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.

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?”

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.

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.

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 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.

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.