Recent Research on the Adverse Psychological And Social Effects of Induced Abortion
Thomas W. Strahan

Association for Interdisciplinary Research in Values and Social Change
Vol. 11 No. 2 May/June 1997
Reproduced with Permission

This article describes some of the recently published studies on the psychological and social effects of induced abortion. Many of these studies were on populations outside of the United States. The reason is because this is where the vast majority of research on the effects of induced abortion is being done at the present time. These recent studies are examples of the growing body of literature on the adverse psychological effects of induced abortion.

Commitment to the Pregnancy as a Factor in Pregnancy Decision-Making And in Post-abortion Negative Psychological Reactions

Pregnancy Decision-Making as a Significant Life Event: A Commitment Approach, John Lydon, C. Dunkel-Schetter, C.L. Cohan, T. Pierce, Journal of Personality and Social Psychology 71 (1): 141-151, 1996

In this study, women from Los Angeles and Montreal were interviewed at a health clinic prior to receiving pregnancy test results (T1) and within 9 days after receiving test results (T2). A third interview was conducted 4-7 weeks after the pregnancy test (T3). At T1 and T2 participants responded to questions regarding intentionality of the pregnancy, the meaning of pregnancy, commitment, affective states, pregnancy concerns and wantedness of the pregnancy. The questions were repeated at T3 for those who had not aborted the pregnancy. Questions about smoking behavior were asked of all women at T1 and T3, where women were asked to report their smoking status. If they reported currently smoking, they were also asked how many cigarettes per day they had smoked.

It was found that feelings of commitment were highly predictive of actual behavior. Those who had aborted, and those who felt relatively more committed to the pregnancy, reported fewer positive and more negative reactions. Concerns about the pregnancy, religiosity, and wantedness were examined as potential correlates of commitment. Women, who reported that the pregnancy created concerns about their future goals, reported lower levels of commitment than did those who did not report such concerns. Women, who reported concerns about the baby's health, reported greater commitment. The importance of religion (but not religious background) correlated with commitment. Also, the wantedness of the baby correlated highly with commitment. The number of abortions a woman had had prior to her commitment to the current pregnancy was significantly positively related to the current pregnancy, but the number of live born children was not significantly related to commitment to the pregnancy.

For those continuing the pregnancy, commitment engendered anxiety about a current goal or life task, i.e. having a baby. In contrast, for those aborting the pregnancy, commitment engendered feelings of depression, guilt and hostility about terminating the pregnancy. The patterns of responses among women who had the highest commitment score but still aborted found that feelings of depression, hostility and guilt were initially modest while anxiety was at ceiling. A month later, anxiety had dropped but instead depression, hostility and guilt had increased.

Women who carried to term decreased their smoking behavior while those who had abortions did not do so.

The decision to continue the pregnancy was associated with a significant decrease in smoking, from T1 to T3, - based on self-reported behavior that would facilitate a more successful pregnancy outcome. On the other hand, those who aborted the pregnancy did not report a change in smoking behavior. Moreover, those who continued their pregnancy reported less smoking at T3 compared to those who aborted their pregnancy.

Comments: This is one of the very few studies which initiated research prior to the women being aware of her pregnancy and prior to any pregnancy decision. For that reason alone it should be treated more seriously than other studies.
This study found that among those women, who chose to carry to term, cigarette smoking decreased, while those who had abortions did not report any decrease in smoking behavior. This is the first direct evidence that the pregnancy decision itself influences smoking incidence among women.
This study is also consistent with the growing body of research, which has recognized that negative post-abortion psychological reactions are more likely to occur if the woman has a higher degree of attachment to her unborn child. For example, an earlier study (Congleton and Calhoun, 1993) found that women, who reported post-abortion distress, were more likely to report a sense of loss or emptiness or desire to replace the lost fetus, compared to women not reporting post-abortion distress. Similarly, a 1995 Canadian study (Conklin and O'Connor, 1995) found that women, who have had an abortion and who tend to believe fetuses are human, scored lower on well-being variables than women, who had not had an abortion.
This study also made an important finding that prior abortion increased the woman's commitment to the current pregnancy. The study also found that greater commitment to the pregnancy resulted in more negative affect, if the woman aborted her current pregnancy. This is consistent with other studies, which have demonstrated that psychological and social health and wellbeing is worsened as abortion is repeated.

Women Seeking Repeat Abortion

Repeat Abortion: A Comparative Study, M. Tornbom, E. Ingelhammar, H. Lilga, A. Moller, B. Svanberg, Journal of Psychosomatic Obstetrics and Gynecology 17: 208-214, 1996

A Swedish study published in 1996 on women, age 20-29, living in central Goteborg, Sweden, in 1988, compared women applying for a repeat abortion to those applying for abortion for the first time. The study also compared women seeking abortion to women who were continuing their pregnancies to term. The reason for the study was that, despite family planning programs, the incidence of induced abortion was rising steadily in the area. The study found: (1) The women carrying to term had a more stable lifestyle with a significantly greater number having a lease on their apartments (86% vs. 56%), were more likely to live in private homes and had a better day-to-day economic situation compared to women seeking abortion. (2) Women applying for a repeat abortion had a significantly higher prevalence of psychological problems (45%) compared to women seeking abortion for the first time (25%), or women carrying pregnancies to term (21-23%). (3) Women applying for a repeat abortion had a significantly higher percentage, who had contact with the social service system (44%) compared to women seeking abortion for the first time (21%), or women carrying to term (24%). (4) More than one-half of those seeking abortion stated their decision was difficult or very difficult compared to only 4%-6% of those carrying to term. (5) Women seeking abortion were significantly more likely to report an unstable relationship with their partner (27%) compared to women carrying to term (3.5%). (6) Women repeating abortion were less satisfied with their relationship with their partner than women carrying to term. The authors of the study concluded that women applying for repeat abortion need social and psychological support at different levels based upon the experience of the woman.

Comments: This study is well designed, because it compares two types of women seeking abortion (initial and repeat), as well as comparisons to women carrying to term. It also emphasizes psychological or social wellbeing, or its absence, based upon life circumstances, as opposed to feelings and emotions, such as self-esteem, which may be based on subjective responses and not reflect the actual life situation the woman is experiencing.
The findings of this study are similar to an earlier Finnish study (Niemela et al., 1981) published in 1981, which found that women, who repeat abortion, compared to women with a single abortion, had poorer competence to build the socioeconomic framework of their lives, as measured by lower net household income and poorer housing conditions and weaker solidarity with their partners. A study (Shepard and Bracken, 1979) by researchers at Yale Medical School, published in 1979, also found that women with repeat abortions were more likely to be divorced and more likely to be a welfare recipient than women with a single abortion. The psychological and social effects on women of repeat abortion are most important, as recent studies have reported that 60% of U.S. women, who have a first abortion, will repeat abortion by age 30.

Women Overdosing on Drugs

Overdose and Termination of Pregnancy: An Important Association?, Helen Houston, Lionel Jacobson, British Journal of General Practice 46: 737-738, December 1996

A British study of 10,000 patients and 5 physicians in a general practice consisting of all female patients, age 15-34 years, who were registered with the practice in October 1994. Their records were examined to determine any drug overdose requiring hospital treatment, excluding termination for congenital abnormality and/or maternal infection, and age at termination. Out of a total of 1,359 patients, 163 (12%) had a history of termination of pregnancy and 47 (3.5%) had a history of taking a deliberate overdose. 15 patients had a history of both events. Among the 163 women with termination of pregnancy, 136 had a single termination, 25 had two terminations and 2 had three terminations. 99 terminations (51%) occurred in women 19 years of age or less. The study found that there was a statistically significant association between the termination of pregnancy and drug overdose.

There was a tendency for the overdose to occur prior to the termination of pregnancy, although this was not significant. 73% of the events occurred within two years of each other. In their discussion of the findings, the authors cited recent studies suggesting a possible link between termination of pregnancy and self-harm. They point out the similarity between the psychosocial factors associated with overdose and those associated with termination of pregnancy, and the link between para-suicide and intro-punitiveness. They also note that women who are less "in control" are more likely to become pregnant. The authors recommended more research to explore possible effective interventions.

Comments: This study is part of the growing body of literature recognizing that induced abortion can be either the cause or effect of self-destructive behavior that occurs in a significant number of women. The fact that many of the drug overdoses occurred before the abortion-experience suggests that abortion may be part of a pattern of general destructive behavior. Some women view abortion as an attempt to destroy the bad part of themselves (Pines, 1990). Others may experience death-anxiety in the months following their abortion (Butterfield, 1989) or for many years afterward. Still others experience suicidal ideation or suicide attempts following induced abortion (Franco et al., 1989).

Suicide and Abortion

Finnish Study

Suicides after Pregnancy in Finland, 1987-94: register linkage study, M. Gissler, E. Hemminki, J. Lonnqvist, British Medical Journal, 313: 1431-1434, December 7, 1996

A Finnish register linkage study, based upon nationwide data, linked women who committed suicide in 1987-1994 to Finnish birth, abortion and hospital discharge registers. The mean annual suicide was reported as 11.3 per 100,000. The suicide rate associated with birth was 5.9 per 100,000; the suicide rate associated with miscarriage was 18.1 per 100,000; and the suicide rate associated with induced abortion was 34.7 per 100,000. The study found that women who committed suicide tended to come from lower social classes and were more likely to be unmarried than other women who had a completed pregnancy. The study concluded that the increased risk of suicide after an induced abortion indicates either common risk factors for both or harmful effects of induced abortion on mental health.

Suicide after Ectopic Pregnancy

Suicide after Ectopic Pregnancy (letter), J. Farhi, Z Ben-Rafael, D. Dicker, The New England Journal of Medicine, March 10,1994, p. 714

A study of Israeli women at the Golda Meir Medical Center found that among 160 women treated for ectopic pregnancy over a 10-year period, 3.75% attempted suicide within one year thereafter. In addition, 0.625% committed suicide compared to a matched non-pregnant population rate of 0.04-0.06% and 0.002% respectively. The authors concluded that women with ectopic pregnancy should be considered at high risk for suicide following surgery. They concluded that the insult to self-image that leads to the breaking point is due to the failure of the pregnancy, together with the trauma of surgery and the threat to future reproduction.

Comments: Previous studies (Rosenfeld, 1985) have reported that women may mourn the loss of a child via ectopic pregnancy, but this is the first report that their reaction can be as severe as a suicide.

Suicide Attempts among Male Military Recruits

Psychopathological Effects of Voluntary Termination of Pregnancy on the Father, Called Up For Military Service, J.C. DuBouis-Bonneford, J.R. Galle-Tessonneau Psychologie Medicale 14 (8): 1187-1189, June 1982 (abstract)

A French study presented several case studies of 18-22 year-old males who came from disadvantaged backgrounds and were recent military recruits. All had extreme depression and/or had attempted suicide, brought on by the news of their wives or girl friends having had a voluntary induced abortion. The men believed that becoming a father would make them more mature or respectable, and the abortion brought on feelings of self-recrimination and self-punishment.

Comments: A 1990 U.S. study (Buchanan and Robbins, 1990) of adolescent males found that young men whose girl friends had abortions were more distressed than the men who became fathers. Anecdotal reports of male reactions to induced abortion also have found that males can be particularly devastated by abortion, and even commit suicide as a result (Strahan, 1994).

Hospitalization of Women for Major Psychiatric Disorders

Psychosocial Characteristics of Psychiatric Inpatients with Reproductive Losses, T. Thomas, C.D. Tori, J.R. Wile, S.D. Scheidt, Journal of Health Care for the Poor and Underserved 7 (1): 15-23, 1996

Recent studies estimate that social service agencies supervise more than 2 million children in the U.S. and that a large proportion of these out-of-home placements are due to the mental illness of a parent. Recent research has shown that 60% of the children with major psychiatric disorders are not raised by their mothers. In order to study these and other similar social problems, a study of the records of 82 female patients, admitted to the psychiatric unit at San Francisco General Hospital over a one-year period, was undertaken. 93% of the women were unmarried at the time of hospitalization, 54% had never been married, 67% had been pregnant at least once, with the average number of pregnancies being 2.6. Of all pregnancies, 71% resulted in births, 21% were terminated by induced abortion, and 8% ended due to spontaneous miscarriages. Only 11% of the mothers reported they were the primary caretakers of their children. 61% reported being Caucasian, 21% African-American, 9% Asian and 8% Hispanic.

The 82 women were divided into those who had had an abortion (22), those who relinquished children either temporarily or permanently (28), and those with no children (32). The women in the relinquishment group had no abortion experiences; the women in the abortion group included women, both with and without relinquishment experiences. Overall, it was reported that the women had few economic resources, many were unemployed or receiving public assistance, most had no health insurance and were covered by Medicaid programs. The average number of abortions per individual in the abortion group was 1.54 (SD=0.60).

Women in the abortion and relinquishment groups received the diagnosis of psychoactive-substance-abuse disorder (DSM-III-R criteria), statistically more frequently than childless women (45.5% vs.15.6%). Eighty-one percent of the abortion group compared to 37.5% of the childless group had substance abuse. The drugs used were alcohol, cocaine, marijuana and amphetamines. Women in the abortion group were also more likely to have been subjected to sexual or physical abuse, either as children or adults (72.7%) compared to the relinquishment group (35%-50%) or the no-children group (28%-37%).

Women who have had abortions may be more functionally impaired ... than childless women.

The authors concluded that substance-abuse may be more related to reproductive events than previously realized, and suggested that women who aborted may be more functionally impaired in community settings than childless controls. They concluded that patients with reproductive losses were at greater risk for re-hospitalization than women with no children. They also expressed concern for the high percentage of women in the abortion and relinquishment groups, who were ethnic minorities. With respect to the high prevalence of sexual and/or physical abuse in the abortion group, they noted that "it is well established that sexual and physical abuse often result in self-hatred, hostility and suicidal inclinations," and that the women who aborted may be experiencing the sequelae of abuse.

Comments: An earlier study, (Borins and Forsythe, 1985), published in 1985, at a women's psychiatric clinic, incorporated within a university teaching general hospital in Toronto, Canada, also found that physical or sexual abuse was significantly related to abortion, and that trauma and abortion were significantly correlated. Another 1992 study (Hanley, et al., 1992) of women who were receiving outpatient mental health services in Grand Rapids, Michigan, found that distressed women with a history of abortion were significantly more likely to exhibit Post-Traumatic Stress Disorder (DSM-III-R criteria), and were more likely to report that they believed abortion to be morally wrong. A high percentage of women outpatients with a history of abortion also had experienced physical and/or sexual abuse in the past, either as children, adolescents or adults and before and/or after their abortions.
This is an example of yet another study, which correlates alcohol and drug abuse with induced abortion. Induced abortion appears to be both a cause and effect of alcohol and drug abuse. Studies have shown that women who have had induced abortions are more likely than women in the general population to be heavy drinkers. Those who report being stressed by abortion, or have claimed they were exploited or coerced, those who have repeat abortions, or have difficulty assimilating their abortion experience, appear to be most likely to abuse alcohol or drugs.

Psychological Effects from Abortions Induced by Mifepristone

Psychiatric Morbidity and Acceptability Following Medical and Surgical Methods of Induced Abortion, D.R. Urquhart, A.A. Templeton, British Journal of Obstetrics and Gynecology 98: 396-399, April 1991

There has been little study on the psychological effects of chemically induced self-abortion using mifepristone (commonly known as RU-486). In this study, 91 women were asked to complete a multiple-choice questionnaire, both before and after induced abortion, to screen for anxiety and depression either when mifepristone/prostaglandin chemical abortion was used, or when vacuum-aspiration-surgical abortion was used. Two days before the abortion over 60% of the women in both groups had high scores for anxiety and depression, which was compatible with psychiatric morbidity.

Negative reactions to RU-486 abortion included women who had seen aborted remains.

Women were interviewed at 1-week and 4-week intervals, following their abortion. 25% of the women who underwent the chemical abortion, versus only 6% of those who underwent vacuum-aspiration said, they would use a different method if a future termination was ever required. There was a tendency for the women who responded negatively to the chemical abortion to be younger, nulliparous, to have required more analgesia and to have seen the aborted remains. Pre-abortion guilt was reported to have diminished in intensity on follow-up. The article stated that "a similar minority in each group remained distressed and had feelings of regret about their decision." According to the study, no differences were noted in psychiatric morbidity among women in the two groups, one month post-abortion, with less than 10% having high scores at that time.

Comments: Women seeking abortion have been found to undergo severe personality changes shortly before their abortion. This includes pre-abortion guilt, grieving, hostility and anxiety. Thus, the high percentage of women with pre-abortion psychiatric morbidity may include factors related to the abortion decision itself, such as anticipatory grief, stress and anxiety.
Women seeing the remains of their aborted child have been found to experience post-abortion depression and/or trauma. In one instance, a woman saw the head and arm of her aborted child after an incomplete first-trimester abortion. She began sobbing uncontrollably and was unable to sleep. She preserved the remains in a formaldehyde jar. Whenever she tried to sleep she thought of the "baby she had killed," (her words), and began sobbing again. She was treated for depression with Prosac.
Psychological Responses Following Medical Abortion (using Mifepristone and Gemeprost) and Surgical Vacuum Aspiration, R. Henshaw, S. Naji, I. Russell, A. Templeton, Acta Obstet Gynecol Scand 73: 812-818, 1994

A study in Aberdeen, Scotland studied 363 women undergoing induced abortion up to 63 days gestation. Women with a preference for a particular method of abortion were allowed to select that method, while others were allocated at random. The two methods used were medical abortion using mifepristone 600 mg. followed 48 hours later by gemepost 1 mg. vaginal pessary, or vacuum aspiration performed under general anesthesia. Women completed a Hospital Anxiety and Depression Scale and a semantic rating scale, designed to measure self-esteem prior to the abortion and again 16 days following their abortion. The study reported no significant differences between women allocated at random to medical abortion or vacuum aspiration in post-abortion anxiety, depression or low self-esteem. Women who had high levels of mood disturbance prior to abortion, who were smokers or who had medical complications following abortion were at the highest risk of post-abortion mood disorder. Anxiety scores at follow-up correlated with the number of cigarettes smoked, with the most anxious women having the heaviest smoking habits. Depression scores at follow-up were significantly related to post-abortion medical complications, such as severity of pain and bleeding on discharge from the hospital, or the need for an unplanned consultation with the family doctor for a complication relating to the abortion. The study concluded that either method was associated with high incidence of psychological benefit.

Comments: This study provides more direct evidence that induced abortion increases smoking in women, because post-abortion anxiety correlated with increased smoking in women.

Post Traumatic Stress Disorder in Marriage/Couple Therapy

Post traumatic Stress Disorders in Women Following Abortion: Some Considerations and Implications for Marital/Couple Therapy, D.A. Bagarozzi, Int'l Journal of Family and Marriage 1: 51-68, 1993; also Identification, Assessment and Treatment of Women Suffering from Post Traumatic Stress After Abortion, D.A. Bagarozzi, Journal of Family Psychotherapy 5(3): 25-54, 1994

In a study by a clinical psychologist, 18 women were referred with their husbands for marital/sex therapy by gynecologists, and physicians were unable to find a physical cause for the sexual dysfunction experienced by these women. The symptom disorders were characteristic of post-traumatic-stress disorders (DSM III-308.30) for 12 of the 18 women. Six other women did not seek help for marital problems although all six were married and had psychiatric symptoms. Women had primarily obtained abortions for pragmatic reasons and a major consideration was an attempt to maintain the relationship with the men who had impregnated them. The vast majority reported that their husband's/partner's reaction to the pregnancy was negative. It was reported that a unique difference between these women and other victims of post-traumatic stress was their complete denial that undergoing abortion was indeed a traumatic experience. The study found that impacted grief, guilt and unresolved mourning were primary issues.

Long-term Grieving in a Sample of Protestant Women

Prolonged Grieving after Abortion: A Descriptive Study, Douglas Brown, T.E. Elkins, David B. Larson, The Journal of Clinical Ethics 4(2): 118-123, Summer 1993

In 1987, the Surgeon General invited several religious leaders from across the United States to Washington, DC, to comment on the possible adverse consequences of induced abortion in the experiences of women in their congregations. Among the invitees was the pastor of a large Protestant congregation in Florida, which was predominantly white, urban and middle- to upper-class. After informing a Sunday gathering, which included 1,600 to 2,000 women, the pastor asked for descriptive letters from women, who had negative experiences, that they perceived to be linked with a past abortion. One week later, 61 replies, mostly anonymously forwarded through the mail, had arrived. Of these replies, 5 came from significant others (2 husbands, 2 sisters and 1 parent) and 11 letters were too brief to be useful. The remaining 45 letters were analyzed and published.

The ages of the women ranged from 25 to over 60 years, and 87% of those who mentioned their age were less than 40 years old. The age at the time of their abortion ranged from 16 to their early 40's, and 81% indicated they had undergone first-trimester abortions. Of the women who mentioned marital status, 75% were single at the time of the procedure and 71% placed the time of their abortions after Roe vs. Wade. Of those who indicated the reason they had sought abortion, 18% attributed overt family pressure, 4% medical reasons and 9% financial reasons. Two of three respondents mentioned that they were not practicing Christians or active members of that particular church when they had their abortions. Of the 45 respondents, 64% spoke of more than incidental and transient grief immediately after the procedure, and 42% reported negative emotional sequelae endured over 10 years. One woman endured such experiences for 60 years. After years of turmoil, few expressed confidence that their symptoms could be eradicated.

The content of the letters were categorized for symptoms of masking (hiding inner feelings beneath an apparently stable and peaceful outward manner), anger, loss, depression, regret, shame, fantasizing, suicidal ideation and guilt. The mention of negative sequelae was consistently more frequent for women who felt coerced. The most frequently mentioned long-term experience was the continued feeling of guilt (73.3%). Fantasizing about the aborted fetus was the second most frequently mentioned (57.8%). Masking their experience with the appearance of well being was reported by 35.5%. Women who had abortions before age 21, and those who had abortions prior to Roe vs. Wade were more likely to report masking their psychological pain. Suicide ideation (15.5%), recurrent nightmares (13.3%), marital discord (15.5%), phobic responses to infants (13.3%), fear of men (8.9%) and disinterest in sex (6.7%) were also listed as negative sequelae.

Many of the respondents said they were writing the most difficult letter they had ever written, and half referred to their abortions as murder. Others used such phrases as "a horrid mistake," "my worst experience," "a living hell." Several mentioned that hearing the word abortion would evoke painful memories.

Many of the women said the letter they wrote was the most difficult letter they had ever written.

Half of the women who admitted fantasizing about the aborted infant referred to the aborted fetus as "my baby." Several commemorated the anniversaries of the abortion and of the aborted child's projected birthday. Thoughts about the aborted child's sex, talents, appearance and interests were mentioned. Some found relief in vividly anticipating a reunion with their aborted infants in an afterlife. Unavoidable reminders such as Mother's Day, receiving news of a friend's pregnancy, being invited to a baby shower, seeing children on a playground and planning a birthday for their own children kept many of these women moving from one painful fantasy to the next.

Some women found relief in vivdly anticipating a reunion with their aborted infants in an afterlife.

Twenty percent of the women related negative responses to the abortion-procedure itself. Some recall crying continuously, others recalled trying to stop the procedure once it had started. Every woman who mentioned the procedure expressed dissatisfaction with the lack of, or superficial, counseling she received, and with the doctors involved in the procedure.

The authors acknowledged that the participants came from a self-selected population group (the Protestant congregation) with a known bias against induced abortion. They further acknowledged that the study design fell far short of a double blind longitudinal study and only negative responses were solicited. They concluded that the study reinforces the need, if possible, for clinically valid studies of the syndrome of delayed grief among some women. They stressed that case studies of negative experiences should not be discounted on methodological grounds or exploited in public debate and that the real issue is patient care.

The narrative stories of the women were challenged as being unscientific.

The publishing of the article evoked vigorous, varied, erroneous as well as some insightful comments in editorials written at the time the study was published. In one editorial written by two medical doctors from East Tennessee State University, Jo Ann Rosenfeld and Tom Townsend, entitled, "Doesn't Everyone Grieve in the Abortion Choice?", they questioned whether the article was science, psychology, emotions recalled or maybe just published repentance. They concluded that the moral mind of the women had changed since their abortions, and appeared to be concerned that the authors may be claiming that abortion was immoral. They stressed the emphasis on rationality and discounting of emotions in decision-making. They did acknowledge, however, that emotions do offer a momentary insight into a person's sense of wellbeing. They criticized the lack of scientific method as the primary and most conspicuous fault of the study. They pointed to the non-random, biased and pre-prejudiced selection of the women and the quoting of letters as neither scientific nor objective. However, the article caused these medical doctors to re-evaluate their own feelings and acknowledge that there are women who have an emotionally difficult time after abortions and that sensitive and caring decisions should be made between women and their doctors.

One commentator believed that psychological counseling before abortion imposed on a woman's autonomy.

Another editorial by Nada Stotland, an Associate Professor of Psychiatry at the University of Chicago, entitled "Realistic Reflections on an Emotional Subject," had a distinctly ideological approach. She criticized what she called "anti-choice" groups for persistently arguing that abortion, in and of itself, is psychologically damaging and argued that there is a strong association between the attitudes of each side toward abortion and their attitudes toward the role of women in society. She criticized the study because it was limited to the negative sequelae of childbirth, which she believed were more common than the negative sequelae from abortion. She stated that "psychological counseling before abortion is not required -- not because the mental health provider community opposes it, but because many people believe it imposes on women' autonomy." She further stated that "Women are not required to undergo counseling before other surgical procedures, or before deciding to carry pregnancies to term." She acknowledged that abortion is a sad choice and that an attempt should be made to minimize the human suffering as a result.

A large number of women have repressed memories and feelings about their pregnancy termination.

A third editorial written by psychiatrist Philip Ney stated that few physicians are interested in discussing abortion, and that there a large number of women who have repressed memories and feelings about their pregnancy-termination. He thought that the article was much less about post-abortion grieving than it was about the objectivity of science and the ethics of publishing. He thought that the authors should have been forthright about taking issue with abortion, instead of gently attempting to expose the fallacious idea that abortion is therapeutic. He finished his article by saying, "The best evidence indicates that what is destructive to the pre-born infant-abortion is harmful to the mother, too."

Anecdotal knowledge can provide important insight about the negative sequelae of abortion.

A subsequent letter written by Ann Hunsaker Hawkins, a Ph.D. at Penn State University, College of Medicine, pointed out that there is not infrequent discrepancy between physicians' anecdotal knowledge, and information that is statistically valid. She said that anecdotal knowledge can play an important role in directing future research. She also pointed to another body of writing, which provides insight about the negative sequelae of abortion: autobiographical and fictional writings of women about abortion.

There is nothing in the culture to reflect or assuage profound post-abortion anguish.

She refers to the story by Alice Walker, The Abortion, which focuses on its meaning and its consequences. The story explores a variety of extended negative sequelae, stemming from her husband's failure to understand the implications of abortion for her, society's ambivalent messages about abortion, and the nature of a legal "assembly line" abortion, where her doctor doesn't have time to wait for the anesthesia to take effect. Another book she cites is entitled Soul Crisis, written by Sue Nathanson, a clinical psychologist who herself had an abortion. She had to repress her emotions about the logical decision she and her husband had made. Further, she found nothing in the culture to reflect or assuage her profound post-abortion anguish. She says, "I hope that by sharing my story, I will provide others with the all-encompassing mirror that had been missing for me."