Too often drowned out in the politics of abortion is the little noticed revelation that both sides can and do agree on something about abortion. Few realize this reality: some women are psychologically injured as a result of their abortion and considerable research suggests which women are more likely to be at risk. A recent study reported that between 5.8% - 24.7% of the annual prevalence of certain mental disorders in the U.S. could be prevented if women did not elect abortion. This information is not readily promoted and is all too often obfuscated. To understand how and why this is so, it would be well to first examine the role of one of the world’s largest associations of mental health providers on this issue. Secondly, which women are more likely to be at risk will be explored. And lastly, the implications of what can be agreed upon will be discussed in the context of improving the informed consent process and pre-abortion counseling.
THE AMERICAN PSYCHOLOGICAL ASSOCIATION – A Case in Point
Consider the American Psychological Association (APA) as an example. In 2008, the APA issued a report of their Task Force on the Mental Health of Abortion. After a biased and selective review of the literature, the Task Force report concluded: (1) there is no credible evidence that a single elective abortion of an unwanted pregnancy in and of itself causes mental health problems for adult women, and (2) the mental health risks of abortion are no greater than that of childbirth. These findings were not surprising given the biases of the task force’s members and the history of the APA which has long been supportive of unrestricted abortion rights.
Four carefully chosen words used by the APA in their nuanced conclusions are key to understanding what they are really saying. These words are: (a) credible, (b) single, (c) causes and (d) adult.
On the question of abortion, should the APA’s report be considered credible? Long before Roe v Wade was decided, the APA advocated for unrestricted abortion as a woman’s “civil right” as enumerated in their 1969, 1980, 1989, & 1992 resolutions and various state and federal level amicus briefs opposing any regulation or restriction of abortion practice. How does the APA remain objective and scientific when reviewing research which indicates harmful emotional effects of abortion given their pre-determined beliefs and resolutions? Honestly, it simply can’t and this constitutes a significant conflict of interest and credibility gap. Others have noticed this as well. Recently, the APA was barred from submitting its mental health and abortion report as an amicus brief by the 8th Circuit Court of Appeals regarding a South Dakota informed consent statutory challenge, Planned Parenthood v Rounds.
From a scientific viewpoint, should the report of the APA’s Task Force be considered sound and accepted as such? Psychologists who are both pro-choice and pro-life have been highly critical of the APA’s methods and conclusions. When subjected to an objective and dispassionate methodological analysis, significant evidence suggests that abortion can compromise women’s mental health.   On the topic of the psychological health risks of abortion, the APA’s report should not be considered objective or scientifically rigorous.
Single Versus Multiple Abortions
The APA only refers to a “single” abortion in drawing its conclusions. Yet nearly half of all U.S. women terminating their pregnancy each year have had a previous abortion. Most research on the psychological impact of abortion entirely ignores this important issue of recidivism. Given the considerable number of women who have had a second and third abortion, it is apparent that the APA’s report can provide no assurance whatsoever that multiple abortions are psychologically safe and/or beneficial for women.
Causation in Social Science
The APA abortion report asserts that a single abortion does not “cause” mental health problems for adult women. It is noteworthy that very little social science research is causative versus correlational (i.e., association) in nature since it is unethical to randomly assign women to various treatment outcome groups (e.g., abortion, adoption, keep child) so as to absolutely determine what outcome caused what mental health effect. It has also long been accepted that childbirth of either a wanted or unwanted pregnancy has a well-documented low incidence of adverse mental health effects and is in fact, protective against depression and suicide. By focusing on causation, the APA skirts normative methodological convention and raises the scientific bar to a level which is largely unattainable in social science research, a standard they themselves caution against: “cause cannot be determined with certainty.” That being said, the vast bulk of knowledge attained about human behavior is ethically and scientifically obtained through examination of association as opposed to causation by obtaining a representative sample and controlling for intervening variables. For the APA to use the causation standard of proof for psychological injuries resulting from abortion is both a foil and duplicitous.
Adult Women Versus Adolescent Having Abortion
Nearly two out of ten abortions in the U.S. are not performed on adult women, but rather on adolescents. According to the Guttmacher Institute, 18% of U.S. women obtaining abortions are teenagers; those aged 15-17 obtain 6% of all abortions, teens aged 18-19 obtain 11%, and teens under age 15 obtain 0.4%. Here too the APA attempts to influence public policy by solely focusing on adult women, excluding this not insignificant proportion of abortions performed on minors who are at increased risk for mental health problems as a result of abortion. Of note, informed consent forms at abortion clinics make no differentiation between adult women and adolescent girls, nor between those who are having a first or a repeat abortion.
SO WHAT CAN BE AGREED UPON? SOME WOMEN ARE CERTAINLY MORE AT RISK THAN OTHERS
Little to no attention has been paid to the APA’s Task Force report that identified certain women who are more at risk than others of adverse psychological outcomes following an abortion. Specifically, the APA Task Force on the Mental Health of Abortion concluded that the evidence is compelling that the following women are indeed at risk of emotional injury:
- women who have multiple abortions (about 47% of all abortions performed annually)
- women who abort a wanted pregnancy because of coercion or pressure to abort from third parties (may range from 20-60%)
- minors who have abortions (approximately 12%)
- women with preexisting mental health problems (may range from 10-40% of abortion seeking women)
The American Psychological Association is not alone in asserting that some women are more likely than others to be at risk for psychological problems following abortion. The National Abortion Federation, the primary professional association of abortion providers in North America, has also acknowledged the following predisposing risk factors predictive of increased mental health risks for women who elect abortion:
- Low self-efficacy: expecting depression, severe grief or guilt, and regret after the abortion
- Low self-esteem prior to the abortion
- An existing mental illness or disorder prior to the abortion
- Significant ambivalence about the decision
- Lack of emotional support and receiving criticism from significant people in their lives
- Perceived coercion to have the abortion
- Intense guilt and shame before the abortion
- Belief that a fetus is the same as a 4-year old human and that abortion is murder
- Fetal abnormality or other medical indications for the abortion
- Usual coping style is repressing thoughts or denial
- Unresolved past losses and perception of abortion as a loss
- Experiencing social stigma and antiabortion demonstrators on the day of the abortion
- Past childhood sexual abuse
Others risk factors have also been identified by those who support abortion rights. One of the largest abortion clinics in the Midwest apparently screens for the following risk factors in addition to the above:
- Believing that God won't forgive her and doubting either her own ability to forgive herself, prolonging deep guilt and shame.
- Feeling undecided 50/50 about whether or not the abortion is best, but proceeding with the abortion anyway.
- Finding thoughts of abortion very troubling, but dealing with it by going back to old habits: blocking it out of her mind completely or drinking and using drugs rather than seeking emotional support.
- Having a personal history of doubting past decisions and using “if only” thinking. “If only I had the baby my boyfriend would have stayed…my mother would love me…my life would have turned out better,” etc.
- Belonging to a church or believing in a religion that emphasizes a punishing God, sin and judgment rather than a loving God, forgiveness and redemption.
- Blaming someone else rather than taking responsibility for making the decision.
IMPROVING INFORMED CONSENT & PRE-ABORTION COUNSELING
A woman’s consent for an abortion cannot be informed without the provision of adequate and appropriate information regarding the possible risks and benefits to her physical and mental health from this procedure, as well as informing her of the comparative risks and benefits of keeping or placing her child. Nor can her decision be truly informed if her decision is not her own, i.e., fully voluntary and without coercion or pressure.
In 2008, the Royal College of Psychiatrists altered its previous position statements regarding the psychological safety of induced abortion and stated: “Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.” This is also a theme repeated by a long-term follow-up study for women viewing their abortion experiences at menopause . It is noteworthy that there is no such recommendation or regulation similar to this, statutory or otherwise, in the U.S.
When women are not provided adequate or sufficient information in pre-abortion screening they are more likely to suffer adverse emotional consequences from their decision to terminate their pregnancy. When women are not provided professional counseling that includes full exploration of their decision options, pressure/coercion, risks and benefits of each, exploration of risk factors and focus on individual risk factors relevant to them, examination of past pregnancies and psychosocial history, and be afforded sufficient time and respect to do so, then they receive unprofessional and substandard counseling which is injurious to women’s mental health. The deficiencies of current pre-abortion counseling are well known and require remediation.
In 2004, Drs. Rue, Coleman, Rue & Reardon published their research in the journal Medical Science Monitor and reported that 51.9% of American women (N=217) who had an abortion needed more time to make a decision, that only 17.5% received counseling on alternatives at the abortion clinic, 64% felt pressured by others to make the decision to abort, 54% were not sure of their decision at the time of the abortion, and only 10.8% believed they received adequate counseling.
This year, Drs. Coyle, Coleman & Rue published their research on perceived adequacy of pre-abortion counseling. Data were collected through online surveys from 374 women who had a prior abortion and 198 men whose partners had experienced elective abortion. For women, perceptions of pre-abortion counseling inadequacy predicted relationship problems, symptoms of intrusion, avoidance, and hyperarousal, and meeting full diagnostic criteria for posttraumatic stress disorder (PTSD) with controls for demographic and personal/situational variables used. For men, perceptions of inadequate counseling predicted relationship problems and symptoms of intrusion and avoidance with the same controls used. Incongruence in the decision to abort predicted intrusion and meeting diagnostic criteria for PTSD among women with controls used, whereas for men, decision incongruence predicted intrusion, hyperarousal, meeting diagnostic criteria for PTSD, and relationship problems. These findings suggest that both perceptions of inadequate pre-abortion counseling and incongruence in the abortion decision with one’s partner are related to adverse personal and interpersonal outcomes.
Given the concurrence of risk identified above, it is clear that there is a growing need for health and mental health professionals to screen and counsel women concerning the psychological risk factors of abortion. By improving pre-abortion screening and counseling, adverse mental health outcomes can be better prevented. By being alert to the increasing reality of multiple abortions, developmental challenges during adolescence, prior mental health issues, medical and mental health providers should re-evaluate the counseling and pre-abortion screening they offer women considering abortion. Counseling should be sensitively and comprehensively approached, maximizing information sharing, respecting individual differences among patients, and identifying those women who are more at risk than others of having negative post-abortion psychological outcomes.
The cumulative evidence of abundant research suggests the need for health care providers, including those providing abortions, to screen women for known risk factors that are predictive of adverse psychological outcomes after an abortion, particularly their mental health. When risk factors are identified, those women at greater risk should be provided more, not less counseling. They should be treated sensitively and carefully assessed to determine whether or not abortion is in their best interests as opposed to adopting a “one size fits all” attitude.
In the final analysis, it is not the pronouncements of the APA or those organizations devoted to abortion rights that matter. It is the voice of the women who have had abortions, their friends, partners and families that will be the loudest, most compelling, and credible. A woman who had five abortions has perhaps said it best: “The fierce war between people who have differing views on the legality of abortion has turned into a war that is hurting women, as people go out of their way to minimize women's problems after an abortion, and ‘blame the woman’ for any trouble she is having.”
 Suicidal ideation (5.8%), social phobia (6%), any mood disorder (6%), any substance use disorder (22.7%), and drug abuse (24.7%). Table 2 in Mota, N., Burnett, M. & Sareen, J. (2010). Associations between abortion, mental disorders and suicidal behavior in a nationally representative sample. Canadian Journal of Psychiatry, 55:239-247.
 American Psychological Association, Task Force on Mental Health and Abortion. (2008). Report of the Task Force on Mental Health and Abortion. Washington, DC: Author. Retrieved from http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf
 “WHEREAS . . . termination of unwanted pregnancies is clearly a mental health and child welfare issue, and a legitimate concern of APA; be it resolved, that termination of pregnancy be considered a civil right of the pregnant woman . . .” American Psychological Association, Retrieved from http://www.apa.org/about/governance/council/policy/abortion.aspx
 See for example: P.K. Coleman’s critique on our Resources page under “Mental Health Research and Abortion.”
 Coleman, P.K., Coyle, C.T., Shuping, M. & Rue, V.M. (2008). Induced abortion and anxiety, mood, and substance abuse disorders: Isolating the effects of abortion in the National Comorbidity Survey. Journal of Psychiatric Research, 43: 770-6.
 Cohen (2007). Repeat abortion. Guttmacher Policy Review, 10(2):8-12, Retrieved from: http://www.guttmacher.org/pubs/gpr/10/2/gpr100208.pdf
 Letter of U.S. Surgeon General C. Everett Koop to President Ronald Reagan, January 9, 1989, page 2.
 Thorp, J.M., Hartmann, K.E., & Shadigian, E. (2005). Long-term physical and psychological health consequences of induced abortion: A review of the evidence. Linacre Quarterly. (February), 44-69.
 Major, B. et al. (2009). Abortion and mental health: Evaluating the evidence. American Psychologist, 64:863.
 Jones, R K, Finer, LB & Singh, S. (2008). Characteristics of U.S. abortion patients. NY: Guttmacher Institute.
 Baker, A., Beresford, T., Halvorson-Boyd, G., Mogul Garrity, J., (1999) Informed Consent, Counseling, and Patient Preparation, in Paul, M. et al., (eds.) A Clinician’s Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, p. 29. National Abortion Federation.
 Hope Clinic, Granite City, Illinois, Retrieved from http://www.hopeclinic.com/counseling.html
 Royal College of Psychiatrists, Position Statement on Women’s Mental Health in Relation to Induced Abortion 14th March, 2008, Retrieved from http://www.rcpsych.ac.uk/rollofhonour/currentissues/mentalhealthandabortion.aspx
 Dykes, K., Slade, P. & Haywood, A. (2010). Long Term follow-up of emotional experiences after termination of pregnancy: Women's views at menopause. Journal of Reproductive and Infant Psychology, 1-20.
 Rue, V.M., Coleman, P.K., Rue, J.J. & Reardon, D. (2004). Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Medical Science Monitor, 10:SR5-16.
 Coyle, C.T., Coleman, P.K., Rue, V.M. (2010). Inadequate preabortion counseling and decision conflict as predictors of subsequent relationship difficulties and psychological stress in men and women. Traumatology 16: 16-30.
 Mota, N., Burnett, M. & Sareen, J. (2010). Associations between abortion, mental disorders and suicidal behavior in a nationally representative sample. Canadian Journal of Psychiatry, 55:239-247.
 Afterabortion.com, Retrieved from http://www.afterabortion.com/pass_details.html