In Canada, transgender and gender diverse people continue to face barriers to healthcare due to discrimination when seeking safe care. Research illustrates that health care professionals sometimes refuse to provide treatment or don’t have the training or knowledge to treat a transgender person’s health condition, or folx have difficulty getting a referral to a specialist. There are deficiencies in the physiotherapy sector as well – although the numbers are growing, still only a few physiotherapists have been qualified or are comfortable to assist with gender affirmation surgery preparation and recovery. Perhaps even fewer who are comfortable with the topic of sexual health. 

Sex and intimacy are functional daily activities, and thus, require more attention from pelvic health physiotherapists. Prior to gender affirming surgery, folx may already experience pelvic pain especially pain with sex/intimacy due to long-term tucking and/or using a gaff, or packing. Tightness or improper use can lead to urinary dysfunction, bowel dysfunction, breathing dysfunction, pelvic pain and adductor tightness. These lifestyle habits can be treated pre-operatively to ensure better preparation for better outcomes from the surgery. 

Pelvic health physiotherapists can support breathing patterns with rib and diaphragm mobility, provide tender point releases of abdominal, back, hip and leg muscles, improve pelvic floor coordination, and maximize pelvic floor capacity including strength, endurance and coordination. Beyond preparation towards healthy tissues, goals and expectations of surgery must be discussed from a rehabilitation perspective especially regarding post-operative penetrative intercourse and emotions around sex and intimacy. 

An important point that I try to get across to my clients is: Sex should be affirming to the person who experiences it. Sex does not need to be one specific activity and does not need to involve genitals. However, if penetrative intercourse via genitals is an essential component in sexual health for a person who undergoes gender affirming surgery, then it should be strongly addressed in rehabilitation. 

Post-operatively, hygiene tips, scar mobilization and management take the lead for all gender affirming surgeries including upper body and lower body surgeries. Then, clients slowly regain functional mobility, breathing patterns, desensitization of the surgical area (down-regulation of the central nervous system and treatment of the peripheral nerves) and focus on posture correction with strengthening and endurance training. 

For folx who undergo vaginoplasty, physiotherapy plays a crucial role in teaching and managing dilator therapy. The new vagina tends to retract and develop scar tissue and thus, cylindrical tools are inserted into the new vagina a few times a day, gradually increasing in size of dilators. This helps to keep the location, depth and width of the new vagina. Additionally, after a vaginoplasty, it is less likely to be able to self-lubricate and thus, lots of safe, gentle lube will be required for any penetration. Pelvic health physiotherapists are available and ready to provide educational resources to those who are seeking more information. For folx who undergo phalloplasty, maintaining an erection may require some support from mechanical devices. There are many physiological changes that require lifestyle adjustments and an element of compromise. These facts need to be discussed pre-operatively and post-operatively in a realistic manner.

Research around sexual satisfaction post gender affirmation surgeries is limited. However, there has been a review of research on sexual functioning, mostly conducted in Europe, illustrating rates of lowering of sexual desire among transgender women and increased sexual desire of transgender men with hormone therapy and gender affirmation surgery. Pelvic health physiotherapists need to practice with a whole person approach by keeping open lines of communication. This may support folx to speak about their concerns around sexual functioning and satisfaction to medical staff and ask questions relating to how physiotherapy can improve their sexual function. 

Essentially, pelvic health physiotherapy needs to be carefully integrated into the medical health care system and be readily accessible to folx who are seeking information, undergoing, and recovering from gender affirmation surgeries. Most importantly, physiotherapists require a trauma lens to be able to empathize with folx who have experienced discrimination and adversity within our community, especially relating to sexual health. We must continue to advocate for an inclusive system so that we can provide a safe space for all individuals.

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Michiko Caringal (she/her) holds a Master’s of Science in Physical Therapy as well as a Master’s of Health Science in Bioethics from the University of Toronto. She is a Registered Pelvic health Physiotherapist in Vancouver, BC, with over 15 years of experience in clinical, research, education, and leadership roles in rehabilitation, health care and fitness. She is the founder of Happy Down There Physiotherapy, and also works part-time at the University of British Columbia Bladder Care Centre. Michiko became passionate about pelvic health physiotherapy and sexual health after her own personal experience with severe sexual dysfunction and pelvic pain. Her personal accounts and professional work have been published in medical journals and she is regularly interviewed for her professional insight in popular magazines and podcasts. In the clinical setting, Michiko strives to provide the type of inclusive, patient-centred care that she wants herself. She believes that combining the clients’ expertise on their own body with her expertise in pelvic health and sexual health, helps to achieve client goals and a better quality of life. 

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