Sexual assault can have lasting physical and emotional effects on the pelvic floor. Even after treatment for PTSD, a recent study found that survivors of sexual assault were significantly more likely to experience sexual dysfunction (like vaginismus) and pelvic floor dysfunction (like lower urinary tract issues, IBS, vulvodynia, and general stress). We turned to Pelvic Floor Physical Therapist and Clinical Specialist at Origin, Dr. Ashley Rawlins, to learn more about how the pelvic floor can hold onto trauma and how pelvic floor PT can help.
Why does sexual trauma often lead to sexual dysfunction and pelvic floor dysfunction?
Dr. Rawlins: While there’s no way to say, “this is exactly what happens,” we know there’s a correlation between pelvic floor dysfunction and trauma. The pelvic floor muscles are like a guard dog for the body. They contract to protect us when they sense that something is emotionally or physically unsafe, as part of the fight-or-flight process. In some, this can lead to persistent muscle tension, and myofascial pain that is exacerbated by sexual activity. The experience of pain during sex most often leads to even more muscle tension, pain, and emotional distress — and then you can imagine how the tension and pain form a self-perpetuating cycle. In fact, we call this the vaginismus pain cycle.
As a physical therapist, what do you tend to notice when someone’s in this tension-pain cycle?
Dr. Rawlins: Over time, I’ve seen pain and trauma show up in the body (particularly in the pelvic floor) in fairly consistent ways: The first is overactive muscles, which can feel tight or tense. It can feel very difficult to lengthen or release the pelvic floor, even when it doesn’t need to be working.
The second pattern I see is one of trigger points. This is when painful points or knots can develop within a more “normal” feeling muscle, which can cause pain and muscle dysfunction throughout the pelvic area.
Trauma may also show up as numbness. In these instances, the person may have trouble feeling their pelvic floor at all. There can be some dissociation or disconnection from this part of the body, especially when it’s associated with a trauma.
In all of these instances, when the pelvic floor muscle dysfunction limits your ability to connect with, and properly use your muscles, it tends to be that pain and sexual dysfunction isn’t your only issue — you may also start to notice new or increased bowel and bladder dysfunction as well.
How do you approach supporting someone with a mind-body trauma like sexual assault?
Dr. Rawlins: Aside from the responsibility to provide affordable and convenient access to this type of care, I think the most important thing we can do to help anyone with pelvic floor dysfunction, especially when due to sexual assault, is to educate them about it. Not knowing why something is happening can make it feel even bigger and more overwhelming than it already is. It can really help someone to know that this pain they’re experiencing is part of the body’s natural alarm system. I always tell clients that what they’re experiencing is real and valid, and that there are steps we can take to safely heal the pelvic floor and prevent the trauma response.
We start working together to help their pelvic floor muscles regain balance. So, if someone is experiencing tightness, we try to introduce ways to release the pelvic floor and restore flexibility. If it’s numbness, we work on awareness and reestablishing control. We work on learning how to lengthen and contract pelvic floor muscles in a pain-free way.
As physical therapists, we use lots of tools to help people find that balance: PT exercises, manual therapy, neuromuscular reeducation, working with trigger points, dilators, sensate focus, biofeedback, pelvic wands, myofascial release, and more. All our tools are a part of reconnecting mind and body, retraining the sense that muscle movement is safe and normal.
We don’t always know when someone is coming in with a history of sexual assault. How do you work with all your clients to create a safe space?
Dr. Rawlins: I don’t assume that everyone has a history of trauma. But I do assume that someone coming in with pelvic floor pain is bringing their entire unique life history with them. Pelvic floor dysfunction doesn’t just occur in isolation — lots of things can contribute in a puzzle-piece way.
All physical therapists know how to treat the physical symptoms. And we all want to make sure there’s consent at every step. No one ever wants to retraumatize a patient. I always suggest finding someone with that added layer of trauma-sensitivity training. As a provider, they can bring an added layer of education and sensitivity to treatment.
For example, a provider who understands the polyvagal theory of pain can help establish safety with a client before diving into work. As someone providing trauma-sensitive care, I am always trying first and foremost to help my clients feel safe. That’s the only way we can learn new things and repattern. I truly believe in spending weeks connecting and grounding with patients. Providers who don’t have trauma training might skip that step. But if there isn’t safety in that patient-provider relationship, we could be making things worse.
I also think it’s key to work with a multidisciplinary team to address trauma. You might imagine a pelvic floor physical therapist, a trauma-sensitive psychotherapist, a sex counselor, etc. Physical therapy is often a great entry point to care. And then we make trusted referrals to help someone build their care team.
How can pelvic floor PT help people reconnect with pleasure and a feel-good sex life?
Dr. Rawlins: Arousal is a huge component of sexual health — without it, it’s actually hard for pelvic floor muscles to function as they should during sexual activity. Arousal is physiological, in that it brings blood flow to the tissues and lubrication to the vagina. It even allows the vaginal canal to lengthen and open (known as vaginal tenting). Lack of arousal can cause more pain and tension in the pelvic floor (which contributes to that cycle we’ve been talking about). So, I do a lot of education with clients about the sexual response cycle. It can be different for different people. For some people, desire is spontaneous — it just happens. For others, desire is more responsive, meaning that desire comes after some sort of welcomed sexual stimulus (like touch, physical closeness, or erotica). I always tell my clients that it’s worth it to figure out how pleasure works for them. They deserve to experience pleasure. It’s healthy!
Sexual counselors (like Origin’s Dr. Alex Bertucci) are also such an important component of this work. Sexual counseling can help us understand that pleasure is part of wellness and there’s nothing shameful about it. Pairing physical therapy exercises with pleasure education can be such a healing combination.
If someone is curious about pelvic floor physical therapy for physical healing after sexual assault, what’s a good first step?
Dr. Rawlins: Well, they’re already in the right place with Origin. Making an appointment with a trauma-sensitive physical therapist is an excellent place to start. In-person appointments are available in many states and we offer virtual care nationwide. For many people who have experienced sexual assault, a virtual setup can actually work better. You can take the call from the comfort of your own home and go at your own pace. I also want everyone to know that a pelvic exam is never required to heal your pelvic floor. You are in control of your body at all times.
However you begin, the most important thing is to work with a provider who makes you feel safe. In that trusted relationship, you can start to explore more of a balance in your pelvic floor over time. I really believe in the power of pelvic floor physical therapy to heal.