The de-moralisation of a woman’s right to choose

Next week, the Human Fertilisation and Embryology Bill is set to come back for further debate in the UK parliament. The Bill deals primarily with research and treatment involving human embryos. The law it seeks to update, however, also contains a clause about abortion, which means abortion will be up for debate amongst MPs (1).

With only one day set aside for discussion of the Bill, it is unclear how much debate there will be about the abortion issue. On 10 October, however, Angela Watkinson MP, Ann Widdecombe MP and others tabled an amendment that would make it a legal requirement that doctors offer women seeking abortion ‘a suitable opportunity to receive counselling’, and ‘a description of… the potential post-termination physical, psychological and psychiatric risks associated with the termination of pregnancy’.

The provision of counselling and information about post-abortion feelings is already a routine part of abortion services. This amendment suggests that what abortion providers are currently doing is inadequate. It plays off the assumption that induced abortion must have very significant ‘psychological and psychiatric risks’ that providers currently underestimate and, further, it demands that women should be able terminate a pregnancy only when they have been informed that abortion places their mental health at risk.

But does abortion damage women’s mental health? What does the scientific evidence actually say?

What the evidence reveals

In August 2008, the American Psychological Association (APA) issued findings from a comprehensive two-year review of published research on abortion and mental health. The APA concluded that 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’ (2).

The APA evaluated studies published in peer-reviewed journals since 1989. They found that some women experience sadness, grief and feelings of loss following an abortion, and some may experience ‘clinically significant disorders, including depression and anxiety’. However, the taskforce found ‘no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors’.

The report noted that other co-occurring risk factors, including poverty, prior exposure to violence, a history of emotional problems, a history of drug or alcohol use, and prior unwanted births, predispose women to experience both unwanted pregnancies and mental health problems after a pregnancy, irrespective of how the pregnancy is resolved. According to the report, women terminating a wanted pregnancy, who perceived pressure from others to terminate their pregnancy, or who perceived a need to keep their abortion secret from their family and friends because of stigma associated with abortion, were more likely to experience negative psychological reactions following abortion.

The taskforce’s conclusions are consistent with the conclusions of a similar APA review of studies published prior to 1989. Results of that review were published in Science in 1990 and in the American Psychologist in 1992. In the UK, the Royal College of Obstetricians and Gynaecologists’ 2004 guideline on induced abortion states: ‘[S]ome studies suggest that rates of psychiatric illness or self-harm are higher among women who have had an abortion compared with women who give birth and to non-pregnant women of similar age. It must be borne in mind that these findings do not imply a causal association and may reflect continuation of pre-existing conditions.’ (3)

From a clinical standpoint, the APA review is the best starting point for abortion providers seeking to ensure they update their practice and inform women about abortion in line with the evidence. From a sociological and political point of view, the legal debate about mental health and abortion raises a set of other issues.

The context of the claims

Arguments about why abortion should be considered a problem have changed considerably in recent years. Writing in the 1980s, the American philosopher LW Sumner stated: ‘Abortion is a moral problem… What is at stake for the fetus is life itself… What is at stake for the woman is autonomy – control of the use to be made of her body.’

In the early twenty-first century the issue appears far less clear. A whole range of issues – fetal viability, fetal sentience, and a range of areas relating to the effects of abortion on women’s health – are just as likely as moral questions to animate participants in the abortion debate. What these issues have in common is their (pseudo) scientific and medical character. In all these examples, the language of risk and safety replaces that of right and wrong. Heated debates about ‘the evidence’ take the place of that about political outlook.

The debate about abortion and its mental health effects is an example par excellence of this development in the abortion debate. This is not to say that there is no ‘proper’ research that considers the relation between abortion and women’s state of mind. There is: and the review by the APA does a fine job of summarising what this research tells us.

But the reason why mental health has come to feature so often in the public debate about abortion, and the reason why so many claims are now made about whether abortion makes women depressed, is not because most of those who talk the talk about the health risks of abortion have made a sober assessment of this body of work – rather it is because many involved in the abortion debate have made a decision to de-moralise their arguments, in favour of talking up scary stories about the effects of abortion for women. The main culprits here are abortion opponents.

This phase of the abortion debate began some time ago, in the early 1980s in the USA. At this time, the major American anti-abortion organisations began to refer to a newly discovered mental illness, ‘Post-Abortion Syndrome’ (PAS), in their publications and in their comments in the press. The abortion opponent Dr Vincent Rue has been credited with first developing the argument for PAS and its diagnostic criteria, a condition he claimed is ‘a variant of Post-Traumatic Stress Disorder’ (PTSD). His argument was that abortion is sufficiently stressful to lead to women developing a form of PTSD afterwards, and he explicitly compared the ‘symptoms’ of PAS with those which are said to be characteristic of problems first identified by psychiatrists in soldiers returning from the Vietnam War.

It is understandable why those opposed to abortion developed this line of argument. Firstly, by the early 1980s it had become evident that moral arguments against abortion were unlikely to succeed in overturning the 1973 Supreme Court decision, in Roe v Wade, to make abortion legal. Another sort of argument was needed. Secondly, there was the emergence of what has been termed a ‘post-traumatic culture’, ‘therapy culture’ and ‘victim culture’.

In the USA first of all (and later in other countries, including Britain), ‘trauma’ and ‘PTSD’ came to be used routinely to describe more and more experiences and their effects on people. If PTSD started the 1980s as a condition associated with war veterans, it latterly came to be viewed as a problem of everyday life. Its ‘victims’ have been identified as women who have been raped, women who have just given birth, people involved in car crashes, people who have been bereaved, and journalists reporting from war zones, plus many more. PAS emerged around this time, as just one of many psychologically oriented claims for victim status.

The argument for PAS had its greatest influence in the USA between 1987 and 1989. It was during this time that the then US Surgeon General, Everett C Koop, undertook, at the behest of President Ronald Reagan, an inquiry into the health effects of abortion, in large part in response to claims that there had been an underestimation of the damage done by abortion. Recognition of this damage, it was suggested, should lead to a revision of the law allowing women to terminate pregnancies. However, professional organisations, including the APA, which contributed to the inquiry, found no evidence to support the claim for PAS. To the great chagrin of those opposed to legal abortion, no changes were, as a result, made to the law at this point.

The report published by the APA this year in effect updates its work from the late 1980s. One notable point is the disparity between what has taken place in the world of research and what has taken place in public and legal debate. As the APA review makes clear, there is very little evidence from the past 20 years which suggests abortion is any more depressing than was considered the case previously. Yet the volume of claims-making about mental health risks, and the place of this issue in the political and legal arena, has expanded significantly.

The new discourse of the anti-abortion movement

In the USA, the failure of the Koop inquiry to lead to restrictions on legal abortion did not diminish the impetus to medicalise arguments against abortion. American campaigners against abortion have come to sound most frequently like counsellors and therapists, and have established countless agencies to warn women that abortion will damage their mental health. And legal debates have consistently made reference to mental health, and in some cases – for example the ban on the procedure D&X, often termed ‘partial-birth abortion’ – the idea that abortion severely affects women mentally has been the main justification for legal restrictions (4).

The therapeutic approach of anti-abortionists reached British shores in the early 1990s. In 1995, the anti-abortion lobby staged its own version of the Koop inquiry: the Rawlinson Commission. Headed by Lord Rawlinson and administered by the anti-abortion group Care for Life, this was established purportedly to gather and assess evidence about the physical and mental effects of abortion, and explicitly not to consider the moral aspects of abortion. As with the Koop inquiry, the Commission was a failure from an anti-abortion perspective, leading to an angry exchange with the Royal College of Psychiatrists but no related legal or policy modifications. Yet as in the USA, abortion opponents have continued to pursue the argument and devoted time and resources to promoting objections to abortion on mental health grounds.

At present, it is likely that the new APA report will, quite rightly, influence the public debate in Britain – and the lack of substance in a research sense for the claims made by abortion opponents about the damage abortion causes will be further exposed. The intervention of those like the APA plays an important part in limiting the medicalisation of the abortion debate. It encourages a sober assessment of the evidence, and helps calm the forces that seek to turn medical issues about the care of women seeking abortion into legal ones, about whether women should be able to have an abortion in the first place.

However, those who feel uncomfortable with the turn to a medicalised abortion debate in Britain should only expect so much from interventions by groups such as the APA. This professional association remains something of a lone voice in the current British context. Indeed, it is striking that it is the hard work of an American scientific body that has proved most helpful for those in Britain who want to know what the research about mental health really says.

By contrast, the relevant British organisations have tended either to stay silent – neither the Royal College of Psychiatrists (RCPsych) nor the British Psychological Society took the opportunity of submitting evidence to the 2007 Science and Technology Committee’s investigation of the scientific and medical aspects of abortion – or to provide comment that has, on balance, confused people further. This confusion appears to be the main effect of the statement published by the RCPsych earlier this year on the mental health effects of abortion, which stated that: ‘The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved. The current research evidence base is inconclusive – some studies indicate no evidence of harm, whilst other studies identify a range of mental disorders following abortion.’ (5)

Since it is possible to read the content of this statement in contrasting ways, it has understandably been the subject of much claims-making, most obviously by anti-abortion groups worldwide, who have taken it as support for their views (6). The RCPsych’s position statement was reported in one British newspaper under the headline ‘Royal college warns abortions can lead to mental illness’. The newspaper report said: ‘Women may be at risk of mental health breakdowns if they have abortions, a medical royal college has warned.’ (7) Noticeably, the RCPsych has made no subsequent public comment to clarify its position.

More broadly, arguments about the damaging mental effects of abortion are rarely fundamentally challenged. Sometimes counter-claims simply replace one set of scare stories about risk with another. Hence, argue some, the real risk for women is childbirth and motherhood, both of which now tend to be routinely represented as a depressing and traumatic ordeal, associated with ballooning rates of PTSD and post-natal depression. While only some have so far suggested that pregnant women should be counselled about the damage childbirth and motherhood will wreak on their minds, the structure of the debate remains highly medicalised. Alternatively, debate gets stuck in the intricacies of the methodological soundness of studies about abortion and its psychological effects. This means few other than trained statisticians can find a way to understand what is being discussed, and most importantly what is at stake is rarely clarified.

Perhaps what is needed most of all is clarity about the remits of this discussion. A line needs to be drawn between where research about mental health is and is not relevant. Some brave individuals, such as law professor Emily Jackson, have drawn some boundaries (8). Ultimately, they have argued, the mental health issue is a red herring of a debate, for the law at least. Whether a woman should be able to have abortion is not a question that can be resolved by reference to psychologists’ studies, however good they are. Put another way: even if some women do get depressed after abortion, the law should still allow women the free choice to have one. Access to rights is not contingent on the level of our happiness that results from us exercising them.

Ellie Lee is a senior lecturer in social policy at the University of Kent. An earlier version of this article appeared on Abortion Review. A more developed account of the social history of the debate discussed here can be found in her book Abortion, Motherhood and Mental Health: Medicalising Reproduction in the United States and Great Britain (Aldine Transaction, 2003). Buy this book from Amazon.

(1) Fertility reform held up by MPs says watchdog

(2) APA taskforce finds single abortion not a threat to women’s mental health: Calls for better-designed future research, American Psychological Association press release, 12 August 2008

(3) The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7, RCOG, September 2004

(4) Gee, Graham, (2007) ‘Regulating Abortion in the United States after Gonzales v Carhart’, Modern Law Review: 70(6) 979-100

(5) Position Statement on Women’s Mental Health in Relation to Induced Abortion, Royal College of Psychiatrists, 14 March, 2008

(6) See for example the Christian Medical Fellowship website

(7) Royal college warns abortions can lead to mental illness, The Sunday Times, 16 March 2008

(8) Jackson, Emily, (2001) Regulating Reproduction, Hart