Why does sex hurt?
For women and people with vulvas and vaginas, painful sex is far more common than most people realise — and it's rarely spoken about. Many of my clients have quietly put up with pain during sex for years, assuming it's just how their body is. It isn't. Painful sex almost always has an identifiable cause, and most causes respond well to the right support.
The umbrella medical term for painful sex is dyspareunia, and it helps to think about it in two broad categories: pain at the entrance of the vagina, and pain felt deeper inside. They tend to have different causes, so noticing where and when you feel pain is useful information — both for you and for anyone supporting you.
Vaginismus: when penetration feels impossible
The most common cause of painful sex I see in my practice is vaginismus - an involuntary contraction of the pelvic floor muscles around the vaginal entrance. It exists on a spectrum: for some people, nothing can be inserted at all, not even a tampon or a finger; for others, smaller objects are manageable but penetrative sex isn't possible. It can also be context-dependent, appearing only in certain situations (with a partner but not alone, for example) or in all situations. Crucially, vaginismus is not something you're doing on purpose - it's your nervous system's protective response, and vaginismus can be treated and unlearned.
You may not have vaginismus but instead a hypertonic pelvic floor, where the muscles are chronically tight and need to learn how to release and relax. This often responds well to a combination of sex therapy and pelvic health physiotherapy.
Painful sex during menopause and perimenopause
Sex can also hurt because of vaginal atrophy (now often called genitourinary syndrome of menopause, or GSM). This is a very common cause of painful sex during menopause and perimenopause, when falling oestrogen levels cause the vaginal tissue to become thinner, drier, and less elastic. Similar oestrogen dips can happen after childbirth and while breastfeeding, and with some medications. This is very treatable - your GP can advise on options including local oestrogen and vaginal moisturisers.
A long gap without sex can have a similar effect: without regular blood flow to the vaginal tissue, the walls can become thinner and more fragile, making penetration uncomfortable when you return to it.
Painful sex after having a baby
Painful sex after childbirth is extremely common, and it isn't only hormonal. Scar tissue from tearing or an episiotomy can remain tender or tight long after it has healed on the surface, and recovery from a caesarean can also affect how sex feels. Add in exhaustion, a changed relationship with your body, and the pressure some people feel to "get back to normal", and it's little wonder that returning to sex after birth can be difficult. If sex is still painful months after delivery, you don't have to simply wait it out - support is available from pelvic health physiotherapists, your GP, and sex therapy.
Skin conditions and irritants that cause vulval pain
There are conditions affecting the genital skin and nerves that cause vulval pain, including vulvodynia (persistent vulval pain without an obvious cause) and its most common subtype, vestibulodynia, where pain is felt specifically at the entrance, often on touch or penetration. Lichen sclerosus, a skin condition affecting the genital area, can also make sex painful and needs medical management.
Sometimes the culprit is simpler: irritation or an allergic reaction to perfumed soaps and washes, latex condoms, spermicides, or certain lubricants. If pain or soreness appeared around the time you changed products, that's worth investigating first.
Infections: thrush, UTIs, and STIs
Pain can be caused by thrush, a urinary tract infection (UTI), or a sexually transmitted infection (STI) - all of which need medical treatment rather than therapy. If pain is new, persistent, or accompanied by other symptoms such as unusual discharge, bleeding, or itching, it's always worth seeing your GP or a sexual health clinic first to rule out physical causes.
Deep pain during sex
Deep pain during sex — felt inside the pelvis, often position-dependent or worse with thrusting - tends to have different causes from entrance pain.
Endometriosis is one of the most important and most overlooked. It affects around 1 in 10 women, and deep pain during or after sex is a hallmark symptom, often alongside painful periods, pelvic pain, and fatigue. Related conditions such as adenomyosis, fibroids, and ovarian cysts can also cause deep pain during sex.
Pelvic inflammatory disease (PID) - an infection of the reproductive organs, often linked to an untreated STI - can cause deep pain too, and needs prompt medical treatment.
If you experience deep pain during sex, please don't dismiss it as normal. It's a symptom worth taking to your GP, even if you've been told before that "everything looks fine".
Arousal, desire, and the sex you're actually having
Sometimes pain isn't about the body malfunctioning at all. You may not feel attracted to your partner, or there may not be enough build-up for your body to become fully aroused - the vulva and vagina need time to lubricate, lengthen, and soften before penetration is comfortable. You may also simply not be having the style of sex that works for you. Discomfort is often your body's way of telling you something about the sex itself, not just your anatomy.
Past experiences and trauma
For some people, painful sex has roots in past experiences - sexual trauma, a painful or frightening medical procedure, or earlier experiences of sex that hurt. The body remembers, and it can respond protectively even when your conscious mind feels ready. This is nothing to be ashamed of, and it doesn't mean sex will always be painful. Therapies that work with both mind and body - including EMDR and somatic approaches - can be particularly helpful here.
The pain cycle: why painful sex keeps happening
Whatever the original cause, painful sex often creates its own cycle: pain leads to anticipating pain, which leads to anxiety and muscle tension, which makes the next experience more painful. Breaking this cycle is a core part of the therapeutic work.
How sex therapy can help with painful sex
When you work with a sex therapist, they'll ask detailed questions to understand the root of the problem - physical, psychological, relational, or a combination - and may suggest a medical check alongside therapy. From there, they'll create a tailored plan using psychological and physical tools, including home-based exercises, with the aim of helping you have sex that's comfortable and pleasurable, wherever that's possible.