facts and opinion Abortion in 1975: The Psychiatric Perspective With a Discussion of Abortion and Contraception in Adolescence PETER D. BARGLOW, M D A psychiatrist professionally concerned primarily with the area of obstetrics and gynecology shares his views on the impact of legalized
,abortion, with a focus on adolescents. He emphasizes his view that adolescents should be given more realistic, relevant sex education and counseling, especially regarding methods of contraception.
How did perspectives on abortion change in America in 1975? Such a broad question implies numerous clarifications, limitations, and subquestions and requires an immediate statement of the respondent’s frame of reference. I am a psychiatrist, psychoanalyst, clinician, and researcher-not a politician, social scientist, lawyer, or religious zealot. I accept the theoretical position that the law represents and follows the needs and attitudes of large segments of society. According to this position, therapeutic abortion as legitimized by the U.S. Supreme Court on January 22, 1973, was only one consequence of the liberalizing sociocultural ferment that also produced the anti-war, civil rights, women’s liberation, and more recently, the consumer’s movements. The social consequences of legal abortion can hardly be disentangled from the implications of these other complex trends, but perhaps there are some discernable changes in the daily practice of a psychiatrist preoccupied with obstetrics and gynecology.
BEFORE 1973 I have not interviewed, for years now, a woman like a patient I once treated for emotional difficulty in adjusting to permanent infertility, secondary to the peritonitis and bowel fistulae resulting from a Chicago Southside motel abortion. Now that almost a million legal U.S. abortions January/February 1976 JOGN Nursing
are performed each year, the old disputes about psychiatric sequelae of this procedure have almost disappeared from the psychiatric literature. Marked differences of “scientific” opinion about the psychologic outcome of abortion reported over many decades apparently mirrored disagreement within public opinion and were the product of differing moral, religious, and philosophic positions. Early clinical studies of psychic aftermaths of abortion uniformly reported major psychologic damage, but psychiatric papers during the 1950s and 1960s contained descriptions of marked mental benefits from the procedure.’ I too participated in one of the larger studies2 We found that most of the 48 womerl in our study qualified for abortion by the then accepted criteria and that, with rare exceptions, they did well afterward. Diagnostically, the majority of patients seemed to belong in either the “borderline psychotic” or “psychotic” category. Most had histories characterized by inadequate life functioning, psychiatric hospitalizations, suicide attempts, or psychotic episodes. All experienced a worsening of their emotional status during the pregnancy, and very few could imagine carrying the pregnancy to term. It seemed certain that these women would have deteriorated psychiatrically if forced to continue the unwanted pregnancy. Our study indicated that two-thirds of the group would have been 41
serious suicidal risks or undergone psychotic decompensation, i.e., loss of ability to function nonpsychotically if not granted an abortion. However, a sample of this large number of patients in subsequent years did lead surprisingly normal lives, despite their neuroses. The remaining one-third were clearly psychologically ill and confronted by adverse life circumstances but did not meet the legal criteria for therapeutic abortion. Despite this, they all obtained legal abortions. We found very few instances of genuine conscious manipulation by the patients to account for this discrepancy. Therefore, it is likely that distortion occurred either in the way they presented themselves inadvertantly, or else had its source in the examining psychiatrists. It can be speculated that the structure of the preabortion interviews emphasized psychopathology, unlike the research interviews which encouraged denial of pathology. The manifest function of the preabortion interview was to reveal rather than to suppress pathology. Long-term effects of abortions were, on the whole, quite favorable. Approximately three-fourths of the patients reported subjective impressions of improved emotional status, and psychiatric histories were consistent with these impressions. Two patients, each of whom reported submitting to the abortion against her will, experienced prolonged adverse effects which they attributed to the abortion. Twelve patients experienced conscious guilt, but only two of these would have decided not to have the abortion if given the choice again. Eight patients reported that the abortion experience eventually led to emotional growth. It was concluded that, with rare exceptions, abortion was genuinely therapeutic.
SINCE 1973 This conclusion about the psychiatric effects of abortion certainly reflects the contemporary opinion of the psychiatric profession as a whole. Recently we have also seen documentation of results following refusal to perform abortion. H ~ o k ein , ~an 8- to 10-year followup of 294 women denied an abortion, found that 24% had continued significant negative emotional sequelae. Most of them had demonstrated pathologic reactions including frequent punitive hate reactions against the child and major social difficulties connected with care or placement of the child; 31% were judged to be providing an unfavorable environment for their child. Forssman4 compared 134 children whose mothers were refused abortions with a group of children whose mothers wanted the pregnancy. The former group had less education and showed more family 42
instability, antisocial and criminal behavior, need for psychiatric care, and requests for public assistance. Caplan’ describes disturbances in the relationships of mothers who were refused abortions to the children who resulted. For these reasons and many others, anti-abortionists have abandoned the “ill-effects” and psychologic arenas to concentrate their efforts on the political-legal battlefield. No special expertise qualifies a physician to evaluate the impact of making the fetus a human being with all the rights of a citiOf course, we can worry about the possibility that the conferring of :personhood” on a fetus may imply civil and criminal legal charges against the woman who accidentally damages a pregnancy, or that the IUD or postpregnancy hormones may constitute conception-disrupting murder rather than acceptable contraception. Psychologists can admire the propaganda still inherent in the anti-abortion “right-to-life” concept. (What monster can be against life?) But the formula, child-equals-fertilized-ovum, adroitly confuses the acorn with the oak tree, a potentiality with an actuality. Recently, Dr. D. Purpura of Albert Einstein University located the beginning of human life between the 28th and 32nd week of pregnancy on the basis of cerebral cortex maturity established by fetal neuroanatomic cellular structure.‘ But such issues belong to the realms of social activism and philosophy rather than to the lives of individuals grouped by psychodynamics. There are, however, new and clearer issues emerging that vitally concern psychiatrists and should concern all those involved in Ob/Gyn health care. There exists a new group for whom psychiatric assessment of responses to interruption of pregnancy is particularly important and which demonstrates these issues. I refer to girls who have reached adolescence in the 1970s. Abortion in Adolescence Two years ago we investigated the psychologic reactions of adolescent girls undergoing abortion during the first trimester of pregnancy at the Michael Reese Hospital Pregnancy Termination Unit.’ By July 1, 1973, the Unit had served 365 patients, including 78 adolescents with broadly varied ethnic and economic backgrounds. On the average, these girls, particularly the younger ones, had been pregnant longer than adult patients seen at the Unit, partly because of delays in awareness of pregnancy (due to ignorance or subconscious defensive denial) and partly because of conscious concealment due to fear of parental disapproval or anger. Parents and boyfriends exerted considerable influence on the January/February 1976 JOGN Nursing
abortion decision, especially when the adolescent was very young or emotionally immature. The parents often reassumed total, often dictatorial, responsibility for the adolescent’s life, with potential positive and negative consequences. The adolescent might feel protected, narcissistically supplied, and grateful, and could alleviate guilt by blaming the decision on the parent. On the other hand, the abortion acceptance might symbolize a passive acquiescence to the intruding parent, heightening dependency conflicts and exacerbating depression. Developmental immaturity contributed not only to ambivalence about the decision but also to a distorted perception of the procedure and to a variety of pathologic reactions. Almost all the adolescent subjects experienced the abortion procedure as frightening, dangerous, and punitive, and often as temporarily overwhelming. An attempt was made to follow up 50 of the girls 1 to 3 months after their abortions, but only half of them could be contacted. Twenty-one of those contacted were doing well psychologically, and most of them felt that the abortion procedure had been a positive and beneficial event. However, they all had experienced a multiplicity of psychic and somatic symptoms which were transitory and limited in severity. These symptoms were considered to be evidence of the mourning process, precipitated by the loss of an “expectation” rather than by an object loss. The other 4 girls had conscious regrets and doubts about the abortion. Two of them were severely depressed: One showed excessive hypochondriasis, and the other developed a paranoid psychosis. These symptoms, in the writers’ opinion, represented pathologic mourning. Two of the 4 patients had prior histories of psychiatric difficulties, and one had decompensated prior to the abortion. We concluded that more careful screening and diagnostic evaluation permitting earlier psychiatric intervention should minimize the possibility of most adverse postabortion reactions. The complications just described constitute a reminder that abortion for adolescents involves much more than a technician removing a carelessly embedded splinter from a youthful finger. This observation is buttressed by the behavior and dreams of several of our subjects. For instance, a 16-year-old girl was chosen by chance to be the first patient aborted that day. She wept and screamed in terror continuously during the procedure while tensing her voluntary musculature. The social worker was called in and calmed her by holding her hand and talking reassuringly to her. The following was her postabortion dream: “ I dreamed the devil performed the abortion. He January/February 1976 JOGN Nursing
just reached up his black hand, pulled it out, and then danced around me with it in his arms while laughing and yelling.” Evaluation of this adolescent revealed that the father had not lived with the family for many years. The patient had been acting out sexually and aggressively, actively defying maternal wishes and prohibitions since attaining puberty. Her Black Muslim mother claimed she had to resort to threats of physical punishment and future Hell’s damnation in order to control her daughter. The patient had felt that “my mother would kill me” when she became pregnant and that abortion was “a sin for which God will punish me.” The patient’s superego clearly was primitive and self-punitive, with the hallmarks of delay in the internalization of standards, i.e., failure to adopt personal standards of behavior. Fears of violence were often expressed by the manifest content of repetitive dreams. A single 16year-old student was psychiatrically evaluated for severe depression with suicidal preoccupation a few months following her second abortion. She said that her psychotherapist had “forced her to give up her pregnancy.” A review of her history prior to this abortion indicated that she had refused consciously to be aborted but had made numerous suicidal threats. This factor and a variety of incapacitating psychosomatic symptoms persuaded her to give a reluctant consent to the abortion. Further investigation indicated that she had been struggling for several years to establish her independence from an infantilizing, intrusive, overpossessive mother who had attempted to maintain her symbiotic relationship to the patient. Before the abortion, she revealed the following dream: “ I had a nightmare that there was atomic war and that I alone was left in the world.” Another girl dreamed as follows on the night of an abortion: “There was some motorcycle guys who came and shot my dad. They didn’t kill him. Then one of the motorcycle guys shot me with a machine gun. Then my dad woke me up, so I don’t know if I died or what happened.” Often we observed a counterphobic, exaggerated calmness. For example, one patient told us: “ I had a dream that there were little children all around me. They formed a circle around me and soon started to swirl around me very fast as if it were a kaleidescope of children all laughing. I wasn’t frightened; I felt relieved and content. I felt that they would all be all right without me.” The abortion procedure was viewed by the majority of adolescents as a lifethreatening stress, not a routine surgical procedure. Effective dissemination of factual information may, in the future, change this perception. In the mean43
time, additional trained personnel and supportive psychotherapeutic procedures are clearly indicated for adolescent patients.
Why Not Contraception? Such observations also call attention to the fact that the widened use of abortion during adolescence reflects a failure-a failure in the intelligent, effective dissemination of information on contraception methods. How can we account for this? Social research indicates that contemporary adolescents are initiating premarital sexual experiences at an earlier age than previous generations. The major attitudinal characteristic of this generation of teenagers seems to be a refusal to be forced into marriage in order to initiate and maintain a sexual relationship. They are seeking affectional and sexual satisfaction without a marriage bond and, in many instances, without inordinate guilt.’ Does earlier and more frequent sexual exposure correlate with increased contraceptive use? No! Our study of adolescents followed up after abortion indicated that less than one-third were using contraceptive^.^ Stated reasons included: “ I couldn’t be pregnant twice at such a young,, age” or I won’t ever have sexual relations again. Likewise our earlier followup of unwed pregnant adolescents indicated that 26 of the original 78 project participants were pregnant again within one year. None had consistently used contraceptive^.^ (This is a marked contrast to Sarrel’s lo and Osofsky’s ’’ groups of adolescents who had comprehensive contraception counseling with high success.) Statistics about the level of illegitimacy among adolescents vary, but the National Center for Health Statistics l2 reports that these levels haven’t changed in 30 years-stating that in 1940, 48% of the recorded illegitimate births were to teenagers. In 1965 the figure was 44%. What factors oppose successful use of contraceptive agents, thereby necessitating the use of abortion in this age group? Sexual intercourse is the final common pathway for at least three activities having different goals: 1) the sexual drive with its goal of pleasure and tension release, 2) the reproductive drive with its goal of offspring, and 3 ) the expression of adult love and affection as it manifests itself in close, intimate dyadic heterosexual behavior. Ideally, successful contraception should not interfere with the sexual pleasure-seeking drive, should use reality-principle operations of postponement of immediate satisfaction until the optimal conditions of heterosexual activity are present, and “
“
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should not involve, unless chosen, permanent impairment of fertility or procreative a b i l i t ~ . ” ’What ~ goes wrong with this ideal during real life? 1. Misinformation About Sex
Sexual attitudes and contraceptive information are always acquired somewhere. For modern adolescents they too often originate from the peer group or the popular communication media. Most studies report a pervasive absence of sex education in the presence of regular early unsupervised dating. Several studies of pregnant adolescents show that 75 to 90% of them believe they wouldn’t have become pregnant if birth control measures had been available to them, but most studies of adolescents indicate a widespread lack of accurate information about contraception and a great poverty of understanding about the real nature of sexual activity. Typical is a report by Carter and O ~ t e n d o r f ’of~ questions asked by junior high school students in inner-city schools. These demonstrated a high degree of misinformation about menstruation, sexual intercourse, and oral contraception. The girls asked questions such as, “Does intercourse hurt?,” “Does a boy know when the girl is pregnant?,” “Does not having enough intercourse lead to mental illness?,” “How does the baby get out?,” and “Do young boys produce sperm?” Distortions and superstitions are passed from generation to generation. Ideas that diaphragms or IUD’s can be “lost inside” and that sexual desire is inhibited by the use of oral contraceptives are still popular in many adolescent groups. However, good studies on the level of information and understanding in middle and upper middle class groups are particularly lacking. Gabrielson l5 reported a high positive correlation of general sex knowledge and birth control knowledge in a nonpregnant group of adolescents seeking contraception in contrast to groups seeking abortion or planning to carry a pregnancy to term. 2. Religious, Cultural, and Societal InfEuence
Adolescents have been exposed since early childhood to the exploitation and mechanization of sex presented by the mass media. The perjorative and degrading presentation of sexuality which unfortunately constitutes a major aspect of most adolescents’ sex education is restricted, superficial, and distorted. It adds to the adolescents’ confusion, increases the sense of guilt and shame about sexuality, and discourages the obtaining and use of accurate contraception information. The Catholic church prohibits premarital sex and all forms of birth control except the rhythm method. Sanctions against January/February 1976 JOCN Nursing
premarital sex are apparently easier to ignore if sex can be experienced as spontaneous, unplanned, or the result of strong passion. The use of birth control, on the other hand, implies premeditation. A variety of other cultural and ethnic attitudes toward fertility constitute barriers to the acceptability of contraception in some populations. The standards, ideals, and values of minority groups may act to facilitate or inhibit the wish for children. For example, the cult of machismo (virility) is usually a psychologic bar to reduction in family size. If a group wishes to gain political power through numerical increase, large families might be associated with high prestige. This was true in Germany during World War 11. The barren woman is considered accused in the Bible and is a person to be shunned in the Islamic religion.” A contemporary black leader recently told a federal commission that birth control “is a form of genocide. . .the destruction of the Black people.”“ Blair” found that 25% of blacks consider family planning methods harmful to health. Contraception services are often unpopular in rural, isolated communities with low educational levels and high unemployment. Members of these groups often evidence an attitude of fatalism and mistrust of professional services.
3. Physician Attitudes The ethical position and attitude of the physician toward adolescent contraception is crucial. Emphasis in the relevant medical literature of the early 60s was on the physician’s moral and ethical dilemma in providing contraception to minors. In the 70s it is clear that the problem for the medical community has evolved to dealing with the growing number of out-of-wedlock teenage pregnancies. In April 1971 the American Academy of Pediatr i c ~ ~recommended * that “the teenage girl whose sexual behavior exposes her to possible conception should have access to medical consultation and the most effective contraceptive advice and methods consistent with her physical needs; the physicians so consulted should be free to prescribe or withhold the contraceptive advice in accordance with their best medical judgement and in the best interest of the patient.” Their counsel on child health further states that “contraceptive advice and prescription for the sexually active teenage girl should be accompanied by investigation and alteration of contributing issues wherever possible. Continuous long-term support directed toward facilitating personality development is an integral part ot the care situation. Abortion must never be allowed to reJanuary/February 1976 JOGN Nursing
place adequate preventive care or contraceptive >, measures. In May 1971 the American College of Obstetricians and Gynecologists issued a statement substantially in agreement with the above but which went further to suggest that legal barriers which restrict the provision of these services to unemancipated minors who refuse to involve their parents should be removed-this within the context of counseling the patient to involve her parents. Despite these official position statements, the individual physician still brings his various attitudes, moral judgments, and psychologic biases to the treatment situation. Nationwide statistics on physician attitudes and their effect on contraceptive dispensing are not available. Pauly and GoldsteinZ0 report the results of a questionnaire surveying 937 Oregon physicians about the acceptability, in their minds, of premarital intercourse : one-third reported acceptability often or always; one-third, sometimes; and one-third, seldom or never. Physicians frequently are still unable to admit their own discomfort with sexual behavior in minors. Those who do approach this as a moral issue sometimes censure the sexual activity of the patient. It is obvious, however, that this sexual activity will not be affected at all, despite lack of exposure to contraception in the future. Most practicing physicians today are educationally deficient in all aspects of human sexuality, including the various methods of contraception. The average physican is not familiar with available community facilities, hospital and local health department adolescent clinics, and Planned Parenthood clinics. A sense of inadequacy in sexual counseling is frequently the basis of a physician’s reluctance to involve himself with his patient’s contraceptive needs. This can be complicated by the physician’s own sexual anxieties, which can be ultimately deleterious to the adolescent patient. Also, the possibility of litigation is still a real one in the minds of some physicians. However, in most states adolescents over 18 or under 18 and married are legally able to give their own consent for contraception. There are now laws in almost all states allowing various forms of medical treatment without parental consent, and several states have passed laws permitting minors to give their own informed consent without parental involvement. Local health departments can provide the current legal status of medical provision of contraceptives to minors without parental consent. In any case, Pilpel and Weschlerzl contend that it would be extremely unlikely that a suit could be successfully prosecuted against a physician who provided for his patient in this way. 45
Our review of the literature has found no report of such a suit.
5 . Parental Attitudes
Parental ambivalence about pregnancy can influence contraceptive practice even if the parent 4 . Psychologic (Intrapsychic) Reasons for Avoid- overtly disapproves of premarital sex and out-ofwedlock pregnancies for her daughter. Simultaneance of Contraception ously, a parent may encourage these by deliberately Most studies report that adolescents desire that withholding sex or birth control information, refussexual intercourse be a spontaneous, unpremeding money for the cost of such services, or by suspiitated event. Spontaneity and naturalness, the cardiciously checking closely on the monthly menstrual nal virtues of the current generation, are said to period. In some segments of the population, adolescontradict the artificiality of chemical or mechanical cent pregnancy is frequently the acting out by the intervention. More frequently, however, this serves child of a parental wish. Premature sexual activity as a rationalization for an, as yet, poorly developed can also be reinforced by overt messages from the capacity for impulse control, typical of this develparents that remaining single or not having estabopmental period. Adolescents are not always ready lished heterosexual relationships by late adolesto assume the responsibility for behavior which they cence is abnormal. espouse so vocally. The capacity to plan ahead or to project one’s self 6. Peer Group Pressure into the future is also a development goal of this The influence of peer group pressure on adolesperiod for the younger adolescent. It seems to be cents must not be underestimated. Most young easier for older adolescents, who have acquired a people will correlate their behavior to the mores of greater sense of being in control of their own lives, to guard against the risk of pregnancy in their sex- the group. Pressure on girls to be attractive, to ual activity. Numerous studies report large numbers please, to acquire and keep a boy subjects the adoof adolescents unwilling to admit to themselves that lesceht girl to the psychologic conflicts of her male they are having intercourse regularly or that there is partner. Boys of this age are struggling with the even a remote possibility of becoming pregnant. internal issues of developing a sense of masculine Adolescent girls, who have intercourse accom- identity compounded by cultural pressure. panied only irregularly by contraception, usually 7. Unconscious Motivation for Pregnancy believe that the wish not to have a baby would somehow prevent conception despite the lack of Occasionally, out-of-wedlock pregnancy appears contraceptive use. Also frequently reported is the to be a repetition of a parental pattern, either in the idea, “I’ve had intercourse before so many times service of maternal identification or as a defiant without contraception and never got pregnant; it demonstration of hostility to one parent. The acting won’t happen to me.” This as yet poorly developed out of conflicts with parents around the issue of reality-testing capacity is not atypical for early ado- birth control can be extended to manipulative use lescents. of transgressions in this area to punish parents who In one sample of adolescents who were sexually are withholding privileges or who are not underactive,* 45% reported carelessness and forgetful- standing. Unfortunately, deliberate but unwanted ness as reasons for intercourse without con- pregnancy is sometimes used as a way of removing traception, and 38%reported that it was simply too oneself from an intolerable home or family situamuch trouble. This demonstrates the typical early tion. adolescent ambivalence toward accepting one’s sexRejection or failure of contraception can be in the uality, which is at first characterized by denying its service of the transference reaction to mother or existence. Adolescents are curious about themselves father or even a physician. Producing a child can and are beginning to experience unfamiliar and unconsciously represent to a girl a bond with a gift powerful new feelings which must be gradually ac- to or a punishment for a parent. The oedipal concepted, integrated, and explored. They frequently flicts of childhood are resurrected in the adolescent don’t experience the sexual relationship or their period. In girls, this reawakened attraction to father partner as real but rather as if they were engaging substitutes can be made more difficult by the addiin a fantasy. “It is almost as if I wasn’t really having tion of erotic sensations. The resultant avoidance of intercourse. Many adolescents are maturationally the father can result in overt or covert seductive ill-equipped to handle the situations in which they behavior on his part in an understandable but exagfind themselves and the new sensations and wishes gerated attempt to delay giving up “his little girl.” In an attempt to resolve this situation, the daughter for intimacy which they experience. 7,
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commonly makes an exaggerated search for nonincestuous sexual partners to replace the father as the loved object, to provide a wished-for baby for the father, and to relieve the oedipal guilt. Discussion Every unwanted pregnancy terminated by abortion represents, then, an implicit challenge to the health care team to prevent future unwanted pregnancies by utilizing their knowledge of the issues. Attempts to prevent conception in adolescents must involve considering the realities of normal adolescent development states and the realities of society. Changes in anatomy and body image and the emotions characteristic of the maturing adolescent are often experienced traumatically. These changes, conflictual attitudes towards sex, and spurts in emotional growth are crucial and largely ignored factors in conception prevention. Most adolescent girls are not adequately equipped with physiologic, psychologic, and sociologic facts to grasp the meaning of their own sexuality and its repercussions for themselves and others. Teachers in the biology, physiology, psychology, and sociology of sexual activity need a great sensitivity to the anxieties aroused by the didactic material presented. Since adolescents are not always seen regularly by physicians, medical nursing involvement in school programs is particularly important. The objective presentation of the advantages and disadvantages of all contraceptives with demonstrations and a description of all major moral and ethical alternatives of sexual behavior should be offered. Beyond this, the burden of moral persuasion and the engendering of a specific value system is the task of the parent. There is clear-cut evidence demonstrating the adolescent’s abysmal lack of knowledge of the basics of sex and contraception and the inability of parents alone to provide this information. Refusal to provide adolescents with adequate programs offering sexual and contraceptive information will not stop sexual activity in this group. It is clear from many studies that knowledge of pregnancy risk does not interfere with continued nonuse of contraception, pregnancy risks are still repeatedly ignored and home remedies are relied on (i.e., soda pop douches, Saran-wrap condoms). The capacity for impulse gratification delay, good reality testing, the ability to project oneself into the future, and a stability in object relations are directly related to contraceptive success. Acting-out tendencies, overwhelming object hunger, magical thinking, and precarious self-esteem produce conJanuary/February 1976 JOGN Nursing
traception failure. How well does the adolescent patient regulate drives, needs, impulses? How does she react to the likelihood of transient loss of the procreative function? What specific contraceptive method best engages her reality principle operations and avoids the influence of neurotic conflicts and symptoms? Answers to these questions determine the outcome of contraceptive efforts. Conclusion Suitable emotional settings must be provided in which adolescents can integrate their own developing feelings and opinions with the contradictory values of their parents and those of society at large. Today’s adolescents will not respond to “establishment” moral judgments. Provision of comprehensive educational facilities with sensitive medical intervention must then confront the needs, drives, and impulses of the sexually active or potentially sexually active adolescent, must accept the sex drives and make realistic assessment of possible consequences, especially that of pregnancy. This effort will ultimately minimize the psychologically traumatic impact the abortion solution offers both society and individual adolescent patients. Acknowledgment Adapted from a presentation at the Fourteenth Annual Seminar in Psychiatry, “Social Change: Its Impact on Psychiatry and Medicine,” at Central State Psychiatric Hospital, Continuing Education Department, Vanderbilt University, Nashville, Tennessee, May 1975. References 1. Simon, N. M., et al.: “Psychiatric Illness following Therapectic Abortion.” A m J Psychiatry 124:97, July 1967 2. Patt, S. L., R. G. Rappaport, and P. Barglow,: “Follow-up of Therapeutic Abortion.” AMA Arch Gen Psychiatry 20:408, 1969 3. Hook, K . : “Refused Abortion.” Acta Scand Suppl 168:1, 1963 4. Forssman, H., and I. Thuwe,: “One Hundred Thirty Children born after Application for Therapeutic Abortion Refused.” Acta Psychiatrica Scand 42:71, 1966 5. Caplan, G.: “The Disturbance of the Mother-Child Relationship by Unsuccessful Attempts at Abortion, Mental Hygiene.” 38:67, 1954 6. Chicago Daily News, p. 26, May 18, 1975 7. Barglow, P., and S. Weinstein: “Therapeutic Abortion during Adolescence: Psychiatric Observations.” f Youth Ado1 2(4):672, 1968 8 . Sorenson, R. C . : Adolescent Sexuality in Contemporary America, World Publ. Co., New York, 1973 47
9. Barglow, P. et. al.: Some Psychiatric Aspects of Illegitimate Pregnancy in Early Adolescence, Am J Orthopsychiatry, 38, No. 4:672, 1968 10. Sarrel, P.: The University Hospital and the Teenage Mother, Am J Public Health, 57:1308, 1967 11. Osofsky, H. : Adolescent Out-of-Wedlock Pregnancy: an overview, Clin Obstet Gynecol 14:442, 1971 12. National Center for Health Statistics, Trends in Illegitimacy United States 1940-1965, February 1968 13. Pollock, G. : Psychoanalytic Considerations of Fertility and Sexuality in Contraception, Isr Ann Psychiatry 10:203, 1972 14. Carter, I., and Ostendorf, M: The Awakening of Adolescent Feminity, J Sch Health 40:203, 1970 15. Gabrielson, I. W. et al.: Adolescent Attitudes toward Abortion: Effects on Contraceptive Practice, Am J Public Health 61:730, 1971 16. Barglow, P., and Klass D.: Psychiatric Aspects of Contraceptive Utilization, Am J Obstet Gynecol 114:93, 1972 17. Chicago Sun Times, P. 42, June 23, 1971 18. Blair, A. 0.:In Bogue, D. J., ed. Sociological Contributions to Family Planning Research. Community and Family Study Center Publications, 1967 19. Am. Head Pediatrics-Committee on Youth, Teenage Pregnancy and the Problem of Abortion, Yediat-
rics 49:303, 1972 20. Pauly, I., and Goldstein, S . : Physician Attitudes toward premarital and extramarital intercourse. Med Aspects of Human Sexuality 5:32, 1971 21. Pilpel, H. F., and Weschler, N. F.: Birth Control, Teenagers and the Law; A New Look, 1971, Fam Plann Perspect 3:1, July, 1971 Address reprint requests to Peter D. Barglow, MD, Associate Professor, Department of Psychiatry, Northwestern University Medical School, 320 East Huron, Chicago, IL 60601.
In addition to carrying a private practice, Dr. Barglow is an Associate Professor in the Department of Psychiatry and Associate Director of Graduate Education at Northwestern University Medical School in Chicago, and Head of the Psychosomatic Division of Prentice Women’s Hospital and Maternity Center of Northwestern Memorial Hospital. He is a graduate of the Chicago Psychoanalytic Institute, where he moderates a workshop on female sexuality. His publishing credits include articles for such periodicals as the Journal of Reproductive Medicine, the Journal of Youth and Adolescence, Obstetrics and Gynecology, and the Journal of the American Psychoanalytic Association. He is a member of the Chicago Adolescent Society and a Fellow of the American PSychiatric Association.
THE HIGH-RISK MATERNITY PATIENT Registered nurses, public health nurses, and hospital maternity nurses are invited to participate in a continuing education course entitled “Identification and Care of the High-Risk Maternity Patierrt” sponsored by the Division of Maternal-Infant Medicine and the University Medical Center Division of Continuing Health Professional Education, both at the University of Mississippi School of Medicine, and the Mississippi Regional Medical Program, The course will be coordinated by Ms. Linda Wheeler, MN, CNM, FdD. Enrollment is limited to six nurses in each course. Contact hours: 35;CEU’s: 3.5.No fee. It will be offered April 19-23, May 10-14, and May 31-June 4. For registration or further information, write Continuing Education, University Medical Center, 2500 North State Street, Jackson, MS 39216.
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,abortion, with a focus on adolescents. He emphasizes his view that adolescents should be given more realistic, relevant sex education and counseling, especially regarding methods of contraception.
How did perspectives on abortion change in America in 1975? Such a broad question implies numerous clarifications, limitations, and subquestions and requires an immediate statement of the respondent’s frame of reference. I am a psychiatrist, psychoanalyst, clinician, and researcher-not a politician, social scientist, lawyer, or religious zealot. I accept the theoretical position that the law represents and follows the needs and attitudes of large segments of society. According to this position, therapeutic abortion as legitimized by the U.S. Supreme Court on January 22, 1973, was only one consequence of the liberalizing sociocultural ferment that also produced the anti-war, civil rights, women’s liberation, and more recently, the consumer’s movements. The social consequences of legal abortion can hardly be disentangled from the implications of these other complex trends, but perhaps there are some discernable changes in the daily practice of a psychiatrist preoccupied with obstetrics and gynecology.
BEFORE 1973 I have not interviewed, for years now, a woman like a patient I once treated for emotional difficulty in adjusting to permanent infertility, secondary to the peritonitis and bowel fistulae resulting from a Chicago Southside motel abortion. Now that almost a million legal U.S. abortions January/February 1976 JOGN Nursing
are performed each year, the old disputes about psychiatric sequelae of this procedure have almost disappeared from the psychiatric literature. Marked differences of “scientific” opinion about the psychologic outcome of abortion reported over many decades apparently mirrored disagreement within public opinion and were the product of differing moral, religious, and philosophic positions. Early clinical studies of psychic aftermaths of abortion uniformly reported major psychologic damage, but psychiatric papers during the 1950s and 1960s contained descriptions of marked mental benefits from the procedure.’ I too participated in one of the larger studies2 We found that most of the 48 womerl in our study qualified for abortion by the then accepted criteria and that, with rare exceptions, they did well afterward. Diagnostically, the majority of patients seemed to belong in either the “borderline psychotic” or “psychotic” category. Most had histories characterized by inadequate life functioning, psychiatric hospitalizations, suicide attempts, or psychotic episodes. All experienced a worsening of their emotional status during the pregnancy, and very few could imagine carrying the pregnancy to term. It seemed certain that these women would have deteriorated psychiatrically if forced to continue the unwanted pregnancy. Our study indicated that two-thirds of the group would have been 41
serious suicidal risks or undergone psychotic decompensation, i.e., loss of ability to function nonpsychotically if not granted an abortion. However, a sample of this large number of patients in subsequent years did lead surprisingly normal lives, despite their neuroses. The remaining one-third were clearly psychologically ill and confronted by adverse life circumstances but did not meet the legal criteria for therapeutic abortion. Despite this, they all obtained legal abortions. We found very few instances of genuine conscious manipulation by the patients to account for this discrepancy. Therefore, it is likely that distortion occurred either in the way they presented themselves inadvertantly, or else had its source in the examining psychiatrists. It can be speculated that the structure of the preabortion interviews emphasized psychopathology, unlike the research interviews which encouraged denial of pathology. The manifest function of the preabortion interview was to reveal rather than to suppress pathology. Long-term effects of abortions were, on the whole, quite favorable. Approximately three-fourths of the patients reported subjective impressions of improved emotional status, and psychiatric histories were consistent with these impressions. Two patients, each of whom reported submitting to the abortion against her will, experienced prolonged adverse effects which they attributed to the abortion. Twelve patients experienced conscious guilt, but only two of these would have decided not to have the abortion if given the choice again. Eight patients reported that the abortion experience eventually led to emotional growth. It was concluded that, with rare exceptions, abortion was genuinely therapeutic.
SINCE 1973 This conclusion about the psychiatric effects of abortion certainly reflects the contemporary opinion of the psychiatric profession as a whole. Recently we have also seen documentation of results following refusal to perform abortion. H ~ o k ein , ~an 8- to 10-year followup of 294 women denied an abortion, found that 24% had continued significant negative emotional sequelae. Most of them had demonstrated pathologic reactions including frequent punitive hate reactions against the child and major social difficulties connected with care or placement of the child; 31% were judged to be providing an unfavorable environment for their child. Forssman4 compared 134 children whose mothers were refused abortions with a group of children whose mothers wanted the pregnancy. The former group had less education and showed more family 42
instability, antisocial and criminal behavior, need for psychiatric care, and requests for public assistance. Caplan’ describes disturbances in the relationships of mothers who were refused abortions to the children who resulted. For these reasons and many others, anti-abortionists have abandoned the “ill-effects” and psychologic arenas to concentrate their efforts on the political-legal battlefield. No special expertise qualifies a physician to evaluate the impact of making the fetus a human being with all the rights of a citiOf course, we can worry about the possibility that the conferring of :personhood” on a fetus may imply civil and criminal legal charges against the woman who accidentally damages a pregnancy, or that the IUD or postpregnancy hormones may constitute conception-disrupting murder rather than acceptable contraception. Psychologists can admire the propaganda still inherent in the anti-abortion “right-to-life” concept. (What monster can be against life?) But the formula, child-equals-fertilized-ovum, adroitly confuses the acorn with the oak tree, a potentiality with an actuality. Recently, Dr. D. Purpura of Albert Einstein University located the beginning of human life between the 28th and 32nd week of pregnancy on the basis of cerebral cortex maturity established by fetal neuroanatomic cellular structure.‘ But such issues belong to the realms of social activism and philosophy rather than to the lives of individuals grouped by psychodynamics. There are, however, new and clearer issues emerging that vitally concern psychiatrists and should concern all those involved in Ob/Gyn health care. There exists a new group for whom psychiatric assessment of responses to interruption of pregnancy is particularly important and which demonstrates these issues. I refer to girls who have reached adolescence in the 1970s. Abortion in Adolescence Two years ago we investigated the psychologic reactions of adolescent girls undergoing abortion during the first trimester of pregnancy at the Michael Reese Hospital Pregnancy Termination Unit.’ By July 1, 1973, the Unit had served 365 patients, including 78 adolescents with broadly varied ethnic and economic backgrounds. On the average, these girls, particularly the younger ones, had been pregnant longer than adult patients seen at the Unit, partly because of delays in awareness of pregnancy (due to ignorance or subconscious defensive denial) and partly because of conscious concealment due to fear of parental disapproval or anger. Parents and boyfriends exerted considerable influence on the January/February 1976 JOGN Nursing
abortion decision, especially when the adolescent was very young or emotionally immature. The parents often reassumed total, often dictatorial, responsibility for the adolescent’s life, with potential positive and negative consequences. The adolescent might feel protected, narcissistically supplied, and grateful, and could alleviate guilt by blaming the decision on the parent. On the other hand, the abortion acceptance might symbolize a passive acquiescence to the intruding parent, heightening dependency conflicts and exacerbating depression. Developmental immaturity contributed not only to ambivalence about the decision but also to a distorted perception of the procedure and to a variety of pathologic reactions. Almost all the adolescent subjects experienced the abortion procedure as frightening, dangerous, and punitive, and often as temporarily overwhelming. An attempt was made to follow up 50 of the girls 1 to 3 months after their abortions, but only half of them could be contacted. Twenty-one of those contacted were doing well psychologically, and most of them felt that the abortion procedure had been a positive and beneficial event. However, they all had experienced a multiplicity of psychic and somatic symptoms which were transitory and limited in severity. These symptoms were considered to be evidence of the mourning process, precipitated by the loss of an “expectation” rather than by an object loss. The other 4 girls had conscious regrets and doubts about the abortion. Two of them were severely depressed: One showed excessive hypochondriasis, and the other developed a paranoid psychosis. These symptoms, in the writers’ opinion, represented pathologic mourning. Two of the 4 patients had prior histories of psychiatric difficulties, and one had decompensated prior to the abortion. We concluded that more careful screening and diagnostic evaluation permitting earlier psychiatric intervention should minimize the possibility of most adverse postabortion reactions. The complications just described constitute a reminder that abortion for adolescents involves much more than a technician removing a carelessly embedded splinter from a youthful finger. This observation is buttressed by the behavior and dreams of several of our subjects. For instance, a 16-year-old girl was chosen by chance to be the first patient aborted that day. She wept and screamed in terror continuously during the procedure while tensing her voluntary musculature. The social worker was called in and calmed her by holding her hand and talking reassuringly to her. The following was her postabortion dream: “ I dreamed the devil performed the abortion. He January/February 1976 JOGN Nursing
just reached up his black hand, pulled it out, and then danced around me with it in his arms while laughing and yelling.” Evaluation of this adolescent revealed that the father had not lived with the family for many years. The patient had been acting out sexually and aggressively, actively defying maternal wishes and prohibitions since attaining puberty. Her Black Muslim mother claimed she had to resort to threats of physical punishment and future Hell’s damnation in order to control her daughter. The patient had felt that “my mother would kill me” when she became pregnant and that abortion was “a sin for which God will punish me.” The patient’s superego clearly was primitive and self-punitive, with the hallmarks of delay in the internalization of standards, i.e., failure to adopt personal standards of behavior. Fears of violence were often expressed by the manifest content of repetitive dreams. A single 16year-old student was psychiatrically evaluated for severe depression with suicidal preoccupation a few months following her second abortion. She said that her psychotherapist had “forced her to give up her pregnancy.” A review of her history prior to this abortion indicated that she had refused consciously to be aborted but had made numerous suicidal threats. This factor and a variety of incapacitating psychosomatic symptoms persuaded her to give a reluctant consent to the abortion. Further investigation indicated that she had been struggling for several years to establish her independence from an infantilizing, intrusive, overpossessive mother who had attempted to maintain her symbiotic relationship to the patient. Before the abortion, she revealed the following dream: “ I had a nightmare that there was atomic war and that I alone was left in the world.” Another girl dreamed as follows on the night of an abortion: “There was some motorcycle guys who came and shot my dad. They didn’t kill him. Then one of the motorcycle guys shot me with a machine gun. Then my dad woke me up, so I don’t know if I died or what happened.” Often we observed a counterphobic, exaggerated calmness. For example, one patient told us: “ I had a dream that there were little children all around me. They formed a circle around me and soon started to swirl around me very fast as if it were a kaleidescope of children all laughing. I wasn’t frightened; I felt relieved and content. I felt that they would all be all right without me.” The abortion procedure was viewed by the majority of adolescents as a lifethreatening stress, not a routine surgical procedure. Effective dissemination of factual information may, in the future, change this perception. In the mean43
time, additional trained personnel and supportive psychotherapeutic procedures are clearly indicated for adolescent patients.
Why Not Contraception? Such observations also call attention to the fact that the widened use of abortion during adolescence reflects a failure-a failure in the intelligent, effective dissemination of information on contraception methods. How can we account for this? Social research indicates that contemporary adolescents are initiating premarital sexual experiences at an earlier age than previous generations. The major attitudinal characteristic of this generation of teenagers seems to be a refusal to be forced into marriage in order to initiate and maintain a sexual relationship. They are seeking affectional and sexual satisfaction without a marriage bond and, in many instances, without inordinate guilt.’ Does earlier and more frequent sexual exposure correlate with increased contraceptive use? No! Our study of adolescents followed up after abortion indicated that less than one-third were using contraceptive^.^ Stated reasons included: “ I couldn’t be pregnant twice at such a young,, age” or I won’t ever have sexual relations again. Likewise our earlier followup of unwed pregnant adolescents indicated that 26 of the original 78 project participants were pregnant again within one year. None had consistently used contraceptive^.^ (This is a marked contrast to Sarrel’s lo and Osofsky’s ’’ groups of adolescents who had comprehensive contraception counseling with high success.) Statistics about the level of illegitimacy among adolescents vary, but the National Center for Health Statistics l2 reports that these levels haven’t changed in 30 years-stating that in 1940, 48% of the recorded illegitimate births were to teenagers. In 1965 the figure was 44%. What factors oppose successful use of contraceptive agents, thereby necessitating the use of abortion in this age group? Sexual intercourse is the final common pathway for at least three activities having different goals: 1) the sexual drive with its goal of pleasure and tension release, 2) the reproductive drive with its goal of offspring, and 3 ) the expression of adult love and affection as it manifests itself in close, intimate dyadic heterosexual behavior. Ideally, successful contraception should not interfere with the sexual pleasure-seeking drive, should use reality-principle operations of postponement of immediate satisfaction until the optimal conditions of heterosexual activity are present, and “
“
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should not involve, unless chosen, permanent impairment of fertility or procreative a b i l i t ~ . ” ’What ~ goes wrong with this ideal during real life? 1. Misinformation About Sex
Sexual attitudes and contraceptive information are always acquired somewhere. For modern adolescents they too often originate from the peer group or the popular communication media. Most studies report a pervasive absence of sex education in the presence of regular early unsupervised dating. Several studies of pregnant adolescents show that 75 to 90% of them believe they wouldn’t have become pregnant if birth control measures had been available to them, but most studies of adolescents indicate a widespread lack of accurate information about contraception and a great poverty of understanding about the real nature of sexual activity. Typical is a report by Carter and O ~ t e n d o r f ’of~ questions asked by junior high school students in inner-city schools. These demonstrated a high degree of misinformation about menstruation, sexual intercourse, and oral contraception. The girls asked questions such as, “Does intercourse hurt?,” “Does a boy know when the girl is pregnant?,” “Does not having enough intercourse lead to mental illness?,” “How does the baby get out?,” and “Do young boys produce sperm?” Distortions and superstitions are passed from generation to generation. Ideas that diaphragms or IUD’s can be “lost inside” and that sexual desire is inhibited by the use of oral contraceptives are still popular in many adolescent groups. However, good studies on the level of information and understanding in middle and upper middle class groups are particularly lacking. Gabrielson l5 reported a high positive correlation of general sex knowledge and birth control knowledge in a nonpregnant group of adolescents seeking contraception in contrast to groups seeking abortion or planning to carry a pregnancy to term. 2. Religious, Cultural, and Societal InfEuence
Adolescents have been exposed since early childhood to the exploitation and mechanization of sex presented by the mass media. The perjorative and degrading presentation of sexuality which unfortunately constitutes a major aspect of most adolescents’ sex education is restricted, superficial, and distorted. It adds to the adolescents’ confusion, increases the sense of guilt and shame about sexuality, and discourages the obtaining and use of accurate contraception information. The Catholic church prohibits premarital sex and all forms of birth control except the rhythm method. Sanctions against January/February 1976 JOCN Nursing
premarital sex are apparently easier to ignore if sex can be experienced as spontaneous, unplanned, or the result of strong passion. The use of birth control, on the other hand, implies premeditation. A variety of other cultural and ethnic attitudes toward fertility constitute barriers to the acceptability of contraception in some populations. The standards, ideals, and values of minority groups may act to facilitate or inhibit the wish for children. For example, the cult of machismo (virility) is usually a psychologic bar to reduction in family size. If a group wishes to gain political power through numerical increase, large families might be associated with high prestige. This was true in Germany during World War 11. The barren woman is considered accused in the Bible and is a person to be shunned in the Islamic religion.” A contemporary black leader recently told a federal commission that birth control “is a form of genocide. . .the destruction of the Black people.”“ Blair” found that 25% of blacks consider family planning methods harmful to health. Contraception services are often unpopular in rural, isolated communities with low educational levels and high unemployment. Members of these groups often evidence an attitude of fatalism and mistrust of professional services.
3. Physician Attitudes The ethical position and attitude of the physician toward adolescent contraception is crucial. Emphasis in the relevant medical literature of the early 60s was on the physician’s moral and ethical dilemma in providing contraception to minors. In the 70s it is clear that the problem for the medical community has evolved to dealing with the growing number of out-of-wedlock teenage pregnancies. In April 1971 the American Academy of Pediatr i c ~ ~recommended * that “the teenage girl whose sexual behavior exposes her to possible conception should have access to medical consultation and the most effective contraceptive advice and methods consistent with her physical needs; the physicians so consulted should be free to prescribe or withhold the contraceptive advice in accordance with their best medical judgement and in the best interest of the patient.” Their counsel on child health further states that “contraceptive advice and prescription for the sexually active teenage girl should be accompanied by investigation and alteration of contributing issues wherever possible. Continuous long-term support directed toward facilitating personality development is an integral part ot the care situation. Abortion must never be allowed to reJanuary/February 1976 JOGN Nursing
place adequate preventive care or contraceptive >, measures. In May 1971 the American College of Obstetricians and Gynecologists issued a statement substantially in agreement with the above but which went further to suggest that legal barriers which restrict the provision of these services to unemancipated minors who refuse to involve their parents should be removed-this within the context of counseling the patient to involve her parents. Despite these official position statements, the individual physician still brings his various attitudes, moral judgments, and psychologic biases to the treatment situation. Nationwide statistics on physician attitudes and their effect on contraceptive dispensing are not available. Pauly and GoldsteinZ0 report the results of a questionnaire surveying 937 Oregon physicians about the acceptability, in their minds, of premarital intercourse : one-third reported acceptability often or always; one-third, sometimes; and one-third, seldom or never. Physicians frequently are still unable to admit their own discomfort with sexual behavior in minors. Those who do approach this as a moral issue sometimes censure the sexual activity of the patient. It is obvious, however, that this sexual activity will not be affected at all, despite lack of exposure to contraception in the future. Most practicing physicians today are educationally deficient in all aspects of human sexuality, including the various methods of contraception. The average physican is not familiar with available community facilities, hospital and local health department adolescent clinics, and Planned Parenthood clinics. A sense of inadequacy in sexual counseling is frequently the basis of a physician’s reluctance to involve himself with his patient’s contraceptive needs. This can be complicated by the physician’s own sexual anxieties, which can be ultimately deleterious to the adolescent patient. Also, the possibility of litigation is still a real one in the minds of some physicians. However, in most states adolescents over 18 or under 18 and married are legally able to give their own consent for contraception. There are now laws in almost all states allowing various forms of medical treatment without parental consent, and several states have passed laws permitting minors to give their own informed consent without parental involvement. Local health departments can provide the current legal status of medical provision of contraceptives to minors without parental consent. In any case, Pilpel and Weschlerzl contend that it would be extremely unlikely that a suit could be successfully prosecuted against a physician who provided for his patient in this way. 45
Our review of the literature has found no report of such a suit.
5 . Parental Attitudes
Parental ambivalence about pregnancy can influence contraceptive practice even if the parent 4 . Psychologic (Intrapsychic) Reasons for Avoid- overtly disapproves of premarital sex and out-ofwedlock pregnancies for her daughter. Simultaneance of Contraception ously, a parent may encourage these by deliberately Most studies report that adolescents desire that withholding sex or birth control information, refussexual intercourse be a spontaneous, unpremeding money for the cost of such services, or by suspiitated event. Spontaneity and naturalness, the cardiciously checking closely on the monthly menstrual nal virtues of the current generation, are said to period. In some segments of the population, adolescontradict the artificiality of chemical or mechanical cent pregnancy is frequently the acting out by the intervention. More frequently, however, this serves child of a parental wish. Premature sexual activity as a rationalization for an, as yet, poorly developed can also be reinforced by overt messages from the capacity for impulse control, typical of this develparents that remaining single or not having estabopmental period. Adolescents are not always ready lished heterosexual relationships by late adolesto assume the responsibility for behavior which they cence is abnormal. espouse so vocally. The capacity to plan ahead or to project one’s self 6. Peer Group Pressure into the future is also a development goal of this The influence of peer group pressure on adolesperiod for the younger adolescent. It seems to be cents must not be underestimated. Most young easier for older adolescents, who have acquired a people will correlate their behavior to the mores of greater sense of being in control of their own lives, to guard against the risk of pregnancy in their sex- the group. Pressure on girls to be attractive, to ual activity. Numerous studies report large numbers please, to acquire and keep a boy subjects the adoof adolescents unwilling to admit to themselves that lesceht girl to the psychologic conflicts of her male they are having intercourse regularly or that there is partner. Boys of this age are struggling with the even a remote possibility of becoming pregnant. internal issues of developing a sense of masculine Adolescent girls, who have intercourse accom- identity compounded by cultural pressure. panied only irregularly by contraception, usually 7. Unconscious Motivation for Pregnancy believe that the wish not to have a baby would somehow prevent conception despite the lack of Occasionally, out-of-wedlock pregnancy appears contraceptive use. Also frequently reported is the to be a repetition of a parental pattern, either in the idea, “I’ve had intercourse before so many times service of maternal identification or as a defiant without contraception and never got pregnant; it demonstration of hostility to one parent. The acting won’t happen to me.” This as yet poorly developed out of conflicts with parents around the issue of reality-testing capacity is not atypical for early ado- birth control can be extended to manipulative use lescents. of transgressions in this area to punish parents who In one sample of adolescents who were sexually are withholding privileges or who are not underactive,* 45% reported carelessness and forgetful- standing. Unfortunately, deliberate but unwanted ness as reasons for intercourse without con- pregnancy is sometimes used as a way of removing traception, and 38%reported that it was simply too oneself from an intolerable home or family situamuch trouble. This demonstrates the typical early tion. adolescent ambivalence toward accepting one’s sexRejection or failure of contraception can be in the uality, which is at first characterized by denying its service of the transference reaction to mother or existence. Adolescents are curious about themselves father or even a physician. Producing a child can and are beginning to experience unfamiliar and unconsciously represent to a girl a bond with a gift powerful new feelings which must be gradually ac- to or a punishment for a parent. The oedipal concepted, integrated, and explored. They frequently flicts of childhood are resurrected in the adolescent don’t experience the sexual relationship or their period. In girls, this reawakened attraction to father partner as real but rather as if they were engaging substitutes can be made more difficult by the addiin a fantasy. “It is almost as if I wasn’t really having tion of erotic sensations. The resultant avoidance of intercourse. Many adolescents are maturationally the father can result in overt or covert seductive ill-equipped to handle the situations in which they behavior on his part in an understandable but exagfind themselves and the new sensations and wishes gerated attempt to delay giving up “his little girl.” In an attempt to resolve this situation, the daughter for intimacy which they experience. 7,
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commonly makes an exaggerated search for nonincestuous sexual partners to replace the father as the loved object, to provide a wished-for baby for the father, and to relieve the oedipal guilt. Discussion Every unwanted pregnancy terminated by abortion represents, then, an implicit challenge to the health care team to prevent future unwanted pregnancies by utilizing their knowledge of the issues. Attempts to prevent conception in adolescents must involve considering the realities of normal adolescent development states and the realities of society. Changes in anatomy and body image and the emotions characteristic of the maturing adolescent are often experienced traumatically. These changes, conflictual attitudes towards sex, and spurts in emotional growth are crucial and largely ignored factors in conception prevention. Most adolescent girls are not adequately equipped with physiologic, psychologic, and sociologic facts to grasp the meaning of their own sexuality and its repercussions for themselves and others. Teachers in the biology, physiology, psychology, and sociology of sexual activity need a great sensitivity to the anxieties aroused by the didactic material presented. Since adolescents are not always seen regularly by physicians, medical nursing involvement in school programs is particularly important. The objective presentation of the advantages and disadvantages of all contraceptives with demonstrations and a description of all major moral and ethical alternatives of sexual behavior should be offered. Beyond this, the burden of moral persuasion and the engendering of a specific value system is the task of the parent. There is clear-cut evidence demonstrating the adolescent’s abysmal lack of knowledge of the basics of sex and contraception and the inability of parents alone to provide this information. Refusal to provide adolescents with adequate programs offering sexual and contraceptive information will not stop sexual activity in this group. It is clear from many studies that knowledge of pregnancy risk does not interfere with continued nonuse of contraception, pregnancy risks are still repeatedly ignored and home remedies are relied on (i.e., soda pop douches, Saran-wrap condoms). The capacity for impulse gratification delay, good reality testing, the ability to project oneself into the future, and a stability in object relations are directly related to contraceptive success. Acting-out tendencies, overwhelming object hunger, magical thinking, and precarious self-esteem produce conJanuary/February 1976 JOGN Nursing
traception failure. How well does the adolescent patient regulate drives, needs, impulses? How does she react to the likelihood of transient loss of the procreative function? What specific contraceptive method best engages her reality principle operations and avoids the influence of neurotic conflicts and symptoms? Answers to these questions determine the outcome of contraceptive efforts. Conclusion Suitable emotional settings must be provided in which adolescents can integrate their own developing feelings and opinions with the contradictory values of their parents and those of society at large. Today’s adolescents will not respond to “establishment” moral judgments. Provision of comprehensive educational facilities with sensitive medical intervention must then confront the needs, drives, and impulses of the sexually active or potentially sexually active adolescent, must accept the sex drives and make realistic assessment of possible consequences, especially that of pregnancy. This effort will ultimately minimize the psychologically traumatic impact the abortion solution offers both society and individual adolescent patients. Acknowledgment Adapted from a presentation at the Fourteenth Annual Seminar in Psychiatry, “Social Change: Its Impact on Psychiatry and Medicine,” at Central State Psychiatric Hospital, Continuing Education Department, Vanderbilt University, Nashville, Tennessee, May 1975. References 1. Simon, N. M., et al.: “Psychiatric Illness following Therapectic Abortion.” A m J Psychiatry 124:97, July 1967 2. Patt, S. L., R. G. Rappaport, and P. Barglow,: “Follow-up of Therapeutic Abortion.” AMA Arch Gen Psychiatry 20:408, 1969 3. Hook, K . : “Refused Abortion.” Acta Scand Suppl 168:1, 1963 4. Forssman, H., and I. Thuwe,: “One Hundred Thirty Children born after Application for Therapeutic Abortion Refused.” Acta Psychiatrica Scand 42:71, 1966 5. Caplan, G.: “The Disturbance of the Mother-Child Relationship by Unsuccessful Attempts at Abortion, Mental Hygiene.” 38:67, 1954 6. Chicago Daily News, p. 26, May 18, 1975 7. Barglow, P., and S. Weinstein: “Therapeutic Abortion during Adolescence: Psychiatric Observations.” f Youth Ado1 2(4):672, 1968 8 . Sorenson, R. C . : Adolescent Sexuality in Contemporary America, World Publ. Co., New York, 1973 47
9. Barglow, P. et. al.: Some Psychiatric Aspects of Illegitimate Pregnancy in Early Adolescence, Am J Orthopsychiatry, 38, No. 4:672, 1968 10. Sarrel, P.: The University Hospital and the Teenage Mother, Am J Public Health, 57:1308, 1967 11. Osofsky, H. : Adolescent Out-of-Wedlock Pregnancy: an overview, Clin Obstet Gynecol 14:442, 1971 12. National Center for Health Statistics, Trends in Illegitimacy United States 1940-1965, February 1968 13. Pollock, G. : Psychoanalytic Considerations of Fertility and Sexuality in Contraception, Isr Ann Psychiatry 10:203, 1972 14. Carter, I., and Ostendorf, M: The Awakening of Adolescent Feminity, J Sch Health 40:203, 1970 15. Gabrielson, I. W. et al.: Adolescent Attitudes toward Abortion: Effects on Contraceptive Practice, Am J Public Health 61:730, 1971 16. Barglow, P., and Klass D.: Psychiatric Aspects of Contraceptive Utilization, Am J Obstet Gynecol 114:93, 1972 17. Chicago Sun Times, P. 42, June 23, 1971 18. Blair, A. 0.:In Bogue, D. J., ed. Sociological Contributions to Family Planning Research. Community and Family Study Center Publications, 1967 19. Am. Head Pediatrics-Committee on Youth, Teenage Pregnancy and the Problem of Abortion, Yediat-
rics 49:303, 1972 20. Pauly, I., and Goldstein, S . : Physician Attitudes toward premarital and extramarital intercourse. Med Aspects of Human Sexuality 5:32, 1971 21. Pilpel, H. F., and Weschler, N. F.: Birth Control, Teenagers and the Law; A New Look, 1971, Fam Plann Perspect 3:1, July, 1971 Address reprint requests to Peter D. Barglow, MD, Associate Professor, Department of Psychiatry, Northwestern University Medical School, 320 East Huron, Chicago, IL 60601.
In addition to carrying a private practice, Dr. Barglow is an Associate Professor in the Department of Psychiatry and Associate Director of Graduate Education at Northwestern University Medical School in Chicago, and Head of the Psychosomatic Division of Prentice Women’s Hospital and Maternity Center of Northwestern Memorial Hospital. He is a graduate of the Chicago Psychoanalytic Institute, where he moderates a workshop on female sexuality. His publishing credits include articles for such periodicals as the Journal of Reproductive Medicine, the Journal of Youth and Adolescence, Obstetrics and Gynecology, and the Journal of the American Psychoanalytic Association. He is a member of the Chicago Adolescent Society and a Fellow of the American PSychiatric Association.
THE HIGH-RISK MATERNITY PATIENT Registered nurses, public health nurses, and hospital maternity nurses are invited to participate in a continuing education course entitled “Identification and Care of the High-Risk Maternity Patierrt” sponsored by the Division of Maternal-Infant Medicine and the University Medical Center Division of Continuing Health Professional Education, both at the University of Mississippi School of Medicine, and the Mississippi Regional Medical Program, The course will be coordinated by Ms. Linda Wheeler, MN, CNM, FdD. Enrollment is limited to six nurses in each course. Contact hours: 35;CEU’s: 3.5.No fee. It will be offered April 19-23, May 10-14, and May 31-June 4. For registration or further information, write Continuing Education, University Medical Center, 2500 North State Street, Jackson, MS 39216.
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