Have you ever thought about how patients from diverse backgrounds face unique challenges at the intersection of their religious values—such as modesty and conservative views — and the need for pelvic and sexual health support?

Navigating this intersection of pelvic rehabilitation and religious belief systems requires a deep understanding of both the physical and emotional challenges patients may face. In many conservative religious communities, discussions around sexual health are limited, creating significant barriers to seeking care and addressing issues such as pelvic pain, sexual dysfunction, and reproductive concerns.

Let’s take a look at a past patient of mine as an example. Sarah’s case highlights the complexities that arise when religious upbringing, limited sexual education, and physical dysfunction intersect. Her story underscores the need for compassionate, culturally informed care that empowers patients to achieve their health goals while respecting their deeply held beliefs.

Case Study: Sarah
Sarah is a 23-year-old woman presenting for a pelvic health evaluation. When scheduling her appointment, she declined to disclose the specific reason for her visit.

During the patient interview, Sarah shares that she has been married for eight months and that all attempts at intercourse have been unbearably painful. She reports pain at a 14/10 intensity level and describes vocally crying out during any attempt at penetration. She expresses a deep sense of hopelessness, fearing that something is fundamentally wrong with her body, and worries that her vagina is “too small” for intercourse. Sarah admits she has never visually examined her vaginal area, stating it “grosses her out.”

Sarah is otherwise in good health but has never undergone a gynecological exam. Both she and her husband come from conservative religious backgrounds, attended religious schools with limited sex education, and received minimal information about sexual activity prior to marriage. Neither had been sexually active before their wedding. Sarah continues to adhere to her religious beliefs, including a practice that discourages conversations about sex with anyone other than her spouse. She voices a strong aversion to sexual activity, as well as to her husband’s genitalia and semen, and shares feelings of guilt over her inability to have intercourse and “make her husband happy.”

Although Sarah denies any discomfort while sitting or wearing tight-fitting clothing and reports no other general bodily pain, she has recently begun experiencing vulvar pain that precedes any attempt at intercourse. Following these attempts, she has difficulty falling asleep due to persistent pain.

Additional relevant history includes frequent urination (approximately every hour), which she attributes to having a "tiny bladder." Chronic constipation, with bowel movements occurring about once per week, often requiring significant straining (Bristol Stool Scale types 1–2). Regular menstrual cycles, though the first 2–3 days are marked by debilitating pain and the inability to successfully insert tampons.

Sarah’s personal treatment goals are to achieve pain-free intercourse and to become pregnant as soon as possible, aligning with the expectations of her close-knit, religious community.

Let’s think about our next steps with this patient.
What is your next move? Approach the patient with heightened sensitivity, cultural competence, and an awareness of how religious values can shape a patient’s experience of their body, pain, and sexuality. The next steps with Sarah should focus on creating a foundation of trust, safety, and consent while validating her experience and assuring her that treatment will proceed at her comfort level. The initial sessions could prioritize external assessment, observing breathing patterns, posture, and pelvic tension, without internal examination.

What other questions would you like to ask this patient? Gentle, respectful questioning would further clarify the nature of Sarah’s pain, emotional experiences surrounding intimacy, bladder and bowel habits, and her comfort level with educational discussions within her religious framework.

What would your treatment plan look like for this patient? Early treatment could center on pain education, diaphragmatic breathing, pelvic floor relaxation, and bladder and bowel retraining, with mirror therapy and gradual body awareness work being introduced when she is ready. The treatment plan would progress from external desensitization toward eventual internal work and dilator therapy, aimed at achieving pain-free intercourse and healthy pelvic floor function to support future pregnancy.

What other healthcare providers might you refer her to? In addition to pelvic therapy, referrals to a culturally sensitive pelvic health mental health professional, a trauma-informed gynecologist, and possibly a sex therapist and dietitian could be recommended. Throughout care, sensitivity to Sarah’s religious values, empowerment, and compassionate support would be critical to helping her meet her goals.

The Takeaway
As pelvic health providers, we choose this field because we are passionate about delivering the best possible care with sensitivity and compassion. Yet, it can feel overwhelming when we work with patients from religious or cultural backgrounds unfamiliar to us. In our efforts to be respectful, we may find ourselves hesitant to ask the crucial questions necessary for effective care.

I created a course to specifically tackle this sensitive issue; Sex and Religion is a short, one-day remote course held over Zoom that bridges the gap between the worlds of pelvic rehabilitation and religion. This course provides guidance and skills for engaging patients from religiously conservative backgrounds in a culturally sensitive manner. Participants will gain a foundational understanding of the various traditions, customs, laws, and values associated with Muslim, Jewish, Hindu, and Christian faiths as they pertain to sexuality and pelvic health.

Anyone who treats pelvic health concerns can take this course to fill their toolbox with new tools and strategies to enhance their practice. Join Rivki in her upcoming course, Sex and Religion, on May 18^th to ensure that every patient receives the thoughtful, respectful care they deserve.

AUTHOR BIO
Rivki Chudnoff, MSPT

Rivki is a Midwesterner at heart, born and raised in Chicago. At her private practice, Hamakom Physical Therapy, in Bogota, NJ. She focuses on women’s health and pelvic health rehabilitation for women and children. Rivki graduated from Stern College with a BA in Biology and from the University of Medicine and Dentistry of New Jersey (Rutgers) in 1999 with a Master of Science in Physical Therapy. Rivki started her physical therapy career in pediatrics working with children with severe disabilities.

In her practice, Rivki is privileged to work with women at different stages of life. Rivki uses a biopsychosocial approach to guide her patients through the many challenges that they encounter along their journey to healing. Rivki has written extensively on women’s health issues and has presented on pelvic health internationally to sex educators, at community events, and at marriage retreats. In her free time, she enjoys vacationing at Trader Joe’s, burning dinner, and trying to figure out new ways to embarrass her children with her professional life.

Let me share one of my past patients with you.

Several years and many Herman & Wallace courses later, I started treating patients with dyspareunia and pelvic pain in my private practice. My patients’ expressions of anxiety with the unwrapping, of fear of pain with anticipation of touch seemed familiar, I remembered Joe. The body parts may be different, but the nervous system is one and the same.

While Joe’s injury and source of pain and sensitivity was obvious even to the layperson, our patients with dyspareunia and pelvic pain are suffering with pain whose source is often invisible even to the most trained clinical eye.

Yet, the treatment principles are similar. Every day, we help patients feel safe in their own bodies by providing both gentle treatment and teaching self-treatment techniques that empower patients to help heal themselves. Dilator training can be viewed in this lens as a master class in desensitization and sensory integration of the vagina. We are teaching the pelvic floor muscles and surrounding tissue to gradually accommodate to the increased size of the dilator being inserted without setting off a five-alarm fire and cascade of painful responses in the nervous system.

We load our treatment toolboxes with deep breathing, relaxation techniques, and biofeedback to help rewire and re-educate the body's responses to stimuli.

This treatment is often compounded when patients come from religiously conservative backgrounds and are raised with restrictive sexual values. This places them at a higher risk of experiencing dyspareunia and painful intercourse. In addition to their pain, they may also be struggling with sexual shame and lack of sexual education, creating a greater barrier to treatment and care. Gaining patients' trust and “buy in” may require a higher level of cultural competence and religious sensitivity than other less emotionally charged specialties.

So, let’s talk about it in my upcoming course, Sex and Religion: Treating Conservative Religious Patients with Cultural Sensitivity, on May 18th. I created this course to help both seasoned and newer therapists open their skill sets to reach more diverse patient populations. In this course, I delve into these topics and explore challenges that face patients who come from conservative religious communities as they interface with the wild world of pelvic health. You leave my course with practical skills for patient interviewing, treatment strategies, and creating a safe and comfortable space for both patients and providers.

Resources:

1. Patanwala I, Lamvu G, Mizera M, Fisk M, Blanton E. Learning restrictive sexual values may be associated with dyspareunia. Journal of Endometriosis and Pelvic Pain Disorders. 2020;12(2):61-68. doi:1177/2284026519900108.
2. Schermer Sellers, T. (2017). Sex, God, and the Conservative Church: Erasing Shame from Sexual Intimacy (1st ed.). Routledge. https://doi.org/10.4324/9781315560946.

AUTHOR BIO
Rivki Chudnoff, MSPT

Rivki Chudnoff, MSPT (she/her) is a Midwesterner at heart, born and raised in Chicago. At her private practice, Hamakom Physical Therapy, in Bogota, NJ, she focuses on women’s health and pelvic health rehabilitation for women and children. Rivki graduated from Stern College with a BA in Biology and from the University of Medicine and Dentistry of New Jersey (Rutgers) in 1999 with a Masters of Science in Physical Therapy. Rivki started her physical therapy career in pediatrics, working with children with severe disabilities.

In her practice, Rivki is privileged to work with women at different stages of life. Rivki uses a biopsychosocial approach to guide her patients through the many challenges that they encounter along their journey to healing. Rivki has written extensively on women’s health issues and has presented on pelvic health internationally to sex educators, at community events, and at marriage retreats. In her free time, she enjoys vacationing at Trader Joe’s, burning dinner, and trying to figure out new ways to embarrass her children with her professional life.