Congratulations to Dr. Mia Fine (they/she) for achieving their Ph.D. in Clinical Sexology and on their book titled 'From Unwanted Pain to Sexual Pleasure: Clinical Strategies for Inclusive Care for Patients with Pelvic Floor Pain' for their dissertation doctoral project.
Dr. Fine was gracious enough to share a draft of their dissertation with Herman & Wallace and to answer a couple of questions about how this impacts their practice and what they hope other practitioners will take away from their book and course Sexual Interviewing for Pelvic Health Therapists.
Mia's course is for the pelvic rehab therapist and others in the medical profession who work with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns and would like to learn applicable skills from the sex therapist's clinical toolkit. The next course date for Sexual Interviewing for Pelvic Health Therapists is August 13-14,
How does Trauma-Informed Care apply to the skills that you teach in your Sexual Interviewing course?
When I utilize the term ‘trauma-informed’ I am referring to therapeutic work that communicates expectations clearly (including prioritizing people’s access needs with this communication), invites clients awareness of their own agency, and is upfront about my scope of practice and my therapeutic approach, offers mutuality in inviting of questions and ongoing conversation about our work together, awareness that an individual can end therapy at any time, and share information at any time in our therapeutic space.
The modalities I utilize when working with clients who have experienced trauma include Eye Movement Desensitization and Reprocessing (EMDR), Polyvagal Theory, Somatics, and Developmental Theory. While I integrate various theories and modalities into my work with clients, the methods above are empirical in their data to support healing from trauma wounds.
Trauma-informed means humility regarding cultural, racial, gender, sexual, and other minority experiences. I will not know all of the things but I will do my best to self-educate and not leave that responsibility to my clients. When I make a mistake I will appropriately, directly, and compassionately apologize for the harm I caused and invite opportunity for repair should the client be interested. Trauma-informed means collaboration in exploring therapy together, co-creating a space that feels safer to the client and checking in with them when I notice non-verbal cues that indicate activation, honoring a client’s pacing, and bringing awareness to the reality that as a therapist I hold power and while I don’t know a person’s full story there is always the potential for me to unintentionally activate a client so to share this possibility with clients and continuously check in about how our therapy is working for them. I keep my client’s well-being at the forefront of our work and I center their needs at all times while maintaining boundaries that keep everyone as safe and secure as possible.
It is up to us as trauma-informed and inclusive providers to explore a person’s experience of pain by asking questions about onset, process, location, and impact, in addition to offering psychoeducation about anatomy, physiology (arousal, interest, desire), and self-regulation. This must be done alongside commitment to our patient’s co-regulation, normalization, and informed consent concerning the therapeutic process—all of which are needed for comprehensive trauma-informed care.
Can you explain how expanding what 'normal' is to practitioners can impact the patients and clients that they work with?
Sex is not supposed to be painful. How many people have come to me having had painful sexual intercourse for years and reported “pushing through”? The first time having intercourse does not necessarily have to be painful, but when our cultural narratives tell us “the first time having sex is painful for everyone” we end up ignoring the signals our bodies are offering because we have convinced ourselves that the pain is both okay and normal. The “pushing through” is a reflection of misogyny: people assume the first experiences people have with penetration are supposed to be painful. How is this misogynistic? Well, who benefits from a person “pushing through” pain? The partner with the penis. Important to note here as well is that enthusiastic consent is ableist and ignores the mind-body connection because it does not take into account masking or fawning which are common experiences for many.
A quarter of people who experience sexual health concerns share this with their providers. Why such a small fraction? Fear. Fear of embarrassment and shame. Fear that there is something “abnormal” about them that mutates into the shame humans tend to experience in response. Fear that the concern won’t be held or taken seriously by their provider. Fear that, if it is addressed, will be at such a high financial cost that the treatment will be unaffordable. Fear that there’s not enough time or that they won’t be taken seriously. Fear of exclusivity, feeling othered, or misunderstood by their provider. Fear of the unknown because the reality is that people are afraid of what we don’t understand.
One of the major cultural issues we have in the US is the perpetuation of sexual stigma which is largely associated with a lack of comprehensive sex education. People don’t have access to basic information about their own bodies which influences our beliefs about sex, pleasure, agency, communication, and self-awareness. Sex education should be a birthright, and yet we are so far behind the curve that it sometimes feels impossible to break down the barriers.
When I first started in this career it would often take clients months of working with me to feel comfortable enough to talk about where they felt pain during sex, but in developing the tools to co-create safety in our therapeutic relationship and the skills to ask the important questions with compassion and patience, I learned how to better hold space for healing.
Patients don’t often know what information is important for them to share with us (which is why offering visuals of where the pain is located is important). How could they know what information is important to offer when mental and sexual health are so deeply stigmatized? The stress of shame and embarrassment that people feel about their bodies is emotional pain that further exacerbates the physical pain that they came to therapy to address in the first place. It’s a terrible and self-perpetuating cycle.
I teach people the difference between a vulva and a vagina one thousand times a year. If a client does not know the terminology for labia, vulva, vagina, and clitoris, how are they supposed to know when their sexual health is of concern? If a person enters sex therapy with “sexual pain” but is unable to distinguish the difference between their labia and vagina (that they are different body parts, where they are located, and what their functions are) we cannot expect them to accurately articulate the location of pain or comprehend potential solutions. “What is your hygiene process when cleaning your vulva?” may activate the fight or flight response in clients if they do not know what their vulva is or that there could be a good hygiene process, in addition to the shame of not knowing. How are they supposed to know where or to whom they may ask for help?
An online search for “anatomical vulva”, “pelvic floor pain”, “vaginismus treatment” and 99% of the images and figures you will see are those of hairless, slender bodies with white/light skin and small labia. Racism and white supremacy are present everywhere. The anatomical depictions of vulvas are of white bodies, the people modeling in vaginismus treatment advertisements are white, and the language is geared toward and written for white people. I was intentional about not featuring white vulvas in this book because white bodies should not be the default of what is mainstream. This lack of diversity in skin tone and variation of body type is another reflection of racism called “colorism”. White and light skin bodies are viewed as more ‘normal’ and when we continue to center white bodies in visuals “because that is what is available” we perpetuate white supremacy. One goal is to disrupt the idea and practice of whiteness as the default. This is what it means to practice anti-racism and attempt to divorce ourselves from white supremacy.
The impact of shame shows up in the pervasive erotophobia rampant in our society. Erotophobia can be broadly defined as a “fear of sex” or more specifically a “fear of intercourse”. When erotophobia is judgment as a result of societal shame and stigma, we can navigate it by deconstructing the etiology and impact of messages received; when it is a result of a mental health condition such as Obsessive Compulsive Disorder (OCD) or Post Traumatic Stress Disorder (PTSD), we do deep trauma and/or anxiety/exposure work. Because of the vast impact of shame, people fear sharing sensitive information about themselves with others, including therapists who are trained to help them. Often, therapists are untrained in sexual health which also can contribute to erotophobia and shame. When therapists have not done their own work on sexuality, and remain untrained in these areas, they may be afraid to discuss sex with their clients which reinforces the belief that topics regarding sex are shameful.
When people do not have the language to articulate what is happening in their body, as significant as the pain or discomfort might be, talking about sex with a provider is often the last item on a long list of concerns they bring to a medical appointment. Symptoms of sexual pain may be hidden by other “more pressing” concerns such as anxiety, depression, PTSD, or sleep issues. While these are of course vital for a medical provider to know, having 20 minute appointments with a physician who will prioritize the “presenting concern” that they came in to seek treatment for leaves very little time to discuss unwanted sexual pain. After 15-20 minutes of a medical appointment (if it goes well), a patient might feel comfortable enough to bring up their sexual concern, but this might leave 1 minute for it to be acknowledged and no time to conduct a comprehensive assessment or develop an intentional plan. We call these last-minute oh-by-the-way’s “door-knobbing” for a reason. This is a call for medical clinics to have training in sexual health so they can create intake documentation that explores clients’ sexual health and ask the questions that are vital to gather necessary information ahead of time.
In the same way that people lack language and anatomic understanding, people also lack awareness of the mind-body relationship. Due to the ableist sex-negative culture in which we live, people are often not taught to have knowledge of or listen to our own body. We’re not taught that pain is a signal from the body telling us that something’s wrong.
Mia Fine, MS, LMFT, CST, CIIP is the creator of the remote course, Sexual Interviewing for Pelvic Health Therapists. This course is for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit who works with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns. Mia (they/she) is a student of Queer Theory, Intersectionality, and Social Justice and offers holistic, anti-oppressive, and trauma-informed therapy in the Seattle area.
As a Licensed Marriage and Family Therapist, Certified Medical Family Therapist and trained AASECT Certified Sex Therapist, Mia has clocked hundreds of hours in direct client contact, supervision, and consultation. She has also attended numerous sex therapy trainings, continuing education opportunities, and trains incoming sex therapists on current modalities and working with vulnerable client populations.
Sexuality is core to most human beings’ identity and daily experiences. Human beings are hard-wired for connection, intimacy, and pleasure. When there are concerns relating to our sexual identity, sexual health, and capacity to access our full potential, it affects our quality of life and holistic well-being. Practitioners who work with folks on issues of sexual health and decreasing sexual dysfunction are in the position to encourage awareness and healing. Mia shares, “Imagining a world where human beings don’t walk around holding shame or traumatic pain is imagining a world of health and happiness.”
Unwanted sexual pain often goes unaddressed because culture does not teach the interactions between feelings, relationships, and the body. Our society often tells us that there is something wrong with us, that we are defective, for wanting a healthy sex life and for addressing our human needs/sexual desires. People are not taught that sex should not be painful and that pain is our body giving us information that something is going on. It’s not uncommon that most people who experience sexual pain often feel as if they are broken. Mia’s favorite thing to say is that “No person is broken. Each and every one of us are uniquely special beings worthy of being loved and nurtured.”
Providers must be aware of their own biases and be introduced to the various sexual health resources available to providers and patients. Mia further stresses, "Always listen to your patient to understand what they are saying and feeling. Do not respond defensively. Remember that this can feel like a threatening situation for patients. It is vital that providers working with pelvic floor concerns have the necessary education and training to work with patients on issues of sexual dysfunction."
From a business standpoint, happy patients are more likely to return to your practice in the future, recommend your practice to their friends, and pay their bills on time and in full. Patients want to have quality interactions with a healthcare provider who cares about them. As a practitioner, your satisfied patient is more likely to make follow-up appointments and maintain their prescribed treatment plan, which can lead to more positive outcomes.
Sexual Interviewing for Pelvic Health Therapists offers current and empirically-founded sex therapy and sex education resources for both the provider as well as the patient. Mia will broaden your scope of competence in working with patients who experience forms of sexual dysfunction and who hope to live their full sexual lives. This course will add the extensive skills of interviewing for sexual health. It also offers the provider a new awareness and self-knowledge on their own blind spots and biases.
Check out Mia's interview with Holly Tanner on the Herman & Wallace YouTube Channel for more information on the course.
Sexual Interviewing for Pelvic Health Therapists - Remote Course
Mia Fine, MS, LMFT, CST, CIIP is the author and instructor of the Sexual Interviewing for Pelvic Health Therapists remote course scheduled for August 14-15, 2021. Mia’s specialties are sexual health concerns, eroticism, intimacy, alternative sex and relationships (kink/BDSM and non-monogamy), LGBTQIA+ genders/orientations/sexualities, and desire discrepancy. Her course Sexual Interviewing for Pelvic Health Therapists is intended for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit. Mia shares the following blog detailing some of the books that have influenced her.
As a science, psychology, somatics, and sexuality education nerd, books are my go-to psychoeducation sources. The books listed below are resources that I offer to my clients, send to family and friends for birthdays and holidays, and inform the work I do as a clinical supervisor, professor, and therapist. I’m excited to share some of my favorites that might help you and the patients with whom you work.
A prerequisite for anyone with a vulva (or who is partnered with someone with a vulva) is the book Come As You Are written by Emily Nagoski. Before a therapeutic intake session, I invite my clients who have vulvas to read this book. It is important to me that my clients and I share the same language that is offered in this fabulous resource. Nagoski illustrates the Dual Control Model for sexual arousal, interest, and desire in ways that are accessible and digestible for all. When clients understand the difference between Spontaneous Arousal and Responsive Arousal, and why these happen, and when, it is a game-changer for them and their partner. This book is a must for anyone who works with pelvic floor pain. And excitingly, these topics will be covered in my upcoming Herman & Wallace course!
The Politics of Trauma written by Staci Haines (also the author of Healing Sex) is a deep dive into, well, the politics of trauma. In this book, she explores the somatic experiences we humans have when we are activated. Her detailed description of fight, flight, freeze, fawn, and dissociate is nothing short of brilliant. This book is a must for those who are interested in exploring the impact that social justice, racial justice, transformative justice, and restorative justice have on our lived experiences of trauma.
The Body is Not An Apology is another brilliant book by Sonya Renee Taylor. It highlights the many effects of the “isms and obias” (such as Sexism, Racism, Fat-phobia, Transphobia) embedded in our everyday life and how identifying these frees us of the barriers they place on our quality of life. The isms and obias she explores impact the way we view ourselves, talk to ourselves, and relate to others. This book is incredibly inspiring, as is the author, Sonya Renee Taylor.
Additional books I love, many of which are written by close friends and colleagues include:
These books have improved, and informed, my therapeutic work with clients and are recommendations I offer on a weekly, if not daily, basis. For additional resources, check out my website:https://miafinetherapy.com/. I look forward to exploring more comprehensive and accessible resources with you at my upcoming course Sexual Interviewing for Pelvic Health Therapists remote course scheduled for August 14-15, 2021!