For LGBTQ patients, the Middlesex Health physical therapy department can help with the usual issues, and some not-so-usual ones
By Carol Latter / Photography by CT HEADSHOTS
Patients come to see Lisa Gramlich, lead of the pelvic health program at Middlesex Health, for help with a broad range of medical complaints – from chronic pain and other orthopedic issues related to the hips, back and pubic bone … to constipation, incontinence and intimacy problems like erectile dysfunction and pain during intercourse.
Gramlich and her team members – fellow physical therapists (PTs) Marilyn Gross and Sarah Deacon – also treat patients with pregnancy or postpartum issues, or problems related to surgical procedures, such as hysterectomies and prostatectomies.
“Our role is to treat any patient, from the pediatric population all the way through adulthood, with any issue involving the abdominal or pelvic area,” says Gramlich. “I say to my patients, ‘Anything from the belly button to your thighs, we’ll address that.’ ”
For members of the LGBTQ+ community, the pelvic health team offers assistance with all of these issues, and more.
“Everyone needs a pelvic health PT,” says Gramlich. “The LGBTQ+ community has the same issues as the general population, so they can have constipation, pain with intimacy, they’re leaking, they have endometriosis. Really, the diagnoses are largely same in terms of the problems we treat, whether it’s surgical or body system wise or pain or dysfunction wise. The difference is that many people in the LGBTQ+ community don’t seek out care because they don’t feel like they can find a practitioner who has a good comfort level treating them.”
Gramlich, Gross and Deacon are not only sensitive to the particular issues affecting the LGBTQ+ patient population – including, many times, a history of sexual or other types of abuse – but are also trained in transgender care. In fact, Gramlich is a member of Middlesex Health’s transgender committee and recently became the co-chair of its LGBTQ+ employee and ally resource group. As an openly gay woman, she is a fierce defender of, and advocate for, the LBGTQ+ community.
Gramlich and her team members often help transgender patients opting for gender-confirming surgeries, both prior to and after procedures like mastectomy, vaginoplasty (surgical creation of a vagina) and phalloplasty (surgical creation of a penis). They counsel patients about what happens during surgery, what anatomical parts are removed or modified, and what is different afterward, then provide intervention to assist with a full recovery.
For instance, patients who undergo “bottom surgery” will find that their glans or clitoral tissue, involved in orgasm, is now in a different place than for a cis male or female because of the way in which the genitals are reconstructed. In patients who undergo a phalloplasty, the clitoral tissue is at the base of the penis. In a vaginoplasty, the glans becomes the clitoris. Helping patients relearn what gives them pleasure, or how to interact with their partners, is important to a successful transition. Even for patients who don’t choose bottom surgery, sexual counseling can be extremely helpful.
“We’re not sex therapists, but because we understand the anatomy, we do a lot of work around intimacy issues,” says Gramlich. “Obviously, the way in which a man and woman have intercourse is different than the way the LGBTQ+ community may experience intimacy – and especially after gender-confirming surgeries, it’s completely different. So that is our job, to help you [understand and become comfortable with it].”
She says she is very passionate about sexual education and helping patients make their sex lives what they want them to be. “When I talk to my LGBTQ+ patients, I don’t judge any form of intimacy, as long as it’s not abusive. I’m there to support people.”
Finding Her Path
For Gramlich, now in her sixth year at Middlesex Health, the road to her current position as a provider with expertise in and empathy for the LGBTQ+ population is deeply personal.
“I guess I would say my life has sort of been a journey. I started out as a young PT working in a trauma hospital, doing acute care. From there, I started to specialize and work in the NICU with premature infants. I did some outpatient pediatrics and came back to acute care. And then my path called me to step out of my profession for a bit of time. I homeschooled two of my three children, which was the most fabulous, phenomenal experience,” she recalls.
After her divorce, as a single mom, she re-entered the workforce. “I had a daughter who was diagnosed with ADHD and medication wasn’t working so I needed an alternative. My path led me into integrative manual therapy. I learned about functional medicine and holistic healing, and she completely transformed within the span of a year.”
Integrative manual therapy, or IMT, is a gentle, hands-on approach to health that looks for the underlying causes of a person’s pain or dysfunction from a spiritual, emotional, and physical standpoint, and also includes nutritional coaching to promote wellness.
After completing three years of training in the field, Gramlich worked privately and in nursing homes before switching to Middlesex Health, where she could treat patients without the overhead costs of having a private practice.
In a serendipity moment, she bumped into physical therapist Carolyn Daniels, who had started the pelvic PT program at Middlesex Health “as a one-person show. She learned that I had these integrative manual therapy skills and she said, ‘Hmm, why don’t you come observe me for a day?’ ”
A day turned into a week, a week turned into a month, and soon, Gramlich was assigned to the a Middlesex office in Madison, doing outpatient pelvic health. A year later, she was offered the role of lead PT for the Middlesex program in Middletown, where she now not only treats patients but spreads the word in the community and throughout the health system about the critical importance of comprehensive pelvic physical therapy for both cisgender and LGBTQ+ patients.
“My role is really to progress our pelvic health program, make sure we’re really up to date with treatment techniques and education, and bring our pelvic health PTs to the next level. I feel like my path has taken me here because it’s where I need to be.”
Her personal life was also transformed. “I was married to a man for 17 years. I know what it’s like to be a cisgender female, married to a man. And I know what it’s like now, to have a female partner,” so the experiences of many of her patients are very relatable for her. Having seen first-hand the inequalities and discrimination experienced by the LGBTQ+ community, she does everything possible to assist her patients but also empowers them “to take ownership for their own well-being and healing.”
She and Gross are both certified in integrated manual therapy (IMT), which Gramlich says “has given us a better grasp at looking at every person who comes into our treatment room from a spiritual, emotional, and physical aspect.”
Deacon rounds out the pelvic health team trained in transgender care. Her vibrant and caring personality helps patients throughout their treatment, and she, like her colleagues, is a champion for the LGBTQ+ community.
Gramlich feels the results achieved by Middlesex’s comprehensive approach to physical therapy are nothing short of amazing. “I’ve had many patients who have been sexually assaulted and molested, throughout their lifetime, and come in with pelvic pain, difficulty with intimacy, constipation and urinary incontinence. After seven to eight visits, they’re better.”
She adds, “Their constipation resolves, their urinary incontinence resolves, and they’re actually able to have pain-free intimacy, so it’s huge. Now, there are patients who then have to continue on, obviously, to process some of the emotional stuff due to their abuse. But I can think of several patients who were cisgender and LGBTQ+ where this has happened, and they have a completely new outlook on life.”
She says Middlesex Health offers a comprehensive, wrap-around approach to physical therapy, “which is why I feel like our program is one of the best in the state. We all have had patients who have come in from other therapists and have been treated with just biofeedback, or exercise.” But she says understanding how the external and internal pelvic floor works, and taking the time to evaluate it, is key.
Gramlich says patients often end up at Middlesex six months to a year after seeking treatment elsewhere because their problems were not resolved.
“If you have a patient with really high pelvic floor tone but you just give them strengthening exercises, they may come back a week later with more pain than they had when they started. Well, it’s because they needed the internal pelvic floor evaluation and a program that includes biofeedback and meditation along with exercise and manual therapy,” she explains.
“My patients may come in, saying, ‘Well, I’m just here for constipation,’ but they’re also having pain with intimacy and they’re leaking. And I say, ‘My job is to treat all of that, because I’m not going to get you better completely or holistically if I don’t address the other areas.’”
As a pelvic health therapist, she may encounter an 18-year-old trans youth who is going to become sexually active, or who is sexually active but is having pain or difficulty with intimacy. “If it’s a physiological issue related to the pelvic floor, we could definitely treat that.”
Patients are typically offered an external and internal physical examination that may provide useful information about pain weakness and whether the patient has scar tissue from a previous surgery, for example. The PTs also do biofeedback assessments to assess the tone of the pelvic floor and an orthopedic assessment, looking at a patient’s hips and back, and how they walk.
“We also teach patients the basics of meditation, because if your pelvic floor is tense, we need to teach you how to relax it.” And, she notes, she and her team members practice what they preach – Gramlich meditates using transcendental meditation twice a day for 20 minutes. “I have to make the time to do it, but it really has changed my life.”
Basic diet modifications are also part of the therapy. “Again, we’re not nutritionists, but we talk about bowel and bladder irritants, and adequate hydration. We see patients coming in with IBS and Crohn’s and we start to try to help them identify, with diet logs and food logs, any irritation that could be happening with their daily diet. We also offer home exercises and advise them on position modification for work activities, sex, and labor and delivery. So it’s a really encompassing program. With some patients, we only do parts of the program. We never force anything on anyone. But with most patients, they develop a comfort level with us and I say to my patients, ‘My room is a safe room. No question is stupid. I want you to ask it. And if I don’t know the answer, I will find the answer.’ ”
Full Speed Ahead
Middlesex Health has received a lot of positive feedback for its work with the LGBTQ+ community, as has its pelvic health team. “Are we perfect? No. Are we really trying to make sure that every patient who comes through the door has a safe experience and that staff is compassionate and caring? Yes.”
While they may not have had all of the same experiences as their patients, “we all have experienced loss. We all have tragedy. We all have pain. We all have grief,” says Gramlich. “But there’s also hope. I wear my necklace every day and it says ‘hope.’ And I think our pelvic health team gives hope not only to the LGBTQ+ community, but to people suffering from any pelvic dysfunction at all.”
It’s clear that she finds her job extremely rewarding. “I’m obviously very grateful and thankful to have the job that I do. Is it emotionally exhausting? Some days, it’s like, ‘Wow, today was a really heavy day. Lots of people had a lot of stuff going on.’ But on that eighth session, when your patient walks out and they have a completely different look on life and all of their goals have been met, you feel like you’ve changed the world.”