When we consider the intersectionality of sexual orientation and gender identity within the realm of intersex and LGBTQIA+ identities, we must recognize the multifaceted nature of individuals' experiences. For some intersex individuals, navigating aspects of identity may be complex, as their biological sex characteristics may not align with societal expectations of gender. Intersex individuals face a range of challenges in navigating their identities, including medical interventions without their consent, stigmatization, and lack of awareness and understanding from healthcare providers. These challenges highlight the need for clinicians to educate themselves on intersex experiences and provide inclusive and affirming care.

Resources for Clinicians to Support Intersex Patients
While you may be reading this thinking, ‘I don’t know anyone who is intersex,’ or ‘I don’t work with Intersex patients,’ you might be surprised to learn that you probably do! Intersex variations are as common as having red hair. The United Nations Free & Equal Initiative Intersex Fact Sheet states that “According to experts, somewhere between 0.05 percent and 1.7 percent of the global population is born with intersex traits. The upper estimate is bigger than the population of Mexico.” So, if you know, or have ever seen someone with red hair, you probably know or have seen someone who is intersex too.

Clinicians who are looking to better support their intersex patients can benefit from accessing resources specifically tailored to understanding and addressing the unique needs of this community. Two great Intersex-led organizations to help educate you and provide support to intersex patients and their caregivers are InterACT Advocates for Intersex Youth and InterConnect.

These organizations offer information and guidance on how to provide affirming care to intersex individuals and provide help to clinicians who want to educate themselves on intersex identities, familiarize themselves with the challenges faced by intersex individuals, and learn about best practices for promoting the health and well-being of their intersex patients.

Educate yourself, stand with intersex advocacy organizations, and amplify intersex voices to make a difference. Let's strive for a world where every identity is celebrated and respected because diversity strengthens us all. As Maya Angelou once said, "We all should know that diversity makes for a rich tapestry, and we must understand that all the threads of the tapestry are equal in value no matter their color."

So how do I learn more? What resources can I give to intersex patients and their families to support them? Well, to learn more about how to be an ally in healthcare to intersex patients and their families, and for more resources, register today for Intersex Patients: Rehab and Inclusive Care, scheduled for February 8th, 2025!

Additional Resources:

1. InterACT Advocates, Lambda Legal (2018). Providing Ethical and Compassionate Health Care to Intersex Patients: Intersex-Affirming Hospital Policies. This guide incorporates input from medical practitioners, legal experts, and members of the intersex community. The guide offers model policies for hospitals designed to promote best practices and assist hospitals and their providers in delivering appropriate, intersex-affirming care. For example, the policies address issues of confidentiality, non-discrimination, gender identification, infant genital surgery, and sterilization, shared decision-making, and informed consent – issues that, when mishandled, can cause significant harm to intersex patients and their families, as well as open up medical institutions to significant liability. The guide also incorporates background information and explanations for each model policy to provide education in an area that has historically been misunderstood.
2. Intersex Peer Support Australia (IPSA). https://isupport.org.au/. IPSA is a non-profit organization, led by people with variations of sex characteristics (sometimes known as intersex) who are passionate about combatting isolation, shame, and stigma through community connection and peer support. IPSA seeks to tackle the stigma and misconceptions that surround intersex variations through education and advocates on issues affecting the wider intersex community to improve affirmative healthcare, foster intersex pride, strengthen our community, and deepen social culture. IPSA is a peer-led, not-for-profit intersex organization and a registered health promotion charity.
3. InterLink. https://www.ilink.net.au/. InterLink brings people together to talk about living with innate variations in sex characteristics with the support of trained counselors and intersex peer workers. InterLink also provides community care coordination, helping people get linked in with appropriate allied health and community-based services, advocacy, and peer support groups.

One of the most bothersome and common symptoms experienced by patients going through the menopausal transition is hot flashes (Freedman 2015). Vasomotor symptoms can vary in intensity from mild to debilitating (Gold et al., 2000), and patients can suffer from a flushed face up to a full sweat with the removal of clothing and a brisk fan required for relief. Hot flashes can affect a patient’s focus, sleep, and activity tolerance. These pesky flashes are also associated with several medical disorders including heart disease, dementia, and osteoporosis (Biglia et al, 2017).

What causes hot flashes isn’t entirely known. A variety of factors can be at play including genetics, personal experience, cultural influences, and medications (Biglia et.al, 2017), however, one of the predominant factors contributing to these flushes is decreasing or fluctuating estrogen levels. Declining estrogen is linked with the KnDy (kisspeptin-neurokinin B-dynorphin neurons) located in the hypothalamus. These neurons project to the thermoneutral zone also located in the hypothalamus. This zone regulates the temperature in the body. As estrogen levels diminish, these neurons hypertrophy. This causes an increase in activity to the thermoneutral zone making the patient more sensitive to temperature changes (Rance et al, 2013). A small shift in temperature causes a greater physiological response triggering the hot flash.

In their 2022 position statement on hormone therapy, the North American Menopause Society recommends estrogen as one of the most effective treatments for this symptom. It is cited as a safe and effective option which many choose for relief. For some patients, this is not an option due to either personal choice or contraindications from their medical history.

An adjunct or alternative treatment for hot flashes is cognitive behavioral therapy (CBT). It has been proven as an effective diminisher of hot flashes and can be utilized by patients through this transition (The Non-Hormonal Position Statement of the North American Menopause Society 2023). In the book Living Well Through the Menopause, authors Hunter and Smith describe the importance of utilizing cognitive behavioral therapy as a tool for diminishing the intensity and bother of hot flashes.

One of the tools specifically mentioned in their recommendations is diaphragmatic breathing. This is a common skill that can be taught to patients by providers to help manage pain and urinary urgency symptoms. By tapping into the parasympathetic or “rest and digest” aspect of the autonomic nervous system, it facilitates the body to chill out and calm. This can also be recommended to patients in the menopausal transition as one method of hot flash management. Quieting the nervous system throughout the day can aid in stress management and decrease the intensity of hot flashes.

Another tool for management is self-care (Hunter and Smith 2021). Perimenopause can be a time of great stress for many. Busy work schedules, aging parents, and active teenagers can cause patients to forget about prioritizing time for themselves to reflect, recharge, and pause. Patients' lives are often constant caregiving and chaos. With this flurry of activity, the importance of their own health and well-being can be forgotten. Clinicians are integral in reminding patients that taking time for themselves will ensure they are capable of handling the circus of activities they are juggling. Giving the patient permission for self-care can be invaluable. Encouraging exercise, friendships, and taking a rest can help with stress management and in turn can help with sleep and the severity of symptoms (Hunter and Smith 2021).

Ahhhhh sleep, so often disrupted in this phase of life. Hot flashes certainly play a role with this as does stress. Both can play off the other. Educating our patients about the effects of alcohol, caffeine, and bright light bombardment before bed can help them on the road to better rest. Teaching meditation or diaphragmatic breathing before bed can also provide benefits (Hunter and Smith 2021). With better sleep comes less stress and with less stress comes reduced symptoms.

When patients experience vasomotor symptoms, the pelvic health provider has several tools in their toolbox to help with management. There are non-hormonal options out there that can make a difference. Clinicians can help patients navigate through the menopausal transition with tools for decreasing the intensity of symptoms and improving quality of life.

To learn more, sign up for Menopause Transitions and Pelvic Rehab scheduled for February 1-2, 2025. This course is an excellent opportunity to understand the physiological consequences to the body as hormones decline, in order to assist our patients in lifestyle habits for successful aging. Course topics include cardiovascular changes, metabolic syndrome, bone loss and sarcopenia, neurological changes (headache, brain fog, sleeplessness), Alzheimer’s risk, and urogenital changes. Symptoms and treatment options will also be discussed, including hormone replacement, non-hormonal options, dietary choices, and exercise considerations. 

References:

1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022. 29(7): p. 767-794.
2. Biglia, N., et al., Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases? Climacteric, 2017. 20(4): p. 306-312.
3. Freedman, R.R., Menopausal hot flashes: mechanisms, endocrinology, treatment. J Steroid Biochem Mol Biol, 2014. 142: p. 115-20.
4. Gold, E.B., et al., Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. Am J Epidemiol, 2000. 152(5): p. 463-73.
5. Hunter, M.a.S., Melanie, Living Well Through the Menopause: An Evidenced Based Cognitive Behavioural Guide 2021, Great Britain: Robinson.
6. Rance, N.E., et al., Modulation of body temperature and LH secretion by hypothalamic KNDy (kisspeptin, neurokinin B and dynorphin) neurons: a novel hypothesis on the mechanism of hot flushes. Front Neuroendocrinol, 2013. 34(3): p. 211-27.
7. The Nonhormone Therapy Position Statement of The North American Menopause Society" Advisory, P., The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 2023. 30(6): p. 573-590.

Author Bio
Christine Stewart, PT, CMPT

Christine Stewart, PT, CMPT (she/her) graduated from Kansas State University in 1992 and went on to pursue her master’s degree in physical therapy from the University of Kansas Medical Center graduating in 1994. She began her career specializing in orthopedics and manual therapy then became interested in women’s health after the birth of her second child.

Christine developed her pelvic health practice in a local hospital with a focus on urinary incontinence and prolapse. She left the practice in 2010 to work at Olathe Health to further focus on pelvic rehabilitation for all genders and obtain her CMPT from the North American Institute of Manual Therapy. She completed Diane Lee’s Integrated Systems Model education series in 2018. Her passion is empowering patients through education and treatment options for the betterment of their health throughout their lifespan. She enjoys speaking to physicians and to community-based organizations on pelvic health physical therapy.

Did you know that Ramona Horton is going to be speaking at HWConnect in March? Her lecture is titled, “The Do Not Miss List: What many pelvic rehab therapists overlook." I don’t know about you, but we’re pretty excited to hear what she has to say and to learn from the best!

So, who is Ramona C. Horton MPT, DPT?
Ramona completed her graduate training in the US Army–Baylor University Program in Physical Therapy in San Antonio, TX. She exited the army at the rank of Captain and applied her experience with the military orthopedic population in the civilian sector as she developed a growing interest in the field of pelvic dysfunction and received her post-professional Doctorate in Physical Therapy from A.T. Still University in Mesa, AZ. In 2020, Ramona received the prestigious Academy of Pelvic Health Elizabeth Noble Award for her contributions to the field of pelvic health.

Ramona is the lead therapist for her clinic's pelvic dysfunction program in Medford, OR where her practice focuses on the treatment of urological, gynecological, and colorectal issues. Ramona has completed advanced studies in manual therapy with an emphasis on spinal manipulation, and visceral and fascial mobilization.

Not only is Ramona Horton, MPT, DPT speaking at HWConnect 2025 in March, but she has also developed and instructs the Visceral and Fascial Mobilization Course Series for Herman & Wallace. If you haven’t taken a course from Ramona or heard her speak, then we highly recommend that you do!

The top 3 reasons to sign up for a course with Ramona Horton are:
1. Understand the true function and mechanisms of manual therapy.
Manual therapy is presented as a concept and technique that does NOT “release” tight or bound fascia based on the skill or magic hands of the practitioner. The issue is not in the tissue, if the tissue is tight, it’s tight because the brain is keeping it that way. Muscles are marionettes, and the brain is the puppet master. Manual therapy utilizes the fascial system to access the nervous system. In other words, having a conversation with the brain over the tissue that it appears to be protecting while trusting that the homeostatic mechanism is functioning in the body. If this is done in a non-threatening manner, the brain will normalize the tissue it is holding and guarding.

2. Add a whole host of new tools to your practitioner toolbelt.
The myofascial course teaches basic screening techniques that will point you in the right direction toward finding where the body is protecting, not where symptoms are being expressed. You will learn a variety of techniques to approach different fascial layers including direct and indirect fascial stacking for superficial nerves within the panniculus, muscular, and articular restrictions, as well as indirect technique of positional inhibition for trigger points. In addition, the science behind basic neural mobilization, instrument-assisted fascial mobilization, and fascial decompression (cupping) are presented.

3. Learn more about fascia, its origins, and its functions.
Fascia is EVERYWHERE throughout the body; it is the ubiquitous connective tissue that holds every cell together much like the mortar in a brick wall, in addition to cells, it connects every system in the body. Fascia contains a vast neurological network including nociceptors, mechanoreceptors, and proprioceptors just to name a few. The fascial system has multiple layers within the body: starting at the panniculus which blends with the skin, the investing fascia surrounding muscles and forming septae, the visceral fascia which is by far the most complex and the deepest layer of fascia, the dura surrounding the central nervous system extending to the peripheral nerves. All fascial structures, regardless of layer or location have their origin in the mesoderm of early embryologic development. The myofascial course presents evaluation and treatment techniques for three of the four fascial layers while the three visceral courses address the complex visceral fascial layer.

Ramona Horton's Mobilization Series 2024 Course Schedule
The Mobilization courses are available in satellite and self-hosted formats. PLUS Ramona is going on the road this year and will be teaching directly from different satellites for each course. Find out more on the Visceral and Fascial Mobilization Course Series home page. Satellite locations can be found on the main course page and may change, be added or removed, for future course events.

Mobilization of the Myofascial Layer: Pelvis and Lower Extremity - Satellite Lab Course
April 4-6

Bradenton FL
Medford OR
Milwaukee WI
Novato CA
St. Petersburg FL
Torrance CA
Self-Hosted

Mobilization of Visceral Fascia: The Gastrointestinal System - Satellite Lab Course
March 7-9

Appleton WI
Lansing MI
Nashville TN
Portland ME
Tampa FL
Torrance CA
Tuscon AZ
Self-Hosted

June 27-29

Milwaukee WI
St. Petersburg FL
Sellersville PA
Self-Hosted

Mobilization of Visceral Fascia: The Urinary System - Satellite Lab Course
January 31-February 2

Fort Lauderdale FL
Medford OR
Tampa FL
Torrance CA
Wichita KS
Self-Hosted

May 16-18

Atlanta GA
Bradenton FL
Philadelphia PA
Self-Hosted

November 14-16

Milwaukee WI
Stevens Point WI
Self-Hosted

Mobilization of Visceral Fascia: The Reproductive System - Satellite Lab Course
October 17-19

Milwaukee WI
Omaha NE
Torrance CA
Tuscon AZ
Self-Hosted

Mental Health is a very serious global concern! As a health care provider, I have seen my patients anxious, scared, confused, tearful, depressed, and sometimes in sheer panic with debilitating anxiety and pain. As they express these emotions, they look for a glimmer of hope and look up to me with the trust that I as their provider will be able to “fix” all their concerns. I have felt the immense burden they carry and many times their emotions cross over and affect me too.

At that moment, the only thought racing through my mind was how could I decrease their physical and psychological distress to help them “feel better.” How could I decrease the burden they carry not just physically, but mentally and emotionally, and how could I empower them with the tools and strategies to build both physical and mental resilience?

The American Physical Therapy Association (APTA) supports interprofessional collaboration at the organizational and individual levels to promote research, education, policy, and practice in behavioral and mental health to enhance the overall health and well-being of society consistent with APTA’s vision. Physical, behavioral, and mental health are inseparably interconnected with overall health and well-being. It is within the professional scope of physical therapist practice to screen for and address behavioral and mental health conditions in patients, clients, and populations. This includes appropriate consultation, referral, or co-management with licensed health services providers in the prevention and management of behavioral and mental health conditions (1) through its position statement HOD P06-20-40-10.

The APTA also endorses evidence-based complementary and integrative interventions (HOD P06-18-17-47) underscores the importance of incorporating Integrative medicine practices within physical therapy. At the State level, as a member of the American Physical Therapy Association of New Jersey (2), I have been actively involved in Co-Charing the new Integrative Physical Therapy (IPT) Special Interest Group. IPT blends traditional physical therapy methods with holistic practices that address the whole person—physically, mentally, emotionally, and spiritually. This initiative aims to enrich therapists' capabilities in delivering Integrative Physical Therapy by leveraging a variety of methodologies, including Yoga, Mindfulness, Tai Chi, Hydrotherapy, Acupuncture, Acupressure, Zero Balancing, Reiki, Nutrition and Energy medicine to name a few.

According to the National Center of Complementary & Integrative Health (NCCIH), a branch of the National Institutes of Health (NIH), Mental health problems are common. In the United States, they affect about one-fourth of adults in any given year. According to the World Health Organization, mental illnesses account for more disability in developed countries than any other group of illnesses. Anxiety and mood disorders are the most common mental health problems. Researchers are investigating complementary and integrative health approaches for a variety of mental health problems, including anxiety & depression (3).

Anxiety disorders are one of the most common mental health concerns with a major contribution to the global burden of disease. Pharmacology and psychotherapy stand for the conventional treatment for anxiety disorders but these present limited efficacy, especially in the case of chronic anxiety, with high relapse rates often causing adverse side effects (4).

Anxiety is a natural part of the human experience, often serving as a protective mechanism in response to potential threats. However, when symptoms become chronic, disproportionate, or uncontrollable, anxiety can escalate into a clinical disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), anxiety disorders vary in presenting symptoms and may include excessive worry, panic attacks, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances. Beyond these distressing psychological and emotional disturbances, the sequelae of anxiety extend into the realm of physical health. Research has pointed to a correlation between anxiety and increased pain responses, as well as the exacerbation of musculoskeletal disorders (5).

Anxiety disorders have profound implications on both mental and physical health.
There is growing interest in manual therapy modalities, with emerging research to alleviate related symptoms (5). A systematic review by West et al (2024) found that individuals receiving manual therapy interventions displayed a statistically significant reduction in anxiety intensity. The use of Acupressure for Anxiety is a common practice in Integrative Medicine, and the literature supports Acupressure as an effective and feasible alternative treatment for decreasing anxiety. A systematic review and meta-analysis published by He et al. (2019) found moderate evidence that Acupuncture and/or Acupressure was significantly associated with reduced cancer pain and decreased use of analgesics.

Acupressure is part of Traditional Chinese medicine (TCM), which is a comprehensive science that studies human health and disease. A central relational element of TCM is Yin and Yang, which refer to opposites, mutually exclusive yet complementary substances within the human body and the outside world. Based on the theory of the balance of Yin and Yang and the interaction of five elements (五行) (metal, wood, water, fire, and earth), TCM analyzes changes in the five Zang organs (五脏) (liver, heart, spleen, lung, and kidney), six Fu organs (六腑) (gallbladder, stomach, large intestine, small intestine, bladder, and triple energizer), extraordinary Fu-organs (奇恒之腑) (brain, marrow, bone, pulse, gallbladder, uterus, and ovary), meridians (the channels of basic substances transportation and connecting inside and outside of the human body), and qi-blood-body fluid (the basic substances constituting and maintaining the human life activities) (6).

A recent study by Yang et al (2021) cited several key Acupressure points that can help with Anxiety & fatigue (Heart 7, Spleen 6), chemotherapy-induced nausea, vomiting and anxiety in women with breast cancer ( Pericardium 6), primary dysmenorrhea ( Liver 3 ), anxiety & pain in cancer patients (Large Intestine 4, Heart 7), pre-operative cesarean section anxiety (Yintang EX-HN 3 and Heart 7), anxiety from the anticipation of surgery or treatment (Yintang EX-HN3, Heart 7 & Pericardium 6).

The literature also provides robust scientific evidence supporting Acupressure as an effective non-pharmacological therapy for the management of a host of conditions such as insomnia, chronic pelvic pain, dysmenorrhea, infertility, constipation, digestive disturbances, and urinary dysfunctions to name a few.

Case Study
Clinically, our ability to target the nervous system to make a change in a patient’s pain and anxiety is extremely valuable from a pain neuroscience perspective. Recently a patient in her early 60s walked into the clinic with high anxiety and rectal pain rated 15/10. She reported that she spoke to her best friend and her friend who had found relief for anxiety with urinary retention with Acupressure had urged her to see me. She said, “I have tried everything, and you are my last hope!”

This patient had been to the ER twice over a span of 3 months and had undergone extensive testing with no diagnostic pathology. The only position she could find relief was in a side-lying but she was so distressed at the thought of “spending the rest of my life on the couch” that she refused to lie down in that position during the day, even if it meant relief from her excruciating pain.

The first thing I taught her was to notice how shallow her breath was, and how to use her breath deeply and actively to decrease her pain and anxiety by using two key Acupressure points Central Vessel 17 (CV 17), located at the center of her chest and Yintang EX-HN3, located between the eyebrows. CV17 is known to be a point for emotional healing while Yintang (EX-HN 3) is known to have a mentally stabilizing effect in Traditional Chinese Medicine (TCM). Within a few minutes, the patient felt very calm and relaxed and felt that she now had some control over her symptoms.

She was now able to focus and actively listen to me as I explained to her that we needed to work not just on the physical body, but also the mental, emotional, and energy body. I guided her to accept the “positional preference” of her body and “align” herself mentally and physically with what makes her “feel better.” So instead of feeling bad every time she thought about lying down to decrease her pain, I taught her to feel empowered that she had one position that she could use to break the cycle of her pain. This shift in how she approached her pain, as well as the potent Acupressure points to alleviate pain and anxiety, were a tremendous relief to her. I sent her home with a breathwork practice, a pelvic girdle stretching program, and an Acupressure program that targeted key Acupoints for self-regulation. The patient returned the next visit and reported that her pain was down from 15/10 to 5/10.

Over the course of the next few visits, using a combination of Acupressure as a self-regulation tool, targeted stretching of the lower back & pelvic girdle musculature, manual therapy, self-care, and breath work and awareness, this patient gained complete control over her anxiety and pain. She felt much calmer and empowered to have a physical self-regulation Acupressure practice which she could use to improve both her physical and mental health.

As a holistic pelvic health practitioner, who is psychologically informed with an Integrative physical therapy clinical practice, I recognize the deep-rooted mind-body connections and the need to address the “whole” person. In all the ancient and modern Energy healing practices, the breath is the key to working with the physical, mental, emotional, and the energy body. Acupressure is a powerful evidence-based energy healing practice that can be combined with breathing to heal the body in multiple dimensions. When a patient can “breathe better” and “feel better,” they can be steered easily towards building both physical and mental resilience.

As healthcare providers, we share this mental and emotional burden with our patients, and we must empower them with the tools and strategies to live healthy pain-free and anxiety-free lives.

To learn more about Acupressure, please join us for the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for Feb 1st & 2nd. The course will introduce course participants to the basics of Traditional Chinese Medicine (TCM), Acupuncture & Acupressure. Of the 12 major Meridians or energy channels, this course will focus on the Bladder, Kidney, Stomach, and Spleen meridians. In addition, there are other important Meridian points that stimulate the nervous system and can be used for self-regulation to manage Anxiety, pain, and a host of other symptoms. The course also offers two potent Acupressure home exercise and wellness programs.

This course explores Yin yoga as a powerful holistic practice with Acupressure and will offer an evidence-based perspective on how Yin poses within each meridian can channelize energy through neurodynamic pathways with powerful integrative applications to facilitate healing in multiple dimensions.

References

1. The Role of the Physical Therapist and the American Physical Therapy Association in Behavioral and Mental Health: Position statement https://www.apta.org/apta-and-you/leadership-and-governance/policies/role-pt-apta-behavioral-mental-health
2. American Physical Therapy Association of New Jersey: Integrative Physical Therapy Special Interest Group https://aptanj.org/page/IPTSIG
3. National Center of Complementary & Integrative Health (NCCIH) https://www.nccih.nih.gov/health/anxiety-and-complementary-health-approaches
4. Amorim D, Amado J, Brito I, et al. Acupuncture and electroacupuncture for anxiety disorders: A systematic review of the clinical research. Complement Ther Clin Pract. 2018;31:31-37. doi:10.1016/j.ctcp.2018.01.008
5. West KL, Huzij T. A systematic review of manual therapy modalities and anxiety. J Osteopath Med. 2024;124(11):487-497. Published 2024 Jun 24. doi:10.1515/jom-2024-0001
6. Yang J, Do A, Mallory MJ, Wahner-Roedler DL, Chon TY, Bauer BA. Acupressure: An Effective and Feasible Alternative Treatment for Anxiety During the COVID-19 Pandemic. Glob Adv Health Med. 2021;10:21649561211058076. Published 2021 Dec 12. doi:10.1177/21649561211058076
7. He Y, Guo X, May BH, et al. Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis. JAMA Oncol. 2020;6(2):271-278. doi:10.1001/jamaoncol.2019.5233
8. Zhang SQ, Li JC. An introduction to traditional Chinese medicine, including acupuncture Anat Rec (Hoboken). 2021;304(11):2359-2364. doi:10.1002/ar.24782
9. Abbott R, Hui EK, Kao L, et al. Randomized Controlled Trial of Acupressure for Perception of Stress and Health-Related Quality of Life Among Health Care Providers During the COVID-19 Pandemic: The Self-Acupressure for Stress (SAS) Trial. Am J Med Open. 2023;10:100056. doi:10.1016/j.ajmo.2023.100056
10. Chen SR, Hou WH, Lai JN, Kwong JSW, Lin PC. Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2022;28(1):25-35. doi:10.1089/jicm.2020.0256
11. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521.

Author Bio
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University, New York with a Doctor of Physical Therapy degree. Rachna has since been working in outpatient hospital and private practice settings with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer County, New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner, and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. Her clinical practice has focused on an Integrative physical therapy approach blending traditional physical therapy methods with holistic practices that address the whole person - physically, mentally, emotionally, and spiritually. She specializes in working with pelvic health patients who have bowel and bladder issues with high pelvic pain which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and the Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional, and energy body.

One of the things you'll learn when working with the pediatric population is that they're a different species than adults. Some of the common diagnoses may overlap, such as chronic constipation, fecal smearing, or nocturia. The way they present may be similar and the treatment ideas and philosophy may also overlap. However, how these treatments are implemented may vary when treating a child versus an adult. When I think of treating the pediatric population, I like to divide my thought process and approach into five different groups.

To me, pediatrics can be babies/infants, toddlers, preschool-aged children, elementary school-aged children, and then tweens/teens. It may feel excessive to divide this population into so many subgroups, but each of those groups has its own treatment considerations based on the child's development at that time in their lives. An infant may be working on regulating their GI system as they transition from being in-utero to being born. Toddlers and school-aged children are working through various internal and social benchmarks to help them continue to grow and develop. Likewise, a tween or teen may be managing the changes to their genitourinary system as they work through puberty towards adulthood or grappling with their sexuality and sexual identity as they mature.

Regardless of what stage they are in life, patients will potentially present differently and also need a customized treatment plan to meet them where they are at. When I have colleagues jumping into pediatric pelvic health, I rarely worry they have the clinical skills to help with the physical and physiological challenges a child may face. The place I see many clinicians struggle is how to apply the skills they know to these tiny humans in front of them. Treating reflux in an eighty-year-old versus an 8-week old person is very different.

Children can't always tell us what they're feeling and how they're feeling it. An adult that has the ability for interoception can tell us what they're feeling, how they're feeling it, and how our treatment interventions are affecting their condition and goals. A pediatric patient may not be able to provide this feedback so subtle signs such as skin color, facial expressions, and body language may be your only clues. Likewise, being able to interpret a baby or child's negative reactions, such as crying, trying to get away, trying to hide, or otherwise avoiding therapy is a very necessary skill when working with pediatrics. Long story short, we can ask an adult if what we're doing is working, with a pediatric patient, we have to be more creative in determining our efficacy.

Children can't give consent. Children can give assent, meaning that they will comply with what you are asking them to do. This can feel tricky and if you struggle with this I recommend taking Ethics Considerations for Pediatric Pelvic Health on July 27, 2025. When working with pediatric patients, the take-home point is that the therapist will always have more power than the child that they are working with. This means that the therapist has to be very careful in how they wield their power dynamic, to be most beneficial and fair to the child.

Children usually can't be autonomous with their home programs. When I think about home programs, some of my adult clients even struggle to complete these correctly or regularly. Many times, especially when they're under the age of 10 years old, children cannot be autonomous with their home programs. This means that a practitioner has to consider what is going on in the home, the living situation that the child is in, their support system, the financial resources available to the child, and other factors that may act as help or hindrance to their home program activation.

Children need caregiver support and guidance. As we said above, most of the care that we're giving to a child in the home is going to be provided with the support or completely by a parent or caregiver. We have to make sure that the child's guardian is on board with the treatment plan, has the resources and ability to enact the treatment plan, and is being respectful to the child as they work on the program at home. As therapists, we have to help navigate bumps and challenges on this road to recovery for the child and their support system, or else we're not doing all aspects of our job. I am always asking myself questions like:

“Can this family afford this?”

“Do they have time for this?”

“Do they understand why I am asking them to do this?”

“Is me asking this of this family adding unnecessary stress to this child or the caregivers?”

Children deserve to be offered to “buy in” to their plan of care. One of the mistakes I see colleagues make is understanding the wisdom of children. Yeah, they're tiny. Yes, they sometimes eat their boogers and think poop jokes are funny. Still, children are much more intuitive than we frequently give them credit for. I've had kiddos as little as 3 years old be excited to drink their “poop juice” to help move their “poop train.” If we “make it make sense” for them, they become the biggest, most powerful part of their care team! Teaching lifelong good habits is something I know most therapists love about their jobs and working with kids provides this so easily.

If you're a provider who is jumping from adults to pediatrics or if you are new to pelvic floor with pediatrics in general, Pediatric Pelvic Floor Playskills is a class that walks you through challenges and solutions by age, sample treatment plans, and problem-solving case studies to build your confidence and efficacy in treating this population. Hope you decide to come play with us on January 25th!

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

Mora Pluchino, PT, DPT, PRPC (she/her) is a graduate of Stockton University with a BS in Biology (2007) and a Doctorate of Physical Therapy (2009). She has experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. She began treating Pelvic Health patients in 2016 and now has experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much she has not treated since beginning this journey and she is always happy to further her education to better help her patients meet their goals.

She strives to help all of her patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, She opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Ask anyone on the street what one should do for osteoporosis and the typical answer is weight-bearing exercises - and they would be partially right. Weight-bearing, or loading, activities have been shown to increase bone density.(1) But that’s not the whole story. Different exercises have different strain magnitudes, strain rates, and strain frequencies - all of which impact bone density.

• Strain Magnitude - the force or impact of the exercise. Exercises such as gymnastics and weightlifting have a high strain magnitude.
• Strain Rate - the rate of impact of the exercise. Exercises such as jumping or plyometrics have a high strain rate.
• Strain Frequency - the frequency of impact during the exercise session. Exercises such as running have a high strain frequency.

When considering weight-bearing exercises for a home exercise program, the million-dollar question is, “How much weight-bearing is enough to stimulate bone growth, and how much is too much to compromise bone at risk for a fracture?” We know that there are incidents of individuals fracturing from just their body weight upon standing. Recently patients have been asking about heel drops and stomping, and whether they should do them. One size does not fit all.

An alternative is to focus on odd impact loading. A study by Nikander et a (2) targeted female athletes in a variety of sports classified by the type of loading they apparently produce at the hip region; that is, high-impact loading (volleyball, hurdling), odd-impact loading (squash-playing, soccer, speed-skating, step aerobics), high magnitude loading (weightlifting), low-impact loading (orienteering, cross-country skiing), and non-impact loading (swimming, cycling). The results showed that high impact and odd impact loading sports were associated with the highest bone mineral density.

Marques et al found that odd impact has the potential for preserving bone mass density as does high impact in older women in their 2011 study (3). Activities such as side stepping, figure eights, backward walking, and walking in square patterns help “surprise the bones” due to the different angles of muscular pull on the hip. The benefit, according to Nikander, is that we can get the same osteogenic benefits with less force, moderate versus high impact. This type of bone training would offer a feasible basis for targeted exercise-based prevention of hip fragility.

I tell my osteoporosis patients that if they walk or run the same route, the same distance, and the same speed that they are not maximizing the osteogenic benefits of weight bearing. Providing variety to the bones creates increased bone mass in the femoral neck and lumbar spine.(4)

Dancing is another great activity that combines forward, side, backward, and diagonal motions to movement. In addition, it adds music to make the “weight-bearing exercises” more fun. Due to balance and fall risk, many senior exercise classes offer Chair exercise to music. Unfortunately sitting is the most compressive position for the spine and is particularly problematic with osteoporosis patients. Also, the hips do not get any weight-bearing benefit. Whenever safely possible, have patients stand; you can position two kitchen chairs on either side, much like parallel bars, to hold on to while they “dance.”

Providing creativity in weight-bearing activities using odd impact allows not only for fun and stimulation and offers more “bang for the buck!”

Build on your knowledge of osteoporosis management by joining Deb Gulbrandson and Frank Ciuba in their upcoming short course Osteoporosis Management scheduled for January 25! Not only will you gain a deeper understanding of the scope of the problems, and specific tests for patients with osteoporosis, but you will also learn skills for evaluating patients as well as appropriate safe exercises for an Osteoporosis program. 

Resources:

1. Mosekilde L. Age-related changes in bone mass, structure, and strength--effects of loading. Z Rheumatol (2000); 59 Suppl 1:1-9.
2. Nikander et al. Targeted exercises against hip fragility. Osteoporosis International (2009)
3. Marques et al. Exercise effects on bone mineral density in older adults: a meta-analysis of randomized controlled trials. Epub 2011 Sep 16
4. Weidauer L. et al. Odd-impact loading results in increased cortical area and moments of inertia in collegiate athletes. Eur J Appl Physiol (2014)
5. Benedetti MG, Furlini G, Zati A, Letizia Mauro G. The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients. Biomed Res Int. 2018 Dec 23;2018:4840531. doi: 10.1155/2018/4840531. PMID: 30671455; PMCID: PMC6323511.

AUTHOR BIO:
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.

Did you know that the food you eat can directly impact the way your brain processes pain and responds to stress? This may seem like a surprising connection, but research has shown that a maladaptive central nervous system (CNS), can be influenced by dietary choices.

A maladaptive CNS is a condition where the brain's ability to regulate sensory input and adapt to changes is compromised, leading to amplified pain perception and other negative symptoms commonly associated with chronic pain conditions. In this article, we'll explore the impact of diet on the development and function of a maladaptive CNS and discuss how making healthy dietary choices can help improve its resilience and overall cognitive abilities. So, buckle up, put down that bag of chips, and get ready to learn how your diet can affect your central nervous system.

The Maladaptive Central Nervous System
A maladaptive CNS exhibits abnormal changes in its function that leads to amplified pain perception, impaired motor control, or other negative symptoms often associated with chronic pain conditions due to its inability to properly regulate sensory input and respond in an adaptive way. A maladaptive CNS can manifest in a variety of manners including chronic pain from central sensitization, poor descending inhibitory control, and decline in neuroplasticity.

Dietary choices can significantly impact the development and function of a maladaptive CNS by altering the way the brain processes sensory information and responds to stimuli. Research has shown that diet and exercise can have profound consequences for increasing the resilience of the CNS to injuries and for maintaining cognitive abilities. Both can influence the capability of the brain to fight disease and react to challenges.

Healthy diets, such as those high in omega-3 fatty acids and curcumin, contained in foods such as salmon and turmeric, can stimulate molecular systems that serve neuronal function and plasticity in the brain and spinal cord and can elevate levels of molecules important for daily brain function, for example, brain-derived neurotrophic factor (BDNF). Conversely, unhealthy diets that consist of high amounts of saturated fats and sugars, as prevalent in “junk food,” do the opposite. A poor diet high in processed foods and low in nutrients can trigger inflammation throughout the body, including in the central nervous system, potentially leading to increased sensitivity to pain and stress.(1)

The Enteric Nervous System
This brings us to the enteric nervous system (ENS), this second brain both stores and produces neurotransmitters, serving as the scaffolding of interplay between the ENS, SNS, and CNS. Healthy brain function and modulation are dependent upon the microbiota’s [gut bugs] activity of the vagus nerve.(2)

Microbial factors, cytokines, and gut hormones can also impact cognition by finding their way to the brain through the gut mucosal system and its local immune system. This impacts not only cognition, but also emotion, mood, stress resilience, recovery, appetite, metabolic balance, interoception, and PAIN.(3) So, by process of logic, the food we eat, or fail to eat, directly impacts the health or dysfunction of this magnificently orchestrated system. One that directly and profoundly impacts our brain, our body, and our being.

In conclusion, it is evident that our dietary choices play a crucial role in the health and function of our central nervous system. By consuming nutrient-rich foods, we can promote the resilience of our CNS and maintain cognitive abilities. On the other hand, a diet filled with processed and unhealthy foods can have detrimental effects on our brain and spinal cord, leading to inflammation and increased sensitivity. It is up to us to make mindful and deliberate choices when it comes to what we eat, as it directly impacts our overall well-being. As the saying goes, "You are what you eat," and this rings true for the health of our CNS.

Learn how to nourish our bodies and minds with wholesome and nourishing foods, and in turn, strengthen the powerhouse that is our central nervous system. As always, the conversation doesn't end here. Let's continue to explore and discuss the impact of diet on our bodies, CNS, and strive towards optimal brain health. Join Megan Pribyl for Nutrition Perspectives for the Pelvic Rehab Therapist to gain vital and clarifying information in her next course scheduled for February 22-23, 2025.

Resources

1. Gomez-Pinilla F, Gomez AG. The influence of dietary factors in central nervous system plasticity and injury recovery. PM R. 2011 Jun;3(6 Suppl 1):S111-6. doi: 10.1016/j.pmrj.2011.03.001. PMID: 21703566; PMCID: PMC3258094.
2. Turna, J., Grosman Kaplan, K., Anglin, R., & Van Ameringen, M. (2016). "What's Bugging the Gut in OCD?" a Review of the Gut Microbiome in Obsessive-Compulsive Disorder. Depress Anxiety, 33(3), 171-178. doi:10.1002/da.22454
3. Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066

AUTHOR BIO
Megan Pribyl, PT, CMPT, CMTPT/DN, PCES

Megan Pribyl, PT, CMPT, CMTPT/DN, PCES (she/her) is a mastery-level physical therapist at the University of Kansas Health System in Olathe, KS treating a diverse outpatient population in orthopedics including pelvic health, pregnancy, and postpartum rehabilitation – all with integration of health and wellness. She began her PT career in 2000 after graduating from the University of Colorado Health Sciences Center with her Master of Science in Physical Therapy. Prior, she earned her dual degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) in 1998 from Kansas State University. Later, she obtained her CMPT from the North American Institute of Orthopedic Manual Therapy and became certified in dry needling in 2019. Since 2015, she has been a faculty member of Herman & Wallace Pelvic Rehab Institute and enjoys both teaching and developing content. She created and instructs Nutrition Perspectives for the Pelvic Rehab Therapist offered remotely through Herman & Wallace. She also teaches Pelvic Function – Level 1, Pregnancy Rehabilitation and Postpartum Rehabilitation. She brings many years of experience and insight to all courses. As a content developer, Megan has also contributed to the Herman & Wallace Oncology Series, Pelvic Function Level 2A, as well as the Pelvic Function Series Capstone Course.

Megan’s longstanding passion for both nutritional sciences and manual therapy culminated in her creating Nutrition Perspectives for the Pelvic Rehab Therapist designed to propel understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. She harnesses her passion to integrate ancient and traditional practices with cutting-edge discoveries creating a unique experience sure to elevate your level of appreciation for the complex and fascinating nature of clinical presentations in orthopedic manual therapy and pelvic rehabilitation. Clinicians will come away from this course with both simple and practical integrative tools that can be immediately utilized to help clients and providers alike - along their path of healing.

Megan enjoys her many fulfilling roles as an instructor, clinician, wife, and mom to two active teenagers and owner of two rambunctious golden retrievers. She loves to read, cook, be in the great outdoors, travel, and spend time with her family and friends. She has a passion for both the mountains and the beach, exploring scientific literature, and learning all she can about the power of using nature, nurture, and nutrition to heal and sustain health.

As the holiday season approaches, it’s the perfect time to prioritize what truly matters. Join us March 28-30 at HWConnect in Seattle, WA to discover the power of networking, learning, and growth as we come together to celebrate the gift of connecting to one another. At Herman & Wallace, we believe that connection is the heart and soul of meaningful relationships, personal growth, and professional opportunities.

Networking opportunities throughout the event allow attendees to connect with like-minded individuals, share ideas, and build lasting relationships. Through structured networking sessions, informal social gatherings, and interactive activities, attendees will be able to expand their professional network and form meaningful connections with others in their industry. These networking opportunities are a highlight of HWConnect and create a supportive and collaborative environment where new friendships are formed, and partnerships can be forged.

Keynote speakers and topics include Dawn Sandalcidi, PT, RCMT, BCB-PMD lecturing on the “Development of Continence Through The Lens of The Diaphragm, Ribcage, and Pelvic Floor;” Nancy Norton, RN discussing “The Power of Humor for Pelvic Healers,” and Leticia Nieto, PsyD, LMFT, TEP who will be delving into “Trauma Responsive Care for Those We Work With and for Us.”

Other speakers and topics include:

• Ken McGee, PT, DPT - "5 Lessons from Gender-Affirming Care for All Your Clients"
• Carole High Gross, PT, DPT, PRPC - "Eating Disorders and Disordered Eating: Putting the pieces together and the hope pelvic rehabilitation can provide"
• Dr. Cindy Mosbrucker - "Endometriosis and the Evil Triplets: IC, IBS, and Levator Spasm"
• Ramona C. Horton, MPT, DPT

There is scheduled time in the vendor hall where vendor sponsor CMT will be along with other exhibitors including Intimate Rose, PacificRoots (MedRoots), Shift MD, and SRC Health. You can also opt in to morning yoga, meditation, or other breakout sessions throughout the day. Some of our favorite faculty members will be leading these sessions: Dustienne Miller, Nari Clemons, Brianna Durand, Emily McElrath, and Allison Ariail.

Past attendees have provided glowing reviews of the conference, including:

This holiday season, don't miss the opportunity to gift yourself a ticket to HWConnect. Embrace the importance of networking, learning, and growth with inspiring keynote speakers and valuable sessions. Register today and take the first step towards building lasting connections that will enrich your personal and professional life.

As author Leo Buscaglia once said, "Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around." Make the choice to prioritize connection this holiday season and reap the benefits for years to come. Happy holidays, and we look forward to seeing you at HWConnect!

For decades, the G-spot has captivated attention, sparking debates in science and popular culture. Is it a distinct anatomical structure, a myth, or simply the same region as the 'female prostate'? While opinions differ, the heart of the discussion may be less about anatomy and more about semantics. Let’s explore the evidence and why this debate persists.

The Anatomy of the G-Spot and Female Prostate
The term 'G-spot' was introduced by German gynecologist Ernst Gräfenberg in 1950, describing a sensitive area on the anterior vaginal wall linked to the urethra and its surrounding tissues (near the bladder neck). In 1981, sexologists Beverly Whipple and John D. Perry popularized the term in their book, emphasizing that this area could enhance pleasure for some women. Notably, the G-spot was never claimed to be a single 'magic button' but rather a zone of heightened sensitivity.

Modern research has shifted focus to the female prostate, also known as Skene’s glands, which are located near the urethra. These glands share histological and functional similarities with the male prostate, contributing to urinary health, sexual arousal, and orgasm.

Evolving Perspectives on the Debate
Early Skepticism: In 2001, Terrence Hines dismissed the G-spot as a 'modern gynecologic myth,' citing inconsistent evidence and suggesting its existence was more cultural than anatomical.

Reframing as the Female Prostate: A 2022 review proposed reclassifying Skene’s glands as the female prostate. It argued that sensations attributed to the G-spot may stem from the stimulation of these glands and surrounding tissues.

A Matter of Semantics?
Does the debate boil down to terminology? Gräfenberg’s description of the G-spot and modern studies on the female prostate appear to refer to the same periurethral region. Whether we call it the G-spot or the female prostate, the area has been scientifically linked to pleasure. The controversy seems less about function and more about naming conventions.

Orgasms are Diverse: The vaginal (G-spot) orgasm isn’t the only type of orgasm or pathway to pleasure. Research indicates that approximately 70–80% of women require direct clitoral stimulation to achieve orgasm, as the clitoris contains a high concentration of nerve endings, making it particularly sensitive

Statistics on Female Orgasm:
- 40.9% of women orgasm from both clitoral stimulation and vaginal penetration.
- 35.4% orgasm solely from clitoral stimulation.
- 20.1% orgasm solely from vaginal stimulation.
- 16% report pleasurable sensations from cervical stimulation.
- 3.6% are unable to achieve orgasm.

Final Thoughts
The evidence suggests that the G-spot, as a distinct entity, is less about anatomical uniqueness and more about the interplay of surrounding tissues, including the female prostate. What’s more important than terminology is recognizing and embracing the diversity of orgasmic experiences. Whether clitoral, vaginal, cervical, or a combination, all forms of pleasure are valid and backed by science. Moving forward, let’s focus less on labels and more on understanding and normalizing the spectrum of female sexual health and pleasure.

Join Tara Sullivan in her upcoming remote course, Sexual Medicine in Pelvic Rehab, on January 18-29, 2025 if you are interested in learning more about hymen myths, squirting, G-spot, prostate gland, sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm, and function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post prostatectomy; as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus.

References:

The statistics provided on female orgasm are derived from various studies, primarily published in The Journal of Sexual Medicine. Below are the references for these statistics:

1. "40.9% of women orgasm from both clitoral stimulation and vaginal penetration" and "35.4% orgasm solely from clitoral stimulation"
   These figures are from a study published in The Journal of Sexual Medicine, which examined women's orgasmic experiences through self-reported surveys:
   • Herbenick, D., Reece, M., Sanders, S. A., Dodge, B., & Fortenberry, J. D. (2010). Women's Experiences with Vaginal Penetration and Its Association with Orgasm and Sexual Pleasure: Findings from a Nationally Representative Sample of Women in the United States. The Journal of Sexual Medicine, 7(Suppl 5), 324–333. DOI: 10.1111/j.1743-6109.2010.01814.x
2. "20.1% orgasm solely from vaginal stimulation"
   This statistic comes from the same study, which highlighted how a subset of women can achieve orgasm through vaginal stimulation alone but noted variability based on anatomy and personal preferences.
3. "16% report pleasurable sensations from cervical stimulation"
   This finding comes from a 2023 study published in The Journal of Sexual Medicine, which focused on sensations related to cervical stimulation:
   • Schubach, L. A., et al. (2023). Cervical Sensitivity and Orgasm: Self-Reported Experiences from an Online Survey. The Journal of Sexual Medicine, 20(1), 49–59. DOI: 10.1093/jsm/jqac115
4. "3.6% are unable to achieve orgasm"
   This figure is derived from population-level studies on sexual dysfunction and orgasm prevalence:
   • Kingsberg, S. A., et al. (2019). Orgasmic Dysfunction in Women: Epidemiology and Treatment Outcomes.Obstetrics and Gynecology International Journal, 27(6), 10–17.

AUTHOR BIO:
Tara Sullivan, PT, DPT, PRPC, WCS, IF

Dr. Tara Sullivan, PT, PRPC, WCS, IF (she/her) started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage, anatomy, and physiology. During that time, she attended college at Oregon State University earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Masters of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD) treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC) deeming her an expert in pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company Mind to Body Healing (M2B) to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.

Rehabilitation providers experience ethical conflicts every day, whether they realize it or not. Just today, I was cruising through social media on my lunch break and saw a post (edited for autonomy) that posed an ethical concern, potentially without its author even knowing. We’ll refer back to this post throughout the blog so please read:

“We have a patient at my clinic whose partner called and scheduled the appointment for the patient. My colleague did the evaluation this morning and said the partner answered all questions for the patient. The partner was inquiring about decreasing posterior pelvic floor tension for anal sex. The therapist found it strange that the partner was answering all the questions for the patient. At this time, I'm really wondering if the partner is forcing the patient to come to pelvic floor therapy and participate. How would you all handle this situation?”

You know this stopped my scroll immediately. Yes, it is a patient care question. However, this situation also brings up so many other intricacies that we encounter as pelvic health providers. I gave my reply and then read others, and this experience made me glad that Herman and Wallace offered three ethics classes talking about ethics for pelvic floor therapists to attend and be able to collaborate on issues just like the one above.

There are many ways that people like to work through ethical situations and scenarios and the ethics series with H&W usually uses the RIPS model, but just to add some new perspective, today we are going to look at the above scenario through the lens of The Critical Dialogue Method.

Delaney et al. (2024) state “Clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others.” Their article dives into 7 steps of facilitation of such discussions among clinicians. This model is intended to help clinicians identify issues, clarify, and guide them as needed. It also acknowledges that not all ethical problem-solving is linear, chronological, or top-down.

Step One is “setting the scene.”
This is known as an opening statement. This alerts a provider’s peers about the details of the inquiry and allows those participating to be fully present to give their input. As therapists like to do, we should be working to create a safe space for the provider with the questions. In the scenario above, that post was step one as it set the scene for what the therapist had concerns about.

Step two is “listening actively and without interruption.”
This is where therapists get to put all of their experience in being active listeners with patients to the test. Keep in mind these steps don’t need to be linear so listening and replying with questions that show a person was actively listening is important. In our example, we’ve all joined a social media location to collaborate and share clinical questions, thus tacitly agreeing to be active listeners.

Step three is “gathering information and perspectives.”
This is when those active listening skills come in. When it's a social media post, this might be the comments section or even DMs! In our scenario above, therapists were great at sympathizing, empathizing, clarifying, and giving their perspective. They said things like “I’m seeing the red flags you are” and “I’ve had that happen to me and here is what happened…” Someone even kindly took the partner’s side asking if maybe they were a medical provider and that was an explanation for the potentially problematic controlling behavior. Here are some examples of statements or questions that showed a therapist was actively listening.

• What I heard you say is….
• The way you described it, what seems to have happened is…
• I’m hearing that there is some (insert emotion here - confusion, uncertainty, apprehension)....
• Can you tell us more about….
• Can you explain what you meant when you said…

(Adapted from Delaney et al., 2024)

Step four entails "closing in on the ethical question(s).”
This helps move the situation from what has been ethically feeling problematic to what can be done to resolve the issue. In this scenario, I think we can think of a few ethical questions. Some that come to mind are below:

• Is a partner allowed to make their spouse attend a therapy session potentially against their will?
• Is a spouse entitled to privacy with only their therapist if they would like this?
• Is a therapist able to intervene if they suspect abuse is occurring?
• If abuse is suspected, what next steps should be taken?

Step five is about “identifying ways of responding.”
This allows the conversation to move from “What is wrong” to “How do we resolve this?” The first part of this is exploring all of the “possible and available courses of action (Delany et al., 2024).” In this case, we’re thinking about what options are on the table, and what is reasonable while also considering the “what ifs” and things that have already been tried. In our scenario, a variety of solutions were provided to the questioning clinicians.

• Separate the couple in order to let the patient speak about their needs without pressure from the spouse.
• Provide privacy with a closed door and noise machine.
• Address the patient’s goals, reviewing them privately with the patient’s permission, to ensure they align with what their partner may have said previously.
• Check in with the patient’s referring provider to see if they have any concerns about abuse.

Step six involves “identifying and weighing the ethical pros and cons of each possible response.”
In our above scenario, we have a variety of potential pros and cons. We could offend, embarrass, or potentially lose a client by making a false allegation. We could deny a shy, anxious, or scared patient their emotional support human. We could be robbing a partner who feels guilt or worry over possibly causing their partner pain the ability to help correct it. We could also be helping a patient leave an abusive relationship or avoid having to perform an activity they don’t want to. We could be preventing domestic violence or any type of abuse. There is a spectrum, and we can create many scenarios along the way.

Step seven, the last step, is “ethically justified outcomes.”
This means that all of the previous steps have been completed (not necessarily sequentially or singularly) and then an ethically appropriate action is selected. As the RIPS model teaches us, there are many different situations and so some ethical scenarios will be very simple with just one answer, while others may be a dilemma being two potentially right answers, while others may be a whole lot of “it depends” and “I’m not sure!” In our case above, the consensus was that we definitely needed more information in order to make an informed decision on the next course of action!

If you were intrigued by taking a clinical question like this and trying to come up with a “good” solution, you may enjoy taking Ethical Concerns for Pelvic Health Professionals to sharpen, or just use, your ethical and clinical decision-making skills! The next course event is scheduled for January 19th, 2025.

Reference:

• Delany C, Feldman S, Kameniar B, et al. Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible. Journal of Medical Ethics. Published Online First: 08 July 2024. doi: 10.1136/jme-2024-109927 https://jme.bmj.com/content/early/2024/10/24/jme-2024-109927