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THE SURPRISING IMPACT OF A PHYSICAL THERAPIST ON GENDER-AFFIRMING SURGERY
Pre-and post-operative physical therapy treatment can improve gender-affirming surgical outcomes, giving transgender individuals a chance to get back to the activities they love.
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Like many parents, Rebecca Niederlander wants the best for her teen — and when he came out as transgender in 2020, that included the quality of his gender-affirming care.
Niederlander was concerned how her son would heal following chest masculinization surgery.
“Everyone gets so focused on the necessary surgery they don’t consider after-care,” Niederlander says. “I was afraid he would lose strength and mobility because he and I share a hypermobility condition. I wasn’t going to let that happen to my kid.”
Niederlander reached out to Kelsie Kaiser, who had been treating Niederlander for conditions related to her own hypermobility and had previously treated her son for the same issues.
“Kelsie is a brilliant, thoughtful provider,” Niederlander says. “I knew I could trust her with my questions, and she would spend real time thinking about solutions.”
Kaiser immediately started developing pre- and post-op strategies to improve the surgical outcomes.
“I went through this journey with them,” says Kaiser, assistant professor of clinical physical therapy. “I experienced how it impacted their whole family.”
In the process, Kaiser found a passion in offering transition-related healthcare services for transgender, non-binary and gender-diverse patients. “It blends my love of orthopedic and pelvic health,” she says. “I really enjoyed tapping into that.”
At USC, Kaiser’s experience with complex cases and her specialization in persistent pelvic pain set the foundation for treating patients undergoing gender-affirming surgery.
“It’s the same muscles. We just have to think of it in a different way when it comes to tissue-healing timelines and respect the extent of the surgery,” she says. “I also communicate with surgeons about questions I have to improve my knowledge gap. I think that’s how you grow and become more specialized in an area.”
A Need for PT
Seeing how well her son recovered thanks to physical therapy, Niederlander, a board member of Transforming Family — an organization supporting families with transgender, nonbinary and gender expansive youth — started recommending Kaiser to patients seeking this type of care.
Niederlander then connected Kaiser to Jessica Lee, a physician with the gender affirmation surgery program at Children’s Hospital Los Angeles, where her son had surgery.
Over the past year, Kaiser has treated nearly 15 patients undergoing gender-affirming care, typically between the ages of 17 to 24.
“The surgeons are excellent,” Niederlander says. “But they aren’t taught the intricacies of after-care in the way a pelvic floor physical therapist is.”
Tasha, whose daughter, D, underwent gender-affirming surgery at the age of 18 in November 2022, agrees. Initially, D, now 19, didn’t realize the extent of gender-affirming surgery — physical therapy offered a lifeline.
“I felt so much more emotional clarity going to physical therapy,” D says. “Having solutions and answers for issues my doctors couldn’t explain made a tremendous difference to my recovery — the guided help changed everything.”
“It was treated more like a shoulder surgery,” Tasha says. “But there’s a hurricane of emotion tied to that area — it’s like opening Pandora’s box.”
To address the physical and emotional component of healing, USC is developing a group of providers — including physical therapists, occupational therapists, surgeons and mental health experts — to offer more comprehensive gender-affirming care.
“It’s all these different disciplines coming together to make a more inclusive environment,” Kaiser says. “Our goal is to create a gold standard of care.”
Thanks, in part, to providers at USC, Tasha has seen a much more comprehensive approach to gender-affirming care at Children’s Hospital Los Angeles. “There’s more sharing of information,” she says. “They’re starting to get a system in place where it’s more of a team.”
Pre- and Post-op Care
For some, gender-affirming surgery is a vital step in the transitioning process, which can include chest masculinization (commonly called “top surgery”).
PT treatments to aid recovery, which typically takes between two to three months, includes scar management, monitoring healing and improving range of motion and extensibility.
With Niederlander’s son, Kaiser provided interventions to ensure he could regain his arm strength, without feeling restrictions from his chest, and incorporated additional strength training to boost his body confidence.
In addition to interventions to improve skills and help healing, Kaiser was mindful when examining surgical scars. “My teen was thrilled with his surgical outcomes, but his mind was still acclimating to that area being different,” Niederlander says. “Kelsie always asked for consent; she was trauma-informed about the way she approached his body.”
Genital reconstructive procedures, also known as “bottom surgery,” are more complex procedures with longer recovery times.
Depending on the extent of the surgery, recovery can take between one to three years, making physical therapy a valuable piece of the healing process.
“There’s a lot we can do preoperatively and postoperatively for bottom surgery. Doing manual work with muscle relaxation or with tissue extensibility is key for those individuals,” Kaiser says. “I also want patients to be able to do self-touch and be comfortable with their muscles and that area.”
Physical therapy related to vaginoplasty (the construction of a new vagina, clitoris and vulva) involves treatments to improve capabilities of the pelvic floor muscles and dilator training. If a person has vulvoplasty (construction of a new vulva without the vaginal canal), dilation isn’t required, but physical therapy can still be a beneficial resource for pre- and post-care in training muscles.
“Each journey is different for each patient,” Kaiser says. “Some may decide they would like to only have outer genital, gender-affirming surgery (vulvoplasty), without creation of a vaginal canal (vaginoplasty). In both instances, pelvic health physical therapy can be beneficial to a patient pre- and post- surgically.”
Following gender-affirming surgery, D underwent physical therapy for 14 weeks, mainly focusing on dilator training. “After surgery, we were struggling with that, and the surgeons aren’t experts in this process,” Tasha says. “Having a physical therapist watch you dilate and provide feedback, was absolutely invaluable.”
“D had so many complications and regressed so far,” Tasha says. “There were two weeks of sheer panic when she could not dilate at all. The risk is the canal permanently closing and losing everything she had worked for.”
Marisa Hentis, assistant professor of clinical physical therapy, who, like Kaiser, specializes in pelvic health and gender-affirming care, was with D “every step of the way,” Tasha says. “Dr. Marisa was later able to confirm that it was the muscle causing the problem. Without her, we would have just been guessing.”
Like D, a common goal for patients is independence and confidence in self-management of care. “Dilator training is going to be a lifelong tool to maintain the extensibility of the neovagina and canal,” Kaiser says.
Another goal for patients is to return to any activities they enjoy. “If a patient was a runner before, and they want to return to running, we’re going to do that,” Kaiser adds.
Actual Lives Are at Stake
Beyond physical therapy, Kaiser creates an open space to allow patients to express their feelings about their transition and their bodies.
“As much as I can, I try to incorporate a mental health component to care,” she says. “Being able to voice pain and perceptions, I’ve found to be really beneficial for patients.”
For D, this is a critical part of gender-affirming care. “It’s really important to understand and expect the trauma or the negative energy, especially in a vulnerable area,” she says.
The time after surgery is an opportunity to provide a safe space for patients to express the positive impact of the changes in their bodies. “Often times, patients are processing how to feel comfortable, experiencing joy and feeling even more authentically them,” she says.
When treating the pelvic region of any patient for any condition, sensitivity is paramount to Kaiser’s practice. “Respecting a patient’s body and experiences, as well as incorporating a patient’s consent throughout the process is vital,” she explains. “Often times, in this very personal area, there’s a history of trauma — whether it be mental, physical or a combination.
In these instances, Kaiser says physical therapists should incorporate a trauma-informed care approach that clearly outlines the plan of care and treatment.
“However, I believe the most important aspect of this care is sympathy, which is shown through regularly check-ins with the patient on their comfort level, consent throughout each stage of the process and session, and monitoring the overall well-being of the patient,” she says.
Access to the type of gender-affirming care providers that Kaiser, Lee and others provide has become increasingly critical, which is why Niederlander continues to advocate for the trans community.
“Actual lives are at stake,” she says. “I know two teens who have committed suicide. But I know of hundreds of teens who’ve experienced joy in their authenticity. Joy is what I focus on, and joy is what we all deserve as human beings. I have the privilege to support that.”
Kaiser echoes those sentiments. “Through Rebecca, I know people who have been turned away from the medical system because of how they identify,” she says. “These individuals are human, and what they’ve been through only affirms who they are — they shouldn’t be shamed by medical providers. They need a medical team who understands and provides the care they need and deserve.”
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