Adverse Psychological Reactions: A Fact Sheet

After Abortion

Adverse Psychological Reactions – A Fact Sheet

• Introduction
• A Vast Literature on Post-Abortion Response
• A Long History of Concern
• International Scope
• Factors indicating greater risk of adverse reactions
• The American Psychiatric Association
• Common Flaws in Research Methods which Underestimate the Numbers of Women Negatively Affected
• Conclusion
• Large, Peer-Reviewed Studies Included in PK Coleman’s Meta-Analysis
• Notes

Introduction

This Project Rachel program is intended to reach out to women experiencing grief from the loss of a child by abortion, and to offer them reconciliation and healing. It is based on the Catholic Church’s 26 years of experience counseling women who have come to our Project Rachel programs, suffering because of their abortions.

The Project Rachel messages do not speak about, or for, those women who have experienced only relief or satisfaction after abortion. But they can and do reflect — in their own words — women who have suffered because of their abortions.

This outreach is not about the debate in the medical literature regarding whether or not abortion has predictable, adverse psychological consequences for women. At the same time, it would be naive to believe that the visibility of Project Rachel’s messages will not cause some discussion about abortion’s psychological effects. So, it seems necessary to say a few words about the scientific research in this area.

A Vast Literature on Post-Abortion Response

Today there is a vast and growing literature on the topic of psychological consequences of abortion for women. Existing research on the mental health effects of abortion can be categorized into two main camps: (1) those who argue that abortion does not cause psychological problems and that adverse emotional reactions to abortion are no greater following abortion than childbirth (The American Psychological Association’s 2008 Task Force Report is an example); and (2) those who argue that abortion is associated with significant emotional health risks for some women and that these women can be largely identified by known risk factors.

Fortunately, most researchers have been open-minded in seeking the truth about abortion and mental health problems. For example, the largest and most definitive analysis of the mental health risks associated with abortion was published September 1, 2011 in the prestigious British Journal of Psychiatry (Coleman, PK, “Abortion and Mental Health: Quantitative Synthesis and Analysis of Research Published 1995-2009,” BJP 2011; 199:180-186). The meta-analysis conducted by Professor Priscilla Coleman, PhD of Bowling Green State University, examines twenty-two major studies published between 1995 and 2009 involving a total of 877,181 women, of whom 163,831 had abortions.

Taking into account all the mental health problems studied—anxiety, depression, alcohol use/misuse, marijuana use and all suicidal behaviors—here is what this rigorous analysis found:

Dr. Coleman’s meta-analysis excluded weak and potentially biased studies by including only studies that (1) were published in a peer-reviewed journal, (2) had at least 100 participants in the sample, (3) used comparison groups (e.g., women with unintended pregnancy who delivered, women with pregnancy who delivered, and women who had not had an abortion), (4) measured one or more mental health outcomes, such as depression, substance abuse or suicidal behavior and (5) controlled for other variables, such as prior history of mental health problems or exposure to violence.

Previously, Coleman, Coyle, Shuping & Rue (2009) analyzed abortion and mental health data from the National Comorbidity Survey in the U.S. They found abortion contributed to a significantly increased risk of PTSD, panic disorder, drug dependency and alcohol abuse, and major depression. In addition, they reported that abortion contributed to more mental health problems than for those who experienced childhood history of maltreatment (sexual abuse, physical abuse and neglect) and physical assault in adulthood. A 2010 study by Canadian researchers (Mota NP et al., “Associations between abortion, mental disorders, and suicidal behaviour in a nationally representative sample,” Canadian Journal of Psychiatry 2010; 55: 239–47), published after the Coleman et al., ( 2009) study arrived at “strikingly similar” conclusions regarding the increased risk of mental health problems associated with abortion.

A long history of concern

The possibility that abortion might cause adverse psychological consequences to women has been recognized by researchers for over 60 years. At a 1942 medical conference a psychiatry professor at Yale University, Theodore Lidz, MD, reported this:

“At times the guilt over the abortion draws into its dragnet many old guilts, leading to severe depression. In other instances, the overwhelming guilt cannot be managed and leads to pathologic projection. The immediate assimilation of the traumas is no assurance of successful integration: in later years new guilts may reawaken the dormant guilt, and one sees women at the menopause suffering torment over an abortion performed many years before.”[1]

International scope

Academic researchers in numerous countries have investigated women’s psychological reactions to abortions, and a number have reached very similar conclusions. Their studies appear straightforward, and their conclusions are not embedded in tortured language
about the possible political use of their findings in the abortion debate.

Increased Usage of Psychiatry: A Canadian study found that 25% of women who had had abortions made visits to psychiatrists over a 5
year period, as compared to 3% of the control group.[2]

In a widely respected Danish “register linkage” study—i.e., one reviewing state records of women’s lifetime medical histories—researchers found that the rate of psychiatric admissions within three months after the end of a pregnancy was 53% higher among women who had aborted compared to women who delivered their children.[3]

Suicide: In one of the most complete register linkage studies to date, researchers in Finland examined women’s lifetime medical histories and discovered that women who had abortions had a rate of suicide in the year following their abortion three times greater than all women of reproductive age, and six times greater than women who gave birth. The researchers drew two possible conclusions: either abortion poses a risk to mental health, or there are common risk factors for both abortion and suicide.[4]

A Welsh study which followed the Finnish study indicated that the former explanation is more likely. It looked at the medical records of women both before and after their abortions. It did not find any increased risk of suicide before abortion among women having abortions. But it did find that the rate of suicide among women after having induced abortions was twice the rate of women giving birth.[5]

Research Generally Dismissing Negative Abortion Aftermath: Even researchers most reluctant to conclude the existence of any significant amount of post-abortion grief write that some women experience severe psychological reactions following abortions. They seem satisfied that the percentages of women suffering negative reactions are, by their account, less than 50%. Considering that about 1.1 – 1.6 million abortions annually have been performed for almost 30 years, however, a finding that even a few percentage points of women suffer severe post-abortion reactions represents tens of thousands of women.[6]

Factors indicating greater risk of adverse reactions

A rather remarkable consensus among researchers on opposite sides of the psychological question, and researchers from around the world, has formed around the question of what risk factors likely predispose a woman to suffer negative consequences post-abortion. Even a cursory review of the following list reveals two remarkable things: first, it is a rather long list; and second, many of the categories describe potentially very large numbers of women having abortions in the United States:

Youth.[7] Eighteen percent of all abortions in the United States are had by teenagers.[8]

Multiple abortions.[9] In the United States, 47% of all abortions are repeat abortions. Nineteen percent of abortion patients have had three or more abortions.[10]

Being divorced, separated, or widowed at the time of the abortion.[11]

Medical or genetic indications (or in the words of another researcher, a “meaningful or intended” pregnancy gone wrong).[12] In the United States, about 13% of women having abortions (169,000 annually) cite a suspected or confirmed fetal anomaly (mild to severe) among their reasons for having an abortion.[13]

Pregnant women and new mothers who have had a prior abortion.[14]

Having a “complicated reason” for the abortion, including “abortions you were pressured into.”[15] In the United States, 20% of abortion patients say that they are having their abortion, in part, because their boyfriend (14%) or parents (6%) want them to have it.[16]

Experiencing conflict with important others[17] at the time of the abortion, or other disturbing life events. Fifty-one percent of U.S. abortion patients say that one reason they are seeking their abortion is relationship problems or fear of single parenthood, and 31% say they are having an abortion because they don’t want significant others to know they are pregnant or had sex. Less than 1.5% cite rape or incest.[18]

Having a history of sexual assault.[19]

Mid-trimester abortions.[20] In the United States today, about 12% of abortions per year occur in the second or third trimester of pregnancy.[21]

Those outside a woman’s normal values or morality.[22]

The American Psychiatric Association

Although the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR)[23]
did not officially recognize “post-abortion syndrome” nor did it acknowledge “Battered Women’s Syndrome” and “Rape Trauma Syndrome” which are commonly accepted in society and in court. The DSM-IIIR did in fact list abortion as a type of “psychosocial
stressor” which can produce post-traumatic stress disorder. In a more recent edition (DSM-IV – 1994), abortion was deleted.

Common flaws in research methods which underestimate the numbers of women negatively affected

Many researchers — including those on opposing sides of the issue of psychological harm — have exposed flawed research methodologies which are likely to produce underestimations of the numbers of women suffering adverse reactions to abortion. Some of these flawed methodologies are:

Failing to account for the fact that — when asked in a survey whether or not they have ever had an abortion — up to 50% of women who have had abortions, do not admit to one.[24] This denial may itself be an indication of an adverse psychological response to abortion, yet these women are not accounted for in studies. In one poll, however, which did not ask individuals to answer any personal questions about
abortion, 67% of women and 55% of men 18-29 chose “being involved in an abortion,” as the number one situation that would make a person feel “bad about himself.”[25]

Following women’s psychological state for too short a time after their abortions is also a serious methodological shortcoming.[26] Often researchers attempt to measure women’s state of mind very soon after the abortion, and not later. Immediately after abortion, women regularly report relief. But empirical evidence indicates that this relief “fades” over the next several months and years.[27] Also, overwhelming anecdotal evidence from post-abortion counseling programs reveals that many women seek help for their suffering 5-12 years after their abortion.

A high “drop out” rate (50% is common) of women between the time they are first asked about their reaction to abortion, and a second or third time weeks or months later. Furthermore, studies show that the women most likely to drop out are those more likely to be experiencing adverse reactions to their abortions.[28]

Time variance problems. No survey asking a woman’s emotional state at a given point in time can claim to show with certainty that the woman will continue to cope at a later time, or that she has not been distressed in the past.

Using meaningless measurements of post-abortion well-being is another example of research that is seriously deficient. A good example: in a study by Nancy Russo, Ph.D., Russo measured “well-being” solely by the women’s self-reported self-esteem.[29] The presence or absence of self-esteem contributes nothing to the question of whether abortion is associated with significant mental health risks. Russo reported high rates of self-esteem following one abortion, versus two or more. High self-esteem can also be associated with narcissistic personality disorder, which has been a focus of concern in post-abortion counseling..[30]

Conclusion

Abortion is the most commonly performed surgery on women in the United States. For decades, our nation’s abortion rate has fluctuated between 1 and 1.6 million abortions annually. If even a small percentage of these women are suffering — whether at the level of extreme psychological distress or with less traumatic grief, spiritual pain, and family dysfunction–a vast number of women are affected.

This is the experience of the Catholic Church in the United States. For over 25 years we have counseled women and men seeking solace after abortion. It is also the experience reflected in numerous web-sites where women share their stories after abortion. It was the reaction of former Surgeon General Koop, to the misreporting of his 1989 review of post-abortion literature. In a later conversation he said: “Instead of saying I could ‘not find sufficient evidence to issue a scientifically statistically accurate report about whether or not abortion caused women predictable harm,’ I was wrongly reported as saying I could ‘find no evidence,’ of post-abortion trauma.” But, he continued, “I know there are detrimental effects [of abortion]. I have counseled women with this problem over the last 15 years. There is no doubt about it.”[31]

Large, Peer-Reviewed Studies included in PK Coleman’s 2011 Meta-Analysis

Coleman PK, Reardon DC, Strahan TS, Cougle JR. The psychology of abortion: a review and suggestions for future research. Psychol Health 2005; 20: 237–71.

Coleman PK, Coyle CT, Shuping M, Rue VM. Induced abortion and anxiety, mood, and substance: abuse disorders: isolating the effects of abortion in the National Comorbidity Survey. J Psychiatr Res 2009; 43: 770–6 & Corrigendum 2011, 45:1133-1134.

Dingle K, Alati R, Clavarino A, Najman JM, Williams GM. Pregnancy loss and psychiatric disorders in young women: an Australian birth cohort study. Br J Psychiatry 2008; 193: 455–60.

Fergusson DM, Horwood LJ, Boden JM. Abortion and mental health disorders: evidence from a 30-year longitudinal study. Br J Psychiatry 2008; 193: 444–51.

Pedersen W. Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study. Addiction 2007; 102: 1971–8.

Coleman PK, Reardon DC, Cougle J. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol 2005; 10: 255–68.

Steinberg JR, Russo NF. Abortion and anxiety: what’s the relationship? Soc Sci Med 2008; 67: 238–52.

Coleman PK, Maxey DC, Spence M, Nixon C. The choice to abort among mothers living under ecologically deprived conditions: predictors and consequences. Int J Ment Health Addiction 2009; 7: 405–22.

Coleman PK, Reardon DC, Rue V, Cougle J. History of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obstet Gynecol 2002; 187: 1673–8.

Coleman PK, Reardon DC, Rue V, Cougle J. State-funded abortions vs. deliveries: a comparison of outpatient mental health claims over four years. Am J Orthopsychiatry 2002; 72: 141–52.

Cougle J, Reardon DC, Coleman PK. Depression associated with abortion and childbirth: a long-term analysis of the NLSY cohort. Med Sci Monit 2003; 9: CR105–12.

Cougle J, Reardon DC, Coleman PK, Rue VM. Generalized anxiety associated with unintended pregnancy: a cohort study of the 1995 National Survey of Family Growth. J Anxiety Disord 2005; 19: 137–42.

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry 1995; 167: 243–8.

Gissler M, Hemminki E, Lonnqvist J. Suicides after pregnancy in Finland, 1987–94: register linkage study. BMJ 1996; 313: 1431–4.

Pedersen W. Abortion and depression: a population-based longitudinal study of young women. Scand J Public Health 2008; 36: 424–8.

Reardon DC, Cougle J. Depression and unintended pregnancy in the National Longitudinal Survey of Youth: a cohort study. BMJ 2002; 324: 151–2.

Reardon DC, Cougle J, Ney PG, Scheuren F, Coleman PK, Strahan TW. Deaths associated with delivery and abortion among California Medicaid patients: a record linkage study. South Med J 2002; 95: 834–41.

Reardon DC, Cougle J, Rue VM, Shuping M, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003; 168: 1253–6.

Reardon DC, Coleman PK, Cougle J. Substance use associated with prior history of abortion and unintended birth: a national cross sectional cohort study. Am J Drug Alcohol Abuse 2004; 26: 369–83.

Rees DI, Sabia JJ. The relationship between abortion and depression: new evidence from the Fragile Families and Child Wellbeing Study. Med Sci Monit 2007; 13: 430–6.

Schmiege S, Russo NF. Depression and unwanted first pregnancy: longitudinal cohort study. BMJ 2005; 331: 1303.

Taft AJ, Watson LF. Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women’s experience of violence. BMC Public Health 2008; 8: 75.

Notes

[1] “The Abortion Problem: The Proceedings of the Conference of the National Committee on Maternal Health, Inc., at the New York Academy of Medicine.”

[2] Badgley et al., Report of the Committee on the Operation of the Abortion Law, Ottawa: Supply and Services, 1977: 313-21.

[3] David et al., “Postpartum and Postabortion Psychotic Reactions,” Family Planning Perspectives, 13: 2 (1981) 88-91, 89.

[4] Gissler M et al. , “Suicides after Pregnancy in Finland, 1987-94; Register Linkage Study,” British Medical Journal, 1996; 313: 1431-34.

[5] Morgan et al., Letters, British Medical Journal, 1997; 314: 903. Another study supporting the former explanation was published
by L.G. Peppers, “Grief and Elective Abortion: Implications for the Counselor,” in Disenfranchised Grief: Recognizing Hidden Sorrow,
ed. Kenneth J. Doka, Lexington Books: Lanham, MD, 1989:135 (Grief measurements of the same women pre- and post-abortion showed that significantly different groups of women suffered high grief reaction scores at the two points in time.)

[6] One researcher, cited regularly by supporters of legal abortion as determining conclusively the absence of significant post-abortion grief, found the following: two years post-abortion, 19% percent of women (this would translate annually to 260,000 women in the United States) reported that they would not do it again; 12% more were undecided. When asked if their decision was right or wrong two years later, 16% (208,000) said it was the “wrong” decision. This same researcher found that 1% (10,000 women per year) suffer symptoms meeting the clinical definition of post-traumatic stress syndrome. Brenda Major, Ph.D. “Beyond Choice: Myths and Facts about Adjustment to Abortion,” Oct 9, 1997 California Wellness Foundation Lecture, University of California Wellness Lecture Series:1-34.

[7] Gary B. Melton, ed. “Report of the Interdivisional Committee on Adolescent Abortion,” American Psychiatric Association, 1986: 84 (On average, teens have more negative responses following abortion than adults); Campbell et al., “Abortion in Adolescence,” Adolescence, 1988; 23(92): 813; Major, Beyond Choice: 23, supra note 6.

[8] Jones RK, Finer LB and Singh S, Characteristics of U.S. Abortion Patients, 2008, New York: Guttmacher Institute, 2010; www.guttmacher.org/pubs/US-Abortion-Patients.pdf; accessed October 20, 2011.[9] Franco et al., “Psychological profile of dysphoric women postabortion,” Journal of the Amer. Med. Women’s Assn.,1989; 44(4):113; Somers, “Risk of Admission to Psychiatric Institutions among Danish Women who Experienced Induced Abortion: An Analysis on National Record Linkage,” Dissertation Abstracts International, Public Health 2621-B, Order No. 7926066 (incidence of psychiatric hospitalization increased in direct relationship to number of abortions had); Freeman, et al., “Emotional Distress Patterns Among Women Having First or Repeat Abortions,” Obstetrics and Gynecology, 1980; 55(5): 630.

[10] Jones RK et al., Repeat Abortion in the United States, Guttmacher Institute, Nov. 2006. http://www.guttmacher.org/pubs/2006/11/21/or29.pdf; accessed October 20, 2011. .

[11] Hedegaard et al., “Psychological Distress in Pregnancy and Preterm Delivery,” British Medical Journal; 307:234-38, 1993 (divorced, separated and widowed women who aborted had rate of psychiatric admissions within 3 months of abortion, 5 times higher than other women who have abortions); see also David, et al., “Postpartum and Post-abortion Psychotic Reactions,” Family Planning Perspectives, 1981;13: 88-91.

[12] Buchegger, “Couple treatment following abortion in prenatal diagnosis,” Schweiz Med Wochenschr (Switzerland), 127(3): 69-72, 1977 (couples feel short-term relief but require “long-term counseling”; grief is similar to that following stillbirth); Chandler and Smith, “Prenatal screening and woman’s perception of infant disability: a Sophie’s Choice for every mother,” Nursing Inquiry (Australia), 5(2): 71-6, June, 1998 (post-abortion grief and guilt, and marital breakdown occur following abortion due to problems detected in prenatal screening); Ashton, “The Psychiatric Outcome of Induced Abortion,” British J. of Obstetrics and Gynecology, 1980; 1115-22.

[13] Finer et al., “Reasons U.S. Women Have Abortions: Quantitative & Qualitative Perspectives,” Perspectives on Sexual and Reproductive Health, 2005, 37(3):110–118; www.guttmacher.org/pubs/journals/3711005.pdf; accessed October 20, 2011.

[14] For both pregnant women and for mothers shortly after delivery of a baby, having had an abortion is one of the most significant predictors of clinical depression. Kitamura, et al., “Clinical and Psychosocial correlates of antenatal depression: a review,” Psychother Psychosom (Japan),1996; 65 (3): 117-23. Bergant, et al., “Prevalence of Depressive Disorders in Early Puerperium,”Gynakol Geburtshilfliche Rundsch (Austria), 1998; 38(4): 232-37; Bradley, “Abortion and Subsequent Pregnancy,” Canadian Journal of Psychiatry, 1984; 29:494.

[15] Nada Stotland, MD, Abortion: Facts and Feelings, American Psychiatric Press, Inc.: Washington D.C., 1998: 110.

[16] Finer et al., “Reasons U.S. Women Have Abortions: Quantitative & Qualitative Perspectives,” Perspectives on Sexual and Reproductive Health, 2005, 37(3):110–118; www.guttmacher.org/pubs/journals/3711005.pdf; accessed October 20, 2011.

[17] Major, Beyond Choice, 24-24, supra note 6.

[18] Finer et al., “Reasons U.S. Women Have Abortions: Quantitative & Qualitative Perspectives,” Perspectives on Sexual and Reproductive Health, 2005, 37(3):110–118.

[19] Women with a history of sexual assault tend to have greater distress before, during and after their abortions due to association between the abortion and the sexual assault. Zakus, “Adolescent Abortion Option,” Social Work in Health Care, 1987;12(4): 87; Makhorn, “Sexual Assault and Pregnancy,” in New Perspectives in Human Abortion, eds. Mall and Watts, University Publications of America: Washington, DC: 1981.

[20] Osofsky and Osofsky, et al., Mt. Sinai Journal of Med., 1975; 42: 456; Rooks and Cates, Jr., Family Planning Perspectives, 1977; 9: 276. Adler, David, Major, Roth, and Russo, “Psychological Factors in Abortion, A Review, American Psychologist, 1992: 1194-1204.

[21] Guttmacher Institute, Facts on Induced Abortion in the United States, August 2011; www.guttmacher.org/pubs/fb_induced_abortion.html; accessed October 2011.

[22] Adler, “Emotional Responses of Women Following their Abortion,” Amer. J. of Orthopsychiatry, 1975; 45:446-54. Major “Beyond Choice”: 23-25, supra note 6.

[23] Washington, DC: American Psychiatric Assn.; 1987.

[24] Jones, and Forrest, “Under reporting of Abortion in Surveys of U.S. Women: 1976-1988,” Demography, 1992; 29(1): 113-26.

[25] Adler, “The Curse of Self-Esteem,” Newsweek, February 17, 1992; 119:46-51.

[26] Major, “Beyond Choice”: 9, supra note 6.

[27] Major, “Beyond Choice”:14, supra note 6 (Positive reactions to abortion faded beginning with period immediately following abortion, to 2 years later. Even though relief was always the experience of more than 50%); Kent et al., “Emotional Sequelae of Therapeutic Abortion: A Comparative Study,” presented at the annual meeting of the Canadian Psychiatric Assn. of Saskatoon, Sept. 1977; B. Raphael, The Anatomy of Bereavement, Basic Books: NY; 1983: 238; Miller, et al., “Testing a Model of the Psychological Consequences of Abortion,” in The New Civil War. The Psychology, Culture and Politics of Abortion, eds. Beckman, et al., American Psychological Assn.: Washington, DC, 1998. (Guilt and uncertainty about the decision increased from 2 weeks to 6-8 months post-abortion. Recommended post-abortion longitudinal research from 2-20 years).

[28] Soderberg H, “Selection Bias in a study on how women experienced induced abortion,” Eur J Obstet & Gynecol (Sweden), 1998; 77(1):67-70 (Thirty three percent of women who dropped out of study had characteristics associated with increased vulnerability, illness, and increased childbirth rate in the following two years); Adler, “Sample Attrition in Studies of Psycho-social Sequelae of Abortion: How great a problem,” Journal of Social Issues, 35, 100-10. (1979).

[29] Russo and Zierk, “Abortion, Childbearing, and Women’s Well-Being,” Professional Psychology: Research and Practice, 1992 vol. 23, no. 4: 269-280.

[30] D. Reardon, “The Complexity and Distortions of Post-Abortion Research,” posted at www.afterabortion.org.

[31] Interview with the Rutherford Institute, Spring 1989.