Congratulations to Dr. Mia Fine (they/she) for achieving their Ph.D. in Clinical Sexology and on their book titled 'From Unwanted Pain to Sexual Pleasure: Clinical Strategies for Inclusive Care for Patients with Pelvic Floor Pain' for their dissertation doctoral project.

Dr. Fine was gracious enough to share a draft of their dissertation with Herman & Wallace and to answer a couple of questions about how this impacts their practice and what they hope other practitioners will take away from their book and course Sexual Interviewing for Pelvic Health Therapists.

Mia's course is for the pelvic rehab therapist and others in the medical profession who work with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns and would like to learn applicable skills from the sex therapist's clinical toolkit. The next course date for Sexual Interviewing for Pelvic Health Therapists is August 13-14,

How does Trauma-Informed Care apply to the skills that you teach in your Sexual Interviewing course?

When I utilize the term ‘trauma-informed’ I am referring to therapeutic work that communicates expectations clearly (including prioritizing people’s access needs with this communication), invites clients awareness of their own agency, and is upfront about my scope of practice and my therapeutic approach, offers mutuality in inviting of questions and ongoing conversation about our work together, awareness that an individual can end therapy at any time, and share information at any time in our therapeutic space. 

The modalities I utilize when working with clients who have experienced trauma include Eye Movement Desensitization and Reprocessing (EMDR), Polyvagal Theory, Somatics, and Developmental Theory. While I integrate various theories and modalities into my work with clients, the methods above are empirical in their data to support healing from trauma wounds.  

Trauma-informed means humility regarding cultural, racial, gender, sexual, and other minority experiences. I will not know all of the things but I will do my best to self-educate and not leave that responsibility to my clients. When I make a mistake I will appropriately, directly, and compassionately apologize for the harm I caused and invite opportunity for repair should the client be interested. Trauma-informed means collaboration in exploring therapy together, co-creating a space that feels safer to the client and checking in with them when I notice non-verbal cues that indicate activation, honoring a client’s pacing, and bringing awareness to the reality that as a therapist I hold power and while I don’t know a person’s full story there is always the potential for me to unintentionally activate a client so to share this possibility with clients and continuously check in about how our therapy is working for them. I keep my client’s well-being at the forefront of our work and I center their needs at all times while maintaining boundaries that keep everyone as safe and secure as possible. 

It is up to us as trauma-informed and inclusive providers to explore a person’s experience of pain by asking questions about onset, process, location, and impact, in addition to offering psychoeducation about anatomy, physiology (arousal, interest, desire), and self-regulation. This must be done alongside commitment to our patient’s co-regulation, normalization, and informed consent concerning the therapeutic process—all of which are needed for comprehensive trauma-informed care. 

Can you explain how expanding what 'normal' is to practitioners can impact the patients and clients that they work with?

Sex is not supposed to be painful. How many people have come to me having had painful sexual intercourse for years and reported “pushing through”? The first time having intercourse does not necessarily have to be painful, but when our cultural narratives tell us “the first time having sex is painful for everyone” we end up ignoring the signals our bodies are offering because we have convinced ourselves that the pain is both okay and normal. The “pushing through” is a reflection of misogyny: people assume the first experiences people have with penetration are supposed to be painful. How is this misogynistic? Well, who benefits from a person “pushing through” pain? The partner with the penis. Important to note here as well is that enthusiastic consent is ableist and ignores the mind-body connection because it does not take into account masking or fawning which are common experiences for many.

A quarter of people who experience sexual health concerns share this with their providers. Why such a small fraction? Fear. Fear of embarrassment and shame. Fear that there is something “abnormal” about them that mutates into the shame humans tend to experience in response. Fear that the concern won’t be held or taken seriously by their provider. Fear that, if it is addressed, will be at such a high financial cost that the treatment will be unaffordable. Fear that there’s not enough time or that they won’t be taken seriously. Fear of exclusivity, feeling othered, or misunderstood by their provider. Fear of the unknown because the reality is that people are afraid of what we don’t understand. 

One of the major cultural issues we have in the US is the perpetuation of sexual stigma which is largely associated with a lack of comprehensive sex education. People don’t have access to basic information about their own bodies which influences our beliefs about sex, pleasure, agency, communication, and self-awareness. Sex education should be a birthright, and yet we are so far behind the curve that it sometimes feels impossible to break down the barriers.

When I first started in this career it would often take clients months of working with me to feel comfortable enough to talk about where they felt pain during sex, but in developing the tools to co-create safety in our therapeutic relationship and the skills to ask the important questions with compassion and patience, I learned how to better hold space for healing.

Patients don’t often know what information is important for them to share with us (which is why offering visuals of where the pain is located is important). How could they know what information is important to offer when mental and sexual health are so deeply stigmatized? The stress of shame and embarrassment that people feel about their bodies is emotional pain that further exacerbates the physical pain that they came to therapy to address in the first place. It’s a terrible and self-perpetuating cycle. 

I teach people the difference between a vulva and a vagina one thousand times a year. If a client does not know the terminology for labia, vulva, vagina, and clitoris, how are they supposed to know when their sexual health is of concern? If a person enters sex therapy with “sexual pain” but is unable to distinguish the difference between their labia and vagina (that they are different body parts, where they are located, and what their functions are) we cannot expect them to accurately articulate the location of pain or comprehend potential solutions. “What is your hygiene process when cleaning your vulva?” may activate the fight or flight response in clients if they do not know what their vulva is or that there could be a good hygiene process, in addition to the shame of not knowing. How are they supposed to know where or to whom they may ask for help?

An online search for “anatomical vulva”, “pelvic floor pain”, “vaginismus treatment” and 99% of the images and figures you will see are those of hairless, slender bodies with white/light skin and small labia. Racism and white supremacy are present everywhere. The anatomical depictions of vulvas are of white bodies, the people modeling in vaginismus treatment advertisements are white, and the language is geared toward and written for white people. I was intentional about not featuring white vulvas in this book because white bodies should not be the default of what is mainstream. This lack of diversity in skin tone and variation of body type is another reflection of racism called “colorism”. White and light skin bodies are viewed as more ‘normal’ and when we continue to center white bodies in visuals “because that is what is available” we perpetuate white supremacy. One goal is to disrupt the idea and practice of whiteness as the default. This is what it means to practice anti-racism and attempt to divorce ourselves from white supremacy. 

The impact of shame shows up in the pervasive erotophobia rampant in our society. Erotophobia can be broadly defined as a “fear of sex” or more specifically a “fear of intercourse”. When erotophobia is judgment as a result of societal shame and stigma, we can navigate it by deconstructing the etiology and impact of messages received; when it is a result of a mental health condition such as Obsessive Compulsive Disorder (OCD) or Post Traumatic Stress Disorder (PTSD), we do deep trauma and/or anxiety/exposure work. Because of the vast impact of shame, people fear sharing sensitive information about themselves with others,  including therapists who are trained to help them. Often, therapists are untrained in sexual health which also can contribute to erotophobia and shame. When therapists have not done their own work on sexuality, and remain untrained in these areas, they may be afraid to discuss sex with their clients which reinforces the belief that topics regarding sex are shameful. 

When people do not have the language to articulate what is happening in their body, as significant as the pain or discomfort might be, talking about sex with a provider is often the last item on a long list of concerns they bring to a medical appointment. Symptoms of sexual pain may be hidden by other “more pressing” concerns such as anxiety, depression, PTSD, or sleep issues. While these are of course vital for a medical provider to know, having 20 minute appointments with a physician who will prioritize the “presenting concern” that they came in to seek treatment for leaves very little time to discuss unwanted sexual pain. After 15-20 minutes of a medical appointment (if it goes well), a patient might feel comfortable enough to bring up their sexual concern, but this might leave 1 minute for it to be acknowledged and no time to conduct a comprehensive assessment or develop an intentional plan. We call these last-minute oh-by-the-way’s “door-knobbing” for a reason. This is a call for medical clinics to have training in sexual health so they can create intake documentation that explores clients’ sexual health and ask the questions that are vital to gather necessary information ahead of time. 

In the same way that people lack language and anatomic understanding, people also lack awareness of the mind-body relationship. Due to the ableist sex-negative culture in which we live, people are often not taught to have knowledge of or listen to our own body. We’re not taught that pain is a signal from the body telling us that something’s wrong. 

Holly Tanner Short Interview Series - Episode 3 featuring Lauren Mansell

Lauren Mansell shares, "We're never ready to do this work. We're never ready to be perfect." Her course, Trauma Awareness for the Pelvic Therapist, is for all practitioners, not just physical therapists. Anyone licensed who works with patients can benefit from this topic. However, it can be offputting to put ourselves into a vulnerable position by registering for a course on this topic. Lauren understands this and comes prepared to teach other practitioners about trauma-informed care in the gentlest way possible.

Lauren Mansell, DPT, CLT, PRPC, CYT curated and instructs this course. Lauren worked in counseling and advocacy for sexual assault survivors before becoming a physical therapist. She also brings her experience as a 2017 Fellow of the Chicago Trauma Collective to teach trauma-informed care to medical providers. Trauma-informed care is especially important as the field of pelvic rehabilitation becomes more inclusive.

Pelvic rehabilitation and pelvic therapists really do treat the whole patient. Patients can present with pain, long-term issues, and undisclosed trauma that can be compounded when it includes sex, bladder, or bowel issues. Trauma Awareness for the Pelvic Therapist addresses several topics under this umbrella and spends time on each of the following:

• Explaining and describing compassion fatigue, trauma-informed care as well as anatomy, neurobiology, physiology of trauma, and the polyvagal autonomic nervous system
• Identifying risk factors and Adverse Childhood Experiences (ACEs)
• Formulating techniques for reducing compassion fatigue, secondary trauma, and retraumatization

To learn more about trauma-informed care join H&W this weekend at Trauma Awareness for the Pelvic Therapist this September 25-26, 2021. The course will be offered again in 2022 if you are not available this weekend!

When looking through past blogs from The Pelvic Rehab Report, I ran across this gem submitted by Lauren Mansell explaining Trauma-Informed Approach and her course Trauma Awareness for the Pelvic Therapist. While it is not policy to recycle past articles, this was too good not to share again. Lauren succinctly explains the Trauma-Informed Approach that is instructed in her remote course, Trauma Awareness for the Pelvic Therapist, and it is as pertinent today as it was when first published in 2018.

[as written by Lauren Mansell]…

In my experience, trauma creates the trauma, and the body responds in characteristically uncharacteristic ways.

People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal, and caring manner. Always. Every time. To the best of my ability, and without shame or blame.

Let’s talk briefly about Trauma-Informed Approach. This is a (person), program, institution, or system that:

• Realizes the widespread impact of trauma and understands potential paths for recovery
• Recognizes the signs and symptoms of trauma in clients, families, staff, and others affected
• Responds by fully integrating knowledge about trauma into policies, procedures, and practices
• Seeks to actively resist retraumatization

The tenets of Trauma-Informed Approach are:

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment, voice, and choice
• Cultural, historical, and gender issues

Trauma specific interventions:

• Survivors need to be respected, informed, supported, connected, and hopeful- in their recovery
• Interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, anxiety, musculoskeletal presentation, and acute crisis- including suicidal/homicidal ideations (coordination with other service providers)
• Work in a collaborative way with survivors, families, and friends of the survivor, and other service providers in a way that will empower survivors.

Types of trauma are varied, but I usually treat survivors of emotional, verbal, sexual, and medical trauma. I have even treated patients who felt traumatized by other pelvic floor physical therapists (again, no judgment). Since most of my clinical experience includes sexual and medical trauma survivorship, I try to reframe these experiences as potential post-traumatic growth, especially when working with my oncology patients. For my pelvic patients who divulge sexual trauma, I don’t dictate or name anything. I allow the survivor to make the rules and definitions. Survivors of sexual trauma need extra care when treating pelvic floor dysfunction.

First, when treating survivors of sexual trauma: expect ‘characteristically uncharacteristic’ events to occur. These include the psychological/somatic effects of passing out, flashbacks, seizures, tremors, dissociation, and other mechanisms of coping with the trauma. Have a plan ready for these patients.

Triaging the survivor to assess their needs, when trauma has been verbalized/disclosed:

• Are you safe right now?
• Do you need medical treatment right now?
• What do you need to feel in control of (PT session/immediately after disclosure of trauma)?
• You have choices in your treatment and in your response to trauma.
• I believe you.
• Lastly, is this a situation for mandated reporting?

After assisting the survivor in their journey towards healing, it is imperative that you take care of yourself. Make healthy boundaries (with patients and others) and take time to decompress, create healthy ritualistic behaviors, mindfulness/relaxation, and somatic release (like yoga, massage, or working out). These are crucial to successfully treating patients who have experienced trauma and who have shared that trauma experience with you.

Because I use gentle yoga for both my trauma survivors’ treatment and for my own self-care, my course implements evidenced-based trauma-sensitive yoga. Additionally, modifications for manual therapy are explored. The class is designed to be informative and experiential while integrating the Trauma-Informed Approaches of Safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice and cultural, historical and gender issues.

Join Lauren Mansell and H&W to learn more in the remote course Trauma Awareness for the Pelvic Therapist, scheduled for September 25-26, 2021.