Readers React to “Abortion Trauma Syndrome”

Abortion Trauma Syndrome – A Different Perspective

As an active member of the “anti-abortion movement,” I read the article “Abortion Trauma Syndrome”¹ in the September issue of Psychiatric Times with great interest.

I was mildly surprised that a piece such as this appeared in the news section rather than as an editorial. I was much more surprised, however, that a statement so final and definitive as “abortion does not cause psychiatric damage” (emphasis mine) was quoted in the article, which then went on to discuss the multi-flawed nature of the research that currently exists for or against this postulation.

For those who are open to a more in depth discussion about this issue, I would like to propose a thought experiment. Is there anything else in all of human existence that one could substitute with complete confidence for the word “abortion” in the above quote, given the complexity of the human psyche? Can we say with absolute certainty that any other type of surgery or medical condition or treatment can never cause psychiatric damage? If the physical and mental changes associated with pregnancy, the post-partum period or the menstrual cycle itself can be accepted as sometimes having psychiatric sequelae, why should we be so quick to exclude abortion from consideration?

The feminist writer Frederica Mathewes-Green² once wrote “No one wants an abortion as she wants an ice cream cone or a Porsche. She wants an abortion as an animal, caught in a trap, wants to gnaw off its own leg.” It seems that the evidence for such a perspective may be mounting over time. A pro-life organization called Priests for Life has recently initiated a campaign called “Silent No More” where they help to connect individuals grieving over a past abortion with resources for healing. So far about 4,000 people have registered on the campaign Web site and many have posted about the specific negative psychological and other consequences of their abortion.³ In addition, a post-abortion healing weekend retreat program, Rachel’s Vineyard, has helped over 60,000 women (and men) in various countries since 1995 with the pain they are experiencing after a previous abortion experience (the retreat’s cost averages just over $100 per person)⁴ Can we discount the possibility of any psychiatric illness caused or exacerbated by abortion for all of these 60,000 or more people?

Another pro-life organization, Feminists for Life, has identified evidence of an appalling lack of “choice” on our nation’s college campuses for many pregnant students whose health insurance plans do not cover prenatal or maternity care and who have no family housing or child care services available to them on campus. Given such circumstances, is it any wonder that about half of the 1.2 million annual U.S. abortions are performed on college-age women?⁵ Are all of these women really “choosing” abortion as freely as we might like to believe? If they aren’t, does that alter their risk of future negative repercussions?

While it may be true in some cases that abortion is being used as a political football, we all know that this does not mean that either side of the debate is completely wrong. More research is needed to know the whole truth, but some basic facts are easy to overlook when considering a topic as controversial as abortion. One point worthy of keeping in mind is our knowledge that having a minor child at home is often a protective factor against suicide. Another may be whether psychiatrists themselves are taking the time to elicit a history of abortion or assessing for any possibility of a connection to other symptoms or behaviors during the patient interview. Subjects such as a past abortion are not necessarily likely to be brought up spontaneously by a patient; the examiner may have to ask about this directly. In neither Kaplan and Sadock’s Comprehensive Textbook of Psychiatry⁶ nor Kaplan and Sadock’s Synopsis of Psychiatry⁷ is there any reference to asking the patient specifically about a past abortion (or any prior pregnancy) experience in the interview section. I think it would be safe to assume that the question is rarely asked in clinical practice. Is it possible we could be missing something as a result, especially given the frequency of abortion?

The pro-life community acknowledges that there are some women who believe that their abortion was the right decision and show no evidence of any negative psychological effects afterward. On the contrary, there are certainly some women who suffer very intense grief and depression after an abortion. A recent case with some notoriety involved a British artist, 30-year-old Emma Beck, who hung herself in early 2007 shortly after aborting the twins she was carrying (at 8 weeks’ gestation). Her suicide note read, in part, “I should never have had an abortion. I see now I would have been a good Mum. . . I was frightened, now it is too late. I died when my babies died. I want to be with my babies . . . they need me, no-one else does.” The coroner later remarked in reference to the case “It is clear that a termination can have a profound effect on a woman’s life.”⁸

Both personal and professional experiences have proved to me the wisdom of the coroner’s comment. On September 4, 1993, at age 17, I aborted my first child at 5 weeks’ gestation. Like Emma, I feel that I died, emotionally, that day, and I have never been the same since. I had functional impairment for several months afterward, with symptoms including nightmares, flashbacks, panic attacks, significant guilt, a severely depressed mood, crying spells, impaired concentration, insomnia, anhedonia, decreased libido, fatigue, irritability, anger, a loss of interest in most of my regular activities and other symptoms that I managed to hide from everyone because my fear of someone finding out about the abortion outweighed all of my other concerns at the time.

I can say with certainty that if I had been evaluated by a psychiatrist both before and after the abortion I would have met criteria for at least one psychiatric illness afterward that I did not have before the abortion. It took many years before I was gradually able to admit to myself, and others, that I had made a horrible mistake. To truly accept complete responsibility for permanently destroying such a vast reservoir of potential for growth, development and meaning in my own life (and the lives of others) as was contained in that tiny “clump of cells” required gradually breaking through many layers of denial and defense mechanisms.

Every time I see my 2 beautiful toddler-age daughters, I ruminate about how their lives, and mine, would have been better had I given them the opportunity to know their sibling, who would now be 15. Every time I hug or kiss them I think about the child I will never get to hug or kiss. Is this indicative of any psychiatric “damage”? Who can definitively say? I have been raped, severely physically abused, and came near death after a freak accident that permanently disabled me, but my abortion is by far the most traumatic experience of my entire life.

All I know for sure is this: I am a mother, wife, family medicine physician, and psychiatrist. I received a full scholarship to college – several colleges, actually. I have a house, 2 cars, a dog and 2 great jobs. A lot of people might look at me and say that I had a “better outcome” because of my abortion, as the original article implied is the result when a woman who chose abortion later finishes school or has a better financial status than a young mother. But I would gladly give every title, every possession, and every penny to my name in return for the opportunity to once again be that terrified 17-year-old on that cold exam table, sobbing, waiting for the doctor to come in, and to choose what I knew in my heart was really the right thing to do.

Andrea Chamberlain, MD
Dr Chamberlain is an adult psychiatrist who is establishing a practice in Florida.

References

1. Kaplan A. Abortion trauma syndrome. Psychiatric Times. 2009;26(9):1, 8-9, 18.
2. Mathewes-Green F. Real Choices: Listening to Women; Looking for Alternatives to Abortion. Ben Lomond, CA. Conciliar Press; 1997.
3. Priests for Life. Silent No More Awareness Campaign. 2009. http://www.silentnomoreawareness.org/about/. Accessed October 26, 2009.
4. Rachel’s Vineyard Ministries. 2008. http://www.rachelsvineyard.org. Accessed October 6, 2009.
5. Feminists for Life. Women Deserve Better than Abortion. 2009. http://www.feministsforlife.org. Accessed October 6, 2009.
6. Sadock BJ, Sadock VA, eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2000.
7. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003.
8. Artist hanged herself after aborting her twins. Telegraph.co.uk: News. 22 February 22, 2008. http://www.telegraph.co.uk/news/uknews/1579455/Artist-hanged-herself-after-aborting-her-twins.html. Accessed October 6, 2009.

A DSM Diagnosis By Any Other Name

Regarding the article “Abortion Trauma Syndrome” by Arline Kaplan, I would note the irony of the claim that this syndrome is “conceived by anti-abortion activists to advance their cause,” given the obvious pro-abortion attitude of everyone associated with Kaplan’s article.

Would not the reader be expected to doubt the validity of the article if the reviewers and presenters had been so clearly opposed to abortion as they are instead in favor of its availability? Kaplan might have provided at least one researcher an opportunity to rebut the primary content of the article, rather than allowing Drs Stotland and Robinson to make their comments unchallenged.

Whatever the politically correct view of the APA and Psychiatric Times regarding the impact of abortion, my own clinical experience (which I don’t think is unique) is that most women who have been subjected to this procedure are left with emotional scarring and are reluctant to even discuss the event in retrospect. If this occurred as a result of any other cause, there is no doubt in my mind that there would be a DSM-IV diagnosis of some kind for it (especially given the proliferation of diagnoses in that manual).

Robert Murdock, MD

Political Agendas Make For Poor Science

“Abortion Trauma Syndrome” provides a case example of how the scientific distortion is just as bad when the agenda is coming from the left as when it comes from the right.

Whereas the article correctly points out that pro-life forces previously twisted isolated findings to imply that all women who have abortions are psychologically scared, it fails to point out the methodological problems with work by researchers such as Gail Robinson. Almost every argument that Dr Robinson makes concerning abortion trauma has also been made in an attempt to refute the existence of PTSD as a whole.¹ Statements such as “among women who have a single, legal, first-trimester abortion of an unplanned pregnancy for nontherapeutic reasons, the relative risk of mental health problems is no greater than the risks among women who deliver an unplanned pregnancy,” involve such a convoluted control group as to belie the face validity test. In other words, it makes it obvious they were looking for a particular outcome. The fact is that soldiers who deploy to combat zones have mental health disorders that are similar to those who do not deploy,² but clearly some soldiers do come back with PTSD. Similarly, anyone who has actually worked with patients would realize that some women are traumatized by having had an abortion, just as some are traumatized by being forced to have a child for whom they did not plan.

Rather than trying to advance a particular political agenda, our role as psychiatrists and researchers should be to help patients recover from their mental anguish-whatever its cause.

- MD, PhD (Name withheld by request)
San Diego, CA

References

1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ. 2001;322:95-98
2. Larson GE, Highfill-McRoy RM, Booth-Kewley S. Psychiatric diagnoses in historic and contemporary military cohorts: combat deployment and the healthy warrior effect. Am J Epidemiol. 2008;16:1269-1276.

Be Not “Anti” or “Pro”-But a Tireless Advocate

“Abortion Trauma Syndrome” does not exist in the DSM nomenclature. But this is not the same thing as saying that patients-both female and male-do not present to psychiatrists asking for help in dealing with the emotional aftermath of having made this decision, just as they come with the need to work through any other issue that carries with it high emotional valence. There are no scientific studies on most of the unique and personal issues that clinicians confront daily, but that doesn’t mean that we refuse to listen with caring thoughtfulness to whatever concerns our patients choose to express.

As we try desperately to think of our syndromes as science (to my knowledge there will be no definitive biological illness markers in all of DSM-V), we can probably help our cause more by not declaring ourselves “anti” or “pro” anything in the political realm-but rather as ceaseless advocates for those who are troubled for whatever reason and come to us seeking our help.

M. Richard Fragala, MD
Distinguished Life Fellow
American Psychiatric Association

A Misuse of Science

I found the article “Abortion Trauma Syndrome” disturbing, but not surprising given the politicized agenda of the American Psychiatric Association and its leadership.

While I fully agree that there is little to no scientific data to support the existence of “Abortion Trauma Syndrome,” APA pro-abortion advocates are disingenuous when they decry this “fabricated mental disorder.” APA’s pro-abortion stance is a political one without empirical evidence in methodologically sound studies that abortion on demand is necessary to promote or maintain women’s mental health.

Also, as much as many of us would wish it to be different, there are many “syndromes” and disorders (Rape Trauma Syndrome, Munchausen by Proxy to name a couple) that lack adequate research evidence for inclusion into DSM, but are frequently bandied about, without producing the emotional and aggressive response on the part of APA and its leadership that this subject has.

We should all refrain, from misusing our positions as psychiatrists to promote the misuse of science to advance our causes. Dr Nada Stotland is a vociferous advocate of abortion on demand. Her advocacy for abortion rights, including partial birth abortion, is as bereft of scientific support as the position of antiabortion forces who claim that abortion produces psychopathology.

Dr Stotland is correct that the issue of abortion is a moral one, not so that it is a religious one. Perhaps there are those in the APA who believe that labeling a moral imperative against abortion as “religious” marginalizes it in some way. For those of us in the APA who believe that abortion is the taking of an innocent human life, it is frustrating to see our dues monies wasted on political causes with which we not only disagree, but also find morally repugnant.

The APA is well on its way to becoming as unrepresentative of its membership as the AMA.

Eileen P. Ryan, DO
Associate Professor of Psychiatry & Neurobehavioral Sciences
University of Virginia Health System
Charlottesville

Drs Robinson and Stotland respond

We appreciate the depths of feeling and the personal and professional experiences of the writers of these letters. In the space allowed here, we can make only a few major points.

According to the Guttmacher Institute, approximately one-third of women in the United States have abortions before the age of 45. Therefore every psychiatrist who treats women should be aware of the literature on the psychiatric aspects of the procedure. 

There is no credible scientific evidence of a discrete psychiatric syndrome caused by abortion. Women react to abortion, as to childbirth, with a wide variety of emotions-including sadness, guilt, and a sense of loss; the predominant reaction is one of relief.  These emotions can be contradictory, and they often change over time. Emotions are not psychiatric syndromes or disorders. Neither is regret a psychiatric disorder. There are many decisions in each of our lives that we come to regret-sometimes bitterly. This does not always mean that the decision was the wrong one given our situation and knowledge at the time.

We acknowledge that some women may become upset or even depressed around the time of an abortion. The circumstances that lead a woman to have an abortion may be traumatic and these circumstances, rather than the abortion itself, may cause the woman to feel distressed.

In addition to domestic abuse, abandonment, and insufficient social and financial support, there is evidence that anti-abortion misinformation and clinic demonstrators exacerbate the stress of having an abortion. The evidence that assertions about “abortion trauma”are politically motivated comes from the anti-abortion literature itself. Making a distinction between religion and science denigrates neither.

Lastly, we strongly object to being labeled “pro-abortion.” Since 1973, The American Psychiatric Association has advocated for the right of each woman who alone can assess the situation in which she finds herself pregnant and make decisions about that situation. The APA has also advocated the importance of that right to her mental well-being. Each of us and the APA are pro-life, when it comes to: 

• The lives of the hundreds of thousands of women who die or who are grievously injured by unsafe abortions in places where they cannot obtain safe ones.

• The lives of the children for whom they are already responsible.

• The lives of women whose pregnancies would trap them in abusive, even life-threatening, conditions.

We are advocates for the lives of the children they already have because these women were able to make decisions that allowed them to create circumstances in which they can love and care for those children.

Readers of Psychiatric Times who are interested in more extensive reviews of the literature may wish to consult the very extensive report published last year by the American Psychological Association.¹ They can also read a review performed by a committee of the Group for the Advancement of Psychiatry (a committee of which we were members), recently published in the Harvard Review of Psychiatry.² 

References

1. Major B, Appelbaum P, Beckman L, et al. Mental health and abortion. Available at http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf. Accessed October 20, 2009.
2. Robinson GE, Stotland NL, Russo NL, et al. Is there an “abortion trauma syndrome”? Critiquing the evidence. Harv Rev Psychiatry. 2009;17:268-290