When Sex Hurts Part 2: What Healing Can Look Like With Dr. Heather Jeffcoat

Hello and welcome back everyone. We are here today with Dr. Heather Jeffcoat for a part two. Welcome back, Heather.

Dr. Heather Jeffcoat, PT, DPT (00:07)

Thanks for having me back, Ginger. Sorry I had to split at the last one. I think I got a patient, gotta go.

Dr. Ginger Garner PT, DPT (00:13)

Yeah, well, that’s why we do what we do. And we are responsive to that and totally understand, and I know our audience does too, but this means they get a part two. So for those of you who have not listened to part one, circle back and go get the full bio and all of the juicy details in part one. For those of you who don’t know ⁓ Dr. Heather Jeffcoat yet, she is a pelvic floor physical therapist and the owner of Fusion Wellness and Femina PT.

physical therapy in Los Angeles and has just so many accolades and amazing things that she’s done. Plus you can see in the background if you’re watching on YouTube her book, ⁓ which is right behind you. You wanna hold that up for the audience?

Dr. Heather Jeffcoat, PT, DPT (00:56)

yeah!

My second edition came out in March, last March, yeah.

Dr. Ginger Garner PT, DPT (01:02)

Yay, congratulations. Yeah, sex without pain. Fantastic. So we left off last time with talking about positions, sexual positions, biomechanical tips, reducing strain on the pelvic floor, you know, for people in pain. So that leads us kind of into a natural ⁓ part two of that question, which is about alternate pleasure pathways. And

Dr. Heather Jeffcoat, PT, DPT (01:05)

Thank you.

Dr. Ginger Garner PT, DPT (01:31)

finding pleasure beyond penetration. Now, we’re talking about, you know, talking about, you know, all genders, et cetera, but let’s get a little bit more specific about that because you teach that satisfying sex doesn’t require penetration at all. So what are some of those pleasure pathways? Let’s get nerdy a little bit for a second. What are some of those pleasure pathways that people with pelvic pain often overlook or they don’t even know about?

Dr. Heather Jeffcoat, PT, DPT (01:58)

Yeah. And that like, you know, just to kind of kick that off, it is a really important conversation that I have with patients that all pelvic PTs, OBGYNs, any provider that does any kind of pelvic care should have with their patients because what does sex equal for them? Right? Like is their goal even penetration period? Like, you you want to align your goals with their goals. but in the meantime too, if that is their goal and they still want to experience like pleasurable touch.

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

Yeah.

Dr. Heather Jeffcoat, PT, DPT (02:27)

but they’re afraid or fearful or have pain with penetrative intercourse, then yes, let’s talk about alternate pathways. So I think kind of the obvious one is that like direct clitoral stimulation over the clitoral glands, which is that little piece of the clitoris peeking out of the hood, right? It’s just a small part of the clitoris. ⁓ Kind of noting that for people who might be listening that aren’t providers, sometimes people think that is the whole clitoral structure, but it’s actually much larger.

and extends down. Yes, exactly. ⁓ so thankful for the visual aid, right? So the little hook part there at the top, that’s like the clitoral glands. And then you have like the legs down the side, which are like the outer part of the V and the bulb of the clitoris, which is the inner part of the V, the sort of like thicker bulbous looking structure. And so that whole thing can be stimulated, right? So not just the little clitoral ⁓ glands, the piece under the hood.

Dr. Ginger Garner PT, DPT (03:01)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (03:24)

But that can be stimulated either directly or indirectly because we have some patients that have clitoral pain. then of course they don’t want, or like hypersensitivity to the clitoris, that’s not a pleasurable sensation. So you don’t have to touch directly over the glands. You can also stimulate around the hood, moving it like up and down or back and forth or side to side or circles or whatever, not over the sort of like unexposed hood portion.

⁓ Also, if that moving of the hood is not ⁓ comfortable, too, you should definitely be evaluated by your skilled provider to see if there could be like adhesions or sometimes there’s little like pearls, they call them, that get stuck underneath that do need to be cleaned out for comfort. And sort of why people develop them, I don’t think is really known. Like I’ve had patients that get like dozens of little

Christali Pearls and their, they’re like, you know, vulvo vaginal specialist is like, have no idea why these keep forming. So, you know, only if it’s pleasurable, right? But that is one alternative pathway that we can experience ⁓ pleasure. And then going down over like the rest of the vulva. So thinking like that rest of the clitoris that you’re holding up there, which would be behind the labia that we see, like those outer lips we would be able to see at first glance.

Dr. Ginger Garner PT, DPT (04:25)

Mm-hmm.

Yeah.

Mm-hmm.

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (04:48)

So

it would be deeper to that. That can also be stimulated and be pleasurable for people, you know, either to touch or to vibration. So it doesn’t have to be like manual with hands or like oral stimulation. There’s also anal stimulation might be pleasurable for some people externally or internally.

breast and nipple stimulation is another erogenous pathway that, so like nipple and breast touch and play. Other erogenous areas like behind the ear, the low back, the inner thigh can really get people aroused and experiencing pleasurable touch. And then sometimes even just like massage.

Dr. Ginger Garner PT, DPT (05:39)

and just

sorry to interrupt for just a second, but I was showing ⁓ examples. So for those of you when Heather was like, there it is, the one you’re showing. Obviously, if you’re not watching on YouTube, swing back to the last five minutes and then you’ll see the models that I was demonstrating. But anyway, go ahead.

Dr. Heather Jeffcoat, PT, DPT (05:57)

Exactly, exactly. Thank you. ⁓ So yeah, so even just like massage can be really like arousing to some people. So just like a general erotic massage, whether it’s like with hands or with, you know, like a feather, like light touch kind of massage like that, it doesn’t have to be like a traditional massage that you might think of it in that sense. And it’s really, you know, what feels good to you. So it’s playing with some or all of those things and you know what

does not cause you pain, what does give you pleasure.

Dr. Ginger Garner PT, DPT (06:30)

I mean, we can, we have so many other questions to ⁓ get to, so we won’t dive into kind of the nerdy, geeky aspects of this, but there are also, this just, want the listener, want you guys to, ⁓ folks to just feel that sense of hope that there are other pathways there, because you’re.

pelvic floor PT, whomever you end up speaking to about this, can get a little bit more in detail about the different types of receptors that respond to whether it’s light touch, deep pressure, vibration at different Hertz frequencies. There’s a lot of great science out there to support these alternate pleasure pathways. So it’s a really exciting thing. It’s a very hopeful thing. And yeah, so just wanted to point that out.

Dr. Heather Jeffcoat, PT, DPT (07:04)

Mm-hmm.

Yeah, and I think

just, yeah, to know that your body is wired for pleasure beyond the vagina. So I think that’s really helpful to know. And you know, some of that may have like, you know, there was gender crossover for people there, but ⁓ you know, for folks, anally, if they have a prostate, if they’re like a signed male at birth, that can be another like pleasure pathway for them.

Dr. Ginger Garner PT, DPT (07:23)

Yeah.

Mm-hmm.

Yeah. Is there, are there particular, and this may be, you know, too specific, but I also think that ⁓ we need to de-stigmatize people coming in, sitting down with their pelvic floor PT, and thinking that talking about sexuality and preferences and pleasure is not a part of pelvic PT. I actually do get that a lot where they’re like, well, as a matter of fact,

They don’t check dyspareunia, painful sex, they don’t check any of that until they get in two or three sessions in and then they’re like, yeah, well, I didn’t want to mention it because I figured it wasn’t related, right? So are there any, are there any just ⁓ messages that you could share and or ways to kind of move beyond, I guess, de-stigmatizing really that aspect? And then the second part of that is,

you know, anything specific for ⁓ male pelvic pain in terms of higher tension or tone there, because we think about it a lot in terms of, you know, female ⁓ dysparenia, but I also want to just kind of toss that out there too.

Dr. Heather Jeffcoat, PT, DPT (08:57)

⁓ Just as far as being able to get that information that you need from the patient, like on visit one, how to help them open up.

Dr. Ginger Garner PT, DPT (09:05)

Yeah, guess, know, to just, you know, part of it is ⁓ also just creating awareness that talking about sexuality and preferences and pleasure is a part of pelvic PT instead of patients coming in and thinking they’re just something separate, right?

Dr. Heather Jeffcoat, PT, DPT (09:18)

Mm-hmm.

Yeah, so I have a couple of thoughts on that actually. So first and foremost, when I’m evaluating somebody, they always get pre paperwork like that they have to fill out. And so there’s usually questions on there that are asking about sexual function. So hopefully I’ve planted that seed before they come in. But then when I’m interviewing them in that first session, I set up, this is how our session will run. I’m going to ask you some follow up questions

clarifying

questions, ⁓ dig deeper into everything that you filled out beforehand so that we have a really clear picture of what is going on and what your priorities are. And then we’ll do like a two-part physical exam, kind of orthopedic, whole body screen, know, assessments there and followed by like a pelvic floor and like vulvovaginal assessment ⁓ or rectal assessment depending on what their problem is.

but I kind of verbally give that expectation. And then when I’m talking about their history, I say, you know, we’re gonna talk about bowel bladder and sexual function because one affects the other. So we kind of have to talk about them all together. And I just say it very matter of fact, and I haven’t had any pushback in my little, you know, preemptive spiel that I’m giving people, but you know, adjusting the sexual conversation based on their.

perceived comfort level with it. But honestly, I people are pretty open. They’ll just say like what their difficulties are, or they’ll just say that like, or they’ll start crying because they’re very upset that it’s a fact that they, ⁓ you know, have to deal with and it’s distressing to them. I just, I personally talk about it every time. Now, my other thought is, you know, for patients listening out there and also for pelvic PTs, like I kind of think if you’re a pelvic provider,

Dr. Ginger Garner PT, DPT (10:57)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (11:14)

You just need to be a good human. You need to be open to all types of conversations that your patients may have with you. You need to be open to perhaps their gender identity struggles ⁓ and just understand that that plays into possibly some of their bowel bladder or and or sexual dysfunction and or their complex chronic pain syndrome. You know, they have ⁓ life stressors, especially now.

that are heightened in our country that we just have to be really sensitive to. So please, just think pelvic providers in general, be good humans, like just outright, because I have seen like anti-trans comments from pelvic PTs. And I just think that why, like why are you in this field if you’re just not going to care for everybody? So, said my piece on that and, ⁓ we just really need to be supportive of everybody that walks in the room without judgment. And so,

Dr. Ginger Garner PT, DPT (12:10)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (12:10)

⁓ If you don’t have that at your core, you are going to make patients uncomfortable because you’re going to be projecting your beliefs on them in a clinical setting, which is completely inappropriate. ⁓ So, I hope I answered your question. ⁓

Dr. Ginger Garner PT, DPT (12:17)

Mm-hmm.

Mm-hmm.

Well, I think

it also depends on location, you know, across the country, across the world. Like, I’m in the South where that’s still very much a thought process of things being just segregated, right? ⁓ And separated, like not discussing and overlapping, or they’ve been dismissed so much.

Dr. Heather Jeffcoat, PT, DPT (12:51)

Mm-hmm.

Dr. Ginger Garner PT, DPT (12:51)

And they’ve been told the typical stuff that we hear all the time, you just need to relax. You just need to have a glass of wine and relax. You just need to accept that it’s age. You just need to accept that you had three kids and that’s the way it is. Yeah. ⁓

Dr. Heather Jeffcoat, PT, DPT (12:57)

Yeah.

Well, I get that in Los Angeles too though. So patients that are still being told those things. So, ⁓

you know, it’s just my sort of my belief that we are not supposed to do harm, right? Like we should be held to the same standard physicians should be held to and we should not be doing harm to our patients. They are coming to us for help.

So I think for any patients that are listening out there, you can kind of tell by going to a provider’s website if they have content on there that aligns with you. And if they don’t, then that might be a flag that maybe they’re not the provider for you. If they don’t have sort of articles on there that align with your problem, you know, like even just going back like someone that has pelvic pain or painful sex, if the only content they have on their entire website is

pregnancy care and urinary incontinence, then maybe they’re not the provider for you. Like maybe they just don’t really treat painful sex or that’s just not their passion and that’s fine. So I think you can really tell a lot by visiting them before you visit them ⁓ and just see if they align with your belief system, with what your problems are ⁓ and if, you know, there’s lots of ways to find out if they’re the right provider for you.

Dr. Ginger Garner PT, DPT (14:17)

Right, and I think for depending on where you’re listening, or if this is the first time you’re even thinking about pelvic floor physical therapy, it’s just to be aware that those questions are gonna be on the intake. It’s very much an integral part of talking about your pelvic floor, your pelvic girdle, all those things. And that I want this to land as kind of a message of relief to people who haven’t considered, what pelvic floor therapy does, and that it includes this component as well.

Yeah, for sure. ⁓ So what about people with, and this is kind of a good segue question because I’m talking about like the social cultural perspective of people not being, know, being afraid to talk about sexual health. ⁓ They’ve reached the point where they are aware of pelvic floor therapy and what it may do, but they have no idea what happens beyond that. And they may have trauma histories or pain triggered anxiety. How do you help them reconnect because

Obviously, if someone doesn’t feel safe, they won’t be able to talk to you about it as a practitioner. But also when they get into the bedroom with their partner, if they don’t feel safe, how do they reconnect with pleasure slowly and safely?

Dr. Heather Jeffcoat, PT, DPT (15:31)

Yeah, so I’ll sort of talk about in the framework of like the clinic first and then how that might translate to home. So, you know, in the clinic, I’m asking for consent sort of like every step of the way, but not in an over asking kind of way, because I feel like that’s awkward. So I tell patients like, you know, when we get especially it’s like to the pelvic floor area, we’re going to we’re going to go slow. I’m going to tell you what I do before I do it and make sure that that’s okay with you.

⁓ with everything we do. So I’ll have my gloves on and they’ll be on their back with a nice comfy pillow under their legs and sort of knees spread apart. And I’ll just place a hand on their inner thigh and I’ll just say, okay, so we’re gonna move towards the pelvic floor exam. Is that okay with you if I proceed? And then they’ll say yes. And ⁓ then I’ll just say, okay, I’m just gonna kind of slowly move my hand.

And then the next place I’m going to go is I’m just going to place my finger over the vulva or over the vaginal opening or whatever is the case at that time. then I’ll say, is that OK if I move to that area? And so I feel like I’m asking without like in a way that’s like, is that OK? Is that OK? There’s just a way you can say things that you can put them at ease and give them

the ability to know what you’re doing before you do it. then you, before all of that, even say, if you feel uncomfortable at any time, just tell me to pause or stop. And that’s fine. And we can just go with what we know. I’ve evaluated a lot of other things that we’ve talked about to this point that are indirectly contributing to your symptoms. So we can work on those for now if we can’t complete the pelvic floor exam. So that’s where that orthopedic exam is so important before, because I’ve already gathered so much data. And if…

they can’t do the pelvic exam or can’t complete it. I still have so many other data points I can start treating. And so they feel really comfortable. I’ve explained as we’ve gone along. And so there doesn’t have to be any shame in not being able to complete the pelvic exam because I already know these other things I saw are contributing because of XYZ. They’re informed of those connections and they still feel like they can proceed with a plan of care even though we didn’t do any specific vulvodaginals.

Dr. Ginger Garner PT, DPT (17:24)

Yeah. Yeah.

Mm-hmm, yeah.

Dr. Heather Jeffcoat, PT, DPT (17:48)

So.

Dr. Ginger Garner PT, DPT (17:49)

I think that’s so important. I I see a lot of patients where we really don’t get to do internal. Sometimes we get to a point where we don’t actually have to do it, but sometimes we don’t get to it in the first visit, just like you’re saying, because, you know, it’s about their comfort level, their empowerment, their sense of agency over the entire process, and that they’re in the lead on that. And so speaking of empowerment, actually…

There are so many different products that can actually help with that, ⁓ reconnecting ⁓ and moving past pain and back into pleasure. So if we talk tools for a little bit, right? So what are some of your, and there’s all kinds of brands and things. We can talk really about products versus brands, but what are some of your favorite go-to pelvic floor friendly kind of products from?

Dr. Heather Jeffcoat, PT, DPT (18:36)

is

Dr. Ginger Garner PT, DPT (18:43)

Well, there’s all kinds of things from vibrators, dilators, wands, lubricants that increase comfort, reduce pain. What bubbles through the surface in terms of what you actually end up using the most, do you think?

Dr. Heather Jeffcoat, PT, DPT (18:56)

Well, the most I think would be lubricants because we, it just decreases friction. ⁓ And that alone can reduce so much pain in folks. there’s always the lubricant talk and then around that, without going into specific brands, just talking about what’s your normal vaginal pH and just defining that somewhere around 4.5, a little less, maybe like four to 4.5.

Dr. Ginger Garner PT, DPT (18:59)

Mm-hmm.

super important.

Dr. Heather Jeffcoat, PT, DPT (19:25)

pH and then looking for products that align with that and then giving them that discussion of like osmolality so they don’t dehydrate their tissues. So looking under like 380 and it should be on a manufacturer’s website what the osmolality is. And if it’s not, then maybe they don’t want to advertise it because those that know know and do advertise that number. So you’re looking for something typically under 380 for the vagina.

⁓ And, you know, I would say lubricants are kind of the big discussion and, know, around that, what type of contraceptive are they using? So just educating them to not use oil-based lubricants because that can degrade those latex condoms. So, you know, use a water-based or silicone-based instead, which are condom compatible. So I’d say lubricants for sure are a big discussion. Also avoiding like…

fragrances and dyes and glycerin free if they’re prone to yeast infections, ⁓ paraben free just because of that sort of endocrine disruptor. Because it could be an endocrine disruptor, I guess I meant to say that. So, you know, glycerin free, paraben free, low osmolality, pH around vaginal pH is the most common discussion.

Dr. Ginger Garner PT, DPT (20:26)

Mm-hmm.

Mm-hmm.

Can

you talk for just a second about, because I don’t think that our listener might be aware of just how important vaginal pH is, especially as you approach what could be postpartum, perimenopause, absolutely in menopause, where the loss of estradiol begins to shift the pH and what kind of symptoms that might actually present as for them.

Dr. Heather Jeffcoat, PT, DPT (21:11)

Yeah. So, ⁓ I mean, it could be like vulva or vaginal burning or irritation, painful penetrative intercourse. ⁓ they are more prone to UTIs. So if they’re all of a sudden getting urinary tract infections, that could be like a early symptom of like dropping estrogen and going into perimenopause, menopause or postmenopausal syndrome. ⁓

Dr. Ginger Garner PT, DPT (21:23)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (21:41)

I think those would be some big flags for them to check that out. But if, and if they’re experiencing that, like I’ve had patients that just say, like just when they’re walking, just feels like, like it just feels a little sandpapery. So I’ll then educate them in vaginal moisturizers, which would be one of the other top products that I talk about with people and help them understand the difference between a vaginal lubricant and a vaginal moisturizer. So the moisturizers being for.

Dr. Ginger Garner PT, DPT (21:54)

Hmm.

Dr. Heather Jeffcoat, PT, DPT (22:10)

like all day use, like put it in, you’re good, but it’s not meant to sort of hold up to lubricate enough for intercourse like a vaginal lubricant would do. So vaginal moisturizers are really good for just like chronic dryness and like those genitourinary symptoms in menopause that we get. But you know, also as a pelvic PT and I’m working with chronic pelvic pain so much, dyspneumonia or painful intercourse,

vaginal dilators, which some people call trainers, but vaginal dilators are a big one. And for those of you that are listening that don’t know what those are, they’re medical devices that can be different materials. They can be plastic, silicone, glass, stainless steel. Am I missing one in there? I don’t know, but yeah, they can be made of all sorts of things. And they are

Dr. Ginger Garner PT, DPT (23:02)

It seems to cover it.

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (23:08)

usually sold in sets, although you can also purchase them individually. They will start very skinny, like maybe the width of a pinky finger. But they usually have more length so that you can use it like a handle to do specific internal pelvic floor muscle release techniques. And then they get gradually bigger so that you can kind of progress to gradually larger sizes that get up to the size of your partner. And dilators only come so big, the medical dilators.

So sometimes I do have to have patients get a vibrator of larger sizes if they really need that ⁓ next step up or two to help transition to intercourse. So that will bring in like the vibrator discussion, but not just vibrators for penetrative intercourse. That was sort of my progression from the dilators, also talking about clitoral stimulators, vibrators, or the like air suction style vibrators that are out there.

Dr. Ginger Garner PT, DPT (24:05)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (24:07)

for clitoral stimulation. If people don’t like the vibration, they might like the airflow. And I know it’s advertised as suction, but it’s not really sucking it up. It’s more just a circulation airflow, I would say. So I’d put them on my hand before, and it’s not like it’s sticking and pulling my skin. It’s not sucking, and I think that does scare people. like, no, just view it as more of an airflow thing that’s stimulating.

Dr. Ginger Garner PT, DPT (24:20)

That’s a good distinction. Yeah. Yeah.

Yeah.

Dr. Heather Jeffcoat, PT, DPT (24:31)

And then they also have sort of like a dilator alternative for working on tight pelvic floor muscles. It might be harder to reach with a straight dilator. We’ll talk about pelvic wands as well, which usually have some sort of curve in them or are like S-shaped so that patients can just reach harder to get to areas or like deep hip muscles that are kind of like tucked around corners that can contribute to.

hyper-tinnicity or overactive muscles or like short, tight muscles in the pelvic floor. So I think those would be kind of my top products, but I’ll also talk about like them with sex pillows, like wedges that they sell and different ⁓ sex supportive devices that you can find on websites that are made for like…

Dr. Ginger Garner PT, DPT (25:02)

Yeah.

True.

Dr. Heather Jeffcoat, PT, DPT (25:17)

you know, they kind of advertise that they’re like in velvet and they can be like for kink and they have like straps that come up, which is fine and fun for those that are looking for that, but they can also just increase comfort and not just a little vaginal comfort, right? Like at the core we’re physical therapists. So how can we modify their position if they’ve had hip surgery, right? Or back surgery. So those types of tools are also very relevant to our patients because it’s not just

Dr. Ginger Garner PT, DPT (25:36)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (25:45)

vulvovaginal penetration why they might be avoiding intercourse. Like maybe their hip is killing them and that’s why they’re not having sex, right? But we also know the relationship between hip dysfunction and pelvic floor dysfunction, both with regards to pain and incontinence and that’s been well researched on both spectrums. you know, they probably also like they have pelvic floor tension, but maybe they don’t even realize it because their hip just bothers them so much they can’t have sex.

Dr. Ginger Garner PT, DPT (25:58)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (26:11)

So we have to think about other positions of comfort too, not just with penetration.

Dr. Ginger Garner PT, DPT (26:16)

Right, ⁓ considers ⁓ the partner and what they might actually be going through. Maybe they have back pain too, or maybe something else is going on and they need a better angle or an easier angle or something like that. ⁓ Nobody needs to get injuries while actually trying to seek pleasure, right? And that’s a big part of ⁓ addressing it. Another part of that with…

Dr. Heather Jeffcoat, PT, DPT (26:27)

Hey.

Exactly, exactly.

Dr. Ginger Garner PT, DPT (26:42)

consideration to the partner is, do you have guidance for people who want to introduce products to a partner who may feel intimidated or feel like that’s a replacement or they’re unsure and they just, don’t know how to go about it. What do you say to that?

Dr. Heather Jeffcoat, PT, DPT (26:56)

Mm.

You know, I think it’s just bringing it up as an enhancement to or as a bridge, right? Like, so if, if they, if their goal perhaps, let’s say is penetrative intercourse, but the only way they can experience pleasure is through external stimulation, ⁓ having their comfort or having, I’m sorry, having their partner use the device on them, maybe like hand over hand so that they can provide

Dr. Ginger Garner PT, DPT (27:09)

It’s a good word.

Dr. Heather Jeffcoat, PT, DPT (27:31)

guidance. know, there’s also partner or there’s also like wearable devices for the partner to wear that can be controlled with remote control. And so it’s like a almost like a gamified sexual experience. And, you know, there’s just there’s tools like that out there that you can introduce. And I think, yeah, maybe noting it as a bridge, not a replacement. ⁓

And then maybe like you’ll both end up really enjoying it. Maybe that’s now just even when you can’t have penetrative intercourse, that’s just another tool to kind of like mix things up a little bit. So it’s not always like, all right, you get on your back, you’re on top, missionary, you know, like just more ways to experience pleasure.

Dr. Ginger Garner PT, DPT (28:07)

Mm-hmm.

Yeah, I mean, that does lead to a really important part of pleasure and that is partner communication. You know, what kind of language helps someone with pelvic pain communicate boundaries, needs, or, you know, stop, go slow, like signals during intimacy.

Dr. Heather Jeffcoat, PT, DPT (28:32)

So I think having that talk before being intimate is really important, like almost like safe words, you know. So whether that’s like stop or pause, you know, if something is painful.

Dr. Ginger Garner PT, DPT (28:41)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (28:49)

And just like maybe communicating with them, start going slow. Cause I don’t know how I’m going to respond, right? We haven’t done this in a while or maybe we’ve never done this. Like, you please just go slow. So, so I can give feedback, right? And so then when something feels bad, you can adjust, but also something feels good. They didn’t kind of like blow past the area and you’re like, ⁓ that felt good. Like two seconds ago, like, I don’t know where you were. Where were you two seconds ago? No, I don’t know. was just into it. So,

Dr. Ginger Garner PT, DPT (29:12)

Yeah. Yeah.

True.

Dr. Heather Jeffcoat, PT, DPT (29:18)

So they’re going slow is really important so they can like move back to where they were or you just have a moment to process if you want them to stay there. So I think that’s really important. And then just the conversation of your comfort level with trying penetration versus not. And, and if you’re not comfortable with attempting penetration with your partner just yet, then just setting the boundary, like let’s do just external stuff only tonight. And

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

I think.

Dr. Heather Jeffcoat, PT, DPT (29:48)

But here’s all the green areas, know, can make green light areas. Like my breasts are fair game, my ears, my thighs, my clitoris, like, but just please don’t go near the anus. Like just please stay away from that if that’s your preference. Don’t go to the vaginal opening that’s going to make me really nervous, right? Those are, but you’ve kind of given them four other areas they can go to. And then it’s a, it’s not a one way communication, right? We don’t want the, we don’t want this to be a monologue.

Dr. Ginger Garner PT, DPT (29:53)

Yeah.

Yeah.

Dr. Heather Jeffcoat, PT, DPT (30:19)

So then talking to the partner, since we are not doing penetration, what would feel good to you? Sometimes our patients have TMJ dysfunctions. They can’t do oral sex, right? So what else feels good to you beyond the penis? We can touch the penis. We might not do oral sex. It might be penetration. But other than the penis, what else is a green light and feels good to you? Or can I just feel free to explore?

Dr. Ginger Garner PT, DPT (30:34)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (30:48)

So having that conversation ahead of time.

Dr. Ginger Garner PT, DPT (30:52)

And I think that’s probably the most critical piece of ⁓ the messaging there is having the level of vulnerability and openness where you can sit down ahead of time and say, hey, this is what’s happening. And also being able to say, and hey, this is what my pelvic floor therapist was going over with me. Can we try that, you know, as some kind of foreplay moving into that that can bring, you know, one of the products devices, something like that into it in

Dr. Heather Jeffcoat, PT, DPT (31:05)

Thank

Dr. Ginger Garner PT, DPT (31:21)

and have it be like a therapeutic conversation, you know? And again, the word bridge is a really good one for that, to bridge, to serve as a bridge of where they’re going. Yeah. So, okay, one more question about partners. How do you think, and this gets into kind of the psychological side of things, but as you well know, as a physical therapist, we have to be psych-informed, you know, with what we do.

And in that way, ⁓ we have close relationships with mental health therapists and referrals out and stuff like that. from your perspective, how do you think partners can support healing without pressure, guilt, or taking pain personally?

Dr. Heather Jeffcoat, PT, DPT (32:08)

Yeah. So that definitely gets, you know, beyond the scope where if the, because you can tell the partner, like, don’t feel rejected if I, if I can’t have sex, but you know, you can’t control how they’re going to feel. So I do feel like that’s definitely something in like a couple of therapy that’s focused around the sexual barriers is just really important. But hopefully having the conversation with them ahead of time, knowing what’s on the table, what’s off the table.

Dr. Ginger Garner PT, DPT (32:17)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (32:38)

⁓ celebrating the things they can do that maybe they couldn’t do before. Like maybe their clitoris was so hypersensitive they couldn’t even explore that option. ⁓ Or maybe, ⁓ you know, like oral sexes like on the table and before they were just too, just in their own head about just any touch there. And so even like any kind of touch, whether like orally or manually or with a vibrator. ⁓

feel safe again. So I think celebrating those wins as they come up and just, you know, yeah, I think it’s just a big conversation with a partner that we’re trying to redefine our intimacy. We’re trying to like create bridges towards these goals that we’ve created and that it’s a like physiologic problem. It’s not like a partner relationship problem. it’s, it’s, yeah.

Dr. Ginger Garner PT, DPT (33:08)

Mm-hmm.

Yeah, that’s a huge distinction. That is so

important because that helps shift ⁓ shame or guilt or pressure, know, and performative pressure away from the partner that it’s not, they aren’t the problem, you know, that there’s a separate problem. And I think also if we look at it like, if they had a hip replacement, if they had a hip surgery, if they had something else happening, there would be orthopedic limitations.

Dr. Heather Jeffcoat, PT, DPT (33:58)

Mm-hmm.

Dr. Ginger Garner PT, DPT (33:58)

And it’s

so much easier, right, because that’s not stigmatized to say, you’re on crutches. Okay, well, you’re gonna need some, you’re gonna need some, you know, educational how to use those crutches, et cetera. ⁓ If you think about, you know, the pelvic health and sexuality as an extension of, you know, orthopedic function, right, and we treat it in the same way we would treat it if someone had a broken wrist or something like that, it becomes much easier to talk about it and takes the pressure off the partner. ⁓

and also reframes those sexual expectations too that real sex is only penetrative intercourse, right? Which are some of the things that then I think as therapists we would say, ⁓ this is where a sex therapist could really help you dig into those conversations about reframing sexual expectations, of removing the stigma of being able to talk about that stuff, making it easier.

Dr. Heather Jeffcoat, PT, DPT (34:35)

Right.

Yeah, exactly.

Mm-hmm.

Dr. Ginger Garner PT, DPT (34:56)

So if we could boil things down, and we know it’s not this simple, however, we’re in a podcast, so right? We’re gonna make things approachable, digestible, accessible. ⁓ So let’s talk a little bit about practical step-by-step kind of guidance. If a listener wants to begin to a return to intimacy plan after a long period of pain, what are…

like the top three things that you’d recommend they consider. Or they’re going to a pelvic floor PT, what should they expect?

Dr. Heather Jeffcoat, PT, DPT (35:32)

Right. I mean, I think, you know, a lot of our goals to our first around removing pain and then

There should be simultaneously with that, still experiencing intimacy and pleasure. So I think that would be the expectation that you’re working on like multiple goals at once. So translating that to home, for example, removing penetration, like off the pleasure menu, if you want to call it that. So that that sort of physical stressor is removed and like how that ties, you know, to being an emotional stressor. So that conversation,

with your partner that that’s off the menu for now you’re working on it. Your physical therapist has given you this dilator set and ⁓ it’s going to help me progress pain free up to your size so that we can have this goal towards pain free intercourse if that’s their goal. So I’d say that’s all kind of part one, I guess, that expectations. then, ⁓ you know, then along with…

Dr. Ginger Garner PT, DPT (36:31)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (36:37)

that having conversations with your therapist on the other erogenous zones and ideas for stimulating that they can take back to their partners and they can play around with. It’s like the fun kind of homework, hopefully. The kind of homework too that the partner gets excited about when they’re involved in this way. then just don’t be afraid to use lubricant and use a lot of it. ⁓ We use it in PT.

Dr. Ginger Garner PT, DPT (37:03)

Love it.

Dr. Heather Jeffcoat, PT, DPT (37:05)

with every patient, you should use it at home with every, even just like external, because if you have dryness, like, you know, just let’s minimize the contributors to pain. So lubricant can be used even just for external, like vulva play. It doesn’t have to be reserved for like only when you’re having penetrative intercourse. So I would, in the meantime, explore with your PT, your favorite lubricant as well. So when you are using that at home, you have that at the ready.

We sell like five different lubricants in my office. So from silicone based to ⁓ water based to CBD based, like we have them all for people to try. have samples of all of them for them to take home and try. So ⁓ I think knowing that that’s an option and it’s, there’s no shame around needing lubricant and don’t feel like you’re overcoming some like, I don’t know. just.

I don’t need lubricant. Like, I don’t know. That’s not a badge of honor, right? Like, I’d rather be like, lubricant for all. Yeah, and you get lube. Yeah, Oprah style.

Dr. Ginger Garner PT, DPT (38:01)

No, it’s not.

You get lubricant and you get lube and you get lube. ⁓

That’s right. I love it. tell me, tell the audience a little bit about when they should seek out the help of a pelvic floor PT or someone in sexual medicine therapy. Like at what point, you know, you’re at home, you’re trying these things. It’s not working. Like what do you do? When are the yellow flags where you’re like, you know, I think I need to make an appointment.

Dr. Heather Jeffcoat, PT, DPT (38:38)

Yeah, so I mean, I would say for sure if there’s any pain, you just first need to be cleared by your like urologist or OBGYN or primary care doctor that you don’t have an infection or something organic going on. Like, because you can get cysts in that area, right? That ⁓ you might have a sexually transmitted disease. You might have like a bacterial infection. It’s not a sexually transmitted disease, right? Like there’s so much going on that pelvic PT is it’s not in our scope of care.

Dr. Ginger Garner PT, DPT (38:54)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (39:06)

So if your physician says, I don’t see anything wrong. Like I’ve done all these tests, but of course there’s something wrong because you still have pain. That’s when you should consider pelvic PT. I did, my doctor said there’s nothing wrong. Okay, well, clearly there’s something wrong. Let’s take a look and see if it could be like your muscles, fascia, know, nerves, whatever. ⁓ Something biomechanical driving it, right, with that two part exam. So even with mild pain,

Dr. Ginger Garner PT, DPT (39:21)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (39:34)

I think you should come. Just don’t let it sit on it. If it doesn’t feel right, go to a pelvic PT. If it doesn’t feel right, your doctor said nothing wrong equals go to pelvic PT. Because we, think, are kind of the masters of figuring it out when, quote unquote, nothing is wrong. And not just vulvar vaginal pain, abdominal pain cramping, we treat things like that as well. any kind of unknown pain, I would even extend it to anywhere in the body. My doctor says nothing wrong. But your shoulder hurts. So OK.

Dr. Ginger Garner PT, DPT (39:47)

Yeah, true.

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (40:03)

maybe

you need PT, try a PT, right? So that would be one ⁓ big thing. ⁓ I would say, you know, and any spectrum. So of course, if it’s more severe than you’ve been ruled out, like any spectrum of pain, mild, moderate, severe, ⁓ see a pelvic PT. ⁓ Even like things like burning, tearing, ripping sensations.

Dr. Ginger Garner PT, DPT (40:30)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (40:31)

Like

pelvic PT can help with that. That might just be like having to do with like the muscles pulling on the tissue, ⁓ making it feel like it’s tearing or ripping. I mean, I’ve had some patients that actually do have tearing or ripping. ⁓ So I had patients too that still had like intact hymen or had something called like a septate vaginal canal where it’s almost like it didn’t fully.

divide so they almost have like two vaginal canals and the OB-GYN missed it. So sometimes it’s the pelvic PT that picks it up because we’re taking the care, multiple visits, and we can pick things up that even could be medical and missed. So I would just don’t feel stuck if you are having pain of any kind. ⁓ Then that would be the time to start seeing a pelvic PT.

Dr. Ginger Garner PT, DPT (41:23)

Awesome. All right, so for all of our listeners who every single one of them want to feel hopeful, what’s a success story or a moment that reminds you this work truly transforms sexual health?

Dr. Heather Jeffcoat, PT, DPT (41:37)

Yeah, so this is one of my favorite stories to tell actually. I mean, I’ve had so many, but this was a woman, she was about 60, 59, 60, let’s say. just remember she was younger than Medicare age. And this was like a good decade ago. And she was referred by her urologist for IC, interstitial cystitis. And this was back before they started calling it painful bladder syndrome. So she was referred for IC because she had to pee like…

Dr. Ginger Garner PT, DPT (41:56)

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (42:03)

30, 40 times a day. Like it was just out of control. She just always felt she had to pee ⁓ and it was very disruptive. So in her first visit, this goes back to what we were talking about at the beginning of the hour, Ginger. Today we’re going to talk about your bowel, bladder and sexual function because all of those relate, right? So by the time we got to the sexual function questions, she was like, yeah, I saw those on your questionnaire. She’s like, my husband, I haven’t had sex in 20 years because it’s hurt too much.

Dr. Ginger Garner PT, DPT (42:07)

Mm.

no.

Dr. Heather Jeffcoat, PT, DPT (42:33)

right? And I said, well, we’re going to work on that too. I’m like, I know you’re here for the bladder. If that’s your goal, would you like to have sex with your husband again? my God, yes. I didn’t know that was possible was her response. Right. And if I start crying, it’s because I start crying when I tell stories. So just know this about me. ⁓ because I just very much like, don’t like, I can be with my patient and be, you I’m very professional at it, but I’m telling these stories after the fact. I’m just like water.

Dr. Ginger Garner PT, DPT (42:46)

⁓

I did too. Yeah.

Dr. Heather Jeffcoat, PT, DPT (43:02)

sometimes because it’s so impact. I just reflect on the impact that we’re having and in the moment I’m doing my job. Stories I’m reflecting and I get emotional. anyways, back to her story. she, yeah, she’s like, yes. So I was like, we’re gonna work on that too. And honestly, when working on the bladder stuff with what we found in your evaluation, right? When I was wrapping up at the end, we’re kind of working on it all together. Like it’s gonna improve both things simultaneously.

Dr. Ginger Garner PT, DPT (43:03)

Yeah.

Dr. Heather Jeffcoat, PT, DPT (43:29)

Literally in less than a couple months, she was having pain-free penetrative sex with her husband. The bladder stuff took a little bit longer to resolve. The first goal that she hit was pain-free penetrative intercourse. And I’m not lying, her husband sent me flowers.

Dr. Ginger Garner PT, DPT (43:42)

⁓

Dr. Heather Jeffcoat, PT, DPT (43:49)

And

Dr. Ginger Garner PT, DPT (43:50)

my gosh.

Dr. Heather Jeffcoat, PT, DPT (43:51)

yes, and like it had such a huge impact on their life like so basically it was since she hit menopause Like perimenopause it started to hurt and then they just eventually stopped having sex right and It was like, okay. Well, guess that’s my life now, but it didn’t have to be and I think this is a big misconception that people have is These changes that occur home hormone only are just things you have to live with because it’s a part of life. Absolutely not

Dr. Ginger Garner PT, DPT (43:58)

Yeah.

⁓ and that’s.

Dr. Heather Jeffcoat, PT, DPT (44:18)

There is so much more attention now. Like this is literally the hot moment, pun intended, to be going through menopause because there’s so much more awareness being drummed up with celebrities that are coming out with their misdiagnoses, delayed diagnoses with symptoms that they had from painful sex to diagnosed with STDs falsely because of having global vaginal burning, right? Like that Halle Berry story. So there’s…

Dr. Ginger Garner PT, DPT (44:26)

Totally, yep.

Mm-hmm.

Dr. Heather Jeffcoat, PT, DPT (44:48)

so much more that’s being done and you don’t have to live with those changes. So she, 20 years before this happened, which was 10, 12 years ago now, probably 15 years ago maybe, right? Like, so I think 35 years ago, no one was talking about menopause and doing anything about it, right? And so that completely impacted her sexual life with her husband. But she got it back, she was excited, her husband was excited, her husband started coming to every visit with her. Got flowers that first day he came.

Dr. Ginger Garner PT, DPT (45:01)

Right.

I love it.

Dr. Heather Jeffcoat, PT, DPT (45:17)

And it’s like, I mean, that’s like the kind of impact that we can have. And by the way, we did that without hormones because 15 years ago, they weren’t talking about that either. So that was just from musculoskeletal changes that occurred over time. That’s all I was doing and giving her education on like bladder health stuff, Bladder irritants, timed voiding, like just doing the basics stuff, right? That had that kind of impact on her.

Dr. Ginger Garner PT, DPT (45:17)

of it.

Yeah.

I weren’t.

Yeah.

Dr. Heather Jeffcoat, PT, DPT (45:46)

the

pelvic therapy, the wand home therapy. that’s like just such, think it, because it encompasses multiple systems, right? It’s not just sexual function. It had an impact eventually on her urinary symptoms and just affected her whole life. They could go on long car trips, right? We know that is, if you have to pee every 20 minutes. You’re not going, you’re not driving from Los Angeles to San Francisco. You’re not even going to Santa Barbara. That’s, you know, it’s just not a feasible trip.

Dr. Ginger Garner PT, DPT (45:56)

It does.

You’re going, no, you’re going nowhere. Yeah. ⁓

The other powerful thing about ⁓ this incredible story that if I sat here and let myself really sink into it, I would start crying too because it’s that powerful. When you lose that part of yourself, that’s part of the baseline of Maslow’s hierarchy of needs.

lodging like a roof of your head, food, hydration, sleep, sex. You take that away. You know, there’s a good deal of evidence base that supports when you look at neurophysiology and sexual medicine, that ability to have, you know, a sex life and have pleasure is also what makes us creative, able, know, cognitively like

Dr. Heather Jeffcoat, PT, DPT (46:36)

Yeah.

Dr. Ginger Garner PT, DPT (47:02)

⁓ sharp human beings too. So there’s a reason it’s there on the baseline and for her to get that back is life shifting in so many ways. yeah. So that leads me to my last question, which is where can people find your book, your clinical work and supportive resources to get started?

Dr. Heather Jeffcoat, PT, DPT (47:22)

Yeah, so my book, Sex Without Pain, A Self-Treatment Guide to the Sex Life You Deserve is available on Amazon. And you can get it on like audio, ⁓ print, or ebook. If you want an immediate PDF download, you can get that on sexwithoutpain.com. And on that website, I have a code for your listeners, ginger20. They can get 20 % off. ginger20. And that’ll just run indefinitely.

Dr. Ginger Garner PT, DPT (47:48)

Awesome.

Dr. Heather Jeffcoat, PT, DPT (47:52)

date on that. My practice is fusion wellness and feminine physical therapy. So I’m at femina pt.com for our more female centric services. We have tons of content on there for you. And then our inclusive brand for all folks, including pediatric pelvic health is at fusionwellnesspt.com.

So we have a site dedicated content over there for you as well. And then personally too, I do telehealth and coaching, so does my staff. So we can also help you if you’re not able to come see us in Los Angeles.

Dr. Ginger Garner PT, DPT (48:32)

That’s incredible and thank you for that discount code for our listeners. ⁓ What was it, Ginger 20? We will put that in the show notes for you so you will have that. You won’t have to write that down. Thank you so much, Dr. Heather Jeffcoat for joining me again for this part two. This has been invaluable with so many practical techniques and a lot of hopeful messaging. Thank you.

Dr. Heather Jeffcoat, PT, DPT (48:35)

Thank

Yeah.

Yeah, absolutely. Thanks for having me again, Ginger.