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(The letter from C. Everett Koop to President Reaganregarding the President's request that he preparea report on the physical and mental health effectsof abortion.) January 9, 1989Mr. Ronald ReaganThe President of the United StatesThe White House1600 Pennsylvania Avenue, NWWashington, DC 20500Dear Mr. President:On July 30, 1987, in remarks at a briefing for Right toLife leaders, you directed the Surgeon General to preparea comprehensive report on the health effects of abortionon women. It was clear from those remarks that such areport was to cover the mental, as well as the physical,effects of abortion. A review of the scientificliterature, the expertise of the Public Health Service,and the experience of national organizations with aninterest in this issue form the basis for my conclusion.The health effects of abortion on women are not easilyseparated from the hotly debated social issues thatsurround the practice of abortion. Therefore, everyeffort has been made to eliminate the bias which soeasily intrudes even into the accumulation of scientificdata. In this study I have purposely avoided any personalvalue judgement vis--vis abortion as a social issue.
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I have approached this task as I did in writing the AIDSreport which you requested in 1986. Scientific, medical,psychological, and public health experts were consulted.I met privately with 27 different groups which hadphilosophical, social, medical, or other professionalinterests in the abortion issue. The process involvedgroups such as the Right to Life National Committee,Planned Parenthood Federation of America, the U.S.Conference of Catholic Bishops, the American College ofObstetricians and Gynecologists, and women who had hadabortions.In summary of the situation, each year approximately 6million women become pregnant; of that number 54 percentor 3.3 million of those pregnancies are unplanned. Over1.5 million women, or 25 percent of those pregnant, electabortion each year. Since the legalization of abortion in1973, over 20 million abortions have been performed. Evenamong groups committed to confirming a woman's right tolegal abortion there was consensus that any abortionrepresented a failure in some part of society's supportsystem, - individual, family, church, public health,economic, or social.
 
At the time the report was requested, there were thoseadvising you and intimately involved with the socialissues of abortion who truly believed that such a reportcould be put together readily. In the minds of some ofthem, it was a foregone conclusion that the negativehealth effects of abortion on women were so overwhelmingthat the evidence would force the reversal of Roe v.Wade.There were also others who truly believed differently.While they acknowledge that any surgical procedure done1.5 million times a year may have some negative healtheffects on women, in their minds the positive effects ofabortion - release from the unwanted pregnancy - faroutweighed the perceived negative results.It is difficult to label the opposing groups in theabortion controversy. Those against abortion callthemselves pro-life. On the other hand, those who are notpro-life say the are not pro-abortion; rather, they referto themselves as pro-choice and supporters of a woman'sright to choose abortion.It is also true that some who are pro-choice arepersonally opposed to abortion. It is not clear to themwhere the lines should be drawn between the right of thefetus and the right of the mother. So the pro-choiceforces are not monolithic.Nor are the pro-life forces monolithic. Many ardent pro-life individuals who are dedicated to preserving the lifeof the fetus do not consider contraception to beethically, morally, or religiously wrong. But others inthe pro-life camp do; indeed, some equate contraceptionwith abortion.I believe that the issue of abortion is so emotionallycharged that it is possible that many who might read thisletter would not understand it because I have not arrivedat conclusions they can accept. But I have concluded inmy review of this issue that, at this time, the availablescientific evidence about the psychological sequelae ofabortion simply cannot support either the preconceivedbeliefs of those pro-life or of those pro-choice.Today considerable attention is being paid to possiblemental health effects of abortion. For example, there arealmost 250 studies reported in the scientific literaturewhich deal with the psychological aspects of abortion.All of these studies were reviewed and the moresignificant studies were evaluated by staff in several ofthe Agencies of the Public Health Service againstappropriate criteria and were found to be flawedmethodologically. In their view and mine, the data do notsupport the premise that abortion does or does not causeor contribute to psychological problems. Anecdotalreports abound on both sides. However, individual cases
 
cannot be used to reach scientifically sound conclusions.It is to be noted that when pregnancy, whether wanted orunwanted, comes to full term and delivery, there is awell documented, low incidence of adverse mental healtheffects.For the physical situation, data have been gathered onsome women after abortions. It has been documented thatafter abortion there can be infertility, a damagedcervix, miscarriage, premature birth, low birth weightbabies, etc. But, I further conclude that these eventsare difficult to quantify and difficult to prove asabortion sequelae for two reasons. First, these eventsare difficult to quantify because approximately half ofabortions are done in free-standing abortion clinicswhere records which might have been helpful in thisregard, have not been kept. Second, when compared withthe number of abortions performed annually, 50 percent ofwomen who have had an abortion apparently deny having hadone when questioned. Further, these events are difficultto prove, as sequelae of abortion because all of thesesame problems can and do follow pregnancy carried to termor not carried to term, - indeed can occur in women whohave never been pregnant previously. Clearly, however,the incidents of physical injury is greater in instanceswhere abortions are performed or attempted by those notqualified to do them or under less than sterileconditions.I have consulted with the National Center for HealthStatistics and Centers for Disease Control about thedesign of appropriate studies which could answer thequestions dealing with the physical and psychologicaleffects of abortion.There has never been a prospective study on a cohort ofwomen of child-bearing age in reference to the variableoutcomes of mating. Such a study should include thepsychological effects of failure to conceive, as well asthe physical and mental sequelae of pregnancy, - plannedand unplanned, wanted and unwanted - whether carried todelivery, miscarried, or terminated by abortion. To dosuch a study that would be above criticism would consumea great deal of time. The most desirable prospectivestudy could be conducted for approximately $100 millionover the next five years. A less expensive yetsatisfactory study could be conducted for approximately$10 million over the same period of time. This $10million study could start yielding data after the firstyear.There is a major design problem which must be solvedbefore undertaking any study. It is imperative that anysurvey instrument be designed to eliminate thediscrepancy between the number of abortions on record andthe number of women who admit having an abortion onsurvey. It is critical that this problem of "denial" bedealt with before proceeding with further investigations.
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