Abortion and Mental Health Deniers’ Attack and Distract Strategy

Ad Hominem Attacks, Guilt by Association, Shifting Standards, Avoiding Simple Truths

A Commentary by David C. Reardon, Ph.D.

The abortion and mental health controversy shifted into high gear following the recent publication in The British Journal of Psychiatry of a meta-analysis review that combined results of 22 studies and reported that women who have abortions are 81 percent more likely to experience subsequent mental health problems.

The study included all studies between 1995 and 2009 which met strict inclusion criteria. The data included 877,181 women from six countries. Every one of the 22 studies, even those where the authors concluded there were no significant mental health risks, revealed higher rates of mental health problems associated with abortion for at least one symptom, and many for more than one symptom.

Even if one ignores the exact numbers produced by the meta-analysis, the graphs in which these results are laid out side by side show a trend in the data, across every study design, which is unmistakable (as I’ve discussed in a YouTube video review of the study).

Using a standardized statistical technique for combining the results of multiple studies, the meta-analysis revealed that women with a history of abortion face higher rates of anxiety (34 percent higher) and depression (37 percent higher), heavier alcohol (110 percent higher) and marijuana (230 percent higher) use, and higher rates of suicidal behavior (155 percent higher).

The study also found that women who delivered an unplanned pregnancy were significantly less likely to have mental health problems than were similar women who aborted unplanned pregnancies. Women with a history of abortion were 55 percent more likely to have mental health problems than women who did not abort an unplanned pregnancy.

The meta-analysis was conducted by Dr. Priscilla Coleman, a research psychologist at Bowling Green State University in Ohio. Any literature search will show that Coleman is the single most published researcher in the field of abortion and mental health.  She knows the literature as well as anybody, and probably better than anybody — which is why there was a barrage of attacks against the study, the author, and even the journal for choosing to publish it.

Before examining the accusations being raised against Coleman, her study, and the entire body of research examining the association between abortion and mental health, it is useful to put the debate over this issue into its historical context.

Views on Abortion and Mental Health Prior to Legalization

Abortion was legalized in most Western countries in the 1960’s and 70’s, in large part based on the view that legal access to abortion would improve women’s mental health, and their marriages, by reducing the stresses associated with bearing and raising unwanted and/or unplanned children.

There wasn’t much, if any, data to support the view that abortion would improve women’s mental health and satisfaction with their lives, but it seemed to be a reasonable view. Unexpected pregnancies are always stressful. And stress is a major cause of both mental illness and physical illness.

Perhaps more importantly, the push for legalized abortion which had been building during the 50’s and peaked in the 60’s was largely driven and funded by advocates of population control. The threat of a “population explosion” had produced compelling political pressure for allowing abortion as a means to curb the birth of children who were not only unplanned by their parents, but unwanted by an “overpopulated” society.

One of the most influential leaders in the American population control movement was Lawrence Lader, who founded the National Association for the Repeal of Abortion Laws (NARAL) with Dr. Bernard Nathanson.  In his memoir, Abortion II, Lader describes how he persistently lobbied his friend Betty Friedan, author of the The Feminine Mystique and founder of the National Organization of Women (NOW), to accept the idea that “feminist demands hinged on contraception and abortion.”  While Lader reports that Friedan was initially resistant to this idea, he eventually convinced her. Lader was ecstatic. The population control movement had found a new ally in the growing feminist movement. Women, not the population controllers, would from that point forward carry the banner for abortion rights.

By 1967, the American Psychological Association had adopted an official policy to lobby in favor of abortion as a “civil right.”  This was done without any evidence that abortion would improve women’s emotional health or family stability, but purely on the assumption that laws against abortion were unjust and unnecessary.

New Concerns Regarding Abortion Mental Health After Legalization

With the legalization of abortion, a few studies regarding emotional adjustments after abortion were published. Most were restricted to asking about negative feelings within the first hour after the abortion. Only a few did follow-up beyond a day (up to two weeks at most) after the abortion.  And even these saw high rates of women who refused to answer any questions.

All of the studies published in the 70’s reported that some minority of women reported negative reactions during the short time frames for follow-up, but the researchers generally paid little attention to this “minority report.” Instead, they focused their conclusions on the reassuring news that the majority of women who agreed to follow-up interviews appeared to be adjusting well to their experiences, and thus by implication had experienced mental health benefits from having access to abortion.

This prevailing viewpoint began to be challenged in the late 1970’s, when “the few” women who had experienced intense emotional problems after abortion began seeking each other out in peer support groups. These efforts did not have a national impact until 1982, however, when Nancyjo Mann started a group called Women Exploited By Abortion(WEBA) that organized peer counseling programs in nearly every state.

The formation of WEBA marked the start of the social movement of women who had experienced traumatic abortions to minister to each other. At approximately the same time, a small number of psychologists had begun to recognize that women they were treating who had a history of abortion had clusters of symptoms that fit into the newly published criteria for post-traumatic stress disorder (PTSD).  In 1981, family psychotherapist Dr. Vincent Rue was the first to attempt a systematic definition of post-abortion syndrome (PAS) as a variant of PTSD.  He was almost immediately threatened with legal action by the general counsel of the American Psychiatric Association if any notes he published making reference to the PTSD diagnosis for abortion did not include a specific disclaimer stating that the APA denies that there is “any clinical evidence for the basis of the diagnosis of ‘post-abortion syndrome.”(7)

These initial steps toward broader recognition of post-abortion trauma, however, were quickly opposed by abortion supporters.  On the public relations front, the testimonies of women such as Nancyjo Mann were dismissed as “guilt tripping” by a small minority of women.  Even if a few women regretted their abortions, it was argued, at least they “had a choice” and their regrets should not threaten the welfare of the vast majority of women.

At the same time, the academic world quickly closed ranks. While even poorly designed studies “proving” that abortion was safe readily found their way into publication, papers by Rue and other therapists and researchers reporting negative psychological effects of abortion were hostilely received and rejected.  In a few cases, these articles were refused publication with the frank admission of editors that their findings and viewpoints are simply too controversial. It was not until 1992 that Rue’s description of PAS was finally accepted for publication in an official journal of the American Psychological Association, The Journal of Social Issues. Even in this instance, Rue’s paper was invited by the editors of the journal to “bring balance to the special issue,” though all of the eight other published papers were written by pro-abortion authors who disagreed with Rue.

During the 1980’s, researchers supporting abortion produced a new round of studies showing that the majority of women do not report “significant” psychological problems in the first few months following abortion. None of these studies, however, directly addressed the trauma-related symptoms proposed by Rue.  In many respects, it appeared as if these studies, generally done at abortion clinics in collaboration with abortion providers, were designed to avoid looking too deeply or too long at how women’s lives were changed after an abortion.

During this time a new line of reasoning emerged in defense of abortion. To explain the fact that a significant minority of women report negative reactions no matter how a study is designed,  researchers began to suggest that the negatively effected women were those who were most psychologically fragile before their abortions and therefore would have been worse off if they had carried to term.  In other words, the same “blame the victim” approach that had been used in the case of hysteria and “shell shock” was being applied to abortion patients.  According to this theory, only defective, “weak” women had problems adjusting to an abortion.  But, the researchers speculated,  these women would probably have had more problems if they had carried to term.

By the mid-1980’s, the disagreement between those who denied a connection between abortion and mental health problems and those who believed in this connection — whether by personal experience (WEBA) or by clinical experience (Rue and others) — had caught the attention of politicians. Anti-abortion lobbyists had begun to embrace evidence that some women are harmed by abortion as a new argument against unrestricted access to abortion. This argument naturally provoked a strong counter-reaction from political organizations favoring abortion rights.

A Public Spotlight on the Abortion and the Mental Health Issue

In 1987, an aide to President Ronald Reagan convinced the president to ask Surgeon General C. Everett Koop to prepare a report on the physical and psychological effects of abortion. Suddenly, the issue of abortion’s impact was big news.

Koop saw his task as an impossible one. He asked the president to excuse him from this politically contentious request, but his request was denied. In the end, in 1989 Koop delivered a letter to the president stating that all of the research in the field was so methodologically flawed that he could not offer any firm conclusions either for or against the safety of abortion.

In the aftermath of Koop’s letter, a sharp divide emerged among researchers about whether or not there was any meaningful connection between abortion and subsequent mental health problems.  One of the most prominent leaders of the group denying any connection was Dr. Nada Stotland, an outspoken feminist who would later become the president of the American Psychiatric Association.

In a 1992 commentary entitled “The Myth of Abortion Trauma Syndrome” published in the prestigious Journal of the American Medical Association, Stotland unequivocally declared that post-abortion trauma “does not exist” and that “there is no evidence of an abortion trauma syndrome.”  In making this proclamation, she avoided any direct reference to the published works of Rue or other abortion skeptics.  Moreover, the results of studies she did cite were blatantly misrepresented.

Notably, seven years later Stotland published a case study in which she admitted being surprised by the profound delayed negative reaction to abortion that was experienced by a former patient who returned for counseling after experiencing a miscarriage that triggered unresolved issues with a prior abortion.

The Decades Following Koop’s Non-Report

In the two decades since “abortion trauma syndrome” was declared a myth, dozens of studies were published that followed women over longer periods of time and used more control variables and control groups. Nearly every one has affirmed an association between abortion and mental health problems for at least a significant minority of women — generally not less than 10 percent, and often several times more.

In every case, deniers of the abortion and mental health link have pointed to weaknesses in the study’s designs and argued that the results were not clear and conclusive enough to warrant public concern, or even disclosure of the findings to abortion patients.  Conversely, believers in the abortion and mental health link have argued that these statistical findings affirm that the self-reports of women and case studies of clinicians are not isolated cases, but describe symptoms that can be found in a substantial percentage of abortion patients.

As a the body of studies published since 1995 grew, so did the pressure to re-evaluate the evidence in one or more comprehensive reviews of that literature. The first and most influential of these reviews was published in 2008 by the American Psychological Association Task Force on Abortion and Mental Health.

Since the APA already had an official policy position to defend abortion rights, the task force was hand picked and included only abortion rights proponents from within the APA.  The report was seriously flawed both in its design and presentation. It lacked any objective evaluation of the evidence, such as a statistical meta-analysis, and relied entirely on subjective criticisms regarding why each study had flaws that justified ignoring their findings. Almost none of the actual statistics reported by the various studies were reported on, and the conclusions of the review were nuanced and misleading, supported by only one study.

The APA report was in turn widely criticized for itself being biased.  And the accusations of bias have been flying back and forth ever since.

Coleman’s meta-analysis was an attempt to take bias out of the way that the studies published since 1995 are weighed.  Her approach was to simply apply the standardized statistical techniques of meta-analysis as they are applied in other areas of research and public health.

Publication of Coleman’s report was at least an attempt to bring abortion and mental health research up the same standards of evaluation that are used in pharmaceutical trials.  But her effort immediately triggered charges that she, and everyone else involved in studies finding negative mental health effects with abortion, are biased.

In some of these accusations, I myself have been specifically cited as “proof” that Coleman is biased and her meta-analysis is unreliable.  Since I have collaborated with Coleman on a number of studies, this is an attempt at “guilt by association.”

Below is an unpublished letter which I drafted for the British Journal of Psychiatry in response to these charges. It also addresses other concerns raised by critics of the abortion/mental health link and seeks to put these findings into a reasonable context.

Letter in Response to to Critics of the Coleman Meta-Analysis

(originally submitted in a somewhat modified form to the British Journal of Psychiatry)

Dear Editor,

The letter of Drs. Robinson, Stotland and Nadelson concisely invokes many accusations and misrepresentations. It totally ignores the remarkable consistency in the trend of findings and instead resorts to the age-old tactic of attacking the author with ad hominem and guilt by association charges.

The authors argue that the peer reviewers and editors of the British Journal of Psychiatry  failed to serve the public interest when they decided to publish Coleman’s work, which they insist is riddled with “deficiencies and biases.”  But the objectivity of these critics is itself called into question because of their own open advocacy for abortion and unequivocal assertions that abortion has no mental health risks.(1)

More importantly, what is the evidence that these authors presented for the deficiencies and bias of Dr. Coleman’s analysis? It consists of nothing more than ad hominem attacks, charges of guilt by association, shifting standards for evaluating medical evidence, and a hodgepodge of misrepresentations.

Since I am one of the “tarballs” hurled at Dr. Coleman, I feel obliged to respond to a number of the charges raised and to put the quotes attributed to me into their proper context. I will also address other charges and misrepresentations they have made.

Regarding Guilt by Association

  • Contrary to their assertion, I am not in any way Dr. Coleman’s “leader.” We have no institutional or financial entanglements. Her views are her own, as are mine. I have every reason to believe that Coleman is just as intelligent, independent, and pro-woman as are Drs. Robinson, Stotland and Nadelson. I am very thankful for the times Dr. Coleman has agreed to analyze data sets which I have gathered or received access to. But it is sheer nonsense to conclude that I am her “leader” — or the “leader” of anyone else with whom I have co-authored papers.
  • I am a biomedical ethicists, not a research psychologist. Since I have gathered data that would benefit from analysis by research psychologists, I have actively sought to collaborate with such experts, including Dr. Coleman. I am keenly aware of my limitations and also my need to rely on the expertise of others. At the same time, my training in the sciences allows me to understand, respect, and follow the scientific process and to recognize the differences between fact-based scientific conclusions and philosophical arguments.
  • As a biomedical ethicist, I explore the intersections of medicine, science, philosophy, theology, ethics, and the law. When writing papers intended for each of these fields, I seek to use the language and tools appropriate to that field. With regard to the studies I have co-authored, that task is made easier by collaborating with specialists, such as Dr. Coleman, who will instantly correct any slips on my part.
  • The quotes attributed to me by Robinson et al. (for the purpose of accusing Coleman of bias by association) are from an article I wrote for Ethics & Medicine.(2) Contributors to this journal on medical ethics are expected to present their positions in the languages of philosophy, theology, science, and law. The cited article was my response to a critic who posed his arguments against my work specifically in moral and religious terms. I responded within that same framework. By cherry-picking these quotes to reprint, out of context, in their letter, Robinson et al. are seeking to imply (a) that I am a religious nut who is unable to distinguish between scientific conclusions and ethical arguments, and (b) that Coleman is guilty by association of the same cognitive disability. Neither accusation is true.
  • Specifically, the Ethics & Medicine article was a response to a pro-life philosopher who argued that any evidence of emotional suffering of women following abortion is essentially irrelevant to the moral argument against abortion and counterproductive to pro-life efforts.(4) The core of my response was that Christians have an obligation to “consistently demonstrate as much concern for women as for their unborn children,” and that “our advocacy for women must be consistent and unconditional both for those who are facing crisis pregnancies and for those who have had abortions.” I further argued that “the harm abortion does to women is just as real as that done to the human fetus.”(2)
  • The arguments raised by this pro-life philosopher underscore how women who dare to voice their emotional trials following an abortion face rejection from people on both sides of the abortion debate. On one hand, at least some of those see abortion as a fundamental women’s right that needs to be protected from slander tend to dismiss these women as “rare” exceptions, or even “whiners.” On the other hand, some pro-lifers (hopefully a small minority) view women who have had abortions as sinners who deserve to suffer a lifetime of grief, guilt, self-hatred, and more.
  • I am among those involved in the post-abortion healing movement who simply advocate for the view that people on both sides of the debate should (a) listen to the experiences of women grieving a past abortion, (b) show them empathy and respect, and (c) strive to create a more non-judgmental, healing environment for those who do struggle with a past abortion. But even that mild position comes under attacks from zealots on both sides of the abortion debate. On one hand, pro-choicers have accused me of manipulating gullible women into falsely blaming unrelated life problems on their abortions.(3) On the other hand, some pro-life advocates have accused me of encouraging an unprincipled, narcissistic worldview that diminishes the moral absolutes regarding abortion and the sanctity of life.(4)
  • My Ethics & Medicine paper was an attempt to respond to the latter accusation. It should be read in that context. I was debating with a Christian who was making appeals to a largely Christian audience. Appealing to the same audience, I proposed that Christian ethics require pro-lifers to demonstrate authentic compassion toward both those women who might be having abortions tomorrow and those who have already had abortions. My challenge to them was not to abandon pro-life principles but rather to embrace pro-woman principles with equal vigor.
  • I fail to see the logic in Robinson et al.’s suggestion that my voicing such views disqualifies me (much less any and all persons I have ever collaborated with, such as Dr. Coleman) from being trustworthy in regard to our statistical analyses of rates of psychological hospitalization following abortion, delivery, or miscarriage.(5) Just as judges are expected to set aside personal views when judging evidence applying to a particular trial, I too strive (as I hope all researchers and peer reviewers do) to set aside personal views when interpreting the results of a specific study. I have seen no evidence in the studies we have published that I or my co-authors have failed to make these distinctions.
  • More pointedly, why is my concern and empathy for women who have had abortions more disqualifying then Robinson et al.’s concern and empathy for women?

Regarding Subgroups of Women at Higher Risk

  • In 1982 I became aware of hundreds of women who independently formed their own peer support group for help in coping with their past abortions.(6) I interviewed and surveyed these women to discover what their experience and recovery process was like. In my surveys, over half reported subsequent suicidal thoughts and emotional conflicts associated with their abortions.(7) The type of language used by women I interviewed was very similar to that used in the widely publicized suicide note of a woman named Emma Beck, in which she explained why she could no longer endure the emotional pain which followed the abortion of her twins.(8)
  • Obviously, any research with a self-identified population of women reporting problems with a past abortion cannot be reliably projected on the entire population of all women. On the other hand, the task of identifying symptoms that women attribute to their abortions is an essential step in the process of designing studies to investigate these phenomena in the general population. Unfortunately, the step of exploring what those who complain of a problem actually have to say for themselves has frequently been skipped by other researchers.
  • My interviews with these women convinced me that many of the women who are most devastated by their abortion experiences actually underwent unwanted abortions. Unwanted abortions occur when women feel or are coerced or or manipulated into “choosing” an abortion against their own moral values or maternal preferences.
  • My additional reviews of the published literature affirmed my view that there are clearly discernible subgroups of women who are at greater risk of experiencing more negative reactions to abortion.(9) The recent APA task force report on abortion has also affirmed this conclusion, listing at least fifteen risk factors for greater psychological distress following an abortion.(10)
  • This brings us to the core issue in medical ethics that I have sought to raise. If there are some subgroups of women, no matter how small or large, who are vulnerable to coerced or unsafe abortions, what are a physician’s obligations in those cases? If a woman is “requesting” the abortion only because she has been coerced or abandoned, is the doctor who does such an abortion contributing to an act of self-actualization or an act of self-immolation? If a woman is requesting an abortion based on misinformation and false expectations, does the attending physician have a duty to correct those false expectations?
  • Screening for risk factors is an essential component of all ethical medical care. I have argued that this process should not be waived simply because a woman is requesting an abortion. Unless doctors carefully screen for known risk factors, I have argued, it is impossible for them to properly evaluate the potential risks and benefits relative to each individual woman’s unique medical and psycho-social profile.(9)

Regarding Heightened Resistance to Negative Findings

  • To the degree that better screening practices may help to curtail unwanted, unsafe, or unnecessary abortions, one would think that people on both sides of the abortion debate could agree that such screening should take place to minimize the incidence of unwanted, unsafe, or unnecessary abortions.
  • Unfortunately, not all health care providers view abortion decisions purely from a medical perspective. Some view abortion as a tool for social engineering. They argue that the priority of reducing birthrates among certain classes of women excuses turning a blind eye to coercion and other risk factors in order to maintain a high rate of abortion among groups of women who would not be “good mothers.”(9) Naturally, such abortion proponents (who are hopefully in the minority) are particularly hostile toward any evidence that abortion is ever contraindicated — especially among those women who are in the most disfavored classes.
  • Another source of disproportionate hostility toward any evidence that abortion may hurt some women arises among health care providers who have taken part in the abortion decisions of their patients. Countless therapists, for example, have had clients ask, “I’m thinking about having an abortion. What do you think?” Women who are already in counseling when they discover they are pregnant may have many reasons for asking this question. Some are seeking moral approval. Others may be seeking affirmation that they can be good mothers and things will work out. Still others just want information about how they are likely to cope either way.
  • Whatever the woman’s key interest in involving her therapist, therapists who have assured clients that the abortion might be a good choice are now at least partially involved in that abortion decision. Many have been involved in dozens or even hundreds of abortion decisions. Naturally, each involvement adds to the caretaker’s psychological investment in the belief that abortion helps women.
  • Maintaining this belief is important because health care providers want to be healers. But this psychological investment also creates resistance to evidence suggesting that abortion may be harmful to some patients. No one wants to contemplate the idea that the reassurances one gave to a patient may have led to disaster rather than freedom. So the easiest way to avoid introspection and re-evaluation is to simply dismiss any evidence of negative findings as “junk science.”
  • In short, it is not uncommon for medical professionals to readily acknowledge that a medical procedure carries risks, especially for certain subgroups of patients who have pre-existing factors that may be associated with a higher rate of negative reactions. From that perspective, one would expect health care workers to readily accept that abortion may be problematic for some women. But because of the highly politicized nature of abortion, and its identification as a hard-won and essential right of modern women, and because of the large number of health care workers who have been involved in the abortion decisions of patients or family members, the resistance to studies identifying risks associated with abortion may be far higher than that which would apply to any less controversial procedure.

Regarding Accusations of Incompetence and Ignorance

  • Robinson et al. throw out a blanket accusation that the studies Coleman and I have been involved with are methodologically flawed.  It would be more accurate to say that every study done in this field has methodological weaknesses. Ours are no exception. There are no perfect studies because it is simply impossible to undertake randomized double-blind studies of human abortion. However, the peer review process has ensured that the balance of strengths and weaknesses in our studies are not substantially dissimilar to those of other studies in the field.
  • They also accuse us of “repeatedly fail[ing] to control for pre-existing mental health problems.” That is simply not true. Most of our studies include numerous controls. Our Medi-Cal studies, for example, excluded women with a history of psychiatric inpatient treatment in the year prior to their pregnancy.(9, 11) Another of our Medi-Cal studies, examining sleep disorders following pregnancy outcome, excluded women treated for sleep disorders in the year prior to the pregnancy.(12) Still, another controlled for pre-pregnancy self-esteem and locus of control scores.(13)
  • Because the data available to us has always been limited, we would not claim that any of our analyses have sufficiently controlled for the women’s complete psychiatric history. But no other study can make such a claim, either.
  • This is a difficult field of research with many possible confounding effects, most of which may not be documented or accessible for analysis. So, it is easy to point out possible confounding variables that we, and every other researcher, have failed to investigate. But the lack of perfect data should not stop publication of research using the best data available, in this field or any other. We are making at least incremental advances.
  • The bottom line is that Robinson et al. have no objective justification for identifying our studies as weaker than any others in the field. Indeed, ours were among the first to employ at least remedial controls for prior psychiatric history and were also among the first to compare women who abort to control groups (to women who carried to term, women who carried an unplanned pregnancy to term, or women who had miscarriages.) By contrast, most studies published prior to 1995 were simply descriptive studies of how women who had abortions coped, based on follow-up interviews within two weeks to one year after their abortions. Most pre-1995 studies lacked any control group for comparisons. It is for that reason that so many studies were excluded from Coleman’s  meta-analysis, which specifically required control groups.

Regarding the Causality Issue

  • Robinson et al also accuse us of “consistently fail[ing] to differentiate between an association and a causal relationship.” This, too, is categorically false. Examination of the cited studies, or indeed any of our studies, shows that we have never claimed that the statistical associations described in our results prove a causal relationship between abortion and the observed outcomes. We know the difference between association and causal relationship, as do our peer reviewers and editors.
  • While proving causal relationships is possible in physical sciences, it is difficult if not impossible to do so in the social sciences — especially in the context of a single study. The accusation that we do not understand these principles is simply demeaning and absurd.
  • Moreover, the causal question cuts both ways. In the 1960’s it was predicted that greater access to abortion would improve women’s mental health because it would spare them the stresses associated with bearing and raising unwanted children. But hundreds of studies since have failed to show any statistically-significant mental health benefits that are even associated with abortion, much less causally attributable to it. To the contrary, the entire body of literature consistently finds subgroups of women who report difficulty coping with a past abortion, both in the shorter and longer term.
  • Faced with these findings, two interrelated arguments have been advanced to justify the practice of constantly reassuring the public that abortion has no mental health consequences.
  • The first argument blames all observed effects entirely on pre-existing mental health problems. This approach is similar to the blame-the-victim argument made against “malingerers” who suffered shell-shock during World War I. Fit men, it was argued, would not crumble under the pressures of war. Therefore, those who became mentally unfit during wartime must have been mentally unfit beforehand.(14)
  • The second argument asserts that those of us who have identified risks associated with abortion have failed to prove that abortion “in and of itself” is the sole cause of the higher rates of mental health problems. In other words, abortion should be assumed innocent until proven guilty beyond a reasonable doubt.
  • But this latter challenge ignores the accepted standard of proof that applies to all other forms of medical treatment, which places the burden of proving efficacy and safety on those advocating for a proposed treatment. Trials of new drug therapies, for example, are expected to show that the proposed treatment (a) is the direct cause of benefits, and (b) has nominal risks relative to the proven benefits. Why doesn’t the same standard of proof apply to abortion?
  • It may be that women fitting a certain psycho-social profile do benefit from abortion. But to my knowledge, no study has yet identified what benefits are most associated with what characteristics. Instead of rising to the challenge of proving the circumstance under which abortion is most likely to benefit women, abortion defenders have mostly just asserted that abortion is a special case and standards of proof should be reversed. Moreover, they appear to be arguing that abortion is such a special case that is inappropriate to publish studies and reviews which question the doctrine that abortion is safe and beneficial, until there is unimpeachable evidence that abortion is the sole, direct cause of the mental health problems.
  • Regarding the question of causality, neither I, nor any other researcher I know, would ever suggest that causal paths can be proven by any single study. But certainly informed people should be free to form their own opinions regarding the likelihood that abortion contributes to mental health problems in light of the available evidence. That includes women considering an abortion.
  • In my own personal view, the strongest evidence for concluding that abortion has a direct impact on psychological health are the claims to that effect made by thousands of intelligent, self-aware women. I personally tend to accept what they claim at face value.
  • The evidentiary value of these self-assessments are affirmed by trained therapists who have worked with these women through the process of healing.(7, 15) The experience and conclusions of these therapists assure us that these women are not delusional in attributing their psychological distress to their abortions. Moreover, there is evidence that therapy which recognizes abortion as a significant psychological loss is effective in reducing symptoms.(15)
  • In a case study published by Nada Stotland, co-author of the Robinsen et al letter, even Dr. Stotland has acknowledged observing and treating unexpected, disturbing, and complex psychological reactions to abortion.(16)

Abortion as a Contributing Cause of Mental Health Problems

  • Starting from the premise that these women and their therapists are not liars, it has always been my view that where there is so much smoke there has to be some fire. I certainly do not believe that abortion is the sole cause of everything that has been reported. Instead, I generally consider most human experiences and human reactions to be due to “multiple factors of causation.”
  • From that perspective, I feel confident in asserting that there is clear and convincing evidence that abortion contributes to mental health problems. Since every person has mental health flaws, it seems likely that abortion, like any stressful life experiences, will exert stress along the fault lines to which each individual is most pre-disposed. In this respect, abortion can be a precipitating factor or an aggravating factor in subsequent mental illness. It may also be a complicating factor that prolongs or delays recovery from a pre-existing mental illness. Abortion may also be link in a chain of experiences (i.e., child-abuse, sexual abuse, substance abuse, adolescent pregnancy, abortion) which feed an accelerating trend toward increasing alienation or self-destructive behaviors. Abortion involves medical intervention, and is also a medical intervention associated with higher rates of pre-existing problems that, left untreated, will continue to undermine the physical and mental health of patients. It therefore seems clear to me that doctors should recognize a request for abortion or a history of abortion as a marker for identifying women who may benefit from additional screening and counseling services.
  • In short, while I do not exclude the possibility that abortion can be the sole cause of some mental illness, I assert that it is absurd to deny that abortion contributes to at least some manifestations of mental illness. From that view point, I would not challenge the hypothesis that other factors in Emma Beck’s genetic or environmental experience may have predisposed her to despair and suicide. But given her suicide note attributing her suicide to her abortion, it is simply absurd to pretend that her abortion did not contribute to her suicidal act of despair and self-destruction.(8)

Concluding Observations

When one examines the tables in Coleman’s meta-analysis, which visually lay out the findings of 22 studies side by side in a standardized way, there is clearly a remarkable consistency in the trend of findings. Most importantly, the studies employ many different designs, with different strengths and weaknesses. This suggests that the trend is real and substantial.

But even if abortion is not the direct cause of mental health problems, it is at least a marker for higher risk of mental health problems. A history of abortion, therefore, can and should be used as a flag to identify patients who may benefit from a referral.

It is also clear that a substantial number of women attribute some portion of their mental health problems to their abortions.(7, 17) To my mind, the question of whether abortion is the sole, direct cause of certain mental illnesses is far less important than the fact that many self-aware women want help coping with a past abortion experience. Why is it so hard to simply accept their self-assessment and stated need?

Many women have reported that when they try to raise the issue of unresolved abortion issues with their therapists, their abortion history is dismissed as being essentially irrelevant.(7) Some report being told that they should instead just focus on how they were treated by their parents or some other issue with which the therapist is more familiar.

Women deserve better than this.

Clearly, the evidence presented in this meta-analysis should at least encourage everyone to listen more carefully to those women who do attribute emotional problems to their past abortions.

Is anything really gained by dismissing their claims as misguided? Why not simply accept their assertions of cause and effect as at least a reasonable hypothesis and move on to address their current needs with as much compassion as we can? The alternative, in my view, is terribly insensitive, alienating, and counter-productive.


1. Stotland NL. The myth of the abortion trauma syndrome. JAMA. 1992 Oct 21;268 (15):2078-9.  See also, JAMA Gymanstics: Jumping Through Hoops to Prove Abortion is Safe.  Also, Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M. Is there an ‘abortion trauma syndrome’? Critiquing the evidence. Harv Rev Psychiatry 2009; 17: 268-90.

2. Reardon DC. A defense of the neglected rhetorical strategy (NRS) Ethics Med. 2002 Summer;18(2):23-32.

3. Baezlon E. Is There a Post-Abortion Syndrome? New York Times Magazine. January 21 2007

4. Beckwith FJ. Taking abortion seriously: a philosophical critique of the new anti-abortion rhetorical shift. Ethics Med. 2001 Fall;17(3):155-66.

5. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ. 2003 May 13;168(10):1253-6.

6. Reardon DC. Aborted Women: Silent No More. Chicago, Ill: LoyolaUniversityPress; 1987.

7. Burke T, Reardon DC. Forbidden Grief: The Unspoken Pain of Abortion. Springfield, Ill: Acorn Books; 2002.

8. Artist hanged herself after aborting her twins. The Telegraph. 22 Feb 2008.

9. Reardon DC. Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment. J Contemp Health Law Policy. 2003 Winter; 20(1):33-114.

10. American Psychological Association Task Force on Mental Health and Abortion. Report of the American Psychological Association Task Force on Mental Health and Abortion. APA, 2008.

11. Coleman PK, Reardon DC, Rue VM, Cougle JR.State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. American Journal of Orthopsychiatry, 2002; 72(1):141-52.

12. Reardon DC. Coleman PK Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006 Jan;29(1):105-6.

13. Reardon DC, Coleman PK, Cougle J. Substance use associated with prior history of abortion and unintended birth: a national cross sectional cohort study. Am J Drug Alcohol Abuse 2004; 26: 369-83.

14. Herman J. Trauma and Recovery: The Aftermath of Violence–from Domestic Abuse to Political Terror. New York: NY: Basic Books; 1997.

15. Layer SD, Roberts C, Wild K, Walters J. Postabortion grief: evaluating the possible efficacy of a spiritual group intervention. Research on Social Work Practice 2004: 14(5) 344-350.

16. Stotland N. Abortion: Social Context, Psychodynamic Implications. Am J Psychiatry. 1998; 155(7):964-967. See also and Nada Stotland Admits Psychological Impact of Abortion

17. Rue VM, Coleman PK, Rue JJ,ReardonDC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit, 2004 10(10): SR5-16.

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