Pelvic pain and trauma. Three words that typically aren’t used together. However, the more I delve into and think about the topic of pelvic pain, the more I am convinced that we need to be aware of its connection with trauma.

Why? So those with pelvic pain can feel understood and treated in a sensitive way, and so those who care for and about them will understand and treat them with sensitivity. Trauma is a word that’s being used more frequently, which unfortunately, doesn’t mean that it’s always used appropriately. Let’s start by defining the term. In their book Sensorimotor Psychotherapy: Interventions for Trauma and Attachment, Drs. Pat Ogden and Janina Fisher (2015) defined trauma as “Any experience that is stressful enough to leave us feeling helpless, frightened, overwhelmed or profoundly unsafe.” A trauma response can occur after a single event or in prolonged situations of overwhelming stress. Prior to the COVID-19 pandemic, an estimated 90% of the population had experienced at least one traumatic event. This percentage would surely be higher now.  

What’s traumatic to one person is not necessarily traumatic to another, or to the same extent. For example, hospitalization in childhood, a car accident, death of a loved one, assault, or surviving a natural disaster or war, can have very different effects on two different people, even if they’re siblings. The Adverse Childhood Events (ACEs) Study established that certain events experienced in childhood can have a negative and lasting impact on mental and physical health, life opportunities and relationships. Multiple research studies have found that experiencing abuse in childhood is a significant risk factor for developing a pelvic pain condition (see Notes). In addition, the trauma of discrimination, oppression or exclusion combined with childhood trauma and persistent pain can compound and magnify its effects.

When we are faced with a threat, our nervous system automatically responds with a ‘fight, flight or freeze’ response. This built-in reaction is designed to help us survive and bypasses the thinking brain. A small number of people who experience trauma will be diagnosed with post-traumatic stress disorder (PTSD). Some will move on without any lasting psychological effects. Other people will develop a sense of not feeling safe in the world, with others and in their own body. Trauma can sensitize the nervous system to be in a constant state of alarm, which can cause anxiety, depression, difficulties in social functioning and a wide range of physical symptoms. Research has established that trauma can over-sensitize the nervous system, predisposing many people to chronic pain.

Consider some common experiences of people with pelvic pain. Some have happened to me or people I know/have heard about.  Many of these experiences are relevant to other types of persistent pain: 

• Feeling misunderstood or dismissed by a healthcare provider 
• Feeling unable to pursue your hopes or dreams for a career, relationship, or family 
• Feeling broken
• Going from one healthcare provider to another, being told there’s nothing wrong with you
• Being misdiagnosed
• Being asked if you think the problem is ‘in your head’ or suggesting that it’s in your head
• Being subjected to invasive tests, painful procedures or surgery, and your symptoms are not better or worse
• Believing that you can’t have a relationship that involves sexual intimacy
• Believing that there’s no remedy or hope

Any of these events would be at the very least stressful, and possibly traumatic. They can leave us feeling helpless and overwhelmed. Persistent pain and feelings of not having control or being at the mercy of our pain, can create chronic traumatic stress. The brain perceives a threat and goes on guard, which can create a lot of tension in the pelvic region, increasing pain and anxiety. Anxiety increases tension, which increases pain; creating a vicious cycle. This is described as a state of ‘hyperarousal’. Another possible response in the face of threat is a state of freeze or collapse, which can result in depression, numbing or disconnection or ‘hypoarousal’. In between these two states is a place where we can feel at ease, able to exercise our ability to think deeply, feel a wide range of emotions, and connect with others. This comfort zone is called our ‘window of tolerance.’ Trauma therapy and mind-body practices can help people widen their window of tolerance by noticing when they are out of their comfort zone, developing strategies to come back into, and for staying inside their window.

A feeling of safety is necessary to be in our window of tolerance. Trauma and persistent pain can cause us to feel vulnerable and vigilant, leading to tension, anxiety, and pain that will not subside unless the body and the brain feel safe. When it comes to pelvic pain and trauma, yoga and mindfulness meditation are two ways to cultivate feelings of safety.

Interoception is the ability to tune into bodily sensations with awareness. Interoception is key to start feeling safe in the body. Trauma and persistent pain can cause us to become disconnected from parts of our bodies. Yoga and mindfulness invite us to gently reinhabit our bodies by starting to notice internal sensations.

Despite their benefits, yoga and meditation practices have the potential to retraumatize a person if they are not taught in a skilled and sensitive way. A trauma-sensitive approach is built on the assumption that everyone has trauma, and it can be activated in a yoga class or during meditation. Some people with trauma or pain find it extremely difficult or overwhelming to be still and pay attention to internal sensations. For example, asking a person to focus on their breath or a place in their body that is painful, or lie down with eyes closed in a yoga class can activate a trauma response.  If a yoga or meditation practice is too much for the person ie: it’s happening too quickly, lasting too long, or asks them to focus on something that activates a fight/flight/freeze response, a person loses their ability to stay present with their body.

A trauma-sensitive approach dials down the intensity of the experience and allows a person to make choices about how they practice. A person can choose their pace and opt out or modify the practice so they can stay present with their body. This is critical to feeling in control and being able to access interoception.  A common practice for yoga teachers is to ‘adjust’, or ‘assist’ a student’s alignment using their hands.  Before I became a yoga teacher, I attended a yoga class where during Savasana (the integration at the end, where people are lying down with eyes closed), the teacher went around the room and gave people a shoulder and neck massage. This was extremely uncomfortable for me, and I never went back to her class. Without consent, (or even with consent, when a participant feels obliged, pressured, embarrassed or any other factor that compromises their free will), this constitutes unwanted touch. Some people may feel compelled to accept the teacher’s ‘assistance’ because of the power imbalance or fear of rejection, humiliation, or criticism when their body and brain are saying no.

A trauma-sensitive approach normalizes the experience of trauma, and everyone can benefit. Trauma-sensitive yoga teachers avoid touching the people they’re working with. Instead of asking people to raise their hands in advance or flip a consent card to communicate their consent to be touched from moment-to-moment, a participant can focus on their internal experience. Many people with trauma and persistent pain have a great deal of anxiety generated by their thoughts and symptoms. Trauma-sensitive practitioners recognize the importance of reducing anxiety caused by external sources. I ask my clients to tell me at the start and as we work together what I can do to enhance their comfort. For example, this might mean modifying or avoiding certain postures because they are painful or activating, adjusting the lighting, or allowing them to choose where they want to sit in a group class.

Trauma-sensitive yoga is an evidence-based approach to help people with trauma. Research continues to emerge helping us better understand how trauma and persistent pain affect the nervous system and the most effective approaches for healing.

Persistent pelvic pain is treatable, and you can have a better quality of life!

Notes:

• One of the largest, long-term studies published in 2018, Childhood abuse linked to greater risk of endometriosis, found an association between endometriosis and childhood abuse. The discussion section of this journal article, Early life abuse and risk of endometriosis, cites previous studies with similar findings about chronic pelvic pain

Kathleen Pratt is a social worker and trauma-sensitive yoga instructor in Kingston, Ontario. Her specialties include yoga for pelvic wellness, persistent pain, and grief. She offers in person and virtual yoga sessions across North America. 

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