Why PT Needs More LGBTQ+ Affirming Pelvic Floor Specialists

By: Serra Shelton, SPT

I am a 2nd year physical therapy student about to start my clinical rotations, and I have been interested in pelvic floor PT since the beginning of my academic journey. However, since it is a somewhat niche specialty, my general coursework provided only 2 lectures on pelvic floor therapy in the entire program . Despite seeking out exposure to pelvic floor education in other ways, such as taking a courses with the Herman and Wallace Institute and a pelvic health elective at the University of Washington, I wanted to learn more than the brief glimpse I had seen so far—and that is how I found myself creating an independent study course with Dr. Brianna Durand, an LGBTQIA+ pelvic floor/outpatient orthopedic physical therapist. Let me give you a sense of what this experience was like.

It was the first day of my independent study in which I would shadow Brianna as she practiced.

We started off the day with a returning patient, and Brianna began by asking for updates on her symptoms. As the patient recounted her status since her last session, Brianna typed away at her computer, asking for more details here and there.

When the patient had finished, Brianna turned away from her computer, made eye contact, and said “So to recap, since our last session you had a nasal endoscopy with negative findings, you saw an endocrinologist for the first time who ordered new tests, you had another biopsy, and you had a particularly stressful week at work.” The patient nodded emphatically. I was impressed—

I had never observed a physical therapist summarizing the patient’s words back to them. It seemed like a simple yet highly effective technique for the patient to feel fully seen and heard, and to make sure no important information had been missed.

Brianna sat back in her chair, her expression concerned, and said, “It sounds like you’ve been through an incredible amount of medical stress since our last session. No wonder you weren’t able to stick with your home dilator schedule.” The patient nodded even more, and I raised my eyebrows in surprise— we had talked about the importance of empathizing with the patient’s emotions in classes, but this was the first I had seen it in action.

“Here’s my plan for the session,” Brianna continued as she listed off the types of interventions she wanted to do that day, and why. Finally, as the icing on the cake, she added “are there any things you would like to address with today’s session?”

I was awestruck.

It was new for me to watch a physical therapist outline the exercises they planned to do with the patient prior to the session, explain the clinical reasoning behind them, and encourage the patient to contribute.

It was a beautiful way to give the patient agency over their treatment and allow them to give true consent to the session, rather than being herded from one exercise to another with little explanation, as I had been trained to do so far.

As I watched Brianna treat several more patients that day, I realized that this type of care was not isolated to the first patient, and was applied to pelvic floor and orthopedic patients alike. Every session I noticed her repeating back the patient’s subjective, validating any strong emotions the patient might be feeling, outlining the planned treatment session, and asking for input. This was simply her standard of care for everyone who walked through her door, and I was impressed by the skill and care with which she executed it.

I think Brianna delivers such consistently exceptional patient care in part because of her training in pelvic floor physical therapy.

Due to the sensitive nature of that body region, pelvic floor physical therapy faces the practitioner with some of the most vulnerable, traumatized, ashamed, and fearful aspects of the patient’s life.

From what I have seen so far, the specialty has evolved to meet the needs of its patient population by leaning into gentleness, empathy, deliberateness, and a return of agency to the patient in a way that the wider world of physical therapy could benefit from. For example, one lecture from a pelvic floor elective class I took discussed consent and trauma-informed care more thoroughly than all the rest of the two years of my program combined.

Additionally, a Herman and Wallace pelvic floor class I attended last spring went in-depth into exam strategies to give the patient more agency and how to build comfort for saying “no.” The instructors counseled us to use these strategies with all of our patients, whether we are aware of a trauma history or not, because every pelvic floor patient benefits from this level of thoughtful care. I would take it one step further, and argue that every physical therapy patient in any setting or specialty benefits from this type of communication and care.

I think pelvic floor physical therapy should be included more in the core curriculum of physical therapy doctorate programs.

The philosophy behind pelvic floor care would improve student’s abilities to engage with difficult patient experiences, whether they practice pelvic floor therapy after graduation or not. Experience of trauma is not limited to the pelvic region, and any instance where someone’s body is touched against their will can create a traumatic experience.

We do not know if something seemingly harmless, such as a tactile cue to the low back, could cause a patient to feel out of control of the situation or bring back traumatic memories. I have often wondered this as I watch the way our profession tosses exercises at patients, thrusting weights and straps into their hands, bundling them onto a machine before explaining what the machine does, correcting and poking and instructing with little respect for the incredible trust it takes to allow yourself to be touched by a stranger. Could we take the time to be more thoughtful about the dynamic we create with patients? Would we see better health outcomes if we did?

I first became interested in pelvic floor physical therapy before applying to graduate school, when trying to connect myself with the community of queer physical therapists in my area. Not surprisingly, many of the LGBTQIA+ therapists I networked with were also pelvic floor specialists.

Because the genital region is the site of so much social, medical, and political trauma for those of us who are sexual and/or gender minorities, I think there is a desire to provide the type of safe, sensitive medical care to our community that we have struggled to find ourselves, to be one provider not adding to the horror stories our queer friends come home with every time they visit the doctor.

I believe that because of our insertion of ourselves into this specialty, the pelvic floor world has adapted to inclusivity in ways the rest of the physical therapy field is still struggling to catch up to. If you are treating a shoulder, you can culpably ignore the lived gender experience of your patient; however, if you are examining their pelvis, you cannot so easily bury your head in the sand. The difference has been stark in my experience as a student—within the general anatomy courses of my program, professors struggled and resisted using gender-neutral anatomical terms and persisted with language such as “male anatomy” and “biologically female,” despite widespread student protest.

From the first moment of my Herman and Wallace Level One Pelvic Floor course I took last spring, however, the instructors all consistently used gender neutral language such as “pregnant people” and “pelvis containing a penis” without fuss or fanfare. It was enough to make me want to weep with joy, to see how possible it was to have an inclusive and non-gendered medical education. The same experience was repeated later that year, when I took a pelvic floor elective as part of my second year coursework—even though my other coursework at that institution had no policy on inclusive language, the professors of this one elective course made a point of using gender neutral anatomical language throughout.

This is another huge gift that the pelvic floor community has to offer the wider field of physical therapy—an honest look at the impact our current medical language has on LGBTQIA+ patients, and how we can shift our teaching styles to do less harm. I think if pelvic floor physical therapy were more integrated into physical therapy core curriculum, we as a profession would become better healthcare providers to LGBTQIA+ patients across every physical therapy setting.

The nine weeks I worked with Brianna was an eye-opening experience.

She demonstrated a type of patient-centered care that I hope to emulate in my own career. I was reaffirmed in my reasons for being drawn to pelvic floor physical therapy, and gained a new appreciation for what pelvic floor physical therapy skills will add to my quality of care, across all settings and all patients I treat.

I was able to have vulnerable conversations about providing the best possible healthcare to members of my LGBTQIA+ community, and discuss queer-related patient care questions with her that professors at my program do not know how to address. I appreciate that doctorate programs are already intense educational experiences with little room to add to the curriculum, but in this case I think it is crucial for pelvic floor physical therapy to become a larger part of the core curriculum. It’s not just a matter of exposing students to a potential niche specialty, it’s about integrating a style of practice that will change the culture of our field of physical therapy to one that is more patient-centered, inclusive, empathetic, and intentional.