Sex & Pelvic Pain

Sex has been a challenge for my partner and me lately. Molly* has been experiencing pelvic pain, which makes sex uncomfortable at best, and really unpleasant at worst.

Molly’s pain has a few different causes. She has endometriosis, which can be really excruciating. In the two decades we’ve been together, she’s had four surgeries for it and while they’ve helped, they’re stopgap measures at best. Her most recent surgery was a few years ago, right after she finished grad school, and the stress of school and managing her pain until graduation set off shingles. If you’re not familiar with shingles, it’s the result of the chicken pox virus taking up residence in your nerves and then expressing itself later. It’s painful no matter where it is on your body, but hers showed up on one of her pelvic nerves and one of the nerves running down her leg. And Molly is super flexible, which means that she gets sprains more easily than most. She’s had ankle injuries and leg injuries, some of which affected her body mechanics and put pressure on her pelvic muscles.

One of the tricky things about the pelvis is that everything affects it. When you move your arms, your latissimus dorsi muscle often comes into play. It attaches on your sacrum, so arm motion can pull on your pelvis. If you hurt your foot, limping can cause your pelvic muscles to work in ways they’re not used to, resulting in spasms. Just as everything in our lives connects to sex, everything in our bodies connects to the pelvis.

Another tricky thing about the pelvis is that the pelvic floor muscles aren’t so well-designed. Four-legged animals have pelvic muscles that are vertical, which means they aren’t weight-bearing. But once humans walked upright, a whole set of fairly small muscles suddenly got asked to carry more pressure than they’re really suited for. They’re some of the hardest working muscles in your body- other than when you relax them to urinate, defecate, or receive penetrative sex, they’re working. Other than the heart, there’s really no other muscle in the body that works so hard. That means that they don’t get much chance to rest and relax.

But that’s not all. Your pelvic floor is also really sensitive to your emotions. When a dog or a cat gets scared, it’ll tuck its tail under. Humans have a similar physiological response to fear, but between walking upright and not having tails, it’s much less visible. Fear, anger, and shame can all cause the pelvic floor to tighten, which can have obvious effects on one’s ability to relax and enjoy sex. Plus, if you try to force or convince your body to have sex in those moments, there’s a good chance that those muscles will tighten further, causing a self-reinforcing feedback loop.

Pain can also create that kind of feedback loop, especially when it’s pelvic pain. So between the endometriosis, the shingles, and the assorted injuries, there are multiple reasons for Molly to have pelvic pain.

Fortunately for Molly and me, this is something that I know about from personal experience. While I don’t have to worry about endometriosis, what with not having a uterus and all, I have had pelvic pain, too. Several years ago, I injured my lower back and spent two weeks on the couch, unable to get up without help. I had another two weeks of not being able to walk upright without pain. And during that time, all of the muscles between my waist and my knees took turns going into compensation spasms to try to stabilize the injury.

I was fortunate to get referred to an amazing chiropractor and to one of the best bodyworkers I’ve ever known. Chester Mainard was one of the original teachers at the Body Electric School and he specialized in pelvic massage. Most practitioners won’t go anywhere near the pelvis, even externally, out of fear that they’ll be accused of sexualizing the massage. But there are muscles that you can’t get to any other way, and there are some that you can only reach from the inside. When those are the muscles that are in spasm, you’re out of luck unless you can find someone who can give them the treatment they need.

There was never anything sexual about it, any more than having Chester work on my neck or feet was sexual. Just as a backrub can be sexual or not, depending on the intention of the giver and the interaction between them and the receiver, pelvic massage can be sexual or not. Trust me- between the pain of releasing a muscle that had been in spasm for months, the different emotions that release evoked (usually fear), and the very clear focus that we both had that this was a therapeutic massage, there really wasn’t any erotic energy in the room.

Having had that experience gives me some understanding of what Molly is going through. It’s imperfect, of course. I’ve never had the nerve pain she had with the shingles, nor have I had endometriosis. But at least it helps me remember that healing pelvic pain is a slow process that needs support and the room to move through its various stages.

So what have we been doing? Molly’s been getting some amazing physical therapy at the Pelvic Health and Rehabilitation Center. For the first couple of months, she needed me to drive her because she wasn’t up for driving home after the session. Besides, it helped to have me hold her hand when it got painful. Things have been improving pretty quickly for her, partly because she does her exercises at home and because she does a lot of yoga. Yoga can be an excellent training in how to mindfully relax and release muscles, so Molly is able to bring her attention to the places in her body that need some help in calming down. And in our last session, I learned how to do some of the techniques that we can do at home.

It’s an amazing thing. There’s no reason to think that the muscles of the pelvis wouldn’t need physical therapy after an injury, just like the muscles of your arm or leg need PT when they’re recovering from something. And yet, there are very few places to get treatment and very little talk about it.

Pelvic pain can happen to anyone of any gender for many different reasons. Injuries from things like car accidents or falling on your tailbone, pregnancy, labor, and childbirth, sexual assault, health issues like endometriosis or prostatitis, or even just straining from chronic constipation can set it off. But many people who experience it won’t tell anyone, not even their doctors or partners. There are different reasons for that, ranging from shame and embarrassment to not knowing how to raise the topic to simply thinking that it’s all in their heads. Plus, a lot of women just learn to expect sex to be painful and try to bear it, rather than speak up about it. And even when they do bring it up, some doctors will suggest a glass of wine to relax instead of exploring medical treatment. Mostly, that’s out of ignorance rather than malice, but it still keeps people stuck.

Making it more complicated, pelvic pain can have some big effects on a relationship. It’s hard for partners to not take it personally. And when someone simply can’t have sex, it’s difficult to remember that unavailability isn’t the same as rejection. Even knowing that from both sides as I do, there are times when it feels like a rejection. Managing those feelings takes a certain amount of emotional intelligence and practice. Between being shamed away from their emotions and not having as many opportunities to learn them, a lot of men in particular lack those skills. Further, chronic pain, pelvic or otherwise, takes a lot of energy to manage. Sometimes, the choice is between the draining effects of the pain or using pain medications, with all of their other effects. Pelvic pain can take a toll.

Fortunately, things are getting better. For me, just seeing that there’s positive movement, even if it’s slow and has ups and downs, makes a big difference in my ability to cultivate patience. It also helps that this has been a journey for the two of us. Even though sex isn’t yet available, the fact that we’re working on this together helps to bring us closer. And I’m fortunate that we have a long history of being in an open relationship, so I can enjoy sex elsewhere. Molly find that helps her to relax and not worry about whether I’m resenting things, so for us, it works. I’m looking forward to being able to have sex with Molly again, but I can wait until that’s possible.

If you have pelvic pain, there are more resources than there used to be. In addition to their hands-on work, the folks at the Pelvic Health and Rehabilitation Center will do phone consultations. My friend and colleague Dr. Heather Howard offers counseling and consultation, both in person and via phone/video. I’d also trust any referral they offer- there are other professionals who address pelvic pain and they know who to trust. Feel free to tell them where you heard about them.

I also suggest that you speak with your doctor about it. If your doctor doesn’t take it seriously, keep trying or see if you can find someone else. Pelvic pain is real and you deserve the medical care you need. You can also check out some of the books on the topic. I think A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes is one of the best places to start.

If you’ve never talked with your partner about it, sit them down and tell them that sex can be painful for you. You might need to try different positions or techniques. You might need a lubricant. You might need medical help. But whatever helps you, it’s important to be able to let your partner know. There might be some problem-solving you can do together. They would get a lot out of A Headache in the Pelvis, too. And remember- it’s not in your head. It’s real and you deserve the care you need to heal.

*not her real name, but she prefers me to use a pseudonym for her