New Study Debunks “Abortion Trauma Syndrome”
A new study in the Harvard Review of Psychiatry called “Is there an ‘Abortion Trauma Syndrome?’ Critiquing the Evidence” looks at all of the studies related to abortion and mental health to conclusively determine what impact, if any, abortion has on a woman’s mental health. “Abortion trauma syndrome” has also been called “post-abortion syndrome.” In a review of 216 peer-reviewed articles on the subject of abortion and mental health, the authors of this study found that “the most well controlled studies continue to demonstrate that there is no convincing evidence that induced abortion of an unwanted pregnancy is a per se significant risk factor for psychiatric illness.” (p. 276)
For starters, let’s contextualize abortion. According to the 2005 World Health Report
- 211 million pregnancies occur worldwide each year; 46 million end in induced abortions.
- 40% of these abortions occur in unsafe conditions, resulting in 68,000 maternal deaths.
- In the US, 1.3 million of the 6 million pregnancies each year end in induced abortion.
- 20% of American women have had an abortion.
- The risk of death in the US from abortion is 1:160,000, which is lower than the risk of death from childbirth, appendectomy, or tonsillectomy.
Given the relatively low risk of death, the debate about abortion has shifted to focus on the perceived mental health impacts of abortion in order for abortion opponents to claim that they are concerned about the health and welfare of women. However, “Abortion Trauma Syndrome” and “Post-Abortion Syndrome” are not recognized by the American Psychiatric Association as mental illnesses, and they are not listed in the Diagnostic and Statistical Manual of Mental Disorders.
In their review of 216 peer-reviewed articles on the topic of mental health and abortion, the authors found numerous methodological flaws with the studies that purport to find a link between abortion and mental health.
1. Sampling Errors
According to the authors, “in some of the studies of abortion outcome, researchers recruited women who had already self-identified as suffering negative psychological effects from abortion, and then used the self-reports of these women as evidence for high rates of ill effects in all women who have had abortions.” (p. 270)
Some of the surveys asked respondents to report on the effects of their abortion years after the event actually occurred.
The use of retrospective reports from women who had an abortion years earlier is problematic. Recall bias can affect any individual’s perspective on a historical event. Mood-related memory effects also may bias recall of both the abortion experience and the timing of previous psychiatric episodes–especially if many years have passed. Later feelings about abortion may be influenced by subsequent reproductive experiences, failure to recall the circumstances leading to the decision to abort, current depression related to stressful life events, or the effects of public campaigns attributing psychological problems to abortion. (p. 270)
Additionally, studies must be limited to women who have had abortions within the first trimester if they are to be representative of all abortions, because most abortions (88.7%) occur within the first twelve weeks of pregnancy. (Source: Guttmacher Institute)
Delay in seeking abortions may be related to inadequate coping mechanisms, more ambivalence, less social support, barriers to access, poor maternal health, and detection of fetal abnormalities (which may involve terminating a wanted pregnancy).
All of these factors can independently effect a patient’s mental health. Therefore, it is inappropriate to generalize these experiences to that of all women who seek abortions.
2. Selection of Comparison Groups
According to the authors:
Some studies of abortion fail to use a comparison group, or use as a comparison group women in general or women who have never been pregnant, who have never delivered (with the wantedness of the pregnancy unspecified) but have never had an abortion, who are currently pregnant who had a spontaneous abortion, or who have delivered following wanted pregnancies . . . [These circumstances] are not comparable to those associated with a voluntary, elective abortion . . . At a minimum, the appropriate comparison group for assessing the relative risks of negative mental health outcomes of such abortions is women who carry unwanted pregnancies to term. An unwanted pregnancy is different from an unplanned pregnancy. Women with unwanted pregnancies are more likely to suffer from a number of co-occurring life stressors, including childhood adversity, relationship problems, exposure to violence, financial problems, and poor coping capacity, all of which contribute to emotional distress. These factors increase the risk of poor mental health, whether or not a woman has an abortion. (p. 270, emphasis mine)
3. Independent and Dependent Variables
If you’ve taken a basic stats class, you know that independent and dependent variables can effect the outcome of a study. One of the flaws in many of these studies was that depression is not defined by the researcher, and many of the studies had respondents self-report feelings of depression, rather than including a clinical diagnosis of depression from a physician. “Depressive feelings should be distinguished from clinical depression,” and “feeling regret is not a psychiatric condition . . . Moreover, few studies ask about positive outcomes that may offset any existing negative feelings or put them in perspective; for example, women may feel slightly sad and guilty about having an abortion, but extremely relieved and satisfied with their decision.” (p. 271)
Many of these studies also failed to take into account the context in which women receive services.
- Did the women have to travel far distances to obtain an abortion?
- Was there a waiting period involved that delayed the abortion?
- Did the patient have to walk through a crowd of protesters in order to enter the clinic?
- Did the physician read a state-mandated script about abortion that described (with varying levels of scientific accuracy) the risks of abortion, fetal development up to the term, and unsubstantiated allegations of fetal pain at early periods of gestation?
All of these questions may impact the woman’s feelings about her abortion. Ironically, any negative mental health outcomes of abortion can be directly attributed to the anti-choice movement itself, which is purportedly seeking to protect women from negative mental health impacts. On the other hand:
[Entering] abortion clinics through a group of anti-abortion demonstrators [is] a stressor that has been shown to be associated with psychological distress . . . [And] increasing a women’s belief in her ability to deal with having an abortion decreased her likelihood of experiencing depressive symptoms following abortion. Such findings suggest that insofar as inaccurate “informed consent scripts” undermine a woman’s belief in her ability to cope after an abortion, they may contribute to her risk for depression. (p. 270, emphasis mine)
After analyzing all of the possible variables that could effect the outcome of these studies, the authors concluded that “even if a study were to include all know covariates, however, it is essential to remember that correlation does not prove causality.” (p. 272)
It is true that some women have feelings of sadness or regret, and that some women can be made to feel stigmatized and guilty, about choosing to terminate an unwanted pregnancy. For women who have more significant problems, the causal contribution of the abortion is not clear; a wide range of factors, both internal and external, affect women’s responses–and interact in complex ways. These women should receive appropriate support and counseling. It should also be remembered that the best predictor of mental disorder after an abortion is a pre-exsiting mental disorder, which is strongly associated with exposure to sexual abuse and intimate violence; to ignore these factors would be potentially to ignore the actual causes of women’s distress following an abortion.
Conclusion
Aside from the obvious questions this study raises about the intentions of the researchers who claim a link between abortion and mental health, I think it’s important to contextualize the idea of a “post-abortion syndrome,” or “abortion trauma syndrome” within the larger move to pathologize women’s bodies. Women have historically been deemed as mentally unfit by the psychiatric industry. The term “hysteria” comes from the same root as the word “hysterectomy,” and hysterectomies were actually used as a treatment for mental illness at the turn of the Twentieth Century.
Pro-choice advocates need to be savvy and educate themselves about the so-called “science” behind the claims that the other side is using to eliminate access to women’s health. Hopefully my summary of the HRP study was easy enough to understand – the article itself was a lot to chew on. If you have any confusion, please leave a comment and I’ll do my best to answer it or recruit someone who can.
1Kate
wrote on 24 August 2009 at 17:00
Damn, Serena. Well done.
2freewomyn
wrote on 24 August 2009 at 17:10
Thanks, Kate. It’s been 4 years since I took a stats class, so I felt pretty proud of myself for being able to read and understand the technical jargon in the review. My stats prof should be proud!
3NancyP
wrote on 25 August 2009 at 13:39
thank you for drawing attention to this study. This will be useful reference in future. Interestingly, one of the authors of this metaanalysis is at a Catholic university.
4freewomyn
wrote on 25 August 2009 at 13:47
Nancy, I’m glad that you found the post useful.
5Martha
wrote on 25 August 2009 at 17:54
This is new published paper is a review. not a study, and not a metaanalysis.
Within the qualification of the conclusion that all these studies do not provide “convincing evidence” is the implicit admission that there is evidence of a connection between abortion and mental health problems.
First, there is the evidence of countless women who attribute mental health problems to their abortions and seek help from both licensed mental health providers and lay post-abortion peer support groups. Some of the evidence even include signed suicide notes, as in the widely covered case of Emma Beck, attributing their suicides to their abortions.
Second, there is the evidence of trained therapists confirming that abortion caused or exacerbated mental health problems. One of the authors of this review, Dr. Stotland, herself reports on being taken aback by a strong delayed post-abortion reaction in a patient. The latent reaction was triggered by a miscarriage which aroused unresolved issues. (See Abortion: Social Context, Psychodynamic Implications” Am J Psychiatry, 1998.)
Third, the reams of studies reviewed consistently show statistically signficant associations between numerous negative mental health outcomes and abortion. There is an especially large amoung of literature showing a positive association with abortion and increased subseqeunt substance abuse.
The approach of deniers is to insist that proponents of a connection have not “proven causality.” It is, of course, difficult to prove any causal connections in the field of mental health since the human mind is very complex, so this is always a safe area on which to plant one’s claim that the evidence is not sufficiently convincing to change one’s mind. The same “no causal proof” argument is raised by the deniers of global warming — and for many decades, by the tobacco industry.
Politically, this shift to a demand for causal proof is a two edged sword, however. The simple fact is that there is also not causal proof that abortion BENEFITS women. In fact, all the studies tend to show higher rates of negative affects statistically associated with abortion but few if any positive effects.
All the looked for benefits promised in the 70’s which would arise by sparing women the burden of caring unwanted pregnancies to term have failed to be measurable in any randomized statistical analysis of hard data. It appears that the best evidence for all the “benefits” of abortion still can be found only in anecdotes, presumptions, and ideology.
Every study has methodological weaknesses. Pointing to the weaknesses of studies linking abortion to mental health problems is fair, but it does not mean they should be dismissed out of hand. And it also comes with the expectation that those who support abortion must be able to bring forward superior studies which not only show less harm but actual benefits from abortion.
6caheidelberger
wrote on 25 August 2009 at 19:18
I live in South Dakota, where Judge Karen Schreier gave us a split decision last week, upholding the “the abortion will terminate the life of a whole, separate, unique, living human being” script but struck down the “increased risk of suicide ideation and suicide” line. It’s good to see this study back up the latter part of her decision. Thanks for posting!
7CIndy Lugo
wrote on 26 August 2009 at 14:25
Abortion does NOT terminate the life a a whole, separate, unique, living human being. I am sick of anyone trying to force women to bear children they do not want.
A whole, separate human being would not be developing zygotes. Get your religious beliefs out of our lives.
You did not live during the time where women died regularly from backroom botched abortions, because of you religious wingnuts. Keep you religion and your “belief system” away from the rest of us.
You have no right – keep your religious beliefs within your own religous community. You may NOT, based on religious and personal beliefs. Judges who use the bench to uphold religious/beliefs not facts, should be removed from the bench!
8Aspen Baker
wrote on 1 September 2009 at 14:05
Well done. The ins-and-outs of what is good science can be tough to grasp and tough to explain, especially as a non-scientist like me. And yet, these distinctions are really important.
There are a couple of points that I’d like to address about mental health. First, abortion and people’s personal experiences of abortion are absolutely connected to and can impact their mental health. Mental health is a concept which seeks to define how we deal with our lives, emotionally and cognitively. We may cope well with an abortion, or we may not, both responses are a gauge of our mental health. Wikipedia has a great definition: http://en.wikipedia.org/wiki/Mental_health
What the Harvard literature review and other similar literature reviews point out is that there has been no perfect-sciency study done that provides real evidence that there is a direct correlation between abortion and mental ILLNESS, or a psychological disorder. Which also doesn’t mean one doesn’t exist, it just means no study has shown it to exist.
As the Founder and Executive Director of Exhale, http://www.4exhale.org, what we think is most important to understand about the emotional experience of abortion, is that frankly, there is one. And that emotional well-being is possible for every woman who has had one and her loved ones.
The spectrum of feelings that women and men can have after an abortion – from relief and empowerment to grief and sadness – all deserve to be heard and supported. The presence of normal, natural human emotion does not in fact predetermine mental illness. Quite the opposite, in fact. A person’s ability to identify and cope with their feelings around an abortion experience is a very positive action and one that puts them in charge of promoting their own emotional health.
Exhale believes that more research needs to be done to better understand the emotional experience of abortion and the kinds of strategies women can use to promote their own well-being. That is why we advocated that the NIH do more research on this topic and are proud to be a partner with the Advancing New Standards in Reproductive Health program at UCSF that has launched a series of new studies to do just that. You can learn more about our NIH advocacy here: http://aspenbaker.wordpress.com/2009/05/22/the-science-of-support-why-we-need-research-that-promotes-well-being-after-an-abortion/ and about ANSIRH’s work here http://www.ansirh.org/research/aspects.php
The current social climate around abortion is definitely not the most conducive environment to a woman’s wellbeing after an abortion. And yet, we know from listening to women on our talkline, that they have everything they need to be well after an abortion. The best each of us can offer is to listen and be a witness to their unique story.
9Ashley
wrote on 6 September 2009 at 20:54
This was a clear, thoughtful, and extremely informative post. Well done.
10Mallory
wrote on 18 October 2009 at 16:35
Martha, I am gladd that you posted your comment. You put into words everything that I was thinking about this artice!
On another note: An unborn child is a human isn’t it? Shouldn’t all humans have a right to life?
Aren’t we blessed to be adults and able to comment on this artice today alive and well? Thank God that someone cared for us when we were too small to care for ourselves.
I want to stand up for those small people hidden in their mother’s wombs that cannot stand up for themselves. I want to protect their lives from those that seek to destroy them. Even if that person is their own mother.
11Kiwi
wrote on 11 December 2009 at 9:03
Mallory,
“Thank God that someone cared for us when we were too small to care for ourselves.” So how many single parents and poor parents are you supporting? How much money are you giving to needy children? How many children have you adopted and how many foster children are living with you in your home right now? How many women’s medical bills (for carrying a fetus to term) have you paid for? Finally, give me your contact info– if I ever get pregnant, I will send all my bills to you since you are so hell bent on “protecting lives.” Or is that not what you meant? Maybe you don’t actually care about other humans, just want to ruin women’s lives with unwanted pregnancies?? (I’m not even going to touch your tenuous grasp of biology.)
I don’t know you personally, but your desire to “protect lives” is meaningless and pernicious unless you are doing all the things I mentioned above.
Kiwi
12RN student
wrote on 15 February 2010 at 15:32
Just one observation you probably will not want to consider
“if there is no relation to poor mental status and the post abortion client why would you need to a write about the lack of relationship?” In other words why are you so articulate about proving the non-existance of a phenomena, do you have articles this passionate about the existance or lack thereof for the tooth fairy ?