[TW: As noted in the title, this post includes discussion of trauma] Scroll to the end for tips on self advocacy with providers.
This country has a problem with consent. The courageous folks of the #MeToo movement have furthered the discussion around consent, sexual assault, and sexual harassment, bringing these important topics out of the shadows. I would like to spotlight another often overlooked facet of these issues - medical consent and trauma.
My job as a pelvic floor physical therapist is truly very weird. It involves asking people the most private details about their lives and some of the time, touching them in the most intimate places.
I know it takes a lot to come see me. I know many of my patients have struggled for years with pain, embarrassment, loss of function, and incomplete personal relationships due to their symptoms. Not only can it take a long time for them to find me, but it takes a lot of vulnerability, trust, and hope to sit across from me in that chair.
This means I am in a position of immense power. I have valuable knowledge and the potential answers to my patients’ problems. I may even hold the possibility of their recovery, the future that they’re striving for, in the palm of my hand.
This is dangerous because I don’t really feel so powerful from this side of the table. Pelvic floor PT isn’t where the money and influence is, in the context of the world. This is even true of my physician colleagues too. Although ob/gyns have way more power than I have, they rank about 12th on the list for highest paid physician specialists and don’t even get me started on pay for primary care physicians, nurse practitioners, midwives, or ED residents/interns who are also doing many pelvic exams…
This lack of insight into our power as providers can be a problem, because we may assume that when we say, “ok, so-and-so, I would like to do a pelvic exam now”, it implies there’s a choice for the patient, but I would argue that it doesn’t feel like a choice for them. How can a patient who desperately wants to get better say no to a provider who might have the answers?
Consider too the time constraints on health care providers. Their appointments are short and they need to get to the next patient, to documentation, through the day. Are they taking the time to examine a patient’s mental state looking for hesitation? For signs of trauma?
Let’s stack another set of issues onto the list: as providers, this is our everyday work experience. Sure, it may have been anxiety producing and awkward the first few times, but after a while, our days can feel like a revolving door of undressed pelvises and doing a pelvic exam becomes not a big deal for us, a blip on our radars…
But a patient’s experience is very different and it is paramount that providers keep this in mind.
This normalization of our jobs leads to the truly bizarre phenomenon of some providers casually discussing their weekends, lunches, or funny anecdotes while penetrating a patient with a speculum, ultrasound probe, or gloved finger. From the provider’s perspective, this may be an effort to make the patient feel relaxed and comfortable, but I say it negates the patient’s experience and is akin to gaslighting.
How can a patient feel heard or validated if they experience anxiety, pain, or mental discomfort when their provider is acting like a pelvic exam is as everyday as a handshake? How can a provider truly monitor the reactions of their patients if they don’t acknowledge and respect the intimacy and intensity of the experience?
Let’s add too that a patient may not disclose trauma experiences to providers. Even if a provider specifically asks about sexual trauma and abuse, patients may not mention it. This makes sense. It takes a lot of vulnerability to tell a complete stranger about one of the worst experiences of your life. Also, some patients may not be aware that they endured trauma, or haven’t had the therapy to process it, but their past experiences left them with an overwhelming dread of being touched and this potentially paralyzing anxiety may show up during an exam.
How many providers include questions about medical trauma when taking a history? I would guess very few. But medical trauma happens. I’ve had patients with endometriosis who went to the ED because of crippling pelvic and abdominal pain, certain they must be dying, who then suffered through an excruciating pelvic exam only to be told there’s nothing physically wrong with them; that it’s all in their head. I feel palpably the anguish of my patients with vaginismus who are terrified of speculums because of past experiences seeking medical care. I lift up the voices of my patients across the gender spectrum who have been misgendered in a provider’s waiting room, and disrespected and mistreated in the office - probed deeply with potentially unnecessary questions about their sexuality and surgical history, while missing the questions needed to diagnose their pain or symptoms, reducing them to a single dimension of their lives. These bad experiences can understandably breed a lot of distrust in providers.
Providers need to earn a patient’s trust before many people will share their trauma and that may take time and demonstration of competent and compassionate care.
In the meantime, providers should treat everyone they see as if they have experienced trauma and they must keep in mind the power dynamics at play.
As providers, we should never forget the vulnerability we ask of patients when we request that they take their clothes off.
Providers need to remember both sides of the word patient. Yes, there is the medical meaning, but there is also the exhausted and desperate patience embodied by those looking for a provider, the time spent on the appointment waitlist, sitting in the waiting room, and the effort to explain once again their symptoms in hopes that this new provider will help. Providers must show respect for those seeking care and act with their own patience by truly taking the time to hear them, to earn their trust, to help.
There is no replacement for enthusiastic consent. There is no end to the value of explaining thoroughly the what, the how, the why of the exam and treatment process. Providers need to answer questions and validate concerns. Knowledge and control are power and we should be enhancing the power of our patients. Consent is fluid and patients should have the power to change their mind and stop an exam at any time. Period.
Sometimes, I can tell a patient isn’t ready. They are verbally saying yes, but their body is tense, their shoulders are high, their arms or legs tightly crossed, their whole visual message is a NO. If, as a patient, you are saying “Do what you need to” or “Let’s get it over with” to me, then you probably aren’t ready for an exam! In these cases, I tell the patient the exam can wait until another time, or it can be modified to something less invasive. Often I then see them exhale and watch the tension drop from their body. I see the apprehension leave their eyes and know I made the right choice.
Giving my patients the power in the room can be a revelation for them. I let my patients know that they are in control at every visit, during every exam. I tell them they can and should let me know if they change their mind, if something is hurting, if mental images or intense feelings are stirred up. But I don’t wait for that either. I don’t put all the onus on them. If I notice a change, if someone is no longer meeting my eyes, if they have retreated into themselves, if they’re tensing, guarding, or pulling away, I stop. I check in. I back off. It doesn’t matter if we accomplished more at a previous visit; every treatment is a blank slate and there can’t be pressure to always push forward. A person’s present experience of their symptoms or trauma may hinge heavily on their current stress level, sleep, triggering events, or many other conflicting factors that interact to form a unique picture every session. That is ok! Accepting this and removing expectations for continuous forward progress leaves space for safety and allows the room for each person to recover at their own pace.
There is nothing gained by continuing a painful, traumatizing exam. Unless the patient is emotionally present and fully participating, providers should stop. Otherwise, they have left behind the most basic tenet of medical care: do no harm.
We can further damage a patient’s physical, emotional, and mental wellbeing by rushing through, by forgetting about the power gradient, by pushing forward when it’s inappropriate or unnecessary. This is not about blaming providers. Most likely, they chose this career to help and to heal. Their hearts are in the right place and there are many pressing, ugly sides of our healthcare system that limit providers’ time, support, and their own emotional and mental bandwidth.
Truly integrating consent into daily practice is one way for providers to embody the word care. Providers must slow down and explain. They must give patients real space to say no and have other options to complete an exam. Providers should weigh carefully whether an invasive exam is really appropriate and necessary.
I honor the bravery, strength, and resilience it takes for my patients to reach out, come in, and try to heal.
Patients, I know how difficult it can be to advocate for yourself with providers. I have had this experience myself. Please know though, your needs matter. If you need something different, please tell your providers.
For some folks, this concept is so foreign, they don’t even know what they could ask for!
Here’s some ideas:
As a patient, once you find a provider you trust, stick to them like glue! I recommend that patients with a history of any type of trauma avoid bouncing around to different providers. The more a provider knows and understands your individual needs, and the more you trust your provider, the better things will go.
I am sending you compassion, strength, and courage to discuss and advocate for your individual needs with your providers. Please feel free to share this post and my contact information with your providers if it’s tough to put it into words yourself!
Jessica Abele, PT
Therapy Roo Physical Therapy
I get this question a lot and the short answer is: usually, yes! A typical pelvic floor exam is an internal vaginal exam, but unlike going to the gyno, there’s no speculum or stirrups involved. We aren’t checking your cervix, we’re assessing your muscles.
Only one gloved, lubricated finger is used for the internal component. Your therapist will first look externally to examine your skin and watch how your muscles activate. The internal exam will involve gentle touch and pressure to your vaginal muscles to make sure none of them are sore or tight. Your therapist will ask you to squeeze your muscles and assess your strength, coordination, and endurance. That’s pretty much it!
If you’re pregnant and want to be evaluated by a pelvic floor PT, we do ask you to check with your ob or midwife first. We want to make sure your medical team is aware of all treatments and to be certain that you can safely have a vaginal exam during pregnancy. For conditions like placenta previa, or preterm labor risk, your medical team may place you on “Pelvic Rest”, restricting you from intercourse or a vaginal exam during pregnancy. If this is you, we won’t do an internal exam.
If your ob/midwife doesn’t restrict you from vaginal intercourse during your pregnancy, they are almost definitely fine with you doing pelvic floor PT. Intercourse is much more invasive than what we do!
It’s helpful to mention what’s involved in a pelvic floor exam when you ask your ob/midwife...surprisingly lots of doctors/midwives don’t really know what we do! I’ve gotten a lot of strange responses from medical professionals like “Ok, as long as you don’t manipulate the cervix” or “Yes, if they wear gloves”. Don’t worry! We steer clear of the cervix and I’ve definitely never done a vaginal exam without gloves!?!”
If your doctor does say no or if you are uncomfortable with an internal exam, we can always do an external assessment, it just isn’t as informative.
Although a pelvic floor exam is used when a client is experiencing leakage, pelvic heaviness, and for perineal stretching/massage, there are other reasons to see a pelvic floor PT during pregnancy that don’t need a pelvic exam at all!
Pregnancy often comes with all sorts of fun issues...like back pain, rib pain, round ligament pain, pelvic girdle instability/pain, (you’re getting the hint that it can cause pain), core weakness, carpal tunnel syndrome, neck issues etc...
Sometimes pregnant women tell their medical team about these problems and they hear “It’ll be better when you aren’t pregnant, just stick it out”. I think it’s worth your comfort and quality of life to give treatment a try. Whatever the issue, you don’t need to suffer through symptoms alone, we’re here to help!
My last post was about the importance of self care and creating space postpartum to process your birth and prioritize your physical and emotional recovery. Maybe you want to add in more self care, but you don’t have time to think of ways to help yourself. So, let’s do it together!
What are some of the things that helped you with self care? Comment below!
I often get pushback when I say this, but I think you are just as important as your child. I know that little babe is helpless and needs constant care, but sometimes you still need to come first. As they say on airplanes, put on your own oxygen mask before helping those around you.This is often really difficult for women. Societal expectations raise us to put ourselves after others and we are taught to be caregivers. Any deviation from this can make many women feel guilty or selfish. This is amplified into your identity postpartum. Our society tells women that caring for yourself is selfish and being a good mom is about selflessness. This is dangerous rhetoric. You’re a woman with many interests, but now your thoughts and conversations mostly center around your baby’s growth and milestones. Your identity becomes Mom.
Although this is wonderful and your children add richness to your life, it’s important to keep your needs and recovery at the forefront. As an added bonus, you will do a better job caring for your children if you are healthy, rested, pain-free, and emotionally present.
Please take a moment to (without judgement) think through your recent days: did you treat yourself as a priority? Did you feel guilty taking a shower? Eating a sandwich? It’s natural biologically to tense and run over when your baby starts crying. I understand, but is someone watching out for you too? Have you caught your breath enough to think about how you’re feeling? Are you in a state of hyper-vigilance all the time?
Sometimes I am working with a client on her scar and all of a sudden, she starts crying. The intensity or even trauma of birth can be overwhelming, but there’s rarely time to process it. You are immediately a mom, with a new life and new priorities. So, you may put any grief, fear, or anxiety you had about the birth in a lockbox. Seeing a pelvic floor PT is often the first time a woman starts processing these emotions, when the scar brings them bubbling up.
It is also natural to feel some grief for the loss of the person you were. You feel different, you look different, you are different. Someone is constantly needing you and you no longer have time to yourself. Women often experience guilt about these thoughts, especially if you expected to feel only gratitude and all encompassing love. But having a baby is like throwing a bomb into your life. Even if it was an absolutely desired and sought after event, you are still picking up the pieces. Please be gentle and kind to yourself during the process. Prioritizing your physical and emotional recovery is an important, but often neglected, part of the postpartum experience.
Compassion and care for others requires self compassion and self care. As the great Ru Paul says, “If you can’t love yourself, how in the hell are you going to love somebody else?”
I just caught a commercial for a new brand of tampons and pads. The gist of the commercial was natural products and female empowerment and I’m all for it! Until the part where they proudly said “We bleed, We leak…” and I was throwing my shoe, cursing: “$*&% Noooooo!! WE DON’T NEED TO LEAK!”
Yes, it is extremely common for women to have bladder leaks. 26% of women between the ages of 18-59 experience involuntary urinary leakage and this problem affects more than 25 million people in the US overall. But COMMON does not mean NORMAL. Normalizing bladder leakage adds to the problem. Our medical system often waves people away if they complain of urinary incontinence (bladder leaks), especially if the person voicing their concern happens to be older or postpartum.
I’m all for products that will help people be more comfortable and confident on their path to recovery, but the cynical side of me recognizes that these companies have a lot to gain from this normalization and lack of treatment. Especially since the incontinence industry was estimated at $65.9 billion in 2007, with projected costs up to $82.6 billion in 2020 and some women spend as much as $900 per year on leakage products and costs related to incontinence.
It doesn’t need to be this way. There’s a lot we can do to treat bladder leaks! Some thoughts to consider:
2. Koyne KS, et al. (2014). Economic burden of urinary urge incontinence in the United States: A systematic review. Journal of Managed Care Pharmacy. 20(2). 130-140.
3. Subak, L, et al. (2006). The “Costs” of urinary incontinence for women. Obstetric Gynecology. 107(4). 908-916.
4. Bump, R., et al (1991). Assessment of kegel pelvic muscle exercise performance after brief verbal instruction. American Obstetrics and Gynecology. 165(2). 323-329.
5. Henderson, JW., et al. (2014). Can women correctly contract their pelvic floor muscles without formal instruction? Female Pelvic Medicine & Reconstructive Surgery. 19(1). 8-12.
As a pelvic floor PT, I find my clients feel really unprepared for returning to intercourse after birth. Many women go to their 6 week postpartum visit, are told they can have sex, and feel COMPLETELY overwhelmed by this prospect. “You think I can do what?? Already?!” Though you’re often given the go ahead at 6 weeks, you may receive little advice about how to return to sex and it may feel taboo to ask your doctor about it. So let’s get into it! There’s basically nothing I won’t talk about...
Dear New Mom,
Like many women, you may have waited a full six weeks before seeing your OB after giving birth. You struggled and pushed and stayed up all hours, and maybe had major abdominal surgery (hi, c-section), and then a few days later you were waved out the door with an infant and no instruction manual. Six weeks of a whole new life: crying, rocking, pain, joy, struggle, love, and drama. Then, you get to your six week postpartum visit, sleep deprived and overwhelmed, and your OB says that you’re “healed” and “good to go” back to exercise, sex, and work. And you were probably thinking, “What?!?!”
I want you to know that no woman has ever told me they felt back to normal at six weeks postpartum. You are not alone. The six week visit can be traumatic because of the vast chasm between how you feel now and what you knew as normal before. You may look at your OB and wonder if they really recognize you, do they really see you?
To give your OB the benefit of the doubt, they likely mean you are progressing normally through this recovery process. Their time with you is so limited, they really only have the opportunity to check on healing of your uterus, any perineal tears or c-section scars, and talk to you about birth control. It is relatively rare the OB will check for prolapse or diatasis recti and they almost never assess your pelvic floor muscle awareness or strength. This brief visit and the recommendation to return to all activities can result in the unrealistic expectation that you should feel back to normal after 6 weeks.
This interaction may make you feel behind the curve or ashamed of your current body and how different it is. You may worry your OB is saying this is your “new normal”, and that this is all the recovery you can hope to achieve. This shame or worry may stop you from sharing how you really feel with others. You look around at other postpartum women, who seem to be happily coping and focused on their babies, and wonder, “Is this just me?” No, it’s not just you, and we need to talk about this together!
I want you to know that we’re here to help. Your body took nine months to prepare for this and will need time to recover. Fun fact: just the uterus shrinking back down to normal size takes about 11-12 weeks! There will be so many changes and you need knowledgeable, caring providers supporting you through this process.
In some other countries (bonjour, France!), this is standard care. Every postpartum woman gets referred to pelvic floor physical therapy after every birth. This makes sense! Your whole body changes during pregnancy and the delivery process can be very physically (and emotionally) traumatic. In the US, if someone tears their ACL, they often receive up to 6 months of rehab. Well, a lot more than your knee is affected during pregnancy and birth...
Postpartum women need support here in the United States AND we need to talk openly about our bodies and how we really feel.
Things are slowly changing in the US and the American College of Obstetrics and Gynecology has revised their recommendations for the postpartum period, to offer earlier postpartum visits and extend care through 12 weeks. Until more of these changes take effect though, you will need to continue to self advocate and seek out support. You do not have to get used to incontinence, painful sex, feeling weak in your core, or pelvic pain. Please reach out to pelvic floor PTs, The Lotus Method, postpartum doulas, lactation consultants, and support groups to help you on this journey.
Jessica Abele, PT, DPT, NCS
Therapy Roo Physical Therapy
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