Expert Q&A: Gender-Affirming Care with Brianna Durand, PT, DPT

We recently connected with the incredible Brianna Durand, PT, DPT, to talk about gender-affirming physical therapy. Dr. Durand first starting advocating for LGBTQ+ care in graduate school, when she co-founded the special interest group 'PT Proud' at the American Physical Therapy Association, with the goal to improve the education, equity, and inclusion of LGBTQ+ clinicians, students, and patients.

Now the owner of award-winning Empower Physiotherapy in Seattle, WA, Brianna provides pelvic floor and whole body care to members of the LGBTQ+ community. Just a few of her related specialities include PT for intersex individuals, people in hormonal and/or surgical transition, and trans and gender-nonconforming individuals who are preparing for or recovering from childbirth. Brianna is also competitive powerlifter and enjoys helping strength athletes get relief from bladder leaks and other common symptoms of pelvic floor dysfunction.

Whether you're a patient looking for gender-affirming care or a PT who is interested in additional training, watch our info-packed conversation below or scroll down for the full transcript.

What are some of the ways that you support LGBTQ+ patients in your practice?

There are a lot of ways that PT can be impactful within this community. For example, a lot of trans folks — and even gender non-conforming individuals — we'll avoid using public restrooms for fear of, at best, dirty looks and, at worst, physical violence. When someone doesn't go to the bathroom regularly, it can influence the tone of the pelvic floor. It can also contribute to things like infections, which can lead to pain and discomfort later.

Then we have some really interesting data showing the prevalence of pelvic pain in transmasculine individuals, especially transmasculine people who have penetrative vaginal sex because of how it atrophies the vaginal tissue, making it drier and easier to tear. Pelvic floor PT can help address this type of pain.

For transfeminine people or folks assigned male at birth who still have a penis and engage in things like tucking — which is to create a flat front surface — that can increase pelvic floor dysfunction that pelvic floor PT can treat. Tucking can increase the risk of urinary tract infections because of the position of the urethra close to the to the anus, but also just the amount of pulling and pressure on the fascia and muscles can be damaging.

And we have some interesting studies showing that folks who get vaginoplasty who have pelvic floor dysfunction before surgery still are likely to have it after surgery. Fortunately one of the ways that pelvic floor PTs are being most utilized to serve trans people is specifically in the role of pre and post-op vaginoplasty using dilators. This treatment is common for cisgender heterosexual women who are having pain with intercourse and can also be very relevant for folks who have a surgically created vagina and want to use that vagina for sex later on.

How can gender-affirming PT help support chest biding?

Chest binding is a practice that's often done by folks assigned female at birth who may be non-binary or more androgynous, agender, trans-masculine. They want to create a flatter surface of the chest, and so they will flatten the chest tissue in a variety of ways. A commercial binder is the healthiest way to do it, as opposed to using something like saran wrap, an ACE bandage, or duct tape, or doubling-up a tight sports bra.

(The same goes for tucking — instead of using tape, there's something called a gaff, which can make it easy for someone to go to the bathroom. Because once someone has tucked, if it's taped, they don't want to take it off.)

There are also better ways to position the chest tissue, generally to the side is better than just straight down. Either way binding, especially for folks who have larger tissue, it can restrict the movement of the rib cage and the diaphragm. And most pelvic floor PTs will talk to you about how important the diaphragm is for pelvic floor health because the diaphragm and the pelvic floor should move in synchronization with every breath.

If the diaphragm and the rib cage cannot move properly, we have changes in the pressure inside the abdomen, which can impair how the pelvic floor is able to move and contract. And folks don't even have to bind to experience this. Folks who have large chest like to really round their upper back, which compresses the rib cage and the diaphragm. It's really hard to just take a deep breath in this position. This also impacts the pulling of the tissue and the skin and the fascia and how it can influence their outcomes with top surgery down the line, should they choose to get it.

Why isn't gender-affirming care more widely available?

Queer and trans people just aren't covered in physical therapy school, period. When I was in grad school, I founded PT Proud, an organization within the American Physical Therapy Association because I was privileged enough to go to conferences and meet other students. And, in talking to them, I realized nobody had equal coverage of LGBTQ issues in school. Some people had a semester, some people had a guest lecture, but most programs, including my own, had zero mention of this community.

Then, when I was in school and we started learning about how hormones influence things like ACL tear risk, my mind started wondering, well, what about folks who take exogenous hormones like folks who are are trans? And none of my professors had answers for me. They were all really supportive in me looking for it on my own, but nobody seemed to know or was talking about it.

There really has only been this groundswell of research and discussion in the last decade or so. So in terms of how we can change this, I think that it needs to be discussed in graduate programs in school. And then there needs to be more con ed about it, so I create continuing education specifically on this topic.

I think a lot of providers would like to serve this community, they're just afraid to cause harm because they don't feel like they know enough. And even if they want to learn more, there's just not a lot of opportunities to learn.

How can someone find a pelvic floor PT like you, who specializes in gender-affirming care?

In terms of trying to find someone who's going to be able to serve you in an affirming way, the folks who have found me — almost all of them — have found me through other queer and trans people or through a network of providers. So if you are a queer trans person looking for an affirming pelvic floor therapist, folks find us on subreddits, on Facebook exchanges, on message boards. Once a PT is is known for providing affirming care to the community, word spreads. I would encourage folks to reach out to their local community and see if anyone has had pelvic floor care in the past.

I really wish there was a directory that we could give you. There is a directory of pelvic floor therapists, Pelvic Rehab, but you can't search by affirming care. If a PT doesn't explicitly say they serve the LGBTQ plus community, I'll look for "pelvic floor PT for all genders" in their bio.

Here in the Pacific Northwest and there's a really phenomenal virtual clinic called Queer Doc that has a directory of pelvic floor therapists for all the states that they serve, which it's a growing number. I think it's over 15 at this point. If you're on the coast, you're gonna probably have a little bit easier of time because there are more resources there. But a lot of PTs do virtual visits at this point. You can have a virtual check-in with an affirming provider while seeing a general PT in person. I've often coached someone through how to navigate their care remotely, and it works.

Getting care can be a big step. How do you encourage people to take it?

We know that there are a lot of microaggressions committed by medical providers towards queer and trans people. And we know that that creates a pattern of behavior, of avoiding care and avoiding preventative care. You are worth getting care.

It is going to be more difficult for you to find someone who is more affirming, but it is so worth it if you can find that provider. And you absolutely do not have to stick with a provider who is not affirming to you. It is not your responsibility to educate your provider. It is not your responsibility to tolerate misgendering or being called by your dead name.

You have absolutely every right to ask the provider if they've treated folks like you in the past. You have every right to get a second opinion. And also, if you have a negative experience — while it makes sense that you may want to postpone care, I highly encourage you to try to seek out folks who will provide the care that you deserve.