Pelvic Health Support for All Patients with Alex Papale PT, DPT

Alex Papale PT, DPT (they/them) is a pelvic health physical therapist, consultant, sex educator and international speaker based in Boston MA. They specialize in queer and trans health, and treating patients of all genders at Flourish Physical Therapy. 

Alex especially loves to help patients with pelvic pain, difficulties around sex, peripartum care, pelvic floor support with HRT, orthopedic support for pain related to chest binding or genital tucking, and healing from gender affirming surgeries. 

When they’re not in the treatment room, you can find them writing and teaching gender affirming, sex positive, kink-informed courses for current/future healthcare providers, or for anyone who wants to learn more about sexuality, their bodies, and pelvic health. 

Alex has also created the course “Physical Therapy Care of Trans/Gender Diverse Patients: Multi-Day Con-Ed for Pelvic Health Providers”. 

PT Website: https://flourishphysicaltherapy.com/ 

Website: https://alexpapale.com (Under Construction)

Substack: https://alexpapale.substack.com/ 

Instagram: https://www.instagram.com/alexpapalept/

Courses: https://www.academy.pelvicglobal.com/alex-papale-courses

Transcript

Alex Iantaffi: 0:35

Hello and welcome to another episode of gender stories. I know I always say I'm excited but I am I'm always so excited and so thrilled about my guests. I just have the best gift we're gonna say sorry other podcasts. So today I'm really excited and thrilled to welcome Alex Papale who is a physiotherapist, doctor and physiotherapy. I think it's DPT that's what it stands for Right? And is a pelvic health physical therapist, consultant, sex educator, and international speaker based in Boston, Massachusetts. They specialize in queer and trans health and treating patients of all genders at flourish physical therapy. Alex especially loves to help patients with pelvic pain, difficulties around sex, peripartum care, pelvic floor support with HRT, or to be the support for pain related to chest banding or genital tucking, and healing from gender affirming surgeries. When they're not in the treatment room, you can find them writing and teaching gender affirming sex positive, kinky informed courses for current and future health care providers, or for anyone wants to learn more about sexuality, their bodies and pelvic health. Alex has also created the course physical therapy care of trans and gender diverse patients multiday con ad for pelvic health providers. And I had the absolute pleasure of actually seeing Alex speak at the spring insect transcribing, I think we call that Virtual Training Institute. And you were fantastic. So I am so glad that you made time for this interview. Thank you so much for being here with us today.

Alex Papale: 2:14

Thank you so much for having me that that really means the world.

Alex Iantaffi: 2:18

It was so great. I feel like I learned so much. And I've been in the field like a hot minute, but I truly feel like I've learned quite a few things. So I'm so excited to get to share this with Gender Stories listeners. So let's start maybe from even describing what pelvic health is, a lot of people don't know about the field of pelvic health. And they don't know that there is a whole field of physiotherapy that is called pelvic physiotherapy. Like, I didn't know before I became a sex therapist. I don't know, 20 years ago, whenever it was, you know, the general public usually is not necessarily like aware of this field. So how would you describe the field?

Alex Papale: 2:58

How would I describe the field I think that it sounds like very like specific of like we're working primarily with your pelvis. And I like to start with first and foremost our pelvis, I would argue is one of the more central points of our body. So a lot of different things are interacting with our pelvises and our pelvic floors. So after for me I graduated PT school, I was kind of a generalist, or like an orthopedic physical therapist, and then I went on to take further continuing to specialize in pelvic health. And so all pelvic health providers can do that kind of basic, like the orthopedic. I say basic, lovingly, very important. Orthopedic, physical therapy. So more like elbows, shoulders, knees, stuff like that. And then I then also like, so pelvic PTs can do that. And then orthopedic PTs would like me to kind of do that continued continued out there. And so it's not far removed from the world of physical therapy. But pelvic health particularly is focusing on bowel function, bladder function, sexual function, and then anything related to pain. So that can include for instance, and like the bowel realm, if somebody has the well honestly like the TLDR is that like everyone should go to pelvic PT at some point in their lives? Absolutely bowel wise, like thinking like constipation or issues with like urgency, like zero to 100, or issues with incontinence that also goes for urinary function. If anybody has anything funky going on, if there's any pain when they're urinating, if there's like if somebody has interested in interstitial cystitis or painful bladder syndrome, that's something that I work with folks on a lot. Any realm of leakage. So even if you're like, Oh, well, it's like, not a huge deal, but I leak a little bit of urine every time I like cough, sneeze, laugh or lift something or anything in that realm. Like there's definitely stuff that we can do about it. In the realm of sexual function, so if anybody has pain or difficulty with anything penetrative and that can be anywhere. I think oftentimes it gets the rep of like just being for folks with vulvas. That's definitely not true. If folks have erectile issues, that's definitely something that pelvic PT can be useful for. If somebody has painful periods. That's something that pelvic PT can be useful for. If somebody has endometriosis, this is something that often gets recommended and is very supportive. If somebody has just like low back pain that is not getting better, and they've tried, you don't have to try everything else first. But oftentimes, I've seen folks who have tried a lot of other stuff first, and it turns out, it might be more of their pelvic floor muscles, impacting their low back. Same with their bellies as well. I'm oftentimes treating someone's like back shoulders, bellies like hips, knees, it's not all just pelvic floor focused, and are everybody has a pelvic floor also. And so it's a like a bowl of muscles that kind of sit at the bottom of our pelvis. And they're really responsible for support for anything kind of coming in and out of our bodies in that area, including what it says a big roll in like lymph drainage, things like that. It there's a lot going on pelvic floor wise. And so yeah, I really will die on the Hill of everyone should go to pelvic PT at some point in time, I do just think it's, it can be a total game changer.

Alex Iantaffi: 6:50

It really is a game changer. I have gone to pelvic pt. And I will likely go again, at some point, I do have interstitial societies. You know, and I think a lot of people I'm so glad that you mentioned like everybody has a pelvic floor. I think there is this misconception that often pelvic health is seen as part of women's health. And in fact, in some clinics in may even be under the Women's Health Clinic umbrella. And I know that's been really impactful on any kind of masculine folks transverses that I've tried to send to kind of a pelvic PT, because you know, if they're under women's health, I even had clients like being turned away because they look the wrong gender, whatever that means, right in air quotes. And so it can then that it's already so hard, I think, for people to go to pelvic PT, because it feels so vulnerable, right? And that can be a lot of anxiety. And then if there is this other barrier where people, you know, maybe somebody in the front office is like, Oh, you look like you're in the wrong place, right? Because there's a scene as part of women's health, it can even put people off even more. So I don't know, if you want to say anything about that experience of traditionally feels like it was under their realm. And now it's like, you know, most places are doing it separately from women's health, but not everywhere, in my experience, at least where I am.

Alex Papale: 8:11

Yep, I, I totally agree. I think that the field is coming along slowly. But surely, it's even better than when I first started practicing, which was in 2018. It's definitely come a bit. I mean, the American Physical Therapy Association, which is kind of like the big the big PT Association, is they had in the last several years, I forget which year, I want to say maybe post 2020, they had changed their section on women's health to be called the Academy of pelvic health instead. That was a big, it was a big move, which did not actually have like the full agreement of the section, which I thought was pretty. That makes a lot of sense. I think even though I think that public health and public health care is pretty radical, or it tends to be it's not, that's not always true. That's not everybody's thought. But I also just thought it was doing a disservice to women as well as like, that's more like women are more than just their vulva, and vaginas and pelvic floors. Like there's actually far more that goes into like, really, truly being like holistically supporting women. And that includes like all women, not just the cisgender women or women with all of us. And so I think, yeah, I'm so happy to see the shift. But I definitely see that it's, it has a long way to go. And I still do see that there are I'm always looking if I'm referring people in different states or things like that, as I'm looking up like other pelvic health providers, I'm like, What is your language around what you treat like who you see if you can always kind of pick it up pretty quickly. And that's definitely like a note does give me it gives me pause, but I do have hope that it's it's coming along.

Alex Iantaffi: 9:59

I agree. I think it is coming along. And I definitely have seen like my referral network get broader and broader. Right. And of course, then we have to deal with insurance, which is where sometimes then people run into issues because like, I know you've suggested this person, but my primary care provider, my insurance, say I can only see this person in my referral network and I'm like, Oh, you can try I have no idea or I do know that they're under the Women's Health umbrella. So be prepared, you know, for maybe a different experience when you arrive and check in right because we know that And we try to access health care. It's the whole experience is not just seeing the provider is also the front office staff and you know, the even just where the clinic is located in terms of is it under like a women's health or OBGYN umbrella or whatever it's going on in the hospital or the clinic that is hosted in so, so many things to consider? I, yes, I feel like that could be its own conversation about. Right like, and maybe we'll circle back to it. But I want to stay with why it's so important to take care of our pelvic health. I know as a trauma therapist, and a sex therapist and also Somatic Experiencing practitioner, I know there's a lot of connection, for example, so between pelvis and jaw, like right there often like, you know, people with TMJ, or if you have really tight kind of jars that can really be connected to your pelvis as well. And I know when I do kind of work on sexual trauma somatically, often like anything to do with the pelvic area can be super activated, even sitting on one of those big bouncy gym balls, and just like gently, like moving around Trey, that can be very activating for folks, which is part of the healing work that can be done. So you've done such an amazing job of saying why somebody might come in to see a pelvic physiotherapist, what the issues might be to begin with, but how can seeing a pelvic physiotherapist improve somebody's overall health? I think not just the issue that come into see you for.

Alex Papale: 12:11

Yes. So another misconception that comes up with pelvic health that I feel like is very tied to this is that we are only focusing on the pelvic floor during a pelvic health session. And I am spending a lot of time working with somebody on their breathing, for instance, there's a lot that we do that has actually like nothing to do like, proximity wise, I don't want to say that like that. Like that's not directly pelvic floor. And so I'm oftentimes working with like, yeah, how can we like change the way that your body is responding to your breath? Like, where can we get a little bit more space, where can we get a little bit less tension. And so that is also very closely tied to our nervous systems. And a big part of what I do is helping people, wherever they might be at in this journey, there's no cookie cutter, at least definitely not in my practice, but where they can be to try to tune into what their body is telling them at any point in time. One of the big things is like we're really like learning how to listen to our bodies. And so I think that that is a huge kind of way in which pelvic PT can really be a game changer for someone's experience of, just like of life, I think that oftentimes people are under the impression that if something is going awry, pelvic floor wise that it's because of a singular event that happened, or like they gave birth, or there was an accident, or there was trauma or something happened, the most responsive part of our body to stress is our pelvic floors. And we have a pretty limited amount of brain space dedicated to our pelvic floors. If you think about, like doing a pelvic floor contraction, or like a kegel, you're trying to like pull your pelvic floor muscles up in in, you're doing kind of all of those muscles are moving at the same time. Even though you have many individual muscles that make up your pelvic floor, you can't isolate just one of them or just one side, it all kind of goes together. And when people hear that, like decreased kind of brain space for pelvis is that doesn't mean that there's less nerve endings, we know that there's a lot of nerve endings in our pelvic floors. But it's different than the space that is allotted for our faces or our hands where we have like all these fine motor movements, or like micro expressions, like we can't do that with our pelvic floors. So thinking about that very sensitive part of our body to stress that we also it's harder to feel and it's harder to engage with, when we're experiencing a lot of stress that kind of tends to build in our pelvic floors. And so then sometimes there is it does feel like it's like this one event that happens and all of a sudden, everything is gone, gone awry. But it tends to be like a bit of a build up over time that can be really challenging to tune into. And so we're working on how to like feel the stress in our bodies, like what kinds of signs we are getting from our bodies or our nervous systems that things are getting a little bit funky like what those sensations can be like. And another big part about pelvic PT is that we don't actually need to be working directly on the pelvic floor for folks to see a difference and for folks to like see improvements. And so we're oftentimes working like like what you're saying, I'm always asking people, if they have any, like anything interesting going on jaw wise any like headaches, things like that if they're like lower legs or bothering them any like their feet are bothering them, that can be also very related, pelvic floor rise, everything's connected. Yeah. And so I'm working kind of like with more of the whole body situation. So it definitely helps like all of the above, and changing those, like breathing mechanics, like makes a big difference. If someone wants to start a new like, movement routine, like figuring out like, when to breathe, when to like, support yourself with your breath, versus getting a little bit more movement with your breath. Like, all those things make a big difference. Absolutely,

Alex Iantaffi: 16:25

I remember, I remember going to a pelvic ed for the first time and going, coming home and going, I don't know how to breathe out. I didn't manage to go for like 40 plus years of life, and I didn't know how to breathe, right. And they're like, like, let me tell you, this is like blowing my mind, you know, and I was like, I'm just, I'm not breathing, right. And then this is how, you know, it's impacting everything else. We are kind of just like this whole system, right? That it's all it's all connected. And I think that with Western medicine, we treat our bodies as if we could dissect them in some way. times, we even treat our mental health that way, right? Like, you know, specialize on depression, or anxiety or trauma. And people specialize, like, I need to see like different Orthopedic Specialists for like, my spine, and my hips and my knees, but ever, it's, it's like my whole body, right? Having a connective tissue disorder, it's everywhere. And it's impacting every part. And so pelvic PT can make a huge difference. Absolutely. You know, and, and I think that touches on some, the anxiety, sometimes people have go into pelvic PTS, like, I'm not ready for somebody to like, touch me in my pelvic area, or, you know, that could be really triggering, if anybody has any sexual trauma or sexual abuse, even from childhood. And so how do you approach kind of pelvic PT from like a trauma informed in a trauma informed way? And also kind of maybe reassuring people that you know, it can you don't even have necessarily to like, drop your pants for your pelvic PT. person? Because I think people have a lot of anxiety around that. Does that make sense? Sorry, I'm just Yeah, right. Sometimes, but you know, what I'm, you know,

Alex Papale: 18:17

I know exactly what you're talking about. I know exactly what you're talking about. Yeah. So when I see somebody for the first time, when they're first coming in for our intake session, I will always ask them, like what they know about pelvic PT, like what they've heard of, by and large, even I work in private practice. And so it's takes like a little bit of extra work and thought, I think to come in, then if someone is going through insurance. And so even then, like, I still find that most of the patients who come in are like, I don't know, someone told me someone told me to come in, or I've tried everything else, or I don't know what else to do, or Tiktok told me to do this. And and I then will describe kind of like, what the options are for our sessions. And so the most important part to me is the patient's story. And it's what their experiences have been, what things feel like in their bodies. There's no right or wrong way to describe something, if I am often hearing like, this might sound really weird, but and then they say something that like totally makes perfect sense. I've actually heard several times like I think that it can feel really isolating to have any of the issues that I've described, they're things that no one ever wants to talk about. Like you never want to talk about having like, urinary incontinence when you laugh, or like pain with penetrative sex, like those are hard things to just like, bring up with even a partner or someone that you really know, well, versus like a medical provider, you don't know it's challenging. There's a lot of stigma attached to it. And so I like to kind of just right off right from the go. There's nothing that's required in this session that we can spend the whole time just talking and I can send you home with things to start with. We do not need to yeah, there's this is what a pelvic health assessment like a pelvic floor assessment looks like. It's different than a GYN assessment. And there's layers of like how kind of significant we want to be like going into that direction today. We can go externally over clothes, we can go all the way to doing like, an internal assessment as well. But none of it is required. And that also doesn't mean that we have to do it next time. It's really Whatever it's I tried to make it very clear with folks that it is really a choose your own adventure of here are our options. This is the layout. These are some things that we can look at, we can do the subjective intake today of just like hearing someone's story. And then maybe we do an orthopedic assessment, let's look at posture, let's look at, maybe you sit at a desk with that setup can edit some things there may be like, let's look at how you're bending down to pick something up and see if that if we can kind of make some edits, there's a lot of places we can start. And there's been I've had a lot of success with folks who have pretty significant pelvic floor issues that we've actually never worked directly pelvic floor wise, there's so much that you can do and it's so connected, it really kind of depends on Yeah, what someone's up where, where someone where someone's at, I think a good amount of people are in the boat of like, okay, great, that's so good to hear. Because I didn't actually feel like I was really up for that. But I was gonna, like push myself through that and like, Nope, we're not, we're not doing that this is not a no pain, no gain situation, nor will it ever be. So we're taking we're taking our time here.

Alex Iantaffi: 21:41

And then that is so important for listeners to hear, because I think so many people are so used to go into a medical provider and be like, I'll just do whatever you tell me right. And even when I prepare therapy clients to go see a pelvic PDSA, you know, if you especially if there is significant sexual trauma or trauma in that area, I'm like, you can say I do not want a physical visit the first time and if they insist, we'll find your different pelvic PT, and I will fight with your insurance if we need to. I will be like, I know that this is the only pelvic PT you cover. And this is what happened when my client went and this is why we're asking for you to cover like a different service right? For from the provider, because I think it's so important people are so used to, we're also used to writing our own nervous system and always a disabled person, there's plenty of time where I'm like, I'm just gonna override my own nervous system to survive the specialist visit or this exam, you know, and with things that, quite frankly, we don't need to put up with, we can have more boundaries with our providers and say, This is not what I'm ready for today. Yeah,

Alex Papale: 22:49

yeah. And I think about that a lot, especially with like the financial component, since so much in pelvic health is out of network, or like not taking insurance, that there can be like, there's a lot of pressure where someone's like, hang out of pocket, like a good amount of money to come to see me and that sometimes they're like, Well, I have to do all of the things. And like actually, like, I try to also tell them that like it is not, it's not great practice for your nervous system. And we're doing a lot of nervous system work here. And also, that if I'm trying to actually get an accurate assessment of someone's pelvic floor, if they're experiencing like a lot of stress and pain, I'm not going to get an accurate reading of what's going on. And so that also tends to help a little bit of like, okay, you're not just doing this like for you in your nervous system. It's also like not going to give me accurate information. And we can kind of work on the like nervous system component as we're as we're going. But But yeah, I find that I feel like it's really important to just like give, everyone gets the options, I show people, their anatomy of their pelvic floor with like a ton of different visuals, I have a little model, I have some like, printouts, I've got some pictures. And I'm going to show them like exactly what I'm going to do pelvic floor assessment wise, but then we're just so that they have a general sense. Like before I'm doing it, we kind of set the rules of like, I will only move after I tell you what I'm going to do and you tell me it's okay. This is like how this will start. This is like what you can kind of expect sensation wise, like I'm going to check in this amount, all that kind of stuff. Absolutely.

Alex Iantaffi: 24:25

I often think how simple it can be for a lot of providers to be more trauma informed, you know, a lot of conversation sometimes for providers, I'm like, Well, the main thing is just like just tell people why you're about to do before you do it, you know, after not like you know, not during, like say, this is what I'm gonna do next, you know, and just even one breath so that the person can be like, hang on a minute, or do you have any oil ask Do you have any questions? Like it doesn't have to be super complicated. And so let's, you know, let's circle back to what we're saying also about like gender and axis right? How we can make it you know, so one layer that can make it difficult for people to add pelvic PT to their health care. Kind of set is, you know, this fear that they're not ready to kind of have a physical exam or anything like that. And that's not necessary. You know, like you said, but another layer is that it has been so gendered for cis women historically. And so even the language sometimes, you know, or their assumptions, and I have to say that sometimes even trans friendly probably riders have made some missteps. You know, cis, I should say cisgender transparently providers not not trans folks themselves, if that makes sense. You know, in other providers who like in their eagerness for example of being trans affirming when I seen them like, like made assumptions about whether I have genital dysphoria or not or sad, like this must be really unpleasant or like, actually, you don't know what this experience is for me. I mean, yes, it is. And now it's even more unpleasant because you said that, you know, while trying to affirm me, right? And so it's so complicated, because I don't know, you know, about you, but for me, I know when I, I have to see a lot of health care providers because of aging with Ehlers Danlos Syndrome. And often I have to be like, Okay, I have to see the provider already. That's a lot. And then I have to think, oh, how are they going to interact with my gender? What language are they gonna use? That they're gonna and not just misgendered? Me, but like, what language are they gonna use for my body? What language are they gonna use in their notes? Right? What assumptions are they gonna make about my body? Whether they are trans affirming or not? Actually, because like I said, sometimes people can be overly eager to be trans affirming, and in their eagerness really missed the person in front of them. So yeah, does that make sense? Any reflections on that? Or like, Yes. What's your experience? With that?

Alex Papale: 26:59

Yes, that it makes a ton of sense. And it is something I think a lot about, in my experience, especially talking about the pelvic floor, I think that a lot of people, including sis people, including sis women, don't have a great sense of what words to use when. And so we're starting with a lot of education about like what body parts were talking about in the first place. And when you add the like, like a trans experience on top of that, I like to just offer it as like, okay, like, I think this would be really helpful to kind of just go through like the anatomy that you're describing. And I want to like, like, show you like a visual. And so I tried to have like unlabeled visuals, if I can. So it's kind of taking out that part where it's like this gendered language. And if I'm asking folks like, what they use, like what words they like to use to kind of describe their bodies, some a lot of times, people as like an I'm thinking like trans folks in this instance, when I'm talking to them about this, that they're like, Wow, I have not actually been asked that before by a provider, I'm not totally sure. And I can offer like, okay, we can use, like the medical terms that do tend to have like, the more gendered language, but I do like to just try to opt to use more descriptive gender neutral language, so more about what something looks like or its function. So for instance, the word vagina can be pretty loaded for folks. Yeah. And so if that feels like unless someone is explicitly like, totally fine, you can use medical language like it's all good, then I will opt for like, okay, and I'll tell them like what I'm referring to and looked at the model. And like, okay, front opening back opening. That's right, or, like, if somebody has, if I'm referring to someone's penis or someone's clitoris, erectile tissue, gender neutral, but we I know exactly what we're talking about here. Sometimes we can fall kind of into, I think, well, meaning providers can ask the like, Okay, well use language that you use, but a lot of times folks aren't using language that a provider would then know what they're talking about necessarily. Like,

Alex Iantaffi: 29:19

how many times do we talk about our job with anybody who's not like a sexual partner or lover? Right? Not that men? Right, you know, right. In my experience, I mean, I guess as a sex therapist, I do talk about it more than more often than most, but you know, just generally outside of work, and not a lot of conversations that we have about our genitals, right or, yeah, like the colloquial term I use, right, or junk just because, yeah, so like down to earth, but it's hard, right? And when providers have asked me that, I was like, Oh, no language I want to use in a medical visit, for example. Right?

Alex Papale: 29:59

Yeah. Right. Or sometimes Yeah, if someone was like, I would truly only refer to my genitals have my junk or my bits or whatever it was like, well, that's not telling me anything about what you're exactly referring to. Or for instance, if somebody has labia, then it's like, okay, we're going like outer folds, inner folds even then I'm using like outer and inner labia period because I think the labia majora and menorah like that, like it that can be tricky because a lot of people have like larger inner labia than I'd really be. Yeah, stuff like that. So I like to use the terms that are more descriptive and then Once somebody is more familiar with them, then we can kind of we can build off of that. But yeah, I think that's it's really important to just give someone the option of like, what they want to hear what how you're referring to their body. Absolutely.

Alex Iantaffi: 30:45

And I think that your solutions are so elegant, right, and rectal tissue front opening back opening that is so immediately understandable to me. And yeah, it doesn't have that loneliness, because I think also when we talk about our genitals is so loaded on a socio cultural level, I think that people have a lot of shame. I think the generals are often weaponized in a lot of different ways, whether it's weaponizing, size of genitals, whether it's weaponizing smell of genitals, and, like, right, and Pete, so people also just, like, even just somebody who doesn't have necessarily any sexual trauma. Often, I think there's just some feelings right there that we have, because there's so much shame, I guess, absolutely. That shame that's weaponized in like, different ways in the dominant culture. And so I don't know if you find that with clients, and especially with like, trans clients, like trans non binary, gender expansive clients, but really with everybody, how do you manage to support the client's through that kind of shame? Or that even misinformation that they might have about how their genitals or their pelvic area works?

Alex Papale: 31:57

That? That's a great, that's a great question. I also wanted to say, regarding the the language or having more gender neutral language, definitely want to shout out, Lucy Fielding. And yeah, and Heather Edwards, as well as another like really wonderful, like sex educator, pelvic PT, who like kind of helps, like hone in on those on that terminology a lot more. And so when folks like do bring up, like stuff that feels like a little bit more shame you like, for instance, one of the first things I thought of is just the amount of time and this honestly happens a lot more when I see, like, cisgender heterosexual women than queer and trans folks, but like, as an example, apologizing for not shaving ahead of time. Yeah, that makes me sad, ya know, and that's like, that's the big one. And I don't want to add to that, by being like, oh my god, like, all right, I try to just like answer in a more like, neutral. Like, that's, I hear you. And I also want to, like add in like, it's totally okay. Don't I don't want you to ever feel like you need to do any realm of preparation before our sessions like that. And also, like, hair is actually really useful here. And like, here's all the reasons why. Sometimes that can just like give a give a little nugget of education there to just like, normalize it a little more of like, everybody's got hair here. And like, this is why this can be useful. And also like, feel free to, I never want to also then like shame somebody for the fact that they shaved or anything like that. It's like you do what you want to do with your body. But I don't want you to ever do it for me on my behalf. Yeah, yeah. And like the shame components can be, yeah, can be challenging. And I like to also depending on where some where someone's gotta get a little curious of like, oh, like, where did you where'd you learn that? Or, like, where do you hear that from? Especially if it's sort of a like, oh, like, I'm sorry, if, like my pelvic area, like smells, or something like that. I didn't get to shower like right before sessions like, oh, well, like, yeah, like, are you? Are you concerned about that? Like, kind of asking, like, is this something like, kind of where this is coming from? Like, if you're worried about if you're like, oh, like I just am recovering from like, an infection like that, that makes a lot of sense. But are you generally like always worried about like, your, like, the smell of your of your of your junk of your bits, like, then that's something that we can also like, talk about and duel that maybe a little bit of, like, education or like reframe on depending on where someone's at with that, too. Sometimes it's not, that's not the vibe, and that's totally okay, too.

Alex Iantaffi: 34:37

Absolutely. And education feels like such a pivotal, important part of this work, right. And of course, you're also a sex educator, as well as being, you know, a PT and a pelvic PT especially, and, you know, you that you have a doctorate as a physiotherapist, right, you've done a lot of studying in this area. And so I got to ask the question, and then I lost it, because I was like, finding out about awesome you are, and we're all education. Yes, education is such a pivotal area, and it's obviously something you're really passionate about as well, because you do educate other providers. So, you know, what makes you passionate about educating other providers around working with transport specifically, when it comes to public health because like we said, pretty much a lot of people and in fact sometimes, and that's my experience in sex therapy to actually assist folks might have a higher level of shame because they haven't had to do The work that trans and queer folks have had to do around our bodies, including our genitals and how we feel about it and all that good stuff. And so, yes, does that make sense? Like, yeah,

Alex Papale: 35:46

yeah. Yeah, I just underline I really have had the experience of like the folks who have kind of the most like, stickiness around like changing what they have, like societal expectations of, especially when it comes to like how bodies like should, in quotes, like work during sex is tends to be the folks who have not had the experience of like having to really renegotiate societal expectations around like gender and sexuality to relieve Yeah, totally on that one. And regarding the education for providers on how to like, work with trans folks a little bit smoother, I would say that it definitely comes from like my personal experience with like, trying to find I also was in pelvic PT. So I totally, I totally get that. And like that was, I was really lucky in that I actually had, like, as an aside, I had a lot of pelvic floor issues growing up that I didn't even realize were pelvic floor issues until I was actually on a clinical rotation in school for pelvic health. And I was just kind of like, casually complaining to my clinical instructor about something that I was experiencing. And then she was like, Wait a second, and kind of asked a couple more questions. You actually use it and I was like, mind blown. I was like, What are you talking about? And then I was like, Oh, my God, if I am literally in PT school for pelvic health, and I didn't even realize I needed it. Like, who knows? Who needs it? You know, what I mean? Like, how does anybody if you don't know, and then in regards to, so as like a little aside, like that felt really kind of important. So I was trying to navigate like being trans and also trying to like enter as I was entering the world of pelvic health, so they always felt like very close together. And it was really hard to, like, had, I want to say this. There weren't very many people who were doing what I was doing at that point in time. And that was really, in the very recent past, like, 2018, it's really not that long ago.

Alex Iantaffi: 38:04

Oh, and even like, five, six years ago, it was like impossible to find somebody doing this work. Yeah,

Alex Papale: 38:11

And it was a very different different world. And I yeah. had gotten involved with that, like, the first or one of the first continuing ed courses for pelvic health providers on treating trans people that had come up because a trans patient who had had a vaginoplasty, at a Boston clinic, ended up accidentally going to see a pelvic PT, when she thought she was going to see a gynecologist. And the pelvic PT was like, Wait a second, like, I have never seen anybody who's had a vaginoplasty before, but it does sound like you should be here. And then that kind of got back to the surgeons, the surgeons were like, Oh, my God, wait, we need to know about this, too. And then there was a meeting between like the surgeons and the public health providers in the area who were trying to like figure out like, Okay, what do we need to be doing here, and it was felt very clear that there was also a lot of pelvic health providers who like really wanted to care for these people, but like, just kind of didn't know where to start or what to do. And so, that felt very, like, integral to like, the beginning of my career as well. So I was always kind of thinking about like, okay, like, how can we get more people to be doing this because I had a hard time finding other pelvic health providers, particularly who are trans and who were also like, then treating, like, in this realm, I definitely know other physical therapists who are trans who they didn't want to do trans health which is so fair, or they were just interested in other things. And yeah, I love that when you don't actually have to like when you can't separate your career and identity I think that's can be wonderful. And I love that I don't I don't do that and I love it all. But I always just like wanted there to be like a million of me or like, I should not be like one of the very few people doing what I do I want there to be like a million people doing what I do. I want to like be able to like refer somebody who reaches out who are like, yeah, middle of nowhere state somewhere, you know, landlocked state, something like that. Or like it's harder to find folks and I'm honestly like, just really hoping that as like, things start to like, I've started to improve a lot more in the realm of like trans either representation and also just like trans informed care I like I I just I feel like there just needs like everyone needs to be trans informed. Like I don't want my I don't want What'd I do to be a specialty? You know?

Alex Iantaffi: 40:37

100% I totally understand that because I remember when, you know, even when I came to Minnesota, and I was like, Where are the trans MFTs, even as a therapist or the transect stairway? And I'm like, oh, you know, and now I'm like, not only in my practice, but in practice, like, Oh, here's, like, 20 people that you can go see, you know, that's, that's, like, I want to make myself obsolete. And maybe one day I'll even retire, who knows, you know, and like, 10-15 years, but it's like, so amazing to see more people in the field, right? And even like, Yeah, bring Institute I was like, Oh, this amazing, wonderful trans presenters. And we could have add three times as many, right? If we have a budget and time to do a three day conference. And it's, it's wonderful. And you are one of the very few, like, trans pelvic PT is that I know, and actually the only one I know, who actually does this work of educating other providers. So if there was, you know, three things, let's say that you wanted every physiotherapist or pelvic PT or even just a health care provider to know about working with like trans non binary, gender expansive, folks, what would those things be? Do you think? Just off the top of your head, you know, like, okay,

Alex Papale: 41:56

okay, my Three Things would be that there are more similarities than differences. In any, any genital arrangement, any pelvis, we have all the same muscles, we just because the external bits may be in also the internal bits organize a slightly different way, but the same kind of layout. And another thing that I would really like people to know is that it's not, we need to move past the pronouns, we need to move past the like, wanting to learn the like, the DI kind of component to it, which is important. It's important, like, please note, please do your god it's 2024 Like know how to use pronouns, but also, like, the bars just on the floor. Like I think that sometimes, like we get really caught up in wanting to make sure that we're saying the right things, I got a lot of questions about, like, what's the difference between like, non binary and age, gender and gender queer and all these things, which is they're important distinctions, of course. And also, that's not what's really making a provider. Exceptional or inclusive. It's really like being able to, like meet someone where they're at, like listening to them, treating them in their bodies, like with respect, and yes, of course, having some, like, know how of like, okay, yeah, we might want to be careful of the gendered language like, yes, obviously, you do want to use the right pronouns, and asking people how they want to refer to themselves, like all that kind of stuff that does require a little bit of training. But after that, like unless you are entirely specializing in folks who have had gender affirming surgery, when you do what kind of want to know you want to take there's maybe some continuing add on, like what's going on there. But otherwise, like, the vast majority of trans folks don't get surgery, they never seek any realm of medical transition. So how can we also support them? And that's not something that you like, yeah, you need to know the difference between pansexual and bisexual to be able to help out with that. So I'd say like, yeah, it's okay. Like I one of the first things I tell people, when I'm teaching providers is like, take a breath, like, you probably already know what you actually need to know, in this situation. I'm just gonna give you some like, insight, some tools and some things to think about. But this is not, you're not going to like, learn a whole new realm of like pelvic health, just because you're working with trans folks. You know, yeah, you want to be prepared for the few folks that you might see who yeah, I've had surgery. And I mean, I hope that all trans folks who have surgery in any realm, not just bottom surgery, but in any realm can go to see a pelvic health provider. That's a huge access problem. But that would be my My dream is that that's true, and that it's free. Also, that would be amazing. Yeah. It's free, and that pelvic health providers are getting paid what they deserve. And that yes, it's not getting it's not on the patients to pay for that. That's to be clear. Yeah, I think

Alex Iantaffi: 44:51

Universal Healthcare what? That kind of stuff. I know. I'm with you.

Alex Papale: 44:58

Yeah, yeah. And it's one of those things where it's like, wow, we're really still saying that that's like revolutionary to healthcare, just to be able to not have to, like, travel like, an hour and a half away to your provider who isn't going to like, treat you disrespectfully. I know anyway, but the other thing that I would say is to be comfortable with what you don't know and to be able to say that that you don't know things and that I think that a big part of being in inclusive and affirming providers. the humility of just like you just gotta be humble. And that, I think that it's important to encourage folks of any gender, that, like, they know, they're the people who know the most of other bodies. Like, just because I have a degree does not mean that I know more about your body than you do. And like your lived experience of it. So building that, like trust that somebody has that knowledge already there. We're already doing that work. And so I think that that's just like, we're taking it like a little bit further, where we're encouraging people to, like, feel comfortable with, like, the fact that they they know about how their bodies are working. And then we also want to, like turn that back on ourselves with like, okay, yeah, we don't know everything. And that's okay. And I don't actually think that people expect us or patients expect us to know everything. But to be able to be like, You know what, that's a great question. I don't know, I'm going to look into that for you. Or like, like, I'm not totally sure about that component. And we're not asking our patients to teach us things. But we're like, okay, great. Like, is that okay? If I kind of follow up about this? Like, is it okay, if I, like, I'm just gonna, well, can we pin this one, and I can get back to you on this specific thing? And not being like, can you tell me more about this thing that I can Google?

Alex Iantaffi: 46:49

Absolutely. I saw resonate with that, you know, the best providers I've seen are the ones who can say, Oh, I don't know about that. Or, you know, my therapists we've seen for almost 16 years now, you know, the was like, I've never done a letter of support for body modification surgery, you know, and I was like, That is not a problem. We can do this together. You know, I've done a lot, but I can't write my own, you know, so, yeah, we are, you know, and I'm still seeing that therapists. And same with like, medical providers, you know, the ones who are like, Oh, actually, I don't know about this. So let me find out. Let me consult, right, with somebody, I know know more about this. I'm like, Yes, that's how we do it. Right? Like you said, we're not asking our clients or patients to educate us, but to it's so colonial to think that we would know everything, how can we know everything about everybody? At all times? Right? It's okay. The relationship so I can be like, let me let me get back to you about this. I do want to consult with a colleague who maybe knows more about this, or, or, you know, look at what research is out there, because this doesn't come across, you know, in my work before, so, no, I love that. And talking about educating providers, you're also kink affirming, right provider. And I think that's so important. And as somebody who not only works with kink clients, but as part of the community, I think that's another area where people can have a lot of what's the word? I want to use hesitation in kind of disclosing, right, because there is so much stigma, I think around kinky practices, and how is kink relevant to pelvic health? I have my own thoughts about it might be relevant. But I would love to hear from you as a pelvic PT. Like, why is it relevant to be open about being kink affirming as a pelvic physiotherapist?

Alex Papale: 48:44

I love that. I love that question. It is important because if as a pelvic health provider if I'm trying to help somebody have more like embodied experiences, and I am not like

Alex Iantaffi: 48:53

Absolutely. And I find that even folks who might educated or willing to talk about kink, like I might be missing, like a whole window of someone's life to be like, okay, yeah, like maybe they, for instance, like maybe they have difficulty with like, they have painful penetration, or painful penetrative sex. And so that's maybe what they're coming in for and I might be making, if I didn't have this, like, kind of kink informed background, or be part of like a kink community in Boston, that I might make the assumption that that's the only way that someone is engaging sexually, or that's kind of the, this is kind of like, this is sex for this person. And in reality, it might just be like, a fun thing that they do sometimes, or something that they're, that is actually like, not part of their regular sexual practice. And that there could be like, other things that they might be doing that may also be like, kind of causing some some symptoms or something that really impacting their, their experience of their bodies that that might be harder to bring up like, Oh, hey, yeah, like I have, I have these issues, like after a like, do some like rope bottoming like, I don't know, like, if that's like, okay to be even bringing up kind of stuff. So, yeah, I definitely think it's, it's deeply related. And it's also a huge way in which I think a lot of especially queer and trans folks like, can, like exist in in their bodies and like, feel like, like, experience pleasure and like, it's like, just kind of we're already moving out of this like, like, cis heteronormative like view of how our bodies function. And so being able to, like lean into, like the like, the kink experience of this is it's huge. Um, yeah. And so I like to try to tell people like, it can be shared, I found it to be like mixed results of just being like, is there anything like kind of like in, like trying to like figure out like how to ask somebody about it because obviously kink is a huge world. And so like, how are we? Yeah. And so I just like to mention it was like, oh, like a little about me. And like the beginning of our sessions, it's like, I'm a sex educator, like, here's some things that I like to that I've talked about, this is what I educate providers on. And so then that kind of can open up the door of like, if somebody wants to bring up like a relevant thing. Whereas like, if there's anything that's causing any discomfort in this realm, or if anything's ever, like irritating your pelvis or something along those lines, like, kind of, like, open up the door a little bit more for people to bring it up. But yeah, hugely impactful. not identify as kinky might engage in some kinky practices, you know, as sex. I do find, like cishet folks who maybe are engaging in like a, you know, some restraining with handcuffs, right? Or like, oh, yeah, my partner really likes to, you know, peg me, and is really obsessed with like dilation, you know, and things like that. I'm like, yeah, that's, that's kinky, like, and then might have an impact on kind of, like, on your health care. And it can be so hard, I think, to bring it up to healthcare providers because of that stigma. And so being able to actively be like, I am a kink affirming provider, you can just share anything, you want to share that you think it's relevant, you know, and maybe even something that you don't think it's relevant, but might be relevant, right? So, yeah.

Alex Papale: 52:21

Oh, it really does. I tell people all the time that, like my patients that usually the most relevant statements come after, I don't know how relevant this is, but

Alex Iantaffi: 52:33

my God all the time, I remember from pelvic PT, but also with my acupuncture is I remember being like, this is probably nothing but um, you know, this is happening in my body. And they're like, no, no, I want to know, I want you know, that kind of hyper interoception as a neurodivergent person, you know, it can be like, either too much into reception, or too little. I'm definitely leaning more on that too much. Sometimes. When you do that, like there's this tingling in my like left ear or something, right. And you're like, oh, actually, that's connected here. So it's connected. And I'm like, My mind is blown every time because I'm like, this is probably silly. But every time I mentioned it providers like, Nope, that's relevant. So just encouraging your listeners to share the weird stuff. It's okay.

Alex Papale: 53:20

Yeah, yeah. Yeah, yeah, absolutely. And

Alex Iantaffi: 53:25

I feel like I could have this conversation for hours and hours. And I also want to be respectful of your time. So is there anything that we haven't talked about that you were hoping we would cover in our conversation today?

Alex Papale: 53:42

I think this was, I feel like this was like, we hit on a lot of the big points of what I have what I do. I'm trying to think, yeah, I also feel like in the conversation, like, it is nice, I like to be able to also like touch on the kink stuff. Because I think that oftentimes, it's very, like sex ed and trans health focus, when I'm speaking with people in the pelvic health realm. And I even noticed, like even in that, it's, it can still be challenging to like, bring up the kink topics. And so I love talking about them. And that is something that I also Yeah, I love to like do, like I love to educate providers on how to be more kink informed, too. And so it's, it's a big deal. So, yeah, no, I think you brought up all of the all of the big things. Yeah,

Alex Iantaffi: 54:27

absolutely. I do think it's like people can be so hesitant and providers can be so hesitant in asking questions, or they can make assumptions. Like I remember, PCP was see me for years, who it never came up and she never asked and then I was like, Oh, I think we should also do some like STI testing. And she was like, why? And I was like, Well, I have a new partner and she was like, what? And I was like, I'm not monogamous and polyamorous have been for like over 20 years and she was like, Oh my God, how did I miss this right and I was like, Well you never asked was never relevant. You made a lot of assumptions.

Alex Papale: 55:05

Oh my god. Yeah,

Alex Iantaffi: 55:06

it was a great moment, right? Same with kink and I'm like, Yeah, people if providers don't ask, people are not necessarily going to volunteer that information, if it's not relevant, you know, you have this short time with your provider. You're going through the thing and then it's not relevant until it's relevant.

Alex Papale: 55:22

Right if that makes right. Yeah, yep. Yep.

Alex Iantaffi: 55:25

I assume it is similar for kind of pelvic PT, you know, even knowing kind of sex or people having how are they engaging? with their pelvic floor, right? It's probably relevant to the care you provide your clients, I'm assuming?

Alex Papale: 55:40

Yes, it's definitely relevant. Yeah. Well,

Alex Iantaffi: 55:43

like I said, I could have this conversation for hours and hours, I'm sure. 500 tangents in my brain, but I will be kind to your schedule and also to the listeners, because if it was up to me every episode be like five hours long. So I'm like okay. Well, don't tempt me. Alex, don't you know, we're both Alex's, we're both Italian, we could ust keep going and going.

Alex Papale: 56:15

(laughs) Talking forever hands flying across the screen.

Alex Iantaffi: 56:22

Sadly, yeah, and for you, listeners, if you didn't know, The podcast is also on YouTube now. So if you want to watch me talk to my guests, you can do that. But we will be well behaved. And if people want to find out more about your wonderful work, you know, whether they're a physiotherapist who want to go into pelvic PT or pelvic PT themselves, or, you know, potential clients, or just folks in general, or like, Alex was just like, opened up a whole new world of the pelvic world to me, and I want to find out more about their work. How can they find you?

Alex Papale: 57:01

I am currently I'm working on having better, better like, like, sort of like resource like places to find me. But I do have a website. It is under construction, but it's just Alexpapale.com. And you can also find me for like PT work, it's going to be at flourish physical therapy. That's, that's where I that's where I am. And then I'm also on Instagram. So it's alexpapalept. On Instagram. I am not on Instagram a ton. And I'm like constantly shadowbanned classically so. So yeah, I don't expect very much coming from that. But that is where you can find me. And I have also recently started a sub stack. And so I'm trying the newsletter format. I'm really liking it so far. I need to be more consistent with it. Maybe this will help me do so. But yeah, so you can definitely find me on there. And it's myself stack is my name again. And it's actually like the name of it is containers.

Alex Iantaffi: 58:02

Oh, okay. I will find all those links and put them in the episode descriptions so that they're all ready for you dear listeners, and I so feel you on the consistency. I feel like whatever job we do now, we also have to be social media experts. Like posts regularly and have emailed newsletters. It's a lot. It's like a job on top of.

Alex Papale: 58:23

Yeah, it is. And then I'm like, Alright, I have to plug like the courses that I have. And like, I'm just like, oh my god, there's just so many things.

Alex Iantaffi: 58:30

There are so many things and they only have so many hours. So I feel like well, thank you so much for making time for this conversation in your you know, what is the busy schedule, I really appreciate it and the gender stories, listeners. I hope you appreciated this conversation as well. And until next time, please take care of your pelvis.