By Emma McGowan

CW: Sexual assault, sexual trauma

The aftereffects of an assault can last way beyond the assault itself. For many, there is the initial “acute” injury — physical injuries that occur during the assault and persist for a relatively short time after — as well as long-term physical, psychological, and physiological effects. And while every survivor is different, one of those effects may be pain during sex. 

“Trauma can cause painful sex in many different ways, in the sense that your genitals can be physically harmed during sexual assault or even the thought of having sex can really shut people down,” sexual assault and trauma expert, Jimanekia Eborn, says. “Survivors’ bodies might react in ways that don’t allow for penetration. People are trying to ‘do the thing’ but their body is like, ‘No, no — we’re good! We’re not here to receive this!’”

Having a trauma response to a non-traumatic sexual experience is your body’s way of trying to protect you.

These long-term trauma responses to sexual situations are likely caused by dysregulation of the autonomic nervous system, which has two parts: the sympathetic and parasympathetic nervous systems. The sympathetic nervous system produces the “fight, flight, or freeze” response during times of stress, while the parasympathetic responds to help you calm down with the “rest-and-digest” response. 

Your body goes through the sympathetic/parasympathetic response multiple times per day. In that process, there’s something called the “window of tolerance,” which is when your body is able to self-regulate from a normal stressor, like getting cut off in traffic or forgetting to send an important email. The stressor happens (someone cuts you off), your sympathetic nervous system kicks in (you get angry, scared, and flushed as your heart rate goes up), and then your parasympathetic nervous system kicks in (your heart rate goes down, you feel calmer) when you’re out of the immediate danger.

But a traumatic event pushes you past the window of tolerance. You can’t self-regulate anymore and you’re “stuck” in either an overstimulated or under stimulated state. In the case of a survivor of sexual trauma, that out-of-whack nervous system response can be triggered by even thinking about the event. And if you’re in a position that your body recognizes as similar to the situation that traumatized you – like sex – then it might try to protect you by kicking up that autonomic nervous system response again.

A trauma response can present in psychological ways — like crying, a panic attack, or disassociation— as well as physical ones — like genito-pelvic pain/penetration disorder (aka vaginismus and dyspareunia), difficulty getting or staying aroused, and clenched pelvic muscles, to name just a few. For people who have suffered from chronic sexual trauma, like child sexual abuse, the physical results can be chronic and include diffuse pain, abdominal or pelvic pain, and a lower pain threshold, among others.

“As a clinician, I’ve always been aware of trauma being a very common occurrence in people with pelvic pain,” Dr. Ashley Rawlins, PT, DPT, says. “The sympathetic nervous system is the thing that doesn’t allow you to respond. That fight, flight, or freeze response is blocking you, preventing you from learning, changing, and healing.”

Having a trauma response to a non-traumatic sexual experience is your body’s way of trying to protect you. Your body has learned that certain sights, acts, or smells lead to pain, so it responds by cramping up or not allowing anything to enter it or hurting when something does enter it. But the good news is that just as your body learned to respond in this way to sexual situations, so too can it learn to respond in new ways. Here’s how.

Will I ever be able to have sex again?

As a first step toward being able to have pain-free sex again, Eborn recommends not having sex at all! Well, at least not with another person. 

“There are ways that you can figure out for yourself what feels good to you,” Eborn says. “Masturbate. Figure out what your body likes at a low-stakes level. There’s no one else there; you don’t have to feel embarrassed. And if you have a trigger moment and you throw your leg up, you don’t have to kick anyone in the face!”

Relearn what your body likes, which also leads to giving permission to explore and reconnect with whatever your present day needs are.

Eborn recommends trying out toys, both more “traditional” sex toys like vibrators and dildos as well as sensation toys that don’t immediately seem sexual at all. For people with vaginas, another tool that can help — especially if you’re dealing with genito-pelvic pain/penetration disorder — is vaginal dilators.

As for partnered sex, Eborn encourages survivors to talk to their partners about taking certain sex acts off the table, at least for a little while. If penetrative sex is a trigger, explore together to figure out what other sex acts might work instead. 

“Learn what your body likes now,” Eborn says. “Maybe the things we used to love, we hate now. That could be connected to trauma or could be it just doesn’t feel good for our bodies now, even if it felt good before. Relearn what your body likes, which also leads to giving permission to explore and reconnect with whatever your present day needs are.” 

Eborn recommends getting that conversation and exploration going with a Yes/No/Maybe list, which is a list of erotic acts that you and your partner can mark with yes, no, or maybe. It’s a great way to see where you each are at, what sex acts are off the table (at least for now), and where your interests overlap. There are almost as many lists available as there are sexual preferences, but to get started Scarleteen has a great, comprehensive Yes/No/Maybe list and Autostraddle has one that gets deeper into psychological responses as well. 

“No matter what kind of sex you’re having, please lube,” Eborn says. “Lube is your friend. Just lube it down — slip and slide."

What kind of medical treatment can someone experiencing painful sex after sexual trauma get?

Another great option for survivors who are experiencing pain during sex as a result of sexual trauma is pelvic physical therapy. Dr. Rawlins helps her patients first by helping them calm down that over-activated nervous system.

“When someone is coming up very un-regulated or in a trauma state because of their sexual history, we start by recognizing it and teaching coping skills, she says. “It can be as simple as shifting focus away from what’s in their head to getting them to move their body. We’ll do some grounding, like yoga or lying on the floor — literally grounded — and breathing.” 

Dr. Rawlins thinks of the nervous system as a “bell curve of emotions,” starting with a neutral baseline, creeping up to fight or flight, freezing at the top, and then arching back to neutral as the system regulates. Her goal is to get people who are at the top of that cycle back down to the “ground,” both physically and emotionally. “Even something as simple as painting your fingernails can help,” she says. 

After that grounding practice, the other parts of the session vary depending on the patient’s needs. Dr. Rawlins says that it’s not uncommon for someone with sexual trauma to have multiple presenting problems, including but not limited to pelvic pain, bladder pain, IBS, or fecal incontinence. She also sees a lot of cross-pelvic sensitization, where pain or an issue in one area causes problems in another.

“There’s a lot of angry muscles in our pelvis,” Dr. Rawlins says. “They’re locked in, tense, in fight or flight response. They’re the guard dogs to pelvic health, tensing up when something comes too close.” 

Dr. Rawlins works with her patients to teach their muscles that genital touch doesn’t have to lead to pain. She uses physical methods — like pelvic dilating, internal wands, and internal stretching — in addition to the grounding methods mentioned above. Over time, the muscle memory changes and the patient is able to experience sex without pain again.

“Muscle memory can be a friend and a foe,” Dr. Rawlins says. “We usually think about it from a sports or dance perspective. But with dyspareunia and vaginismus, muscles learn to be tight. We want to give that range of motion back to the muscle, which is stuck with bad blood flow, irritated nerves, and a cycle of pain.”

What can you do if you’re afraid that medical treatment is going to re-traumatize you?

If you’re a survivor and you felt all of your muscles clench up at even the description of treatment above, you might be reluctant to get medical treatment for fear of re-traumatization. Dr. Rawlins wants to assure you: That’s totally normal — and totally okay.

“Medical trauma is a real, serious thing,” she says. “Pelvic health practitioners are trained from the beginning to be trauma-informed so as to not re-traumatize patients. It’s foundational to success for pelvic PT.”

Providing trauma-informed pelvic PT includes well-informed consent, which includes telling her patients what the treatment is going to look like, exactly what will happen, and how it will feel. Dr. Rawlins likes to show her patients on a pelvic model and even demonstrate how much pressure to expect by pressing on their arm — with consent, of course. She also makes sure that her patients know that just because they’re giving consent now, doesn’t mean they can’t take it back at any point during the session. 

During that process, Dr. Rawlins also looks for “fawn” responses, which are a common coping mechanism for survivors. Patients might downplay their pain or their trauma, presenting it as less impactful than it really is. 

“They’ll say things like, ‘“I’m fine, it’s fine, everything is fine,’” she says. “Or ‘everyone has pelvic pain,’ which might be true, but doesn’t take anything away from your pain.”

To help patients move away from fawning, Dr. Rawlins might say something like, “I hear what you’re saying, but if I had pain with sex all of the time with my partner, that would be really hard. I wonder what that would feel like and how it would affect me emotionally or socially.” That takes the pressure off the patient and helps them talk about the issue while skirting some of the more difficult feelings.

Eborn also recommends going to all medical appointments very prepared. 

“Write down questions before you get there,” she says. “And/or getting a note card that says ‘Yes I have been sexually assaulted, here are the triggers that I know. Please walk me through every step.’ You can train people how to take care of you. And remember that they’re working for you, so ask all of the questions that you need to feel comfortable. It’s not about them — this is totally about you and your body and your understanding of it.”

The impacts of sexual trauma can be vast — and sometimes survivors feel like there’s no way they’ll ever heal. But there is hope. There can be healing.

"I want to make sure that people do know that they’re not alone and that trauma is so common, amongst all of us,” Dr. Rawlins says. “It’s affecting you in real ways. And just because it’s intense and feels big and hard, doesn't mean that there aren’t people out there who want to help and can help — we can work through it together. There’s a lot in knowing you’re not alone that is so healing.”