Any parent can experience mental health difficulties in the perinatal period (from conception to one year following birth), regardless of gender or biological connection to the child. This is common in men with around 1 in 10 fathers experiencing depression and anxiety in the perinatal period. Awareness is growing in relation to the effects that traumatic birth experiences have on fathers, too. But which fathers does this evidence refer to? I am a Reader at the University of Huddersfield and recently co-authored a good practice guide on involving and supporting fathers and other family members in perinatal mental health services. My research in perinatal mental health began with exploring maternal mental health assessment within maternity (where standardised questions are routinely used at the initial antenatal appointment). Venturing into paternal (fathers’) mental health research, it was easy to interpret the differences between mothers’ and fathers’ mental health experiences and perspectives on help-seeking as being primarily related to gender. But, from my own experiences as a non-birthing parent in a two-mum family, I wasn’t convinced. Who is included by terms like ‘maternal mental health’ and ‘paternal mental health’? Who is left out? And how may these terms limit our learning? Most of what we know about fathers’ perinatal mental health comes from research with cisgender men (men whose personal identity and gender is the same as their sex assigned at birth) who are in a heterosexual relationship with the baby’s mother, with whom they live. Often, fathers are considered secondary to mothers — perhaps part of a secondary research objective — and typically recruited to research studies via the mother as a gatekeeper. What about other groups of fathers? Fathers who aren’t the partner of the mother or birthing person. Fathers who aren’t biologically connected to the child but have a parental role. Fathers who themselves have been pregnant and given birth, and fathers whose male partner has. Fathers who are in a co-parenting relationship with the child’s parent(s) without being in an intimate relationship. And the focus here: fathers who have become parents through surrogacy. Two-father families through surrogacy are a growing group but accurate numbers are difficult to establish. In part, this is because there are many ways that these families are formed, meaning that different datasets may each capture only part of the picture. It is also because sexual and gender minority parents aren’t adequately visible in data or in services. Research involving gay fathers through surrogacy has focused on children’s development and parenting quality, the main message being: the children are fine. There is research too on surrogates’ experiences and the politics of surrogacy, particularly concerning cross-border commercial surrogacy (i.e., international arrangements where the surrogate accepts payment in addition to being reimbursed for expenses that occur throughout the surrogacy process). From a perinatal mental health perspective though, what is known about these fathers? Photo by Kelly Sikkema on Unsplash Approaching this piece, I am mindful that all of my research has involved expectant or new parents where one (or more) of the parents has themselves been pregnant; none has concerned surrogacy. However, in turning to the literature and meeting with Michael (whose personal experience blog on this topic was published yesterday), what strikes me — alongside aspects that are heightened or distinct — are the commonalities. Pre-conception, Michael’s experiences of heteronormativity (where binary gender identity and heterosexuality are assumed to be the default position) within assisted conception systems resonate with existing literature. Michael’s comments about the imagery of “posters of happy cis-gendered heterosexuals” show that feeling excluded is accompanied by not feeling able to challenge the lack of inclusivity— because of feeling as if they should be “privileged” to be allowed into this space. The “who’s the real dad?” message is repeatedly conveyed by forms, systems and interactions with professionals, being physically excluded from appointments, being instructed by a sonographer: “just the ‘real Dad’ please”. Together, these deepen feelings of exclusion and ultimately, feeling “less important” or less valid as a parent. Notable in Michael’s experiences is the contrast between pregnancies. Research on psychological aspects of pregnancy and parenthood often concern the ‘transition’ to parenthood for a first-time parent, but we see here the need to also consider subsequent parent experiences. Michael locates this difference with changed dynamics: him having a genetic connection with the couple’s first child and not their second. Lack of legal and social recognition as a parent are repeatedly identified as contributing factors for perinatal mental health difficulties amongst LGBT+ (lesbian, gay, bisexual, and transgender/transsexual) parents but research has not explored how this may vary with different children. Moreover, we see that with Michael and his partner, Wes, each experiencing both types of connection, there is potential for shared understanding. This may contrast with some of the experiences of fathers in cisgender heterosexual relationships who have reported not knowing what was going on for their partner or how to help. Instead, we see Wes helping prepare his partner for the potential that this second experience with the birth of a child may be different, sharing his own experiences with Michael for the first time. In doing so, Michael appears better able to voice some of his struggles, and for these struggles to be normalised — without being minimised. This helped to put in place practical steps around the birth, to be actively included, for example through skin-to-skin time with their son. Likely, the conversations also helped to overcome possible barriers to seeking help with his postnatal depression. Here, we see the need to not limit our learning to vulnerability factors but to instead also consider how protective factors may vary. Barriers to help-seeking exist for all parents, commonly linked to stigma, including fear of being seen as a “bad” parent. Some have been framed as gendered, arguing that men face different, possibly greater, barriers concerning mental health support. Notable in Michael’s account is an aspect distinct to sexual and gender minority groups in this context: fear of “let(ting) the LGBTQ+ parenting side down” — of playing into negative stereotypes of LGBT+ parents being inadequate. This extends previous research where lesbian parents felt their parenting was judged more harshly compared with their heterosexual peers. Photo by Kelly Sikkema on Unsplash We know little about the psychological health of gay fathers through surrogacy. Let’s suppose that — in numerical terms — there are no differences in gay fathers through surrogacy compared with other possible comparison groups (e.g., cisgender fathers in heterosexual relationships, or non-birthing co-mothers). Indeed, studies suggest groups may be similar. It follows that some will experience perinatal mental health difficulties and would benefit from formal support. What support is offered to fathers in these circumstances? And how are they identified? Perinatal services offer routes into mental health support for expectant and new parents. Some are focused around the child (e.g., health visiting and infant mental health services) but most are focused around the birthing parent (e.g. maternity services and specialist perinatal mental health services). Research with cisgender heterosexual fathers finds fathers feeling overlooked by healthcare professionals and services, with limited support available to them. Although there has been a policy shift to introduce evidence-based mental health assessment and signposting for fathers, it is in the context of being a partner of a mother who has perinatal mental health difficulties. Here, there is no birthing parent, meaning that gay fathers by surrogacy fall into greater gaps with existing perinatal services. It is not surprising that in Michael’s experience we see missed opportunities for support — healthcare professionals who were not expected to routinely assess his or his husband’s mental health, and perhaps did not pursue certain lines of conversation for fear of “saying the wrong thing”. Thankfully, Michael contacted his GP and his GP took his concerns seriously, validating that he had postnatal depression and helping him to get appropriate support. It is vital that we have greater awareness that any parent may need help with their mental health at this time of enormous change and that we have services in place to provide help when it is sought. Editor's Note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him. A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view. A blog written by Joseph Straker, where he discusses his own personal experiences of postnatal depression. A blog written by Vaheshta Sethna, a lecturer in Psychiatry and Mental Health (Education) at King’s College London, where she discusses her research in relation to the topics discussed by Joseph Straker in his blog. A blog written by Jamie Cowen, where he discusses his experience of learning to live with trauma after the loss of his son during his wife’s pregnancy. Dr Kristi Sawyer’s blog which looks at the impact of perinatal loss on Fathers’ mental health. The blog written by Michael, discussed throughout this piece, where he discusses his own personal experience of surrogacy and his ‘Struggles with ‘Imposter Dad’ Syndrome’. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.

I’m Michael and I’m married to Wes. We met by complete chance in June 2012 at Birmingham Pride no less, both single and not looking for a relationship, and pretty much from our first meeting I knew I’d met someone that was going to take my life in a direction that I’d been waiting for. Four months later we were engaged and in August 2014 we married in front of all our friends and family. We’re Dads to our two children; Talulah is 5, and Duke is 2. Wes also has a 17-year-old daughter named Katie, she also lives with us in our noisy, bustling sanctuary we call home. Being a parent isn’t without its challenges, we all know that, but being a same-sex family adds another dimension, added pressure. Society was already preaching to us what family should look like. We realised that ‘those poor children need a mother’, would be something we’d hear regularly. There was a vulnerability with our family, and one that others would scrutinise. So, we had to get this right. Not let the LGBTQ+ parenting side down. More pressure. Great! We’re a little different from most families, but something we have in common was the desire to create a family, the love we hold for our children and the dreams we strive to make happen for them. We’d do anything for them, just like any other parent would do for theirs. I came out when I was 22, in the early 00’s. I had a failed heterosexual marriage behind me, and a new, authentic life ahead of me. I’ve always wanted a family. From an early age, I imagined what it would be like, to parent — to produce a mini-me. Knowing that I was gay would make this almost impossible, or so I thought. There were no role models to aspire to when I was younger, the gay men on TV were ridiculed by the media, always the punch line, forever the joke. It’s why I married my ex-wife, back in 1999. It would make the ‘gay go away’, and I could then create a family, make my parents happy and complete my dreams. Terribly selfish on reflection. Thankfully it never worked out like that, and my ex-wife and I parted amicably. Without a doubt, my coming out saved my life, but I knew the path wasn’t going to be easy — the treatment of gay men in our society was still a fractious place — but this was my time now. Ten years later I’d meet Wes, and our route to parenthood would finally begin its journey. I’m genetically linked to our daughter, and Wes is genetically linked to our son. We always wanted two children and deciding who would provide their gametes (an organism’s reproductive cells) first was an easy decision to make. There was no resentment, we’d discussed this from the beginning. The task of beginning fertility treatment and finding a surrogate (an individual who agrees to bear a child for another person or persons) commenced in 2015. From the moment we began our fertility treatment it was evident that we were having to fit into a heteronormative (where binary gender identity and heterosexuality are assumed to be the default position) pathway. The forms in the clinic weren’t inclusive, boxes had to be aggressively scribbled out, and embarrassing excuses were made as to why the forms weren’t ‘quite right’. Wes felt very much like a spare wheel. Most of the dialogue and the appointments were aimed at me, but he’s the Dad too. He’d be the one left in reception, sitting alone wondering what they were talking to me about. In fact, this is the beginning of the triggering behaviour that would follow us to the present day. A feeling of exclusion and detachment from the process of family-building, and feeling less important than the genetically connected father in our family. Fertility clinics are strange and stressful places, and the enormity of their impact on your life is overwhelming and profound. Posters of happy cis-gendered (those whose personal identity and gender is the same as their sex assigned at birth) heterosexuals everywhere. You feel grateful for even being in their presence, so challenging them over a form, seems petty. Or it did at the time. It was February 2016, we had our embryo transferred into Caroline (our surrogate) on the 13th of February. Next followed the two-week wait (2WW). On day 10, our surrogate took a pregnancy test and messaged us asking if we could speak. We were concerned as she sounded urgent. We answered the call and she simply said ‘Congratulations, you’re going to be Daddies!’ We cried, we hugged, and we cried some more. We were pregnant! The next 10 weeks flew by. Our next appointment was at our NHS Hospital — to have our scan. I remember us walking into the busy waiting room, only to be stared at and smirked at by other parents. Caroline had three men at her side, one was her husband. Her name was called, and we all got up — to be told ‘no, just the ‘real Dad’ please’. Here we go… The term ‘real’ Dad is something that cuts deep, and sadly hasn’t gone away. Strangers will also ask us ‘whose sperm did you use!’, ‘who does the Mum jobs?’ and ‘don’t you feel guilty she doesn’t have a mother?’. When Talulah was born it was magical, better than I expected but harder than I imagined! We were parents and I was a Dad now too. It wasn’t until we were pregnant with Duke that Wes pre-warned me and spoke up for the first time about what was to come. He had remained silent and dealt with the demons all alone, why? He didn’t want to let the side down. Duke was born on the 20th of August 2019, it was just as wonderful as Talulah’s birth. We made adjustments to accommodate my own fears. Wes knew potentially what was coming. I would cut the cord, I would have skin on skin contact as I had raised concerns about my own bonding, and how others viewed me. The imposter Dad. That’s exactly how I felt. The first 8 weeks of Duke’s life were dark for me, I was sleep-deprived and this was impacting my marriage. I resented Wes for being biologically related to Duke, I hated people telling me how much Duke looked like Wes, I would remind them I was his Dad too — and I’d see their puzzled face as if to say ‘we know you are!’. I was overcompensating at every opportunity, and it was chipping away at me. I felt like I was being excluded in conversations about Duke. I was the third wheel, and it almost broke me. Frequently, healthcare professionals didn’t engage for fear of saying the wrong thing. These deepened my feelings of exclusion and also meant there were missed opportunities to talk about our mental health and how we were coping. I made an appointment to speak to my GP. I had been putting this off deliberately for that fear I mentioned. I was misrepresenting my community, or so I felt. I had created a platform [Instagram] where we showcased our life and family to the world, I was blogging about it — but not all of it. I was trying to ‘usualise’ families like mine, showing the world gays have kids too, but I was too afraid to say I was struggling, and parenting is challenging. What I was experiencing was postnatal depression (a type of depression that many parents experience after having a baby) and I was supported by Wes and my GP to ensure I got the help I needed, getting counselling and medication — and knowing that I wasn’t failing. Implications Counselling (which the Human Fertilisation and Embryology Association requires couples have when considering surrogacy) is designed to tackle this, by helping to reflect on and understand the implications of treatment for individuals and any children. But no one prepared me for these experiences — and I didn’t know what I didn’t know, so how would I know? Duke is now 2 years old, and I’m in a great place. My physical and mental health is much better and whilst there are still triggers with regards to biology, I’ve learnt how to deal with them. I have a tighter network of professionals around me that are there to talk to should I need them. Parenting is a tough gig but suffering alone is much tougher. Talking and making time for me has helped me not only become a better husband, Dad and friend but also a kinder person to my own self. I’ve got this. Photo by Jason Leung on Unsplash Editor’s note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him. A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view. A blog written by Joseph Straker, mentioned throughout this piece, where he discusses his own personal experiences of postnatal depression. A blog written by Vaheshta Sethna, a lecturer in Psychiatry and Mental Health (Education) at King’s College London, where she discusses her research in relation to the topics discussed by Joseph Straker in his blog. A blog written by Jamie Cowen, where he discusses his experience of learning to live with trauma after the loss of his son during his wife’s pregnancy. Dr Kristi Sawyer’s blog which looks at the impact of perinatal loss on Fathers’ mental health. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.

“I was so anxious and couldn’t enjoy being pregnant, because I was so worried to attend every scan in case it was bad news; I couldn’t bear to think about history repeating itself and us losing another baby”. Photo source: nct.org.uk As a researcher working in the field of Perinatal Psychiatry, with mothers who have experienced mental health problems during pregnancy or postnatally (the period after childbirth), this is, unfortunately, a sentiment I have heard more than once. Therefore, it comes as no surprise to me, when reading Jamie’s powerful blog, that stillbirth (the death or loss of a baby before or during delivery), along with other types of pregnancy loss and complication, can be related to poorer mental health in parents. In my own work, these awful experiences are one of the most common reasons that women give for feeling particularly anxious or low in any subsequent pregnancies they may have, and there are studies to support this too. But, the studies I work on, along with many others in the field, including the one above, are primarily focused on the mental health of mothers, as this seems like the obvious place to start. Don’t get me wrong, we are not close to being finished with our understanding of mothers’ mental health and developing solutions that might help. However, I am not proud to say that we are still even further behind in our understanding of what the mental health impacts for fathers might be. But, reading Jamie’s story, and others’ written so eloquently and emotively in their book ‘DAD’, it is clear to all of us just how important it is to keep the mental health of fathers at the front of our minds, right there next to mothers. I would like to pause here to mention that while in this blog I will refer to ‘mothers’ and ‘fathers’, I am acutely aware that these issues extend far beyond this, and are perhaps even exacerbated in some groups who identify as ‘birthing’ and ‘non-birthing’ parents in the broader sense, to include parents of other gender identity and sexual orientation groups. Nevertheless, the notion that we should be focusing on paternal mental health is nothing new — a study from 1995 reported that paternal anxiety and depression were still high when measured two months after a pregnancy or neonatal loss. Even in 2006, researchers conducted a review of papers published from 1966–2005 about the psychological effects of stillbirth and neonatal death on fathers. This paper found just 17 studies that were suitable to include, and the authors concluded that more good quality research is needed. Importantly, though, it also stated that “the social role of fathers as carers for their partners needs recognition when planning care for bereaved families”. So why, like Jamie, are so many fathers left out of psychological support provisions after the loss of a pregnancy or newborn? Some of the reasons include things that have already been spoken about by Jamie, and by Elliott Rae in an earlier blog where he is interviewed by Professor Carmine Pariante, the Editor in Chief at InSPIre the Mind. The lived experience stories of these fathers are telling us the same as the scientific literature: “in comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs.” Photo by Pixabay on Pexels Another summary of studies reported that men were typically more hesitant to disclose their feelings and had increased use of avoidance and distraction techniques, such as throwing themselves into their work to avoid thinking about painful experiences. While this may work for many people, it is possible that this outward appearance of being able to work effectively might lead to the false assumption that the person requires less emotional support. Men may also turn to other coping and self-support mechanisms, such as heavier alcohol consumption. You might be surprised to read that men score higher on some grief scales than women following perinatal loss, but they are less likely to score highly in terms of “active grief”, that is, overtly showing sadness and crying. It is often these overt sadness behaviours that elicit support from others, so this may be another reason why women are typically offered more support following a loss. When asked to describe their experiences, many of these men reported that they felt “overlooked, alienated and marginalised” in comparison to their female partners. All of the results of these studies point to a need for increased accessibility of support services for men (in fact, the whole family) following pregnancy or neonatal loss. Importantly, not only should men talk about their feelings for their own benefit, but studies show that if fathers are unwilling to talk to their partners following a stillbirth, then the mothers are 5 times more likely to develop depression. Although this study was conducted to investigate the effect of fathers talking on the mental health of mothers, it is likely that the same is true in reverse, so support to get couples talking together could be incredibly beneficial. If these services were more widely available and open to fathers, perhaps men would feel more validated in their feelings of grief. Instead, during the height of the COVID-19 pandemic, things were made worse for fathers, as they were not even able to be by the side of their partners when they received such devastating news. Countless stories have been told of men sitting in the car parks while their partners are being told that there’s a pregnancy complication, or that they cannot find a heartbeat. Unfortunately, the pandemic seems to have widened the gap between the medical care the mother (or birthing parent) receives, while the co-parent is left outside, feeling like a secondary parent. Photo by Josh Willink on Pexels If you ask most people, they’d probably tell you that mental health problems during the perinatal period are far less common in men than women — but is that true, or are we just not asking them the right questions? In fact, a recent review of studies estimated that rates of paternal depression are about 8.4%, which isn’t too far from the estimated rates of 17% in pregnancy and 13% postnatally for women. During pregnancy, all medical care is focused on the mother. Only recently has it become best practice that all women are asked about their mental health during antenatal appointments. This is one of the main ways that we are learning more about the mental health needs of mothers during the perinatal period. Why are we still not asking men or co-parents how they are feeling too? Even without the need for medical care themselves, fathers are still going through the same psychological transition processes as mothers, as they prepare to become a parent or add another child to their family. The perinatal period is a time of huge upheaval for the whole family, not just the mother. More needs to be done to ensure that men don’t just feel like a support system for the mother, but feel valued as individuals with their own needs. Only then will men feel like they “deserve” (to use Jamie’s word) the same psychological care, particularly when pregnancy goes wrong. After all, we know how important social support can be for preventing anxiety and depression in parents experiencing a pregnancy loss. As I sit here, writing this blog during ‘Baby Loss Awareness Week’ (9th-15th October), I am struck, as I am every year, by the number of stories that people in my network post on social media, sharing their pain as they remember their lost babies. More than ever, we are getting better at speaking about these painful experiences, rather than just the joy of when pregnancies go right. As Jamie has said, the healing power of talking and sharing stories cannot be underestimated. Let’s just always remember to ask Dads how they are doing too. Editor's Note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him. A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view. A blog written by Joseph Straker, mentioned throughout this piece, where he discusses his own personal experiences of postnatal depression. A blog written by Vaheshta Sethna, a lecturer in Psychiatry and Mental Health (Education) at King’s College London, where she discusses her research in relation to the topics discussed by Joseph Straker in his blog. The blog written by Jamie, mentioned throughout this blog, where he discusses his experience of learning to live with trauma after the loss of his son during his wife’s pregnancy. Yesterday’s blog, discussed throughout this blog, written by Jamie Cowen where Jamie discusses his own personal experience of perinatal loss. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.

Learning to live with trauma Photo taken by Jamie Cowen, in his Mother-in-Law’s garden where he and his wife stayed for a while after the loss of their son Hi. I’m Jamie. At the time of writing this, I’m 43 years old, living in north London with Kath, my wife, and our two kids Jacob, nearly 12, and Ella, 8. I work in book publishing, enjoy reading, playing music, a good game of footie and a natter down the pub. So far, so unremarkable. Another unremarkable thing, given that it’s so frighteningly common (one baby in every 200–250 births, depending on who you ask), is that our first son, Sam, was stillborn at 7 months. The cause of his death was primarily a defective heart, but we also discovered via an autopsy that he had Down Syndrome — the two were possibly linked, but either way, he was just too poorly to make it. Discovering that Sam had died was, by a distance, the most traumatic thing that has ever happened to me. I remember bits of that first hospital visit: the nurse trying for what felt like an eternity to find a heartbeat, the consultant called in to confirm and then deliver the bad news, but it’s really all a blur. I think that blurriness is intentional on the part of my subconscious (about which I have passively learned a great deal since Sam’s death): the way I see it is that my mind was, and still is, protecting me against re-living that experience, and the appalling shock that accompanied it, over and over in my memory. Conversely, I’ve found that memories of that time have tended to come back to me more clearly when I’m feeling stronger and happier; my reading of this is that my subconscious is judging me somehow as being in a good place to process some of those memories and feelings. I have no idea if this guesswork has any basis in fact, but I do find it comforting to feel like my brain is at least partly on my side. The immediate aftermath of Sam’s death was all procedural and medical, and was — rightly — completely focussed on Kath. She was induced and went into labour a couple of days after we were told that he had died. This collection of hours was, in many ways, worse than the shock of the discovery — an awful, inevitable and horribly slow march towards our dead son’s birth. More trauma, in other words, but of a more insidious kind. What followed Sam’s birth was the process of attempting to restart our lives after this roundly horrific experience. “One of the best things I ever did was come out and speak about it, because with communication you can get over any hurdle. But keeping it all to yourself and not communicating with others, you’re a bottle of champagne being shaken and shaken, waiting for the top to explode.” I read this quote, by the heavyweight boxer Tyson Fury, in an interview about his well-publicised struggle with mental well-being in the paper this morning (at time of writing). It’s not every day that someone who has made a career out of being punched in the head sums up your entire life of mental health in the most succinct, articulate manner possible, but apparently, today is that day. This quote is particularly relevant to me, and my own mental health, because I quickly realised after Sam’s death that my previous method of coping with difficult times in my life (namely bottling everything up and hoping for the best) was absolutely not going to work here. The grief I was going through was so enormous that there was no way I could keep it in. So, I chose to talk about it. Any time someone asked me how I was, I would tell them. Not in a gushing, oversharing kind of way, but as honestly as I could. OK, OK, I see that raised eyebrow. I probably did gush, and I probably did overshare. But I viewed that inevitable collateral damage as being frankly worth it, in the grand scheme of things. Photo by Pixabay on Pexels What I discovered was that, in the majority of cases, people would respond with love, care and — to my surprise — stories of their own. Many of these stories would be about their own experiences of stillbirth, miscarriage or similarly traumatic experiences, and this process of mutual sharing did something extraordinary for me: it helped take away the feeling that we were somehow out on our own as statistical weirdos and medical freaks. It’s worth pointing out at this stage that I wasn’t, at any stage, offered any professional help to deal with the psychological impact of Sam’s death. I don’t begrudge this of the NHS whose staff were — almost without exception — utterly astonishing in the care that they showed to Kath and I. It is also true that I could have sought this help myself privately or otherwise, but not having had any prior experience of therapy or counselling I wasn’t really aware of how to go about this, or even whether I really needed or deserved it. Photo taken by Jamie Cowen, in his Mother-in-Law’s garden where he and his wife stayed for a while after the loss of their son The truth is that I have learned to live with the trauma of Sam’s death (one metaphor I have found helpful to visualise is a tree’s roots growing around a rock), and the realisation that I had to talk about it was hugely beneficial to me then and has continued to help me in my life since. But I came to that realisation largely on my own, with the help and love of family, friends and colleagues. Inevitably, there will be many more people attempting to live with similar trauma who don’t come to this realisation for themselves, or maybe find that this approach doesn’t help them as it did me. And for those people, professional help is crucial. So yes, I was, and continue to be, very lucky. I’m in a job I love, with a wonderful wife and family, and two fantastic, healthy kids. My mental health is… well, not too bad really. But saying I’ve been lucky is really just another way of saying I rolled a metaphorical dice and it came up a six. I don’t like to think about what would have happened if it had been a one. Editor’s note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him. A blog written by Clinical Psychologist, Dr Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view. The blog written by Joseph Straker, mentioned throughout this piece, where he discusses his own personal experiences of postnatal depression. The blog written by Dr Vaheshta Sethna, a lecturer in Psychiatry & Mental Health Education at King’s College London, where she explores the research looking at postnatal depression in men in response to Joseph’s blog. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.

Mental Health of Women and Children in conflict zones: Their Bodies and Health are the Battlefields of War. Over the last two months, the world watched in horror and despair, as the Taliban toppled the Afghanistan government. After 20 years of the USA and its allies’ invasion of Afghanistan following the 9/11 terrorist attack in the USA at New York’s World Trade Center, the Pentagon, and in Pennsylvania; what was once called “the beginning of an era for Afghan women’s rights” is now being eradicated by seconds. I am a Core Trainee Psychiatrist working in Cornwall. I am part of the executive committee for the Royal College of Psychiatrists’ Women’s Mental Health Special Interests Group. I am a passionate advocate of gender equality and women’s rights. I have written articles, such as the need for women leadership in the UN, and how COVID-19 unmasked the ongoing pandemic of gender-based violence. The plight of Afghan women losing their human rights continues, amidst grave fears for their safety and staying alive. We should not “normalise” victimisation of women in war conflicts, which is continuing elsewhere in the globe but remains overlooked in the upstream media. From 15th August this year, the Taliban takeover meant that Afghan women’s rights to freedom and choices were overturned by the misogynists’ hatred of women in religion. Whilst I was listening to BBC’s Woman’s Hour, Lynne O’Donnell (a journalist who was in Kabul, until 15th August 2021) had escaped from Kabul to save her life. She fears for the women’s and girls’ education, safety, and lives, as well as highlighted the removal of Afghan women’s free choices. On the fact that the Taliban are forcing women to wear hijabs and burqas under the cover of Islam, Lynne said “to force Afghan women to wear hijabs and burqas, it removes the women’s free choice on how to connect oneself to God”. Women are removed from workplaces or forbidden to go outside without a male chaperone. Billboards and photographs featuring women are being painted over, as well as the windows of hairdressing salons and fashion retailers. Girls are no longer allowed to attend secondary school, hence fears of early child marriages to Taliban soldiers. On the 20th anniversary of the 9/11 attacks, the Taliban announced that women will only be allowed to study at universities in gender-segregated classrooms taught by female teachers, and Islamic dress will be compulsory. With the limited availability of female teachers and facilities to offer such gender apartheid under the new regime, women’s education will be limited. Despite promises of the new Taliban regime being “inclusive” and “respective of women’s and girls’ rights within the Islamic network” — not a single woman remains in the new Afghanistan’s cabinet and women have been banned from sports. Taliban spokesman Sayed Zekrullah Hashimi said that the role of women was “to give birth and raise children….not necessary that women be in the cabinet”. The empty promises by the Taliban that claim that “women and children” would be the center of their policymaking under their new regime, fall short by the lack of application and overlooking in international institutions. This highlights the double standards and dichotomy for an authoritarian misogyny ruling. In 2010, Hilary Clinton said that “the subjugation of women….is a threat to the common security of our world”. She is right; societies that oppress women are more likely to be violent and unstable. Boko Haram and ISIS promise their recruiters “wives” as rewards for war. The “wives” are the school-aged girls or women of a young family, whose husbands and sons have been massacred in front of them. The women and girls are violently raped by multiple war soldiers, enduring severe physical and emotional trauma. However, the war on women doesn’t end there. Rape and female-based violence are the cheapest forms of war weapons that man can use because the post-war period subsequently leads to these women being left in derelict conditions. Nobody wants to recognize them, and nobody wants to marry them. These women are ostracised from the communities, living in tents and camps amidst stenches of blocked latrines, with a lack of food and water. Nevertheless, this perpetuating failure to protect women and children (especially young girls) in peace talks is nothing new and hasn’t changed over the years. In Northeastern Syria, where a battle is fought between the Kurdish- led Syrian Democratic Forces (SDF) and the Turkish invaders, a desolate camp called al- Hol accommodated 70,000 women and children as “families of ISIS suspects”. Reportedly those sons over the age of 12 were snatched by SDF guards during the nights, the medical clinic was shut for days, and overflowing latrines with scarce amounts of food and water. According to the International Rescue Committee, between December 2018 and September 2019, nearly 340 children have died in the al-Hol camp — most from severe diarrhea or malnutrition, which could have been treated. The Rome Statute of the International Criminal Court states, under Article 7, that Crimes Against Humanity describe any acts when committed as part of a widespread attack directed against any civilian population, including “Rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or any other form of sexual violence of comparable gravity”. Yet despite this, these criminalizing acts and abuse are being permitted to continue, and the enforcers are protected with impunity. Women and children play the largest role in society, yet during the war and armed conflicts, they are the lowest echelons in society. As community infrastructure, such as health education and other social services sectors, are destroyed, women and children are exploited to all types of abuse and are the most affected by traumatic events. The ostracisation and the disintegration of these victims lead to forced migration and asylum. Many women endure assaults and sexual violence by rival groups or working guards. Following collapses of facilities and health centers, the deplorable negative impact of war affects the mental and physical wellbeing of these victims. As a result, STDs (Sexual Transmitted Diseases), physical trauma to the female genitalia, unwanted pregnancies, and psychological abuse and trauma are left untreated. Furthermore, the psychological responses to the shock of war and conflict significantly impact the children, including nightmares, physical symptoms (i.e., stomach aches), selective mutism, difficult concentration, and hyper-vigilance. The lack of counseling support and security prevents women and children to overcome the inhumane psycho-social and physical pain. The continuing circular of motion includes war, lack of security and continuous exposure of violence against women (both direct and indirectly). When the women and children are continuously being failed by their own government officials’ protection, the whole nation fails, subsequently leading to a never-ending break from this cycle of armed conflicts and civilians suffering. For this cycle to be broken, it requires collective global responses from world leaders. The CAPE Vulnerability Index identifies a number of fragile states where the experiences of women and children are similar to those described here. Global decision-makers, for example, United Nations, G20, and local regional state holders, should consider the interests of half the population, including having more women who advocate for women’s rights and gender equality, at the table of peace talks. Between 1992 and 2019, only 13% of negotiators and 6% of signatories of peace deals were female. If we have any hope to understand the world and end this war against displaced women and children (at the end of 2020, 82.4 million people were forcibly displaced worldwide; approximately 50% represent women and girls), the global decision-makers need to place the women and children as 1st priority in correlations to their major role in serving their country’s economic, agricultural, security and healthcare stability. Photo by Ehimetalor Akhere Unuabona on Unsplash

We Can All Learn From Each Other: How opening the doors for exchange can benefit us working in Arts and Health A few weeks ago, I attended the Arts & Health collaborative workshop at the Southbank Centre in London. As an academic health researcher in the field of community arts intervention and mental health, I was hoping to make new connections and learn from fellow health researchers in the field. Oh boy, I was wrong — I was a fish out of water in a room full of artists; but it was so much more interesting this way! The Arts & Health Hub is an artist-led not-for-profit organisation that works with artists, health and care professionals working in the field of arts and health. They offer much-needed peer support, commissioning, offer events and continuously support an online community. Shortly before the start time of the workshop, dozens of artists started flooding the room — yes, you could tell they were artists by their joyfulness and un-awkwardness that tells them apart from us scientists. Enough with the stereotypes Carolina! The workshop was led by two artists and members of The Hub, Daniel Regan and Eve Loren and started with a group agreement co-created with us participants ahead of any sharing activities. The audience suggestions included: “be mindful”, “respect”, “ask questions,” written out on a flipchart. Professor Carmine Pariante and Dr Lynn Lu then showcased their collaborative work, where research, health and art merged into two projects. The first project, “The hand that rocks the cradle”, was a participatory performance touching on postnatal depression and “love-bombing”. Participants wrote thoughts and feelings never voiced before and sealed them in envelopes, that were then burnt. Participants were then “cradled” on a hammock — as if in their mothers’ wombs whilst listening to a binaural soundscape created from a conversation between Dr Lynn and Prof Pariante. If you want to know more, you can read the blog on “Seven Things Lynn Did Not Know About Pregnancy, the Postpartum, and Why She Became Depressed” that resulted from the conversations that Lynn and Carmine had about her lived experience of postnatal depression. Remarkable stuff, right? The second, “BLOOD: Life Uncut,” is an award-winning installation and participatory performance, focusing on depression, blood inflammation and “regret”. Participants’ blood (only a drop or so!) was donated to the project in exchange for a sip of anti-inflammatory beetroot juice; their regrets were transcribed into paper, using red ink and pinned to the wall, where a sound installation was playing recordings of “regrets”. The installation was inspired by Carmine’s research on blood inflammation in depressed patients and two other fascinating pieces of research: how transfusions of blood from young mice to older mice reversed ageing and how a protein in beetroot could be used as a substitute in human blood transfusions. We were then asked to reflect on challenges in working in the intersection of arts and health and discuss how to overcome these. The overarching, shared issue appeared to be funding for the arts, especially when the projects are not directly linked to medical research. Another issue that was brought up was the dismissal of scalability and continuity of projects, as most are limited to small pilots. When it comes to research, the focus is on rigid quantitative data (a research strategy that focuses on quantifying the data using scales and scores); another artist on my table commented, when the arts lend themselves to a wealth of qualitative data (data collected using questionnaires, interviews, or observations and is very descriptive) and personal accounts of the experience of being an artist or a participant. One point that was made by an artist and researcher was that this field is not ready for hybrid people like her, not affiliated with a higher education institution, but producing valuable bodies of research. Funnily, as I heard people share, I was reminded how the incredible programme that I work in, SHAPER, the world’s largest programme on arts and health, that addresses scalability, artist co-creation and provides a stable source of funding for over 36 months for three arts organisations. The final activity was prompted by the quote “We are only as needy as our unmet needs” by John Bowlby, the father of attachment theory. Here we reflected on which needs need to be met for our collaborations to flourish. This was an activity to be done solo and as I enquired about my own needs, I immediately thought that I needed a mentor in the arts with experience working within the academia-arts interface. Luckily for me, I can think of two extraordinary people I work with in SHAPER that could be my mentors if I were to ask them, Dr Tony Woods and Nikki Crane. The workshop ended with an insightful talk and tour around the Art by Post exhibition, a creative community art project involving thousands of participants in the UK, facilitated by the Southbank Centre. I’ll leave you, reader, with the words of Daniel Regan, Director of Arts & Health Hub: “It was an absolute pleasure to bring together so many people from across the arts and health sectors to think together about the challenges and solutions of collaboratively working. It was great to see so many familiar and new faces, those that are already working in the field and those just starting out, offering support and advice to one another. A huge thank you to our fantastic facilitator Eve Loren and to artist Lynn Lu and psychiatrist Carmine Pariante for their motivating discussion of how powerful collaborations can be. We’re looking forward to working with the Southbank Centre in future for our artist peer groups — facilitating spaces to highlight the important and valuable work that artists bring to arts and health”. Find out more about how you can get involved with the Arts & Health Hub here.

Barriers to NHS Healthcare Faced by Transgender and Non-Binary Patients: The example of cervical screening I am an academic foundation trainee doctor in London, with a keen interest in Obstetrics and Gynaecology, and I am passionate about the care transgender and non-binary individuals receive from obstetric and gynaecology services in the UK. Over the past year, I have been working with a paediatrician, Dr Rebecca Trenear, who has developed trust-wide guidelines for the care of transgender and non-binary clients accessing obstetric and neonatal care services. Together we have been implementing the guidelines and have created a teaching programme for all staff. Our aim is to ensure transgender and non-binary patients can access excellent quality healthcare in a safe and secure environment, free from discrimination. It has been incredibly eye-opening to me how underserved transgender and non-binary individuals are in all healthcare settings throughout the UK. Most allied health professionals receive little or no teaching on specific issues transgender and non-binary patients experience, and are subsequently not aware of how difficult it can be for these patients to access and use NHS services. Furthermore, whilst many healthcare professionals aim to be inclusive, many transgender and non-binary patients report being misgendered and verbally abused whilst using healthcare services. Stonewall, a charity that advocates for improving the lives of LGBTQ+ people throughout the UK, found that 14% of LGBT people and 37% of trans people have avoided accessing healthcare services for fear of discrimination. Clearly, attitudes and practices need to change, so that transgender and non-binary clients can be assured they will be treated with respect and compassion when accessing services. Cervical screening: An important example Cervical screening is a key area where there are discrepancies between the care cisgender and transgender or non-binary patients receive. The cervix is the lowest part of the womb, providing a connection between the main body of the womb and the vagina. The purpose of the cervical screening programme is to detect high-risk strains of human papillomavirus (HPV) in the cervical cells. HPV is a virus that can be spread through both skin-to-skin contact and anal, oral or vaginal sex. Certain types of HPV can cause abnormal changes to the cells of the cervix, which can eventually lead to cancer. Most people who are identified as having HPV will not go on to develop cervical cancer, but early detection allows more comprehensive follow up to be started, so that, if any changes consistent with cancer occur, treatment can be started earlier. The national cervical screening programme is designed to screen all people with cervixes for cervical cancer every 3 years between the ages of 25 and 49, and every 5 years between the ages of 50 and 64. Besides cisgender women, this would include transgender men and non-binary people who have not undergone a total hysterectomy to remove their cervix. Patients whose gender is recorded as ‘female’ on their GP records are automatically invited for screening before their 25th birthday. The screening process is usually performed by a specially trained nurse, and all patients should be offered a chaperone. A speculum is inserted into the vagina, and cells are taken from the cervix using a brush. The sample is then sent to a lab to test for HPV. Patients will usually receive a copy of their results within 6 weeks, with details of any next steps required. Difficulties Faced by Transgender and Non-Binary Patients Seeking Cervical Screening The NHS recommends all transgender men and non-binary people with cervixes should be screened for cervical cancer as per the cervical screening programme guidelines. Despite this, transgender men and non-binary people who are registered with their GP as males will need to request regular screening appointments, as their information is not stored within the national cervical screening database. The converse is true also — transgender women who are registered as female on their GP records will be called for cervical screening, despite not requiring the service. This presents the first issue to cervical smear testing — that the onus is put on transgender and non-binary patients to identify themselves in order to receive invites that cisgender women would receive automatically. This requires patients to be informed about the cervical screening programme, how often the screening needs to be performed, and the fact they are not automatically included in the database. Studies have demonstrated that, whilst patients are aware of the importance of cervical cancer screening, screening reminders in the form of letters or text messages are associated with significant increases in screening rates. Not providing this service to transgender and non-binary patients is likely to reduce engagement with the programme, and potentially put them at risk of late detection of cervical cancer. Having to directly ask for cervical screening could also cause gender dysphoria to surface. Gender dysphoria is defined by the NHS as a sense of unease a person may experience because of a mismatch between their biological sex and their gender identity. This may be more prevalent with cervical screening than other areas of healthcare, as the very nature of cervical screening may cause transgender and non-binary people to be more aware of their genitalia, which may not align with their gender identity. Automatically being referred for cervical screening may decrease some feelings of dysmorphia and anxiety, making transgender and non-binary patients more likely to attend screening. Some transgender men and non-binary people have also reported being told by healthcare professionals they do not require cervical screening before they could explain they had a cervix and required the service. The resulting conversation could be difficult for patients to navigate, and in cases could damage the rapport between the practitioner and the patient. Once again, teaching on transgender and non-binary issues for healthcare professionals would emphasise that it is possible for men and non-binary people to require cervical screening and that they should explain to patients that cervical screening is recommended for all patients with a cervix between 25 and 64 years of age. Transgender and Non-Binary Patients’ Experiences of Cervical Screening Whilst the process of cervical screening should not be painful, many patients report they find the experience uncomfortable and embarrassing. A British study demonstrated that 70–80% of eligible cisgender women underwent cervical screening, compared to 58% of eligible transgender or non-binary patients. Many transgender and non-binary patients reported they were uncomfortable having healthcare workers they did not know examining their genitalia, and others reported feeling the experience was traumatizing and caused gender dysphoria. The NHS and Jo’s Trust websites provide advice on how to make cervical cancer screening more comfortable for all patients. They recommend trying to schedule a pre-examination appointment with the healthcare professional who is scheduled to perform the screening test, and bringing a trusted person to the appointment, who can provide support. Whilst these steps may be helpful for some individuals, unfortunately, due to COVID restrictions there are limitations on the number of face-to-face appointments which can be offered, and most clinical spaces cannot accommodate support people due to social distancing requirements. One option which could increase screening uptake is to provide at-home cervical screening kits. These were distributed in some areas of London during the second wave of the coronavirus pandemic, where face-to-face appointments were strictly regulated. Self-administered tests allow clients to have more control whilst the screening is occurring, and as clients can perform them in the comfort and security of their own home they have greater flexibility of when they carry out the test, who is with them and the environment they are in. Studies have demonstrated that 99% of people are able to perform a self-swab effectively, and therefore this presents a safe alternative for transgender and non-binary clients who do not want to attend in person cervical screenings. Conclusion Ultimately, cervical screening is opt-out, and individuals should feel empowered to opt-out if they believe the cons of the screening outweigh the pros. However, if we can ensure that transgender and non-binary clients are treated with respect and courtesy, and measures can be implemented which make the screening process less uncomfortable and less likely to induce feelings of gender dysphoria, hopefully, uptake of cervical screening among transgender men and non-binary people will increase, and subsequently, rates of cervical cancer in this population will continue to decrease. Steps such as including transgender men and non-binary people with cervixes in the national screening database, and giving people the option of at-home testing, may also contribute to higher levels of engagement with the cervical screening programme. It is also important to acknowledge that cervical screening is not the only area in which transgender and non-binary patients may receive poorer care compared to cisgender patients. Teaching on the role of gender, language and inclusivity in healthcare is required moving forward, to ensure healthcare professionals are providing a high standard of healthcare to all patient population groups. Useful information Jo’s Trust — Cervical screening for trans men and/or non-binary people NHS — What is cervical screening? Stonewall — LGBT in Britain — Trans Report Header Image source: La Porte Country Public Library

‘With the elation came a significant adjustment to the novel, demanding and various roles that accompanied the arrival of Olive’. In Joe’s blog published yesterday, he shares his experience of becoming a new dad. Photo by Cottonbro on Pexels I am a Lecturer in Psychiatry and Mental Health (Education) at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London (KCL). My academic career in the early life course, involves looking at the interconnections between biology, psychology, and socio-environmental processes linking perinatal mental health to children’s development. In particular, my research focuses on the role of fathers (their influence on maternal health and child outcomes) in the early parenting environment. A Major Life-Altering Moment for Men During the period of transition to fatherhood, many new dads may engage in self-reflection to positively modify their own health behaviours — often triggered by a feeling of intense responsibility, and the identification of being a role model for their baby. While some fathers adjust to their new role, it is increasingly common for others to find it difficult to cope with the demands of family and work life. This may leave some first-time dads feeling overwhelmed and particularly vulnerable to mental health difficulties. Joe recalls experiencing periods of low mood and anxiety symptoms since he was a teenager; his partner's pregnancy and the arrival of their baby (a stressful life event) triggered a relapse of his symptoms. Research has shown that in the postnatal period, depression rates are double that of the general population of men. Studies that consider the mental health of fathers report that when one parent experiences emotional difficulties their partner may also struggle with mental health problems. Low mood experienced by fathers in the first six months after birth, may have an influence on their partner's emotional well-being. Thus, placing their child’s health at risk. Hence, shouldn’t fathers be included in perinatal health? Joe emphasises, that generally when fathers are in good health, they can provide the necessary support mothers may need, and positively influence their child’s healthy development. Indeed, evidence supports this idea — for instance, emotional support from fathers helps mother’s to cope with their fatigue and childcare tasks, bond with their babies, in turn promoting their child’s wellbeing. Furthermore, fathers independently promote their children’s development in early life. Paternal sensitivity (the ability of the father to correctly interpret and respond appropriately to their infant or child’s signals) and engagement as early as 3-months influences children’s cognitive skills. Yet, some men may have trouble admitting that they feel depressed even to themselves, and society expects men to ‘man up’ during this period of increased emotional and financial burden. Justifiably, the focus and development of services is on the mother and new baby, and traditionally the mental health of fathers in the perinatal period has received less attention. But is manning up really a part of the answer? Our discussion turns to 2006. A developing interest in the role of the family in early child development, set me on a three-year journey to learn more about postnatal depression in fathers. During this time, there were various instances when I was asked what my PhD research involved — and often my enthusiastic response was promptly tweaked, ‘So, do you mean postnatal depression in mothers’? Paternal Postnatal Depression: It’s real! Since then, updated meta-analytic evidence (obtained by merging the findings from 74 independent studies) has indicated that approximately 8 out of every 100 fathers globally, experience depression during pregnancy and until 12 months after birth. The prevalence of paternal postnatal depression (PPND) being much higher — between 24% and 50% — in men whose partners suffer from postnatal depression. Like mothers, depressive symptoms occur from the start of pregnancy in fathers and can continue to two years after childbirth. Thus, PPND justifies early (pre-conception, i.e., before pregnancy) detection and appropriate support efforts. Notably, there are no official criteria to make a diagnosis of PPND. Mental health conditions are diagnosed using a guide. One such guide is the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition) also known as DSM-5. Maternal postnatal depression is diagnosed using DSM-5 (covering depressive episodes occurring during pregnancy, as well as in the four weeks following delivery). Fathers also tend to show symptoms such as anger attacks and an increase in alcohol use and video gaming, not often recognised in the diagnosis of maternal postnatal depression. Others may escape from the family, overworking or indulging in excessive sport. Hence, a diagnosis should include a broader range of symptoms beyond those covered by the criteria used for mothers. Photo by Lucie Liz on Pexels Screening tools (short questionnaires) can be used to support the diagnosis. So far, the most widely used self-report questionnaire in fathers is the Edinburgh Postnatal Depression Scale (EPDS). This scale was originally developed for mothers and screens for depression and anxiety symptoms. Since men are less expressive about their feelings than women, they would likely score lower on depressive and anxious symptoms — yet experience the same level of distress as mothers. Another more recent tool is the Perinatal Assessment of Paternal Affectivity (PAPA), which does consider some of the additional symptoms’ fathers may experience. The consideration of stress (which is a risk factor for PPND), has also been utilised. More work is needed in this area to identify a suitable screening tool for fathers. Photo by Josh Willink on Pexels Factors associated with PPND seem to be the same as those reported for mothers. A history of mental health difficulties (and specifically depression), coupled with a difficult childhood environment, may leave fathers vulnerable to depression in pregnancy and after the birth of their child. Maternal depression has consistently been found to be the most important risk factor for depression in fathers during pregnancy and in the postnatal period. Couple conflict, lack of social support, high levels of stress in pregnancy, an unexpected pregnancy, and complications during pregnancy and birth, have also been linked with PPND. It is common for some of these risks to co-exist. At this stage in our conversation, Joe and I recognise the many challenges to help-seeking by fathers. On the personal level, some new fathers may experience stigma and self-blame, reduced awareness of their own symptoms and perceptions of mental health. Likewise, the availability of resources for fathers and family members, and communication with health professionals, potential challenges. High on the agenda, concerns about compromising the support available to women and the consequences of disclosing mental health problems. I reflect on similar challenges reported by health professionals and services from our recent research study — ‘at the practitioner level (e.g., knowledge, skills, confidence, attitude and scope of practice, fear of causing offence) and at the service level (e.g., lack of onwards referral options, resources/workload issues (time pressures), and tools being unavailable in different languages)’. A defining moment: Including fathers in the perinatal mental health agenda Yet, Joe and I agree that this is a time of significant progress and insight for all involved. Partnerships across parents/wider family members, academics, perinatal health professionals, voluntary/third sector, and peer support organisations, have helped in our understanding of PPND. Notably, mothers and fathers have played a significant role in this effort — sharing their own experiences, providing a safe space for speaking, and campaigning tirelessly not only for the awareness of PPND but for assessment recognition and support for fathers. This is also very much a global effort. Currently, several services and organisations in England are engaged in tremendous work to support fathers with their own mental health, family relationships, their role in supporting mothers and their family, as they transition to parenthood. Some examples are available in a good practice guide, which was developed for commissioners and colleagues working to support women and their infants in specialist perinatal mental health services. Photo by Josh Willink on Pexels Our collective efforts are gradually translating to a change in policy. For instance, the National Health Service’s (NHS) long term plan aims to involve and support fathers and partners of women accessing services. They will be provided with an assessment for their own mental health and signposted to relevant support. Another example comes from Sweden where the shared parental leave reform will enable the involvement of fathers in childcare. There is yet a long way to go. But as we conclude our conversation, it is very clear that the health and happiness of mothers, babies, and families, depends on the wellbeing of fathers. It is about time they are included in the perinatal agenda. Editor's Note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him. A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view. The blog written by Joseph Straker, mentioned throughout this piece, where he discusses his own personal experiences of postnatal depression. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.

Becoming a Father during lock-down and Postnatal Depression Photo by Juan Pablo on Pexels Ever since around 17-years of age I’ve suffered from some form of mental health issue at various stages of becoming a man, mainly anxiety, which I am certain was linked to quite a troubled upbringing in the North East of England. An aggressive, adulterating father, who worked away most of the time, resulted in my parents divorcing when I was 7. My brother and I were then brought up singlehandedly by a soon-to-become-alcoholic mother. We had no one, apart from our grandparents, who we saw once a month. A blistering career in aviation commenced in my early 20s and, against all the odds of my upbringing, I have a job and income that I should be immensely proud of, although I am often met with my own thoughts of “imposter syndrome”, which comes and goes as much as confidence ebbs and flows. I’m 34 now and over the years my anxiety has also come and gone in its various forms, often self-medicated with alcohol, learned from those around me in my youth as a coping mechanism. I remember being in my 20s and trying to get to the bottom of this monkey on my shoulder, which could distribute the most intense panic attacks at any moment. It was a real stigma back then in the so-called “noughties” and I would have been hugely embarrassed for any of my friends to find out I was suffering. Photo by Andrew Neel on Pexels However, I always thought at various stages of my life that my mental health issues would be cured by a big change — getting on the career ladder, meeting the girl I loved, buying our first house, and most recently, having a baby. On each occasion, I have applied immense pressure to ensure each event is life-changing, but each time the pleasure has been short-lived and replaced with feelings of not deserving the good things in life. Anyway, in February 2020 I was excited to find out my partner was pregnant, although was immediately anxious for what lay ahead, knowing my life would never be the same again. Within 2 weeks we were on holiday in Vienna and we had the time of our lives, enjoying each other’s company and talking about our future with a new human. I spent my birthday in Vienna and this was also the day the world changed completely. Covid-19 had become very real for Europe and we were informed by the airline that we must return on an earlier flight. Not a great one for dealing with worldwide disasters, my anxiety was increasing by the day as we were told by the government what was to come. The pandemic resulted in redundancies at the airline I work for, which fortunately didn’t include me, although everyone would have to accept a salary cut for the foreseeable future. Prams and cots were out of the picture for a while! This all sent me into a bit of a mental health black hole and by the end of March, I was drinking quite heavily to try and cope with everything that was going on, including knowing our baby was coming into this new, crazy world. I stopped for a long time after this, although the remainder of the pregnancy was a struggle for both of us, as I was not allowed into any of the baby scans, which was very upsetting for my partner and I. My partner went into labour in early October 2020 and on the 6th of the month, I took her to the Royal Derby Hospital to be assessed. Again, I wasn’t allowed into the Hospital. This was it, though! This was my baby being born! And I wasn’t even allowed in the building! I was sent home until the baby was really close and after about 1 hour’s sleep, at 1 am, I received a phone call from my partner to come to the hospital ASAP. After an unsuccessful water birth attempt, we were taken into an adjacent room where stirrups (a device used to hold up the legs) were successfully applied and Olive was born just after 6 am on 7th October 2020. Half an hour later my partner became very pale and unwell and, after realising she was losing a lot of blood, the Midwife called for the Emergency Response Team and within less than one minute around twelve doctors and nurses charged into the room and applied some form of an emergency operation to prevent further blood loss. I remember when it had all calmed down that I was overcome with emotion and went out of the room to call my mother in tears. In all the emotion I had pulled my mask down and was quickly approached by the receptionist to pull my mask back up. Covid-19 never escaped even the most emotional of moments. Three days in the hospital for my partner and a new baby followed while they were both monitored, and I was allocated a one-hour slot per day to visit. Getting them home was a relief, but within days the feelings of elation were being replaced with feelings of my life being over, being trapped because now I have a dependent child, worrying about how I can support this person for the rest of my life. What if I don’t love her? What if she doesn’t love me? Coupled with concerns about the pandemic, these were overlaid with thoughts about my own mortality. When will I die? What my partner and I soon also realised is that we had very different ideas of how we will bring this baby up. Nearly a year later we still do, she insists on constantly holding the baby and won’t even put her in the cot, which is very frustrating for me but I feel like I don’t have any say in the matter being the Dad. Photo by cottonbro from Pexels The intimacy in our relationship immediately ceased after having a baby, which is understandable for many reasons, but it has yet to return a year later. I am not ashamed to say this but after having Olive my mental health dropped to the lowest it had been for many years and all of a sudden it wasn’t just anxiety about work deadlines or a social situation I was unsure about. This was depression. This was Postnatal Depression (PND). Something I never thought happened to men. And something I certainly never thought would happen to me, as although my anxiety is always there, I am generally a positive, happy person. I remember vividly waking up one morning and just feeling like I couldn’t cope with the day ahead. It might seem a stupid idea to some, but I thought reaching out to my friends on our WhatsApp group might lighten me up. This did in fact turn out to be a stupid idea, as I was told in a roundabout way to “man up” and “get yourself on MumsNet”. Interestingly, away from the toxic masculinity of the group, within a few minutes, one or two of them sent me private messages offering support. My PND affected our relationship, and it was only right that I spoke to my GP about the situation. After speaking with him I was assigned a counsellor for weekly talking therapy sessions, which I must say I did not feel helped very much and while I am aware that many people can be helped by antidepressant medications, I have not wanted to try them myself. It is also very important for me to note that probably the biggest challenge of this whole period has been trying to juggle managing 18 engineers from a remote work-station in my kitchen diner, with a baby in close proximity. It simply does not go hand in hand and there have been a few times I have had to leave the house for a few hours or even a couple of days to ensure I stay on top of my work. Now, a year after the birth of Olive, things feel a bit more in control in my life. The ending of lockdown has allowed my partner and I to get out together on the odd occasion, to see live music or have a meal and that has improved our relationship. I have also increased my exercising, the most natural anti-depressant in my opinion, and this culminated in completing a 26-mile hike for Macmillan Cancer Support, as well as the Great North Run for Mind, raising money for some very important charities in my life. My salary has also finally returned to normal, and we are returning to Vienna in December to complete the holiday that was cut short at the start of this entire whirlwind of an era in all our lives. Photo by Maria Lindsey on Pexels I do feel there should be a lot more support available for new dads and I know there are a number of organisations putting steps in place to make this happen, which I am trying to be involved in as much as possible. Mental health issues, particularly in men, are no longer the stigma they were. Back in my youth, it was as if they had a similar reputation as AIDS had many years ago. Whether it is anxiety or postnatal depression you suffer from, it is important to remember it’s ok to not be ok and seek help from your GP or another medical professional. Editor's Note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him. A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. Tomorrow, Dr Vaheshta Sethna, will publish her blog which follows on from Joe’s blog where she will discuss her research looking at postnatal depression in men. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.

One More Reason for a Healthy Lifestyle: Exercise might increase vaccines' effectiveness The COVID-19 vaccine holds great promise for restoring normal life. However, several factors can affect the vaccines’ efficacy, some of which are under our control. In my research group, led by Prof. Alejandro Lucia at Universidad Europea de Madrid (Spain), we aim to study the benefits of an optimal lifestyle on health with a particular focus on the potential role of exercise as a preventive or therapeutic option against different diseases. In the present blog, I will focus on how regular physical activity has proven to exert numerous benefits on immune health, which could have important implications for COVID-19. Should it be considered an adjuvant to vaccination programs? The coronavirus pandemic (COVID-19) has had — and continues to have — a dramatic impact on society. Promising to restore life back to as we knew it, there are huge expectations on how effective they are. Important research suggests that the vaccines’ efficacy may not only depend on the make-up of the vaccines themselves but also on other, controllable factors. Regular exercise and vaccines’ efficacy Although there is yet no specific evidence for the role of lifestyle on the efficacy of COVID-19 vaccines, evidence from previous vaccination programs (such as those against the flu) suggests that a healthy lifestyle — particularly being physically active — might help increase the vaccines’ efficacy. For instance, a recent study observed that young elite athletes had a better immune response after being vaccinated against the flu (higher increase in T-cells and neutralizing antibodies, the two main characters in charge of defending the organism against virus infections) than the general population. These benefits have also been observed in people who try to stay physically active. Indeed, older adults who regularly perform high levels of physical activity (i.e., walking around ~18,500 steps per day, or doing 60 minutes of moderate-intensity exercise three times per week) present a better immunological response after being vaccinated against the flu compared to their peers who are less active. These results are of paramount importance, particularly given that older adults are among the most susceptible to becoming infected and are at a greater risk of poor outcomes once infected. How about exercising directly before getting the vaccine? Although the above-mentioned findings are highly relevant, even more shocking are the findings that suggest a single bout of exercise before getting the jab might also improve the vaccines’ efficacy. Some decades ago, researchers observed that, in animals, stressful situations before vaccination seemed to maximise immune responses. Later studies confirmed a similar trend in humans: stress-induced through exercise of relatively high intensity (e.g., sixteen minutes of high-intensity cycling or doing arm rises with a heavyweight) before getting vaccinated maximised immune responses. A further study demonstrated that acute exercise reduced the vaccines associated side effects. It must be noted, nonetheless, that evidence in this regard is still preliminary and no research has been specifically conducted with COVID-19 vaccines. Conclusions Ensuring vaccination efficacy is critical, particularly for those most vulnerable such as older adults or adults with obesity. Not only regular physical exercise but also a single exercise bout of relatively high intensity before getting vaccinated might help maximise immune responses to vaccines having implications both for the individual receiving the vaccine and for society overall. In conclusion, a healthy lifestyle — including regular physical activity, but also a healthy diet and optimal sleep patterns, among other factors — should be considered a cornerstone in the armamentarium against COVID-19.

Could the COVID-19 Pandemic Have Led to Increased Rates of Psychosis? Earlier this week, the Guardian reported that the number of people referred to mental health services for a first suspected episode of psychosis rocketed during the Covid-19 pandemic. The article originally claimed there had been a 75% increase in such referrals between April 2019 and April 2021, but subsequent investigation by James Kirkbride, Professor of Psychiatric & Social Epidemiology at UCL, revealed that the real figure is probably closer to 30%. Although such a substantial correction should give us all pause for thought about rushing to conclusions, this nonetheless appears to be a very significant increase. These are referrals rather than confirmed cases of psychosis, but it does suggest many more people have been experiencing significant struggles with their mental health. I am an independent expert on mental health and social policy, previously working in Parliament, for Mind, and in the civil service. I retrained as a Mental Health Social Worker in 2018 and now work in the NHS alongside freelance writing and research. I co-host the podcast Notes on the Mind, and I have previously written for InSPIre the MInd about the concept of “madness”. I was fascinated by this Guardian article and wanted to write about it. Clearly, the most pressing concern in response to this news is whether people have been getting access to the support they need. But I also think it’s worth stepping back and considering why the conditions we have been subjected to during the pandemic might have led to more people seeking support for suspected psychosis. We can all relate to the distress caused by Covid-19, the social constraints it necessitated, and the economic fallout — many people reported poor and deteriorating wellbeing as the pandemic progressed. It is also widely recognised that groups already facing social and economic disadvantages experienced the harshest impacts of the pandemic. Psychologically, it seems to have been a particularly tough time for young people. It is easy to see how these conditions might have led someone to become anxious and depressed, but I suspect many people will find it harder to join the dots to the more unusual experiences that are associated with psychosis. Exploring these connections might therefore offer insights into why people have such experiences, and what lessons we can draw to help reduce the number of people becoming unwell. I should be clear from the start that I am offering reflections on this subject based on my experience of supporting people as a Social Worker in mental health services, rather than as an authority on the subject of psychosis. However, many of the people I support hear, see or believe things that others don’t, and I have a strong personal and professional interest in psychosis and the relevant academic evidence. There is a broad consensus about the type of ‘risk factors’ that can make it more likely that people experience psychosis, even if the relative role of each is disputed: genetic inheritance, trauma, social and economic disadvantage, substance misuse. However, there is much less clarity and agreement about how and why exposure to these factors leads to experiences such as hearing voices and holding unusual beliefs. The explanatory framework I’m most attracted to, and that fits best with what I have observed when supporting people in frontline practice, is known as the ‘cognitive model of psychosis’. This suggests that unusual sensory and perceptual experiences that we all might experience from time to time can be reinforced and sustained as a result of how someone’s predispositions and circumstances shape their thinking, understanding, emotions and behaviour. In essence, psychosis can emerge as a result of how someone interprets and responds to ‘psychosis-like experiences’. I will refer back to this model as I explore how the impact of the pandemic might have shaped people’s risk of becoming unwell. When Covid-19 first hit, I was working as a care coordinator in a community mental health team. This meant I was responsible for supporting a caseload of people with long-term mental health problems, most of whom had experience of psychosis. I spent much of those early days helping people to understand what was going on and what restrictions they needed to abide by. The thing that sticks in my memory about this period is how many people joked with me that the unfolding events of the pandemic weren’t actually having a huge impact on their day-to-day lives. They were used to spending much of their time alone at home, fairly cut off from the outside world. They weren’t suddenly cut off from work, friends and family. Their mental health problems, their economic circumstances, and their social marginalisation had left them locked out, long before the pandemic had put them in lockdown. In contrast, for many people, the pandemic rapidly and dramatically altered their lives. The social isolation, particularly for people living alone, was acute, only mitigated slightly by virtual social contact. Young people, still developing and passing through significant milestones, have perhaps lost the most from the restrictions on social contact. People with limited social networks may have previously relied entirely on incidental interactions as they went about the day-to-day activities that were now heavily restricted under lockdown Studies suggest that social connection supports our psychological health by reducing stress and helping us to maintain a shared sense of reality. In the absence of social contact, the brain may be more likely to produce the types of thoughts and experiences that could develop into psychosis. People are more likely to have these types of experiences when they are alone, and it is easy to imagine how unsettling and confusing this could be with no one to talk to or seek reassurance from. Living with others during this period was a source of great comfort for many, but it trapped some people in abusive relationships and situations. The pandemic has seen increased reports of domestic abuse from partners and family members. The trauma of such abuse is known to make people more likely to develop mental health problems, and it is thought that dissociation from these experiences could form part of a journey towards psychosis. Many people have also experienced immense pressure and stress around their finances during the pandemic. Millions had to turn to the benefits system for support after losing their jobs, often facing a huge drop in income as a result. Financial difficulties have been shown to increase the risk of psychosis. Stress connected to such difficulties can be mentally all-consuming, and the cognitive model of psychosis suggests that maladaptive coping mechanisms can exacerbate and accelerate the development of psychosis. Alongside all of these consequences of the pandemic, it is important not to forget just how terrifying the threat of Covid-19 itself has been. Over 8 million people in the UK have had the virus and over 160,000 people have had Covid-19 mentioned on their death certificate. It has been a period of huge collective trauma but also many individual ones, whether through being unwell or losing loved ones. It has also been a profoundly strange couple of years and it isn’t hard to see how these things in combination could throw someone’s thoughts and perceptions out of kilter — few of us have found it easy to take it all in our stride. Even though referrals for support with psychosis have significantly increased over the last two years, it also seems likely that many people will have put off seeking help, or lacked the encouragement from others to do so, because of the context of the pandemic. Since the start of 2021, I have been working in a mental health crisis team where I have seen people presenting with severe problems that may well have been picked up earlier in normal times before they had progressed to include psychosis-like experiences. Given the vast and sprawling impact the pandemic has had, and the fact that I have approached this question with a particular explanatory framework in mind, I am sure there are many other factors I’ve failed to consider. But the apparent links between the pandemic and increased rates of suspected psychosis suggest that the types of social and economic determinants I have touched on have played a critical role. As well as properly funding mental health services and ensuring timely access to support, we need to be addressing the social and economic problems the pandemic has both highlighted and exacerbated. We also need to improve awareness and understanding of what psychosis is and how it might develop, so that we are better able to support ourselves and each other to endure difficult circumstances, as so many have had to over the last couple of years. Header image by happypixel18 on Pixabay

“How exciting!” “Aren’t they gorgeous!” “How’s your sleep?!” Just a few of the typical responses new parents are greeted with after welcoming a new baby into the world. But what if, as a new parent, you don’t feel that your experience of having a baby is anywhere near the ‘typical’ experience that you had expected, or perhaps the media has led us to believe is the ‘norm’? For many new parents, having a baby is indeed a wonderful experience, filled with many highs and an abundance of love — alongside an overwhelming lack of sleep. However, this is not always the case. A small percentage of new parents feel cheated out of these positive idealistic new beginnings with their baby, stuck in an exhausting and emotionally-demanding cycle of reliving elements of their — or their partner’s — labour and birth, over and over again. As a Clinical Psychologist, I have focused my career on researching and supporting families during the perinatal years (the period comprising pregnancy and the first year of a baby’s life) and into the early years of childhood. I’ve been struck by the number of conversations I’ve had with families who are still haunted by their, or their partner’s, labour and birth experience, perhaps even decades later. Not only can this impact on new parents, but children grow up hearing these stories, weaving this event into the narratives of their lives. I started my research career in the early 2000’s, jumping headfirst as a newly-graduated psychology student into a PhD looking at the experience of birth trauma and postnatal depression in mothers and fathers. At the time this was particularly novel for two reasons: (1) birth trauma was largely unrecognised, with little research having looked at this area. This was therefore an experience that professionals had very little understanding into, and was frequently misunderstood and mistreated as postnatal depression (something we now know is not the case). Subsequently, new parents had even less of an awareness of this phenomenon, which made these lived experiences even more terrifying and isolating. And (2) fathers, or partners, — despite their prominent existence within the population (!) — were largely ignored when it came to considering, understanding and supporting their mental health. Thankfully the last two decades have seen a shift in both these areas; birth trauma is now much more widely spoken about. And fathers’ and partners’ mental health needs are now recognised in their own right. Labour and birth experiences vary widely, with many factors contributing to the ways in which a newborn enters the world. Cultural and personal beliefs will influence decisions parents make about how they wish their baby to be born, alongside healthcare needs for the mother and infant. Nowadays it is common practice for fathers and partners to be present during the birth of their baby. Partners are often seen as an important source of support during this time, offering encouragement or practical support. However, although many parents experience positive elements of the labour and birth, for some these experiences involve aspects which can be incredibly scary, unexpected, unpredictable, and overpoweringly emotional. This can vary between an isolated instance during the event, or a long-drawn out experience involving multiple traumatic moments. Fathers and partners often talk about being a bystander during this experience. They witness things from a very different perspective to the mother herself, often feeling like a spectator watching things unfold before their eyes, with very little control or ability to play a significant role in the event. The diagnostic criteria for posttraumatic stress disorder (PTSD) — a psychological response to a traumatic event — defines a trauma as an event in which a person witnessed actual or threatened death or serious injury (DSM-V). When considering fathers’ or partners’ experiences of labour and birth, we can see that there are two significant individuals this could apply to — both the mother and the baby. If for just one moment the father perceives that either is at significant risk of harm, then the event holds the potential to be experienced as traumatic. As Arran described in his personal experience blog published with InSPIre the Mind, during the birth of his two daughters there were many terrifying moments: his unborn daughters’ heartbeats dropping, the prospect of emergency caesarean sections being mentioned after long drawn-out labours, his newborn daughter Sakura not crying at birth and being whisked off to the special care baby unit, and his partner’s haemorrhage after the birth of their second daughter. And many moments being left on his own, not knowing what was happening, left to fear the worst. Not all traumatic events lead to the experience of posttraumatic stress; some people naturally recover, finding ways to overcome these moments of fear without long-lasting distress. The research into postnatal birth trauma in fathers shows mixed findings but suggests that up to 5% of fathers may experience childbirth-related PTSD reaching threshold for a ‘diagnosis’, with many more experiencing distressing symptoms. Although this may sound like a small percentage, when considering that 2020 saw over 615,000 live births in the UK (ONS), this translates to up to 30,000 fathers or partners potentially experiencing PTSD relating to the birth of their baby, from one year alone. This is staggering and cannot be ignored. Posttraumatic stress symptoms will vary between individuals, but typically involve experiencing intrusive, distressing memories, flashbacks or dreams, often leading to the sensation that the event is happening all over again — including smells, sounds and visual aspects replaying over and over. Many things can trigger this off, particularly if something has a strong association with the event itself. Often this will be a subconscious connection, happening automatically without conscious awareness. For Arran this was the sequin; the bright red colour transported him back to the hospital, to the distress he experienced when he witnesses the red of his partner’s blood, and he found himself reliving the event over again. It is not hard to see that this can be incredibly distressing; posttraumatic stress involves a wealth of negative thoughts and feelings, including low mood, increased anger and irritability, and increased hypervigilance to the environment (feeling incredibly jumpy and overly-alert). This can make life with a newborn baby very challenging, when parents are already experiencing a huge number of transitions and changes, not least adapting to caring for a new member of the household and the lack of sleep that often comes along with this. Given how distressing this is, it’s not surprising that fathers may find that they start to avoid things associated with the birth, or things that trigger the intrusive memories and flashbacks. For Arran, he was able to throw the sequin away, helping to metaphorically throw the memory — and the event — into the bin. But for others, the consequence of avoiding reminders may lead to additional difficulties in day-to-day life, particularly if the reminder is actually the mother, the infant, or healthcare providers. We can see how this avoidance could start to creep in and take over everyday life. As Arran later recognised, just trying to ignore and throw these memories away doesn’t always work; we need to bring them back out of the ‘bin’ (or the back of our mind) and process them in a way which allows our memories to be stored differently, reducing the emotional response this has over our day to day lives. As Arran described, “going over it [the trauma] can help reduce that tidal wave feeling of emotion”. There are many successful psychological treatments for posttraumatic stress, which help overcome these symptoms. However, perhaps one of the biggest challenges we need to overcome now is in helping fathers and partners recognise these symptoms and seek the support they need and are entitled to. Although I commented earlier that perceptions of fathers’ mental health has changed, and that recognition of birth trauma has changed alongside this, there is still some way to go in finding ways to help fathers access the support they need. As Arran said, “it’s important that we break the cycle of dads who feel unable to share their feelings”. And this is the challenge we — both professionals and society — need take on and change to improve longer-term outcomes for infants and their families. Editor's Note: If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK. As part of this series, please find our already published blogs including: - Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD. - Our blog written by Arran Williams, mentioned throughout this blog. Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects. In this piece Dr Jane Iles, a clinical psychologist with an interest in family mental health across the perinatal period, explored the mental health aspects of birth trauma and PTSD from a scientific perspective in response to Arran William’s piece. We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.