Pelvic Floor Physical Therapy
LGBTQ+ people with IBD and IBS, including those who engage in anoreceptive intercourse (or bottoming) often face unique anal health challenge, such as pain, spasm, or incontinence, especially related to anal sex or gender-affirming procedures.
Pelvic floor physical therapy addresses not just symptoms, but also empowers patients around identity, consent, and sexual wellbeing.
Why Pelvic Floor Physical Therapy?
Why Pelvic Floor Physical Therapy?
Many LGBTQ+ individuals with IBD and IBS experience pelvic floor symptoms related to anoreceptive (anal) sex, such as pain, tightness, or difficulty with bowel movements.
Pelvic Floor Physical Therapy (PFPT) can offer affirming, evidence-based care that improves both function and comfort and enable you to enjoy things you like (whether that is bottoming or whatever you want to do), and daily life as well without painful anal spasms and such.
Pelvic Floor Physical Therapy (PFPT) is a specialized form of physical therapy focused on the muscles of the pelvic floor, including those involved in bowel function, sexual activity, and core stability.
Tip: try masturbation! I know it sounds wild, but masturbation is actually more effective than Kegels for strengthening the pelvic floor and is associated with positive outcomes in pelvic floor health.
The benefits of pelvic floor physical therapy include helping prevent and treat several of the symptoms that people with IBD experience.
For example, fecal incontinence is one of the most commonly reported troublesome experiences people with IBD face (and roughly 14.29% of us experience it!)
Improved pelvic floor awareness can help with bowel control, teaching people about their pelvic floor muscles and how they function.
Increased awareness of these muscles (prioproception) allows people with IBD to better understand and control their symptoms, such as managing urgency or improving the coordination of bowel movements.
Constipation is another uncomfortable problem people with IBD often face, even during remission- As many as 34% of us with IBD may have issues with constipation!
Sluggish bowel muscles make it hard to keep things moving regularly. And we all know what happens next!
The big B’s: bloating, blockages, and sometimes even blood when you finally pass a stool.
Working on pelvic floor muscle coordination and function through pelvic floor physical therapy can can help regulate bowel movements and can help with constipation or diarrhea.
Pelvic floor dysfunction can also cause pain.
You might feel it under your belly button, in your lower back, or as rectal, vaginal, or perineal pain.
Techniques like manual therapy, massage, and stretching, or relaxation exercises can help soothe bloating and discomfort help with pain management
Anal pain or tightness.
Constipation or incomplete evacuation.
Fecal incontinence or leakage.
Pain during or after anal sex.
Spasm or overactivity of the pelvic floor muscles.
What does pelvic floor physical therapy do?
Pelvic Floor Physical Therapy focuses on the muscles that support the rectum, bladder, and genitals.
For LGBTQ+ people, especially those engaging in receptive anal sex or managing gastrointestinal disorders, these muscles can become:
Overactive or tight (causing pain, spasm, or difficulty with bowel movements)
Weak or poorly coordinated (causing incontinence or urgency)
Sensitive to touch, trauma, or dysphoria.
What can cause pelvic floor muscles to become “dysfunctional”?
For people with IBD, it’s often our body’s response to pain.
If going to the toilet is painful, you might clench and have trouble letting go, or the opposite. Both can cause issues.
Individuals with IBD experience significant negative or adverse experience with the bathroom and with defecation that can be quite traumatizing, and therefore when they get in remission, they still have a negative association with the bathroom and might have fear of going to the bathroom despite being in remission.
If you are transgender or gender non conforming, this can be heightened - for fear of using public restrooms due to current events and bathroom bans, etc.
For LGBTQ+ people, pelvic floor dysfunction can be caused by a few things, including minority stress and gender affirming surgery or procedures.
For transgender women, pelvic floor health can be influenced by several factors, including
How reproductive organs are tucked or bound can disturb the flow of blood and lymph (a fluid that helps fight off bacteria in the body).
Tucking and binding can also impact on muscle activity if you do it for far too long or use the wrong material (i.e, ace bandage wraps instead of proper binding or tucking material)
Tucking reproductive organs for too long, or too vigorously, can cause pain and may have an impact on pelvic floor health.
We also know that tucking and binding can be an important part of managing gender dysphoria and being able to get out there in the world with confidence.
Lower surgery to create a vagina (vaginoplasty) does carry the chance of introducing pelvic floor dysfunction, but these are things that you can talk to your gender affirming surgeon with and a pelvic floor PT to address - it’s fixable!
Physical therapy with a pelvic floor specialist, before and after gender-affirming vaginoplasty, has been shown to improve the outcomes in pelvic floor function.
This is why it’s important to find a balance between feeling good in your body, and making sure you’re binding and tucking safely.
If you are transgender and you’re considering gender affirming lower surgery, talk to your health professional about your overall health, the health of your pelvic floor and the current functioning of your bladder and bowel.
Making sure your pelvic floor is in good working order, before surgery, is a great way to set yourself up for the best possible recovery.
For transgender men, pelvic floor health can be influenced by several factors including..
Pelvic floor health can be impacted by exogenous (GAHRT) testosterone therapy as well.
Depending on the dosage, testosterone can affect vaginal tissue - increasing the risk of atrophy and inflammation of the vagina and/or cervix.
Lowering estrogen can affect tissues needed for skin resilience, vaginal pH, lining bladder pipe, and vaginal lubrication.
Often you can use vaginal estrogen without increasing systemic estrogen, which can be useful when transitioning, talk to your doctor about this! They have options that can help.
Get tested! While not directly related to the pelvic floor, it’s all part of health down there!
We know there are barriers to trans men getting tested, but there are services out there that do better in this space.
Ask around, find someone you trust, don’t give up! Untreated STIs are no fun.
Everyone with a cervix needs a cervical screen every 5 years. You can now ask to self-collect (you swab yourself, instead of having a nurse or doctor do it).
If you’ve got a small frame, the increased muscle mass as result of testosterone therapy could lead to changes in posture which may impact on the pelvic floor muscles.
Binding of the chest can cause pain and difficulty breathing. Diaphragmatic breathing affects the pelvic floor and has an influence on the contraction and relaxation of the muscles.
Always bind safely! There are resources out there about safe binding techniques.
What happens during pelvic floor physical therapy for anal concerns (particularly from bottoming)?
They will do an intake, and see what is going on, and discuss what you are needing.
This assessment may involve (all done with consent and your permission)
Questions about gender identity, anatomy, and sexual practices.
Screening for muscle overactivity, dyssynergia, or pelvic floor trauma.
An optional external and/or internal (anal) pelvic exam using a gloved finger - you can choose what you want to allow, it is all up to you and under your control.
Evaluation of muscle tone, strength, coordination, and trigger points.
What can it help with?
Pelvic floor physical therapy can offer a lot of benefits, depending on what you are going into it for!
Manual therapy: Releasing tight or spastic muscles.
Breath work and relaxation strategies.
Biofeedback to retrain pelvic floor coordination.
Dilator education or re-introduction to pleasurable anal touch.
Bowel training and toileting mechanics.
Relief from pain, spasm, and tightness.
Improved bowel control and ease.
More confident, pleasurable anal sex.
Better communication with partners about comfort and boundaries.
Empowerment in knowing your body and options.
They can also provide education, including….
Tips for comfortable, safer sex (lubrication, warm-up, positioning)
Anatomy-affirming strategies for trans patients (e.g., tucking, packing considerations)
Concerns Pelvic Floor Therapy Can Treat or Help With
Persistent tightness or burning.
Painful bowel movements or constipation.
Fecal incontinence or leakage.
Loss of comfort or confidence with anal play.
Discomfort after gender-affirming surgery.
A small study in 2019 found pelvic floor therapy was most helpful for people who are in remission or currently have inactive IBD.
For people in this group, symptoms improved in 68% of people with evacuation difficulty and 80% of people with fecal incontinence.
For people with an ileoanal pouch (also known as a J-pouch), pelvic floor muscle training didn’t appear to reduce the risk or severity of fecal incontinence.
Importantly, you need to find an expert to get the benefits of pelvic floor therapy.
Some signs your pelvic floor may need attention are problems urinating or an increase in frequency; leaking bladder when coughing or sneezing; pain or discomfort when having sex; and pelvic, back, hip or sacroiliac pain.
Who Can Benefit?
People experiencing anal discomfort after sex.
People with IBD, IBS-C, hemorrhoids, or fissures.
Trans and nonbinary people navigating pelvic health changes.
Anyone seeking more confidence and comfort with anal intimacy.
Pelvic floor physical therapy is an effective, affirming approach for LGBTQ+ individuals experiencing pelvic or anal dysfunction, especially post-anal sex. It restores both physical function and sexual wellbeing, respecting personal identity and active consent.
When seeking or referring for PFPT, prioritize providers with expertise in pelvic muscle rehabilitation, anal health, and cultural competence in LGBTQ+ health.
Vaginismus and IBD
Most Vaginismus information focuses on the experiences and data tailored to cisgender women (who’s health and information absolutely matters and is 100% important!), there is very little tailored or contextual to LGBTQ+ individuals, especially LGBTQ+ individuals with IBD.
Vaginismus is a condition where there is involuntary tightening of the vaginal muscles, making penetration during sex or any type or intercourse or self pleasure, medical exams, or tampon use, painful or impossible.
This may include experiences of involuntary tightness, burning, or sharp pain with any vaginal penetration, including fingers, toys, medical instruments, or during intimacy.
LGBTQ+ patients, with or without IBD, often face added layers of stigma, dysphoria, or invalidation in medical settings, making it harder to access care for something as intimate as pelvic pain.
In people with IBD, especially those with active perianal disease, chronic pelvic pain, or trauma from medical procedures, vaginismus may develop as a physical response to pain, inflammation, or fear.
For LGBTQ+ individuals, this can intersect with experiences of gender dysphoria, medical stigma, or prior negative healthcare encounters, further complicating diagnosis and care.
Chronic GI Pain and Trauma and Vaginismus
Depending on how long you have been diagnoses, IBD can involve years of invasive exams, bowel prep, and procedures like colonoscopies, fistula surgeries, or abscess drainage.
These experiences may contribute to pelvic floor dysfunction and heightened pain sensitivity around the genitals and anus.
In some people, particularly transmasculine individuals, transgender men, or those who already feel medicalized or hyper-surveilled due to years of medical intervention or something similar, this can lead to physical guarding, fear of penetration, and the onset or worsening of vaginismus.
IBD, Pelvic Tension, and Guarding
These physical symptoms may lead to unconscious pelvic floor tightening, especially if there’s trauma from rectal exams, colonoscopies, or anal fissures and fistulas.
This guarding can eventually spread to the vaginal area, particularly in people who also experience sexual trauma, gender dysphoria, or distress around their genitals.
Transmasculine individuals may especially experience increased muscle tension in response to gynecological care that feels dysphoric or dehumanizing or otherwise adverse/bad experiences.
IBD-Specific Triggers in LGBTQ+ Patients
IBD flares, ostomy bags, surgical scars, and medication side effects (like steroid-related body changes) can all affect body image, genital comfort, and feelings of sexual autonomy.
For queer and trans patients, these changes may collide with identity and self-expression.
Fear of leakage, pain, or urgent bowel movements during intimacy can make it harder to relax, causing subconscious tightening of the pelvic floor, pelvic floor dysfunction (PFD) which can be associated with vaginismus.
Some people with IBD and vaginismus describe a sense of not trusting or disconnect with their body during sex, which makes muscle tension even worse.
Vaginismus and Impacts on Sexual Health
For many LGBTQ+ people, vaginismus can interfere with intimacy and pleasure.
Some may avoid certain kinds of touch, while others may feel shame or anxiety during sex.
This can create tension in relationships or reinforce internalized stigma about being “too complicated” or “not normal” (these things are NOT TRUE of course!)
Some trans or nonbinary individuals may feel disconnected from parts of their body already, and vaginismus can worsen this disconnect.
Trauma-Informed Pelvic Health Interventions
If you are able to, a multidisciplinary approach works best, being able to have a healthcare team of a GI doc, pelvic floor PT, PCP, who can coordinate around your care.
LGBTQ+-affirming pelvic floor physical therapy can help patients gently regain control and comfort over their pelvic muscles and reduce symptoms of vaginismus and also help address other pelvic floor issues you may be having and sexual health concerns (see more info here on pelvic floor PT)
Therapy might include biofeedback, mindfulness, dilator work, or manual therapy (see more here, and of course, a pelvic floor physical therapist and affirming gynecologist will be the best source of information regarding your specific situation) but always with patient consent and control.
Mental health care, especially trauma-informed or sex-positive therapy, can be critical for addressing the emotional layers of pain, shame, or avoidance.
Affirming Pleasure and Autonomy
Vaginismus is treatable!!
For people with IBD, the goal of treatment should center not only on reducing pain but also on restoring agency and pleasure in their own body.
Providers should validate all types of sex and intimacy, and emphasize that health care should never come at the cost of dignity or desire.
Healing vaginismus is not just about penetration, it is a combination of ensuring your physical and emotional safety and self-trust, and reclaiming connection. If your provider doesn’t, you should be able to seek care elsewhere where you feel affirmed.
For transgender men, transmasculine people, and everyone using testosterone as gender affirming hormone therapy or in general as hormone replacement therapy, vaginismus and/or vaginal atrophy may occur, and it is nothing to be worried about - totally treatable!
Testosterone use is associated with decreased estrogen in the vagina and atrophic vaginal tissue, which may be associated with decreased vaginal lubrication and/or discomfort during sexual activity.
Testosterone GAHT is associated with vaginal atrophy, which may be associated with decreased lubrication and/or discomfort during sexual activity. At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function.
At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function (and increased libido/sex drive, etc) .
There is, once again, little to no research on transgender men/transmasculine individuals with IBD using GAHRT (testosterone and other masculinizing hormones), which may compound or worsen the vaginismus experienced due to IBD-related pelvic floor dysfunction or trauma in the pelvis area (the causes listed above)
But, conversely, there may be an opposite experience - the alleviation of dysphoria from use of GAHRT may release tension and increase sex drive/libido and sexual health and improve overall quality of life, which then improves overall pelvic floor function - it really depends on each individual person, and there really is not enough research.
Seeking Care
Because of this (and like everything!) it’s essential to recognize that vaginismus is not just a "women’s health issue."
It can affect people of all genders with vaginas, including cisgender women, transmasculine people, transgender men, nonbinary individuals, and intersex patients - anybody that has not had a vaginectomy, essentially.
It’s important to find a healthcare provider you are comfortable with discussing these concerns with - if you are using GAHT like testosterone, it can be your endocrinologist, and they can prescribe or refer you to someone who can help, or if you are comfortable discussing these topics with your GI doctor, you can bring the topic up to them and they can develop a gameplan to help address your concerns.
It is important for people diagnosed with pelvic floor dysfunction or vaginismus seeking care to look for providers and qualified pelvic floor therapist who is specialized in GI and evacuation disorders, as well as LGBTQ+ health if available!
These are generally physical therapists or occupational therapists who complete extra training in pelvic floor therapy and are knowledgable and experts in how the physiology and anatomy of our bodies!
It is important that if you are seeking out care, whether that is pelvic floor PT or general vaginismus care from an LGBTQ+ health perspective knowledgeable in GI conditions your provider is informed about LGBTQ+ health and GI conditions.
This is because our bodies and needs may be different from how a different condition may present, and being LGBTQ+ affirming is important when approaching care in a sensitive area.