The Context for the Development of 'Post-Abortion Syndrome'
By Ellie Lee

Prepared for the Symposium 'The psychological sequelae of abortion - myths and facts',
Berne, Switzerland, 31/5/01

*Thanks to Dr David Paintin for his help in the preparation of this paper

As a sociologist, my research interest lies in the study of the construction of social problems. My research investigates the social processes through which certain activities, actions and other social phenomenon come to be perceived by members of society, in particular by law and policy makers, as problems that require laws to be passed or policies to be made.

The abortion issue is particularly fascinating. This is because the extent to which abortion is perceived as a problem, why it is considered to be a problem, and by whom it is perceived in this way, has changed so much over time, and varies so much between different societies.

In pre-modern societies abortion was certainly widely practiced, and there is little evidence to suggest that abortion was considered a social problem. Legal regulation of abortion in the Roman Empire, for example, was almost non-existent, and law held that 'a child in the belly of its mother' was not a person, and hence abortion was not murder (Luker 1984: 12). Even under early Catholic law, early abortions were legally ignored, and only late abortions could be prosecuted (ibid: 13-14)

Abortion, in the US and Britain, was not considered a social problem, that required a legal response, until the early 19th century. The common law of England prohibited abortion after quickening but this did not become a statute law felony until Lord Ellenborough's Maiming and Wounding Act of 1803. The same act also made abortion before quickening a misdemeanour for the first time. It has been suggested that among the underlying reasons for including abortion in this comprehensive revision of the criminal law were policing the behavior of single women and moving control over early pregnancy from midwives and handy women to the medical profession (McLaren 1990: 190-1).

Thus, when abortion was originally outlawed in Britain (and North America) the most influential advocates of prohibitive laws were in fact not religious or legal organisations, but doctors. It was doctors who argued that abortion was a problem, and that women should not be allowed to abort pregnancies at will. There was no significant political and church-based anti-abortion movement that we are now so familiar with.

The anti-abortion movement as we know it today emerged much more recently, following the re-legalisation of abortion, and the emergence in the 1970s of the modern movement for women's rights. The debate on the rights of the fetus on the one hand and the rights of women on the other has been specific to quite recent history.

The nature of the abortion debate, and the way in which abortion is presented as a problem, has thus varied quite considerably over time. As the title of this paper indicates, it has in recent years come to be the case that abortion opponents have argued that law and policy makers should consider abortion a problem in a different way again. Abortion, they have argued, can lead to a serious psychiatric condition, termed 'Post -Abortion Syndrome'. They have attempted to suggest this is so frequent and so severe that abortion that should be legally prohibited or, at the very least, women should be discouraged from having abortions, and warned through counselling that they are likely to suffer psychologically if they do so.

In this paper, my aim is to consider why this particular construction of the abortion 'problem' has emerged. It is important to note that the claim that abortion can lead to PAS has now emerged in a number of societies, including the US, the UK, Australia, and now Switzerland. Its origin, however, is in the US, and thus I will restrict my comments to events that have happened there. But opponents of abortion have cross-national links, and arguments developed by the most powerful anti-abortion movement in the world, that in the US, are often used in other societies after a period of time.

The emergence of Post Abortion Syndrome (PAS)

By the mid-1980s in the US, the major anti-abortion organisations had begun to make reference to PAS in their publications and in their comments in the press. A particular individual, Dr Vincent Rue, has however been credited with developing the argument for PAS, and its diagnostic criteria. In the early 1980s Rue gave a number of papers at conferences organised by anti-abortion organisations where he put forward his argument that abortion can lead to PAS. Since that time he, together with Anne Speckhard, has published a number of book chapters and journal articles about this issue.

In their writings on abortion, Rue and Speckhard emphasise that the psychological effects of terminating pregnancy should not be underestimated; rather, it is 'possible that the decision to elect abortion can generate significant resulting psychosocial distress' (Speckhard and Rue 1992: 96). In 'Post-abortion Syndrome: A Variant of Post-Traumatic Stress Disorder', a contribution to a collection of essays about PAS, Rue argues that:

while abortion may indeed function as a 'stress reliever' by eliminating an unwanted pregnancy, other evidence suggests that it may also simultaneously or subsequently be experienced by some individuals as a psychosocial stressor, capable of causing posttraumatic stress disorder (PTSD)......We suggest that this constellation of dysfunctional behaviors and emotional reactions should be termed "Postabortion syndrome (PAS)" (Rue 1995:20).

The argument made is therefore that abortion is sufficiently stressful to lead to post traumatic stress disorder, and that the particular form of PTSD that results from abortion should be 'named' as a specific psychological disorder, called PAS.

A noteworthy feature of this argument is the representation of the 'symptoms' of PAS. Rue explicitly compares the 'symptoms' of PAS and those which are said to be characteristic of PTSD, a condition first 'named' by psychiatrists following the return of soldiers from the Vietnam war (Scott 1990, Young 1995). He argues 'the symptoms are the same: flashbacks, denial, lost memory of the event, avoidance of the subject' (Rourke 1995: E-1). He has also developed 'diagnostic criteria' for PAS, along the lines of the criteria for PTSD given in the American Manual of Psychiatric Disorders, the DSM. According to these criteria, the abortion experience is defined as a stressor, sufficiently traumatic so as to cause the symptoms of re-experience, avoidance and impacted grieving. Thus, PAS is presented as a form of a specific psychiatric condition, PTSD.

However, it is important to bear in mind that often the diagnostic criteria given shift from a definition of the 'symptoms' of PAS where the proposed comparison with PTSD is made clear, to a much broader collection of 'symptoms' that could perhaps more accurately be described as negative feelings.

In the same chapter where the above 'diagnostic criteria' for PAS are given, Rue lists a wide range of feelings, and forms of behavior that he argues might be evident in women who have had an abortion. These include feelings of helplessness, hopelessness, sadness, sorrow, lowered self-esteem, distrust, regret, relationship disruption, communication impairment and/or restriction and self condemnation (Rue 1995: 20).

Associating this broad range of 'symptoms' with a diagnosis of PAS is a significant aspect of the argument, since it lets its proponents argue that large numbers of women may suffer from the syndrome. To put it simply, as the 'diagnostic criteria' for PAS becomes broader, it is easier to claim that many women may suffer from the 'syndrome'.

PAS and the 'moral stalemate'

How and why did this argument emerge? I suggest there are three main factors that explain its development. The first factor can be termed the 'moral stalemate' in the abortion debate in the US. As I noted earlier, abortion has, since the 1970s at least, been construed a problem because it 'takes a life'. Abortion has therefore be presented by its opponents as a moral question, with those who support its availability as morally wrong.

But this argument has had limited success in convincing those involved in law and policy making, and the general public, that they should oppose abortion. It had become evident by the early 1980s, a decade after abortion was made legal in the US, that the moralised focus of anti-abortion argument had succeeded in generating much debate about the 1973 Supreme Court ruling, Roe v. Wade, that legalised abortion, but no consensus in favour of overturning this law. It was the case, and remains the case today, that whilst many might believe abortion to be a morally difficult issue, or even morally wrong, they do not believe it should be made illegal.

By the early 1980s it had become evident that there was a degree of frustration amongst anti-abortion activists that they had not managed to overturn Roe v Wade. Arguably this led to a diversification of their arguments and tactics. The aim became not simply to reverse Roe v. Wade on the grounds of the right to life of the fetus, but also to find other ways of arguing for restricting access to abortion. The argument that abortion should be restricted because it leads to PAS develops as part of this strategy.

The argument for PAS had its greatest influence in the U.S. between 1987 and 1989. It was during this time that the then Surgeon General of the US, Everett C. Koop undertook, at the behest of President Ronald Reagan, an enquiry into the health effects of abortion. It has been suggested by those who have studied the events of this time that the context for the Koop enquiry was a 'stalemate' on the abortion issue in the U.S., where, according to Wilmoth, 'pro-life advocates were unable to expand their political goals beyond the successes of the early 1980s' (Wilmoth 1992:2). According to Brian Wilcox of the American Psychological Association (APA), who contributed a literature review on the psychological effects of abortion to the Koop enquiry, anti-abortion movement leaders had concluded that it would in fact be impossible to muster an anti-abortion consensus on moral grounds, so they decided to follow the model supplied by the antismoking campaign and develop a case on public health grounds (Holden 1989).

The turn to health-based claims against abortion thus reflects the limited success of morally based claims. To put in bluntly, the anti-abortion movement has come to frame its arguments in terms of health because it has failed to convince others that abortion should be made illegal on moral grounds alone.

It is important to note that the development of health-based arguments against abortion do not concern only mental health. For example, abortion has been construed as a problem on the grounds that it leads to infertility, and more recently that it causes breast cancer. This last claim is currently perhaps the most visible in the US and the UK at the present time.

PAS is therefore firstly a response to the failure of the anti-abortion argument based on morality. There are, however, further issues which explain why abortion is specifically presented as a cause of a psychiatric syndrome, as I will discuss next.

Abortion and its relationship to mental health

The argument that abortion has a negative effect for women's mental health did not begin with the anti-abortion movement in the 1980s. For most of the 20th century, many psychiatrists, psychologists and sociologists construed childbearing as positive psychologically, and abortion as negative.

As British feminist psychologist Mary Boyle (1997) has pointed out, there are powerful ideas at work in society about maternity and its alternatives that can fly in the face of scientific evidence to the contrary. Boyle cites research by Brewer, who found a five to six times greater risk of psychosis after childbirth than abortion. Other research has shown that fairly serious psychological distress has been reported in around 20 per cent of women in the first year following childbirth. Yet public discussion often highlights the 'trauma' associated with abortion, rather than the psychological effects of maternity. Boyle argues that the strength of the perception that abortion is psychologically problematic for women rests on powerful ideas concerning the desirability and 'naturalness' of motherhood for women that have a long and complex history. In her account of the debates about abortion in Britain, and the US, she argues that maternity has over many years been powerfully represented by the law, the medical profession and the media as the desirable, natural outcome of pregnancy. The perception that abortion will generate emotional or psychological problems therefore rests on a construction of abortion as against women's nature.

The argument that abortion leads to psychological problems because it represents a rejection of motherhood was made most directly in the years before legal abortion. Taking attitudes to abortion in the medical profession as their example, researchers Sarvis and Rodman have shown that a perceived connection between the psychological risks of abortion and the naturalness of motherhood was dominant in the 1950s and 1960s. They suggest the view of the American doctor Galdston was typical of medical opinion at the time; he argued in the 1958 that '..woman's main role here on earth is to conceive, deliver, and raise children...When this function is interfered with, we see all sorts of emotional disorders...This is not just textbook theory, as all who practice psychiatry very well know'. (Sarvis and Rodman1973:109). Such views about abortion were based on a perception that the woman seeking abortion was 'abnormal'.

Following the legalisation of abortion in the US, and other countries, it became more difficult in the face of new research findings to sustain the argument that psychiatric illness would result in women who aborted unwanted pregnancies. In the last 20 years in particular the notion that abortion leads inevitably to mental ill-health has been questioned, and the possible negative effects of unwanted motherhood highlighted. Nevertheless, the idea that abortion is in some way traumatic has retained visibility and resonance. It is against this background that the claim emanating from anti-abortion groups, that women suffer from serious psychological problems after abortion, emerged. The argument for PAS is an attempt to draw on existing perceptions and assumptions about the negative emotional effects of abortion, and the positive effects of motherhood.

However, it is very important to reiterate that the PAS claim does not simply draw attention to the possibility that a woman can experience negative feelings after abortion (which is uncontentious). Rather, as I noted earlier, the PAS claim frames the psychological effects of abortion in terms of a 'syndrome' or specific psychiatric disorder resulting from abortion, which as I have suggested earlier, it presented as a form of PTSD.

PTSD and PAS

I will therefore, comment briefly on why, in particular, PAS is presented as a form of PTSD. The category PTSD was first specified as a category of psychiatric disorder in the US, in 1981. Its development as a category has a long a complicated history, but is a response to the problems faced by American soldiers returning from the Vietnam War. Many soldiers after this war did undoubtedly experience mental health problems, but in addition they returned to a society that did not teat them as heroes, but as something of an embarrassment. A collection of anti-war psychiatrists, social workers, and others working with veterans, were angry that society in general, and military psychiatry in particular, was ignoring the needs of the soldiers. They lobbied for compensation and for treatment for the soldiers, and after a hard campaign over the 1970s, were successful in forcing American psychiatry to accept that the soldiers suffered from a psychological illness, which they named PTSD, and should be treated as a result.

Sociologists who have studied the history of PTSD have noted that once it was accepted in 1981 by official American psychiatry, it became what Eric Dean has called a 'disorder du jour' (Dean 1997: 201). It became common place to accept those who had experienced difficult events would get PTSD. More and more groups of people, who had experienced such events, such as domestic violence, rape, or child abuse, came to be represented by their advocates as victims, suffering from PTSD. Their claim for treatment and compensation came to rest in part on the argument that others should recognise their suffering on this basis.

By the mid 1980s, PTSD was part of the psychiatric and social vocabulary in the US and had become widely accepted as a psychiatric disease that follows negative experiences. This concept was central to the arguments made by groups claiming victim status for those they represent. I suggest the anti-abortion movement sought to co-opt and use the same approach and vocabulary in relation to women who have had an abortion. Those who argue for PAS compare the psychological experience of women who have had abortion directly to that of Vietnam veterans, women who have been raped and those who suffer domestic violence. Women who terminate pregnancy are thus represented as victims of their experience, who have been traumatised by their abortions. Through utilising this approach, anti-abortion movement activists attempt to present themselves as 'on the side' of such victims, lobbying for their needs and interests. Their claim is that they not only concerned about the fetus, but also about the woman.

Conclusion

PAS could only have emerged in the 1980s, because its origin lies not in the practice of abortion, or a change in its likely psychological effects, but rather, in the politics of the anti-abortion movement. Its context is a time when moral claims against abortion had reached a stalemate, and when a new category of psychiatric illness, PTSD, was being widely discussed in American society.

It is significant for the well being of women that PAS has not enable the opponents of abortion to achieve their aims. In no country have law and policy makers accepted that abortion leads to PAS. Abortion has not been outlawed anywhere on this basis, although in some American states, dominated by anti-abortion politicians, women do receive legally enforced counselling that warns them about PAS. In Britain it has had no effect on law and policy.

The reason for this is that in the US in particular, the medical profession - the American Psychological Association (APA), the American Psychiatric Association and the American Medical Association - have all vigorously refuted the claim. They have, very publicly and visibly, made it clear that they do not agree that abortion leads to severe psychological damage, and that there is no evidence for PAS.

For example, Brian Wilcox of the APA, who contributed a literature review to the Koop study, argued in the prestigious journal Science : 'although we searched and searched and searched, there was no evidence at all for the existence of the "postabortion syndrome" claimed by some right-to-life groups' (Holden 1989). Nancy Adler from the APA was quoted in Time magazine, stating that '..abortion inflicts no particular psychological damage on women' (Thompson 1989). A study carried out by the APA, reported on in 1990, found that 'severe negative reactions after abortions are rare and can best be understood in the framework of coping with a normal life stress' (Brotman 1990). In an often quoted article, psychologists associated with the American Psychological Association and other influential scientific bodies argued in Science that: 'A review of methodologically sound studies of the psychological responses of U.S. women after they obtained legal, nonrestrictive abortions indicates that distress is generally greatest before abortion and that the incidence of severe negative responses is low'. In May 1990, a panel at the American Psychiatric Association conference argued that government restrictions on abortion are far more likely to cause women lasting harm than the procedure itself would, and that Association officials absolutely reject the definition [PAS], on the basis there is no evidence at all to support it (Specter 1990). Nada Stotland of the American Psychiatric Association , wrote an article in 1992 for the American Medical Association journal, entitled 'The Myth of the Abortion Trauma Syndrome', which begins: 'This is an article about a medical syndrome that does not exist,' and suggests that the only evidence is support of the claim that there is such a syndrome is to be found in a '...small number of papers and books based on anecdotal evidence and stressing negative effects have been presented and published under religious auspices and in the nonspeciality literature'. Stotland argued that while women may experience abortion as a loss, and thus feel sad afterwards, a feeling is 'not equivalent to a disease', and that negative feelings should always be distinguished from psychiatric illness (Stotland 1992).

The role of such medical experts in the American debate has been very significant. Without the support of the medical profession, it is very difficult indeed for opponents of abortion to convince law and policy makers of their arguments. I would suggest that, given the high profile of such respected medical organisations in the US in this debate, and the extensive discussion it has received in the medical press, it is unlikely that PAS will become recognised anywhere in the world as a real psychological illness. However, the invention of the concept of PAS has made women considering abortion feel more anxious and worried than they might otherwise be. It is important for the well being of women that they and the health professionals they consult should know that there is no sound evidence for the existence of PAS.

References
Boyle, Mary. 1997. Rethinking Abortion, Psychology, Gender, Power and the Law. London: Routledge.

Brotman, Barbara. 1990. 'Both sides in abortion issue also remain divided over post-operation stress', Chicago Tribune, April 15.

Dean, Eric T.. 1997. Shook Over Hell, Post-Traumatic Strees, Vietnam and the Civil War. Cambridge, Mass. and London: Harvard University Press.

Holden, Constance. 1989. 'Koop Finds Abortion Evidence "Inconclusive': Right-to-lifers fail to get hoped-for evidence to reverse Roe v. Wade when Supreme Court reconsiders the issue this spring'. Science 243. February 10: 730.

Luker, Kristin. 1984. Abortion and the Politics of Motherhood. Berkeley, Los Angeles, London: University of California Press.

McLaren, Angus. 'Policing pregnancies: changes in nineteenth-century criminal and canon law'. In Dunstan, G. R. (ed.). TheHuman Embryo. Exeter: University of Exeter Press.

Rourke, Mary. 1995. 'Forgive-but not forget', Los Angeles Times, July 19.

Rue, Vincent. 1995. 'Post-Abortion Syndrome: A Variant of Post-Traumatic Stress Disorder'. In Doherty, Peter. Post-abortion Syndrome - its wide ramifications. Dublin: Four Courts Press.

Sarvis, Betty and Hyman, Rodman. 1973. The Abortion Controversy. New York: Columbia University Press.

Scott, Wilbur J. 1990. 'PTSD in DSM-III: A Case in the Politics of Diagnosis and Disease'. Social Problems 37(3): 294-310.

Speckhard, Ann and Rue, Vincent. 1992. 'Postabortion Syndrome: An Emerging Public Health Concern'. Journal of Social Issues 48 (3).

Specter, Michael. 1990. 'Psychiatric Panel Condemns Abortion Restrictions'. Washington Post May 16 (A03).

Stotland, Nada L. 1992. 'The Myth of the Abortion Trauma Syndrome'. Journal of the American Medical Association. 268: 2078-9.

Thompson, Dick. 1989. 'A Setback for Pro-Life Forces'. Time 133 (March 27): 82.

Wilmoth, Gregory H.. 1992. 'Abortion, Public Health Policy, and Informed Consent Legislation'. Journal of Social Issues 48(3): 1-17.

Young, Allan. 1995. The Harmony of Illusions: Inventing Post Traumatic Stress Disorder. Princeton: Princeton University Press.

Zimmerman, Mary. 1981. 'psychosocial and Emotional Consequences of Elective Abortion: A Literature Review'. In Sachdev, Paul (ed.). Abortion Readings and Research. Canada: Butterwoth and Co..