When Joan Hughes first told her boyfriend that sex was painful, he wasn’t fazed. He knew exactly what she needed to do: Put on a “fun” playlist, try out a few different kinds of lube. It’ll be no big deal, he promised.

“You just need to relax.”

Hughes really wished he hadn’t said that. This pain felt chronic — not something she could wish away with the perfect song and some strategic mood-setting. But when Hughes, 25, from Wichita, finally asked her OB/GYN about it, her advice was maddeningly similar: Do a little deep breathing, try some different kinds of foreplay. She asked Hughes if she’d been particularly stressed lately.

The American College of Obstetricians and Gynecologists estimates that 3 in 4 women will experience painful sex at some point during their lifetimes. It can happen for all kinds of different reasons. Pain during sex could be the body’s response to sexual trauma, or to a new type of birth control. The problem might be vaginismus, when the muscles in the vagina involuntarily contract, or vulvodynia, any kind of burning or irritation around the vulva. It’s also routine for sex to hurt after women go through menopause, when the vagina is likely to feel dryer than it did before. For others, there is no clear reason sex hurts: It just does. (Sex can be painful for men, too, but it’s much less common.)

There is very little research on why sex can be painful for women. Lili Loofbourow broached the subject in a viral 2018 essay for the Week, noting that PubMed lists just 43 clinical trials on vulvodynia and 10 on vaginismus — but 1,954 on erectile dysfunction. Since that piece, there’s been more reporting on painful sex — but considering just how many women experience it, the subject is still woefully undercovered.

Maybe that helps explain why painful sex can be so hard to talk about. I spoke to 16 women who experience pain during sex, for all kinds of different reasons, and heard from 38 more through an online form. Many said they waited months or years before consulting a doctor, and some never have. When sex hurts, “large proportions” of women don’t even tell their partners, according to a recent study.

It’s like this, one woman said: If you had severe pain in your leg every time you walked, or a piercing pain in your stomach every time you ate, you’d probably go right to the doctor. But pain during sex is different. The experience, several women said, can seem more like a personal problem than a serious medical condition — something to deal with on your own, with bath salts and the right mind-set.

If all else fails, said Sonia, a 32-year-old lawyer based in Denver, you “just wait for the sex to be over.”

After her doctor’s appointment, Hughes spent weeks trying to “relax” — which actually turned out to be extremely stressful. Her boyfriend wasn’t being supportive, either.

“I think his mentality was, ‘You’re being a wimp. You just need to power through it.'"

Hughes broke up with him and opted to stop having sex altogether. This solution would work for now, she told herself — maybe forever.

“I got to the point where I was like, ‘I’m okay with never being with someone.’”

It was for the best, Hughes decided. She wanted to focus on her career anyway.

It’s been almost seven years since Sonia graduated from law school, but she still thinks about the ski trip she took one winter weekend. She went with a group of friends, including the classmate that she’d liked for months. One night, he’d leaned in toward her, trying to make a move. She told him it wasn’t a good idea.

She didn’t know what else to do: Since she was 17, sex had been excruciatingly painful. Sonia couldn’t imagine telling this guy the real reason she couldn’t hook up, she remembers — even though, looking back now, she’s sure he would have understood.

“I didn’t want him to think of me as the damaged goods I thought I was,” said Sonia, who has vaginismus and asked that we not use her last name. “I had this overwhelming sense that I was defective, because I had proof.”

Things might have turned out differently if sex had started to hurt later in life, Sonia said, when she had more confidence in herself and a better understanding of a healthy relationship. But in her late teens and 20s, she assumed all men would immediately expect sex. And if she couldn’t have sex, she remembers thinking, who would want to be with her?

“You don’t realize how much sex is a part of daily life, pop culture, until you experience something like this,” she said. “It’s everything about being alive and being young.”

During her three years at law school, Sonia stopped dating altogether.

Sara Mitchell, 30, has also avoided talking about the pain she feels during sex. Her long-term partners, past and present, she said, would probably be shocked to learn about it. For Mitchell, who works for a women’s advocacy organization based in Washington, D.C., the issue has never seemed worth bringing up. She thoroughly enjoys everything that comes before penetration, and never wants to risk spoiling the mood.

“Even if I’m feeling pain, I don’t want to ruin it. It just makes me feel like I’m being a buzzkill.”

Mitchell knows it’s ironic that she feels this way, working for a nonprofit dedicated to women’s equality and empowerment. In her advocacy work, she promotes “enthusiastic consent” during sexual interactions: open communication and regular check-ins to make sure the other person is having a good time. Still, she said, in her own sex life, she can’t shake her natural impulse to “grin and bear it.”

Mitchell has never told a doctor about her experience with painful sex. It never occurred to her to think of it was a “medical condition,” she said, because sex doesn’t always hurt. With certain partners, it’s only painful sometimes. With a few, it hasn’t been painful at all.

“I don’t know. I guess, to me, it just doesn’t register as something to talk to a medical professional about.” Mitchell paused. “But now that I’m explaining it,” she said, pausing again, “I think someone might say it should be something you go to the doctor for.”

Hannah Schoonover, a pelvic floor therapist based in Washington, D.C., sees a lot of patients who feel this way. Schoonover works with people of all genders, specializing in care for the LGBTQ community. They find that women, in particular, often to assume that any pain they feel during sex is “normal.” (Schoonover identifies with gender neutral pronouns.)

“Women are not typically told that their orgasm matters, that their pleasure matters. So women are looking at how they can be of service to our partners,” Schoonover said. They suspect that this kind of cultural conditioning keeps many women from ever coming to their office. “Men often don’t have those same conundrums.”

Most of the women interviewed for this article did eventually decide to consult a doctor. And for some, the initial appointment allowed them to fully address their problems. They left with a diagnosis and a treatment plan — maybe hormonal therapy, for women dealing with dryness after menopause, or pelvic-floor physical therapy, which stretches out muscles in the vagina and pelvic floor, for women with vaginismus.

For other women, though, doctors were far less helpful. Adrienne Alden, a sex therapist in Raleigh, N.C., who specializes in painful sex, regularly works with women who have been misinformed by their doctors. Because there is so little clinical research, she says, many doctors aren’t well-versed in medical conditions like vaginismus and vulvodynia. Others, she says, just don’t seem to take this kind of pain seriously.

“I wish I could put this message on a billboard everywhere: ‘If you have painful sex and your OB somewhat dismisses you, go find another doctor,” Alden said. “If you have an injury, you can’t just ‘relax’ to heal it.”

At age 13, Alaire Comyn, now 26, from Durham, N.C., told her OB/GYN that she was having a hard time inserting her first tampon. When the doctor tried to push it in with more force, Comyn fainted.

Hughes had a nearly identical experience with her own doctor. After counseling Hughes to “relax,” the OB/GYN insisted on administering a pelvic exam. As she inserted the speculum, Hughes was in so much pain that she fainted. (Both women have since been diagnosed with vaginismus.)

When sex started to hurt for Jen Mostafa, about one month into her marriage, she immediately scheduled an appointment with her doctor. He prescribed a series of different treatments and medications, without ever diagnosing a specific problem, said Mostafa, a 35-year-old mental health counselor based in Sydney. Nothing worked. Eventually, Mostafa read an article about vulvodynia in a health magazine, thrilled she’d discovered a named medical condition that matched her symptoms so precisely. But when she showed the magazine to her doctor, she remembers, he frowned.

“He looked at it and told me, ‘I don’t really believe in this kind of stuff,’” Mostafa said. “And I was like, ‘Well, this is where our relationship ends.’”

Robbin, a 55-year-old woman based in Kansas City, Kansas, also sought out her OB/GYN as soon as sex became painful. (She asked that we not use her last name.) Robbin knew exactly what the problem was: Post menopause, her body was producing far less estrogen, leaving her vagina feeling much dryer and tighter than it had before. The condition prevented her from having sex with her husband, she said, but her doctor seemed largely unconcerned. She didn’t ask any follow-up questions, Robbin remembers, and quickly changed the subject. The problem didn’t seem like a priority for the doctor; Robbin still wonders if her age had something to do with it.

“When this happened, I became very conscious about how 50-something women start to disappear, no longer considered sexy or attractive. I don’t want to be evaluated as a sex object anymore, but I don’t want to be a completely nonsexual being either.”

Robbin and her husband tried to get creative, trying out different kinds of non-penetrative sex. But after more than 20 years of marriage, Robbin said, it wasn’t the same. When she told her husband how she felt — “frigid,” “like some kind of neutral gender” — he said he didn’t know what she was talking about.

“I think you’re sexy,” he’d say.

But she worried he was just being polite.

Hughes had been rehearsing the conversation in her head for years: If she ever met another man she wanted to be with, how would she tell him about the pain she felt during sex? She’d half-hoped she’d never have to broach the subject again. When she tried to explain her situation the last time around, her boyfriend — the one who told her to “relax” — hadn’t been receptive.

But two years had gone by, and she’d met someone new. When she explained, a few weeks into their relationship, he pressed his forehead against hers.

“He was like, ‘Oh my god yes, I love you and I want to be with you. The sex part can come and go.’”

By this point, Hughes had been to see a pelvic floor therapist. She knew which positions were more manageable, and what exercises she had to do to better control her vaginal muscles. With her new partner, Hughes successfully had penetrative sex for the first time. When it starts to hurt, she said, she usually doesn’t even need to say anything. He can tell — and he’ll suggest they try something different.

It wasn’t easy for most of the women I interviewed to tell their partners about the pain they experienced during sex. But once they did, for the majority, the condition became much easier to manage. Most said their partners were overwhelmingly supportive, eager to communicate openly during sex about what hurts and what doesn’t, or try alternatives to penetration.

When Comyn, the 26-year-old who fainted as her OB/GYN tried to insert a tampon, told her boyfriend about the pain, he learned some of the exercises prescribed by her pelvic floor therapist. Before they attempt anything sexual, he’ll use dilators to help her stretch her internal muscles, giving Comyn more control over when and how they contract. (Comyn has not yet been able to have penetrative sex.)

Before Comyn met her boyfriend, she’d regularly use dating app Tinder to meet new people. She would always tell potential partners about her vaginismus upfront, as soon as they started messaging about meeting up in person.

“I would say, ‘Look, I want to let you know something about me. Some people find it off-putting,’” she said. “‘Here is what I can do, sexually, and here’s what I can’t do.’”

Some guys would disappear after that, but that didn’t bother Comyn. If they didn’t want to be with her because she couldn’t have penetrative sex, she said, she wasn’t too interested in being with them, either.

There is a lot that women can do to make sex less painful, says Schoonover, the pelvic floor therapist, which is what makes the lack of research so frustrating. The majority of patients are responsive to physical or hormonal therapy, or some combination of both. The first step, Schoonover said, is always to validate their pain, and make sure they realize it’s not normal.

When Mostafa finally saw a sex therapist familiar with vulvodynia, she said, she cried. The doctor posed the kinds of questions that she’d been waiting years to be asked, Mostafa said — about how her condition was affecting her mental health and her relationship.

“Oh my god, I was so happy,” she said. She’d been worried that her husband might get impatient with the limits of their relationship. “I just felt like it was the first glimpse of hope.”

In Durham, Comyn now regularly sees a sex therapist and a pelvic floor therapist. With their help, she said, she feels confident that she’ll be able to have penetrative sex one day; Her goal is to have kids without in vitro fertilization or a surrogate. But Comyn didn’t always have access to those kinds of resources: Where she used to live, in rural Virginia, there were no pelvic floor specialists and very few OB/GYNs. As a teenager, she continued to see the same doctor, even after she fainted from the tampon insertion. She was “terrified,” she said, but there were no other options.

Even with the right doctors and therapists, there isn’t always an obvious diagnosis for painful sex. Lauren, 31, also from Durham, has been struggling to have sex for five years. (She asked that we not use her last name.) She’s done everything she can think of: She’s seen multiple doctors and pelvic floor therapists, and read every article she can find about different conditions that make sex painful. She hasn’t come across anything that describes pain similar to hers. Lauren’s pain isn’t muscular, she said. Instead, it feels like it’s right on her cervix.

“Everything is about vaginismus,” she said. “And so I just kind of want to say, ‘Hey, I’m here, too.’”

Many of the women I interviewed remember the first time they read or heard about pain that sounded like theirs. Maybe it was a conversation with a doctor or a therapist, or a written description in a magazine or academic journal. A few referenced the essay in the Week.

For Hughes, it was a blog post, written by a friend of someone she knew in college. When Hughes told her friend about the painful sex she experienced, she had the best possible reply: “Hey, I think I know someone else who had that.”

The post matched the experience of Hughes exactly. For the first time, Hughes realized she had an actual medical condition. She immediately decided to find a new doctor. Reading and rereading the post, Hughes says, she started to feel a little guilty: Was it wrong to be so giddily happy about another person’s pain?

Whoever this woman was, Hughes decided, she didn’t think she’d mind.