“The pregnancy test was negative,” Gretchen recounted through tears. Her tears were not a straightforward reflection of disappointment and longing, as one might assume. They accounted for a complex stew of relief, guilt, and shame about the relief and fear of this ongoing cycle that was proving to be torturous and emotionally exhausting due to Gretchen’s unmanageable anxiety.
Gretchen and her partner had been trying to get pregnant for several months. Having a biological child was something they both very much wanted. Each month, in the weeks leading up to a possible positive pregnancy test, Gretchen would be excited about the prospect in theory, but utterly terrified about the reality. She often had panic attacks, was inundated with worries about the ways pregnancy and childbirth can go wrong, and was physically repulsed by the idea of a human life growing inside her. The idea of pregnancy made her feel trapped—the state being inescapable and the thought of that, unbearable.
Even before trying to get pregnant, Gretchen had struggled for years with tokophobia, an intense fear of pregnancy. Her extreme difficulty with managing even the process of trying to conceive reinforced Gretchen’s belief that she certainly couldn’t handle an actual pregnancy.
Another client, Octavia, had also been struggling with tokophobia, although hers looked quite different. In our most recent session, she was also in tears. After hooking up with a man she’d gone on a few dates with, Octavia had “spiraled” for days after. “I just couldn’t stop thinking that I’d somehow gotten pregnant,” the notion of this outcome intolerable to her. She was consumed with fear, despite the fact that they hadn’t had sex, let alone gotten fully undressed in their encounter.
Octavia recounted to me the hours she’d spent researching obscure ways of getting pregnant and the repeated phone calls to friends and family seeking reassurance. She knew logically, somewhere in her brain, that it was impossible and felt embarrassed, but Octavia couldn't shake the fear. In the end, she cut things off with the guy.
Tokophobia wrecks a person’s ability to move forward with their life goals or get close to people—or allows them to do so only under extreme and unrelenting distress. Both Gretchen and Octavia exist in a state tinged with deep pain and impairment—a life not quite lived.
Unfortunately, although this phenomenon is widely experienced, it is not thoroughly researched. There are some, but not enough, comprehensive studies and little in the way of specific treatment guidelines. People are suffering and likely not getting much help—or even realizing that what they are experiencing has a name.
In the literature, tokophobia is broken down into two main types: primary (fear of pregnancy/childbirth without having direct experience) and secondary (fear following a traumatic pregnancy or childbirth experience). In doing more reading and reflecting on my clinical observations of clients like Gretchen and Octavia, I came up with the following distinctions, or subtypes, with the idea that each requires a tailored therapeutic approach, and therefore it’s important to make the distinction.
For an avoidant tokophobic like Octavia, it wouldn’t make sense to delve into the meaning and source of each of her thoughts or try to dispute each specific worry, when an approach like Exposure and Response Prevention (ERP)—the most effective treatment for OCD—is more likely to ultimately bring some relief. And while it is tempting to treat Gretchen’s reluctance as ambivalence, helping her explore alternative options for growing her family, she is clear in her conviction, but unequipped to manage her physical and psychological anxiety.
Most importantly, I think our job as therapists when working with a client with tokophobia is to 1) take it seriously and 2) conceptualize and treat it appropriately.
My sense is that those struggling with phobic fear of pregnancy and/or childbirth typically feel dismissed, confused, and ashamed (related either to the fact that they feel such fear and aversion to something they expect “should” come naturally to them or to their avoidance and rituals that they recognize as embarrassing/extreme/out of touch with reality).
So when I encounter a client with tokophobia, I often say something like, “Yes, this is a real thing, you are not alone, and furthermore, we can take steps to reduce the shame and nudge you towards the life you want.”
I can offer legitimacy to their experience and compassion to their suffering, while paying attention to the distinct ways tokophobia can manifest person to person. Clients like Gretchen and Octavia don’t have to feel so isolated or hopeless.
File under: The Art of Psychotherapy, Couples Therapy, Therapy Training
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Gretchen and her partner had been trying to get pregnant for several months. Having a biological child was something they both very much wanted. Each month, in the weeks leading up to a possible positive pregnancy test, Gretchen would be excited about the prospect in theory, but utterly terrified about the reality. She often had panic attacks, was inundated with worries about the ways pregnancy and childbirth can go wrong, and was physically repulsed by the idea of a human life growing inside her. The idea of pregnancy made her feel trapped—the state being inescapable and the thought of that, unbearable.
Even before trying to get pregnant, Gretchen had struggled for years with tokophobia, an intense fear of pregnancy. Her extreme difficulty with managing even the process of trying to conceive reinforced Gretchen’s belief that she certainly couldn’t handle an actual pregnancy.
Another client, Octavia, had also been struggling with tokophobia, although hers looked quite different. In our most recent session, she was also in tears. After hooking up with a man she’d gone on a few dates with, Octavia had “spiraled” for days after. “I just couldn’t stop thinking that I’d somehow gotten pregnant,” the notion of this outcome intolerable to her. She was consumed with fear, despite the fact that they hadn’t had sex, let alone gotten fully undressed in their encounter.
Octavia recounted to me the hours she’d spent researching obscure ways of getting pregnant and the repeated phone calls to friends and family seeking reassurance. She knew logically, somewhere in her brain, that it was impossible and felt embarrassed, but Octavia couldn't shake the fear. In the end, she cut things off with the guy.
***
Pregnancy understandably creates a certain amount of anxiety (with a whole extra layer heaped on top given current pandemic circumstances), but for some, the concept itself prompts excessive fear, strong physical responses of anxiety and repulsion, and behavioral avoidance that is debilitating and outside the norm.Tokophobia wrecks a person’s ability to move forward with their life goals or get close to people—or allows them to do so only under extreme and unrelenting distress. Both Gretchen and Octavia exist in a state tinged with deep pain and impairment—a life not quite lived.
Unfortunately, although this phenomenon is widely experienced, it is not thoroughly researched. There are some, but not enough, comprehensive studies and little in the way of specific treatment guidelines. People are suffering and likely not getting much help—or even realizing that what they are experiencing has a name.
In the literature, tokophobia is broken down into two main types: primary (fear of pregnancy/childbirth without having direct experience) and secondary (fear following a traumatic pregnancy or childbirth experience). In doing more reading and reflecting on my clinical observations of clients like Gretchen and Octavia, I came up with the following distinctions, or subtypes, with the idea that each requires a tailored therapeutic approach, and therefore it’s important to make the distinction.
- Reluctant: A person with tokophobia who wants to get pregnant
- Avoidant: A person with tokophobia who avidly does not want to get pregnant and experiences obsessive and extreme worry as well as significant OCD-like avoidance and compulsions.
- Ambivalent: A person with tokophobia who is uncertain about whether to pursue pregnancy.
For an avoidant tokophobic like Octavia, it wouldn’t make sense to delve into the meaning and source of each of her thoughts or try to dispute each specific worry, when an approach like Exposure and Response Prevention (ERP)—the most effective treatment for OCD—is more likely to ultimately bring some relief. And while it is tempting to treat Gretchen’s reluctance as ambivalence, helping her explore alternative options for growing her family, she is clear in her conviction, but unequipped to manage her physical and psychological anxiety.
Most importantly, I think our job as therapists when working with a client with tokophobia is to 1) take it seriously and 2) conceptualize and treat it appropriately.
My sense is that those struggling with phobic fear of pregnancy and/or childbirth typically feel dismissed, confused, and ashamed (related either to the fact that they feel such fear and aversion to something they expect “should” come naturally to them or to their avoidance and rituals that they recognize as embarrassing/extreme/out of touch with reality).
So when I encounter a client with tokophobia, I often say something like, “Yes, this is a real thing, you are not alone, and furthermore, we can take steps to reduce the shame and nudge you towards the life you want.”
I can offer legitimacy to their experience and compassion to their suffering, while paying attention to the distinct ways tokophobia can manifest person to person. Clients like Gretchen and Octavia don’t have to feel so isolated or hopeless.
File under: The Art of Psychotherapy, Couples Therapy, Therapy Training