In April 2007 the Supreme Court altered the terrain of American abortion law when it held in Gonzales v. Carhart that Congress's partial-birth abortion ban was constitutional. Justice Anthony Kennedy's majority opinion also made history for breaching a new area: the psychological effects of abortion on women. Years from now it may be this latter aspect of Gonzales that is more remembered than its purely legal pronouncements.
In 1992 Justice Kennedy exercised the Court's swing vote on abortion in Planned Parenthood vs. Casey, the case that upheld Roe v. Wade. In Casey, Justices Souter, O'Connor, and Kennedy set national abortion policy in their three-judge concurring opinion by staking out a position that would allow early abortions but might also permit some abortion regulations to stand. With the arrival of liberal Justices Ruth Bader Ginsburg and David Breyer in the 1990s Kennedy lost his place as the fifth vote in abortion decisions, and the Court revealed it was unwilling to allow even minor restraints on abortion.
That appears to have changed with the retirement of Justice Sandra Day O'Connor and the seating of Samuel Alito on the Court in 2006. Once again, Justice Kennedy casts the deciding vote on abortion cases, and the Gonzales decision reveals that Kennedy's interpretation of Casey may have new life. Whereas O'Connor would overturn abortion regulations for virtually any reason, Kennedy seems poised to read Casey more restrictively. Three major features of his abortion jurisprudence are discernible. First, abortions performed before viability will receive high-level constitutional protection with no substantial interference allowed. Second, the state's interest in preserving and promoting fetal life after viability may permit substantial restrictions. And, third, abortion is not benign, and its capacity to harm some women is no longer deniable.
On the last point, Kennedy stated for the Court in Gonzales, "While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained." Kennedy then noted matter-of-factly that "[sjevere depression and loss of esteem can follow." At this point Kennedy cited a brief filed by the Justice Foundation which argued that abortion can inflict psychological harm on the women who have them. The brief contained excerpts from the affidavits of 178 post-abortive women describing the emotional impact of their abortions.
The significance of the Court's statements on abortion's psychological health effects has been recognized widely. For example, Yale Law School professor Jack M. Balkin assessed this aspect of Gonzales by noting that the "new rhetoric of the pro-life forces" - claming that abortion hurts women - ".. ..is no longer just rhetoric. It is now part of Supreme Court doctrine. That is the big news [about the decision]."
Balkin is undoubtedly correct, but the Court and the public should be further aware that peer-reviewed, scientific evidence, published in the last decade or so, has identified that abortion can place some women's mental health at risk. In fact, a large number of studies recently published in reputable medical and scientific journals have shown that abortion is strongly associated with a variety of serious and lasting mental health problems.
One study, published in 2006, was sufficiently startling to merit widespread media attention.1 The lead researcher was Professor David Fergusson who began and directs the Christchurch Health and Development Study - a twenty-five year study of a birth cohort of 1265 children born near Christchurch, New Zealand in mid-1977. This research, as Fergusson's webpage notes, "has produced over 250 published books and scientific articles that span a wide range of disciplines including: psychology, psychiatry, epidemiology, pediatrics, health economics and sociology."
Fergusson and his colleagues' 2006 abortion study tracked about 500 young women and found that "[t]hose having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders." The study findings were striking because it was not just depression, or any one mental health problem, but a broad range of mental health problems that increased after abortion. Additionally, Fergusson reported that the association between abortion and the mental health problems "persisted after adjustment for confounding factors."
Fergusson is pro-choice and was almost apologetic about his findings, which, as he noted, were at variance with a 2005 American Psychological Association ("APA") statement concluding that the risk of psychological harm from abortion is low and that "the percentage of women who experience clinically relevant distress is small and appears to be no greater than in general samples of women of reproductive age."2 To the contrary, he pointedly observed that the APA's conclusion was "based on a relatively small number of studies," which suffered from methodological limitations, and that their conclusion had ignored studies that reported evidence of abortion-related mental health problems. Fergusson concluded: "... the present research raises the possibility that for some young women, exposure to abortion is a traumatic life event which increases longer-term susceptibility to common mental disorders."3
In fact, Fergusson's study is only one of many such studies in a growing body of solid research showing strong associations between abortion and a range of mental health problems.
For example, in 2003 a systematic review was published in Obstetrical and Gynecological Survey. This review examined all large, long-term studies available in English through 2002 related to women's health following surgical abortion.4 These were studies which lasted more than 60 days and contained 100 or more patients. The authors concluded that abortion was clearly associated with an increased risk of depression and attempts at suicide or self harm. It concluded that women should be warned in the informed consent process, a point not lost in the aftermath of Gonzales. Within the medical community, the study was deemed to be a solid piece of research. The lead author, John Thorp, Jr., M.D., is the McAllister Distinguished Professor of Obstetrics & Gynecology at University of North Carolina Medical School, and the article was accredited for continuing medical education for physicians.
Going back further, a 1996 study led by Mika Gissler and published in the British Medical Journal analyzed Finnish medical records and death certificates. Gissler found that women who had had an abortion had six times the risk of death from suicide compared to women who carried to term.5
Subsequent studies have shown the same pattern of increased suicide rate after abortion. A 2002 study of more than 173,000 California Medicaid patient records found that the increased rate of suicide persisted for the eight years studied, and was not explained by prior mental illness.6 Also, a 1997 record-based U.K. report in the British Medical Journal, comparing suicide attempts before and after abortion, concluded that the increase in suicide attempts after an abortion was not related to prior suicidal behavior but was most likely related to adverse reactions to an abortion.7
Those in favor of abortion rights have been quick to discount this connection by attributing the suicide deaths and depression after abortion to the stress of unplanned or unwanted pregnancies or the emotional fragility of women prior to abortion. However, a number of reports tend to indicate that it is the abortion itself that is the problem. For example, there are published reports of individual patients who have attempted suicide on the anniversary of the abortion or on the anniversary of the anticipated due date of an aborted baby - indicating that at least some women are specifically overwhelmed by their abortion experience.8
Fergusson's study, discussed above, also provided strong evidence on this point. He compared three groups of young women: those who were never pregnant, those who were pregnant but did not abort, and those who were pregnant and obtained abortions. Looking specifically at depression and suicidal thoughts and behaviors, the never-pregnant group were statistically the same as the pregnant-but-never-aborted group across all ages, while the post-abortive group had significantly higher depression and suicidal ideation.
In fact, for all the various mental health problems Fergusson examined - with the exception of alcohol dependence - the young women who had become pregnant but did not abort were statistically the same as the never-pregnant group. It was the young women who had had abortions who also had various mental health problems.
Numerous studies have produced evidence of increased substance abuse after abortion with some showing more specifically the onset of substance abuse after an abortion, not before.9-10 But again, the question could be raised - is the adverse behavior caused by the stress of the abortion or is it related to the stress of having had an unwanted pregnancy?
A 2005 study led by Priscilla Coleman, Ph.D., of Bowling Green State University, looked at substance abuse among pregnant women.11 Coleman found there was no difference in rates of substance abuse between those who said they wanted the pregnancy compared with those who did not. But higher rates of drug abuse during pregnancy were found in women who had a previous abortion compared to women with no prior abortion. This study found no association between drug abuse and having had a prior miscarriage or stillbirth. Only abortion was associated with an increase risk for substance abuse other than cigarettes.
Coleman's results were striking. Post-abortive women had a 198% increase in use of crack cocaine, a 406% increase in use of cocaine other than crack, and an increased likelihood in the use of other drugs during pregnancy. Numerous other studies have also yielded increased rates of substance abuse during a pregnancy subsequent to an abortion - in some cases with increases much higher than those Coleman described here.12-13-14-15-16-17-18-19 That being said, Coleman's study clarified that it is not a pregnancy's wantedness but the history of past abortion that is associated with substance abuse during a subsequent pregnancy.
Increased substance abuse during subsequent pregnancies may also be related to the existence of posttraumatic stress disorder (PTSD) in some post-abortive women. A 2004 study led by Vincent Rue, Ph.D. of the Institute for Pregnancy Loss was published in Medical Science Monitor. It compared Russian and American post-abortive women using a psychological test which had been previously established as reliably identifying victims of trauma.20 Both Russian and American women demonstrated elevated trauma scores which were higher than the scores documented in an earlier study for a population of battered women. Women with pre-existing PTSD symptoms were excluded from the study.
Rue also assessed post-abortive women using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.)("DSM-IV"). Among the U.S. women, 14.3% met full criteria for PTSD while 65% experienced multiple symptoms of PTSD. A unique feature of this study is that the women were specifically asked if they believed the abortion caused their PTSD symptoms, and only the symptoms which the women attributed to their abortion were included. The results of this study appear credible when compared with other studies. For example, an earlier study by Catherine Barnard found that 18% of post-abortive women met diagnostic criteria for PTSD, with nearly half the women having many, but not all, the symptoms.21
To put this in perspective, the U.S. Department of Veterans Affairs reported that 15.2% of all male Vietnam veterans received a diagnosis of PTSD, and that an additional 22.5% of the men had what was called "partial posttraumatic stress disorder."22 Those with partial PTSD were considered to have experienced "clinically serious stress reaction symptoms," even though not meeting all the diagnostic criteria. (Female soldiers in that era would have had limited combat exposure and had less PTSD - 8.1% receiving a diagnosis of PTSD and 21.2% having partial PTSD.)
People experiencing PTSD typically have intense distress when encountering anything that reminds them of the initial trauma. Those experiencing PTSD typically shun people, places or things that bring back painful memories and avoid thinking about the past trauma. This may be an explanation for the increased substance abuse during subsequent pregnancies. The baby and the pregnancy experience may be a reminder of the pregnancy that ended in abortion, and intensely painful emotions can be triggered. The application of posttraumatic symptoms to abortion trauma was first identified by Speckhard & Rue in 1992.23 Coleman (see above) has suggested that alcohol and drugs may be used to suppress those painful memories in post-abortive women.
In a review article, Coleman (2005) cited several studies indicating a strong association between PTSD and substance use disorders within the general population - not merely post-abortive women.24-25-26-27-28-29 For example, a 1995 study indicated a 7.6% lifetime rate of drug abuse or dependence in women without a history of PTSD, but the lifetime rate climbed to 26.9% in women with a history of PTSD. Coleman reported that recent research shows "the onset of PTSD typically precedes the onset of substance use disorders, suggesting a causal relation."30
Additionally, biologically based research has shown that the same area of the brain that is activated in response to the anxiety of PTSD is also inhibited by common drugs of abuse - indicating a possible biological mechanism in the relationship between PTSD and substance abuse.31 Consequently, it is plausible that PTSD in post-abortive women may be driving their increase in substance abuse - especially substance abuse during subsequent pregnancies.
Aside from the substance abuse issues, PTSD is a serious disorder with long-lasting effects. The National Comorbidity Study found that more than one third of patients with PTSD fail to recover after many years.32 Further, research shows that PTSD is associated with poor general health.33 Even "partial PTSD" is serious because all trauma is cumulative. Each new stress continues to add to the burden of trauma carried by a person and increases his or her vulnerability to new problems. If a person has some symptoms of trauma but not enough to meet all criteria for PTSD later additional trauma may cause the person's symptoms to worsen, or new symptoms may develop. Cumulative trauma may continue to negatively impact psychiatric symptoms for years into the future.34-35
As this discussion of the scientific literature suggests, there is growing evidence that abortion is not a risk-free "choice." In addition to clinical data gathered in published studies, women have started to come forward on their own, to seek help through grassroots self-help abortion-recovery groups. Of these women, thousands are speaking out to warn others. The 178 affidavits that the Supreme Court considered in the Gonzales case represent a growing trend of women attesting to the fact that their abortions were more hurtful than helpful.
By acknowledging the brief containing affidavits from those with first-hand knowledge of abortion's impact, Justice Kennedy validated their experiences while setting an important precedent. As more women come forward with complaints against the abortion industry and the medical community that failed to warn them of abortion's psychological consequences, federal and state courts, and legislatures will likely find themselves playing catch-up to address the legitimate need for statutes and regulations that can help minimize abortion-related emotional harm.
4 J. M. Thorp Jr., K. E. Hartmann, and E. Shadigian. "Long-Term Physical and Psychological Health Consequences of Induced Abortion: Review of the Evidence," Obstetrical & Gynecological Survey 58 (2003): 67-79. [Back]
6 D. C. Reardon, P. G. Ney, F. J. Scheuren, J.R. Cougle, P. K. Coleman, and T. Strahan. "Deaths Associated with Pregnancy Outcome: A Record Linkage Study of Low Income Women," Southern Medical Journal (95) 2002: 834-41. [Back]
11 P. K. Coleman, D.C. Reardon, and J. Cougle. "Substance Use among Pregnant Women in the Context of Previous Reproductive Loss and Desire for Current Pregnancy," British Journal of Health Psychology (10) 2005: 255-68. [Back]
12 P. K. Coleman, D. C. Reardon, V. Rue, and J. Cougle. "History of Induced Abortion in Relation to Substance Use during Subsequent Pregnancies Carried to Term," American Journal of Obstetrics and Gynecology (187) 2002: 1673-8. [Back]
14 D. Yamaguchi and D. Kandel. "Drug Use and Other Determinants of Premarital Pregnancy and Its Outcome: A Dynamic Analysis of Competing Life Events," Journal of Marriage and Family (49) 1987: 257-70. [Back]
15 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing J. Kuzma and D. Kissinger. "Patterns of Alcohol and Cigarette Use in Pregnancy," Neurobehav Toxicol Teratol (3) 1981: 211-21). [Back]
16 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing J. Gladstone, M. Levy, I. Nulman, et al. "Characteristics of Pregnant Women Who Engage in Binge Alcohol Consumption," Canadian Medical Association Journal (156) 1997: 789-94). [Back]
17 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing D. A. Frank, B. S. Zuckerman, H. Amaro, et al. "Cocaine Use During Pregnancy: Prevalence and Correlates," Pediatrics (82) 1988: 888-95). [Back]
18 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing K. Graham and G. Koren. "Characteristics of Pregnant Women Exposed to Cocaine in Toronto between 1985 and 1990," Canadian Medical Association Journal (144) 1991: 563-8). [Back]
19 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing A. S. Oro and S. D. Dixon. "Prenatal Cocaine and Metham-phetamine Exposure: Maternal and Neo-natal Correlates," Pediatrics (111) 1987: 571-8). [Back]
20 V. M. Rue, P. K. Coleman, J. J. Rue, and D. C. Reardon. "Induced Abortion and Traumatic Stress: A Preliminary Comparison of American and Russian Women," Medical Science Monitor (10) 2004: SR5-16. [Back]
22 National Center for PTSD Fact Sheet. "Epidemiological Facts about PTSD," United States Department of Veterans Affairs. Last accessed online Sept. 19, 2008 (at: http://www.ncptsd.va.gov/ncmain/ncdocs/fact shts/fs_epidemiological.html). [Back]
25 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing R. C. Kessler, A. Sonnega, E. Bromet, et al. "Posttraumatic stress disorder in the National Comorbidity Survey," Archives of General Psychiatry (52) 1995: 1048-60). [Back]
26 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing K. T. Brady, S. E. Back, and S. F. Coffey, "Substance Abuse and Posttraumatic Stress Disorder," Current Directions in Psychological Science (13) 2004: 206-9). [Back]
27 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing H. D. Chilcoat and N. Breslau. "Posttraumatic Stress Disorder and Drug Disorders," Archives of General Psychiatry (55) 1998: 913-7. [Back]
28 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing L. K. Jacobsen, S. M. Southwick, and T. R. Kosten. "Substance Use Disorders in Patients with Posttraumatic Stress Disorder: A Review of the Literature," American Journal of Psychiatry (158) 2001: 1184-90. [Back]
29 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing A. J. Saxon, T. M. Davis, K. L. Sloan, et al. "Trauma, Symptoms of Posttraumatic Stress Disorder, and Associated Problems Among Incarcerated Veterans," Psychiatric Services (52) 2001: 959-64. [Back]
31 P. K. Coleman. "Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence," Current Women's Health Reviews (21) 2005: 21-34 (citing J. L. Armony and J. E. LeDoux. "How the Brain Processes Emotional Information," in R. Yehuda and A. C. McFarlane, eds., Psychobiology of Posttraumatic Stress Disorder (New York, NY: The New York Academy of Sciences, 1997): 259-70). [Back]
34 F. Neuner, M. Schauer, U. Karunakara, C. Klaschik, C. Robert, and T. Elbert. "Psychological Trauma and Evidence for Enhanced Vulnerability for Posttraumatic Stress Disorder through Previous Trauma among West Nile Refugees," BMC Psychiatry (4) 2004. Published online 2004 October 25. dio: 10.1186/1471-244X-4-34 (last accessed Sept. 20, 2008). [Back]
35 R. F. Mollica, K. Mclnnes, C. Poole, and S. Tor. "Dose-effect Relationships of Trauma to Symptoms of Depression and Post-traumatic Stress Disorder among Cambodian Survivors of Mass Violence," British Journal Psychiatry (Ml) 1998: 482-8. [Back]