Abortion, Informed Consent,
and Mental Health
By Nancy Felipe Russo
and Lisa Rubin
Unintended pregnancy, whether
resolved by an abortion or by giving birth, is a common life event
that is typically perceived as stressful, sometimes profoundly
so. In general, however, exercising the option of legal abortion
is not 'more dangerous' to physical or mental health than giving
birth - indeed many reviews of the scientific literature have
established that having legal abortion, particularly if it is
in the first trimester, poses little particular threat to mental
health for most women (see Adler, 1990, 1992; Russo, 1992, 1995;
Russo & Denious 2000 for reviews).
The informed consent process
has become a pawn in pro-life movement efforts to restrict access
Scientific evidence not withstanding,
under the guise of a 'kinder and gentler' approach in what have
been called the 'abortion wars' (Solinger, 1998), the pro-life
movement is waging a campaign around the world to portray abortion
as a threat to women's mental health. Such efforts contribute
to a larger strategy to undermine access to legal abortion that
involves subverting the informed consent process.
The campaign began in the United
States, where successful construction of a 'postabortion syndrome'
could help political forces opposing abortion overturn Roe
v. Wade, the Supreme Court decision that legalized abortion,
by arguing that the Court failed to balance its concern for the
negative effects of unwanted pregnancy with the alleged "fact"
that abortion is detrimental to women's mental health.
In response to these allegations,
the American Psychological Association established a Task Force
on Postabortion Emotional Reponses to examine the issues. The
Task Force reviewed the scientific literature and found no scientific
basis for such claims.
The Task Force did not view itself
has having a vested interest in its conclusions: indeed one could
even argue that if abortion had been found to be a widespread
and severe risk to mental health, then psychologists could argue
for more funding to conduct research and provide psychological
services aimed at helping such women. Nonetheless, in order to
avoid charges of pro-choice bias in having come to their conclusion
that the scientific findings did not support portraying abortion
as a severe threat to public health, the initial report of the
Task Force was submitted to Science, an independent, highly respected
scientific journal that accepted it after an extensive peer review
(Adler et al, 1990). Other reviews of the literature, spanning
nearly three decades, have come to similar conclusions (e.g.,
Adler, 1990, 1992; National Academy of Sciences, 1975; Schwartz,
1986; Russo, 1992; Russo & Denious 2000).
Despite a consistent consensus
of scientific findings and failure to justify 'postabortion syndrome'
as a recognized psychiatric diagnosis, pro-life advocates have
turned to prolife legislators who craft bills mandating informed
consent scripts that exaggerate abortion's physical and mental
health risks while downplaying the risks of giving birth in blatant
disregard of research findings. A disturbing illustration of the
approach of some politicians involved in these activities is found
in the words of Illinois State Representative Dan Reitz, who introduced
a mandatory informed consent bill and when criticized for its
misleading context was reported in the March 12, 2001 edition
of Newsweek as saying: 'I'm not really sure about the science
intent was strictly about limiting abortion'.
By misrepresenting health risks,
pro-life activists use fear to encourage pregnant women to have
unwanted births and to deter them from exercising their legal
right to an abortion. Such activities also attempt to deter physicians
from providing abortions by passing legislation making them civilly
and criminally liable for damages from such 'injuries'.
Although the pro-life campaign
started in the United States, it is being exported to other countries.
For the last several years, a campaign to construct 'postabortion
syndrome' has progressed around the world, including such countries
as England, Scotland, Australia, New Zealand, and Switzerland.
Recently, the campaign has been
taken to a new level in Britain. According to Kaiser Foundation's
Daily Reproductive Health Report (http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=11737
) [accessed June 14, 2002], a British woman has announced
her intention to sue the United Kingdom's National Health Service
for 'negligence' by failing to warn her of the possible psychological
consequences from obtaining an abortion four years previously.
In the report, she describes herself
as having experienced feelings of 'guilt and self-hatred' after
having an abortion, and coming to 'the brink of a nervous breakdown'
after giving birth to a son two-and-a-half years later: 'After
I had my son, I realised what I had lost. ... I just looked at
him and I just realised what I had done'. The woman, a former
employee of the National Health Service, agrees she was counseled
about the possible physical risks and side effects of the procedure,
but says she was not apprised of the possible psychological effects.
This case is a prime example of
how women's psychological problems can be put to the service of
the prolife political agenda and add a drumbeat to the theme that
physicians are deliberately betraying their abortion patients
in the informed consent process. Indeed, pro-life advocate Nuala
Scarsbrick, a trustee of the antiabortion group Life, is reported
as following up the story with the claim that the case demonstrates
that women are "deliberately not being told the whole truth"
about abortion and are 'not given the chance to make informed
decisions', adding that she hopes the case, which is still at
a 'very early stage of development', will 'encourage other women
to speak out and take action' (BBC News On-line, 12 June, cited
in Kaiser's Daily Reproductive Health Report).
Subverting informed consent
for political ends undermines women's mental health
Such activities are of concern
to all individuals - whether pro choice or pro life - who put
a priority on fostering positive mental health in women. In addition
to subverting the informed consent process, they compound the
stress that a woman experiences when facing an unwanted pregnancy,
and damage her confidence in her ability to cope. They distort
her appraisals of her experiences and emotionally charge the experience
of abortion. As a result, abortion comes to serve as a 'lighting
rod' for negative emotions originating in conditions preexisting
to and concurrent with pregnancy. Finally, they undermine the
therapeutic process by distracting women from dealing with the
deeper issues associated with those conditions.
No one can argue with the importance
of providing patients with informed consent about any medical
procedure, including abortion. However, women who seek abortions
are diverse: young and old, rich and poor, highly educated and
uneducated, married and divorced, and healthy and unhealthy, among
other things. Any particular woman's risks will depend on her
personal history and circumstances.
As the American Psychological
Association has pointed out in amicus briefs in abortion cases,
informed consent for pregnant women is not attained by exposing
women to prewritten mandatory counseling 'scripts' written by
prolife legislators in the service of their political agenda.
Providing appropriate informed consent requires establishing good
communication between physician and patient -- communication that
is accurate and understandable, and tailored to the patient's
individual situation and needs. Mandated abortion scripts subvert
Achieving informed consent
for mental health outcomes after abortion requires thoughtful
consideration of all options
Informed consent for a pregnant
woman is not achieved by providing a 'laundry list' of every possible
negative outcome of having an abortion. The positive and negative
outcomes for all alternatives - including having an abortion,
giving birth and rising the child, and giving birth and having
someone else raise the child - must be considered, put in perspective,
and weighed in the context of the particular woman's value system.
Relative risks of abortion versus
its alternatives will differ depending on the context. For example,
the extent to which abortion might lower mental health risk relative
to that of birth depends on how much stress women are experiencing
from rearing children they already have.
When a woman seeks an abortion
to delay a birth, she is engaging in a stress management process
and not simply a matter of selfish convenience. In the United
States, in 1987 nearly one-half of abortion patients were already
mothers, and nearly one in four of those mothers had a child under
two years of age (Russo, Horn, & Schwartz, 1992). When children
are born less than two years apart, the health of both children
is affected. Spacing births more than two years apart reduces
the risk of low birth weight and neonatal death - in 1991 by an
estimated 5 to 10 percent in the United States (Miller, 1991).
Relative risks depend on the cultural and societal context, but
one study found the younger child 2 1/2 times more likely to die
than a child who is born more than two years after an older sibling.
For the older child the increased risk was less, but can still
be substantial: 63 per cent (Potts & Thapa, 1991).
The one-sided scripts anti-abortion
advocates seek to mandate do not consider the negative consequences
of unwanted childbearing and rearing. The remedy is not simply
adding the 'other side' to mandatory scripts, however. Mandating
the specific content of what a physician must say to all patients
is, in fact, the antithesis of providing informed consent. Ultimately,
it must be up to the physician and, if needed, an abortion counselor
to work with the patient to assess and weigh the risk of various
factors in the unique context of the particular patient.
Although having a legal abortion
does not directly increase risk for anxiety and depression, it
can indirectly lower such risk by enabling access to coping resources
(e.g., an education and higher income), and permitting women to
avoid stressful circumstances (e.g., early, excessive, or unwanted
childbearing; becoming tied to violent men). Women's concerns
about the potential impact of a child on their lives and their
ability to meet childbearing responsibilities are backed by a
host of data documenting the negative effects of having too many
babies, too early, and too closely spaced together. (For a discussion
of research on effects of unwanted childbearing, see the essay
on the effects of unwanted pregnancy and childbearing by Russo
and David http://www.prochoiceforum.org.uk/psy_ocr2.php).
Identifying and weighing mental
health risks is a complex enterprise
Providing informed consent for
mental health outcomes of a pregnant woman's options is complex,
particularly when a major determinant of how a woman responds
to an abortion is how she appraises the meaning of abortion and
its alternatives. Abortion can be viewed as a profound threat,
a coping tool, or both.
As Brenda Major and her colleagues
(Major, et al., 1998) concluded from their longitudinal research
on the effectiveness of women's coping responses after experiencing
it is each woman's personal
appraisals of the abortion that matter--how stressful or anxiety
provoking she regards it, and how well she expects to be able
to cope with it. These appraisals are shaped, in part, by the
personal resources that the woman has to draw upon, including
personality attributes such as high self-esteem and perceived
control, as well as the support of significant others… (Major
et al., 1998, p. 750).
These findings have profound implications
for the informed consent process as well as effective prevention
and intervention. They point to the importance of providing informed
consent in ways that will help women to understand the role their
appraisal process plays in shaping their psychological responses
to however they choose to resolve their pregnancy.
Informed consent is also complicated
by the fact that mental health outcomes can be difficult to define
and may not be easily separated from the effects of preexisting
conditions. Pregnant women may have a history of mental problems,
lack coping skills, and live in unsupportive social environments.
As a result, they may be anxious and depressed and at risk for
unwanted pregnancy. If such women have histories of physical and
sexual abuse or have violent partners, they may even suffer from
posttraumatic stress (McGrath, et al., 1990).
Such women are at risk for mental
health problems regardless of how they resolve an unwanted pregnancy
(see Russo, 1992). If they chose abortion, however, the cognitive
distortions and negative emotions associated with their preexisting
depression and posttraumatic stress may make them particularly vulnerable
to pro-life propaganda designed to convince them that their symptoms
were caused by their abortion experience. The fallacious implication
is that having an unwanted birth would have alleviated their distress.
Given that women who have unwanted
pregnancies are much more likely to have experienced childhood
physical and sexual abuse and intimate violence, the pro-life
targeting of the appraisal process is particularly disturbing.
The myths and misinformation of pro-life propaganda reinforce
the historical silencing of women around violence issues, and
may distract women from dealing with the effects of preexisting
conditions. In particular, women suffering from posttraumatic
stress due to experiencing violence can recognize their symptoms
and 'see themselves' in postabortion syndrome propaganda.
Women need to understand the importance
of their appraisals of abortion and its alternatives in determining
their mental health outcomes and be alerted to the fact that they
may encounter pro-life propaganda designed to make abortion traumatic
by manipulating those appraisals.
Making Abortion Traumatic
We do not argue that all symptoms
are necessarily due to pre-existing conditions - abortion can
be made to be a traumatic experience, particularly if it is illegal
or stigmatized, or if the decision-making process involves juggling
deeply held but conflicting values. Pro-life activists, however,
create and enhance abortion trauma by attacking the most important
immediate determinant of a woman's postabortion emotional responses
- her appraisal, or interpretation, of the meaning of the event.
Women's responses to unwanted
pregnancy terminated by a voluntarily chosen legal abortion can
range from feelings of satisfaction and empowerment derived from
successfully dealing with the challenge of unwanted pregnancy
- to guilt and shame for not having the psychological, social,
and/or economic resources to commit to the future child. Abortion
can be experienced as a relatively benign experience or a threat
to a women's self-construal and her relationships with significant
others, depending on how a woman appraises it.
Resolving an unwanted pregnancy
involves a profound and personal decision, arguably the most important
decision a woman will make in her entire life. The easy path would
be to just let 'nature take its course' and 'let come what may'.
The responsible path, however, forces a woman to examine her values,
responsibilities, and realities, and involves a process that can
involve painful self-judgments. Making a thoughtful decision,
whatever alternative is chosen, requires the courage to strip
illusions from one's self, relationships, and circumstances, the
strength to take responsibility for one's irrevocable actions,
and for women who are or want to become mothers, the caring to
put the well-being of one's current and future children first
and foremost in what is a complicated decision-making equation.
A woman may feel sad or guilty
after an abortion - such feelings are normal given she has just
had an unwanted pregnancy that required her to examine her self
and her circumstances without protection of stress-buffering positive
illusions. That doesn't mean that she is mentally ill. Most women
who report mild feelings of sadness also say they are happy and
satisfied with their decision, and get on with their lives.
But abortion can become traumatic
when women believe the myths they are told, interpret what otherwise
might be temporary feelings of sadness and distress as signaling
serious difficulties, lose confidence in their ability to cope
with an abortion, and come to fear death and disability after
having one. In addition to fostering concerns about mental health,
one of the crueler campaigns has involved putting the claim that
'abortion causes breast cancer' on signs in buses and subways
(see the website of the National Cancer Institute Cancer Facts:
Abortion and Breast Cancer at http://cis.nci.nih.gov/fact/3_53.htm
or read Melbye, et al. (1997) for reputable scientific information
on this issue).
An abortion decision can also
be made traumatic even for a mentally healthy woman if the decision
is coerced or stigmatized by others (e.g., by a partner, parent,
or important authority). Portrayals of fetal pain can also be
disturbing to women who are uninformed about fetal development
and don't know that the neocortical physiology involved in pain
perception doesn't even begin developing until about the 20th
week of pregnancy.
Even the relatively benign experience
of early legal abortion can be a source of fear and terror (a
critical factor in the development of posttraumatic stress) in
a context in which abortion providers are murdered and abortion
clinics are bombed and vandalized. The screaming at, stalking,
and photographing of women at clinics takes on an added dimension
of threat in such a context.
If women feel troubled after abortion
they should seek help from a licensed mental health provider.
Their feelings should not be trivialized or dismissed, but need
to be examined beyond focusing on the abortion per se or
the 'baby that might have been'. A host of issues need to be explored,
including negative self-discrepancies in women's visions of themselves
as good and worthy persons, intimate partners, mothers, and daughters,
among other things (for examples of the complexities underlying
negative feelings in response to abortion see Torre-Bueno (1996)
or visit http://www.peaceafterabortion.com).
Informed consent requires that
a women and her abortion provider (physician and/or pregnancy
counselor working with the physician) discuss a woman's situation
calmly and thoughtfully until she is ready to make what must be
her own decision - a decision that she must come to terms with
and put to rest. The bottom line is that there are no absolute
risks for legal abortion that apply to all women. For any individual
woman, both the absolute and relative risks of the negative physical
and mental heath outcomes of abortion and its alternatives will
be unique to her personal history and situation. Given the intense
campaign to manipulate the appraisal process, her risk will depend
on her future exposure to pro-life propaganda as well.
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