Gender expression is an important part of self-identity in the LGBTQ+ community. In addition to dressing in a certain way or modifying the voice, individuals may physically change their bodies to affirm gender.

Some transgender and gender-expansive individuals choose non-surgical procedures including binding (chest compression) and packing (use of penile prosthesis) to alter body appearance. Others may elect surgery, such as breast augmentation or a vaginoplasty (construction of a vagina) for more comprehensive changes.

While providing a positive image, practices to affirm gender identity can cause negative musculoskeletal and pelvic floor conditions such as chest pain and bladder problems that require therapeutic care.  MossRehab therapists trained in inclusive care understand how to treat these conditions and minimize future problems.

“I’ve learned best practices to care for LGBTQ+ individuals by researching primary scientific literature and through colleagues and patients,” explains Teresa Gero, DPT, who specializes in chronic pain and holistic care in treating the whole person at MossRehab Tabor Road.

Orthopedic Care

MossRehab orthopedic physical therapists with LGBTQ+ competency treat a variety of muscular conditions including those caused by upper body practices. “LGBTQ+ individuals may be referred to an orthopedic physical therapist for pain and discomfort whether related to gender-affirming practice or not,” says Gero.

For example, Danielle Monica, DPT, OCS, who works with outpatients at MossRehab Jenkintown, treats LGBTQ+ individuals with orthopedic complaints such as knee and back pain caused by everyday life or medical conditions, and those recovering from general surgeries such as hip and knee replacements. Because she identifies as a lesbian, Monica relates to many of her LGBTQ+ patients and has experienced some of the same biases directed toward this population.

“As part of wellness care, I’ve treated LGBTQ+ patients with back, shoulder, and elbow pain, and other orthopedic issues,” says Monica. “I’ve taken courses to understand best practices for patients and am sensitive to their needs for privacy when conducting physical therapy.”

For a patient with chronic lower back pain caused by working prolonged hours at a computer, Monica’s therapy included range of motion exercises to improve back stiffness and spine flexibility progressing to core strengthening and endurance exercises using functional movements like squatting and lunging. “I always practice respectful care when doing any therapy, asking permission when I use my hands on their body,” notes Monica.

Non-Surgical Top Augmentation

In addition to wellness care, MossRehab orthopedic therapists treat conditions related to non-surgical top interventions.  LGBTQ+ individuals who practice binding to minimize the chest profile, for instance, can experience back, neck, or chest pain due to compression and/or have breathing difficulties because of restricted ribcage movement. “A therapist could help improve chest wall mobility and breathing issues associated with binding,” explains Gero. “We can workshop together to create a plan to minimize the risk of future complications.”

One MossRehab patient who was binding to present a flatter profile experienced pain in the back and around the shoulders because of restrained mobility. They also had breathing difficulties because the bind restricted rib expansion. A MossRehab orthopedic physical therapist who understands the side effects of unhealthy and/or prolonged binding provided the right care to address these impairments. Mobility exercises, muscle lengthening stretches and breathing exercises helped to alleviate pain and breathing problems.

“MossRehab orthopedic physical therapists who care for LGBTQ+ individuals understand how to assess and treat conditions caused by upper body practices,” says Sabura Shiffrin, DPT, who specializes in orthopedics and works with outpatients at MossRehab Tabor Road. 

She explains that when treating patients with upper body complaints, she initially conducts a comprehensive musculoskeletal exam to check for resting muscle length, short muscles that might affect an individual’s pain, and the mobility of the mid-back part of the spine. “I also look for skin indentations that indicate blood restriction in certain areas,” reports Shiffrin. “Using this information, I prescribe therapy to address an individual’s specific issues and education to reduce potential future risks.” 

Gero further elaborates that treatment is based on individual needs, desires, beliefs, and preferences. “In addition to understanding the problem, I want patients to share their story, explaining types of therapeutic approaches already tried and treatment preferences,” Gero notes. “After gathering patient wisdom, I ask if I can share my insights as a medical professional so we can work as a team.”

Non-surgical Bottom Practices

MossRehab pelvic floor therapists address groin pain and other pelvic-related dysfunctions related to lower body non-surgical treatments, such as tucking and packing as well as general pelvic, bladder, and bowel problems.

To affirm a gender identity on the lower body, LGBTQ+ individuals may practice packing or tucking (inwardly folding genitals). While helping to present a more positive body image, these practices can cause urinary, testicular, and skin irritation problems.

“Packing can inadvertently result in urinary tract infections while prolonged or inappropriate tucking can result in testicular, penile or pelvic pain, and tightness or pain around the pelvic floor, hips and legs,” says Ann Nwabuebo, DPT, a board certified pelvic health provider who works with outpatients having pelvic health issues at MossRehab.

Shiffrin notes that individuals who pack or tuck might not have appropriate bathroom accessibility throughout the day. This can result in different bladder symptoms such as increased urgency or pain with urination. “It can become a vicious cycle if not addressed,” explains Shiffrin who is training in pelvic health at the Herman and Wallace Pelvic Rehabilitation Institute (a continuing education resource focused on pelvic health).

When a patient complains of side effects associated with these practices, Nwabuebo notes that she initially conducts a thorough subjective exam, gathering information on past medical history, current pain issues, gender-affirming practices, and any social factors that may contribute to their issues. She, then, physically examines the patient, checking posture and flexibility from the spine through the pelvis and legs.

“With permission, I also can assess pelvic floor muscles internally and externally, looking for tender or trigger points in this area,” reports Nwabuebo. “From this evaluation, I move into treatment that might include manual therapy techniques to gently stretch tight areas around the abdomen, spine, hips, and pelvic floor. I also provide patient education and resources on safe practices and what adjustments might be needed to make them more comfortable and ease their symptoms.”

Shiffrin says that therapists take a collaborative approach to problem-solving as no one solution fits people with different impairments. “We understand that each person has different job constraints and social environments that present different challenges,” notes Shiffrin. “We ally with patients to problem solve and make behavioral changes such as diet and exercise to decrease pelvic issues.”

MossRehab Offers Compassionate Care

Nwabuebo notes that it can be challenging for individuals in the LGBTQ+ community to get appropriate medical attention, especially related to gender-affirming practices. “MossRehab offers a compassionate environment that welcomes and understands LBGTQ+ individuals,” says Nwabuebo. “We understand how to treat ailments related to different gender-affirming practices, pay close attention to what is important to patients such as using affirmed pronouns, and conduct therapy with sensitivity to provide the best care.”

MossRehab orthopedic and pelvic floor therapists foster a relationship with the Einstein Pride Program from which they receive referrals. For therapeutic services, contact the Einstein Pride Program. A pride patient navigator will help coordinate different healthcare services for patients seeking gender-affirming care.     

Check out the Gender-affirming Therapies that MossRehab offers to the LGBTQ+ community.

In Part 2 (coming soon), we will explore orthopedic and pelvic floor therapies that help resolve problems before and after gender-affirming surgeries.