What Every Queer Person Should Know About Their Pelvic Floor

Any queer or transperson who has sought medical treatment is probably quite well aware that there are a lot of harmful misconceptions and myths about healthcare pertaining to them. One of the least discussed is the pelvic floor. Pelvic floor health has long been assumed to be relevant only to cis women, and specifically to pregnant cis women.  While pelvic floor health has been gaining greater attention in the medical community and society at large, the conversations have been primarily centered around pregnancy-related care and (assumed) cis women’s experiences. In fact, during one of my recent guest lectures, a student asked me about urinary incontinence and made the assumption that this condition only affects people with vulvas. We all have a pelvis and therefore a pelvic floor – regardless of our genitals or genders.  And because we all have a pelvic floor, we all can be susceptible to dysfunction or injury of the pelvic floor just like any other body part. 

Don’t get me wrong, pregnancy-focused health care and women-focused health care are both important, historically marginalized, and should be talked about.  However, by centering the conversation on pregnancy in cis women, the health of other patients is neglected. So let’s talk about anatomy, function, and symptoms of when something’s wrong because let’s face it, almost everyone wants to be able to pee, poop, and have sex without pain. 

So, what exactly is the pelvic floor and moreover, what does it do? Let’s start with some basic anatomy:

• The pelvic floor has 16 different pelvic floor muscles (PFM) separated into 3 layers.
  • Layer one is the most superficial and can even be felt externally. This layer is responsible for closing the anal sphincter as well as clitoral and penile erections!
  • The second layer’s main purpose is to close the urethral sphincter (to prevent leakage of pee). 
  • The deepest layer includes one of the more well-known groups of muscles called the Levator Ani. This muscle group is crucial for strength, support, and preventing prolapse.
• We also have the pudendal nerve, connective tissue called fascia, and even a few ligaments! The pudendal nerve allows us to feel external sensation in the genital region and sends nerve signals to the pelvic floor muscles causing them to contract.

Interestingly, pelvic floor anatomy is almost completely the same regardless of genitals. 

You’ve probably heard of a Kegel, which is a contraction of the PFM and is vital for controlling the urge to pee among many other things, but have you heard of a reverse kegel? A reverse Kegel is an elongation of the pelvic floor and necessary for PFM relaxation to pass a bowel movement. These are only a few examples of the many functions of the pelvic floor. Let’s break it down a bit more using a mnemonic called “The 5 S’s”:

1. Sphincteric–
   • One of the most well-known functions of the PFM is the use of our urinary and anal sphincters.
   • This is important for the prevention of incontinence.
2. Sexual
   • Did you know that an orgasm is, in part, a rhythmic sustained contraction of the pelvic floor?
   • Strong, powerful orgasms can be facilitated by a strong, coordinated pelvic floor.
   • Conditions such as erectile dysfunction, premature ejaculation, changes in orgasm strength, and pain with sex (penetrative or not) can be indicative of dysfunction. 
3. Support
   • Have you heard of Pelvic Organ Prolapse (POP)?
   • This is a condition where some internal structures such as the bladder, uterus, and rectum start move downward in the vaginal or anal canals. While society most affiliates this to folx in the postpartum stage, POP can happen to anyone- not just those who have had vaginal deliveries. While your organs are not going to just fall out of your body and onto the floor, your fascia prevents that, it is still beneficial for many reasons to keep them in the correct position inside your body. 
4. Stability
   • Are your 6 pack muscles the ones you think of when someone mentions “the core”? Maybe you also know that part of your core are the muscles in your back?
   • Both of these are true, but in the deepest layer of your core lies 4 key muscle groups, one of which is the pelvic floor!
   • That’s right, your PFM actually helps to support your spine and maintain good intra abdominal pressure, so sometimes the only obvious symptom of pelvic floor dysfunction is nagging back or hip pain that just hasn’t gone away. 
5. Sump Pump 
   • Last, we have the “sump pump” which is just another way to describe the muscle pump action of the PFM.
   • All of our muscles help to pump fluid back up towards the heart via our blood and lymph vessels and the pelvic floor is no exception.
   • When this function is not working properly we might see swelling in the lower body for no apparent reason, however this is more common in folx who have had significant trauma to the pelvis such as a forceps or vacuum-related vaginal delivery. 

Now that you’re a little more familiar with the pelvic floor and its many functions, let’s take a look at some more trans-specific symptoms:

• Pelvic pain & pain with sex after various gender affirming “bottom” surgeries like vaginoplasty, vulvoplasty, phalloplasty, and metoidioplasty 
• Urinary incontinence or increase in urinary frequency/urgency after surgery due to change in the length of the urethra
• Post-op constipation due to scar tissue in the pelvic floor muscles that were cut during surgery
• Pudendal nerve pain which can range from numbness or burning to a sharp, stabbing pain in the buttocks, genitals, or perineal region (space between vagina and rectum or scrotum & rectum)

These symptoms are not exclusive to those who have undergone surgery, however. There is some evidence that hormonal changes during HRT can influence the pelvic floor. Other behavioral factors like holding your pee for a long time if you don’t feel safe using the restroom can also contribute to some of these symptoms. 

Many people experience pelvic floor symptoms that disrupt their lives without knowing that they can be treated! If you are experiencing any pain, unexpected or uncontrolled urination, or any other symptoms mentioned above, please consider reaching out to a local pelvic floor specialist for an individualized assessment. 

Brianna Durand earned her Doctor of Physical Therapy at Texas Woman’s University in Houston, TX and her Bachelor’s of Athletic Medicine at University of Texas San Antonio. During and after graduate school, she received training on pelvic floor physical therapy in addition to her orthopedic manual skillset. As a competitive powerlifter, Brianna enjoys working with athletes who experience stress urinary incontinence. She is passionate about providing care to individuals in the LGBTQ+ community, especially those undergoing hormonal/surgical transition. Additional clinical interests of hers include: prenatal/postpartum care, vestibular and balance rehab, and sports-related injuries. In her spare time, Brianna enjoys playing board games, lifting heavy, and watching stand-up comedy.  You can find Brianna on Instagram at @empower.physio  and her website is https://empower.physio