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Abortion and mental health

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Post-abortion syndrome (PAS), is a highly controversial term first proposed by psychologist Vincent Rue to describe a variant of post-traumatic stress disorder (PAS) where the stressor was a traumatic abortion. The term "post-abortion syndrome", however, has been popularized by opponents of abortion in such a way that it is more generally understood to refer to any negative emotional or psychological reactions to abortion, not just traumatic symptoms.

The American Psychological Association and the American Psychiatric Association do not recognize PAS as a valid diagnosis and it is not included in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR or ICD-10 list of psychiatric conditions. It has been argued that the concept of abortion causing traumatic reactions is a "myth" created by opponents of abortion for political purposes.

"Post-abortion stress syndrome" (PASS) and "abortion trauma syndrome." are additional terms sometimes used to discuss emotional problems purportedly associated with abortion. For the sake of reference, these terms are also used by those who deny that there any unique emotional problems are in fact caused by abortion.

As PAS, PASS, and "abortion trauma syndrome" are commonly understood to refer to any negative emotional reactions to abortion, and they are also used in the overarching debate of whether abortion causes or contributes to mental health problems at all, this article addresses the issue of abortion and mental health in all respects. In doing so, it examines both history and controversy surrounding questions related to abortion and mental health and the peer reviewed studies related to abortion and mental health.


Brief History of the Abortion Mental Health Controversy

American Psychological Association - 1969

In 1969, American Psychological Association Council member Henry P. David proposed the the APA should adopt a postion favoring legalization of abortion as a civil right. The petition was

WHEREAS, termination of unwanted pregnancies is clearly a mental health and child welfare issue, and a legitimate concern of APA; be it resolved, that termination of pregnancy be considered a civil right of the pregnant woman, to be handled as other medical and surgical procedures in consultation with her physician...

In addition, the APA established the Task Force on Family Planning to "(a) to prepare "a review of the current state of psychological research related to family planning and population policy and (b) to make recommendations for encouraging greater research and professional service participation by psychologists in this emerging area of social concern."

Vincent Rue, Ph.D.

In 1981 psychologist and trauma specialist Vincent Rue testified before Congress that he had treated women who had experienced traumatic reactions to abortion resulting in the same type of post-traumatic stress disorder he had treated in VietnNam Vets, with the exception that the stressor in this case was abortion rather than battlefield violence. He proposed the name "Post-Abortion Syndrome" (PAS) and the term was soon picked up and used by abortion opponents to refer to any negative emotional reactions associated with abortion, not just PTSD as Rue had intended it.

Soon after giving this testimony, Rue was threatened with legal action by the general counsel the American Psychiatric Association if any notes he published making reference to the PTSD diagnosis for abortion did not include a specific disclaimer stating that the APA denies that there is "any clinical evidence for the basis of the diagnosis of ‘post-abortion syndrome."

Surgeon General Koop's Letter

In 1987 President Reagan directed U.S. Surgeon General, C. Everett Koop to issue a report on the health effects of abortion on women. Koop subsequently began review of over 250 studies pertaining to the physical and psychological impact of abortion. In a letter to President Reagan in January of 1989 Koop stated that he could not issue a conclusive report because the available "scientific studies do not provide conclusive data about the health effects of abortion on women." To address the inadequate research in the field, he recommended a $100 million dollar prospective study would be required to conclusively examine the mental health effects of abortion. In the letter Koop also stated the view that "In the minds of some , it was a foregone conclusion that the negative health effects of abortion on women were so overwhelming that the evidence would force the reversal of Roe vs. Wade." He also noted that while the psychological effects of abortion had not been adequately studied "...doctors had long ago concluded that the physical results of abortion are not major health factors and required little additional study."

In subsequent testimony before a congressional committee regarding his review of the literature, Koop stated that while the scientific studies available at that time were not methodologically sound enough to draw unimpeachable conclusions, "There is no doubt about the fact that some people have severe psychological effects after abortion, but anecdotes do not make good scientific material." In yet a subsequent Congressional hearing, when Koop was pressed to address the question of whether his view of the inadequate studies he had reviewed indicated that abortion posed a public mental health threat, Koop stated that in his opinion it was "miniscule from a public-health perspective."

1987-1990 APA Task Force

When Koop was assigned to review information on abortion, he invited input from any individuals and organizations with material to present. The American Psychological Association's task force on abortion issues presented material to Koop and subsequently published a synthesis of their findings in which they concluded that "The weight of the evidence does not pose a psychological hazard for most women."

The task force concluded that "research with diverse samples, different measures of response, and different times of assessment have come to similar conclusions. The time of greatest distress is likely to be before the abortion. Severe negative reactions after abortions are rare and can best be understood in the framework of coping with normal life stress."

In 2007 APA established a new task force to review studies on abortion published since 1989. The new task force report is expected to be published in 2008.

Nada Stotland, M.D.

In a 1992 commentary published in the Journal of the American Medical Association (JAMA), psychiatrist Nada Stotland of the University of Chicago (who is currently vice president of the American Psychiatric Association) argued "There is no evidence of an abortion-trauma syndrome.” To support her thesis, she cited research showing that only 11% of patients had significant short term emotional problems related to their abortions. Her term "abortion trauma syndrome" was different than that of Rue.

In a subsequent 1998 paper, Stotland describes her surprise at treating a patient experienced a severe delayed reaction to a prior abortion following a a subsequent miscarriage. She reports discovering first-hand "the psychological complexities of induced abortion" and concludes that the failure to address these issues "leaves the person vulnerable to reminders and reenactments, to difficulties that may surface in life and in subsequent psychotherapy." Despite a woman's political or moral views of abortion, she writes, "abortion is experienced by that woman as both the mastery of a difficult life situation and as the loss of a potential life. There is the danger that the political, sociological context can overshadow a woman's authentic, multilayered emotional experience."

David M. Fergusson, Ph.D. and the APA's Response

In 2006, a team of researchers at the University of Otago Christchurch School of Medicine in New Zealand, published results relating to abortion reactions from a longitudinal study tracking approximately 500 women from birth to 25 years of age. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. The study concluded that compared to other women in the group those who had an abortion were subsequently more likely to have "mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors." The authors wrote, "The findings suggest that abortion in young women may be associated with increased risks of mental health problems," and "on the basis of the current study, it is our view that the issue of whether or not abortion has harmful effects on mental health remains to be fully resolved."

The team was led by Professor David Fergusson, a self-described "pro-choice atheist," complained the to press that they had run into political bias at journals which did not want to publish their results, saying they "went to four journals, which is very unusual for us, we normally get accepted the first time."

The team particularly objected to the 2005 position paper by the American Psychological Association which "concluded that ‘well designed studies of psychological responses following abortion have consistently shown that risk of psychological harm is low...the percentage of women who experience clinically relevant distress is small and appears to be no greater than in general samples of women of reproductive age'" According to the researchers, "This relatively strong conclusion about the absence of harm from abortion was based on a relatively small number of studies which had one or more of the following limitations: a) absence of comprehensive assessment of mental disorders; b) lack of comparison groups; and c) limited statistical controls. Furthermore, the statement appears to disregard the findings of a number of studies that had claimed to show negative effects for abortion."

In response to Fergusson's criticisms of the APA, the APA's spokesperson on abortion and a member of the 1989 task force, Dr. Nancy Russo, told a Washington Times reporter that the APA's official position on abortion developed from the viewpoint that abortion is a civil right and that "To pro-choice advocates, mental health effects are not relevant to the legal context of arguments to restrict access to abortion." She further stated her opinion that "pre-existing mental health problems, relationship quality, and whether the pregnancy was wanted or unwanted are key factors determining postabortion mental distress, not the abortion itself," She rejected the significance of Fergusson's study stating: "There has yet to be a well designed study that finds that abortion itself contributes to increased risk for mental health problems," and noted that feelings of guilt and shame after abortion may result from social disapproval and efforts to cast abortion as a moral failing, rather than from the procedure itself. Fergusson resopnded that better research was needed, but that "...the abortion debate and its implications drive out the science."

Subsequent to the New Zealand team's criticisms of its position papers, the APA convened a new task force to publish a new report in 2008 regarding abortion and mental health.


Academic research

A number of studies have examined the relationship between abortion and negative psychological symptoms. While most studies have found an statistical association between abortion and depression, a causal connection has not been proven.

Neutral and positive effects of abortion

Some studies have indicated that women who have undergone abortion have experienced positive or no change to their mental health and well-being. A 1989 study of teenagers who sought pregnancy tests found that counting from the beginning of pregnancy until two years later, the level of stress and anxiety of those who had an abortion did not differ from that of those who had not been pregnant or who had carried their pregnancy to term. Another study in 1992 found that having one abortion was positively associated with higher global self-esteem, particularly feelings of self-worth, capableness, and not feeling one is a failure. It also noted that adverse emotional reactions to the abortion are influenced by pre-existing psychological conditions and other negative factors and, furthermore, that women's well-being was separately and positively related to employment, income, and education, but negatively related to total number of children. Abortion, as compared to completion, of an undesired first pregnancy was not found to directly pose the risk of significant depression in a 2005 study.


Denmark

A study conducted at University of Copenhagen has shown legal abortion is associated with few adverse effects on sexual function among women in Denmark. The study was conducted among 941 women who chose elective abortion. Among the many statistics of note, the authors wrote, "Diminished libido was experienced by 15.3% at 8 weeks follow-up, and 6.0% experienced diminished orgasm ability (self-rated changes). Libido was unchanged in 72.4% of the women, 69.7% had no change in orgasm ability and 3.3% had never experienced orgasm." The study concluded that "Overall, 51.0% of the women recommenced coitus within 2 weeks after TOP (Termination of Pregnancy). This figure was significantly higher among women aged 18–24 years (60.6%) than among women in higher age groups (41.7–47.8%)."

Finland

A Finnish study has shown a correlation between miscarriage (or spontaneous abortion) with depression and suicide, as well as between medically induced abortion with depression and suicide among women in Finland. The study found that among 8,980 women, "In total, 30 suicides were committed after women gave birth (42% ), 29 after an abortion (40%), and 14 after a miscarriage (19%), of which two were after an extrauterine pregnancy." The study was unable to establish a causal link between abortion and suicide because it was not clear if abortion causes depression and suicide, or if women who are depressed and suicidal are more likely to elect to have an abortion. The article concludes that an "explanation for the higher suicide rate after an abortion could be low social class, low social support, and previous life events or that abortion is chosen by women who are at higher risk for suicide because of other reasons."


Norway

A study in Norway compared the mental distress of women who experienced a spontaneous abortion (miscarriage) and those who had a voluntary abortion. Women who had had a miscarriage exhibited significantly quicker improvement on Impact of Event Scale (IES) scores for avoidance, grief, loss, guilt and anger throughout the observation period. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group after two and five years. Compared with the general population, women who had undergone induced abortion had significantly higher Hospital Anxiety and Depression Scale (HADS) anxiety scores at all four interviews, while women who had had a miscarriage had significantly higher anxiety scores only at ten days. The conclusion of the study showed that women who had experienced a miscarriage experienced more mental distress after 10 days and six months than those who had induced abortions. Furthermore, "The responses of women in the miscarriage group were similar to those expected after a traumatic and sad life event. However, the women in the induced abortion group had more atypical responses. This may be because the mental health of the aborting women was somewhat poorer than that of the miscarrying women before the pregnancy termination event. The more complex nature of the induced abortion event, which includes economic and relationship issues, may also account for differences in the course of psychological responses between the two groups." The study recommended that women be informed about common psychological responses to pregnancy termination and that they be offered talks with health personnel..

South Africa

A study of 155 women seeking voluntary induced abortion sought to investigate whether different forms of pain control had a different effect on pain and psychological distress after the abortion. The researchers examined levels of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation. The authors found that cortisol levels are elevated in women who chose a local anesthetic and that while the choice of anesthetic "does not appear to impact on longer-term psychiatric outcomes or functional status" psychologiclal distress was prevelent among both groups of women. Specifically, they found that 11.4% of women met the criteria for a diagnosis of post-traumatic stress disorder (PTSD) prior to their abortions and that the overal rate of PTSD among the sample rose to 18.2% three months after their abortions, a rise of 61%. However, rates of depression and anxiety were lower after abortion than immediately before. In discussing their findings, the authors write that "Presently the weight of evidence suggests that abortion does not cause lasting negative consequences," but that from their findings regarding mid-term PTSD reactions "t would follow that screening women pre-termination for PTSD and disability and post-termination for high levels of dissociation is important in order to help identify women at risk of PTSD and to provide follow-up care."

Spain

Spanish Social Work researchers claim that some psychopathological characteristics are frequently observed in women who have voluntarily aborted. These include "dreams and nightmares related with the abortion," and "feelings of guilt". Using a cohort of 10 women, Gomez, Lavin C., & Zapata examined ways to categorize PAS under the assumption that it exists and is related to Post Traumatic Stress Disorder. Abortion is illegal in Spain.

Reactions Associated With Abortion

Although many studies have found a significant statistical association between abortion negative emotional reactions, no irrefutable causal link has been proven to show that abortion itself causes the reactions which are statistically associated with it. In other words, negative reactions may be incidental to abortion, not caused by abortion. It may be that women who are predisposed to have these emotional problems are also more predisposed to have abortions. In any event, the following emotional and mental health problems are statistically associated with abortion.

  • Guilt
  • Anxiety
  • Depression
  • Sleep disorders
  • Anniversary reactions
  • Elevated risk of suicide
  • Bi-polar disorder

Peer reviwed studies have shown that some women are more likely than others to report emotional or mental health problems after an abortion. The statistically associated risk factors include:

  • Low self-efficacy for coping with the abortion
  • Low self-esteem
  • External locus of control
  • Difficulty with the decision to have an abortion
  • When there is emotional investment in the pregnancy
  • Perceptions of one's partner, family members, or friends as non-supportive
  • Timing during adolescence, being unmarried, or poor
  • A poor or insecure attachment relationship with one's mother or a childhood history of separation from one's mother for a year or more before age 16
  • Involvement in violent relationships
  • Traditional sex-role orientations
  • Conservative views of abortion and/or religious affiliation
  • When a pregnancy is initially intended
  • Abortion during the second trimester
  • When the woman is in an unstable partner relationship
  • Being forced into abortion by one's partner, others, or by life circumstances



References

  1. Vincent Rue, "Abortion and Family Relations," testimony before the Subcommittee on the Constitution of the US Senate Judiciary Committee, U.S. Senate, 97th Congress, Washington, DC (1981).
  2. Prior to 1994, the DSM III-R listed abortion as a "psychosocial stressor." Specifically, in Chapter Two, page 20 of that edition, a psychosocial stressor was described to include a "physical illness or injury: e.g., illness, accident, surgery, abortion." Abortion in this context is pregnancy loss before 20 weeks that can be spontaneous or therapeutically induced.
  3. ^ Stotland NL. The myth of the abortion trauma syndrome. JAMA. 1992 Oct 21;268(15):2078-9. PMID 1404747.
  4. ^ Cooper, Cynthia L. Abortion Under Attack Ms. Magazine
  5. http://afterabortion.com/pass_details.html What is PASS?] www.afterabortion.com, an abortion neutral online peer support network, which is not to be confused with nor related to the Elliot Institute's www.afterabortion.org]
  6. ^ David, H. "Retrospectives" From APA Task Force to Division 34" Population & Environmental Psychology Bulletin 1999, 25(3):2-3.
  7. Abortion and American Psychology Warren Throckmorton, PhD
  8. Vincent Rue, "Abortion and Family Relations," testimony before the Subcommittee on the Constitution of the US Senate Judiciary Committee, U.S. Senate, 97th Congress, Washington, DC (1981).
  9. See Appendix A,"The Politics of Trauma", in Theresa Burke's Forbidden Grief: The Unspoken Pain of Abortion. (Acorn Books)
  10. ^ A copy of the Koop letter to President Reagan ishere.
  11. New York Times: Koop Says Abortion Report Couldn't Survive Challenge
  12. ^ Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. "Psychological responses after abortion." Science, April 1990, 248: 41-44.
  13. ^ Abortion and American Psychology Warren Throckmorton, PhD
  14. Stotland NL.The myth of the abortion trauma syndrome JAMA. 1992 Oct 21;268(15):2078-9.
  15. Ibid, citing B. Lask, "Short-term psychiatric sequelae to therapeutic termination of pregnancy," Br J Psychiatry. 1975; 126:173-177 (1975).
  16. NL Stotland. Abortion: Social Context, Psychodynamic Implications" Am J Psychiatry, 155(7):964-967, 1998.
  17. ^ Fergusson, D.M., Horwood, L.J., & Ridden, E.M. (2006. Abortion in young women and subsequent mental health. Journal of Child Psychology and Psychiatry, 47(1), 16-24.
  18. Ruth Hill, “Abortion Researcher Confounded by Study” New Zealand Herald 1/5/06, See also: Abortion increases mental health risk: study an ABC interview with Fergusson.
  19. ^ Warren Throckmorton. "Abortion and mental health."] Washington Times. January 21, 2005.
  20. American Psychological Association. "APA research review finds no evidence of 'post-abortion syndrome' but research studies on psychological effects of abortion inconclusive." Press release, January 18, 1989.
  21. Zabin, L.S., Hirsch, M.B., Emerson, M.R. (1989). When urban adolescents choose abortion: effects on education, psychological status and subsequent pregnancy. Family Planning Perspectives, 21 (6), 248-55. Retrieved September 8, 2006.
  22. Russo, N. F., & Zierk, K.L. (1992). Abortion, childbearing, and women. Professional Psychology: Research and Practice, 23(4), 269-280. Retrieved September 8, 2006.
  23. Schmiege, S. & Russo, N.F. (2005). Depression and unwanted first pregnancy: longitudinal cohort study Electronic version. British Medical Journal, 331 (7528), 1303. Retrieved 2006-01-11.
  24. Sexual behavior during the first eight weeks after legal termination of pregnancy
  25. Suicides after pregnancy in Finland, 1987-94: register linkage study
  26. ^ The course of mental health after miscarriage and induced abortion: a longitudinal, five-year follow-up study - Norway
  27. ^ Suliman S, Ericksen T, Labuschgne P, de Wit R, Stein DJ, Seedat S (2007). "Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation". BMC Psychiatry. 7: 24. doi:10.1186/1471-244X-7-24. PMID 17565666.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  28. ^ Gomez, Lavin C., & Zapata, Garcia R. (2005). – "Diagnostic categorization of post-abortion syndrome". Actas Esp Psiquiatr, 33 (4), 267-72. Retrieved Setepmber 8, 2006
  29. ^ Sexual behavior during the first eight weeks after legal termination of pregnancy
  30. ^ Legal abortion: a painful necessity - Sweden
  31. Abortion and guilt, France
  32. ^ Psychological effects of abortion Portugal
  33. Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study, Norway
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