ABSTRACT Lina Amy Hack interviews anatomist Gil Hedley, PhD, about the pelvic floor. Hedley proposes a new and inclusive term for the intimate structures of the pelvic floor – the pars intima. They also talk about the ethics of manual therapy in the neighboring tissue of those intimate structures. Hedley discusses the shapes of the pelvic floor more as a sling and a funnel. The path of the pudendal nerve is also discussed.
Editor’s note: This article has mature subject matter, including a candid discussion about the anatomy of intersex, detailed images of the male and female structures of the pelvic floor, and part of the conversation references birth trauma.
Lina Amy Hack: Hi, Gil. Thank you for talking with me on our theme, ‘A Regional Study of the Pelvis’. I want to focus on the topic of the pelvic floor specifically. Your anatomy expertise is vast, especially your contribution to fascial anatomy, and your pelvic floor lectures stand out as ushering in a fresh view. You used to be a Rolfer, so you understand what our readers do and what kind of territory we deal with in structural integration.
What is the new term you have coined for the genitalia of the human body? And can you tell us about that idea?
Gil Hedley: Sure, that would be ‘pars intima’, another neologism to add to the pile!
I was raised Catholic, as are about a billion people on the planet, so not a small niche to be a part of. I wrote my PhD dissertation on Catholic marriage teachings, and I was an ethicist before I was an anatomist. The Church’s emphasis with respect to marriage is the procreation and the education of children, which is the purpose of one’s pelvic floor, as it were, from that perspective.
Genitalia and genitals are words describing the generative aspect of this region of the body. And hats off, those words have power. A person is in the generative aspect of their lives, that is to say, they tend to make their future generations, if they so choose, from ages eighteen to forty, generally speaking. The generative aspect is an essential reality of the pelvic floor.
The intimate aspect is another essential reality. Ever since we’ve been able to selectively not generate ourselves, we haven’t given cause to shut down our bodies because of that. We remain intimate, and that’s an essential aspect of our social nature as human beings.
And so for me, I thought, “I’ve made my way out of the umbrella or fold of the Catholic Church.” For my own sake, I want to stop referring to this aspect of my body as my genitals. I’m done generating. I’ve had my children, and now, for the remainder of my life, this part of me is the intimate dimension of my life. Pars intima, intimate parts, or the intimate aspect. I also like it for its generic aspect as opposed to its generative emphasis.
LAH: Yes, it’s non-binary.
GH: Exactly. It’s non-binary and it’s not preferential to procreation.
LAH: When I think about the anatomy of the pelvic floor, I think about water. The bowl imagery that is often used for the pelvis resonates with me – how my spine orients my pelvic bowl has an impact on my visceral contents. There is a spilling out and there is holding, but overall, the pelvic floor is just so deeply personal. It’s hard for me to talk about it with my clients because my empathy for what we might encounter is so huge. You bring much compassion to this part of the human body with your words, and I’d like to deepen my understanding.
GH: There’s a lot to encounter there. We store a lot of energy there and we block a lot of energy there. There is a whole lot going on. And it’s a two-way street, right? In terms of energy, it’s not just going in one direction.
LAH: Right, exactly. And as I think about this, with my children, I am very direct and clear about our pars intima. I speak clearly with them about their bodies, celebrate what they have, and joyfully educate them. It’s a value of mine to be very open.
GH: I appreciate that value. And I’ve also enjoyed speaking openly with my children about something that was in my life just an unknown, a mystery, a sideways comment.
LAH: Let’s start with talking about the pelvic floor embryologically. The human embryo starts out as a sphere of cells that cavitates inward to make tubes that connect. The undergraduate level biology teaches that the ‘mouth tube’ and the ‘anus tube’ form at the same time, and they find each other making the gut tube through the organism. But that is for sea urchins. For human embryos, our tubes don’t quite form
GH: Not quite. You’re describing the gut tube of sea urchins. For the human pars intima development, we have our Wolffian and Müllerian ducts that kick in due to the presence of certain hormones at certain times in development. Although we have many tissue homologues between the female and male versions that can express, basically there is also the dissolution of certain proto-structures in development. Which, if they don’t dissolve, you can get interesting combinations that create hermaphroditism and variations on that theme.
I’m not personally offended by the word hermaphrodite. People often use the word intersex now rather than hermaphrodite, just because hermaphrodite is kind of an old word, but if you look at the story of the hermaphrodite, it’s a love story. In Greek mythology, Hermaphroditus was the son of Hermes and Aphrodite. The water-nymph Salmacis fell in love with him and prayed they would always be together (Seymour 2011). Their love was so profound that they merged bodies into one. This is how hermaphrodite became the name for male and female in one body, a love story of a union.
Sadly, our culture doesn’t embrace it as a love story of a union. For people who are born intersex, our system tries to return them to a binary version of humanity. That pressure is very real, yet people are born with both every day and they are present all over the planet. And I find the unceremonious and unwilling surgical corrections imposed early in life to be an insult to the individual’s integrity, as much as is infant circumcision, because both represent procedures for which there can be no genuine informed consent (Jorge et al. 2021).
LAH: It’s very serious, I agree. I learned a lot from your intersex video in your Live with Gil series.1 In that video where you dissected a donor who had an intersex presentation of their pars intima, you said this is as common as one in two thousand births.2 Ambigendered people, that was the term you used, ambigendered, like ambidextrous. I thought that was smart. You are good at making new words.
GH: I do like creating new words! There are a lot of versions of being ambigendered as well. And if you included all the potentialities inherent in non-binary versions of humans that are born daily, the percentages of occurrences would probably increase.
LAH: Makes sense.
GH: And if you talk with advocates in this area, they’d say it’s as common as being a redhead. That might be from a perspective of advocacy, maybe a slightly broad count. It would possibly include many presentations pathologized by our medical community or not fitting exactly into the social framework.
LAH: This is valuable information. We don’t work directly with the pars intima of our clients, yet as Rolfers, we consider ourselves experts in human anatomy. We need to be aware and educated about all the forms people have, this anatomy in particular is part of a person’s sense of themselves and their identity in the world. We need to have this knowledge to support a client that may trust us enough with this information about themselves, that we may support their integration and embodiment in the gravitational field.
When I think about the collection of structures that we call the pelvic floor, it’s a place where we let go. I wonder if we guard this space so securely because letting go is just so personal, whether we’re letting go of our waters, our food bolus, or letting our babies go, it’s all very profound.
GH: Yes, there’s a lot of letting go there and a lot of holding on too.
LAH: That’s true.
GH: We may fear other people’s judgment about our letting go, but we probably fear our own judgment of letting go even more. And, we judge others for letting go. We’ve got to own that.
LAH: This is the charge that can be in the anatomy of the pelvic floor, it can be a lot to hold space for, is that your experience?
GH: Our North American culture has holding on built into it. In our history, we are not very skilled at letting go. Add to that the religious commitments and shaping of our culture over the last hundreds of years – as a people, we hold on to a lot.
I spent time in Haiti as a volunteer in Port-au-Prince for about three months when I was in my early twenties. The culture shock hit me hardest on the way home rather than on the way there. While I was there, the learning was, “Wow, not everybody has what I grew up with.” But the Haitian culture had more letting go than I was used to. The emotional cycle was not neurotic. I didn’t understand that. In that culture, when you’re angry and you express your anger, you express it loudly and in the moment. And then it’s gone, you’re laughing, and it’s passed, the emotion cycled very quickly.
This was when I realized, “Wow, when I get angry, I just stew about it, I internalize it, I hold on to it, I don’t express it, and I get madder.” That became the definition of neurosis for me, and I didn’t even know what it was at the time, but it was like a cockroach – when you see it, you know what it is. I saw my own neurosis when I was in a culture that was so much less neurotic than the one I had been raised in. We are in a holding culture, and we do it with every cell of our bodies, including our pelvic floor.
LAH: What a profound direct learning. I was raised by two atheists, which still has these tendencies you’re talking about – silence, holding, and staying in our own silos.
In the Live with Gil video about the anatomy of the clitoris, you talked about how practitioners put up these kinds of imaginary fences on our client’s bodies when we’re working with them. Fences that we never cross out of an abundance of caution.
Rolfers do not directly work with the pars intima structures. But if we build a fence too far away from the intimate parts of our clients, we are going to be avoiding important and relevant anatomy. This is a balance between the ethics of respecting ‘no-go zones’, tissues that we never touch, and also creating a compassionate therapeutic relationship with the client so we can work near these structures without confusion as to our intention. To complete a Rolfing ‘Ten Series’, specifically during the ‘Fourth Hour’, we need to work with the fascias attached to the ischial tuberosity, the pubic rami, the sacrotuberous ligament, and the coccyx, to name just a few. We are talking about tissues that are very close to the pars intima. If the imaginary fence is too big, we miss important structural and functional spaces.
Could you talk about that idea a little bit, how when it comes to the pelvic floor, practitioners can have some pretty big fences?
GH: Right. There’s a concept in the ethics of the Jewish religious tradition called fences around the law. You have the Mosaic Law and you really don’t want to break those laws. And so, you put a fence around the law so that the fence appears as the law itself, for social construct purposes. You don’t want to boil a kid goat in its mother’s milk. That’s the law. So, you build a fence. You actually go so far as to put the meat and the milk in different fridges. And then the likelihood of boiling a kid in its mother’s milk is extremely remote, and yet that fence remains on the chance that you might accidentally have some milk in the fridge that you’re boiling your goat in. Right?
LAH: This idea is new to me and rings so true when I think about my fences that I have placed on behalf of my clients and me. Rules I have made in my own head about where to touch and where not to touch.
GH: Exactly, it gets to be so similar in practice. There is the law in therapy, don’t have sexual intercourse with your client. Something really basic, right? Or, don’t put your hands inside your client’s pelvis. There’s the law.
LAH: Yup, that’s the law.
GH: And then we install fences around the law. I see it in the delivery of whole-body massages, where they literally don’t touch your entire inner thigh or anything between your anterior superior iliac spine (ASIS) and south of the naval. You have this no-go zone between your knee, your pubic bone, your ASIS, and your navel, that’s just this dead zone in practice. It’s like, “Well, I don’t really have to work there because there’s a fence there. And no one will mistake my massage for a sexual massage if I avoid that zone.” That’s a fence around the law that might be excessive.
LAH: We could miss big structural pieces if we build the fence there. I relate to what you are saying. Being one-on-one with a person and doing the job of touch is a very personal interaction. Doing a Rolfing SI Ten Series, we have to go well past those particular fences, and I feel them when I do. So, I proceed with awareness, compassion, and open dialogue.
Would you agree that even though there is a law around the pars intima of manual therapy clients, there are also good neighborly fences to be agreed upon, and that territory is essential to be considered?
GH: Oh my gosh, it’s so important.
LAH: As you know, in Rolfing SI we are looking for our clients to experience their highest expression of self, organized in gravity, and that includes a person’s pelvic floor being able to move. People will tuck their pelvic floor under. People will joyfully show it, that’s the whole twerking move. We’re laughing in our pelvic floors. We’re breathing there.
GH: It’s immensely essential in speaking to the whole person and the movement of energy through them, the movement of movement through them, the movement of breath through them, and if you leave that out – you’ve left out a lot.
LAH: In my practice, people tell me they need help with this zone of their body. They will point to their upper thigh, the medial aspect of their hip, and they will say, “My groin has pain when I’m running.” They know I have the skills to address this territory through fascial manipulation. We know that the fascia of the pelvic floor has a lot to do with the comfort and movement of the spine. People come to their practitioners with high expectations and profound hope for help.
GH: In the town where I used to live in Florida, I would go to this wonderful Chinese massage place. It was not a massage parlor. It was an excellent therapist who was the main person for her busy practice. But there was a cultural difference there that I treasured because their fences weren’t drawn so widely. I got a whole-body massage without it being a sexual massage. They weren’t afraid of your thighs and butt cheeks, and it was awesome. I felt like, “Oh my gosh, this is the first time I’ve ever gotten a real massage.” This was a seventy-year-old woman with her elbow coming right up on my gluteal muscles. This is the way it should be taught, but we have our fences.
LAH: For me, as a woman, as a practitioner, and as a person raised in North American culture, I’ve had to challenge myself so that I can do that great work. It’s a detail I have to be continuously mindful of, and after nineteen years of being a Rolfer, I’ve become comfortable with being communicative. My clients may notice that I have a shy personality and that I’m using compassionate words to overcome that nature to deliver quality pelvic floor work.
GH: And it does require that kind of awareness. We’re not in China, so it requires a different conversation with ourselves and with the client to do that work here. Rolfing SI, as I learned it, crossed the fences that were set up in the Swedish massage world. It can be a matter for an important open conversation to say, “Hey, in this practice, we’re going to go past your knee, up your thigh.”
LAH: Right. In my experience having those conversations and then doing that work, people are relieved, similar to what you described in your experience with your Florida practitioner.
Part of doing this interview with you is my interest in challenging my own fences, offering our readers a contemporary view of the anatomy of the pelvic floor. To supplement our conversation, I have some Thieme anatomy images for us to refer to. Looking at Figure 1, when I was first learning Rolfing SI, this image took me a while to figure out – the difference between the ‘false pelvis’ and the ‘true pelvis’.
GH: This classic image gives an interesting look that reveals certain things and hides others. When people talk about the pelvic floor, to have a meaningful conversation, I ask them, “What do you think that is?”
LAH: Exactly, there can be different interpretations.
GH: I ask people, “What tissues are you including?” The metaphor of a ‘floor’ doesn’t really work that well for me. It’s kind of like the respiratory diaphragm, people tend to have a mental image of a transverse plane cutting across the body. ‘Pelvic floor’ seems also to conjure this sense of a transverse plane. It doesn’t really look like that when you dissect out the muscles that people will name when they’re trying to account for the pelvic floor. In dissection, you will produce completely different images depending on the direction in which you cut into those structures.
I like to speak about a pelvic sling and a pelvic funnel as two distinct moments in a pelvic floor story. They each require a different kind of attention, they accomplish different things, and they respond differently to the breath.
LAH: Let’s explore these ideas further. The sagittal view of Figure 1 with the pelvis cut along the midline is a common view to learn about the pelvis. My question for you is, how can I understand the fascial layers of the pelvic floor from this point of view?
GH: I think that our love of fascia sometimes tends to have us preferentially think about it and demand that it be specific ways so that we can get a grip on it because it’s our favorite thing.
LAH: Yes, I can own that bias for sure.
GH: You have to remember that part of the story of the pelvic floor is about the viscera and another part is about the musculature. Person to person, the shapes of these structures are highly variable. Also, the relationships between the structures are extremely variable in such a way as to render generalizations about the fascia, in particular, a little suspect.
Something as simple as this Figure 1, just looking at these two images, I’m looking at the relationship of the anus to the coccyx. In the right-side version, we see they are closer together. And on the left, the space between is slightly further. This is something to notice because, as artistic renderings, we can wonder if they needed room in the drawing for a uterus. I’ve seen anococcygeal ligaments four inches long. In other words, the distance between the anus and coccyx can be very far or much closer. That’s just one point of extreme variability.
LAH: This is an important detail to note the individual difference, anatomy images depict one person, and clients will appear as a variation of that image.
GH: Another thing about Figure 1 that stands out is the absence of the fatty distribution described here, these two pictures would be of a person who starved to death. It’s hugely inaccurate in terms of the fatty deposition around the anus and the colon. If you were working on an actual human being, it would be more accurate to find a fistful on either side of those structures of fatty tissue. On any human that would be true, not just on a person with a fleshy morphology, it is this way in any person.
LAH: Well, as a fleshy morphology person, it piques my interest that the drawing has an anti-fatty tissue bias embedded in its teaching. I’m glad to know that.
GH: Last note about this image, you don’t quite get a sense of the funnel-like aspect of the rectum and pelvic floor from this image. It’s a perspective thing and when you’re looking from the outside in, the pelvic floor appears to be a funnel. And when you’re looking from the inside out, it appears to be a floor because of the puborectalis muscle coming off the pubic ramus.
LAH: Let’s look at this next drawing (see Figure 2), it’s the superior view of the muscles of the pelvic floor.
GH: Yes, from above, that’s not a bad picture. It’s not an easy one to get in terms of dissection. That’s not an image that you’ll stumble across in any dissection manual. It’s kind of a creative and beautiful rendering of a scene that would be nearly impossible to create with a knife. Although, don’t put it past me. I’ll keep trying.
LAH: It’s a common angle to study as a manual therapist, but hard to translate to the client lying on the table.
GH: Let’s look and find puborectalis, coming off of the pubic bone, and then it basically creates a sling underneath the rectum. Now, there’s no rectum in the picture, so you wouldn’t know that it had that essential function from this drawing. Right?
LAH: Totally. I did find a more three-dimensional view of puborectalis for our readers (see Figure 3).
GH: Let’s look to the other view, the inferior view of the same stuff (see Figure 4). Here we can see the prerectal fibers by the urogenital hiatus and the bottom of the levator ani group. Now, the way that they have drawn the levator ani group in this picture, and the only way that you could imagine the levator ani group by looking at this picture, is that it’s a match for what you saw in the other one.
LAH: Right, and this is the dominant picture I have in mind when I think about the pelvic floor.
GH: Well I have to tell you, what I see one hundred percent of the time, and I’ve dissected cadavers that were twenty-eight years old, forty-two years old, thirty-eight years old, fifty years old, seventy-five years old, and one hundred and four years old, and they all have a Snuffleupagus sticking out their butt. It’s more like a cone than what is drawn here.
LAH: I thought you might say that, and to my delight, I found this next image in the pelvic floor packet (see Figure 5).
GH: Oh, there you go. Now we’re talking. That’s great. This is an excellent rendering. That’s the best I’ve ever seen. The way they did the shadows conveys what I call the Snuffleupagus-look from Sesame Street.
LAH: That analogy works for me; I remember that character.
GH: Right? It was some sort of prehistoric mammoth with a big trunk as its face. The first time I dissected the anal area of the pelvic floor, I was like, “Oh my gosh, we have a Snuffleupagus.” What I also like about this picture is the distinct lengths of the anococcygeal ligament that I was just referencing. It would be very hard from that other image, which is extremely prevalent, to conjure this in your mind.
LAH: And this is what you mean when you say the pelvic floor is, in part, like a funnel?
GH: You got it. The one on the left also does a nice job of conveying depth, the dropping down and distance are accurate, and a formation of a cone. So, the puborectalis, to me, is the pelvic floor sling, and the levator ani group is the funnel. The two have different tissue angles and different relationships, and you can see clearly in Figure 5 that the levator ani makes a funnel.
The sling that the puborectalis makes is the closest thing we have to a floor, but still, it is more that it has depth as a deep bowl accounting for the bottom of the pelvis. It’s not like it’s ever going to be flat, and I don’t think anyone mistakes it for flat, I hope. So even the aspect we often refer to as the pelvic ‘floor’ is more like a bowl than a flat plane.
LAH: Very helpful to have your take on this content. As you know, in structural integration, we also spend a lot of time learning the ligamentous structures of the pelvis, so I wonder your thoughts about this next anatomy image – what is the dissection insight you have for Figure 6?
GH: That inguinal ligament may be my favorite illusion of all in this type of drawing. I’ve also seen this in laboratories where I go into the laboratory and they have a pelvis somewhere on a shelf. And that bony specimen has its inguinal ligament intact. This ligament is where the external obliques find anchor points in its tendinous aponeurosis at the pubic bone and the ASIS, where it kind of curls up on itself like a cresting wave. If you cut away the aponeurosis and leave the remnant curling wave, that’s your inguinal ligament.
LAH: Interesting, this drawing leaves the observer to think it’s like a string of connective tissue linking ASIS to the pubic tubercle of the pubic bone.
GH: The difference with this ligament from other ligaments in the body system is that there’s no joint between the bony origin and insertion. The idea of any ligament is that they’re relating one bone to another bone. Well, here you have a ligament that’s relating a bone to itself basically, which doesn’t make a whole lot of sense. But really, it’s a rolling bit of fascia. If you flatten it out, you will have the remainder of the sheet that’s curled up on itself. I’ve flattened it out many times just to show this to people.
I’m not saying that there’s not a band of tissue there that you can work with, that’s not what I’m saying at all. I’m just saying what it is, it is the inferior border of the aponeurosis of the external oblique curling up on itself and when it’s demonstrated in this way in images like Figure 6, it’s kind of falsified a little bit. Although I get why they do it this way, but I like to put it in context. And I don’t think it’s a bad thing to know this stuff. It’s more of an academic point.
LAH: Point welcomed; this is the kind of detail I appreciate learning.
Speaking of fascial continuities, I stumbled across your dissection of the cadaver named Gypsy Rose while looking at your website videos, which had a great presentation of the continuity of the adductor compartment with the pelvic floor structures.
GH: Oh yes, Gypsy Rose is a champion demonstrating the pelvic floor. And I look forward to sharing more of that content, there’s more to be edited before being published on my website.
She was a perfect model for demonstrating the puborectalis, which I backlit, and you could see that bowl/sling relationship from one side and then from the other side, the funnel. And to see the puborectalis from both sides and how it could be mistaken in these drawings.
LAH: Exactly, I was also captivated by all the structures above and below the pubic rami that you were demonstrating with the cadavers, those fascial tissue fibers are continuous with each other. Adductor magnus is continuous with investing fascia of the pelvic floor. Yet anatomy books don’t place these pictures side by side, these next images were fifteen chapters away from each other (see Figure 7). In the body, the upper medial leg is continuous with the pelvic floor, your dissection of Gypsy Rose demonstrated that continuity.
My question is, as manual therapists working with the adductor compartment of the upper leg, how much influence do you think we have over the pelvic floor?
GH: Oh, significantly. A friend of mine, Bonnie Thompson, LMT, CNMT, CFT, upon being exposed to the fascial relationships in that dissection in the lab, took it upon herself to develop wonderful techniques for non-orgasmic women doing neuromuscular massage therapy type of work on the fascia of this region. She realized she could access pars intima from gracilis. She’s helped many non-orgasmic women get over that issue.
Another friend of ours here in Colorado Springs, Kandi Marquardt, CMT, has done incredible work with men along these similar lines. That’s a whole other story, but accessing from the sacrotuberous ligament. Do you have an image of the sacrotuberous ligament?
LAH: Yup, see Figure 8.
GH: You see the sacrospinous ligament, below is the lesser sciatic foramen, and above is the greater sciatic foramen. The sciatic nerve is going to pass through the greater sciatic foramen and branches can be found up underneath those ligaments, there is some branching happening as the sciatic nerve comes out of the sacrum. One of those branches has my least favorite name, the pudendal nerve, referencing ‘the parts of shame’.
This is another structure that I’ve changed the name of in the story. I’ve renamed it the delectatal nerve, meaning the delightful nerve, probably to the chagrin of anyone who studies anatomy, except for folks who are of our ilk who don’t mind renaming structures for the sake of kindness toward the self. If your great-grandfather decided his great-great-grandson must be named “Shameful,” would you use that name for your kid or pick another? We change names for anatomical structures regularly, it is what nomenclature committees exist to do. The time has come to change the name of the “pudendal nerve.”
Now, where does this nerve come from? If we go to that greater sciatic foramen and look at the most inferior and most medial corner of the circle, if you can have a corner of a circle, right there is where your delectatal nerve is going to part company with the sciatic nerve.
LAH: We will add an arrow to Figure 8 to indicate where you are describing.
GH: Great. Now lower to that point, there’s something called Alcock’s canal running deep to the sacrotuberous ligament, formed through the fascia overlying the obturator internus muscle tissue. That’s a pathway of this sex nerve, let’s call it, just in case people can’t follow either of these big fancy Latin words [delectatal nerve; pudendal nerve].
LAH: I appreciate that note, I hadn’t thought of us having a ‘sex nerve’.
GH: Yup, well, we do, this delectatal nerve emerges from the same sacral spinal nerves as the lower contributions to the sciatic nerve, and has to pass through Alcock's canal as described, and it’s going to supply this whole area quite thoroughly.
LAH: I had no idea.
GH: Hardly anybody knows this, I have to thank my friend and long-time colleague, Sallie Thurman, a massage therapist in the Palm Springs area, who put me onto a careful exploration of it.
LAH: That is quite a gem of information.
GH: The more I’ve studied it, and the more I’ve looked at it in the lab, it’s very variable, the nerve doesn’t just pass under it, there’s a canal, there’s a tunnel in the thing.
GH: Now, it’s not always a completely circumferential tunnel. It is, let’s say, embedded, at the very least, deep to the sacrotuberous ligament, whose tensions are very variable, right? And whose vectors of force are variable.
LAH: Absolutely. I have images of the inferior view of the delectatal/pudendal nerve in the female and male pelvis (see Figure 9).
GH: Right, look at the bottom edge of gluteus maximus, there it is. Its path has a potentially huge impact, if distorted, upon that sex nerve.
We were doing a dissection, maybe two or three years ago, where I was going off on this topic. And Kandi Marquardt, that local therapist and colleague here in Colorado Springs that I already mentioned, she was thinking about her client who was impotent, suffering disappointment that, for ten years, he was not able to get an erection. Seeing this nerve path information, a light bulb went on for her. She went back, worked around his sacrotuberous ligament, and he had sex with his wife for the first time in ten years, as he and his spouse had hoped. Don’t rule out these possibilities in your understanding of pelvic floor function.
Looking at Figure 9, in that aspect of the sex nerve pathway, we can see how the area is thoroughly innervated. But in this drawing, as noted earlier, it gives you more of a ‘floor’ sense than a funnel sense, though they do try a little bit of depth with the shadowing.
Back to looking at those nerves, where we see the pudendal nerve labeled, it traverses the territory between the ischial tuberosities and branches over to the anus and to the clitoris – all through this area, branching, branching, branching. What they don’t show is the fat, it’s as if they think adding it would obscure the other stuff they are trying to show. But it’s there.
LAH: Sure, that makes sense, in vivo there would be fat tissue.
GH: Right? I’m telling you, on either side of the anus, filling in like a wedge, there’s a huge wedge of fat. All those nerves are running through and alongside that fatty tissue, and they’re super accessible. Now, they’re not just like wires running through the fat. They’re following planes of tissue in that fat, and in those drawings, they didn’t show the branches that are going into the fat. Our fat is very happy fat down there. It has love and life in it. It’s not just some dispensable blob.
LAH: That’s lovely, that’s what I appreciate about your point of view, you remind us about love and life in the fat.
I want to show you one more image as we finish our chat, take a look at Figure 10. My births were both Cesarean sections, so I have no personal experience with vaginal birth, and these images are from a surgical textbook. I’ve only known anecdotally what an episiotomy is, I didn’t know where they cut for an episiotomy. I wanted to ask your insight about where episiotomies take place to help the practitioners reading this article understand what clients mean when they tell us they have experienced this kind of birth intervention.
Looking at the top left image of Figure 10, which shows the possible locations of episiotomies, is that typically where they are in actuality?
GH: That’s an important image. They understate the midline episiotomy here. My sister, who is a home birth midwife with decades of experience, would testify to the repetitive witnessing of clear midline incisions from the vagina to the anus.
LAH: I’ve heard women describe this trauma.
GH: Just draw a red line through the entire perineum there, along that midline. And she said those sorts of things are done unceremoniously and sometimes despite being asked not to. It’s a terrible travesty in our medical system. The thing is, some episiotomies can be quite large, and there can be natural tears that are also quite large. But the difference between a natural tear and an episiotomy is a scalpel and tissue grains.
I know from tearing tissues apart for decades with my hands, that they come apart very differently when they’re torn along their grains. Tissues have grains. The grains are a function of perifascia following nerves, blood vessels, and muscle tissues in such a way that if you did tear them, it wouldn’t offend every natural contour of the tissue that the knife does. The knife has no respect for the perifascial membranes surrounding a nerve. A tear could be creating an ugly and tortuous wound but it is one that follows the fractal forms of the vasculature and nerves. As opposed to the Euclidean form of the blade and its sharpness, the blade does damage that’s not as easily repaired by the body as the natural tears. It’s disruptive, very disruptive.
But someone’s got to sew that up. My sister is willing to sew up a natural tear and has practiced that. But that repair takes a long time, longer than you may want to devote to your four births that afternoon. The cut is to expedite the movement of that head through the space. I could go on and on with this particular pelvic floor topic; it is important. We are never more a mammal than at the point of birth. We drop into a very special space as a species when birthing. It’s a very powerful space.
LAH: I feel you and everything you are saying. I could also talk for a long time about the tangent of birth and medical care choices made in North America. Interestingly, my sister is a doctor who works in the hospital, supporting women during their low-risk deliveries. There is a lot of deserved controversy involved in the medical control of birth.
And, as manual and movement therapists, these are the topics our clients have lived through when they say, “I had natural tears during that delivery,” or “the doctor had to do a deep episiotomy.” But you are right, some women have the story that they asked to be allowed to tear and the doctor intervenes with the scalpel. This is what I meant at the start of our conversation, the thing that gives me pause about this territory of the pelvic floor, these high-voltage stories embedded in the anatomy.
GH: What remains are these scars and the stitchery that surrounds them. If you have these scars, then you need to treat them, and because of the aforementioned fences and law, it can be difficult to get that help.3
I bet Sharon Wheeler [LMP, Certified Advanced Rolfer, and founder of ScarWork] would have something to say on this topic, she’s very good with scar work. As is Alastair McLoughlin [founder of McLoughlin Scar Tissue Release®], who basically teaches people how to self-treat perineal scars with his techniques.
Still looking at Figure 9, I think they’ve overdrawn ischiocavernosus quite a bit here. I love ischiocavernosus, it’s a very cool muscle. I don’t see it going up that high on the crura of the clitoris. I tend to think of it like a handshake from below. Yes, I would call that depiction overdrawn.
LAH: Let’s look at another set of drawings to discuss that (see Figure 11). What do you love about the ischiocavernosus?
GH: It is either the legs of the penis or the legs of the clitoris, and I just love the idea about those legs and what that means. We have skeletal muscle that can either be actively contractile or involuntarily contractile in an orgasm. As part of our pars intima, we have legs, that’s fun.
LAH: That is fun to think about. Thank you for talking with me about the story of the human pelvic floor, your integrated anatomy point of view is extremely valuable to our readers as well as your compassion for this special territory. Any final thoughts for our readers?
GH: There’s nothing and nowhere in our body that isn’t accessible one way or another, and beautiful also, it’s all a gift and a treasure. We sometimes have alienated ourselves from this area in particular and it has so much to offer us. There are so many presents here to unwrap for our lives in terms of our movement, our energy, our intimacy, our social relations, our way of being in the world, our way of standing in a grocery line, that invites us to learn more about the pelvic floor.
And we didn’t even get into talking about the esoteric stuff, where this area is a bottomless cauldron of energy that can go up your spine and squirt out your head in an insanely delicious way that will transcend your human experience and bring you to a different level. That’s another thing this area is a resource for, so keep an open mind. I appreciate chatting with you, it’s been fun.
Live with Gil sessions are an educational video series offered at www.gilhedley.com.
Intersex population figures are complex; a good summary can be found at https://ihra.org.au/16601/intersex-numbers/. The United States Government commemorates October 26th as Intersex Awareness Day, see https://www.state.gov/on-intersex-awareness-day/ for more information. Another resource would be by Juan Carlos Jorge and colleagues (2021) who tracked the growing international agreement to prohibit non-consensual medical intervention to intersex persons and compared those standards with the current medical protocols for intersex care in the United States in their peer-reviewed article, “Intersex care in the United States and international standards of human rights.”
As already mentioned, Rolfers do not work directly with pars intima anatomy. Yet, some physical therapists in the United States do have specialized training for internal pelvic floor work as part of their scope of practice. For more information, see https://www.physio pedia.com/An_Overview_of_Physiotherapy_Assessment_and_Treatment_of_the_Pelvic_Floor? utm_source=physiopedia&utm_ medium=search&utm_campaign= ongoing_internal. [Click 'Read Article.] Correct evaluation and treatment of pelvic floor structures must include a comprehensive conversation about risks, benefits, and informed consent in advance of any contact by the practitioner.
Gil Hedley, PhD, has been teaching integral anatomy in the lab, lecture hall, and online at www.gilhedley.com since 1995 to professionals from a whole range of healing and fitness modalities. He is the producer of ‘The Integral Anatomy Series’, the author of several books of poetry and prose, and has now created the “Anatomy from A to Z” project, more than two hundred hours of a comprehensive on-camera tour of human anatomy based on his integral, whole-body approach. Hedley is based in Colorado Springs, Colorado, where he presides over the Board of Directors of the Institute for Anatomical Research, a 501(C)(3) non-profit corporation focused on expanding the study of integral anatomy through cadaver studies.
Lina Amy Hack, BS, BA, SEP, became a Rolfer® in 2004 and is now a Certified Advanced Rolfer (2016) practicing in Canada. She has an honors biochemistry degree from Simon Fraser University (2000) and a high-honors psychology degree from the University of Saskatchewan (2013), as well as a Somatic Experiencing® Practitioner (2015) certification. Hack is the Editor-in-Chief of Structure, Function, Integration.
Jorge, Juan Carlos, Leidy Valerio-Pérez, Caleb Esteban, and Ana Irma Rivera-Lassen. 2021. Intersex care in the United States and international standards of human rights. Global Public Health 16(5):679-691.
Seymour, Jane. 2011. Hermaphrodite. The Lancet 377(9765):P547.
pelvic floor; genitals; pars intima; embryology; intersex; consent; boundaries; pelvic sling; pelvic funnel; inguinal ligament; adductor compartment; pudendal nerve; delectatal nerve; sciatic nerve; root chakra; birth; viscera; Fourth Hour; episiotomy; perineum scar; ischiocavernosus. ■
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