While this is not the most comfortable of topics to discuss, it is something that greatly affects a number of my clients and a number of men and women all over the world. Interestingly, this is also a topic that directly influenced my career path, whether I was aware of it at the time or not.
Every 68 seconds an American is sexually assaulted and every 9 minutes that victim is a child [1]. RAINN (The Rape, Abuse and Incest National Network) reports that 1 in every 6 women and 1 in every 33 men will experience an attempted or completed rape in his or her lifetime (14.8% complete, 2.8% attempted) [2]. These are extremely disturbing and disheartening statistics, but unfortunately this is our reality. The effect that this type of experience has on each individual is unique and, oftentimes, difficult for the victim and their support system to process. Sexual assault can contribute to an array of physical, psychological, social and emotional impacts. In this piece we are going to focus on one of the physical impacts that sexual assault and sexual trauma may have on the body, pelvic floor dysfunction.
As a pelvic health physical therapist, my clients typically come to me with varying degrees of pelvic floor dysfunction. This might be described as pelvic pain, bladder dysfunction, bowel dysfunction, and/or sexual dysfunction. For those of my clients who also have a history of sexual trauma, it is not uncommon to describe dysfunction in two or more of these areas. Research supports this statement as there is a higher prevalence of multiple synchronous pelvic floor complaints in clients with sexual trauma in their history [3].
My Professional Path
I began my physical therapy career in 2010, passionate about sports and orthopedics and never really experiencing the desire to treat pelvic floor dysfunction. Not until I started experiencing pelvic pain myself. It began seemingly “out of nowhere”, manifesting itself as what I interpreted as ovarian pain which slowly worsened over time, presenting alongside intermittent deep hip pain and intermittent SI joint pain. I didn’t really give it a second thought, relating it to a normal discomfort surrounding my monthly cycle and the fact that I had trained for my first marathon and was continuing my training program for other races throughout 2011-2013. It wasn’t until I started experiencing pain with intercourse in 2013 that my thought process started to evolve and that perhaps I was missing something. This new experience was so foreign and it definitely caught my attention.
Instead of seeking help from a healthcare professional, I decided to attend my first pelvic floor continuing education course with Herman and Wallace to self-diagnose. The course opened my eyes to a clinical topic that I wasn’t terribly familiar with and it provided me with the education to realize that I personally fit the mold of an individual with pelvic floor dysfunction. While we were learning how to assess each other and how to identify the musculature of the pelvic floor, my partner touched an area that immediately reproduced my ovarian, deep hip and SIJ pain and, furthermore, the pain I was experiencing with intercourse. All of the sudden I was able to connect the dots a little bit more…I was experiencing pelvic pain and painful intercourse secondary to dysfunction in my pelvic floor muscles. With further exploration of this, we came to the determination that my muscles were hypertonic or "high tone”; essentially the muscles were in a holding pattern, a spasm, unable to fully relax to a normal and healthy baseline. After completing this course, the trajectory of my career path immediately changed.
What I couldn’t fully wrap my head around was why were my muscles in a holding pattern? I was a young, healthy, and active female and I hadn’t yet experienced pregnancy or childbirth…so why were my muscles in my pelvis so dysfunctional? It wasn’t until much later in my career (and in my personal life) that I realized an event that occurred back in college was likely the underlying driver of my dysfunction.
During my sophomore year at Ohio University I experienced a sexual trauma. It was an event that impacted, and still impacts, many of my relationships and my body. Following the assault, a rape kit was conducted, a police report was filed and written testimonies were collected from both parties and from witnesses. This in itself was traumatizing for me, however, also cathartic, but it is certainly not the norm. For reasons that are very hard to explain and/or understand (unless you have experienced it yourself), more than 90% of sexual assault victims on college campuses do not report the assault to the police [1]. And of those reported, 995 out of every 1,000 the perpetrators will walk free [1]. Unfortunately, this was my exact experience. My case never progressed past the pile of paperwork and testimonies, all but one (you can guess which one) supporting me and validating the fact that this was serial behavior from the perpetrator (his roommates included). But, just like that…the case was dropped, never to be revisited.
For me, processing the trauma and the events that unfolded afterwards is a continual work in progress, almost 20 years later. Occasionally it feels as though the work is never-ending, but it slowly continues to integrate itself into my life’s story. At times, in the most unexpected ways.
How does the pelvic floor respond following sexual trauma?
The pelvic floor is known to be an integrated structure, influenced by psychological and physical causes. As a result, sexual trauma can directly influence the pelvic floor. In my experience, both personally and with my clients, it lends towards developing a holding pattern. The body has a tendency to hold on to trauma, especially when the individual has yet to fully process the trauma itself.
Pelvic floor dysfunction can present itself as pelvic pain, bladder dysfunction, bowel dysfunction and/or sexual dysfunction. If you are experiencing any of these, I would highly recommend seeking out a pelvic health physical therapist to get assessed and begin a path towards healing.
It is also integral to take a multi-disciplinary approach to this topic, including other healthcare professionals who are trained to treat clients with a history of sexual trauma. For me, finding a mental health professional who could guide me through the process was essential in my path towards healing.
It’s never too late to begin the healing process. Know that at times the path will feel tortuous, but change and growth never comes from staying in your comfort zone.
To health + wellness for your pelvis,
Kelly
Recommended Books:
The Body Keeps The Score (Van Der Kolk)
Life, Reinvented (Erin Carpenter)
The Courage to Heal (Bass)
Trumping the Rape Culture and Sexual Assault (Allred)
Find Your Voice (Paz)
After Silence: Rape and My Journey Back (Raine)
Missoula (Krakauer) – Trigger Warning
Milk and Honey (Kaur)
Speak
References:
1. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2019 (2020).
2. National Institute of Justice & Centers for Disease Control & Prevention, Prevalence, Incidence and Consequences of Violence Against Women Survey (1998).
3. J. Beck, H. Elzevier, R. Pelger, H. Putter and P. Voorhamvan der Zalm. Multiple Pelvic Floor Complaints Are Correlated with Sexual Abuse History. The Journal of Sexual Medicine. 2009; 1(6): 193-198.
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