The identification of a pregnancy as "unintended" or"unwanted" is usually based on relationship factors with such pregnancies more common when relationships are just beginning, nearing an end, or are otherwise unstable. Decisions regarding resolution of unplanned pregnancies are likewise relational, involving the couple's connection to each other and each partner's relationship to the developing fetus. When pregnancy is terminated, the abortion becomes a part of the couple's shared history with potential to affect their future. Although relational aspects of abortion decision making and adjustment may seem obvious, the experience of abortion is typically framed individually rather than relationally in the scientific literature. Compared to research focusing on the individual woman, few studies have adopted a relationship perspective on abortion decision-making and adjustment. This has rendered the contemporary understanding of abortion one that is excised from social and interpersonal realities of people's lives.
An attempt is made in this article to integrate the limited available evidence in order to formulate a clearer picture of how abortion may adversely impact partner relationships. Answers to the following questions are explored:
Partner conflict may logically arise during abortion decision-making if there are differences in opinion regarding pregnancy resolution and/or if relationship based information, such as commitment, desire to ever have children, confidence in a partner's parenting abilities, life style factors, and long term intentions such as school or career plans are addressed. Post abortion psychological effects on the part of one or both parties may conceivably add to earlier conflicts and/or new relationship problems could arise after the procedure. For example, the abortion could introduce negative emotions including anger, guilt, grief, depression, and/or anxiety (reviewed in detail below), thereby increasing the risk for ambivalent, withdrawn, antagonistic, or aggressive partner directed behavior.
Post abortion partner communication problems have been identified (Freeman, 1980), and an increased risk for separation or divorce following an abortion has been reported (Barrett, Freudenberg, Wille, 1992; Bracken & Kasi, 1975; Freeman, 1980; Lauzon, Roger Achim, Achim, & Boyer, 2000; Rue, Coleman, Rue, & Reardon, 2004). Lauzon and colleagues (2000) found that 12% of the women and 18% of the men sampled indicated an abortion performed up to 3 weeks earlier had adversely affected their relationship. Rue and colleagues (2004) reported that 6.8% of Russian women and 26.7% of American women indicated relationship problems caused by an abortion experience; whereas relationship benefit was reported by very few Russian women (2.2%) and American women (.9%). Finally, in a large, well-controlled, prospective study, 22% of German women's relationships with their partners had ended a year later (Barrett et al., 1992).
Minimal research attention has focused on abortion as a predictor of domestic violence. However a few studies have shown an association between a history of abortion and increased risk for partner perpetrated aggression during a subsequent pregnancy (Amaro, Fried, Cabral, Zuckerman, 1990; Hedin & Janson, 2000).
Research has demonstrated that women with an abortion history are at an increased risk for sexual dysfunction (Fok, Siu & Lau, 2006; Bianchi Demicelli et al., 2002; Boesen, Rorbye, Norgaard, & Nilas, 2004; Miller, 1992; Rue et al., 2004; Tornbom & Moller, 1999). For example, in a recently published study, 6.2% of the Russian women and 24% of the American women sampled reported sexual problems that they directly attributed to a prior abortion (Rue et al., 2004). In a Swiss longitudinal study of over 100 women, 31 % reported a minimum of one sexual problem 6 months after an abortion (Bianchi-Demicelli et al., 2002). Sexual desire, frequency of sexual intercourse, orgasm ability, and sexual satisfaction are among the female sexuality variables explored in the literature. In a recent review, Bradshaw and Slade (2003) concluded that 10 20% of women experience sexual problems in the early weeks and months after an abortion while 5 20% of women report sexual difficulties a year later. Male responses to a partner's abortion have not been extensively studied; however, post abortion sexual problems in the first three weeks post abortion were indicated by 18% of men who were significantly affected by a partner's abortion (Lauzon et al., 2000). More research on abortion and male sexuality, particularly longterm effects is needed.
Few of the existing studies on abortion related sexual difficulties have probed very deeply into why the problems arise; but the results of one study revealed that decreased sexual desire was associated with not feeling worthy of one's partner (Tornbom & Moller, 1999). Further, in studies examining sexual problems associated with involuntary perinatal loss and/or loss of a child in which sexual problems have been identified in over 60% of couples, reasons for disinterest in sexual activity have been described and include depression, fatigue, numbness, preoccupation, and discomfort with sexual activity. The discomfort was based on sexual activity serving as a reminder of the previous conception, fear of pregnancy and another possible loss, and viewing sexual pleasure as incompatible with mourning (Hagemeister & Rosenblatt, 1997; Wing, Clance, Burge Callaway, Armistead, 2001). In this literature, gender differences have been documented wherein bereaved men are more inclined to find sexual intimacy comforting and to experience significantly less loss of interest compared to women (Hagemeister & Rosenblatt, 1997; Schwab, 1992; Wing et al., 2001). Although studies designed to examine the issues behind postabortion declines in sexual activity are generally missing from the literature, logical explanations include any of the following: 1) perceptions of a partner as insensitive or insufficiently supportive, 2) negative abortion related emotions on the part of one or both individuals, 3) altered self perceptions which may result in feelings of estrangement from one's partner, 4) anger due to relationship based information (e.g., commitment, long term plans, etc.) derived through the abortion decision-making process, and/or 5) history of unresolved grief and trauma in one or both partners.
The idea of the fetus possessing personhood and moral objection to abortion seem to be commonly held beliefs. For example, research on women who had first trimester miscarriages revealed that 75% felt they had lost more than a pregnancy (Cote Arsenault & Dombeck, 2001). Further, Smetana (1981) found that 25% of women facing an abortion decision considered the fetus to be human and regarded abortion as the taking of life. Allanson end Astbury (1995) reported that 25% of women seeking an abortion agreed with the statement "abortion is against my beliefs." A number of other studies have shown that many women have abortions despite moral opposition to the procedure (Allanson & Astbury, 1995; Kero & Laos, 2000; Smetana, 1981). In a recent study, 50.7 % of American women and 50.5% of Russian women who had an abortion felt abortion was morally wrong (Rue et al., 2004). Further, the results of a study by Lanzon et al. (2000) revealed that the presence of a moral dilemma was identified as the greatest contributor to men's anxiety prior to a partner's abortion. Specifically, over a third of the segment of men who reported being anxious about a partner's pending abortion (56% of those sampled) identified moral issues as the source of their anxiety. Obviously, then, for a significant number of women who abort and their partners, the decision is not an easy one and it is likely to have been resorted to based on personal or situational pressures.
Each partner brings his or her personal perspective regarding the meaning of abortion into the experience of an unintended pregnancy and its resolution. However, no quantitative studies have specifically examined each partner's beliefs about abortion as predictors of post abortion relationship quality. The probability of discrepant views initiating conflict would seem to be quite high, particularly if one individual views abortion as the taking of a human life and the other does not. There are studies suggesting that women who feel pressured into an abortion by a partner have more postabortion mental health problems (Speckhard & Rue, 1992), as do men whose partners have opted to abort against their will (Moseley, Follongstad, Harley, & Heckel, 1981; Shostak, McLouth, & Seng, 1984); however relationship factors were not examined in the studies conducted to date.
Professionals within the medical community and researchers alike continue to adopt disparate views of abortion, resulting in very conflicting messages regarding what constitutes normal post abortion psychological adjustment. A lack of consensus has slowed progress toward understanding the real life experiences of women and efforts to support women in resolving any psychological pain or relationship difficulties resulting from abortion. In an interesting admission pertaining to her efforts to assist a client working through an abortion, psychotherapist Kluger Bell (2000, p.7) states "What kept coming up in session after session was her guilt and regret over the abortion she had had six years before. Probably because of my own commitment to the legal right to abortion, I considered first-trimester abortion a fairly straightforward medical procedure with few if any long lasting effects....I failed to recognize that in her present circumstances the abortion felt like a huge, irrevocable mistake." According to psychiatrist Philip Sarrel (1988, p. 244): "Abortion is frequently a negative turning point in a relationship leaving scars which can undermine the future of the couple either together or as individuals."
Research conducted by Patterson, Hill, and Maloy (1995) revealed that women's reasons for choosing abortion were overwhelmingly tied to their life situation as opposed to abstract, moral or religious principles and there are studies described previously indicating that many women who are ethically opposed to abortion make the decision to abort despite their personal views of abortion. This discrepancy between women's beliefs and behavior is likely to engender guilt feelings, which are very common among women who have aborted. Available evidence specifically indicates that between 29% and 75% of women acknowledge feelings of abortion related guilt (Kero, Hoegberg, Jacobsson, & Lalos, 2001; Miller, Pasta, & Dean, 1998; Rue, et al., 2004). In a recently published study by Rue and colleagues (2004), the results revealed that even among Russian women residing in a culture that is very accepting of abortion, levels of self reported guilt were quite high (49.8%). As the crisis of the pregnancy and the pressure to make the decision regarding termination have passed and women have had time to process the experience, those who are morally opposed to abortion may begin to feel as though their reasons for terminating the pregnancy (e.g., in order to stay in school, save money, please a partner, etc.) were insufficient justification for terminating a human life. In a recent study by Keros, Hoeberg, and Lalos (2004) in which women were asked to choose words expressing their feelings about an abortion when facing the procedure and one year later, only 11% selected "injustice," at the time of the procedure, but 24% chose the word one year after the abortion.
Feelings of guilt may take on an existential dimension that becomes more pronounced with time, leading to preoccupation with the ramifications of the abortion. For example, women who feel as though they really should have carried to term may find the guilt causing them to obsess on what the child's life would have been like. For those who experience abortion as traumatic and are guilt ridden, there may be continual self punishment and an inability and/or unwillingness to be free of the attendant guilt. Hess (2004) reported that many women who have experienced an abortion in the distant past felt as though they had been on an emotional roller coaster for decades and found themselves frequently thinking about their abortions and the children they never delivered. Similarly, in a study by Coleman and Nelson (1998), 73% of college women and 64% of college men whose partner had a past abortion reported having thought about what the child would have been like.
Many human behaviors that lead to feelings of guilt can be compensated for by apologizing to the offended party and/or by engaging in corrective behaviors; however, the finality of an abortion precludes engagement in such restorative behaviors to absolve one from guilt. Pregnancy termination is irreversible and if women are unable to come to terms with an abortion that evokes considerable guilt, the negative feelings may lead to more generalized feelings of self reproach and/or they may cause the individual to engage in negative behaviors targeted towards one's partner. As psychotherapist Kluger Bell (2000, p. 96) has noted "many women carry around unresolved feelings of guilt and shame which can tend to get expressed in self punishing thoughts and behavior." For example, a woman who is consumed by abortion related guilt may begin to feel as though she does not deserve to be happy or to be the recipient of a partner's love. As a result, she may consciously or unconsciously engage in antagonistic behaviors that lead to relationship problems.
Anger after abortion has only received scant attention; however a few studies have identified anger as one of various negative postabortion emotions (Kero et al., 2004). In the study by Kero et al. (2004), abortion related anger was reported by 13% of a sample as they faced the abortion and by 14% one year later. If a woman has a negative abortion experience, anger may be directed inward or outward. Externally projected anger could be targeted toward professionals involved in the abortion or significant individuals, such as a partner who is perceived as not having provided sufficient emotional support prior to, during, or after the procedure. Anger may also be logically directed at a partner because he encouraged or pushed for an unwelcome abortion. In addition to precipitating anger, guilt may cause psychological problems. Guilt has a well established history of an association with mental illness, particularly depression (American Psychiatric Association, 2000; Harder, 1995).
Grief involves a wide range of emotional and cognitive responses to a death (Wing et al., 2001) and it frequently draws the individual toward the missing person in response to awareness of the discrepancy between the way life is and the way one believes life should be (Parkes, 1993). Wing and colleagues (2001) note that the nonlinear nature of bereavement results in many individuals revisiting various components of their grief numerous times as they work their way through the process. Grief has been conceptualized as "a voyage of healing and a rebuilding of meaning and representations of self" (Hsu, Tseng, Banks, & Kuo, 2004, p. 409).
Williams (2000, 2001) provided evidence of a common grief response among women who aborted and described abortion as a distinct form of perinatal loss. In a study by Lloyd and Laurence (1985), 77% of women who terminated a pregnancy due to fetal malformation reported acute grief. Further, Coleman and Nelson (1998) found that approximately 30% of college students who had an abortion or had a partner who aborted agreed or strongly agreed with the following statement: "I sometimes experience a sense of longing for the aborted fetus" and in a study by Kero and colleagues (2004) approximately 20% of women described severe emotional distress in conjunction with an abortion, with 43% reporting grief right before the abortion and 31% reporting feelings of grief one year post abortion. In a study by Rue and colleagues, 33.6% of Russian women and 59.5% of American women who had an abortion responded affirmatively to the statement "I felt a part of me died." Only one study measuring male bereavement was identified (Kero & Lalos, 2004) and the results revealed that nearly 35% of those sampled reported feelings of grief and/or emptiness four months after a partner's abortion. Kero and Lalos concluded that abortion as a remedy for unwanted fatherhood was met with relief for many, but indicated that their data revealed the abortion was simultaneously deemed a "sad, ethically painful, and problematic act." (p: 141).
In an older study, White van Mourik, Connor, and Ferguson-Smith (1992) investigated the psychosocial sequelae of second trimester abortions for fetal anomalies two years post event. The authors found that most couples reported a state of emotional turmoil after the abortion with 20% of wives still complaining of crying bouts, sadness and irritability whereas husbands reported increased listlessness, loss of concentration, and irritability one year post event. The authors of this study concluded that a lack of synchrony in the grieving process, increased social isolation, and lack of communication resulted in marital disharmony in the aftermath of the abortion.
Bereavement is a complex and dynamic process marked by considerable individual variation (Wing et al., 2001); however healthy bereavement generally results in the ability to resume other relationships and engage in new ones (Heller & Zeanah, 1999). As noted by Ney and colleagues (1994), women who experience prolonged perinatal grief reactions indicative of unhealthy bereavement have difficulty thinking rationally about other aspects of their lives including relationships. Without sufficient opportunity to grieve a fetus lost through abortion, problems in relationships with partners may develop if one or both partners viewed the abortion as a loss.
No studies to date have examined feelings of post abortion grief as predictors of relationship problems occurring in the aftermath of abortion. However, one study indicated that up to 90% of bereaved parents separate or divorce within a year of a stillbirth or neonatal death (Schiff, 1986). Two of the most frequently cited reasons for marital discord after a nonvoluntary pregnancy loss are incongruent bonding and incongruent grieving. Women bond earlier to an unborn child than men (Mekosh Rosenbaum & Lasker, 1995); therefore at the time of the loss (whether nonvoluntary or voluntary), it is possible that the woman has a stronger connection to the fetus than the man and may be more inclined to suffer from a significant grief reaction.
If both partners do experience grief in association with an abortion, the nature and timing of their bereavement responses may differ considerably based on evidence of gender differences related to other forms of loss. For example, men tend to exert greater control over the expression of painful emotions, intellectualize grief, and cope alone; whereas females tend to be more expressive and employ process oriented forms of coping (Cook, 1983; Peppers & Knapp, 1980; Rollins, 1988; Wing et al., 2001). Men are also inclined to identify their primary role as supporter for their partners following perinatal loss (Puddifoot & Johnson, 1997). Puddifoot and Johnston (1999) found that although men displayed less immediate "active grief," they were more prone to frequent feelings of despair long after a perinatal loss than women. In a longterm study of paternal responses to perinatal loss, grief intensity diminished over time, but remained mild to moderate 5 years later (Wagner, Higgins, & Wallerstedt, 1997). Men are apparently more inclined to experience a chronic form of grief with perinatal loss, because they tend to be overlooked for support at the time of the loss (Lasker &Toedter, 1994). According to Wing et al. (2001), the source of much of the distress of incongruent grieving is the belief that people who are united by intense common experiences should process the grief similarly. There may also be misinterpretation of a partner's grief response. For instance, women may read the more stoic male response to be an indication that their partner was unbothered by the loss and/or does not care about their suffering (Wing et al., 2001). On the other hand, men may misinterpret the woman's need to frequently communicate openly as unnecessarily creating more pain and suffering for both of them (Wing et al., 2001).
There is evidence indicating that differences between a woman's and her partner's perinatal grieving of a nonvoluntary perinatal loss can introduce extreme conflict and stress in their relationship (Peppers & Knapp, 1980; Stierman, 1987). When post abortion responses are dramatically different, the potential for conflict would seem to be quite high. Even in the situation wherein both individuals experience grief, the nature and duration of each person's grief could be highly variable based on the degree to which they would have preferred to continue the pregnancy in addition to their views of abortion and the humanity of the fetus. Future research on post abortion relationships should explore the degree and nature of each individual's perinatal grief response while also examining each individual's perceptions and emotions regarding their partner's response to the abortion.
The best evidence indicates that a minimum of 20% of women who undergo an abortion experience report pronounced and/or prolonged psychological difficulties attributable to the abortion (Adler et al., 1990; Bradshaw & Slade, 2003; Major & Cozzarelli, 1992; Zolese & Blacker, 1992). Women who are negatively affected by an abortion may experience any of the following mental health problems: anxiety (Cougle et al., 2005; Moseley, Follingstad et al., 1981), depression (Coleman & Nelson, 1998; Cougle et al., 2003; Gould, 1980; Moseley et al., 1981; Reardon & Cougle, 2002; Thorp, Hartmann, & Shadigian, 2003), sleep disturbances (Barnard, 1990; Gould, 1980; Reardon & Coleman, 2006), substance use/abuse (Coleman et al., 2002; Coleman, Reardon, & Cougle, 2005; Reardon & Ney, 2000; Reardon et al., 2004; Yamaguchi & Kandel, 1987), and/or increased risk of suicide (Gissler, Kauppila, Merilainen, Toukomaa, & Hemminki, 1997: Reardon et al., 2002). A number of the studies pertaining to mental health effects of abortion have focused on anxiety and a recent review of the literature revealed that 8-40% of women experience anxiety in the aftermath of abortion, with up to 30% of women suffering from clinical levels of anxiety and/or high levels of generalized stress at one month post abortion (Bradshaw & Slade, 2003).
Compared to the amount of research on women's post abortion psychological responses, considerably less attention has been given to men's psychological adjustment to a partner's abortion. Nevertheless, the available data do indicate that male responses to a partner's abortion may include guilt, depression, anxiety, feelings of voicelessness/powerlessness, repressed emotions, and anger among other negative reactions (Coleman & Nelson, 1998; Coyle & Enright, 1997; Holmes, 2004; Rue et al., 2004; Shostak et al., 1984).
There are numerous mechanisms through which post abortion mental health problems may adversely affect relationships. Among the logical, yet to be studied relevant factors are reduced emotional energy, withdrawn behavior, communication difficulties, feelings of self doubt, limited personal control, or decreased self esteem, and/or blaming one's partner for suffering incurred. There is also a well established link between mental health problems, particularly anxiety, and substance use. The development or exacerbation of a substance use problem would be expected to increase the probability of relationship difficulties (Brady, Back, & Coffey, 2004; Jacobsen, Southwick, & Kosten, 2001). A final possibility is that individuals who suffer from postabortion psychological disturbances may dismiss the abortion as the cause of their suffering based on common views of abortion as a benign medical procedure and look for reasons for their suffering within the partnership. Research is needed to examine how post abortion psychological responses of venous forms in one or both partners may adversely affect relationship quality.
At this stage in the development of the literature, the prognosis for relationship problems post abortion seems quite probable if one or both partners view abortion as the taking of a human life, would have preferred to avoid the abortion, developed an emotional connection to the fetus, experience negative emotions such as grief, guilt, and anger in association with the abortion, and/or suffer from adverse mental health effects of the abortion. There are obviously many other variables that may play a role in the association between abortion and relationship quality, including various relationship factors (e.g., length, commitment, respect, trust/loyalty/dependability, and open communication), religiosity, whether or not the couple already has children together, history of previous perinatal losses, and personality characteristics to name a few. The cloak of silence surrounding abortion has left couples, some of whom may very well be at an increased risk for experiencing relationship difficulties, struggling alone to understand and respond to relationship challenges in the aftermath of abortion. An essential first step toward change is open acknowledgment of the dark potential of abortion to disrupt individuals' lives and wreak havoc on intimate bonds. Like an insidious cancer, the destructive nature of abortion often lives on in the hearts of men and women long after the life of their fetus has ended.