Show the full module text
Module 20 — Pain During Sex
Stop pushing through pain, and find help together.
For one of you, sex has started to hurt, or has always hurt. The other may have stopped reaching out, afraid of causing pain, and the subject has gone quiet. This module walks through a session about pain during sex: how to talk about it, who else can help, and what can stay in your sex life in the meantime.
When sex hurts
Summary: what usually happens in the session
1 Your therapist says nobody pushes through pain. Pain is a reason to stop, at home and in this work.
2 Your therapist asks whether a doctor has examined the pain. A medical check runs alongside therapy, not instead of it.
3 The partner with pain describes it. What it feels like, when it starts, and what has been tried.
4 You map how pain and fear feed each other. The thought before sex, and what the body does next.
5 The other partner says what this has been like. What they have felt, wanted to ask, and may have missed.
6 You agree what comes off the menu for now. And what stays, because closeness does not have to stop.
7 You plan your care team and one small step. Who helps with what, and one thing this week that is not about sex.
One way this session can go, not a script. Your therapist will shape it to the two of you and to their own way of working.
Step 1. Your therapist says nobody pushes through pain
The session is all talk, the two of you at home with your therapist on screen. Pain during sex can affect anyone, of any body. Much of this module is about pain in the vulva, the vagina or the pelvis, because it is what couples most often bring. If the pain is somewhere else, the same conversation applies.
Many people with pain have kept going anyway, sometimes for years: to keep the peace, to feel normal, or because they thought pain was part of sex. Some neurodivergent people learned early to hide discomfort in order to fit in, and that habit can reach into the bedroom. So your therapist usually starts by saying plainly that pain is a reason to stop.
Penetration is optional. The aim of this work is not intercourse. It is safety, comfort, choice and pleasure, for both of you.
If you do not feel safe. This work is for relationships where both of you can say yes, no, wait or stop without being punished for it. If sex has happened under pressure, or if either of you is afraid of the other, tell your therapist on your own. The work on sex pauses while that is looked at.
How your therapist may open. If it hurts, you stop. That holds at home and in our sessions. Nobody in this work is asked to push through pain.
Step 2. Your therapist asks whether a doctor has examined the pain
Pain during sex has many possible causes, and some are physical: dryness, endometriosis, changes after childbirth or surgery, or pelvic floor muscles that tighten without being asked to. If no one has examined the pain yet, your therapist will usually suggest seeing a doctor. That runs alongside therapy, not after it. Pain that is new, lasting or getting worse is worth seeing a doctor about soon.
The names you may hear. Doctors may use words like vaginismus, vulvodynia or genito-pelvic pain. The diagnostic manual now groups several of these under one name, and many clinicians still say vaginismus.1 Which name fits matters less than being examined.
It is often treatable. In one trial for one kind of this pain, most of the women treated improved.2 Treatment often starts with learning how this part of the body works, and with a pelvic floor physical therapist, before anyone tries penetration again. Some problems need a specialist, and your therapist will help you decide which.
The medical question. Has a doctor looked at this yet? If not, that can start now, alongside what we do here.
Step 3. The partner with pain describes it
Your therapist asks the partner with pain three things. What does it feel like: sharp, burning, pressure, tightening, or something else? When does it happen: in the worry beforehand, at the start, in some positions, afterward, or all the time? And what have you already tried, and did any of it help?
Many neurodivergent people find body signals hard to put into words. You can write your answers first and read them out, or choose from words your therapist suggests. Your partner’s part in this step is to listen. Their questions come a little later.
Too much, or pain? In autistic people’s own accounts, touch and the other senses can make sex better or worse, and some sensations are distressing.3 Your therapist may ask whether something feels too strong, too sudden, or actually painful. They can feel alike from the inside, and each needs something different.
Naming the pain. What does it feel like, and when does it start? Use any words that fit. If you are not sure, that is an answer too.
Step 4. You map how pain and fear feed each other
Your therapist may describe a pattern many couples recognize. Expecting pain makes the muscles tighten. Tight muscles make it hurt more. The pain leaves fear of next time, the fear leads to avoiding sex, and the next attempt begins with even more expecting.
The tightening is the body trying to protect itself. It is not done on purpose, and it cannot simply be relaxed away.
This is why pushing through tends to make things worse, not better. Each painful time teaches the body to brace sooner. For many neurodivergent people, not knowing what will happen is stressful in itself, so uncertainty can add to the bracing.
The partner with pain maps their own version. What thought runs through your head before or during sex? What does your body do when it arrives? And what do you wish your partner understood?
Mapping it. What goes through your mind when it seems sex might happen? And what does your body do then?
Step 5. The other partner says what this has been like
Then it is the other partner’s turn. Your therapist asks what it has been like to watch this, what you have wanted to ask and have not, and where you think you may have been getting it wrong.
Partners often carry feelings they have kept quiet so as not to add to the pain: guilt, fear of hurting the person they love, loneliness, or feeling turned away. Some have stopped touching altogether. Both experiences are real, and neither of you is the problem.
You can always say it. If any of this starts to feel like too much, you can say I am uncomfortable. That is a complete sentence. Nobody has to explain it or defend it. We stop, we look together at what is happening, and we decide as a group whether to stay with it or to understand first what is getting in the way.
Saying where you may have been getting it wrong, or hearing it, is often the hardest moment in this session. It is a step toward each other, not a judgment of either of you.
Your turn. What have you wanted to ask, and not asked? This is a good place for it.
Step 6. You agree what comes off the menu for now
Together you sort three things: what is off the menu for now, what stays on it, and what might be worth exploring slowly. Many couples take penetration off the menu at first.
Sex without penetration is sex.
Taking one thing off the menu often lets other touch come back, because nobody is bracing for where it might lead.
Anything you try happens at home, only if you have both agreed to it in a session, at the pace of whichever of you needs it slower. The partner with pain sets the timing, and touch happens only when invited. If pain shows up, you stop. Sensate Focus, One Step at a Time describes one slow way to bring touch back later.
Sorting the menu. What would you both like off the menu for now? And what is still there that you would like to keep?
Step 7. You plan your care team and one small step
Last, you talk about who else is helping, or could be. Your therapist works on the fear, the pacing and the relationship, alongside the people who work with the body.
If a first doctor finds nothing, it can be worth asking about a specialist. Pelvic pain is often missed at first.
If the past is part of it. Pain is sometimes tied to earlier experiences. If that is true for you, you can tell your therapist on your own. Nobody is asked to tell that story in a joint session.
Then you each choose one small thing for the week ahead that is not about sex. Some couples go to a physical therapy appointment together. Others choose a non-sexual touch ritual, a two-minute check-in each day, or simply agree that penetration will not be asked for this week.
One small step. What is one small thing you could do for each other this week that has nothing to do with sex?
After the session
The Pelvic Pain Conversation Guide worksheet on our site follows this conversation in writing. The partner with pain fills in the first two parts, the other partner the third, and you fill in the last two together.
The workbook below is for after the session, on your own first. Bring what you notice to your next session, along with anything your doctor or physical therapist has said.
If this is hard to do. If this is too much right now, there is no need to push through. Spend some time with your partner talking about what makes it hard, and share what comes up: grief for the sex life you had or hoped for, guilt, or fear of hurting or being hurt. That conversation is part of the work.
Should we keep trying to have sex if it hurts?
In this work, pain is a reason to stop. Each painful time can teach the body to brace sooner, so pushing through tends to make things worse. Penetration is optional. The aim is safety, comfort, choice and pleasure for both of you, and many couples take penetration off the menu at first while keeping other closeness.
Do we need to see a doctor as well as a therapist?
If no one has examined the pain yet, your therapist will ask you to see a doctor, alongside therapy rather than after it. Some causes are physical. Pain with penetration is very treatable, and treatment often starts with learning how the body works and with a pelvic floor physical therapist. Your therapist will help you decide if a specialist is needed.
Why does expecting pain make it worse?
Expecting pain makes the muscles tighten, and tight muscles make it hurt more. The pain leaves fear of next time, the fear leads to avoiding sex, and the next attempt begins with even more expecting. In the session the partner with pain maps their own version of this, so you can both see it.
What about the partner who is not in pain?
They get a turn too. Partners often carry guilt, fear of causing pain, loneliness or a sense of being turned away, and some stop touching altogether. Your therapist asks what it has been like, what they have wanted to ask, and where they may have been getting it wrong. Both experiences are real, and neither partner is the problem.
Your workbook
Your answers save to this device only - we cannot see a word of what you write. Fill this in after the session, on your own first.
After the session
Answer these on your own first. Your answers stay on this device, so if you share it, your partner may be able to see them. Pick the closest option.
In this work, I am: — The partner with pain, The other partner, We both have pain
Has a doctor examined the pain yet? — Yes, An appointment is booked, Not yet, Not sure
How much does expecting pain shape our sex life right now? — A lot, Somewhat, A little, Not sure
What did we take off the menu for now? — Penetration, Any touch near where it hurts, Nothing yet, Something else, Not sure
How do I feel about that? — Relieved, Mixed, Sad, Worried, Not sure yet
One small step
A few words is enough. If something about safety or the past is part of this, tell your therapist on your own.
One small thing I agreed to this week that is not about sex
One thing I wish my partner understood
Where this comes from
Every source below was checked against the published record. They are grouped by the kind of evidence they are, so the numbers may not run straight down the page — a number points back to where the source is used in the lesson.
Research discussion
The steps in this session come from our clinical work with neurodiverse couples and from our Pelvic Pain Conversation Guide. They have not been tested in a formal trial. The sources below support the reasons behind the steps.
The point about names comes from a commentary by a group of researchers and clinicians1 on the diagnostic manual’s decision to fold vaginismus into a broader category. It is an expert argument, not a study.
The trial behind “often treatable” randomly assigned 70 women with lifelong difficulty with penetration, and their partners, to a short exposure treatment or a three-month wait.2 After treatment, 31 of the 35 treated women reported having had intercourse, compared with 4 of 35 who were waiting. That trial measured success by intercourse; our aim is broader. The treatment was given in person at a hospital by specialist therapists, which is different from our online sessions, and the study did not look at autism or ADHD.
The accounts of sex and the senses come from more than 120 autistic people writing in books, online forums and a survey.3 They show the range of experiences but not how common each one is, and they are not about pain specifically.
Who this research was done with. The studies behind this module, none of them of neurodiverse couples, drew heavily on white, comparatively well-off, English-speaking participants. If your household carries pressures those samples did not — money, immigration, racism, disability, unsafe housing — the practice still applies, but the room you are practicing in is harder. That is the room, not you.
Clinically reviewed by Harry Motro, PsyD, LMFT · California LMFT #53452 · Founder and Clinical Director, Neurodiverse Couples Counseling Center · Clinical supervisor · Updated October 5, 2026
Peer-reviewed research
1. Reissing ED, Borg C, Spoelstra SK, ter Kuile MM, Both S, de Jong PJ, van Lankveld JJDM, Melles RJ, Weijenborg PTM, Weijmar Schultz WCM (2014) "Throwing the baby out with the bathwater": The demise of vaginismus in favor of genito-pelvic pain/penetration disorder. Archives of Sexual Behavior, 43(7), 1209-1213. https://doi.org/10.1007/s10508-014-0322-2 A commentary by researchers and clinicians on the DSM-5 decision to merge vaginismus and dyspareunia into a single diagnosis, genito-pelvic pain/penetration disorder, arguing that the distinct features of vaginismus risk being lost. Limitation: an expert commentary, not an empirical study.
2. ter Kuile MM, Melles R, de Groot HE, Tuijnman-Raasveld CC, van Lankveld JJDM (2013) Therapist-aided exposure for women with lifelong vaginismus: A randomized waiting-list control trial of efficacy. Journal of Consulting and Clinical Psychology, 81(6), 1127-1136. https://doi.org/10.1037/a0034292 Seventy women with lifelong vaginismus and their partners were randomly allocated to therapist-aided exposure (up to three 2-hour sessions in one week at a university hospital, with two follow-up sessions) or a 3-month waiting list. At posttreatment 31 of 35 treated participants (89%) reported having had intercourse, against 4 of 35 (11%) controls, with improvements in coital pain, coital fear and sexual distress; no effects on other aspects of sexual functioning. Limitation: a single specialist center, in-person exposure, a waiting-list rather than active comparison, and no data on neurodivergent participants.
3. Gray S, Kirby AV, Holmes LG (2021) Autistic narratives of sensory features, sexuality, and relationships. Autism in Adulthood, 3(3), 238-246. https://doi.org/10.1089/aut.2020.0049 Qualitative analysis of publicly available narratives from 5 books and 13 online forums (72 usernames) plus 49 survey responses, over 120 autistic people in total, coded deductively against Dunn's model of sensory processing and inductively for further themes. Touch, sight, sound and smell shaped sexual experience in both positive and negative ways; some described distress at particular sensations, others sought more intense sensation or used intimacy to calm and regulate; strategies included talking with partners and using substances to dull sensation. Limitation: qualitative and self-selected; cannot say how common any pattern is.
Further reading
• Neurodiverse Couples Counseling Center (2026) Pelvic Pain Conversation Guide. Practice materials, Neurodiverse Couples Counseling Center. https://www.neurodiversecouplescounseling.com/worksheets/pelvic-pain-gpppd-conversation-guide The practice's structured conversation for couples navigating pelvic pain, in five parts: naming the pain, the fear loop, what the other partner needs to know, what comes off the menu, and the care team with one small commitment. Limitation: a clinical tool developed in use, not a validated instrument.
When sex hurts, help for both of you
The Neurodiverse Couples Counseling Center works with couples where one or both partners are autistic, ADHD or AuDHD, including when sex has become painful. We work alongside your doctor and any specialist, at the pace of the partner with pain, and nobody is asked to push through. Therapy for clients in California, coaching worldwide, all by telehealth. A first conversation costs nothing.
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