As you know, I’m a women’s pelvic health physiotherapist and becoming increasingly concerned about the unwanted physical effects of gender-related medical interventions.
Pelvic health physiotherapists treat continence problems, pelvic pain, bowel dysfunction, scar restriction and sexual dysfunction. We don’t treat gender dysphoria or provide psychological therapy. But recognising co-morbidities, assessing anatomy and function, and referring appropriately are core competencies for managing complex presentations of any origin. I don’t see that managing issues pertaining to gender is any more challenging than those caused by neurological disease, multiple fractures or frailty.
Physios are regulated by the HCPC, most of us are members of the Chartered Society of Physiotherapy, and many are part of the specialist group, Pelvic, Obstetric and Gynaecological Physiotherapy. At present, to my knowledge, none have provided guidelines for the clinical management of physical consequences of gender-related medical interventions. To be fair, neither have other professional bodies.
Anecdotally, referrals to pelvic health clinics for females taking testosterone, males following genital surgery or prolonged tucking, people discharged from gender clinics, and individuals who have detransitioned are increasing. We don’t know how many people there are because no systematic data are being collected.
That’s a problem, because this field desperately needs data. Cochrane reviews are recognised as high-quality examinations of current evidence and one was attempted on feminising hormone therapy in males. It found the evidence was too weak to draw any conclusions. Despite decades of gender clinical practice and publications, there is not yet evidence robust enough to generate Cochrane Reviews. What we definitely do know is that low-quality evidence does not equal low clinical importance.
Dr Ruth Parry and I were concerned about this and presented our state-of-the-art review at the CSP conference last November. We included first-person accounts from individuals who had desisted or detransitioned. Our findings were consistent: pelvic floor morbidity appears common in those who medically transition.
Da Silva and colleagues reported pelvic floor dysfunction in 94.1% of females taking testosterone without genital surgery, and that is striking. Fewer than 10% of women aged 20–39 years have a pelvic floor disorder and for women over 80 it’s about 50%. Between 60-80% of elderly, frail women in residential care have urinary incontinence, so this figure of 94% pelvic floor dysfunction is considerably outside expected population norms - that’s a professional way of saying “good grief, what’s going on?”
The Da Silva study reported rates of urinary and bowel leaking, urinary urgency, pelvic pain and sexual dysfunction, including, for females, severe post-orgasm pain lasting for up to three days. We know these symptoms impact on sleep, travel, relationships and ability to exercise, and the people experiencing them have decades of life ahead of them…so why is our guidance mostly focussed on terminology?
These conditions are bread and butter for pelvic health physios, and yet physiotherapy input is rarely described in gender care pathways. Access to specialist pelvic health services is inconsistent, and for those who de-medicalise, it is often entirely absent. Do we expect these people to manage the predictable and difficult consequences of gender interventions alone?
In the absence of specific guidance, physiotherapists do what we are best at - we listen, examine, establish what is working well and what could be improved (by drawing on established evidence from parallel fields: post-prostatectomy rehabilitation, radiotherapy-related pelvic injury, obstetric anal sphincter injury, menopause-related pelvic floor dysfunction and chronic pelvic pain syndromes), jointly agree a plan that is worth a shot, see what happens, review and progress accordingly.
Management of females might include pelvic floor relaxation or strengthening, pain management, bladder and bowel retraining, and signposting for vaginal oestrogen.
Males who have used high doses of oestrogen, prolonged tucking or had genital surgery present with chronic pelvic or perineal pain, difficulty peeing, incontinence, scar restriction and sexual dysfunction. Physio focuses on reducing muscle spasm, scar management, restoring movement and retraining bladder and bowel patterns.
Tucking is an under-studied and under-considered cause of pelvic pain. It is the practice of prolonged compression of the male genitalia to reduce bulk under clothing and linked with skin breakdown, urinary tract infection and difficulty peeing. The most effective way to reduce tucking-related problems is to reduce, or stop, tucking.
Detransitioners, or, as some prefer to be referred to, de-medicalisers, are a group about whom we know very little. This is a person who has undergone medical or surgical gender-related interventions and later seeks to mitigate or reverse them. Low detransition rates are frequently, and loudly, cited, but robust longitudinal follow-up data are lacking. As the Cass Review highlighted, adult gender services do not systematically follow up individuals who fail to attend. People who self-medicate or have surgery abroad are, inevitably, missing from the data. The best guesstimate to how many there might be can be found in online peer-support spaces. Reddit is, obviously, not peer reviewed, but it is clear that a growing number of people are gathering in informal online groups to exchange advice and seek support - presumably because their needs are not being met by clinicians.
Am I an “Openly Gender-Critical Activist”?
This essay is based on a talk I recently delivered to healthcare professionals. I received feedback from one person who described me as an “openly gender-critical activist,” and alleged deliberate misgendering, use of pejorative language and a lack of clinical relevance in my talk.
I think this might be because I referred to trans-identified males and trans-identified females, because there is strong evidence that using sex-based language is clearly understood by most people, wheras gender based language is not. Describing documented outcomes is part of the aim of scientific meetings - if critical thinking is perceived as hostile, then I don’t think the problem is the data but, rather, suggests professional scrutiny has been confused with a political agenda. I suppose that’s fair, I do have a political view - which is that people who have gender issues deserve the same level of evidence supporting their care as any other population.
There is some evidence that gender-related distress reduces in some individuals following medical transition. There are also senior voices who argue that affirmation is not a benign intervention for children. Affirmation does not seem to be effective in resolving debilitating pelvic pain, remodelling scar tissue or restoring bladder and bowel symptoms.
My point, supported by the limited evidence we have to work from, is simple - gender-related medical interventions have common and significant negative consequences and it has to be someone’s job to develop services to manage them.
Nothing should be beyond discussion in healthcare. Difficult conversations need to be had, and criticism, including of me, should be encouraged. I honestly would be relieved to find that I have misunderstood things because if my interpretation of the evidence is correct then healthcare is failing an unknown number of people with predictable complications. Solutions won’t be found by dismissing data, or people, as “gender-critical” but through good, old-fashioned reflective practice and debate.
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