Basic Science to Neuroscience in Gender Surgery Rehab

Sandra Gallagher has served on varied committees and boards at the state and national level, most recently as the chair of the CAPP-OBC committee for the Academy of Pelvic Health of the APTA. She has presented on the role of PT in gender-affirming vaginoplasty at UCSF Transgender Health Summit, APTA Combined Sections Meeting, and at the 2018 international meeting of the World Professional Association for Transgender Health (WPATH). Join Transgender Patients: Pelvic Health and Orthopedic Considerations with instructors Sandra Gallagher, PT, DPT, WCS & Caitlin Smigelski, PT, DPT on April 29th.

In working with surgeons that perform and patients undergoing gender-affirming genital surgery I’ve had the chance to recognize that some of our most basic skills of assessing tissue and tissue healing play a huge role and optimizing healing.  I personally have loved taking another look at some of the wound healing principles that I used early in my career in the 90s, to assist in developing timelines for post-surgical recoveries of gender surgeries.

In addition to the basic science of tissue healing, we’ve integrated current and novel neuroscience to develop Graded Motor Imagery guidelines to improve the sensory outcomes of vaginoplasty and phalloplasty surgeries. Graded Motor Imagery (GMI) is a treatment approach commonly associated with treating pain. It is generated from understanding the underlying neuroplasticity of complex pain conditions such as phantom limb pain. (1) Graded Motor Imagery in rehabilitation means that the focus is placed on synaptic exercise and health. The use of neuroplasticity to change sensory experiences occurs in other parts of rehab and goes under different names.  Sensory integration, cortical integration, or mapping, are some other terms used. In addition to being used for reducing pain in complex regional pain syndrome, the techniques are used for reducing limb neglect in stroke rehab, and restoring limb function in complex hand surgeries (2,3,4,5).  In pelvic rehab, we are using these concepts with urinary urgency suppression and in cis females with vaginal pain. There are handfuls of article exploring the presence and phenomena of phantom penis in trans men (6,7,8)

Using GMI for Phalloplasty

When using GMI for phalloplasty, the primary goal is to improve erogenous sensation in the penis. This is done with three main techniques: visualization of static and dynamic functions of the penis, tactile stimulation starting with a simple touch and progressing toward sensory stimulation, and sexual/erogenous stimulation (9).  As people move through the process they use stimulation of the buried erectile tissue and other erogenous parts of their body while touching the penis. This can be a partnered or independent activity. This can be adapted regardless of the number of stages involved in the surgery.

Using GMI for Vaginoplasty

With vaginoplasty, the attaining pain-free and erogenous sensation typically progresses more directly than in phalloplasty, as there are fewer complications with vascular and nerve recovery. The clitoris and its neurovascular bundle are intact and continue to be perineal tissue. We use traditional pelvic rehab interventions of clinical EMG, and a robust home program of dilation, exercise, TENS, and self-care including patient-directed manual interventions. The addition of GMI guidelines for vaginoplasty more commonly is directed toward reducing vulvovaginal pain. Whereas the phalloplasty sensory protocol is initiated early in the surgical process, the vaginoplasty guidelines are more commonly applied when post-surgical pain limits someone's function. The GMI process here uses visualization and activities of seeing vulvas in one's surrounding environment, such as flowers, folded fabrics, and Georgia O'Keefe artworks. This is intended to be a neutral practice. Similar to the desensitization process in limb rehab, using various textures and depth of touch, combined with watching the light touch can help with pain reduction. As pain abates using stimulation of other erogenous tissue while touching the vulva or dilating can be added.

For providing optimal care, knowledge of the intricacies of gender transition is essential. Join me in Transgender Patients: Pelvic Health and ORTHO Considerations on April 29th to learn more regarding gender-affirming genital surgeries, discussion of other gender-affirming surgeries, and medical interventions that people transitioning might choose. We provide that overview in this course. Topics covered include: 

• Societal influence on gender transition including interactions with healthcare providers
• Recognizing the difference between sex, sexuality, and gender
• Understanding the complexities of the legal system for the person transitioning genders
• Tips and tools for a trauma-informed intake and examination
• Health effects of hormones for gender transition as related to differential diagnosis in rehabilitation
• Supporting healing after gender-affirming surgery
• Operative procedures for face and chest
• Operative procedures for masculinizing and feminizing genital surgery
• Preoperative evaluation, treatment, and education issues
• Post-operative evaluation, treatment, education and follow-up for genital surgeries
• Outcome measures with rehab focus for people undergoing gender-affirming surgeries
• Fertility and pregnancy in gender-diverse people

References:

1. Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006 Dec 26;67(12):2129-34. doi: 10.1212/01.wnl.0000249112.56935.32. Epub 2006 Nov 2. PMID: 17082465.
2. Smart KM, Wand BM, O'Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2016 Feb 24;2(2): CD010853. doi: 10.1002/14651858.CD010853. Pub2. Update in: Cochrane Database Syst Rev. 2022 May 17;5:CD010853. PMID: 26905470; PMCID: PMC8646955.
3. Leifert-Fiebach G, Welfringer A, Babinsky R, Brandt T. Motor imagery training in patients with chronic neglect: a pilot study. NeuroRehabilitation. 2013;32(1):43-58. doi: 10.3233/NRE-130822. PMID: 23422458.
4. Simon JJ, Welfringer A, Leifert-Fiebach G, Brandt T. Motor imagery in chronic neglect: An fMRI pilot study. J Clin Exp Neuropsychol. 2019 Feb;41(1):58-68. doi: 10.1080/13803395.2018.1500527. Epub 2018 Aug 6. PMID: 30080434.
5. Kahn LC, Moore AM. Donor Activation Focused Rehabilitation Approach: Maximizing Outcomes After Nerve Transfers. Hand Clin. 2016 May;32(2):263-77. doi: 10.1016/j.hcl.2015.12.014. PMID: 27094897.
6. Chris Straayer (2020) Phantom Penis: Extrapolating Neuroscience and Employing Imagination for Trans Male Sexual Embodiment, Studies in Gender and Sexuality, 21:4, 251-279, doi: 10.1080/15240657.2020.1842075.
7. Ramachandran VS, McGeoch PD. Occurrence of phantom genitalia after gender reassignment surgery. Med Hypotheses. 2007;69(5):1001-3. doi: 10.1016/j.mehy.2007.02.024. Epub 2007 Apr 8. PMID: 17420102.
8. Gherovici, Patricia. (2020). A Phantom Phallus? Studies in Gender and Sexuality. 21. 296-301, doi: 10.1080/15240657.2020.1842070. 
9. Peters BR, Annen AA, Berli JU, Gallagher S, Smigelski C, Kahn LH, Skelton HE. Neurosensory Re-education following Gender-affirming Phalloplasty: A Novel Treatment Protocol. Plast Reconstr Surg Glob Open. 2022 Oct 24;10(10):e4616. DOI: 10.1097/GOX.0000000000004616. PMID: 36299822; PMCID: PMC9592297.

Transgender Patients: Pelvic Health and ORTHO Considerations

Price: $500 .00         Experience Level: Beginner           Contact Hours: 17 hours

This course is appropriate for any physical rehabilitation professional, regardless of their specialty area, who has an interest in better serving the people who are gender diverse. There is specific content aimed at teaching pelvic health therapists how to expand their skills for working with people of all gender identities. There will be particular education regarding gender-affirming genital surgeries as well as discussion of other gender-affirming surgeries and medical interventions that people transitioning might choose.

Course Dates: April 29 and August 19