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Abortion and mental health

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Short description: Mental effects of undergoing an abortion

Scientific and medical expert bodies have repeatedly concluded that abortion poses no greater mental health risks than carrying an unintended pregnancy to term.[1][2][3] Nevertheless, the relationship between induced abortion and mental health is an area of political controversy.[4][5] In 2008, the American Psychological Association concluded after a review of available evidence that induced abortion did not increase the risk of mental-health problems. In 2011, the U.K. National Collaborating Centre for Mental Health similarly concluded that first-time abortion in the first trimester does not increase the risk of mental-health problems compared with bringing the pregnancy to term.[3][6] In 2018, The National Academies of Sciences, Engineering, and Medicine concluded that abortion does not lead to depression, anxiety, or post-traumatic stress disorder.[1] The U.K. Royal College of Obstetricians and Gynaecologists likewise summarized the evidence by finding that abortion did not increase the risk of mental-health problems compared to women carrying an unwanted pregnancy to term.[7] Two studies conducted on the Danish population in 2011 and 2012 analysed the association between abortion and psychiatric admission found no increase in admissions after an abortion. The same study, in fact, found an increase in psychiatric admission after first child-birth.[8] A 2008 systematic review of the medical literature on abortion and mental health found that high-quality studies consistently showed few or no mental-health consequences of abortion, while poor-quality studies were more likely to report negative consequences.[9]

Despite the weight of scientific and medical opinion, some anti-abortion advocacy groups have continued to allege a link between abortion and mental-health problems.[10] Some anti-abortion groups have used the term "post-abortion syndrome" to refer to negative psychological effects which they attribute to abortion. However, "post-abortion syndrome" is not recognized as an actual syndrome by the mainstream medical community.[11][12] Post-abortion syndrome (PAS) is not included in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR[13] or in the ICD-10 list of psychiatric conditions.[14] Medical professionals and pro-choice advocates have argued that the effort to popularize the idea of a "post-abortion syndrome" is a tactic used by anti-abortion advocates for political purposes.[4][10][15][16] Some U.S. state legislatures have mandated that patients be told that abortion increases their risk of depression and suicide, despite the scientific evidence contradicting such claims.[9][17]

Current scientific evidence

Systematic reviews of the scientific literature have concluded that there are no differences in the long-term mental health of women who obtain induced abortions as compared to women in appropriate control groups—that is, those who carry unplanned pregnancies to term. These studies have consistently found no causal relationship between abortion and mental-health problems.[9] While some studies have reported a statistical correlation between abortion and mental health problems, these studies are typically methodologically flawed and fail to account for confounding factors, or, as with results of women having multiple abortions, yield results inconsistent with other similar studies.[2][18] The correlations observed in some studies may be explained by pre-existing social circumstances and emotional or mental health problems.[2][18] Various factors, such as emotional attachment to the pregnancy, lack of support, and conservative views on abortion may increase the likelihood of experiencing negative reactions.

Major medical and psychiatric expert groups have consistently found that abortion does not cause mental-health problems. In 2008, the American Psychological Association reviewed the literature on abortion and mental health and concluded that the risk of mental health problems following a single, first-trimester induced abortion of an adult women is no greater than carrying an unwanted pregnancy to term. While observing that abortion may both relieve stress and "engender additional stress," they explicitly rejected the idea that abortion is "inherently traumatic."[2] Among those women who do experience mental health issues following an abortion, the APA concluded that these issues are most likely related to pre-existing risk factors.[2] Since these and other risk factors may also predispose some women to more negative reactions following a birth, the higher rates of mental illness observed among women with a prior history of abortion are more likely to be caused by these other factors than by abortion itself.[2] The panel noted severe inconsistency between the outcomes reported by studies on the effect of multiple abortions. Additionally, the same factors which predispose a woman to multiple unwanted pregnancies may also predispose her to mental health difficulties. Therefore, they declined to draw a firm conclusion on studies concerning multiple abortions.[2][19][20]

In December 2011, the U.K. Royal College of Psychiatrists undertook a systematic review to clarify the question of whether abortion had harmful effects on women's mental health. The review, conducted by the National Collaborating Centre for Mental Health and funded by the U.K. Department of Health, concluded that while unwanted pregnancy may increase the risk of mental-health problems, women faced with unwanted pregnancies have similar rates of mental-health problems whether they choose to carry the pregnancy to term or to have an abortion.[3]

A 2020 long term-study among US women found that about 99% of women felt that they made the right decision five years after they had an abortion. Relief was the primary emotion with few women feeling sadness or guilt. Social stigma was a main factor predicting negative emotions and regret years later.[21]

Some women do experience negative emotions after an abortion, but not at rates different from women who wanted an abortion and did not have one or from women who have miscarriages.[2][18][22] Women having abortions may receive support from abortion providers,[4][23] or national call centers like Exhale,[24][25] as well as All-Options.[26]

Post-abortion syndrome

The idea that abortion has negative psychological effects was widely promoted by crisis pregnancy centers in the 1970s and the term "post-abortion syndrome" has widely been used by anti-abortion advocates to broadly include any negative emotional reactions attributed to abortion.[4][15][22][27]

Post-abortion syndrome has not been validated as a discrete psychiatric condition and is not recognized by the American Psychological Association, the American Psychiatric Association, the American Medical Association, the American College of Obstetricians and Gynecologists, nor the American Public Health Association.[10][16][22][28][29][30] The Guttmacher Institute reports that as of August 2018, of the 22 U.S. states that include information on possible psychological responses to abortion, eight states stress negative emotional responses.[31] Recent literature that has addressed the psychological impacts of abortion have emphasized a need to study women who have a predisposition to mental health risk before having an abortion.[32]

Legal and political history

Under the 1967 Abortion Act, abortion in the United Kingdom was legalized only when two doctors agreed that carrying the pregnancy to term would be detrimental to a woman's physical or mental health. Consideration of mental health also played a role in the 1973 U.S. Supreme Court decision Roe v. Wade which ruled that state governments may not prohibit late terminations of pregnancy when "necessary to preserve the [woman's] life or health".[33] This rule was clarified by the 1973 judicial decision Doe v. Bolton, which specifies "that the medical judgment may be exercised in the light of all factors—physical, emotional, psychological, familial, and the woman's age—relevant to the well-being of the patient."[34][35][36] It is by this provision that women in the US can legally choose abortion when screenings reveal abnormalities of a viable fetus.[37][38][39]

In 1987, U.S. President Ronald Reagan directed U.S. Surgeon General C. Everett Koop, an evangelical Christian and abortion opponent,[40] to issue a report on the health effects of abortion. Reportedly, the idea for the review was conceived as a political gambit by Reagan advisors Dinesh D'Souza and Gary Bauer, who believed that such a report would "rejuvenate" the anti-abortion movement by producing evidence of the risks of abortion.[41] Koop was reluctant to accept the assignment, believing that Reagan was more concerned with appeasing his political base than with improving women's health.[40]

Koop ultimately reviewed over 250 studies pertaining to the psychological impact of abortion. In January 1989, Koop wrote in a letter to Reagan that "scientific studies do not provide conclusive data about the health effects of abortion on women."[42] Koop acknowledged the political context of the question in his letter, writing: "In the minds of some of [Reagan's advisors], 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."[43] In later testimony before the United States Congress, Koop stated that the quality of existing evidence was too poor to prepare a report that "could withstand scientific and statistical scrutiny". Koop added that "there is no doubt about the fact that some people have severe psychological effects after abortion, but anecdotes do not make good scientific material."[43] In his congressional testimony, Koop stated that while psychological responses to abortion may be "overwhelming" in individual cases, the psychological risks of abortion were "minuscule from a public health perspective."[4][41][44][45]

Subsequently, a Congressional committee charged that Koop refused to publish the results of his review because he failed to find evidence that abortion was harmful, and that Koop watered down his findings in his letter to Reagan by claiming that the studies were inconclusive. Congressman Theodore S. Weiss (D-NY), who oversaw the investigation, argued that when Koop found no evidence that abortion was harmful, he "decided not to issue a report, but instead to write a letter to the president which would be sufficiently vague as to avoid supporting the pro-choice position that abortion is safe for women."[45]

Later in 1989, responding to the political debate over the question, the American Psychological Association (APA) undertook a review of the scientific literature. Their review, published in the journal Science, concluded that "the weight of the evidence from scientific studies indicates that legal abortion of an unwanted pregnancy in the first trimester does not pose a psychological hazard for most women." The APA task force also concluded that "severe negative reactions after abortions are rare and can best be understood in the framework of coping with normal life stress."[44][46]

In 1994, the U.K.'s House of Lord's Commission of Inquiry into the Operation and Consequences of The Abortion Act published a report (commonly referred to as the Rawlinson Report) which concluded that there was no scientific evidence that abortion provided any mental health benefits but instead may put women at risk for psychiatric illness greater than if woman carried to term.[47][48][49] The Commission recommended that abortion providers "should initiate independent and long-term follow up of those clients considered to be most at risk of emotional distress." In a press release, the Rawlinson commission stated that the Royal College of Psychiatrists (RCP) had provided written testimony stating that there are "no psychiatric indications for abortion," noting that this "raises serious questions given that 91% of abortion are carried out on the grounds of the mental health of the mother."[48] In response, the RCP issued a statement that the Rawlinson commissions summary of their written statement was "an inaccurate portrayal of the College's views on abortion," adding that "There is no evidence of increase risk of major psychiatric disorder or of long lasting psychological distress [following abortion]".[48]

In 2006, the U.K.'s House of Commons Science and Technology Committee undertook another inquiry into scientific developments and included a request for the RCP to update their 1994 statement on abortion in light of more recent studies.[50][51] In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.[51][52][53] The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion."[51] This modified opinion was influenced by a growing body of literature showing a link between abortion and mental health problems, including a 30-year longitudinal study of about 500 women born in Christchurch New Zealand,[51][52][53] and a Cornwall inquest into the abortion related suicide of a well known British artist, Emma Beck.[52][54] This recommendation resulted in the 2011 review conducted by the National Collaborating Centre for Mental Health.[3]

See also

References

  1. ↑ 1.0 1.1 National Academies Of Sciences, Engineering; Health Medicine, Division; Board on Health Care Services; Board on Population Health Public Health Practice (2018). The Safety and Quality of Abortion Care in the United States : Health and Medicine Division. doi:10.17226/24950. ISBN 978-0-309-46818-3. http://www.nationalacademies.org/hmd/Reports/2018/the-safety-and-quality-of-abortion-care-in-the-united-states.aspx. Retrieved 2019-10-01. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Major, B; Appelbaum, M; Beckman, L; Dutton, MA; Russo, NF; West, C (2008). Report of the APA Task Force on Mental Health and Abortion. Washington, DC: American Psychological Association. pp. 4–5, 11–12. https://www.apa.org/pi/women/programs/abortion/mental-health.pdf. 
  3. ↑ 3.0 3.1 3.2 3.3 "Induced Abortion and Mental Health: A systematic review of the evidence" (PDF). National Collaborating Centre for Mental Health. December 2011. http://aomrc.org.uk/publications/reports-a-guidance/doc_download/9432-induced-abortion-and-mental-health.html. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Bazelon, Emily (21 January 2007). "Is There a Post-Abortion Syndrome?". The New York Times Magazine. https://www.nytimes.com/2007/01/21/magazine/21abortion.t.html. 
  5. ↑ "Post-Abortion Politics". NOW with David Brancaccio (PBS). 20 July 2007. https://www.pbs.org/now/shows/329/index.html. 
  6. ↑ Dreaper, Jane (December 9, 2011). "Abortion 'does not raise' mental health risk". BBC. https://www.bbc.co.uk/news/health-16094906. 
  7. ↑ "The Care of Women Requesting Induced Abortion". Royal College of Obstetricians and Gynaecologists. https://www.rcog.org.uk/globalassets/documents/guidelines/abortion-guideline_web_1.pdf. "Women with an unintended pregnancy should be informed that the evidence suggests that they are no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy and have the baby." 
  8. ↑ Steinberg, Julia R.; Laursen, Thomas M.; Adler, Nancy E.; Gasse, Christiane; Agerbo, Esben; Munk-Olsen, Trine (2018-08-01). "Examining the Association of Antidepressant Prescriptions With First Abortion and First Childbirth" (in en). JAMA Psychiatry 75 (8): 828–834. doi:10.1001/jamapsychiatry.2018.0849. ISSN 2168-622X. PMID 29847626. 
  9. ↑ 9.0 9.1 9.2 "Abortion and long-term mental health outcomes: a systematic review of the evidence". Contraception 78 (6): 436–50. 2008. doi:10.1016/j.contraception.2008.07.005. PMID 19014789. 
  10. ↑ 10.0 10.1 10.2 Stotland NL (2003). "Abortion and psychiatric practice". J Psychiatr Pract 9 (2): 139–49. doi:10.1097/00131746-200303000-00005. PMID 15985924.  "Currently, there are active attempts to convince the public and women considering abortion that abortion frequently has negative psychiatric consequences. This assertion is not borne out by the literature: the vast majority of women tolerate abortion without psychiatric sequelae."
  11. ↑ Cohen, Susan A. (2006). "Abortion and Mental Health: Myths and Realities". Guttmacher Institute. https://www.guttmacher.org/pubs/gpr/09/3/gpr090308.html. 
  12. ↑ "Q&A: Abortion and mental health". August 2008. https://www.rcog.org.uk/en/news/campaigns-and-opinions/human-fertilisation-and-embryology-bill/qa-abortion-and-mental-health/. 
  13. ↑ American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR. American Psychiatric Pub. ISBN:978-0-89042-025-6.
  14. ↑ "ICD-10 Version:2016". https://icd.who.int/browse10/2016/en. 
  15. ↑ 15.0 15.1 Mooney, Chris (October 2004). "Research and Destroy: How the religious right promotes its own 'experts' to combat mainstream science". Washington Monthly. http://www.washingtonmonthly.com/features/2004/0410.mooney.html. 
  16. ↑ 16.0 16.1 Stotland NL (October 1992). "The myth of the abortion trauma syndrome". JAMA 268 (15): 2078–9. doi:10.1001/jama.268.15.2078. PMID 1404747. 
  17. ↑ Lazzarini Z (November 2008). "South Dakota's Abortion Script – Threatening the Physician-Patient Relationship". N. Engl. J. Med. 359 (21): 2189–2191. doi:10.1056/NEJMp0806742. PMID 19020321. "The purported increased risks of psychological distress, depression, and suicide that physicians are required to warn women about are not supported by the bulk of the scientific literature. By requiring physicians to deliver such misinformation and discouraging them from providing alternative accurate information, the statute forces physicians to violate their obligation to solicit truly informed consent.". 
  18. ↑ 18.0 18.1 18.2 Horvath, S; Schreiber, CA (14 September 2017). "Unintended Pregnancy, Induced Abortion, and Mental Health.". Current Psychiatry Reports 19 (11): 77. doi:10.1007/s11920-017-0832-4. PMID 28905259. 
  19. ↑ Carey, Benedict (2008-08-12). "Abortion Does Not Cause Mental Illness, Panel Says". The New York Times. https://www.nytimes.com/2008/08/13/health/research/13brfs-ABORTIONDOES_BRF.html. 
  20. ↑ Major, Brenda; Appelbaum, Mark; Beckman, Linda; Dutton, Mary Ann; Russo, Nancy Felipe; West, Carolyn (2009). "Abortion and mental health: Evaluating the evidence". American Psychologist 64 (9): 863–890. doi:10.1037/a0017497. PMID 19968372. 
  21. ↑ "Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma". Social Science & Medicine 248: 112704. March 2020. doi:10.1016/j.socscimed.2019.112704. PMID 31941577. 
  22. ↑ 22.0 22.1 22.2 Kelly, Kimberly (February 2014). "The spread of 'Post Abortion Syndrome' as social diagnosis". Social Science & Medicine 102: 18–25. doi:10.1016/j.socscimed.2013.11.030. PMID 24565137. 
  23. ↑ Allen, Samantha (July 1, 2015). "Pro-lifers harass women after abortions". https://www.thedailybeast.com/pro-lifers-harass-women-after-abortions. 
  24. ↑ Walter, Shoshana (Jan 14, 2011). "Post-Abortion Counseling Group Finds Itself on the Firing Line". The New York Times. https://www.nytimes.com/2011/01/14/us/14bcexhale.html. 
  25. ↑ "Aspen Baker of Exhale, a "Pro-Voice" Group". NOW on PBS. July 20, 2007. https://www.pbs.org/now/shows/329/abortion-counseling.html. 
  26. ↑ "All-Options – all-options pregnancy support". https://www.all-options.org/. 
  27. ↑ Kranish, Michael (2005-07-31). "Science in support of a cause: the new research". The Boston Globe. https://www.boston.com/news/nation/washington/articles/2005/07/31/science_in_support_of_a_cause_the_new_research/. 
  28. ↑ Casey, PR (August 2010). "Abortion among young women and subsequent life outcomes.". Best Practice & Research. Clinical Obstetrics & Gynaecology 24 (4): 491–502. doi:10.1016/j.bpobgyn.2010.02.007. PMID 20303829. 
  29. ↑ "Controlling birth: science, politics, and public policy". J Soc Issues 61 (1): 181–91. 2005. doi:10.1111/j.0022-4537.2005.00400.x. PMID 17073030. 
  30. ↑ Dadlez, E.M.; Andrews, William L. (7 July 2009). "Post-Abortion Syndrome: Creating an Affliction". Bioethics 24 (9): 445–452. doi:10.1111/j.1467-8519.2009.01739.x. PMID 19594725. 
  31. ↑ "Counseling and Waiting Periods for Abortion". 2016-03-14. https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion. 
  32. ↑ Reardon, David C (2018-10-29). "The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities". SAGE Open Medicine 6: 205031211880762. doi:10.1177/2050312118807624. ISSN 2050-3121. PMID 30397472. 
  33. ↑ US Supreme Court (January 22, 1973). Roe V. Wade (410 U.S. 113) (Report). https://www.law.cornell.edu/supremecourt/text/410/113. Retrieved 1 October 2015. 
  34. ↑ US Supreme Court (January 22, 1973). Doe V. Bolton, 410 U.S. 179 (Report). IV.C. https://www.law.cornell.edu/supremecourt/text/410/179. Retrieved 1 October 2015. 
  35. ↑ "Frontline / Abortion Wars / Roe v Wade and Beyond". https://www.pbs.org/wgbh/pages/frontline/clinic/wars/cases.html. 
  36. ↑ "The Right to Choose at 25: Looking Back and Ahead". https://www.aclu.org/right-choose-25-looking-back-and-ahead. 
  37. ↑ Dailard, Cynthia (June 1999). "Issues and Implications, Abortion Restrictions and the Drive for Mental Health Parity: A Conflict in Values?". The Guttmacher Report on Public Policy 2 (3). https://www.guttmacher.org/pubs/tgr/02/3/gr020304.html. Retrieved 2 October 2015. 
  38. ↑ Palley, Marian Lief and Howard (2014). The Politics of Women's Health Care in the US. New York and London: Palgrave Pivot. pp. 74. ISBN 9781137008633. https://books.google.com/books?id=Pa7mAgAAQBAJ&q=institute%20women's%20health%20doe%20bolton&pg=PA74. Retrieved 5 October 2015. 
  39. ↑ "Abortion after the First Trimester in the United States". Planned Parenthood Federation of America. February 2014. https://www.plannedparenthood.org/files/5113/9611/5527/Abortion_After_first_trimester.pdf. 
  40. ↑ 40.0 40.1 "The C. Everett Koop Papers: Reproduction and Family Health". National Library of Medicine. http://profiles.nlm.nih.gov/ps/retrieve/Narrative/QQ/p-nid/88. 
  41. ↑ 41.0 41.1 Mooney, Chris (October 2004). "Bucking the Gipper". Washington Monthly. http://www.washingtonmonthly.com/features/2004/0410.mooney2.html. 
  42. ↑ Tolchin, Martin (1989-01-11). "Koop's Stand on Abortion's Effect Surprises Friends and Foes Alike". The New York Times. https://www.nytimes.com/1989/01/11/us/koop-s-stand-on-abortion-s-effect-surprises-friends-and-foes-alike.html. 
  43. ↑ 43.0 43.1 Leary, Warren (1989-03-17). "Koop Says Abortion Report Couldn't Survive Challenge". The New York Times. https://www.nytimes.com/1989/03/17/us/koop-says-abortion-report-couldn-t-survive-challenge.html. 
  44. ↑ 44.0 44.1 "Psychological responses after abortion". Science 248 (4951): 41–4. 1990. doi:10.1126/science.2181664. PMID 2181664. Bibcode: 1990Sci...248...41A. 
  45. ↑ 45.0 45.1 Joyce, Christopher (1989-12-16). "Reagan's officials 'suppressed' research on abortion". New Scientist. https://www.newscientist.com/article/mg12416951.000-reagans-officials-suppressed-research-on-abortion-.html. 
  46. ↑ "Study Finds Little Lasting Distress From Abortion". The New York Times. 1990-04-06. https://www.nytimes.com/1990/04/06/us/study-finds-little-lasting-distress-from-abortion.html. 
  47. ↑ Great Britain Commission of Inquiry into the Operation and Consequences of The Abortion Act (1994). The Physical and Psycho-Social Effects of Abortion on Women. London: HSMO. 
  48. ↑ 48.0 48.1 48.2 How claims spread : cross-national diffusion of social problems. Best, Joel.. New York: Aldine de Gruyter. 2001. pp. 59–61. ISBN 978-0202306537. OCLC 45023173. 
  49. ↑ House of Commons Science and Technology Committee (2007). Scientific Developments Relating to the Abortion Act 1967. Volume 2. London: HSMO. https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045ii.pdf. 
  50. ↑ House of Commons Science and Technology Committee (2006). Scientific Developments Relating to the Abortion Act 1967. Volume 1. London: HSMO. pp. 47. 
  51. ↑ 51.0 51.1 51.2 51.3 Fergusson, David M. (September 2008). "Abortion and mental health" (in en). Psychiatric Bulletin 32 (9): 321–324. doi:10.1192/pb.bp.108.021022. ISSN 0955-6036. 
  52. ↑ 52.0 52.1 52.2 Templeton, Sarah-Kate (2008-03-16). "Royal college warns abortions can lead to mental illness" (in en). The Sunday Times. ISSN 0956-1382. https://www.thetimes.co.uk/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h. 
  53. ↑ 53.0 53.1 Casey, Patricia; Oates, Margaret; Jones, Ian; Cantwell, Roch (December 2008). "Invited commentaries on… Abortion and mental health disorders" (in en). The British Journal of Psychiatry 193 (6): 452–454. doi:10.1192/bjp.bp.108.059550. ISSN 0007-1250. PMID 19043145. 
  54. ↑ "Artist hanged herself after aborting her twins" (in en-GB). Daily Telegraph. 2008-02-22. ISSN 0307-1235. https://www.telegraph.co.uk/news/uknews/1579455/Artist-hanged-herself-after-aborting-her-twins.html. 

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