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Sex and chronic pain


Per­sis­tent pain can impact on mood and on many areas of life such as work, exer­cise and social­is­ing. This leaflet is designed to give advice to peo­ple who have found it more dif­fi­cult or have had to give up sex­u­al activ­i­ty because of pain

It is often a dif­fi­cult top­ic for peo­ple to com­mu­ni­cate about and health care pro­fes­sion­als may not always feel skilled and con­fi­dent in address­ing sex­u­al dif­fi­cul­ties. Those not in a rela­tion­ship may lose con­fi­dence and assume that a roman­tic rela­tion­ship is now out of the ques­tion. Exist­ing rela­tion­ships can suf­fer, par­tic­u­lar­ly if main­tain­ing inti­ma­cy is chal­leng­ing. Stud­ies show that indi­vid­u­als with chron­ic pain are more like­ly to expe­ri­ence dif­fi­cul­ties with sex than those with­out pain, and to be anx­ious about sex­u­al activity.

Myths about sex

Lots of ‘ideals’ or myths about sex­u­al activ­i­ty are con­stant­ly pro­mot­ed by the media (news­pa­pers, mag­a­zines, TV, films etc.). It is real­ly dif­fi­cult not to take these ideals on board and you may hold them as a stan­dard which your sex lives should live up to. Some­times hav­ing these ideas in your head can make main­tain­ing an active sex life along­side chron­ic pain even more chal­leng­ing than it would be any­way. Some com­mon­ly held myths are:

  • Sex should be spon­ta­neous – you should nev­er have to plan it or talk about what you like.
  • Sex should be adven­tur­ous and dif­fer­ent every time.
  • Sex is only for young, beau­ti­ful and able 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.

It is easy to see how these ideas add to the pres­sure which you all feel, to have a ‘per­fect’ sex life. If you are find­ing sex painful, then these myths of how sex ‘should’ be can lead you to feel that it is not even worth try­ing, as you are so far from this ‘ide­al’.

Bad expe­ri­ences with pain

Over time, unpleas­ant sen­sa­tions before or dur­ing sex, or a flare-up of pain after­wards, may mean that, as with any oth­er activ­i­ty, you reduce how often you do it, or avoid it alto­geth­er. If you con­tin­ue to be sex­u­al­ly active, this may be because of wor­ry about your part­ner miss­ing out, rather than because you are enjoy­ing it. The social myths about sex mean that you may not talk to any­one else about this lack of sex, includ­ing your part­ner, and this can feel very iso­lat­ing. Despite the fact that not all cou­ples are sex­u­al­ly active and that these dif­fi­cul­ties are very com­mon in pain, you may feel that you are the only per­son who is strug­gling with this. Keep­ing qui­et about it may mean that you don’t realise that in fact your expe­ri­ences are very normal.

Build­ing up gradually

When sex becomes painful, you tend to avoid it when you can, only approach­ing it when you feel that you ‘should’ or when your part­ner wants to be inti­mate. This leads to an ‘all-or-noth­ing’ pat­tern of sex­u­al activ­i­ty, for exam­ple hav­ing no sex­u­al con­tact for a cou­ple of months and then hav­ing pen­e­tra­tive sex fol­lowed by a severe flare-up of pain. This ‘all or noth­ing’ pat­tern doesn’t usu­al­ly work well for some­one with per­sis­tent pain. A more help­ful approach is to have reg­u­lar sex­u­al con­tact, which doesn’t nec­es­sar­i­ly involve pen­e­tra­tive sex. As well as help­ing your body to get used to sex­u­al activ­i­ty in a way which does not trig­ger a flare-up, it reduces your anx­i­ety and helps you to stay inti­mate with your part­ner rather than avoid­ing any phys­i­cal con­tact. There is a well-estab­lished grad­ed approach to build­ing up sex­u­al con­tact known as ‘Sen­sate Focus’ which works well in reduc­ing your anx­i­ety as well as min­imis­ing the risk of flare-ups. This ‘step-by-step’ approach involves tak­ing your sex­u­al rela­tion­ship back to a lev­el where you feel your pain is man­age­able, stay­ing at this step for a while (for exam­ple, a few weeks), and then mov­ing up to the next level.

Desen­si­ti­sa­tion

Many per­sis­tent pain con­di­tions have ele­ments of ‘hyper­sen­si­tiv­i­ty’. That means that sen­sa­tions which should nor­mal­ly be pleas­ant and nor­mal, such as touch and stretch, can feel painful. We now have stud­ies explain­ing that this can be because of changes in your ner­vous sys­tem and not nec­es­sar­i­ly because you are caus­ing any harm. The good news is that the ner­vous sys­tem is capa­ble of chang­ing the response and the tech­nique used is called ‘desen­si­ti­sa­tion’. For this tech­nique to be effec­tive, it is impor­tant to feel reas­sured that some tem­po­rary increas­es in pain do not mean that it is harm­ful. 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 going to a peb­bled beach and being in pain the first time you run across the beach but grad­u­al­ly, as you do it more fre­quent­ly, the soles of your feet 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.

Med­ica­tion side-effects

Med­ica­tions for pain are some­times asso­ci­at­ed with unwant­ed side effects that can affect sex­u­al desire and per­for­mance. You can dis­cuss this with your GP or pain spe­cial­ist if this is a con­cern. Some­times peo­ple use med­ica­tion to man­age tem­po­rary increas­es in their usu­al per­sis­tent pain, often known as ‘break­through’ med­ica­tion. It can be use­ful to take break­through med­ica­tion pri­or to sex­u­al activ­i­ty if a flare-up of pain is like­ly after­wards, though you must take it as pre­scribed. Devel­op­ing non-med­ical strate­gies for these flare-ups can be very helpful.

Com­mu­ni­ca­tion

As with any activ­i­ty involv­ing some­one else, you need to com­mu­ni­cate to get what works best for you both. This can feel dif­fi­cult whether you are in an estab­lished rela­tion­ship or with a new part­ner. It can feel par­tic­u­lar­ly dif­fi­cult if you ‘buy into’ the myth that sex should always be spon­ta­neous and so nev­er needs to be dis­cussed. To help with com­mu­ni­cat­ing about sex, you may want to rehearse what you are going to say, and in the case of a new part­ner, when you are going to say it. Empha­sis­ing how much you want to be close to them, and that you want to avoid your pain get­ting in the way, will reas­sure your part­ner that you are not using your pain as an ‘excuse’ to avoid sex. If it feels dif­fi­cult to talk, you could con­sid­er show­ing your part­ner this leaflet to read, as a start­ing point for a con­ver­sa­tion. It is dif­fi­cult to com­mu­ni­cate about what you would like with­out know­ing it your­self, so you may want to start the desen­si­ti­sa­tion or sen­sate focus steps described above on your own, so that you know what you can do with­out trig­ger­ing a severe flare-up of pain. You can then involve your part­ner at a lat­er stage.

Pri­ori­tis­ing sex

Like any activ­i­ty which you want to do reg­u­lar­ly, you need to pri­ori­tise sex­u­al activ­i­ty so that it becomes a nor­mal and an enjoy­able part of your life. It is very easy for it to get ‘lost’ in all the oth­er pres­sures of day-to-day life, whether you have per­sis­tent pain or not. You also need to pri­ori­tise the ele­ments of your roman­tic rela­tion­ship which will help you to stay close, such as being affec­tion­ate and spend­ing time togeth­er. Some­times these ele­ments can suf­fer when sex is dif­fi­cult, as there is a wor­ry that any phys­i­cal affec­tion will lead to sex, which will be painful. Com­mu­ni­cat­ing about this so that you can con­tin­ue to be affec­tion­ate often makes a big dif­fer­ence to how close you feel to a partner.

Before sex

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. Self-man­age­ment approach­es can be help­ful here. There may be strate­gies you can use to man­age the pain pri­or to inti­ma­cy, par­tic­u­lar­ly those that help you feel relaxed. You may wish to involve your part­ner in these strate­gies such as hav­ing a bath or show­er togeth­er, hav­ing a mas­sage or lis­ten­ing to relax­ing music.

Man­ag­ing flare-ups

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, as this reduces your anx­i­ety about them. Ide­al­ly you also com­mu­ni­cate this to your part­ner so that they under­stand what you 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 your­self that the flare-up will pass.

Self-help resources:

  • Relate: 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.

Sarah Edwards (Clin­i­cal Psy­chol­o­gist), Katrine Petersen (Phys­io­ther­a­pist in Pain Man­age­ment), Katie Her­ron (Clin­i­cal Psy­chol­o­gist) 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.

If you would like to know more about the sources of evi­dence con­sult­ed for this pub­li­ca­tion please click here.

Sex and Chron­ic Pain © Sarah Edwards, Katrine Peter­son & Katie Her­ron. All rights reserved. Revised March 2019. To be reviewed March 2022. First pub­lished Novem­ber 2017.

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