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Give and Take

Notes on the Public and Personal Exchange of Views on the Psychological Effects of Abortion Between Nada Stotland and David Reardon

 In 1992, the Journal of the American Medical Association published a commentary by psychiatrist Nada Stotland, entitled "The Myth of Abortion Trauma Syndrome." In her commentary Stotland, chair of the Department of Psychiatry and Substance Abuse Services at the Illinois Masonic Medical Center, emphatically insisted that post-abortion trauma "does not exist." Her arguments for this absolutist position were strained and inconsistent with the studies she herself cited (see "JAMA Gymnastics").
In May 1997, I presented a paper on the risk factors predicting psychological problems after an abortion at the 150th American Psychiatric Association Conference in San Diego. (See "Identifying High Risk Abortion Patients" for a partial list of material presented in that paper.)

On June 20th, 1997, Stotland wrote to me saying: "I found your symposium ‘Predictive Factors of Postabortion Maladjustment' very interesting.  Could you please send me a copy of the papers?"
 I immediately complied with her request.  In addition, I included a note asking if she, as the chair of a department dealing with a focus substance abuse would be interested in collaborating on a project to investigate whether or not there was any statistical association between abortion and substance abuse.  Approximately fifteen studies have found such an association, but more research is necessary.  She did not respond to that offer.

In her subsequent book, Abortion: Facts and Feelings (1998), Stotland repeated the assertion that "Abortion does not cause emotional problems or mental illness" (page 106).  But after making this proclamation, the chapter goes on to briefly list feelings of guilt, regret, depression, a sense of loss, anniversary reactions, and depression as possible reactions to abortion.  Then in the next section titled "Emotional Risks," Stotland listed only two situations which "make women more vulnerable to an intense emotional reaction or episode of mental illness after an abortion: 1) especially complicated circumstances, and 2) having a mental illness before the abortion" (p 110).

Unfortunately, Stotland does not provide readers of her book with any definition or explanation for what she describes as "especially complicated circumstances" which put women at adverse risk of psychological sequelae. Her vague comment is especially problematic since most women who abort are doing so precisely because they feel they are caught up in "especially complicated circumstances."
 Despite these admissions of emotional distress after abortion, at least for some women, Stotland concluded the chapter with another broad generalization exonerating abortion from any risks. "Abortion does not cause mental illness," she wrote, "but a stressful situation around a pregnancy can make an existing mental illness worse or, rarely, trigger a new one." (p 114) Even in this reassuring statement, however, she failed to explain why she would exclude abortion from the list of "stressful situation[s] around a pregnancy" that can aggravate or trigger mental illness.

Prior to 1998,  Stotland's position would clearly seem to have been that whenever psychological problems follow an abortion, they must have been caused by something other than the abortion experience itself.  She has never provided any supporting evidence for this conclusion, but it has been the underlying presumption of her repeated assertion that abortion is not the problem; problems only occur when women are already emotionally defective.

Stotland may have begun to softened her position by late 1998, however. At that time she published another paper in which she describes a patient whose miscarriage triggered an unexpected release of intense grief over a prior abortion. In counseling this patient, both the patient's and Stotland's preconceptions about the benign nature of abortion were shook. Her experience with this patient inspired Stotland to write the article to call attention to "the psychological complexities of induced abortion." She observed that no matter what a woman's political perspective may be, "an abortion is experienced by that woman as both the mastery of a difficult life situation and as the loss of a potential life. There is the danger that the political, sociological context can overshadow a woman's authentic, multilayered emotional experience." The failure to address this loss, Stotland writes, "leaves the person vulnerable to reminders and reenactments, to difficulties that may surface in life and in subsequent psychotherapy." ("Abortion: Social Context, Psychodynamic Implications" Am J Psychiatry, 155(7):964-967, 1998).

While Stotland clearly did not retreat from her pro-choice views, it clear that she has started to break through her own denial. She has learned that post-abortion trauma cannot be so easily dismissed as a "myth."  Indeed, her admission that abortion reactions may involve "reenactments" can be interpreted as an oblique concession that abortion may cause post- traumatic stress disorder, at least in some cases, since reenactment is the most reliable element in making a PTSD diagnosis.

On January 19th, 1999, shortly after this article was brought to my attention, I wrote to Dr. Nada Stotland to express appreciation for her article which encouraged therapists to reexamine their own biases regarding the presumption that abortion has no psychological consequences.  With that letter, I also sent along a copy of Hope and Healing asking her to particularly note the article "Beyond the Politics of Abortion" in which I had made a similar appeal for people to be more sensitive to the emotional pain of those who are troubled by a past abortion regardless of their political views on abortion. 

On February 16th, 1999, Stotland replied by letter in the following manner:

Dear Dr. Reardon:

Thanks for your thoughtful reaction to my American Journal of Psychiatry paper.  With regard to "Hope and Healing," I appreciate your piece page on page three.  I can't endorse the whole publication, however, because it is cruelly inaccurate and misleading.  It is not true that four out of five women fall into a high risk category for adverse psychological reactions; if it were true, many more such reactions would be observed. And it fails to note that the women who are at high risk after abortion are at equally or higher risk if they continue their pregnancies.  This is an unconscionable manipulation and misrepresentation of the scientific findings in the service of a one-sided agenda that is a clear and heartless danger to women's psychological and physical health. And I see that the publication is yours.

Nada L. Stotland, M.D.

Following was my response to Dr. Stotland, dated March 9, 1999

Dear Dr. Stotland,

I received your letter dated Feb. 16th.   I am frankly puzzled by your charge that Hope and Healing is "cruelly inaccurate and misleading."  Your only specific charge of inaccuracy is the claim: "It is not true that four out of five women fall into a high risk category for adverse psychological reactions; if it were true, many more such reactions would be observed." 

This is especially puzzling since you had previously requested a copy of my paper "Predictive Factors of Postabortion Maladjustment" which I had presented at the APA convention in 1997 describing it as "very interesting" (letter dated June 20, 1997).  Did you not read it? [link to related article documenting risk factors]

 Regarding the latter point first (that more adverse reactions would be observed if so many were at risk), it is clearly unknown what percentage of women having risk factors actually have post-abortion problems.  This is why I am certainly not claiming that 80% have psychological maladjustments, rather that 80% have one or more of the statistically significant risk factors that have been identified, for the most part, by pro-choice researchers.  (I will expand on this figure more below.)  It is quite possible that only a small percentage of those at risk have significant problems.  If that is the case, that is would explain why post-abortion problems are not more frequently observed in clinical practice.  It does not however alter the fact that a significant majority of abortion patients fall into one or more of the higher risk category.

 Secondly, your assertion assumes that therapists are properly observing and recognizing post-abortion problems.  From reports that I receive from women who have seen therapists subsequent to an abortion, it would appear that most therapists do not inquire about pregnancy loss. Indeed, many women report that even when they specifically make mention of their past abortion, almost always with great hesitancy, many therapists have dismissed it as not significant, in essence either (1) encouraging women to push it back under, or (2) reinforcing the feeling that any post-abortion problems they are facing are so "weird" or "unjustified" that even therapists don't want to bother with them.  Yet when these same women finally find a therapist who understands post-abortion counseling, they make tremendous progress in resolving a wide variety of issues.

 From your paper "Abortion: Social Context, Psychodynamic Implications" it would appear that an inquiry into pregnancy loss has not, at least in the past, been a routine part of your patient evaluation.  This is especially unfortunate since several studies have found strong statistical association between abortion and substance abuse.  Most recently, Thomas et al., found in a population of 82 inpatients admitted for over a one-year period that a prior abortion was associated with more substance abuse, a diagnosis of psychoactive substance abuse disorder, and a history of reported sexual or physical abuse either as children or adults. The authors concluded substance abuse may be more related to reproductive events than previously thought and that women with a history of abortion may be at greater risk of rehospitalization than women with no children.  (T. Thomas, C.D. Tori, J.R. Wile, S.D. Scheidt, "Psychosocial Characteristics of Psychiatric Inpatients with Reproductive Losses," Journal of Health Care for the Poor and Underserved, 7(1):15-23, 1996.)

 As in all of science, we will often fail to observe the obvious if we don't begin by asking the right question.  Conversely, therapists who are trained in post-abortion counseling and ask about pregnancy loss frequently find themselves treating post- abortion issues even when it is not the presenting problem.  For example,  Kent reports that in the course of psychotherapy for 50 women, none of whom were originally seeking treatment for abortion-related problems, deep feelings of pain and bereavement about a prior abortion emerged during the time the patient was recovering from the presenting problem  (Kent, I.,, "Emotional Sequelae of elective Abortion," BC Med J, 20:118-9 (1978)).  He concluded that an underlying sense of loss and pain can only be reliably identified in a clinical setting, and certainly only by a therapist who invites, or at least allows, this issue to be developed.  It is quite likely that another therapist who was not open to examining unresolved post-abortion grief, treating the same patients, would have failed to observe what Kent did.

 Regarding the assertion that it is "not true" that 4 out of 5 women have risk factors, lets look at just a few facts.  To establish a base line, look at Belsey, E.M., et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV," Soc. Sci. & Med., 11:71-82 (1977).  In this study the researchers used just five screening criteria--(1) a history of psychosocial instability, (2) a poor or unstable relationship with the male partner, (3) few friends, (4) a poor work pattern, and (5) failure to take contraceptive precautions and determined that 68 percent of the 326 abortion patients studied should have been referred for more extensive counseling.  Of this high risk group, 72 percent actually did develop negative post-abortion reactions during the three-month follow-up period.  "From a clinician's point of view," Belsey writes, "this result can be viewed as erring on the right side, for a [pre-abortion screening] system that tends to select more women for counseling than is actually necessary is preferable to the reverse." Belsey's five criteria alone suggests that the group of women with risk factors is at least in the neighborhood of 68%.

 Clearly there are many more than these five risk factors Belsey identified.  While certainly there is overlap among the identified risk factors, a review of these factors would tend to identify an increasing percentage of women as being at risk.  Consider, for example, the risk factors identified by Brenda Major and the percentage of women reported having each risk factor: low expectation of coping well (40%), high self character blame (47%), high chance blame (52%), high other person blame (35%), high situation blame (50%), accompanied by partner (33%) (B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599 1985)).

 Now let's look at some of the more generally agreed upon risk factors.  adolescence ( around 30%); prior live birth (around 50%) (add these two together alone and you're at 80%); prior negative moral view of abortion (60 to 70% perhaps as high as 80%), Catholic (around 30%), Evangelical or conservative Protestant (around 25%),  prior abortion i.e., multiple abortions (around 45%); prior emotional instability (I'll let you fill in the blank for the general population). A history of sexual abuse is also complicating factor for post-abortion problems, and I have heard it claimed that as many as 50% of women have been sexually abused as children, though I confess I have no citation for this figure at this time.

 Of special interest, to me at least, is that various studies have found that 65 to 70 percent of women seeking abortions have a negative moral view of abortion. (Zimmerman, Passage Through Abortion (New York: Praeger  Publishers, 1977); Osofsky, eds., The Abortion Experience (New York: Harper and Row, 1973); Reardon, Aborted Women-Silent No More, (Chicago: Loyola  University Press, 1987).)  

 This evidence is supported by a national random poll conducted by the Los Angeles Times which found that 74% of those admitting a past abortion stated that while they believed women should be able to choose for themselves, they personally believed that abortion "is morally wrong."(Los Angeles Times Poll, March 19, 1989, question 76.)  These findings are consistent with polls of the general public which have repeatedly shown that more than 70 percent of Americans admit believing that abortion is immoral.  According to one major poll, 77% of the public believe abortion is the taking of a human life, with 49% equating it with murder.  Only 16 percent claimed to believe that abortion is only "a surgical procedure for removing human tissue." Even one-third of those who describe themselves as strongly pro-choice concede that abortion is the taking of a human life. (James Davison Hunter, Before the Shooting Begins: Searching for Democracy in America's Cultural War (New York: The Free Press, 1994), 93. ) 

 These statistics indicate that for the majority of women, abortion is not a choice that clearly reconciles itself to their moral framework.  It is not embraced but at best accepted as a compromise, a giving into "practical needs," or even submitting to it as an "evil necessity."

 I believe it is the lack of consistency in what women and men believe versus what they have chosen to do which is at the root of so much of the post-abortion problem. 

 I believe it is noteworthy, also, that in Zimmerman's Passage Through Abortion, Zimmerman found that the number of patients divided almost equally between those who were "affiliated" (having strong social a support, focus toward future and career) and those who were "disaffiliated" (weak social support, more dependant on male, less career oriented and more maternal oriented).  She found that the disaffiliated had considerably more post-abortion maladjustments than the affiliated.

 I bring this up because I believe it is a common mistake of feminists to generalize the abortion experience based on the experience of other feminists, the type of women with whom they normally socialize.  But these women are not necessarily representative of the entire population of women choosing abortions.  If may well be true that more educated, career oriented women have fewer problems, if any.  But this more positive experience should not be generalized to include women who have a strong maternal orientation and may be more vulnerable to violating their consciences to satisfy the demands of unwanting or manipulative male partners.

 I would be happy to explore these questions further with you, but I think we must both agree that our experience is limited by the type and number of women we meet who have had abortions.  It may well be that your experience is biased by exposure to women who are least likely to have problems.  It is very clear, I admit, that my experience is limited primarily to those women who report severe remorse, shame, grief, and other emotional sequelae.  I have collected the stories of literally thousands of these women.  I honestly admit that I have less of an understanding of the "other side."  I would hope that you could do the same.  If so, then perhaps we can agree that an ongoing discussion and exchange of information can help both of us broaden our perspectives.

 In your letter, you also make the charge that Hope and Healing "fails to note that the women who are at high risk after abortion are equally high or higher risk if they continue their pregnancies."  I would be most interested in any studies you could point me to that substantiate this claim.  And what, specifically, are they at they at higher risk of suffering?  I would assume that the constellation of problems would be significantly different than those associated with abortion. Certainly you don't believe that women with abortion risk factors who carry to term are at "equally high or higher risk" of experiencing the same kinds of grief, shame, and remorse associated with abortion? 

 In many respects, this is like comparing apples to oranges.  This is why it is a very difficult task that cannot be resolved simply with ideological generalizations.  If in your comment you are simply asserting an anti-motherhood, "common sense" claim that "crazy women" are more likely to be made even more "crazy" by the stresses of motherhood, I believe you are doing women a grave disservice in framing such an unsubstantiated, ideological claim as a fact.  Where is the evidence to support this claim?  From my own knowledge of the literature, it is clear that childbirth compared to abortion is significantly associated with lowerrates of suicide, drug abuse, alcohol abuse, and smoking, to name just a few tangible behavioral measures.

 I would truly appreciate any documentation of your claim for I certainly agree that childbirth, like abortion, will forever change a woman's life.  The question before us, however, is how to measure in some reasonable way how each experience effects the psychological and physical health of women, for good or ill, so that these two options can be meaningfully compared and discussed with pregnant women.  We should not simply assume that childbirth is "worse" nor that abortion is as simple and safe as "turning back time" so that the woman's situation is precisely as it was before she got pregnant.  Abortion, like childbirth, is an experience that will forever alter her life, for good or ill.

 You have described our publication with words like "cruelly inaccurate" and a "clear and heartless danger to women's psychological and physical health."   This begs the question by presuming that abortion is "clearly" beneficial to women's physical and psychological health. 

 Moreover, it runs counter to our experience with the publication.  Neither we nor the editors of the papers in which it has been inserted (total circulation to date around 200,000) have received  even one single complaint from any woman, much less heard a charge that was "cruel" or "heartless."  From this I can only conclude that your complaint does not appear to be shared by a significant number of women. Instead, to the contrary, we have received a great deal of praise and thanks for our compassion.  Women who have had difficult abortion experiences are especially relieved to find that they are not "weird" or alone in their feelings.  They are tremendously relieved to have their feelings validated and understood.  Would it not be far more "cruel" and "heartless" to deprive them this understanding and compassion?

 On the other hand, for women who have not been bothered by their abortions, how can this be "cruel" or "heartless?" If they are not bothered themselves, why should they be bothered that I am reaching out to those who are?  I think you give them too little credit.  Even women who have not been hurt by their abortions can believe and accept that abortion may not be a positive or even a neutral experience for all women.  Certainly they can appreciate that many women were manipulated others into undergoing an unwanted abortion, in violation of their consciences and maternal desires, for the "benefit" of others.  How can it be cruel to reach out to these women?

 There can really be only two groups: those who are not troubled by their abortions, and those who are.  How can reaching out to those who are hurt be "cruel" or "heartless" to either group?  Those who are untroubled will remain untroubled.  Those who are hurt, are appreciative of the understanding and are actively supporting our efforts.

 As I have said, I believe my experience with the hurting group is much greater than yours.  They are guiding and encouraging everything that we are doing.  As an institution, we would not exist without their financial support.  I know theydon't consider it "cruel," exactly the opposite.

 If, on the other hand, you are speaking for those who have not been troubled by their abortions and whose lives have been benefitted by their abortions, I truly fail to see how our outreach efforts to those who are hurting can be hurtful for those who are not.  I would be most interested in an elaboration of your belief on this point.

 I hope you will respond to some of the points and questions I have made in this letter.  I am confident that an on-going discussion of these matters would be very productive.  I am certainly open to learning from you and would hope that you would be willing to gain insights from me as well.


 David C. Reardon, Ph.D.

 P.S. —  I have enclosed a review of the inpatient study by Thomas et al., and a review article of short-term and long-term grief reactions related to abortion which may be of interest to you.

As of this date, February 7, 2000, Dr. Stotland has not responded to my letter, commented on the citations I presented in support of my four out of five estimate, nor provided any citations to bolster her position regarding the rarity of post-abortion problems or her claim that giving birth is more psychologically damaging than abortion.  I remain open to calm and rationale exchange of information and opinions with her.

(Final note: These notes and letters have not been proof read.  Please have mercy on those of us who do not always proof read their work! — DCR)

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copyright 2000 Elliot Institute
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