CS: The following post is written by LGBTQ-informed pelvic physiotherapist Michelle Fraser, who has taken the time to share some of her knowledge regarding pelvic health in the context of trans birth. There is mention of vaginal/rectal health, as well as a mention of trauma with no details.
What is pelvic health physiotherapy?
Pelvic health physiotherapists are most known for helping to balance out the muscles of the pelvic floor (the group of muscles, ligaments and fascia that closes off the bottom of your torso). Imbalance of the pelvic floor is typically associated with urinary incontinence (leaking urine when you don’t want to be leaking urine). However, a pelvic health physiotherapist will be able to help you with many other symptoms that you might be experiencing, for example…
Do you have trouble starting the stream of urine, especially when in a public washroom? Or do you have trouble fully emptying your bladder?
Do you have low back, upper back, or hip pain that is not going away even though you have been strengthening?
Do you tend to be constipated?
Are you working on strengthening your core, but you can’t seem to get stronger?
Do you have pain with any aspect of sexual activity?
As a pelvic health physiotherapist, I love asking clients personal questions such as these… and then I love helping to connect the dots between the pelvic floor, urinary symptoms, bowel issues, sexual symptoms, and pain. This leads to brainstorming with clients to find solutions.
Being pregnant, being in the postpartum period, and being transgender are three more dots to connect. The first two may be intuitive, because there is a direct connection to the pelvic floor… the third, however? What does being transgender have to do with the pelvic floor health as related to pregnancy? Doesn’t everybody have the same muscles of the pelvic floor?
To understand this, let’s take a step back and look at what you may want to work on with your pelvic health physiotherapist for perinatal care (care before, during, and after labour and delivery). You may wish to:
balance the muscles of your pelvic floor (which muscles are weak? tense? working just fine?)
balance the pelvic floor muscles as part of the inner core (this will be different during pregnancy vs. afterwards)
reduce tension in the muscles that are compensating for your inner core, if it is not working optimally
ensure sufficient strength and movement of your thoracic spine
strengthen your wrists shoulders and posture muscles
relax and mobilize the muscles/ soft tissue of your pelvic floor to help with ease of delivery
learn to soothe your (potentially upregulated) nervous system*
encourage healing of rectus diastasis (separation of the abdominal muscles to allow for the growth of your baby during pregnancy).
[*upregulated nervous system means a nervous system that is quick to respond to what it deems a threatening situation and can take the form of being very sensitive to touch, pain, shutting down, etc. It may be due to either physical or emotional trauma, or both].
A trans-informed physiotherapist should also be aware of the following. Please note that some of these examples don’t only apply to the birth parent; they may affect all caregivers. Here are some examples:
A person who binds may develop excess tension in the pelvic floor, which may in turn lead to pelvic pain, which may increase the tension – it can be a self-perpetuating situation. Developing the ability to soften the pelvic floor muscles would be helpful for labour and delivery.
A person who is taking testosterone may be more vulnerable to developing tendonitis. Adding repetitive lifting of an ever-growing baby may increase that vulnerability at the wrists and shoulders. Gradual strengthening in the prenatal period will reduce that risk.
It is known that social determinants of health such as physical safety, social support, economic/ work security, education, and access to health care can be adversely affected for the LGBTQ population (Trans PULSE Project, 2015; Olsen 2015; The Kaiser Family Foundation, 2001). This can lead to heightened anxiety or other stress responses that may then lead to increased tension in the pelvic floor. Increased tension in the pelvic floor can contribute to pain, difficulty urinating, constipation, hemorrhoids, and breathing issues. Therefore, becoming familiar with your stress responses and learning how to work with them can be very powerful.
I am nervous about seeing a pelvic health physiotherapist – seeing medical professionals is uncomfortable for me.
Transgender persons may experience a reluctance to seek out health care when needed, including emergency health care (Perrin et al., 2004; Polek et al., 2008; Neville & Henrickson, 2009; TransPULSE, 2010; and Grant et al., 2011). Many have experienced an anti-transgender bias in care (Canadian Mental Health Association; 2016; Lambda Legal, 2010). A session with a pelvic health physiotherapist may be a particularly vulnerable encounter, emotionally and physically. Your physiotherapist will ask questions related to areas that you may have been trying hard to keep hidden. Additionally, the muscles of the pelvic floor are ideally assessed through internal palpation (vaginal and/or rectal). Any emotion that you may experience that may elicit a stress response may lead to increased tension in your pelvic floor. This creates a conundrum!
This is where the development of a relationship of trust and safety with your pelvic health physiotherapist is very important. Because this is a new field for many physiotherapists, they may not have all of the answers… but they will try to figure it out. Resources are becoming more available to physiotherapists in Canada (for example, through Pelvic Health Solutions, an educational organization for physiotherapists) and programs are being developed specifically addressing the needs of the trans population (for example, the Transition-Related Surgeries Program that is currently being developed at Women’s College Hospital).
Consultation with a trans-informed pelvic health physiotherapist can be a highly transformative experience to your pregnancy, and the benefits may extend well beyond the perinatal period.
A list of pelvic health physiotherapists can be found here: http://pelvichealthsolutions.ca/find-a-health-care-professional/ontario-physiotherapists/. This website lists physiotherapist according to geographical location, and it lists courses taken by individual physiotherapists, so that you can get an idea of their areas of expertise.
Guest post by:
Michelle Fraser, PT
Orthopaedic and Pelvic Health Physiotherapist
Certified Yoga Instructor
BA, BScPT, FCAMPT, CYT, MEd
Michelle is a pelvic health advocate and educator who works with persons of all genders experiencing pelvic floor dysfunction or interested in understanding the complexities of pelvic health. She is on a mission to empower people in Canada and internationally to take charge of their pelvic health, which can often be a life changing experience for anyone who has suffered pelvic health dysfunction.
In addition to being an orthopaedic and pelvic health physiotherapist, Michelle is a certified yoga instructor, enriching her finely tuned treatment methods with yogic philosophy and the benefits of mindful movement. Michelle’s dedication to making pelvic health internationally accessible is furthered by her commitment to her own continuing education. She’s earned her Masters of Education at OISE, specializing in global health education, and has been involved with teaching physiotherapists pelvic health and advanced orthopaedic skills both in Canada and in Nicaragua. She is an associate instructor with Pelvic Health Solutions, where she helps physiotherapists understand how to evolve towards LGBTQ-informed practice.
Canadian Mental Health Association Ontario (2016)
Grant, J., Mottet, L. Tanis, J. , Harrison, J., Herman, J. & Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force.
The Kaiser Family Foundation (2001). Inside-Out: A Report on the Experiences of Lesbians, Gays and Bisexuals in America and the Public’s Views on Issues and Policies Related to Sexual Orientation: statistics concerning violence, vandalism, harassment, discrimination, and overt hatred impacting gay men and lesbians. https://kaiserfamilyfoundation.files.wordpress.com/2013/01/new-surveys-on-experiences-of-lesbians-gays-and-bisexuals-and-the-public-s-views-related-to-sexual-orientation-chart-pack.pdf
Lambda Legal. (2010). When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal)
Neville S & Henrickson M (2009) The constitution of ‘lavender families’: a LGB perspective. Journal of Clinical Nursing 18, 849–856.
Olsen, LC. (2015). Health Care for Modern Families: Practical Suggestions Concerning Care for Families of Gay Men and Lesbians. Health, Culture and Society, 8:1. ISSN 2161-6590 (online) DOI 10.5195/hcs.2015.198. http://hcs.pitt.edu
Pelvic Health Solutions, http://pelvichealthsolutions.ca/
Perrin EC, Cohen KM, Gold M, SavinWilliams RC & Schorzman CM (2004) Gay and lesbian issues in pediatric health care. Current Problems in Pediatric and Adolescent Health Care 34, 355–398 doi:10.1016/j.cppeds.2004. 08.001.
Polek C, Hardie T & Crowley E (2008) Lesbians’ disclosure of sexual orientation and satisfaction with care. Journal of Transcultural Nursing 19, 243–249.
TransPULSE Project, 2010 http://transpulseproject.ca/
Trans PULSE Project, 2015 http://transpulseproject.ca/resources/resource-guide/
United States Office of Disease Prevention and Health Promotion. (2017). Social Determinants of Health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health: Health 2020
Women’s College Hospital http://www.womenscollegehospital.ca/programs-and-services/Transition-Related-Surgeries/