The Pleasure Prescription with Dr. Dee Hartmann

Welcome everyone back to the vocal pelvic floor. I am here today with Dr. Dee Hartmann. Welcome.

Dee Hartmann PT DPT (00:06)

Thank you. It’s an honor to be here. Thanks for the invitation.

Dr. Ginger Garner PT, DPT (00:10)

Yeah, absolutely. I’m so glad that you’re here. ⁓ Dee is a, I just want to introduce her to y’all for a second. So she is such a trailblazer in women’s health ⁓ and sexual health and in pelvic health also in general. She has a doctorate in physical therapy and over 27 years of hands-on experience. And she’s helped thousands of people overcome pelvic pain and reclaim their pleasure.

Dee co-created the first national certification in pelvic physical therapy and co-authored groundbreaking research on vulvar pain. Such important stuff. After retiring from clinical practice, she co-wrote the book, The Pleasure Prescription, and I would hold the book up, but it’s at my office. Hold it up for us. Yeah, I keep all my books in my clinical office and I’m in my other office, so ⁓ I don’t have it, but thank you for showing everybody.

Dee Hartmann PT DPT (00:56)

I can walk without, I happen to have one right here.

Yep. wonderful.

Thank you for that one.

Dr. Ginger Garner PT, DPT (01:08)

The pleasure

prescription, a surprising approach to healing sexual pain, offering a powerful new path for women ready to move from pain to pleasure. Welcome, Dee.

Dee Hartmann PT DPT (01:19)

Yes,

thank you, thank you, thank you for the intro.

Dr. Ginger Garner PT, DPT (01:23)

So, ⁓ to the listener, what if the key to healing sexual pain wasn’t just medical, but pleasurable? So today on the vocal pelvic floor, we’re talking with Dr. Dee Hartmann, a pioneer in pelvic health who spent nearly three decades in this space helping women move from pain to pleasure. She’s going to be talking about simple, powerful techniques you can start using right now to reconnect with your body.

reduce discomfort and rediscover intimacy on your own terms. So whether you’re healing from pelvic pain, feeling disconnected from desire or just ready for more ease and joy in your sex life, this episode is for you. So let’s dive in.

From your years of experience, mean, what would you say are foundational techniques that anyone can start using to improve their sexual health? Because I know there’s like specific details, but I know you probably have in your bucket foundational pieces of that.

Dee Hartmann PT DPT (02:29)

Well, interestingly, in the course of my practice, and again, I specialized in the treatment of women with chronic vulvar pain, typically vulvodynia. I came on the scene, it was just really being diagnosed and named. So that’s really where I spent my time. And I found that there were a number of things that I could have my patients do prior to me doing any work at all that helped decrease the pain palpable just at the opening of the vulva.

⁓ It’s five exercises. I created a video right before I retired because I really wanted to leave something out there primarily for physicians. Because as you know, as a women’s health PT, if you’ve dealt with this, you’ve had all too many women come into your office and say, I have seen so many physicians. They all want to stick this massively huge speculum in me. I cry, I wince, they do it anyway. And then I go home and I cry for two weeks. I have pain for two weeks.

It’s terrible. So I wanted to leave something primarily for physicians prior to any type of internal assessment that women could do to begin to help themselves decrease pain. ⁓ There’s a video, the video is available on YouTube under my name if you’d like to look at that. ⁓ But it’s five very simple exercises. It’s deep abdominal breathing, deep diaphragmatic breathing, excuse me, to calm the nervous system.

⁓ stretching of the hip muscles in all directions. ⁓ There’s a Uracus pull, a pull in the lower abdominal that gets into fascial and visceral tension down into the pelvis. ⁓ I have them do active bridging and back down. And I also have them do active pelvic floor muscle exercises. And every time I would do that with a new patient, I would have her come in. I would assess again with my finger at three, six, and nine where her pain was.

Dr. Ginger Garner PT, DPT (04:17)

Yeah.

Dee Hartmann PT DPT (04:26)

And I would check each time she did each of those exercises to see if there was a difference. Sometimes there was, sometimes there wasn’t, sometimes some helped, others didn’t. But I really found over time that those were the five things that women really can do. Because that’s really, that is the baseline of how I treated patients. I didn’t fix anybody. I didn’t fix anybody.

Dr. Ginger Garner PT, DPT (04:47)

You know, what you’re saying is so important. I just want to draw out several kind of key points there. One is that you’re acknowledging that everyone’s an individual and not everything is going to work for everyone. And sometimes it’s only one thing that works for that person or two things, which is why having multiple foundational techniques is good. And you also spoke to the specificity, like…

individualization of trying these different movements and different patterns and realizing that, know, for ⁓ some women, you know, relaxation happens in different ways. ⁓ You also gave a nod to the fact that just because someone has pelvic floor tension doesn’t mean that they’re avoiding using the muscles in that area. Yeah.

Dee Hartmann PT DPT (05:37)

Yeah, then that’s where I sometimes take a hit from some of my colleagues here in the States. I started my practice early on when I opened my clinic ⁓ and went and worked with Howard Glazer. And I know if you’ve read about Howard Glazer, he was a psychologist in New York City and he had women with vulvar pain come into him and he’d give them a vaginal sensor and it wasn’t one of the teeny tiny ones we do now. Say go in the bathroom, put this in, leave the cord out and come in and I’ll…

check and see what’s going on. And lots of people didn’t like him. Lots of people had problems with how he did things, but he really is the one that brought that overactivity to the forefront in women with vulvar pain. And he had great results. So that really had an impact on how I treated my patients because I saw that just with that normalization of pelvic floor muscle function, they were able to do better. Now, obviously as a PT, we do all sorts of things and we look at

the whole body and take care of everything, not just the pelvic floor. So that’s how that kind of got integrated into my practice from the early stages.

Dr. Ginger Garner PT, DPT (06:48)

I love hearing the early stories and you just gave me a flashback to when we were using the sensors over 20 years ago, like remember of the big, we had this giant computer screens and the monitors were like, know, two feet deep, it seemed like, you know, and that was so fancy and high tech back then. ⁓

Dee Hartmann PT DPT (06:56)

Yeah.

You

Right, right. Well, yeah, and when

I started with Howard, we didn’t have ⁓ MS DOS now. were still in what was it? HDI? I know what I can’t even remember what it was. What it was before we’re doing now and I used to you had to type in the certain things and I used to swear because I couldn’t do it. Was really bad.

Dr. Ginger Garner PT, DPT (07:16)

you

Right. Pull it up. Yeah. Yeah, it

reminds me the first time I saw a mouse, I was like, wow, that’s fancy.

Dee Hartmann PT DPT (07:30)

my god, how far have we come? well.

Dr. Ginger Garner PT, DPT (07:34)

So the good thing is,

we’ve been, and in those early days, was pretty, I mean, it wasn’t rudimentary, that was high tech for us back then, but pelvic PT has been around for a while. Now, relatively speaking, it’s brand new, right? In the history of healthcare, but it has been around for a while. And so one of the truths I wanna pull out from what you just said is that,

We don’t just evaluate a pelvic floor as a pelvic PT. And I think that’s a misconception. And hopefully we can clear that up as a listener that if this is the first time you’ve been introduced to pelvic floor PT or pelvic health in general, you’re like, you know, only just do that. I have back pain. I can’t go to them. It won’t be applicable. It’s very applicable because sometimes your back pain is pelvic floor stuff, or sometimes your pelvic floor stuff is hip or further up in the respiratory diaphragm or

This is the vocal pelvic floor all the way up into the jaw and the voice. Yeah. Yeah. And we want to be able to evaluate those things accordingly. I love the phrase moving from pain to pleasure. And you talk about that a lot, moving from pain to pleasure. And there’s also this fine line. I want to come back and kind of address that later as we move deeper into the sexual health realm. But what are some…

Dee Hartmann PT DPT (08:30)

Yeah, we’re all connected. We’re all connected, you know, and you can’t

Dr. Ginger Garner PT, DPT (08:56)

first practical tips that were steps that someone can take at home to begin that journey to move out of that pain, place of pain and back towards pleasure.

Dee Hartmann PT DPT (09:06)

Yeah, you know, it’s really interesting and I’ll put this in here now. ⁓ I talked about sex from like way back. Way, way back I always talked about it. ⁓ But I’ve realized in hindsight I didn’t do nearly enough because I didn’t talk about what you’re talking about right now. know, when we’re talking about pleasure, there are all sorts of types of pleasure. know, there’s research out there that asks people to talk about their pleasure and they’re like,

My sex? No, no, not sex, but pleasure. What do you do for pleasure? And people are kind of clueless, because we don’t talk about general sensual pleasures. Right, so there’s sexual pleasure and there’s sensual pleasure. And sensual pleasure is what we need to do every single day. Regardless if we have pain, if we have depression, if we have anxiety, it’s really stopping

Dr. Ginger Garner PT, DPT (09:46)

Isn’t that sad?

Dee Hartmann PT DPT (10:03)

to look at the gorgeous clear blue sky, to hear the birds chirping, to listen to a baby giggle, whatever the case, to feel your skin and how wonderful your skin feels, or to smell something luscious cooking on the stove. Those things, increase endorphins, those things just in and of themselves make us feel better. So many times, how many times do you leave your house, you get in your car in your garage,

You drive to work, you pull into a parking garage, you get out, you go inside, you’re never outside, you’re never exposed to the sunshine, you’re never exposed to the breeze, you’re never exposed to the rain. And we do, you know, this all too often, you know. It’s easy. never, there’s never a shortage of it. It never expires and it never runs out. But you have to literally just take those few minutes to appreciate.

the beauty that’s out there and it’s everywhere. People may think it’s not everywhere, but it is there.

Dr. Ginger Garner PT, DPT (11:07)

It is, it is, because

I will say this morning, I was parked outside, so not in garage, so I went out, got in my car, it’s drizzling rain, I think about the way that I got dressed, got out, get to work, get to the clinic, see patients this morning. ⁓ And there are all kinds of little tidbits of beauty along the way, even like misting on your face, you know? And for those of you who are like, she said this, but I wasn’t sure what she’s doing, if you’re not watching this on YouTube and you’re listening,

Dee Hartmann PT DPT (11:29)

Uh-huh.

Dr. Ginger Garner PT, DPT (11:37)

Dee was saying, we do this a lot and she held up her cell phone. And that’s, we are so, so we are so guilty of doing that. I will, I’m just gonna admit something right now. This is what I did. I finished my paperwork, my documentation. I was eating into my lunch hour. How many of us do that as clinicians? I’m eating into my lunch hour. Just, need to finish this documentation. Close my laptop, ⁓ go outside, head up the stairs out of my office. And what do I do?

Dee Hartmann PT DPT (11:57)

nothing.

Dr. Ginger Garner PT, DPT (12:08)

whip out my phone and check my email. I was just in my office finishing documentation on my computer less than a minute ago. And then I stop and do that. And I catch myself doing it. And I laughed and I put it back in my pocket. And then I went back and smelled the rain and the air, you know, got in my car, turned on music I love, and then sang my way home so I could get to this podcast, you know, to my office here. So yeah, you’re right.

Dee Hartmann PT DPT (12:26)

Yeah. There you go.

Yeah.

Dr. Ginger Garner PT, DPT (12:36)

the beauty is we can shift from something painful and that is like emotional pain, not just the physical pain that can happen in the pelvis, is shift that mindset towards what we can pull out of it. ⁓ Like we’re just coming out of the holidays and I had, ⁓ who doesn’t have stress at the holidays? And so I had a particularly stressful ⁓ holiday, stressful holiday.

Dee Hartmann PT DPT (12:56)

Yeah.

Yeah.

Dr. Ginger Garner PT, DPT (13:05)

And as I was talking to a friend, ⁓ I began to shift out of that mindset of, that was so heavy to finding some humor in it and some lightheartedness in it. And also seeing the lesson that we look back 20 years later or five years later or five minutes later and go, that didn’t require the attention that I thought it required or I didn’t have to feel as stressed. So that is a really great way to move out of it, which kind of

brings up mind-body stuff. Like, that’s what we’re saying, right?

Dee Hartmann PT DPT (13:37)

You know, it really

is. And it really is what we perceive. I mean, if we, there was just a great, there was just a quote that I saw on social media. ⁓ Trauma is a, and I’m just going to, sorry, I’m going to look at my phone here because I want to quote, I took a picture of it and I want to make, trauma creates autonomic nervous system dysregulation. It is not an identity.

Dr. Ginger Garner PT, DPT (13:56)

Yeah.

Dee Hartmann PT DPT (14:07)

Trauma or anxiety or depression or name your whatever dysfunction Trauma creates an autonomic nervous system dysregulation your nervous system gets really cranked and Twisted and isn’t doing what it’s supposed to be doing but that trauma is not your identity Because I think so many people who have have pain who have tension anxiety

Dr. Ginger Garner PT, DPT (14:07)

say it again, say that again.

Dee Hartmann PT DPT (14:36)

sexual dysfunction have that irregularity in the central nervous system that’s creating and causing the problem. But instead of really trying to fix that and get that back on its wheels the way it should be going, they take and they hold that identity instead. And I think that’s something that we as PTs can work beautifully.

with patients, we should be able to do that. We are very physical, that’s what we do, but we also are very multimodal and just getting those little things in with what we do makes such a difference.

Dr. Ginger Garner PT, DPT (15:15)

Yeah, so body awareness, mind-body approaches are incredibly powerful in healing sexual pain, pelvic pain. So if you could identify, what would be a go-to if someone, because that thing, what you just read is so important, trauma is not your identity, but your body doesn’t necessarily pick up on that memo.

and it can hold things when even your mind is saying, please don’t hold onto that, and you’re doing your therapy and working through it, your body is like, no, we’re still gonna hold onto it. So what have you used ⁓ that helps people reconnect with the pelvic area when they’ve been through that?

Dee Hartmann PT DPT (16:02)

That’s a good question. ⁓ I always started out just with really basic anatomy to help them have an appreciation that they weren’t just crazy, that this wasn’t just on their head, that the trauma that they’ve experienced, anybody who has chronic vulva pain has had trauma, period, end of story. You can’t have problems with painful vulvas and painful sex without having some trauma related there. Trying to show them the basic anatomy of what is going on in their pelvis.

how it works, explain to them how it works, show them how it works, and then help them have that understanding of the physical function. ⁓ To me, that’s bringing it out of the psyche and into the, ⁓ okay, they don’t look at their vulvas they don’t like their vulvas, they don’t want to touch their vulvas, they don’t want anybody else to touch their vulvas, but by doing and using what we started with, the five exercises,

They may have pain, you know, six, seven, eight, nine out of 10 around the vulva, but we could do these exercises. They could be back in their bodies and by doing these very simple things, reduce that pain. I’m suggesting that it took it away. Absolutely not. But 99.5 % of the time, their pain would decrease, giving them some agency and ownership of like, oh, this isn’t in my head. I just did these really silly exercises.

and it feels a little better. So that getting out of that woe is me, this is all in my head kind of mentality into that basic anatomy I think was what was really important.

Dr. Ginger Garner PT, DPT (17:28)

Mm-hmm.

Can you talk us through an example of that? Let’s just say someone has vulvadenia and they come in. I mean, you could think of thousands of cases like this. So if we could kind of manufacture a typical case where someone comes in, how would you take us through that little lesson, that anatomy lesson, and then maybe a basic movement or relaxation exercise?

Dee Hartmann PT DPT (17:41)

and prepare those for the next meeting.

Dr. Ginger Garner PT, DPT (18:02)

So if you’re not watching this on YouTube, I would encourage you to go watch it on YouTube as well, but we’re gonna do our best to talk you through it if you’re just listening.

Dee Hartmann PT DPT (18:11)

Yeah, you know, ⁓ this is I don’t know which number of pelvis this is in my house. Had to buy a number of them because I wore them out. ⁓ But would really just go through the instruction of the pelvis, the joint, the pubic symphysis in the front and the two layers of the pelvic floor with the clitoris, the urethra, the vagina and the rectum all at the midline. The most superficial, really small pelvic floor muscles almost form a triangle

of support around the vaginal opening and then continue almost in a figure eight pattern to come back and support the anus and attach back to the tailbone. If we get rid of that pelvic floor, believe me from the number of vulva pain patients that I saw that when I do this, go, oh, no, oh, what did you just do? Deep pelvic floor muscles are a lot bigger and broader. They start in the front on either side of the joint and they come back

Dr. Ginger Garner PT, DPT (19:00)

Yeah.

Dee Hartmann PT DPT (19:10)

and they attach to the coccyx or the tailbone. Much bigger and broader, but really help to support the organs in the body. The bladder sits right behind the pubic symphysis. The urethra, excuse me, the uterus is high behind that, and the rectum goes down and behind that. So it’s really important that these muscles work. When they don’t work or when there’s pain,

It’s most common for this perineal body. Let’s see if I can put the superficial pelvic floor back on here. That this part, this is a perineal body in between the anus and the vagina. When there’s overactivity in those pelvic floor muscles, this piece of the anatomy gets pulled up and in the pelvis. So if you will please take a mirror, which people don’t like to do, take a mirror and lay down. And if you can’t see this little piece of anatomy,

there’s a really good chance that your pelvic floor muscles are saying, leave me alone, stay away, I’m gonna get as tight as I can and keep you out of here because I don’t want anything here because it hurts. I talk a lot about that with physicians, with psychologists, with people I talk about because you can see it. If a physician puts a woman up in the stirrups and they can’t see the perineal body, don’t be.

Dr. Ginger Garner PT, DPT (20:17)

Mm-hmm.

Dee Hartmann PT DPT (20:33)

shoving yourself in there, the body is saying to you, stay away. So that’s how I start. That’s how I start.

Dr. Ginger Garner PT, DPT (20:42)

And I just

want to encourage women who are listening, that’s such a common ⁓ experience after many things that can happen. If you look at the rate of sexual trauma, domestic partner violence, ⁓ most women are going to end up giving birth at some time, not all, but most. ⁓ You’re going to have trauma. You’re going to have trauma, almost guaranteed. And if you manage to escape that, welcome to perimenopause and menopause and postmenopause.

Dee Hartmann PT DPT (21:11)

No.

Dr. Ginger Garner PT, DPT (21:11)

it’s something is going to happen down

there and you’re going to have to at some point take your pants off and get in front of a mirror and look and see what’s going on down there. So discard that stigma, discard, I’m not supposed to self-pleasure, discard all of that because you need to be able to do that to like maintain it. Like if you were changing the oil in your car, you’ve got to be able to lift the hood. So get used to it, like lift the hood. You’ve got to do this on your car.

Dee Hartmann PT DPT (21:27)

you

Great analogy. Yes. And thank you.

What I’m talking about isn’t really just women diagnosed specifically with vulvodynia, which we know is totally under diagnosed around the world. We have problems forever. And we have problems throughout the life cycle as vulva owners. It may start when you try to put that first tampon in. It may start when you try to touch with your finger, try to use the toy.

But it may also start after you have a baby or again during perimenopause when everything is changing and going wonky and then menopause, well there we are. However, I’m here to tell you that it can work and stay and you can stay pleasurably functional throughout all of those cycles because I’ve been there. So it is possible.

Dr. Ginger Garner PT, DPT (22:24)

Yeah, testify, testify, testify. That’s the encouraging message

I always wanna send ⁓ to my patients as well. And I’m so glad that you mentioned that because those of us who’ve done all that stuff and we’re living on the other side of it, ⁓ you can assuredly say you don’t need to be a pelvic floor PT, all right, to still get what you need out of your body, but you probably should see one.

Dee Hartmann PT DPT (22:47)

Right. Yeah,

100%. I think education goes so far. It just goes so far. Women are really, from my perspective, women are really able to help themselves if they can really understand how things work. If they have that sense of what’s supposed to happen, now they have to work to do that. And that’s where we get involved and help them with all of the thousands of things that we as PT’s do.

But they can, most of the time, not always, we can’t get everybody where they wanna be. Wouldn’t it be nice if we could? Some of them can’t find their way out of pain and that’s the sad part. And then they need to find somebody else because we can’t help everybody. And that’s just the basic bottom line.

Dr. Ginger Garner PT, DPT (23:36)

Yeah, the

holistic way in which ⁓ pelvic practitioners, could be PT, could be OT, the holistic way in which we approach things, in which I know you have approached things your entire career, you can throw that ball pretty far in helping people overcome and manage. And I think that as the listener, it’s important to know that…

A therapist who’s trained in these techniques are going to also have the luxury of time to spend with you. At least 45 minutes. I spend hours, sometimes people come into the clinic and they’ve booked from out of state and it’s six, seven hours in a row for several days that they’ll book. But a therapist is gonna be able to spend the most time with you, unlike if you go in and you see a physician, they might have five minutes, seven minutes, 10 minutes.

but they’re also not gonna be trained in all the techniques that we’re trained in to be able to help you comprehensively handle it. One of the other things that I’ve thought of too is, we’ve been talking about how pelvic floor tension of course impairs sexual health, that kind of thing. But I wanna move into kind of like touch self-exploration, part of reclaiming pleasure. But I think one thing I don’t wanna leave out, cause we did touch on it’s all connected, voice to pelvic floor

Dee Hartmann PT DPT (24:39)

Yeah.

Mm-hmm.

Dr. Ginger Garner PT, DPT (25:00)

and even below that, all the way down to the feet, it’s connected. But we don’t often touch on posture. And I think, you know, I think as a listener, if I was hearing this topic for the first time, I’d be like, posture, what does posture have to do with sex? What does how I stand have to do or what my desk chair has to do with, you know, how things are gonna go in the bedroom? Can you speak to that a little bit?

Dee Hartmann PT DPT (25:25)

Well, I mean, again, we’re all connected. ⁓ And we know that the pelvic floor muscles are part of our core muscles. And if our core muscles in general become dysfunctional, weak, or we’re not using them as we should, the pelvic floor muscles can go along. I mean, the opposite, obviously, of that overactive pelvic floor is that underactive pelvic floor that may leave women leaking urine or having issues with defecation or emptying their bowels.

But it all has to work together to be normal, to hold us in a posture that keeps us where we need to be. It’s very difficult with aging because that’s kind of the worst piece of it. But it has to be, it’s not unlike central pleasure. We have to be aware of it. We have to be aware of being able to hold our shoulders back, of trying to hold our stomach in, keeping our shoulders over our hips, over our knees. And I think, again, it’s all a part of the whole.

And that’s kind of where we need to go with

Dr. Ginger Garner PT, DPT (26:29)

You know, I had a question yesterday from a patient too, because those of us who’ve been in the therapy space, and before I was in the therapy space, I was in the sports medicine, athletic training, you know, personal training world. So I’ve been in fitness or therapy like, you know, 40 years. Yeah, a long time. ⁓ And you remember way back when, when everybody was wearing like leotards and doing step aerobics, right? Remember that?

Dee Hartmann PT DPT (26:45)

Hold on.

I remember doing ⁓

Dr. Ginger Garner PT, DPT (27:00)

Right? I taught classes like that. ⁓

Dee Hartmann PT DPT (27:00)

it.

Dr. Ginger Garner PT, DPT (27:04)

And we were, this was a, this patient is in her 60s. So she would have come of age during that time as well, where I’ve had to work really hard at teaching her how not to guard and constantly brace the abdominals.

Dee Hartmann PT DPT (27:23)

Yeah,

yeah, and I think dancers are the same thing any kind of any kind of athletics skaters You know, yeah, it’s it’s a normalization and you know, yeah, and I’ll leave I’ll leave the rest to you But you’re you’re right it we have to we have to be in balance and that’s and that’s that’s key and we have to be able to move so many times you get so tight and and into that

Dr. Ginger Garner PT, DPT (27:27)

Yes.

Dee Hartmann PT DPT (27:51)

holding posture. I’m a big advocate for stretching, overall stretching, on a regular basis. Whether you have pain or not, everybody should be doing it as they age. I think it’s really important.

Dr. Ginger Garner PT, DPT (28:04)

Yeah, ⁓ so what happened, you with that patient to speak to what you’re talking about is when I was doing imaging with her, ultrasound imaging, so musculoskeletal ultrasound imaging, which several therapists, know, the many therapists use and sports med too. But what was happening just to speak to the rigid abdominal wall and the importance of posture is that she was holding

the upper part of the abdominal so hard that no matter what task she did, even if she was just trying to speak, it was a downward pressure gradient, just pushing the bladder down and of course leakage, right? That kind of thing. And pelvic pain, painful intercourse, she was having dyspareunia, so painful intercourse. So all of that had to be retrained to let the belly go, to just breathe and be fluid with it, to let posture kind of organically happen.

Dee Hartmann PT DPT (28:41)

Yeah. Right. Right.

Dr. Ginger Garner PT, DPT (29:01)

instead of thinking we need to hold something, but that process has taken about 12 weeks, which isn’t long. If she’s been doing it for 30 years, okay, 12 weeks is not that bad. But if you are holding the abdominal wall rigidly, that can of course connect down into the pelvic floor. So talking about touch and exploration and movement practices for somebody experiencing pain,

Dee Hartmann PT DPT (29:08)

Yeah.

Dr. Ginger Garner PT, DPT (29:30)

and numbness, what’s a gentle way to start reintroducing touch or exploring pleasure safely?

Dee Hartmann PT DPT (29:36)

Sexual pleasure, I’m assuming you’re talking about, yes?

Dr. Ginger Garner PT, DPT (29:39)

Yeah, you know, but I guess sometimes it starts further away. Like I’ve had patients who can’t even touch their abdominal region, like touching their belly, maybe a C-section scar is too sensitive, you know, that kind of thing. Then moving down further, when I mentioned the mirror, they’re like, I don’t know if I can do that.

Dee Hartmann PT DPT (29:46)

Bye.

I

mean, desensitization from whatever area, I think, is the place that we all start and to begin to re-regulate our brains to what pleasurable touch feels like. Because it may be that someone was pushed or shoved and any time any of this part of their arm is touched, they hyperventilate and they go into fight or flight because of that memory. So it really is just that desensitization of

anywhere on the body that’s a problem. And stories are so diverse, you know, of how people got the way they were. I’m just, always have been a big fan of what you’re talking about with deep diaphragmatic breathing. You know, if people have a sense that they may have this problem, if they just look in a mirror and take a deep breath and see what happens, you know, and if when they take a deep breath, their shoulders go up or their chest comes out, chances are,

There’s something going on down below that’s distracting the respiratory diaphragm that’s restricting it and not allowing it to go down. And we really need that, not only for pelvic floor muscle function, because pelvic floor muscles go the same way, but from a visceral perspective, that deep diaphragmatic breathing on a regular basis also helps to keep all of our abdominal viscera as mobile as it should be. And that’s really important.

Dr. Ginger Garner PT, DPT (31:02)

Yeah.

Mm-hmm.

Dee Hartmann PT DPT (31:22)

When we get so stiff, that stiffness can be from muscle, but it can be from fascia, can be from viscera, it can be from joint dysfunction. I mean, it can be from all sorts of things. So it really is just figuring out where it is and as you’re doing with this woman, just continuing to work with her.

Dr. Ginger Garner PT, DPT (31:29)

Thank

Yeah, one of the things that I see a lot is in working with patients with endometriosis. And of course, my last season on the podcast was dedicated solely to endometriosis. And this is a continuation of that in discussing the importance of endo. But when we talk about those patients who’ve had endo, those women who have had endo, ⁓ their body doesn’t get the memo, even if they’ve had expert excision surgery, their body does not get the memo that

that bowel endo or thoracic endo or wherever the endo was, bladder, rectum, wherever the spaces were that it existed, yeah, that it’s now been excised. And their whole abdominal region is still guarding. So if you’re feeling that, and you don’t have to have endo to feel that, you could just have straight up back pain, pelvic pain to feel it. But if you’ve had endo, you know this feeling. You know this feeling of things guarding when…

Dee Hartmann PT DPT (32:14)

Yeah, I’m one of the right now.

Dr. Ginger Garner PT, DPT (32:35)

you didn’t give it permission to guard and your body’s just doing that, even if you’ve had excision surgery, which speaks to the importance of having rehab after, particularly to regain sexual function. So when you were describing the importance of diaphragmatic breathing, I just thought to myself, you know, does the audience, does everyone, has everyone really truly experienced the freedom that diaphragmatic breathing gives you? Because, you know, if you

If you’re listening now and you are not driving, don’t take your hands off the wheel if you’re driving and listening to this, but if you stack your hands on top of each other about a foot to 18 inches apart and you inhale and you move your hands down at the same time, and then you exhale and your hands come back up, that’s your diaphragm on top and your pelvic floor on the bottom. And that’s what should happen. But too many patients can’t do that. They’ll take an inhale.

Dee Hartmann PT DPT (33:27)

Yeah.

Dr. Ginger Garner PT, DPT (33:33)

and I’ll be doing imaging with him and nothing moves in the pelvic floor.

Dee Hartmann PT DPT (33:39)

Yeah, and yeah, what I always try to do or did in my practice was have people put their hands on their lower rib cage and then take a deep breath. Sometimes they would take two deeper breath, obviously, as you know, and you have to say, no, that’s quite so big. But you don’t want the chest to go up. You don’t want their boobs to go up. I don’t want their belly to go up. I don’t have a problem with belly breathing, with yoga, and et cetera, et cetera. But with this, I’m pretty picky. I didn’t want the chest to go. I didn’t want the belly to go. I only wanted…

the ribs to come out like the opening of an umbrella. And as you breathe in, that umbrella is open. And as you breathe out, that umbrella gets closed. Because again, what that does is that’s bringing that diaphragm directly down and really transferring that pressure all the way down to the pelvic floor. ⁓ And that seemed to help. mean, there are thousand different things you can tell people, I’m sure. ⁓ But that was the one that I would use.

And you know, and as you do that, down regulate the central nervous system. You have calm everything down. It’s like, okay. That was nice.

Dr. Ginger Garner PT, DPT (34:44)

It’s really hard to

learn how to ⁓ umbrella breathe. And we’ll put these links that we’re mentioning, the link in the video that Dee mentioned in the beginning, and then we can put a link to umbrella breathing in there because there are multiple breath types. But if when you take an inhale, your chest is already rising, you already know the breath is going to the wrong place. And very, very rarely,

Does someone walk in with enough rib mobility to actually be able to do what you just said, Like, hardly any.

Dee Hartmann PT DPT (35:16)

Yeah,

and how many people are upper chest breathers that come into your office?

Dr. Ginger Garner PT, DPT (35:21)

like 100%, but they do not realize it.

Dee Hartmann PT DPT (35:24)

I know.

It’s really astounding and it’s something that’s just so simple, you know, see? Really? It’s like, yeah.

Dr. Ginger Garner PT, DPT (35:31)

Yeah, it seems so

simple. you know, people can’t, you can’t, it is possible to over-breathe and distend the belly so far, because I have seen that too, and I work with a lot of hypermobility, ⁓ people with hypermobility, and they have either leakage from hypermobility or prolapse from hypermobility, whatever it may be. And so it’s important to get that rib cage movement going with umbrella breathing, because everyone knows a diaphragm breath, know, belly comes out on the inhale, goes back in on the exhale.

And that’s how the pelvic floor and the diaphragm should move together on that stacked hand kind of piston analogy that we as clinicians know, but it’s not regularly something you talk about with friends over coffee, right? So you may not know about that piston breath, but it’s great to have the umbrella breath, because that’s the next level breathing that you need is umbrella breathing. And it’s ⁓ harder than it seems to master.

Dee Hartmann PT DPT (36:24)

Yep. Yep. I totally agree.

Dr. Ginger Garner PT, DPT (36:26)

Definitely.

So talking about, ⁓ one more thing on touch too, is that touch can be like anywhere. Maybe your hand is over for a lot of people. Yeah, we did it. Let’s talk a little bit about like a voice to all the way up from the jaw and then all the way down to the pelvic floor. Where would you have people start doing touch first?

Dee Hartmann PT DPT (36:37)

Yeah, we didn’t get down to the…

whatever feels good. And

⁓ I don’t know. They have to do something that they can do that feels good because if they’re not, they’re not going to do it more. And again, it may be that they just start rubbing behind their ear. It may be that they love having their hair played with. Yes, every time. ⁓ But just really finding what feels good first. to calm the central nervous system and increase those endorphins.

Dr. Ginger Garner PT, DPT (37:05)

Mm-hmm.

Mm.

Dee Hartmann PT DPT (37:20)

kind of go from there.

So there’s a very old process called Sense8 Focus that was used years ago and created to help couples who have sexual dysfunction. It’s basically a three step process. You begin by standing fully clothed with your partner and telling each other areas on your body that feel good to touch. No genitals, no breasts, no genitals at this time, but just finding a place that

feels good. And if your partner touches you somewhere that doesn’t feel good, begin to tell them, I don’t like that. I like this. I like behind my ear. I like my shoulder. I like my hips, but don’t go other places. The second step is doing the same thing. However, you’re adding in touch of genitals, still fully telling each other what feels good and what doesn’t feel good.

The third step is unclothed, where you’re now able to touch genitals, touch the breast, touch the vulva, touch the penis, the anus, wherever you want. But the same rules apply. You have to let your partner know what feels good and what doesn’t feel good. And you do these steps and you follow each step until you can do it and find pleasure in what you’re doing. It’s not uncommon.

You go through, have hugs and kisses along the way. You get to that undressed stage and lo and behold, you’re like, let’s, okay, yeah, let’s just do it. And that’s where we wanna be. So that’s a very old, that’s a very old, but very simple way of introducing that pleasurable touch into your relationships.

Dr. Ginger Garner PT, DPT (38:53)

Yeah

Yeah.

Well, it improves just basic connection so much because I think that we learn a lot of, you know, bad things or things that don’t work from watching whatever it is that people are watching, even just regular movies people are watching and thinking that things progress this way when they actually don’t and don’t work for everyone if they did for someone else. So it’s really good connector and helping, ⁓ you know, partners rebuild.

intimacy, pleasure in different ways, especially when there’s pain, when you’ve experienced pain.

Dee Hartmann PT DPT (39:39)

Right. Well, and again,

in doing all of that, I think it’s really important as with the education of the pelvis that we also provide the education for the female sexual organs. Talk about this. This is a clitoris. If you’re not on with this, you need to be on with this and take a look at this. This is an incredible anatomically correct model that we actually import from Germany. They’re made in Germany and have them here for sale. But it really helps us to understand the full

Dr. Ginger Garner PT, DPT (39:50)

Yes, let’s talk about that.

Dee Hartmann PT DPT (40:08)

anatomy of the female genital organs. This is like – I sure can. This is a two-part model. This is the vaginal opening. This is the urethra, and that clitoris sits right on top of that. I’m going to get rid of that because I just want you to see the whole of the clitoris. You know, they always talk about how clitoris is just a baby penis. I always get really mad. said, it’s even close to a baby penis. But the pink parts of this model

Dr. Ginger Garner PT, DPT (40:12)

Can you describe it to us? Okay.

That’s right.

Dee Hartmann PT DPT (40:39)

are analogous to the part of the penis that becomes hard and erect with arousal. We don’t really think there’s an erection with the clitoris, but that’s still a little unclear. The yellow part is the glands of the clitoris, or what people think of as the clitoris. It’s just that little nub that sticks out just below the bone in the pelvis.

But it connects with, you see this purple coming down, it connects with the vestibular bulbs. The vestibular bulbs, unlike this, do not get erect, but they get absolutely packed and filled with blood. So they begin to swell. They have all sorts of fabulous corpuscles, feel-good corpuscles, nerves in there that feel good. And the more arousal you get, the more pleasure you get from touching all pieces of this anatomy.

Now, the difference is that boys anatomy that they get to touch and do is all on the outside and ours is all on the inside. But that means it’s still there and it’s really, really important that the boys grow up learning to touch and feel their penis and feels good and they potty train and they’re really taught multiple times today what it feels like and how to use it. When they get aroused,

it’s great they know what to do. Not so much because the clitoris is primarily internal. Interestingly, these are the crura of the clitoris itself and it’s actually enclosed by the superficial pelvic floor muscles, bullispondiosis. If you’re looking, the clitoris sits right here.

Dr. Ginger Garner PT, DPT (42:23)

So describe that to the listener if they’re not viewing.

Dee Hartmann PT DPT (42:34)

Okay, on the pelvis. So that if you bring your finger right down the middle and you go far enough and you rub across this way, you can feel, this is the body of the clitoris, you can feel that clitoris. You might feel your pelvic floor start to, start to move a little bit. You might feel a little flutter down there. But the crura are actually encompassed and enclosed in these muscles just under, that are connected just under the arch of the pelvic bone.

Dr. Ginger Garner PT, DPT (43:04)

And describe

that for the listener, because if you’re not viewing and just listening, yeah.

Dee Hartmann PT DPT (43:09)

Well, think probably maybe the easiest thing to think about is that all both the the legs or the cruer of the clitoris and the vestibular bulbs are encased in muscle. But the muscle is very tiny and very small, but it’s still nonetheless encapsulated. So we can feel it when it gets aroused, it begins to swell, it feels good to the touch. So the muscle is there.

but it’s so thin. I’ve talked to number of people who’ve done the dissection that the pelvic floor, superficial pelvic floor muscles, I know, depends on who we’re dissecting and all that, but that they’re very small. we can, the point of the matter is we can still get, we can stimulate. We don’t just need to stay at that nub or that gland. We can stimulate here. We can stimulate here all the way down just underneath that pubic rim, or we can.

put our fingers just inside the vagina and feel the vestibular bone.

Dr. Ginger Garner PT, DPT (44:07)

So describe that other place, because you said this, what you’re describing, the clitoral legs, you know, as they come down, describe to the listener exactly then where that’s going to land for them. If they were like doing self-touch and exploration, but they can’t see you right now, where would you tell them to put their hands?

Dee Hartmann PT DPT (44:12)

Yes.

Mm-hmm.

If

you were doing this on your own, I would have you bring both hands down and feel, you can feel your pelvic bone in there, the hard bone in there. And if you go down just a little bit, you’ll feel that the bones on either side kind of go spread out, almost forming a V. If you follow that hard bone down just a little bit, and then you slide just inside and down,

That’s where these crura are. That’s where the legs are. But again, they’re more difficult to find. They’re smaller and they’re more difficult to get to. But the vestibular bulbs, which is where I’m kind of pushing to get people to go, is really easy because you can put one finger inside your vagina and just pull the other fingers down, slide it down on the outside and get that bulb in between your fingers and feel it and see what it feels like.

Now, we also have some great research now looking at vibration. don’t know if you’ve seen any of that research. It’s so exciting. Interestingly, the newest research was done by a urogynecologist in a sexual, she was doing a sexual health fellowship. she, prototype, the protocol for her study was to use just a little vibrator.

Dr. Ginger Garner PT, DPT (45:24)

Yeah, yeah, let’s talk about that.

Dee Hartmann PT DPT (45:46)

two or three times a week, three to five minutes for three months, not for sex, not for orgasm, not for arousal, but just to use it basically over this clitoral body, which is where the nerves, the clitoral nerves rest, and it improved quality of life, improved sexual function, and it was fabulous. It was fabulous.

Dr. Ginger Garner PT, DPT (46:12)

So pleasure

can be trained like a muscle.

Dee Hartmann PT DPT (46:15)

It can be trained like a muscle. Well, you know, it’s really just teaching our body what it feels like to be aroused. So many people have no idea what it feels like to be aroused. And that’s one way to it. You can do it in your house. You can do it fully clothed. You can be by yourself. You don’t have to have a gym membership or tennis shoes. It’s just feeling what’s going on there and knowing that, like any learned behavior, like any exercise, it needs to be

done at least on a regular basis and you’ll figure out where you need to put that vibrator that feels the best for you. At some point you’re going to say you know this is feeling even better and better I’m going to keep this until I have an orgasm and ⁓ okay then there you go. And we know that it improves pelvic floor muscle function so it’s just a no-brainer and it doesn’t matter your age it doesn’t matter what’s going on. did it I was fortunate enough

Dr. Ginger Garner PT, DPT (47:00)

Hahaha

Exactly.

Dee Hartmann PT DPT (47:14)

last year to be able to go to India and talk with them about that. And they have a horrible female sexual dysfunction problem in India from all sorts of cultural things. I did my best to say, just try this. It’s not invasive. It’s not sexual. It’s letting them do it by themselves, but it will help them. And I just recently got a protocol that they are doing. They are doing the study.

in India, so I’m very hopeful. And with anybody, this is the one thing that I talk about all the time. It’s so simple, and I think it can be so successful.

Dr. Ginger Garner PT, DPT (47:51)

Yeah, I think that that’s sometimes what we overlook.

mean, if we’re in this space, okay, we understand these things, but for the listener who thinks, just, you know, I have painful sex, it must be a part of aging. And I hear actually Doc say this too much to patients is, you have some pain there? well, you had a baby, that’s gonna happen. Or you’re going through perimenopause, that’s part of it. And I’m like, no, that’s not part of it.

Sex should never be painful. And it’s just so good to reiterate the truth that, yeah, pleasure can be trained like a muscle. It is a use it or lose it thing. And that’s why that regular, just like we have to work our bodies out, just like we have to change the oil in our car, you’ve got to maintain it. This is regularly scheduled maintenance.

Dee Hartmann PT DPT (48:39)

Yes.

I love it. Weekly, weekly maintenance. And again, her protocol was very, very loose. Was very, very loose and they still had great results with it, but you’ve got to do it. You know, it’s not expensive. You don’t have to, you know, you don’t have to go wait, you know, have a big training session. It’s very, very simple. And I can’t, I can’t, I’m very excited about it. I also did, did some, have done some work with this looking at pelvic floor muscle function.

with a rattle on orgasm, and this is a clitoral vibrator. So we’re seeing all sorts of impacts of what clitoral vibration can do to pelvic floor muscle function. I would love to see a study using vibration for incontinence patients for all sorts of issues. I think we can… Oh yeah, yes. This is a YNS.

Dr. Ginger Garner PT, DPT (49:23)

Yeah.

Right. Yeah. So D right now is holding up a device. So…

Dee Hartmann PT DPT (49:37)

This is a consumer product. It’s not a research product. They’re made in California. ⁓ It’s lioness.io, if you’re looking for it online, not lioness.com, because you’ll find a lot of pictures of baby lions. ⁓ But it’s a really, really, really cool tool that is helping us to understand what’s happening in the pelvic floor muscles with arousal, orgasm, and recovery. At rest, arousal and orgasm and recovery, ⁓ because we don’t know.

We don’t know anything. Let me restart – We really don’t know anything from the bottom up about female sexual function because nobody talks about it. We’re always told that this is the woman’s sex organ. It makes me so crazy. We know what happened from the top down. There is definitely input from the brain and I’m not beginning to suggest that there isn’t. But from a functional perspective, we need to help people understand that there are things down below.

that are happening that you can control outside of just watching porn. Okay. Yeah.

Dr. Ginger Garner PT, DPT (50:38)

Mm-hmm, so much, so much. So there are so many, there’s

wands, there’s dilators, there’s all these biofeedback devices and tools. ⁓

Get curious, right? Listeners, get curious about your body. Yeah, get yourself a handheld mirror or you can use your makeup mirror that’s on a stand. Because I will often when I’m teaching patients have them use that tool, whatever tool they have, there’s so many out there. Get curious about it and do a little research on those. And of course, if you’re curious and don’t know,

Dee Hartmann PT DPT (51:00)

Oh yeah, it’s just, yeah.

Dr. Ginger Garner PT, DPT (51:15)

I am sure if you contact Dee or if you contact us here at the podcast, we will tell you more than you want to know about all the different devices out there. ⁓ And then practice, you know, looking and seeing what’s going on. Practice that touch. Start with these basic, ⁓ just reintroduction, you know, to yourself, to your body, because you might be in your second decade, third decade, fourth and beyond and haven’t really understood the anatomy. So hopefully this really clears things up.

Dee Hartmann PT DPT (51:18)

Thank you.

Thank you.

Dr. Ginger Garner PT, DPT (51:45)

and also just destigmatizes it because just like you would, you know, wash your face or inspect a mole before you, you know, like, hey, I need to go to the dermatologist to check this out. Why aren’t we doing that, you know, with all bits and pieces of lady parts down there too, so.

Dee Hartmann PT DPT (52:01)

Well, you

know, and before we close, lady parts and bits and pieces, I have to tell you as you get mirrors out, and women will tell you all the time, I don’t like it, it’s ugly. Have you ever looked at it? Well, no, but I just know it’s ugly and it’s stinky and smelly and I don’t like it. The only thing that I can tell everybody without hesitation is that the only thing normal about the labia, the labia minora, the lips in particular, the inner lips,

The only thing normal about them is diversity. Not unlike your right hand or your left side hand, one being bigger than the other, one foot being bigger than the other, those labia can be very different and very different in shape. They can be really big, they can be really teeny, and all of that is perfectly normal. You aren’t supposed to look like what the women look like in porn and in the books.

Dr. Ginger Garner PT, DPT (52:57)

Mm-hmm.

Dee Hartmann PT DPT (52:58)

⁓ You know, there’s there’s a labiaplasty, I don’t know if you’re familiar with this, where women really go in and get their inner lips cut off. And the most popular plastic surgery for that is they want the Barbie doll where you can’t see it. And that’s not normal. That tissue is very sensitive to, to arousal as well. it’s part of the arousal network and we need it. We don’t want to be cutting it off. It’s very important. Yeah. Yeah.

Dr. Ginger Garner PT, DPT (53:17)

It is, part of the experience.

Yeah, keep that, that needs to hang around. So

are there any kind of, ⁓ cause we talked about like ⁓ somatic stuff, touch, tools, breathing, that kind of thing. But I think also like journaling, reflection practices, like uncovering emotional and psychological blocks around sexual pleasure. Is there anything that you use as a prompt or a journal or a tool or a phrase that you have women focus on?

Dee Hartmann PT DPT (53:34)

Mm-hmm.

You know, I really wish I could say yes to at least one of those things. And I think that when I was in practice, we mostly just talked about normal function and what it is and how it should feel. And so I can’t really suggest that I did have anything that I told them. And again, I will start where I will come here to the end where I started. I didn’t do nearly enough in my practice for these women.

Dr. Ginger Garner PT, DPT (54:02)

Yeah.

Dee Hartmann PT DPT (54:20)

Again, I talked about sex, but not anywhere even close to what I’m doing now. I really didn’t really get into this until my dear friend and co-author wrote the pleasure prescription. And now that’s where I’m, I am really trying to get people not to make the same mistakes I made. That’s my most important ⁓ personal purpose for being out and talking about these things.

Dr. Ginger Garner PT, DPT (54:39)

Mm.

Yeah, for the young women

in the next generations, ⁓ my kids are Gen Z and Alpha right now, is for them to be body positive, to be sex positive, to realize when they feel frustrated or discouraged, and whether it is a reflection practice or a mindfulness practice or journaling or talking to a therapist, because there are counselors, there are sex therapists, there are so many different resources available to us now that a part of that

Dee Hartmann PT DPT (55:09)

Yeah. ⁓

Dr. Ginger Garner PT, DPT (55:16)

could be pelvic PT, right, or pelvic OT, but then a part of it could be ⁓ sex therapy or sex counseling as well. ⁓ So if there’s, go ahead.

Dee Hartmann PT DPT (55:23)

100 % 100 %

No, just 100 % again, we’re very complicated. We’re very complicated beings And it’s not just physical and it’s not just psychological. It’s it’s everything all together. So yeah

Dr. Ginger Garner PT, DPT (55:38)

It’s all of it. It’s all of it. So if somebody

listening is ready to start today, they’re like, okay, I’m feeling so much better about this. What’s one thing, you know, or two things or three things you’d tell them to do this week to move toward more pleasure and less pain.

Dee Hartmann PT DPT (55:55)

⁓ using the senses first and foremost to get sensual pleasure because it’s gonna make them feel better in general. the second is to even before they get a vibrator, a vibrator would be my recommendation, is that they figure out that if they take their fingers down the middle of their pubic, down the middle of the bone in the front and they move it back and forth, that they’re gonna feel what’s happening.

in the clitoris and finding it. It may be the first time they’ve ever had that sensation and I probably most of them will be the first time they’ve ever had that sensation. But to begin to get a sense of very gently, very easily, they can feel what’s going on and then take it from there into any of the number of things that we’ve talked about. But getting a vibrator would be right on top of my list as well.

Dr. Ginger Garner PT, DPT (56:48)

I love it. love it. Dr. Dee Hartmann

thank you so much for being on the show today on this episode. Can you let authors know what some of your resources are? Where can they most easily find you?

Dee Hartmann PT DPT (57:00)

Hey, I am not on Instagram. The thought of having to do that every day makes, me a headache. So I basically am just on, I’m on Facebook and I’m on LinkedIn. I do have a website, Dee Hartmann Physical Therapy, if people want to reach out. My co-author is working on the Pleasure Movement, which is a new website. I think it’s still out there, but I’m not sure. And my email, I am, because I’m no longer in clinical practice, I’m not nearly as busy as you are.

I’m very happy to talk and to discuss with people if they want to shoot me an email or if they want to set up a call. That’s my gift back from what the honor that I’ve had in dealing. Having these women come in and talk to me all those years was a true honor. Sharing their most intimate secrets,

Dr. Ginger Garner PT, DPT (57:46)

Yeah.

Well, thank you so much for offering that and we will be putting those links in the show notes so that you can get in touch if needed. Thank you so much for joining me.

Dee Hartmann PT DPT (57:56)

Loved this. Thank you. I appreciate it. It’s great.