sex may remain. Luckily though, we can re-learn those patterns.

Equally important are the behavioral patterns that tend to linger after pain is gone. We all develop patterns and routines to minimize distress when we live with a chronic issue, whether it’s pain or depression or a bad relationship. Our patterns and routines are designed to protect us from the worst of it, whatever our issue is.

So with sexual pain, someone may have begun to avoid sex, to carefully control sex, or to grit teeth and get through sex without expecting pleasure. If someone has maintained these patterns for a while, the patterns become well learned and don’t automatically change when the pain goes away. Again though, we can become aware of these patterns and choose to do things differently.

Q. Can you discuss some of the ways that you can help men or women who have emotional issues surrounding pain with sex? 

 A. Dr. Marchand: One of the things I work on with clients is to distinguish emotions from thoughts or beliefs about their situation. For example, pain may lead you to feel sad and worried. Those are emotions. From that place, it would be understandable to think, “I’m so sad. This is hopeless.” Hopeless is a thought, or a prediction, about what it means to feel so sad and what’s going to happen. But it’s not that helpful. It makes you sadder to think that things are hopeless. Being able to feel sadness without concluding that things are hopeless is a much more helpful skill.

Another thing we work on is de-personalizing difficult emotions to take away some of their power. For example, we’ll often say, “I’m sad” or “I’m anxious” to describe a feeling we’re having. There’s something very personal about that, like the feeling is part of us instead of something we’re experiencing. Instead, we might say something like “I’m feeling some anxiety right now.” That feels less personal and pervasive and permanent. We might also describe what that anxiety feels like, how intense it is, what it “looks” like, how big it is, etc. This gives us some perspective and control where the feeling is concerned. Being “a person experiencing anxiety” feels very different than being “an anxious person.”

This really helps with another tool, which is feeling difficult emotions but still doing what you value. A lot of times we think we should be free of anxiety or sadness before trying things, e.g., “Once I don’t feel so anxious I’ll start having sex again.” This can be a trap that keeps us from getting back to our lives. Instead, we might work on how to feel that anxiety and still have some sex anyway, if that’s what you want.

Finally, I really work with people on being friendly to themselves and allowing themselves pleasure and comfort and the best conditions for success. Often we push ourselves to hurry and get better or berate ourselves for our problems, but it’s usually more helpful to learn to talk to ourselves as a supportive friend would. I try to help people do this.

Q. Lastly, can you recommend some resources that are available for those dealing with emotional issues around sexual pain?

There are lots of great books out there! Here are a few of our favorites:

Full Catastrophe Livingby Jon Kabat-Zinn, which is about a mind-body program for living with pain.

  • When Things Fall Apart by Pema Chodron, which is about dealing with negative emotions without getting overwhelmed by them.
  • When Sex Hurts by Andrew Goldstein and colleagues is great for information about sexual pain.
  • The Guide to Getting it Onby Paul Joannides,
  • The New Male Sexuality by Bernie Zilbergeld,
  • and The Elusive Orgasmby Vivienne Cass all offer great insight and strategies for sexual exploration, especially when your sexual functioning has changed.

Plus, different clinics throughout the country offer mindfulness-based stress-reduction classes that are perfect for learning to cope with pain. You can google “mindfulness-based stress-reduction” and your city to find what might be nearby.

And of course, sex therapy and couples therapy can really help with managing sexual pain and the emotions and behaviors that occur with pain. Couples therapy in particular can help you and your partner work through some of the difficulties that sexual concerns bring to a relationship.

If you have any questions at all about the issues discussed in this blog post, please leave them in the comment section below. And to read part one of our sexual pain series, click here.

rose h

Rose Hartzell, Ph.D., EdS, performs psychotherapy and is a sexuality researcher at San Diego Sexual Medicine, where she is responsible for addressing the sexuality, relationship, and intimacy concerns of individuals and couples who attend the clinic. For more information about Dr. Hartzell, check out her website.






Headshot 2012Erica Marchand, Ph.D., is a licensed psychologist specializing in couples and sex therapy in Los Angeles. You can find her online at, on her blog at, or on twitter at @dr_erica_joy.

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