Sex Hurts. Help!

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It is a relatively common myth that penises can be too large.

As a professional, I can assure you they generally are not.

From time to time I receive a query from a girlfriend wondering if her potential new partner is perhaps too large. One of the perks of having an obstetrician and gynecologist as a friend is you can ask everything — and get informed answers.

I remind them that vaginas have been finely tuned by hundreds of thousands of years of evolution to stretch. If they are interested and if this gentleman is a safe choice, personally and medically, then break out the lubricant and have a ball. If it hurts, stop and give me a call — not immediately, but perhaps the next day.

It is also not uncommon for me to hear about penis size from people I barely know. Once I was out for dinner with my future ex-husband and some people I had never met. When the opportunity presented itself, the woman turned to me, just as I was taking a mouthful of pasta, and said, “We can’t have sex. His penis is just too big.”

It was one of those record-scratch freeze-frame moments, because I can almost guarantee that this man did not miss his calling in the pornography industry. If they both want to believe it is huge, great. But the truth is they probably do not have a size problem; they more likely have a medical condition known as dyspareunia.

“Does it feel like he is hitting a wall?” I asked.

They both looked at me as if I were psychic. I am not. Women for whom tampons and sex are painful because the vagina feels too tight or small almost always have a condition called vaginismus. This means the muscles of the pelvic floor that surround the vagina are inappropriately taut. Typically these muscles relax with sexual stimulation and then contract rhythmically with orgasm. When they are tight it can cause pain with sex, a fit issue and even pain or difficulty with orgasm. Sometimes the pain can be worse after sex.

This woman I met briefly is no different than the patients I have been seeing for 25 years. She has pain with sex, she had told multiple providers, and not only had she never been offered a treatment, but she also had never even been given a diagnosis. The best modern medicine has left her with is internet mythology — and not even vaginal mythology, but penis mythology! This enrages me.

Pain with sex is common; almost 75 percent of women have experienced it. For many, the pain comes and goes and reasons for this transient pain include inadequate foreplay, breast-feeding (which lowers estrogen), infection and other causes.

Pain that is more persistent affects 7 to 22 percent of women, and up to 45 percent of menopausal women and 60 percent of cancer survivors report pain with sex. Pain with sex is up there in prevalence with migraine and low back pain, and yet it is woefully understudied and rarely discussed. The number of articles indexed in PubMed, a search engine for scientific literature, for dyspareunia is 3,694, and the number for erectile dysfunction, one type of sexual problem for men, is 19,796.

Muscle spasm (my dinner diagnosis) is one of the most common diagnoses, but other common causes include nerve pain, skin conditions, low estrogen and endometriosis.

There are psychological factors, but that does not mean that it is in your head. Ever. Sexual trauma can be a factor and start a cycle of pain. If sex hurts, many women begin to anticipate the pain, which increases the pain response and diminishes lubrication and libido. If every time I offered you the finest chocolate in the world I hit you with a hammer at your first bite, you would soon learn to dread and fear chocolate. You may also reflexively flinch at the smell of chocolate, or even when I walked into the room, and lose your taste for chocolate altogether. For some women sexual trauma can also be a factor and start a cycle of pain.

Getting facts ahead of fallacies in medicine is hard enough, but with sex there are many more layers. Most people receive a less than adequate sex education, and many do not learn how to talk about sex. When I ask a woman if she has discussed her pain or her sexual needs with her partner, it is not uncommon for me to hear, “I can’t.” That many doctors do not feel comfortable discussing sex only compounds the issues.

There are also some other solutions:

Addressing the sex itself. Treating pain with sex involves addressing the physical aspects, making sure technique is appropriate, discussing emotional consequences, and, of course, looking at the relationship. If you are deeply unhappy, you may not get the kind of sexual stimulation you need or be able to mount an adequate sexual response. No medical therapy can compensate for not liking your sexual partner.

Lubricant can help many women who have pain with sex, and no, it does not mean there is something wrong. The other myth that I frequently dismantle is this idea that women should achieve some kind of fantasy wetness. I have heard many women tell me that lubricant helps their pain, but their male partner does not like it or judges them for it. That, my friends, is messed up. No one thinks you are less if you need glasses. Some people have always needed glasses, and some of us, ahem, need glasses as we age. Who cares as long as you can see?

Foreplay is part of the sexual response cycle, but what is needed or desired varies greatly from person to person. At the dinner table the gentleman was quick to note that there was “enough” foreplay. I looked at my plate to keep my professional side-eye in check. This is why I always initially see women for consultation without their sexual partners. While foreplay alone rarely cures painful sex, most people actually want more than they are getting, so doubling up on foreplay is good sex hygiene, and, most important, it is fun.

Finding a good doctor. Many women who find the right practitioners will have their pain with sex treated. In addition to a doctor and physical therapist, a sex therapist and psychologist may be helpful. For some women, treatment can be challenging because they may not find the right providers and a few have conditions that are difficult to treat. Some therapies are costly, and others do not fit with the person’s sense of self. Some women have past sexual traumas that have never been discussed or are simply too painful to address, but doing so can go a long way.

Treating pain with sex is incredibly rewarding; it is the only medical condition I treat in which my patient shows up giggling at her follow-up visit. “I didn’t know it could feel so good!” is a common response. Even when we don’t resolve the pain completely, getting a diagnosis can be incredibly validating and many women tell me just being taken seriously is very helpful.

A woman who experiences painful sex is not broken. She has a medical condition, and she is hardly alone.

Dr. Jen Gunter is an obstetrician and gynecologist practicing in California. The Cycle, a column on women’s reproductive health, appears regularly in Styles.