A physical therapist specialising in the pelvic floor and founder of the pelvic health practice Inclusive Care, Dr Krystyna Holland provides pelvic care to people across the gender identity spectrum. She also uses social media to educate people about an area of their body that often goes undiscussed.
We started with the basics:
“Your pelvis is a bowl. You have your two bony hip bones at the front, you have your tailbone in the back, and you have muscles that run from the front to the back of your pelvis, and they sit like a sling. These muscles run around your urethra, vagina and rectum, and play are role in bladder and bowel function – being able to keep everything in and let everything out – as well as sexual function, orgasm, arousal, and strength and stability.”
As well as educating people on the muscles and their functions, Dr Holland is passionate about addressing the emotional aspects of pelvic healthcare, such as the impact of shame. She explained that shame can change what people recognise as their medical options in treating pelvic health issues like leaking and pain, especially as it relates to sex and sexual dysfunction. She said shame also plays a role in people’s experience and embodiment of pelvic pain.
“We’re still not talking about what people – especially people with vulvas – should expect during intercourse, or any sexual encounter. Shame can have a really big impact when something doesn’t go well, because our nervous system can interpret shame as something that is dangerous. And when our systems don’t feel safe, we are more likely to have pain. So it becomes a big cycle of ‘I have pain, I have shame’, or maybe even ‘I have shame and then I have pain’. This becomes ‘I have more pain, I have more shame’ and it goes round and round.”
She observed that societal messaging around sex and women’s bodies contributes to this cycle.
“Shame is such a big way that patriarchy manipulates women. There are so many patriarchal norms around what both transgender and cisgender women’s bodies are supposed to do, supposed to look like, even supposed to smell like.
“And when we have this narrative of ‘there’s something wrong with me, I’m broken’, our systems become more sensitive, because it is perceived as dangerous. This can also contribute to pain, and it certainly impacts pleasure. A lot of the people who see me are not even trying to have pleasurable sex, they just want to have sex that doesn’t hurt.”
The language we use in general conversation as well as how healthcare providers talk to their patients can also contribute to this narrative around painful sex. Krystyna said the first thing that medical professionals can do to change this is to stop being so heteronormative in their questioning.
“The entire conversation about sexual pain is still probably 75% about penetrative intercourse, which oftentimes we associate with a cisgender man and a cisgender woman, and a penis and a vagina. And that is super problematic, and also not factually accurate. Penile penetration is not the holy grail of sexual encounters, it’s not the only one that counts, and often it’s not even the best one. But we don’t talk about what all the other options are and how we can support our clients in having positive experiences that don’t involve penetrative intercourse.
“That’s not to say that having penetrative intercourse isn’t a great goal, and it’s something I help people with all the time, but it’s not the only thing you can do to experience pleasure or be physically intimate with your partner. And these are all things that medical providers could do a much better job talking about.
“We know from the literature that healthcare providers are not comfortable asking people about their sex lives, so they don’t. And if we want to use our language to support and prioritise people’s pleasure more often in medicine, we need to start with talking about it at all.”
Dr Holland’s drive for providing affirming, supportive care – and for using social media to educate people on how to advocate for themselves in healthcare settings – comes from her own experiences when she needed pelvic healthcare. Despite studying to be a pelvic physical therapist at the time, she explained, her opinions were disregarded and her questions were not answered.
“I’m a middle-class white lady with private insurance in the States. I had a tonne of privilege and I still couldn’t get good, affirming, value-based care. And from that I experienced medical trauma, even though I had all these things on my side. If that’s happening to me, someone who has a lot of privilege, what is happening for everybody else?
“That experience of being dismissed and feeling like other people were dictators over my body was super impactful. So I don’t do that. I tell people all the time: I am an expert in the muscles of the pelvis, you are an expert about your body. I offer you options and education, but I am never going to know what it’s like to experience this unless you tell me, and then we can work on it together.”
Her advice? Know that you know what it’s like to live in your body. Get comfortable telling healthcare providers when something doesn’t feel right for you. Know how to say that you’re not getting the benefits and results you’re looking for, and ask who else you can see. You don’t have to accept that ‘this is just how it is’.
“There are often treatment options that you’ve not been privy to. This applies to intercourse, it applies to leaking, it applies to pain – there are often things you can do. You don’t just have to live with it. There may be times, because of the circumstances of your life, that you might not be able to access all the things, all of the time. But there are often things that can be done that you may not be aware of.“
Part of Dr Holland’s pelvic health advocacy involves countering the fearmongering, shaming, and incorrect messaging that circulates online. She explained that she tries to acknowledge what she knows is being said, then she provides answers in a medically accurate, non-judgmental, inclusive way. But healthcare requires nuance, and social media doesn’t provide for this.
“It’s my least favourite thing. Part of what I really don’t like about TikTok is there are no captions, so it’s literally whatever I can fit on the video, which does not leave room for nuance. You just have to say ‘hey, there’s no room for nuance, you need to know that, let me direct you to a blog article or something else.’ On Instagram, my answer to this is talking too much. I write very long captions with lots and lots of information, and I over-explain for the sake of being extremely clear.”
Krystyna’s latest project has been creating a Painless Sex Playbook full of the strategies she commonly gives people.
“It’s set up as a Choose Your Own Adventure. You start with the type of pain you’re experiencing or the diagnosis you have, and it gives you things you can at least try to start with. It’s not going to replace a one-on-one consult, but not everyone has access to that. I think it’s also a good resource for people who just want to support their sex life. The strategies I talk about can be helpful to anybody, like what kinds of foreplay are helpful in terms of where to touch and why. The information is primarily centred around people who have vulvas or are supporting, loving, having intercourse with people who have vulvas.”
Photo courtesy of Conscious Design