Transgender practices and the pelvic floor: Binding, tucking, and surgery.

Updated: Jul 7

TLDR


We all have a pelvic floor, we wouldn't be standing upright without one! There is misconception out there regarding the pelvic floor, specifically that the only people who need to pay attention to theirs are cis-women. Admittedly, it is partially the fault of healthcare providers and the education they receive, and a lack of awareness in society regarding our bodies.

Transgender individuals are not immune to pelvic floor dysfunction, although there has been little in the way of research regarding the population. The aim of this blog post is to briefly cover unique practices to transgender individuals and how they relate to their pelvic floor and overall health.



Binding


The purpose of binding is to flatten out the chest with use of tight wrappings, whether it be clothing, bandages, or compression garments.


Binding has the benefit of allowing an individual to change their appearance to match their gender identity. This may help boost self-esteem and confidence, and positively impact body dysmorphia.


There are health conditions associated with binding, however, that are important to keep in mind when using this practice. A study conducted by Peitzmeier 2017 found that 97% of participants experienced a least one negative outcome attributed when they experienced binding. We won't cover all of the negative health impacts in this blog article, but we will highlight a relevant few to the pelvic floor:

  • Musculoskeletal pain (chest pain, shoulder pain, back pain, rib fractures, spine changes, abdominal pain)

  • Digestive issues

  • Pelvic floor issues

  • Postural changes / issues

  • Breathing difficulty and restricted chest expansion

Anytime we change our alignment and our posture, whether it's due to pain or weakness, it can throw off important body functions we need to stay healthy. The pelvic floor needs a healthy diaphragm and abdominal wall to function as desired. Without it, we can experience incontinence (leaking any amount of urine, feces, gas when undesired), constipation, pelvic pain (and the surrounding areas), and changes in our sexual health and function. If you bind as part of your identity, and you're experiencing any negative health impacts, reach out to your trusted health care provider to assist you.


Recommendations / tips for Binders:

  • Use a soft measuring tape

  • Do not wear compressive clothing over chest when measuring

  • Consult the size chart for every brand

  • Hand wash & hang dry, do not put in dryer

  • Wear a think shirt or tank top under binder to prevent skin irritation and smell

  • Wear no more than 8-12 hours per day

  • Schedule an "off day"

  • Avoid elastic bandages, duct tape, or plastic wrap

  • Remove when sleeping

  • If experiencing pain and negative health outcomes, seek out care from a trusted healthcare provider

  • Read more about binding here

Tucking


Tucking is practiced by some to flatten the genital area, minimizing or hiding the bulge of the genitals to create a look that best conforms with their gender identity.


Tucking may be mildly uncomfortable, however it should not be painful. If there is any pain, you should stop, or relax and try again when ready. Tucking has less of an impact to the pelvic floor than binding, but any pain can often alter the way we move and thus create potential pelvic floor dysfunction.


We will not cover how to tuck in this blog post, you may read so here, but it important to recognize and learn about any negative health outcomes so you may avoid them. Tips include:

  • Be careful not to cut off any circulation while tucking.

  • Regularly check the skin around the area you tuck, and note any skin breakdown or irritation. Infections can arise with skin breakdown, and you'll want to catch them fast or prevent them if possible. If you notice skin breakdown and irritation that does not resolve, see your trusted healthcare provider for further care & instruction.

  • Know that tucking may sometimes impact fertility (especially in combination with hormone therapy), so if fertility is important to you speak with your trusted healthcare provider on how to proceed.

  • Note if you have any blood in your urine or ejaculate. Stop tucking if you do, and once again seek out care prior to resuming if the issue does not resolve.

Gender Affirmation Surgeries


There are a wide range of gender affirming surgeries available to transgender people. These include (but are not limited to):

  • Vaginoplasty

  • Phalloplasty

  • Scrotoplasty

  • Metoidioplasty (clitoral release or enlargement)

  • Facial procedures

  • Reduction thyrochondroplasty

  • Voice surgery

Anytime we undergo surgery, there are consequences in our musculoskeletal system. Muscles and nerves can experience trauma, and scar tissue limiting mobility may arise. Any consequence can impact the way we move, resulting in pain or safety concerns. Physical Therapy should always be part of the plan of care, whether before or after (or preferably both), in order to avoid or mitigate any issues that may arise.


In terms of surgery and the pelvic floor, it is recommended the individual see a pelvic floor physical therapist first. Many people prior to surgery may already have a pelvic floor dysfunction, and not resolving that may compound the issue further. A study performed by Jiang 2019 found that:

  1. Pre-operatively, 42% of participants already have pelvic floor dysfunctions including bowel disorders.

  2. 90% of individuals have had trauma to their pelvic floor in the past (this can include giving birth or sexual assault / harassment trauma).

  3. 86% of who received both pre-operative and post-op pelvic floor PT had a decrease in pelvic floor dysfunction.

  4. 28% of participants who received care from a pelvic floor PT only after surgery had a decrease in pelvic floor dysfunction.

Post-operative PT visits after surgery may include:

  • Breathing work

  • Dilation (vaginoplasty)

  • Internal and external pelvic floor muscle release

  • Connective tissue manipulation

  • Lymphatic drainage

  • Scar tissue mobilization

  • Myofascial release and tissue balance

  • Visceral manipulation

  • Muscle strength, coordination, and timing

  • Central nervous system balancing

Recommendations for those undergoing a surgery, especially surrounding their pelvic floor:

  • Consult with a Pelvic Floor Physical Therapist prior to the surgery to correct any existing dysfunctions. Read a bit more about pelvic floor PT here

  • Implement a home exercise program given by a PT to help correct any posture abnormalities or musculoskeletal conditions that can create discomfort / pain when recovering from surgery. You'll be laying on a surgical table for awhile, just that alone can create discomfort or trauma.

  • Gather a team of trust medical providers around you to help support you before the surgery, so you have the care you would need afterwards without having to wait.


TLDR

  • Binding is a practice of flattening the chest to help contour your body to your gender identity. Roughly 97% of those who bind will experience pain or negative health outcomes. Tips include only binding for 8-12 hours at a time, and scheduling off days.

  • Tucking is a practice of flattening the genital area help contour your body to your gender identity. Skin breakdown or chafing, as well as pain, are important to pay attention to. Seek medical care / attention if either gets worse or does not resolve on its own.

  • Gender affirming surgeries, as well as any surgeries, result in musculoskeletal consequences like pain and strength / mobility loss. It's important to work with a PT prior to surgery to help mitigate & prevent these issues. Roughly 42% of individuals have pelvic floor dysfunction prior to surgery, so seeking pre-operative pelvic floor physical therapy is vital to improving outcomes.

  • We all have pelvic floors. While these practices are unique to transgender individuals, it's important to pay attention to our pelvic floors and seek care when issues arise. Not just the pelvic floor, our whole bodies truly. The greatest investment you can make is in your health.


 

About the Author:

Caroline Gamwell, DPT is a Doctor of Physical Therapy, specializing in Pelvic Floor and Women's Health. She is the founder of Worth It PT based in Denver, Colorado, a clinic whose focus is to help others achieve their health and wellness goals through a higher quality of healthcare.



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