“The times they are a-changin,” Bob Dylan once sang.(1) Dylan’s song may have been from 1964, but the lyrics can be applied to the present day. Very recently, the world, and the United States in particular, has seen rapid changes in political landscapes.

For instance, America has seen an increase in anti-transgender legislation over the last several years, but also in the past few weeks and months. Many of these laws seek to ban gender-affirming care for transgender, gender non-conforming, and non-binary people, youth in particular., Another bill was introduced just 1 week prior to this post that would make it illegal to identify as transgender on legal documents in Texas, calling it “gender identity fraud,” and carrying with it potential felony charges and jail-time.(2)

What many don’t know is that in addition to charges like the one above, many of these bills also contain exceptions that allow for non-consensual surgeries to be performed on intersex infants and children. The Human Rights Watch states that these procedures on intersex children “are justified by decision-makers on the grounds that they will reduce stigma and prevent gender dysphoria, but they often have the opposite effect and also carry risks of scarring, loss of sensation, lifelong sexual dysfunction, urinary incontinence, psychological trauma, and permanent sterilization.”(3)

For example, in January 2025, an Executive Order from the United States government stated that it would “not fund, sponsor, promote, assist, or support” gender-affirming care for children under the age of 19 “and it will rigorously enforce all laws that prohibit or limit” gender-affirming procedures and treatments.(4) Many American hospitals immediately paused surgical and hormonal gender-affirming treatments for patients under the age of 19 following the order.(5) However, it was found by March 2025 that despite gender-affirming surgeries being paused, non-consensual surgeries were allowed to continue and were still being performed on Intersex infants and children during that time. These non-consensual Intersex procedures were performed by many of the same providers at hospitals who had stopped performing the gender-affirming procedures.(6)

On January 16, 2025, the United States Department of Health & Human Services released the Advancing Health Equity for Intersex Individuals report. This report affirmed the rights of Intersex people to bodily autonomy and informed consent, mentioned health equity barriers for Intersex people, and said that “health care providers and parents can work together to decide that it is in the best interest of the child to delay any non-emergent medical interventions until an intersex child is old enough to be involved in the decision-making about their sexual and reproductive health.”(7) InterACT Advocates for Intersex Youth, called the HHS report, “a victory for the right of intersex children to make their own choices about their own bodies.”(8)

Just days after the release of the HHS report, new government Executive Orders were issued that redefined words like “male,” “female,” “woman,” “man,” and “sex.”(9) This order was intended to impact the transgender and gender diverse communities. However, these Executive Orders impact the Intersex community, as well, as Intersex people can have any gender identity. InterACT says that “many grow up with a gender identity that does not align with their assigned sex at birth – meaning that there is overlap among transgender and intersex communities.”(10) These orders impact cisgender Intersex people, as well. According to InterACT, as “a woman with Complete Androgen Insensitivity (CAIS) may be assigned female at birth, and identify as a woman all her life, while having internal testes – yet the Order would define her sex by her gonads and the reproductive cells they produce.”(10)

***It’s important to note that with the introduction of the new Executive Order, the HHS report has been removed from the HHS and other government websites. InterACT saved the HHS report, and it is accessible on InterACT’s website at this time.***

As laws, reports, and orders are quickly shifting, the healthcare world is rapidly transforming with it. We may not know what local, national, or global changes are on the horizon for the world of politics, the world of healthcare, or the world in general. But one thing that we do know is that healthcare providers need to continue to be advocates for and continue to provide the best evidence-based healthcare to all of our patients, including those who are intersex or transgender.

To learn more about how to be an ally in healthcare and provide better evidence-based care to intersex folx, come take Intersex Patients: Rehab & Inclusive Care with me on May 3, 2025!

Resources

1. Dylan, B. (1964). The Times They Are A-Changin [Album]. Columbia Records.
2. Yurcaba, J. (2025, March 10). Texas Bill Would Make Identifying as Transgender a Felony Punishable By Jail. NBC News. https://www.nbcnews.com/nbc-out/out-politics-and-policy/texas-bill-identify-transgender-state-felony-rcna195642.
3. Human Rights Watch. (2022, October 26). S. Anti-Trans Bills Also Harm Intersex Children. https://www.hrw.org/news/2022/10/26/us-anti-trans-bills-also-harm-intersex-children.
4. The White House. (2025, January 28). Protecting Children from Chemical and Surgical Mutilation. https://www.whitehouse.gov/presidential-actions/2025/01/protecting-children-from-chemical-and-surgical-mutilation/.
5. Betts, A. (2025, February 3). U.S. Hospitals Suspend Healthcare for Transgender Youth After Trump Order. The Guardian. https://www.theguardian.com/us-news/2025/feb/03/trans-youth-healthcare-hospitals-trump.
6. Rodriguez, B., & Sosin, K. (2025, March 10). Hospitals that Paused Youth Gender-Affirming Care Continued Controversial Intersex Surgeries, Group Says. The 19^th*. https://19thnews.org/2025/03/hospitals-intersex-surgery-gender-affirming-care-youth/.
7. S. Department of Health & Human Services Office of the Assistant Secretary for Health. (2025, January 16). Advancing Health Equity for Intersex Individuals. InterACT Advocates for Intersex Youth. https://interactadvocates.org/wp-content/uploads/2025/01/intersex-health-equity-report.pdf.
8. (2025, January 16). Intersex Health Equity Report. https://interactadvocates.org/hhs-supports-bodily-autonomy/.
9. United States Presidential Actions. (2025, January 20). Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government Executive Order. https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/.
10. InterACT Advocates for Intersex Youth. (2025, January 21). Trump’s Executive Order Ignores Science to Push Discriminatory Agenda. https://interactadvocates.org/trumps-executive-order-ignores-science-to-push-discriminatory-agenda/.

AUTHOR BIO
Molly O’Brien-Horn, PT, DPT, CLT, PCES

Molly O’Brien-Horn, PT DPT, CLT, PCES graduated from Rutgers School of Biomedical & Health Sciences (formerly the University of Medicine & Dentistry of New Jersey) with her Doctor of Physical Therapy degree. She is a Pelvic Health Physical Therapist, a Certified Lymphedema Therapist and an LSVT BIG Parkinson’s Disease Certified Therapist. Molly is also a sex counselor, a trained childbirth doula, and a trained postpartum doula. Molly is a member of the American Physical Therapy Association Academy of Pelvic Health Physical Therapy and is also a Teaching Assistant with the Herman & Wallace Pelvic Rehabilitation Institute.

Molly is passionate about providing accessible healthcare to pelvic health patients of all age ranges, all gender identities, all sexualities, all body variations, and all ability levels.

She also has experience in a variety of physical therapy settings over the years, including pediatric and adult oncology, school-based pediatrics, inpatient and intensive care unit hospital-based settings, skilled nursing facilities, outpatient and sports-based orthopedics, and wound care.

Discover Inclusive Care for Gender and Sexual Minorities in this interview with Brianna Durand, an expert in inclusive care for gender and sexual minorities. In this insightful video, Durand discusses the importance of tailored and compassionate healthcare for individuals who identify as LGBTQ+.

Gain valuable insights as Durand shares her extensive knowledge on the unique challenges faced by these communities and how to provide comprehensive and inclusive care. With a focus on creating safe and welcoming spaces for all individuals, this video provides valuable information for healthcare professionals and anyone looking to support the LGBTQ+ community.

Are you looking to improve your knowledge and understanding of inclusive care for the LGBTQ+ community? Look no further! Our remote course on Inclusive Care for Gender and Sexual Minorities is here to guide you through the most important principles and best practices in providing compassionate and equitable care for individuals of all gender identities and sexual orientations.

Led by industry expert, Brianna Durand, this comprehensive course will cover topics such as terminology, cultural competency, and the unique healthcare needs of gender and sexual minorities. By the end of the course, you will have the tools and resources to confidently offer inclusive and affirming care to all patients, regardless of their gender or sexual identity.

Don't miss this opportunity to learn from one of the top leaders in inclusive healthcare. Enroll now in the December 9th Inclusive Care for Gender and Sexual Minorities Course and take the first step towards becoming a more inclusive healthcare provider.

Holly Tanner Short Interview Series - Episode 4 featuring Brianna Durand

Inclusive Care for Gender and Sexual Minorities is a remote course created by faculty member Brianna Durand. This course is for anyone, even if you are unsure about the pronouns or the terminology to use. Brianna created this course to provide the basic foundational knowledge around inclusive and gender-affirming care. The second day of the course provides detailed physiological considerations from the pelvic health and general health standpoint for folx undergoing medical transition.

Brianna became interested in pelvic health research pertaining to the LGBTQ+ community when she was in grad school. She was struck by how the community was not mentioned in most formal education and wanted to meet this knowledge gap.

Gender-affirming care describes ideal medical, surgical, and mental health services sought by transgender, non-binary, and gender non-conforming people. This can range from hormone therapy, to top or bottom surgery, facial hair removal, modification of speech, reduction thyrochondroplasty (tracheal cartilage shave), and voice surgery (1). Also common is the practice of genital tucking or packing, and chest binding. All of which the World Professional Association for Transgender Health lists as medically necessary procedures(2).

Hormone therapy is a common medical intervention and allows for the acquisition of secondary sex characteristics which are more aligned with the individual's gender identity. Research, such as that by Gómez-Gil et al, concludes that there are psychological improvements after gender-affirming treatments such as hormone therapy and surgery (3). Likewise, the denial of access to gender-affirming care is associated with worsened psychological health and high-risk behaviors (4).

Inclusive Care for Gender and Sexual Minorities attendees can expect to be gently guided into the sometimes confusing realm of gender and sexual orientation and identity. This course will provide a safe space to ask all the questions about caring for LGBTQ+ patients and practicing the skills needed to help advance your practice.

Inclusive Care for Gender and Sexual Minorities is scheduled for October 9-10 and covers pelvic floor physical therapy specifically, however it is appropriate and useful for any medical professional as we all have patients in the LGBTQ+ community.

1. Madeline B. Deutsch, MD, MPH. Overview of gender-affirming treatments and procedures. UCSF Transgender Care & Treatment Guidelines. June 17, 2016
2. WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People WorldwideWPATH. Transgender Health Information Program. [cited 2014 Jan 21].
3. Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Hormone-treated transsexuals report less social distress, anxiety, and depression. Psychoneuroendocrinology. 2012 May;37(5):662-70.
4. Sevelius JM. Gender Affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013 Jun 1;68(11-12):675-89.

Molly O'Brien-Horn, PT, DPT, CLT is a pelvic health physical therapist in California. She is a teaching assistant with Herman & Wallace and will be acting as a TA in the upcoming remote course, Inclusive Care for Gender and Sexual Minorities. Molly is a Certified Lymphedema Therapist (CLT), an LSVT BIG Parkinson’s Disease certified therapist, a trained childbirth doula, and a trained postpartum doula. She is a member of the American Physical Therapy Association Section of Pelvic Health. She has experience in a variety of physical therapy settings, including pediatric oncology, school-based pediatrics, outpatient orthopedics, and wound care. Her passion, however, is working in the field of pelvic floor physical therapy with children, teens, and adults of all gender identities, all sexualities, and all ability levels. In her spare time, Molly enjoys doing yoga, hiking, and relaxing at the beach.

October is LGBT History Month. This annual occurrence is a month-long observance of lesbian, gay, bisexual, and transgender history, and the history of the gay rights and related civil rights movements. H&W is proud to offer courses for treating the whole patient across the gender and age spectrum. The remote courses featured in this blog are Inclusive Care for Gender and Sexual Minorities with instructor Brianna Durand, and Transgender Patients: Pelvic Health and Orthopedic Considerations with co-instructors Sandra Gallagher and Caitlin Smigelski.

Many LGBTQ+ individuals, drag artists, and cisgender and heterosexual persons engage in binding, tucking, packing, and padding for several reasons. These techniques can be life-changing. Many people use these techniques for gender expression, but they can also be used for gender affirmation.

Gender dysphoria occurs when an individual feels distress due to a mismatch between their assigned gender at birth and their own gender identity. For many folx who are transgender, non-binary, queer, or intersex, these practices help reduce gender dysphoria. Instead, they provide feelings of gender euphoria by creating joy, enhancing mental well-being, and improving quality of life through affirming gender identity. Additionally, these methods can provide safety by helping to protect folx in unsafe and unfamiliar environments. Some of these devices, such as packers, can even be used for sexual function and urination

So how does it all work? Binding is when a person wears a device, called a binder, to flatten or minimize the appearance of their chest. Many folx who identify as transmasculine and non-binary engage in binding. However, not all people who bind identify as transmasculine or non-binary. For example, cis and queer women, and cisgender men with gynecomastia may use binders. Also of note, not all people who bind use the same binding methods. Compression shirts and tops, sports bras, and tape are a few examples of the many different binding methods available.

Conversely, padding can be used to enhance the shape and appearance of one’s body, often at the hips and gluteal regions. Padded bras can also be used to enhance breast size and shape. Many transfeminine, queer, intersex, non-binary, and cisgender women often use some form of padding or shapewear devices to help create a more effeminate silhouette. Drag artists often use some form of padding to modify their appearance for their performances to achieve the optimal look for their drag persona. Transmen and cismen can also use padding. Furthermore, wigs and prosthetics (e.g. silicone breast forms, breastplates, and prosthetic vaginas) can be used by these populations to achieve a desired appearance.

Regarding prosthetics, many transmasculine folx, cisgender men, intersex folx, and queer individuals use prosthetics for packing. When someone packs, they use a phallic-shaped device to enhance the prominence of their genitals, often to create the appearance of a bulge in their pants. Some packers can extend the length of a phallus for sexual play, as well. This can be helpful for transmasculine folx post metoidioplasty, intersex folx who may have anatomical differences in sexual or reproductive anatomy, as well as cisgender men who suffer from erectile dysfunction. Packers are often made of silicone and can also include or not include certain features like pubic hair, moveable foreskin, and testes. However, packers don’t have to be made of silicone and can instead be made from other items, such as a pair of socks. They can have multiple functions and be used for things other than packing, such as standing for urination, sexual pleasure for oneself, and sexual pleasure for partners.

While packing increases the prominence of one’s genitals, tucking, conversely, is used to minimize the prominence of external genitalia by creating a flatter appearance between the legs. This act gets its name from the tucking of one's testicles into the inguinal canals, after which the penis and scrotum are then tucked between the legs back towards the anus. Frequently gaffs, tape, or tucking underwear are used to maintain the genitalia in these positions. Tucking is commonly used by transfeminine, non-binary, and intersex persons. However, tucking is not just limited to these groups, as cismen, drag artists, and other populations can tuck also.

While binding, packing, tucking, and padding have many positives, there can be some inherent drawbacks. For example, tucking can increase the risk of Urinary Tract Infections due to the position of the urethra close to the anus. Binding can alter posture and impact breathing by reducing diaphragmatic and rib mobility. Pads can be uncomfortable and hot, while packing devices, Stand-to-Pee devices, in particular, require regular cleaning to prevent unwanted smells and/or infections. All of these practices carry the risk of skin breakdown or irritation if performed too frequently or with improper technique. However, it is important to remember that even with these and other various drawbacks, these acts can be so lifesaving, gender-affirming, and life-protecting for many folx, that at times, the benefits of performing these practices greatly outweigh the risks.

The ins and outs of binding, packing, tucking, and padding can be quite complex, and there is so much to learn about proper usage and technique.

Want to learn more about these and other things related to LGBTQ+ health? Check out these remote course options:

• Inclusive Care for Gender and Sexual Minorities, Brianna Durand and her TA Molly O'Brien-Horn will dive deeper into these and other topics surrounding LGBTQ+ healthcare to educate pelvic health practitioners on how to provide better, safer, and more skilled care for the LGBTQ+ populations.
• Transgender Patients: Pelvic Health and Orthopedic Considerations, co-instructors Sandra Gallagher and Caitlin Smigelski will expand your skills for working with people of all gender identities. This course includes particular education regarding gender-affirming genital surgeries as well as discussion of other gender-affirming surgeries and medical interventions that people transitioning might choose.

What are you waiting for? Sign up and join us today!