Introduction: Sexual health and wellness generally falls under the domain of psychologists, sex therapists and physicians such as urologists, gynecologists and psychiatrists, and even family physicians to some extent. How is physiotherapy linked to sexual health and what role does a physiotherapist play in improvement of sexual function of women? Physiotimes find answers to these and many such questions puzzling the young therapists through an exclusive interview with Talli Y. Rosenbaum, Urogynecological Physiotherapist & an AASECT certified sexuality counselor, specializing in pelvic floor rehabilitation.
Q: How do you define optimum sexual health?
There are several working definitions of sexual health, but one I like is the following: the integration of the physical, emotional, intellectual and social aspects of sexual being, in ways that are enriching and that enhance personality, communication and love. (WHO)
Q: Which are the factors that have a negative impact on sexual function in women?
Physical presentations that may limit sexual activity include decreased mobility, alterations in sensation, decreased genital circulation, and pain. This includes all types of pain including chronic back pain and other musculoskeletal conditions, as well as genital and pelvic pain. Urogenital issues such as urinary incontinence, frequency, urgency, prolapse, urinary tract infection and bladder pain can affect sex as can ano-rectal problems. Other factors include hormonal changes, stress, fatigue, and medications. Conflicts and attitudes about sex, relationship factors, self and body image, as well as several other psycho-social issues can all affect sexual function.
Q: What should be the approach to treatment of sexual health problems? Is it the job of a single specialty or does it require a multi-disciplinary approach? Why do you think so?
Optimal treatment of sexual health problems is multi-disciplinary. The multidisciplinary approach to sexual health combines the professions of medicine, mental health, and complementary medical management. Medical treatment of sexual problems includes a complete assessment of the many possible, multi-factorial physiologic components involved and may include consultation, medication, surgical intervention, or referral to a mental health provider and/or physiotherapist. Therefore, practitioners from a wide variety of medical and paramedical professions are involved in the promotion of sexual health.
Q: Which are the most common conditions you encounter in your practice that are affecting a women’s sexual health at different stages of her life & what is the role played by physiotherapy in these conditions?
I commonly treat women and couples who are unable to enjoy a satisfactory sex life due to a wide variety of female sexual pain disorders. These include vaginismus and dyspareunia due to localized or generalized vulvodynia, dyspareunia after childbirth and post menopausal dyspareunia. I also specialize in treating couples with the problem of unconsummated marriage. I also work with women who don’t have orgasms or experience a lack of sexual desire and arousal. The role of physical therapy is very important in women who have vaginal pain. Many of these women are anxious and we can teach them techniques on how to relax and overcome their anxiety. The physical therapist may also help with all sorts of techniques that help decrease pain and muscle hypertonus. We can help them use vaginal dilators to slowly increase the amount of penetration that the woman can allow. We can also help with stretching tight tissue and teaching self stretching exercises at home. If there is pain due to adhesions from a childbirth related perineal tear, we can use gentle massage and stretching to help the area heal.
Q: Does physiotherapy also play a preventive role in these conditions?
It can. I sometimes see women before they begin a sexual relationship to prepare for sex. It is common in the traditional populations in Israel where I live and practice, to commence a sexual relationship only upon marriage. Providing sexual education, particularly about genital anatomy and physiology can be very helpful in preventing problems.
Q: How has technological advancement been of significance in this area of Sexual health in terms of treatment options available to physical therapists? Could you please share some of the latest techniques such as bio-feedback & others used globally by the therapists in this area and in which conditions?”
Biofeedback is used to provide feedback for patients on the activity of the pelvic floor. It is a great treatment tool for dealing with hypo and hypertonus conditions of the pelvic floor. One valuable new technological advance for physiotherapists working with pelvic floor, particularly in research, appears to be ultrasound imaging. With this you can see how the muscles are being recruited.
Q: What role counseling plays in resolving these problems? What is the treatment approach followed in counseling?
The majority of what I do in my practice, in addition to providing physiotherapy, is counseling. Counseling first involves listening very empathically to what your client is telling you, and asking probing questions in order to better understand them. Counseling also involves providing permission. This means offering the clients a safe place to discuss anything related to sex and to normalize it. Counseling also involves providing limited information, and specific suggestions for treatment.
Q: Despite modernization, sex continues to remain a sensitive topic. In such a scenario, what is the biggest challenge for a counselor in resolving the problems? Can you recall any interesting case or an event from your clinical practice that you would like to share with our readers?
The challenge for counselors is very often to discover what the sexual issues being discussed evokes in them. While sex remains a sensitive topic, I have never yet met a client who was upset at me for bringing it up. Most clients are more then relieved to be asked. So, when there is discomfort in the room, it often is coming from the therapist. I co-coordinate and teach a pelvic floor course here in Israel and one of the important lectures I give is in how to discuss issues of a sexual nature in a sensitive way with clients as well as how to ask about sexual abuse.
One important aspect of this is communication and language. I always tell the following humorous story to my students. I am not a native Israeli and English is my first language. So, when I first moved here and was interviewing a couple and asking about their sex life, I used a term which I thought meant “when you are having sex “ but actually meant it in a more vernacular , graphic way . Fortunately the couple was not offended. They actually thought it was pretty hilarious.
Q: Cultural beliefs have a lot to do with sexual health as well. Would the treatment approach differ in different cultural set ups? How has been your experience dealing with patients of different cultures? What is common and what is the differentiating factor?
Great question. I work with all sorts of populations in Israel. Most are Jewish but range from secular to ultra-orthodox. I also have Arab patients of Christian and Moslem faiths. There are many issues regarding sexual practices in religious and traditional populations which definitely guide my practice with them. It is not unusual for me to consult with the clients Rabbi or other religious leader in putting together a treatment regimen. A common factor between all the groups is that the sexual sense of self is a very individual thing. In other words, if you see someone in elaborate head coverings and modest clothing this does not mean they are sexually repressed and in fact they may have a very strong and healthy sexual life. People are the same in their basic desire for human intimacy. The differentiating factors may have to do with certain restrictions that vary with cultures.
Q: What role does manual therapy play in restoring sexual health in woman and in which conditions it is particularly more effective and which all techniques?
Manual therapy plays an important role in the treatment of pelvic and genital pain syndromes. The application of trigger point massage in the pelvic area and transvaginally has been described in the treatment of pelvic pain and interstitial cystitis and for the treatment of vulvar pain syndromes, and pudendal neuropathies. Additional techniques include massage, connective tissue and scar tissue release and osteopathic techniques such as visceral and urogenital manipulation. Other techniques available to the physiotherapist treating musculoskeletal dysfunction associated with pelvic and vulvar pain include muscle energy, contract/relax, and passive and resisted stretching designed to normalize postural imbalances, improve blood circulation in the pelvic and vulvar area, and improve pelvic and vulvar mobility. Dilators are used not only to help overcome penetration anxiety but to stretch the introital opening. Perineal massage and stretching is useful in women with postpartum dyspareunia.
Q: Being a physical therapist, what prompted you to take up this special field of sexual counseling as a career option?
First of all, as a physical therapist specializing in the pelvic floor, it was almost impossible to not to deal with sexual issues, as sexual function is intimately related to the pelvic floor. I find that people with sexual problems are often drawn to physical therapy because we tend to validate their physical complaints more than mental health professionals. On the other hand, we don’t always have the tools to determine the impact of our interventions. I found that people didn’t always do what I told them to and realized that sexual problems can not be dealt with only physically and that you can’t just tell people what to do. You have to understand them and find out about the context of their lives and what their challenges are.
Q: Over the years what has changed significantly in this area of sexual health for a woman? Has the problem remained more or less the same as they used to be or the present lifestyle has contributed to additional issues?
Much has changed for women, couples and families. We spend far more time on the internet. We work long hours and have less leisure time. Many young and not so young couples, particularly when there are small children, don’t find or make the time for a satisfying intimate life. Women in their childbearing years often feel overwhelmed with demands and find that their sexual desire suffers as a result.
Q: Have you ever been to India. Is yes, how was the experience. If not, any plans of visiting India in the near future?
India is a popular destination for Israelis but unfortunately I have never been. I would love to visit India given the opportunity.
Q: What is the approach to sexuality education and therapy in Israel and what is the awareness level in general public about seeking treatment & the role of physical therapy?
Sexuality education and therapy are fairly well developed fields in Israel. There is a large and active sex therapy organization and there is also a large women’s health physical therapy group. The role of physical therapy in sexual health has not reached a high level of awareness, however, amongst the lay population. This is an ongoing challenge but one which I believe is changing. In fact, a colleague and I just published an article in Hebrew in the leading Israeli medical journal on the role of physical therapy in female sexual health and I believe this will increase awareness amongst doctors.
Q: What is the scope for practice in this area for a physical therapist and how can one become a sexual counselor after completing graduation in physiotherapy?
Currently the scope of practice for physical therapists is limited to providing physical therapy. I provide counseling under my certification as a counselor, and I am also completing my masters’ degree in sociology and mental health counseling. My counselor certification is provided by AASECT. I encourage all interested physiotherapists to join AASECT. Although it is essentially an American organization, it is branching out to become international and even has members from India. I suggest reading carefully through the AASECT website (www.aasect.org) in order to discover the various opportunities available to enrich knowledge in sexuality. Specific requirements for certification for sexuality counselor are described on the page: http://www.aasect.org/certification.asp.
Joining AASECT is a great start. It is a good idea to begin to take academic level coursework or AASECT sponsored or approved continuing education course given through workshops and conferences
Q: What is your message to the young therapists and our readers in India on this important issue of sexual health in woman and what advice would you like to give them?
My best advice to physical therapists in India and everywhere is that for women and men “sex is an ADL too”. Physical therapy treatment is geared towards restoring the ability to function and perform ADLs independently and painlessly and to promote wellness. Sexual health is an integral component to overall wellness, and sexual relations are a valued human activity. Sex can be affected by many of the conditions we treat, including orthopedic and neurological. So, why aren’t we asking our patients about sex and sexual activity? When we treat patients, mention that the presenting condition may impact sexual activity. Ask permission to discuss the topic and give permission to discuss the topic. Listen, be direct, but appropriate with language, consider the client’s body language, and finally, feel personally comfortable or don’t bring it up.
About Talli Rosenbaum: A graduate of the Physical Therapy program at Northwestern University Medical School, Ms. Rosenbaum is an internationally recognized expert in the treatment of pelvic and genital pain and sexual pain disorders. Ms. Rosenbaum has presented at international conferences and has published book chapters and peer reviewed journal articles on the topics of the role of the pelvic floor in sexual health, the role of physiotherapy in the treatment of sexual pain disorders, the treatment of unconsummated marriage, and Judaism and sexuality.
She currently serves on the Professional Advisory Boards of the Women's Sexual Health Foundation, Alexander Foundation for Women's Health and The Intercultural Center for Human Sexuality and Family Life. She is a member of the board of directors of the International Society for the Study of Women's Sexual Health (ISSWSH), Women's Health Section of the Israeli Physiotherapy Society and represents the Israeli delegation to the IOPTWH (International Organization of Physiotherapists in Women's Health). She currently serves as Chairman of the AASECT Counselor Certification Committee and the International Outreach Committee. She is currently completing an Msc degree in clinical sociology and mental health counseling. She lives in Bet Shemesh, Israel with her husband and four children. More information about her can be obtained from her website www.physioforwomen.com.