Sex and Chronic Pain
Persistent pain can affect lots of areas of life such as work, exercise, socialising, and mood. This leaflet is for people who find sexual activity difficult or have given up because of pain. People with chronic pain are likely to have difficulties with sex, and to be anxious about sexual activity because of pain. It is often a difficult topic for people to communicate about and health care professionals may not address sexual difficulties or offer help. For people who are not in a relationship, it is easy to lose confidence and assume that a romantic relationship is now out of the question. For people in a relationship, avoiding sex can lead to difficulties in the relationship, and loss of intimacy between partners.
Myths about sex
There are lots of myths about sexual activity in the media (newspapers, magazines, TV, films, etc). These can seem to show what sex ‘should’ be like, and add to the pressures. Some commonly held myths are:
- Sex should be spontaneous – we should never have to plan it or talk about what we like
- Sex should be adventurous and different every time
- Sex is only for young, beautiful, able-bodied people
- Everyone else is having sex frequently – at least three times a week
- If a partner isn’t sexually satisfied, they will look elsewhere for sex and intimacy
For someone who finds sex painful, these myths of how sex ‘should’ be can make them feel that it is not even worth trying.
Bad experiences with pain
Over time, unpleasant sensations before or during sex, or a flare-up of pain afterwards, can lead to less frequent sex or stopping altogether. We may continue to be sexually active to appease a partner, rather than because of our own enjoyment. It is not common to talk to anyone else about difficulties with sex, including our partner, and this can feel very isolating. Despite the fact that these difficulties are very common in pain, we may feel that we are the only person who is struggling with this. Keeping quiet about it may mean that we don’t realise that in fact our experiences are very normal.
Building up gradually
When sex becomes painful, we tend to avoid it when we can, only trying when we feel that we ‘should’ or when our partner wants to be intimate. This leads to an ‘all-or-nothing’ pattern of sexual activity, for example having no sexual contact for weeks or months and then having penetrative sex followed by a severe flare-up of pain. This ‘all or nothing’ pattern usually leads to having sex less and less. A more helpful approach is to have regular sexual contact which doesn’t necessarily involve penetrative sex. Finding sexual activities that do not trigger a flare-up reduces anxiety.
A well-established graded approach to building up sexual contact known as ‘sensate focus’ reduces anxiety and the risk of flare-ups. This ‘step-by-step’ approach involves starting sexual activity at a level where pain is manageable, Staying at this step until confident is important in progressing to the next step, and gradually moving up levels without causing flare-ups.
Persistent pain is associated with ‘hypersensitivity’, meaning that sensations which are usually pleasant and normal, such as touch and stretch, are painful. Studies explain that this is because of changes in the nervous system, not damage to the body. The good news is that the nervous system can be retrained towards a normal response using ‘desensitisation’. For this technique to be effective, it is important to keep in mind that some temporary increases in pain does not result in any real harm. It is possible for a lot of people to gradually build up their tolerance by exploring self-touch regularly. The desensitisation process can be compared to being on a pebbled beach and hurting the first time you run across the beach but gradually, as you do it more frequently, the soles of your feed get used to it – they ‘desensitise’.
Once confidence grows in self-touch, a partner can be involved as long as there is clear communication about what, how long and where touch, stretch and intimacy can be tolerated. For this purpose, sensate focus techniques can be useful as a step-by-step approach to introducing intimacy without the pressure of achieving full penetrative intercourse.
Medications for pain are sometimes associated with unwanted side effects that can affect sexual desire and performance. If this is a concern, you can discuss it with your GP or pain specialist. Some people find it helpful to take painkillers before activities that may increase pain, such as sexual activity and if you do take medication you must take it as prescribed. It can also be very helpful to develop non-medical strategies for these flare-ups, which we will now explore.
As with any shared activity talking about it is the only way to get what works best for both people. This can feel difficult whether we are in an established relationship or with a new partner. It can feel particularly difficult if we ‘buy into’ the myth that sex should always be spontaneous and so we should never need to discuss it. To help with communicating about sex, we may want to rehearse what we are going to say, and in the case of a new partner, when we are going to say it. Emphasising wanting to be close, and to avoid pain getting in the way helps to reassure our partner that we are not using pain to avoid sex. Partners can also be worried about causing pain, and need to know from you what you can manage.
If it feels difficult to talk, we could show our partner this leaflet as a starting point for conversation. It can be difficult to communicate about what we would like without knowing it ourselves, so we may want to start the desensitisation or sensate focus steps (described above) by ourselves, to get to know our body and what we can do without triggering a flare-up of pain. We can then involve our partner when we are ready.
Like any activity which we want to do more, we need to prioritise sexual activity in order for it to become a normal and enjoyable part of life. It is very easy for it to get ‘lost’ in the pressures of day-to-day life, whether we have persistent pain or not. We also need to prioritise our romantic relationship, such as being affectionate and spending relaxed time together. These elements of a relationship can suffer when sex is difficult, as there is a worry that any physical affection will ‘lead to’ sex and pain. Communicating about this so that we can continue to be affectionate often makes a big difference to how close we feel to a partner.
Remember that pain can be ‘wound’ up by several factors including activity, mood, environment and biological changes. Some of these factors may be possible to change and some not. Through self-management approaches for pain, we can manage aspects of life that wind up the pain, including intimacy. There may be strategies you can use to manage pain before intimacy; particular those that help you feel relaxed, such as having a bath or shower together, having a massage, or listening to relaxing music, and involving your partner in these can help you both.
Flare-ups of pain are a normal part of living with persistent pain, and if they happen after sex it is best to have a plan for how to manage them, ideally shared with our partner so that they understand what we are doing. A flare-up plan for pain may involve, for example, having a hot bath, taking pain medication, using an ice pack, doing some stretches, and reminding ourselves that the flare-up will pass.
- Relate: www.relate.org.uk – for online resources and couples counselling, including counselling around sexual relationship difficulties
- Overcoming Sexual Problems – Vicki Ford, 2010 – self-help book on cognitive-behavioural therapy for sexual difficulties (not just pain-related),including details on the sensate focus approach
The authors: Sarah Edwards (Clinical Psychologist), Katrine Petersen (Physiotherapist in Pain Management), and Katie Herron (Clinical Psychologist).
The authors of this leaflet are part of the multidisciplinary team at the Pain Management Centre at University College London Hospital. They deliver self-management support to people with abdomino-pelvic pain (APP) via group programmes and individual sessions. Their work frequently involves supporting people with persistent pain with improving sexual activity and managing relationships, using approaches drawn from established pain management research and sex therapies. Following several years of experience, the authors have presented and published their clinical work internationally to encourage clinicians to facilitate open discussions and offer therapeutic interventions on sexual activity in the context of persistent pain to their patients.
Sex and Chronic Pain © Sarah Edwards, Katrine Peterson, & Katie Herron. All rights reserved. November 2017. To be reviewed November 2020.