Pelvic PT Part 3: Patients Who Don't Fit the Usual Boxes

Introduction

During my first semester of physical therapy school, my class was fortunate enough to have a guest lecture from one of eleven Board Certified Women’s Health Specialists in the state of Texas. It was during this lecture that I was first introduced to the practice of pelvic floor physical therapy (PT). Learning about the effects of pregnancy on the body and the hormonal and biological differences between men and women that influence their risks for various ailments fascinated me. For example, ACL injuries are 2 - 10 times more common in female athletes than male athletes playing the same sports¹. Additionally, there is an established relationship between knee laxity and hormonal changes during a menstrual cycle² in addition to a link between testosterone and improved athletic performance³. Prior to this lecture, I never considered the idea of something like our sex hormones having such a great impact on our musculoskeletal health. I became curious about how the exposure to both testosterone and estrogen would affect people who are transgender. This extended into a broader interest in the topic of trans health care, including the biological and psychosocial components of providing high quality service.

Before exploring the topic further, it is important to have a basic understanding of the terminology associated with this demographic.

Sex - biological characteristics of chromosomes and anatomy (ie. male, female, intersex, etc.)

Gender - societal and cultural categorization based on one’s sex (ie. boy, girl, etc.)

Cisgender - describes one who identifies with the gender assigned to them at birth

Image courtesy of advancedreportingtimes.wordpress.com

From Transgender - describes one whose gender does not match the sex they were born with (may be abbreviated trans)

Transwoman/MTF - born male and identifies female

Transman/FTM - born female and identifies male

Top surgery - breast removal (FTM) or augmentation (MTF)

Bottom surgery - reassigning one’s genitalia to the anatomy they identify with

Gender identity - the gender that someone associates with internally

Gender expression - the external gender that someone shows the world through appearance and behavior

Sexual orientation - the gender(s) that one is attracted to. (Transgender is not a sexual orientation.)

Gender 101. Trangsender Health Information Program, Provinicial Health Services Authority Web site. http://transhealth.phsa.ca/trans-101/gender-identity. Accessed Aug 13, 2016.

There can be many combinations of the terms above. Someone could feel male, but live outwardly as a woman. Also, gender and sexual orientation do not always add up in a heteronormative fashion. A person could be cisgender and bisexual (an XX female attracted to both men and women) or transgender and lesbian (an XY MTF woman attracted to women) or any other combination. Furthermore, not all people who are transgender have surgery or undergo hormone therapy, but this does not change their gender identity.

Why does it matter?

For many health care providers, there is high emphasis placed on maintaining respect and tolerance for all patients, regardless of their beliefs or lifestyles. However, for some unique populations, providing high quality care must extend beyond tolerance and into awareness. The July 2016 issue of the APTA’s PT in Motion magazine displayed “Managing patients who are transgender” on the cover. There were some fantastic examples of why it is important to be aware and knowledgeable about patients who are trans. One physical therapist, Daniela Mead, states, “If someone who identifies as a woman comes in reporting hip pain and I don't know that she is biologically male, I'm not going to screen for something like prostate cancer … because that's not going to be on my radar.”⁴ Dr. Kimberlee Sullivan, a PT and clinic-owner in Austin, TX, explained that physical therapists will see patients who are post-op MTF sex reassignment surgery to address pain and scar tissue. PTs work with this population with vaginal dilators to prevent stenosis so that they are able to have successful intercourse. “Since pelvic PTs have more creative liberty in regards to discussing sexuality and function; they are in unique positions to have a profound impact,” says Dr. Uchenna Ossai, a Board Certified Women’s Health Physical Therapist at Houston Methodist. 

There are many other instances in which someone’s status as transgender could impact the pathology a PT addresses with their intervention. For example, some people who are FTM practice binding their breasts, which can lead to compressed ribs, collapsed lungs, and back pain⁵. If a patient who is FTM undergoes removal of both breasts, PT could be indicated to improve scar mobility, prevent keloids, and maintain upper extremity range of motion during healing. A survey from the Williams Institute at UCLA claims that “Fifty-four percent of respondents reported having some sort of physical problem from trying to avoid using public bathrooms, all of whom reported that they ‘held it,’” including dehydration, UTI’s, and kidney infections⁶. In regards to being efficient primary care clinicians and screening for non-musculoskeletal causes of symptoms, it is important to consider a sexually transmitted infection in the case of groin or low back pain. In one study, the prevalence of both syphilis and HIV were more than twice as common in the transgender group compared to the cisgender group⁷.

During the subjective interview with a patient, physical therapists screen for cognitive and emotional conditions that may interfere with PT or warrant a referral to another professional. For this reason, PT’s should be made aware that mental health disorders, often secondary to ‘minority stress’ are higher in the LGBTQ community. According to the National Alliance on Mental Illness, suicidal ideation is experienced in 38-65% of transgender individuals⁸. There are other psychological components specific to this demographic, such as gender dysphoria, which is diagnosed when one displays “a marked difference between the individual's expressed/experienced gender and the gender others would assign him or her,” often to the point of causing significant distress and social/functional impairments⁹.

The transgender population also carries with them some distinct barriers to health care access, including PT. Currently, only 18 states have laws to protect a person who is trans from being fired solely on the basis of their gender identity¹⁰. Considering how many people obtain health insurance through their employer, a patient may harbor anxiety and fear of losing access if they are terminated. Furthermore, there is no nation-wide legislation in place requiring health insurers to cover transition-related to health care¹¹. If a patient is paying for most of these services out of pocket, they may not want to spend additional time and energy on PT because it is perceived as less necessary.

What can we do?

As a second year PT student, I have noticed that there is absolutely no mention of this demographic in my curriculum. Considering that the research on this (incredibly diverse) group of people is scarce, that is somewhat understandable. But the best method to increase awareness for our patients who are trans is starting early education! Even just one lecture by a specialist to expose students to the idea and provide them with more resources would be excellent. Creating more resources for practicing clinicians by way of continuing education courses and seminars would also help spread information. Something that could be done locally within your own clinic could be allowing in-services on trans healthcare to be given by interning students or employees. Since the resources may be limited and it may not seem like a pressing topic because the population is small, it could be as simple as creating a work environment where these discussions are welcome.

There are so many other efforts that PT clinics can employ to put patients at ease. The article in PT in Motion mentioned having a rainbow flag in the waiting room to let patients know they are in a safe space. “While I was shadowing at a clinic in Seattle, some of the PT’s wore a small pin to indicate peace and acceptance of other cultures. Another idea could be intake forms with more than one gender choice to include transgender and genderqueer. You as an individual employee may not be able to accommodate patients by providing gender neutral bathrooms, but if they already exist at your facility it wouldn’t hurt to know where they are located and offer it to patients. This may make them feel more comfortable and convey respect, helping to build rapport.

If you are a clinician, or future clinician, who would like to make a conscious effort to practice this awareness but don’t know where to begin, have no fear! There are so many things you can do in your day-to-day interactions with patients to convey that you are trying to open up your world view. For example, if you have a patient who you know or suspect is transgender/non-binary you can start with pronouns. If they came into the clinic with someone, you can wait for their friend/family member to address them as a certain pronoun. I use ‘they/them’ since it is gender neutral until I have a better idea of how someone identifies. If you are unsure, it is okay to privately ask them! This is far less triggering than misgendering someone. “I believe in a professional medical setting, they should always ask how their patient identified. When my primary care physician's nurse found out I was on testosterone, she immediately asked me what my preferred name was. It was a great feeling,” states Elliott T., a transman from Ohio. “My doctor on the other hand offhandedly asked me why I was on testosterone. Even though he's had transgender patients before, it was very obvious that he was not educated or trained on how to approach the subject.”

Dissenting Opinion

As with any controversial topic, there are opposing viewpoints. Some health care professionals believe that the field has become too politically correct (PC). From this perspective, it is thought that being PC is sugar-coating problems and inhibiting a clinician from addressing the impairments at hand. For example, Dr. Dominic Carone claims that “...we should not abandon the use of scientific terminology because someone does not like the stigma attached to it. The problem that emerges when we start to substitute euphemistic phrases for scientific terminology is that we start to de-emphasize the seriousness of the problems.”¹² In his article, he is primarily talking about using the words ‘unhealthy weight’ rather than ‘obese’, but he also gives many other examples including cancer, anorexia, and diabetes. Similarly, a clinician may choose not to pay extra attention to the unique aspects of all patients because it is too time consuming and detracts from time that could be spent treating. One could also argue that using person first language like ‘person with a disability’ rather than ‘disabled person’ makes no fundamental difference or is negating an important part of someone’s identity.¹³

Summary

Ultimately, being mindful of different life perspectives only serves to benefit you and those you treat. If all of the other suggestions seem too far-fetched or difficult, I challenge you to do something simpler. Even if you disagree with other sexual orientation and gender non-conforming lifestyles, you can practice awareness by not making assumptions about your patients. Although the apparent shock at discovering someone’s differences may not be malintended, it can come across as embarrassing to the other person. This can hurt the therapist-patient relationship and hinder outcomes. As PT’s we strive to care for others and help restore or improve function to promote optimal health and quality of life. This includes all patients, regardless of their gender identity or sexual preference. If there is something you could start doing to be an even better therapist, why not give it a try?

Disclaimer: I can only correctly represent the part of the community that I identify with. The views expressed are my opinions and may not be generalizable to all LGBTQ persons. I am thankful to be given a platform to address a topic that is so rarely discussed, but if I have made any errors or misrepresentation, please forgive me.

Please visit Part 1: It's Not Just for Women and Part 2: Training the Pelvic Floor Musculature...Are Your Patients Missing Out? of this series for more information on pelvic floor health in general and how to implement techniques to train this unique muscle group without your patient populations. 

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Sources

1. Timothy E. Hewett P. Why women have an increased risk of ACL injury. AAOS Now. 2012(Nov).

2. SHULTZ S, KIRK S, JOHNSON M, SANDER T, PERRIN D. Relationship between sex hormones and anterior knee laxity across the menstrual cycle. Med Sci Sports Exerc. 2004;July 36(7).

3. Wood R, Stanton S. Testosterone and sport: Current perspectives. Horm Behav. 2012;January 61(1):147-155.

4. Hayhurst C. Managing patients who are transgender. PT in Motion. 2016;July.

5. Health consequences of chest binding. Transgender Cosmetic Surgical Procedures Web site. http://www.ftmtopsurgery.ca/blog/ftm-faq/health-consequences-chest-binding/. Published 18 December 2014. Updated 2014. Accessed Aug 13, 2016.

6. Herman J. Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender People’s lives. The Williams Institute: UCLA School of Law.

7. Toibaro J, Ebensrtejin J, Parlante A, et al. Sexually transmitted infections among transgender individuals and other sexual identities. Medicina (B Aires). 2009;69(3):327-330.

8. Lgbtq. NAMI: National Alliance on Mental Illness Web site. http://www.nami.org/Find-Support/LGBTQ. Accessed Aug 16, 2016.

9. Gender dysphoria. In: Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Association; 2013. http://www.dsm5.org/documents/gender%20dysphoria%20fact%20sheet.pdf. Accessed Aug 17, 2016.

10. Transgender FAQ. Human Rights Campaign Web site. http://www.hrc.org/resources/transgender-faq. Accessed Aug 17, 2016.

11. Transgender health care. Healthcare.gov Web site. https://www.healthcare.gov/transgender-health-care/. Accessed Aug 18, 2016.

12. Carone D. How political correctness interferes with healthcare. KevinMD Web site. http://www.kevinmd.com/blog/2011/12/political-correctness-interferes-healthcare.html. Updated 2011. Accessed Aug 18, 2016.

13. Ladau E. Why person-first language Doesn’t always put the person first. Think Inclusive Web site. http://www.thinkinclusive.us/why-person-first-language-doesnt-always-put-the-person-first/. Updated 2015. Accessed Aug 18, 2016. 

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About the Author: Brianna Durand is a 2nd year Doctor of Physical Therapy student at Texas Woman's University in Houston. As a military brat, she has a love of travel, but her heart is nestled in Seattle. She enjoys weight lifting, yoga, cycling, and heartfelt discussions about changing the world.