Reflections on abortion and
psychology: the hidden issues
By Professor Mary Boyle
In June, a great deal of media
attention was given to the story of a woman who was to sue the
NHS for psychological trauma (guilt and self-hatred) she claimed
she suffered from an abortion four years ago. As one of the psychologists
on the British Psychological Society media list under 'abortion',
I received several calls from journalists following up the story.
Their questions seemed quite straightforward:
What kind of mental problems do women face when they have abortions?
Is there any research on post-abortion distress? Should the woman
have been warned about post-abortion trauma? And I could provide
reasonably straightforward answers: Yes, there is a good deal
of research on the psychological consequences of abortion and
it consistently shows that few women experience significant or
enduring psychological distress; the most prominent emotion reported
by women after abortion is relief; distress may be associated
with not feeling supported by others in the decision; feeling
the decision was made by others and having a previous psychiatric
history. I could have mentioned that in the late 1980s, in the
hope of strengthening opposition to legal abortion, President
Regan instructed his Surgeon General, Everett Koop, to report
on the psychological effects of abortion. The American Psychological
Association provided detailed submissions (Adler et al,
1992) and having reviewed the evidence, Koop, a noted anti-abortionist,
refused to issue an official report. When questioned by Congress,
however, he testified that from a public health perspective, the
psychological risks of abortion were 'minuscule'. As to what the
woman in this case should have been told, The Royal College of
Obstetricians and Gynaecologists has published evidence based
guidelines as part of the procedures for establishing informed
consent to abortion. These recommend that abortion providers tell
women that only a small minority of women experience any long-term
adverse psychological sequelae after abortion.
The problem with the journalists'
questions and these possible answers, however, is that they do
not begin to do justice to the issues raised by this case. I wanted
to ask the journalists why they were so interested in the case;
why they seemed to assume that women suffered 'post-abortion distress';
why so little is written about women who have abortions and seem
satisfied with the outcome.
But the journalists were simply
treading a path already well-worn by researchers who have been
intensely preoccupied with abortion's potential to harm women
psychologically, to the point where many researchers seem unable
to imagine any other outcome or don't think it important enough
to investigate: one article reviewed fifteen studies of the psychological
effects of abortion which measured a total of fifty-two outcome
variables, pre-defined by researchers. Forty-two were entirely
negative (depression, anxiety, paranoia, shame, etc); five referred
to 'relief', while only one unequivocally positive variable (happiness)
was measured, in one study. Similarly, a review of theoretical
models of 'possible long-term consequences of abortion' featured
seven models, five of which did not 'allow' other than negative
outcomes; one allowed negative outcomes and relief and another
allowed both positive and negative outcomes, but the only positive
change suggested was that women might use contraception more effectively.
Why this preoccupation with possible
negative effects? After all, women choose abortion as their preferred
solution to a problematic pregnancy. It is as if we have difficulty
imagining women as capable of making rational decisions in their
own best interests. Or perhaps we find it difficult to imagine
them making this decision rationally. The social construction
of motherhood as natural and central to women's lives, together
with psychology's and medicine's tendency to link women's reproduction
to psychological vulnerability, certainly encourages us to see
abortion as potentially harmful.
These constructions have been
very prominent on all sides in legislative debates on abortion,
as has the theme of women as morally deficient, as liable to choose
abortion for unworthy reasons. And these debates have drawn implicitly
on psychological theories about motherhood and moral development
which have themselves been shaped by cultural assumptions about
women, so that there is a strong symbiotic relationship between
psychological theory and the content of abortion debates (Boyle,
1997). The result for women can be a no-win situation where one
side argues that they will be harmed by having an abortion, while
the other side argues that they will be harmed by not having one
and both sides argue that women cannot be trusted to make the
decision themselves. In Britain (and most other countries) women
have no choice but to approach abortion from a position of psychological
weakness and British law requires doctors who decide on the abortion
to record the current or anticipated medical disorder which justifies
the decision: over ninety percent of abortions in England and
Wales are officially carried out because the woman is suffering
from or vulnerable to mental disorder. Of course, this may not
reflect the woman's actual situation (and anticipated mental disorder
rarely features amongst the reasons women themselves give for
having abortions) but it is the reality created by the law and
attempts to amend it have met with little success. Thus the law,
like much psychological research, offers women little opportunity
to make public the full complexity of the experience of abortion
while at the same time reinforcing perceived links between abortion
and psychological vulnerability.
The problem is that responding
to media questions about this assumed vulnerability simply by
reciting the evidence against it (evidence which is so plentiful
partly because of the assumption that abortion would harm
women) still keeps us within an agenda which focuses on abortion's
intrinsic potential to harm women. This makes it difficult to
raise more fundamental questions about abortion research. What
I wanted to convey to journalists was that it is impossible to
separate how we think about abortion and how women experience
it, from how we as a society still think about women (the group
who are not supposed to have 'irresponsible' sex; who are supposed
to nurture life and not destroy it - a role traditionally reserved
for men - ; the group whose powers of moral reasoning and judgement
are not entirely trustworthy, particularly when hormones are involved,
and the group for whom motherhood should take precedence over
other life goals, so that it can only be averted for 'deserving'
reasons). I also wanted to convey that psychological research
has rather let us down in relation to abortion in largely ignoring
the significance of the fact that only women have abortions and,
in an attempt to be 'objective', has framed women's responses
to abortion as pre-defined intra-psychic attributes rather than
experiences which can only be understood in a social context.
Studies in which women give their own accounts of the experience
(e.g. Gilligan, 1993; Boyle and McEvoy, 1998) show clearly that
it is inseparable from context: some women talk about the difficulty
of making a decision which seems to put them and not others first;
others talk of their fear of being 'found out' and thought cruel
and selfish. Women are very aware of what they are 'supposed'
to feel after an abortion (grief, regret, sadness) and may feel
bad if they feel none of these. In another study in preparation,
some women talked about feeling failures, and ashamed because
they had 'allowed' themselves to get pregnant; the idea that women
are more responsible than men for preventing pregnancy was clearly
conveyed by statements like 'I wasn't using condoms...'
Interestingly, the potentially positive psychological effects
of abortion are not often discussed but these include feeling
more in control of one's life and relationships with partners,
and making more complex moral judgements.
But it is not only researchers
who have neglected the social context of abortion. The woman in
the legal case featured in the media is being supported by the
anti-abortion group 'Life' who in 1998 announced a helpline for
women who had suffered from abortion, and that they would encourage
these women to take legal action against the doctors involved.
Ellie Lee, a sociologist who has studied the strategies used by
anti-abortion groups, has noted that as the strategy of depicting
the foetus as a person with legal rights has not resulted in abortion's
being made illegal, the groups have increasingly turned to a strategy
of claiming that abortion harms women. Their claims focus on 'post-abortion
syndrome' (PAS) modelled on the idea of post-traumatic stress
disorder. But because the function of PAS is to support anti-abortion
legislation, then abortion must be made to look intrinsically
harmful to women, rather than a procedure the experience of which
is inseparable from cultural constructions of abortion and gender.
Psychological researchers have arguably smoothed the path of anti-abortion
groups more than they might have intended by themselves decontextualising
abortion as a (mental) health issue for individual women.
Against this background, it is
interesting that following the news story, the British Association
for Counselling and Psychotherapy issued a press release saying
that women need counselling before they undergo abortion, although
it should be voluntary, and that "anyone who chooses to have
an abortion should also be free to choose counselling to help
cope with the emotional consequences. It is a basic component
of a woman's right to choose." But although none of us would
wish to prevent women (or men) seeking counselling, this language
of needs and rights is potentially problematic. Research shows
that the majority of women have made a definite decision about
the abortion before they approach their doctor usually after discussion
with partners, parents or close friends. Routinely offered counselling
is a powerful way of conveying which decisions are socially acceptable
and which socially problematic (we don't, for example, routinely
counsel people who decide to get married or have children); it
can also suggest that women's own decisions are not to be trusted.
This was partly why one of the major abortion providers recently
stopped routine counselling and now provides it on request, but
without trying to present it as part of the right to choose abortion.
This news story may well raise
questions about women's risks of being harmed by abortion and
research certainly helps us answer them. But the story also emphases
the importance of not just quoting 'the evidence' but of trying
to engage the media in critical discussions about research itself,
to encourage them not just to see us as providers of research
data and themselves as consumers but to see research as part of
much wider social processes.
Adler, N. E. David, H.P., Major,
B.N., Roth, S.H., Russo, N.F. and Wyatt, G.E. (1992) Psychological
factors in abortion: A review. American Psychologist, 47, 1194-1204.
Boyle, M. and McEvoy, J. (1998) Putting abortion in its social
context: Northern Irish women's experience of abortion in England.
Health 2 283-304.
Boyle, M. (1997) Re-thinking Abortion. Psychology, Gender, Power
and the Law. London: Routledge.
Gilligan, C. (1993) In a Different Voice: Psychological Theory
and Women's Development 2nd Edn. Cambridge, MA: Harvard University
Website co-sponsored by APA Division 35: www. prochoiceforum.org
(link to 'psychological issues')
Department of Psychology
University of East London
E15 4 LZ
This article originally appeared
in The Psychologist, vol 15, October 2002 502-503.