Ethical Considerations in Pediatric Pelvic Health

Working with children in pelvic rehabilitation is a deeply meaningful and highly specialized area of practice. It also comes with unique ethical responsibilities. Pediatric pelvic health involves treating conditions such as enuresis, constipation, pelvic floor dysfunction, and developmental delays — all within the context of a child’s developing autonomy, family dynamics, and sensitive anatomical areas.

As clinicians, our ethical frameworks must evolve to accommodate not only clinical best practices but also the emotional, developmental, and psychosocial needs of the child.

Here, we examine the critical ethical principles that should guide our work in pediatric pelvic rehab.

Consent, Assent, and Autonomy
Unlike adult patients, children cannot legally provide informed consent — this must be obtained from a parent or legal guardian. However, ethical practice also requires assent from the child: their affirmative agreement to participate in the therapy process. This includes:

• Explaining the treatment plan in age-appropriate language
• Respecting a child's refusal or hesitation
• Avoiding coercion, even indirectly, from caregivers

When working in the pelvic region, where the potential for discomfort or boundary violation is high, ongoing, iterative assent is essential. Even young children have a right to bodily autonomy and should feel empowered to say “no” at any time.

Scope of Practice and Referral Boundaries
Pediatric pelvic dysfunction can sometimes signal deeper issues: developmental disorders, psychosocial stressors, or even trauma. Therapists must maintain clarity around scope of practice, referring out when behavioral or psychological concerns arise that are beyond the purview of physical therapy.

Examples include:

• Suspected abuse or trauma history
• Complex toileting behaviors tied to anxiety, OCD, or family systems
• Significant delays in emotional regulation or sensory integration

Collaborative care — with pediatricians, psychologists, occupational therapists, and social workers — is often essential for truly holistic treatment.

Privacy and the Triadic Relationship (Child–Parent–Therapist)
Pediatric pelvic rehab takes place in a triadic dynamic: therapist, child, and caregiver. This requires delicate communication boundaries. While transparency with caregivers is important, so is the child’s right to privacy, particularly as they age into adolescence.

Key ethical questions to consider:

• How much of the session content should be shared with parents?
• Does the child want to speak with the therapist alone?
• Are we creating a space where the child can speak freely without fear of being reported back to their parent?

Navigating this triad ethically means validating the caregiver's role while protecting the developing autonomy and emotional safety of the child.

Touch and Trauma Sensitivity
Because pelvic therapy inherently involves close proximity to intimate body regions, we must always practice trauma-informed care, regardless of the child’s known history. That includes:

• Using neutral, non-threatening language to describe anatomy
• Modeling consent with every interaction
• Offering alternatives to internal assessment (e.g., external palpation, biofeedback, or movement-based therapy)
• Ensuring the child never feels “examined,” but instead “participates” in treatment

Even well-intentioned treatment can be experienced as invasive if delivered without attunement to the child’s comfort and nervous system cues.

Gender Diversity and Inclusive Care
As gender-diverse children and adolescents become more visible in healthcare, it is ethically incumbent upon us to provide affirming, inclusive care. This includes:

• Using the child’s chosen name and pronouns
• Avoiding assumptions about anatomy, gender identity, or toileting goals
• Providing education and support for caregivers navigating unfamiliar terrain

If you’re not yet comfortable or informed in this area, seek training — not just for ethical compliance, but to provide competent and compassionate care.

Documentation and Legal Reporting
Ethical practice in pediatric care also includes accurate, sensitive documentation — especially when required to interface with schools, insurance providers, or legal systems.

Additionally, as mandated reporters, pelvic health professionals must know the signs of possible abuse or neglect and report concerns appropriately. This responsibility is both legal and ethical and should never be avoided due to discomfort or fear of disrupting rapport.

Ethical care in pediatric pelvic health is not just about following rules — it’s about respecting the whole child, honoring their voice, and creating a space where healing can happen safely. In this sensitive area of practice, our ethics must be as carefully honed as our clinical skills.

Through trauma-informed care, developmental awareness, and collaborative practice, we can offer children and families the support they need — while upholding the highest ethical standards of our profession.

Take the next step in this learning journey, and earn your ethics CEUS by joining Mora Pluchino, PT, DPT, PRPC, in Ethical Considerations for Pediatric Pelvic Health on July 27th. This one-day remote course covers ethical considerations for professionals working in the area of pediatric pelvic health. In general, healthcare professionals have many day-to-day ethical considerations to “do no harm.” This includes fundamental decisions related to billing, patient care, safety, and compliance.