Episode 109: Pelvic Power

Published September 8, 2017.

Aminatou: Welcome to Call Your Girlfriend.

Ann: A podcast for long-distance besties everywhere.

Aminatou: I'm Aminatou Sow.

Ann: And I'm Ann Friedman. On this week's agenda, a very special pelvic health extravaganza.

Aminatou: Oh my god, we're finally doing it.

[Theme Song]

Ann: Before we get into the pelvises around the world we have an exciting announcement.

Aminatou: Oh yeah, duh! [Laughs] I love that I forgot and I was so excited about it. If you live in Chicago or Minneapolis we are coming to you.

Ann: Oh my god, it is what I have long dreamed of, the CYG Midwest Mini Tour which will be -- I think we're in Minneapolis on October 21st which is a Saturday and then in Chicago on the 23rd which is a Monday.

Aminatou: I am so, so, so excited. So you can go to callyourgirlfriend.com/events and all of the information will be there, but we'll see you on . . .

Ann: October 21st and October 23rd.

Aminatou: Yes, we'll be there.

Ann: Okay, on to the long-awaited pelvic health episode. I'm so excited about this. How are you feeling?

Aminatou: You know, my pelvis feels amazing so I feel great. [Laughs]

Ann: Maybe we should go back because I was just asking you about this. I almost forgot about the original inspiration that made us want to do this episode which was each of us having some bad experiences with the gynecologists/doctors who were looking at our pelvic region.

Aminatou: Yeah. So a couple of months back I think that we both got really vulnerable about bad gyno experiences. Yours was hyper specific and mine was very much like I cry every time, it's the worst, but also my new feminist doctor was like scoot your butt all the way to the end and that was revolutionary for me. [Laughs]

Ann: [Laughs] Butt scooch revolution?

Aminatou: Oh yeah, it sounds so . . . it almost sounds really funny because the gyno is one doctor that if you are a woman or somebody who identifies as a woman you will go to at least once and there is nothing pleasant about it. And unfortunately for health reasons you'll probably go to it a lot, and so a lot being at least once a year. Hot tip, when you make your gynecologist your primary care physician it's very exciting.

Ann: So yeah, so after we talked about these bad experiences we got so many emails both from people who had also had bad experiences with their gynecologists but also from some people offering information and resources. And so we've long been plotting an episode where we talk to actual experts, not just Google, M.D.s like us, about what's up with pelvises. Pelvic health. [Laughs]

Aminatou: And let me tell you first of all we have so many pelvic sheroes in the CYG community it's kind of baffling.

Ann: I know you can't see me but this is my not surprised face but also I'm super proud because this is the best community. [Laughs]

Aminatou: It is the best community. And also it's really fascinating because I think this is what I've learned from it, right? It's that for a long time on this show I have complained in some form or fashion about pelvic exams and how much I hate them or about my cramping in general. You know, about all of the everything is unpleasant down there and it's not cool. And every time I would do that at least one or two people, one of our listeners, would email and say "Hey, have you talked to your doctor about pelvic health?" [Laughs] And it's like a real-time reminder that oh, this is what friends do. When you complain about pain in your body they're like, you know, not trying to diagnose you like Amina is crazy but they're just like oh, this sounds like a thing that we talk about all the time. And so it was such a real-time reminder for me that this is one of the added benefits of friendship and also of the fact that women make themselves emotionally vulnerable is there's a world in which somebody is listening to what your situation is and might even have solutions for you.

Ann: Totally, and also provides the reality check that hey, actually maybe you don't just need to grit your teeth and put up with a really unpleasant medical experience. Maybe there's a better way or maybe there are more resources for you. Like I have relied on friends so many times to remind me of that, so yeah, shout out to our extended friends.

Aminatou: Totally. [Laughs]

Ann: Who else said that? Yeah.

Aminatou: The real lesson here -- you're right -- is if you are in pain about anything, that is not a normal state of being and there's a different state of being that you can be in.

Ann: Right.

Aminatou: And so a couple of months ago, also when we both talked about the importance of having progressive, holistic OBGYNs, there's hella nurses in this family and people emailed and one of the common refrains that I heard was if you want a doctor who is progressive, feminist, and probably into some holistic stuff you should consider seeing a midwife. And I was like what? I thought midwives were for people who were imminently having children. Like if I was honest I didn't know the difference between a midwife and a doula. I thought a doula was a hipster midwife. [Laughs] And so, you know, tomato, to-ma-to. It's the same thing. But it turns out that actually midwifery is really fucking badass and you don't have to be pregnant to go see a midwife and they're very respectful of taking your entire situation into hand when you go see them.

Ann: Ugh, I love that. And I also have to just say that maybe part of this is an optics issue, like shout out to midwives who have online presences that do not center around childbirth because I think that one thing for me when I first learned about this, thanks to all these emails, I was surprised by the fact that all of the messaging on a lot midwives' publicly-accessible pages is still centered around childbirth. So even though maybe they provide these services to people who aren't imminently having kids it can be hard to figure that out without some inside knowledge too.

Aminatou: Totally. So the first lady that I talked to was one of the listeners who emailed us, Amy Roberts, and she was a total badass obviously. She started talking to me about medical literacy and I was like what? What is medical literacy? I didn't even know that was a thing you're supposed to be literate about, or realize how illiterate I was about a lot of stuff. She's a feminist. She also talked about how because the history of obstetrics is really unfortunate that's part of the problematic history of OBGYNery and really where a lot of the distrust comes from people. Everything through the lens of history makes sense why we make the choices that we make now.

Ann: Right. The medical establishment, not historically super feminist. [Laughs]

Aminatou: I know, not historically super feminist, but also I was like oh, this is also what happens for me when a lot of my care team is not female, where they're . . . and not to say that you should discriminate in your care team because I've had great dude gynos for sure. But I realized because I was not seeing representation at that level it was a thing that I was not thinking about. There's a reason kind of for all of these things happening. So anyway, Amy and I talk about what pelvic floor therapy is and kind of a little bit into my own experience with it so listen to her. She's really smart and awesome.

[Interview Starts]

Amy: My name's Amy Roberts and I am a registered nurse.

Aminatou: You wrote us kind of an incredible note about nurse midwives and how it's possible that there are these great progressive feminist holistic doctors and medical professionals out there. [Laughs] Which kind of blew our minds. But I was wondering if you could talk specifically about the work that a nurse-midwife would do and how that could apply both to women who are thinking about having children, women who have children, or women like me who are child-free?

Amy: Definitely. As a nurse I really just worked alongside midwives but midwifery really has reemerged from having been this well-established profession globally to being kind of a response to obstetrics doing a little bit of what I think you and Ann have been talking about on the podcast which is maybe not empowering female patients and maybe knocking them out rather than letting them be awake to make choices during childbirth. So a lot of midwifery in general is very informed by a desire to react to that and do something better.

Aminatou: I was really struck by when we had that episode a while ago about your standard OB/GYN visit how many nurses wrote us. I . . . every time I go to the doctor, obviously I deal with nurses, but it was really unclear to me what that whole scope of work is that they do. And so now I understand that a nurse can also give you like a well woman's visit and examine you and that's not something I was aware of before.

Amy: Yeah. Nursing is a really definitely like varied profession, and then just like with midwives there's kind of different nurses too. Like you might be at your doctor or nurse midwife's office and the person who takes your vitals, like takes your temperature and your blood pressure, they might not be like a registered nurse. They might just be a medical assistant. But registered nurses, yeah, we have a pretty broad scope of practice and awareness and also we have the advantage of sometimes being a fly on the wall so we don't have to take responsibility for everything that ultimately happens but we also can observe and be like this happened, and maybe question mark, and maybe when the provider leaves the room I'm going to try to smooth things over a little bit.

Aminatou: All of these nurses that are emailing us are amazing, but is there something intrinsic to the way that you -- most nurses are trained that is different from how doctors are trained? That makes them like better listeners and more caring and like, you know . . . I feel like you would have . . . well, more caring is the wrong characteristic but maybe more attuned kind of, you know, to the kind of emotional needs that you have. And, you know, I don't know. I'm just like wow, look at all these feminist nurses everywhere.

Amy: Aww.

Aminatou: If I could pick a medical professional and there was a box on ZocDoc or whatever thing you use to find your doctor, I was like I want a feminist healthcare provider. [Laughs] But I feel like that's -- like that's a hard thing to signal for.

Amy: Yes. Okay. Well, I mean, your question is a really good one and I don't want to generalize because I know a lot of physicians who are wonderful and pick an OB or a midwife and it's going to be awesome, you know?

But, yeah, it's true. A lot of the role of the nurse is kind of to try and identify like what are people actually understanding? Like medicine is more the science and nursing is kind of in some ways how are you applying this to real people? So that's like emphasized, at least in my bachelor of science and nursing program, it was very strongly emphasized.

Aminatou: Before we started recording you used the term medical literacy which is great. [Laughs] Can you kind of expand a little bit more on that? Like what you mean by that term and what, as patients, we should know?

Amy: Ooh, okay. Two different things. The first one may be easier than the second one because I mean there is so much we should know as patients. I mean that even applies to me even though I like work in healthcare. But so medical literacy is just the ability to understand things that are being talked about in like a medical scenario, like when I say blood pressure, does somebody even know what that means and what the implications are? And they may not. If I talk about like reducing the sodium in your diet because you have high blood pressure do you know what sodium is and what foods it might be in? And then just all the things, like those are kind of things I imagine you are like yeah, I know what sodium is. Lots of people don't though. Like a huge number of people don't. [Laughs]

Aminatou: I know what sodium is because my mom was obsessed with not having high sodium like anything in the house but that's literally the only reason I know. [Laughs]

Amy: That makes it hard to eat at home sometimes I'm sure. Yeah, and then medical literacy I think becomes an even bigger deal as anybody including me is throwing around words like preeclampsia and just talking about this and being like you have it, but it's like the person may not even understand the whole rest of the conversation because they don't know what you're talking about in the first place. And then ways we can improve our medical literacy, gosh, I mean it's tricky out there. Like I imagine you're a New York Times reader and they're constantly publishing medical columns but it . . .

Aminatou: Yeah.

Amy: It tends to be sort of like either alarmist or more peripheral things. 

Aminatou: Yeah, or they're like medical mysteries like this Dr. House would diagnose you with Lyme disease every single time. Yeah.

Amy: Right. Exactly. Yes. 

Aminatou: We're done talking about House, but yes.

Amy: And you know that, and I feel your medical literacy is . . . I would just assume you would know anything I would say to you from that point forward.

Aminatou: No, I don't though. I think that it's, you know, it's . . . I think that it's a combination of when you go to the doctor for especially like a well woman's visit, you feel really vulnerable.

Amy: Yes.

Aminatou: And it's hard to kind of advocate for yourself and know what you're supposed to do, but also nobody kind of tells you how that visit is supposed to go.

Amy: Yeah.

Aminatou: I'm almost like embarrassed to say oh, for a long time I didn't know what the difference was because the different kinds of people I talked to when I went to the doctor. It's like this person is a tech. This person is a nurse. This is the doctor. Like to me they were all people that were trying to poke and prod me.

Amy: Yeah.

Aminatou: And I'm just trying to get out of there with no bad news.

Amy: Yeah, I mean actually when Ann was telling her story on that episode it spoke to me personally because who hasn't had an experience of going to the gynecologist and they may say something weird? Like their fingers are inside you and they make some comments and you're like . . . like some words that have been said to me are like burned into my brain forever.

Aminatou: You also sent us this article about like 12 ways to be a feminist healthcare provider.

Amy: Yeah.

Aminatou: That we're going to put -- we're going to put in the show notes. 

Amy: Oh, good.

Aminatou: And like all of the advice is really, really good but I guess my question is like how do you . . . like how do you find these people? 

Amy: Right.

Aminatou: Besides just the constant whispers between all of us. [Laughs]

Amy: Right. I know.

Aminatou: Like I'm really lucky that I found a feminist OB/GYN but it's literally because she was referred to me. Like I would've never, you know, from looking up her doctor profile, ever figured that out.

Amy: Right.

Aminatou: And, you know, as somebody who is like a trauma survivor and all of this stuff it's so important to me to have a doctor who will be like sensitive and really just radically listen to me.

Amy: So that's actually why I wrote you guys to be like "FYI, midwives." Because I do think that with the differences in backgrounds of nurse-midwives coming from nursing and choosing midwifery, like if you're a person who does know what a midwife is you found out about that for some reason related to what your interests are whether it be feminism or a little bit of like a granola of sensibility or whatever.

And so everyone I know who's gone into midwifery has been just super concerned about these issues and it's like absolutely at the forefront because they're like, you know, medicine wants to tell everybody what to do. Medicine wants to like hold its knowledge up in an ivory tower and then order people around including patients, and midwives are like "No, we want our patients to be the ones who are in the driver's seat and we're just giving them all the information we can to make the best choice for them." So I think if you're trying to find a provider who's a feminist midwives are like an awesome place to start.

Aminatou: Can you go to a midwife if you are not pregnant?

Amy: You absolutely can, yes.

Aminatou: What?

Amy: In fact I do. my experience with like the two midwives I've been to just for GYN it's been really just like very casual. I just feel comfortable talking with them. I've had really good experiences. And again I don't want to diss OB/GYNs. I wrote you in my email, like OBG/GYNs, I worked in labor and delivery for two years. They very literally save lives and sometimes a C-section is what you need.

Aminatou: Yeah, absolutely.

Amy: Like I'm eternally grateful that that is like a service that is provided so well. But, you know, I think sometimes, yeah, that feels like the history of obstetrics is a bit unfortunate. Like they used to just sort of spread childbirth fever from the cadaver to the woman giving birth and then when they took everybody into the hospital it was like very easy to spread all these infectious diseases that were ultimately really bad for people. But, you know, everybody I know who's gone into OB/GYN who is younger, not to be ageist, I think is a lot more motivated to also do the same things I'm talking about midwives wanting to do.

Aminatou: It's also true. You know, not to be transactional. You know, it's not like shopping. But for a lot of other things it's like it has to be a fit and I think the kind of medical care and the kind of doctor that you go to also have to be a fit for you.

Amy: Yeah. I mean we live in a capitalist society. Everything is like shopping at the end of the day.

Aminatou: I know. I mean I shopped for a good doctor and I love her.

Amy: That's awesome. I'm so glad you found one.

Aminatou: It just took a long time. Yeah, it just took a long time and now I look back at honestly the emotional turmoil that it was and it's like a lot of this was wrapped up in not understanding the language, not speaking up for myself, not feeling like I was being heard or my pain was being taken as seriously as it could've and all of that stuff. But, you know, we're all on a journey.

Amy: Sincerely like the number one thing is you feel like somebody isn't listening to you and taking you seriously, if you are in a position to do so, find someone else. Like we're not all so fortunate that we can always shop around. People are in lots of different situations with their insurance coverage and where they live. But if you have choices and someone is making you feel like that, there really are . . . I can tell you as a nurse who's observed hundreds of providers, there are people who very much have like their own standard for how other people should live their lives and they want to apply it to you and it's not about your health. So if something's making you feel that way, like move on.

Aminatou: That's great. That took me . . . I don't think that I would've known that in my 20s.

Amy: Yeah.

Aminatou: Just because of my own personality, and also it's the you always defer to the expert.

Amy: Yeah.

Aminatou: I'm just like this doctor has my life in their hands even though I'm literally going in to check my blood pressure. It's just like this is . . . 

Amy: Right.

Aminatou: This is insane. What's one thing you wish, if you could live your patients or future patients with one piece of advice, what would it be?

Amy: Okay, my advice is if you're at the gynecologist, which of all the things that your listeners might be doing that's probably the likeliest, I would say remember you always should have a chaperone in the room with you if you want one, and if that's not like a baseline assumption, particularly with male providers at the office you're going to, ask. And if people are not receptive like I would take that as a red flag. And my story is I worked at a hospital with an OB who was actually doing like illegal things to patients, like filming them and taking pictures. Not to make everyone paranoid, yeah.

Aminatou: What?

Amy: It's a really sad story actually. And it was a new nurse who hadn't worked with him previously who reported the behavior when she was observing as a chaperone and it was acting in front of her with like a disguised pen. And that's why that ended up becoming a whole big thing that kind of blew up.

Aminatou: Oh my gosh. That's insane.

Amy: Yeah. Not to make people paranoid. That was like . . .
Aminatou: Yeah. But so -- so that's good to know. So you can ask for a nurse to be a chaperone? Like and have another person in the room?

Amy: Very much so, yeah.

Aminatou: Great. I did not know that.

Amy: In fact that's like a baseline expectation, especially if it's like a male provider, yeah, I think that that's just a good standard.

Aminatou: That's good to know. Oh my gosh, Amy, I could talk to you forever. Thank you so much for just giving us some of your time and expertise today.

Amy: Oh, well thank you so much for calling me Amina. I'm a huge fan of the podcast and to speak to you in person is wild so thanks for everything you guys have done with Call Your Girlfriend.

Aminatou: [Laughs]

[Interview Ends]

Ann: Yeah!

Aminatou: Yeah! [Laughs] Sorry, you said that and . . .

Ann: That's how I feel when I get good info. Yeah!

Aminatou: Yeah! [Laughs]

[Music and Ads]

Ann: Ugh, okay, tell me about the next brilliant expert that you spoke with.

Aminatou: Oh my god, the next lady I spoke with, her name is Laura Todaro. She's a certified nurse-midwife. Can you sense a theme here? [Laughs]

Ann: Mm-hmm. Mm-hmm.

Aminatou: Like I didn't know anything about midwives and now I'm just like, you know, after astronauts the most important job we have.

Ann: I know. If there's one thing you leave this episode with, midwives doing the most important job. Well, one of the most important jobs. [Laughs]

[Interview Starts]

Laura: My name is Laura Todaro and I am a certified nurse midwife. For me personally that means that I both care for pregnant and not-pregnant patients in the community clinic and then I also deliver babies at our county hospital.

Aminatou: Yeah, I'm like I'm a professional sick person. Great. [Laughs]

Laura: [Laughs]

Aminatou: Well, the reason that we're talking today is because you wrote us a great note after we had that episode where we talked about body shaming at the doctor and just complaining about pelvic exams.

Laura: Yes.

Aminatou: Which is, let's be serious, like two-thirds of our episodes.

Laura: Yeah.

Aminatou: But you said why wouldn't you consider seeing a midwife?

Laura: Right.

Aminatou: And that had never occurred to either of us. So I talked to another woman today who was a registered nurse and she also recommended seeing a midwife, like she sees a midwife herself, and it had never kind of occurred to me that if you were not pregnant or planning on being pregnant that, you know, you could be in business with a midwife.

Laura: You know, I care for young women who are coming for birth control counseling or STD testing or today was kind of a typical day actually where I saw someone who was 36 weeks pregnant and getting her ready for the delivery. Then I had someone for a pap and I had someone who came in for STD testing, someone for birth control, and then a woman who was coming for a breast exam and needing a mammogram. The whole gamut.

Aminatou: The whole spectrum. That's great.

Laura: Yes.

Aminatou: And you also said that you are trained specifically in performing gentle pelvic exams especially for women who have a history of sexual or reproductive trauma.

Laura: For sure. Yeah. In my clinic, unfortunately but this is actually true in most settings, I have a lot of patients who have had either sexual or reproductive trauma and it's really of the utmost concern that we care for them in a way that feels respectful and that honors their autonomy. And I would say that that's one of the core practices of midwifery is that we're treating the whole woman and that could include all of her experiences up until the point that we see her.

And some of that might mean actually that I limit the amount of exams that I do. Like I actually had a patient who came to me with concerns about vaginal discharge that looked like she might've had some kind of vaginal infection going on but she couldn't tolerate a pelvic exam because of sexual violence that she's had in her life. And so we didn't do one. Like I diagnosed her based on symptoms and a sample that I could get without doing a speculum exam. And then I talked to her today about maybe in the future coming back and we could kind of work towards it because at some point in her life she will need a pap smear. She didn't need one that visit that I saw her for. What I also will do in those cases is have women insert the speculum themselves or at the very least . . .

Aminatou: Oh wow, so that helps you maintain a level of control I guess.

Laura: Yeah, for sure. If I have a woman even in labor, let's say if I'm going to check a woman in labor and she had difficulty tolerating exams which is very common, it's really uncomfortable, then I will have her separate her own labia and be a part of the process and get her in as comfortable a position as possible.

And in the clinic, you know, when we do need to do a speculum exam or certainly for procedures -- you know, I do lots of IED insertions and so forth, we do a lot of just getting them as comfortable as possible in the stirrups. It was you that talked about the whole thing of getting your butt basically hanging off the table to relax the pelvic core.

Aminatou: Oh, that's been a game changer for me. I'm just like oh, when my butt is relaxed this appointment is 50% better. I had no idea.

Laura: Yes. Yeah, totally makes sense. So, yeah, these are just all things that, you know, are just kind of common practice to me and are becoming I think more common practice across the spectrum in terms of the medical profession and women's healthcare. But midwives have always been the ones who have been advocating for respectful care.

Aminatou: Yeah, and I mean I know that we framed, at least on our show, this discussion a lot around -- you know, since it's Ann and me, around kind of straight, cis women. But I know that you obviously are also trained in how to care for lesbian women and bisexual women and transgender women as well.

Laura: Yeah. Yeah.

Aminatou: So I think that's something we haven't emphasized a lot on the show but clearly, you know, it's not just like straight ladies from L.A. and Brooklyn who go to the doctor. [Laughs] Yeah.

Laura: For sure. Yes. Yeah. Here, I mean I'm in the Bay Area. I live in Berkeley and I have had really the privilege of being able to serve a really diverse patient population. And my introduction to healthcare really came working at the Berkeley Free Clinic. This was 20 . . . I don't know, 25 years ago now where I did my initial training when I worked with patients who were [0:32:07], either a lot of homeless patients or patients who had mental health problems or sex workers and that kind of led me into doing doula work and attending birth and for many years I taught childbirth classes. And in particular I taught a class for lesbian and bisexual women through an organization that's still around called MAIA Midwifery, and I both cared for lesbian and bisexual women throughout their lifespan and specifically through pregnancy and fertility issues. So I got to have a lot of experience working with those families and families really of all kinds. There's just no one way that women access care, right? Like anyone who has a vagina and a uterus and needs reproductive healthcare deserves to be honored in their full -- their whole person, right? And so for transgender women in particular that can be a real concern. So, yes, at UCSF we have a lot of training with that as well.

Aminatou: Yeah, that's really cool. So you definitely are trained in and you definitely advocate for this progressive, holistic option, you know, to get this kind of care. But if you're a patient and you don't live in the Bay Area how do you kind of go about finding professionals that have this same philosophy?

Laura: Right. I mean I do think . . . so there's the American College of Nurse-Midwives which anyone can look up. It's called ACNM.

Aminatou: The American College of Nurses and Midwives?

Laura: Of Nurse-Midwives. The American College of Nurse-Midwives.

Aminatou: Of Nurse-Midwives. Got it.

Laura: Or ACNM. So you can actually go to that website and there'll be a ton of information and then there's a search option there as well. And then you can also look, every state will also have . . . you know, we have the California Nurse Midwives Association and it varies from state-to-state.

Aminatou: I know that you also can provide abortion care, right? Even though it's kind of restricted based on the clinic that's receiving federal funding.

Laura: Correct.

Aminatou: But I didn't realize that that was part also of the . . . like can you tell I know nothing about midwives? [Laughs]

Laura: Yeah, right.

Aminatou: I'm just like this is amazing.

Laura: Yeah, yeah.

Aminatou: I'm just -- yeah, I had no idea.

Laura: Right. Well I mean abortion care is just part of the reproductive life of a woman. That's one of the things that kind of kills me about our current political climate is I'll have a patient that I'm caring for who has actually a really serious condition and needs to be treated fairly quickly and I could not for the life of me find a place for her to go to get her DNC within a few days because there just weren't -- there just aren't enough providers.

Aminatou: This is so -- this is so nuts.

Laura: I know.

Aminatou: It's such a routine part of healthcare.

Laura: Completely. You know, I have hope that I will further my training and be able to offer that service in the future.

Aminatou: Oh, that makes me happy that there's really . . . I feel like everyone I've talked to today, just the level of compassion and professionalism that you have is just really . . . I don't know, I find that really heartening. Thank you for everything you do. That's cool.

Laura: Thank you, yeah. You know, we're just doing the best we can in a pretty broken system but you can always be guaranteed that a midwife is going to meet you kind of where you are in that moment with love and kindness and give you the best possible care that she can.

Aminatou: Yeah. So I guess my last question is if you could impart one bit of wisdom or clear up a misconception or something that a patient would have or that you wish that more people knew about the specific thing that you do, what would that be?

Laura: I think it would be simply that midwives have traditionally been the ones who have promoted and advocated for kind of a more holistic way of approaching women's healthcare and in particular reproductive and sexual health and that you would be more likely to get some of those needs met with a midwife than with other providers in the same setting.

Aminatou: That's great. I am so pro-midwife. I'm like I want to wear a t-shirt that says "I love a midwife." I want a bumper sticker. Everything.

Laura: We've got them. We've got them. I'll totally send them to you.

Aminatou: Oh my god, anything for a midwife.

Laura: [Laughs]

Aminatou: Let me know if you ever need anything.

Laura: You are hilarious.

Aminatou: That's my promise. No, it's true. You know, I think there's a part of me that's like ugh, I feel so vulnerable right now and also just very dumb. I feel very nave and dumb, like how can you be 32 and not know how to take care of yourself? And the only thing that keeps me going is that I realize that a lot of people have these questions; they're just equally as embarrassed to ask. And I'm like I will bite the bullet for all of us. This is ludicrous.

Laura: I totally appreciate that and I want to say that it's not an accident that you don't know about midwives either. I mean there was an actual successful attempt to get rid of midwives, you know, a few centuries ago and almost did. I mean midwives were the . . .

Aminatou: Wait, what happened?

Laura: Well, it was the -- part of who got burnt at the stake, right? The witches that got burnt at the stake were midwives.

Aminatou: The witches and the midwives. God damn it.

Laura: That is a real thing. And so, you know, there was a time when we could've been obliterated but we are back. And most people I know who are midwives, and of course I'm part of that community, found it to be a calling. And, you know, we're going to keep up the fight. We do actually have I would say . . . I have a little plug. In California right now we have a bill that is heading to the Senate right now, it passed the assembly, called AB 1612 which is to help nurse-midwives in California have parity with other midwives across the country because California's only one of six states that still require . . . our licensure requires physician supervision even though that doesn't mean that a physician actually has to be present for any of the work that we actually do. But they have to sign our admitting orders when we admit a patient to the hospital. And so we're looking to remove that wording and that would actually allow for midwives to practices in places like in 45 counties in California where there is no obstetrics provider at all. And so women have to travel really far to get GYN care or to have prenatal care.

Aminatou: It's funny, it's like this . . . everything that has to do with women's healthcare, they make it just a little harder to access. Thank you so much, Laura. You like made my day.

Laura: [Laughs] Thank you, Amina.

[Interview Ends]

Aminatou: And so if you live in California AB 1612 is a bill that you can push for locally and, you know, be a good friend to the CNMs near you.

Ann: I'm excited about this as a Californian.

Aminatou: I'm telling you, how do we make more midwives? Please.

[Music]

Aminatou: The next person that I talked to is Dana Taussig. She's a physical therapist and she is great. She works with outpatient orthopedic problems and she specializes in pelvic health specifically.

Ann: So tell me a bit about how is what she does different than what a certified nurse-midwife would do? Is it she specifically specializes in pelvic stuff? Is that it?

Aminatou: Yeah, so she is like a PT. Her whole thing is specializing in pelvic health which I'm really grateful for. My doctor really recommended pelvic physical therapy before because of the amount of pain that I always felt in that region in general. Like I've always been really tight. It's always been an issue. And it had never, until people started emailing me about it, it's something that I had never considered. And then it was like the double whammy of then I started going to a feminist doctor and that was the first thing she talked to me about.

Ann: Yeah. Also I love this too because often when there's a conversation about kegels or what you're doing for your pelvic muscles it's done in the context of here's how to have better sex or pleasure, which don't get me wrong, is a fine lens, but I like a model that recognizes no, often thinking about this comes about because you're experiencing pain and talk to an expert. Bodies are different. It's not as straightforward as your favorite women's glossy magazine makes it seem.

[Interview Starts]

Dana: My name is Dana Taussig. I am a physical therapist and I work with general outpatient orthopedic problems but I also specialize in pelvic health.

Aminatou: This is kind of exciting for me. [Laughs] I went to pelvic physical therapy for the first time last week and it was a game-changer.

Dana: Awesome. That's so good to hear.

Aminatou: How did you decide that this is what you wanted to do? Like what's the path to doing what you do?

Dana: So for me I first heard of pelvic physical therapy when I was already in PT school. I went to a conference for PT students and heard a woman who specializes in -- it's also called women's health physical therapy though we're kind of in the process of broadening that to pelvic health because as it turns out more than just women have pelvises and also . . .

Aminatou: Shocker. [Laughs]

Dana: Yes. So, you know, we're going for pelvic health. But I heard somebody giving a talk on what at that time was more broadly called women's health and it really kind of plucked at my feminist heartstrings. A lot of what we do in physical therapy from my perspective is about empowering the patient anyway and then to bring in the vagina is a whole other level of empowerment that I felt uniquely suited to help people address.

Aminatou: This makes me so happy. Without going too much TMI into my own issues, I've been dealing with some uterus vagina problems for a while now and literally I would say four or five years of constantly going to the doctor and at last I have a new gynecologist that I really like. She's a feminist. She's great. And she suggested pelvic therapy and I had never heard of it. And I was honestly like -- it was kind of a moment like wow, the more you know, and I had no idea. So why would a human -- what is the spectrum of pain you have to be on to go to your kind of doctor?

Dana: In the physical therapy perspective we focus on function kind of above all else. So in all honesty part of my job both when we're focusing on the pelvis and when we're not focusing on the pelvis is telling people that pain is a part of life, so there is some amount of bodily pain that is somewhat expected.

But when it starts to interfere with your function in life meaning your ability to do the things you love to do, to participate fully with your friends and your lovers, to do things joyfully, then it's a problem that you should be reaching out to someone about.

Aminatou: So with stuff like bladder pain, endometriosis pain, any kind of urinary or like fecal leakage . . .

Dana: Yes. Yes.

Aminatou: And like that general area?

Dana: Pretty much. We pretty much can broadly categorize that into any pain that has to do with the pelvis. So, yeah, bladder, pain in the vulva so kind of external what people would call vaginal pain or internal vaginal pain, tailbone pain, perineal pain. Those are all distinct things.

And then on the other side of the broad strokes -- broad stroke spectrum, we have the incontinence type problems as well. So one of the types of urinary leakage or fecal leakage. Those -- yeah, those all fall into the realm of things people might see us for.

Aminatou: I know this but for our listeners what does kind of a typical visit look like? When you go in. Depending on the kind of pain you have I guess.

Dana: Yeah. And it will -- it will vary certainly depending on the patient and it will also vary to some extent depending on the provider. And that's . . . it's a small variance. There are certainly some things that we are all expecting to do but typically with most physical therapy when you first walk in you are going to talk to your therapist for a while and get -- we want to get a sense of what you're coming in for, what your functional problems are, meaning how it's affecting you in daily life.

Sometimes with a pelvic problem you'll be asked to fill out a bladder or bowel diary ahead of time because that also gives us a sense of how your muscles are functioning down there and we'll kind of talk about all that stuff to start. So sometimes I end up talking to people for 15 minutes; sometimes we end up talking for 45 minutes depending on how long the story is. We'll ask about sexual activity and hopefully you'll also be asked about any history of sexual trauma, anything we need to be aware of moving forward.

And then once we've kind of wrapped up the basics of what we're going to talk about at that first appointment we'll move on to a physical exam. What I would -- will do next is a more general physical exam to start, so we look at posture, generally look at leg strength. We generally check out the abdomen for any scars, probably feel at your belly, look at how you're breathing which you mentioned at some point in the past couple of weeks is a thing for you. [Laughs]

Aminatou: Yeah, it's like who know? If your pain is so sharp that you can't breathe you should probably get off WebMD and go to the doctor.

Dana: Right. That's a life lesson I guess.

Aminatou: It's a process. It's a process. I'm learning. I'm learning. I'm learning to listen to my body.

Dana: But also just how you breathe can affect how your pelvic floor is functioning as well so it can kind of be a little bit of a vicious cycle. So we look at breathing and then once we get through all that general stuff, depending on if the patient is up for it, we'll do an internal exam. And internal exams will be either vaginal or rectal depending on what's going to be more pertinent for the problem.

You know, everything we do is really step-by-step and it's patient consent every step of the way so we'll both look at and palpate, so touch for any painful spots externally to start. So pressing around the vulva seeing if there are any particular tender points there. That can cue us into if there's something going on internally, and then potentially moving on to an internal exam. Our internal exams, that everyone should realize, we don't use speculum.

Aminatou: Oh?

Dana: Well, I don't. You may have had one that did. And generally the training that I went through is we generally don't because by and large what we're looking for is how the muscles feel both when they're contracting and when they're resting. The visual aspect of what is going on internally is not as critical for what we're addressing. In general people have been screened by a gynecologist before they've come to me anyway so anything that needs to be assessed with a speculum has already been assessed.

Aminatou: That makes sense.

Dana: So that ends up being just a single lubricated finger for the internal exam and it's a combination of feeling around at different angles, both lower down in the vaginal canal where there's one layer of pelvic floors and then higher up there's a whole other layer of pelvic floor muscles that most people don't really recognize are there. And so you might end up getting poked in places that you didn't realize you had.

Beyond the feeling of the muscles, then we also usually kind of assess how well they're working. So we ask people to squeeze and relax and cough to see if the muscles are doing what you think they're doing when you ask them to do those things, and that gives us a general sense of if the muscles are doing what they're supposed to do.

Aminatou: I want to go back to a thing that you had said earlier about people coming also to physical therapy, if they're survivors of any kind of sexual trauma. And so is that something that your OBGYN would refer you to or is that something you kind of need to know? And also how open are physical therapists to really working through that trauma with you as opposed to like the body stuff?

Dana: Right. So, you know, the first part of your question just in terms of is that a thing you'll be referred for, it's all about the healthcare community you're in and just increasingly in our healthcare system we need to self-advocate. So it's just kind of good to know what options are out there for you, and if it doesn't necessarily come up from your provider it's just always good to bring it up to them and see if they think it's a valid option for you. In terms of physical therapists being open to working with that, so we are a certain type of therapist. We're not another type of therapist.

Aminatou: That makes sense.

Dana: We hear a lot from people -- when you work on somebody's body, things come out. People share a lot with you. However we are not trained as psychotherapists, so often we recommend that people are simultaneously in psychotherapy or in counseling so that they're doing that with somebody who can really give them the correct tools to work with that. We shouldn't be the people who are working with patients on that. However we should be people who are respecting boundaries that are dependent on that, being respectful of triggers and needs because of those kinds of experiences. In general the pelvic specialty within physical therapy, it's continuing education training that we have to go through outside of physical therapy school. So if you're working with a therapist who has gone through one of the kind -- there are two main schools that you can go through for that training, we will have been exposed to working with survivors. The training is not super extensive but it is a thing that is definitely on our radar.

We also, because we are a type of therapy, we have an opportunity . . . unlike a lot of other providers these days we get to see patients more often than a lot of other providers do and we get to see them for a longer period of time than a lot of other providers do so we have the tremendous privilege of getting to take our time with patients. It's not ideal but I have had a patient who it took, oh gosh, almost six months of working with her regularly before she was comfortable doing an internal exam. And was that a particularly productive six months? Kind of in that it got us to the point of her being comfortable enough to do an internal exam but she was able to go exponentially further with her therapy once we got to that point.

Aminatou: From my own experience at least too I feel like -- and probably you don't love hearing this, but part of what you do is really coaching and empowering your patients because you have to feel comfortable every step of the way. I think I was really struck by how consent is so key in the process.

Dana: Yeah, absolutely.

Aminatou: And so it makes you . . . it sounds really like duh, but I feel like you don't always get that at the doctor. And so I was just really struck by that where it's like whoa, this is a thing I'm terrified about and instead because my provider was very conscientious and was like yeah, consent was part of every step of the way, so I felt very heard and listened to.

Dana: Yeah.

Aminatou: I don't know. It made that go way better than expected.

Dana: Yeah, absolutely. I mean there was a study done that I definitely don't know the author off the top of my head where they used sensors on women's pelvic floor muscles and showed them scenes from scary movies and when we saw scary movies or saw scary things by and large the muscles tightened. It's a . . .

Aminatou: That makes sense. [Laughs]

Dana: Right, it's a built-in reflex. So if you are working with a patient with pain and they are not comfortable and they are at all on guard or fearful, you're just not going to get anywhere.

Aminatou: No, it's true. I realize that a lot of my discomfort, usually during any kind of physical exam, was that. It was like oh, wow, I'm so tense from the information and the fear that my body is just like nobody is coming in.

Dana: [Laughs]

Aminatou: And I realized that was 50% of what was going on with me but that took a long time to kind of figure out what was going on there.

Dana: Right, and then begin to override is a whole other thing too.

Aminatou: Yeah. And now that I'm part of the pelvic mafia . . .

Dana: Yeah, awesome. [Laughs]

Aminatou: Do you know about this hashtag on Twitter?

Dana: I am familiar. I am not on Twitter but I see references to it via other social media.

Aminatou: I died. Pelvic health hashtag is amazing. It's all about like . . .

Dana: Yes.

Aminatou: Pelvic pain and like women's health and just like getting your pelvis straight. It's perfect.

Dana: [Laughs] There's a lot more conversation about it out there if you know where to look.

Aminatou: It sure -- you know, it's just you were saying before we started recording how it's just a part of health that people don't talk about a lot. And it's, you know, and like I . . . I know that. I know that firsthand. And it's crazy because of how much pain you can be in.

Dana: Mm-hmm. Yeah, and it also goes for kind of the other diagnoses we see for the incontinence diagnoses too. People don't -- you're not going to talk to people about that generally.

Aminatou: I'm ready to talk about the peeing because I've had this really bad cold all week and every time I sneeze I pee a little and I'm concerned.

Dana: Oh, yeah.

Aminatou: How much pee is normal pee? I'm willing to go on the record about this because I'm concerned.

Dana: Well good, I'm happy. Not about your peeing.

Aminatou: [Laughs]

Dana: So there is -- in general it's not normal for women to leak.

Aminatou: Like at all?

Dana: Pretty much. Aside from like the six months post-partem we should have healthy enough pelvic floor muscles that we should be able to control it.

Aminatou: Well good thing I'm in physical -- in pelvic physical therapy right now because . . .

Dana: Yes, absolutely.

Aminatou: [Laughs] Now I have a new thing to talk about.

Dana: You should mention it. And they can totally be intertwined as well because muscles that are too tight don't necessarily do their job well.

Aminatou: I mean this cold is really bad and it's every time I sneeze.

Dana: I'm sorry.

Aminatou: But it was concerning. I was like this has never happened to me before. Ugh, it's true, you turn 30 and your whole body falls apart.

Dana: Oh my gosh, you start noticing. I know. [Laughs]

Aminatou: It's true. It's so true. I'm literally falling apart and melting every day.

Dana: Yeah, I say that to people frequently. I was in PT school when I was in my 20s and I learned about how your body falls apart as you age but it literally took me hitting 30 to be like oh, no. [Laughs]

Aminatou: Yeah, it's crazy. It's like first the hangovers get bad and then everything falls apart. But so, okay, so I'll talk to my doctor about that, but this is easily fixable right? It's like do some kegels, like get your floor straight, right? Or is it like I'm going to have to do everything they say in the incontinence commercials now?

Dana: [Laughs] It's work.

Aminatou: I'm like please diagnose me over Skype. [Laughs]

Dana: So no, it's work. It gets a little bit more complicated when -- and this is one of the big conversations that is happening in the sphere of the Internet that actually talks about this is that kegels aren't just the answer. There have been a handful of articles in the past few years about how that's not all that we're doing. Because they're not necessarily appropriate for everybody, and if you are the kind of person that does have pain odds are you shouldn't be jumping into cranking out kegels because your muscles aren't in a happy place to do it.

But if it is just an incontinence situation then -- then odds are it is more of a straight kegels path. There is a statistic that something along the lines of 30% of women who are just like verbally instructed on how to do kegels or who just get a handout on doing kegels will actually do them wrong in some way.

Aminatou: Yeah. I mean I still kind of don't know what they're supposed to be. It like baffles me, because nobody can check that you're doing them right, you know?

Dana: Except for a pelvic physical therapist.

Aminatou: Yes! [Laughs] I love that I just went on the record about my possible incontinence but at least I'm with the right doctor.

Dana: Yes!

Aminatou: Oh my gosh.

Dana: It is being talked about.

Aminatou: I mean, yeah, that's the other thing too is like the more . . . and this is kind of why we wanted to do this episode. It's that the more that you talk about this stuff, you know . . . like some stuff is very serious, and by all means like be very private about it and deal with it in the realm of your own private sphere. But some of the stuff it's like the only way to demystify it is if we all admit that every once in a while you sneeze and you pee. It's okay.

Dana: Right. [Laughs] It's the only way to know, you know, when you're crossing the line into it being a problem and that there are resources out there to handle it when it does become a problem.

Aminatou: What do you want people who are your patients or who are prospective patients -- what are things that you would like them to know? Either to demystify for them or to make them feel better about or a common misconception.

Dana: Well, we kind of already touched on one of the most common misconceptions. I just had too many kind of older women come in with more significant incontinence and when I asked them how long it's been going on for they'll be like "Oh, well I leaked just a normal amount for years." And you're just like what do you mean leaking a normal amount?

Aminatou: That's me! That's me! [Laughs]

Dana: Nip it in the bud now so it doesn't become an abnormal amount. We shouldn't be leaking. Oh, and there was a thing in the CrossFit community a few years ago too saying it was cool for women CrossFitters to pee because they were working out so hard and also not true.

Aminatou: Oh my gosh.

Dana: Wetting yourself isn't cool. Know that there are things to be done if you are having pain and there are conservative things to be done. So in the healthcare scheme of things, when we talk about conservative measures, we're talking about minimally or completely non-invasive interventions. So whereas the most invasive would be a surgery and then the least invasive being learning how to breathe properly. [Laughs] You don't necessarily need to jump into medicating yourself and you don't necessarily need to jump into a spiral of surgeries which is a thing that too many women do with pelvic problems as well. There are less invasive things to try first and it is worth it to try because the less invasive, the less likely they are to have side effects and problems down the road as well.

Aminatou: Ooh, that's good. I mean so in terms of going to physical therapy, like my insurance covered it and my doctor referred me but is it -- you know, without knowing everybody's insurance information, it's something that's fairly accessible right? It's not like you have to go to Switzerland to get a fancy operation.

Dana: Yeah, no. Though it's not well talked about it is definitely a growing field. You can find pelvic physical therapists in a lot of places. There are a couple of kind of key websites you can go to to find people who have gone through the two specific training schools that I mentioned before.

Aminatou: Ooh, what are those websites?

Dana: If you search for "Find a PT" via the APTA which is the American Physical Therapy Association's section on women's health, if you look at their Find a PT or PT Finder function. And then the other main school is called Herman and Wallace. And that way you know you're finding someone who has gone through these specific training paths. In terms of it being covered by insurance, generally the way insurance works is Medicare sets the rules and Medicare does cover this to a large extent. A lot of times insurances -- though the physical therapists legally don't require a referral from your doctor, a lot of times insurance wants a referral from a physician before you go to a physical therapist. So you might need to go through that path anyway. But those are kind of the things to keep in mind. You can find someone who is abundantly trained to do it and you might want to get a referral even though the physical therapist might not necessarily require it.

Aminatou: Thank you so much for joining us Dana. This was really eye-opening.

Dana: Awesome. I'm so happy we got to talk. Thank you so much.

Aminatou: I know. Thank you for treating my incontinence and for diagnosing all of my other pain issues.

Dana: [Laughs]

[Interview Ends]

Aminatou: I've never been to any kind of physical therapy before -- LOL, because I'm not an athlete I joke -- but I'm a pelvic athlete. [Laughs]

Ann: [Laughs] Au contraire, your pelvis is working overtime.

Aminatou: I know. I'm a pelvic athlete, so that's what I go to the doctor for. And, you know, again I work with a team that is mostly women. They're all super respectful. They're great. And they go to really great lengths to explain to you what is going on. So if you're somebody who is really uncomfortable with manual exams and that kind of stuff, the first couple of sessions of physical therapy actually might not even involve that for you. And this is another place where having full disclosure with your care team about what you're comfortable with and if you have experienced trauma or if these kinds of things are hard for you, really letting them know upfront, because I know that it's really hard to be vulnerable but actually everybody wants to work with you and nobody wants to shame you and nobody wants you to be in pain or to do anything that you don't want to do.

Ann: And if they do they should not be in the health profession.

Aminatou: That's kind of the thing honestly that I learned talking to all three women today is if you can find the courage to advocate for yourself the system can work for you and if it's not working that's kind of your sign that you should go somewhere else.

Ann: All right. Well, see you in the midwife's office? [Laughs]

Aminatou: That's right. Find you a feminist. Find you a feminist care team. You can find us many places on the Internet, on our website callyourgirlfriend.com, download it anywhere you listen to your favorite podcasts, or on Apple Podcasts where we would love it if you left us a review. You can tweet at us at @callyrgf or email us at callyrgf@gmail.com. You can also find us on Facebook or on Instagram at callyrgf. You can even leave us a short and sweet voicemail at 714-681-2943. That's 714-681-CYGF. Our theme song is by Robyn, all other music you heard today was composed by Carolyn Pennypacker Riggs and this podcast is produced by the beautiful Gina Delvac.

Ann: Come see us in Minneapolis or Chicago maybe?