Interviewed by Yulia Kriskovets
Sexual well-being and Pelvic Floor: what is the connection?
Sexual well-being is one aspect of a person’s self-image. Some definitions may be useful to discuss the connection between the pelvic floor and sexual well-being.
First, Moshe Feldenkrais’ definition of self-image says that self-image is composed of four parts: thinking, moving, sensing, and feeling. Each part influences how you act and how you consider yourself. Each element contributes to your well-being and can be enlarged, or diminished.
Second, the definition of sexual health from the World Health Organization (WHO) says that ‘sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.’ Interestingly, the WHO’s definition of sexual health is close to Feldenkrais’ definition of health in that health is not merely the absence of disease. Health is a measure of one’s ability to recover from injury or illness, or one’s resilience.
Third, the pelvic floor is involved with many functions: sexual expression, elimination, maintaining continence, breathing, managing the intra-abdominal pressure, birthing, support for the soft organs, and balance. The parts of this coordinated pelvic floor system include muscles, connective tissues, bones, joints, and nerves. This system is under both voluntary control as well as reflexive, and autonomic control. The elements of one’s self-image: thinking, moving, sensing and feeling will affect all the functions of the pelvic floor, including sexuality.
I have developed Feldenkrais Awareness Through Movement® (ATM®) lessons to improve the pelvic floor system through full body movements and directed attention in order to develop awareness of what pelvic floor coordination feels like. For some, just learning to sense this internal musculature and its connections is the goal, for others, it may be learning to sense one’s habits of use. If you can feel it, you can better know what you are doing.
I was initially interested in solving the problem of urinary incontinence that affects 20-25% of women. Incontinence is more prevalent after menopause, yet, there are also many younger women who have involuntary urine leakage when they laugh, cough, sneeze or do vigorous exercises. I began to teach these lessons in my Pelvic Health and Awareness workshops in 2003.
After these workshops, women began to report back that their sexual activity had become more pleasurable, enjoyable, less painful, orgasms were stronger and that they felt a deeper connection to their sexual self.
Some women asked how the men in their life could benefit from this work. As a generalization, everyone is shy about talking about pelvic floor issues, and men even more so, but their intimate partners knew of their issues. Men can benefit from improved pelvic floor function to increase the blood flow necessary for a strong erection and it will also be helpful for men with an enlarged prostate or recovering from prostate cancer surgery or treatment.
You have recorded a very popular audio series on the pelvic floor? What drew you to working with the pelvic floor in the first place?
My journey with investigating the pelvic floor and how to improve function began in 1992. I had developed a personal problem with stress incontinence that seemed to get a little worse each year even though I did dozens of traditional Kegel exercises every day. I had completed my Feldenkrais® training in 1987 and I don’t remember any mention of the pelvic floor or lessons addressing problems that are more familiar to women, but can affect men and children, too. I was confused as to why incontinence was happening to me and why I could not improve. I had risk factors for developing incontinence: two vaginal births with tearing, in 1980 and 1985 and abdominal surgery in 1963,
I also had several women clients who would tell me that they knew their sacro-illiac (SI) joints were ‘out’ because they were leaking urine. I was curious about the relationship of the SI joint to incontinence and began to look at the anatomical relationships of the pelvic bones, the muscles, connective tissues and habits of use.
There are several significant influences on my pelvic floor work. Beginning In ’92, my colleague from Australia, who is now my husband, told me of the lessons that Judy Pippen and Barbara Bell had developed in their From Prolapse to Power series and he reminded me of Ruthy Alon’s Sphincter series (Ruthy Along is a Feldenkrais trainer who had worked with Moshe Feldenkrais). Exploring these lessons brought up even more questions about how the pelvic floor worked as a system, and coordinated with the whole self in action, and how best to promote awareness of this part of the body. As I realized, the pelvic floor system is more than the deep muscles in the pelvis.
I took several great courses with Physical Therapists (PT) who specialize in women’s health to learn what they were doing. I discovered that for any exercise the PTs used, there was an ATM lesson that could do it better, and help people improve the ability to sense and feel the pelvic floor.
I began to explore ATM lessons that especially facilitated better coordination of the components of the pelvic floor system, i.e., the deep abdominals, the deep spinal muscles, the hip rotators, and the respiratory diaphragm as well as the pelvic floor muscles. I learned how improving the auxiliary muscles of the system, such as the hip adductors and the buttocks could be helpful to gain more normal tonus of the pelvic floor, no matter if the person was hypotonic (under contracting) or hypertonic (over contracting).
I tested my hypothesis by using an internal vaginal pressure sensor as I explored various ATM classes to find what the response was in my pelvic floor. I read fascinating research articles that looked at the relationship of pelvic floor dysfunction to back pain, balance, breathing and other basic functions. I used ultrasound imaging to observe the effect of different images and movements on the lifting action of my pelvic floor.
I applied all this data to construct ATM lessons that would be good for anyone, knowing that people with pelvic floor dysfunction may also have other problems such as back pain, abdominal surgeries, balance issues, hip replacements, be deconditioned, overweight, and have diminished sensation or awareness of the genitals, and more. My criteria for the lessons were that they were easy to do, focused on the quality of movement coordination, did not increase back pain or other pain, and improved the awareness of the pelvic floor response in daily actions.
When I teach classes and workshops on the pelvic floor, I make them very neutral to create a sense of safety and gender inclusivity. This is especially important for people who have experienced sexual trauma. I am aware of choosing my language to be less triggering, because people are already embarrassed about such issues as pain, leaks, constipation, or inability to have orgasms.
I began teaching Pelvic Health and Awareness workshops for women in 2003, then later added co-ed workshops. I explored the lessons in these initial workshops and when I was happy with the results that my students reported, I recorded the program as Pelvic Health and Awareness for Women and Men. I used that program in 2009 for my physical therapy doctoral research project and proved the program was effective for women with mild-moderate incontinence. In 2020, during the pandemic, I developed the material further with two new online courses at MovementandCreativity.com
I am sure that I am following the legacy of Moshe Feldenkrais in designing lessons for improving pelvic floor function. I have applied the principles of learning and awareness to improve my own health and that of others. I have used the available scientific research to make lessons that work with the function of the pelvic floor system and involve aspects of the whole self. I have often said that if Moshe had been a woman and had pushed a baby out of her body, she would have developed lessons to restore pelvic floor function, just as Moshe, the man, designed lessons to improve his knees, eyes, the hands of his surgeon, and so much more.
What are the most common myths about the pelvic floor and its functions?
Myth one: the pelvic floor acts by itself and functions apart from the whole action system of the self. Not true, extensive research from the lab of Paul Hodges and Ruth Sapsford in Australia clearly demonstrates the synergistic relationship with the abdominals, and the other muscle groups of the pelvic floor system. Yet, there are still movement educators and health care providers who tell people to only isolate and contract the pelvic floor muscles, such as traditional Kegel exercises, apart from the whole synergistic and coordinated pattern.
Myth two: the way to strengthen the pelvic floor is to practice stopping the flow of urine several times while urinating. Not true, and this is a harmful habit that can lead to more problems with continence because you are interfering with a reflexive relationship between the pelvic floor and the bladder. The pelvic floor relaxes and bladder contracts. Peeing is a parasympathetic activity. We can urinate comfortably by just sitting down, relaxing and letting the bladder do the job. I advise against ‘power peeing’, pushing the urine out. You have to relax the pelvic floor to urinate. Men, too, may find it helpful to sit to urinate and allow flow to happen. It’s okay to experiment occasionally to see if you can stop mid-stream, as that demonstrates a strong and healthy response, but do not do it every day or every time you pee.
Myth three: Incontinence is a normal result of aging. Not true, research shows people of all ages can improve their ability to stay dry. Unfortunately, this myth is alive and well. Incontinence is one of the top reasons a person goes to a nursing home.
Myth four: the only way to treat erectile dysfunction is with drugs. Not true, research shows that pelvic floor exercises can be as effective as Viagra for increasing blood flow to the penis and therefore help men get and maintain an erection.
Myth five: sexual satisfaction is a result of pelvic floor strength. Not true, sexual feelings, pleasure and satisfaction are woven from multiple systems, but especially the mind–one’s thoughts, feelings and self-image.
Are there any Feldenkrais® lessons you have encountered that have a powerful impact on the pelvic floor?
Yes. There are many lessons with a powerful impact. It’s important to consider not only what one is doing, but, how one is doing it, the quality of the movement, the continual breathing and the awareness suggestions provided by the teacher. Once you gain awareness of the pelvic floor, you can feel it in most lessons especially those that explore rotation of the spine for twisting, side bending, lifting the top leg while lying on the side, sitting on a chair and shifting the contact of the pelvic bones. There are many variations of these kinds of lessons. There’s the need for lessons to explore freedom of the hips, spine, and breathing to find more comfort in positions used for sexual activity. Then there are lessons that help one to be more comfortable in positions for sex.
Of course, you need to be able to feel the pelvic floor. To do this, each person is at a different place on the continuum of awareness. Some may need to do classic lessons to learn to sense and feel the whole body, to develop their sensitivity and sensory-motor skills. I think that Feldenkrais Teachers can add awareness directions to the pelvic floor. In some of Feldenkrais’ lessons he does ask students to sense between the legs. And his book, The Potent Self, is a great resource.
This is not an exclusive list of suggestions. As I work with a student, and myself, I could probably create another 30 lessons that would work to improve functions that involve the pelvic floor.
How would you talk about aging and sexuality?
You’ll learn that just like any other function, sexuality changes with aging. One may need more time, different ways of exploring with oneself or a partner, or have to deal with physical limitations, or pain. Desire, however, does not necessarily disappear as one ages. This article from Harvard health thoroughly explores this topic and I recommend reading it.
Feldenkrais lessons for older people can help to renew pleasurable sensation in one’s body, improve joint and muscle use, to learn how to be more comfortable in more positions, and in the pelvic floor, to keep the muscles in a healthy state, ready to function for all the uses of the pelvic floor system. The positive effects on one’s self-image happens across the lifespan. In my experience, it’s the changes in one’s attitudes, habits, and movement that result from ATM lessons that will foster sexual well-being at any age.
Deborah Bowes DPT is a Feldenkrais® Trainer and Physical Therapist in San Francisco. She teaches in Feldenkrais Training programs in the US and internationally. She is an adjunct faculty at Saybrook University. Her doctoral research examined using Awareness Through Movement ® lessons to improve pelvic health. She can be reached at [email protected]