Post-abortion syndrome

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Post-abortion syndrome (PAS), post-traumatic abortion syndrome and abortion trauma syndrome, are terms used to describe a set of adverse psychopathological characteristics which are proposed to occur in a small percentage of women following an induced abortion.[1] Primarily a term used by pro-life advocates,[2][3][4] PAS is not a medically recognized syndrome,[5] and neither the American Psychological Association nor American Psychiatric Association recognize it. Some physicians and pro-choice advocates have argued that PAS is a myth created by opponents of abortion for political purposes.[6][7][8]

A number of researchers have concluded that abortion has positive or neutral effects on women's psychological well-being. While some studies have shown a correlation between clinical depression, anxiety, suicidal behaviors, or adverse effects on women's sexual functions and abortion, these correlations may be explained by preexisting social circumstances and emotional health.[9] According to a 1989 press release from the APA, various factors, such as emotional attachment to the pregnancy, lack of support, and conservative views on abortions, 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.[10]

Contents

[edit] Academic research

[edit] Neutral and positive effects of abortion

A number of studies have indicated that women who have undergone abortion have experienced positive or no change to their mental health and well-being. 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.[11] Another study in 1992 found that having one abortion was positively associated with higher global self-esteem, particularly feelings of self-worth, capableness, and not feeling one is a failure. It also noted that adverse emotional reactions to the abortion are influenced by pre-existing psychological conditions and other negative factors and, furthermore, that women's well-being was separately and positively related to employment, income, and education, but negatively related to total number of children.[12] In a 2005 US study, the evidence was inconclusive as to whether abortion as compared to completion of an undesired first pregnancy was related to increased risk of depression.[13]

[edit] Studies on abortion and depression or stress

In 1989, the American Psychological Association (APA) convened a panel of psychologists to review the data available to determine the existence of "post-abortion syndrome". The panel 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."[14]

[edit] Denmark

A study conducted at University of Copenhagen has shown legal abortion is associated with few adverse effects on sexual function among women in Denmark. The study was conducted among 941 women who chose abortion. Among the many statistics of note, the authors wrote, "Diminished libido was experienced by 15.3% at 8 weeks follow-up, and 6.0% experienced diminished orgasm ability (self-rated changes). Libido was unchanged in 72.4% of the women, 69.7% had no change in orgasm ability and 3.3% had never experienced orgasm." 51% of the women overall resumed sexual activities within 2 weeks after abortion. This rate was "significantly higher among women aged 18–24 years (60.6%) than among women in higher age groups (41.7–47.8%)." [15]

[edit] Finland

A Finnish study has shown a correlation between miscarriage (or spontaneous abortion) with depression and suicide, as well as between medically induced abortion with depression and suicide among women in Finland. The study found that among 8,980 women, "In total, 30 suicides were committed after women gave birth (42% [of deaths among the women in the study]), 29 after an abortion (40%), and 14 after a miscarriage (19%), of which two were after an extrauterine pregnancy." The study was unable to establish a causal link between abortion and suicide because it was not clear if abortion causes depression and suicide, or if women who are depressed and suicidal are more likely to elect to have an abortion. The article concludes that an "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."[16]

[edit] New Zealand

A longitudinal study by University of Otago Christchurch School of Medicine completed in 2006 used data gathered from children and young women (ages 15-25) living in New Zealand who sought abortions over a 25-year period. The study found an increased occurrence of clinical depression, anxiety, suicidal behavior, and substance abuse among women who had previously had an abortion compared to women who did not have abortions. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. The study concluded that those who had an abortion were more likely to have "mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors." The authors write, "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."[17]

[edit] Norway

A study in Norway compared the mental distress of women who experienced a spontaneous abortion (miscarriage) and those who had a voluntary abortion. Women who had had a miscarriage exhibited significantly quicker improvement on Impact of Event Scale (IES) scores for avoidance, grief, loss, guilt and anger throughout the observation period. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group after two and five years. Compared with the general population, women who had undergone induced abortion had significantly higher Hospital Anxiety and Depression Scale (HADS) anxiety scores at all four interviews, while women who had had a miscarriage had significantly higher anxiety scores for only ten days. The conclusion of the study showed that women who had experienced a miscarriage experienced more mental distress after six months and 10 days than those who had induced abortions. Furthermore, "The responses of women in the miscarriage group were similar to those expected after a traumatic and sad life event. However, the women in the induced abortion group had more atypical responses." The study cited possible reasons for its psychological findings as poorer mental health among women prior to having induced abortions, difference in economic status, and relationship issues. The study recommended that women be informed about common psychological responses to pregnancy termination and that they be offered talks with health personnel.[18].

[edit] South Africa

A study of 155 women seeking voluntary induced abortion sought to investigate whether different forms of pain control had a different effect on pain and psychological distress after the abortion. The researchers examined levels of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation. The authors found that cortisol levels are elevated in women who chose a local anesthetic and that while the choice of anesthetic "does not appear to impact on longer-term psychiatric outcomes or functional status" psychologiclal distress was prevelent among both groups of women.[19] Specifically, they found that 11.4% of women met the criteria for a diagnosis of post-traumatic stress disorder (PTSD) prior to their abortions and that the overal rate of PTSD among the sample rose to 18.2% three months after their abortions, a rise of 61%. However, rates of depression and anxiety were lower after abortion than immediately before. In discussing their findings, the authors write that "Presently the weight of evidence suggests that abortion does not cause lasting negative consequences," but that from their findings regarding mid-term PTSD reactions "[I]t would follow that screening women pre-termination for PTSD and disability and post-termination for high levels of dissociation is important in order to help identify women at risk of PTSD and to provide follow-up care."[19]

[edit] Spain

Spanish social work researchers claim that some psychopathological characteristics are frequently observed in women who have voluntarily aborted. These include "dreams and nightmares related with the abortion," and "feelings of guilt". Using a cohort of 10 women, Gomez, Lavin C., & Zapata examined ways to categorize PAS under the assumption that it exists and that it is related to Post Traumatic Stress Disorder. [20]

[edit] United States

In 1987, President Ronald Reagan asked United States Surgeon General C. Everett Koop to issue a report on the health effects of abortion. In 1989, Koop wrote a letter to Reagan stating that the existing research was inadequate to draw any definititive conclusions.[21] That same year, the American Psychological Association convened a review panel which in 1990 published an article in Science stating that "well-designed studies" did not find statistically significant links between abortion and psychological harm. The authors concluded: "Severe negative reactions after abortions are rare and can best be understood in the framework of coping with a normal life stress."[22]

In 1992, Nada Stotland, now the vice-president of the American Psychiatric Association, wrote in a commentary published in the Journal of the American Medical Association that: "There is no evidence of an abortion-trauma syndrome." She also wrote that abortion carries the same psychological risk as giving birth. [6] In a subsequent 1998 paper, however, Stotland described her surprise at treating a patient experienced a severe delayed reaction to a prior abortion following a a subsequent miscarriage. She reports discovering first-hand "the psychological complexities of induced abortion" and concludes that the failure to address these issues "leaves the person vulnerable to reminders and reenactments, to difficulties that may surface in life and in subsequent psychotherapy." Despite a woman's political or moral views of abortion, she writes, "abortion is experienced by that woman as both the mastery of a difficult life situation and as the loss of a potential life. There is the danger that the political, sociological context can overshadow a woman's authentic, multilayered emotional experience."[23]

In an issue of Journal of Social Issues published in 1992, Dr. Gregory Wilmoth, concluded: "There is now virtually no disagreement among researchers that some women experience negative psychological reactions postabortion. Instead the disagreement concerns the following: (1) The prevalence of women who have these experiences..., (2) The severity of these negative reactions..., (3) The definition of what severity of negative reactions constitutes a public health or mental health problem..., [and] (4) The classification of severe reactions..."[24]

In 2005, the Journal of Social Issues dedicated an entire issue to research and controversy surrounding reproductive health issues.[25] In this issue, Russo and Denious described the promotion of post-abortion syndrome as part of a campaign to develop a rationale for suing physicians who provide abortions and thus deterring the provision of legal abortion services. The authors wrote that: "There is no scientific basis for constructing abortion as a severe physical or mental health threat," describing as "most worrisome... the publication of deeply flawed studies that contain miscoded data and meaningless findings (e.g., Reardon & Cougle, 2002) which are then used as 'evidence' that abortion is harmful to women."[8]

[edit] Surgeon General

The former U.S. Surgeon General C. Everett Koop, an opponent of abortion, conducted a review in 1989 of over 250 studies pertaining to the psychological impact of abortion, but told a congressional committee in 1999 that there was not enough sound evidence to assess the psychological effects of abortion on women and that a reliable scientific report was not possible.[26] In a letter to Ronald Reagan, Koop wrote, "In the minds of some [abortion opponents], 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." He went on to note that, "...doctors had long ago concluded that the physical results of abortion are not major health factors and required little additional study."[27] He recommended a $100 million dollar prospective study would be required to conclusively examine the mental health effects of abortion.[28]

In subsequent testimony before a congressional committee regarding his review of the literature, Koop stated: "There is no doubt about the fact that some people have severe psychological effects after abortion, but anecdotes do not make good scientific material."[27]

[edit] Feelings experienced after miscarriage or abortion

Various 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 find a causal relationship between abortion and depression or stress, many studies cite the pre-existence of depression and stress in many women who seek abortions. Some women may experience some or all of the following feelings after an abortion.

Some empirical research suggests that some women are more likely than others to develop stress after after a miscarriage or abortion. The risk factors found in some clinical studies include:

  • Low self-efficacy for coping with the abortion[35]
  • Low self-esteem[36]
  • External locus of control[37]
  • Difficulty with the decision to have an abortion[38][39]
  • When there is emotional investment in the pregnancy [40][41]
  • Perceptions of one's partner, family members, or friends as non-supportive[42][43]
  • Timing during adolescence, being unmarried, or poor[44][45][46]
  • A poor or insecure attachment relationship with one's mother or a childhood history of separation from one's mother for a year or more before age 16[47][48][49]
  • Involvement in violent relationships[50][51]
  • Traditional sex-role orientations[52]
  • Conservative views of abortion and/or religious affiliation[53][54][55]
  • When a pregnancy is initially intended[56][57][58][59][60]
  • Abortion during the second trimester[61]
  • When the woman is in an unstable partner relationship[62][63]
  • Being forced into abortion by one's partner, others, or by life circumstances[64]

[edit] Recent research and APA's Response

Fergusson, a self-described "pro-choice atheist", argued that the APA's position statement implies a greater degree of certainty than Fergusson feels actually exists.[65] In response, Dr. Nancy Russo, who was referred to a Washington Times reporter by the APA, explained that "pre-existing mental health problems, relationship quality, and whether the pregnancy was wanted or unwanted are key factors determining postabortion mental distress, not the abortion itself". Russo also stated that "There has yet to be a well designed study that finds that abortion itself contributes to increased risk for mental health problems," and noted that feelings of guilt and shame after abortion may result from social disapproval and efforts to cast abortion as a moral failing, rather than from the procedure itself. Fergusson argued that better research was needed, but that "...the abortion debate and its implications drive out the science."[66]

[edit] References

  1. ^ a b Gomez, Lavin C & Zapata, Garcia R."Diagnostic categorization of post-abortion syndrome", Actas Esp Psiquiatr. 2005 Jul-Aug;33(4):267-72.
  2. ^ Chris Mooney"Research and Destroy" Washington Monthly, October 2004
  3. ^ Bazelon, Emily. The New York Times Magazine. Is There a Post-Abortion Syndrome?
  4. ^ Science in support of a cause: the new research, by Michael Kranish. Published in the Boston Globe on July 31 2005; accessed November 27 2007.
  5. ^ Grimes DA, Creinin MD (2004). "Induced abortion: an overview for internists". Ann. Intern. Med. 140 (8): 620–6. PMID 15096333. Key summary points of article state that "Abortion does not lead to an increased risk for breast cancer or other late psychiatric or medical sequelae." On p. 624, the authors state: "The alleged 'postabortion trauma syndrome' does not exist."
  6. ^ a b Stotland NL. The myth of the abortion trauma syndrome. JAMA. 1992 Oct 21;268(15):2078-9. PMID 1404747.
  7. ^ Cooper, Cynthia L. Abortion Under Attack
  8. ^ a b Russo NF, Denious JE (2005). "Controlling birth: science, politics, and public policy". J Soc Issues 61 (1): 181–91. PMID 17073030.
  9. ^ TIME. Abortion on Demand
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