Within weeks of the release of the APA Task Force Report, the late Dr. David Fergusson, a self-proclaimed pro-choice New Zealand researcher with an extensive publication record (over 500 peer-reviewed articles), and I drafted a petition letter to Dr. Alan Kazdin, President of the APA. The interest in writing a petition letter originated with Dr. Fergusson, who served as an official reviewer for the Task Force Report. I was also a reviewer of the Task Force report, and we were both upset by how the Task Force ignored the reviewers’ feedback. Together Dr. Fergusson and I drafted the letter, and then we solicited support from other well-published researchers and compiled an extensive list of articles authored by the signatories. The letter was submitted to Dr. Kazdin on September 1, 2008, and the key points we raised are summarized below. At the end of our letter, we requested that the APA revisit this issue and seriously consider a retraction or revision; however, no action was taken.
a) Wholesale dismissal of most of the evidence in the field was unacceptable.
b) In no other area of public health research has a highly contested issue been resolved based on a single, out-of-date research study in the way that occurred in the APA Task Force report.
c) The APA Task Force report was not an impartial assessment of the mental health risks of abortion, and its conclusions were unduly colored by the views of its authors.
The review relied upon most heavily by the NAS team was published in 2011 by the National Collaborating Centre for Mental Health (NCCMH) within the Royal College of Psychiatrists. The NCCMH review incorporated four types of studies: 1) reviews of the literature; 2) empirical studies addressing the prevalence of post-abortion mental health problems; 3) empirical studies identifying risk factors for post-abortion mental health problems; and 4) empirical studies comparing mental health outcomes between women who choose abortion and delivery. In each category, there were studies that were ignored and many studies that were entirely dismissed for vague and/or inappropriate reasons. With regard to the first type of study, only three reports were considered (APA Task Force Report, 2008; Charles et al., 2008; Coleman, 2011). The authors of the NCCMH report "missed" 19 reviews of the literature (listed below), published between 1990 and 2011. Moreover, no criteria were identified for the selection of particular reviews. Narrative reviews not addressed included the following
Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological responses after abortion.Science 1990 6; 248(4951):41-4.
Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992; 47(10):1194-204.
Adler NE, Ozer EJ, Tschann J. Abortion among adolescents. Am Psychol. 2003; 58(3):211-7.
Allanson S, Astbury JJ. The abortion decision: reasons and ambivalence. Psychosom Obstet Gynaecol. 1995; 16(3):123-36.
Bhatia MS, Bohra N. The other side of abortion. Nurs J India. 1990; 81(2):66, 70.
Cameron S. Induced abortion and psychological sequelae. Best Practice & Research. Clinical Obstetrics & Gynaecology 2010; Vol. 24 (5), 657-65.
Coleman PK, Reardon DC, Strahan T, Cougle R. The psychology of abortion: A review and suggestions for future research. Psychology & Health 2005; 20(2), 237-271.
Dagg PK. The psychological sequelae of therapeutic abortion--denied and completed. Am J Psychiatry. 1991;148(5):578-85.
Harris AA. Supportive counseling before and after elective pregnancy termination. Midwifery Women’s Health. 2004; 49(2):105-12.
Lie ML, Robson SC, May CR. Experiences of abortion: a narrative review of qualitative studies. BMC Health Serv Res. 2008; 8:150.
Lipp A. Termination of pregnancy: a review of psychological effects on women. Nursing Times 2009; 105 (1), 26-9.
Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009; 64(9):863-90.
Major B, Cozzarelli C. Psychosocial Predictors of Adjustment to Abortion. Journal of Social Issues 1992; 48 (3), 121-142.
Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M. Is there an "abortion trauma syndrome"? Critiquing the evidence. Harvard Review of Psychiatry 2009; 17 (4), 268-90.
Rosenfeld JA. Emotional responses to therapeutic abortion. Am Fam Physician. 1992; 45(1):137-40.
Speckland A, Rue V. Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Pre and Perinatal Psychology Journal 1993; 8 (1):5-32.
Stotland NL.Clin Obstet Gynecol. Psychosocial aspects of induced abortion.1997 Sep; 40(3):673-86.
Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a critical review of the literature. Women Ther. 1990; 9(4):49-68.
Zolese G, Blacker CV. The psychological complications of therapeutic abortion. Br J Psychiatry. 1992; 160:742-9.
In relation to the third type of study (addressing risk factors for post-abortion psychological problems), only 27 studies were included in the NCCMH report. Below are citations to 20 relevant and unmentioned articles published in highly respected peer-reviewed journals. They were not listed in Appendix 7 of the NCCMH report, which contained all included and excluded studies.
Allanson S. Abortion decision and ambivalence: Insights via an abortion decision balance sheet. Clinical Psychologist 2007; 11 (2), 50-60.
Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: a descriptive study. J Clin Ethics 1993; 4(2):118-23.
Fielding SL, Schaff EA. Social context and the experience of a sample of U.S. women taking RU-486 (mifepristone) for early abortion. Qualitative Health Research 2004; 14 (5), 612-27.
Hill RP, Patterson MJ, Maloy K. Women, and abortion: a phenomenological analysis. Adv Consum Res. 1994; 21:13-4.
Kero A, Lalos A. Ambivalence--a logical response to legal abortion: a prospective study among women and men. J Psychosom Obstet Gynaecol. 2000; 21(2):81-91.
Linares LO, Leadbeater BJ, Jaffe L, Kato PM, Diaz A. Predictors of repeat pregnancy outcome among black and Puerto Rican adolescent mothers. J Dev Behav Pediatr. 1992;13(2):89-94.
Mufel N, Speckhard AC, Sivuha S. Predictors of posttraumatic stress disorder following an abortion in a former Soviet Union country. Journal of Prenatal & Perinatal Psychology & Health 2002; 17(1), 41-61.
Osler M, David HP, Morgall JM. Multiple induced abortions: Danish experience. Patient Educ Couns. 1997; 31(1):83-9.
Østbye T, Wenghofer EF, Woodward CA, Gold G, Craighead J. Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals. American Journal of Medical Quality 2001; 16 (3), 99-106.
Prommanart N, Phatharayuttawat S, Boriboonhirunsarn D, Sunsaneevithayakul P. J Maternal grief after abortion and related factors. Med Assoc Thai. 2004; 87(11):1275-80.
Remennick L, Segal R. Socio-cultural context and women's experiences of abortion: Israeli women and Russian immigrants compared. Culture, Health & Sexuality 2001; 3(1), 49-66.
Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients' perceptions of care. J Fam Plann Reprod Health Care. 2001;27(2):72-7.
Tamburrino MB, Franco KN, Campbell NB, Pentz JE, Evans CL, Jurs SG. Postabortion dysphoria and religion. South Med J. 1990;83(7):736-8.
Thomas T, Tori CD. Sequelae of abortion and relinquishment of child custody among women with major psychiatric disorders. Psychol Rep. 1999; 84(3 Pt 1):773-90.
Törnbom M, Ingelhammar E, Lilja H, Möller A, Svanberg Repeat abortion: a comparative study. B.J Psychosom Obstet Gynaecol. 1996; 17(4):208-14.
van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008; 15(6):378-85.
Vukelić J, Kapamadzija A, Kondić B. Investigation of risk factors for acute stress reaction following induced abortion. ed Pregl. 2010; 63(5-6):399-403.
Wiebe ER; Adams LC. Women's experience of viewing the products of conception after an abortion. Contraception 2009; 80 (6), 575-7.
Wiebe ER, Trouton KJ, Fielding SL, Grant H, Henderson A. Anxieties and attitudes towards abortion in women presenting for medical and surgical abortions. J Obstet Gynaecol Can. 2004; 26(10):881-5.
Wells N. Pain and distress during abortion Health Care Women Int. 1991; 12(3):293-302.
The NCCMH authors stated that, “Because the review aimed to assess mental health problems and substance use and not transient reactions to a stressful event, negative reactions and assessments of mental state confined to less than 90 days following the abortion were excluded from the review.” This is highly problematic for the following reasons:
a) Elimination of studies that only measured women's mental health up to 90 days does not effectively remove cases of transient reactions. Just because the authors of these dozens of studies did not follow the women long-term, it does not mean that the women were not still suffering quite significantly beyond the early assessment.
b) When investigating the mental health implications of an event, it is logical to measure outcomes soon after the event has occurred as opposed to waiting months or years to gather data. As more time elapses between the stressor and the outcome(s), healing may naturally occur, there may be events that moderate the effects and more confounding variables may occur.
c) Finally, focusing only on mental health events that occur later in time effectively misses the serious and more acute episodes that are effectively treated soon after exposure. Many of the studies removed from the analyses due to the abbreviated length of follow-up had incorporated controls for prior psychological history and other study strengths. As a result, the samples of studies included in each section of the NCCMH review were not representative of the best available evidence. Many of the eliminated effects coincidentally revealed adverse post-abortion consequences. In the category wherein the authors sought to derive prevalence estimates, only 34 studies were retained, including a majority without controls for previous mental health.
The NCCMH review has numerous factual errors. Specifically, in “Section 1.4.4: Summary of Key Findings from the APA, Charles, and Coleman Reviews,” the first 6 points are not reflective of the conclusions derived from my review, and the 7th and final point in this section wrongly states, with reference to my meta-analysis that “previous mental health problems were not controlled for within the review.” My review incorporated more studies into the final analyses with controls for prior psychological problems (14 out of 22) than the NCCMH review. Moreover, the conclusions derived from my review were also based on more studies with controls for prior psychological history than the Charles and the APA reviews.
The NCCMH review was pitched as methodologically superior to all previously conducted reviews, largely because of the criteria employed to critique individual studies and rate the overall quality of evidence. However, the quality scales employed to rate each individual study are not well-validated and require a significant level of subjective interpretation, opening the results to considerable bias.
The NCCMH quality scales used to rate studies were problematic for the following reasons: 1) the categories missed key methodological features, such as initial consent to participate rates; 2) the relative importance assigned to criteria was not based on scientific consensus; 3) requirements for assigning a “+” or “-” within categories were not provided; and 4) no explanation was given for how combinations of pluses and minuses added up to overall ratings ranging from “Very Poor” to “Very Good.”
Similarly, when it came to evaluating the quality of evidence associated with specific outcomes, such as anxiety, depression, suicide ideation, drug or alcohol abuse, psychiatric treatment, etc. with regard to the comparative studies, the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) protocol was inappropriately employed by the NCCMH. The GRADE system was not designed for individual studies but analysis of systematic reviews (Burford, Rehfuess, & Schünemann, et al., 2012). The anchors on this scale are vague, and oftentimes only one reason is identified by the NCCMH as the basis for a "Very Low" rating. For example, in the category of "Any Psychiatric Treatment," which only included the Munk-Olsen et al. study, the basis for the "Very Low” (very uncertain about the estimate) rating was for not having controlled for pregnancy intention. When the study was again evaluated later in the report, it was rated as “Good” in the comparison category. There are loose, poorly conceived rationales with inconsistencies like this throughout the report.
Each section in the NCCMH report included conclusions based on a very small number of studies that were not properly rated for quality. For example, relative to the risk factors for mental health problems category, the authors stated (based on 27 studies) that: "The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to abortion" and "A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortion in general and towards a woman's personal experience of the abortion, may have a negative impact on mental health." In reality, however, the literature on risk-factors is not mixed, and professionals, both practitioners and academics alike, are in agreement regarding the specific variables that operate as robust predictors of post-abortion mental health problems.
An extensive 40-year history of peer-reviewed research has definitively shown that women are at an elevated risk for post-abortion mental health problems when specific physical, demographic, psychological, and situational factors are present. Many of the risk factors have been known to the research community for decades and have been recognized and affirmed by professional organizations. There is an undisputed opinion among researchers and practitioners alike that pressure to abort, coercion, commitment to the pregnancy, decision difficulty/ambivalence, conflict with personal values, pre-existing mental health problems, and young maternal age, among other factors, place women at increased risk for mental health problems, including depression, anxiety, suicide ideation, suicide, and substance abuse (e.g., Baker, et al, 2009; Coleman, 2005; Ely et al., 2009; Franco et al.,1989; Hern, 1990; Mufel et al. 2002; Paul et al. 2009; Pope et al., 2001; Soderberg et al., 1998; Urquhart & Templeton, 1991).
III. Increased Risk for Mental Health Problems Associated with Abortion
For a significant number of women, abortion initiates powerful negative feelings and alienation from others (Kero, Hogberg, & Lalos, 2004; Kero & Lalos, 2000; Kero, Wulff, & Lalos, 2009; Kimport, 2012; Kimport, Foster, & Weitz, 2011; Söderberg, Janzon, & Sjöberg, 1998). A Clinician's Guide to Medical and Surgical Abortion is a textbook written by leading
abortion providers (Paul, et al., 1999) for training abortion providers. The chapter on counseling in this text outlines several negative reactions that women may experience after abortion, including depression, severe guilt, shame, and unresolved grief (Baker et al., 1999). According to the Clinician’s Guide, symptoms of depression include the following: crying, suicidal ideation, poor performance in school or work, loss of interest in enjoyable activities, and feelings of worthlessness. Symptoms of severe guilt entail the following:
1) self-punishing behaviors such as substance abuse or indiscriminate sex;
2) nightmares about killing or saving babies;
3) blocking out the experience;
4) avoiding anything that triggers memories of the event;
5) fearing God's punishment; and
6) interpreting misfortune, illness, or accident as signs of God's punishment.
Symptoms of shame include the following:
1) relentless thoughts of being a bad person;
2) engaging in self-destructive behaviors;
3) fear of anyone finding out about the abortion. Finally, according to the authors of the abortion text, symptoms of unresolved grief involve engaging in thoughts and behaviors that perpetuate a strong emotional investment in the pregnancy or that prevent the redirection of emotional energy into moving forward with life.
Over the past several decades, the number of peer-reviewed studies identifying adverse mental health outcomes associated with abortion has increased dramatically, as has the scientific rigor of research on this topic. The literature base, comprised of hundreds of studies, has revealed that women who choose abortion experience increased risk of mental health problems, including substance abuse, anxiety, depression, suicidal ideation, and suicide, among other conditions and symptoms (e.g., Bradshaw & Slade, 2003; Coleman et al., 2002a, 2002b; Coleman, 2005, 2006; Cougle et al., 2003, 2005; Dingle, 2008; Fergusson et al., 2006, 2008; Gissler et al., 2005; 2015; Mccarthy, 2015; Mota et al., 2010; Pedersen, 2007, 2008; Rees & Sabia, 2007; Sullins, 2016).
The scientific evidence linking abortion to increased rates of mental health problems is published in leading peer-reviewed journals in psychology and medicine. There are now dozens of large-scale prospective studies with 1000's participants incorporating different types of comparison groups and other control techniques, effectively fortifying the level of confidence in the results derived. Potentially confounding variables, controlled in the various studies, including prior mental health, reproductive history, experience of abuse of various forms, and several demographic variables, thereby increasing the reliability and validity of the findings.
In a 2013 narrative review of the literature published between 1995 and 2011, incorporating 30 peer-reviewed journal articles by Italian researchers Bellieni and Buonocore, the authors concluded, "The studies analyzed here show that abortion is a risk factor for mental illness when compared to childbirth."
As mentioned earlier, in 2011, I published a meta-analysis titled “Abortion and Mental Health: A Quantitative Synthesis and Analysis of Research Published from 1995-2009” in the British Journal of Psychiatry. A meta-analysis is a specific form of systematic literature review wherein quantitative data from multiple published studies are converted to a common metric and combined statistically to derive an overall measure of the effect of exposure such as abortion. This methodology gives the results more statistical power and much more credibility than the results of any individual empirical study or narrative review. In a meta-analysis, the contribution or weighting of any particular study to the final result is based on objective scientific criteria (sample size and strength of effect), as opposed to an individual's opinion of what constitutes a strong study.
My review offers the largest quantitative estimate of mental health risks associated with abortion available in the world. After applying methodologically-based selection criteria and extraction rules to minimize bias, the sample consisted of 22 studies, 36 measures of effect, and 877,297 participants (163,880 of whom experienced an abortion). Results revealed that women who aborted compared to women who did not, experienced an 81% increased risk for mental health problems. When compared specifically to unintended pregnancies delivered, abortions were associated with a 55% increased risk of mental health problems.
Separate effects were calculated based on the type of mental health outcome. The results revealed the following increased risks: anxiety disorders 34%; depression 37%; alcohol use/abuse 110%; marijuana use/abuse 220%; and suicide behaviors 155%. Calculation of a composite Population Attributable Risk (PAR) statistic revealed that nearly 10% of the incidence of mental health problems was directly attributable to abortion.
On April 8, 2015, Dr. Elizabeth Suhay challenged readers in U.S. News to recognize the dangers of agenda-driven science and work to reverse an inherently formidable trend: “Right now, too many people are willing to accept the scientific process only when it leads to conclusions that bolster their political, economic and religious outlooks. This leads to a dangerous distortion of scientific understanding. It inhibits our ability to see the world clearly, formulate science-based policy to meet important challenges, and reach across the political aisle to implement that policy….A critical first step in combating this all too human prejudice is simply to recognize its existence and commit to overcoming it.” Ironically and sadly, the NAS originated out of strong interest in preventing what is now a widespread political orientation to the use of scientific data in pursuit of socio-political agendas. The NAS report on the safety of abortion constitutes a repudiation of the NAS founding ideals.
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