Abortion and mental health

The relationship between induced abortion and mental health is an area of controversy. The issue has been part of the political debate over abortion, dating at least to 1988 when President Ronald Reagan directed U.S. Surgeon General C. Everett Koop to produce a report on the physical and psychological effects of abortion in the expectation that such a report could be used as a justification to restrict access to abortion. There is no scientific evidence of a causal relationship between abortion and poor mental health, though some studies have found a statistical correlation. 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.

In a 1990 review, 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 revised and updated its findings in August 2008 to account for the accumulation of new evidence, and again concluded that termination of a first, unplanned pregnancy did not lead to an increased risk of mental health problems. The data for multiple abortions were more equivocal, as the same factors that predispose a woman to multiple unwanted pregnancies may also predispose her to mental health difficulties. As of August 2008, the United Kingdom Royal College of Psychiatrists is also performing a systematic review of the medical literature to update their position statement on the subject.

Some proposed negative psychological effects of abortion have been referred to by pro-life advocates as a separate condition called "post-abortion syndrome." However, the existence of "post-abortion syndrome" is not recognized by any medical or psychological organization, and some physicians and pro-choice advocates have argued that the effort to popularize the idea of a "post-abortion syndrome" is a tactic used by pro-life advocates for political purposes. In response to such activism, 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 supported by the scientific literature.

Post-Abortion Syndrome
The term "post-abortion syndrome" was first used in 1981 by Vincent Rue, a psychologist and trauma specialist, 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. He 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 pro-life advocates to describe a broad range of adverse emotional reactions which they attribute to abortion. 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 efforts to popularize the term "post-abortion syndrome" are a tactic used by pro-life advocates for political purposes.

While some studies have shown a correlation between abortion and clinical depression, anxiety, suicidal behaviors, or adverse effects on women's sexual functions for a small number of women, these correlations may be explained by pre-existing social circumstances and emotional health. According to the American Psychological Association, 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. Studies have either failed to establish a causal relationship between abortion and negative psychological symptoms experienced by women, or been inconclusive.

In 2008, a team at Johns Hopkins University in Baltimore reviewed 21 studies involving more than 150,000 women, and determined: "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." Dr. Robert Blum, the senior author on 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 wrote: "Scientists are still conducting research to answer politically motivated questions."

Psychological effects of abortion
Some studies have indicated that those who have undergone abortion have experienced positive or no change to their mental health. A 1989 study of teenagers who sought pregnancy tests found that counting from the beginning of pregnancy until two years later, the level of stress and anxiety of those who had an abortion did not differ from that of those who had not been pregnant or who had carried their pregnancy to term. A study done at the University of Washington found no correlation between a history of abortion and suicide following a subsequent pregnancy.

Another study in 1992 found that having one abortion was positively associated with higher global self-esteem, particularly feelings of self-worth, capability, and not feeling one is a failure, but that this positive association was not significant after controlling for childbearing and resource variables. It also noted that adverse emotional reactions to the abortion are influenced by pre-existing psychological conditions and other negative factors and, furthermore, that well-being was separately and positively related to employment, income, and education, but negatively related to total number of children. The authors concluded that "No evidence of widespread post-abortion trauma was found."

Some studies suggest that some women experience stress after a miscarriage or abortion. The kind of stress and the amount of stress women experience varies from culture to culture. Studies also suggest that an individual woman's stress level is influenced by her economic status, family situation and the status of her mental health before the pregnancy. Although no studies have been able to establish a causal relationship between abortion and depression or stress, many studies cite the pre-existence of depression and stress in a sub-set of women who procure abortions. No causal link has been established between abortion and mental illness. Emotional distress may occur in a minority of women who are contemplating or have had an abortion due to a number of factors, including pre-existing mental health problems, the status of the woman's relationship with her partner, poor economic status, poor social network, or conservative views held on abortion.

United States Surgeon General
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 pro-life 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 risk of significant psychological problems was "miniscule 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, who oversaw the investigation, argued that when Koop found no evidence that abortion was harmful, "he therefore 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
In response to Surgeon General Koop's review, the American Psychological Association prepared and presented a summary of the literature and recommendations for Koop's report. After Koop refused to issue their findings, the APA panel published a synthesis of their own findings in the journal Science, concluding that "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." The panel also noted that "...women who are terminating pregnancies that are wanted and personally meaningful, who lack support from their partner or parents for the abortion, or who have more conflicting feelings or are less sure of their decision before hand may be a relatively higher risk for negative consequences."

The APA task force also concluded that "research with diverse samples, different measures of response, and different times of assessment have come to similar conclusions. The time of greatest distress is likely to be before the abortion. Severe negative reactions after abortions are rare and can best be understood in the framework of coping with normal life stress." Nancy Adler, professor of psychology at the University of California, San Francisco, has 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 a lack of quality data 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 multiple abortions.

Royal College of Psychiatrists
On March 14, 2008, the United Kingdom Royal College of Psychiatrists released a statement saying that "The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved. The current research evidence base is inconclusive&mdash;some studies indicate no evidence of harm, whilst other studies identify a range of mental disorders following abortion." The statement noted that the Royal College is undertaking a systematic review of the medical literature with the intent of updating its position and possibly recommending changes to the informed consent process for abortion.

The Royal College's statement was interpreted variously by the media. The Times wrote that "women may be at risk of mental health breakdowns if they have abortions" and that "women should not be allowed to have an abortion until they are counselled on the possible risk to their mental health." In contrast, the Daily Mail reported that "Updated guidance from the Royal College of Physicians points out that there is still no evidence that abortion causes mental health problems... The college rejects claims by the pro-life lobby that abortion causes mental health problems." The Daily Mail also noted that the Royal College of Psychiatrists report came out at a time when there was a controversial proposal before Parliament to reduce the term limit for abortions from 24 weeks to 20 weeks.

Nada Stotland
In 1992, psychiatrist Nada Stotland of the University of Chicago and 2008 President of the American Psychiatric Association wrote in the Journal of the American Medical Association, "...there is no evidence of an abortion-trauma syndrome." Stotland identified three groups of women as being at risk of negative psychological reactions to abortion: those who were psychiatrically ill before pregnancy, those who undergo abortion under external pressure, and those who underwent abortion in "aversive" circumstances such as abandonment or stigmatization. In a 2003 review article, Stotland wrote: "Currently, there are active attempts to convince the public and women considering abortion that abortion frequently has negative psychiatric consequences. This assertion is not borne out by the literature: the vast majority of women tolerate abortion without psychiatric sequelae."

Nancy Adler
In 1990, Nancy Adler, a professor of medical psychology, conducted a review of methodologically sound studies of women's mental health before and after abortion. She concluded, "...nonrestrictive abortions indicates that distress is generally greatest before the abortion and that the incidence of severe negative responses is low. Factors associated with increased risk of negative response are consistent with those reported in research on other stressful life events."

Adler is referenced in an article titled, "Is there a Post Abortion Syndrome?" in the New York Times Magazine: ...Nancy Adler found that up to 10 percent of women have symptoms of depression or other psychological distress after an abortion&mdash;the same rates experienced by women after childbirth... Researchers say that when women who have abortions experience lasting grief, or more rarely, depression, it is often because they were emotionally fragile beforehand, or were responding to the circumstances surrounding the abortion&mdash;a disappointing relationship, precarious finances, the stress of an unwanted pregnancy.

Brenda Major
In a 2000 study, Brenda Major and colleagues from the University of California, Santa Barbara examined women's emotions and mental health after abortion. Major concluded that, "Most women do not experience psychological problems or regret their abortion 2 years postabortion, but some do. Those who do tend to be women with a prior history of depression." She goes on to say:

Ultimately, the psychological risks of abortion must be compared with the psychological risks of its alternatives. When women become pregnant unintentionally, they have few alternatives, any of which could be a source of regret or distress. Studies of women who give up a child for adoption suggest that feelings of loss and sadness are common, although no well-controlled studies have compared the reactions of these women with reactions of women who have an abortion. In contrast, studies comparing the mental health of women who have an abortion and women who carry an unintended pregnancy to term and keep the child are more common. These studies consistently find that the former are at no greater risk for psychological problems than the latter. Thus, for most women, elective abortion of an unintended pregnancy does not pose a risk to mental health.

Major has also criticized the methodology of some studies done by David Reardon and his co-authors that analyzed data from the medical records of 56,000 low income women in California. Reardon and his co-authors concluded that women who had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered. Major wrote an accompanying editorial on this article in the Canadian Medical Association Journal, stating:

David Reardon and colleagues describe how they conducted a record-linkage study of psychiatric admissions among a sample of low-income women who had received state funding for either an abortion or delivery in 1989. They report that subsequent psychiatric admission rates were higher for women who had an abortion than for women who delivered. Their conclusion implies that this was the result of problems related to aborting a pregnancy. This conclusion is misleading... It is a fundamental tenet of science that one cannot infer cause from a correlation between 2 variables... Politics and values shape the way that research on women's psychological responses to abortion is conducted and interpreted. On the basis of correlations such as the one reported here, abortion-rights opponents assert that scientific evidence indicates that abortion causes psychological harm. Because they are not experts in scientific reasoning, most people are unable to evaluate the validity of these claims. Statistics such as those reported by Reardon and colleagues thus run a high risk of being used in ways that misinform and mislead the public.

Sarah Schmeige and Nancy Russo
In a 2005 study by Sarah Schmiege and Nancy Russo comparing rates of depression following an unwanted first pregnancy carried to term versus an unwanted first pregnancy that was aborted, the authors concluded that, "under present conditions of legal access to abortion, there is no credible evidence that choosing to terminate an unwanted first pregnancy puts women at higher risk of subsequent depression than does choosing to deliver an unwanted first pregnancy." Their research failed to reproduce the findings of David Reardon and J.R. Cougle, who found had previously used the same dataset to report higher rates of depression after abortion of an unintended first pregnancy: Our results provide no support for the claim by Reardon and Cougle that terminating an unwanted first pregnancy contributes to risk of subsequent depression. Instead, our finding that the group that delivered before 1980 had a significantly higher risk of depression than all other groups directly contradicts the claim that terminating an unwanted first pregnancy puts women at higher risk of subsequent depression, particularly for younger women.

Mika Gissler
A government record-based study of all Finnish women found that the suicide rate associated with abortion (34.7 per 100,000) was significantly higher than that associated with giving birth (5.9 per 100,000). The study concluded: "The increased risk of suicide after an induced abortion indicates either common risk factors for both or harmful effects of induced abortion on mental health." The authors of the study noted that women who committed suicide after having an abortion tended to be from lower social classes and also tended to be unmarried. The authors state:

The relation between suicide, mental disorders, life events, social class, and social support is a complex one. Abortion might mean a selection of women at higher risk for suicide because of reasons like depression. Another explanation for the higher suicide rate after an abortion could be low social class, low social support, and previous life events or that abortion is chosen by women who are at higher risk for suicide because of other reasons. Increased risk for a suicide after an induced abortion can, besides indicating common risk factors for both, result from a negative effect of induced abortion on mental wellbeing. With our data, however, it was not possible to study the causality more carefully. Our data clearly show, however, that women [in Finland] who have experienced an abortion have an increased risk of suicide, which should be taken into account in the prevention of such deaths.

David M. Fergusson
In 2006, a team of researchers at the University of Otago Christchurch School of Medicine in New Zealand published results relating to abortion reactions from a longitudinal study tracking approximately 500 women from birth to 25 years of age. The study concluded that those who had an abortion were subsequently more likely to have "mental health problems including depression, anxiety, suicidal behaviours and substance use disorders." The authors wrote, "The findings suggest that abortion in young women may be associated with increased risks of mental health problems," and "on the basis of the current study, it is our view that the issue of whether or not abortion has harmful effects on mental health remains to be fully resolved."

The study was criticized both on methodologic grounds (for using an inappropriate comparison group), and on grounds that the authors overinterpreted their findings. A 2008 review article argued that "the poor design of the study undermines the intent to inform policy with evidence," and that the study was too flawed to serve as a basis for changes to abortion policy.

In their 2008 summary of evidence on the topic, the American Psychological Association panel on abortion and mental health cautioned against generalizing Fergusson's finding to the U.S. population. The panel noted that abortion was more difficult to obtain in New Zealand and required the concurrence of two specialists that the pregnancy would result in mental or physical harm to the mother.

Men
The psychological response of male partners to abortion has been the subject of limited research. A study of 75 men in Sweden found that most participating men agreed with their partner's decision to have an abortion, and that many experienced a complex mix of emotions including anxiety, responsibility, guilt, relief and grief. Other small studies have suggested that abortion can be a point of conflict when partners disagree about it, and that like women, many male partners experience an ambivalent mix of emotions in response to their partner's abortion, underscoring the complexity of the abortion issue.