Before You Glove Up: Are They Ready, or Are They Compliant?

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Transcript

Welcome back to the OTs and Pelvic Health podcast. Today's topic is all about trauma-informed dyspnea reduction.

But I want to start with a confession. When I was earlier in my pelvic floor career, if someone came to see me in New York City where my private practice got started, if they came to see me for pain with penetration, I, nine times out of ten, I would say that my brain immediately went to internal work, right? Layer one, layer two, layer three, tone differentiation, manual release, maybe dilators. And none of that was wrong.

It was skilled. It was evidence-informed. It was what I had trained for.

But over time, especially when I started practicing on my own, I really started to notice something subtle in the room. Sometimes when I would suggest an internal assessment, I could see a tiny shift in the client in front of me. Maybe their breath changed.

Maybe I might see their jaw tighten. A yeah, that's fine reply that didn't quite feel enthusiastic. And I had to ask myself something uncomfortable.

Are they ready? Or are they just being compliant? Because internal work is not automatically trauma-informed. It becomes trauma-informed only if the nervous system is actually on board. And that realization shifted my practice more than any manual technique ever has.

So today I want to walk through how I now approach dyspnea, not by abandoning internal work, but by widening the lens before I use it. 

Intro 

When someone presents with dyspnea, readiness is rarely binary.

It's not yes or no. It's more often somewhere in the gray. Sometimes they're curious, but want more information, right? Sometimes they want information, but maybe not touch.

Sometimes they're intellectually consenting, but their body is bracing. And then sometimes they're actively not ready and just don't have the language yet to say that. So I've stopped framing internal assessment as the next step.

Instead, I frame it as an option. It's just an option. It's an option that could give us information, but an option we don't have to decide on today.

So I say something like, this could be helpful, but I want you to sit with it this week. Notice what comes up. Curiosity, neutrality, hesitation, all of that is data.

And what's interesting is that when I give space like that, the quality of consent shifts. If they come back to me and say, you know, I've been thinking about it and I feel ready, the nervous system feels really different in the room. If they come back and say, I actually feel anxious about it.

That's not a setback. That's clarity. We talk a lot about informed consent in pelvic health, but I think enthusiastic consent is a deeper layer.

And enthusiastic consent feels regulated. You can see it in the breath. You can see it in your shared eye contact.

You can see it in the tone. And if I don't see that, I don't escalate because pacing is a clinical skill. There's also something we don't name often enough.

And that is power. Even in the warmest, most relational, beautiful, cozy treatment rooms, there is a power differential. We have credentials.

We have anatomy knowledge. We have the plan of care. We are the ones suggesting gloved interventions.

And many of our dyspnea clients have histories, whether overt trauma or subtle conditioning or overriding their internal cues. They've pushed through discomfort. They've tolerated penetration that wasn't pleasurable.

They've said it's fine when it wasn't fine. They've prioritized someone else's experience over their own nervous system. So when I ask, would you like to do an internal assessment? I have to hold the possibility that their yes may be about being a good patient.

And that changes how I listen. Sometimes the most trauma-informed thing we can do is to not escalate. Not because we're afraid, but because we're pacing.

And that restraint is clinical sophistication, not avoidance. So what do we do when internal work isn't a clear yes? We zoom out. If someone is guarding internally, I almost always find it externally.

Inner thighs holding tension, right? Glutes subtly gripping in supine. Hamstrings active when they don't need to be. And when I explain this to the client, you know, how the adductors and pelvic floor are part of the same functional system, it feels less invasive to start there, right? So now we're doing things like foam rolling adductors, and that's becoming exposure work.

Pelvic tilting on a towel roll becomes proprioceptive mapping. Rocking between sit bones becomes nervous system repatterning. And here's the key.

They are in control. They choose the pressure. They choose the duration.

They choose the depth. You know, even something as simple as sitting on a semi-inflated therapy ball and gently rocking between pubic bone and tailbone can introduce a new experience, right? I recently had this client who, when we were doing that exact exercise, she turned to me and said, this part of my body can feel pressure and warmth without pain. And I am shocked at that.

And all I could think of when she said that to me was, this is exposure therapy at a nervous system level, at a pace that makes sense for her mind and body to be able to say something like that to me. And sometimes after just a few weeks of that kind of work, internal assessment feels completely different, or potentially unnecessary. Okay, I want to talk a little bit more explicitly now about the nervous system piece, because I use a, I call it a nervous system rating scale in almost every dyspronia case now, and it's zero to 10.

Okay, zero to 10. Zero is fully regulated. 10 is a flipped lid, right? Sympathetic dominance, thinking brain offline.

And my goal during any potentially provocative intervention is to stay at three or below. If someone's nervous system jumps to, I don't know, let's say like a seven or an eight during the internal assessment, even if they don't verbally withdraw consent, we stop. Because flipped lid is not therapeutic territory.

I often teach the hand brain model early on. The spinal cord at the wrist, the brainstem in the palm, limbic system as the thumb, cortex as the fingers, and when someone flips their lid, the thinking brain goes offline. And that metaphor really works when we're talking about this concept with our clients, right? And it gives them language to say to their partner, hey, I flipped my lid, right? And that's occupational therapy too, really giving language that reshapes relational dynamics.

Now, I think that's also why I ended up coming up with the menu of options. So the menu of options for the internal exam is only something taught at the functional pelvis. We're the only ones having these kinds of conversations that give you scripts.

So you know exactly how to talk about the menu of options with your client. And the most important thing about this is that we present them all as equal so that the client doesn't feel biased. Remember what I said about power a few moments ago? That power can influence their decision-making process.

So when we hand it over to them and give them agency to choose which menu of the option they want for us to assess their pelvic floor, ranging from fully dressed to supine on their back in the internal exam pose, that is nervous system language that we layer in and give them agency to choose. Now, let's talk about the next thing, which is sex ed, because sometimes dyspnea can be fueled by misinformation. So I don't know how many vulva-owning clients still believe that penetration alone should produce orgasm.

When it doesn't, they assume something is wrong, right? So when we educate about the clitoral body, its size, its internal structure, its similarity to erectile tissue, I see so much relief in the room. And it's almost like they realize nothing is wrong. And that anatomy was just misunderstood, right? We can also teach the dual control model, which can be equally powerful, right? That comes back to Emily Nagoski.

Well, she mentions it in her book. She was not the pioneer in that, but that she really made that accessible. And so before we hit the gas pedal of penetration, we had to put gas in the car.

And that is sleep, nutrition, stress management. We also have to release the parking brake. That's shame, pressure, performance anxiety.

Only then does shifting into neutral make sense, right? Trying to force penetration while brakes are engaged is like flooring the gas with the parking brake on, right? And when clients start to understand their brakes, we stop pathologizing their own bodies. Okay, I want to walk through a composite case now, because I think this is where integration can really land in this conversation. So I have a client, she's 32 years old, eight months postpartum.

She's breastfeeding, you know, the typical being cleared at six weeks, has attempted penetration twice, both painful, both reporting dryness. And she says, I just want to get back to normal. I want to feel like myself again.

So on the exam, we noted the pelvic floor tone was elevated. Her adductors were guarding, her glutes were subtly active, her breath was shallow. Internal assessment is an option.

But let's pause, because during lactation, estrogen can drop to menopausal levels, right? Dryness is expected. Those tissues are a lot more sensitive. So she internalized that six-week clearance narrative and feels behind, right? How familiar is this? She says self-touch even feels clinical, right? And that sentence is everything.

It's everything, because she tells me she is no longer experiencing touch as connection. She's experiencing touch as an evaluation. And if I respond by increasing evaluation, I reinforce that pattern.

So maybe, maybe week one is education and nervous system mapping. Week two, pelvic tilting and adductor work. Week three, a warming hands sensory exercise, just noticing texture and temperature without a goal.

Week four, maybe we revisit the menu of options. Maybe we revisit the internal assessment. But sometimes at week four, we don't need it.

Because safety changed tone. That's occupational therapy. We're not just addressing muscle fibers.

We're addressing identity shifts, relational expectations, societal timelines, hormonal context, and meaning. Dysprunia postpartum is not only a pelvic floor problem. It's a life transition problem.

I also want to speak to language. If a client says, I failed my homework, that tells me something. If they say, I should be further along, that also tells me something.

If self-touch has become a checklist of does it hurt here? Does it hurt here? Does it hurt there? That question itself primes the nervous system. So I coach a language shift. Instead of, does this hurt? I ask, what do I notice? If pain is there, it will show up.

It always does, right? We don't have to hunt for it. When we hunt for it, we amplify it. That shift, right? That shift from pain-seeking to curiosity-based noticing can really be a surprising regulatory measure.

Now, before we close, I want to leave you with some questions, right? Number one, what is your client's nervous system reading today? How are they sleeping? Are they breastfeeding? Are they perimenopausal? Are they menopausal? What language are they using about themselves? Is the internal assessment aligned with their goals or your clinical momentum? Is there curiosity in the room or obligation? These questions alone have changed my outcomes more than any specific release technique. So if there's one thing I hope you take away from today, it's this. You do not have to be the reason someone gets better.

You do not have to deploy your most advanced tools immediately. Sometimes your most advanced tool is pacing. Sometimes it's restraint.

Sometimes it's saying, we don't have to decide today. If someone leaves your clinic feeling safer in their body, that is progress. If someone learns to pause intimacy when they flip their lid instead of pushing through, that is neuromotor retraining.

If someone realizes penetration does not define sexual success, that is occupational liberation. We're not just treating muscle tone. We're shaping meaning.

We're modeling consent. We're recalibrating safety. And safety over time is what allows tissues to soften.

So the next time dyspnea comes to your clinic, I invite you to ask, what else might this body need before it needs my hands? Thank you for the work you do. Thank you for practicing thoughtfully. Thank you for expanding the lens of pelvic occupational therapy.