Has anyone ever told you that your sexual concerns are all in your head? Well, that’s not always the case. There is another treatment option worth exploring. Pelvic Floor Physiotherapy can help treat sexual and pelvic concerns such as painful intercourse or penetration, early or delayed ejaculation, and can also support the recovery from gender affirmation surgery. Excited to learn more? We invited Michiko Caringal to GET SOME to discuss pelvic pain for penises and vulvas from a physiotherapy and sex therapy perspective. Time to take a deep breath and Get Happy Down There! Show notes: 02:50 What is Pelvic Pain and how do you know you are having it? 04:50 How about period pain? 05:30 Please, don’t swallow your pain! 10:00 Early ejaculation can, in many cases, be treated by pelvic health physiotherapy 13:15 Constipation can be a clue 18:10 Transgender pelvic health. Recovery, scars, and comforts 20:25 You can choose to have a penis, a vagina, or both 26:40 From 18 to 88, it’s not about the age, it’s about the symptoms 29:00 Will I have to put something into my vagina to treat pain? 32:05 Partners are very welcome to attend appointments, with consent 37:30 What is the first step to seeing a pelvic floor physiotherapist? 42:00 Breathing! Neat Techniques 48:00 Interested and curious to learn more? 50:00 Don’t do kegels just because social media told you to! 51:00 Michiko: Physiotherapy changed my life from every perspective 53:00 Where can I find you, Michiko? Every gender is super welcome Michiko Caringal, MScPT, MHSc in Bioethics Michiko Caringal is the Founder and Owner of Happy Down There Physiotherapy in Vancouver, British Columbia. Michiko holds a Master of Science in Physical Therapy as well as a Master of Health Science in Bioethics from the University of Toronto. She works part-time as a pelvic health physiotherapist at the University of British Columbia Hospital in the Bladder Care Centre with renowned Urologists and Urogynecologists. website: www.happydownthere.ca @happydownthere.ca If you have questions or topic suggestions for the podcast, submit them here. As well, you can now record your messages for us! Please record your message/question in a quiet room and use your phone’s headphones with a built-in mic if possible. Send your questions or show ideas to Michelle@getsome.ca Guest Opinion Disclaimer: All opinions expressed by podcast guests / participants are solely their current opinions and do not reflect the opinions of GETSOME Inc. or affiliates or the companies with which the podcast guests / participants are affiliated, and may have been previously disseminated by them. The guests / participants opinions are based upon information they consider reliable, but neither GETSOME Inc. nor its affiliates, nor the companies with which such guests / participants are affiliated, warrant its completeness or accuracy, and it should not be relied upon as such. Follow us on Instagram: getsome_podcast
Has anyone ever told you that your sexual concerns are all in your head? Well, that’s not always the case. There is another treatment option worth exploring. Pelvic Floor Physiotherapy can help treat sexual and pelvic concerns such as painful intercourse or penetration, early or delayed ejaculation, and can also support the recovery from gender affirmation surgery. Excited to learn more? We invited Michiko Caringal to GET SOME to discuss pelvic pain for penises and vulvas from a physiotherapy and sex therapy perspective.
Time to take a deep breath and Get Happy Down There!
Show notes:
02:50 What is Pelvic Pain and how do you know you are having it?
04:50 How about period pain?
05:30 Please, don’t swallow your pain!
10:00 Early ejaculation can, in many cases, be treated by pelvic health physiotherapy
13:15 Constipation can be a clue
18:10 Transgender pelvic health. Recovery, scars, and comforts
20:25 You can choose to have a penis, a vagina, or both
26:40 From 18 to 88, it’s not about the age, it’s about the symptoms
29:00 Will I have to put something into my vagina to treat pain?
32:05 Partners are very welcome to attend appointments, with consent
37:30 What is the first step to seeing a pelvic floor physiotherapist?
42:00 Breathing! Neat Techniques
48:00 Interested and curious to learn more?
50:00 Don’t do kegels just because social media told you to!
51:00 Michiko: Physiotherapy changed my life from every perspective
53:00 Where can I find you, Michiko? Every gender is super welcome
Michiko Caringal, MScPT, MHSc in Bioethics
Michiko Caringal is the Founder and Owner of Happy Down There Physiotherapy in Vancouver, British Columbia. Michiko holds a Master of Science in Physical Therapy as well as a Master of Health Science in Bioethics from the University of Toronto. She works part-time as a pelvic health physiotherapist at the University of British Columbia Hospital in the Bladder Care Centre with renowned Urologists and Urogynecologists.
website: www.happydownthere.ca
@happydownthere.ca
If you have questions or topic suggestions for the podcast, submit them here. As well, you can now record your messages for us!Please record your message/question in a quiet room and use your phone’s headphones with a built-in mic if possible. Send your questions or show ideas to Michelle@getsome.ca
Guest Opinion Disclaimer: All opinions expressed by podcast guests / participants are solely their current opinions and do not reflect the opinions of GETSOME Inc. or affiliates or the companies with which the podcast guests / participants are affiliated, and may have been previously disseminated by them. The guests / participants opinions are based upon information they consider reliable, but neither GETSOME Inc. nor its affiliates, nor the companies with which such guests / participants are affiliated, warrant its completeness or accuracy, and it should not be relied upon as such.
Follow us on Instagram: getsome_podcast
[00:00:00] [Theme music]
[00:00:08] Michelle: Welcome to GETSOME. My name is Michelle Fischler, your host, certified sex therapist. And today we're going to be talking about pelvic health physiotherapy. And not just for people who have vulvas, but for people with penises too, including pelvic health physiotherapy for trans people that have undergone gender affirmation surgery. Today, I'm delighted to introduce Michiko Caringal, the founder and owner of Happy Down There
[00:00:42] Michelle: Physiotherapy in Vancouver, BC. Michiko has over 15 years of experience in clinical research, education, and leadership roles in rehabilitation, healthcare, and fitness. She holds a Master's of Science in Physical Therapy, as well as a Master's of Health Science in Bioethics from the University of Toronto. She also works part-time as a pelvic health physiotherapist at the University of British
[00:01:11] Michelle: Columbia Hospital in the Bladder Care Center with renowned urologists and urogynecologists. Michiko's mission is simple, to provide a safe space to improve the quality of life of individuals. Welcome, Michiko. I am so happy to have you here.
[00:01:35] Michiko Caringal: Aw, thank you so much, Michelle. I'm super excited too. Thank you.
[00:01:38] Michelle: Me too. I've heard so many, such great feedback from the people that I have worked with that have also worked with you when you were in Toronto and were all very sad to have seen you go. But you know what? Vancouver is so lucky to have gained you.
[00:01:59] Michiko Caringal: Thank you so much. Those are such beautiful words. Thank you. I appreciate it so much. I do miss Toronto, but Vancouver is good too. Yeah.
[00:02:09] Michelle: Oh my gosh, I bet. I thought it might be helpful to start off with asking you to talk a bit about what is pelvic pain and how do you even know if you're having it?
[00:02:26] Michiko Caringal: Yeah, that's an awesome question, because I think there's this misconception or, you know, people with vulvas, they tend to, and people with penises too, they just tend to think, oh, I feel some kind of achiness. or, you know, they go to the doctor even or a specialist and they say, you know what, I'm feeling some kind of achiness, some burning, some tingling, maybe sharp kind of knives, paper cut kind of feeling. They could feel pain during intercourse.
[00:03:00] Michiko Caringal: any kind of penetration, anything. And maybe they might go to a therapist or a medical health professional and they might say, oh, that's normal. But really, it's not normal. It's very common. So I think it's quite brushed off as what is pelvic pain and people don't think it's actually recognized very well. So that's why pelvic pain is very common. But it is also these many terms to describe it. It's an overarching kind of word.
[00:03:34] Michelle: Yeah. I had somebody ask me to ask you if it feels the same as period pain, cramps.
[00:03:46] Michiko Caringal: Yeah. And that's really interesting because dysmenorrhea, which is period pain, which is intense period pain, is actually considered pelvic pain too. So it's just a type of part of pelvic pain. There's so many different kinds that I think that we could definitely hone into different kinds. And for example, with sexual health, it's a very different kind of pain feeling than pelvic cramps. So yeah, totally, totally different.
[00:04:18] Michelle: Yeah. Yeah. I often have clients that are coming in, usually people with vulvas who describe the beginnings of penetration or even like just upon entry as well as deeper inside of them and not really realizing that that's not that that that painful experience is not something that they should be having because there have been times where people
[00:04:52] Michelle: have gone say to a medical doctor who has said well you know just give it a bit of time or once you get used to having penetration it's not going to be as painful or even hey once in a while um it's it's painful and that's just sort of part of I know part of the like oh
[00:05:23] Michiko Caringal: I just want to I just want to tear my face apart I know I need to so badly it's just it's just it gives me such a like it makes me want to cry because you know um the pain especially so we do distinguish between superficial penetration pain, which is for people with vulvas, and deep thrusting pain. So two different kinds of pain. And we treat it really differently too. So, you know,
[00:05:52] Michiko Caringal: I think that, I think that, hey, you know, give it some time or, you know, oh, this is the normal part of... life or, you know, those kind of false beliefs or like just comments are really detrimental to someone who also may have some kind of other mental, physical, emotional, poor attachment to the body. And then they think that this is normal. And, you know, they go about their life,
[00:06:24] Michiko Caringal: and they kind of just come to a point where they really just suck it up. And, you know, they, they really bear through the pain, which actually is only a vicious cycle to make the pain worse. So I think this is something that really needs to be discussed. And I'm so glad that you bring it up.
[00:06:42] Michelle: Yeah. And I guess when you say it just makes the cycle get worse, it's almost like then you start to anticipate the pain even before, let's say, you have penetration. And so are you saying like, it's probably at that point, maybe people will start to clench up because your body is physically trying to protect you, right?
[00:07:04] Michiko Caringal: Exactly. So there's definitely, there's two, Michelle, there's two parts. So the first part, I would say is the tissue, the actual level of the tissue where the muscle, like you said, clenches up. But the brain also has a memory of what that pain was before. And therefore the brain will also become hypersensitive and sensitized to the fact that, hey, this is going to be a painful experience. We're just going to send some, like, all these,
[00:07:30] Michiko Caringal: like, emotions and, you know, this fear-based sensations so that this next experience is going to be just as worse or even worse, more worse, you know?
[00:07:43] Michelle: Yeah. And it takes you away from what sex, a healthy sexuality should be and is, is, is pleasure, right? You want, you should want to have sex because it is, it feels pleasurable for you. And so I think the pushing through isn't what you're going to want. And it also isn't going to be what your partner
[00:08:13] Michelle: is going to want, right? Your partner doesn't want to push through.
[00:08:20] Michiko Caringal: Absolutely. And so, you know, it's so I totally agree is that, you know, communication, I think that's kind of what we're leaning towards kind of communication between the two partners of sex and intimacy is so important about this pain and discussing what pelvic pain is and how pelvic pain means to you because every person's pelvic pain is different.
[00:08:42] Michelle: Absolutely. And I think people are also shocked when they find out that people with penises can really benefit from pelvic health physiotherapy as well.
[00:08:57] Michiko Caringal: Absolutely. Yeah. So I would, um, Treat individuals with penises for erectile dysfunction, premature ejaculation, hypersensitivity at the penis glans, so at the tip, especially post any kind of surgeries, post-operative care. There's also rectal pain, but also there's testicular pain. So all those kinds of pelvic pain and pelvic sexual dysfunction, I do treat.
[00:09:30] Michelle: So when somebody comes in with premature ejaculation, right? So I guess how we would define that if we were to look at the, you know, the DSM or it would be one minute.
[00:09:47] Michiko Caringal: Yes.
[00:09:47] Michelle: Or less.
[00:09:48] Michiko Caringal: Yes.
[00:09:49] Michelle: Right?
[00:09:50] Michiko Caringal: Yes.
[00:09:50] Michelle: And what then is, would you say is causing the person to ejaculate quickly that you as a pelvic health physiotherapist might be able to treat?
[00:10:09] Michiko Caringal: Yes, that's a great question because I had an individual with a penis who came in to see me. I think it was a few years ago, and this individual was diagnosed with premature ejaculation. So, of course, I had to work in conjunction with psychologists, with psychiatrists, as well as social workers. But as a team, we decided that the pelvic health physio role was to assess the tone of the muscles, the strength, the coordination, and the endurance of all these muscles.
[00:10:43] Michiko Caringal: So by doing so, I am usually with individuals, I would say 90% of I'm just giving a number, but the majority of people who experience premature ejaculation actually have very hypertonic muscles, meaning that they're very tight. So they're tight and weak, and they're uncoordinated. So they can't do a rhythmical contraction, or the endurance is very low.
[00:11:07] Michiko Caringal: So by practicing not only imagery and, you know, all these other psychological things and emotional things, we do actually do tender point releases inside the pelvic floor with manual release. So and then I train to do quick contractions or slow contractions, endurance work. You know, we do a lot of different kinds of work just because it's kind of like how you have a knot in your shoulder. you just kind of have a knot inside your pelvic floor. So what you need to do is you kind of need
[00:11:39] Michiko Caringal: to release all these tension. Yeah. And then there's obviously things like posture awareness, correcting your, you know, movements and, you know, every, it's a very much a whole body comprehensive treatment to treat sexual dysfunction.
[00:11:55] Michelle: And it is a really nice option. for people who have penises that have tried everything, right? We're talking imagery, mindfulness, all the techniques to try to slow themselves down. And yet what they go on, and I guess after they've tried all of those things, it's like, well, maybe you just ejaculate
[00:12:24] Michelle: fast. Yeah. Right. And without having the part of the assessment that you do, actually, it, it, it takes away that chance of them finding a cause for this. Right.
[00:12:42] Michiko Caringal: Yeah. And you know, what's interesting, Michelle, and maybe I should add in here is that when individuals experience sexual dysfunction. It's very common, not necessarily all, but common that individuals have experienced constipation or they have bladder symptoms because the pelvic floor supports all these organs. So because the musculature is so tight that the feces can't come out. So if you figure out diet modification and lifestyle modification, sometimes the pelvic floor itself
[00:13:16] Michiko Caringal: will fix itself and then sexual dysfunction is also treated so it's like a hand in hand like you have to look at the whole picture in order to treat any kind of sexual dysfunction such as premature ejaculation
[00:13:29] Michelle: would it also if you did find that there was a release that needed to be done, would that impact the experience of orgasm? Because I know some people with premature ejaculation are so anxious about coming fast that the orgasm is just like, you could almost
[00:13:57] Michelle: miss it. It's just very unsatisfying. And I was wondering if that adds any benefit.
[00:14:05] Michiko Caringal: yeah I wonder I mean yeah like I've never actually thought about that one that's a really good one um because leave it to the leave it to the sex therapist to come up with all of these things
[00:14:17] Michelle: I've talked about premature ejaculation so much
[00:14:22] Michiko Caringal: yeah I know because I was like wow with the I think it's the person's you know what it's probably the individual's perception of what the orgasm is and you know um so I'm not really sure if muscular tension release will actually impact directly impact the orgasm yeah yeah yeah
[00:14:43] Michelle: and then it sounds like it's also can be helpful for delayed ejaculation yeah which is a problem that i see in my practice and i say And probably... Because it is around the time that if I'm working with a couple that they're wanting to get pregnant. Quote unquote naturally. Yeah. Right?
[00:15:17] Michelle: And delayed ejaculation has always been a thing. And obviously there are what I always am assessing for is how do you masturbate? what's your technique right because we want to get it we want to try to understand that piece that what that might how those ways may be impacting the delayed ejaculation but I wondered what the physiological piece could be when it comes to pelvic health
[00:15:51] Michiko Caringal: yeah so that with delayed ejaculation specifically, I actually, from my professional experience, I have really seen a various tone or when I do the assessment of the pelvic floor, I've really seen a very hypotonic, which is like loosey-goosey pelvic floor or a hypertonic, really tight and like weak pelvic floor. So, and based on that current state of pelvic floor, I will actually provide the program
[00:16:23] Michiko Caringal: that's needed, the treatment program that's needed. So, and with delayed ejaculation, I haven't actually had a, like a straight up, you know, which side are you? It's actually been like 50-50 for me. So yeah. So I can't really say.
[00:16:38] Michelle: It's just super nice to have another option for people when you've gone through the biopsychosocial, right? And you've, you've just tried everything.
[00:16:49] Michelle: And I guess it just hasn't been maybe advertised or promoted in the way that other like clinicians, family doctors know that and are putting the message out there that, yeah, like people with penises struggle with concerns that you can work with as well.
[00:17:14] Michiko Caringal: Absolutely. Yeah, I think it's just not enough information out there or just not enough. You know, people just don't know about it. Maybe there's more stigma. You know, there's, there's a lot of things. But yes, I'd like to echo you and say that, you know, conservative management is one of the key things. And, you know, physiotherapy is one of those treatment options. Yeah, yeah. Definitely.
[00:17:40] Michelle: Let's talk about trans health.
[00:17:43] Michiko Caringal: Okay.
[00:17:44] Michelle: Transsexual health.
[00:17:45] Michiko Caringal: Yeah.
[00:17:45] Michelle: Trans bodies, right? And talk more about, I know that you're a huge advocate for trans health when it comes to pelvic health physiotherapy.
[00:17:56] Michiko Caringal: Yes.
[00:17:57] Michelle: Talk a bit about what you think. seen? What things you treat?
[00:18:04] Michiko Caringal: Yeah. So essentially, I do treat any individual who chooses to undergo gender affirmation surgeries, whether it's male to female, female to male. But I think the most treatment that I provide is with pelvic pain or scar mobilization or because I think
[00:18:34] Michiko Caringal: I think the main thing is it's comfort and the quality of life that needs to be addressed at the at the end of a surgery so what we usually tend to do is we talk about preventative measures of infections or, you know, like not to get infections, but also to ensure that the skin is mobile enough so that other, like whether it's penetration that is required or needed or
[00:19:03] Michiko Caringal: wished in the future, or, you know, maybe they just want to be able to walk like a few meters without pain or sit without pain or so all those kinds of things. But we do also do dilator work for individuals who have a neovagina. And yeah, for any individuals who also have both decide to, for example, like I'll just give an example, but if an individual chooses to have a neophallus,
[00:19:41] Michiko Caringal: but decides also to keep their vagina.
[00:19:44] Michelle: Can you just define neophallus?
[00:19:46] Michiko Caringal: Yeah. Yeah. So it's just they create a penis. So neo and phallus, phallus mean that a penis. So they create the penis and they can also keep the vagina or they can keep their uterus. So there's all these sex organs that are there and you can choose to actually transition a certain way. And just like gender,
[00:20:14] Michiko Caringal: It's very fluid. So, you know, you have all these fluidities in terms of how much and how little you want to do gender affirmation as well in surgeries. So I think this is really important to note that, yeah, like transgender care, pelvic health physiotherapy especially, is really important for not only the current state where you want to manage pain, but also postoperatively.
[00:20:42] Michelle: And post-operative pain, how long is that generally present for?
[00:20:56] Michiko Caringal: That really varies. Yeah, I think it's the extent of the surgery. But also it's like you said before, it's the biopsychosocial effect as well. You know, how prepared you are, how, you know, how much emotionally you are stable in terms of like how you feel about your body and how satisfied you are. And I think it's all linked together. Pain is a very complex phenomenon.
[00:21:30] Michelle: Yeah. Yeah. Yeah. When somebody has gotten a new vagina, what is the process of making sure that the vaginal opening stays open and also so that it doesn't create scar tissue to affect the elasticity?
[00:21:55] Michiko Caringal: Absolutely. Yeah. That's the biggest concern. So stenosis, that's what it's called. So when the vaginal canal like starts to scar and close and tighten. So it's really important to use strong, stiff dilators. So and they have they're quite straight and then they have a little curve at the end. And there are little dots to define what the depths are. So you do want to insert, it's not just the width that's important, it's also the depth.
[00:22:27] Michiko Caringal: So it's, yeah, so we train individuals to insert and hold and continue to penetrate or insert the dilators for quite a long time. And we actually allow that to, that process looks like they do learn about it preoperatively, how to use these dilators. They're educated quite intensively.
[00:22:59] Michiko Caringal: And then postoperatively, they do come again to get another assessment and as well, you know, reassess and practice the dilator so that they're comfortable at the home environment doing it on their own.
[00:23:14] Michelle: Yeah. And how do transgendered people find out about you? Are people coming to you because they're being referred from the hospital where they've had their surgery? or like what is it that you do to show people that you're open to working with trans people and and and so that they feel safe when they come into your practice knowing that they're welcome
[00:23:46] Michiko Caringal: yeah I think that's wonderful um I think the main thing that I do is I well first of all clients usually just find me through word of mouth. And I think It's because I do work in, I do work inside a clinic, which is very welcoming of all genders. So I really appreciate that. And I do support that clinic quite a bit.
[00:24:17] Michiko Caringal: But the other thing is at UBC Hospital, the gender affirmation surgery center, where they do also specifically gender affirmation surgeries. So, yeah, and then those individuals also come in for care for the physiotherapy directly there. And for private care, I honestly, there's people that just find me from TransBC, you know, different kinds of areas, a community. Yeah, like, honestly, like I said, Michelle, it's a lot of word of mouth.
[00:24:50] Michelle: Yeah, yeah, yeah. Yeah. What is the age range of the people that you work with?
[00:24:59] Michiko Caringal: I think that age is a very important part to consider when we talk about pelvic health physiotherapy because age is honestly just a number. To me, my clients range from 18 all the way to 88.
[00:25:21] Michiko Caringal: So these individuals all experience very, very different kinds of symptoms, but also very similar to whether you're 88 and 18, these individuals may experience pelvic pain, which is mostly I've seen like tingling sensations with penetration. But I've also seen incontinence. And why are 18-year-olds incontinent?
[00:25:50] Michiko Caringal: Well, you know, because they're probably athletes that are so tight and weak, their muscles are so tight that they actually can't contract their muscles anymore. They're at maximum contraction that the bladder, when it actually, you cough, bladder or the, there's the intra-abdominal pressure that goes down and the pelvic floor is already so tight that they can't contract anymore to support the bladder and you, so you leak. So an 18-year-old who is this like super gymnast athlete will leak urine.
[00:26:23] Michiko Caringal: But an 88-year-old will also leak urine too because perhaps their musculature has become hypotonic after menopause. Or, you know, like there's – so there's so many different people.
[00:26:35] Michelle: That's so interesting. In my mind when you were talking about that, I was imagining a person with a vulva. Is that what you were – or is this –
[00:26:44] Michiko Caringal: It can be a person with penis too. really yeah yeah so you know there's I think that when I look at any kind of um any kind of condition like I I never really think about the the sex of the organs really like the actual genitals i'm like you know it's the symptoms and how do we treat the symptoms um because the musculature something's going on there yeah yeah yeah yeah
[00:27:13] Michelle: and for people with vulvas that are going through menopause through perimenopause they're menopausal and having pain during penetration, is that, would that be a reason that people might come to see a pelvic floor, pelvic health physiotherapist?
[00:27:36] Michiko Caringal: Absolutely. Yeah. So there is, um, uh, due to the hormonal levels, um, you know, changing, um, muscle atrophy. So the muscles kind of weaken, um, and kind of, you know, just become a little bit less toned. We can strengthen them through pelvic health physiotherapy, the muscles themselves, but also we can talk about options such as how do we do vaginal moisturizers beyond vaginal lubricant? What is the difference between moisturizers and lubricants? A lot of people don't
[00:28:10] Michiko Caringal: know. Or what kind of device, like tools can we use in order to ensure that sexual dysfunction is relieved. There's a lot of tools out there like O-Nut and, you know, there's also, you know, pelvic wands and, you know, all these things that we can actually use. Yeah.
[00:28:32] Michelle: Yeah. I know I have a lot of people with vulvas who are experiencing at vaginismus during penetration and are terrified of going to, let's say, get a pap at their
[00:28:57] Michelle: family doctor and also terrified of going to see a pelvic health physiotherapist because there is this assumption that you're just going to try and put something inside of the vagina. And I will often say to them, go to the first appointment. Just go and learn about what's
[00:29:31] Michelle: going on that if you don't want to have anything go inside of your vagina, they will not go there.
[00:29:44] Michiko Caringal: Exactly.
[00:29:45] Michelle: Tell me about how do you work with people who have this real fear of even somebody coming close to their vulva area?
[00:29:57] Michiko Caringal: Yeah, that's good. Um, so I think there's three things maybe. So the first thing is I will not, will not without consent do any kind of internal examination. So, um, that would be, uh, for example, if I would actually, one individual, I did not do any kind of examination, did not disrobe anything with this individual for at least five sessions. We developed a building rapport. We talked about more
[00:30:28] Michiko Caringal: of the psychosocial digestion. We talked about lifestyle modification. There are so many other things to talk about than just vaginal, internal digital vaginal examinations. So the second thing that I would also say is when a person with a vulva is very concerned about any kind of examination, I always tell them there's an option to do a digital rectal examination. so they can actually do a rectal examination and I could still palpate all the muscles
[00:31:01] Michiko Caringal: the same muscles so and do tender point releases so they do not have to and it's not painful so I would do it very slowly and the third option is I would actually make them do it themselves active participation is really important to learn about your own body self-awareness huge, huge progression rather than another individual touching you. So I would say those are the three key points.
[00:31:32] Michelle: Yeah. And are partners allowed to come in for the visit?
[00:31:38] Michiko Caringal: Absolutely. Yeah. And you know what? I think that's so important because partners can come in, but of Of course, if the individual does not want the partner to be inside during the internal examination, then I do not want, like, that's a no-no. But if the individual is really wishing to do so, then I will ask the partner to be at a side and slowly, gradual come to where my position is.
[00:32:11] Michiko Caringal: I don't want any kind of harsh movements. You know, everything has to be really according to the individual patient. And the patient will have a mirror to know who's touching what. So it's really, really an active participation.
[00:32:28] Michelle: Oh, yeah. And I think it also builds trust too when they know that their partner is wanting to come in and learning and listening to you about how even you might help. And I'll get to that in a moment, but I was going to say help with the insertion if they're working with dilators at home, right? Because I think.
[00:33:00] Michelle: I think when I send people off to pelvic health physiotherapy, they are getting the, you know, it's more of a, what's the word? It's not sexual.
[00:33:15] Michiko Caringal: Yeah.
[00:33:16] Michelle: Right?
[00:33:16] Michiko Caringal: That's a huge thing.
[00:33:18] Michelle: Yeah. Yeah. It's not sexual. And so they come home with their homework and they're working through it.
[00:33:25] Michiko Caringal: Yeah.
[00:33:25] Michelle: And then they'll usually say to me, like, it's not sexual. Like, I feel like I've got to do this thing. And they have complicated feelings about doing the exercise, right? Because they have a complicated relationship with their vagina and their vulva because it hasn't been their friend.
[00:33:44] Michiko Caringal: Yep. Yep.
[00:33:45] Michelle: Right? And so a lot of the work on my end is, okay, so once you get used to doing the dilators and you get to where you need to be, then maybe the next step is to bring your partner into the room, if that's something that you want. and maybe they could just first watch you, right? Yeah. To see how you do it.
[00:34:14] Michelle: Because there is always this fear of the transition from a dilator to a penis, right?
[00:34:21] Michiko Caringal: Totally, totally.
[00:34:22] Michelle: And then it's like, okay, and then we steadily work towards, now let's try to see if we can feel some pleasure while the dilator is inside of you, right? So it's just this like really slow transition. into it be starting to feel um less let's say medical and more sexual
[00:34:44] Michiko Caringal: exactly exactly um i i tend to call that i don't know if it's correct but i just use it exposure therapy and so i'm just like you know like um for example with even with dilators a if let's just see if you can touch the dilator first are you going to be okay with it you know touch it and see how it goes and then And, you know, maybe you just want to look at it and put it in water. And like, you know, like there's just so many things to try out before actually putting it inside your body, you know? Oh, for sure. Yeah. So, and that's the same with a partner.
[00:35:18] Michiko Caringal: It's like maybe try, you know, touching is the first, you know, placing a hand, a warm hand, you know, like maybe temperature is super important. Maybe the weight of touch is important, you know? There's so many things. Oh, my gosh.
[00:35:32] Michelle: Yeah. And also just so individual depending where they are at. Yeah, yeah. There's such a range with that. I know that when I refer my clients to people like you, I know what their reaction is usually, which is surprise that this profession exists. What do your clients or patients… say when you say, you know, you might want to consider speaking to a sex therapist?
[00:36:06] Michiko Caringal: Yeah. I think a lot of people already want to. Oh. Yeah. Like it's already in their head for me. And so when I say, you know, what do you think about considering talking to a health or a sex therapist or a sex psychologist or anyone relating to sexual health? And they'll say, yeah I was thinking maybe that might be a consideration like a good idea and I said you know what it's never hard no harm to try just give them a call you know see how that goes
[00:36:41] Michiko Caringal: everyone's different and I think that's that's the key thing is just being curious and open-minded because treatment is so different individualized and so different for everyone yeah yeah
[00:36:52] Michelle: Yeah. Do people need a referral to go and see you? What is the best first step? Is it going to their family doctor? Is it going to see you? What do you prefer?
[00:37:13] Michiko Caringal: Yeah. I think that the first step is, there is no referral needed. Let's just say that. So you can just Google pelvic health physiotherapy near your house or, you know, I would say if it was the East Coast, you could also look into any kind of sites such as, I think, Pelvic Health Solutions. They list healthcare professionals who are specialized in pelvic health near you. So you can find someone through that,
[00:37:45] Michiko Caringal: Or you can call me up and just say, you know what, I want a 15 minute free consultation. You can also do that. But you can also go to your medical professional if you have like a GP. And if you have concerns over pain, and hope, like, I would hope that they would know to say, why don't you check out a pelvic health physiotherapist? But it's still a very kind of underground, not really well known, a specialized therapy, I would say. Not yet.
[00:38:19] Michiko Caringal: Even though in Europe it's just, it's huge. It's for decades and decades. So, you know, like I think we're just a little bit slower. Yeah.
[00:38:27] Michelle: Yeah. Yeah. And within, I know that to become a pelvic health physiotherapist, you have to go through the physiotherapist training program at school. Yeah. And then to get to a position, like, well, can any physiotherapist do pelvic for? Right. Okay.
[00:38:49] Michiko Caringal: Pelvic health physiotherapy. Yeah. So you graduate with the degree of a master's of physiotherapy in Canada. that and then um and if it's in the united states be a doctorate. And then, then you specialize and take courses, continuing education. So there's level one, two, three, like there's continuous levels of whether you want to specialize in pain or trans health or anything of that sort. And then I actually also did some work. I traveled
[00:39:19] Michiko Caringal: to New York and did my education and continuing learning about trans health. So, and I also did some education in UK. So there's quite a bit that you can take from, I'm just the type of person that's like, I like to take from everyone and then kind of mesh it for myself and, you know, see if I can individualize care for everyone. So, yeah.
[00:39:44] Michelle: I'm so with you on that, right? It's like when you have all those different ways, different kinds of ways of learning and thinking about things, you can really, you just have such a, your toolbox is so much bigger to be able to do that individual specific work for sure. When it comes to treatment, what are some of the treatments that you might send people off with to go home and work on in
[00:40:19] Michelle: between sessions.
[00:40:21] Michiko Caringal: Oh, okay. So, so many things. Yeah. I don't know where to start. Okay. Let's,
[00:40:29] Michelle: let's, what if we were talking about somebody that was experiencing vaginismus?
[00:40:38] Michiko Caringal: Okay. Vaginismus. Okay. All right. So if you were, okay, the most common form that I see is a lot of tension, a lot of tension. And it's not just the pelvic floor, it's everywhere. So it could be tight hip flexors, it could be tight glute med, IT bands, adductors, your inner thighs, your inner thighs refer pain to your vulva. So, you know, I would do a lot of not direct
[00:41:10] Michiko Caringal: care at the beginning of your pelvic floor, I would actually do the direct pelvic floor care at the session. And at home, I would do more care in terms of stretching, yin yoga, I would do a lot of more so things such as dietary modification, toileting practice that is properly done. You know, there's a lot of different sleeping positions, how to approach sex. You know, there's just, oh my God, there's just.
[00:41:41] Michelle: Even breathing.
[00:41:43] Michiko Caringal: Yeah, like breathing.
[00:41:45] Michelle: Like how to release. How about that?
[00:41:47] Michiko Caringal: Yeah, or like releasing your butt tension. Like, you know. Yeah, like releasing the tailbone. Like there's so much that.
[00:41:54] Michelle: Yeah. One cool thing I had a client tell me, I'm always saying. So what did you learn in your physio appointment today? Because I'm curious what they're being taught, right? And they said, well, one really interesting fact was you would think that when you're about to have penetration, you would breathe out. But she was taught that actually when you breathe in, it relaxes the vaginal opening. And I was like, what? Yeah. And then obviously, like, I try.
[00:42:29] Michelle: Like I think to myself, okay, like let me try to like work through this in my mind and do it. And it totally makes sense. Yeah.
[00:42:36] Michiko Caringal: So if, I don't know if this is video recorded. I think it is, right?
[00:42:40] Michelle: It is, yeah.
[00:42:40] Michiko Caringal: Okay, so this is the pelvic floor and this is the diaphragm, which is the lungs are up here. So if you breathe in, this moves down and the pelvic floor also moves down. It moves in unison. So if you breathe in, it relaxes the pelvic floor and things can kind of open up. So if you breathe in, it relaxes. If you breathe out, it contracts. So everything is just works in unison. Yeah.
[00:43:04] Michelle: And then like the other really cool thing was, so one of my clients was talking about that anticipation of pain during penetration and that there are some techniques that the physiotherapist was using to kind of disconnect that relationship. Yeah. Yeah. What is that called? What is that called? Do you know what I'm talking about?
[00:43:29] Michiko Caringal: Was it a manual therapy or was it something else?
[00:43:32] Michelle: It was manual. And it was more like maybe attaching somewhere else on the body. There was something going on. And I was like, what is that?
[00:43:43] Michiko Caringal: I wonder if it was non-nociceptive input. It's a different kind of technique. It's an advanced technique where you actually balloon the tissue towards the painful area in order to kind of trick the brain. And then, yeah, and then eventually like that sensation of pain goes away and you don't bear through the pain and then you slowly be able to penetrate. It's a trick.
[00:44:07] Michelle: Yeah.
[00:44:07] Michiko Caringal: It was a trick. Yeah. It's really cool. Yeah.
[00:44:11] Michelle: Really, really amazing. Super geeking out on this.
[00:44:14] Michiko Caringal: I know.
[00:44:15] Michelle: I have a sticker back there that says sex geek.
[00:44:20] Michiko Caringal: Oh, awesome.
[00:44:22] Michelle: And you're a physio geek. Totally. Oh, I know. I have another question. I've had clients who say, depending on when they're ovulating, that they, it's almost as though their cervix drops down a little bit. Like they can feel, it feels like they can feel deeper penetration more.
[00:44:46] Michiko Caringal: Yeah, that's very common.
[00:44:48] Michelle: So that is actually a thing.
[00:44:51] Michiko Caringal: well I think it's just I think I don't know if it actually physically really happens maybe it does I'm not yeah but um I know I have many clients that have told me that too. And, you know, with sexual penetration, they, they are concerned with deep thrusting pain. So on those occasions, I say, why don't you try something called the O-nut, where it's kind of like a bumper to the object that's going into your penis, I mean, into your vagina. And yeah, and then see if the depth is actually kind of
[00:45:23] Michiko Caringal: changes. And then maybe there's less pain. So I think there's ways around it, you know,
[00:45:30] Michelle: Yeah. I have another question. Okay. So when somebody who has a vagina enjoys that sensation of being filled up and they maybe use, they're a little bit more kinky and they have partners that will use sort of bigger objects to go inside of them.
[00:45:58] Michelle: Is there a worry around what, like, any kind of issue that could cause down the road?
[00:46:05] Michiko Caringal: Huh, okay. Like, with kink, like, I don't really think it's, I don't think it's a health hazard per se. I mean, I'm not familiar with how, like, for example, like, I just don't know. I mean.
[00:46:25] Michelle: Because there are those really big, big penises. I don't know if you've ever, like, seen them. They're, like, massively big, right?
[00:46:31] Michiko Caringal: Yeah, yeah.
[00:46:32] Michelle: And so I guess, yeah, you probably have people coming to you who have really, like, vaginas that are really tight.
[00:46:40] Michiko Caringal: Yeah.
[00:46:40] Michelle: And then I guess there's also the opposite.
[00:46:43] Michiko Caringal: Right, right. Yeah, so the opposite there is. Like if you're at the end of the spectrum on both sides, yeah, there is going to be problems. You know, there's going to be symptoms that where it will affect your function, whether it's bladder, bowel, you know, uterine, like anything, penile, like anything. So prostate too. So I think there's a lot of things to note and just be really considerate about if you're doing any kind of sexual activity that may harm your body. But, you know, just listen to your body. I think that's my number one thing.
[00:47:17] Michiko Caringal: I mean, just listen to your body.
[00:47:19] Michelle: Yeah. Are there any books for people who maybe aren't quite ready to go to their doctor or make an appointment with somebody like you? Do you have any recommendations for either a book or a website or an app that might be a nice little step towards learning a bit more about what could be happening for them?
[00:47:47] Michiko Caringal: Yeah, that's great. My recommendation is because I actually used to experience sexual dysfunction. I had pain with sex. That's why I became a pelvic health physiotherapist. So when back in the day, there was really nothing. But now there's a lot of things like, you know, pelvic health support in Canada or in BC. I think it's an organization in eastern Canada. There's lots of forums to look into, you know, just ask questions.
[00:48:19] Michiko Caringal: I think there's books are very good as well. But I think it's, for myself, it's really hard to just read about all these like, informations. I find it overwhelming. So it's very clinical. Yeah, that's why I like the fact that you said, you know, apps and stuff, because there are podcasts like yours, that are like, really great. So just casually listening to them is really good. And giving a call to a friendly pelvic health physiotherapist is also nice, just a 15 minute free consultation.
[00:48:51] Michiko Caringal: They should be able to provide that to you, which just because, you know, you just want to build rapport and see if they are a good match for you. Pelvic health physio is such a private and intimate therapy that you just don't want to just go to anyone.
[00:49:07] Michelle: Yeah, and you just and you also don't want to go with this mainstream idea that you should be just do your kegels.
[00:49:15] Michiko Caringal: Yeah, no, no. Right? Michelle, no.
[00:49:18] Michelle: Right. I know. I know. Okay, so don't do that.
[00:49:22] Michiko Caringal: No, don't do that. Don't do that. Don't do that. No, you're going to give me nightmares. No, just don't do Kegels just because the media tells you to. No. Yes. Yeah, yeah. So, yeah, you just have to know if Kegels are actually right for you. If they are, then great.
[00:49:39] Michelle: Exactly. But you need to have somebody who is trained in working in this area to give you that information.
[00:49:47] Michiko Caringal: Yeah, totally.
[00:49:49] Michelle: Right?
[00:49:49] Michiko Caringal: Absolutely. Yeah. 100%.
[00:49:50] Michelle: Yeah. Any last thoughts?
[00:49:54] Michiko Caringal: Oh, last thoughts.
[00:49:55] Michelle: About pelvic health that you want to put out into the world that maybe I haven't asked you about?
[00:50:03] Michiko Caringal: Yeah. Hmm. You know, meeting every one of my clients has changed everything for me. You know? I think I am so grateful for doing my job. I'm so passionate about my job. Each individual has taught me what the journey of pelvic floor pain or dysfunction is to them and how what's important to them. It was interesting. Each
[00:50:33] Michiko Caringal: individual has a different goal. One person has told me, I want to learn how to do a handstand and that's what I want to do. And I was like, okay. And the other person's like, I want to be able to have sex for a penetrated sex for two hours. I'm like, okay. Like there's so many different goals, you know? And I'm like, wow, like everyone's desire is so different. And so physiotherapy has changed my life by opening my brain. and just being like, okay, let's be creative. And physiotherapy, pelvic health physio is not just
[00:51:06] Michiko Caringal: one size fits all. You have to really understand what that individual, who that person is and wants. And I think that, you know, meeting each person, like I always say, has changed everything for me.
[00:51:20] Michelle: Yeah. And I bet that given that you have experienced pelvic pain yourself, that it gives a, I don't know, I think just an empathy and awareness. How do you feel that your experience with pelvic pain has impacted your practice?
[00:51:45] Michiko Caringal: Yeah, it's such a huge impact on my practice because when a 19-year-old girl or a boy comes and or a transgender individual comes into my clinic and says, I cannot have penetrative sex because I feel pain and I can empathize. And it has really, it makes me understand that individual in a whole next level.
[00:52:14] Michiko Caringal: You know, the impact it has on the social life, how self-esteem, body image, everything. So I really truly believe that this is something that has impacted my life and my job and how personally and professionally invested I am. Yeah. Yeah.
[00:52:32] Michelle: Yeah, because is this why you pivoted into pelvic health physio? Really? Because you were in bioethics.
[00:52:40] Michiko Caringal: Yeah. And I was doing physio and I was doing, I just took my bioethics degree in the middle of it all. And I really focused on mental health and consent. And then I went into physiotherapy, more management. And I was like, wow, like I really need to go to pelvic health physio. So I did a lot of more training in pelvic health physio. And then I just opened up my clinic and I just went from there. Like, and I just went straight shooter. So.
[00:53:08] Michelle: Amazing.
[00:53:09] Michiko Caringal: Oh, thank you.
[00:53:10] Michelle: Michiko, where can people find you?
[00:53:12] Michiko Caringal: Oh, of course. I would love to hear from anyone on my website, www.happydownthere.ca. Or just emailing me at info@happydownthere.ca. Or just give me a shout. So check me out.
[00:53:29] Michelle: Or follow you on Instagram because you're super fun to watch. Michiko has great stories.
[00:53:35] Michiko Caringal: My Instagram, happydownthere.ca. That would be great. Follow me and we can chat and just I can DM you.
[00:53:43] Michelle: Yeah, and maybe you'll catch her on a skateboard.
[00:53:46] Michiko Caringal: Oh, my God, totally. That's all I do. And my pitbull mochi.
[00:53:51] Michelle: Oh, my God, I love that. And I'm just going to remind people to check out my Instagram page at... getsome_podcast. Follow me. And you can email me at Michelle, M-I-C-H-E-L-L-E at GetSome.ca with questions, feedback, and topic ideas that you want to hear about. Michiko, thank you. You're amazing.
[00:54:20] Michiko Caringal: Thank you, Michelle.
[00:54:20] Michelle: And we are all going to come off of this podcast with bigger brains and a better understanding of our bodies.
[00:54:31] Michiko Caringal: Thank you so much, Michelle.
[00:54:33] Michelle: Thank you. Bye.
[00:54:36] Michiko Caringal: Bye.
[00:54:37] Michelle: If you have a question, a confession, or an inspirational story, send me an email to the confession booth at michelle@getsome.ca. and you just might hear it on the air. I hope you enjoyed GETSOME. If you'd like to listen to more episodes, subscribe to wherever you like to listen to podcasts. And until then, be kind to yourself, be curious, and when you're ready, your sexual journey will unfold.
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