Abortion and mental health

The relationship between induced abortion and mental health is an area of political controversy. Major medical bodies have found that women who have had a single first-trimester induced abortion are no more likely to have mental-health problems than those carrying pregnancy to term, but the evidence was unclear for other cases such as repeat abortions and late termination of pregnancy due to foetal abnormality. Pre-existing factors in a woman's life, such as emotional attachment to the pregnancy, lack of social support, pre-existing psychiatric illness, and conservative views on abortion increase the likelihood of experiencing negative feelings after an abortion. Although studies have correlated negative mental health outcomes with more than one abortion, such outcomes could be caused by the same circumstances that caused the multiple abortions in the first place.

In 1990, the American Psychological Association (APA) found that "severe negative reactions [after abortion] are rare and are in line with those following other normal life stresses." The APA updated its findings in August 2008 to account for new evidence, and again concluded that a woman's first termination of an unplanned pregnancy in the first trimester did not increase the risk of mental-health problems. 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. In December 2011, the U.K. National Collaborating Centre for Mental Health published a systematic review of available evidence, similarly concluding that first-time abortion in the first trimester does not increase the risk of mental-health problems compared with bringing the pregnancy to term.

Despite the weight of medical opinion that first-time abortions in the first trimester (the majority of abortions) do not result in increased risk of mental health issues when compared with live birth, some anti-abortion advocacy groups have continued to allege a link between abortion and mental-health problems. 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 American Psychological Association, the American Psychiatric Association, or the Royal College of Obstetricians and Gynaecologists; 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. Some U.S. state legislatures have mandated that patients be told that abortion increases their risk of depression and suicide, despite the fact that such risks are not acknowledged by the major mental health organizations or the higher-quality science publications on the issue.

Mental health and abortion law

Main article: Abortion in the United States

Under the 1973 US 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. 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." It is by this provision that women in the US can legally choose abortion when screenings reveal abnormalities of a viable fetus.

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.

Current and historical reviews

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. 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. Higher-quality studies have consistently found no causal relationship between abortion and mental-health problems. The correlations observed in some studies may be explained by pre-existing social circumstances and emotional health. 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 consequences on mental health can be due to any pregnancy outcome.

United States Surgeon General (late 1980s)

In 1987, President Ronald Reagan directed U.S. Surgeon General C. Everett Koop, an evangelical Christian and abortion opponent, 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. Koop was reluctant to accept the assignment, believing that Reagan was more concerned with appeasing his political base than with improving women's health.

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." 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."

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." 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."

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."

American Psychological Association (1990, 2008)

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.

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." 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."

In 2007, APA established a new task force to review studies on abortion published since 1989. The APA task force issued an updated summary of medical evidence in August 2008, again concluding that a single first-trimester abortion carried no more mental health risk than carrying a pregnancy to term. 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 predipose her to mental health difficulties; therefore, they declined to draw a firm conclusion on studies concerning multiple abortions.

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.

Thorp et al. (2003)

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."

Johns Hopkins (2008)

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." 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."

Steinberg (2011)

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."

Royal College of Psychiatrists (2011)

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, found that abortion did not increase mental health risks. An unwanted pregnancy was associated with a greater risk of mental-health problems, but the risk was equivalent whether women had an abortion or gave birth.

Stotland (2011)

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

"Post-abortion syndrome"

The term "post-abortion syndrome" was first used in 1981 by Vincent Rue, a anti-abortion advocate, in testimony before Congress in which he stated that he had observed post-traumatic stress disorder which developed in response to the stress of abortion. Rue proposed the name "post-abortion syndrome" ("PAS") to describe this phenomenon.

The term "post-abortion syndrome" ("PAS") has subsequently been popularized and widely used by anti-abortion advocates to describe a broad range of adverse emotional reactions which they attribute to abortion. "Post-abortion syndrome" has not found widespread acceptance outside the anti-abortion community; the American Psychological Association and the American Psychiatric Association do not recognize PAS as an actual diagnosis or condition, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR or in the ICD-10 list of psychiatric conditions. 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.

Counseling

Anti-abortion religious groups and crisis pregnancy centers provide the bulk of counseling for the minority of women who experience negative mental health outcomes after abortion, but non-religious organizations have also been formed in order to promote counseling that is non-judgmental, and Planned Parenthood provides emotional support to patients.

See also

• Postpartum depression
• Postpartum psychosis
• Psychiatric disorders of childbirth

External links

Reviews by major medical bodies

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