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Reflections on abortion and psychology: the hidden issues
By Professor Mary Boyle
September 2002

In June, a great deal of media attention was given to the story of a woman who was to sue the NHS for psychological trauma (guilt and self-hatred) she claimed she suffered from an abortion four years ago. As one of the psychologists on the British Psychological Society media list under 'abortion', I received several calls from journalists following up the story.

Their questions seemed quite straightforward: What kind of mental problems do women face when they have abortions? Is there any research on post-abortion distress? Should the woman have been warned about post-abortion trauma? And I could provide reasonably straightforward answers: Yes, there is a good deal of research on the psychological consequences of abortion and it consistently shows that few women experience significant or enduring psychological distress; the most prominent emotion reported by women after abortion is relief; distress may be associated with not feeling supported by others in the decision; feeling the decision was made by others and having a previous psychiatric history. I could have mentioned that in the late 1980s, in the hope of strengthening opposition to legal abortion, President Regan instructed his Surgeon General, Everett Koop, to report on the psychological effects of abortion. The American Psychological Association provided detailed submissions (Adler et al, 1992) and having reviewed the evidence, Koop, a noted anti-abortionist, refused to issue an official report. When questioned by Congress, however, he testified that from a public health perspective, the psychological risks of abortion were 'minuscule'. As to what the woman in this case should have been told, The Royal College of Obstetricians and Gynaecologists has published evidence based guidelines as part of the procedures for establishing informed consent to abortion. These recommend that abortion providers tell women that only a small minority of women experience any long-term adverse psychological sequelae after abortion.

The problem with the journalists' questions and these possible answers, however, is that they do not begin to do justice to the issues raised by this case. I wanted to ask the journalists why they were so interested in the case; why they seemed to assume that women suffered 'post-abortion distress'; why so little is written about women who have abortions and seem satisfied with the outcome.

But the journalists were simply treading a path already well-worn by researchers who have been intensely preoccupied with abortion's potential to harm women psychologically, to the point where many researchers seem unable to imagine any other outcome or don't think it important enough to investigate: one article reviewed fifteen studies of the psychological effects of abortion which measured a total of fifty-two outcome variables, pre-defined by researchers. Forty-two were entirely negative (depression, anxiety, paranoia, shame, etc); five referred to 'relief', while only one unequivocally positive variable (happiness) was measured, in one study. Similarly, a review of theoretical models of 'possible long-term consequences of abortion' featured seven models, five of which did not 'allow' other than negative outcomes; one allowed negative outcomes and relief and another allowed both positive and negative outcomes, but the only positive change suggested was that women might use contraception more effectively.

Why this preoccupation with possible negative effects? After all, women choose abortion as their preferred solution to a problematic pregnancy. It is as if we have difficulty imagining women as capable of making rational decisions in their own best interests. Or perhaps we find it difficult to imagine them making this decision rationally. The social construction of motherhood as natural and central to women's lives, together with psychology's and medicine's tendency to link women's reproduction to psychological vulnerability, certainly encourages us to see abortion as potentially harmful.

These constructions have been very prominent on all sides in legislative debates on abortion, as has the theme of women as morally deficient, as liable to choose abortion for unworthy reasons. And these debates have drawn implicitly on psychological theories about motherhood and moral development which have themselves been shaped by cultural assumptions about women, so that there is a strong symbiotic relationship between psychological theory and the content of abortion debates (Boyle, 1997). The result for women can be a no-win situation where one side argues that they will be harmed by having an abortion, while the other side argues that they will be harmed by not having one and both sides argue that women cannot be trusted to make the decision themselves. In Britain (and most other countries) women have no choice but to approach abortion from a position of psychological weakness and British law requires doctors who decide on the abortion to record the current or anticipated medical disorder which justifies the decision: over ninety percent of abortions in England and Wales are officially carried out because the woman is suffering from or vulnerable to mental disorder. Of course, this may not reflect the woman's actual situation (and anticipated mental disorder rarely features amongst the reasons women themselves give for having abortions) but it is the reality created by the law and attempts to amend it have met with little success. Thus the law, like much psychological research, offers women little opportunity to make public the full complexity of the experience of abortion while at the same time reinforcing perceived links between abortion and psychological vulnerability.

The problem is that responding to media questions about this assumed vulnerability simply by reciting the evidence against it (evidence which is so plentiful partly because of the assumption that abortion would harm women) still keeps us within an agenda which focuses on abortion's intrinsic potential to harm women. This makes it difficult to raise more fundamental questions about abortion research. What I wanted to convey to journalists was that it is impossible to separate how we think about abortion and how women experience it, from how we as a society still think about women (the group who are not supposed to have 'irresponsible' sex; who are supposed to nurture life and not destroy it - a role traditionally reserved for men - ; the group whose powers of moral reasoning and judgement are not entirely trustworthy, particularly when hormones are involved, and the group for whom motherhood should take precedence over other life goals, so that it can only be averted for 'deserving' reasons). I also wanted to convey that psychological research has rather let us down in relation to abortion in largely ignoring the significance of the fact that only women have abortions and, in an attempt to be 'objective', has framed women's responses to abortion as pre-defined intra-psychic attributes rather than experiences which can only be understood in a social context. Studies in which women give their own accounts of the experience (e.g. Gilligan, 1993; Boyle and McEvoy, 1998) show clearly that it is inseparable from context: some women talk about the difficulty of making a decision which seems to put them and not others first; others talk of their fear of being 'found out' and thought cruel and selfish. Women are very aware of what they are 'supposed' to feel after an abortion (grief, regret, sadness) and may feel bad if they feel none of these. In another study in preparation, some women talked about feeling failures, and ashamed because they had 'allowed' themselves to get pregnant; the idea that women are more responsible than men for preventing pregnancy was clearly conveyed by statements like 'I wasn't using condoms...' Interestingly, the potentially positive psychological effects of abortion are not often discussed but these include feeling more in control of one's life and relationships with partners, and making more complex moral judgements.

But it is not only researchers who have neglected the social context of abortion. The woman in the legal case featured in the media is being supported by the anti-abortion group 'Life' who in 1998 announced a helpline for women who had suffered from abortion, and that they would encourage these women to take legal action against the doctors involved. Ellie Lee, a sociologist who has studied the strategies used by anti-abortion groups, has noted that as the strategy of depicting the foetus as a person with legal rights has not resulted in abortion's being made illegal, the groups have increasingly turned to a strategy of claiming that abortion harms women. Their claims focus on 'post-abortion syndrome' (PAS) modelled on the idea of post-traumatic stress disorder. But because the function of PAS is to support anti-abortion legislation, then abortion must be made to look intrinsically harmful to women, rather than a procedure the experience of which is inseparable from cultural constructions of abortion and gender. Psychological researchers have arguably smoothed the path of anti-abortion groups more than they might have intended by themselves decontextualising abortion as a (mental) health issue for individual women.

Against this background, it is interesting that following the news story, the British Association for Counselling and Psychotherapy issued a press release saying that women need counselling before they undergo abortion, although it should be voluntary, and that "anyone who chooses to have an abortion should also be free to choose counselling to help cope with the emotional consequences. It is a basic component of a woman's right to choose." But although none of us would wish to prevent women (or men) seeking counselling, this language of needs and rights is potentially problematic. Research shows that the majority of women have made a definite decision about the abortion before they approach their doctor usually after discussion with partners, parents or close friends. Routinely offered counselling is a powerful way of conveying which decisions are socially acceptable and which socially problematic (we don't, for example, routinely counsel people who decide to get married or have children); it can also suggest that women's own decisions are not to be trusted. This was partly why one of the major abortion providers recently stopped routine counselling and now provides it on request, but without trying to present it as part of the right to choose abortion.

This news story may well raise questions about women's risks of being harmed by abortion and research certainly helps us answer them. But the story also emphases the importance of not just quoting 'the evidence' but of trying to engage the media in critical discussions about research itself, to encourage them not just to see us as providers of research data and themselves as consumers but to see research as part of much wider social processes.

References

Adler, N. E. David, H.P., Major, B.N., Roth, S.H., Russo, N.F. and Wyatt, G.E. (1992) Psychological factors in abortion: A review. American Psychologist, 47, 1194-1204.

Boyle, M. and McEvoy, J. (1998) Putting abortion in its social context: Northern Irish women's experience of abortion in England. Health 2 283-304.

Boyle, M. (1997) Re-thinking Abortion. Psychology, Gender, Power and the Law. London: Routledge.

Gilligan, C. (1993) In a Different Voice: Psychological Theory and Women's Development 2nd Edn. Cambridge, MA: Harvard University Press.

Website co-sponsored by APA Division 35: www. prochoiceforum.org (link to 'psychological issues')

Mary Boyle
Department of Psychology
University of East London
Romford Road
London
E15 4 LZ
M.E.Boyle@uel.ac.uk

This article originally appeared in The Psychologist, vol 15, October 2002 502-503.

 
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