Abortion: Just the Tip of the Iceberg

Author’s note: Throughout this commentary, I use female pronouns and terms to designate the people who have abortions. I am aware that there are individuals who identify as male, transgender, or nonbinary who have abortions, but the vast majority of pregnancies and abortions happen to women.

The US Supreme Court has defied the court’s tradition and the expressed intentions of some of its members during their confirmation hearings by overturning the court’s 50-year-old precedent, Roe v. Wade, which had enshrined abortion as a right. As soon as this Dobbs decision was rendered, many states in this country applied or enacted laws either severely limiting or banning abortion.

As this commentary is being written, a 10-year-old girl, pregnant by rape, had to be taken out of state, having been denied abortion in her home state. As a pregnant 10-year-old, she was at high risk, not only for exacerbations of the trauma she had already experienced, but for complications of pregnancy and childbirth, not to mention those of motherhood. It is notable, and relevant, that the first response of her state’s governor, and of The Wall Street Journal, and other media was to declare that the “story” was untrue. No apologies were offered when the rapist was arrested and confessed. Next, the physician who performed the abortion was accused of not recording the procedure as required by law. When the girl’s evidence was produced, there was no apology or retraction. This is the country in which we now practice not only obstetrics and gynecology, but also psychiatry.¹ This is the country where our patients live.

Across the board, pregnancy causes orders of more danger of morbidity and mortality than abortion.² Abortion is one of the safest procedures in all of medicine. One-fourth of the women in the United States will have an abortion during their lifetimes. Before the Dobbs ruling, something under 1 million abortions were being performed in the United States each year. Around the world, abortions are less common in places where they are safe and accessible. Clandestine, unsafe abortions deprive hundreds of thousands of children of the mothers subject to those procedures. Abortion has been practiced throughout history and long before the advent of anesthesia and antibiotics.³ Maybe the danger of abortion without those protections is the reason abortion is mentioned in the Hippocratic Oath. In any case, it means that abortions were happening in the fifth century BC.⁴

In the United States, notably, the distribution of religious affiliations among women who have abortions is the same as that of the general population.⁵ Women who oppose abortions have abortions every day—and many go on actively opposing abortions.

The terms commonly used to characterize positions for and against abortion are deeply prejudicial. Pro-choice likens a decision about a pregnancy to a choice between menu options or minor purchases. A decision about a pregnancy concerns the lives of the potential mother, the potential child, and many other individuals. All the evidence indicates that women consider abortion to be a serious decision. Pro-life implies that individuals who have abortion do not care about life. It is notable that the anti-abortion movement is completely divorced from any activism to support life other than that of a conceptus. It is not linked to concerns about war or the death penalty, not to mention the lives of children born into circumstances where their mothers doubt their ability to provide for and protect them (poverty, domestic violence, immaturity, the needs of other children). The terms pro-choice and pro-life carry misleading and damaging meanings. One positive effect of the Dobbs decision is the emergence of the word “abortion” from the shadows.

Commentators decrying abortion prohibitions are especially exercised about laws that do not make exceptions for rape and incest. Stop for a minute and consider the unescapable, excruciating assumptions that underlie those exceptions. Abortion opponents consider and proclaim themselves to be protectors of the unborn. If the embryo or fetus is a human being, why should it be deprived of life because of the circumstances over which it had no control? It is because the woman pregnant by rape or incest was not responsible for the sexual act that caused the pregnancy. Exceptions for rape and incest lay bare the unspoken, unacknowledged belief that women who willingly engage in sex and become pregnant should be punished by having to stay pregnant. The punishment is usually rationalized by casting it as “responsibility.” It is twisted logic to consider that having a baby when one is not going to be able to care for it properly is “responsible.” It is twisted to make what, under good circumstances, is a blessing—a baby—into a punishment.

We are still operating under the conviction that the ills of society were caused by Eve eating the apple in the Garden of Eden—and she was responsible for seducing Adam. But it does not work that way. Women with untenable pregnancies are unlikely to have conceived out of carefree unbridled lust—and what if they had?

Another unspoken assumption is that women have abortions because they do not care about children. In reality, they have abortions because they want to have wanted children—children they can provide for. In the United States, where sex education—if provided at all—may be full of misinformation, young people become pregnant because they do not know how to avoid it.⁶ There are all sorts of reasons women become pregnant under circumstances adverse for motherhood. They cannot afford contraceptives. Contraceptives fail. Their male partners refuse to use condoms. Their male partners force them to have unprotected sex. There are many ways to force sex on someone without committing what is legally defined as rape.

Some women are living in violent relationships. Most women who have abortions already have children. Especially in the United States, which offers minimal—if any—parental leave and subsidized childcare, adding another child would deprive the existing children of essential care and protection. Some women have psychiatric and/or other medical disorders that, at a given time, would prevent them from providing good maternal care.

What about the hidden part of the iceberg? The Supreme Court’s Dobbs decision leaves the country in a legal and clinical quagmire. On the basis of a ragbag of dubious constitutional arguments and false statements about the psychiatric sequelae of abortion, it removes the already attenuated protections of Roe v. Wade, leaving abortion’s legality to be decided by each of the 50 states. Some of the results are already apparent, and many others are expected. We have some forewarning about the implications because Catholic hospitals and inhospitable parts of the country have already significantly limited care. Catholic (and Evangelical) hospitals are not required to, and do not, inform patients that medical staff are not allowed to so much as mention contraception or abortion. This prohibition also extends to psychiatrists.

We know that, in Catholic hospitals, women with incomplete spontaneous abortions, ectopic pregnancies, and fetuses with anomalies incompatible with extrauterine life are left to bleed, suffer pain, and risk ectopic rupture rather than having their pregnancies terminated as medically indicated—as long as the clearly doomed fetus is considered to be alive.⁷ There are approximately as many spontaneous miscarriages each year as abortions. In many or most cases, it is impossible for a clinician to distinguish a miscarriage from an attempted abortion.⁸ Some of these laws will allow state officials to review medical records, question patients and doctors, and perhaps examine whatever tissue was removed in the hospital in an attempt to uncover an unlawful abortion.⁹

We know that physicians in some places cannot obtain misoprostol, which has been approved for the treatment of serious medical conditions, because it is also used as an abortifacient. We know that many women have been tried, and some incarcerated, to punish them for behaviors that legal—not medical—practitioners have deemed deleterious to the fetus—including attempted suicide.⁸ In just 1 illustrative case, a woman experienced a stillbirth at home. The authorities went through her computer and found that, at some point, she had searched for information about abortion pills. There was no evidence that she had ordered, obtained, or used them. The woman had to endure 3 years of anxiety before the case was dropped. We know that, although white women and women of color are equally likely to use street drugs while pregnant, it is only poor, minority women who suffer these consequences.⁸

As psychiatrists, we need to know the psychiatric aspects of abortion. Research clearly demonstrates that, although abortion is more likely in highly stressful life situations—which may include mental illness—and circumstances that raise the risk of mental illness, abortion itself does not cause psychiatric illness; the most common response is relief.¹⁰ Publications purporting to demonstrate psychiatric harm from abortion have been thoroughly and emphatically debunked because of unacceptable, biased methodology. There is no evidence that abortion leads to later regret any more than any other life decision. There is, of course, a taboo against the expression of regret that one has had a child. Often, a woman who expresses regret about a past abortion, when asked to remember the circumstances at the time, will say that the abortion was the best option under those circumstances.

Many states have laws requiring a waiting period between the time a woman presents for abortion care and the performance of the abortion. This is a major hardship for women who have to travel to reach an abortion provider and provide coverage, if possible, for the absence from work and home. No other medical procedure, no matter how serious, requires a waiting period (except when there is a wait for available care). There is no evidence that abortion decisions are made on impulse. Abortion is similarly unique in being the subject of state laws mandating specific language that abortion providers must use with patients. This language generally conveys misinformation, including statements that abortion causes adverse psychiatric sequelae. Some laws require that a patient seeking abortion undergo—and view—ultrasound imaging of the embryo or fetus. Anti-abortion protesters outside abortion facilities, of course, cause distress. All these restrictions and mandates add stress to having an abortion.⁵

Many laws require that the parents of an underage girl be informed about or consent to her abortion. These laws seem commonsensical; youngsters need parental guidance and support. But there is no evidence that mandated parental involvement is beneficial. Most pregnant girls choose to inform and involve their parents. Abortion providers will assist those who need help approaching their parents. Some girls realistically anticipate that their parents would punish or reject them if aware of their pregnancy—and/or force them to remain pregnant. The logic of mandated parental involvement is flawed. The situation is not difficult to understand; one will have a baby, or one will not. The young woman deemed too immature to make the decision to abort will otherwise, in a few months, become the mother of an infant for which she will have legal responsibility.¹¹

There is also the idea of fetal personhood: Many existing and pending state laws explicitly state that, from the moment the sperm fertilizes the egg, that fertilized egg is entitled to all the legal rights of a person. The conceptus, the embryo, the pre-viable fetus, can only survive inside the body of a woman. Pregnant women may be made to undergo surgery or other interventions aimed at improving the well-being of the fetus. This is a unique exception to American law, under which it is illegal to forcibly invade the body of a nonconsenting adult, even to remove 1 drop of blood that will save another person’s life. Many fertilized eggs are washed out of the body with menstrual blood, are resorbed, or otherwise disappear. How the states propose to protect them is unclear; when a law protecting them was passed in Indiana, protesting women sent used tampons to the state capitol.

Giving personhood to the unborn places every woman who could become pregnant at risk of state investigation, control, intrusion, and prosecution.¹² There are laws mandating that every woman seeking abortion care be registered in a state database, inviting intrusion and harassment not only by the state, but also by anti-abortion individuals or organizations.¹³ A Texas law, which is already under consideration elsewhere, offers $10,000 to any individual who identifies and sues someone who helps a woman obtain an abortion. Pharmacists are refusing to fill pregnant women’s prescriptions for clinically indicated medications, and oncologists are refusing to provide chemotherapy for pregnant women with malignancies. All these laws destroy the confidence and privacy of the doctor-patient relationship. Fetal personhood completely undermines the personhood of the pregnant woman.¹⁴

At this moment, potential medical students and medical students planning to train as ob/gyns have to decide whether to consider institutions in states where abortion is forbidden.¹⁵ Obstetricians are refusing care for women having spontaneous miscarriages and ectopic pregnancies for fear that they will be prosecuted for homicide.¹⁶ Firms placing ob/gyns in locum tenens positions find that prospects are unwilling to consider anti-abortion states.

Millions of women stand to lose ob/gyn care. Proposed and existing anti-abortion laws are so varied and often so ambiguous that we will have decades of litigation about them. For example, states propose to criminalize traveling from an anti-abortion state to another state to have an abortion. Is there not a right to travel freely between states? If there is not, what apparatus will states need to enforce such a prohibition—or will states rely on friends and neighbors to spy on and report one another? States propose to forbid mailing abortion medications to residents of their states. Can they legally control postal services? When challenges to these laws wend their way through the judicial system, they will arrive at the same Supreme Court that has just overturned the right to abortion.

The fate of in-vitro fertilization (IVF) is in doubt. When a woman’s ovaries are hyperstimulated and produce eggs, as many eggs as possible are harvested and fertilized to maximize the possibility of a successful pregnancy. Generally, they are genetically tested and those with abnormal genes are discarded—what if they are people, with legal rights? As it is, state laws vary widely about control over frozen embryos. Infertility programs in some states have begun shipping their frozen embryos to “safe” states. Some will relocate their practices, leaving states that deem every embryo they create a human being entitled to state surveillance and protection. There has also reportedly been a major increase in the number of men seeking vasectomies.

A US senator who is an obstetrician recently reminded us at a senate committee hearing about reproductive rights that there are 4 times as many pregnancy crisis centers in the United States as abortion clinics. A crisis pregnancy is one for which the pregnant woman is considering abortion. These centers exist to keep women from having abortions. They offer sonograms—which are often provided by untrained, nonmedical personnel—to demonstrate the heartbeat and any human-appearing features of the embryo or fetus. They dismiss concerns about circumstances and extol the joys of motherhood. They inform the woman that state laws require the father of a baby to provide for it, but they do not offer information about how rarely those laws are effective in the circumstances of the women they counsel. They exaggerate the support the state provides for mothers and babies. They attempt to delay the process in hopes that the pregnancy will progress beyond the abortion limit of the state. And they have an explicit policy of offering the bare minimum of support for the baby they hope the woman will have (a few diapers or something similar)—and they do not share this policy with those who are seeking help.¹⁷ Our patients may seek help at these centers.

Resources for Professionals and Patients

The Guttmacher Institute: provides up-to-date information about abortion laws and statistics in the United States and all over the world.
National Advocates for Pregnant Women: provides support and information for the public and pregnant women, whether they intend to abort or not; information about criminal cases against pregnant women; and advocacy.
Physicians for Reproductive Health: a group of clinicians who use evidence, training, and organized action to champion health care rights (I am a past member of the board).
American Civil Liberties Union: provides information about legal challenges to abortion restrictions.
Planned Parenthood: provides access to care and resources.
Grossman D, Perritt J, Grady D. The impending crisis of access to safe abortion care in the US [published online ahead of print, 2022 Jun 23]. JAMA Intern Med. 2022;10.1001/jamainternmed.2022.2893.
- This article includes a list of organizations that help patients find abortion care in a wide variety of ways.

So, we now practice psychiatry, and teach medical students and residents, in a country with a patchwork of changing, ambiguous laws about abortion—some of which trample the cherished privacy of the doctor-patient relationship.¹⁸ Our well-educated, well-off white patients will continue to have access to abortions wherever they live; they can travel and are unlikely to get into trouble with the law. They will, however, continue to be at risk of dangerously delayed treatment for miscarriages and ectopic pregnancies—and of having fewer obstetricians in their states. Exceptions for the life of the mother are often interpreted to mean that, while the fetus is alive, despite having no chance of ultimate survival, the woman’s condition must deteriorate to the brink of death before her pregnancy is terminated.

Our most vulnerable patients in many states will lose their ob/gyn care. They will live in fear of a problem pregnancy and of government surveillance and criminal accusations. So, some of our patients will be enraged and frightened by the Dobbs decision. We can help them strategize and to develop plans to protect themselves and those they care about. Our most vulnerable patients, if not pregnant at the moment, may be too preoccupied with the exigencies of their daily lives to focus on their loss of rights and care. Many of our patients will fall somewhere between these categories. Our responsibility is to know and communicate the facts, and to help patients making pregnancy decisions review, consider, and act on their own values, beliefs, and circumstances.

The topic of abortion suffers from 2 disadvantages. One is the general stigma (the idea that abortion is “anti-life”), and the other is that people do not like to contemplate unpleasant, painful life possibilities. We like to believe that untenable pregnancies only happen to other people. These disadvantages probably at least partially explain why those who support access to abortion vote for legislators who do not support it. Often, our treatment requires us to help patients contemplate and plan for contingencies they would prefer to ignore, such as continuing to take medication even when they feel better.

Now all our patients capable of becoming pregnant need to be prepared to cope with a pregnancy that is untenable—for any reason. Perhaps every person who could become pregnant should be equipped with both Plan B—the “morning-after pill”—and a home medication abortion kit. Perhaps in some cases we will need to prescribe them.

Dr Stotland has a lifelong interest in psychosocial issues in women’s reproductive health. She is the editor or author of Psychiatric Aspects of Abortion and Abortion: Facts and Feelings, both published by the American Psychiatric Press. She has represented the American Psychiatric Association in testimony before the US Senate and Surgeon General and in several state courts about proposed and challenged laws related to abortion.

The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times™.

How will this impact patient care in your practice? Share your questions, concerns, and potential solutions via PTEditor@mmhgroup.com.