Abortion and mental health

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The relationship between induced abortion and mental health is an area of political controversy.[1][2] Abortion is associated both negative feelings and clinically significant disorders among some women, but similar problems are also associated with carrying an unwanted pregnancy to term.[3][4] Given these two alternatives, the best evidence suggests that a single, first-trimester induced abortion for adult women poses no greater mental-health risks than carrying unwanted pregnancies to term.[3][5] The evidence is less clear in situations such as repeat abortions, and late termination of pregnancy due to foetal abnormality.[3]

Among those women who do experience mental health issues, the American Psychological Association's Task Force on Mental Health and Abortion concluded that these issues are most likely related to pre-existing risk factors, including "terminating a pregnancy that is wanted or meaningful, perceived pressure from others to terminate a pregnancy, perceived opposition to the abortion from partners, family, and/or friends, lack of perceived social support from others. . . [and] various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life) and a history of mental health problems prior to the pregnancy."(p11)[6] Since these and other risk factors may also predispose some women to more negative reactions following a birth, the Task Force concluded that the higher rates of mental illness observed among women with a prior history of abortion are more likely to be caused by these other factors than by abortion itself.[6] The best predictor of mental health issues following an abortion is a history of mental health issues prior to the pregnancy.[6][5]

In December 2011, the U.K. National Collaborating Centre for Mental Health similarly concluded that first-time abortion in the first trimester does not increase the risk of mental-health problems compared with bringing the pregnancy to term.[5][7] A 2008 systematic review of the medical literature on abortion and mental health found that high-quality studies consistently showed few or no mental-health consequences of abortion, while poor-quality studies were more likely to report negative consequences.[8]

Despite the weight of medical opinion that first-time abortions in the first trimester (which constitute the majority of abortions)[9] do not increase the risk of mental health issues, some anti-abortion advocacy groups have continued to allege a link between abortion and mental-health problems.[10] Some anti-abortion groups have used the term "post-abortion syndrome" to refer to negative psychological effects which they attribute to abortion. However, "post-abortion syndrome" is not recognized as an actual syndrome by the mainstream medical community,[11][12]. Physicians and pro-choice advocates have argued that the effort to popularize the idea of a "post-abortion syndrome" is a tactic used by anti-abortion advocates for political purposes.[1][10][13][14] Some U.S. state legislatures have mandated that patients be told that abortion increases their risk of depression and suicide, despite the scientific evidence contradicting such claims.[8][15]

Mental health and abortion law[edit]

Under the 1973 U.S. Supreme Court decision Roe v. Wade, state governments may not prohibit late terminations of pregnancy when "necessary to preserve the [woman's] life or health", even if it would cause the demise of a viable fetus.[16] This rule was clarified by the 1973 judicial decision Doe v. Bolton, which specifies "that the medical judgment may be exercised in the light of all factors-- physical, emotional, psychological, familial, and the woman's age-- relevant to the well-being of the patient."[17][18][19] It is by this provision that women in the US can legally choose abortion when screenings reveal abnormalities of a viable fetus.[20][21][22]

In the United Kingdom, abortion (late term or otherwise) is allowed under the 1967 Abortion Act, but only when two doctors agree that carrying the pregnancy to term would be detrimental to a woman's health, physical or mental. In Northern Ireland, where most abortions are illegal, this law is not applicable.[23][24][25][26][27]

In a 2013 literature review of studies comparing mental health following abortion versus carrying an unplanned pregnancy to term, David M. Fergusson and his colleagues concluded that there was no medical evidence of any mental health benefits to justify a recommendation of abortion over childbirth.[4] They concluded there are no mental health benefits associated with abortion but there is small to moderate increased risk of substance use and suicidal behaviors following abortion. They argued that access to abortion should not based on a pretense of psychological benefits, but rather on the social, economic, and educational needs of women and their immediate families.[4]

Current and historical reviews[edit]

Systematic reviews of the scientific literature have concluded that there are no differences in the long-term mental health of women who obtain induced abortions as compared to women in appropriate control groups.[8] While some studies have reported a statistical correlation between abortion and clinical depression, anxiety, suicidal behaviors, or adverse effects on women's sexual functions for a small number of women, these studies are typically methodologically flawed and fail to account for confounding factors, or, as with results of women having multiple abortions, yield results inconsistent with other similar studies.[3] Higher-quality studies have consistently found no causal relationship between abortion and mental-health problems.[8] The correlations observed in some studies may be explained by pre-existing social circumstances and emotional health.[28] Various factors, such as emotional attachment to the pregnancy, lack of support, and conservative views on abortion, may increase the likelihood of experiencing negative reactions. However, negative mental health impacts[29] can result from any pregnancy outcome.[30]

United States Surgeon General (late 1980s)[edit]

In 1987, President Ronald Reagan directed U.S. Surgeon General C. Everett Koop, an evangelical Christian and abortion opponent,[31] to issue a report on the health effects of abortion. Reportedly, the idea for the review was conceived by Reagan advisors Dinesh D'Souza and Gary Bauer as a means of "rejuvenat[ing]" the anti-abortion movement by producing evidence of the risks of abortion.[32] Koop was reluctant to accept the assignment, believing that Reagan was more concerned with appeasing his political base than with improving women's health.[31]

Ultimately, Koop reviewed over 250 studies pertaining to the psychological impact of abortion. Koop wrote in a letter to Reagan that "scientific studies do not provide conclusive data about the health effects of abortion on women."[33] Koop acknowledged the political context of the question in his letter, writing: "In the minds of some of [Reagan's advisors], it was a foregone conclusion that the negative health effects of abortion on women were so overwhelming that the evidence would force the reversal of Roe vs. Wade."[34]

In later testimony before the United States Congress, Koop stated that the quality of existing evidence was too poor to prepare a report "that could withstand scientific and statistical scrutiny." Koop noted that "... there is no doubt about the fact that some people have severe psychological effects after abortion, but anecdotes do not make good scientific material."[34] In his congressional testimony, Koop stated that while psychological responses to abortion may be "overwhelming" in individual cases, the psychological risks of abortion were "minuscule from a public health perspective."[1][35][32][36]

Subsequently, a Congressional committee charged that Koop refused to publish the results of his review because he failed to find evidence that abortion was harmful, and that Koop watered down his findings in his letter to Reagan by claiming that the studies were inconclusive. Congressman Theodore S. Weiss (D-NY), who oversaw the investigation, argued that when Koop found no evidence that abortion was harmful, he "decided not to issue a report, but instead to write a letter to the president which would be sufficiently vague as to avoid supporting the pro-choice position that abortion is safe for women."[36]

American Psychological Association (1990)[edit]

The American Psychological Association prepared a literature summary and recommendations for Koop's report. After Koop refused to issue their findings, the APA panel published them in the journal Science, concluding:

Although there may be sensations of regret, sadness, or guilt, the weight of the evidence from scientific studies indicates that legal abortion of an unwanted pregnancy in the first trimester does not pose a psychological hazard for most women...

Women who are terminating pregnancies that are wanted and personally meaningful, who lack support from their partner or parents for the abortion, who have more conflicting feelings, or who are less sure of their decision beforehand may be a relatively higher risk for negative consequences.[35]

The APA task force also concluded that "severe negative reactions after abortions are rare and can best be understood in the framework of coping with normal life stress."[35] Nancy Adler, a professor of psychology at the University of California, San Francisco, testified on behalf of the APA that "severe negative reactions are rare and are in line with those following other normal life stresses."[37][38]

Thorp et al. (2003)[edit]

A 2003 review by Thorp et al. in the journal Obstetrical & Gynecological Survey found that induced abortion increased the risk of "mood disorders substantial enough to provoke attempts of self-harm."[39]

Charles, et al (2008)[edit]

In 2008, a team at Johns Hopkins University conducted a systematic review of the medical literature, concluding that "the best quality studies indicate no significant differences in long-term mental health between women in the United States who choose to terminate a pregnancy and those who do not."[8][40] Robert Blum, the senior author of the study, stated: "The best research does not support the existence of a 'post-abortion syndrome' similar to post-traumatic stress disorder." The researchers further reported that "... studies with the most flawed methodology consistently found negative mental health consequences of abortion", and they wrote: "Scientists are still conducting research to answer politically motivated questions."

American Psychological Association (2008)[edit]

In 2008 American Psychological Association (APA) Task Force on Mental Health and Abortion published a major review of the literature on abortion and mental health. They concluded that "it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety."[6] But giving birth to an unplanned pregnancy may also be stressful. Examining the evidence comparing these two options, the Task Forced concluded that the risk of mental health problems following a single, first-trimester induced abortion of an adult women is no greater than carrying an unwanted pregnancy to term. While observing that abortion may both relieve stress and "engender additional stress," they explicitly rejected the idea that abortion is "inherently traumatic."[6]

Among those women who do experience mental health issues, the Task Force concluded that these issues are most likely related to pre-existing risk factors, including "terminating a pregnancy that is wanted or meaningful, perceived pressure from others to terminate a pregnancy, perceived opposition to the abortion from partners, family, and/or friends, lack of perceived social support from others. . . [and] various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life) and a history of mental health problems prior to the pregnancy."(p11)[6] Since these and other risk factors may also predispose some women to more negative reactions following a birth. the Task Force concluded that the higher rates of mental illness observed among women with a prior history of abortion are more likely to be caused by these other factors than by abortion itself.[6] The best predictor of mental health issues following an abortion is a history of mental health issues prior to the pregnancy.[6][5]

The panel noted severe inconsistency between the outcomes reported by studies on the effect of multiple abortions. Additionally, the same factors which predispose a woman to multiple unwanted pregnancies may also predispose her to mental health difficulties; therefore, they declined to draw a firm conclusion on studies concerning multiple abortions.[3][41] In 2009, an abridged version of the APA's 2008 review was published in the APA's peer reviewed journal American Psychologist[42]

The APA report also notes that women who terminate a pregnancy because of abnormalities discovered through fetal screenings have a similar risk of negative mental health outcomes as women who miscarry a wanted pregnancy or experience a still-birth or the death of a newborn.[3]

Robinson et al. (2009)[edit]

A 2009 review led by Gail Erlick Robinson found that studies which had been cited to support a link between abortion and mental health problems suffered from methodological flaws, including "poor sample and comparison group selection; inadequate conceptualization and control of relevant variables; poor quality and lack of clinical significance of outcome measures; inappropriateness of statistical analyses; and errors of interpretation, including misattribution of causal effects."[43]

Cameron (2010)[edit]

In 2010, Sharon Cameron reviewed the evidence regarding abortion and mental health problems and found that "most of the better-quality studies have shown no increased risk of mental health problems in women having an abortion." The same review reported that only a minority of women who have abortions experience regret afterward.[44]

Steinberg (2011)[edit]

In 2011, Julia Steinberg of the University of California, San Francisco reviewed the literature regarding whether later abortions due to fetal anomalies harmed women's mental health, concluding that policies based on the view that they do are "unwarranted."[45]

National Collaborating Centre for Mental Health (2011)[edit]

In December 2011, the Royal College of Psychiatrists undertook a systematic review to clarify the question of whether abortion had harmful effects on women's mental health. The review, conducted by the National Collaborating Centre for Mental Health and funded by the British Department of Health, examined three questions:[5]

1. How prevalent are mental health problems in women who have an induced abortion?
2. What factors are associated with poor mental health outcomes following an induced abortion?
3. Are mental health problems more common in women who have an induced abortion, when compared with women who deliver an unwanted pregnancy?

In reviewing studies relevant to the first question, the NCCMH concluded that there were too many limitations on most studies to confidently profile the prevalence rates, but that studies controlling for prior mental health reported lower rates of mental health problems following abortion compared to studies that did not control for prior mental health.(p64)

In regard to the factors that predict poor mental health outcomes following an abortion, the NCCMH concluded that pre-existing mental health problems are the most reliable predictor of mental health problems following an abortion. A number of other risk factors were identified in the literature, but these had not been as consistently measured as prior mental health, and many of these may overlap with the risk factors associated with live birth. (p90)

In regard to the third question, comparing abortion to delivery of an unwanted pregnancy, the NCCMH concluded that the available studies all had methodological limitations. When pregnancy intention is not controlled for, studies reveal elevated rates of psychiatric treatment, suicide, and substance misuse following an abortion. But when other studies control for pregnancy intention, there is limited evidence of higher rates of self-harm following abortion, but insufficient evidence of elevated rates of other problems. The NCCMH concluded that while an unwanted pregnancy may lead to an increased risk of mental health problems, and that women who have abortions are already at higher risk of mental health problems, it is most likely that women faced with unwanted pregnancies face similar rates of mental health problems whether they carry to term or have an abortion.(p118)

Stotland (2011)[edit]

A 2011 review by Nada Stotland identified fatal methodological flaws in then-recent studies claiming that abortion caused adverse mental health outcomes.[46]

Fergusson (2013)[edit]

A 2013 review by David M. Fergusson and colleagues undertook a re-appraisal of the all the studies (14 in total) examined in previous reviews that compared mental health outcomes between women who had abortions and women who carried an unintended/unwanted pregnancy to term (thereby excluding women who carried a wanted pregnancy to term).[4] Their review revealed that there no evidence that abortion has any therapeutic mental health benefits, i.e.; women who aborted unwanted pregnancies did not fare any better in regard to any mental health outcome examined as compared to women who carried unwanted pregnancies to term. Conversely, there was statistically significant evidence suggesting a small to moderate increased risk of substance use and suicidal behaviors following abortion versus delivery of unwanted pregnancies.[4]

"Post-abortion syndrome"[edit]

"Post-abortion syndrome" is not included in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR or in the ICD-10 list of psychiatric conditions, nor is the term commonly used outside of the anti-abortion community. Some physicians and pro-choice advocates have argued that the focus on "post-abortion syndrome" is a tactic used by anti-abortion advocates for political purposes, and that PAS does not really exist.[10][14][47][48][49]

The term "post-abortion syndrome" ("PAS") has widely been used by anti-abortion advocates to broadly include any negative emotional reactions attributed to abortion.[1][13][50] The idea that abortion negative psychological effects was widely promoted by crisis pregnancy centers in the 1970s[51] based on psychiatric literature pre-dating the legalization of abortion in the United Kingdom and the United States.[52]

The term "post-abortion syndrome" was more narrowly defined as a form of post-traumatic stress disorder by psychotherapist Vincent Rue in testimony before Congress in 1981.[53][54] The rationale for PAS as a form of PTSD was developed in the doctoral dissertation of Anne Speckhard in 1985 based on interviews with 30 women recruited specifically because of their "highly stressful" abortion experiences, a group that was not representative of the national population.[6]

Counseling[edit]

Counseling for women and men who may struggle with a past abortion is available from both anti-abortion crisis pregnancy centers and religious groups[1] and also from pro-choice/pro-voice groups, like Exhale.[55][56] Planned Parenthood provides emotional support to patients.[57][58]

See also[edit]

References[edit]

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External links[edit]

Reviews by major medical bodies