Painful Sex & Genital Pain — Symptoms and Treatment
Photo by Shingi Rice on Unsplash
When I tell people I am a Sex Therapist (intern), I usually get the question— “What do people see you for?”
This question can be answered in a multitude of ways, so much so I think I may write a separate article on what Sex Therapy is, however here is a basic list of issues I tend to deal with most: arguing with a partner, can’t orgasm with a partner, partners have different desires and painful sex.
Painful sex is actually one of the most common issues I work with, and clients tend to be in disbelief when I tell them how normal this is. When sex is painful there may be genital pain that is causing the uncomfortable experience, however, it’s important to understand that there are many layers to painful sex. Due to these many layers, I am going to discuss exactly what the painful sex diagnosis is, what the symptoms are, how normal this is, how to get diagnosed, and who to see for help.
What is Genito Pelvic Pain/Penetration Disorder?
Genito Pelvic Pain/Penetration Disorder (GPPD) is a newer diagnosis that was added to the most recent edition of the DSM-5 (which is a therapist manual for diagnosing). GPPD became the umbrella term that encompassed two diagnoses that were in past editions of the DSM— vaginismus and dyspareunia.
Vaginismus diagnosis required involuntary spasming around the vaginal canal and opening. Many folx who experience this tend to have trouble inserting tampons, toys and may feel that penetration is impossible.
Dyspareunia diagnosis required persistent or recurrent genital pain with sexual intercourse. This experience can happen in both AFAB and AMAB bodies.
Since we have a better understanding of these disorders, DSM-5 updated their diagnosis to the umbrella term, GPPD, to reflect these changes. This understanding was that there was not enough research to support the “vaginal spasms” for vaginismus and that dyspareunia is first a “pain disorder that directly interferes with sex, rather than a psychosexual disorder that resulted in pain” (Meana et al, 2015, p. 191). While we do have the new umbrella term to encompass these experiences, the diagnosis only applies to AFAB bodies due to the current lack of research of AMAB dyspareunia. Due to this, this article will be AFAB focused.
So what is GPPD currently? In the shortest sentence possible, GPPD is a disorder that involves pain and sex.
Symptoms
Difficulty with vaginal intercourse
Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
Diagnosis
According to the DSM5, to have a diagnosis of GPPD, you must have persistent or recurrent difficulties with one or more of the following for a minimum of 6 months:
Vaginal penetration during intercourse.
Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
Additionally, to qualify for this diagnosis, the symptoms must cause significant distress in the individual who experiences it and the disorder must not be better explained by another diagnosis. This diagnosis is also specified by mild, moderate, or severe and whether this has been lifelong or acquired.
Prevalence
You’re probably wondering. WHO experiences this? Like how old are these people, have they had babies, why am I experiencing this so young? Many of the folx I get in my office are people in their mid-to-late twenties. The direct prevalence is unknown, however, there is an approximation that 15% of womxn in North America report recurrent pain during intercourse (Lauman et al. 1999). GPPD can pop up whenever, it doesn’t care what age you are with DSM-5 stating that complaints of painful sex peak during early adulthood and pre/perimenopausal period. Many of the younger folx I have seen are untangling the shame, trauma, and stigmas they experience around sex that are leading to the pain. Some other folx I have seen are rebuilding their sexual life and re-learning desires after a traumatic birth experience and entering parenthood. Paterson et al. (2009) found that there may be an increase in genito-pelvic pain–related symptoms in the postpartum period. GPPD can also strike in older
Treatment
Let’s talk treatment! This is where I would come in as a provider.
Folx start their path to diagnosis and treatment in a variety of ways. Sometimes I’m the first person to learn about the painful sex that someone is experiencing, and sometimes the OB/GYN or PCP might be the first to know. Either way, the first step to diagnosis is letting a provider know that you are having symptoms of genital pain and it is causing you distress.
Step One: go see your doctor, get a physical exam
Ideally, the first provider you should see is your primary care doctor (PCP) or OB/GYN. As stated before, there are many layers to genital pain, and making sure there is nothing medically wrong is the first layer to work through. Once your doctor has confirmed that all your parts are in working order, they may give you a referral to a Pelvic Floor Physical Therapist and a Sex Therapist.
Step Two: pelvic pt appointments
I was absolutely STUNNED when I learned about the magic of Pelvic Floor Physical Therapy. The name describes exactly what it is— physical therapy for your pelvic floor muscles. Getting your pelvic floor muscles to check out is a very important step because the Pelvic PT will determine if you are contracting AND relaxing your muscles appropriately. Did you know you can work out your pelvic floor muscles?
Think Kegels. If you don’t know what Kegels are, it is when you clench your pelvic floor muscles (like when you are done peeing). There is tons of information circulating the internet with motivation to practice your Kegels. However, most of the information out there focuses on the clenching, or contracting, of the pelvic floor muscles. This is great, but it is very important that you also are focusing on slowly releasing, or relaxing, the muscles after the contraction.
When you focus too much on the contraction, your pelvic floor muscles can become too tight and after years of clenching, they have no range to contract within. If your pelvic floor muscles are too relaxed, incontinence can occur. The Pelvic PT can help determine what your pelvic floor muscles are needing and will give you an exercise regimen that is developed just for you.
What to expect at a Pelvic PT appointment:
The physical therapist will begin by going over treatment and consent. Then they may do an internal examination where they might start with an observation of a kegel, a cough, and bearing down.
A kegel involves squeezing or contracting your vaginal muscles as if you were to stop the flow of urine.
Bearing down involves pushing out like you were going to pass gas
Once this observation is done, then they might palpate (feel) externally to see if there are any tight spots, like a knot in a muscle.
Then if agreed by the patient, the therapist using a glove and lubricant will use their finger to internally assess the muscles and ask you to kegel again to determine your strength and endurance. Depending on your history of the therapist’s finding, the therapist might expand upon this short examination. The internal exam is important as the therapist is determining which of the three layers of the pelvic floor need to be strengthened or lengthened.
The therapist will then move onto the Orthopedic Exam (although some therapists do this first). This is where the therapist will run through the muscles and joints in your hips and back and see how you move with a range of motion, flexibility testing, and looking into your strength with manual muscle testing.
Your Pelvic PT will then come up with a course of treatment that will include frequency of visits and at-home exercises.
Step 3: sex therapy, relationship therapy, and individual therapy
Wow, so you’ve gone to the doctor AND you’ve visited the Pelvic PT. Now you’re probably wondering… “now what?”
Well, you’ve tackled two of the layers of genital pain— seeing the doctor for any potential medical issues and seeing the Pelvic PT to determine pelvic floor strength. NOW, you land in an office like mine— a Sex Therapist. What exactly is a sex therapist? A sex therapist practices mental health therapy with the added bonus of knowing how to treat sexual dysfunctions, sexual health concerns, and navigating untraditional relationship structures. So how do Sex Therapists fit into the equation?
A sex therapist’s role in GPPD is a special one. We help unpack the many different layers of genital pain by differentiating your experience within the larger context of your system, meaning— we look at your history, your cultural influences, your relationship, etc. When you land in a sex therapist’s office, the first few visits will be spent getting an in-depth sex history from you. The therapist will get to know your entire past through the lens of your sexuality and family history in order to get a clearer picture of how your current sexual issues have developed.
Once the sex history intake has been completed, you and the therapist will work together to create a treatment that works for you (which looks different for everybody). Treatment will depend on the type of genital pain and whether it’s been lifelong or acquired. Some treatments will include addressing thoughts and behaviors, others will help you navigate past trauma, and some will help you analyze your desires (and some treatments include all these things!). Like I said, your treatment will depend on you. There is no one prescription to help GPPD and it takes time to overcome, which is why the mental health support that a therapist can provide is essential.
The OhNut
A sex therapist may also help educate you on sex toys that may help or ease the experience. One amazing product that helps with deep internal pain (towards the pelvis rather than vaginal opening) is the OhNut. The OhNut is soft, stretchy, and oh-so-comfy, and a simple and convenient way to adjust when penetration feels too deep. Made of 4 interlocking rings, you can customize the depth without sacrificing sensation. Explore adding and removing rings at any time with any position, so that both you and your partner(s) can focus on what matters most to each other. Pelvic MD approved.
GPPD is conquered the best when any partner(s) you have are also involved in the therapy process. This can look like a number of different ways. Perhaps you are seeing your own sex therapist, your partner(s) are seeing their own therapist, and all parties together are seeing a therapist. Having different types of therapists for all individuals and the relationship as a unit will help tackle the problem the best with as much support as possible.
Concluding Thoughts
GPPD has become one of my favorite sexual dysfunctions to work with as a budding Sex Therapist. I think it’s because it’s one of those things where folx tend to think “this won’t happen to me.” There is also a huge assumption that this doesn’t happen to young folx, when in fact GPPD peaks during early adulthood. It’s always rewarding having a twenty-something-year-old sitting in my (virtual) office and I see them breathe the biggest sigh of relief when I tell them how normal it is. It’s even more rewarding the day they come in and tell me that they had a sexual experience that wasn’t painful or are no longer experiencing the pain.
It’s possible to overcome this and I know it can be scary if you are suddenly experiencing it. Trying to think the pain away will only make it worse and may cause further resentment towards sexual experiences (which can lead to further sexual dysfunctions). I hope you learned through this article all the different types of support you can seek and how we are willing to help you. This is a completely normal experience and us provides want you to assist you in having a pleasurable experience in your own body.