C. Everett Koop is widely viewed as having been among the country’s most influential surgeons general. He was appointed by President Ronald Reagan, and served from 1982 to 1989. Upon his death earlier this year, Koop received acclaim for his courage and leadership in educating the public about HIV and AIDS, and in pushing the U.S. government to take on AIDS as an urgent public health issue. He instigated a major antismoking campaign that led to permanent changes in Americans’ behavior. On abortion, he made his mark for what he did not do.
Contrary to the hopes and expectations of antiabortion activists who had lobbied Reagan to appoint Koop because of his well-known opposition to abortion, Koop declined to use his bully pulpit to promote his personal views. Accordingly, late in Reagan’s presidency, abortion foes pressured the president to direct Koop to conduct a scientific review of the literature on the supposed negative physical and mental health effects of abortion. In January 1989, after an exhaustive 15-month long investigation, Koop dismissed any evidence of physical health risks of abortion. Describing his findings later at a congressional hearing, he agreed with the American College of Obstetricians and Gynecologists that "the physical sequelae of abortion were no different than those found in women who carried pregnancy to term or who had never been pregnant."1 This has not deterred opponents of abortion from continuing to insist—despite clear evidence to the contrary—that abortion causes breast cancer and infertility, among other physical health problems.
As to the psychological impact of abortion, Koop declared that it was "miniscule from a public health perspective." However small, this left an opening for antiabortion activists to exploit. Indeed, decades later, their claim that abortion causes mental health problems has developed from one based solely on anecdotes to one where they claim to have science on their side. Several prestigious scientific institutions have recently conducted large-scale literature reviews and analyses, however, and all have confirmed that abortion still does not pose any increased mental health risk to women. Nonetheless, states and activists hostile to abortion rights remain undeterred as they promote laws and policies premised on the assertion that abortion harms women mentally and emotionally.
Weight of the Evidence
As long ago as 1989, mere months after Koop concluded there was no public health case against abortion, the American Psychological Association (APA) conducted an exhaustive review of the scientifically valid research on the subject and concluded that legal abortion of an unwanted pregnancy "does not pose a psychological hazard for most women."2 University of California at San Francisco Professor Nancy Adler testified in Congress on behalf of the APA at that time that "severe negative reactions are rare and are in line with those following other normal life stresses."3 She observed that given the millions of U.S. women who had had abortions, "if severe reactions were common, there would be an epidemic of women seeking treatment. There is no evidence of such an epidemic."
In the last five years alone, at least three more major reports reached similar conclusions. In 2006, the APA revisited the issue and created another task force on mental health and abortion. Its updated and comprehensive report, issued in 2008, reinforced its findings from two decades earlier: "The best scientific evidence published indicates that among adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy."4
In 2008, researchers at Johns Hopkins Bloomberg School of Public Health published their own analysis in which they concluded that "the highest-quality research available does not support the hypothesis that abortion leads to long-term mental health problems."5 They found a "clear trend" by which "the highest quality studies had findings that were mostly neutral, suggesting few, if any, differences between women who had abortions and their respective comparison groups in terms of mental health sequelae." Notably, the Hopkins teams also stated that it was the "studies with the most flawed methodology [that] found negative mental health sequelae of abortion."
Finally, in 2011, the Academy of Medical Royal Colleges (AMRC) commissioned and published a systematic literature review, funded by the United Kingdom Department of Health and conducted by the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists. The authors employed a higher standard of review than all the previous work done in this area, disqualifying studies with methodological flaws, bias or other factors undermining the reliability and accuracy of the results, including many studies most commonly cited by abortion opponents (see box).6,7,8
The AMRC concluded that "rates of mental health problems for women with an unwanted pregnancy were the same whether they had an abortion or gave birth."9 The authors determined that it was the "unwanted pregnancy [that] was associated with an increased risk of mental health problems" and that the "most reliable predictor of post-abortion mental health problems was having a history of mental health problems before the abortion."
Less research has been done focusing on teenagers. In 2010, however, researchers from Oregon State University and the University of California, San Francisco (UCSF) conducted the first study of a nationally representative sample of adolescents examining depression and low self-esteem as potential outcomes of abortion. Few studies have compared adolescents whose pregnancies ended in abortion with those who gave birth, and followed them over a long period of time. The authors concluded that "the young women in this study who had an abortion were no more likely to become depressed or have low self-esteem within the year of the pregnancy or five years later than were their peers whose pregnancies did not end in abortion. Consistent with previous studies of abortion and psychological outcomes, the strongest predictors of depression and low self-esteem were prior depression and prior low self-esteem."10
Evidence-Free Zones
Despite the overwhelming consensus in the legitimate scientific community that there is no causal link between abortion and mental health disorders, antiabortion activists have long gotten considerable traction in state legislatures and even the courts with their spurious scientific case. As the APA acknowledged in 2008, antiabortion activists have been able to successfully exploit the small ambiguities in the research because "there is unlikely to be a single definitive research study that will determine the mental health implications of abortion ‘once and for all’ given the diversity and complexity of women and their circumstances."4 As long as the case is not definitively closed, apparently, it is wide open for the purpose of politics.
The vast majority of states require women seeking abortion to receive counseling. Of course, complete, accurate and unbiased counseling is the standard of care among all medical professionals in the interest of ensuring informed consent for an abortion, as with any medical procedure. This type of counseling would include talking to women about the range of emotions they might experience following an abortion, including sadness either shortly afterwards or many years later. Such emotions are not unique to women who have had an abortion, however. They are also common among many women who have placed a baby for adoption or raised an unplanned child under adverse conditions, not to mention the postpartum depression that commonly afflicts women even after a wanted pregnancy.
The APA has found that for most women having an abortion, the time of greatest distress is just prior to the procedure.4 Afterwards, women most frequently describe feelings of relief and even happiness. Perversely, evidence shows that the stigma that a woman may feel because she believes that her partner, family or community will condemn or ostracize her for having an abortion—the stigma that antiabortion activists have worked for decades to promote—is itself a key driver of negative mental health outcomes. According to the APA, the "most methodologically strong studies…showed that interpersonal concerns, including feelings of stigma, perceived need for secrecy, exposure to antiabortion picketing, and low perceived or anticipated social support for the abortion decision, negatively affected women’s postabortion psychological experiences."
Numerous states hostile to abortion rights simply disregard these facts, though, and have turned the concept of informed consent on its head (see "State Abortion Counseling Policies and the Fundamental Principles of Informed Consent," Fall 2007). Of the 22 states requiring women to receive information about the range of psychological responses to abortion, for example, eight only mandate that negative information be provided.11 This kind of "misinformed consent" extends to perpetrating myths about the physical risks of abortion as well. Six states mandate the provision of information that inaccurately describes an increased risk to future fertility and five compel women to hear false information on the link between abortion and breast cancer.
This campaign is not new, but it is ongoing. Just this year, antiabortion legislators in Alaska relied on the debunked theories of Bowling Green State University’s Priscilla Coleman to promote a bill aimed at narrowing the circumstances under which the state would subsidize abortion for its low-income citizens. (Alaska’s Supreme Court ruled in 2001 that as long as Alaska funded maternity care for the poor, it must also fund all medically necessary abortions as a matter of equity.) Coleman testified that "abortion is a substantial contributing factor" in mental health problems and a "risky choice" for women with mental illness.12 She strongly recommended that Alaska exclude coverage of abortion for mental health reasons from the definition of what is considered "medically necessary." This time and in this instance, the bill failed.
Bad science is driving bad law not only in state legislatures but also in the courts. Of the "mandatory misinformation" measures in effect, South Dakota’s 2005 law is among the most extreme. It requires physicians to advise women that abortion will increase their risk of suicide and suicidal thoughts. (This is the same state that also requires doctors to provide abortion patients a written statement saying that "the abortion will terminate the life of a whole, separate, unique, living human being," and that they have "an existing relationship with that unborn human being" that is constitutionally protected.) Planned Parenthood Minnesota, North Dakota, South Dakota challenged the law on the grounds that compelling doctors to provide women with false information violates their free speech rights. In July 2012, however, the Eighth Circuit Court of Appeals ruled that "the suicide advisory presents neither an undue burden on abortion rights nor a violation of physicians’ free speech rights." The majority opinion deferred to the state’s supposed fact-finding process and noted that the advisory had legitimacy, citing Coleman’s work. Notably, the court acknowledged that the research upon which the statute is based shows merely a correlation between abortion and suicidal tendencies, rather than a causal relationship. "The statute does not require the physician to disclose that a causal link between abortion and suicide has been proved," the court said.
"Paradoxically," wrote the researchers from the Oregon State/UCSF team, "laws mandating that women considering abortion be advised of its psychological risks may jeopardize women’s health by adding unnecessary anxiety and undermining women’s right to informed consent."10 Fortunately, at least so far, nothing in these laws precludes medical providers from supplementing the state-required misinformation with the actual facts. Indeed, doing so is their ethical and legal obligation in the interest of informed consent.
Full Circle
Despite decades of mounting and conclusive evidence to the contrary, antiabortion activists now have enough published research to cite—however dubious—to rationalize their assertions that abortion is harmful to women’s mental health. States hostile to abortion rights have racked up laws designed less to inform than to coerce women to carry unwanted pregnancies to term through disinformation. Worse, federal courts are validating the right and legitimacy of states to maintain that having an abortion leads to mental health problems. The fact that the research on which their conclusions are based sometimes has been published in peer-reviewed journals—even if proven to be severely flawed—seems to be all the license they need.
No amount of repetition, however, can make this true. The evidence and the observable reality of 40 years of legal abortion in the United States do not comport with the idea that having an abortion is any more dangerous to a woman’s long-term mental health than delivering and parenting a child that she did not intend to have or placing a baby for adoption. While the number of abortions occurring each year has declined to 1.2 million from its all-time high of 1.6 million in 1990, it is still far from rare among U.S. women. Indeed, three in 10 will have had an abortion by age 45. Any negative effects of abortion would have resulted in an epidemic of mental illness years ago.
Koop turned out to be an unlikely hero for abortion rights advocates because he was able and willing to let the science—not his politics—drive policy. Now, the debate is not just between science and anecdotes or science and politics, but also between science and junk science—and how to distinguish between them. Fortunately, there are established, legitimate scientific bodies that provide guidance on this. And on the subject of abortion and mental health, they stand united and in line with what Koop found 24 years ago.
Methodology Matters
To determine whether abortion has any long-term effects on a woman’s mental health requires the use of scientific methods that take into account the numerous confounding factors that could lead to a false conclusion. For example, having a history of childhood sexual abuse, stress or emotional problems, or intimate partner violence may be linked to psychological problems later in life. Because such histories may also be more common among women who have unintended pregnancies and abortions, a study that does not account for them may wrongly appear to link abortion to later psychological problems. Additionally, women suffering from depression or other health problems might be more likely than other women to admit having had an abortion, perhaps from a desire for something to blame for their present condition. This "reporting bias" is a common challenge in studies that gather information from individuals retrospectively, in contrast to research designed to collect information from medical records or prospectively over time from women with unintended pregnancies or abortion patients.
A prominent example of a fatally flawed approach is a 2009 analysis conducted by Bowling Green State University’s Priscilla Coleman and published in the Journal of Psychiatric Research (JPR); that study has been cited frequently by antiabortion activists and relied upon by Coleman in subsequent work.6 Coleman describes herself as the most-published author of peer-reviewed articles on abortion and mental health, and in all of them she concludes that abortion leads to serious psychological problems, including substance abuse. The problem, however, is that Coleman fails to distinguish between mental health conditions that existed before the abortions and those that occurred afterward. Eventually, after repeated criticism from other researchers, even the editor-in-chief of JPR and the principal investigator of the study that generated the national dataset Coleman used for her analysis published their own rebuke of Coleman’s study in JPR.7 They noted that Coleman and her colleagues utilized a "flawed" methodology and that their "analysis does not support their assertions that abortions led to psychopathology" using the dataset relied upon.
By contrast, a very strong method for ascertaining the difference between causation and association is to use a prospective approach. This is uncommon because such studies are expensive and take a long time. In the mid-1990s, however, one such study was sponsored by the Royal Colleges of Obstetricians and Gynaecologists and of General Practitioners in the United Kingdom.8 It was a long-term prospective cohort study and is considered as close to an ideal design as might be possible. Over an 11-year period, the researchers monitored more than 13,000 women in England and Wales with unintended pregnancies, and compared the women who had abortions with those who delivered a baby. After controlling for any history of psychiatric illness, the only difference between the two groups in the years following the pregnancy outcome was that among women with no history of mental illness, those who delivered a baby had a significantly higher risk of having a psychotic episode than those who had an abortion.
References
1. Statement of Surgeon General C. Everett Koop, Department of Health and Human Services, House Committee on Government Operations, Mar. 16, 1989.
2. Adler NE et al., Psychological responses after abortion, Science, 1990, 248(4951):41–44.
3. Statement of Professor Nancy Adler, University of California at San Francisco on behalf of the American Psychological Association, House Committee on Government Operations, Mar. 16, 1989.
4. American Psychological Association, Task Force on Mental Health and Abortion, Report of the Task Force on Mental Health and Abortion, 2008, <http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf>, accessed May 23, 2013.
5. Charles VE et al., Abortion and long-term mental health outcomes: a systematic review of the evidence, Contraception, 2008, 78(6):436–450, <http://www.jhsph.edu/sebin/o/a/Charles_2008_Contraception.pdf>, accessed May 23, 2013.
6. Coleman PK et al., Induced abortion and anxiety, mood, and substance abuse disorders: isolating the effects of abortion in the national comorbidity survey, Journal of Psychiatric Research, 2009, 43(8):770–776.
7. Guttmacher Institute, Study purporting to show link between abortion and mental health outcomes decisively debunked, news release, Mar. 5, 2012, <http://www.guttmacher.org/media/nr/2012/03/05/>, accessed June 11, 2013.
8. Gilchrest AC et al., Termination of pregnancy and psychiatric morbidity, British Journal of Psychiatry, 1995, 167(2):243–248.
9. National Collaborating Centre for Mental Health, Induced Abortion and Mental Health, London: Academy of Medical Royal Colleges, 2011, <http://www.aomrc.org.uk/doc_view/9432-induced-abortion-and-mental-health>, accessed Apr. 27, 2015.
10. Warren JT, Harvey SM and Henderson JT, Do depression and low self-esteem follow abortion among adolescents? Evidence from a national study, Perspectives on Sexual and Reproductive Health, 2010, 42(4):230–235, <http://onlinelibrary.wiley.com/doi/10.1363/4223010/full>, accessed May 23, 2013.
11. Guttmacher Institute, Counseling and waiting periods for abortion, State Policies in Brief (as of June 2013), 2013, <http://www.guttmacher.org/statecenter/spibs/spib_MWPA.pdf>, accessed June 11, 2013.
12. Demer L, Alaska Senate panel rebuts abortion experts’ testimony, Anchorage Daily News, Feb. 28, 2013, <http://www.mcclatchydc.com/2013/02/28/184410/alaska-senate-panel-rebuts-abortion.html#.UZ5sONKp2I4>, accessed May 23, 2013.
