Written by Dr Bex Parkes

CONTENT WARNING: This article discusses sexual violence and trauma.

Why are we talking about the relationship between chronic pain and trauma? I’d love to tell you. First we need to talk about “trauma” and understand what it is

So what is “trauma”? From a psychological perspective, trauma is an event (or series of events) which cause a significant emotional response. There’s what we call “Big T Trauma”; these are the types of events that meet the first criteria for a diagnosis of Post Traumatic Stress Disorder (PTSD), where you are fearful of death or serious injury, either for yourself or someone else. This includes, but is not limited to, things like car accidents, combat trauma, physical assault, sexual violence, medical emergencies etc.

But there’s also “little t trauma” which includes situations or events where you are not fearful for your life or physical safety, but which are repeated events where you have a significant stressful emotional response. This could include situations like verbal abuse, non-physical bullying, emotional neglect etc.

And why is trauma a problem?

Apart from the obvious negative - that you’ve had a really awful, and potentially life-threatening experience – trauma has a bunch of negative impacts on the body and brain. These can include experiencing distressing psychological symptoms like flashbacks, hypervigilance, intrusive memories, nightmares, anxiety, panic attacks, and depression. Not a good time.

Both the initial trauma experience, and the above symptoms can cause a cascade of neurotransmitters in your brain, like cortisol and noradrenaline (among others). These are excellent when you really need to get out of a dangerous situation quickly, as they give you that energy to move your body quickly, however they do this by redirecting the blood from your less essential systems (like digestion and reproduction) to your big leg muscles (to run away). Ever experienced an anxiety vom/nervous poo before a big event like a speech or performance? That’s your brain and body going into fight or flight and shutting down your digestive system in preparation to run for your life!

Having a massive dump of neurotransmitters is great when you’re in a situation where you really need it. But when it happens regularly over a period of time, you start to experience some pretty negative side effects, and you can end up with Hypothalamic Pituitary Adrenal (HPA) Axis dysfunction. The high cortisol levels caused by HPA axis overactivation include damage to the prefrontal cortex (the rational thinking part of your brain) and hippocampus (the part that forms memories), an increase in the risk and severity of conditions like anxiety and depression, suppressed immune system function, and disruption of the gut-brain axis which can lead to a number of digestive disorders and issues with microbiome.

It’s the nervous system dysregulation and hyperarousal that is the biggest problem when it comes to chronic pain. People who experience this are more likely to develop central sensitization, be more sensitive to pain stimuli, more hyper-aware of internal body processes (including pain), and if the pain is related to the specific trauma that occurred e.g. pelvic pain after sexual assault, then the pain can set off a trauma response, which then heightens the pain response, and before you know it you have a vicious cycle of pain and trauma responses making each other worse.

Sexual trauma

Chronic pelvic pain and sexual trauma are closely interlinked. Did you know that 15-25% of the female population have experienced sexual violence or abuse of some kind? Absolutely horrific stats, and unfortunately probably an underestimation of the actual prevalence of sexual violence and sexual abuse, as plenty goes unreported. For women who are violently sexually assaulted, pelvic pain can be caused by a few different factors (and is usually a combination of them). The first is that the person may have suffered painful internal injury as a result of the assault. The second is that after a sexual assault, a person’s brain and body (understandably) tend to have a protective response, which can often involve what is referred to as “guarding”, which means that the pelvic muscles clench up tightly to prevent any future sexual violation. The most extreme versions of this are vaginismus (literally the muscles of the vagina clench up and prevent entry of even something as small as a cotton bud into the vagina), and dyspareunia (which is pain during sex, usually due to tense muscles before, during and after).

Unfortunately over time this guarding of the pelvic muscles can lead to chronic pelvic pain. You can actually test this out on yourself by balling your hand up into a tight fist, and seeing how long you can do this before your muscles start to get really sore and tired. If you do it for long enough, those muscles will start to cramp up. Because of the way the muscles, tendons, ligaments, nerve pathways, and pelvic organs are arranged in the pelvis, it doesn’t take much of this chronic guarding, before the effects spread and contribute to other kinds of pelvic dysfunction like pelvic floor disorders,  IBS, and Interstitial Cystitis (painful bladder syndrome). 

If I have this trauma and chronic pain combo, what can I do about it?

First of all, I’m so sorry that you have experienced trauma that has led to the development of chronic pain. The good news is that there are things that you can do about it.

If you are able to access psychology input, then this is really important. If the trauma can be treated/processed effectively, then your body will be able to relax and come off “high alert”. This will then help your nervous system to regulate, and your muscles to relax over time. If you have pelvic floor dysfunction, then it is essential that you also see a pelvic physiotherapist who can assist with massage and exercises to help improve your pelvic floor dysfunction – therapy alone usually doesn’t cut it.

If you are looking into trauma therapy, then I strongly recommend seeking out an experienced trauma therapist who practices one of the types of therapies that involve working with both emotional and physical symptoms of trauma, like Eye Movement Desensitization and Reprocessing (EMDR) therapy, Internal Family Systems (IFS) therapy, and/or Somatic therapies. Just talking about it is usually not enough. If you have experienced a sexual trauma in New Zealand, you may be eligible to access ACC Sensitive Claims therapy. You can find therapists on the ACC website www.findsupport.co.nz. You do not need to have reported the assault to the police.

Depending on what is going on for you, you may need to see a gynaecologist, urogynaecologist, gastroenterologist, pelvic physio or pain specialist. The most important attribute of all of these specialists (apart from their specific skill set) should be whether they practice in a trauma informed manner. You can find this out by asking directly “how do you practice in a trauma informed way?”. A trauma informed clinician will respond with things like – “you can bring a support person”, “we are client/patient led”, “informed consent is important to us”, “we will not do any internal examinations unless you feel comfortable” etc. They will also regularly check in with you in regards to your comfort, and will respond in a warm and validating manner if you do disclose a trauma history. If you need surgical or intrusive interventions, it will be really helpful for yourself and your treating team if you can disclose that you have experienced trauma – this can help them to ensure you feel as safe and comfortable as possible.

I could talk about this topic all day, but I’ll wrap it up here for now. The most important takeaways for you if you have a trauma history and think it might be contributing to your chronic pain are:

· Your pain and your symptoms are real and valid.

· Seeing trauma informed clinicians is important to avoid re-traumatisation

· A psychologist can help to treat the trauma, which can result in your body being able to relax and therefore pain can be reduced.

· Pelvic physio is extremely important if you have experienced sexual trauma.

· If this article has brought up any difficult memories or emotions for you, you can access support by texting or calling 1737.

· If you have experienced sexual violence in NZ, you can find an ACC Sensitive Claims therapist via www.findsupport.co.nz. This service is free.