If sex hurts, you are far from alone, and you do not have to just live with it. Somewhere between 16 and 20 percent of women will experience painful sex at some point in their lives, according to Healing Painful Sex by Deborah Coady, MD, and Nancy Fish. That makes it more common than asthma or heart disease. And it isn't only a women's issue. People with penises deal with pelvic pain too, from pain after ejaculation to discomfort that shows up hours after sex.
So why does it feel so lonely? Because most people never talk about it. Plenty of folks wait years before telling a doctor, and some never tell their partner. Many grit their teeth and keep going, hoping it will sort itself out.
Here's the good news. Painful sex is treatable, and the best results usually come from two kinds of specialists working together: a pelvic floor physical therapist and a sex therapist. This post walks through what each one does, how to tell who to call first, and why the combo works so well.
Why sex hurts: your body and your brain are in this together
Painful sex is almost never "all physical" or "all in your head." It's usually both, and each side feeds the other.
On the body side, the pelvic floor is a hammock of muscles, nerves, fascia, and connective tissue that supports your bladder, bowel, and sexual organs. When those muscles get too tight, weak, or uncoordinated, sex can hurt. Common culprits include tight or guarded pelvic floor muscles, irritated nerves, childbirth or surgery, hormonal shifts like postpartum or menopause, and conditions like vulvodynia, vaginismus, endometriosis, or chronic prostatitis/pelvic pain syndrome.
On the brain side, pain is shaped by what we expect and what we fear. As Coady and Fish put it, anticipating pain can make it worse, and so can worrying about it. Once sex has hurt a few times, your nervous system starts bracing before anything even happens.
That's how the pain cycle gets going:
Sex hurts.
You start expecting it to hurt next time.
Your body braces, and your pelvic floor tightens without you realizing it.
Arousal drops, lubrication drops, and tight muscles make penetration more painful.
Sex hurts again, which confirms the fear.
Layer on top of that the guilt ("I'm letting my partner down"), the avoidance (dodging any touch that might "lead somewhere"), and the relationship tension that builds in the silence. Before long, the pain isn't just in your pelvis. It's in your whole sex life. Breaking that loop usually means working on the muscles and the mind at the same time.
When to see a pelvic floor physical therapist
A pelvic floor PT is the body specialist. They're trained to assess the muscles, nerves, and connective tissue of your pelvis, hips, and core, and to help them work the way they're supposed to. Principles and Practice of Sex Therapy notes that physical therapists are the ones best positioned to assess muscle problems like an overly tight pelvic floor.
Consider a pelvic floor PT if:
Penetration hurts at the entrance, deep inside, or is not possible at all
You feel burning, aching, or stabbing pain during or after sex
You have pain with tampons, pelvic exams, or sitting for long periods
Sex started hurting after childbirth, surgery, an injury, or a change in hormones
You notice bladder or bowel symptoms too, like urgency, frequent peeing, constipation, or pain with bowel movements (these can be signs of a tight pelvic floor)
You have pain in the penis, testicles, perineum, or rectum, or pain with erections or ejaculation
What does it actually look like? A first visit usually includes a conversation about your history and goals, then an assessment of posture, breathing, and how your pelvic floor contracts and relaxes. With your consent, that may include an internal exam. You are always in charge of what happens and when, and a good PT will never rush you. Treatment can include hands-on work to release tight muscles and trigger points, breathing and relaxation training, biofeedback, stretching and movement, and gradual work with dilators at your own pace.
When to see a sex therapist
A sex therapist is a licensed mental health professional with specialized training in sexuality, intimacy, and relationships. Sex therapy is talk therapy. There is no nudity and no physical exam, ever. It's a space to untangle the fear, shame, and relationship stuff that so often grows up around pain.
Consider a sex therapist if:
You feel anxious, dread, or panic before sex, even on days it might not hurt
You've started avoiding touch or affection so it doesn't "lead to sex"
Your desire has dropped off, or arousal feels hard to reach
You feel broken, guilty, or like you're failing your partner
You and your partner keep having the same tense conversation (or have stopped talking about it at all)
You have past experiences, trauma, or messages about sex that make it hard to relax
The physical side is improving, but sex still doesn't feel good or safe
In sessions, a sex therapist helps you understand the pain cycle, notice catastrophic thoughts ("it's always going to hurt") and soften them, and build a slower, pressure-free path back to pleasure. That often means widening your definition of sex beyond penetration, so intimacy can feel good again while your body heals. Partners are welcome too. Pain affects both people, and working on communication together can take a huge weight off the relationship.
Why working with both works best
If you read both lists and thought "wait, that's me on both," that's normal. For most people with painful sex, the answer isn't PT or therapy. It's both, at the same time.
The research backs this up. Principles and Practice of Sex Therapy (6th ed., Hall and Binik) describes a multidisciplinary model of care for genito-pelvic pain that most experts in the field now support. The benefits it lists include faster treatment, more engaged patients, and tackling several parts of the pain at once. The book also stresses that treatments work best when they happen concurrently rather than one after the other, so each one can boost the other.
Here's what that looks like in real life:
PT calms the body, therapy calms the alarm system. Your PT can release a tight pelvic floor, but if your brain still expects pain, your muscles will clamp down again the next time you try. Therapy helps turn down that alarm so the physical progress actually sticks.
Therapy makes PT easier to start. Pelvic floor work can feel vulnerable, especially if you have a history of trauma or medical experiences that didn't go well. A sex therapist can help you feel ready for that first appointment and process what comes up along the way.
PT gives therapy something to build on. It's hard to rebuild confidence when sex still physically hurts. As pain eases, therapy can focus on desire, pleasure, and connection instead of just coping.
Your partner gets brought in, not left out. PTs often give partners practical guidance, and therapists help couples talk about it without blame. Together, you get both the how and the feelings.
One of the biggest things both providers do is help you drop the question "is this physical or psychological?" The answer is yes. Once you see your pain as body and mind, treatment gets a whole lot more effective.
Where to start
You don't have to figure out the perfect order on your own. A few simple guidelines:
Get checked by a medical provider if the pain is new, sudden, or comes with bleeding, unusual discharge, fever, or sores. You want to rule out infections or other medical causes first.
Start with whoever feels easier to call. If an internal exam feels like too much right now, starting with a sex therapist is a great first step. If the emotional side feels fine but your body clearly isn't, start with a PT.
Ask about collaboration. A good sex therapist will have pelvic floor PTs they trust and refer to, and vice versa. With your permission, they can talk to each other so your care feels like one plan instead of two separate ones.
Bring your partner in when you're ready. That might be a couples session, or just sharing what you're learning.
Sex is supposed to feel good. If it hurts, that's your body asking for help, not a sign that something is wrong with you.
At Snow Lake Counseling in Logan Square, our certified sex therapists work alongside pelvic floor physical therapists to help clients of all genders and orientations get out of the pain cycle and back to pleasure. We offer sessions in person in Chicago and virtually across Illinois, Wisconsin, Florida, and Oregon, and we accept Aetna, Cigna, BCBS, and United, with sliding scale options available. Book a free consultation or call us at 312-509-3113.
Sources
Coady, D., & Fish, N. (2011). Healing Painful Sex: A Woman's Guide to Confronting, Diagnosing, and Treating Sexual Pain. Seal Press.
Hall, K. S. K., & Binik, Y. M. (Eds.). (2020). Principles and Practice of Sex Therapy (6th ed.). Guilford Press.
Gronski, S. (2020). Pelvic Pain: The Ultimate Cock Block.
Mayo Clinic: Painful intercourse (dyspareunia): diagnosis and treatment
AASECT: Find a certified sex therapist
Written by: Stephanie Franzoni, MA, LCPC, CST