A sexual difficulty
Painful sex
The pain is real. Medical assessment comes first, and psychological work proceeds alongside it.
It hurts, and from expecting it my body tightens on its own.
Medical assessment comes first
This is the starting point, before any other consideration. Pain during sex has organic causes that are common and treatable: infections, endometriosis, vulvovaginal atrophy, dermatological conditions, the aftermath of surgery or childbirth. In men, prostatitis and frenulum problems.
None of these is ruled out by psychological interpretation. The reference point is a gynaecologist or a urologist, and in many cases that is where the path begins.
The pain is not "in your head"
It is worth saying explicitly, because it is what many people have been told — sometimes within healthcare itself — and what has kept them from asking for help.
Pain is a real experience produced by the nervous system, regardless of where its initial cause lies. That a psychological component participates in maintaining it does not make it imaginary, and does not make the person responsible for feeling it.
The forms it takes
Dyspareunia means pain during intercourse, and it can occur at the entrance or deeper: two pictures with different causes. Vaginismus is an involuntary contraction of the musculature that makes penetration difficult or impossible, and it is neither a choice nor a form of refusal.
The distinction matters because it changes both the medical assessment and the work that follows.
The pain–anticipation–tension loop
Once pain has occurred several times, the body begins anticipating it. The musculature contracts in advance, and the contraction produces or increases the pain it was anticipating.
At that point there is a second problem alongside the first. It is also why pain can persist even after an organic cause has been resolved: the loop has become independent of its origin.
When it enters the couple
Avoidance is the natural and reasonable consequence: things get postponed, occasions reduce, intimacy contracts. The partner often does not know how to behave and is afraid of causing pain, and that worry can add tension rather than remove it.
Talking about it becomes difficult exactly when it would help. A session together, in some cases, is what gets the information moving again.
How the work goes
Alongside the medical path, not instead of it. The psychological work concerns the anticipation loop, the relationship with muscular tension, and gradually reducing avoidance — in agreed steps, never by forcing.
We start from what is happening now, and I ask the questions. Reticence is the norm in this area and it is not an obstacle.
Frequently asked questions
No. Pain is a real experience produced by the nervous system, regardless of where its initial cause lies, and a psychological component participating in its maintenance does not make it imaginary. That said, "it's psychological" is sometimes used as a conclusion when investigations found nothing — and in that case it is worth checking that all the indicated ones were actually done.
A gynaecologist or a urologist, or your family doctor if you would rather start there. Organic causes of pain are common and largely treatable, and they need ruling out first. Psychological work does not replace that step: it proceeds alongside, and the two paths often run together.
No, although it is more frequent in women. In men, pain during sex can relate to prostatitis, frenulum problems or dermatological conditions, and the loop between pain and anticipation establishes itself in the same way. Medical assessment remains the first step either way.
Dr. Giuseppe Iannone — Psychotherapist
FIRST STEP