POP in a Nonbinary and Transgender Population
POP is a condition that affects individuals throughout the gender spectrum. However, the overwhelming majority of POP information and advocacy excludes men, trans, and non-binary individuals, making it more difficult for those individuals to seek and receive quality care.
The 2015 US Transgender Health Survey included the following findings:
19% reported being refused care outright because they were transgender or non-binary
28% reported very high levels of postponing medical care when sick or injured due to discrimination and disrespect
28% were subjected to harassment in medical settings
50% reported having to teach their medical providers about transgender care
The conversation about pelvic health care for trans people must fundamentally begin with recognizing and eliminating barriers to healthcare in all respects. As providers of care that involves the pelvis (a highly sensitive area even for the cisgender population), our goal must be to respectfully deliver care that recognizes the uniqueness of the trans experience and the specific physiological changes that are unique to these clients.
Things we need to consider:
The whole person.
While much attention is paid to the effects of hormonal and surgical transition, we must first begin with ensuring that our communication with trans-identifying clients creates an environment in which they feel safe and respected.
✨Hormone therapy✨ The contribution of hormone therapy to risk of POP has not been formally studied. It appears that the muscle fibers of the levator ani, urethral sphincter, and the smooth muscle of the female urogenital tract express androgen receptors. Furthermore, the expression of androgen receptors in the cardinal ligament was 3-4x greater in those with uterine POP than in those with no POP. This means that the effect of testosterone administered as a part of hormonal transition may be notable in these tissues, and theoretically correlated with increased risk of POP. However, no literature appears to exist on the ultimate effect on symptoms and presentation of POP in trans men. (Hormone therapy is not limited to testosterone, of course. There is range of treatments and potential treatment outcomes that need to be considered in the presentation and experience of POP symptoms and anatomy).
✨Surgery✨ The penile‐scrotal skin flap technique is considered the gold standard for vaginoplasty in male to female gender affirmation surgery. This creates a “neovagina” using penile skin to line the vaginal vault, and scrotal skin to create labia majora. Without the connective tissue supports inherent in female anatomy at birth, this surgery creates risk of vaginal vault prolapse, which can create aesthetic changes and difficulties with intercourse due to vaginal shortening. Sacrospinous ligament fixation of the neovaginal vault appears to be a safe and effective way to reduce risk of POP. For those receiving gender affirming surgery that includes vaginal closure, the risk of POP as we define it is eliminated, as the introitus is sutured.
Is your pelvic health practice inclusive?
We want to ask this question of all of us (including ourselves) who are working in pelvic health and movement spheres: are our practices inclusive? Are you asking for pronouns in your intake questionnaire? Are you affirming of a person’s gender? Are you using the correct pronoun(s)? Are you educating yourself on the needs of the trans and nonbinary population? Are you learning from, listening to, and elevating trans and nonbinary people? Are you using inclusive marketing? Are you making your services accessible to the trans and nonbinary community? Are you considering how hormone therapy and surgical transition could impact a person’s movement? Are you considering the psychosocial wellness of trans and nonbinary people in the gym and clinic? Are you ensuring the safety of trans and nonbinary people in and beyond your spaces? Are you collaborating with professionals who are trans- and nonbinary-inclusive?
If not, you can start R I G H T N O W. Your inclusivity at this very moment is important but it isn’t nearly as important as how inclusive your next steps are. We can ALL do better. We ALL have exclusionary elements of our businesses that we could improve upon. We ALL have this responsibility. We’re ALL in this TOGETHER.