Why Does Sex Hurt? A Psychologist’s Take on Painful Sex

Why Does Sex Hurt? A Psychologist's Take on Painful Sex

Here's something that doesn't get said nearly enough: painful sex is common, it is not your fault, and it is not something you just have to live with.

I've spent 15 years working with women who experience pelvic and sexual pain, and the pattern I see most often isn't a particular diagnosis. It's a person who has been hurting quietly for months or years, who has been told things are "normal" on a pelvic exam, or who has simply never felt safe enough to bring it up. Sexual pain is one of the most underreported health issues there is — not because it's rare, but because the shame around it keeps people silent.

So let's talk about it.

How common is this, actually?

Depending on the study and how the question is asked, somewhere between 10 and 20% of women in the United States experience recurrent painful intercourse (dyspareunia), and lifetime estimates range from 10 to 28% (Harlow & Stewart, 2003; Mitchell et al., 2017). Among postmenopausal women, rates climb considerably higher — some studies put it between 40 and 84% when vulvovaginal atrophy is the cause (NCBI, 2026). Postpartum, around 64% of women report some discomfort at the three-month mark (Loutfy et al., 2022).

And yet most women don't seek help. Many don't even mention it to their doctor.

So why does sex hurt?

There isn't a single answer, which is part of why it's so hard to treat. Sexual pain is almost always multifactorial — meaning there are usually several things going on at once. The causes broadly fall into a few categories:

Physical causes include things like vulvodynia (chronic vulvar pain), provoked vestibulodynia (pain specifically at the vaginal entrance), vaginismus (involuntary pelvic floor muscle contraction), endometriosis, hormonal changes affecting tissue quality, vaginal atrophy, skin conditions like lichen sclerosus, and infections. These are real, diagnosable conditions. They are not in your head.

Physiological and neurological factors matter too. Pain is processed by the nervous system, and chronic pain changes how the nervous system functions. Over time, the pain pathways can become sensitized, meaning the system fires more easily and more intensely than it should. This is why pain that began with a specific cause can persist even after that cause has been treated.

Psychological factors are not the cause of pain, but they are always part of the picture. Anxiety about sex, history of trauma, catastrophizing, hypervigilance to sensation — all of these are associated with increased pain experience and sexual distress (Mitchell et al., 2017). This is not a character flaw. It is how the nervous system responds to a threatening experience.

Relational context also shapes the experience of pain. Research consistently shows that sexual pain is associated with relationship strain, reduced desire, and avoidance — and that the partner's response makes a real difference to how distressing the pain becomes (Bergeron et al., 2014).

The part nobody talks about

There's a concept I use with my clients called the pain-fear-avoidance cycle. It works like this: sex hurts, so you become anxious about sex, so your body tenses up and becomes more reactive, so sex hurts more, so you avoid it, so intimacy erodes, so the anxiety increases. Round and round.

Breaking that cycle requires addressing the physical, the psychological, and the relational at the same time. Treating the physical cause without addressing the anxiety rarely produces lasting relief. Addressing the anxiety without treating the physical cause is equally incomplete. This is why a team approach — pelvic floor physiotherapy, medical management where indicated, and psychological support — tends to produce the best outcomes.

A note on getting help

Most women with sexual pain report that their concerns have been dismissed or minimized by healthcare providers (Reed et al., 2012). If that has been your experience, I want to be direct: it isn't acceptable, and it isn't the end of the road. You are entitled to a thorough assessment and a provider who takes you seriously.

Effective treatment exists. It is not always fast and it is not always linear, but sexual pain is one of the most treatable conditions I work with — and the research supports that. CBT, pelvic floor physiotherapy, and sex therapy all have solid evidence bases for reducing pain and improving sexual function and quality of life (Bergeron et al., 2016; ter Kuile et al., 2009).

You don't need to keep hurting.

If this resonates, my free Pelvic Pain Self-Assessment is a good starting point for understanding your experience before your next appointment. And if you're ready to talk, I offer a free 15-minute consultation — book here.