So welcome everyone, we're glad that you're here. If you could please silence or turn off your cell phones, we appreciate that. And then there's no audio or video recording allowed during these sessions. There are evaluation forms, you can find those in the app, and we would encourage you to please fill those out for the speakers. It helps us also in planning for future conferences. And then just a reminder to go and visit the pavilion if you haven't already. There's all kinds of fun things to do there. Lots of great networking happens there. But there's also puppies and dogs to pet, which who doesn't want to go do that? So for those of you that were not here this morning, the sessions today are all kind of focusing on pelvic cancers and pelvic floor treatments, as well as kind of sexual dysfunction and the treatment of that. So we're really excited for the next session. I'm going to introduce Claire. So Claire Hamnett got her doctorate of physical therapy from Columbia University. She did her residency in women's health at Baylor Scott and White Institute for Rehabilitation. She's a board-certified clinical specialist in women's health physical therapy. She has a pelvic rehabilitation practitioner certification. She's also a certified lymphedema therapist. She's associated faculty at Columbia University Program in Physical Therapy, and she's currently in private practice in New York City treating abdominal pelvic patients of all ages and genders. So Claire, thank you for joining us. Thank you. All right. Hi, everybody. Excited to be here talking about pelvic PT and all things pelvic. So we will get started. Hopefully I can use this well. I have no relevant financial relationships or disclosures. My objectives for this talk are really to define what pelvic PT is. I think it's really helpful, especially in referring patients, to be able to articulate really well what patients are going to see when they get to pelvic PT. Also to describe signs and symptoms that warrant a referral to pelvic PT, and identifying questions that you can ask patients that may lead to a PT referral. And additionally, especially after some of last talk, want to make sure that everybody has the resources to find good pelvic PTs in their area. So what is pelvic PT? So really it's the treatment of any bowel, bladder, or sexual dysfunction. I always say I treat all ages, all genders, and that's true. With any of these kinds of dysfunctions. It really is also orthopedic, but also neuro treatment. So some of the things I do maybe would fall under more of a traditional neuro PT umbrella versus an orthopedic PT umbrella, but it all kind of comes together in treating these kinds of conditions. So in addition to the manual work, PTs work on activity modification, lifestyle changes, and of course exercise, strengthening mobility, that kind of thing. So pelvic floor physical therapy, the PT's doing that have a wide variety of backgrounds and abilities. We touched a little bit about this in the last session as well, but there's no technical definition for what a pelvic PT is. Anybody can call themselves a pelvic PT regardless of whether they've been trained to do internal vaginal or rectal assessment, or if they've been just trained in external assessment, or whatever it is. There's no rules. So there are rules around being a board certified specialist, and some of the other certifications that I'll talk about later in the talk. But anybody can call themselves a pelvic PT, and so ensuring that you are making contact with pelvic PTs in your area, and making sure that you know the abilities of the therapist that you're referring to can be really, really helpful. Sometimes this field is called women's health physical therapy, and this is something that our professional organization is moving away from in multiple ways. My board certification is in women's health physical therapy, even though the questions and the areas of knowledge of the test include pelvic health of all ages, all genders. It comes from a history of being originally more obstetric type PTs, and it then moved to women's health for conditions that disproportionately affect women, including things like lymphedema, and that's part of how all of this comes together to be abdominal pelvic PT, so that's kind of the background for that. There's also a board certified specialist for oncology PT, which is not what I am. I'm a board certified women's health PT that treats patients with oncologic diagnoses, but there could also be a board certified oncology PT that treats pelvic also, so again, just knowing the providers in your area. So brief overview of conditions that pelvic PTs treat, and this goes for, again, regardless of the cancer history. These can come up in really any kind of population. I could give probably a full talk on each of these and have a great time doing it, but from here, it's really, again, any bowel, bladder, or sexual dysfunction, there can be a musculoskeletal or neurologic component to it that PT can help with, so this is kind of a list of some of them for bladder and bowel, and then orthopedic, hip, back, all of this is all, they all function together, they all come together. It's again, treating related orthopedic areas. You know, you don't just assess the one area, you assess neighboring areas, and so all of these, again, part of this, but prenatal, postpartum, post-surgical, et cetera, and then sexual dysfunctions, which is a major topic of what we're going through today, but these, again, in patients with and without a cancer diagnosis can have sexual dysfunctions of any kind. So the role of the pelvic floor, I like to really kind of summarize it here as there's the support role, a sphincteric role, sexual function, and stabilization. You can remember it as all these S's and really kind of speak to it in that way, but the pelvic floor is really an essential part of the core. In a class that I teach in the PT school at Columbia, I am working on trying to get students to think about how the pelvic floor is the core, and if you're treating the core, which all PTs do, you're treating the pelvic floor, and so really trying to integrate that knowledge into the regular orthopedic knowledge you already have can be really a helpful way to describe it and think about it and refer out if needed. So additionally, pelvic floor has, of course, a sexual function, and then bowel and bladder, and of course, like I was saying, the core part of it as well. So we're going to breeze through some of the anatomy pieces here, just talking about the skeletal muscle in the area that PTs tend to focus on, this being the superficial layer of the pelvic floor, which is primarily involved in sexual function but can tell you a lot about the deeper layers too, especially if some of these muscles are tense, et cetera. Next is just a kind of more involved view of the same thing. You have that superficial pelvic floor, but you can also see the deeper pelvic floor and then some of the associated fascial and structural pieces to it, which, again, can be influenced by PT, et cetera. This is a look at layer two of the pelvic floor, which is more in a urinary system and function in that way. All of these pictures so far have been in patients with female anatomy. However, the analogous structures in patients with male anatomy are very similar. So just an effort to be brief here, we're just going through the female anatomy. Part of this, as this relates to cancer diagnoses especially, is any kind of hormonal treatments and or radiation, et cetera, can affect these structures. And so a lot of times my patients will say to me, well, if those things caused this, how is pelvic PT going to be helpful? And my answer to that is that I could probably assess 10 random people and find pelvic floor dysfunction in half of them at least. And not everyone has to have an absolutely perfectly functioning pelvic floor. Not everybody has to have a perfectly functioning pelvic floor in order to live their best life and function normally in the world. However, if you have something working against those structures, you maybe do have to hold your pelvic floor to the highest standard in order to function appropriately in all the ways that you really want to be able to function. And so that's a way to kind of describe how pelvic PT can be really helpful, even if their original dysfunction is from something else. And then here's a look at what traditionally we think of when we think of the pelvic floor. This is the deeper pelvic floor. This is the bowl or the hammock or however you've learned to describe it. You have the traditional levator ani, which is mostly what's sling from the front to the back, and then the obturator internus kind of on this side. You can see there. These muscles, they all work together, and this is part of how I also explain some of the line of questioning that I have with patients. And I show them this model and I say, see how these muscles sling from the front to the back here? This is part of why I ask you questions about bowel, bladder, and sexual function, because a lot of times these muscles, they function together and then they dysfunction together. And so that can help people be really on board where they think they're coming to see me for just one thing, but again, they function together and dysfunction together, so we have to be talking about bowel, bladder, and sexual function kind of all together in a way that helps everything be cohesive and then, of course, makes sense to the patient. So brief anatomy overview. So oncology PT generally is working on treating functional deficits, orthopedic complaints, and side effects of treatments, no matter what they may be. And so there, of course, as I was mentioning earlier, there are physical therapists that primarily work with oncology populations that may or may not be gynecological or prostate cancer, but these are the kinds of things that they would be really focusing on in terms of measures of improvement and things that they're assessing and ensuring in patients. And so lymphedema screening is hugely important, something that I do a lot with my patients, even though, again, they're not typically coming to see me with lymphedema complaints. There's a lot of room, too, for circumferential measurements, bioimpedance technology, a lot of which I saw in the exhibit hall today as well, so it's out there. But all of those can be done preoperative or pre-treatment for cancer treatment or in the post-treatment kind of realm or really anywhere between and on the spectrum of this. Additionally, of course, we're looking at strength, balance, function, general functional abilities like being able to get in and out of a chair, being able to get out of a chair and then walk at a speed that would be appropriate for different kinds of like community ambulation, things like that, working on posture. And general fatigue can happen as a side effect of a lot of the treatments, etc. So again, this is kind of an overview of what oncology PTs generally do. And again, we're working on the side effects of some of these medications, so making sure that people can breathe well, function well, sometimes focus on shorter and more frequent exercise bouts and improving cardiovascular fitness in that way versus also musculoskeletal side effects, making sure people are having good stabilization, working on orthopedic side of it, weight-bearing, working on preparing for any kind of osteoporosis management, prevention, risk factors, etc. And then changing any kind of activity to be what it needs to be in order for people to be able to do it. So making, modifying activities so that patients can have success in doing what they need to be able to do. Additionally, of course, any kind of joint pain, muscle weakness, anything that you would see in a typical orthopedic setting, of course, also applies here. Lastly, the neuromuscular kinds of side effects from chemotherapy would be any kind of balance, making sure people are getting assistive devices if they need it, and different kinds of compensations to again be able to function normally. Radiation side effects, these are often worked on in conjunction with PT in terms of if there's pain or, again, lymphedema screening, etc., and making sure that, again, people have good range of motion regardless of what's restricting the area, etc. So, again, this is kind of more the general oncology PT, but this doesn't mean your pelvic PT can't do this, but this is, again, part of why making sure you know who the pelvic PTs you're sending to are, and if you're expecting them to do this, or if you're not expecting them to do this, or whatever the goals are, it's important to make sure that you're kind of talking with the whole team and making sure that people are getting what they need. So moving to gynecological cancers in pelvic PT and what maybe I would do more specifically from a general physical therapist or even a general oncologic physical therapist, we're looking really, again, at basically bowel, bladder, and sexual dysfunction. I am, of course, looking for lymphedema, increased risk, etc., and still dealing with fatigue, weakness, all of these things that are very associated, particularly in gynecological cancers. If there's been a surgery, I'm looking at scar tissue, and if they have been referred for a vaginal stenosis after any kind of radiation, etc., or a narrowing of the vaginal canal, of course, that would be what we would be really looking at. I always make sure that I'm screening for all of these, but making sure that I'm also really paying attention to what the patient is coming to me for and really focusing on their main goal. But of course, if their main goal is sexual function and they have significant bowel and bladder dysfunction, we kind of have to address all of it together. And of course, all of these are highly dependent on what kinds of cancer treatments or any other medical treatments, medications, etc., that patients may be on. So this is kind of a really big umbrella view of this. So things that I do, again, basically orthopedic treatment, low back, hips, abdominal pelvic area, what you would typically think of what a PT would do, and any kind of scar mobilization. This manual therapy, to me, includes an internal vaginal and or rectal assessment based on what the patient is presenting with and what their goals are in PT. The neuromuscular reeducation piece of this, we want to make sure that all the muscles are working together as a team really well, especially after any kind of surgical or medical intervention in the area. It can be difficult to have all these muscles get back on the same team afterwards, and so making sure that they can be cohesive like that can be really, really important. And it's really just a coordination piece. And so especially muscles that are tense often tend to then be weak and then aren't part of the team. And so lengthening them, strengthening them, and making sure they're part of the team they're supposed to be part of can be really, really helpful. The education piece is also a huge part of what I do. I find that when people have low back pain, they will go to work and complain about it. They complain about it to their friends. They'll mention it to providers more often across the board. They may have a special chair at work, or generally talking about it and complaining about it. If you have vaginal pain, you don't go to work and be like, wow, my vagina really hurts today. And so people feel more alone than I think that they should be. But because of this also, we have less education even just between friend groups and peer groups, families even. I also think that, and I know that Laura will talk about this more, some of this ends up being sort of like a generational trauma of like mom had pain with sex, sex just should be painful, things like that. And so people often think that it's normal because their immediate groups think that it's normal. And this is, again, not something maybe people are talking about widely. And so a lot of this education happens with me. I wish that it happened everywhere. And I'm sure that it will be happening with all of you in the time that you have. But I also have the privilege of time and that I get an hour with my patients. And so a lot of times I'm the person that is doing a lot of these re-education pieces. So sometimes it's sexual positioning re-education in terms of like what positions will help to improve the tension of pelvic floor versus deeper penetration depths or less penetration depths. And there are other like assistive devices that you can use to reduce penetration depths and things like that. Sometimes intimacy education, I certainly have a professional boundary of how much intimacy education I feel comfortable giving to people before I then refer to sex therapy. And of course, we're going to hear from a sex therapist, so I'm not going to get too much into that, but it is a little bit of what I do. Different kinds of lubricant education can be for different skin issues, muscle issues, etc. So there's like, I could do probably five slides on lubricant. And again, I'd love to, but we're going to be brief today. Lymphedema education, some people haven't been told that they need to be kind of watching out for lymphedema. They don't know the risk factors, things like that. So that can be an education piece for me. Sometimes it's a vaginal moisturizer education, which is going to be an over-the-counter topical medication. But, of course, that's something that I'm usually checking in with physicians about ahead of time, being like, is there a reason that there was like a cream wasn't prescribed? Is it okay if we do a vaginal moisturizer, that kind of thing? So I really love the intercollaboration that I get to do a lot as a pelvic PT. Additionally, taking medications as prescribed is something that I talk about all the time because I find a lot of my patients will have something topical and then they're telling me how they're putting it on. And I'm like, that is not how you do that, definitely. And so, I wouldn't say it just like that, but anyway. And so just making sure that people are taking medications as prescribed and having conversations with referring providers about how they want things to be, and then I can help enforce that happening. Because not only do I have the privilege of time, I'm often seeing my patients once a week, maybe twice a week. And so I'm really, I'm in there a lot. And for example, I have had providers that prescribe suppositories for different kinds of pain syndromes, especially in the cancer population. And I have one physician in particular who I know that if the person is struggling with inserting it, I can tell them that they can cut it in half or whatever it is. But I know that physician, I would only do that for that physician's patients. But this is part of the intercollaborative care that I think helps patients get really where they need to go. Quick note here on just the kind of detail of the anatomy in the vulvar area, in that each different part of this anatomy picture has different implications for medications, what physicians they need to be seeing, what medications. And so I'm doing kind of a detailed exam of like where exactly is the pain, where exactly is pain, is it moving, is it getting better between these areas? Because a lot of people will say, oh, my vagina hurts, but they actually mean vulva or actually maybe even just the vestibule here. And so being specific about this, not only in terms of like a physician referral to PT, but also from my perspective, can be really helpful in terms of making sure that we're getting where we're going. And a quick anatomy side view here, I just wanted to show all of the viscera on top of the pelvic floor here in a way that you could imagine any kind of oncology type treatment or surgery in this area was really going to affect everything around it. And so especially in terms of scar tissue and radiation, etc., all of this is going to be affected. And truly, all of it needs to, in a sense, then make sure that we don't have any kind of bowel, bladder, sexual dysfunction. So everything, you know, it functions together, it just functions together, etc. So this brings us into some of the more specific techniques that I would use to help patients be able to, especially with a vaginal stenosis or any kind of pelvic pain when we're looking at muscular pelvic pain, or sometimes even just for desensitization, all of the things. This is just a very common piece. I also have found patients either have found on Reddit that they're supposed to order these or someone has told them, hey, you should buy dilators, and that's all of the information they get. I find it really, really helpful to have at least a session where I'm explaining to a patient how this works. I find that if I tell patients, hey, buy dilators, they do weird stuff with them. And so you really want to make sure that someone is instructing patients in use on the wand and dilator. I'll tell patients to buy some, and then I'll be like, when they come in in the mail, don't look at them, don't touch them, don't think about them, put them in your bag, bring them in, I'm gonna do them with you. And then I always show patients kind of in the air how to use it, and then I show them kind of like on a model, and then I give them the option. I say, either you can use this on you, or I can use this on you, or both. And that's kind of really how we get to them really understanding how to use it. Because I find even when I've demonstrated in the air and demonstrated on the patient, sometimes they still don't actually know how to use it. And so it's really important to have the hands on how can you use this in a way that makes sense to the patient, especially because this can be kind of scary. And so making sure you're getting dilators that are the right size and are like graduated. I don't have patients always buy this whole set. It really depends, it depends on the patient and their situation, et cetera. But, and I give them my best clinical judgment. I usually use dilators more when I'm looking for like a true dilation, I like to explain it as. So we're looking for improved width and improved depth of the vaginal canal. I do also sometimes have patients use these rectally, but I always really wanna make sure the patients also know that you should not insert anything rectally that doesn't have a flared base. That is news to a lot of patients that I work with. And so these are technically vaginal dilators, but these ones have a flared base. There are vaginal dilators on the market that don't have a flared base. And so those ones would not be appropriate to use rectally. And additionally, if you use one of these rectally, you'd never use it vaginally again. And again, that is also news to patients. And so a lot of this education ends up being very, very detailed and takes a lot of time. Oh my gosh, sorry, whacking this. I will use a wand for patients instead of dilators when it's really more of like that obturator internus or lateral pain, because I find this replicates the internal vaginal work that I do a little bit better. Because that hook that I know looks really scary is really just like a hooked finger of mine. And so I then, but the same rules for this, I don't want people to use this at home until I've taught them how to use it and they bring it in, I teach them, et cetera. This can also be a really good way to get people out of PT and onto a really good home program. I don't have people do that forever, but I say don't throw it away in case you need it. That kind of thing. The other side of that wand, that's not the hook, the straight part, that is actually a rectal wand. And so sometimes I have patients use that rectally. And again, I would teach them how to use it, all of these. But again, there's something on the bottom so people can use rectally. These are some images of basically an overview of how I would teach people to use it. It's not a stabber, you want to use the whole length of it, but there's a lot of detail to this. And this person is using like that quote unquote vaginal side rectally, you totally can, but then again, you're not bringing that back to being used vaginally. So quick overview of using the wand and dilators are similar, but again, I'm going through this with patients in a lot of detail and we're practicing it together. Okay, switching over to prostate cancer. Again, these impairments are pretty similar. And of course, they very, very much depend on the types of medical and surgical treatment that patients will have had. I would say the most common issue that patients are coming to me with prostate cancer are they're either about to have surgery, they've had surgery and they have pain, and they've had surgery and they now have leakage. And so it really depends, again, on what they're coming in for, but all of these I'm screening for, all of these I'm making sure that people are aware of, et cetera, and then focusing on the main dysfunction that they're coming in to see me for. And so this also looks quite similar. Scar tissue is going to be more internal, and so that's a lot of more internal rectal work and release work to the musculature. But again, it's muscle strength control coordination, sometimes working on prolonged holds of the pelvic floor, but for the most part, the pelvic floor works with the core. And so a lot of generalized core work and then making sure that the core is flicking on when it's supposed to for larger movements is really more where I think the profession of pelvic PT is going. It's not a bunch of people sitting around doing Kegels. It's really making sure that the pelvic floor is just a thought while we're thinking about the core in addition to the manual treatment that we also do. And so I wanted just to note that because I don't really talk a lot about Kegels, and I think maybe a lot of people would think that I would, but that's really why I don't. But it's not a component, but it's usually a part of a bigger movement that I'm having somebody do. And again, we're talking about intimacy, lymphedema, taking medications as prescribed by their providers, and then the difference in prostate cancer is that we see a lot of sexual dysfunction in terms of erectile dysfunction. I always say that there's at least some things that I can do as a pelvic PT to help with erectile dysfunction, but it depends on the cause of if I can really get people where they're going with it. There's a lot of blood flow issues, muscle tension, that kind of thing. And then knowing how to use penis pumps, penis cuffs. Usually it's a physician provider or another provider telling them to get that in the first place, but sometimes it's me. And then masturbation reeducation, which also kind of flows into sex therapy, where again, I have a line of how much of that I'm willing to do before I refer out to sex therapy. And again, this is really the same side view picture I just wanted to have in terms of making sure that we're really thinking about all of these viscera together, how it sits right on the pelvic floor, and so any kind of problem in that area can make a problem for the whole system and result in a bowel, bladder, or sexual dysfunction. So in a PT evaluation of mine, I'm doing a thorough medical surgical history. I wanna know all the medications that people have been on. The intake form that I have has quite a lot on there, and so sometimes I don't make them go through all of it again in detail, like specific parts of it. But in my hour-long eval, especially with a medically complicated patient, I'm sometimes spending 30, 40 minutes of that on the subjective eval. Of course, you wanna take vital signs, making sure we're working towards the goal that the patient actually thinks is the biggest goal, while also integrating the bowel, bladder, and sexual function, the whole piece of it. So patient education, as in the previous slides, then general orthopedic assessment treatment. In a lot of the sessions that I do, you would think if you just were to be a fly on the wall, you would think I'm just a regular orthopedic therapist, other than the internal work piece that I'm doing. But home programs consist of exercise always, muscle release techniques for themselves, dilators, wands, et cetera. Again, activity modifications, and any kind of lifestyle change that's appropriate for their bowel, bladder, or sexual dysfunction. I could do a whole talk on lifestyle changes for each of those. So again, abbreviated talk, but hopefully getting a good overview of all this. But a big piece of what I do is coordination of care with referring provider and medical team generally, and referring out to other providers as appropriate. I'll talk a little bit more about that in future slides, but it's a huge part of what I do as a pelvic PT. A plan of care in pelvic PT, I would say is typically six to 12 visits, but can vary hugely. I tell people to expect to see a difference in two to four follow-up visits, but that they're not gonna be fine in that amount of time. But how much better I feel like they get in two to four follow-up visits, I would better be able to tell them how long I think it would take in total. And I also am, of course, working with the physicians and other referring providers throughout this time. I also, I don't use syrups or speculums or anything like that. A lot of patients have a sigh of relief when I say I don't use a speculum. But yeah, it can be, we do have like plastic, like disposable ones, because sometimes that's what people's goals are, to be able to use a speculum, and then they feel really comfortable with me. And then like, I just can open it and see where we're at. But I'm not using it in a medical sense. Of course, we can defer an internal assessment if people don't wanna do it. A line that I use a lot is, it's my job to give you all of the best information that I have, and it's your job to make your own best life choice with that. And so I definitely explain in detail why an internal exam will be helpful. But I'm not pushy at all about it. I just get the information that I can get. I also don't want anything in pelvic PT to be truly painful. I'm okay with some of it being uncomfortable, because that's part of how we make progress. But I don't want any of it to be truly painful. So I always say, stop me if you feel like we're getting to that. Because a lot of people have this, no pain, no game attitude, and that doesn't really work in PT generally, but it especially doesn't work in the pelvic floor, because it really is gonna create a feedback of being fearful, et cetera. And again, this is kind of what my exam would look like in assessing these different muscle layers. And so this is just a few different views of the different muscles that I'm assessing, kind of all at once in a sense. But of course, this is an exam that all of you can also do. And I just have this here just to appreciate how all of this really flows together. And again, mostly being an orthopedic PT, all of these muscles and viscera are really right here, so they end up being affected and you kind of have to treat like a general PT in a lot of ways. So what questions should you ask? I like to preface some of the more detailed questions, because a lot of times patients really think they're only coming in for urinary dysfunction or bowel dysfunction, and then we kind of get into all of it. So I usually say, I'm gonna ask some more specific questions about bowel, bladder, and sexual function to get a more complete picture of what your pelvic floor is up to. Because these muscles, they typically function together and then they dysfunction together. And then people are at least a little bit aware that I'm about to ask some more of those questions and they have a little bit more time to mentally prepare. But of course, asking questions about sexual activity, and I like to make it as gender neutral and sexuality neutral as possible. Say, do you have any difficulties with any kind of sexual activity? And usually that leads people into telling me what those difficulties are. Sometimes I will then ask, are those position dependent? And then if they just say yes, I say, can you tell me more about that? So again, general open-ended questions with a lot of these more difficult topics will often lead your patient into giving you the information you wanted without having to say like, what positions is it painful in? And it's usually more comfortable for everybody that way. So just some food for thought on that. But again, another way to ask about incontinence is do you ever leak urine or do you ever leak stool? I find I get more people saying yes to those when you phrase it that way than if you say, are you incontinent? Because people are like, no, I'm not incontinent, I just leak a little bit. And like, that is technically incontinence. And so I think people don't wanna be part of, have the incontinence label, et cetera. So again, just trying to be as broad and zoomed out as possible can be really helpful. But then these are kind of some of the other questions you could read. So when do I send to you? So I wanted to put this in here, I was kind of inspired by this from her last session, and that I get a lot of patients that come to me from the street. PTs have some form of direct access in all 50 states. I get a lot of patients from gynecologists, urologists, GIs, even family practice, et cetera. And so I am often the person who has the idea to send to a PMNR physician. Of course, in conjunction with the rest of the care team, I'm talking to the other providers, everyone's on the same page. But it's often kind of my idea. I also get patients who come straight from social media, they come because their friend saw me, or they're coming from orthopedic PT friends of mine elsewhere in the city who are like, no, I think you need to see a pelvic PT, et cetera. So then I'm often the first person sending, again, to PMNR. But different pain physicians, of course, as we were talking about in the last session, have different toolboxes. And so this is another reason why it's really important for all of us to talk to each other a lot, because I sometimes, I think I know what is in the different providers' toolboxes, and then I'm sending to patients two different providers based on what I think is in their toolbox and what I think the patient needs. But having a better understanding of what is in your toolbox would really help me know if you're a good fit for this patient, et cetera, and then kind of sending back. And I also send out because I think every provider disproportionately offers what they have in their own toolbox. That's true across healthcare. And I explain it to patients like that, and I'm like, this is what I think is in my toolbox, and then sending to somebody with a different toolbox can be helpful. This is a little bit on training backgrounds. I did a residency training. It's not super common for PTs to have done residency. When I applied to residency in 2018, there were only 10 programs, and they all only took one or two. This is for pelvic specifically. Every specialty area has them. Now there's 22. I'm a board-certified clinical specialist in women's health physical therapy, which is, again, the pelvic area. And I just looked this up today. There are 864 of us in the country right now, and there's a ton of us in New York City, so I know there are a lot of areas that don't have a board-certified specialist. And it doesn't necessarily make you a great PT, but it can be helpful if you don't know anything about any of the PTs in your area to kind of look for some of these things. The other one is pelvic rehabilitation practitioner certification. Herman Wallace is the company that does a lot of pelvic PT education. And so if you take all six of their classes, you are then really set up to take this exam, which is basically just another version of the WCS. But I took both because I'm not well, but that's it. There's no reason for that. Certified lymphedema therapy can be helpful depending on your patient population. If you are screening a lot for lymphedema or seeing a lot of it, having someone with that can also be really helpful. And there's also CAP is what this last one is called. This is through the American Physical Therapy Association. Also, you can be CAP pelvic or CAP OB, which is just another way to say that you've passed another test, but I didn't take a third one. Thank you. This is ways to find pelvic PTs. This is the APTA's website. To be listed on this one, you have to be an active member of the APTA or our PTA Professional Association. I know a lot of my friends and et cetera are not members of it. It's expensive to be a member of the APTA. I'm a member. You can find me on there, but it's expensive. It just doesn't include everybody. But it does also have a special filter for people who are board certified specialists, if that's important to you in your area. These other two, Pelvic Rehab and Pelvic Guru, anyone can request to be listed on there. They will often also have their certifications listed. Again, if that's important to you. But there are also really great pelvic PTs out there that have none of these certifications. They don't necessarily matter. But again, if you're just looking and you have nothing to go off of, this is something. But yeah, anyone can request to just be listed. And then lastly, when should you refer to pelvic PT? So really, any kind of bowel, bladder, sexual dysfunction, definitely. But any kind of orthopedic issue, really in the abdominal pelvic region, sometimes can be better served by a pelvic PT, especially if maybe they're not telling you about a urinary dysfunction or things like that. Or people who have given birth a lot or had a lot of pregnancies or any of these surgeries in this area. Any issue to the whole area is sometimes, again, better served by a pelvic PT. But not always. So it depends on your patient, et cetera. But just something to think about and have a one in your area. So really, any functional deficit in this area in terms of bowel, bladder, sexual function, but any physical or quality of life issue. And then lastly, I think it can be also important to really make sure that the medical clearance piece is there, especially with some of the radiation, the insufficiency fractures after radiation we were talking about this morning. Those are things that I try to screen for, but I am really also looking to physician providers to have cleared that. And so I will send if I think something like that is happening. But knowing that that's cleared before I get a patient can also be really, really helpful. And knowing what tissues I can push through. We were looking at some radiated tissue earlier today and I don't know that I would press on that, but if I thought it was really important, I would message the provider and be like, is it okay if I work through this, or depending on what it looks like, et cetera. So really, the medical clearance piece is really the most important factor. Make sure people are cleared to be there. But other than that, that's my part. Thank you. Thanks. Thank you, Claire. We're gonna do questions at the end. Next up, we're excited to have Laura Jones with us. So she is an ASEC certified sex therapist and a licensed clinical social worker. She specializes in sexual health dysfunction, body image concerns, and medical trauma in oncology patient populations. She oversees behavioral health and supportive patient services at University of Louisville Brown Cancer Center. She directs the oncology screening and outreach service line at UofL Health, and she's a group facilitator at Gilda's Club, Kentuckiana. She's a study interventionist and psychotherapist at Memorial Sloan Kettering Cancer Center. So thank you, Laura. Thank you so much. All right, I don't have any disclosures. And before we get into sex therapy, I wanna talk about what sexual health is. And I love this definition from the World Health Organization that dictates that sexual health is not merely the absence of disease, dysfunction, or infirmity, but the possibility of pleasure and the pursuit of pleasure is very important. And also that the rights of all persons must be respected, protected, and fulfilled. So I think this is just a really good definition to kind of start off. So what is sex therapy? I get a lot of different and quizzical looks when patients are proposed with this or this is brought up by a provider. So sex therapy is a form of psychotherapy designed to help both individuals and couples address physical, psychological, emotional, and relationship issues. So kind of similarly to we were talking about certifications in the PT world, licensed psychotherapists that specialize in this can call themselves sex therapists. So if you're looking for somebody who's had specific training in the area of sex therapy, ASECT is a great website and it's a great referral source. And you can find a provider specific to whatever state or region that you're in as well. All right, so I've got some interesting pictures here. We had the pleasure of going to La Jolla last night and saw a bunch of sea lions engaging in some amorous activity. I thought that would be an interesting or just kind of topical good segue into this. So I don't know if that's what's going on or if it's more of a powwow, but there was some interesting noises going on, so I thought I would put that up there. But when we're talking about sex, basically we're not talking about it, right? So, and this is across a lot of different areas. So healthcare providers, again, some studies show only 6% of healthcare providers regularly address this with their patients. And why is this happening? So we talked about this this morning. In some studies it shows over 70% of patients are expecting their providers to bring this up, and 70% of providers are expecting patients to bring this up if it's important to them. So then we have this standoff where we're just not talking about it. And there's some reasons behind that, right? So I know a lot of providers that I talk with are, you know, I don't wanna ask these questions, I don't wanna bring this up because I'm gonna open this can of worms and I don't have referral sources for this. So again, it's so important to have a list of people that you trust that are in your network that you can refer in case something does come up. And you don't have to be a specialist in every area, but having those list of providers that can help is gonna be huge and it's gonna make it more comfortable to bring these issues up with patients. And it's interesting to see the patients that we do ask, it's normally those patients that look like us, right? So when you see providers that are asking patients about this, it's usually those patients that are the same sex or gender that they are, or that have the perceived same sexual orientation that they do. And we also think of, okay, well this is gonna be an issue where this is pertinent for younger patients, or patients that have the potential for better health outcomes. So oftentimes, this leaves out these huge groups of patients and people that we work with. I also wanna touch on, there's this myth of the asexual older adult, that sex stops after a certain age, and that older adults are not sexual. And we see in studies, this is absolutely not true. Many older adults definitely want and prioritize intimacy and sexual relationships, but they feel this too, right? And so we have this taboo around talking about sex with older adults, and that's very apparent in healthcare as well. So when we think about the sexual response cycle, typically, people think about, okay, well there's this pattern of arousal, that kind of plateaus, there's an orgasm, and that's it. And that's very limited. This idea comes from Masters and Johnsons, and I'll show a model of that later. But in order for this to happen, you need an intact vascular and sensory parasympathetic nervous system. Well, cancer really impacts that. And so that may not look like the typical kind of sex timeline that we think of when we think of sexual experiences. I also want to talk about the difference between desire and arousal. So arousal is the physical manifestation of what happens when, or how we think about what happens when someone is anticipating sex, so what happens physiologically. Whereas desire really focuses on the emotional, the mental, the psychological want or drive for sex. And in an ideal world, these two things are aligned. So when there is that desire, arousal happens. When those don't match up, there can be quite a change in, or just frustration from the patient. So I have this desire, I want to have sex, I'm not having arousal. And what also happens on the flip side, although it's more rare, is that my body's feeling aroused, and I do not want sex right now. Again, that's more rare, but it certainly happens, and it's distressing for patients. So it's important to make that distinction between those two things. Also spontaneous and responsive desire. So, so much of the work that I do is really focusing on, yeah, there's been a loss of that spontaneous desire. There's more steps, or there's more work that has to go into having a sexual encounter. And that is, that's difficult. And so I think it's important to acknowledge that. That's frustrating for patients. The spontaneity is gone, and there's a lot of grief with that, and I'll talk about that later. But there's a difference there. And so that spontaneous desire, where if there's a stimulus or something happens, and then I feel that arousal, versus there's all these steps that have to take place, or there's all this preparation that has to take place in order for me to feel arousal or desire. Those are, I think, very important distinctions to make. So this is kind of, again, the Masters and Johnson's sexual response cycle. This is kind of what we typically think of when we think of a sexual encounter. There's that arousal, plateau, again, orgasm, and then resolution. There you have it, very linear. A more appropriate way to think about this is Rosemary Besson's model of sexual desire. And again, this is circular. So this is really an expanded model that incorporates relationships, it incorporates things that are going on during the day. There's all of these pieces that can affect desire that aren't necessarily just arousal. And so as you can see, there are many things that can impact this, many steps along the way. So pain, fatigue, chronic illness, body image, all of those things are going to affect the arousal and desire model for a lot of our patients. So I don't want to spend too much time on this. I know that we've gone through a lot of this already, but some of the most common concerns that we see for gynecological oncology patients, pelvic floor dysfunction, you just heard a lot about that, anorgasmia, the genital urinary syndrome, and menopause. And what I deal with is a lot of the psychological distress, the medical trauma piece, depression, mood, relationship dissatisfaction. So cancer does not exist in a vacuum, and many patients are coming in to a diagnosis with maybe some significant relationship issues. And in fact, a lot of times these can be exacerbated or made worse by a cancer diagnosis. So many of the patients I see that are going through the middle of treatment, they're dealing with a lot with their partners. Is that going to affect sexual function? Absolutely, so it's important to ask those questions and really assess is, again, is this happening in a purely physiological manner, or is this a combination of multiple factors? Looking at prostate cancer, and again, I want to, I know we're focusing on kind of gynoc and prostate cancers today, but nearly every single cancer is going to affect sexual function in some way. So when you look at men, the most common cancer diagnoses that affect sexual function are going to be, of course, yes, prostate cancer, bladder cancers, GI cancers, again, those cancers that really affect the pelvic floor. But we also see this in hematological malignancies, specifically with patients that have gone through stem cell transplant or other cellular therapies. Head and neck cancer patients, the significant change in salivary production definitely affects sexual function, and lung cancer from a disease progression standpoint. And some of the main diagnoses that really emerge from those cancer diagnoses are erectile dysfunction, loss of libido, orgasm dysfunction, ejaculation concerns, reduced penile length, this I see quite a bit, mood disorders, and body image concerns. And again, I think for a lot of our male patients, it's not comfortable to talk about body image concerns or mood disorders, there's more reticence to kind of engage in those conversations, and they're a big deal. Especially for patients that are on ADT, there can be a significant change in weight in a very limited amount of time. So a significant weight gain, loss of testosterone, definitely gonna affect sexual function. So how do you ask patients about this, and what does this look like? So the PLCIT model has been around for a very long time, but it's a great kind of tool to use as you're looking to how to engage patients in these conversations. So the most important part of this is that permission giving. So even by asking a patient about their sexual function, you're giving them permission to talk about this. And then, again, there's a lot of information. Our patients that we see are given so much information, especially if they don't have a medical background, it's so overwhelming, and so giving patients limited and very specific information is gonna be more impactful than kind of throwing so much at them very quickly. And again, kind of that goes into that specific suggestion. So there are so many things that patients can do, there's lifestyle changes, there's interventions, and all that is great, but again, this may be the first time a patient has ever talked about sex, ever. And many times that is the case, especially depending on what area of the country that you work in or what region that you're in. So giving very specific suggestions, keeping this to a limited conversation can be helpful. And again, if you anticipate that there is a larger psychological need, referring out for more intensive therapy. This is another model to use. So this is when working with patients to see, hey, what are those expectations, what is this gonna look like from an assessment perspective? So being able to describe, having the patient describe what's going on, what are your current concerns, how long has this been happening? So onset, and really getting the patient's understanding of why this could be happening. There could be a really disconnect, a big disconnect between why the patient thinks that they may be having sexual health concerns versus a provider. What have they already done? So a lot of times patients have tried things on their own or they've seen another provider. And so that's helpful too to understand what have they already done to address these issues? And then what are their expectations? Do they think, oh, this is gonna be completely resolved in a month? That may not be the case. And then again, we're doing a lot of grief work around that too. So what are some of the interventions? Again, I know kind of that there's a big umbrella of what sex therapy is. And I will say for a lot of the time, I'm not talking about sex with patients. We're doing a lot of grief work. We're talking about trauma. We're talking about relationships. To get to the point that we can have these conversations about sex and sexual function. A lot of this is gonna be psychoeducation about what's normal. What's a normal trauma response? What's a normal response to going through something like a chronic illness or cancer? And I liken this to, if you're in that survivor flight or fight mode and your partner says, do you wanna have sex? You're gonna say no. If you're in a burning building and someone turns to you and says, do you wanna have sex? What are you talking about? And so I think that really helps people to kind of contextualize, why have I had such a significant loss of libido? And so really providing that education for patients. Doing cognitive behavioral therapy. So this can help with, especially for patients that have been abstinent for a long period of time or felt like they were not able to have sex, reintroducing sexual activity with them. And also, if you've got patients that are, say, requiring injections for erectile function, there's a lot of mental blocks there and that's understandable, right? So helping patients kind of work through those pieces and find some comfort with that. This is really the bulk of what I do is a lot of mindfulness work. Behavioral interventions, sensate focus, doing somatic therapy interventions with patients. And then helping with communication skills with couples. And then I highlighted this part because this is so much of, and it's such an important part of any psychotherapy, but specifically when we're talking about sex is thinking about grief work. And so much of what I do, again, is just grief work. And then that transcends both grief, we talked about that loss of spontaneous desire, but also with body image. And if you've had a very quick change in what your body looks like, which we see with any patients who have had major surgeries or they're on hormonal therapy and they've had very rapid changes in weight, or they've had skin changes, radiation, and it's happening very quickly, that's gonna be traumatic for a lot of patients. So working through, again, the grief around that and letting them sit with those feelings. So I'm gonna describe, and I'll kind of go through this somewhat quickly so we have time for questions, but I did wanna talk about what does an intervention look like? So you may know, okay, this is what my patients may be doing in therapy. So Sense8 Focus is a great tool to use and it's a graduated way to incorporate touch back into relationships. So this can be done both partnered and with individuals. And again, this is an intervention, so before this happens, I've done a full assessment with the patient, we've talked about any other traumas or concerns that they have. We've rolled out any kind of substance use disorders that may be going on. And before we would do this, if this is gonna be a coupled or partnered patient, I'll have both partners present for this education. So Sense8 Focus, again, is a graduated touching exercise to increase libido, but also to create comfort around engaging in sexual activity again. So the majority of patients I see have completed treatment, they're kind of on the tail end of treatment, and they have been absent from any kind of sexual encounter for a very long time. And that would say this is about the bulk of the patients that I see. So there's a lot of anxiety, a lot of concern about re-engaging in sex, whether that's because a couple has tried to have sex on occasion and then it's been very painful, and so then there's that reticence to engage in that again. Or if there's just, again, if there's pre-existing conditions, if the couple has relationship dissatisfaction that's existed prior to cancer. So there's many reasons why couples may not have engaged in sex. And this is a great tool to use even if a couple's actively having sex, but they feel like they wanna increase that intimacy or that libido. So we wanna create a safe space to incorporate sex where we're really taking the pressure off of any kind of sexual encounter. So I have couples create what I call the nest. So this is basically, what is a safe space where you all can be with each other and be intimate for a selected time period. And this is where kids aren't barging in the room, where there's not someone that's calling you, you don't have the phone on, or people dinging you all day. So this is really a carved out time to, again, create that space for intimacy. And you can kind of see some of the situations here that I have for patients as we kind of go through this. But that phase one is gonna be, again, graduated touching with erogenous zones off limits. So again, we're taking away those areas that may be anxiety provoking for patients. So that may be different for other patients that I ask them, you know, what's an erogenous zone for you? That may be very different from somebody else that I see. But genitals, breasts, and chest are definitely off limits in this phase. And what I normally have couples do is engage in touching for about 10 to 15 minutes, switch, take turns, and then just kind of see how that felt for them. I usually have patients not talk to each other during this time, because I want to avoid that, how was this for you? And then that extra pressure that we add on to patients there. And then this is, again, if you're looking at SynthSate Focus, or you're doing any research, this is gonna be kind of a standard phase progression of that touch. But every patient is so different. So you may have patients that, you know, that I'm never gonna get to that phase five, and that's not my goal, and that's fine. So we talk about what's important for you all as a couple, what does sex look like now? And then kind of going from there. What are some modifications to sex? So, again, if penetrative sex is not in the couple's repertoire, it's not a goal, it's not an interest, that's fine, and it may be validating that. And really kind of curating this, either that's a behavioral intervention or SynthSate Focus to meet their needs specifically. Handwriting, I do wanna talk about this. So for a lot of partners I see are nervous to touch or, you know, engage in sexual interaction with their loved one who's been through cancer because they don't wanna hurt them. And you have patients that say, well, I don't wanna tell my partner that they're hurting me because I don't wanna hurt their feelings. And then you've got pain. So handwriting is a great tool, and that basically looks like just putting your hand on top of your partner's and moving it gently, and this is what we talk about, you know, really removing judgment from this. So moving the hand somewhere else or moving the body part somewhere else. But this is a great tool for couples to use if they wanna, again, remove that fear of I don't wanna hurt you and I don't wanna be hurt. It gives control back to the patient in that way. And again, a lot of patients that I see also have a history of sexual trauma. We know that cancer does not exist in a vacuum, and so patients come to us with a multitude of trauma histories, sexual or not. And so if I notice that a patient, or we come to that in the assessment phase and the patient does have a history of trauma, we're gonna talk about modifications of any interventions to meet that patient's needs. And what I don't want for patients to do is, again, have this just get through this mentality. So if there is pain, it's just, you know, that power through, Claire talked about this, with just, you know, no pain, no gain, and we don't want that for sex ever. And so really changing those mindsets with patients. And then again, self-sensate focus. So sensate focus is not only to be used in partnered exercises, and this can be a way to talk about masturbation, talk about what feels good, what changes and what feels good. Oftentimes, couples have a menu of what they do sexually, and when something is off the table, that's thrown in the menu at the door, and so all of a sudden, I don't know what to do, and then we're just not having sex. So it's really kind of thinking through, well, what's gonna work now, what's changed, what's different, and something that felt good before may not now, and on the flip side, something that feels, that wasn't a huge thing may be really pleasurable now. So a lot of what this is is really exploration, and most of what this is is just being able to talk about sex with somebody who is a safe person to do that with. So I'll go through this quickly. So some sexual health myths, and I apologize for the small font up there, but libido and sexual activity are permanently gone after treatment. Not true, and again, these are a lot of myths that may seem obvious, but these are things that patients come to me, and they really believe this, and again, we don't do a good job of addressing this early on. I think a lot of the interventions are very reactive instead of proactive, and so we're waiting to have these conversations, again, until well after treatment has been completed. Again, we talked about this, talking about your sexual health concerns with your healthcare providers is inappropriate. Absolutely not. Even though there's the standoff that we see a lot, it's very important and practical to bring this up and bring it up early in the treatment course. Cancer survivors should not engage in sexual activity due to risk of harm, and while there are some situations where there should be barriers or there should be limited sexual activity due to the treatment course, again, this needs to be talked about up front, and so patients assume this. Oh, I've been on chemotherapy, is it safe to have sex? Maybe yes or no, it depends on the treatment regimen, and we need to be talking about that earlier on. Intimacy and sexual activity are only about intercourse. Again, absolutely not, and a lot of what I do is redefining what sex looks like for patients and their partners, and that may include penetrative intercourse, and it may not. Changes in sexual function mean the end of a satisfying sex life, no, and again, we talked about, especially for older adults, sex may look very different from when it did when they were in their 20s or teens or whatever, and that's okay, and finding those models that work for them, finding things that feel good for them, and finding ways to increase intimacy, whether that includes penetration or not. And then, of course, both parties, especially in partnered patients, are going to be affected by changes in sexual health. So, when do I refer? So, when the sexual dysfunctions persist, despite rehab or medical interventions, or if patients express emotional distress around their sexual function. So, if a patient's bringing this up to you or you're talking to a patient and they are upset or seem emotionally distressed, that's a great time to refer the patient. And patients have ongoing difficulties with intimacy, anxiety around sexual activity, need more education. When patients have a history of sexual or other trauma, including medical trauma, this is also a good patient population to refer. And then, when patients struggle with body image issues, loss of desire, sexual avoidance, anxiety, or excessive worry around resuming sexual activity. All right, and I have a resource list here. So, this is kind of broken out into men's sexual health and women's sexual health, but a lot of these are applicable to both. The Movember resource is a great tool for patients, prostate patients, to look at. So, they're able to identify which treatments they've had and what potential side effects there are and what potential solutions there are. So, it's a great tool for patients to use when they're thinking of, what questions should I ask my provider? And then, I've got a list of provider resources as well. All right. Thank you. Thank you. We're gonna take questions. Okay, great. So the question- Hold on. Oh, good. Go ahead. Hello? Can you hear me? Yeah. Yeah, okay, great. So the question, just to repeat for people at home, is a lot of cancer care can be very expensive, and so things like dilators, vaginal moisturizers, et cetera, can also be very expensive, so what are kind of cheaper ways to do that? So firstly, in terms of vaginal moisturizers, sometimes coconut oil is enough. And then sometimes, equally effective from my perspective, is sometimes it can end up being a prescription estrogen or estrogen testosterone cream or something like that, and so then if these are people who have met their deductible and out-of-pocket max and things like that, sometimes a prescription is gonna end up being cheaper than a cheap thing over the counter, and so of course, if that's an issue, I'm gonna be talking to providers, et cetera, and seeing if we can get that for patients. Again, sometimes people are hesitant to take topical hormones if they have a cancer diagnosis, but really, the research on that is actually pretty good in that it is safe to do. Of course, make your own best life choice, but I am often encouraging people who have prescriptions already that it is okay to use, especially after providers have already prescribed it. So that is a lot on that side, but again, coconut oil can also be good. And I have a list of eight of them that I usually send people. I also have samples, and I can give people a bunch of samples and of the list of eight, I'm sure some of them are cheaper than others. I don't know the price off the top of my head, but people have choices, so does that answer your question? Okay, oh, the dilator piece. There are cheaper dilators. Sometimes I don't think that they are as good for the brain-body piece. The really cheap ones are hollow, and the hollowness to them, sometimes if you insert it vaginally, it'll just eject out if people have a lot of tension. So it's not an awful solution, but it's not usually the best one. So sometimes, especially if people are coming to me who have already bought dilators, I always work with what they have. I don't make people buy new ones, unless I feel really strongly about the texture or the weight of it making a big difference, in which case I'll be like, okay, well, let's use yours until we can't anymore, and then maybe we'll get one of these and things like that. Okay, great. Most of the dilators, you can buy one size at a time. So like finding the, you know, work with the physical therapist to find where a good starting size is, and that could spread the cost out a little bit too. Yeah, it's not often that people need the full set. They certainly, those patients exist, but it's not everybody, so. Yes, that is actually my ideal world. I would love for that to happen all the time. Please send me those patients. Oh, the question was, is there a world where prehab for PT or sex therapy happens for patients with cancer diagnoses, etc.? Yes, I would love for that to happen. There is some good research on this. There's not a ton of it that I've seen anyway, but in terms of, I see that more people are sending to me preoperative for prostate than other kinds of cancers, because making sure that, again, pelvic floor function is as best as it can be before then having something done that will make your pelvic floor function worse, especially for a period of time during healing, etc. So yes, it can be helpful. I would also extend that to patients with other kinds of treatments, because no matter what, there's going to be some kind of medical trauma to the area regardless of the treatment. And a lot of things, like I was talking about a little bit in my talk, are people have these dysfunctions ahead of time that are not necessarily related to the diagnoses, so then making sure that their pelvic floor is in, you know, tip-top shape can be really, really helpful. But yes, I would love for that to be my whole job, even. So, thank you. And I think similarly for sex therapy, I noticed when I see patients early on in the process, we're able to do some of that work prior to, and again, especially partnered couples or couples in relationships, we can talk about how are they anticipating those changes, what does that look like, and that makes things not so shocking when things do happen. And so that's really helpful. We can talk about some communication strategies prior to, again, surgery or changes in sexual function, and that we have a lot better outcomes when that happens. Absolutely. Absolutely. So if I'm seeing a couple, what I'll normally do is I'll see them both initially, and then I'll see them individually, and then back together we'll kind of have a game plan, talk about goals of therapy and what that looks like. If I'm seeing an individual in therapy, but we're talking about a partner in exercise, then I will definitely bring the partner in, and that's helpful too on occasion, whether or not we're talking about Sense8 Focused, for me to kind of get that full picture of how has this been for the partner, right? And again, we have what we call the conspiracy of silence, which is I don't want to put more stress on my partner, so I'm not going to ask for sex, or I'm not going to ask about how they feel about sex. I don't want to put that pressure on them while they're going through something like cancer, but then I have a lot of patients that say, well my partner just stopped initiating, and that's been really hurtful to me. Is it because I've had a significant change in my body image or the way that I look? And so then again, that creates the separation there. So it's very helpful to bring a partner in, whether or not I'm seeing them as a couple or as an individual. But certainly, if we're doing a partnered intervention, we'll definitely bring both people in there. Otherwise, it's kind of that game of telephone, and that rarely works out. Yes, in pelvic PT, sometimes people will bring their partners. I would, it's not overly common, but when they do, I kind of think that they know at least a little bit about what it is that I do, and so I do the whole beginning of like open-ended subjective history, bowel function, bladder function, and then before I switch to sexual function questions, I'll usually say, I'm gonna switch to questions about sexual activity now. Is that okay? And so then I have had people then have their partner leave, or sometimes like if I'm treating like a teenage girl, she wants her mom to leave, and like that's okay for that part of the eval. I mean, there's a lot of other things there. But down the line, in terms of treatment as well, sometimes, especially like with dilators, sometimes it can be really helpful. It depends on the patient and situation, but it can be really helpful to have the patient use the dilator themselves, and then have the partner use the dilator, because they're losing a little bit of the control, but it's still not a sexual situation. So there's sometimes ways to incorporate partners. I've taught partners to do different kind of manual release techniques as well. It just depends on how much they want to be involved, but I definitely kind of have a conversation of like, is it okay that everybody's here? And then they'll bring them to different sessions versus others, etc. So that's it. Yeah. Yes, and so you would, Bill, as you would another psychotherapy session, and I will say I feel very privileged in our academic cancer center, where I'm able to provide sex therapy at no cost to our patients. So I know that that's certainly unusual, and that's been a great resource for patients, especially those who, you know, either are underinsured or, you know, are really struggling with the financial toxicities of cancer. So even with private practice, so again, you would, Bill, just like you would a regular psychotherapy session. Any other questions? All right. Thank you, everyone.

pelvic cancers

pelvic physical therapy

bowel dysfunction

bladder dysfunction

sexual dysfunction

manual therapy

oncology patients

sex therapy

Sensate Focus

patient quality of life

Claire Hamnett