Perceptions of Preabortion Counseling Inadequacy and Decision Disagreement as Predictors of Subsequent Relationship Problems and Psychological Stress in Men and Women

Association for Interdisciplinary Research in Values and Social Change
by Catherine T. Coyle, RN, PhD, Priscilla K. Coleman, PhD,
Vincent M. Rue, PhD

Vol. 22, No. 1, Winter 2010

Reproduced with Permission


The association between elective abortion and psychological stress in women has been established in numerous studies.[16, 17, 18, 21, 24, 28, 61, 62] Considerably less research has investigated the relationship between induced abortion and stress in the male partners of women who abort.[23]

The study described here is one of the few to include both men and women. Furthermore, it is the first scientific study to investigate perceptions of the counseling experiences before the abortion and the agreement over the abortion decision between the parents of the unborn child. These two factors are then studied as they relate to post-abortion relationship problems and post-abortion psychological stress among women and men. In a previous issue of this bulletin, results of an online pilot study were published.[23] The study described here is a modification and expansion of that pilot study.

Web-Based Research

For this study, data was collected from women and men via an online survey. In the last decade, online research studies have become more common.[85] There are numerous advantages to web- based research including efficiency in time and money, [27, 99] the ability to access populations that would be difficult to reach using traditional methods,[51, 100] increasing the comfort and motivation of participants,[2, 35] and providing more diverse samples.[35]

In addition, those who complete web surveys do so on a strictly voluntary basis which may result in clearer and more complete responses to survey questions.[64, 95] Since online surveys offer complete anonymity, responses are less likely to be contaminated by attempts to impress an interviewer and therefore are more likely to be accurate or honest.[71] Finally, data collected via online surveys have been found to be equivalent to data collected using more traditional methods.[6, 37, 44, 7]

Women and Abortion

Much research has demonstrated a relationship between elective abortion and anxiety, substance abuse, depression, suicidal ideation, and suicide among women.[13, 18, 19, 21, 29, 31, 32, 61, 62, 66, 67, 68, 69, 86, 93] It is well-known that traumatic stress can have powerful, negative effects on the quality of people's lives.[40, 52, 78, 96] and clinicians have identified abortion as a potential cause of psychological trauma.[3, 4, 15, 24, 87, 88, 94] Research findings have also provided evidence for the association between abortion and symptoms of psychological trauma.[45, 55, 76, 90, 92] Following abortion, Rue et al.[76] and Suliman et al.[92] reported 12% to 18% of women met the criteria for being diagnosed with Post Traumatic Stress Disorder (PTSD). Many women who did not meet the full diagnostic criteria did, nonetheless, experience symptoms of trauma.[7, 76] Other research has found that individuals who experience only some of the symptoms of PTSD are at greater risk for impairment in functioning, comorbidity, and suicidal ideation.[52] Therefore, women who experience trauma symptoms but do not meet the criteria for a formal diagnosis of PTSD may, nonetheless, be at serious psychological risk.

It has been suggested that informed consent through adequate counseling before the procedure may enhance the patient's decision-making as well as adjustment following the procedure.[5] Common sense suggests that women's perceptions of the adequacy of preabortion counseling may influence the amount of stress they experience during and after abortion. While the National Abortion Federation[57] has advised that "there should be an opportunity for discussion of the patient's feelings about the abortion decision,"[p. 3] there is no current standard of care to assure that all patients are provided with individualized and comprehensive counseling concerning their feelings and decision-making. Some of the criticisms of preabortion counseling include: inadequate time allowed for counseling, failure to address the ambivalence or the complexity inherent in abortion decisions, lack of attention given to abortion alternatives, failure to assess coercion to abort, lack of appreciation for individual needs, and, provision of counseling by biased, nonprofessionals.[84, 89, 91] Rue and his colleagues[76] found that only 29% of American women received preabortion counseling. Of those women, 84% stated the counseling received was inadequate.

The nature of the decision- making process may also be associated with the psychological response to abortion especially when there is a perceived lack of partner support for the abortion decision.[12, 19] Predictors of negative outcomes after abortion include ambivalence and absence of partner support.[10, 11, 19, 47, 48, 59] Women who experienced conflict with their husbands or partners over the abortion decision were significantly more angry and depressed after the abortion.[60]

Men and Abortion

A review of the limited research on men and abortion[23] found recurring themes in published studies. Notably, a majority of men whose partners had elective abortions did not perceive the experience as benign.[9, 33, 65, 80, 81, 98] Men's emotional responses to abortion included anger, anxiety, guilt, grief, and powerlessness.[34, 38, 53, 88] Men whose partners underwent therapeutic abortion reported depression at rates of 82%[9], 50%[39], and 47%.[98] In addition, clinicians have described symptoms among men following abortion that are consistent with delayed or complicated grief and with Post Traumatic Stress Disorder or PTSD.[53, 73, 88]

It has been observed that men frequently attempt to support their partners by suppressing their own emotions or desires and deferring the abortion decision to their female partners.[34, 73, 82] Men who disagree with their partners' decisions to abort may experience intense anger.[58, 70] Those men who agree with the abortion decision may still suffer from ambivalence[41, 43] and their relationships may be stressed by or fail subsequent to the abortion.[8, 20, 56, 58, 74, 98] One study[14] found that abortion may have long-lasting effects for men. Specifically, these researchers reported that adult men who had experienced abortion during adolescence were more psychologically distressed than adult men who became fathers during adolescence.

Several reports have stated men's need and/or desire for counseling concerning abortion.[33, 46, 55, 75, 82] In spite of the expressed need for acknowledging and providing counseling for men who accompany their partners to abortion clinics,[84]] little or no counseling is offered to them.

Objectives and Hypotheses

Given the nonexistence of preabortion counseling for men and the lack of consistency in such counseling for women, one of our research goals was to investigate men's and women's perceptions of the adequacy of preabortion counseling. Another major focus of this study was on abortion decision-making, particularly, the lack of agreement or congruence between partners when the decision to abort was made. We hypothesized that each of these variables (i.e. perceptions of inadequate counseling and abortion decision incongruence) would predict post-abortion relationship problems and/ or psychological trauma.

Research reports indicate that prior mental health,[49] religious beliefs,[1, 48] opinions concerning abortion,[86, 102] number of abortions,[76] and certain sociodemographic characteristics[101] may influence the abortion decision and/or influence post-abortion adjustment. Therefore, each of these factors was controlled for in this study. Since a history of physical or sexual abuse has been found to be associated with emotional problems,[28, 77] those forms of abuse that occurred during childhood and adulthood were also controlled for.

Specific hypotheses were as follows:

  1. Men and women who perceive preabortion counseling as inadequate are significantly more likely to evidence abortion-related anger, relationship problems, and sexual problems, after controlling for sociodemographic and personal history variables.
  2. Men and women who perceive preabortion counseling as inadequate are significantly more likely to experience abortion-related trauma, symptoms of intrusion, avoidance, and/or hyperarousal and are significantly more likely to meet the diagnostic criteria for Post-Traumatic Stress Disorder after controlling for sociodemographic and personal history variables.
  3. Men and women who are not in agreement with their partners concerning the abortion decision are significantly more likely to evidence abortion-related anger, relationship problems, and sexual problems, after controlling for sociodemographic and personal history variables.
  4. Men and women who are not in agreement with their partners concerning the abortion decision are significantly more likely to experience abortion-related trauma, symptoms of intrusion, avoidance, and/or hyperarousal and are significantly more likely to meet the diagnostic criteria for Post-Traumatic Stress Disorder after controlling for sociodemographic and personal history variables.



Data was gathered through an online survey over a three-year period. The survey included questions pertaining to sociodemographics, religious beliefs, abortion history, reasons for choosing abortion, perceived adequacy of preabortion counseling, agreement with the abortion decision, opinions concerning abortion at the time of the procedure, postabortion relationship status with the partner, abuse history, mental health history, abortion-related trauma symptoms, abortion-related anger, relationship problems, sexual problems, and general level of stress attributed to abortion.

Survey respondents were informed that submission of a survey indicated their consent to participate and they were free to withdraw from participation at any time. Referral information was provided for those who desired counseling. Recruitment of participants was facilitated by requests to various organizations that offer postabortion counseling. Potential participants could also become aware of the survey through online searches.


The final sample consisted of 374 women and 198 men, with an average age of 38 years for both sexes (Standard Deviation = 11.1 for females and 12.8 for males). A majority of respondents were from the United States (81% of women and 78% of men). Other countries represented included England (4% female, 6.5% male), Canada (6.4% female, 4.5% male), and Australia (2.7% female, 2.5% male). Lesser numbers of respondents came from Brazil, Czechoslovakia, France, Germany, Ireland, Kenya, Mexico, Nepal, New Zealand, Nicaragua, Norway, Romania, South Africa, South Korea, and Sweden. A large majority of women (85.4%) and men (85.2%) identified themselves as Caucasian. Other ethnic groups represented were African-American (3% of women, 7.7% of men), Hispanic (5.7 % of women, 2 % of men), Asian (.5% of women, 1% of men) and Other (5.4% of women, 4.1% of men). Most participants (75.9% of women and 76.5% of men) had some level of educational training beyond high school.

Religious affiliation was reported as follows: Christian (81.6% of women, 82% of men), Jewish (.3% of women, .5% of men), Other (9.5% of women, 7.2% of men), No affiliation (8.6% of women, 9.8% of men). While no female respondents identified themselves as Muslim, .5% of the males did so. Time lapse since abortion was reported as 15 years by females (Standard Deviation = 11.8) and as 14.7 years by males (Standard Deviation = 12). Prior to abortion, approximately 1/2 of both women and men reported holding liberal views of abortion as indicated by their agreement with one of the following statements: "Abortion should be legal for any reason at any time during pregnancy" or "Abortion "should be legal for any reason during the first trimester of pregnancy."


Participants' perceptions of counseling adequacy were measured by a single question, "Do you think the counseling you received at the abortion clinic was adequate?" Responses were limited to "yes" or "no." Abortion decision agreement was also assessed via a single question asking respondents whether they and their partners agreed or disagreed to abort. The quality of the relationship with partner was determined according to responses to questions concerning whether or not relationship problems and/or sexual problems were experienced after abortion and whether or not participants experienced abortion- related anger.

Embedded within the online survey was the Post Traumatic Stress Disorder (PTSD) Checklist-Civilian Version (PCL-C) which measured psychological stress. The PCL-C consists of 17 items that assess the severity of symptom clusters (i.e. arousal, intrusion, and avoidance) using a 5-point Likert scale with higher scores indicating greater stress. Reliability and validity of the measure has been established[97]. PCL-C scores were also used to determine if a respondent met the diagnostic criteria for PTSD. Diagnostic criteria include: one or more experience(s) of re-experiencing the event, three or more experience(s) of avoidance, and two or more experiences of hyperarousal.


Survey responses indicated that 85.8% of women and 86.6% of men reported that preabortion counseling was inadequate and 50.7% of women and 52.9% of men disagreed with their partners about the abortion decision. In addition, 78.4% of women and 71.1% of men described their abortion experience as causing "high" to "overwhelming" stress. Utilizing controls for factors previously noted, the following results were observed:

Findings related to relationship problems

Findings related to psychological stress


The purpose of this study was to explore whether perceptions of preabortion counseling inadequacy and disagreement concerning the abortion decision would predict postabortion relationship problems and/or postabortion psychological stress. Women and men who perceived abortion counseling as inadequate did, in fact, report significantly greater anger and relationship problems after abortion. For women, inadequate counseling was associated with both symptoms of PTSD and with meeting the diagnostic criteria of PTSD. For men, on the other hand, inadequate counseling was only associated with symptoms of intrusion and avoidance. Similar gender differences have been observed by others63 who reported that women were more likely to experience symptoms of arousal while men were more inclined to experience symptoms of avoidance and detachment.

These differences may have a biological basis, be reflective of sociocultural expectations, or be influenced by both biology and culture. The fact that there was a significant association between perceived lack of counseling adequacy and meeting the diagnostic criteria for PTSD for women but not for men may be explained by the fact that only women are involved in the actual abortion procedure. Still, in this study, a large majority of both women (85.8%) and men (86.6%) reported that preabortion counseling was inadequate and most of them (78.4% of women and 71.1% of men) described their abortion experience as causing "high" to "overwhelming" stress. Uniform standards for preabortion counseling for women have not been established. The current counseling provided them has not been scientifically validated. Counseling for women's male partners is nonexistent. Given the nature of a crisis pregnancy and the gravity of an abortion decision, the women and men involved may need a good deal more counseling than what is currently provided.

Disagreement with partners about the abortion decision was reported by 50.7% of women and 52.9% of men. This decision disagreement predicted intrusive thoughts and meeting the criteria for a diagnosis of Post Traumatic Stress Disorder for both women and men. Decision disagreement also predicted hyperarousal symptoms in men as well as abortion-related anger, relationship problems, and sexual problems for men. Perhaps the observed association between decision incongruence and relationship problems among only the male participants is related to women's unilateral legal power in abortion decisions, leaving men feeling impotent and angry. In any case, these findings call for further research concerning the process of abortion decision-making and how that process may be enhanced for both partners.

The participants in this study constitute a self-selected sample. Therefore, results cannot be generalized to the population at large. Still, given that over 45 million abortions have been performed in the United States (Guttmacher Institute, 2008) and that induced abortion is "one of the most frequently performed surgical procedures in the U.S.,"[30] even a small proportion of women and men reporting severe psychological stress represents a serious public health concern. Further research is essential to establish a protocol for evidence-based care[26, 79] for women and men considering induced abortion. Findings from such research may provide information concerning deficiencies of current counseling, development of consistent and comprehensive standards for counseling, identification of differential and specific counseling needs for women and men, and facilitate a decision-making process that benefits all involved.