Not having sex because you have a headache is one thing, not trying that new position you saw online because it’s a bit tough to get your legs to bend like that is another. However, living with complex and persistent pain most days of the week falls under what is medically defined as chronic pain. 

Chronic pain has a massive impact, with 20% of those over the age of 45 having chronic pain, and an increasing number of younger people living with this daily struggle. Nationwide it affects over 3.2 million people and over 1.4 million of those will suffer depression as a consequence of the daily fight with pain. 

The most common types of pain people experience are: headaches, migraines, neck pain, lower back pain, endometriosis and complex regional pain syndrome or post-surgical pain syndrome. 

While there is no scope to openly and fully discuss each type of pain and the unique mechanisms behind them within this piece, the underlying tenets are the same. The effect on sexuality, intimacy and arousal is similar across all types of persistent pain, with a globally reported reduction in libido and sexual desire, and a fear of physical intimacy or an embarrassment about a lack of physical ability. 

While women are more likely to have complex pain issues, these impacts to sexuality affect everyone across the binary and non-binary gender spectrum and can make finding a partner and maintaining a relationship complex. 

The major areas to discuss under the banner of sex and chronic pain are: physical intimacy, emotional intimacy, arousal, psychological health and relationship management. Here, we’ll break down the physical side of things. 

We have to talk about the management, the medication and how to have a healthy sexual relationship with an uninvited third partner (hello chronic pain, thanks for joining us).

Those people who suffer from chronic pain tend to have an increase in sedentary behaviour and generally suffer from weight gain, which can be associated with a number of regularly prescribed medications and mental health stress. 

Arousal, erectile dysfunction and vaginal dryness are all affected by medication and each needs to be managed independently, having a massive impact on physical intimacy. 

When physical endurance is reduced the body’s ability to regulate and understand pain is completely distorted. Normal and gentle touch can be perceived as painful, creating barriers to a fulfilling sexual encounter.    

Sex is not off the table (the firm surface may even help) when you have chronic pain. It is achievable, and should not be thought of as a once in a while or a special occasions grin-and-bear-it experience. When managed well and when openly discussed it is possible to have a fulfilling sexual relationship with pain.

Sex is not off the table (the firm surface may even help) when you have chronic pain.

So how do we keep the spark alive?

Focus on intimacy not orgasm

This seems like a simple idea, but when developing a new type of sexual relationship or returning to your previous level of sexual activity with pain in the background, it is important to focus on intimacy first and orgasm second. 

Spend time with your partner, utilise mutual masturbation to learn what works, what you can and cannot do and where your limits are. 

As time progresses it is easier to know what works and how you and your partner can find a rewarding sexual relationship by moving the focus away from climax and about the shared experience. 

Soft touch, external stimulation and focus on the other erogenous zones will help to build back confidence. 

If you find a position that works, keep doing it

For people with pain, trying something new can be daunting, ongoing lower back pain may mean you can’t lie on your back, or that kneeling is out. Endometrial pain or post childbirth pain may mean that penetration is not possible. 

If you take all of this into account and are willing to try some different positions or new ways of reaching orgasm, then don’t be afraid to ask for what you know works. 

Examples include seated and supported positions, which work well for those with back pain (finally a use for all the throw cushions on the couch), spooning positions help to reduce penetration depth and doing it in the dark is usually better for those who have recurrent head and neck pain. 

Simple fixes make a big difference and usually once you try it, it becomes a habit to include this position into your repertoire 

Foreplay also becomes more important than ever, and you may find that you achieve orgasm with foreplay more often then sex itself.   

Learn about treatment and management

Medication, doctors and physio visits all can have an impact, not only on libido but also in finding enough time to fit sex in (no one wants to schedule their sex lives around appointments). 

So it is important to talk to your partner and educate them about what your medication does to your body. Explain that after you take it your libido dips or after physio you will be too sore to contemplate any type of physical intimacy. 

Working together to better understand your pain management and cycle will massively help to maintain a healthy sexual relationship. 

If your libido or abilities are affected, it is also important to discuss with your health care team to see if there is an alternative medication that may suit you better. 

Do it yourself

We don’t want to remove all aspects of intimacy and romance, but sometimes what you need is a DIY climax. Sometimes a specific type of pleasure or orgasm only you can achieve and solo is the way to go. 

Don’t feel ashamed by needing to use masturbation and toys to help achieve physical release. This actually goes a long way in teaching your body once again that sex is good, orgasm is good and that it is achievable. It also helps you to develop a list of positions, ideas and ways in which you can work with your partner to rebuild or redevelop your relationship. 

Don’t go it alone

While the previous point was about getting to know yourself, the final point is make sure when you need help you reach out. 

If it is medication management see your GP or specialist. If mental health, depression or anxiety affect you and your performance, speak to a psychologist. If you can’t find a pain-free position or penetration becomes impossible, talk to a physio about modifications that will help. 

The biggest point about not going it alone is to communicate with your partner. Discuss how you feel, discuss your pain, what works, what doesn’t work and new things you want to try. If I can leave you with anything it is to communicate, communicate and communicate.    

This article was contributed by Alex Mackay, a Senior Physiotherapist who specialises in musculoskeletal, pelvic health and pelvic pain at Brisbane’s Ironside Sports and Physiotherapy.  If you want to hear more from Alex you can follow him on Twitter @MackayPhysio.