The impact of childhood trauma on pregnancy and childbirth: understanding and preventing traumatic reenactment in maternity care

When you think of childbirth you might imagine personal transformation, joy, and even empowerment. For many parents, this is true. But for individuals with a history of childhood sexual abuse (CSA), pregnancy and childbirth can kick up unwelcome reminders of past trauma. And because trauma healing is not linear, the journey to bring new life into the world can reopen old wounds.

I want to take you on a quest to explore the ways in which maternity care can reenact past abuse, even when care is provided with the best intentions. As a psychologist specializing in perinatal mental health and trauma, I have come to understand how inextricably intertwined a person’s trauma history can be with their experience of pregnancy and childbirth. Understanding this connection is critical for therapists working with women and pregnant individuals during this meaningful period of their lives.

What do you think happens when the process of childbirth itself—the intimate procedures, the potential for perceived loss of control, the encounters with strangers—feels hauntingly similar to the past experiences of abuse? The answer can be found in a qualitative study conducted by Montgomery et al. (2015), where the experiences of nine women who had been sexually abused as children were analyzed to understand how maternity care can unintentionally mirror past abuse. Despite efforts to provide sensitive care, the study found that certain aspects of childbirth can still replicate aspects of past sexual abuse.

One of the most striking findings of this study was the role of intrusive medical procedures on triggering memories of abuse. For women who had been sexually abused, vaginal examinations—a necessary part of maternity care—could evoke feelings of violation and fear, even when the procedure was done with care. For example, one participant in the study shared that she felt violated during a routine examination, linking it directly to her childhood experiences.

What do you think happens when the process of childbirth itself—the intimate procedures, the potential for perceived loss of control, the encounters with strangers—feels hauntingly similar to the past experiences of abuse?

Pain is an inevitable reality of childbirth, and for women with a history of CSA, labor pain can disturbingly overlap with the emotional and physical pain they experienced during past traumatic events. In the study, several women described how the anticipated and experienced pain of childbirth transported them back to their abuse. One woman expressed fear that her childhood trauma memories would “get into her head” before she gave birth. Another participant reported finding herself unable to breathe during labor and delivery; a response that she later connected to her childhood abuse. In the throes of labor, her body remembered what her mind could not consciously hold. This research suggests that, for sexual trauma survivors, pain management in childbirth is not just about physical relief; it is about creating a space where they can feel safe and in control of their bodies.

It comes as no surprise that control is a central theme in both trauma and childbirth. For sexual abuse survivors, the legacy of their trauma often centers around the loss of control over their bodies. In childbirth, this loss of control can be re-experienced, particularly when medical interventions become necessary. Even pregnancy itself can make expectant parents feel disempowered. One of the participants in the study described feeling like the “baby was taking over” her body. Her words echo the experience of many trauma survivors who feel as though their bodies are once again being controlled by an external force during pregnancy. This loss of agency, combined with the medicalization of maternal healthcare and childbirth, can destabilize the expectant parent.

These research findings highlight why working with survivors during pregnancy requires a clear understanding of their trauma history and a sensitivity to how medical interventions can inadvertently trigger a trauma response. Trauma-informed providers and therapists alike must recognize how the body can remember past trauma. Even when the rational mind knows that a medical procedure is distinct from abuse, the body can respond as if it is the same.

In the throes of labor, her body remembered what her mind could not consciously hold.

What can be done to protect CSA survivors from re-experiencing trauma during pregnancy and childbirth? Building trust between healthcare providers and women with a history of CSA is essential. Montgomery et al. (2015) emphasizes the importance of creating a safe, respectful environment where women feel in control of their care. This might mean allowing them to make decisions about how procedures are conducted or ensuring continuity of care so that they can build a trusting relationship with their provider. Therapists working with pregnant women and individuals can prepare their clients for how pregnancy and childbirth might bring up traumatic memories and equip them with resources to navigate childbirth effectively. Therapists can also help women advocate for themselves during pregnancy and childbirth. They can support them in articulating their needs, setting boundaries, and ensuring that they feel empowered throughout the process. Trauma-informed care is not just about avoiding triggers; it’s about creating an environment where women feel safe, respected, and empowered.

If you’re a provider interested in learning more about birth trauma and recovery, I encourage you to take my Birth Trauma Recovery Training. Together, we can create a community of trauma therapists dedicated to supporting women through one of the most meaningful experiences of their lives.

References:

Montgomery, E., Pope, C., & Rogers, J. (2015). The re-enactment of childhood sexual abuse in maternity care: A qualitative study. BMC Pregnancy and Childbirth, 15, 194. https://doi.org/10.1186/s12884-015-0626-9

Understanding masking through Taylor Swift’s “I Can Do It With a Broken Heart”

Taylor Swift’s sparkly ballad “I Can Do It With a Broken Heart” highlights a harsh reality for many individuals struggling with their mental health: the need to hide their pain behind a mask of resilience. As a clinical psychologist, I see this behavior often—individuals who, due to societal expectations or internalized shame, feel compelled to conceal their emotional distress. This is commonly referred to as “masking."

Lights, camera, bitch, smile, even when you wanna die

Masking refers to the conscious or unconscious camouflaging of one’s true emotions or mental state in order to fit in, appear "normal," or meet societal expectations. People who mask often present a facade of well-being or competence while struggling internally with trauma, depression, anxiety, or other forms of mental distress. The phrase “Lights, camera, bitch, smile, even when you wanna die” from Swift’s song concisely reflects this performative pressure: smiling through overwhelming emotional pain.

For trauma survivors, masking can operate as a coping mechanism that ensures survival in environments that are not conducive to vulnerability. Furthermore, unresolved trauma can hijack the nervous system in a way that makes individuals feel perpetually unsafe, even in neutral or safe situations. As a result, masking for the trauma survivor becomes a reflexive protective mechanism against anticipated harm.

If we were to unpack the psychological factors that drive the need to mask emotions, we’d find three central determinants: survival, social pressure, and fear of rejection. Related to survival, it is commonly accepted that trauma activates the brain’s survival system. As a result, when a person feels threatened, they may hide their distress to avoid further emotional or physical harm. Research has shown that childhood trauma, in particular, is associated with chronic hypervigilance, where individuals are constantly on alert for danger (van der Kolk, 2015).

Concerning social pressure, we live in a society where there is extraordinary pressure to conform to social norms and expectations. Swift's lyrics, "I'm a real tough kid, I can handle my shit,"underscore the societal demand to appear “tough” and in control, even when it feels impossible. For many, masking becomes a way to meet social expectations that value stoicism and independence, even when their internal reality is one of excruciating struggle.

Finally, a driving force behind masking is fear of rejection. Recent studies on social stigma and mental health reveal that people often hide emotional distress out of fear of being judged or ostracized (Jones & Grubbs, 2020). Many trauma survivors have a deep-seated fear of abandonment stemming from past relational experiences. Consequently, they may cloak their emotions to prevent others from seeing them as “weak” or “broken.”

All the pieces of me shattered as the crowd was chanting, “More”

While masking may offer short-term protection from emotional pain, it can have serious long-term effects on mental health. Chronic masking can lead to emotional burnout, isolation, and delayed healing. The constant effort of pretending to be okay is mentally and physically draining. Swift’s lyric, “All the pieces of me shattered as the crowd was chanting, ‘More’” refers to the exhaustion of maintaining a facade when you feel like you’ve crumbled inside. Over time, this leads to burnout and emotional fatigue, making it even harder to engage in daily life or form authentic connections. Masking often creates an incongruence between a person’s true self and the image they project to the world. This discordance can create feelings of isolation, as it becomes harder for others to truly understand or support the person behind the mask.

I’m so depressed, I act like it’s my birthday everyday

One of the most tragic consequences of masking to me as a therapist is that it can prevent people from accessing the support they need. When trauma survivors mask their pain, they are less likely to seek help from therapists, friends, or family members. This prolongs their suffering and can worsen symptoms of post-traumatic stress disorder (PTSD), depression, and anxiety. A 2019 study on emotional suppression in trauma survivors found that individuals who chronically suppressed their emotions were more likely to develop long-term mental health issues, including PTSD (Cloitre et al., 2019).

Swift’s “I Can Do It With a Broken Heart” opens up an important dialogue about mental health that can help break down the barriers that force people to mask their pain. As a society, we need to challenge the “fake it till you make it” mentality and embrace vulnerability as a form of strength, not weakness.

References:

Cloitre, M., Khan, C., Mackintosh, M. A., & Garvert, D. W. (2019). Emotion regulation mediates the relationship between trauma exposure and social functioning in adults with and without childhood trauma exposure. Journal of Traumatic Stress, 32(6), 933-944.
Jones, A. J., & Grubbs, J. B. (2020). Understanding the role of stigma in predicting mental health treatment outcomes among trauma survivors. Trauma, Violence, & Abuse, 21(4), 743-758.
van der Kolk, B. (2015). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Penguin Books.

Understanding the red flags of narcissistic abuse through Taylor Swift's “The Tortured Poets Department”

In Taylor Swift's moody synth-pop track “The Tortured Poets Department,” one particular lyric stands out for its raw portrayal of manipulation and control: “You told Lucy you’d kill yourself if I ever leave.” This line sheds light on a troubling dynamic often found in abusive relationships, where threats of self-harm or suicide are used as a tool to maintain power and control over a partner. As a clinical psychologist specializing in trauma, I aim to unpack the implications of this behavior, exploring how it reflects the hallmarks of narcissistic abuse and the psychological impact on those entangled in such relationships.

“You told Lucy you’d kill yourself if I ever leave.”

Narcissistic abuse involves a pattern of behavior characterized by manipulation, control, and exploitation, driven by a narcissist’s need to maintain power and bolster their own fragile self-esteem. Research indicates that narcissistic individuals often employ various tactics to dominate their partners, including emotional manipulation, gaslighting, and coercion.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), identifies narcissistic personality disorder (NPD) by a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy. Individuals with narcissistic traits frequently manipulate their partners to meet their emotional needs, often using threats and emotional blackmail to keep them ensnared in the relationship.

By telling Lucy that he would kill himself if his partner leaves, the character in the song is not just expressing despair but is exerting pressure to force compliance.

Threatening suicide to manipulate a partner is a particularly insidious form of control. This tactic preys on the partner's empathy and fear, effectively coercing them to stay in the relationship out of a sense of duty or terror of the potential consequences. According to a study published in the Journal of Interpersonal Violence, such threats are a common feature of abusive relationships and are strongly associated with psychological distress in the victim (Davis & Richardson, 2015).

The lyric from Swift’s song captures this dynamic succinctly. By telling Lucy that he would kill himself if his partner leaves, the character in the song is not just expressing despair but is exerting pressure to force compliance. This behavior is a classic red flag of narcissistic abuse, revealing a toxic pattern where the abuser manipulates the partner’s emotions to maintain control.

Research highlights the profound psychological toll that such threats can have on victims. A study from the American Journal of Public Health indicates that victims of this type of emotional manipulation often experience heightened levels of anxiety, depression, and feelings of entrapment (Smith, White & Holland, 2013). The threat of suicide creates a hostage-like situation, where the partner feels responsible for the abuser’s well-being, leading to a relentless cycle of guilt and obligation that is difficult to break free from.

The National Coalition Against Domestic Violence (NCADV) reports that one in four women and one in nine men experience severe intimate partner violence, which often includes threats of self-harm by the perpetrator. These threats are not only manipulative but also serve to reinforce the abuser’s dominance, making it exceedingly challenging for the victim to leave the relationship.

The threat of suicide creates a hostage-like situation, where the partner feels responsible for the abuser’s well-being, leading to a cycle of guilt and obligation that is difficult to break free from.

Recognizing these red flags is crucial for identifying and escaping narcissistic abuse. Key indicators include:

Emotional Blackmail: Using threats of self-harm or other manipulative tactics to induce fear and guilt.
Excessive Control: The abuser demands total devotion and compliance, often isolating the partner from friends and family to maintain dominance.
Lack of Empathy: The abuser shows a blatant disregard for the partner’s feelings and well-being, focusing solely on their own needs .

Understanding these patterns can help victims identify the signs of abuse and seek the necessary support and resources to escape the toxic dynamic.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.
Davis, B. A., & Richardson, C. (2015). Manipulation and Coercion in Abusive Relationships: An Empirical Review. Journal of Interpersonal Violence, 30(12), 2301-2323.
National Coalition Against Domestic Violence. (2020). Statistics on Intimate Partner Violence. Retrieved from ncadv.org.
Smith, P. H., White, J. W., & Holland, L. J. (2013). A Longitudinal Perspective on Dating Violence Among Adolescent and College-Age Women. American Journal of Public Health, 93(7), 1104-1109.

Resources for survivors of intimate partner violence:

RAINN

The Safe Helpline

The Voices and Faces Project

It’s On Us

It Happened to Alexa Foundation

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A leaked letter shows how OBGYNs disregard emotional health in childbirth. Here is how this traumatizes birthing people

As a clinical psychologist specializing in birth trauma, I’m all-too-familiar with the many ways the medical experience of childbirth – which 33-45% of birthing people report as being a traumatic experience – can lead to poor mental health outcomes. My clients say, and research confirms, that the most profound components of birth trauma are the experiences of being stripped of dignity in the birthing process, feeling uncared for, and feeling like the birthing person wasn’t treated as an individual.

But I’ve never seen written evidence that some doctors practice in a way that directly causes these adverse outcomes – until now. Late last week, a letter addressed to “expectant mothers” (though not all birthing people identify as women) from a group of obstetricians affiliated with Weill Cornell Medical College of New York Presbyterian Hospital in New York caused outrage among parents and providers alike after being circulated online. The reach of online birth justice communities meant that, moments after being shared, the post ricocheted far beyond its origins.

But I’ve never seen written evidence that some doctors practice in a way that directly causes these adverse outcomes – until now.

In the letter, reportedly included in new-patient information packets, the doctors discouraged patients from creating birth plans, which expectant parents use to outline the experience they hope to have during labor and delivery, from whether they prefer epidurals to what sort of music should play in the birthing room.

The doctors wrote that, while they would love for their patients to have the “perfect birth,” they feel that “the use of birth plans too frequently sets up unrealistic expectations and conditions for potential conflict. We are your care givers and would like to use our knowledge and experience to act in the best interest of you and your baby.”

Weill Cornell has since disavowed the letter, writing in an instagram post that it was “erroneously” included in recent information packets to patients (some recent patients expressed doubt about that in the post’s comments).

"We are your care givers and would like to use our knowledge and experience to act in the best interest of you and your baby."

But it doesn’t much matter whether the letter was given out in error or the hospital is backtracking for PR. The fact that it exists at all is concrete evidence of the widespread trauma birthing people experience regularly at the hands of medical professionals: perinatal mood and anxiety disorders are the most common complications of childbirth. And it shows what my clients have been telling me for years: that medicalized birth is in crisis, and urgently needs reform.

The United States has the worst childbirth-related mortality and severe maternal morbidity (i.e. “near misses”) rates of any other developed nation, with higher adverse outcome rates in birthing people of color. This is related to a confluence of factors, including systemic oppression and racism in medicine, and the U.S.’s profit-driven healthcare system. But it’s also due to the way physicians are still trained to prioritize medical interventions ahead of the people on whom they perform them (Lown, 2014).

Medicalized birth is in crisis, and urgently needs reform.

This includes when doctors diminish patient birth plans, which in my clinical experience is a tool for empowerment and education for the birthing person. To discount patient priorities around labor and delivery is to look at them as bodies rather than people, which leaves emotional health out of the care equation.

This is a recipe for birth trauma in and of itself, but the letter goes even further.

The doctors write, “Some of you may have specific questions about episiotomies, labor induction or augmentation, forceps or vacuum delivery, fetal monitoring or anesthesia in labor. We believe in giving our patients the best of care. In modern obstetrics, this may still include the aforementioned procedures.” This is a scary series of sentences meant to frighten birthing parents into compliance, further silencing any person-centered dialogue in the medical relationship.

In a country where the future of reproductive rights hinges on the opinions of a small group of conservative judges, the medical system must do better.

This is the opposite of what should be happening to start lowering the numbers of people who experience trauma symptoms after childbirth. Given that many birthing people are also survivors of sexual trauma or assault, we need to be focusing on improving trauma-informed obstetric care to this population. Nixing birthing plans does not accomplish this. Doctors need to take time to get to know their patients as human beings to protect their physical and emotional health during the birthing process.

In a country where the future of reproductive rights hinges on the opinions of a small group of conservative judges, the medical system must do better. Obstetrics must do better. People have a right to agency and choices in childbirth. Life-threatening emergencies happen where swift intervention is necessary, but there is no need to shut down communication prematurely.

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Prince Harry swears by EMDR. Here's what it is

Prince Harry talking to Oprah on the Apple TV+ docuseries "The Me You Can't See"

When Prince Harry recently started speaking out about the harmful ways that both his family and the media treated his wife, Meghan -- and how it re-triggered his trauma around his mom’s reminiscent experience and premature demise -- he mentioned what has helped him heal: Eye Movement Desensitization and Reprocessing therapy, or EMDR. He told Oprah in “The Me You Can’t See” that the modality, which he found while exploring ways to save his relationship, ultimately saved his life.

"One of the biggest lessons that I've ever learned in life is you've sometimes got to go back and to deal with really uncomfortable situations and be able to process it in order to be able to heal," he said.

That’s the purpose of EMDR, one of the modalities central to my clinical practice, and one that has tremendous power to relieve clients’ trauma and anxiety responses. I’d go so far as to call it transformative: I’ve regularly seen clients who complete courses of the therapy go on to make permanent positive changes in their lives, like changing jobs, moving, or setting healthy relationship boundaries for the first time. And while I can’t speculate on Prince Harry’s emotional process, it’s possible to observe that, since starting therapy, he stepped back from royal life, disengaged from his family, moved to California, and started new work in content production.

"One of the biggest lessons that I've ever learned in life is you've sometimes got to go back and to deal with really uncomfortable situations and be able to process it in order to be able to heal"

Prince Harry let the public peek into a remote EMDR session in “The Me You Can’t See,” where it showed him, hands crossed on either shoulder, tapping lightly on one side and then the other while moving his closed eyes toward the taps. In-person versions can include following a therapist’s moving finger, tracking a light board, or holding pulsing tappers in either hand.

But how does EMDR work, exactly?

The evidence-based, integrative psychotherapy approach, developed in the 1980s by psychologist Francine Shapiro, alleviates emotional distress associated with disturbing memories through bilateral brain stimulation. By activating both hemispheres of the brain while following a specific protocol guided by a trained therapist, unintegrated memories and experiences are reprocessed fully, providing remarkable relief.

EMDR is based on the idea that emotional distress is rooted in unprocessed and persistently disturbing memories. The brain, usually able to hold onto what is useful from an experience and discard what is not, can be short-circuited by traumatic events, preempting that integration process and leaving a memory stuck in its raw form. When that memory surfaces, brain and body react like it’s something happening now rather than in the past. This is what causes emotional symptoms, negative beliefs about the self, and even physiological effects.

EMDR is based on the idea that emotional distress is rooted in unprocessed and persistently disturbing memories.

In EMDR, clients are guided in a safe environment through the upsetting memory in a way that allows it to be metabolized fully so that it feels like it is truly in the past. This frees them from the painful symptoms formerly intertwined with the memory. Positive self-beliefs replace the negative ones, allowing space for people to refocus their priorities on moving forward instead of treading water.

As Prince Harry put it, “I really feel that we should be focused more on the things that feed our soul.”

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We need to address colorism in the therapy room if we hope to start healing as a nation

When I was in second grade, a classmate approached my desk.

“You’re brown,” he declared, his face contorted with repugnance. I turned and we locked eyes. He was brown like me, maybe a shade lighter. I was shocked. In cursing my brown skin, he was proclaiming his hatred of his own, the complete opposite of the pride I was raised to feel in my heritage.

This entire exchange lasted only three seconds, yet it held the expansive weight of generations of American colorism, a form of discrimination based on the darkness of one’s skin tone. It’s related to racism but also distinct: while all Black people experience discrimination due to the racial category in which they fall, for example, the magnitude, prevalence, and end result of that discrimination will differ greatly by skin tone. The ubiquity of colorism impacts all people of color, cutting across groups of racial and ethnic minorities in America.

This entire exchange lasted only three seconds, yet it held the expansive weight of generations of American colorism, a form of discrimination based on the darkness of one’s skin tone.

That childhood moment followed me into my adult career as a clinical psychologist specializing in trauma, where colorism comes up regularly with my BIPOC clients, but not with my white ones. And after a traumatic year for everyone that disproportionately caused suffering in minority communities, from police violence to COVID deaths to anti-Asian hate crimes, conversations about colorism must be part of the healing process, even -- especially -- in majority-white spaces.

We cannot be anti-racist without being anti-colorist, and we cannot grapple with colorism as a society unless white people -- who make up the majority of mental health professionals here -- join the conversation.

Colorism research has consistently demonstrated that lighter-skinned people of color are privileged in areas of income, education, and housing, even when controlling for other variables. For example, lighter skinned people of color earn more money, complete more years of schooling, and live in wealthier neighborhoods compared to darker skinned people of the same ethnicity. In America, people will opt to hire a lighter skinned person before a darker skinned person of the same race (Hunter, 2007). Most people are not even conscious of this preference for lighter skin; it is deeply ingrained in the systematically racist foundation of American culture.

We cannot be anti-racist without being anti-colorist, and we cannot grapple with colorism as a society unless white people -- who make up the majority of mental health professionals here -- join the conversation.

I’ve found that my work with BIPOC clients deepens when colorism emerges in the psychotherapy process. It’s an experience of mutual understanding about the social/interpersonal/economic consequences of colorism. We talk about how colorism has impacted their life, their relationships, their view of self and others. We talk about the similarities and differences of our appearances and how that impacts the relational dynamics in the therapy process. This is undergirded by a shared knowing around the peril that comes along with existing in non-white skin in America.

With white clients, the dialog of colorism seldom emerges. What surfaces more frequently is a mixture of them sharing their anti-racist activism and expressed white guilt around race.

Psychology as a discipline is attempting to reckon with a past whose theoretical foundations were built by white, Western European men...

But whether or not white clients speak openly about colorism, it’s present in the room, and it’s an ethical responsibility for therapists to acknowledge how psychological theory, research and clinical practice has been impacted. Psychology as a discipline is attempting to reckon with a past whose theoretical foundations were built by white, Western European men, the majority of the burden has been shouldered by BIPOC clinicians. Just last year, a group called Disrupt the Silence, including BIPOC and white clinicians, formed to speak out and change the status quo. But it’s still a reckoning that primarily exists in therapeutic relationships that include BIPOC therapists and clients.

I imagine that it’s easy for white therapists to avoid talking with their white patients about being white, but they need to start doing it. In her 2019 paper, “Whiteness on the Couch,” clinical psychologist Natasha Stovall writes, “The couch in my therapy office is occupied mostly by white people. We talk about everything. Except being white.” She asserts that the field of psychology essentially reflects “the psychology of whiteness.”

Creating space for these conversations in therapy feels like a duty, as if not doing so would represent a form of collusion with racist power structures.

But the current political climate and barrage of news stories spotlighting racist behavior, narratives and hate-crimes puts issues of race and colorism front and center for all of us. Creating space for these conversations in therapy feels like a duty, as if not doing so would represent a form of collusion with racist power structures.

We’ll never create a more just society unless everyone addresses their complicity in upholding its current structure. That includes therapists.

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Millions of pregnant parents have past sexual trauma. We need to support them better

When Nicole* came to see me, she was pregnant with her second child. Nicole, a survivor of childhood sexual abuse, was terrified about giving birth again. And she felt completely alone with her fears and feelings.

Twenty percent of women are sexual assault survivors. Another 20% are survivors of childhood sexual abuse. More than 80% bear children. There is significant overlap between these demographics, and the numbers cut across all racial, ethnic, and socioeconomic groups.

But there is a lack of quantitative research about how sexual trauma affects people’s childbirth experiences; issues that primarily impact women regularly receive less scientific funding than those that impact men. The limited literature that does exist suggests that the overlap carries unique risks during the childbirth process. The changes to childbearing bodies during pregnancy, the frequency of invasive prenatal exams, the loss of control and the pain of labor can cause dissociation, flashbacks and re-experiencing the original trauma (LoGiudice, 2017).

Twenty percent of women are sexual assault survivors. Another 20% are survivors of childhood sexual abuse. More than 80% bear children. There is significant overlap between these demographics, and the numbers cut across all racial, ethnic, and socioeconomic groups.

Pregnancy and labor are arduous -- and, potentially, traumatic -- enough without bringing past horrors into the mix. That’s why it’s time to establish cross-disciplinary universal guidelines around providing trauma-informed obstetric care to survivors of sexual assault. That means medical and mental health professionals need to work together to create and maintain evidence-based best practices that will keep survivors from being triggered or retraumatized while giving birth.

Before we can create these guidelines, we urgently need to devote more resources to learning about how a sexual trauma history can reappear pre- and postpartum, and about the risk and protective factors for survivors. We also need to know more about how to prepare survivors for pregnancy and childbirth, and how to interact with them to help them stay calm enough to engage consciously in the labor process without experiencing retraumatization.

Nicole, a survivor of childhood sexual abuse, was terrified about giving birth again. And she felt completely alone with her fears and feelings.

Here’s what we do know: Women with childhood sexual trauma are more likely to find childbirth terrifying (Leeners et al., 2016), which can re-trigger the emergency survival strategies -- fright, freeze, flight, or fawn -- that helped them cope with their original trauma as it happened. The nervous system may go on alert, causing the person in labor to experience hypervigilance and stress about every unfamiliar sensation they feel; or they may dissociate from the situation altogether, checking out of their bodies in an attempt to psychologically escape.

These nervous system responses can happen in people with known trauma histories, but the birthing process can also cause unconscious memories of sexual violence to reemerge.

As an EMDR therapist who works frequently with perinatal parents, I teach survivors how to stay in what is called the “window of tolerance,” where they can stomach being in the present moment rather than responding with either an over- or underactive nervous system. Together, the client and I focus on resourcing, a stabilization process that involves accessing internal strengths, allowing someone to tolerate remaining present and “calm enough.” This sort of cooperative strategizing is crucial to prepare childbearing individuals for the emotional labor of birth.

For example, Nicole told me she wanted to feel confident and present, and to believe that she would be “OK” when she is giving birth. Since she mentioned her sister as someone who embodied these characteristics, we resourced this for her in our work together. I prompted her to imagine her sister in her mind’s eye, to note all of her senses as she held this image of sister in mind. Keeping this image in mind during the treatment process allowed Nicole to internalize the sense of calm and solace that she associated with her sister to bring into the birthing process. It’s a concrete, repeatable process that minimizes anxiety for many of my clients.

Every professional who comes into contact with pregnant or perinatal people should approach their patients through a trauma-informed lens, starting with sensitively, carefully assessing patients’ history during the very first visit.

How to help pregnant people access inner strengths is the sort of knowledge that shouldn’t -- but currently does -- start and stop in the mental health community. The relationship between patients and prenatal providers is essential, because negative reactions to trauma symptoms from an authority figure can cause a further psychological injury. Every professional who comes into contact with pregnant or perinatal people should approach their patients through a trauma-informed lens, starting with sensitively, carefully assessing patients’ history during the very first visit.

The best solution to grappling with sexual assault and abuse, of course, would be to eliminate it altogether. But in the meantime, protecting new parents from older traumas needs to become the standard of care, incorporated into everything pre- and post-partum caregivers do.

*This is a composite of multiple clients over multiple time periods to protect client confidentiality.

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We need to start talking about birth trauma

Imagine this: there are two people in labor at the same time at a hospital. Both of them planned vaginal childbirths. But their labors didn’t go smoothly, and the well-being of their babies dictated that both undergo emergency caesarean sections.

Both ultimately delivered healthy babies, but that’s where the similarity of experience ended.

Their postpartum journeys were drastically different: One parent healed from the surgery and went on to enjoy the child’s infancy; the other healed physically but started having flashbacks shortly after leaving the hospital. She couldn’t hold her baby without reliving how scared she felt moments before the baby was first handed to her, after a hastily assembled emergency surgery, where medical staff were so focused on the task at hand that the patient felt like an object rather than the vulnerable, terrified person she was in that moment.

Birth trauma is widespread but cloaked in a stigmatized silence that prevents people from seeking treatment.

For a significant minority of people who give birth, the experience ends up more like the second scenario than the first one: as many as 45% of parents who went through labor -- laboring parents are primarily mothers, but not all people who give birth identify as women -- report that the experience was traumatic (Alcorn, O’Donovan, Patrick, Creedy, & Devilly, 2010). And 9% of people who give birth will go on to develop symptoms of post-traumatic stress disorder (PTSD).

Birth trauma, as defined by Cheryl Tatano Beck DNSc, CNM, is caused by an event or series of events during labor and delivery that involves the birthing person experiencing an actual or perceived threat of injury or death to the parent or unborn child -- or by a birth experience that leaves them feeling stripped of their dignity. Beck writes that “birth trauma lies in the eye of the beholder,” meaning that the parent may experience terror, helplessness, powerlessness, or horror while, from the perspective of medical staff or partners, the labor was uneventful.

Like the physical effects of childbirth, which are regularly underdiagnosed and treated, leaving new parents to suffer for years with treatable injuries, birth trauma is widespread but cloaked in a stigmatized silence that prevents people from seeking treatment. And without treatment, it has the potential to destroy the joy of the postpartum period with shame and self-blame.

By the time patients seek my help, they have been dealing with full-blown PTSD or other mood symptoms for months, even years.

As a trauma therapist specializing in perinatal mood and anxiety disorders, I see this all the time. By the time patients seek my help, they have been dealing with full-blown PTSD or other mood symptoms for months, even years. They talk about feeling like they were assaulted in front of their entire family during nonconsensual cervical exams, or of doctors deploying forceps with such force that they were dragged down the hospital bed. Other experiences that can cause birth trauma include a prolapsed cord, a baby needing the NICU, severe postpartum injury, like tearing or hemorrhaging, and a prior history of trauma, like sexual assault/abuse.

In fact, birth trauma has major similarities to sexual assault: both involve women feeling objectified, violated, stripped of dignity, and unable to escape. And – no surprise – both come with a tragic societal stigma around talking about the experience, which makes millions of people suffering from a common experience feel isolated and alone.

We need to continually push to destigmatize birth trauma to create a culture of nonjudgement and acceptance...

This shame-based silence is a tragedy, because both types of trauma are treatable with trauma therapies, which are especially effective if the trauma event is addressed early. Trauma therapy helps undo the painful sense of aloneness, helping people feel connected, and providing a window for them to reclaim their vitality. When taking care of a newborn, sleep-deprived parents need all the vitality they can harness.

We need to continually push to destigmatize birth trauma to create a culture of nonjudgement and acceptance, allowing sufferers to feel empowered to reach out for help.

If a new parent is experiencing flashbacks, a feeling of numbness, hypervigilance, or detachment, remember: it’s not your fault, and it doesn’t have to be this way. Help is out there.

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How today’s trauma can affect future generations – and how to stop it

We are currently living through a confluence of mass trauma events: a global pandemic; oppressive forces of white supremacy; a dangerously partisan political environment; an escalating climate crisis. Mounting evidence suggests that once some of these disasters ebb, the trauma they have inflicted can have lingering effects, even on future generations.

In other words, the current and future offspring of people living through today’s panoply of horrors may well suffer from it even without their own memories of events.

In the United States alone, 23.2 million people have been diagnosed with COVID-19, and more than 385,000 people have died from it, making it the country with the highest number of deaths worldwide, growing daily.

On top of that, the past year has seen multiple killings of Black people by police, leading to historically large and widespread protests against the ongoing legacies of racism in America, generations of racism brought to bear.

Undergirding all this is an ever-escalating climate crisis that wreaked extreme storm damage across the gulf just as COVID made it dangerous to house climate refugees en masse.

The trauma risks to frontline workers, especially healthcare workers during COVID, have already been documented. But the effects 2020 will have on the rest of us are still playing out, and research suggests that those effects may echo far beyond the current generation.

Past studies have indicated an association between parental PTSD and secondary trauma in offspring of refugees, torture victims, and combat veterans, among others.

There is growing recognition in psychology of secondary trauma, where a person experiences post-traumatic stress disorder symptoms via proximity to someone else’s harrowing experience. That is, you don’t need to experience a potentially traumatic event directly to suffer psychological symptoms from it, because learning about terrible things happening to loved ones can trigger reactions akin to experiencing it first-hand. Past studies have indicated an association between parental PTSD and secondary trauma in offspring of refugees (Sangalang & Vang, 2017), torture victims (Daud et al., 2005), and combat veterans (Dekel & Goldblatt, 2008; O’Tool et al., 2016), among others.

In other words, the current and future offspring of people living through today’s panoply of horrors may well suffer from it even without their own memories of events.

A recent research paper published in Traumatology further supports the grim notion that traumas have the potential to affect the children of those who have survived them (Payne & Berle, 2020). The paper is a meta-analysis -- the study of multiple research papers at once, looking for larger trends across data sets -- of prior studies on PTSD in children and grandchildren of Holocaust survivors. The researchers found that children, but not grandchildren, of survivors are more likely than the general population to display trauma symptoms.

It’s unclear how trauma is passed from one generation to the next. Trauma could be hereditary, perhaps through stress hormones, or children may internalize their parents’ trauma through observing behavioral and emotional patterns. Trauma may even be passed down through how parents communicate or interact with their kids. The authors recommend that future studies parse these possibilities further. Regardless, the paper further strengthens the case that if parents suffer from PTSD, their children are more likely to have symptoms, too.

We can’t always stop terrible things from happening to us, but we can, with help, go from strength to strength.

This growing problem has a solution: As we navigate this historically troubling era, we must prioritize systematic screening for – and increasing access to – trauma treatment, notably for the people of color who have long been shut out of our current system. PTSD is treatable, and no one should have to suffer when there are evidence-based treatments that actually work and can prevent trauma’s passage to survivor offspring.

What’s more, working through trauma has additional benefits -- treatment opens a person up to experiencing posttraumatic growth, an experience of positive psychological change as a result of going through a challenging event. People I’ve worked with who have experienced this talk about having increased resilience, empathy, and improved relationships. We can’t always stop terrible things from happening to us, but we can, with help, go from strength to strength.

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Moral injury and COVID: how to protect our front-line healthcare workers

COVID-19 rates are soaring nationwide, setting new records nearly every day. Recent reports show that doctors have learned a lot about how COVID operates in the past eight months – leading to briefer hospitalizations and fewer deaths. But as hospitals reach and then exceed capacity, doctors, nurses and other healthcare workers are again facing situations where resources are dangerously stretched.

These conditions can lead to moral injury, a form of psychological distress that results when someone’s actions, or inactions, violate their ethical code, or when they feel unprepared to face decisions or situations before them. Moral injury was originally described vis-a-vis the military: think soldiers on the front lines, forced to make decisions that will cause civilian casualties.

Moral injury is not, in itself, a mental illness, but it can contribute to PTSD, depression, or anxiety.

Today, our front line is the healthcare profession, and COVID has forced an ongoing stream of Sophie’s choices, where the options get more dire as the pandemic worsens. Which of two equally sick patients gets the last available ventilator? Who gets admitted first when there aren’t enough beds for everyone? When does saving the life of a milder COVID case trump using resources on a severe one when there aren’t enough supplies to do both? All doctors take an oath to avoid doing harm, and the pandemic’s strain on medical resources has made that vow difficult to uphold.

Moral injury is not, in itself, a mental illness, but it can contribute to PTSD, depression, or anxiety. And since doctors already have a suicide rate twice that of the general population – one doctor commits suicide every day in the US – it’s vital that hospitals prioritize helping their staffs process pandemic treatment experiences before, during, and after each COVID spike.

Today, our front line is the healthcare profession, and COVID has forced an ongoing stream of Sophie’s choices, where the options get more dire as the pandemic worsens.

According to a recent paper published in the British Medical Journal, psychological support is key for ensuring that what researchers called potentially morally injurious events (PMIEs) become a foundation for increased psychological resilience rather than a risk factor.

A few studies that have come out recently looking at healthcare workers during COVID-19 point to strategies for supporting them through the pandemic, including:

Prepping healthcare workers for the moral quandaries they are going to face during the pandemic: We know that preparing staff for the job and its associated challenges reduces the risk of mental health problems later on.
Checking in with staff who are “too busy” or routinely “not available” to process experiences in a group setting, since avoidance is a core symptom of unresolved trauma.
Making time to reflect on the extraordinarily difficult experiences healthcare providers are facing to create a meaningful, rather than traumatic, narrative.
Taking practical steps to manage anxiety, such as limiting time spent consuming news.
Encouraging healthcare workers to seek support from trained peers and/or professionals when necessary.

Healthcare workers struggling with the hard emotional fallout of moral injury during COVID have the capacity to eventually experience post-traumatic growth...

It is important to note that most people who endure traumatic events like PMIEs will recover on their own and will not require professional support. Even most healthcare workers struggling with the hard emotional fallout of moral injury during COVID have the capacity to eventually experience “post-traumatic growth,” a strengthening of resilience, self-worth, and values after living through extraordinarily difficult circumstances. But making sure there are supports in place when healthcare workers need them will help ensure that PMIEs won’t contribute to wearing down exhausted front-line workers all the more.

The pandemic has dropped us all in largely uncharted waters, both medically and psychologically. But it’s becoming clear that current conditions, rife with potentially morally injurious events, are putting our healthcare providers at unprecedented risk. What we do know is how to help protect them, and it must become a top national priority.

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