Episode 49: Pelvic pain and trauma - when your body still expects sex to hurt

What happens when pelvic pain improves, but your body still expects sex to hurt?

In episode 49 of The World’s Tightest Community, host Mathilde Olstad speaks with sex therapist Romi Terk Brudno about an experience she recognises personally and in her work: the protective responses that can develop around pain itself. Drawing on her experience of ulcerative colitis and painful sex, Romi explores why physical improvement may leave questions about intimacy unanswered, how pain can affect self-worth, and what care that respects a person’s agency can look like.

Pelvic pain without sexual trauma: when pain itself leaves a mark

Romi was diagnosed with ulcerative colitis as a teenager. Around the same period, she experienced discomfort with tampons and, later, sex. Without an identifiable history of sexual trauma, she struggled to see where therapy fitted into her care. Over time, she began to recognise patterns that deserved attention in their own right: tensing in anticipation of pain, avoiding undressing in front of a partner, and feeling unable to join friends’ conversations about sex. The emotional difficulty included worrying about disappointing someone, as well as the physical discomfort.

Her argument is that care needs to make room for those experiences. Romi describes some responses as “PTSD adjacent”, drawing attention to similarities such as avoidance and negative beliefs about the self. That description does not establish a PTSD diagnosis. The National Center for PTSD’s diagnostic overview explains that diagnosis requires qualifying trauma exposure alongside a defined combination of symptoms, duration and impact. Romi’s wider question is how to recognise distress and offer appropriate support when someone’s experience does not fit that diagnosis.

For a long time I didn't feel like there was really space for me in therapy.

Why progress in pelvic floor therapy can feel different during intimacy

As Romi learned to manage her ulcerative colitis and worked with pelvic floor physiotherapists, she started understanding connections between gut discomfort, tension and the way she held her body. She describes this through her own experience, including what her physiotherapist helped her notice. Yet improved physical symptoms did not automatically mean feeling comfortable during intimacy. She could make progress in one setting and still brace in another. That mismatch helped her see a role for therapy alongside the medical and pelvic floor care she was already receiving.

In her work with clients, Romi pays attention to the transition between those settings: what feels possible in physiotherapy, and what happens with a partner or while dating. She frames the response as something the body has learned in trying to protect itself. Mathilde recognises the frustration of having improved and still finding that anticipation, guarding or avoidance remain. Addressing these experiences can sit alongside continued investigation and treatment of pain. The American College of Obstetricians and Gynecologists’ guidance on chronic pelvic pain describes care that may involve pelvic floor physiotherapists, pain specialists and mental health professionals, depending on a person’s needs.

Painful sex, pressure and self-worth: the meanings attached to intimacy

Romi asks what happens when an experience of pain becomes a conclusion about the person experiencing it. Beliefs about being broken, unworthy of a relationship or unable to have a satisfying sexual life can add pressure to an already difficult situation. Mathilde describes how exhausting different avenues of care can leave someone blaming themselves for the pain that remains. Romi wants those beliefs to be part of the conversation, because they shape how a person approaches their body, their partner and the possibility of intimacy.

She uses the distinction between approach and avoidance motivations for sex to make this concrete. Seeking pleasure or connection is a different starting point from having sex to prove worth, prevent a partner’s disappointment or avoid feared rejection. Romi acknowledges the complexity of pelvic pain: changing a motivation is not a promise that pain will disappear. It is an invitation to notice what is driving an intimate encounter and whether there is room for choice. She also points to social support and the partner’s role as parts of the wider context in which someone experiences pain.

If you feel broken, right, there's this implication that you need to be fixed.

Trauma-informed care for pelvic pain: agency, safety and being believed

For Romi, a central feature of trauma-informed care is agency: listening to a person’s needs, respecting their comfort level and moving at a pace where they feel in control. She raises questions about who research includes and who can be overlooked by screening or referral processes. Her concern is that people with distressing responses to pain may struggle to find appropriate support when they do not fit familiar diagnostic categories. She calls for more research into these experiences, while recognising that there is still work to do to understand which approaches help whom.

The episode returns to the importance of believing people even when the origin of their pain remains unclear. The International Association for the Study of Pain recognises pain as a personal experience influenced by biological, psychological and social factors, and emphasises respect for a person’s report of pain. Romi’s closing message is that an unexplained experience still deserves care. Understanding the cause matters, but uncertainty about that cause does not make the pain less real or make someone less deserving of support. She encourages listeners to trust their experience and allow themselves some compassion along the way.

It's real because you feel it.

Sources and resources

1. Romi Terk Brudno — sex therapy for painful sex and pelvic pain. Guest website, professional background and practice information.

2. National Center for PTSD — PTSD and DSM-5. Official explanation of PTSD diagnostic criteria; relevant to the distinction between trauma-like responses and a diagnosis.

3. American College of Obstetricians and Gynecologists — Chronic Pelvic Pain. Patient information on assessment and treatment, including care from multiple specialties.

4. International Association for the Study of Pain — Terminology. Definition of pain and notes on personal experience, biological, psychological and social influences, and respecting reported pain.