Amer. J. Orthopsychiat. 42(1), January 1972 THEORY AND REVIEW ABORTION IN PSYCHOLOGICAL PERSPECTIVE Henry P. David, Ph.D. Transnational Family Research Institute, American Institutes for Research, Washington, D.C. The literature on psychological aspects of induced abortions and repeated abortion-seeking behavior is surveyed, and ongoing field studies in the United States and other countries are summarized. The relationship of abortion and contraception is considered, and the implications of the prostaglandins as a means of “postconception family planning” are discussed. Ti professional titerature is replete with clinical observations and as- sumptions about psychological aspects of abortion, but systematic studies are few and far between. It is the purpose of this paper to comment on what is known about psychological sequelae of abortion performed and denied, and the dilemma of those faced daily with re- quests to terminate unwanted pregnan- cies. Also considered are the public health implications of repeated abor- tion-seeking behavior and the potential revolution in postconception planning promised by recent research with prosta- glandins. Throughout, emphasis will be on gaps in knowledge and the need for systematic, cooperative, transnational re- search on family planning behavior. PSYCHOLOGICAL SEQUELAE OF ABORTION At present, there is no systematic re- search evidence on psychological or psy- chiatric sequelae of abortion. While the literature on the subject is immense, there is undue reliance on personal im- pressions of professional workers and a near total lack of empirical studies. The situation is of course compounded by the aura of controversy and illegality that continues to shroud abortion in many parts of the world. It is, nevertheless, curious that so few of the published reports mention the emotional relief often seen after abortion. It may well be a truism that there is no psychologically painless way to cope with an unwanted pregnancy. While an Presented at the 1971 annual meeting of the American Orthopsychiatric Association, Wash- ington, D.C. Based in part on material gathered with the support of a Ford Foundation grant. 6162 abortion may elicit feelings of guilt, re- gret, or loss, an alternative solution, such as entering a forced marri an out-of-wedlock child, gi up for adoption, or adding an unwanted child to an already strained marital situ ation, is also likely to be accompanied by psychological problems for the woman, the child, the family, and so- ciety. Much of the extensive psychiatric material on alleged psychological trauma of abortion consists of impressionistic case reports. The 1934-1965 literature has been critically reviewed by Simon and Senturia ® who provide individual comments on twenty-four American and European studies. They note how sober- ing it is to observe the ease with which reports can be embedded in the literature, quoted, and Tequoted many times without consideration for the data the original paper. Deeply held personal convictions frequently seem to outweigh the importance of data, especially when conclusions are drawn. In the papers re- viewed the findings and conclusions range from the suggestion that psychiatric illness almost al- ways is the outcome of therapeutic abortion to its virtual absence as a postabortion com- plication. Simon and Senturia *? also catalog the many deficiencies in sampling and in research design, including frequent fail- ure to study preabortion psychological status, lack of clear definitions of psy- chiatric terminology, and the inability to compare studies within the same country, much less transnational sam- ples. Callahan‘ voices his distress. more strongly: In the light of contradictory professional judgments, the inadequacy of the data and a lack of anything approaching methodo- logical refinement, one might almost feel justified in concluding that the surveys and ABORTION IN PERSPECTIVE the professional opinions are of little help. +. + One searches the literature in vain for the guiding hand of a sociologist in the prep- aration of the surveys or in interpreting their results... . Nor has anyone attempted to study the [poor] data in terms of a com- parison of different cultures and what effect that would have on the meaning of the evi- dence. . . . Studies based on whole popula- tions, those granted and those denied an abortion, are scanty; more are badly needed. Worst of all, there is hardly any attempt to clarify the meaning of the concepts em- ployed. . . . The psychiatric literature is a conceptual desert, employing all sorts of com- mon terms, but practically never telling us what they mean or ought to mean, Lacking such needed clarification, the survey results tell us too little of any value. No wonder, then, that the same data are read in con- tradictory ways and are easily used to justify the most divergent moral evaluations. It is seldom realized that postabortion psychosis is practically unknown." Since there are some 4,000 documented post- partum psychoses requiring hospitaliza- tion in the United States per year, about one to two per 1,000 deliveries, there should be a sizable number of hospital- ized postabortion psychoses if abortion were as traumatic for some women as term delivery.2® It would appear unlikely that a significant number of hospitalized psychoses related to abortion could be “hidden” in the records. Again, whereas “postpartum blues” are well known as typical depressive stress reactions to the end of pregnancy, “postabortion blues” have been observed to be generally brief and mild unless there was serious mental disturbance before abortion. In- deed, Kummer '* suggests that the whole concept of postabortion psychiatric ill- ness may be a myth. ‘The liberalization of U.S. and British abortion statutes provides an oppor- tunity to develop systematic studies and comparisons of the immediate andHENRY P. DAVID longer term effects of differing abortion procedures by differently trained opera- tors in diverse settings." °* The role and training of abortion counselors need to be more fully considered. Very useful would be the development of an easily administered psychological device for predicting with reasonable validity which women are at particularly high risk for psychological sequelae. PSYCHOLOGICAL EFFECTS OF DENIED ABORTION ‘The general hypothesis that “un- wanted” pregnancies and births often have multiple and damaging consequen- ces is hardly new. Reducing the num- ber of unwanted children was one of the objectives motivating Margaret San- ger and the planned parenthood move- ment.® However, there is no published evidence that the unexpected, un- planned, or even unwanted pregnancy is always “bad,” or that a planned preg- nancy more frequently produces a psychologically healthy child. The liter- ature is sparse on the relationship of “unwantedness” or “wantedness” to specific, objective criteria of physical, mental, or social health and/or malad- justment.2? Even less is known about discernible differences between matched samples of “wanted” and “unwanted” children from birth through early child- hood. Little information has been com- piled on psychological motivations of women whose requests for abortion have been approved or denied. With the myriad of difficulties associated, until recently, with abortion in most American states, it was rarely possible to follow the natural history of pregnancies in women who sought but were denied abortion.®: % 87 Reviews of the literature yield only 63 one attempted matched control study of children born to women denied abor- tion, but that study is seriously flawed by major differences between the exper- imental and control children and be- tween their mothers.'! Now in progress in Prague, Czechoslovakia, is a follow- up study of the first seven to nine years of life of approximately 200 children born during 1961-1963 to women de- nied abortion both on initial request and on subsequent appeal.2*: 28 8 The control children were carried to term by mothers who knowingly stopped some form of contraceptive practice or else accepted an unplanned pregnancy and did not seek abortion. In comparing the pioneering Forssman and Thuwe ?? study with the Czech project, it is worth noting that: 1) The Swedish women applied for abortion on psychiatric grounds and were refused once, whereas the Czech women applied for interruption of pregnancy on social and general health grounds and were refused twice; 2) In addition to sex and age, the Czech control children are matched with the experimental children for school class in the same school, age and martial status of mother, parity, education and occupation of father, number of siblings, and birth order; 3) In addition to providing case rec- ords, the Czech children and their par- ents are participating in individual social, psychological, psychiatric, and medical assessment procedures; 4) Whereas the Swedish study focused primarily on later stages of social devel- ‘opment, the Czech study will concentrate on earlier stages, particularly the pre- natal and natal periods, infancy, early childhood, and the first two years of school;& 5) In addition to testing for statisti- cal differences between the two groups, subgroups will be considered in terms of reasons for denial of abortion and demographic variables. The Prague study holds the promise of providing, perhaps for the first time, objective data comparing the physical, mental, social, and educational develop- ment of a group of children meeting an operational definition of “unwanted” with a matched control group of chil- dren operationally defined as “wanted” or “accepted.” The results are likely to be of significance, regardless of out- come, with a bearing on the present state of knowledge in child development and the psychology of pregnancy, as well as providing some evidence of the conse- quences over time of denied abortion and forcing a woman to carry a preg- nancy to term, “compulsory pregnancy” as Hardin ® phrased it ‘THE DOCTOR’S DILEMMA Abortion represents a personal, ethi- cal, and moral dilemma not only for mental health consultants but for many other physicians and paramedical per sonnel. It may well be, as White ** has suggested, that some male physicians fear giving a woman the freedom to decide about abortion: Pregnancy symbolizes proof of male potency. If men grant women the right to dispose of this proof whenever they want to, we men feel terribly threatened lest women rob us of our potency and our masculinity at will. Another obstacle is the abortion com- mittee, a time-consuming and expensive procedure, very vulnerable to individual prejudices. After abortion law reform in 1967, the Colorado Medical Society set “guidelines” for interpretation of the ABORTION IN PERSPECTIVE statute, In many instances these guide- lines were more restrictive than the law implied.* In the first year, five of the state’s fifty accredited hospitals per- formed 81% of the medical abortions, and four of these five were in Denver. Of the other forty-five hospitals, twenty- five did no abortions at all.2* Should abortion laws be declared un- constitutional, many physicians will be forced to develop and act on personal standards for performing or not per- forming an abortion. Medical training with its emphasis on life-giving and life- promoting functions may contribute to a disinclination to participate in life-ra- tioning activities.”* There is considerable need to study in depth the attitudes of medical and paramedical personnel to sexuality, family planning, contracep- tion, and abortion. It is essential to de- termine not only expressed attitudes but also likely behavior in given circum- stances, Available evidence reflects the scant attention to human sexuality in traditional medical education and the inner conflicts and ambivalence of a con- siderable segment of the health profes- sions in diverse parts of the world.” * 20, 22, 24, 26, 30 Sensitive research is re- quired to help develop educational pro- grams designed to enhance awareness and skill for dealing adequately and ap- propriately with abortion and other fer- tility related problems. REPEATED ABORTION-SEEKING BEHAVIOR With the increasing liberalization or repeal of abortion statutes in the United States, and the rapid shift from self-in- duced or illegal abortion by untrained persons to legal abortion at reasonable cost in medical centers, American public health concerns are gradually shifting toHENRY P. DAVID problems associated with repeated abor- tion-secking behavior. Is there a likeli- hood that a significant number of wo- men will rely on abortion as a preferred method of family planning? Is it feasible to identify at first abortion those women who are at particularly high risk for re- peated abortions? If so, is it possible to provide intensive counseling and moti- vate such women to shift to effective contraceptive practice? There are no ready answers. The incidence of repeated abortion secking is increasing in Hungary, Japan, and the Soviet Union, the only countries where safe abortions on request of the woman have been legally available for some years. In Hungary, the percentage of women having had three or more abortions rose from 12% to 17% among those requesting abortions between 1960 and 1965. In a 1970 study of 279 women interviewed by physicians in six Budapest health centers, 66 women (24%) admitted having had three or more previous abortions, and 73% in- dicated that they might again resort to abortion to terminate a future preg- nancy.*® Callahan's * review of studies in Japan cites the trend toward an “abor- tion habit.” In the Russian Socialist Fed- erated Soviet Republics, Sadvokasova ®° noted that of those women who had an abortion during 1958-1959, about 15% had another abortion within the next twelve months. In a more recent study of 1,000 Armenian women coming for an abortion to a Yerevan hospital, a fre- quency of 4.6 previous abortions was noted per woman interviewed." The Demographic Research Institute of the Hungarian Central Statistical Of- fice has initiated a study of demographic and psychosocial aspects of repeated abortion-secking behavior in situations 65 where contraceptives are readily avail- able. Two matched groups of women will be studied. Women in the first group will have had an abortion, instruc- tion in contraception, another abortion, further instruction, and at least a third abortion. The second group will consi of women who, after their first abortion, successfully practiced oral contraception and had no further abortions during the subsequent two years. Psychological items have been included in the extensive questionnaire. Following the completion of pilot studies, it is anticipated that rep- resentative national samples of “repeat- ers” and “nonrepeaters” will be sur- veyed. One of the few American studies in- cluding information on repeated abor- tion-seeking behavior is Lee's 2" report of sixty-nine “well-educated, intelligent, and sophisticated women” who had ob- tained medical advice on contraception after their first abortion, which had been performed by a physician in illegal cir- cumstances more than a year before data collection. Of these sixty-nine women, twenty-eight, or 43%, had had a sec- ond abortion; and of these twenty-cight repeaters, nine, or 32%, had a third abortion. Lee indicates that the repeated abortions observed may be an artifact of the study design and indicative of the difficulties unmarried women had in ob- taining and using effective contraceptives in the United States during the late 1950s and early 1960s. She concludes that, Tt is contraceptive use or nonuse which is the best predictor of multiple abortions, along with the time of exposure.*® An effort to develop better under- standing of the dynamics of repeated abortion-seeking behavior has been ini- tiated at the University of Geneva."*66 Among a group of 3,000 women inter- viewed for a psychosocial research pro- ject on contraceptive behavior, about 500 women admitted having had one legal abortion and 107 women (3.5% ) indicated having had more than one pre- vious abortion. The women having had no abortion, one abortion, and two or more abortions are being compared in terms of social and psychological vari- ables, including social status and level, social norms of abortion, integration, degree of social disorganization, occupa- tional aims, and contraceptive behavior, The study will also endeavor to seck answers regarding psychological accept- ability of abortion versus contraception, degree of character stability, sado- masochistic tendencies, and other psy- chodynamic aspects, provided suitable assessment instruments can be devel- oped. The Swiss researchers are partic- ularly interested in testing the hypothesis that sadistic tendencies toward the fetus and masochistic tendencies toward the self are significant among women re- peatedly resorting to abortion. THE PROSTAGLANDINS In considering future psychological studies in abortion, note must be made of the prostaglandins, a group of fatty acid compounds. Known since the mid- 1930s, research of their function as pos- sible fertility regulating agents dates from 1969 and represents the first funda- mental advance in family planning since the introduction of oral contraceptives.2 Should their promise of delivering an effective method for “postconception planning” materialize, women will be able to control menses at will and thus greatly reduce recourse to more costly surgical procedures. Self-administration of prostaglandins ABORTION IN PERSPECTIVE through the vaginal route is a giant step toward attaining an “ideal means of fer- tility control. . . a nontoxic and com- pletely effective substance which, when self-administered by women on a single occasion, would insure nonpregnancy at the completion of one monthly cycle.” # While initial results with prostaglandins stirred excitement, large-scale field trials will be necessary before recom- mendations can be made for routine clinical use, Prostaglandins have not yet been approved by any national drug regulating authority. Under the strict rules developed by the Food and Drug Administration (in part because of crit- icisms encountered after the relatively rapid approval of oral contraceptives) permission for marketing prostaglandins in the United States is probably some years away. But, it is not too early to envisage the social impact of the avail- ability of prostaglandins in the form of medicated tampons or vaginal supposi- tories, offering women, for the first time in history, the revolutionary freedom of \ducing menses at will. Should the prostaglandins achieve their promise, a dramatic new approach to fertility control will become possible. As Potts?” has noted, No human community has ever shown a marked fall in the birthrate without a signi- ficant recourse to induced abortion and it is unlikely that, in the foreseeable future, con- traceptive procedures alone will provide a sufficient measure of population control in developing nations wishing to lower the birth- rate, It is possible that prostaglandins may become a major resource for those women whose motivation for birth limi- tation becomes powerful only after they have missed a menstrual period and are faced with an unwanted pregnancy.HENRY P. DAVID For one of the rare times in the development of contraceptive technol- ogy and reproductive physiology, be- havioral scientisis have an opportu nity to explore the social-psychologi- cal-motivational-cultural impact of a new birth prevention procedure on women of childbearing age before it be- comes widely available EPILOGUE Reading of the rapidly accumulating professional and public literature on abortion, particularly its psychological aspects, is not conducive to maintaining scientific detachment. As Callahan 4 has phrased it, “Abortion is a nasty problem, a source of social and legal discord, moral uncertainty, medical and psychiatric confusion, and personal an- guish.” How many colleagues in the mental health professions and in the behavioral and medical sciences think of abortion in one way, and speak and write of it in another? How closely does actual practice conform to personally expressed beliefs or to established social, legal, or ethical codes? Cushner * recalls that 80% of Maryland gynecologists supported the drive for liberalization of the abortion statutes but that fewer than 20% actually performed an abortion during the first year of practice under the reform law. There is little mention in the research literature of the right of women to deter- mine for themselves how many children they wish to have and when they want to have them. The right to self-determi- nation and civil liberty, so frequently espoused in our society, is sharply re- duced in abortion for reasons that are primarily referable to sociopolitical considerations, the economic and social status of the women requesting 67 the abortion, the personal and religious con- victions of physicians and abortion commi tee members.* And yet, the evidence is persuasive that numerous abortions are being performed by licensed, competent, and often highly conscientious physicians practicing under illegal conditions infrequently challenged by law enforcement officials. Unwanted pregnancy is a social prob- em of major urgency to society and of central import to individual women who must accept the consequences or seek alternative solutions. In concluding this paper, I wish to repeat my previously expressed support for the right to abor- tion as a fundamental human right, a moral choice a woman should be free to make without undue restrictions im- posed by a male dominated society. Surgical abortion is not, however, the preferred method of birth limitation and every effort should be made to substitute self-administered procedures for pre- venting an unwanted pregnancy or for “post-conception planning” if prosta- glandins prove to be safe, effective, and low cost. REFERENCES 1. ARUTYUNYAN, L. 1968, Some characteris- tics of family planning in the Armenian SSR (according to materials from a special survey). In Proceedings of the All-Union Scientific Conference on Prob- Jems of Population of the Trans Cau- casus. Scientific Research Institute of nomics and Planning, Yerevan, Gos- plan of Armenia, 2.nECK, M. 1970. Abortion: The mental health consequences of _unwantedness. Seminars in Psychiat. 2:263-274, 3. RECK, M, NEWMAN, 8. AND LEWIT, s. 1969. Abortion: A national public and mental health problem—past, present, and pro- posed research. Amer. J. Pub, Hith, 59: 2131-2143. 4. CALLAHAN, Choice and Morality. York. 1970. Aborti Law, ity. Macmillan, New68 S.cusHNER, 1. 1970. Report in American Medical News, June 8. 6.DAFOE, c. 1970. Thoughtful action needed now to find middle ground on abortion. ‘Amer. Med. News, June 8. 7.DALSACE, J. AND. DOURLEN-ROLLIER, 1970, VAvortement. Casterman, Paris. 8.pavip, H. 1971. Abortion: Public health concerns and needed psychosocial _re- search. Amer. J. Pub, Hlth. 61:510-516. 9. Davi, H. 1971. Mental health and family planning. Family Planning Perspectives. 3(2):20-23. FLECK, S. 1970. Some psychiatric aspects of abortion. J. Nerv. Ment. Dis. 151:42— 50. TL. FORSSMAN, H. AND THUWE, 1. 1966. 120 children born after therapeutic abortion refused. Acta Psychiatrica Scandinavia 42(1):71-78. HAMMOND, #. 1964. Therapeutic abortion ten years’ experience with hospital. com- mittee control. Amer. J. Obstet. Gynec. 89:349-355, 13, HARDIN, G. 1968. Abortion or compulsory pregnancy. J. Mart. Fam. 30:246-251 HERNDON, C. AND NASH, E. 1962. Premar- riage and “marriage counseling. JAMA 180:395-401 JANSSON, B. 1965. Mental disorders after abortion. Acta Psychiatrica Scandina 41:87-110. KELLERHATS, J. AND. PASINI, w. 1970. Studies in abortion-seeking behavior. In Proceedings of the Conference on Psy- chosocial. Factors in Transnational Family Planning Research, H. P. David and J. Bernheim. eds. American Institutes for Research, Washington, D.C. xesstL, E. 1970. Pregnancy termination program. Unpublished paper. KUMMER, J, 1963. Post-abortion_psychi- atric illness: a myth? Amer. J. Psychiat. 119:980-983. 19. LADER, L. 1955, ‘The Margaret Sanger Story ‘and the Fight for Birth Control. Doubleday, Garden City, N.Y. |. LEBAN, J. ed. 1969. Teaching Family Planning. Josiah Macy, Jr. Foundation, New York. 21. LEE, N, 1969. The Search for an Abor. tionist. University of Chicago Press . LIEK, H. 1963. What medical schools teach about sex, Bull. Tulane U. Med. Faculty 22:161-168. MATEJCEK, 7. 1970. Report from Prague: a study of unwanted children. Jn Proceed- 10. 12, 14, 15. 16. 17, 18, 23. ABORTION IN PERSPECTIVE ings of the Conference on Psychosocial Factors in Transnational Family Planning Research. H. David and J. Bernheim, eds. American Institutes for Research, Wash- ington, D.C. 24. MEHLAN, K. 1968. The abortion situation worldwide perspective. In Arzt_und Familieuplanung, K. Mehlan, ed. Verlag Volk und Gesundheit. Berlin, GDR. 25. The New York Times, June 8, 1970. 26. PECK, A. 1968. Therapeutic abortion: pa- tients, doctors, and society. Amer. J. Psy- chiat. 125-797-804, 27. POHLMAN, F. 1969. The psychology of birth planning. Schenkman, Cambridge, Mass. 28, POTTS, D. 1967. Legal abortion in Eastern Europe. Eugenics Rev. 59:232-250, 29. porTs, p. 1970. The prostaglandins: a new factor in fertility control, IPPF Medical Bulletin (Oct). 30. sapvoKasova, E, 1969. Social-Hygienic Aspects of the Regulation of Family Size. ‘Meditsina, Moscow, USSR. 31, SCHULLER, VY. AND STUPKOVA, F. 1969. Legal abortion and the possibilities of studying its psychosocial consequences. In Proceedings of the Research Planning Conference for Transnational Studies in Family Planning, H. David, FE. Szabady et al. Budapest, Hungary, Sept. 1969. American Institutes for Research. Wash- ington, D.C. 32.SIMON, N. AND SENTURIA, A. 1966. Psy- chiatric sequelae of abortion. Arch. Gen. Psychiat. 15:378-389, 33, SPEIDEL, J. AND RAVENHOLT, R. 1970. Ideal means of fertility control. Lancet 1:565. 34, szanaby, F. 1969. Hungarian Fertility and Family ‘Planning Studies. Demographic Research Institute, Budapest, Hungary. 35. SZAHADY, E., AND KLINGER, A. 1970. Report from Budapest: pilot survey of repeated abortion seeking. In Proceedings of the Conference on Psychosocial Factors in ‘Transnational Family Planning Research. H. David and J. Bernheim. American Insti- tutes for Research, Washington, D.C. 36.tHETZF, C. 1970. Joint program for the study of abortion. The Population Coun- cil, New York. (Mimeograph) 37. TIETZE, C., AND LEWIT, s. 1969. Abortion. Scientific Amer. 220:21-27. 38. wnrTE, x. 1970. Comments on abortion and psychiatry. In Abortion in a Chang- ing World, Vol. 2. R. E. Hall, ed. Colum- bia University Press, New York. For reprints: Dr. Henry P. David, Transnational Family Research Institute, American Institutes for Research, 8555 16th Street, Silver Spring, Md, 20910