The Cycle of Pain, Fear and Tension
In this article, I would like to address all women who have experienced at some point in their lives that their body seems to resist intimacy and says “no.” When sex is painful, our body may close down, and in that moment we often have no conscious control over it ourselves.
I would like to illustrate the cycle of pain, anticipatory anxiety and tension, while attempting to find a way into the complex phenomenon of painful intercourse that can lead to pain relief and the resolution of the problem.
Pain-free sex is possible. Pain during sex is not inevitable!
Painful Intercourse Is Still a Taboo Subject
When sex is painful, the subject often remains unspoken, because pain during sex is still a taboo subject. Pain during sex is common—but it is not normal simply because it is common.
Women affected by this often do not dare to talk about it and accept the pain as an unavoidable fate. In counseling, they may then complain that they have lost their desire for sex, while at the same time wishing for a solution to what they perceive as their lack of desire.
But it does not have to remain that way! In this article, I take a closer look at the subject of pain during sex and explain how it can best be approached from a sexological, interdisciplinary perspective.
I will explain important facts and provide information and suggestions for reflection that are often conveyed neither by gynecologists nor by couples therapists. They may approach the problem primarily from a medical perspective and focus on a somatic condition—for example, an infection of the urogenital tract—or they may fail to take the physical aspect sufficiently seriously and focus their attention primarily on the person’s history and relationship dynamics.
Pain During Sex Requires a Sexological, Interdisciplinary Approach in Order to Be Comprehensively Assessed and Treated
As a sexologist, I have learned to consider both sexual-medical causes—that is, somatic conditions requiring medical treatment—and physical aspects, such as the person’s learned mode of sexual arousal, psychological factors related to their personal history, and dysfunctional relationship dynamics.
This multidimensional perspective makes it easier to develop an individually appropriate solution. Pain-free sexuality can then become possible again.
Sexual Pain Is Common—but the Numbers Vary
Pain or discomfort during sexual intercourse is common among women. However, prevalence figures reported in studies vary considerably.
This is precisely why it is important to distinguish between occasional pain, recurrent pain, and a clinically relevant sexual pain disorder.
Sexual Pain Can Have Very Different Causes
The term “dyspareunia” refers to pain associated with sexual activity or penetration and comes from Ancient Greek, roughly meaning “having the wrong bedfellow.”
A wide range of physical, neurophysiological, muscular, psychological and relational factors may underlie such pain.
Possible medical causes include, for example, Genitourinary Syndrome of Menopause (GSM), vaginal or vulvar dryness, skin conditions such as lichen sclerosus, vulvodynia or vestibulodynia, or endometriosis.
Such conditions require appropriate medical diagnosis and treatment.
At the same time, other aspects are relevant in order to take into account the different levels that are important for sexual health: the physical, mental, emotional and social or relational levels.
What Does the Current State of Sexological Research Tell Us?
Pain during penetration is initially a symptom, not yet an explanation of its cause.
This is a crucial point. If a person experiences pain during penetration, this initially tells us only that pain is occurring. The question of its cause needs to be considered separately.
An Example Makes This Clear
Imagine a person who experiences severe pain during vaginal intercourse.
Case A: A Clearly Physical Cause
The pain may be caused, for example, by endometriosis, a bladder infection, significant changes in the mucous membrane, or another physical condition.
In this case, the pain is initially a symptom of a physical condition.
The person may very well experience desire, become sexually aroused, feel safe and have no particular fear of penetration. Nevertheless, penetration is painful because of the physical cause.
In this situation, medical diagnosis and treatment of the underlying condition are initially the priority.
If the physical cause is successfully treated, the sexual pain may also disappear. However, this does not necessarily happen, because additional factors may develop over time that maintain the symptoms.
Case B: A Multidimensional Problem
In another person, no sufficient physical explanation for the problem can be found.
For example, they may expect pain, be afraid of penetration and already react to an attempt at penetration with strong involuntary pelvic floor tension. As a result, penetration may become difficult or painful.
This is not simply a matter of “something being physically damaged and therefore causing pain.”
Rather, it involves a complex pattern of penetration difficulty, pain, anticipatory anxiety and/or muscular reactions. It is precisely this combination of different aspects that is also taken into account in the current classification of sexual pain-penetration disorders.
But It Is Not That Black and White
In the reality of women experiencing pain during sex, the different levels often overlap and influence one another.
Here is an example:
A woman has a bladder infection. As a result, she experiences pain during penetration. During the next intimate encounter, she may develop anticipatory anxiety about experiencing pain again. This anxiety may in turn contribute to involuntary tension in the pelvic floor. Increased muscle tension can make penetration even more difficult or painful.
In this case, the problem may begin with pain caused by a physical condition. Subsequently, however, a complex pain/fear/muscle pattern may develop that maintains or intensifies the original problem.
Therefore, the question is not simply: “Is the cause physical or psychological?” Rather: “Which factors are currently causing, maintaining and intensifying the problem?”
This is a very important distinction. Symptoms, causes and maintaining factors must not be confused with one another.
And this is precisely where purely medical treatment—or, conversely, purely psychological support—can reach its limits. An interdisciplinary sexological approach makes it possible to consider the problem holistically and to identify the steps needed to address it on an individual basis.
For example, a person may have a physical condition and subsequently develop pain during penetration. This may lead to anticipatory anxiety, which manifests physically as pelvic floor tension. This, in turn, may cause further pain. The original physical cause does not necessarily explain the entire current symptom picture.
Conversely, in a person with pelvic floor tension, one should not jump to the conclusion: “It is psychological.” The muscular response may, for example, be a protective reaction to actual pain that will likely disappear once the underlying condition has completely healed.
Pain Is Not Merely a Signal From the Tissue
A pain sensation does not arise simply because damaged tissue “reports” a signal to the brain.
Rather, the experience of pain emerges through the processing and evaluation of different types of information throughout the nervous system. Both peripheral and central pain processing may play a role.
This is why processes such as sensitization and altered central pain processing are increasingly being investigated, particularly in chronic genital pain. (2)
This does not mean that the pain is “psychological” or imagined. On the contrary: the experience of pain is real. However, its development and persistence cannot always be explained solely by the extent of tissue changes.
In chronic pain, a negative cycle can also develop in which different factors influence one another: the nervous system may become more sensitive, attention to bodily signals and anticipatory fear of pain may increase. Under certain conditions, persistent protective muscle tension may also contribute to maintaining or intensifying pain.
Pain should therefore not be understood as a purely physical signal, but rather as a complex experience involving multiple levels: tissue, nerves, muscles, central pain processing, emotions, attention, learning experiences and relational context.
And Now: What Do We Do With This?
A biopsychosocial approach means not reducing the problem to a single level.
In my sexological work based on the Sexocorporel approach, I therefore consider, in addition to the biological and medical level, other aspects of sexuality:
- Physical level: How has the person learned to use their body in sexuality?
- Mental level: Which cognitive conditioning limits the person’s embodiment? Which beliefs, prohibitions or lack of knowledge may contribute to the problem?
- Emotional level: What feelings are associated with the person’s own sexuality—desire or frustration, pleasure or shame and guilt? Which needs are they trying to fulfill through sex? What fantasies and desires do they have?
- Relational/social level: What experiences has the person had in their family of origin? What attachment pattern have they developed? What relationship experiences are they currently having? How stable is the relationship?
- Environment: Which social and, where applicable, religious factors play a role in maintaining the problem?
All of these levels are part of a sexological evaluation and appropriate treatment when persistent pain during sex is present.
The sexological, interdisciplinary approach also includes the necessary medical diagnosis and treatment when a physical condition is suspected.
Arousal Mode and Painful Intercourse
A central role in my work is played by the assessment of what is known as the arousal function and the corresponding arousal mode according to the Sexocorporel approach.
The arousal function is a physiological function based on the innate and involuntary arousal reflex and is associated with changes in the autonomic nervous system and genital blood flow.
Sexual arousal arises through sexual stimuli via different sensory channels, fantasies and memories. The brain coordinates a wide range of physical responses in the process.
What Is the Arousal Mode?
In the Sexocorporel approach, the term “arousal mode” refers to the way people have learned over the course of their lives to physically generate and increase sexual arousal. Movement, breathing, rhythm and muscle tone all play a role. Depending on how these physical resources are used, different patterns can develop.
From a Pressure-Based and Mechanical Mode ...
For example, a high level of muscle tone is used here. Breathing may become shallower, body mobility may become restricted, and the stimulating movements may become more mechanical, repetitive and rapid.
... to a Movement-Based or Full-Potential Mode
Here, a greater range of bodily potential comes into play: different movements in the pelvic and neck areas, flexible muscle tension, different rhythms of stimulation and different breathing patterns.
The Pelvic Floor Plays an Important Role
In women experiencing pain during sex, increased pelvic floor tension may play a role. A tense or painful pelvic floor may be a cause, a consequence, or a maintaining factor of pain.
In body-oriented sexological counseling based on Sexocorporel, specific awareness and body exercises can be used to improve awareness of the pelvic floor and rediscover its mobility and flexibility.
When pelvic floor problems are present, specialized physiotherapeutic treatment may additionally be appropriate.
What Did Desjardins Observe?
The Sexocorporel approach was developed by Jean-Yves Desjardins. His many years of clinical observations led to a model that closely links sexual functioning with the way people use their bodies during sexual arousal.
Within this approach, the physical patterns a person has developed during sexual arousal are therefore examined, as well as whether these patterns can be flexibly modified and expanded.
Through awareness and body exercises, the aim is to rediscover and expand the existing physical potential. (1)
The Pain Spiral
When pain occurs, an already restricted physical pattern may become further reinforced.
For example, if a person has experienced pain during penetration once, the memory of that pain may lead to anticipatory anxiety about the next sexual encounter. This anxiety may in turn contribute to involuntary pelvic floor tension. This can make penetration more difficult or painful.
An individual pain spiral may develop:
Pain during sex → anticipatory fear of experiencing pain again → involuntary tension → renewed pain → increasing avoidance → increased anticipatory fear
It is important to emphasize that this spiral is not inevitable and that not every woman experiencing pain develops it. Rather, it describes a possible mechanism through which pain and anxiety can reinforce one another.
Conclusion
Pain during sex is not an unchangeable fate.
It can be caused by a physical condition. It can be influenced by changes in the mucous membranes, nerves, muscles or pain processing. It can be associated with anxiety, learning experiences, attention and relationship experiences. And it can be maintained by a combination of different factors.
This is why it is often not sufficient to look only for a single cause.
The crucial question is rather: What is happening right now in the body, in the person’s experience and in the relationship—and which factors are maintaining the pain?
Good treatment should therefore begin where the individual problem actually arises and is being maintained.
Sexological, interdisciplinary treatment involves combining different approaches.
Because pain-free sexuality is possible.
Footnotes
(1) These statements should be understood as representing the theoretical and clinical-therapeutic foundation of the Sexocorporel approach. The empirical evidence for individual, specific Sexocorporel concepts should not be equated with the evidence available, for example, for the ICD-11 criteria or for certain medical treatment procedures.
(2) A 2024 review of vulvodynia and endometriosis summarizes the available evidence concerning the possible role of central sensitization. The authors describe indications that changes in central pain processing may play a role in both conditions.
Sources and Further Reading
- Trost L, Rowland D, Meston C et al. (2026).
Definitions, classification, and epidemiology of sexual dysfunction: a consensus statement from the Fifth International Consultation on Sexual Medicine 2024. Sexual Medicine Reviews, 14(2).
The current international consensus paper on the definitions, classification and prevalence of sexual dysfunctions. It also contains the current definition of Sexual Pain-Penetration Disorder and explicitly discusses the differing prevalence estimates for sexual pain.
- World Health Organization (WHO).
ICD-11 for Mortality and Morbidity Statistics – HA20 Sexual pain-penetration disorder.
The ICD-11 lists HA20 as a distinct sexual dysfunction.
- Central Sensitization in Vulvodynia and Endometriosis: What Have We Been Overlooking So Far? (2024).
Obstetrical & Gynecological Survey.
Review of the possible role of central pain processing and central sensitization in vulvodynia and endometriosis.
- Genitourinary syndrome of menopause (GSM): recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024).
Sexual Medicine Reviews.
Current recommendations concerning GSM, vaginal dryness, dyspareunia, pelvic floor activity and the sexual consequences of menopause.
