(Written in the early days of womb twin research, 2005)

For every twin pregnancy that ends with the birth of a live twin pair, there are 10 twin pregnancies were only one live baby is born. (1) World-wide, about 1% of births consist of a twin pair, so that means that 10% of the world population consists of sole survivors of twin or multiple pregnancies ("womb twin survivors"). If losing a twin in the womb has any adverse effect at all upon the survivor, this is an area worthy of intensive study because of the very large numbers of people involved.

There are some medical problems of unknown aetiology that are now being linked to being a wombtwin survivor. (2) For example, the most well- known sign that a twin has died in the womb is vaginal bleeding in the first trimester (3) which has been linked to congenital birth defects (4) in the survivor. As more and more medical difficulties, such as cerebral palsy (5) and various malformations of cortical development (6) have been ascribed to this eventuality, it is becoming clear that the womb is an arena in which many previously mystifying health problems may in fact originate.

Materials and methods

In 2002 I set out to investigate the psychological effects of being a womb twin survivor. By means of a dedicated website (www.wombtwin.com) I attracted wombtwin survivors throughout the English-speaking world, by the use of key words such as “vanishing twin” and “twinless twins” as meta tags. There was an attitude questionnaire for interested parties to complete, based on the assumption that all womb twin survivors would feel much the same about their experience. This assumption was quickly proved wrong. After at least 25 questionnaires had been collected in each case, these were examined to see if the questions were working. In each case the three most popular questions were discovered, in the hope that some straightforward diagnostic characteristics would be found. For each new questionannaire, based upon a fresh assumption, different answers were found to be most popular.

In order to clarify what assumptions ought to be made, a small group of 8 wombtwin survivors were followed up by lengthy and detailed email exchanges over the space of two years, 2003-2005. This work served a dual purpose: firstly, this helped to clarify the inner experience of a wide variety of wombtwin survivors, and gradually revealed, by trial and error, what questions ought to be asked in order to find the most characteristic responses.

Secondly, special techniques were used for counselling by email (eg, maintaining confidentiality and anonymity; the use of empathy and intuition and the interpretation of unconscious processes) and a scheme of work was created that was therapeutic, for it enabled wombtwin survivors to begin to come to terms with their past. This scheme was in four stages: (i) to recognise the reality of the lost twin: (ii) to learn about the relationship of the survivor to their lost twin and how this is being re-enacted in present relationships and behaviours; (iii) to enact a ritual of separation and memorial for the lost twin (iv); to decide on a way forward of autonomy and integration.

The material gathered during these exchanges threw a greater light on the assumptions that lay behind the questions. These were gradually evaluated and refined by means of consultations by e-mail, together with a close examination of the contents of the e-mail messages and face-to-face individual counselling with womb twin survivors living locally. With the help and assistance of over 300 wombtwin survivors over a five-year period (2002-2007), a final version of the research questionnaire was at last prepared and uploaded in Feb 2006. In 2006 132 wombtwin survivors completed it, and it is still available. This is of course a very small sample of the 600 million wombtwin survivors world-wide, but the results were considered clear enough for a preliminary report to be issued.

Discussion

When the questionnaire results were first examined, the spread of attitudes was so wide and chaotic that no apparent pattern was noticeable at first, but 37 out of the 41 (90%) gave an affirmative response to the following four questions:

Deep down, I feel alone, even when I am among friends

The first question indicates the way in which most wombtwin survivors engage in paradoxical thought processes, that appear to be a response to contradictory information held in the memory at the deepest possible level. (I have called this the “Dream of the Womb”, for want of a better term.) The twin identities of the weak, dead twin and the strong, living survivor are intermixed, so that how wombtwin survivors feel subjectively is quite at odds with the prevailing objective reality.

E-mail interviews revealed that this fantasy is carefully maintained as a way to resolve the contradictions within it. This was described further by e-mail in various ways, including "being a dreamer" or "being a space cadet" or "dissociating". Among the various paradoxical thoughts that surfaced in e-mail interviews were denial of aggressive feelings; low self esteem; paranoia and defensive hostility. Paradoxical behaviour, such as self harm, was recognised as self-sabotaging by those practising it.

All my life I have felt restless and unsettled

The second question describes the emotional discomfort that seems to prevail in the life of almost every womb twin survivor. In e-mail interviews this was explained as a vague, irrational feeling of "something being wrong", but they did not know what it was. This feeling had been especially difficult to understand before they discovered that they were wombtwin survivors.

The discomfort was also described by some as an “emotional pain that persists, despite all my efforts to heal myself.” E-mail interviews revealed that grief was a strong component of this feeling, but a generalised form of low-level anxiety or depression were also present. The mysterious, vague and confusing nature of the feelings were a major cause of distress. Making sense of the feelings was seen by wombtwin survivors as helpful and therapeutic.

Wherever I am, I scan the faces around me

The third question is perhaps the most well-known of the effects of being a wombtwin survivor - the search for the lost twin. In her book “From Fetus to Child” Allessandra Piontelli (1992) described an infant wombtwin survivor searching the corners of the room for his twin, who had died just two weeks before birth. From all the various responses I have received, it is clear that “feeling incomplete”, the search for “wholeness”, for a "twin soul" or one's "other half" are universal themes among wombtwin survivors.

I like to have plenty of personal space

The fourth question describes further the inner world of the wombtwin survivor, which is a private domain that is shared with very few people. It is a form of self-isolation. Wombtwin survivors have a very active imagination and as children may create fantasy friends or talk for hours to their image in a mirror. It seems to be helpful to explain this as a recreation of the space once shared with the twin and the critical element is that it is populated solely by the surviving twin. A tendency to recreate the original womb situation is so strong that close relationships are quickly sabotaged by withdrawal if they are allowed to become too intimate.

Wombtwin survivors survive in the womb because of some advantage that enabled them to adapt to changing conditions. They appear to have adapted psychologically to their unusual origins by creating a private place in their mind where they can attempt to resolve and understand the paradoxical thoughts, confused feelings and irrational distress that is their lot. The e-mail interviews revealed that most womb twin survivors had never described their deepest feelings to anyone before, simply because the ideas sounded crazy and incoherent. There is widespread scepticism about the strength of feeling experienced by wombtwin survivors, which this research is designed to dispel. Womb twin survivors seek to present a calm, capable exterior and only those in a close and private relationship witness the strength of pent-up emotion that is held in that private space.

Results

The results of this preliminary research seem to show that in the four areas of paradoxical beliefs, emotional discomfort, searching and self-isolation, there are significant psychological effects on the survivors of a twin or multiple pregnancy. It also seems that simply to discover the reality that lies behind these difficult feelings is therapeutic. Many of the psychological issues that were raised, such as self harm and relationship difficulties, are widely discussed. It is hoped that the possibility of being a wombtwin survivor may be taken into consideration more frequently by the professionals involved in providing therapy and treatment.