I would like to begin with a true story of someone I know. She has told her story publicly and has given me permission to share it, but for her privacy I'll call her Donna, which is not her real name.
When Donna was 17 years old, she was in her last year of high school. She was engaged to be married. Her fiancée had a job which required him to go away for training. While he was away, Donna discovered she was pregnant. She was happy about the pregnancy. She wanted her baby.
But when her mother found out about the pregnancy, she told Donna that she could not live at home and remain pregnant. That would be an embarrassment to the family. Donna did not have a job and could not find another place to live. Her mother made an appointment at an abortion clinic.
Donna went to the clinic and told the nurse and the doctor clearly: "I do not give consent for this abortion. I want my baby." But she was not of legal age, and her mother had signed for and paid for an abortion, and the abortion was done. In order to accomplish this, it was necessary for Donna to be drugged and to be pushed down forcibly on the table.
Is anyone surprised to learn that Donna had psychiatric problems for 12 years after this forced abortion?
There are several aspects of Donna's experience I want to call to your attention.
Donna was forced into an abortion she did not want.
But Donna is not the only person with this type of experience. I personally know others who were physically forced, and others who were strongly pressured in many ways. Many young women are told that they cannot live at home if they continue the pregnancy, or that their parents will cut off their college funds. A 2004 study in Medical Science Monitor revealed that 64% of a general gynecology population in the U.S. said they felt pressured to have an abortion1
Abortion doctors know that some women are coerced, and they know that coercion can lead to negative mental health outcomes.
The text book A Clinician's Guide to Medical and Surgical Abortion lists several types of negative reactions that women may have after abortion, including depression, guilt, shame, and unresolved grief2.
The book gives a list of issues that may predict increased risk for negative outcomes. The book cites research showing that women who are coerced or who feel they are being coerced have more negative outcomes. It says that "perceived coercion" puts women at increased risk for mental health problems3.
The Beijing Declaration and Platform for Action condemns all violence against women, and states that forced abortion is a form of violence against women4. The declaration also clearly states that women have the right to make reproductive decisions free of "coercion"5 but in reality women today have no protection against coercion in nations where abortion is legal.
Non-violent coercion often escalates to actual physical violence under the real world conditions of legal abortion in the United States. Research shows that pregnant women are at increased risk of being physically attacked6,7,8, or murdered. Homicide has become the leading cause of death among pregnant women9,10,11,12. In many cases, women have been assaulted or killed for refusing to abort or because the attacker did not want the baby. Many women who experienced violence during pregnancy reported being punched or kicked in the abdomen, usually by the father of their unborn baby13.
There seems to be a continuum of pressure of varying degrees that often makes it difficult or impossible for women to make the free choice to carry a pregnancy to term even though they desire the baby they are carrying. Whether or not they are physically forced, threats of homelessness or other pressures often cause women to abort wanted babies.
As we have seen, Donna clearly wanted her baby, and that is true for many women, that the baby was wanted, though abortion was chosen. In one study, 17.7% of U.S. women reported that pregnancy was "desired" even though abortion was chosen14. While more study is needed to know the true extent of this problem, the published literature confirms the individual reports of many women: wanted babies are being aborted15.
The Beijing Platform for Action clearly states that women should be fully informed regarding their reproductive options including likely benefits and potential side effects16. But often, pertinent information is not shared with women prior to decision making.
The Clinician's Guide lists many issues that predict worse outcomes, in addition to coercion17. For example, if the woman already has mental health problems, she is more likely to have adverse effects from the abortion18,19. But women with psychiatric problems are often advised to have abortions in the false belief that their illness may be helped by eliminating the pregnancy. They are not cautioned that their psychiatric illness is more likely to be worsened by the abortion.
One major new study using U.S. data from the National Comorbidity Survey (a large, nationally representative data set with many controls) showed that abortion was a risk factor for more than a dozen different psychiatric diagnoses in women20. The results were statistically significant. Just as cigarette smoking is a risk factor for a host of illnesses, including lung cancer, chronic bronchitis, emphysema, and more, so abortion increases women's risks for psychiatric disorders including major depression, panic disorder, posttraumatic stress disorder, substance use disorders, and more21.
Here is another interesting finding from this study. All of us intuitively understand that rape is a serious stress for any woman, and we can easily accept that rape places women at risk for psychiatric illness such as posttraumatic stress disorder (PTSD). Interestingly, this study using the data from the National Comorbidity Survey showed that abortion was a risk factor for more different psychiatric disorders than rape22.
However, it's not only one study, but many statistically significant studies published in peer reviewed journals with statistically significant results that demonstrate that abortion puts women at risk for mental health problems23. The website http://www.standapart.org has one bibliography listing more than 40 such studies, and additional studies have been published since that bibliography was posted in 200824.
In the interests of women being "fully informed" about their reproductive options, as mandated by the Beijing Declaration and Platform for Action, one would expect that women would be informed about these known potential side effects of abortion, and that women would receive an unbiased risk assessment as to whether or not they personally would be at increased risk for mental health problems, for example, due to any pre-existing psychiatric problems that may be exacerbated by an abortion.
However, contrary to the expectations of the Beijing Declaration and Platform for Action, some international abortion advocacy organizations have at times attempted to prevent women from accessing full information on these side effects, for example in attempting to promote legislation that would place limits on the information that can be communicated to women who are seeking information about abortion. These organizations frequently oppose legislation that would establish women's rights to full information.
Sadly, in one study, only 11% of American women reported that they believed they had received adequate counseling before their abortion25, indicating a serious need for more information, not less.
Many cases are known in which young women are sexually abused and then taken by the perpetrator for abortion, in some cases, multiple abortions over a period of time. It is likely that if abortion were not available as a means to cover up the sexual abuse, the pregnancy of the minor child would eventually in due course alert parents or other adults to the fact of the abuse which would no longer be possible to conceal. Instead, the abortion allows the fact of the sexual abuse to be concealed, and the young women bear the burden of sexual abuse over a prolonged period of time as well as the repeated trauma of an abortions they may not have requested or wanted26.
Understanding the pre-abortion decision-making process sheds light on the reasons that some women have serious psychiatric problems after an abortion.
The American Psychological Association (APA) published a report in 200827 which gave a carefully worded conclusion that seems at first glance to indicate that abortion harms no one. But it is critically important to examine carefully what the report says and doesn't say.
In reading it carefully, we see that the APA Task Force on Mental Health and Abortion intended their conclusion to apply only to women aborting an unwanted pregnancy, acknowledging that "women terminating a wanted pregnancy," those "who perceived pressure from others to terminate their pregnancy," and those had "feelings of commitment to the pregnancy" have more negative effects28. However, in the real world many women are in the position of aborting wanted babies and are being pressured into unwanted abortions. The conclusion of "no mental health problems from abortion" does not apply to these women.
Likewise, this conclusion was not intended to apply to women struggling with the aftermath of a forced abortion, or to those young women who have had forced abortions due to pregnancy resulting from childhood sexual abuse.
The APA Task Force on Abortion and Mental Health was also very clear that their conclusion applies only to "adult women" and not teens29,30. It is so widely accepted that teens are at higher risk for mental health problems after abortion that this was stated in a 1993 Planned Parenthood Fact Sheet31 which identified a list of risk factors similar though not identical to that found in A Clinician's Guide to Medical and Surgical Abortion. The APA Task Force on Abortion and Mental Health was clear in acceptance of this earlier finding, in that their own conclusions were stated as applying only to adult women32,33.
Additionally, the conclusion applies only to women having a "single abortion," thereby excluding women who have repeat abortions, although the Guttmacher Institute reports that these represent 48% to 52% of all U.S. abortions, and in fact, the Guttmacher Institute reports that 72% of abortions in the state of Maryland were repeat abortions34. (Guttamcher Institute also reports that other nations have high rates of repeat abortion, some higher and some lower than the U.S.) Of concern, the APA report presents evidence that those who have multiple abortions also have more mental health problems, which was the reason the report stated the conclusion applied only to women having a "single abortion"35.
Another problematic issue is that of pre-existing mental health problems. The APA report clearly states that women with a "prior history of mental health problems" have more problems after abortion36. This is consistent with research cited by earlier authors in A Clinician's Guide to Medical and Surgical Abortion37. If indeed these women represent a subgroup more likely to have problems, why is there no routine screening for this and other risk factors, along with an informed consent process that allows women to honestly evaluate their risks in advance of the procedure.
In any case, it is clear that in order to make a statement indicating that abortion causes no problem, it was necessary to exclude the majority of all women from the stated conclusion. The conclusion stated by the American Psychological Association, if true, applies to only a small minority of women who have abortions since it
Interestingly, the authors of the report also had to omit or dismiss a large percentage of the world literature on abortion in order to arrive at a conclusion of "no harm" from abortion. A 2007 study from South Africa, not included in the APA Task Force report, showed an 18% rate of posttraumatic stress disorder three months after abortion41. The authors pointed out that this was almost one in five women, and they considered this a high rate of PTSD, and a matter for concern.
This study involved the physicians directly involved in carrying out the abortion procedure at a Marie Stopes abortion clinic. This study compared use of two different anesthesia protocols to see whether one type of anesthesia or another would reduce the high rate of PTSD they were already observing, but results showed 18% of the women had PTSD at three months, no matter which anesthesia was used.
Ignoring the findings of the South African researchers, the APA Task Force report dismisses the notion that some women experience Post-Traumatic Stress Disorder following abortion, though the 1987 of the diagnostic manual used by psychiatrists, the DSM-III R, identifies abortion as an example of a stress42.
The APA report also disparages the term "Post-Abortion Syndrome," but some historical perspective is helpful in this regard.
It is widely known that in the late 19th and early 20th century, psychiatrist Sigmund Freud received reports of incest and sexual abuse from many women, but he refused to believe the truth of these reports. Today, we know that many women even in so-called good families experience incest and sexual abuse, and women are encouraged to report these experiences and to receive help. A wide variety of support groups, self-help books and various treatments are now available to help women to recover from the affects of sexual abuse.
However, when women report problems associated with a past abortion, their reports often are not believed, or the symptoms are trivialized by providers who do not wish to acknowledge the truth of the women's experience. In a sense this is in a sense history repeating itself.
In some ways, the history of women's response to breast cancer gives further insight. When medical doctors failed to respond to women's emotional issues concerning lost of a breast or the stress of living with cancer, it was the women themselves who initiated the many breast cancer support groups which now exist today.
Similarly, women who have had abortions are in the position of establishing the thousands of abortion recovery groups which now exist throughout the world, many of which are listed online at the Abortion Recovery Care Directory43 and at the National Helpline for Abortion Recovery44.
The diagnosis of posttraumatic stress disorder did not exist in early editions of the diagnostic manual used by psychiatrists prior to 1980. During World Wars I and II, when men came home from the battle front having survived horrific experiences, they were originally described as suffering from "shell shock" or "battle fatigue," in the days before precise diagnostic criteria and an appropriate name for this disorder had found its way into the professional literature.
In the early days of describing the effects that many women experience after abortion, their "shell shock" was originally labeled "Post-Abortion Syndrome" (PAS). Over the past few decades, many post-abortive women do in fact meet criteria for posttraumatic stress disorder, so that when research is conducted, women are studied in regard to posttraumatic stress disorder and other established psychiatric diagnoses.
In returning to the APA Task Force report, we have seen that they have stated a conclusion that applies only to a small minority of the real women who have abortions, and in addition, that they have dismissed or omitted pertinent studies. One additional point is that in formulating their final conclusion, the Task Force chose to rest their conclusion on one study only. This is unusual, since all studies may have some flaw, but the whole body of evidence must be taken together so that the flaws are balanced out from one study to another. But in this case, having dismissed or failed to include numerous studies from peer reviewed journals, they rest their final conclusion on one study alone (Gilchrist, 1995)45, a study which has in fact many problems including a dropout rate of more than 50% of the participants, with unequal dropout rates between the various comparison groups.
In fact, although this one study is cited by the APA report as demonstrating lack of harm from abortion it seems to show the opposite. Among women with no past history of psychiatric illness, "the rate of deliberate self-harm was significantly higher (70%) after abortion than after childbirth"46.
Several of the APA's own reviewers strongly disagreed with the conclusion of the report47,48. Researcher David Fergusson compared the APA's defense of the abortion industry to that of the tobacco industry in having defended cigarettes as safe, without evidence of safety49.
Many women do in fact experience unwanted abortions under conditions of varying degrees of pressure, coercion or force. Many women experience uninformed abortions, with very inadequate counseling if any. These women have no awareness about possible harmful effects of abortion, no information about the full range of options available to them of babies they want, and no information about their own risk factors for possible adverse reactions.
It is essential that harmful mental health effects be acknowledged and that true informed consent be provided rather than allowing women to be rushed into an uninformed decision. Additionally, women must be evaluated to determine whether they are being pressured, and evaluated as to whether they have risk factors for increased problems after abortion.
However, whether it is possible for women to receive true informed consent within the context of an international multi-billion dollar unregulated abortion industry, remains to be seen. Likewise, it appears to be very difficult if not impossible to assure freedom from pressure, coercion and force in the situation of legal abortion as it is practiced in many nations.
Finally, effective treatments must be developed for the millions of women worldwide who have already suffered the harmful mental health consequences of abortion. However, considering the high percentage of women who experience adverse mental health effects, many experts believe that helping women to avoid abortion is a much healthier and safer choice.
2 Baker A, Beresford T, Halvorson-Boyd G, Garrity JM. (1999). Chapter 3, Informed Consent, Counseling, and Patient Preparation. In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, and Stubblefield PG (Eds.). A Clinician's Guide to Medical and Surgical Abortion (pp. 28-29). Philadelphia, PA: Churchill Livingston. [Back]
4 Beijing Declaration and Platform for Action, Fourth World Conference on Women, 1995. United Nations. Paragraph 115. URL: http://www.un.org/womenwatch/daw/beijing/platform/ (accessed March 6, 2010). [Back]
5 Beijing Declaration and Platform for Action, Fourth World Conference on Women. (1995). United Nations. Paragraphs 95-96. URL: http://www.un.org/womenwatch/daw/beijing/platform/ (accessed March 6, 2010). [Back]
12 Curtis K, Murder: the leading cause of death for pregnant women, Associated Press (April 23, 2003), Available at the webpage of the National Organization of Women: http://www.now.org/issues/violence/043003pregnant.html (accessed March 4, 2010). [Back]
16 Beijing Declaration and Platform for Action, Fourth World Conference on Women. (1995). United Nations. Paragraph 106. URL: http://www.un.org/womenwatch/daw/beijing/platform/ (accessed March 6, 2010). [Back]
17 Baker A, Beresford T, Halvorson-Boyd G, Garrity JM. (1999). Chapter 3, Informed Consent, Counseling, and Patient Preparation. In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, and Stubblefield PG (Eds.). A Clinician's Guide to Medical and Surgical Abortion (p. 29). Philadelphia, PA: Churchill Livingston. [Back]
19 American Psychological Association, Task Force on Mental Health and Abortion. (2008). Report of the Task Force on Mental Health and Abortion. Washington, DC: Author. URL: http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf [Back]
20 Coleman PK, Coyle CT, Shuping M, Rue VM. (2009). Induced abortion and anxiety, mood, and substance abuse disorders: isolating the effects of abortion in the national comorbidity survey. Journal of Psychiatric Research 43, 770-776. doi:10.1016/j.jpsychires.2008.10.009 [Back]
26 Elliot Institute, "Forced Abortion in America" Available at: http://www.afterabortion.org/vault/ForcedAbortions.pdf (accessed March 4, 2010). [Back]
27 American Psychological Association, Task Force on Mental Health and Abortion. (2008). Report of the Task Force on Mental Health and Abortion. Washington, DC: Author. URL: http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf [Back]
30 American Psychological Association. (2008). APA task force finds single abortion not a threat to women's mental health. Press Release August 12. URL: http://www.apa.org/news/press/releases/2008/08/single-abortion.aspx [Back]
32 American Psychological Association, Task Force on Mental Health and Abortion. (2008). Report of the Task Force on Mental Health and Abortion. Washington, DC: Author. URL: http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf [Back]
33 American Psychological Association. (2008). APA task force finds single abortion not a threat to women's mental health. Press Release August 12. URL: http://www.apa.org/news/press/releases/2008/08/single-abortion.aspx [Back]
34 Jones RK, Singh S, Finer LB, Frohwirth LF. (2006). Repeat Abortion in the United States. Occasional Report No. 29, November 2006. Guttmacher Institute. URL: http://www.guttmacher.org/pubs/2006/11/21/or29.pdf (accessed March 8, 2010). [Back]
35 American Psychological Association. (2008). APA task force finds single abortion not a threat to women's mental health. Press Release August 12. URL: http://www.apa.org/news/press/releases/2008/08/single-abortion.aspx [Back]
37 Baker A, Beresford T, Halvorson-Boyd G, Garrity JM. (1999). Chapter 3, Informed Consent, Counseling, and Patient Preparation. In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, and Stubblefield PG (Eds.). A Clinician's Guide to Medical and Surgical Abortion (p. 29). Philadelphia, PA: Churchill Livingston. [Back]
39 Operation Outcry. URL: http://www.operationoutcry.org/pages.asp?pageid=61373 (accessed March 8, 2010). [Back]
41 Suliman S, Ericksen T, Labuschgne T, de Wit R, Stein D, 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 2007, 7:24 doi:10.1186/1471-244X-7-24 Accepted: 12 June 2007. [Back]
46 Coleman PK. "Does Abortion Cause Mental Health Problems?" (2008). URL: http://www.standapart.org/images/uploads/Coleman_causation__tables_reformatted_-_final.doc (accessed March 8, 2010). [Back]
47 Coleman PK. "Does Abortion Cause Mental Health Problems?" (2008). URL: http://www.standapart.org/images/uploads/Coleman_causation__tables_reformatted_-_final.doc (accessed March 8, 2010), citing Gilchrist, A. C. et al (1995). Termination of pregnancy and psychiatric morbidity. British Journal of Psychiatry 167, 243. [Back]
48 Throckmorton, Warren. "David Fergusson reacts to the APA Mental Health and Abortion task force report" Blogpost Aug. 13, 2008. http://wthrockmorton.com/2008/08/13/david-fergusson-reacts-to-the-apa-mental-health-and-abortion-task-force-report/ (Accessed March 8, 2010). [Back]