Sexual health

Six pages on the parts of sexual health that consultations tend to skip: what desire actually looks like, why sex hurts, why penetration sometimes will not happen at all, and the practical business of contraception and testing.

What this section covers

Four of the pages here deal with things that are not working: low libido, painful sex, vaginismus and difficulty reaching orgasm. Two deal with practical decisions: contraception and testing for sexually transmitted infections.

They are grouped together because they interact. Pain reduces desire. Reduced desire means less arousal, which means less lubrication, which increases pain. Anticipating pain produces muscle guarding, which produces more pain. Fear of pregnancy or infection reduces the ability to relax into anything. Untangling that loop usually means starting with the most physical, most treatable element rather than with the most emotional one.

Why so much of this goes unreported

Sexual difficulties are among the least reported symptoms in general practice, and the reasons are consistent across surveys: embarrassment, the belief that nothing can be done, the assumption that the problem is psychological and therefore not a medical matter, and previous experience of being dismissed.

The last of those is the most damaging, because it is often accurate. Pain during sex has historically been under investigated, and conditions such as endometriosis, lichen sclerosus and vulvodynia are diagnosed years after symptoms begin. That is a reason to be specific and persistent at an appointment, not a reason to stay away from one.

Specific means describing where the pain is, when it started, whether it happens at entry or deeper, whether it happens every time, and what has already been tried. Those four pieces of information narrow the possibilities considerably, and a clinician who has them behaves quite differently from one who has been told only that sex is uncomfortable.

Physical first

A useful principle for anything in this section: rule out or treat the physical before concluding that the problem is in someone's head. Dryness, skin conditions, infection, pelvic floor overactivity, scarring after birth, and the effects of common medications are all straightforward to identify and treat, and all of them can present as a loss of interest in sex.

That is not a claim that psychological and relational factors do not matter. They matter a great deal, and for many people they are the main event. But they are much easier to work on once penetration does not hurt, and much harder to assess accurately while it does.

Desire is not a fixed quantity

A recurring theme in this section is that desire behaves differently from the way it is usually described. The idea that desire arrives first and then arousal follows fits early relationships and fits many men reasonably well. For a large proportion of women, particularly in long term relationships, it works the other way round: something pleasant begins, arousal builds, and desire appears afterwards. Waiting to feel spontaneous desire before starting can mean waiting indefinitely, and interpreting its absence as a problem creates one that was not there.

Practical matters

Contraception decisions change through life, and the method that suited someone at twenty five is often not the method that suits them at forty two. Perimenopause complicates it further, because fertility falls but does not end and some methods also help with heavy bleeding.

Testing is simple, largely self collected, and available without a general practitioner in most countries. Most sexually transmitted infections cause no symptoms at all, which is the entire reason routine testing exists.

When to stop reading

Any of the following justifies an appointment rather than another page: pain that is new or worsening, bleeding after sex, a lump or ulcer, a changed discharge with pain or fever, pain that persists after treating dryness, or any symptom that has lasted more than a few weeks without explanation.

Last reviewed: September 2026