Welcome back, readers: this is part two of a four-part series on the physical effects of sexual trauma . If you haven’t yet seen part one, check it out here. As always, please be gentle with yourself while working through all of this content, and give yourself the time and space you need to digest it.
The body’s reactions to sexual trauma are varied and complex. Addressing them requires a team approach to care. Survivors can benefit from the help of mental health providers, physicians and allied health professionals, and complementary care providers such as acupuncturists and massage therapists. Support groups and online communities for survivors of sexual trauma (including those on the message boards here at Scarleteen) can also be incredibly powerful places of healing.
In this article, we’ll be focusing on treatment options for pelvic effects that survivors may experience. For survivors struggling with pelvic symptoms, pelvic physical therapy can be an invaluable component of a recovery journey.
Treating Pelvic Problems after Trauma
In my clinical experience, survivors who come to pelvic PT for help often fall into one of two camps: their pelvic floor muscles are constantly tense and tender, or they have completely disconnected from their pelvic region and experience little-to-no sensation there.
Of course, each body is unique: some people will present with a combination of these patterns, and others won’t fit neatly into any classification. Despite this, these two categories provide a useful framework for understanding how a pelvic PT can help you build a treatment regimen tailored to your specific concerns.
Here’s a structure we can use to better understand some treatment options for folks with pelvic health concerns.
| Pelvic Pattern | ||
| “Tense & Tender” | “Disconnected” | |
| Common symptoms |
Pelvic pain Genital pain Constipation Difficulty emptying bladder Pain with sex Difficulty reaching orgasm Leaking pee during sudden movements, sneezing, etc. |
Pelvic pain Genitals feel “numb” Loss of bowel control Urine leakage, sometimes without feeling it Lack of sensation during sex Difficulty reaching orgasm |
| Common exam findings |
Pelvic floor muscles are tight and overly “springy” Patient reports tenderness or sensitivity with contact to these muscles |
Pelvic floor muscles may be slightly “slack”, or they may feel typical Patient states that they “can’t really feel anything” during the exam |
| Treatment goals |
Relaxing and releasing muscle tension Decreasing sensitivity of pelvic muscles (to decrease pain upon contact) Restoring typical sensation in the muscles Restoring muscle coordination (the ability to contract/relax when needed) |
Reconnecting the person’s nervous system (brain, spinal cord, nerves) with their pelvic region Restoring full sensation in the pelvic region Restoring pelvic muscle tone and coordination |
| Common treatments |
Balancing the central nervous system (i.e., reducing excessive activity and alertness) Manual (hands-on) therapies Specific exercises and retraining of muscles/nerves throughout the body Self-care programs to practice on one’s own |
|
These patterns can appear in people of all genders with any kind of genital anatomy : regardless of a survivor’s genitals , they may develop problems in their pelvic tissues as a result of the trauma they have experienced.
Remember, this is a generalized framework: some people will have a combination of elements from both columns. For these folks, it is often necessary to combine elements from both columns to properly treat their condition.
What’s the Brain (and Spinal Cord) Got to Do with It?
In the table above, you’ll notice that “balancing the central nervous system” is a treatment approach that is common to both subtypes. This is because the central nervous system (CNS) is universally affected in survivors of sexual trauma.
Your CNS is composed of your brain and your spinal cord. It impacts the function of nearly every body system, from your muscles and organs to your brain and your hormones . Without a CNS, you wouldn’t be alive!
In short, if we ignore the nervous system during treatment, we’re missing a really critical piece of the puzzle. Let’s take a short detour to discuss this critical element of post-trauma care.
Fight, Flight, Freeze, Fawn: The Trauma Responses of the CNS
You may have heard the term “fight or flight” before: this common phrase refers to the two ways we can react to traumatic events. Some call it the “survival instinct”: when faced with a threatening situation, your nervous system kicks into overdrive to help you respond to the potential threat.
However, there are more than two ways that your CNS can respond to possible threats. Consider the following:
- Fight: pushing back (physically or verbally) against the threat
- Flight: physically removing oneself from the threatening situation
- Freeze: becoming unable to respond (verbally, physically, or both)
- Fawn: attempting to appease the potential traumatizer to prevent trauma from occurring
The details of each of these possible responses are beyond the scope of this article, but you can learn more about them here and here. For now, it’s important to understand that these trauma responses are common, and they can overlap (i.e., a person in a traumatic situation may respond in two or more ways at once).
Secondly, know that all of these responses place the CNS in a state of hypervigilance: the brain and nerves all “turn up to 11” to help the body respond to the potential threat as quickly as possible.
Thirdly, trauma responses are meant to help people respond to traumatic events as they are occurring. The CNS isn’t designed to be in a hypervigilant state for days, weeks, or months on end. If your CNS remains overactivated long after a potential threat has passed, it can exhaust you, physically, mentally, and emotionally.
The Overactive CNS: A Recipe for Pain and Exhaustion
Compared to people who have not lived through traumatic events, those who have experienced trauma are more likely to enter and remain in hypervigilant states. Researchers can track these patterns by measuring stress hormone levels in survivors and comparing them to people who have not experienced trauma. People who have experienced trauma typically have higher-than-average stress hormone levels, particularly when reminded of their traumatic experience(s).
Stress and the hormones it generates aren’t all bad. Stress hormones help our bodies respond efficiently to potential threats: they allow us to survive in adverse conditions, run from danger, and fight back when necessary. These are the chemicals that allow people to perform seemingly superhuman feats, like moving huge pieces of rubble at a disaster site or carrying another person to safety: they help us survive and protect others.
However, the human body isn’t designed to be flooded with stress hormones all the time. These chemicals tell all our body systems to remain on high alert: our muscles stay tense, our digestion slows down, our senses remain heightened. Chronically high levels of stress hormones can quickly exhaust our key organ systems. This is why a hypervigilant CNS can backfire on you. If your body and mind are stuck in high alert mode, you never get a break. Your systems never get the chance to rest, recover, and rebuild. This lack of recovery time can lead to exhaustion and chronic fatigue.
Additionally, when stress hormones like cortisol are present in high levels for an extended period , our bodies no longer respond well to them. The natural signaling patterns between different body regions become disrupted. As tissues become less responsive to the anti-inflammatory effects of cortisol, inflammation increases throughout the body. These changes can cause chronic pain to develop in one or more body regions.
TL;DR: The CNS is the engine driving many of the physical effects that sexual trauma survivors may experience. Many post-trauma treatment techniques aim to “rewire” the CNS, lower cortisol levels, and decrease hypervigilance.
Quieting the CNS in Physical Therapy
If you are experiencing physical symptoms after sexual trauma, you could probably benefit from consulting with a physical therapist trained in post-trauma care. Many people associate physical therapy with exercise, but it can—and should—be so much more.
To benefit from any physical treatment, your body needs to be able to accept healing inputs. However, if your CNS is sending out constant “alert!” signals, it’s difficult for you and your body to focus on anything else. This is why you and your PT may need to start by focusing on techniques to calm an overactive nervous system.
Here are some techniques that can help quiet the CNS and prepare the body for other healing interventions:
- Diaphragmatic breathing (aka “belly breathing”) in specific patterns
- Progressive muscle relaxation
- Body scans
- Gentle soft tissue work/massage
- Acupuncture (provided by a licensed acupuncturist) or acupressure
- Guided meditation
- Gentle, full-body stretching
- Therapeutic (EFT) tapping
- Alternative energy therapies like Reiki or craniosacral therapy
This list certainly isn’t comprehensive, and techniques that work well for some people may be ineffective for others (and vice versa). Your PT and the rest of your care team can work with you to find the strategies that work best for you and your unique CNS.
Remember that every recovery journey is unique. For some people, these initial CNS calming stages can take weeks or months; for others, the changes occur more quickly. Some survivors never fully quiet their CNS or completely resolve all the physical effects of trauma; however, some degree of healing is nearly always possible.
No single situation is “better” than another: it’s most important to give your body the time it needs to reach its unique healing potential.
Next Steps: Getting into the Tissues
While the CNS is a critical piece of the puzzle, it’s not the only contributor to the physical effects that trauma survivors may experience. These effects often center in and around the pelvis, and when they do, a trauma-trained pelvic health physical therapist can help.
Unfortunately, there aren’t many research studies that have specifically categorized all the physical symptoms for which sexual trauma survivors seek care.
However, many of us who work with survivors notice common patterns in their bodies, and we create mental frameworks like the one I showed in the table above. We can use these frameworks to help us determine the types of treatments that are most likely to help each individual. Let’s consider some of those treatment options.
Techniques to Restore Sensation
The nerves in the CNS (the brain and spinal cord) aren’t the only ones affected by sexual trauma. The local nerves in and around the pelvis may also be impacted: some nerves become hypersensitive and others “tune out”. These changes to the pelvic nerves can significantly impair key functions of the pelvis, from peeing to sex to simply standing upright.
If your pelvic nerves become hypersensitive, you may experience pain in response to certain triggers. Sexual activity, pelvic exams, peeing and pooping, prolonged sitting, and even tight clothing may all trigger physical sensitivity and discomfort.
In these cases, extra-sensitive nerves are misinterpreting signals that wouldn’t typically be painful, like the pressure of a passing bowel movement, as potentially dangerous. Nerves generate pain signals to communicate “danger!” messages to your brain – even if there isn’t actually anything endangering you in that moment.
On the other hand, if your pelvic nerves have “tuned out”, they may not be communicating properly with your muscles, skin, or other tissues. Your genitals and other areas may feel numb or disconnected from your body. You may experience difficulty becoming or staying aroused during sexual activity (alone or with partners), and you may struggle to reach orgasm through stimulation to your genitals. (This doesn’t mean you’ll never be able to have an orgasm if you want to: you may simply find that genital touch isn’t your most effective avenue to arousal or orgasm.) Because your pelvic muscles aren’t getting the correct signals from their nerves, you may struggle to control and regulate your bladder or bowels.
Regardless of the state of your pelvic nerves, you can learn strategies to restore their normal sensation. For hypersensitive nerves, desensitizing techniques are often helpful. These may include:
- Gently touching/pressing on the sensitive areas to introduce them to non-painful touch
- Laying or brushing a soft fabric over sensitive areas
- Applying something cool like an ice pack or damp towel
- Applying something warm like a heating pad
People with “tuned out” pelvic nerves typically benefit most from techniques that help “wake up” the nerves. These may include:
- Gently tapping the affected area with your finger pads to stimulate sensation
- Gentle vibration and/or pressure over the affected area
- Self-massage to the area to stimulate blood flow and sensation
- Using a mirror to examine and watch as you gently touch the affected area (this helps the brain and nerves reconnect and communicate better)
- Simple exercises to contract and relax muscles in the affected area
- Gentle electrical stimulation with special devices that stimulate through the skin
If you aren’t sure which category you fall into, a pelvic physical therapist can help you figure it out. Check out these sites to find a pelvic PT near you:
Strategies to Reduce Muscle Tension
Muscle tightness and tension are extremely common reactions to trauma and chronic stress. They arise as the body’s natural reaction to perceived threats, and they are driven by the CNS and the fight/flight/freeze/fawn response.
However, most of our muscles aren’t designed to stay contracted for long periods of time. When forced to do so, they will tire and eventually become painful. This type of muscle tension and pain can occur anywhere in the body, and it can affect multiple areas at once. Many survivors report persistent pain in the back, abdomen, neck, and/or head.
As pelvic PTs, we also encounter these patterns in our clients’ pelvic floor muscles. Excessive muscle tension can disrupt many key functions of the pelvic floor. A tense pelvic floor can make it difficult to fully empty your bladder, cause pain or difficulty when pooping, and make sex painful and/or less pleasurable.
Fortunately, there are multiple tools available to help reduce this muscle tension and the pain it can cause. Here are some of the strategies we commonly recommend to reduce muscle tension:
- Manual (hands-on) therapy like massage, joint mobilization, myofascial release, cupping, etc.
- Stretching with or without assistance
- Functional dry needling
- Exercises to gently contract and then fully relax muscles
- Guided progressive muscle relaxation
- Using medical devices to assist in self-care at home:
- Vaginal trainers to gently stretch the pelvic floor muscles
- Pelvic wands to perform manual therapy on the muscles inside the pelvis
Pelvic PTs have taken advanced training to specialize in pelvic health, but we’re still also whole-body PTs. Because the human body is a complicated system of interconnected pieces, we consider all the parts that could impact an area of pain or problems. Even if you experience muscle tension primarily in your pelvis, you and your PT may identify muscles in other body regions that also need attention.
Reducing muscle tension throughout your body can help restore balance in the areas that are the most painful and problematic. It can be a slow process, but with time and gentle care, your muscles can learn to release and let go.
Methods for Retraining Muscles and Nerves
When traumatic inputs disrupt normal sensation and create excess muscle tension, your body must learn to adapt – but sometimes, these adaptations cause problems. Your muscles may forget how to contract or relax at appropriate times. They may become uncoordinated or lose the endurance they need to function effectively.
However, as your sensation stabilizes and your muscles learn to release excess tension, you can start teaching them to respond properly again. Your pelvic PT can teach you simple exercises to practice at home.
These exercises may target your pelvic floor muscles, the muscles that neighbor the pelvic floor (ex.- abdominals, glutes, other hip muscles), and muscles in other parts of your body. The exercises that are right for you will depend on your unique situation: this is why there’s no “one size fits all” when it comes to physical recovery after trauma.
What if I can’t afford therapy?
I get it. Recovery of any kind can be stressful, time-consuming, and expensive, and many survivors lack the resources to engage in extensive care. Here’s the good news: you can take the reins in your own recovery from sexual trauma.
If you’re concerned about your ability to afford care, I highly recommend sharing those concerns with your provider(s) at your very first visit with them. A good therapist will be willing to work with you, giving you “homework” that you can practice on your own, and teaching you ways to advance that homework when you’re ready. Additionally, many pelvic, mental, and sexual health professionals are in-network with health insurance plans, including federal programs like Medicare and Medicaid. This can help offset the cost of therapy and other recovery services.
If you’re motivated and consistent, you can make a lot of progress in just a few visits. If your provider isn’t willing to meet you where you are, it’s time to seek out someone new.
Professionals like pelvic PTs, mental health counselors, and bodyworkers can all be helpful allies in your healing journey. However, they are there for you as navigators – you are the one driving the car. They can show the tools you need to recover, but it’s up to you to make regular use of those tools.
A word about consent in health care
Speaking of being in the driver’s seat…it’s extremely important that you feel comfortable with the boundaries between you and your providers. Informed consent and patient safety are critical in all areas of healthcare, and perhaps even more so for survivors of sexual trauma.
A good provider of post-trauma care should explain the treatment methods they recommend and why they think these techniques will help. They should give you ample opportunities to ask questions, voice concerns, and set your own boundaries.
Remember: you always have the right to decline any treatment, even if you previously consented to it. Sexual trauma temporarily robs survivors of their autonomy , The experience and aftereffects of sexual trauma can cause many survivors to feel they have been robbed of their autonomy. The recovery process should be an opportunity to reclaim your rights to your body, your voice, and your choices.
