It is of particular importance to identify abortion risk factors in adolescents not only for counseling and public policy reasons, but also to assist judges to determine whether or not an abortion may be in the "best interests'' of an adolescent. Over one-fourth of the abortions in the U.S. are performed on women under 20 years of age, yet few studies compare adolescents with adults in their ability to cope with abortion.
Campbell, Franco and Jurs (1988) in a study at the Medical College of Ohio compared 35 women who had their abortions as teenagers with 36 women who had abortions after the age of 20. They found that teenagers were significantly more likely to report marital difficulties in their family of origin, to attempt suicide after abortion, to have severe nightmares following abortion, and to be less likely to report being coerced into abortion. In addition, the adolescents had significantly higher scores on scales measuring antisocial traits, paranoia, drug abuse, and psychotic delusions. The authors concluded that adolescents are more likely to use immature defenses such as projection, denial or "acting out" after abortion and that these immature coping defenses might become permanent.
Barglow and Weinstein (1973) observed the effects of abortion in adolescents compared with adults and concluded that two major factors distinguish the adolescent emotional response to abortion. First, the abortion decision is more often controlled by parents, peer group or sexual partners. Secondly, developmental immaturity contributes to ambivalence about the decision, to a distorted perception of the procedure, and to a variety of pathological reactions. Other important differences have also been found. Lewis (1980) found that adolescents are less likely to consult with a professional regarding their pregnancies and are more likely to see their pregnancy decision as externally 'compelled'. Smith (1973) found that teenagers are more likely than adults to be ambivalent about their abortion decisions and have an abortion at a later stage of gestation. Margolis et al. (1971) also observed ambivalence and guilt following abortion more often in young women under 18 years of age than in those who were older.
Franz and Reardon (1990) completed a study of 252 women from a support group for women (Women Exploited by Abortion) who suffered negative effects of abortion. Thus, the women were self-selected by joining the support group. The subjects' abortion had occurred an average of ten years earlier. The sample was separated into those having their abortion under the age of 20 and those over the age of 20. The average age at the time of abortion was 21.2 years and varied from 12-40. 3% of the women were under 15, 42% were 15-19, 33% were 20-24, 14% were 25-29 and 8% were 30 years or older. The average age at the time of the survey was 31.2 years and ranged from 16-64 years. The longest time since abortion was 36 years. The least time since the abortion was 7 months. 87% of the sample was white, 92% of the abortions were legal. Only 17% of the women were married at the time of the abortion; 65% were single, 8% were engaged and 11% were separated. Adolescents, defined as women of less than 20 years of age, were significantly more likely to report greater severity of psychological stress (t = 2.75, p < .006), to feel they were misinformed during counseling (t = 2.10, p < .04), and to prefer to keep the baby (t = 1.92, p < .056). The fact that adolescents were more likely to report receiving misinformation could be due to the fact that adolescents have a greater difficulty in understanding and integrating complex information, such as that involving a decision to abort. It is possible that correct information was given or inferred but the adolescents did not understand it. It is also likely that adolescent egocentrism might hinder adequate counseling efforts. Barglow and Weinstein (1973) also found that adolescents in particular "forgot" detailed information on abortion procedures carefully given only minutes before which was attributed to being overwhelmed by anxiety and over stimulation of the experience.
Adolescents were significantly more likely to report, to feel they were misinformed during counseling and to prefer to keep the baby.
Other findings from this study have implications for counseling adolescents considering abortion. A report of "worsened self-image" was significantly related to being least satisfied with the choice at the time (x2 = 59.7, p < .0001), being least satisfied with the services at the time of abortion (x2 = 45.85, p < .007), feeling extreme pressure to have the abortion (x2 = 52.54, p < .001), having the least well-thought-out decision (x2 = 53.25, p < .0008), believing they had received the least information (x2 = 83.55, p < .0001) and very much wanting to keep the baby (x2 = 53, p < .0008). Wallerstein (1972) also found that adolescents had lowered self-esteem explicitly related to the pregnancy and abortion experience. Since adolescents are so heavily involved with establishing a self-image, the possibility of the abortion experience to act as a factor in "worsened self-image" is of great importance. The abortion experience could delay the development of an identity. Counseling procedures should not pressure adolescents into the abortion decision or make them feel they don't have adequate time and information to make an informed decision. (Borten, 1987) This is particularly difficult with adolescents due to their tendency toward egocentrism and difficulty in reasoning in the abortion context.
In addition, age at the time of abortion was significantly correlated with "time since the abortion" (r = .70, p < .0001). The younger the woman was at the time of her abortion, the longer the time until she sought help for post-abortion problems. Age at the time of the abortion was also correlated with satisfaction today (r = .13, p < .03). That is, the younger the woman at the time of her abortion, the least satisfied she was later. These data suggest that the adolescent is apt to deny her problems longer than the older woman and to be more negatively affected by the decision.
A series of t-test comparisons of significance (p= .05) were made between adolescents and older women. The adolescents were significantly more likely to have a long time lag between the abortion and the survey (t = 2.20, p < .03), to have abortions later in the gestational period (t = 2.16, p < .04), to be less satisfied with services at the time of abortion (t = 2.49, p < .01), and to feel forced into the abortion (t = 3.40, p < .0008). These data indicate that adolescents are less apt to want to abort. This was largely confirmed in the total sample of 252 women as 84% said that their pregnancy would not have resulted in abortion if they had been encouraged differently. (Reardon, 1987) This may be typical for young people who often have less actual control over their lives than adults. The lack of control appears to be associated with longer periods spent in denial and with greater psychological stress. A failure to accept the reality of the abortion experience has been shown to interfere with natural grieving processes, which in turn has been associated with post abortion psychological problems. Thus, adolescents may be at greater risk for problems following abortion than older women.
Women were asked the amount of time taken to make a decision to have an abortion. 52% took from one to four days, 24% took one week, 12% took 2 - 3 weeks, 6% took 4 - 6 weeks and 5% reported that it took longer than 6 weeks to decide. Women who reported being rushed the most to have the abortion, i.e. one week or less to decide (x2 = 48.41, p < .003), also reported the greatest severity of psychological problems. (x2 = 48.42, p < .003)
Adolescents tend to be strongly dependent on environmental feedback to establish their sense of who they are and the impression they make on others. Thus, the adolescent personality tends to be heavily dependent on external sources for assurance of its qualities and characteristics. However, the young person has a strong sense of dualism: an inner me and an external me. At this age, it is possible for the person to be aware of an internal "unique, special me" being covered up by an external "proper me". They express frustration that the "true inner me" is not given proper recognition; hence the need to engage in anti-social activities to goad parents and influential adults into a closer examination of their real qualities. (Broughton, 1978)
This tendency in young people has important implications for post abortion counseling. If a teenager has had an abortion, she may be covering up this fact as a part of her hated inner reality. She may perceive all of her interactions with concerned others as superficial and not involving her real self. She may struggle to maintain the separation of the two elements of her being, while, at the same time desiring integration. She may have difficulty accepting responsibility for the needs and problems of her inner self, claiming that her proper, external self didn't agree to the irresponsible actions.
On the other hand, she may perceive the abortion to be something that happened to the minor, unimportant, outer self. Thus, the adolescent is in a position to ignore the importance of the abortion, since it has not touched the essential "inner self". This attitude could produce the characteristic pattern of teens in which they appear to go through the abortion without any problems and with hardly a backward glance. For this immature person, the abortion can be inconsequential. It is possible that the process of maturing helps to trigger knowledge and understanding that forces the young person to grow up. So, the developmental process could be linked to the awareness of the denial regarding the seriousness of the abortion experience. That is, the young woman may at some point go through the process of changing her view of herself as someone who has merely "had an abortion" to someone who has participated in the "destruction of her child".
Due to adolescent egocentrism an adolescent social environment may have reality only in so far as it provides her with feedback about her own personality. She misinterprets many social interactions as being directed entirely toward her inner reality. She cannot conceive of other people having needs and problems which may be motivating their behavior. She sees everything in terms of her own agency and causation.
Every action is carried out in order to see how others respond to it, a response called the "imaginary audience". Clothes are chosen to see what response they will bring in others (shock, approval, envy, etc.), not necessarily how effective they look. The same system applies in interpersonal relations. The date to the school prom is chosen to enhance prestige with the group and to boost the ego. Dating during adolescent years is carried out more to discover the identity of the self than of the date.
The young couple will spend hours preparing for the evening out. The clothes will be carefully chosen and the hair correctly combed. And when these young people meet, they will look into each other's eyes and see - not the other person, but the response to all the effort they have made. Like looking into a mirror, they see only themselves. They both have a need to receive affirmation. They have no understanding of a mutual relationship or of giving of themselves in unselfish love. This is entirely appropriate, since it is the primary developmental task to come to a better understanding of self. Once the self is fully grasped, it is then possible to establish a truly mature, mutual relationship with another person.
For the teenager who has had an abortion, this orientation can give a very distorted view of the causative factors impacting on her behavior. She may be inclined to blame others for her behavior, because she perceives them as functioning only for her. For example, she isn't responsible for getting pregnant, it's her mother's fault for not providing her with contraception, etc. It will be particularly difficult for the adolescent to accept responsibility for her own decision to have an abortion and, consequently, for any problems that occur afterward. Since she didn't plan to get pregnant, "it just happened." Therefore, she has no responsibility for it.
The adolescent girl who has had an abortion may find it very difficult to admit personal responsibility for problems. She will be inclined to blame others for her unhappiness, because she couldn't possibly be responsible herself. She perceives her life in terms of a "personal fable". (Elkind, 1967) She is so special that negative events won't ever happen to her. The statistics that apply to others can't possibly apply to her case. She will deny that she has a problem or that she could develop one. If she is engaging in self-destructive behavior, she will deny that the root cause may be her abortion experience.
An examination of the effects of an adolescent decision to abort suggests that it could destroy the young person's ability to mature and grow in a normal way. The adolescent is naturally inclined to be self-involved and egocentric, which pre-disposes a teenager to have an abortion. The adolescent is not able to conceptualize the long-range implications of the abortion decision or to take responsibility for them, (Piaget, 1954) and thus, is in a position to deny both the responsibility for her actions and the negative after-effects of the abortion. The teenage aborter is most likely to experience abortion with few apparent negative after-effects because she can so easily deny all personal involvement. Because of her interior dichotomy, 'others'’ influence on her inner self is the scapegoat, while her outer self hides the guilt under day-to-day activities.
To encourage the adolescent to abort may lead to delays in normal maturational processes.
Normal grieving is required for the maturing of the individual which requires a passage of time. A mature developmental level requires self control and self responsibility which allows for realistic assessment of one's actions. A delay between the abortion event and the emergence of post abortion syndrome may well be related to developmental changes in the individual woman. To encourage the adolescent to abort therefore may lead to delays in normal maturational processes.
Dr. Franz is a developmental psychologist and professor of child development and family relations at West Virginia University. She has been a consultant to various agencies of the Federal Government and has testified before the US. Congress on child development and issues related to abortion.
Barglow, P. and Weinstein, S., Therapeutic Abortion During Adolescence: Psychiatric Observations, J. Youth and Adolescence 2 (4): 331 (1973)
Borten, Max, MD., Induced Abortion in Obstetrical Decision Making, 2nd Ed., Friedman, E.A. et al (1987) p. 44
Broughton, J. Development of Concepts of Self, Mind Reality, and Knowledge, (1978). New Directions for Child Development, 1, 75-100
Campbell, N., et al Abortion in Adolescence, Adolescence Vol. XXII, No. 92, Winter 1988, p. 813-823
Elkind, Egocentrism in Adolescence, Child Development 38: 1025-1034 (1967)
Franz, W, and Reardon, D., Negative Effects of Elective Termination of Pregnancy in Adolescence, Presented at the annual meeting of the National Council on Family Relations: Seattle, Washington, Nov. 13, 1990
Lewis C., A Comparison of Minors and Adults Pregnancy Decisions, Am. J. Ortho Psychiat. 50 (3): 446-452, July 1980
Margolis et al, Therapeutic Abortion: Follow-up Study, Am. J. Obstet. Gynecol 110: 243-249 (1971)
Piaget, J. (1954). The Constructions of Reality in the Child. New York: Basic Books
Reardon, David, Aborted Women: Silent No More (1987)
Smith, E. M., A Follow-up Study of Women Who Request Abortion, Am. J. Orthopsychiatry, 43: 574-585, (1973)
Wallerstein, Judith, Psychological Sequelae of Therapeutic Abortion in Young Unmarried Women, Archives of Gen. Psychiatry, 27: 828-832, Dec, 1972.
Health issues in Adolescent Pregnancy Decision-Making