“Spread your legs,” the gynecologist says.
Jessica, whose real name was protected for privacy, would discover that it was no easier in the office than it was in the bedroom. Laying exposed on her back atop a cold table, she warns the gynecologist that she can’t even use tampons. It’s too painful. As Jessica bends her knees and places her feet in stirrups, she looks up to see what resembles a medieval torture device. Disregarding Jessica’s experience with sharp pelvic pain, the gynecologist takes the metal speculum “and just shove[s] it as hard as she [can].”
“I remember screaming because it hurt so bad, and she completely ignored it,” Jessica says.
This wouldn’t be the only gynecologist who would carelessly fumble around her insides. Jessica, 26, would endure endless medical gaslighting before finding a doctor who would take her pain seriously. Eventually, she was diagnosed with uterine fibroids — noncancerous tumors that grow in and on the uterus — and vaginismus — involuntary tensing and contracting of vaginal muscles to prevent penetration.
Both conditions contribute to a larger issue, dyspareunia — also known as painful intercourse. This recurring genital pain may occur just before, during or after sex. Causes vary, from physical to psychological. Physical factors include injury, infection or underlying medical conditions. Emotional factors include stress, a history of sexual abuse or psychological issues. Studies show that, in addition to experiencing intense pain, those with dyspareunia may develop depression, anxiety, hypervigilance to pain, negative body image and low self-esteem, all of which lead to a diminished quality of life.
For some women with dyspareunia, painful sex is all they’ve ever known. Others, like Emily Clare Elliott, remember times when intercourse was pleasurable. Until just over a year ago, Elliott had a normal sex life. That is until she saw her gynecologist.
Elliott, 26, wanted to swap birth control pills for an intrauterine device (IUD). The T-shaped device is placed inside the uterus, with no anesthetic, to prevent pregnancy. Elliott’s would be “shoved” inside — several times.
“Oh God, it’s disgusting what I went through,” Elliott grimaces. “Her just digging, digging.”
Without offering any alternative options for birth control, Elliott’s gynecologist tried to insert the IUD. This first procedure resulted in a failed attempt, which Elliott described as “very traumatic and invasive.” So, she had to come in again. And again after that, because while the IUD went in during her second appointment, Elliott was in pain. Her body had rejected the IUD, requiring its immediate removal.
“Weeks after that, I was still in pain,” Elliott says. “Everything was painful. If I wore too tight of undergarments, if I was going to the bathroom, and, of course, intercourse was excruciatingly painful.”
After researching her symptoms, Elliott discovered that they fit dyspareunia to a tee. She saw her gynecologist yet again for confirmation. Originally, she went to her doctor looking for a solution to practice safe sex, only to finally leave knowing that her sex life would never be the same.
“[She] didn’t take into account how much damage she was actually doing. As a result of that traumatic event, I had PTSD down there,” Elliott says, pointing to her genital area.
Most women, approximately three out of four, experience pain during intercourse at some point in their lives, whether it’s during their first time having penetrative sex, while pregnant, or when there’s not enough vaginal lubrication. For the majority, the pain is only temporary. But for those with severe symptoms, it can last a lifetime. Still, the bulk of these women do not seek medical attention, nor are inquired about genital pain, leaving dyspareunia heavily unreported.
Although the effects of dyspareunia are far-reaching, the discourse surrounding it is scarce. Sex is taboo. Sexual dysfunction and female pleasure is even more so. Not only is dyspareunia recognized as a neglected research area, but it’s also neglected by society. It has hardly any, if any, sex education, media coverage or pop culture representation. Consequently, those with chronic vulvovaginal pain feel ashamed, isolated and embarrassed by it, and are reluctant to seek treatment or support.
Suffering in silence
Like most women with the condition, Azia To didn’t know what dyspareunia was until she was diagnosed with it.
At 18 years old, To was excited to finally be in a relationship. But when she had penis-in-vagina (PIV) sex for the first time, her butterflies were quickly killed. Sex hurt and insertion burned — a lot. Penetration felt like “hitting a wall.” To’s vulva was on fire, and she was so tight that nothing could go in unless excruciatingly forced. Soon, she could no longer bear PIV sex. So, her boyfriend dumped her.
“I felt like if I couldn’t succeed in this relationship, I couldn’t succeed in another,” she says.
After being left and labeled as a “prude” by her ex, To felt undesirable and unworthy of a relationship, eventually drowning in loneliness. She was an outcast, unable to have sex, use tampons or wear fitted pants without discomfort.
“At that age, in young teen years and going into college, there’s a lot of pressure around hooking up, body count and identifying self-worth, especially as a female, to be desirable,” she says. “I felt like I couldn’t do the one thing that everyone could do in relationships that mattered most at that age. That brought up feelings of shame and judgment and disappointment in myself, not my partner.”
Dr. Colleen Clemency Cordes, a clinical professor and psychologist with expertise in sexual health, mental health and chronic pain, explained why dyspareunia can have negative consequences on intimate relationships and self-esteem, noting that her evaluation is mostly from a heteronormative standpoint.
“As a society, we tend to focus more on men’s experiences with pleasure and sex than we do women’s,” she says.
The societal focus on climaxing, in the context of penetrative sex, overemphasizes the value of sex in men’s lives and underemphasizes the value of sex and intimacy in women’s lives, according to Cordes. Although women’s sexual health is equally important, it isn’t discussed.
“We don’t talk about pleasure for women, but you’re bombarded by commercials for Viagra that focus on the man’s ability to have penile-vaginal intercourse,” Cordes says.
Over time, people internalize external messages like these that prioritize men’s pleasure and dictate what appropriate, good sex looks like. As a result, women may think that to be a good partner means ensuring their partner is achieving orgasms, and that it’s only done through penetrative sex. If dyspareunia prevents a woman from having what external messages say sex should be, then she may feel like she’s failing as a partner.
“All of those messages invariably influence sexual-esteem, which then can influence self-esteem,” Cordes says.
Sexual health goes beyond just sex. The World Health Organization defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”
If a woman is experiencing (or worried about experiencing) pain, or is concerned about being unable to perform a certain way to satisfy her partner, then dyspareunia can prevent all of the other things that allow for sexual health, Cordes says. Having a partner who is inconsiderate or dismissive of pain also takes away from sexual intimacy and connection.
“That can be both emotionally and physically depleting in many ways,” Cordes says.
Penetrative sex is not an obligation, nor is PIV sex the only way to have sex. If dyspareunia puts penetrative sex off the table, then there are other avenues to achieve a positive sexual experience. But a couple has to be willing to explore those solutions.
“If a couple is unwilling to explore opportunities to change their sexual script, to incorporate toys, lubrication, other things like that, then that can, over time, really degrade a relationship because neither person is having their sexual health needs met and then they’re having problems in their quality of life and in their relationship,” Cordes says.
Another issue is communication. When women are embarrassed by their pain or think that it’s normal, then they won’t speak up about it.
“[Dyspareunia] can impact the relationship quality if people aren’t communicating their sexual needs and their sexual experiences,” Cordes says. “We’re also societally not super comfortable talking about sex oftentimes. So, many people don’t feel comfortable saying to their partners, ‘That hurts.’”
To struggled to speak up. It would take two years before she would seek medical help. When she did, she received a grim prognosis.
Doctors initially dismissed To’s concerns, and she was misdiagnosed four times. Eventually, she was diagnosed with vaginismus and vulvodynia — chronic vulvar pain for which there’s no identifiable cause. The gynecologist who diagnosed her told her that she would have a “miserable sex life” before writing down the names of her conditions and saying, “Here, you can do the research. I have another client now.”
“My experience, pain and trauma felt dismissed and invalidated,” To recalls. “He made me feel like ‘it was all in my head’ and that my issue wasn’t important. It was very hurtful, especially when diagnosed with something I had never heard about before.”
A similar thing happened to Elliott. Her gynecologist told her that she had dyspareunia but offered no solutions, only strategies. No recommendations and no referrals. Just sent Elliott on her way, saying, “Here’s some lube, I guess. Good luck.” Even now, Jessica’s doctors also shrug and say, “We think that’s what you have. Here’s a label, hope it works.”
Now 24, To has done the research, but it wasn’t easy.
After failed treatments and uncomfortable conversations with friends, family and new partners, To realized that she needed to stop attaching her condition to her worth. Feeling bad about herself wasn’t going to fix anything.
“I really had to get used to owning my condition and not feeling ashamed of it,” she says.
In time, To had success with pelvic floor physical therapy, which provides treatments to address dysfunction in the pelvic floor muscles. She additionally found relief using vaginal dilators, which are inserted into the vagina to help stretch tissues and reduce pain and anxiety around penetration.
While To finally knows how to manage her conditions, she also knows that there are countless women who don’t.
“To truly own [her] narrative and release that shame,” To became a sensualist and shared her story with the world.
In 2020, To published her first book, “Tired of Being Tired, Sick of Being Sad,” in which she “inspires women to release themselves from toxic relationships, sexualized body standards and the expectations of others.” In 2022, she began sharing her experience with vaginismus, vulvodynia and dyspareunia on TikTok and Instagram. She aims to increase the accessibility of treatment, awareness and education on chronic vulvovaginal pain conditions so that people don’t “suffer in silence” as she did.
“This condition teaches us a lot about patience, a lot about what we really value in life, a lot about how connected we are to our body and what we’re capable of,” To says. “It just takes time.”
There is no one magic treatment to cure all dyspareunia cases. Every body is different, so treatments vary by individual. But one thing is for certain: Healing isn’t hopeless. Treatment options range from physical therapy, desensitization therapy, sex therapy and more.
“We have all the tools we need to solve the condition for most cases … We are capable and we are worthy of pleasure,” To says.
Yet, most women with dyspareunia aren’t receiving, offered or aware of treatment. The hush-hush nature and societal normalization of painful sex is to blame.
Shifting the narrative
If you were lucky enough to receive sexual and reproductive health education, it was most likely discussed in a functional way in biology class. Students were probably taught how things work, not why or when they don’t. With comprehensive sex education lacking and discourse about sex carrying a stigma, women may be uncomfortable discussing their sex life, whether it’s with a friend, partner or physician.
“My privilege is that I had experience with sex for years before I had this diagnosis,” Elliott says. “So, when this started happening, I was able to be like, ‘Oh, something is different. Something is wrong.’ I had something to compare to. But there’s so many people who don’t have that previous experience to compare to because it’s painful right off the start.”
Experiences with dyspareunia are further complicated when women don’t know there’s a problem to begin with. This is due to the societal normalization of women’s pain. From painful periods to painful intercourse, women are expected to just deal with it. Trivialization of women’s pain starts at a young age, causing women to internalize and accept it. So, women often cope in silence or normalize their own pain, leading to a delay in diagnosis and treatment.
“There’s people suffering and they don’t even know that they’re suffering,” Elliott says.
For her college thesis, Elliott is focusing on dyspareunia.
“There are too many stigmas and taboos around people with uteruses and female pleasure, and I think that we need to stop dancing around this fact because it’s creating gaps in our healthcare system,” she says. “It’s definitely hard when there’s so many stigmas and misconceptions. We’re taught that sex is supposed to hurt and that’s not the truth. So, many women are living in this world with dyspareunia and just think, ‘Oh, this is how it’s supposed to feel.’ In reality, it’s because that’s the narrative they were given growing up. We’re not allowed to ask these questions because then we’re a slut.”
In Elliott’s research, every person she interviewed said that they were taught that sex is supposed to be painful. In her story callout for sources with dyspareunia, she discovered that two of her friends have it. Despite being friends with one of them for more than six years, it never came up.
“Most often as women, it’s after something goes wrong that we start having these conversations that we never thought to have before,” Elliott says. “I never really was comfortable with talking about these topics until I was forced to. I needed answers. Talking with my partner was easy, but I know a lot of people don’t have that privilege where they can open up.”
Just because someone isn’t complaining, doesn’t mean that they’re not in pain. Studies estimate that roughly two-thirds of women distressed by sexual problems don’t seek medical help. Those that do have to initiate the conversation about 80% of the time.
Growing up in a conservative, Christian area, Jessica was continuously told that pain is the norm, but pleasure is not.
“I feel like I’ve been alone in a lot of it, but the one thing I’ve learned is even the people who do experience [dyspareunia], we don’t talk about it,” she says. “We’re not supposed to talk about it. It’s almost expected. I think about the narrative I heard growing up. I grew up in evangelical land. The way that they said, especially with the narrative with sex is, is ‘It’s supposed to hurt. It’s supposed to not be comfortable. It’s normal to feel pain.’ They leave it at that. I wonder now, looking back, how many people actually experience stuff like vaginismus and dyspareunia.”
When anything sexual is deemed impure, there’s an aversion to talking about sex. If women think that a part of their body is inherently wrong, then they already feel shame toward it, according to Jessica. If it isn’t working right, they won’t talk about it because that’s the area they’re not supposed to talk about.
“Even without Christian narrative, in particular for cis-gender women, the narrative around sexuality is still so taboo,” Jessica says. “The thing is that vaginas are sexual organs so therefore anything we discuss about it is taboo.”
The importance of women’s sexual health and well-being is overlooked by the cultural double standard that slut shames women for the same sexual behaviors that it encourages in men.
Dr. Sabrina Baxter, a pelvic floor physical therapist, didn’t know what dyspareunia was or that painful sex is abnormal until she requested a pelvic floor specialty rotation.
“I had no idea that pain with sex was a recurring issue even though I myself had experienced it,” Baxter, 26, says. “I just figured it was something that a lot of women go through, that it was normal and was going to be uncomfortable.”
Baxter also didn’t know what pelvic floor physical therapy was until she pursued it as a career. In fact, most people aren’t aware of its existence. Although it’s not a solution for all women with dyspareunia, pelvic floor physical therapy has been a successful form of treatment for many. But when doctors and gynecologists don’t know or understand what it is, then patients aren’t referred, Baxter says.
When painful sex is thought to be normal for women, and medical professionals grow up thinking the same thing, then efforts to combat it become unheard of.
“You see the narrative,” Baxter says. “All of these different stories are being told over and over again. ‘Don’t call your vagina your vagina, it’s your hoo-ha.’ That creates so much shame and taboo around the area … ‘You have pain with sex, don’t talk about it. That’s weird. You’re abnormal because look at sex on the T.V.’ Sex looks perfect and every girl has an orgasm from penetration, which we know 70% of the population needs clitoral stimulation, but you don’t see a guy rubbing a girl’s clit on T.V. Look at this narrative society pushes on women. Women feel like their problems down there need to be put into this box.”
Now, Baxter runs a podcast, “NO SUCH THING AS TMI,” and a TikTok account where she talks about all things pelvic health related. Awareness about pelvic health issues and treatments is key, she says. But this awareness can only happen if we ignite conversations and shift the decades-long narrative that’s out there about sex.
“Once you’re that person who starts the narrative, you help other people find reasons for their symptoms and problems,” she says. “You could be a source of light for someone else. You could share your story and help someone else.”
It’s time to speak up.