She tried for years with the same partner without successful penetration; the only other person who knew was him. “I really thought I was the only person in the whole world” with the problem, Fleischacker said. “I just felt very alone and really embarrassed. I felt like I had to do everything I could to keep it a secret and not talk to people about it because it just felt really awkward to explain.”
After learning that a friend of hers had dealt with similar problems throughout her marriage, she finally plucked up the courage to bring it up with her GP. “Her first reaction was, ‘Does your boyfriend know how to have sex?'” Fleischacker said.
Her boyfriend knew how what she told her doctor. Penetrative sex was just too painful for them and they had found other ways to get intimate.
Fleischacker is one of many women in their 20s to 30s suffering from female sexual dysfunction, experts who care for women in that age group said. This is often shocking to many women – and their partners – who grew up thinking that sexual problems only affect older women.
“We make a lot of false assumptions that younger adults have easy, totally satisfying sex all of the time, when the reality is that a lot of people in that age group are struggling,” said Mieke Beckman, a social worker and board-certified sex therapist at the University of Michigan. who works with many women in their 20s and 30s.
“Female sexual dysfunction is a big umbrella term for any sexual health issue that bothers a woman,” said Rachel Rubin, a board-certified urologist with fellowship training in sexual medicine and clinical assistant professor of urology at Georgetown University. It “encompasses sexual health issues like issues with desire, issues with arousal, issues with orgasm, and of course issues with pain,” she said.
Even many doctors don’t recognize that young women can have sexual dysfunctions, Rubin added, largely due to a lack of training at many medical schools and even in specialized residencies such as obstetrics and gynecology or urology.
“There is very poor education when it comes to sexual pain conditions or sexual medicine in general,” Rubin said, especially when it comes to younger women. “Too often [they] They are told that it is all in their heads and that they should have a glass of wine and relax.”
Sara Ann McKinney, director of the Vulvar Clinic at Beth Israel Deaconess Medical Center and associate professor of obstetrics and gynecology at Harvard Medical School, agrees. “Many of the conditions associated with female sexual dysfunction … are too commonly attributed to the postmenopausal condition, but many can actually occur before menopause, and women can go decades before they receive a diagnosis, resulting in years of pain.” [and] emotional suffering.”
A 2008 study found that 24.4 percent of women ages 18 to 44 experienced distressing sexual problems, just slightly fewer than 25.5 percent of women ages 44 to 64. A 2016 study estimated that 41 percent of premenopausal women suffer from sexual dysfunction globally. A large proportion of these women are in pain.
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“We have shown that about 8 percent of women by the age of 40 have vulvar pain that lasts 3 months or more,” Bernard Harlow, a professor of epidemiology at Boston University School of Public Health, whose team looked at pain that was so limited or prevent sexual intercourse, wrote in an email. “In a previous publication examining women aged 18 to 64, we showed that most of the prevalence is concentrated in women aged 20 to 30.”
There are multiple causes of sexual dysfunction in women – multiple factors can contribute to even a given woman. For example, “usually there [are] “Three reasons people experience pain from penetration — at least superficial pain from penetration — hormone issues, muscle issues, and nerve issues,” Rubin said.
Fortunately, good treatments are available. These include oral and topical medications, muscle injections, and even surgery, depending on the condition. These medical treatments are often combined with physical therapy and sometimes sex therapy.
“Realistic expectations are [that] Sex shouldn’t hurt, this treatment should be in a biopsychosocial framework – it’s not all in your head – but what it does to your head is very significant because it causes too much trauma and mistrust of the medical community,” Rubin said said.
Pelvic floor physical therapy, which focuses on the pelvic floor muscles, is a mainstay of treatment for several conditions that affect sexual function, particularly pain. In younger women, therapy often focuses on relaxing the pelvic floor muscles to allow for easier insertion, although this may vary depending on the diagnosis. The therapist will first assess the patient and then provide homework in addition to the work done during the sessions.
Unfortunately, a major problem is the limited pool of pelvic floor physiotherapists. Plus, the cost of weekly therapy appointments can add up.
“It’s a huge expense and I already have an amazing health plan,” said Nicole, 26, who lives in New York and asked that her last name not be used for privacy reasons. Nicole was diagnosed with pelvic floor dysfunction after seeking a second opinion over painful sex. Despite the high cost of her own — sessions cost $200 each until she hit her $2,500 deductible — she’s kept coming back because she’s noticed small but noticeable improvements.
Aside from the price, many women are unaware that these treatment options exist. If they become aware of this, they are often confronted with waiting lists lasting several months due to the shortage of skilled workers.
“I’ve had a lot of patients who tell me, ‘I didn’t even know there were doctors who did that,'” McKinney said. “Maybe you don’t have internet access at home and you can’t google and get to these blogs that say ‘go to a vulva specialist’. ”
For young women who seek treatment, most can expect significant or complete improvement, doctors and therapists said. “It just depends on what happens and for how long, but with the right overlap of medical and physical therapy care, many of our patients are completely pain free,” said Stephanie Prendergast, pelvic floor physical therapist and co-founder of the Pelvic Health and Rehabilitation Center. “They do what they want. It’s terrible that many women suffer for so long. … I can’t stress enough not to give up.”
A 26-year-old woman living in DC who asked that her name not be used for privacy reasons initially wrote off her excruciating pain as normal for a first sexual encounter at age 20. It would be another four years of suffering before she realized that this wasn’t normal.
“I was just too tight, too dry – just something didn’t work. So I kind of chalked it up to not being in the right environment, with the right person, in the mood,” she says. “But as I continued to attempt penetrative sex with other people in future encounters, I basically had the same problem.”
When she first raised the issue with a doctor, she told her to use more lube and proceeded with the visit. Eventually, her pain became so debilitating and isolating that she avoided sex.
“I just had such a negative association with sex, talking to a partner about the possibility of sex — I just didn’t talk to partners about the possibility of sex because it was like this secret that I knew didn’t happen would work, but they didn’t know it yet,” she said. “It’s frustrating to feel like relationships weren’t progressing or ending because of this thing that was really out of my control at the time.”
Eventually, at the age of 25, she went to a new gynecologist who diagnosed her with pelvic floor muscle dysfunction and referred her to pelvic floor physical therapy. After months of treatment and home exercises, she finally felt comfortable dating again. The now 26-year-old has been with her boyfriend for 11 months and regularly has pain-free sex.
The gynecologist “was super reassuring and has been to this day [she] is the best doctor I have ever seen and I told her so. I was like, ‘You really changed my life,'” she said.
Netana Markovitz is an intern in internal medicine at Beth Israel Deaconess Medical Center/Harvard Medical School in Boston.