For more than a century, pain during penetrative sex was murkily understood and often presumed to be a physical manifestation of women’s dislike of or anxiety toward sex. Today, as Buehler puts it, it’s less common for people to have to visit 10 different doctors to finally get a diagnosis, but it’s still likely they’d have to see three. The Mayo Clinic explicitly states that doctors still don’t know what causes the condition, and the American College of Obstetricians and Gynecologists calls it a “diagnosis of exclusion.”

Still, researchers and physicians have made significant strides in understanding and effectively treating what’s now recognized as a real and common physical condition. In the process, they’ve helped many couples find hope in a situation that not so long ago felt hopeless.

Vulvodynia can affect more than just a person’s sex life (using tampons, getting pelvic exams, riding bicycles, and even wearing tight-fitting pants can cause pain), and any chronic condition can take its toll on a marriage or relationship. But not many chronic-pain conditions affect relationships in quite as direct and obvious a way as vulvodynia does.

When Buehler meets one of these couples, she first works with them on integrating some forms of affection back into their lives—kissing hello and goodbye at the start and end of the workday, sitting together on the couch, holding hands as they walk to their car. She works with them on how to talk about their feelings toward sex, separating their feelings about sex from their feelings about each other, and she works with them on how to engage sexually in ways that don’t involve penetration. Buehler also puts women in touch with pelvic-floor physical therapists or physicians who can treat the parts of the vulva that experience burning or stabbing sensations through massage, biofeedback therapy, injection of Botox, or surgery. (Frequently, she said, a male partner’s suspicion that his wife or girlfriend is exaggerating her pain level dissolves once he’s observed a physical-therapy session or two.)

After physical therapy, counseling, treatment, or some combination thereof, Buehler said many of the couples she works with are able to enjoy pain-free sex; all at the very least learn new strategies for how to manage the pain and/or maintain intimacy. Many couples leave “feeling like, Wow, we got through something together, and we’ve grown closer because of it,” Buehler said.

Female pain during sex has a long history of being misclassified, misunderstood, and blamed on the women themselves. As Maya Dusenbery writes in Doing Harm, a book about sexism in medicine, vulvar pain was first described in medical texts in the late 19th and early 20th centuries as a sort of recurring but mysterious phenomenon, a pain with no known cause.

Throughout much of the 20th century, however, the burning or stabbing sensation many women reported was considered “more of a marital problem than a medical one,” as Dusenbery puts it. Vulvar pain, which often shows up in tandem with vaginismus (a condition involving spasms of the pelvic-floor muscles that can make it painful or impossible to have intercourse), was frequently believed to be a physical manifestation of unhappiness in a relationship, and thus methods for treatment included things like hypnosis, couples therapy, and numbing ointments—the last of which often made sex possible, though not necessarily enjoyable.