Women who have pain during sex often hide it from their partners. A recent survey of over 2,000 healthy women aged 14 to 45 confirmed that even when women rated pain during sex as moderate to severe, only 61% discussed the problem with a partner. The researchers turned to feminist theory to explain their findings, suggesting that in Western societies, heterosexual women are still indoctrinated to view sex as primarily for pleasing men, so they place the highest priority on the partner’s satisfaction while normalizing some pain during sex as to be expected and ignored as much as possible. Not surprisingly, women who concealed their pain were also less likely to find their sexual experience pleasurable.
In years of trying to help women avoid or overcome sexual pain after cancer, I have heard these stories from many women whose cancer treatment damaged their vagina, vulva, or pelvis. So many women fear their relationship will crumble, because of changes in appearance from chemotherapy, steroids, or cancer surgery; from difficulty carrying out their daily tasks as mothers and providers of affection and support to the man in the couple; from damaged fertility so that they may not be able to “provide” a biological child for the partner. Some partners already have a history of having affairs outside of the relationship, so that a woman dreads being rejected again. Some women actually encourage a man to “find someone else,” despairing of meeting his sexual needs. Admitting that sex hurts becomes another loss inflicted by cancer and its treatment. It is easier to find excuses for avoiding sex as much as possible.
Yet suffering in silence prevents partners from working together to find ways to avoid or reduce pain. Many women are helped by using vaginal moisturizers and lubricants, but try to hide these sexual aids from the partner—lubing up in the bathroom in secret before sex. Yet even the best lubricant only lasts so long and needs to be re-applied during lovemaking. Lubricants work best when kept by the bedside and slathered liberally onto both partners during sexual caressing—repeat as necessary. Many women have pain after cancer triggered by deep vaginal penetration and thrusting. It is important to find positions that give the woman more control over the angle and depth of penetration with a penis or sex toy, but it is much more difficult to make those changes without a partner’s help. Women may also benefit from a sexual aid like the Ohnut, a set of soft silicone tubes that fit around the base of a man’s penis, giving him sexual pleasure during intercourse but limiting the depth of vaginal penetration for the woman. Trouble-shooting use of a new device takes communication between partners, however. Some women have such profound loss of vaginal size and stretch that penetrative sex may no longer be possible, even with medical treatments like vaginal hormone therapy or vaginal “rejuvenation” with laser or heat devices. Many couples can continue to get great pleasure and intimacy by bringing each other to orgasm with hand caressing or oral sex, but it takes discussion and acceptance to switch from our culture’s traditional model of sex that ends with penis-in-vagina intercourse.
What about less traditional couples, like lesbian women or polyamorous partners? We assume that their communication during sex must be very open, but we have little research to confirm our stereotypes. In fact, many longer-term couples develop a routine way to have sex, with little exploration or discussion of what feels good or what hurts.
Hiding sexual problems is not just an issue for women, however. Over many years of treating men’s sexual dysfunctions, I have come to recognize many parallel situations. A man cannot hide a problem getting or keeping erections, but he can handle it by avoiding sex with excuses like fatigue or lack of desire. Just as women get the message that a man’s pleasure is their responsibility, men are told it is their “job” to supply hard erections. If a man’s body has betrayed him, even when the damage came from cancer treatment, all the better if he finds a solution on his own. I could not count how many times men have told me that they have come to see a urologist or sex therapist without letting a partner know. “I’m going to go home and surprise her!” my patients would say—even when it meant secretly injecting medication into the penis to produce an erection. A few men even did not tell a partner about having had surgery to implant a penile prosthesis. Nowadays a man can get an online prescription to try oral medications like sildenafil or tadalafil which make it easier to “perform,” although sadly they are often ineffective for the severe erection problems resulting from cancer treatment.
Sexual “scripts” that involve pleasing a partner by concealing pain or denying fears of losing an erection are equally toxic for women and men. Trying to solve a sexual problem without a partner’s help is often necessary for people who are not in a caring relationship. Finding someone new to date when you have a sexual dysfunction takes a lot of courage. But if you are part of a couple (or throuple) work instead on your sexual communication skills. Intimacy grows when people share their fears of rejection and imperfections.
This educational material is intended for informational purposes only and is not intended to replace, or substitute for, professional advice, counseling, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a condition. Never disregard professional advice or delay in seeking treatment because of something you have read in this educational material.
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