Pelvic Floor Therapy for Gender Affirming Care

What do you consider to be “taboo?” Although there are certainly some things that may fall into this category, seeking compassionate care and support for pelvic pain, incontinence, constipation and gender-affirming modalities and surgeries should not be one of them. There is a lack of awareness and education surrounding pelvic health and the anatomy of our bodies and a misconception regarding who has a pelvic floor. Transgender individuals are not an exception to pelvic floor dysfunction and for some, gender affirming modalities and surgeries are an essential step in the transition process and/or the journey to gender euphoria. The purpose of this article is to educate folks about how pelvic floor therapy can improve outcomes of gender-affirming care. 

How Can Pelvic Floor Therapy Help the Transgender Community? 

Pre- and post-operative pelvic floor therapy can improve gender-affirming outcomes by managing pre-existing pelvic floor dysfunction before surgery as well as address any musculoskeletal and postural impairments after surgery. Pelvic floor therapy can also help with non-operative gender-affirming modalities like binding, packing and tucking. A 2019 study looked at pelvic floor therapy for transgender women undergoing vaginoplasty, and found that 42% of participants already had pelvic floor dysfunction before surgery and 37% of those participants had bowel dysfunction. The study also concluded that 90% of participants had reported trauma to their pelvic floor, including sexual assault or a pelvic floor related injury or fall. Participants that attended both pre- and post-operative therapy saw a decrease in pelvic floor dysfunction; those who attended either pre- or post-operative therapy saw successful dilation at 3 months.^[1]

Pelvic floor therapy for gender-affirming, non-operative modalities 

• Binding 
• Tucking 
• Packing

Binding is a modality in which tight clothing, garments or bandages  are tightly wrapped around the chest to flatten the appearance of breast tissue. Binding allows individuals to increase gender euphoria and match their appearance to their gender identity. However, there can be some negative side effects related to the pelvic floor and other parts of the body caused by binding. Some of these changes include pain in the chest, shoulders, abdomen and back, which can lead to spinal and postural changes. Due to compression at the chest and abdominal area, this can lead to digestive issues and difficulty breathing.

Are you wondering how this relates to the pelvic floor? The pelvic floor relies on a healthy diaphragm and abdominal wall to function properly. Alignment changes can cause pain and weakness, leading to dysfunction in one or all of these areas. Dysfunction in the diaphragm, abdominal wall and/or pelvic floor can present as urinary or fecal incontinence, constipation, pelvic/hip/lower back pain, and changes to our sexual health. A pelvic health PT/OT can help manage these uncomfortable side effects and improve quality of life by prescribing various breathing, strengthening, and mobility exercises to restore overall posture and alignment, and to reduce pain in muscles that are affected by constant compression. 

Tucking, another common gender-affirming modality, is the act of flattening the genital area to hide a bulge that may conflict with a person’s gender identity. Tucking can lead to muscular changes, tension in the legs and pelvic floor area, and changes to how an individual may walk. Compression of the urethra can also lead to increased risk for UTIs and urinary dysfunction. A pelvic health PT/OT can teach you how to perform daily skin checks to assess for irritation and skin breakdown as well as implement techniques to reduce and relieve muscular tension. 

Packing, typically used by trans men, is the method of using something to create a bulge and achieve the look of having a penis. Packers can range from homemade, like a pair of socks, to medical/aesthetic prosthetics. Stand-to-pee packers (STPs) are devices that also allow you to pee while standing up. Similar to tucking, packing can cause changes in the way we walk which can affect other muscles throughout our body, and lead to pelvic pain and urinary issues. Some STPs can also lead to urinary retention and UTIs. Pelvic floor therapy can address any bladder and pelvic pain concerns that may accompany this modality. 

Pelvic floor therapy for gender-affirming surgeries

• Top surgery 
• Bottom surgery

When any kind of surgery is performed, there is trauma to our muscles, nerves, ligaments and other connective tissue. Scars and adhesions can arise and limit mobility and cause pain. Pelvic floor therapy should be part of the plan of care, ideally both before and after surgery, to improve outcomes. For example, any type of chest reconstruction (augmentation or removal) can cause adhesions around the chest, abdomen, diaphragm and spine. Adhesions can affect posture, mobility, the way we breathe, and the range of motion of our upper extremities. We know that dysfunction in posture, diaphragm, and abdominal walls can lead to pressure management issues and pelvic floor dysfunction. A pelvic health PT/OT can perform scar mobilizations, joint mobilizations and prescribe mobility and stability exercises to improve range of motion and reduce pain. Performing scar massage can also reduce the visibility of scar appearance!

Pelvic floor therapy for bottom surgery is crucial in the transition process. Pelvic floor therapy before and after surgery should be the standard of care to provide the utmost support and education to those undergoing genital reconstruction. Pelvic health therapists can provide a good understanding of what to expect during surgery, and ways to modify getting in and out of bed/cars to make transfers more manageable directly after surgery. Pelvic health therapists will screen and treat any pre-existing pelvic floor dysfunction prior to surgery, as well as discuss post-surgical techniques to improve overall bladder, bowel and sexual health. Most importantly, pelvic health therapists can guide you through the dilation process with pelvic floor lengthening techniques, wound management, scar mobilization and help you to re-learn behaviors with new anatomy.

Pelvic health therapists provide essential support and care for the trans, non-binary, and LGBTQIA+ community. At Mind Body Pelvis, we are passionate about meeting the healthcare needs of the trans community through a safe and inclusive space for optimal healing.

Watch Dr. Ochalski’s interview here for more on gender affirming care.

^[1] Jiang DD, Gallagher S, Burchill L, Berli J, Dugi D 3rd. Implementation of a Pelvic Floor Physical Therapy Program for Transgender Women Undergoing Gender-Affirming Vaginoplasty. Obstet Gynecol. 2019 May;133(5):1003-1011. doi: 10.1097/AOG.0000000000003236.

Dr. Natalia (she/her) is a Doctor of Physical Therapy, Certified Pelvic Rehabilitation Practitioner and Pregnancy/Postpartum Corrective Exercise Specialist, specializing in pelvic floor physical therapy in New Jersey. She is the owner and founder of Mind Body Pelvis, LLC, a physical therapy practice with a sole focus on pelvic health through an individualized and holistic approach. Due to the often sensitive nature of conditions in the pelvic region, Dr. Natalia emphasizes not only the root cause of physical dysfunction but also the underlying emotional and spiritual needs of her clients. Dr. Natalia is passionate about meeting the pelvic health needs of the transgender community, and has first-hand experience providing both pre- and post-operative pelvic floor therapy. She believes that anyone experiencing discomfort ‘down there’ deserves to be heard, validated, and have their concerns addressed by a pelvic specialist in a safe and judgment-free environment.