“Abortion Trauma Syndrome”

Abortion trauma syndrome is a fabricated mental disorder conceived by anti-abortion activists to advance their cause and is not a scientifically based psychiatric disorder. So said 2 psychiatrists at the American Psychiatric Association’s recent annual meeting in San Francisco.

“Abortion does not cause psychiatric damage, but the claim that it does is a prime strategy of the anti-abortion movement, which has convinced many people in the US,” said former APA president Nada Stotland, MD, MPH.

“So if it wasn’t a psychiatric issue before, it certainly is now, and we psychiatrists have an obligation to know about it,” she added.

One in 3 women in this country will have had an abortion by age 45 years. Worldwide, 1 in 5 pregnancies ends in abortion, according to the Guttmacher Institute’s 2008 reports. Annual estimates are 1.2 million abortions in the US and 42 million globally.

Major reasons cited in that report for having an abortion include inability to afford a child; interference with work, school, or ability to care for other dependents; not wanting to be a single parent; marital or partner problems; and concern about being responsible for others.

Mental health issues

Controversy about the mental health consequences of induced abortion has been intensifying.

For instance, the Elliot Institute, founded by David C. Reardon, PhD, claims that women who have abortions are prone to abortion trauma syndrome and are at increased risk for substance abuse, clinical depression, sleep disorders, and suicide and that their children are prone to behavioral problems.¹

Countering those assertions is the American Psychological Association’s Task Force on Mental Health and Abortion, which recently collected, examined, and summarized the most current scientific research on mental health and abortion. The task force’s 2008 report concluded that “among women who have a single, legal, first-trimester abortion of an unplanned pregnancy for nontherapeutic reasons, the relative risks of mental health problems are no greater than the risks among women who deliver an unplanned pregnancy.”²

When bills were introduced in the legislature asserting that abortions cause significant and long-lasting psychological damage, Stotland testified that such allegations are contrary to scientific evidence. In her 2004 testimony before a House Subcommittee on Health, which looked at postpregnancy mental health in women, she told members, “Abortion trauma syndrome does not exist in the psychiatric literature and is not recognized as a psychiatric diagnosis.”

The Supreme Court in 2007 issued a 5-4 decision outlawing a type of late-term abortion. The majority opinion said, “Some women might come to regret their choice to abort the infant life they once created and sustained. Severe depression and loss of esteem can follow.”

In response, Stotland wrote to the New York Times and charged that the Supreme Court was “substituting political propaganda for medical science” and that “meticulous research shows there is no causal relationship between abortions and mental illnesses.”

At the APA symposium, Stotland, onetime vice president of the national Lamaze prepared childbirth organization, said that there are 2 different issues going on.

“One is having a religious, moral belief about whether something is right or wrong. . . . The other has to do with the scientific data and research. I feel very strongly about the misuse of psychiatric terms and the assertion of nondata as data,” she said.

Abortion studies

A second presenter at the APA symposium, Gail Robinson, MD, professor of psychiatry and obstetrics and gynecology at the University of Toronto and director of the Women’s Mental Health Program for University Health Network, focused on the studies that have examined the relationship between abortion and women’s mental health. A more comprehensive article is scheduled for the August issue of the Harvard Review of Psychiatry.

Robinson identified methodological issues in studies used to support claims that induced abortion results in an abortion trauma syndrome or a psychiatric disorder. She then compared those studies with others that avoided those methodological errors.

The valid controls for women who have abortions should be women with unwanted pregnancies who are forced to carry to term, Robinson said. The few studies that have included this comparison found that, in general, the group who carried to term had poor outcomes for both the mothers and the children.

We need to question why a woman would have an abortion in the first place and to differentiate between first- and second-trimester abortions, Robinson added. There may be several reasons women delay until the second trimester, possibly related to access or ambivalence. Mixing up the 2 groups likely muddies the results.

Other issues include whether the pregnancy is wanted; whether the abortion is requested because the woman is a victim of violence, rape, or incest; whether she is being coerced by others to have the abortion; whether she has had a prior abortion; and what types of resources and support are available to her.

Assertions that abortion causes mental illness often fail to consider the woman’s mental health before she has an abortion, Robinson said.

“If you have psychiatric problems beforehand, an abortion is not going to cure them, but having the baby isn’t going to cure them either,” said Robinson. “So the greatest predictor of distress afterward is psychiatric distress beforehand, and a lot of studies don’t even look at this.”

Robinson cited several other methodological problems as well:

• Many of the studies used large data sets, but the medical records do not contain information about relevant key variables, such as a woman’s mental health history or reasons for wanting an abortion.

• Some studies use biased clinical samples-women who gather to tell each other how miserable they felt and how every problem in their life is because they had an abortion.

• Some studies confuse emotions with psychiatric illness. Some women may experience sadness, grief, and regret following an abortion, but that does not usually signify psychiatric illness.

• Many of the studies are retrospective, and perspectives can change over time because of intervening events, including marriage, fertility problems, and childbirth.

• Some long-term studies attribute any negative consequences in a woman’s life to her having had an abortion.

• Some studies fail to address the impact of social pressure and misinformation on the mental health of women who have abortions, such as being confronted by demonstrators outside an abortion clinic or being told that the medical procedure they are about to undergo will very likely cause mental and physical problems.

Study examples

In her review of studies with methodological problems, Robinson discussed the work by Cougle and colleagues.³ These researchers compared data on women from the National Longitudinal Survey of Youth who experienced their first pregnancy event (abortion or childbirth) between 1980 and 1992. Eight years later, on average, women whose first pregnancies ended in abortion were 65% more likely to be at high risk for clinical depression than women whose pregnancies resulted in a birth, after controlling for age, race, marital status, divorce history, income, education, and prepregnancy psychological state.

In contrast, Schmiege and Russo⁴ examined the same data and analyzed numerous variables using much more rigid methodological criteria, Robinson said. They found similar scores for depression across the delivery and abortion groups: 28.6% of those in the delivery group were at high risk for depression compared with 24.8% in the abortion group.

Robinson cited 2 additional studies that avoided key methodological errors. Zabin and colleagues⁵ studied young, underprivileged girls in the inner city who got pregnant, and followed them for 2 years. Those who terminated their pregnancy had better outcomes (eg, graduating from high school, better off economically) than those who delivered.

Major and associates⁶ followed 882 women who obtained a first-trimester abortion for an unintended pregnancy, 442 of them for 2 years. Prior mental health was examined as a predictor of postabortion psychological responses. Two years postabortion, 301 of 418 women (72%) were satisfied with their decision; 306 of 441 (69%) said they would have the abortion again. Six of 442 (1%) reported posttraumatic stress disorder. Prepregnancy history of depression was a risk factor for depression, lower self-esteem, and more negative abortion-specific outcomes 2 years postabortion.

Robinson concluded: “The studies with negative findings are very, very flawed. There is no evidence for the existence of the so-called abortion trauma syndrome. Unfortunately, public policy is often being determined on the basis of assumptions and preconceived beliefs rather than on research.”

References:

References1. Elliot Institute. Elliot Institute: Our Mission and Ministry. Post-Abortion Research Education and Advocacy. http://www.afterabortion.org/Resources/Our_Mission_and_Ministry_Brochure.pdf). Accessed July 25, 2009.
2. American Psychiatric Association. Report of the APA Task Force on Mental Health and Abortion. http://www.apa.org/releases/abortion-report.pdf. Accessed July 25, 2009.
3. Cougle JR, Reardon DC, Coleman PK. Depression associated with abortion and childbirth: a long-term analysis of the NLSY cohort. Med Sci Monit. 2003;9: CR105-CR112.
4. Schmiege S, Russo NF. Depression and unwanted first pregnancy: longitudinal cohort study. BMJ. 2005;331:1303.
5. Zabin LS, Hirsch MB, Emerson MR. When urban adolescents choose abortion: effects on education, psychological status and subsequent pregnancy [published correction appears in Fam Plann Perspect. 1990;22:48]. Fam Plann Perspect. 1989;21:248-255.
6. Major B, Cozzarelli C, Cooper ML, et al. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry. 2000;57:777-784.