Fertility Treatments Can Be Particularly Difficult For Survivors Of Sexual Assault
This essay is part of Women’s Health’s coverage of Infertility Awareness Week (April 24-30, 2022), focused on stories that shed a light on the less-talked about aspects of trying to conceive. Editor’s note: This article contains discussions of sexual assault. Take care when reading. If you are a survivor of sexual abuse, you are not alone. Confidential resources are available through RAIIN by calling 800-656-HOPE (4673).
I followed a nurse into an exam room at a fertility clinic in New York. As a psychologist in her mid-thirties who provides mental health care to women throughout the transitions of their reproductive life cycle—many of whom are pregnant or trying to conceive—I’ve been acutely aware of my dwindling fertility and long deliberated about freezing my eggs. After losing a year to COVID, I decided to finally go through with it.
“Waist down,” the nurse said, meaning, undress from the waist down. It didn’t even warrant a full sentence. It floated over her shoulder on her way out the door. Waist down. Two words can undo a person.
Later, I found myself exposed but for a flimsy sheet, waiting for my doctor, the woman with whom I’d done my intake two weeks before. I was in for routine monitoring, including blood work and a vaginal ultrasound.
The nurse returned and said Dr. So-and-So would be doing my ultrasound instead. “He’ll be in momentarily.”
I clenched the sheet, my heart pulsing in my fist. I tried to count those beats, hoping there might be something grounding and reassuring about the order, the predictability that one led to two, and two to three, and so on. Do not get upset, I told myself.
“No, see, I’m here for my doctor. She’s the cool one, last seen in a tie-dye sweatshirt….” My tears betrayed me as I attempted to casually joke myself off a ledge.
“Not in yet.” The nurse thumbed the neck of her scrubs. “Are you comfortable seeing Dr. So-and-So?” She began inching toward the door like I was a bomb.
I felt it too, the ticking.
“I’ll see who else is in,” she said, before I could generate a response. Seconds later she returned with a female doctor who had just walked into the office and been intercepted by the nurse to deal with me.
“I can wait if you need to take off your coat,” I offered. It seemed the polite thing to say.
It’s not that I can’t see male clinicians. It’s more an aversion to unexpected changes at acutely vulnerable moments. When I was told I wouldn’t be seeing my doctor, but some stranger—a “he”—I was overcome by the paralysis I remembered from my sexual assault, the smothering stillness that sets in when fight no longer matters.
“When I was told I wouldn’t be seeing my doctor, but some stranger—a “he”—I was overcome by the paralysis I remembered from my sexual assault.”
Fertility treatment is primed to activate trauma survivors. Yet despite my specialty training in reproductive mental health and trauma, I failed to anticipate this would apply to me too. Perhaps it’s because I thought I had addressed my sexual trauma history. It just didn’t occur to me how fresh it could still feel until I heard waist down and experienced my near-encounter with Dr. So-and-So.
For those with a history of sexual abuse, distress is often elicited by trauma reminders, and during fertility treatment, they’re difficult to avoid. Sounds, motions, sensations, power differentials between patient and provider, false reassurance, pain, sedation, bruising, and the thoughts and emotions that accompany these cues, like shame, fear, anger, guilt, hopelessness, and helplessness, can all bring up terrifying memories and sometimes the sense of reexperiencing them.
It shouldn’t be surprising that trauma survivors might have complicated reactions to our bodies being manipulated to host and sustain others. Nor that in the struggle to conceive, we might be triggered by the prospect of another vital thing being stolen from us. The concepts of sexuality and reproduction can be reminders too, arising each time we’re asked to track our sex lives and discuss our reproductive processes so scientifically we forget humans were meant to be involved.
Even more activating is the lack of control survivors can feel during fertility treatments, knowing they might not work. We’re at the whims of our hormones and egg quality, the lab, our expendable income, and time. We are asked to trust doctors we don’t know well or at all; and while it’s not unusual to see different doctors at every visit, for those who have been betrayed in the past, often by authority figures, it can feel unreasonable to trust in a stranger without prior conversation. Infertility itself can also bring up the familiar feeling that our bodies are betraying us, forcing us to manage expectations and reconcile alternative realities and their impact on our identities. This can cause conflicts around self-esteem and heighten ambivalence around intimacy, a common reaction to past sexual trauma, too, particularly when sex becomes so procedural and loaded.
“Infertility itself can also bring up the familiar feeling that our bodies are betraying us.”
One might not realize the threat that sexual trauma history poses for those trying to conceive. Yet to many who have experienced it, there is nothing like this compromised position—lying down, feet in stirrups—to make that history present and palpable again. Even if we’re physically safe, we can still feel unsafe, which matters too.
These issues are critical given the prevalence of sexual trauma and the increasing frequency with which women are seeking fertility treatment. In the U.S., one out of every five women has been raped, and countless others have experienced events that can make fertility treatment more uncomfortable. It may be that a disproportionate number of women who have endured sexual trauma will end up seeking fertility treatment. Studies have shown associations between sexual trauma history and pregnancy delay as well as sexual dysfunction, particularly in people with PTSD, which may contribute to infertility. Trauma is also associated with relationship difficulties, and may affect some women’s decisions to freeze their eggs until they can trust again.
On top of this, survivors are more likely to experience childbirth as traumatic and exhibit higher risk for dissociation and birth-related post-traumatic stress reactions. Symptoms of PTSD and postpartum depression often co-occur, and both have the potential to impair bonding between mother and infant, which can have lasting consequences.
The American College of Obstetricians and Gynecologists recommends that providers obtain sexual trauma histories to reduce the likelihood of these issues and other pregnancy complications. But these conversations aren’t always happening.
Negative outcomes may be mitigated if providers reduce retraumatization by collaborating with patients to identify triggers and adapt interventions to enhance patients’ autonomy and control. This could mean adjusting their tone to be less dismissive and demanding, eliminating microaggressions that raise systemic injustices that perpetuate trauma, and avoiding words and phrases such as relax, hold still, and it will only hurt a little, as well as scientific jargon that can make one feel like a specimen stripped of identity. (Ovarian failure and resistant ovary can reinforce shame and the sense that one is damaged, broken, or difficult.) It might involve prioritizing privacy by minimizing trainee involvement, allowing patients to insert probes themselves during vaginal ultrasounds, and reducing invasive procedures. For unavoidable discomforts, there are skills patients can learn—relaxation and mindfulness, for example—that can help make the process more tolerable, particularly when paired with strategic assessments of risks and benefits.
Trauma-informed care is recommended as the standard for all patients, but it’s often overlooked. Initial screening and subsequent conversation not only increase the likelihood that trauma-informed care will be utilized but allow for creative solutions that are tailored to individuals and their experiences. This conversation and collaboration is both the means to a solution and a solution itself, inherently undermining the authoritative dynamic between doctor and patient.
“Trauma-informed care is recommended as the standard for all patients, but it’s often overlooked.”
The morning of my near-encounter with Dr. So-and-So ended with the unknown female doctor doing my ultrasound. It lasted only a couple of minutes. She kept her coat on and clicked some buttons. She may have said something understanding when I apologized for inconveniencing her, but all I heard were those grating clicks.
After completing my egg-freezing cycle, I asked my doctor about what I gathered to be a common absence of sexual trauma screening at fertility clinics. She was kind and generous with her time. She acknowledged that it should be standard procedure, though often it is left for patients to raise themselves.
I didn’t disclose my history because by the time it occurred to me that it was an issue, I was already on autopilot. Blindsided by that automatic fear response, I reverted to an instinctive, self-protective avoidance, whereas otherwise I would have had less conflict sharing my past. But my provider’s silence reaffirmed my own, and our collective silence resounded loudest, giving my unspoken history the power I was then trying to deny it, transforming it again into an active danger. It would have been more effective to get in front of it.
“My provider’s silence reaffirmed my own, and our collective silence resounded loudest, giving my unspoken history the power I was then trying to deny it.”
There are many complicated reactions to trauma that can come out in the prenatal, perinatal, and postpartum periods. It’s likely beyond what can be fully addressed in a short medical visit, but it’s still worth acknowledging. Even when being asked doesn’t draw out the words, it reminds us that the dialogue is open. One day I hope mental health providers will be housed within all fertility clinics to help address some of these issues and that our medical system will better accommodate these conversations between patients and physicians. But until this becomes the norm, it will often fall upon survivors to speak up about this and ask for the accommodations we need. While that shouldn’t be the case, if this is you, know that these experiences and reactions are valid, and raising them could benefit your treatment and medical outcomes.
It’s been over a year since I froze my eggs. I don’t know if and when I’ll return to them, but I do often return to the conversation I had with my doctor about how patients and providers should be able to talk about past trauma. When I think about whether my trauma history will reemerge if I proceed with IVF, I’ve been surprised to find an ease accompanying my awareness that it probably will. This presence and openness feels different from the steely, divisionary type of armoring I envisioned I’d put up. In revisiting this for myself, I was able to tap into the bracing power of the collective, rooted in compassion and the strength of all women who face these challenges.
My doctor’s honesty and integrity during our conversation reminded me that the absence of questions about trauma doesn’t always mean providers aren’t receptive to that information. Just knowing the conversation is open now might be enough to carry me through IVF without any other accommodations. It’s a strong reminder of how far communication can go for those who have felt silenced in the past.
Gabrielle Frackman, PhD, is a licensed clinical psychologist in the Women’s Program at Columbia University Medical Center.
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