Priscilla Coleman, Ph.D. Bowling Green State Universi ty

1. The Psychology of Abortion: Addressing the Critical Questions to Maximize Patient Care in 2012 Priscilla Coleman, Ph.D. Bowling Green State University

2. Questions I’ll address today: • Who is most at risk for psychological harm following abortion? • What are common negative post-abortion psychological responses? • How strong is the evidence in 2012? • What are the obstacles to information dissemination and what progress that has been made?

3. Women at risk • I recently searched the MEDLINE, PubMed,andPsycINFO data bases for articles identifying demographic, personal, relational, and situational factors that place women at risk for experiencing post-abortion mental health problems.

4. Descriptors Used in the Searches: • Therapeutic abortion, elective abortion, and induced abortion. • At-risk, risk-factor, predictor, susceptibility, vulnerability. • Psychiatric morbidity, mental health, trauma, psychological adjustment, psychological complications, psychological distress, psychological disorders, psychological harm, psychological problems, emotional adjustment, emotional complications, emotional distress, emotional disorders, emotional harm, emotional problems, suicide, mood disorders, depression, anxiety, Post-traumatic Stress Disorder, substance abuse, substance use.

5. Women at Risk Search Process: 1972-2011 • Over 400 potentially relevant abstracts were identified. • 258 full articles were closely examined for relevancy. • 119 empirical articles were summarized and evaluated.

6. What are the most well-established risk factors for mental health problems in the empirical literature?

7. The pregnant women is pressured or coerced by others to abort(9 studies)

8. She is religious or views an abortion to be in conflict with herpersonal values (10 studies)

9. The pregnant woman was ambivalent about the abortion, experienced abortion decision difficulty, and/ or had a high degree of decisional distress. (21 studies)

10. She was committed to the pregnancy or she preferred to carry the child to term(7 studies)

11. The pregnant woman believed that abortion terminates the life of a human being and /or she experienced bonding to the fetus (6 studies)

12. She had pre-abortion mental health or psychiatric problems(31 Studies)

13. The pregnant woman was an adolescent or young adult (15 Studies)

14. She was in a conflicted, unsupportive relationship with the father of the child (24 studies)

15. The pregnant women experienced negative relationships with others(28 studies)

16. Character traits suggesting emotional immaturity, instability, or difficulties coping, including low self-esteem, problems describing feelings, being withdrawn, avoidant coping, blaming oneself for difficulties etc. were present (42 studies)

17. Indicators of poor quality abortion care (feeling misinformed/inadequate counseling, negative perceptions of staff, etc.) (10 studies)

18. Many of the risk factors are complexly interconnected For example, a woman who feels attached to her fetus and desires to continue the pregnancy may also be pressured from her partner to abort if the relationship is unstable, leading to feelings of ambivalence and stress surrounding the decision. If she suffers from low self-esteem and has trouble articulating her feelings, she may be particularly prone to yielding to the pressure.

19. How Common are the Risk Factors? • 44% of women had doubts about their decision to abort upon confirmation of pregnancy(Husfeldt et al. 1995).

20. How Common are the Risk Factors? • 46% of women who abort report a conflict of conscience (Kero et al., 2001). • 25% of women who abort view it as as terminating a human life (Smetana & Adler, 1979). • 50.7% of American women who abort feel it is morally wrong (Rue et al., 2004).

21. How Common are the Risk Factors? • In a study using 5 screening criteria (psychosocial instability, an unstable partner relationship, few friends, a poor work history, and failure to use contraception), Belsey and colleagues found that 68% of the 326 abortion patients were at high risk for negative psychological reactions,necessitating counseling.

22. Forty years of research has shown that when specific physical, psychological, demographic, and situational factors are operative in women’s lives, they are at a significantly increased risk of experiencing mental health problems following abortion.

23. Even Abortion Doctors Agree on Risk Factors Two decades ago, Hern (1990) emphasized the central role of pre-abortion counseling in evaluating women’s mental status, circumstances, and abortion readiness while stressing the importance of developing a supportive relationship between the counselor and patient to prevent complications. Hern also discussed the necessity of the counselor being trained to assess whether the abortion patient is a victim of subtle coercion.

24. Even Abortion Doctors Agree on Risk Factors • Baker (1995) similarly stressed pre-abortion screening for risk factors 17 years ago in her book titled Abortion & Options Counseling. • She stated: “In the cases where women do react negatively after an abortion, there appear to be predisposing factors linked to those reactions. There is enough valid research from which we can attempt to assess a client’s potential for negative reactions after an abortion…”

25. Even Abortion Doctors Agree on Risk Factors • Baker recommended identifying these pre-disposing factors prior to abortion: • Belief that the fetus is the same as a 4-year-old human and that abortion is murder • Low self-esteem • Ambivalence about the decision • Intense guilt and shame about the abortion • Perceived coercion to have an abortion • Commitment to the pregnancy

26. APA Acknowledged Risk Factors • The APA acknowledged a number of risk factors for psychological distress in their Task Force Report. • A wanted or meaningful pregnancy • Pressure from others • Opposition to the abortion from partners, family, and/or friend • Lack of social support • Commitment to the pregnancy • Ambivalence about the decision • Low perceived ability to cope

27. Many of the risk factors have been known to the research community for decades and have been recognized and affirmed by professional organizations. However, despite the availability of strong research documenting risk factors and professional awareness, abortion providers rarely if ever routinely screen for risk factors &counsel women at risk.

28. Psychological Consequences An abundant literature comprised of methodologically sophisticated studies from around the world now indicates abortion significantly increases risk for the following mental health problems: • Depression • Anxiety • Substance abuse • Suicide ideation and behavior

29. A minimum of 20% of women who abort suffer serious, prolonged negative psychological consequences.

30. Psychological Consequences Abortion is further associated with a higher risk for negative psychological outcomes when compared to unintended pregnancy carried to term.

31. ..and the data indicate that risk for long-term psychological injury is considerably higher with abortion than with other forms of perinatal loss.

32. Meta-Analysis The strongest studies published between 1995 and 2009 are synthesized in my recent meta- analysis published in the British Journal of Psychiatry Coleman, P.K. (September, 2011). Abortion and Mental Health: A Quantitative Synthesis and Analysis of Research Published from 1995-2009. British Journal of Psychiatry.

33. Meta-Analysis Inclusion Criteria 1. Sample size of 100 or more participants. 2. Use of a comparison group (no abortion, pregnancy delivered, or unintended pregnancy delivered). 3. One or more mental health outcome variable(s): depression, anxiety, alcohol use, marijuana use, or suicidal behaviors. 4. Controls for 3rd variables.

34. Meta-Analysis Results The 1st meta-analysis, which included all 36 adjusted odds ratios from the 22 studies identified, resulted in a pooled odds ratio of 1.81 (95% CI: 1.57-2.09), p<.0001. Women who have had an abortion experience an 81% higher riskfor mental health problems of various forms compared to women who have not had an abortion.

36. Meta-Analysis Results A 2nd meta-analysis was conducted with separate effects based on the type of outcome measure. • Marijuana:OR=3.30; 95% CI: 1.64-7.44, p=.001) • Suicide behaviors: OR=2.55; 95% CI: 1.31-4.96, p=.006 • Alcohol use/abuse: OR=2.10; 95% CI: 1.76-2.49, p<.0001 • Depression: OR=1.37; 95% CI: 1.22-1.53, p<.000 • Anxiety:OR=1.34; 95% CI: 1.12-1.59, p=.0001 The level of increased risk associated with abortion varied from 34% to 230% depending on the nature of the outcome.

38. Meta-Analysis Results In a 3rd meta-analysis separate pooled odds ratios were produced based on the type of comparison group: • No abortion: OR=1.59; 95% CI: 1.36-1.85, p<.0001 • Carried to term: OR=2.38; 95% CI: 1.62-3.50, p<.0001 • Unintended pregnancy carried to term: OR=1.55; 95% CI: 1.30-1.83,p<.0001 Regardless of the type of comparison group employed, abortion was associated with a 55% to 138% enhanced risk of mental health problems.

40. Looking at Population Attributable Risk percentages from the pooled odds ratios: Overall: Nearly 10% of the incidence of mental health problems was found to be directly attributable to abortion.

41. Population Attributable Risk Percentages for Specific Outcomes • Anxiety: 8.1% • Depression: 8.5% • Alcohol use: 10.7% • Marijuana use: 26.5% • All suicidal behaviors: 20.9%

42. Studies with different conclusions… • Beginning with the APA report in 2008, there have been several narrative reviews on abortion and mental health along with empirical papers published in prestigious journals suggesting that abortion is not associated with adverse mental health consequences. • Both types of studies have been highly prone to bias, and yet the very public results are actively misleading our society.. with the eager help of the press, of course..

44. Flawed Studies Promoted in the Media By highlighting the flaws in the most recent empirical paper and review, I’ll demonstrate the distortions of basic scientific methods that are behind ideologically driven efforts to manipulate our understanding of the potential for psychological harm that abortion brings to women’s lives.

45. Flawed Studies Promoted in the Media Munk-Olsen, T, Laursen, TM, Pedersen, CB, Lidegaard, O, Mortensen, PB. (2012) First-Time First-Trimester Induced Abortion and Risk of Readmission to a Psychiatric Hospital in Women with a History of Treated Mental Disorder. Archives of General Psychiatry.

46. Munk-Olsen, T. et al. (2012) • Reported main results: Risk of psychiatric readmission was similar before and after first time, first trimester abortion; however risk of readmission was higher after giving birth compared to before birth.

47. Munk-Olsen, T. et al. (2012) • Serious Methodological Problems: • 1) The sample was limited to women who had a first abortion or birth between 1994 and 2007. The older women in the population (births beginning in 1962) are not included in the analyses, because their 1st pregnancies were likely well before 1994. No explanation is provided for this exclusion. • 2) Out of the total sample of 8131 women, 952 (nearly 12%) were in both groups! In order to conduct clean comparisons, these women should absolutely have been removed prior to conducting the analyses.

48. Munk-Olsen, T. et al. (2012) • 3) There were no controls for variables demonstrated in previous studies to be associated with the choice to abort and with post-abortion mental illness, including marital status, education level, religion, income, relationship history variables including abuse, planning of the pregnancy, and pressure to abort, among others..

49. Munk-Olsen, T. et al. (2012) • 4) Follow-up was limited to 12 months after the pregnancies were resolved. By only measuring readmission for one year, women who have delayed responses, sometimes triggered by a later pregnancy, are not included in the analyses. The data are available in the Danish registries and there is no valid reason for cutting off the follow-up period so early.

50. Munk-Olsen, T. et al. (2012) • 5) The authors conducted correlational analyses and inappropriately made inferences of causality. • For example, in the first sentence in the conclusion section of the article they state: “In the present study, we found that first-time first-trimester induced abortion does not influence the risk of readmission to psychiatric facilities.” Such a statement is not permitted with the use of variables that cannot be manipulated (like abortion status), particularly when so few control variables are incorporated.