The stillbirth symbol in genograms uses a full-size person symbol (square or circle) with an X drawn through it, indicating a child who died at or near birth. This distinguishes stillbirths from miscarriages, which use a smaller symbol. Recording stillbirths is clinically essential for understanding family grief, sibling dynamics, and reproductive patterns.
Stillbirth (Male)
Full-size square with X
Stillbirth (Female)
Full-size circle with X
Miscarriage
Small filled circle
Stillbirth: full-size symbol with X | Miscarriage: small filled circle
How Stillbirth Is Shown in a Genogram
In standard genogram notation, a stillbirth is represented by a full-size person symbol—square for male, circle for female—with an X drawn through it, identical to the deceased symbol. The full size distinguishes it from a miscarriage, which uses a small filled circle. If the sex was known, the appropriate gendered shape is used; if unknown, a diamond (gender-unknown symbol) with an X may be used.
The stillbirth is placed in birth order among the siblings, connected to the parents' marriage line by a vertical line just like any other child. This positioning is deliberate: it acknowledges the stillborn child as a member of the family and preserves the birth sequence, which is clinically significant for understanding sibling dynamics.
Standard Notation
According to McGoldrick, Gerson, and Petry: "A stillbirth is shown with a full-size symbol and an X, distinguishing it from a miscarriage (small filled symbol). The stillbirth is placed in birth order position." The gestational age or date may be noted beneath the symbol.
Stillbirth vs. Miscarriage: Key Distinctions
The distinction between stillbirth and miscarriage in genogram notation reflects both medical and psychological differences:
Stillbirth
Full-size symbol with X. Typically defined as fetal death after 20 weeks of gestation. The child is often named, may have been held by parents, and is included in birth certificates in many jurisdictions.
Miscarriage
Small filled circle. Pregnancy loss before 20 weeks. The smaller symbol reflects the earlier stage of pregnancy, though the emotional impact may be equally profound for the family.
Neonatal Death
Full-size symbol with X plus birth and death dates. The child was born alive but died within the first 28 days. Both birth and death dates are recorded.
Therapeutic Abortion
An X through a small symbol, sometimes with an annotation. Induced termination for medical reasons is distinct from miscarriage but may carry similar grief responses.
Including Gestational Age and Date
Beneath the stillbirth symbol, practitioners note the gestational age (e.g., "32 weeks") and/or the date of the loss. If the child was named, the name is included as it would be for any other family member. This information helps establish the timeline and emotional context: a stillbirth at 38 weeks, when the family had prepared a nursery and chosen a name, carries different clinical weight than one at 22 weeks.
Birth Order Placement
The stillborn child is placed in chronological birth order among siblings, from left (oldest) to right (youngest). This is clinically important because the position reveals whether the child was a firstborn, came between siblings, or was the youngest. A child born after a stillbirth (sometimes called a "subsequent child" or "rainbow baby") occupies the next position and may carry psychological significance shaped by the earlier loss.
Clinical Significance
Stillbirth has far-reaching effects on family systems that the genogram helps to identify:
Impact on subsequent siblings: Children born after a stillbirth may become "replacement children," carrying expectations and roles meant for the lost child
Family grief patterns: How the family processed (or avoided) the stillbirth affects emotional openness in future generations
Replacement child dynamics: Parents may unconsciously project the identity of the stillborn child onto a subsequent sibling, affecting that child's sense of self
Anniversary reactions: Family members may experience unexplained distress around the date of the stillbirth, especially if the loss was never fully acknowledged
Marital impact: Stillbirth places significant stress on the couple's relationship; some studies link it to higher divorce rates
Sibling grief: Existing children at the time of a stillbirth may feel confused, guilty, or frightened about their own mortality
Pattern Recognition
When mapping stillbirths, explore how the family has handled the loss: Was the child named? Is the stillbirth discussed openly or treated as a secret? Were subsequent children born soon after? Look for patterns of unresolved grief that may manifest as anxiety, overprotectiveness, or difficulty with separation in the next generation.
Research on Stillbirth and Family Systems
Research consistently shows that stillbirth is one of the most underrecognized losses in family systems. Unlike deaths that occur after a person has lived, stillbirth often receives minimal social acknowledgment—a phenomenon called "disenfranchised grief." The genogram counteracts this by giving the stillborn child a visible place in the family structure.
Studies by Cain and Cain on the "replacement child syndrome" demonstrate that children conceived after a stillbirth may develop identity confusion, anxiety, or a sense of living in the shadow of an idealized sibling who never had the chance to disappoint. The genogram makes this positional dynamic explicit and available for therapeutic exploration.
Special Cases
Twin Stillbirth (One Twin Survives)
When one twin is stillborn and the other survives, both are shown with the twin notation (converging lines from the parents). The surviving twin has a standard symbol; the stillborn twin has an X through theirs. This is a particularly complex clinical situation, as the surviving twin may carry "survivor guilt" and the parents must simultaneously grieve and celebrate.
Multiple Stillbirths
When a family has experienced more than one stillbirth, each is recorded individually in birth order. Recurrent pregnancy loss at later gestational ages may indicate medical factors that are important to note. The pattern of repeated loss, visible on the genogram, often reveals the depth of the family's grief and the courage of their continued attempts.
Stillbirth in Previous Generations
Stillbirths that occurred in grandparents' or great-grandparents' generations should be included when known. Historical stillbirths, particularly those that were kept secret or never discussed, may create "ghosts" in the family system—unnamed presences that influence family dynamics without being acknowledged.
What is the difference between a stillbirth and a miscarriage symbol?
A stillbirth uses a full-size symbol (square or circle) with an X, while a miscarriage uses a small filled circle. The size difference reflects the gestational distinction: stillbirth occurs after 20 weeks, miscarriage before 20 weeks. Both are placed in birth order among siblings.
Should I include the child's name if they were named?
Yes, always include the child's name if one was given. The name acknowledges the child's identity and their place in the family. Many families name stillborn children, and using that name on the genogram validates the family's experience and the child's existence.
How do I note the gestational age?
Write the gestational age beneath the symbol, for example "32 weeks" or "8 months." If the exact date is known, include it alongside: "32 wks, March 2018." This information helps clinicians understand the context—a late-term stillbirth at 38 weeks is a qualitatively different experience from one at 22 weeks.
What if the sex of the child was unknown?
Use a diamond shape (the gender-unknown symbol) with an X drawn through it. This is appropriate for earlier stillbirths where sex was not determined, or for historical family losses where this information was not recorded.
How does a stillbirth differ from a neonatal death on the genogram?
Both use a full-size symbol with an X. The distinction is in the dates: a stillbirth shows only one date (the date of delivery/death), while a neonatal death shows both a birth date and a separate death date (within the first 28 days). The genogram notation is visually similar but the timeline tells a different story.
Should I include stillbirths that happened decades ago?
Yes. Even historical stillbirths can have lasting effects on family dynamics. A stillbirth from the 1950s that was never discussed may still influence how the family handles loss, pregnancy, and parenting. The genogram brings these hidden losses into therapeutic view.
How do I show multiple pregnancy losses in sequence?
Place each loss in chronological birth order. Use the appropriate symbol for each: small filled circles for miscarriages, full-size symbols with X for stillbirths. Note dates and gestational ages for each. A sequence of losses tells a powerful story about the family's reproductive journey and accumulated grief.