Treating Trauma & The Voice in Pelvic Physical Therapy

Caring for individuals who have experienced trauma demands a specialized approach that transcends traditional pelvic health assessments and interventions. Treating trauma and the voice in pelvic physical therapy, though it may sound bold, should be integral and not separate topics. With approximately one-third of women encountering intimate partner violence and rape reporting rates to formal agencies ranging from a mere 5% to 33%, gender-based violence remains significantly underreported. This means that at a minimum 1/3 of the patients you see that are women, need trauma-informed care and a screening of their voice, not just their pelvic floor.

The World Health Organization highlights that violence and sexual violence against women constitute a major global public health issue. Their data estimates that around 30% of women aged 15-49 worldwide have endured physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. Intimate partner violence accounts for the majority of these cases. For men, the reported risk of experiencing intimate partner violence is 1 in 7, while for women, it is 1 in 5, according to CDC statistics.

Trauma, however, is not limited to intimate partner violence. The likelihood of any individual experiencing trauma, including Adverse Childhood Experiences (ACEs), exceeds 70%. The first comprehensive study on trauma and PTSD in the United States, conducted in 1990, revealed that 60.7% of men and 51.2% of women reported at least one exposure to trauma. Lifetime PTSD prevalence was estimated at 5.7% for men and 12.8% for women. Alarmingly, the LGBTQIA community faces even higher risks; transgender individuals are victimized over four times more often than cisgender individuals. Additionally, a 2022 survey found that LGBT individuals experienced 6.6 violent hate crime victimizations per 1,000 people compared to 0.6 per 1,000 for non-LGBT individuals.

The repercussions of trauma are profound, particularly when it leads to PTSD or complex PTSD (cPTSD). A traumatic event, as defined by the DSM-5, involves direct or indirect exposure to actual or threatened death, serious injury, or sexual violence. PTSD is characterized by four symptom clusters:

1. Intrusive Symptoms: Recurrent, unwanted memories, nightmares, flashbacks, and intense distress or physiological reactions to trauma reminders.
2. Avoidance Symptoms: Deliberate evasion of trauma-related thoughts, feelings, or reminders.
3. Persistent Negative Beliefs: Feelings of guilt, shame, or anger, diminished interest in significant activities, detachment from others, and an inability to experience positive emotions.
4. Alterations in Arousal and Reactivity: Irritability, aggression, hypervigilance, reckless behavior, exaggerated startle response, and difficulties with concentration or sleep.

Complex PTSD may also manifest through behavioral, emotional, cognitive, and interpersonal challenges, as well as somatization—leading to frequent medical consultations. Musculoskeletal and lifestyle consequences of trauma or chronic stress include tension, an upregulated sympathetic nervous system, headaches, sleep disturbances, gastrointestinal issues, and cardiovascular risks. Trauma can also negatively affect fertility, sexual function, and immune response, while increasing systemic inflammation.

Trauma Can Steal Your Voice

Notably, trauma—regardless of its type—can profoundly affect the voice. Psychogenic dysphonia or aphonia, characterized by the loss of volitional control over phonation, can emerge following psychological stressors, including anxiety and depression. The COVID-19 pandemic has further underscored the multifaceted relationship between respiratory health, vocal function, and the pelvic floor. Conditions such as muscle tension dysphonia and chronic hoarseness can stem from trauma or prolonged stress, underscoring the importance of a holistic approach to care.

In my clinical practice, I have encountered numerous patients whose voice and pelvic floor issues trace back to unaddressed trauma. These include survivors of sexual assault, individuals recovering from post-COVID complications, and those grappling with medical mismanagement. Many have been told—erroneously—that their voice and pelvic floor concerns are unrelated.

Some of the musculoskeletal and lifestyle biomarkers that can be impacted include:

·  Chronic activation of the HPA Axis

·  Chronic hoarseness, laryngitis, or psychogenic dysphonia

·  Decreased fertility in women and men

·  Headaches

·  Increased heart rate, blood pressure

·  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

·  Increased risk of hypertension and heart attack

·  Increased stress hormones – adrenaline, noradrenaline, cortisol

·  Indigestion, ulcers, IBS, bloating, impaired or slowed gastrointestinal motility

·  Low back pain

·  Muscle tension dysphonia

·  Musculoskeletal tension or “trauma posturing” (aka constant guarding)

·  Poor circulation due to poor breathing patterns

·  Poor cognitive function and executive functioning

·  Sexual dysfunction including decreased sexual desire, and/or erectile dysfunction

·  Sleep disturbances due to clenching, grinding, or nightmares

·  Upregulated glucocorticoids, resulting in decreased immune function and increased systemic inflammation

·  Upregulated sympathetic nervous system response (aka fight or flight)

·  Worsening or influence on PMS and perimenopause/menopause

To address these complex interconnections, I developed the Voice to Pelvic Floor (V2PF) method. This approach integrates the interplay of three diaphragms—the orofacial/cervico-laryngeal, respiratory, and pelvic—within the context of trauma-informed care. The V2PF method emphasizes polyvagal theory, anatomy and physiology, neuropsychology, and sociocultural considerations, equipping clinicians to deliver comprehensive care across the lifespan.

Trauma-informed pelvic healthcare is not just about addressing physical symptoms but also recognizing and validating the multifaceted impacts of trauma. By employing evidence-informed strategies like the V2PF method, we can empower patients on their journey to recovery, offering holistic, compassionate care that acknowledges the profound connection between the voice, pelvic floor, and trauma.

For a deeper dive into the V2PF approach, join me in 1 of 3 new course formats:

• For On-Demand Learning and Professional CEU’s – The Voice & Pelvic Floor at Herman and Wallace Pelvic Rehab Institute
• For Hybrid Learning (On demand and live) and Professional CEU’s – The Voice to Pelvic Floor Connection – Pelvic Global
• For Non-Medical Professionals (no CEU’s) that includes a Yoga-Based Practice – Beyond Trauma-Informed Yoga for Women’s Health

Together, we can advance trauma-informed practices and redefine pelvic healthcare.

About the Author

Dr. Ginger Garner is a longtime vocalist, former jazz singer of 20 years, and clinician dedicated to providing voice to pelvic floor care in women’s and pelvic health. Learn more about Dr. Ginger

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