Q: When does women's health physio fail women?

A: When it forgets that sex matters.

Occasionally, a tweet catches my attention…

Exulansic shared the story on her twitter here.

Femina Physical Therapy is a physiotherapy clinic in California. It is a long established and respected pelvic health practice marketed squarely at women. The website has lots of helpful information and uses mostly sexed language eg “woman” and “mother”, (there’s a couple of “caregivers” and “vulva owners” in the articles, but let’s stick on today’s topic")

The woman who contacted Exulansic was seeking support after expecting a female clinician at the practice she chose specifically because the very-pink website signalled “woman” to her. However, into her dimly lit treatment room, walked a masked, trans-identified male pelvic health physiotherapist.

Think about the steps a woman navigates in order to have a pelvic health appointment:

She has to recognise she has a problem, ignores it at first, tries a few home or over the counter remedies, seeks some advice online, and thinks “I must do something about that” for months or years.

Eventually she might see a GP, look at online reviews or ask friends for recommendations for a private appointment. She finds a clinic, books an appointment, books time off work or arranges childcare and organises her day to accommodate her care.

She works out travel, probably does a couple of chores on the way there, so does some extra hygiene and brings a pair of clean knickers to change into, hoping those are the “right” underwear to be seen in.

She has a think about what she is going to say, how to word the history and speak about her embarrassing symptoms without crying or freezing.

She probably gets there a bit early so there is time for a pee. She feels nervous -talking about your genitals, leaks, or sexual pain is not easy, especially so with someone you have never even met.

In the waiting room she runs her story over in her head: how can she make sure she is taken seriously? She worries that maybe this won’t work, maybe she won’t be fixed.

Then she’s called into a nice treatment room and finds a man willing to examine her vagina.

What would you do?

• Refuse: tell him you expected a woman, demand another physiotherapist.

• Leave: grab your bag, give an explanation, mumble an excuse or say nothing and leg it.

• Grin and bear it: go along with the appointment, because you can’t think straight, and he knows what he’s doing, you’ve waited for ages, you had a male gynaecologist before and this really is sort of the same thing, it doesn’t matter who fixes my fanny as long as it’s fixed, anyway it won’t take long and it’s too late to back out now.

• Overcompensate: enthusiastically answer his questions, let him touch you, make jokes and accommodate anything that makes things easier for him.

Fight, flight, freeze and fawn are common trauma responses. Pelvic health physios should be on the lookout for them, because a woman who defaults to these survival strategies during an appointment is not having her needs met and is not safe.

This particular woman chose flight - she left the appointment and sought support from someone she trusted. Good for her.

I wonder do wonder, though, how many women have been in this situation with this practitioner but were able to advocate for themselves. Many women will swallow down their discomfort and carry on, dissociate during the examination and never go back; or minimise her own feelings and behave in a way that pleases the therapist in order to avoid an escalation of behaviour that she perceives or does not want to be around.

This does harm.

There is no way of building a therapeutic relationship if a patient feels the appointment began with a bait-and-switch. Trauma informed care means ensuring she feels safe - if women lose trust in healthcare they likely withdraw, avoid appointments and their health needs are unaddressed.

However, women know that speaking up in a situation where gender is a factor means risking being labelled “transphobic”, “difficult” or having treatment withdrawn.

Theresa Steele complained and the hospital cancelled her cancer surgery, Theresa is one of the founders of Caring About Dignity, which campaigns for privacy and dignity in healthcare.

Institutional gas lighting of women is common - Baroness Nicolson raised the case in the House of Lords of a woman who was raped in an NHS hospital ward by a trans-identified male and told by staff that there was no rape as there was “no male” on the ward.

Ayrshire and Arran Health Board’s policy was to remove a woman who objected to having a trans ID male on her ward, and treat her as they would manage someone who was racist.

What should we learn from these cases? If a woman’s right to consent is not absolute and respected in practice then healthcare can become coercive and punishing. The woman who already knows this can endure catastrophic consequences for her health, and the women who know that reacted with gusto to Exulansic’s post. As did the people who think women having rights to bodily autonomy is transphobic, here is a tweet demonstrating both.

Employers’ duty of care

The employee has shut down his social media, I assume he has seen the furore online and I expect some of the commentary has been upsetting. The trans-activists furiously defending him and attacking the women have missed an important point, though…

This “safe zone” rainbow sticker is on the practice website - but for whom is it safe? The physiotherapist must realise by now, if he didn’t at the time, that his patient left because she recognised and rejected his sex. That can be challenging for people who would prefer to be the opposite sex. Which, of course, they can never achieve, but if everyone around you says they see you as you wish to be perceived then it can be confronting when someone refuses to join in.

There will be women who are happy to be seen by a male pelvic health physio, and we’re told this person has a passion for working with those who have gender issues (which is great as that population has disproportionate rates of pelvic floor dysfunction) - but an employer who fails in their duty of care to staff by ensuring patients expecting single sex care are not on the list of a trans-identified man could land up managing an employee’s distress, if not their grievance.

Patients can reject clinicians for any reason whatsoever. About a million years ago I was very loudly rejected with two very loud words from a man in a Glasgow hospital because he did not like my name badge. My maiden name is very Irish Catholic and this gentleman had striking sectarian tattoos proudly showing his depth of feeling about football and religious division - which, in Scotland (for inexplicable reasons) are interwined. That was also measured in real time by the blood pressure machine as he became apoplectic at the prospect of being touched by a Tim.

I didn’t take it personally, it didn’t occur to me to be offended. The man was in a coronary care unit and very unwell, he was having a terrible time and no doubt very scared - which he managed that in the default Scottish way of - looking for a fight. What mattered was calming him down before he could do himself a mischief, so I hurriedly got my most Protestant-looking colleague to see him instead. Patient centred care achieved, problem sorted and peace restored - apart from the agitated beeping of his monitoring machines.

An employee’s potentially hurt feelings are always secondary to patient need. Or, they used to be, before people were told to bring their whole self to work.

Gender confusion is not new in physiotherapy

About ten years ago, a physio in the USA asked our international gender in pelvic health physio forum for advice - she was seeing a trans-identified male patient who had complications after genital surgery. He asked whether she thought he could ever have sex with a new partner without disclosing his sex and she was not sure how to answer.

The responses practically came waving pom-poms: “You go girl,” “all vulvas are different,” “lube is your friend.”

I was horrified and advised caution - no UK physio in the group should give that advice because sex by deception is a crime. I had heard a trans organisation recommend “disclose before bedroom” - not only because of the legal aspect but because not disclosing potentially puts the trans identified person at risk of assault.

And what do you think happened? I was called names, told I was unsafe to work with trans identified people, reported to an assortment of organisations, and, eventually, booted out of the group without right of reply. I still don’t understand why me wanting trans ID people to not be assaulted or arrested is transphobic, but I’m reliably told it is.

It was my first online pile-on, and, at the time, it felt brutal. It taught me that nobody will try harder to trash your reputation than the person who is most scared that you’ll tell the truth.

The UK governing body and trade union for physiotherapists is The Chartered Society of Physiotherapy. They have a “Position Statement on Transphobia” which states

“Transphobia: the fear or dislike of someone based on the fact they are transgender, including denying their gender identity or refusing to accept it.”

and that members are “expected to respect the position.”

Some of my professional peers will be of the view that by using sex based language to describe the case in California I am in breach of the position statement. However, I am comfortable with my approach. I have spoken to the woman concerned and she has not mentioned having expectations of her physiotherapist’s sense of self, mental health, hairstyle or preferred pronouns, what she expected was a same sex practitioner - sometimes sex really matters to women.

There is nothing in the above position statement to help members navigate what they should do when a woman’s request for same sex care clashes with the self image of a trans-identified male member of staff.

The statement also says

“However, respecting the human rights of gender non-conforming, transgender, transsexual, genderqueer and non-cis people must go beyond just observing the law as it currently stands.”

“Going beyond the law” is a Stonewall phrase. They entirely misrepresented the law, pretending that the 2010 Equality Act regarded gender identity as a protected characteristic (only sex, sexual orientation and gender reassignment are listed) which was framed as progressive and the right thing to do. Amazingly, not one of the organisations advised by Stonewall considered the impact that “going ahead of the law” would have on women and girls.

For Women Scotland, April 25.

The law in the UK is clear

Thanks to For Women Scotland’s efforts taking the Scottish Government to the Supreme Court in order to clarify the law everyone now knows that women in the UK have always had the right to request female care.

However, what if a male trans-identified doctor considers himself female and says, under oath, that he would treat a woman asking for female only care, as happened in a current tribunal?

When pressed, the doctor shrugged and said that if a patient complained, he’d “find someone else.” Presumably, he thinks women who don’t object because they are unconscious, drugged, in agony, or have a communication barrier are therefore consenting to him treating them?

Michael Foran, a legal scholar explores the Peggie v NHS tribunal on substack at “knowing ius” but I can’t get it to link, so have his Critic article for now, til I fix that.

Sex and motives matter

Stonewall’s advocacy umbrella shelters transvestite males, many of whom are autogynaephilic - that is, sexually aroused by the idea of themselves as a woman. Paraphilias are known to cluster, many men who find cross dressing erotic also find sexual satisfaction from eg voyeurism, pain or urine - and that puts a big old pachyderm in the corner of the pelvic health treatment room…if you are a predatory paraphilic man (hashtag-not-all-paraphilics) who wants to peep at women, hurt them and get them to share details about their urination then why would you NOT train as a pelvic health physiotherapist?

There is no point in pretending this is not an issue - here is the Women’s Rights Network’s report on the thousands of sexual crimes committed by hospital staff every year. Discussing the depravity of some men does not tar all men with the same brush. Nobody, and certainly not I, is saying that men who embrace their femininity, including those who use hormones or surgery to change their appearance, are therefore risks to women. The problem, which continues to avoid mainstream debate, attempts is - how can we tell which men are able to behave themselves around women, and which cannot?

This is why chaperones exist, to protect professional boundaries and safeguarding. “The good men stay out so the bad men stand out” strongly applies in healthcare - a “good” male practitioner will never put himself where his presence is not wanted or assume silence equals consent, and if he has a kink or two he leaves them at home where they belong and takes his professional self to work.

Fetishises swing

It goes both ways - every now and then a physio forum post reads “had an odd one, man asking for advice” and gives a story of a man describing his pelvic floor problem at length, in detail, on speaker phone to staff at a physio clinic. Her gut said something was off - two or three others respond with “weird, I think the same man called us three times last week” and they collectively realise they have been tricked into being part of some boring man’s callous-handed sexual script.

Professional bodies need to be aware of deviant sexual behaviours and training should help us to spot and manage fetishists, otherwise they fail to protect both patients and staff. (Besides, if I’m going to be part of some tedious man’s fantasy I need to be paid a LOT more than I am currently)

Women routinely feel failed by healthcare

Good institutions, clinics and practitioners already know what to do. They offer chaperones without being asked, treat consent as an ongoing (not a tick box) exercise, and leave their whole self at home so they can provide patient centred care by listening to the women they are paid to help. These measures are cheap or free, and yet sometimes HCPs totally forget that the baseline of good practice is respecting a person’s dignity. What on earth possessed these clinicians to make a tik tok mocking their patients? They were all sacked. Good.

Carol Hanisch popularised the phrase “the personal is political“ in her 1969 essay of the same name. I can’t think how much more personal a woman can get than making herself vulnerable in order to share deeply intimate information with a pelvic health physiotherapist whom she allows to palpate the muscles and organs of her pelvis through her abdomen, vagina or rectum.

The very least we can do for her is, if she asks for one, give her a woman - the old fashioned kind - and that should never have been allowed to become a contentious political issue.