Trauma and the Voice to Pelvic Floor Connection

Caring for patients who have experienced trauma requires a skillset beyond basic knowledge of pelvic health assessment and intervention. With one-third of women experiencing intimate partner violence, and estimates of rape reports to formal agencies (e.g., police, medical professionals) ranging from only 5–33% (Fisher, Cullen, & Turner, 2000; Kilpatrick et al., 2007; Krebs et al., 2007; Rennison, 2002), we can safely say that the gender-based violence women uniquely experience is likely grossly under-reported.

Additionally, the World Health Organization reports that violence and sexual violence against women is a major global public health problem. Estimates published by WHO indicate that globally about 1 in 3 (30%) of women ages 15-49 worldwide have been subjected to either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime.

In terms of violence, the vast majority is, sadly, intimate partner violence; that is, violence committed by your own partner. Further, the overall risk of any gender reporting intimate partner violence is 1 in 7 for people who identify as men, and 1 in 5 for people who identify as female, according to the last reported statistics from the CDC.

For trauma risk in general, the chance of any gender experiencing trauma, including ACEs, or Adverse Childhood Experiences, is as high as over 70%. The first comprehensive study on PTSD (post-traumatic stress disorder) and trauma in the US was not conducted until 1990, which reported that 60.7% of men and 51.2% of women reported at least one exposure to trauma. From there, the estimated population lifetime prevalence of 5.7% for men and 12.8% for women (Kilpatric et al 2013).

The statistics on violence against the LGBTQIA community are even more alarming. A survey found that transgender people (16+) are victimized over four times more often than cisgender people and that transgender women and men had higher rates of violent victimization than cisgender women and men. Overall, about 50% of the violent victimizations were not reported to police. A separate 2022 survey showed that LGBT people experienced 6.6 violent hate crime victimizations per 1,000 persons compared with non-LGBT people's 0.6 per 1,000 persons (odds ratio = 8.30, 95% confidence interval = 1.94, 14.65).

If you are working with this population, there is a long list of adverse impacts known to affect all genders who have experienced trauma, especially if they go on to develop PTSD or complex PTSD (cPTSD), and even more so if the person experienced an ACE. A traumatic event is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM5) as a direct or indirect witness (indirect means learning about the trauma of a loved one) to actual or threatened death, serious injury, or sexual violence, either of which can induce PTSD. Four symptom clusters define PTSD in the DSM5:

1. Intrusive symptoms - recurrent and unwanted memories, nightmares, flashbacks, and intense distress or physiological reactivity after exposure to traumatic reminders.
2. Avoidance symptoms - avoidance of trauma-related thoughts, feelings, or reminders.
3. Persistent negative beliefs - negative emotions related to the trauma (such as guilt, shame, anger, horror), loss of interest in significant activities, feelings of alienation from others, and an inability to experience positive or loving emotions.
4. Alterations in arousal and reactivity - irritability or aggression, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, and problems with concentration and sleep.

Some of the signs of cPTSD can include:

• Behavioral difficulties (e.g. impulsivity, aggressiveness, sexual acting out, alcohol/drug misuse, and self-destructive behavior)
• Emotional difficulties (e.g. affect lability, rage, depression, and panic)
• Cognitive difficulties (e.g. dissociation and pathological changes in personal identity)
• interpersonal difficulties (e.g. chaotic personal relationships)
• Somatization (resulting in many visits to medical practitioners)

Some of the musculoskeletal and lifestyle manifestations of experiencing trauma and even just stress include:

• Musculoskeletal tension or “trauma posturing” (aka constant guarding)
• Upregulated sympathetic nervous system response (aka fight or flight)
• Increased stress hormones - adrenaline, noradrenaline, cortisol
• Low back pain
• Headaches
• Sleep disturbances due to clenching, grinding, or nightmares
• Indigestion, ulcers, IBS, bloating, impaired or slowed gastrointestinal motility
• Poor circulation due to poor breathing patterns
• Increased heart rate, blood pressure
• Decreased fertility in women and men
• Worsening or influence on PMS and perimenopause/menopause
• Sexual dysfunction including decreased sexual desire, and/or erectile dysfunction)
• Increased risk of hypertension and heart attack
• Chronic activation of the HPA Axis
• Upregulated glucocorticoids, resulting in decreased immune function and increased systemic inflammation
• Increased risk for chronic fatigue syndrome, metabolic disorders including diabetes and obesity, and depression
• Increased risk for reflux and increased swallowing issues due to laryngeal tension
• Muscle tension dysphonia
• Chronic hoarseness, laryngitis, or psychogenic dysphonia
• Poor cognitive function and executive functioning

With regard to pelvic health, Yehuda et al posit that “because some symptoms of PTSD, such as nightmares, intrusive memories, and insomnia, are so distressing and result in such great restrictions in overall quality of life, sexual dysfunction is often not presented as a top priority by treatment-seeking patients.” The researchers also cite multiple studies which no longer support that sexual dysfunction only arises from sexual trauma. They write, “studies of nonsexual trauma including combat, accidents, and criminal victimization have now also established an association with sexual dysfunction in men and women including sexual desire, arousal, orgasm, activity, and satisfaction.” For example, Cosgrove et al found that male combat-exposed veterans (n = 90) rates of erectile dysfunction were 85% in veterans with PTSD compared with 22% in veterans without PTSD.

Trauma Can Literally Steal Your Voice
Further, trauma, no matter what type, intimately impacts the voice. The condition of losing your voice after trauma is known as psychogenic dysphonia or aphonia. It is characterized by the loss of volitional control over phonation after psychological events such as anxiety, depression, conversion reaction, or personality disorders, cites Baker (2003). It can also develop after viruses, with COVID-19 bringing not just respiratory consequences but a unique multi-system impact with negative consequences for the pelvic floor, such as occurs after prolonged coughing, hospitalization, and/or intubation.

Any emotionally or psychologically taxing event that occurs in proximity to loss of vocal control must be investigated, in order to understand the qualitative variables that may be present in the voice dysfunction. It doesn’t even take trauma to steal your voice, since stress is cited as a top driver for muscle tension dysphonia.

For example, I have had multiple clinical cases where women struggle with their voice decades after experiencing sexual assault in college or in an intimate relationship, but chose to “keep it a secret” and not report it. I’ve also seen patients with post-COVID or long COVID who report severe struggles with return to exercise or full activities of daily living due to concomitant respiratory and pelvic floor difficulties. Further, I have treated patients who presented after accidental damage to the recurrent laryngeal nerve during surgery and are struggling to recover both their voice and pelvic floor function. Finally, I have countless patients who have been medically gaslit and told their voice and pelvic floor pain are unrelated.

Regardless of the reason, we have an obligation as pelvic health clinicians to provide the best evidence-informed care possible. The Voice to Pelvic Floor (V2PF) method is one such way to provide trauma-informed and psych-informed pelvic healthcare. The V2PF approach is a systems-based way to evaluate the patient looking at the connection between three diaphragms:

• The orofacial/cervico-laryngeal diaphragm
• The respiratory diaphragm
• The pelvic diaphragm

The purpose of a V2PF approach is to provide a deeper understanding of polyvagal theory, anatomy and physiology, neuropsychology, trauma-informed principles, as well as sociocultural issues that impact our world, in order to allow us to function as primary care providers in pelvic health across the lifespan.

Want more information? Learn how to assess and plan interventions using a voice-to-pelvic floor trauma-informed approach at Dr. Garner’s course – The Voice and the Pelvic Floor scheduled on September 7th, 2024.

Sources

• Kilpatrick D.G., Resnick H.S., Milanak M.E., Miller M.W., Keyes K.M., Friedman M.J.National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress2013;26: 537- 547.
• Sexual Victimization of College Women | Office of Justice Programs [WWW Document], n.d. URL https://www.ojp.gov/ncjrs/virtual-library/abstracts/sexual-victimization-college-women (accessed 8.6.24).
• CDC, 2024. About Intimate Partner Violence [WWW Document]. Intimate Partner Violence Prevention. URL https://www.cdc.gov/intimate-partner-violence/about/index.html (accessed 8.6.24).
• Campus Sexual Assault (CSA) Study | Office of Justice Programs [WWW Document], n.d. URL https://www.ojp.gov/ncjrs/virtual-library/abstracts/campus-sexual-assault-csa-study (accessed 8.6.24).
• Rennison, C.M., 2002. Rape and Sexual Assault: Reporting to Police and Medical Attention, 1992-2000: (387542004-001). https://doi.org/10.1037/e387542004-001
• Kilpatrick, D.G., Ruggiero, K.J., Acierno, R., Saunders, B.E., Resnick, H.S., Best, C.L., 2003. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology 71, 692–700. https://doi.org/10.1037/0022-006X.71.4.692
• Flores, A.R., Meyer, I.H., Langton, L., Herman, J.L., 2021. Gender Identity Disparities in Criminal Victimization: National Crime Victimization Survey, 2017–2018. Am J Public Health 111, 726–729. https://doi.org/10.2105/AJPH.2020.306099
• First, M.B. (Ed.), 2022. Diagnostic and statistical manual of mental disorders: DSM-5-TR, Fifth edition, text revision. ed. American Psychiatric Association Publishing, Washington, DC.
• Flores, A.R., Stotzer, R.L., Meyer, I.H., Langton, L.L., 2022. Hate crimes against LGBT people: National Crime Victimization Survey, 2017-2019. PLoS One 17, e0279363. https://doi.org/10.1371/journal.pone.0279363
• Yehuda, R., Lehrner, A., Rosenbaum, T.Y., 2015. PTSD and Sexual Dysfunction in Men and Women. J Sex Med 12, 1107–1119. https://doi.org/10.1111/jsm.12856
• Cosgrove, D.J., Gordon, Z., Bernie, J.E., Hami, S., Montoya, D., Stein, M.B., Monga, M., 2002. Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology 60, 881–884. https://doi.org/10.1016/S0090-4295(02)01899-X
• Baker, J., 2003. Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports. J Voice 17, 308–318. https://doi.org/10.1067/s0892-1997(03)00015-8
• VA.gov | Veterans Affairs [WWW Document], n.d. URL https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp (accessed 8.6.24).
• Siracusa, C., Gray, A., 2020. Pelvic Floor Considerations in COVID-19. Journal of Women’s Health Physical Therapy 44, 144–151. https://doi.org/10.1097/JWH.0000000000000180

AUTHOR BIO:
Dr. Ginger Garner PT, DPT, ATC-Ret

Dr. Ginger Garner PT, DPT, ATC-Ret is a clinician, author, educator, and longtime advocate for improving access to physical therapy services, especially pelvic health. She is the founder and CEO of Living Well Institute, where she has been certifying therapists and doctors in Medical Therapeutic Yoga & Integrative Lifestyle Medicine since 2000. She also owns and practices at Garner Pelvic Health, in Greensboro NC, where she offers telehealth and in-person wellness and therapy services. Ginger is the author of multiple textbooks and book chapters, published in multiple languages. She has also presented at over 20 conferences worldwide across 6 continents across a range of topics impacting the pelvic girdle, health promotion, and integrative practices.

Ginger is an active member of APTA, serving as the Legislative Chair for APTA North Carolina, as a Congressional Key Contact for APTA Private Practice, and in the Academy of Pelvic Health. Ginger lives in Greensboro, NC with her partner, 3 sons, and their rescue pup, Scout Finch. Visit Ginger at the websites above and on Instagram and YouTube.