Stefan Ecks, School of Social & Political Science, University of Edinburgh
Stephanie Mair, NHS Greater Glasgow and Clyde
Abstract
Sexual assault is one of the strongest predictors of perinatal mental ill health, and the qualitative literature is now unambiguous that pregnancy, birth, and early postpartum care can reactivate trauma in ways that women themselves describe as a return of the assault. The clinical response has converged on trauma-informed care and routine enquiry. Yet under-detection, distress during care, and reports of retraumatization remain stubbornly common. This article argues that the difficulty is not primarily one of clinician sensitivity or screening completeness. It is a mismatch between how trauma actually persists and how clinical systems are designed to ask about it. Drawing on qualitative evidence and on a framework that treats human experience as coordinated across five dimensions of lived life — bodily life, relational presence, ambient surround, the material world, and language — we re-describe perinatal trauma as a memory phenomenon that lives in lived coordination rather than in narrative recall. The perinatal period is a particularly powerful trigger architecture because it intensifies all five dimensions at once and frequently reproduces enough of an earlier assault's structure to bring it back, not as a story but as a present situation. The most neglected of these dimensions, what we call dwelling — time of day, light, season, temperature, atmosphere — cannot be engineered away by hospital design and may be doing much of the unrecognised work. We argue that conventional screening, organised around verbal disclosure, is structurally misaligned with where trauma actually resides, and we propose a gentler approach: a layered screening that begins by mapping the conditions under which a woman's coordination feels stable or fragile, and only later, optionally, opens onto the body and the relational. The same framework, we argue, allows two further clinical phenomena — the request for elective caesarean section and the avoidance of cervical screening by sexual assault survivors — to be re-read as accurate forecasts a woman is making about her own coordination, rather than as problems to be managed. We close with a one-page tool designed for NHS antenatal use.
1. Introduction
About one in ten women experiences a mental disorder during pregnancy, and roughly one in eight in the year after birth. A history of sexual violence — childhood sexual abuse, adult sexual assault, or coercive sex within an intimate relationship — is among the strongest and most consistent predictors of perinatal depression, anxiety, and post-traumatic stress. Recent meta-analyses put the odds ratio for postpartum depression after childhood sexual abuse around 2.8, and lifetime sexual victimisation increases the odds of perinatal depressive symptoms by roughly half. The clinical reality behind those numbers is now well documented in qualitative work: women with histories of sexual assault frequently describe pregnancy, labour, and postpartum care as a return of the original violation, sometimes in language as direct as "being back in the rape."
The clinical response over the past decade has been thoughtful and substantial. Trauma-informed maternity care frameworks have been developed and widely promoted. NICE guidelines now recommend routine enquiry about domestic abuse, sexual abuse, and childhood maltreatment as part of perinatal mental health assessment. NHS England has issued plain-language guidance on the links between childhood sexual abuse, intimate partner violence, and perinatal psychiatric morbidity. There is good intent and increasing institutional infrastructure.
And yet the same problems keep recurring. Women under-disclose. Distress emerges during routine procedures despite skilled and well-meaning care. Birth experiences are described afterwards in the language of violation. Some women avoid antenatal care altogether. Others arrive requesting an elective caesarean section to avoid vaginal birth, and find themselves having to fight for it. Symptoms appear without their causal history being visible to services, and when services do learn the history, they often find that knowing it does not, by itself, change very much.
This article is about why. Our argument is that the persistent difficulties in this area are not primarily failures of clinician sensitivity, training, or guideline implementation. They reflect a deeper mismatch between how sexual trauma actually persists in a woman's life and how clinical systems are designed to detect and respond to it. Sexual trauma does not live, in its operative form, as a narrative the woman can be asked about. It lives as a patterned vulnerability in how her body, her relationships, her environment, the material world, and language hang together. The perinatal period is unusually likely to disturb that patterning, often catastrophically. Verbal questioning, however well-intentioned, asks for the wrong thing at the wrong level.
The article proceeds in seven steps. We first review what is known about sexual trauma and perinatal mental health, including the adjacent literature on obstetric violence and the better-documented but under-theorised links to caesarean requests and cervical screening avoidance. We then introduce a framework drawn from medical anthropology that treats human experience as coordinated across five dimensions, and we use it to re-describe what is happening when women say that childbirth feels like a return of the assault. We give particular attention to a dimension that has been almost entirely missed: the temporal and atmospheric conditions in which the original trauma occurred and which clinical environments cannot eliminate. We then turn to screening, arguing that the standard approach is structurally misaligned with where the problem actually sits, and we propose a different one. We use the same framework to re-read the caesarean request and the missed smear appointment as forms of clinical communication rather than as problems to be solved. We close with a clinical tool that is meant to be usable in an NHS antenatal appointment without overburdening either patient or clinician.
We write as a medical anthropologist and a perinatal mental health specialist. The framework is theoretical, but the test we apply to it throughout is clinical: does this give us a more accurate description of what we and our patients are encountering, and does it suggest something we can actually do?
2. What the literature shows
2.1 Sexual assault as an upstream determinant
The evidence base is now strong on a basic point. Sexual violence — across childhood, adolescence, and adulthood — is a major upstream determinant of perinatal psychiatric morbidity. A 2024 meta-analysis of twenty-four studies found childhood sexual abuse strongly associated with postpartum depression, with an odds ratio of 2.81. A 2021 systematic review focusing specifically on lifetime sexual victimisation, the first such review of its kind, found that women with such histories had 51% greater odds of perinatal depressive symptoms than women without. Longitudinal work shows that the elevation in symptoms is not confined to the postpartum: it begins in pregnancy and persists well after. Intimate partner violence during pregnancy roughly triples the odds of probable postnatal depression, with similar elevations for antenatal depression, anxiety, and post-traumatic stress.
The same evidence base also documents two downstream behavioural patterns that matter directly for clinical care. The first is the elevated likelihood of requesting an elective caesarean section. The Bidens multi-country European cohort study, following 6,724 pregnant women through routine antenatal care, found that among primiparous women a history of adult sexual abuse roughly doubled the odds of elective caesarean section (adjusted OR 2.12, 95% CI 1.28–3.49) and nearly quadrupled the odds of caesarean section performed for non-obstetric indications (adjusted OR 3.74, 95% CI 1.24–11.24). The second is the avoidance of cervical screening: a 2018 survey by Jo's Cervical Cancer Trust and Rape Crisis England & Wales found that 72% of women with sexual violence histories had either not attended or had delayed cervical screening because of their experience, with only around 15% attending when invited. We will return to both findings in section 6, because we think they are not separate facts but two expressions of the same underlying phenomenon.
The literature is fragmented in a way that matters. It separates childhood sexual abuse from adult sexual assault, sexual coercion within relationships from stranger assault, and physical violence from sexual violence — categories that are clean for analysis but do not match the patterns of women's actual lives. Many women carry multiple, overlapping histories. The effect is that the cumulative weight of sexual trauma on perinatal mental health is almost certainly underestimated by studies that look at one exposure type at a time.
2.2 Retraumatization and the qualitative record
The mechanism literature has advanced substantially in the last few years. A 2023 integrative review of survivors of childhood sexual abuse in maternity care found that post-traumatic symptoms during pregnancy and birth were reactivated by recognisable elements of clinical care: vaginal examinations, male providers, lack of control, restraint, and exposure. Post-traumatic intrusion, dissociation, avoidance, and hyperarousal were all elevated relative to women without sexual trauma histories.
The qualitative studies behind these findings are striking in how directly women themselves draw the connection. Halvorsen and colleagues' study of women's first childbirths after rape is repeatedly cited in later work for documenting that childbirth could feel, as one of their participants put it, like being back in the rape, with women describing themselves as reduced to a body, invaded, dirtied, and out of control. Montgomery's later interviews with childhood sexual abuse survivors in maternity care describe internal examinations, immobilisation by epidural, crowded waiting rooms, and even examination by torchlight as moments where the abuse became present again — not as recollection but as recurrence. One woman reports that being stuck on a bed makes her be the child again, that it is happening again. Lissmann's recent qualitative work with adult sexual assault survivors organises its findings around three themes — control, safety, and trauma — that cut across the conventional symptom categories.
What is consistent across these studies is that women do not, on the whole, struggle to articulate the link. They describe it directly, often in language more precise than the clinical vocabulary available to describe it. The difficulty lies elsewhere.
2.3 Obstetric violence
Adjacent to the trauma literature, and partly in tension with it, sits a more politically charged body of work on obstetric violence. This literature, more prominent in Latin America and parts of continental Europe than in the UK, argues that certain forms of maternity care involve non-consensual procedures, coercion, and violation of bodily autonomy that are not merely experienced as assault but are structurally continuous with it. Mainstream perinatal psychiatry has been wary of this framing, and for understandable reasons: equating clinically necessary procedures with assault risks both alienating clinicians and undermining the legitimacy of medically indicated care.
We share that wariness, but we also think the obstetric violence literature has identified something the trauma literature has not yet adequately discussed: that the experiential features of certain perinatal encounters — bodily exposure, asymmetrical authority, limited control, intimate procedures performed by strangers under time pressure — can be triggering for some women. The framework we develop below allows that observation to be made without collapsing the moral distinction between intended harm and clinically appropriate care. The point is not what was meant but what was reproduced.
2.4 Where the literature stops short
Pulling these strands together, the literature has established that sexual trauma is a major perinatal mental health determinant; that pregnancy, birth, and postpartum care can reactivate trauma through recognisable mechanisms; that women themselves often draw the link in unmistakable language; that the same trauma history predicts caesarean requests and cervical screening avoidance; and that trauma-informed care is now widely recommended. Where it stops short is in offering a clear account of why the perinatal period is such a powerful trigger architecture, and why interventions that focus on disclosure and narrative work, while helpful, often fail to reach what is actually happening. It also stops short of recognising that some of the patterns it documents — the caesarean request, the missed smear — are not problems for clinical care to manage but accurate communications from women about what their coordination can and cannot survive. The remainder of this article tries to supply both accounts.
3. A framework for thinking about lived coordination
To say what we want to say about trauma, we need a vocabulary that does not yet exist in mainstream perinatal psychiatry. We borrow it from a body of work in medical anthropology that treats human experience as the ongoing coordination of five dimensions of lived life. The framework is not psychological in the usual sense — it is not about minds or representations — and it is not sociological in the usual sense — it is not primarily about power relations. It is about how a person's life hangs together moment by moment, and what happens when that hanging-together comes apart.
The five dimensions are these.
Bodily life. The body as it is actually lived from the inside: posture, breath, sensation, temperature, the felt sense of being in it, the experience of having or not having control over it. Not the body as an object that medicine examines, but the body as the condition of any experience at all.
Relational presence. The fact that human life is always with others. Other people are not just present in the environment; they are part of the structure of any given moment — through proximity, trust, asymmetry, the bare geometry of who has the power to do what to whom.
Ambient surround. What we will call dwelling, in a strict and unusual sense. Not the built environment, not architecture, not rooms — but the slower, more diffuse conditions within which life unfolds: time of day, season, temperature, weather, light quality, atmospheric pressure, ambient soundscape.
The material world. Objects, instruments, technologies, built spaces. The things that mediate what bodies can do and what is done to them.
Language and symbol. Words, names, diagnoses, narratives, classifications, explanations. The whole symbolic register through which experience gets articulated, communicated, and acted on.
Most of the time, these five dimensions hang together so smoothly that you do not notice them as separate. You walk into a familiar room, greet a colleague, sit down, pick up a cup. Body, others, surround, objects, and words all coordinate without effort. They become noticeable only when they come apart: when something hurts, when a relationship strains, when a familiar room suddenly feels wrong, when a tool fails, when language stops working.
There is one more piece of the framework that matters for what follows. When this kind of coming-apart happens, it usually shows up first as a felt sense that something is off — before you can say what, before you can name it, before you can decide what to do about it. Clinicians know this experience well in their own work and recognise it readily in patients. A person can be aware that a situation is wrong long before they can articulate why. We will call this the felt sense of misalignment, and we will treat it as the level at which trauma — and especially sexual trauma — actually lives.
What follows from articulation, from the moment a felt sense gets turned into words, is something different. Language gives the experience a shape, a name, a category, and eventually a decision: this is anxiety, this is a flashback, proceed with the examination, do not proceed. These are not the same as the felt sense itself. They are the system's way of stabilising it so that life can go on. Most of the time they work. Sometimes they fail. The argument of this article is that they fail in a particular and predictable way when they are asked to do the work of trauma detection in the perinatal period.
4. Memory as reassembly: the conceptual hinge
The literature on trauma talks a great deal about memory, and almost always in one of two ways: as stored content that can be retrieved, or as content that has been encoded badly and needs to be reprocessed. Both pictures take it for granted that memory is a thing — a representation, an image, a narrative — held somewhere inside the person and brought out, more or less reliably, when triggered.
What the qualitative literature on perinatal trauma actually describes does not fit that picture. When women say that childbirth feels like the rape, or that being held down on a bed makes them be the child again, they are not reporting that they retrieved a memory and were upset by it. They are reporting that the present situation has become structurally indistinguishable from the past situation. Something is happening, not being recalled.
A case from one of our clinical settings illustrates the point. A woman with a history of childhood sexual abuse was seen for a short session to address birth trauma memories from a forceps delivery. She described hearing the nurse state loudly and anxiously, "Oh no, this isn't going to work." A screen was put up so that she could not see what was happening, and she then felt "being cut into." She described the burning sensation of the forceps delivery as if it was happening in real time. That last phrase is critical. She is not saying the memory is vivid. She is not saying it is intrusive. She is saying it is happening. The tense is present, not past. The word "memory" barely applies, because what she is describing is not a retrieval but a reinstatement. The conditions of the original event — bodily invasion she cannot see, loss of control, a panicked voice announcing failure, the burning sensation of being cut — have reassembled in the present, and the felt difference between past and present has collapsed.
We propose that this is what memory actually is in this context: not stored content but recurrent organisation. The sexual assault left behind a particular configuration of bodily, relational, ambient, material, and symbolic conditions. When enough of those conditions reassemble in the present, the past does not get remembered. It gets reinstated. The felt sense the woman has — that this is happening, that she is back there — is not a metaphor or an overreaction. It is an accurate description of what her lived coordination is currently doing.
This shift is small in language and large in implication. It distinguishes three different things that the literature usually collapses under "trigger." A trigger, in the strict sense, is a single cue — a smell, a phrase, a touch — that calls up something. What women in the perinatal period are describing is more than that. We can call it resonance when one or two dimensions of the present situation begin to align with the past, and reassembly when enough of them align that the structural difference between past and present collapses. Triggers can be absorbed and metabolised. Reassemblies cannot. They are not signals about a past event; they are present events.
It is worth being explicit about what this reframing displaces. The dominant clinical models of trauma — exposure-based therapies, cognitive reprocessing, narrative work, EMDR, and most variants of trauma-informed care — all rest, more or less openly, on a representational picture of memory. They assume that the trauma exists somewhere as encoded content, and that healing involves reaching that content, processing it, and re-storing it in a less disabling form. This picture is not wrong about everything. There are aspects of trauma that behave like representations and that do respond to representational interventions. But it is, in our view, a special case rather than the general one. The general case is that trauma persists as a particular way that lived coordination is organised, and that representational content is one product of that organisation rather than its source. If that is right, then interventions that work only on the representational layer will reach only what that layer can reach, and the substantial portion of trauma that lives below it will remain untouched. This is not a marginal claim. It is a claim about why current trauma care can be technically excellent and still fail to reach what most needs reaching.
A further detail from the same clinical case is instructive on this point. An EMDR Flash technique was used: the woman was asked to hold an alternate focus — a holiday with friends — while blinking was used as the bilateral stimulation. She reported that her distress dropped from seven out of ten to two out of ten. She described the image of the birth trauma as feeling "more distant and less threatening." She was also, however, sceptical that this would hold, and agreed only to stay open-minded about it. From the framework we are proposing, her scepticism is both clinically honest and theoretically well-founded. The Flash technique operates on the representational layer: it makes the image more distant, the emotional charge less acute. That is real and useful. But the coordination pattern that produced the distress in the first place — bodily invasion she could not see, loss of control, a panicked voice, the sensation of being cut — sits across embodiment, relational presence, the material world, and language simultaneously. Making the image more distant does not reorganise those dimensions. It changes what is felt about the representation without changing how the coordination itself is patterned. The woman's intuition that the relief might not hold is, in our terms, a recognition that the intervention has reached one layer but not the others.
The clinical relevance of this is direct. If memory in this sense is distributed across five dimensions of lived life, then interventions that work only on one of them — particularly the symbolic dimension, through narrative work, cognitive reframing, or psychoeducation — will reach only a fraction of what is actually happening. And conversely, small changes in dimensions that are usually treated as background — the position of the bed, the temperature of the room, the time of day a procedure is scheduled — can have effects out of all proportion to their apparent significance. They can break the reassembly before it completes.
This same woman had also reported a sleepless night before the session, due to intrusive memories about a childhood incident triggered by recently seeing one of the perpetrators. What is striking about this conjunction is how directly it illustrates the multi-layered and multi-temporal nature of trauma as coordination. Two distinct events — childhood sexual abuse and a traumatic forceps delivery — are operating simultaneously, each reassembled through its own configuration of dimensions. The childhood trauma returns through relational presence: the sight of a perpetrator collapses the distance between past and present. The birth trauma returns through embodiment and the material world: invasion, restraint, instruments, burning. Both are active at once, each compounding the other, and neither is primarily a narrative. The woman is not confused about what happened to her. She is living in a present that is being shaped by two pasts simultaneously, and the coordination of her daily life — sleep, energy, the capacity to care for her child — is what suffers.
5. The five dimensions in the perinatal period
What makes the perinatal period so unusual, and so dangerous for women with sexual trauma histories, is that all five dimensions of lived life intensify and reorganise at once. Most of the time these dimensions shift more or less independently. Here they move together. The probability that enough of them will align with a prior trauma's configuration to bring it back is therefore much higher than in almost any other period of adult life.
5.1 Bodily life
This is the dimension the literature notices most readily. Pregnancy involves profound, sustained, and often involuntary changes in the body's interior — hormonal, interoceptive, postural, painful. Labour involves loss of control over bodily processes that normally feel one's own. Postpartum recovery involves prolonged exposure, soreness, leaking, and a body that does not feel like the body one had. For a woman with a history of sexual assault, none of this is neutral. The original trauma left behind specific sensitivities around invasion, immobilisation, exposure, and involuntary bodily response. The perinatal period reproduces those exact bodily configurations with extraordinary fidelity, often through procedures that are clinically appropriate and well delivered. The bodily memory is not represented in the woman; it is enacted through her. The woman we described in the previous section, who felt the burning of the forceps delivery as if it was happening in real time, is not recalling a bodily sensation. She is having one. The body has not stored a description; it has retained a pattern of coordination, and the pattern has been switched on.
5.2 Relational presence
The original assault was not only a bodily event. It was a catastrophic distortion of who is allowed to do what to whom — of trust, proximity, authority, consent. Sexual trauma leaves behind a patterned sensitivity to particular configurations of relational asymmetry. The perinatal period then places women back into precisely those configurations. Strangers enter their bodies. Authority is asymmetrical. Decisions are made under pressure. Partners may be supportive, absent, or coercive. The newborn introduces a relationship of total dependency. Even when every individual clinician is kind, the relational geometry of perinatal care is structurally close to the relational geometry of assault. A well-meaning male obstetrician performing a clinically necessary examination can, without anyone's intent, reproduce the asymmetry that defined the original violation.
What is particularly telling in the clinical vignette above is the nurse's voice. The woman described hearing the nurse state loudly and anxiously, "Oh no, this isn't going to work." That utterance is not the assault itself. But it transforms the relational configuration of the room. The person who is supposed to be in control has just announced, in tone and content, that control has been lost. For a woman whose trauma is anchored in the loss of relational safety, this is not incidental. It is the moment at which being-with collapses from coordination into something closer to shared helplessness, and the woman's felt sense of the situation shifts from medical procedure to something for which the only available frame is the one her body already knows.
5.3 The material world
The clinical literature notices procedures and equipment, but it tends to treat them as instruments rather than as participants in experience. The qualitative material suggests something stronger: that beds, instruments, positioning, restraint, monitors, examination tables, and the specific spatial arrangement of clinical encounters are not background to the trauma's return but part of what reassembles it. Being confined to a bed after an epidural is not just uncomfortable; it can be the immobilisation that completes a pattern. A torch shone during a vaginal examination, in Montgomery's interviews, becomes almost a direct material bridge to the way an abuser used to look. The lithotomy position is structurally close to positions that featured in the original assault for many women. The room — its size, its enclosure, its crowding — participates in the same way.
In the case described above, the material world contributes a particularly precise element. A screen was put up so that the woman could not see what was happening to her body. In obstetric practice this is routine — it is standard during instrumental deliveries and caesarean sections, usually intended to reduce distress. But from the woman's perspective, the screen does not reduce distress. It eliminates her visual access to her own body at the moment of invasion. She can feel but not see. She is acted upon without being able to witness what is being done. That material configuration — the screen, the table, the instruments she cannot see, the body she cannot control — is not a secondary feature. It is central to the reassembly. It reproduces a particular structure of helplessness and dispossession that sits at the core of many assault experiences: something is being done to my body, and I cannot see it, and I cannot stop it.
This dimension is partly modifiable. Beds can be raised or lowered. Positioning can be changed. Instruments can be removed from the woman's line of sight before she enters the room. Examination can be paced differently, or delayed. The material dimension is the one in which clinicians have the most direct, immediate room to act.
5.4 Dwelling: the temporal and atmospheric surround
This is the dimension we want to dwell on, because it is the one the literature has almost entirely missed, and because we suspect it is doing more of the unrecognised work than any other.
By dwelling we do not mean rooms or buildings or hospital design. Those belong to the material dimension above. We mean something slower and more diffuse: time of day, light quality, season, temperature, weather, atmospheric pressure, ambient soundscape. These are the conditions within which life unfolds and which are not actively manipulated moment to moment. They are the conditions you cannot turn off.
Now consider what perinatal care looks like as a dwelling configuration. Labour very frequently happens at night. Postnatal wards are often dimly lit at the times when women are most exhausted and least able to mobilise their resources. Winter births involve long stretches of darkness. Hospital routines impose their own day–night cycles, which rarely align with the woman's. Sleep deprivation collapses circadian rhythms. The ambient conditions of perinatal care are not neutral, and they cannot be standardised away.
We want to draw particular attention to a feature of UK maternity wards that we think illustrates the point clearly. Maternity wards in NHS Scotland — and in much of the UK more generally — are kept at unusually high ambient temperatures, well above the temperature outside, often combined with bright artificial light and constant ambient noise from monitors, voices, and movement. From a biomedical standpoint this makes sense: thermal regulation for newborns, infection control, and the operational requirements of a busy ward. From a dwelling perspective, it creates a very specific atmospheric state — heavy, enclosed, hot, bright, loud, hard to leave — that has nothing in common with the cool, variable Scottish ambient that the woman's body otherwise inhabits. For some women, this configuration is comfortable. For others, it may align with conditions that featured in the original assault, and the alignment may be doing significant work without ever being recognised.
The crucial point is that dwelling cannot be engineered out of the clinical environment. There is a widespread assumption — built into the very design of modern hospitals — that the clinical environment is a controlled, technologically mediated bubble in which contingent ambient conditions have been neutralised. This assumption is wrong. It holds only for the material dimension. It does not hold for dwelling. Even in the most engineered ward, it is still day or night, still winter or summer, still hot or cold, still bright or dim. The light spectrum still tracks or disrupts circadian rhythms. The atmosphere still has a quality, often intensified rather than neutralised by clinical design.
There are three things about dwelling that make it especially powerful as a source of trauma reassembly. It is slow, which means it is below the threshold of attention; nobody notices the time of day or the temperature unless something draws it to mind. It is diffuse, which means it cannot be located in any specific object or person and therefore cannot be addressed by changing one thing. And it is largely non-modifiable: a clinician cannot eliminate winter or daylight or the season the woman gives birth in. This combination — powerful, unrecognised, unavoidable — is a structural recipe for unmet need.
When clinicians notice that some women find nights disproportionately hard, that some struggle in heat, that some seem to deteriorate in particular weather or particular months, the temptation is to absorb these observations into general categories of mood, anxiety, or fatigue. We want to suggest that they should be taken at face value: as accurate information about the conditions under which a woman's coordination is most likely to fail, and as data about a dimension of her trauma history that she may never have articulated and may have no way to articulate.
5.5 Language and symbol
The dimension the clinical literature is most comfortable with is the symbolic one. Diagnoses, narratives, screening questionnaires, consent forms, explanations, the language of risk and progress and consent. This is the dimension in which most trauma-informed care interventions actually operate.
Language is essential, and we do not want to suggest otherwise. But it is one dimension among five, and in the case of sexual trauma it is probably the dimension that reaches the trauma least directly. The women in Montgomery's and Halvorsen's interviews are not struggling because they lack the right words. They are using words to describe an experience that is happening below words. The symbolic dimension can sometimes help — by giving the woman frames she can use, by allowing her to ask for things, by allowing clinicians to understand what is needed — but it can also harm. Phrases like "we need to proceed" or "failure to progress," however clinically standard, can land in a register the woman is already in, and intensify rather than relieve the situation.
The symbolic dimension can also be misused by clinical systems in a more structural way. When a woman is classified as anxious, depressed, or post-traumatic, the classification stabilises something for the system but may flatten what is actually happening for her. The categories are not wrong, but they sit at a level above the felt sense of misalignment, and they can substitute for engaging with that felt sense rather than supporting it.
6. Why verbal questioning misses what matters
We can now state the central problem more precisely.
Trauma, in this analysis, lives primarily as a felt sense of misalignment in lived coordination, distributed across the five dimensions described above and especially across the four non-symbolic ones. It is anchored at the pre-verbal level. It is fast. It is often dissociated from any narrative the woman could give. It can be reassembled in the present by the right combination of bodily, relational, material, and ambient conditions, with or without symbolic recall.
Clinical screening for trauma, by contrast, is organised almost entirely at the symbolic level. Questionnaires ask about events. Routine enquiry asks for disclosure. Diagnostic categories require the experience to be translatable into language and into the system's classification scheme. The whole apparatus assumes that the trauma is, or can be made, available as a story.
This is not a small misalignment. It is a structural mismatch between the level at which the phenomenon actually exists and the level at which the system is designed to detect it. We can call this a mismatch of fit — a mismatch about what kind of thing trauma is — and it has predictable consequences.
The first is that asking for verbal disclosure is not a neutral act. It requires the woman to take material that lives below words and convert it, on demand, into a narrative shareable with a stranger in an asymmetrical setting under time pressure. That conversion is metabolically expensive even when nothing is wrong. When the underlying material is sexual trauma, the conversion itself reproduces several features of the original violation: exposure, asymmetry, the demand to give something intimate to someone with institutional power. Some women manage it. Many do not, or do so only partially, and the partial disclosures are then read by the system as inconsistent or incomplete.
The second consequence is that what the woman cannot articulate is often treated as if it were not there. If she cannot put it into words, the screening tool registers nothing. The clinician moves on. The woman, meanwhile, has been asked to reach toward something painful and has had the reach itself produce no result. The implicit message is that what cannot be said does not count. This is precisely the wrong message for someone whose trauma lives below words.
The third consequence is that distress which does emerge during care — sudden withdrawal, panic, freezing, dissociation, refusal — gets read as symptom rather than as signal. The system reaches for diagnostic categories: anxiety, depression, post-traumatic stress. These categories are not wrong, exactly, but they are stabilisations of the symbolic level applied to disturbances that originated at a different level. They tell us something has gone wrong without telling us what or where. And once a category is in place, it tends to substitute for ongoing attention to the underlying coordination.
The fourth consequence is the most serious. Clinical systems have to make decisions, often quickly. Decisions are binary — proceed with the examination or not, induce or wait, transfer or stay. These decisions are necessary, and they are usually clinically justified. But they can override the felt sense of misalignment that the woman is, in that moment, unable to put into words. From the system's perspective, care has continued. From the woman's perspective, the situation that she could not articulate has just been pushed past her, and the resulting experience is one of having been overridden. This is, we think, a large part of what later gets described as obstetric trauma or as the experience of having been violated by care that no individual involved intended as violation.
None of this is the fault of clinicians. It is the predictable result of asking a system organised at one level to detect something that lives at another. The question is whether there is a different way of going about it.
We want to be clear about what we are not arguing. We are not arguing that disclosure is harmful or that women should be discouraged from talking about their histories. For some women, particularly those who arrive at antenatal care having already worked through what happened to them, disclosure is wanted, sought, and clinically useful. It tells the team what to expect, gives the woman a voice in her own care, and can be the beginning of a therapeutic relationship that supports her through pregnancy and beyond. Our argument is narrower: that disclosure should not be the only route by which trauma becomes visible to the system, and that it should not be the entry point for a woman who is not ready to take that step. The approach we propose preserves the disclosure pathway in full. It simply does not require it as a precondition for trauma-sensitive care.
We think there is a different way of going about it, and that it follows directly from the analysis above. If the trauma lives across the four non-symbolic dimensions, then the most useful initial information about a woman is not what happened to her but under what conditions her present coordination is most likely to be stable or fragile. That information can be gathered without requiring her to disclose anything about the past. It can be gathered through questions that address dwelling, the material world, and language preferences — three dimensions that are far less likely to trigger the very thing the screening is meant to identify. And it can be deepened, optionally and on the woman's terms, into the more sensitive territory of bodily life and relational presence later, if and when she chooses.
This is not avoidance. It is a different ordering. It treats the woman's felt sense — what works for her and what does not — as the primary data, and it lets that data speak in registers that do not require her to relive anything. It also produces information that is immediately clinically actionable: not "she has a trauma history" but "she finds heat and enclosed spaces difficult, prefers continuity of caregiver, and would like to know what is going to happen before it happens." That is something a clinician can do something with.
6.1 When the request itself is the data
There are two clinical phenomena, both well documented in the literature and both immediately recognisable to anyone working in perinatal mental health, that we think can be re-described much more accurately within the framework we are proposing. Both are usually treated by clinical systems as problems to be managed. Both are better understood as accurate forecasts that the woman is making about her own coordination, expressed in the only currency the system gives her room to use.
The first is the request for elective caesarean section. The link between sexual assault history and caesarean request is now well established. The Bidens multi-country European cohort study (Schei and colleagues, 2014) followed 6,724 pregnant women through routine antenatal care and found that, among primiparous women, a history of adult sexual abuse roughly doubled the odds of elective caesarean section and nearly quadrupled the odds of caesarean section performed for non-obstetric indications. The classic study in this area remains Hofberg and Brockington's British Journal of Psychiatry paper on tokophobia, which explicitly identified childhood sexual abuse and rape histories among women with primary tokophobia and noted that most of those women strongly desired an elective lower segment caesarean section. NHS England's trauma-informed perinatal care guidance now formally acknowledges that previous sexual violence is associated with tokophobia and caesarean requests. The clinical pattern is recognised; it is the interpretation that needs revising.
In current practice, the request for caesarean in the absence of an obstetric indication is typically treated as a problem to be solved through education, reassurance, or persuasion. Tommy's published patient story of "Julie," a UK survivor of childhood sexual abuse, is depressingly typical: she knew before conception that vaginal birth would be impossible for her, researched her options carefully, and was told at her booking appointment that she faced "a massive battle" to get the section she needed. The whole of her pregnancy was organised around fighting for it. Many clinicians will recognise this dynamic from their own caseloads. What is less often remarked is that the energy the system spends arguing with the woman is energy not spent listening to what she is telling it.
We want to suggest that this is a misreading of what the woman is doing. She is not avoiding childbirth in the sense of a phobic flight from a manageable threat. She is making an unusually accurate forecast about which configurations of body, relationship, material world, and ambient surround are most likely to reassemble her assault, and she is acting on that forecast in the only way the system gives her room to act — by demanding the binary procedural option that removes the most resonant features of vaginal birth. She is, in other words, an expert informant about her own coordination thresholds, expressing herself in the procedural language the system understands. The caesarean request is not the problem. It is the woman telling the system, in the only way she can, what it would otherwise have to spend a great deal of time and risk learning the hard way.
Reframing the request this way changes what the conversation should be. It is no longer a matter of explaining to her that vaginal birth would actually be safer, or of negotiating her down from the section in incremental stages. It becomes a matter of asking her what specifically about vaginal birth feels impossible, so that the team can find out which parts of that impossibility are negotiable. Some of those parts will turn out to be genuinely modifiable: choice of caregiver, control over pacing, the right to stop, who is in the room, environmental adjustments, advance notice of any contact. Others will not, and the section may indeed be the right call. The point is that the conversation begins from her expertise rather than against it. This is also why the documentation of her preferences should run across all antenatal contacts, not only the birth itself: clinicians who specialise in perinatal mental health routinely encounter women who have not realised that birth is not the only point at which intimate examinations will be required, and who are blindsided by an antenatal procedure they had not been preparing for. A trauma-informed safety plan that covers the whole of pregnancy, not only the birth plan, is the logical extension of this approach.
The second phenomenon is the avoidance of cervical screening. The statistics here are stark. A 2018 survey by Jo's Cervical Cancer Trust and Rape Crisis England & Wales found that 72% of women with sexual violence histories had either not attended or had delayed cervical screening, with only around 15% attending when invited. The same survey found that 35% said they would rather develop cancer than undergo a smear test. These are not small numbers. They represent a substantial and entirely preventable excess of cervical cancer mortality in a population that has already been disproportionately harmed.
The clinical reflex, again, is to treat smear non-attendance as a public health failure to be addressed through better outreach, more accessible appointments, or stronger reminders. From the framework we are proposing, this is again a misreading. The woman who does not turn up for her smear is not failing to engage with screening. She is making the same kind of accurate forecast as the woman requesting a caesarean section, and she is acting on it through the only mechanism available to her, which is non-attendance. She is telling the system, by her absence, that the standard configuration of cervical screening is too close to her assault for her coordination to survive it. The fact that some women say they would rather die than undergo it is not melodrama. It is a precise statement of how non-negotiable the underlying coordination problem is for them under standard conditions. It also exposes a clinical and ethical failure: the perpetrator has already taken so much from these women, and the standard configuration of cervical care is now silently letting cervical cancer take more.
The clinical implication is the same as for the caesarean request, and it is more actionable than it looks. There already exist services — the My Body Back clinics in London and Glasgow are the clearest UK examples — that offer cervical screening in configurations specifically designed to be survivable for women with sexual trauma histories: extended appointment times, control over pacing, the right to stop at any point, choice of position, attention to language, attention to atmosphere. These are not gimmicks. They are the same condition-based adjustments that the screening tool we propose in the next section is designed to elicit, applied to the same kind of intimate clinical encounter, and they work. Their existence demonstrates that the avoidance is not unmodifiable; it is responsive to changes in exactly the dimensions our framework predicts will matter. A woman who has been unreachable by standard cervical screening for fifteen years can become reachable in a configuration that takes her coordination thresholds seriously.
What unites the caesarean request and the smear non-attendance is that both are routinely misread as problems and are better understood as data. They are the woman's own felt sense of misalignment compressed into the only forms the system can hear: a procedural demand or a quiet absence. A clinical system that learned to read these forms as information rather than as obstacles would not need to argue with women about what they are asking for. It would be able to start from what they already know about themselves and work outward from there. This is, in the end, what condition-based screening is for. It gives the system a way of receiving the information that women have always been trying to give it.
7. A different kind of screening
We propose a screening approach with three features that distinguish it from current practice.
It is layered. It begins with the dimensions least likely to trigger reassembly — dwelling, the material world, and language preferences — and only moves toward bodily life and relational presence at the woman's pace and on her initiative. The deeper material is not avoided, but it is not demanded.
It is condition-based rather than event-based. It does not ask what happened. It asks under what conditions things feel easier or harder. The woman is not required to translate experience into narrative. She is required only to indicate sensitivities and preferences, which she can do in her own register and at her own depth.
It is oriented toward adjustment rather than diagnosis. The output is not a category but a set of clinically actionable preferences. Those preferences can be acted on directly: by changing positioning, pacing, environment, communication, or staffing. If a more formal diagnostic frame is later needed, it can be added, but it is not the point of the encounter.
What follows is a structure for a conversation that can be used in an antenatal appointment by a midwife, GP, or perinatal mental health specialist. It is meant to be light, gentle, and patient-led. It is not a questionnaire to be completed; it is a structure for a conversation. Although we present it here in the context of antenatal care, the same structure can and should be used to organise any intimate procedure across the perinatal pathway, including cervical screening.
A clinician opens the conversation with something like: "Some people find that certain situations or environments make care feel easier or harder. You don't need to explain why. It just helps us support you better if we know what works for you."
The conversation then moves through up to five areas, in this order.
The first area is the ambient surround. Are there times of day, light conditions, temperatures, weather, or atmospheres that feel better or worse? Mornings, evenings, nights? Bright light, dim light, darkness? Warm rooms, cool air? Heat, cold, humidity? Quiet, busy, enclosed, open? The follow-up is always the same: is there anything we can adjust here to make things more comfortable for you?
The second area is the material world. Are there particular spaces, positions, or types of procedures that feel more or less comfortable? Being on a bed versus being able to move? Small or crowded rooms? Particular kinds of equipment? Lying flat, legs raised, being still? Again: is there anything we can adapt to make things easier?
The third area is communication. Are there ways of explaining things, or of talking, that work better? Step-by-step or minimal? Detailed or brief? Gentle, direct, reassuring? Being told in advance or in the moment? Having time to process before decisions are made? How would the woman like the team to communicate with her?
The fourth area is optional. The clinician offers it gently and does not press. Some people have preferences about how staff are around them: how many people present, whether continuity matters, the gender of staff when relevant, personal space and proximity. Is there anything that would help her feel more comfortable with the people around her?
The fifth area is also optional, also gentle. Some people find certain kinds of physical contact or loss of control more difficult than others. Preferences around touch. Wanting advance notice before contact. Being able to pause or stop. Needing control over pace. Is there anything the team should be mindful of?
The conversation closes with: "Thank you. You don't need to explain any of this further unless you want to. We will use what you've shared to make your care more comfortable. If anything changes, you can let us know at any time."
Three things should be noted about this tool. First, no question requires the woman to disclose any past event. She may volunteer one — and this is, in our experience, not uncommon when the conversation is structured this way — but she is never asked to. Second, every answer is clinically actionable. There is no information gathered that the team cannot do something with. Third, the tool is not a diagnostic instrument. A woman with no trauma history may still have strong preferences and sensitivities, and that is fine; the intervention is the same. A woman with a substantial trauma history may not register clear patterns at first, and that is also fine; the conversation can be revisited.
What the tool does is reorient screening from extracting a story to mapping a set of conditions. It is gentler not because it is more cautious but because it is asking a more accurate question. And because the same structure works equally well for cervical screening, antenatal examinations, and the planning of birth itself, it offers a way of carrying a single coherent approach across the whole of perinatal and gynaecological care, rather than treating each encounter as a fresh negotiation from zero.
8. Discussion
We have argued that perinatal mental health problems following sexual assault are not adequately understood as the recall of a stored memory triggered by reminders. They are better understood as the present-tense reassembly, across five dimensions of lived life, of the conditions that defined the original assault. The perinatal period is unusually likely to produce such reassembly because it intensifies all five dimensions at once, often in configurations that are structurally close to those of the original event. Symptoms of depression, anxiety, and post-traumatic stress that emerge in this context are real, but they are downstream stabilisations of repeated unresolved disturbances at a level the clinical system rarely sees.
The dimension we have given the most attention to — dwelling, the temporal and atmospheric surround — is the one that has been almost entirely missing from the trauma literature. We think it is also the dimension that may be doing the most unrecognised work. It is slow, diffuse, below the threshold of attention, and largely non-modifiable. It cannot be standardised away by clinical design, no matter how well engineered the ward. And because it carries an imprint of the original assault that the woman is unlikely ever to articulate, it can generate distress that appears, from the system's perspective, to come from nowhere.
The clinical vignette we drew on throughout this article illustrates something further about the limits of current interventions. The EMDR Flash technique used with the woman reduced her distress rating substantially and made the traumatic image feel more distant. That is a real and worthwhile change. But the technique operates within the representational layer: it changes what is felt about the image without reorganising the multi-dimensional coordination pattern that produced the distress in the first place. The woman's own scepticism that the relief would hold is, from the perspective of this article, a form of clinical wisdom. She knows, at the level of her felt sense, that what has been reached is not all there is. What remains unreached is the bodily pattern of invasion, the relational collapse when the nurse's panicked voice announced failure, the material configuration of screen and table and instruments, and whatever dwelling conditions — time of day, season, atmosphere — were operative at the time. The Flash technique did not fail. It succeeded at the level it can reach. The question is what to do about the levels it cannot reach, and the answer this article proposes is to work directly on the conditions of coordination in the present rather than relying entirely on the reprocessing of representations of the past.
The framework we have used has several implications worth stating clearly. The classification of clinical complaints in the perinatal period as anxiety, depression, or post-traumatic stress is not wrong, but it is too coarse. These categories sit at a level above where the disturbance lives and, when used in isolation, can substitute for engaging with the underlying coordination. Verbal questioning about trauma, however well-intended, is not a neutral instrument; it asks for a kind of conversion that can itself reproduce features of the original violation, and it tends to leave behind exactly what we most need to know. Premature decision-making — the institutional reflex to stabilise an ambiguous situation by acting — can override the felt sense of misalignment that the woman is unable to articulate, and this overriding is, we suspect, a substantial part of what later gets reported as obstetric trauma.
The same framework, applied to two phenomena that the literature has long documented but inadequately understood, allows the request for elective caesarean section and the avoidance of cervical screening to be re-read as accurate forecasts a woman is making about her own coordination, expressed in the only forms the system gives her room to use. This re-reading has direct clinical consequences. It changes the caesarean conversation from one of persuasion to one of inquiry: not why she should have a vaginal birth, but what specifically about it feels impossible and which of those specifics might be modifiable. It changes the cervical screening conversation from one of public health outreach to one of configuration: not how to convince her to attend the standard appointment, but what an appointment would have to look like for her coordination to survive it. And it points to a broader principle: that women whose trauma is operating below words have always been finding ways to communicate it through the procedural and behavioural channels available to them, and that the clinical system's failure has not been a failure to ask but a failure to listen to what was being said.
There are several limitations we want to acknowledge. The framework is theoretical. The screening tool we propose has not been formally evaluated, although it draws on established trauma-informed care principles, on the qualitative literature we have reviewed, and on the clinical experience of services like the My Body Back clinics that already operate on related principles. The empirical question of whether condition-based mapping outperforms event-based disclosure, in terms of detection, distress, and downstream outcomes, is open and worth testing. We also recognise that some women will want to disclose, will benefit from disclosing, and will be poorly served by an approach that does not give them the opportunity. Our argument is not that disclosure should be avoided. It is that it should not be the entry point, and it should not be the only route by which trauma can become visible to the clinical system.
Finally, there is a broader implication that we want to flag without developing here. The general lesson — that clinical systems can be organised at a level above where the phenomenon they are trying to address actually lives, and that patients have often already worked out how to communicate the underlying problem in forms the system fails to read — is not specific to sexual trauma or to perinatal care. It is, we suspect, a general feature of how clinical systems handle phenomena that resist symbolic articulation. Sexual trauma in the perinatal period is a particularly clear case, but it may not be the only one. If the analysis we have offered here holds up, similar reframings may be useful elsewhere.
9. Conclusion
The question is not whether women can tell us what happened to them. Many can. Some cannot. Some have already told us, in the procedural language of caesarean requests and in the silent language of missed appointments, and we have not heard them. The question is whether we can recognise how what happened continues to organise the conditions under which their present care becomes possible or breaks down.
Sexual trauma does not, in its operative form, live as a story to be told. It lives as a patterned vulnerability in how a woman's body, her relationships, her environment, the material world, and language hang together. The perinatal period intensifies all five at once, and for many women it reassembles enough of an earlier assault's structure to bring it back, not as recall but as present situation. The most useful thing we can do, as clinicians, is not to ask better questions about the past, but to learn to read the present more accurately and to adjust the conditions of care accordingly.
That is a smaller and more modest task than the one trauma-informed care has often set for itself. It does not require heroic empathy, exhaustive disclosure, or specialist training. It requires only the recognition that the conditions under which a woman's coordination is stable or fragile are themselves clinical information, that they can be gathered with care and without asking her to relive anything, and that when a woman is already telling us what she needs — by what she requests, by what she avoids, by what her body does in our rooms — our task is to listen rather than to argue.