Physiotherapy for Survivors of Sexual Violence

Original Editor - Jeniffer Chepkemoi from The Center for Victims of Torture as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell and Rishika Babburu  

Introduction[edit | edit source]

Survivors of sexual violence present with unique health care needs.[1] Given the prevalence of sexual violence, physiotherapists are likely to encounter sexual assault patients and are often on the frontline of caring for these patients. Consideration for physiotherapy interventions that recognise the complex impact trauma can have on a person’s well-being is paramount. Trauma-informed care appreciates how a person’s life history may have impacted their development, their behaviours, and their current situation.

A Trauma-Informed Approach to sexual abuse care is vital. The power differential between the health care professional and the patient, as well as an invasive physical examination, can cause victims of sexual assault to re-experience the trauma of an assault during health care interactions.[2][3][4] In particular, the medical forensic examination and interview are invasive by nature and therefore have high potential for re-traumatisation. Trauma-informed care is a framework that recognises the impact of trauma and the role of health care providers in addressing trauma with their patients.[5] Trauma-informed care advocates for patient safety and control by building patient-provider collaboration, with the long-term goal of supporting trauma recovery, making it essential to quality care for sexual assault patients. [4][6] As rehabilitation professionals who frequently encounter clients who have experienced or are experiencing traumatic events, physiotherapists are in an excellent position to foster positive health care experiences and holistic rehabilitation by working from a trauma-informed perspective and supporting the health and resilience of both patients and therapists.

Table.1 Five Key Principles of Trauma Informed Care.
Safety The physiotherapist creates a therapeutic environment in which patients feel safe (physically and emotionally), respected, validated and understood. Safety is so vital that people usually can’t start processing their trauma until they feel safe. It is important for people to feel as safe as possible, so it is crucial that physiotherapists build a relationship of trust before they start the examination process.
Trustworthiness It is often hard for survivors of trauma to trust people, and being touched can be very difficult, particularly for survivors of physical or sexual abuse. In situations where the treatment process involves touching the body and manipulating the joints, it is critical that physiotherapists not touch patients without permission. Therefore, the physiotherapist should work with a patient to develop a trusting relationship prior to undertaking any physical treatments.
Choice The choice of the patient and the ability to control their physiotherapy treatments is important. Decisions about their treatment plan are not made for them, but with them.
Collaboration Treatment effects are maximised by working with what the patient is already doing/knowing what works best for them.
Empowerment Physiotherapists should prioritise treatments that empower and build the patient's skills and coping mechanisms in managing their own health. Survivors often come from a place of being disempowered so it’s very important that they have a major say in their physiotherapy intervention, and that they have choices.

The physiotherapist should have a good understanding of pelvic anatomy and neurophysiology as this is critical to accurately diagnosis and manage patients with appropriate physiotherapy techniques.

Goals of Physiotherapy for Survivors of Sexual Violence[edit | edit source]

The main goals of physiotherapy are to:

  1. Increase patient awareness and proprioception of the affected musculature,
  2. Improve the ability to discriminate between muscles and to relax them,
  3. Normalise muscle tone,
  4. Increase elasticity at the vaginal opening and desensitise areas that are painful, and
  5. Decrease fear of vaginal penetration.

Examples of other types of physiotherapeutic treatments recommended for relieving chronic pain and other physical complications in gender-based violence survivors:

  • Pelvic floor exercises
  • Joint mobilisation exercises
  • Massage
  • Vaginal cones exercises
  • Biofeedback
  • Hydrotherapy
  • Thermotherapy 
  • Myofascial therapy
  • Dance therapy

Dyspareunia and Vaginismus[edit | edit source]

Dyspareunia is characterised by pain during sexual intercourse or vaginal penetration. Vaginismus is characterised by spasm of the perineal musculature which makes vagina penetration difficult.[7] Pelvic floor physiotherapy is an important treatment strategy in the multidisciplinary approach to dyspareunia and vaginismus as it improves muscle relaxation, normalises resting muscle activity, increases vaginal elasticity, muscle awareness and proprioception.[8] Methods such as manual therapy, Kegel exercises, posture, core stabilisation, stretching, strengthening, flexibility and coordination exercises should also be included in the rehabilitation programme.[9]

In male patients, instruct patients to isolate and identify the various trunk and pelvic muscles. Pelvic floor isometric strengthening exercises, biofeedback, and electrical stimulation can help with erectile dysfunction and improve control of the ejaculatory reflex. In females, pelvic floor muscle training has been shown to improve quality of life and sexual function in women with urinary stress incontinence. This connection has prompted the recommendation that women with urinary problems should be asked about their sexual function.

Few physiotherapy studies have been done to explore treatment options for sexual abuse survivors. More research is needed about the topic areas below:

Assessment of Dyspareunia and Vaginismus[edit | edit source]

When treating both male and female patients who are experiencing pain with sexual intercourse, there are a several guidelines to keep in mind for optimising your patient’s well-being.[10] Take a thorough history of your patient presenting with pain during sexual intercourse:

  • Facilitate a therapeutic alliance that allows the patient to feel comfortable sharing with you. Start with open-ended questions to give the opportunity for the patient to direct the conversation.
  • Use close-ended questions to gain a more detailed understanding of the source of the pain. It may be a nearby mechanical or structural issue in the low back, hips, or legs.
  • Asking the patient about specific positions in which their pain is evoked is essential to understanding the mechanism of pain.
  • Work to understand the role psychosocial factors and fear may be playing in the patient’s pain.

Your physical examination of the patient should allow you to gain an understanding of mechanical and soft tissue limitations that may affect the patient during sex. Always explain why you need to touch a patient in sensitive areas and gain their consent before proceeding with your exam. If possible, patients should be referred to a physiotherapist who specialises in pelvic physiotherapy. An internal physiotherapy examination (of the vagina or anus) should NOT be conducted by physiotherapists without advanced training in pelvic floor physiotherapy. However, even when there are not qualified pelvic floor therapists available and thus an internal examination or even detailed external palpation of genital musculature is NOT conducted, physiotherapists can still provide skilled evaluation and treatment. Provide a treatment plan consistent with the patient’s goals. Example areas to focus treatment goals:

  • Increase patient awareness and proprioception of the affected musculature
  • Improve ability to discriminate between muscles and relax them
  • Normalise muscle tone
  • Increase elasticity at the vaginal opening
  • Desensitise areas that are painful
  • Decrease fear of penetration

Treatment of Dyspareunia and Vaginismus[edit | edit source]

Treatment tools that may be utilised include:

  • Education: providing anatomical and physiological information to improve patient’s understanding of their own body
  • Cognitive Behavioural Therapy: Vaginal dilators
  • Rehabilitative: Pelvic floor muscle strengthening and relaxation, (with tools to facilitate biofeedback if available)
  • Palliative: to decrease pain and improve mobility
  • Manual techniques such as stretching, massage, soft tissue and joint mobilisation may be utilised as appropriate in order to achieve patient goals

Chronic Pelvic Pain (CPP)[edit | edit source]

Chronic pelvic pain in women is a complex condition, with a high prevalence globally. Chronic pelvic pain is defined as “chronic or persistent pain for at least 6 months, perceived in structures related to the pelvis, and often associated with negative cognitive, behavioural, sexual and emotional consequences and symptoms of lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction”.

Compared with the general female population, women with chronic pelvic pain report poorer total health, a higher number of surgeries in the pelvic area, and more incidences of physical, sexual, and psychological abuse. Altered movement and respiratory patterns are observed, and pain-related fear of movements among other issues are often present.

Sexual Dysfunction in Men[edit | edit source]

Much of the research on male sexual dysfunction has previously been focused on neurological or vascular causes. More recently, studies have turned their focus to the involvement of the pelvic floor. The pelvic floor helps to stabilise the internal organs and gives bowel and bladder control. Research has shown that physiotherapy intervention in the treatment of the pelvic floor musculature is a safe and conservative method for treatment of male sexual dysfunction and pelvic pain. The causes of sexual dysfunction and pelvic pain that can be managed by physiotherapy include erectile dysfunction, ejaculatory/orgasmic dysfunction, and chronic prostatitis/chronic pelvic pain syndrome.

Erectile Dysfunction[edit | edit source]

The muscles involved in erectile dysfunction are bulbospongiosus and ischiocavernosus. Both of these muscles contribute to increased engorgement and expulsion of seminal fluid. These muscles need strength and coordination in order to properly contribute to erection. Pelvic floor exercises have been found to be effective in men with mild to moderate veno-occlusive dysfunction. Literature has suggested that voluntary contraction of the ischiocavernosus can increase penile pressure, thus increasing penile hardness. Literature has suggested that relaxation techniques of the pelvic floor muscles may resolve erectile dysfunction caused by high resting muscle tone.

Treatment for Erectile Dysfunction[edit | edit source]

The following are exercises that can be done with patients to help them gain strength of the pelvic floor muscles and are recommended for treating erectile dysfunction

Knee Fallouts:

  • Have the patient lay supine with their knees bent, feet flat on the floor, and arms by their sides; instruct them to keep their back in a neutral position
  • Have the patient contract their pelvic floor muscles while exhaling. Then have them slowly lower one knee out to the side, keeping the pelvic floor muscles contracted. The muscles or letting their pelvis lift off the floor.
  • Next have the patient bring their knee back to where it started while inhaling and relaxing the pelvic floor muscles.
  • Repeat with the other knee.
  • Have the patient start with 4-5 reps on each side, working towards a goal of 10 reps per side.

Supine Foot Raises:

  • Have the patient lay supine with their knees bent, feet flat on the floor, and arms by their sides
  • Instruct the patient to contract the pelvic floor muscles while exhaling, then lift one foot in the air and straightening their knee
  • Next the patient will lower their foot back to the floor while inhaling and relaxing the pelvic floor muscles
  • Repeat on the other side
  • Start with 4-5 reps on each side, working towards 10 reps on each side

Pelvic Curl

  • Patient lies supine with the knees bent, feet flat on the floor, and arms by their sides
  • Make sure the patient keeps their spine in a neutral position
  • Have the patient contract their pelvic floor muscles and exhale
  • The patient next will push their back flat against the floor
  • They will then slowly lift their buttocks off the floor while pushing their heels into the floor
  • Patient contracts their buttocks as they lift it off the floor; they should lift until they are in a bridge position
  • While keeping their buttocks in the air, have them take 3 breaths in and out and contract the buttock and pelvic floor muscles
  • Next have the patient slowly lower their buttocks to the floor, rolling one vertebrae at a time.
  • Start by doing 3-4 reps, and work towards doing 10 reps as the patient gets stronger

Constipation[edit | edit source]

Constipation is a condition where bowel movements become difficult, painful, and infrequent. Normal bowel movements can occur anywhere from 3 times/day to 3 times/week. Constipation affects multiple aspects of a person’s health, including health-related quality of life. Constipation is influenced by a multitude of factors including an overactive pelvic floor, a diet low in fiber, improper hydration, and certain medications. Other risk factors associated with constipation include history of trauma, history of depression, females, lower socioeconomic status, regular use of constipation medications, and decreased activity (36).

An overactive pelvic floor hinders normal bowel movement. The pelvic floor surrounds the colon and rectum, aiding in the conscious control of elimination of faeces. If the pelvic floor muscles are hyperactively contracting, passing a bowel can be difficult leading to pain, straining, haemorrhoids, anal fissures, faecal impaction, or rectal prolapse. Someone with a history of trauma, postural problems, and psychological/emotional factors can experience an overactive pelvic floor. While this handout can help to teach ways of relaxation of the pelvic floor, it will also be important to treat the underlying causes.

Treatment for Constipation[edit | edit source]

Physiotherapy is a very effective way of reducing the symptoms of constipation and optimising your recovery. Physiotherapists are equipped with knowledge and skills to do a thorough assessment and treatment programme specific to patient needs and goals.

Diaphragmatic Breathing[edit | edit source]

Diaphragmatic breathing is a good way to bring about general relaxation of the mind and body as well as relaxation of the pelvic floor. It stimulates the parasympathetic nervous system (rest and digest) and relaxes the sympathetic nervous system (fight or flight). The parasympathetic system promotes movement of the GI tract, and relaxation of the sympathetic system aids in relaxation of the surrounding back, pelvis, and trunk muscles which may be tense and causing pain. Teaching diaphragmatic breathing can be easy using DASS–Deep, Abdominal, Slow, and Smooth.

  • Have patients lie comfortably with eyes closed. Have them focus on their breathing and eliminate any outside or stressful thoughts.
  • Have them place one hand on their abdomen and the other on their chest, and have them observe which hand moves more with breathing. Guide them to focus on breathing primarily with the abdomen.
  • Breathe in slowly through the nose, deep to the abdomen so it expands with inhalation. Hold for a second or more, and then exhale slowly through pursed lips, allowing the abdomen fall inward.
  • The entire movement should be smooth instead of choppy. If they are experiencing choppy breathing, it may be helpful to breathe more slowly. Try having patients breathe in for 2 counts, then out with three. Numbers can be changed as needed but generally exhalation should be longer than inhalation.
  • This can be done for 3-4 minutes at a time, multiple times each day.

Abdominal Self-Massage[edit | edit source]

Teaching patients to massage themselves at home can be an effective way to move stool along in the colon. The massage will follow the path of the colon.

  • Have patients lie in a comfortable position on their back either with knees flexed or extended.
  • Direct patients to the right side of their abdomen just above the iliac crest of the hip. Gently massage the abdomen, moving straight up from the hip until reaching the ribcage.
  • Next, have patients move straight across the abdomen until reaching the left side of the ribcage.
  • Then massage down the left side of abdomen from the ribcage until reaching the left iliac crest of the hip.
  • Finish massaging by moving from the left hip until they reach you reach the center of the abdomen where the 
  • Repeat this pattern for about 10 minutes at a time.
Tips for Massage:[edit | edit source]
  • Use fingertips to move in a circular motion. The pressure can be gradually increased as tolerated.
  • Spend about 1 minute moving through each direction
  • Always start on the right side and go in a clockwise direction, as the direction that feaces travels through the colon

Diet[edit | edit source]

  • Drink lots of water and tea to help soften stool for easier bowel movements
  • Limit consumption of drinks like soda, coffee, and alcohol. These can remove water fromyour bowels and cause stool to harden. 
  • Eat food rich in fiber like vegetables, ripe fruits, grains, and nuts.

Toilet Posture[edit | edit source]

  • Use a step-stool or box under your feet to bring your knees higher than your hips. This will put the body in an easier position for passing bowel movements.

Exercise[edit | edit source]

  • Moderate aerobic activity such as walking, biking, and swimming can help stimulate the bowels to move.

Faecal Incontinence[edit | edit source]

Information about fecal incontinence is included as this can be common sequelae for those who have experienced anal rape. Fecal incontinence or accidental bowel leakage (ABL) is defined as the inability to control bowel movements resulting in the loss of liquid or solid stool. The cause is often multifactorial including factors such as damage to muscles or nerves, rectal changes, aging, medication and child birth. This condition can have detrimental effects on the quality of life, daily activities and social interactions of those affected. Fecal incontinence is a complex issue often associated with psychological effects and can be a sensitive topic for many. Physical therapists have the ability to reassure their patients that they are not alone and implement accessible, evidence-based interventions and recommendations to help manage their patient’s condition and increase their quality of life.[11][11]

Treatment of Faecal Incontinence[edit | edit source]

Diet and Activity Modification[edit | edit source]

  • Education on weight management can be useful since obesity is a risk factor for developing incontinence
  • Regulating dairy and gluten can be helpful in controlling stool leakage
  • Increased fiber intake has been shown to decrease incontinent episodes
    • Whole wheat grains
    • Fresh vegetables
    • Beans
  • Optimal fluid intake
  • Regular exercise

Bowel Management[edit | edit source]

  • Help patient establish a pattern of bowel evacuation with the use of a bowel diary
  • Keep a diet and symptom diary to help determine what triggers incontinent episodes
  • Teach techniques to reduce straining
    • Toilet posture: sitting on the toilet with knees higher than hips helps prevent blockage of the anal canal and promotes pelvic floor relaxation
    • Leaning forward as bearing down helps increase intraabdominal pressure and reduces straining
    • Deep breathing exercises
    • Muscle relaxation techniques
  • Bowel urge resistance program: instruct patient to hold stool in rectum while sitting on the toilet for increased amounts of time

Pelvic Floor Muscle Retraining[edit | edit source]

  • Pelvic floor rehabilitation has been used successfully in the treatment of FI, and can produce significant functional and quality of life benefits for patients (37).
  • Pelvic floor muscle retraining has been shown to be successful in increasing the endurance, strength and coordination of the muscles and sphincters involved in bowel movements
  • Research shows that strengthening core in addition to pelvic floor musculature is more effective than targeting pelvic floor muscles alone
  • Maximal voluntary contractions, submaximal sustained contractions, and fast-twitch contractions have been shown to be effective in strengthening
  • Teach patient how to correctly activate the correct muscles using verbal cues such as “contract the muscles that you would use to prevent passing gas”
  • Kegels, squeeze and release, bridges, squats, core strengthening are some examples of pelvic floor exercises

Pelvic Floor Dysfunctions[edit | edit source]

  • Pelvic floor weakness that leads to incontinence can be caused by childbirth, obesity, chronic constipation and degenerative changes associated with aging.
  • Overactive pelvic floor that leads to bladder, bowel and sexual dysfunction as well as pain and can be caused by gender-based violence.
    • Constant pelvic floor activation leads to progressive pelvic floor muscle weakness.
  • Female Genital Mutilation (FGM) injury or removal that is partial or complete of the genitalia for religious or cultural reasons. Different regions have different prevalence rates (Kenya and Somalia have high prevalence rates). FGM increases the risk of pelvic floor dysfunctions, infection, anemia, UTI, birthing complications, chronic irritability and nightmares.
  • Anal hypertorus is also associated gender based violence

Common Dysfunctions Associated with Overactive Pelvic Floor Muscles:

  • Bladder problems an example being slower urine flow
  • Bowel problems an example being constipation
  • Sexual problems an example being vaginismus (intense pain with sexual intercourse)
  • Ongoing pelvic floor pain and discomfort that may refer to low back, low abdominals, or hips
  • Pelvic floor muscle fatigue resulting in prolapse

Treatment of Pelvic Floor Dysfunction[edit | edit source]

Relaxation Exercises:[edit | edit source]

  1. Diaphragmatic Breathing:
    • During the inhale, allow your pelvic floor to relax and open. Imagine your pelvic floor is a flower  blossoming.    
    • On the exhale, allow your pelvic floor to pull back in, as if a flower Imagine the flower pulling back into a bud.
  2. Pelvic Floor Muscle Relaxation Exercise:
    • C = Contract - medium squeeze
    • H = Hold contraction evenly for 5-10 seconds
    • R = Relax let PFM relax fully
    • “encourage patient to relax a little further each repetition”
  3. Pelvic Clock Relaxation;
    • Imagine a clock with 9 (right) and 3(left) located on ASIS and 12 being umbilicus and 6 being pubis
    • Start with patient lying supine with knees bent and patient’s pelvis in neutral position
    • Contract abdomen to flatten spin and have patients place either hand on ASIS’
    • 12 o'clock is pulling the belly button in and tilting pelvis up
    • 6 o’clock is tilting pelvis down increasing arch in back
    • 3 o clock is slightly raising left hip and 9 o clock is slightly raising right hip
    • have patient alternate between these positions in random order, each movement should be slow and controlled and each movement should be repeated 3-5 times

Strengthening Exercises:[edit | edit source]

  1. Kegels
    • To perform a Kegel, sit in a chair with your feet firmly planted on the ground. Without using your legs, imagine you need to go to the bathroom, but it is not time yet and you need to hold it in – these are the muscles you want to  use. While performing this movement, contract and hold 5 seconds, then relax for 5 seconds and repeat this exercise 10-15 times
  2. Squats
  3. Bridges
    • Lying on your back, knees bent with feet on ground. Contract gluteal muslces and push pelvis off ground, hold 1-2 and hold 5 seconds, seconds slowly bringing pelvis back to floor
    • Instruct patient to contract pelvic floor along with glutes on way up and relax muscles on way down
  4. Split Table Top
    • Patient lays down with knees bent to 90 degrees so that shank is parallel with floor; have patient start with legs squeezed together and control legs as they let legs fall apart and contract to bring back together
  5. Bird Dogs
    • Patient on hands and knees simultaneously extending opposite arm and legs controlling via stabilizing muscles and switching to opposite limbs

General Tips for Treating Survivors of Gender Based Violence:[edit | edit source]

  1. Avoid: disrobing, unnecessary touch,
  2. Overdoing pelvic floor muscle strengthening is possible and can lead to further problems. Make sure patients have proper treatment parameters
  3. Touch sensitisation can begin with tennis balls utilised by patients first and then trusted companions.
  4. Patients suffering from GBV may not disclose the nature of their torture, all of these treatments are applicable to everyone and do not need to be used with just patients that have disclosed the nature of their torture
  5. For some patients, the focus of their physiotherapy treatment sessions should be on relaxing, or opening up their pelvic floor muscles, rather than strengthening.
  6. Encourage patients to reintroduce self-touch not only to their general body but specifically to their genitalia to normalize touch and reduce fear and pain associated with unanticipated touch; work towards experiencing pleasure associated with touch

Nutrition Recommendations[edit | edit source]

  1. Try to increase daily fiber intake (ideally,  20-30 grams of soluble and insoluble fiber). Remember if you increase fiber you have Increase water intake.                                          
  2. Cooked vegetables are easier on to digest.
  3. Drink at least 6-8 8oz glasses of water or a non-caffeinated, non-alcoholic, and non-carbonated beverage per day. Not getting enough fluid can concentrate the urine and irritate the bladder.            
  4. Caffeine and alcohol can be dehydrating,  so limiting consumption can be helpful.                
  5. Spicy, curried, citrus, acidic, and caffeinated foods and beverages can all irritate the bladder.  

Hygiene Recommendations[edit | edit source]

  1. Wipe from front to back.
  2. Avoid the use of products that have fragrance e.g. tampons and toilet paper.
  3. Wear white cotton underwear and sleep without underwear or bottoms.
  4. Avoid tight clothing/pants
  5. Avoid douching and chlorinated water
  6. With intercourse, avoid lubricants that contain propylene glycol – all natural organic is best. Olive oil may be used. Test a little on the inside of your wrist for allergies.

Resources[edit | edit source]

References[edit | edit source]

  1. Smith SG, Basile KC, Gilbert LK, Merrick MT, Patel N, Walling M, Jain A. National intimate partner and sexual violence survey (NISVS): 2010-2012 state report.
  2. Li, Y., Cannon, L.M., Coolidge, E.M., Darling-Fisher, C.S., Pardee, M., & Kuzma, E.K. (2019). Current state of trauma-informed education in the health sciences: Lessons for nursing. Journal of Nursing Education, 58(2), 93-101. 10.3928/01484834-20190122-06.
  3. Reeves, E. (2015). A synthesis of the literature on trauma-informed care. Issues in Mental Health Nursing, 36(9), 698-709 10.3109/01612840.2015.102531.
  4. 4.0 4.1 Reeves EA, Humphreys JC. Describing the healthcare experiences and strategies of women survivors of violence. Journal of clinical nursing. 2018 Mar;27(5-6):1170-82.
  5. Birnbaum, S. (2019). Confronting the social determinants of health: Has the language of trauma informed care become a defense mechanism? Issues in Mental Health Nursing, 40(6), 476-481.      
  6. LoGiudice JA, Douglas S. Incorporation of sexual violence in nursing curricula using   trauma-informed care: A case study. Journal of nursing education. 2016 Mar 31;55(4):215-9.
  7. Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013
  8. Bradley MH, Rawlins A, Brinker CA. Physical therapy treatment of pelvic pain. Physical Medicine and Rehabilitation Clinics. 2017 Aug 1;28(3):589-601.
  9. Vural M. Pelvic pain rehabilitation. Turkish Journal of Physical Medicine and Rehabilitation. 2018 Dec;64(4):291.
  10. Rosenbaum TY. REVIEWS: Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. The journal of sexual medicine. 2007 Jan 1;4(1):4-13.
  11. 11.0 11.1 Scott K. Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence. Clin Colon Rectal Surg. 2014;27(3):99-105.