In this second installment of the therapeutic care supporting LGBTQIA+ individuals in their gender-affirming practices, we discuss orthopedic and pelvic floor therapies for top and bottom surgeries.
The journey to finding an authentic identity varies in the LGBTQIA+ community. Some individuals adjust their voice or wear makeup, while others bind (tape the chest) or pack (use penile prosthesis) to create a physical appearance that matches their gender identity. Top and bottom surgeries such as chest reconstruction or a hysterectomy (removal of the uterus) are more intensive procedures elected by persons who want to permanently reshape their body.
MossRehab orthopedic and pelvic floor therapists can help in the preparation and recovery of gender reconstruction surgeries. In addition to being licensed in their practices, therapists are specially trained to understand and be sensitive to LGBTQIA+ health issues related to these surgeries.
“Many of our therapists have received training through the Einstein Pride Program, the
American Physical Therapy Association and Herman & Wallace Pelvic Rehabilitation Institute on the different pelvic health and orthopedic considerations of LGBTQIA+ individuals regarding gender-affirming interventions,” notes Ann Nwabuebo, DPT, a certified pelvic health and rehabilitation practitioner who works with outpatients across the gender spectrum with pelvic health issues at MossRehab. “Coursework provides a better understanding of the gender-affirming practices of transgender and nonbinary people and how to care for common ailments.”
Gender-Affirming Top Surgery
For top surgery procedures including mastectomies (removal of breast tissues), chest wall contouring and breast augmentation, MossRehab orthopedic PTs can help prepare the body with a pre-surgical assessment to identify and resolve any musculoskeletal issues to lower the risk of problems and ensure best outcomes. PTs also provide post-surgical care for a faster recovery without complications.
“Ideally, we can evaluate a patient before surgery to resolve any pre-existing musculoskeletal issues and prep the tissue,” explains Sabura Shiffrin, DPT, who specializes in both orthopedics and pelvic floor therapies at MossRehab Tabor Road. “After surgery, we can help manage pain levels and scar tissue. I try to support proper healing and work on restoring mobility and strength while maintaining the surgical precautions of the surgeon.”
Teresa Gero, DPT, who specializes in treating patients with chronic pain at MossRehab Tabor Road and works as part of the network of pride clinicians, notes that there is evidence that prehab vs. rehab helps prepare the patient emotionally and physically before any surgical intervention. “Orthopedic PTs will conduct a thorough physical exam to identify and address any deficits so the body is strong and physically healthy before surgery,” says Gero. “Pre-surgery also is a good time for patients to receive education to understand procedures and recovery, ask questions, and get emotionally prepped to feel empowered instead of nervous,” Guro says.
Orthopedic PTs also can help optimize the healing process post-surgery. "Starting about six weeks after surgery, we can assess the surgical site to ensure proper healing, check on swelling and inflammation and ensure patients are comfortable with pain management," Guro says. "During the course of the healing and recovery process, orthopedic PTs will check on mobility and comfort, address patient issues, and conduct manual therapy or a gentle scar massage to reduce the chance of extra scar formation."
In addition, PTs provide education and emotional support, talking with patients throughout the healing journey. "We create a nice therapeutic space and get to know patients as we see them once or twice a week for an hour for a few months while the medical team might see them in a follow-up visit every eight weeks."
Care for Bottom Surgery
While orthopedic physical therapists concentrate on musculoskeletal conditions associated with gender-affirming top surgery, pelvic floor physical therapists provide patient care related to bottom surgeries such as a hysterectomy (removal of the uterus), phalloplasty (creation of penis) or vaginoplasty (construction of a vagina).
Similar to services offered by the orthopedic PT before top surgery, a pelvic floor therapist can conduct a thorough exam to ensure muscles and pelvic floor tissues are functioning before bottom surgery. "I had a patient referred to me for preoperative pelvic floor therapy in anticipation for a vaginoplasty scheduled six weeks later," explains Nwabuebo. "I focused on understanding their background relating to fitness and exercise along with any history of pain issues and pelvic floor dysfunctions such as bowel or urinary issues. I also assessed the movement of the patient's tissues and spinal and hip mobility to determine the health of the musculoskeletal system."
Because the evaluation showed some degree of tension in the pelvic floor muscles, the patient received therapy treatments focused on relaxing and stretching the pelvic floor muscles before surgery. Nwabuebo also provided education on dilator therapy to maintain the depth and width of the new vagina.
Six weeks after surgery when the patient had begun dilator therapy at home, Nwabuebo addressed any difficulties and pain associated with progressing from a smaller to a larger dilator. She also provided care on scar tissue management using manual therapy techniques that would help to stretch the pelvic floor muscles to minimize tissue restriction and pain. In addition, the patient received behavioral education regarding nutritional and lifestyle changes.
Therapy Improves Quality of Life
Length of therapeutic care after top or bottom surgery depends on the type of procedure and issues presented by a patient. Typically, individuals receive an hour of therapy weekly that can extend over several months, depending on symptoms.
"As gender-affirming surgery presents a major life change, it's helpful for patients to work with a knowledgeable pelvic floor therapist for an hour, once or twice a week," notes Shiffrin. "We build close relationships and get to know individuals very well while supporting them through their journey."
MossRehab offers a safe, competent and caring healthcare environment to all gendered individuals in providing different types of care. "We can treat any number of musculoskeletal impairments, neurological conditions and pelvic floor issues, even those not directly related to the affirmation process," says Shiffrin.
Find out more about the different gender-affirming therapies offered by MossRehab. For scheduling any general LGBTQIA+ Medicine or therapies, visit the Einstein Pride Program.