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In 2007, Helen Mirren shared what made her decide never to have children. In an interview with an Australian journalist, the award-winning English actress admitted it was an explicit video of childbirth, shown to her in her early teens when she attended a convent school. Thirty seconds into what the film deemed “the miracle of childbirth,” two 13-year-old boys fainted and had to be carried out of the classroom. That short break with the lights on—during which all of the children desperately avoided eye contact—gave Mirren the chance to realize she couldn’t watch the rest of the film.

"I swear it traumatized me to this day,” she said. “I haven't had children and now I can't look at anything to do with childbirth. It absolutely disgusts me."

This sentiment is not uncommon. Though there aren’t statistics in the United States for a pathological anxiety over pregnancy and childbirth—known as tokophobia—studies in Australia and Britain have found that 6 percent of pregnant women report a disabling fear of having babies, while 13 percent of women who are not yet pregnant are afraid enough to postpone or avoid pregnancy altogether. First studied in Paris in 1858, tokophobia wasn’t introduced into medical literature until 2000, when it was classified in the The British Journal of Psychiatry. Before then, The Mediterranean Journal of Clinical Psychology noted, “there were already several studies concerning the fear of childbirth, but they described the discomfort of pregnant women facing childbirth as a general fear, often quite natural for an event considered to be unknown and painful.”

Pregnancy and childbirth do come with feelings of anxiety, of course: hopes that the mother and child will be safe and healthy, that there will be little to no complications during childbirth, that the first days and months at home will go smoothly. So when do common pregnancy jitters cross the line into a clinical phobia? And, if the phobia is as prevalent as some research suggests, why isn’t it more widely recognized? The answer may have to do with the difficulty of being open about not looking forward to something that most people consider a miracle—especially when more than six million women in the U.S. alone have problems getting or staying pregnant and may dream of having children.

In the 5th century BC, the first term for a mental health condition linked to a woman's uterus was coined by Greek physician Hippocrates: hysteria. In hysteria, the uterus was thought to cause disease in many possible ways, from “moving” and blocking the health of the body to creating “female semen” that was poisonous if not removed through sexual stimulation. This “sickness” of the uterus was thought to create stress in women, all due to a lack of sexual satisfaction. Though no longer recognized, it was a diagnosis that was around for hundreds of years, whose cure was self-stimulation, manual stimulation by a doctor, or in extreme cases, institutionalization or hysterectomy. It wasn’t until 1980 that the term was removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, as it was often used as a catchall for undiagnosable symptoms or those related to anxiety and similar mental health issues.

While hysteria was a diagnosis imposed on a woman in an attempt to prevent disease, tokophobia is an internal panic; it’s not the uterus itself that’s considered a danger to mental well-being, but what could happen within it—and as a result, to the rest of the body. Tokophobia is categorized in two forms: primary and secondary. The former can be understood through the lens of Mirren’s fear—often happening at a young age—when seeing disturbing images of birth or even resulting from sexual assault. The latter is often described similarly to post-traumatic stress disorder, resulting from a traumatic past birth experience.

A third form that is not recognized medically—known as social tokophobia—was conceived by Brian Salmon, a doula and lactation consultant. “Instead of it being true to secondary tokophobia, it is social—because people suck,” says Salmon. “They tell you the worst stories about their pregnancy, about their breastfeeding; all of these things.”

Salmon estimates he works with roughly 300 couples of various sexual orientations every month, and of those at least one in 10 have a severe fear of birth. “What happens is other people’s stories get ingrained in your head and anticipation of the unknown kicks in,” he says. “Then people are just so tense, they are fighting every minute and aren’t sleeping, so they show up to their birth exhausted because they are working through their early labor and just anticipating that big one that is going to come wallop them.”

Tokophobia seems to manifest in different ways depending on the classification, but avoidance of pregnancy or the desire to schedule a C-section are often seen across the board, even in healthy pregnancies. That is, unless a case of secondary tokophobia developed because of a traumatic experience in the hospital during a previous birth, in which case, many women opt to deliver at home. Studies show that women who already suffer from general anxiety would be predisposed to tokophobia.

There are not many women who openly discuss having tokophobia, though some have spoken out in media or online in recent years to share their stories or seek help. One woman on Reddit, in a channel devoted to people who don’t want children, notes that her tokophobia was so severe she was afraid of having sex with her significant other for fear of becoming pregnant, even when protection was used. “I know it's silly that I'm this afraid,” she writes, “but I can't help it.”

Even childbirth in media can exacerbate tokophobia, as writer Meredith O’Donnell pointed out in The Telegraph in 2008. During a viewing of the film Knocked Up, while the rest of the patrons in the theater laughed at the film, she found herself twisting and turning in her seat, faint and on the verge of throwing up, as images of pregnancy and childbirth were added to the catalog of already traumatizing pictures she had rooted in her brain.     

According to Amy Wenzel, a clinical psychologist and author of Anxiety in Childbearing Women: Diagnosis and Treatment, it is precisely when general anxiety about pregnancy crosses the line into something that has a sustained negative impact on a person’s life that fear turns clinical. “What I would say for any mental health issue is when it causes life interference or distress—in this case, it could be trouble sleeping, avoidance of doctor appointments or frequent calls to the doctor for reassurance—then it is time to seek some help,” she says. “There is a lot of pain associated with labor and delivery and certainly your body goes through such a major transformation, so for a person who has difficulty tolerating risk and uncertainty, it can be an excruciating time.”

Women who have a history of anxiety and depression are already at risk for experiencing postpartum depression or anxiety, so having tokophobia itself isn’t a direct indicator. “People with phobias in general tend to have extensive mental health histories and generally want to get over them and will get help in different ways,” says Barbara Herrera, a former midwife and doula. “I found with tokophobia, however, it was one where women just had a wall in front of them and were unable to even see on the other side of it. Women can actually have visceral reactions when they see a pregnant woman. When they are in the supermarket and they see a pregnant women they actually have nauseous, visceral reactions, that are all-encompassing.”

Herrera suggests this “wall” is one reason women don’t seek psychological help when experiencing symptoms of tokophobia. Another reason she discusses is the shame women may potentially feel. Pregnancy and childbirth are often seen as the happiest time of a woman’s life. Other than the acknowledgment of postpartum depression and anxiety, there’s a general assumption—in Western cultures, at least—that women are supposed to be joyous. So if the idea of being pregnant disgusts a woman, it is only natural to be afraid of being stigmatized, Herrera says. And when a phobia is already present, these feelings of shame will only exacerbate fears.

In the case of tokophobia, should the ultimate goal be to bear children someday, “one of the keys is really exploring where this fear came from, followed by exploring how extreme the anxiety is exhibiting itself on a daily basis,” says Kirsten Brunner, a counselor partnered with Salmon to help couples prepare for the psychological challenges of parenthood. “Then a lot of times, like with any phobia, becoming educated with your options can help ease the distress. The other key is taking the shame away. Women don’t want to admit how extreme their anxieties or feelings of disgust are, but we all have our fears, so I work to really eliminate shame. Sometimes, that is half the battle.”

As someone who has been diagnosed with generalized anxiety disorder, I have already expressed my desire to have a C-section in order to avoid natural labor, even though I am not pregnant and am currently not trying to conceive. It embarrasses me, but I cringe at the sight of pregnant women; my mind immediately goes to the nauseating sounds and sights of a natural childbirth. Explaining this is usually futile, as it is met with reminders that three million children are born each year and many women give birth multiple times. Still, I do plan to have children; for me, the reward of raising a child outweighs my aversion to pregnancy and childbirth.

For now, tokophobia isn’t listed in the Diagnostic and Statistical Manual of Mental Disorders. And, as O’Donnell notes in her article, women who choose a C-section are sometimes deemed “too posh to push.” But if discussion of tokophobia in research and everyday life grows more common, the decision to not have—or postpone—children may become less taboo.

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