By: Nina Chou
This year’s IPPS meeting was held in Toronto, Canada, which is one of the most diverse cities in North America. In fact, the official motto of the city is “Diversity is our Strength.” Today, I want to recap a lecture on the impact of culture on sexuality by Beatrice “Bean” Robinson, PhD. Dr. Robinson is a licensed Psychologist, a licensed Marriage and Family Therapist, professor, and researcher at the University of Minnesota Medical School’s Program in Human Sexuality. In her lecture, she discusses her research methods and findings from two studies: the Somali Women’s Initiative for Sexual Health (SWISH) and the ongoing Our body, Our health NIH study.
Due to the ongoing civil war, families have been fleeing Somalia since the 1990’s, with the majority settling in Kenya, Ethiopia, and Yemen. In the United States, the largest number of Somali refugees can be found in Minnesota. Dr. Robinson reports that 98% of Somali women undergo some form of female genital cutting, otherwise known as female genital mutilation or female circumcision. This practice is defined by the World Health Organization as “procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.” There are 4 types of female genital cutting, and type 3 appears to be most common among Somali refugees.
- Type 1: Partial or total removal of the clitoris, prepuce, or both
- Type 2: Partial or total removal of the clitoris and the labia minora with or without excision of the labia majora
- Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora or labia majora, or both, with or without excision of the clitoris (infibulation)
- Type 4: No removal of genital structures; all other procedures to female genitalia for non-medical purposes; e.g. pricking, piercing, tattooing, scraping, and burning.
In order to better understand how this cultural practice affects female sexuality, Dr. Robinson asked Somali-American women in Minnesota about their thoughts and experiences surrounding circumcision, sexual relationships, orgasms, and deinfibulation, or the re-opening of Type 3.
Some findings from her studies did not surprise me. For example, almost all Somalis are Muslim and have sexually conservative beliefs. They do not discuss sex with friends or professionals, and reported many prohibitions surrounding sex (no oral or anal intercourse, no premarital sex, no sex during menses, etc). The researchers also found that those with a more severe form of female genital cutting were more likely to report pain with intercourse. As a pelvic floor physical therapist, I can imagine how this pain could be related to scar tissue, muscle guarding, and other pelvic floor dysfunction due to the physical and psychological trauma surrounding the circumcision.
However, there were also a lot of findings from her studies that I did not expect. I have always associated this practice with the term “female genital mutilation (FGM).” However, many of the women in this study considered FGM to be an offensive term to describe their cultural practice, and preferred to use “female genital cutting.” Many thought of their cutting as a rite of passage and actually preferred the aesthetics of genitals that looked like theirs. Many of the women also expressed having sexual desires and stated that the Qur’an actually encourages husbands to sexually pleasure their wives and provide sexual satisfaction. Additionally, almost all the women reported that they had the right to tell their partner if they did not want sexual activity. In the preliminary data from the “Our body, Our health” study, Dr. Robinson reported that the overall attitude towards de-infibulation was actually positive and women wanted their doctors to bring this option up to them. Finally, information regarding orgasms was difficult to gather, but only because researchers had a difficult time describing an orgasm in words and translating it into Somali.
This lecture highlights the importance of understanding how someone’s religion, culture, and personal beliefs may impact their healthcare. Thank you to Dr. Robinson for sharing her research with us!
I would also love to hear your thoughts about this lecture and female genital cutting. Did anything surprise you? How would you describe an orgasm in words? Let me know below!
Additional Reading:
Click here to learn more about how pelvic PT can help with painful sex.
Read about how Martha overcame painful sex here and here.
References:
https://www.toronto.ca/city-government/awards-tributes/tributes/history-of-city-symbols/
https://med.umn.edu/bio/familymed/bean-robinson
https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.