Pain with Sex & How Trauma is the Culprit: Raising Awareness About Women’s Pelvic Health
*Please Note: The author of this blog is a Licensed Professional Counselor and does not have medical training. Please consult your physician for further information on your medical health. It is also important to note that despite the focus of this blog being about the impact of mental health trauma on the pelvic floor muscles with a focus of pain with sex, pelvic floor muscle issues are extremely diverse. Issues with the pelvic floor muscles can be caused by a number of diverse conditions unrelated to mental health. There are many other types of medical issues related to the pelvic floor muscles and how these issues can present. It can also cause a number of other problems in the body unrelated to sex. This blog is also focused on the female pelvic floor muscle conditions, but men can also experience medical problems with pelvic floor muscles.
Sex. What a vulnerable topic to discuss! Many experience embarrassment or shame in discussing sex, even more so when they have problems with having sex. Women experiencing sexual difficulties can have feelings of being broken, unattractive, or unlovable, and it can impact their romantic relationships. Sometimes women even think it is normal to have sexual difficulties or pain with sex. I am here to tell you that you are not alone and you are not broken.
Research has consistently proven the impact traumatic experiences have on our body, even years after the trauma has been experienced. The body’s responses are automatic and are often out of our control or awareness. Sexual intercourse is no different. Any kind of trauma related to sexual intercourse can impact your ability to experience pleasurable sex. This includes childhood sexual abuse, sexual assault or harassment, and ideologies or internalized beliefs about sex (e.g., religious teachings/purity culture, gender stereotypes about sex, etc.) You may be thinking, but my partner isn’t the one who abused me. I love them and I know they are safe, so why would my body respond this way. You are right! Your partner is not the problem. It’s your brain! Our brains are more powerful than we realize. Let me tell you how.
Some education on the brain may help you understand why your body is responding this way, despite your partner not being your abuser. There are three parts of the brain that are right next to each other and are involved in the experience of trauma. The amygdala is the guard-dog of the brain. It assesses threats and signals to our hypothalamus to send the message to fight, flight, or freeze. The hippocampus is our memory formation center where new experiences are initially processed, and then up they go to long-term memory in the neocortex. When someone experiences a trauma, sometimes that trauma can get stuck in the hippocampus and the amygdala is responding as if the trauma is happening again. The amygdala is trying to protect you from experiencing your trauma again. The neocortex (the rational part of your brain), has a hard time convincing the amygdala to calm down. The amygdala doesn’t know what your neocortex knows; that your partner is not going to hurt you. This is why it’s important for the partners of those who have trauma to not take the body’s response to physical intimacy personally. Your traumatized partner trusts you, but their amygdala doesn’t and their body’s automatic response is extremely difficult to control.
Now that we’ve discussed how powerful the brain is and how it is impacted by trauma, let’s take a look at how our brains can influence our bodies by discussing physiological responses to sexual intercourse involving the pelvic floor muscles as a result of trauma.
What even are the pelvic floor muscles? Pelvic floor muscles are almost shaped like a bowl inside the pelvis around the vaginal walls and rectum/tailbone. When we think of strengthening our “core,” we often think of our abdominal muscles, but the pelvic floor muscles are a huge source of our core strength and they are a very important part of many bodily functions. In addition, there are many nerves around the pelvic floor muscles and vagina. Nerves send electrical impulses between your brain and the rest of your body, and nerves are responsible for the movement of muscles and the ability to feel sensations through our skin/organs. Nerves allow us to feel the sensations we feel during sex and are part of the reason why we are able to experience orgasms.
Many people with sexual trauma have general problems with physical intimacy. This can range from avoidance of or discomfort with physical affection, to difficulties becoming aroused or interested in sex, as well as trauma responses or direct triggers related to the initial trauma that lead to a severe aversion to sex. Lack of lubrication can also be a trauma response and a cause of pain with sex. Much of this can be worked through in mental health counseling in doing trauma work. However, as a result of trauma, a very powerful bodily response can happen that may require medical intervention. Pelvic floor muscles can become severely tightened and trigger the respective nerves resulting in incredible pain with sexual intercourse, or make sexual intercourse quite literally impossible due to muscle constriction that prevents insertion.
The recommended treatment for this problem includes a multi-faceted approach, depending on each individual and their unique symptoms. It can include a combination of mental health therapy, physical therapy, and seeing a physiatrist to receive direct medical treatment. Physical therapy can involve not only physical exercises, but also direct physical manipulation of the pelvic floor muscles by a physical therapist. Based on information gathered from medical professionals in interviews, doctors (specifically MDs) are not thoroughly taught about medical issues involving pelvic floor muscles in medical school, that includes OB-GYNs and PCPs. However, Doctors of Osteopathic Medicine (DOs) are taught about pelvic health in medical school due to their holistic approach of the patient and their training in osteopathic manipulative medicine. Unfortunately, pelvic health and wellness, specifically issues with pelvic floor muscles are a specialization focus that requires further training after medical school for MDs and this issue is often neglected in medically assessing women’s health. This is why it is important to research for and consult with physicians that specialize in pelvic health or issues with the pelvic floor muscles for a proper assessment and evaluation.
As my profession is focused on mental health, this next section will focus on the mental health side of treatment. Based on interviews with medical professionals described above, trauma and mental health as a cause of physical ailments is grossly under assessed by medical professionals. If you think that your physical ailments could be related to your mental health, it is important to consult with a mental health professional to explore this while receiving medical treatment. In treating pelvic floor issues as they relate to trauma and mental health, trauma treatments such as Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Processing Therapy (CPT), as well as Cognitive Behavioral Therapy (CBT) are recommended.
Here are some quick tips to get you started, but please seek professional consultation for further information about mental health treatment:
- Tight pelvic floor muscles means that there is tension in your body. It will be helpful to practice relaxation techniques, particularly deep belly breathing to get your pelvic floor muscles to relax and release any tension you have. Yoga, massages, and stretching can also be helpful for releasing tension. What does relaxation look like for you? What about playing that perfect playlist that gets you in the mood, or a warm bath, or soothing touch from your partner? Many women experience pressure to quickly become aroused and have sexual intercourse, but that is simply not how their bodies work. For women, foreplay is very important in becoming relaxed and ready for sexual intercourse. It could be helpful to slow things down to decrease performance pressures.
- Sometimes, assumptions in what we think our partner is thinking or feeling causes disconnection and creates a belief system that is solely based on assumptions. It is important for you and your partner to communicate about your feelings and needs, as well as share positive affirmations for reassurance. What makes you feel loved? What is your love language? What is your partner’s? How can your partner support you and facilitate connection in your physical intimacy or relationship in general? It is also helpful to have physical intimacy and spend intentional time together without the inclusion of sexual intercourse to normalize that an orgasm or sex is not exclusively the goal of physical intimacy. Physical intimacy is an expression of connection and love.
- Do you struggle to stay present during sex? Sometimes, this is a trauma response called dissociation or “checking out” as my clients describe it. Mindfulness practice can be helpful in grounding yourself to the present moment. Often our five senses can be the most helpful in grounding yourself. It could be helpful to light your favorite scented candle or make the bed with your favorite sheets to keep yourself grounded during sex. If you’re looking for more tips on mindfulness, please see the blog on Mindfulness in the blog section of PCS’s website.
- Positive Self-Talk. Shame about being unable to have pleasurable sex can make you get inside your head and psych yourself out of becoming aroused. Internalized core beliefs (e.g., I am broken) can drive your emotions and thinking, and therefore your reactions or behavior. Remind yourself to be compassionate and graceful with yourself. Practice a kind inner dialogue to de-escalate your feelings of distress. Science proves that negative self-talk signals the brain to release stress hormones, such as cortisol and nor-adrenaline, while positive self-talk releases happy brain chemicals, such as endorphins. Cognitive Behavioral Therapy (CBT) utilizes the Four R’s of Thought Stopping: Recognize, Reject, Replace, and Rewire your brain. The more we practice positive self-talk, the more automatic positive self-talk becomes.
- Idealized Expectations of Sex. Have you ever watched a reality TV show or a movie and after a great romantic night together, the couple smashes through the door, undressing each other with passion, and then proceed to have sex right there on the kitchen counter? As we well know by now, “reality” tv shows and movies are not always an accurate representation of reality. Pornography can also impact the way we view what sex “should” be and can also cause feelings of inadequacy. Sexual and physical intimacy looks different for everyone. Helpful tip: You are unique and therefore so is your vision of pleasurable sex. Stop comparing your experience of sex to others’ experience and figure out what works best for you. Don’t be afraid to explore your sexuality and think outside the box!
Most importantly, remember, you are not alone and there is no shame in asking for help. It’s not a sign of weakness or inadequacy. Asking for help is a beacon of strength. As women, we need to work together to raise awareness about pelvic health and trauma, and in the words of Brené Brown, we must answer to “the call of courage” and find empowerment in vulnerability.
Take this assessment to see if you need to consult a pelvic floor specialist:
Physical Therapist (Katy, Texas):
What to Expect for a Physical Therapist Pelvic Health Consultation:
Physiatrist Doctor Group (Locations Across USA) – See website for more educational resources:
Definitions of Medical Terminology:
Pelvic Health Support Group:
CBT Positive Thinking Worksheet – Replacing Negative Self-Talk: