Canadian Psychiatric Association Journal Vol. 21
No.7
Ottawa, Canada, November 1976
THERAPEUTIC ABORTION AND PSYCHIATRIC DISTURBANCE IN CANADIAN WOMEN*
ESTHER
Introduction While controversy appears to be the order of the day in most discussions on abortion, the question of whether there are psychiatric consequences remains one of the most controversial. Moreover, an examination of research in this area suggests that the relationship between therapeutic abortion and psychiatric disturbance is far from simple. However, the data do not support the conclusion that therapeutic abortion is an emotional trauma for most women. For example, Ekblad (4) found that only I percent of the 479 Swedish women interviewed after legal abortion were disturbed to the point where their work capacity was impaired, but these women had long histories of neurotic illness. In four of these cases it was the break with their male partner that was related to the decompensation and not the abortion. In the fifth case, Ekblad suggested that it was 'Associate Professor, Department of Psychology, York University. Downsview, Ontario. "This study is part of a larger project sponsored by Canada Council Grants S71-0471, S73-0846 and S74-1322. Manuscript received November 1975. Revised June 1976.
Can. Psychiatr. Assoc. J. Vol. 21 (1976)
R.
GREENGLASS, Ph.D.l
difficulties with an alcoholic husband rather than the abortion which probably contributed to the psychiatric difficulties. In another Swedish study, about 12 percent of the women interviewed after abortion suffered mental health impairment (12), but all of them had various neurotic complaints before the abortion. Because of lack of clarity in diagnostic terms used in previous research it might be useful to examine the incidence of psychiatric disturbance after abortion in studies where relatively objective criteria have been employed. One way of objectively assessing psychiatric disturbance is to record the incidence of women seeking psychiatric help on an outpatient basis, being hospitalized for emotional or nervous disturbance, or attempting suicide after abortion. Research indicates that the percentage of women seeking psychiatric help after abortion ranges from zero to about fourteen (5, 9, II, 14, 18). Other findings suggest that hospitalization for emotional disturbance after abortion is considerably less frequent than the seeking of help on an outpatient basis. In four studies, none of the women were reported to have been hospitalized after abortion (I, 11, 16, 18). Moreover,
453
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when hospitalization has occurred, the doing research with Canadian women who percentage involved has tended to be less live in Canada when aborted. than 10 percent (5, 14, 17). Because of insufficient information on their pre- Method abortion psychiatric state, and the tendency Subjects for investigators not to say how many One hundred and eighty-eight women women had been hospitalized for the first who had legal abortions were individually time, the conclusions to be drawn are interviewed'] for this study in 1972-73, an limited. average of 36.55 weeks after abortion In other studies, 1 to 2 percent of the (range: 17.00-68.00). While most of the women interviewed were reported to have women had obtained their abortions in attempted suicide after abortion - both Canada, 31 reported going to the United legal and illegal (14,15,19). But, psychiat- States for a legal abortion and three had ric sequelae of legal abortions performed in obtained them elsewhere. Table I presents a proper medical setting should be very the demographic characteristics of the different from those associated with illegal women in the study. abortions usually done under medically and emotionally inadequate circumstances. The Interview Therefore, it is necessary to assess these Each woman was asked to provide separately. Moreover, studies reporting the information on three basic measures of incidence of suicide attempts after abortion psychiatric disturbance: whether or not she do not generally include data on pre- had ever sought psychiatric help as an abortion psychiatric health. Without these outpatient; had ever been hospitalized for data, it is difficult to ascertain to what emotional or mental disturbance; or had extent the suicide attempt represented an ever attempted suicide. Any reported disinability to cope among women who might turbance was categorized according to have been emotionally disturbed before the whether it occurred before or after abortion. abortion. Further, there has been little The time of disturbance in relation to' the attention paid to the examination of cir- abortion was also recorded as well as the cumstances other than the abortion which length of any psychiatric treatment. might have been responsible for the recorded suicide attempts. Results Since many studies in this area have been Most of the women, 166 (88.3 percent) done in different countries, where grounds reported having had no psychiatric disturfor legal abortion may differ, it is difficult bance after abortion. In all, 22 (11.7 to compare research results. Thus, ques- percent) reported having had psychiatric tions about the relationship of psychiatric disturbance after abortion on one or more of disturbance in Canadian women and the measures employed here. Most of these therapeutic abortion should be explored by had only sought psychiatric help as outpatWomen who had legal therapeutic abortions were reached in tients on an average of 3.19 months after abortion (N=16, S.D.=3.64, Range: two ways: some contacted the interviewer (there were five interviewers in all, none of whom was the author) and 1.00-12.00). Length of treatment was an requested to participate after seeing an advertisement or flyer average of 17.63 weeks (N=16, describing the study; other women were contacted by an interviewer and asked to participate in the study. Initial S.D.=18.34, Range: 1.00-52.00). An addicontact was made primarily in abortion clinics of a hospital tional two women reported having been where women came for an examination to confirm their hospitalized for emotional disturbance, an pregnancy. The doctor in charge told them about this study and asked them if they were interested in hearing more about it average of 3.25 months after abortion from the interviewer in the 'next room. It was only after the (N=4, S.D.=2.63, Range: 1.00-6.00). woman herself agreed.to see us that she was approached by the interviewer and asked to participate in the study. Thus this Length of treatment lasted an average of study overcame the bias frequently present in many studies of 2.50 weeks (N=4, S.D. =.58, Range: this kind which include only women who take the initiative 2.00-3.00). (One of these women had also and request to participate in a study. Interviews were conducted either in the woman's home or in an office. received psychiatric help). A total of five
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455
THERAPEUTIC ABORTION TABLE I Demographic Variables of Women Who Had Abortions
Variable
Categories
Marital Status
Single Married Divored or Separated
Age
24 years old or less 25 years old or more
Education
Non-university University
Religion
Protestant Catholic Jewish Agnostic and Atheist Other*
Woman's full-time occupational status***
High Low
Husband's full-time occupational status
High Low
Frequency
Percent
100 63 25
53.2 33.5 13.3
188
100.00
91 97
48.4 51.6
188
100.00
130 58
69.1 30.9
188
100.0
82 34 13 49 10
43.6 18.1 6.9 26.0 5.3
188
99.9**
27 69
28.1 71.9
96
100.0
28 29
49.1 50.9
57****
100.0
*Includes Buddhist, Humanist, Hindu, Christian, Spiritualist, Greek Orthodox, Unitarian, Pantheist, etc. **Does not add up to 100% due to rounding _ ***High status occupations include those labeled as professional, proprietaI, managerial, financial, semi-professional and technical. Low status occupations include those labeled clerical, sales, artisan, foreman, skilled factory, repair and service. ****57 of 63 married women reported their husbands working full-time.
women had attempted suicide an average of S.D.=41.87, Range: 1.00-216.00). Treat2.60 months after abortion (N=5, ment lasted an average of 66.26 weeks S.D. =2.30, Range: 1.00-6.00). (Two of (N=39tt S.D.=107.77, Range: 1.00these had also been hospitalized for emo- 468.00). Eight women had been hostional disturbance). pitalized for emotional disturbance an Psychiatric disturbance before abortion average of 49.88 months before abortion was reported by 56 (29.8 percent) of the (N=16, S.D.=43.97, Range: 3.00-142.00) women. Twenty-seven women said that and their stay in hospital lasted an average they had only received psychiatric help on of 5.19 weeks (N=16, S.D.=5.68, Range: an outpatient basis, an average of 39.73 1.00-20.00). (Some of these women had months prior to abortion (N =40, also received psychiatric help). Twenty-onewomen had attempted suicide an average of ttone woman did not give information on the length of her psychiatric treatment. 66. 10 months before the abortion (N = 21 ,
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Vol. 21, No.7
S.D.=55.04, Range: 5.00-188.00). (Eight problems afterwards requiring psychiatric of these women had also been hospitalized intervention. Similar findings have been and some had also received psychiatric reported elsewhere (4, 10, 12). In this present study, of those who did have help.) To what extent did women with distur- psychiatric difficulties afterwards, most of bance prior to abortion also have psychiatric them reported only having sought psychiatdisturbance afterwards? Of the 56 women ric help as outpatients. who reported disturbance before abortion, While it might be tempting to draw a 12 (21.4 percent) showed some signs of causal relationship between abortion and disturbance afterwards (see Table 11). Of the subsequent appearance of some form of the 132 women who had no disturbance mental disturbance, it is noteworthy that for before abortion 10 (7.6 percent) reported four out of the five women who had some disturbance afterwards. attempted suicide, circumstances other than Table 1Il shows the nature of disturbance the abortion may have been the precipitatbefore abortion for women who had distur- ing factor. For example, three ofthe women bance after the abortion and for those who said that they had attempted suicide because had no disturbance. Fifty-three percent who of difficulties with the man involved, or sought help after abortion had some because of 'family circumstances'. In the psychiatric difficulties before. Both of the fourth case, the woman had attempted women who were hospitalized after abor- suicide before the abortion and the pretion had either received help before or had gnancy (suggesting that she may have been been hospitalized and, two of the five somewhat unstable before the abortion) and women who attempted suicide after abor- she also believed that her mother had tion had some disturbance before. Of those pushed her into having the abortion against who showed no disturbance afterwards, her will. Other data suggest that being 26.5 percent had some disturbance before. forced into having an abortion against one's will can lead to neurotic dispositions Discussion afterwards (6). Nevertheless, it would The majority of women who had abor- appear that when a woman chooses to have tions said that they did not have emotional an abortion, it is highly unlikely that she TABLE 11 Women with (no) pre-abortion psychiatric disturbance who reported (no) post-abortionpsychiatric disturbance
Pre-abortion psychiatric disturbance
Post-abortion Psychiatric Disturbance Absent N=166 Present N=22
Total 188 *Row percentage **Column percentage
Absent N=132
Present N=56
Total N=188
122 *73.5% **92.4%
44 26.5% 78.6%
166
45.5% 7.6%
12 54.5% 21.4%
22
132
56
10
188
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THERAPEUTIC ABORTION
457
TABLE III Women with post-abortion psychiatric disturbance who had previously shown pre-abortion psychiatric disturbance
Psych. dist. after Psych. help only
Frequency of women
Percent of total women
15
8.0
Psych. dist before
Frequency of women
Psych. help only Hospitalization Suicide attempt No psych. dist.
6 I I
Total Hospitalization*
2
1.1
Psych. help only Hospitalization Total
Suicide attemprw
5
2.7
Psych. help only Suicide attempt No psych. dist.
Total
166 188
88.3 100.1***
46.7
15
100.0
I I
100.0 6
2
100.0
3
Psych. help only Hospitalization Suicide attempt No psych. dist. Total
53.3 5
7
I I
Total No psych. dist.
Percent of women with (no) psych. dist. before
5
40.0 7 60.0 100.0
19 6 19 122
73.5
166
100.0
26.5 8
*Includes women who have been hospitalized only, as well as those who have received psychological help as well as having been hospitalized **Includes women who have attempted suicide only; attempted suicide and received help; were hospitalized and attempted suicide; and those who attempted suicide, received help and were hospitalized as well ***Does not add up to 100% due to rounding 5Percent of all women who received psychological help only after the abortion 6}>ercent of all women who were hospitalized after the abortion (and who might have received psych. help as well) 7percent of all women who attempted suicide after the abortion (and who might have received psych. help and hospitalization as well) Bpercentof all women with no psychiatric disturbance after the abortion,
will attempt to commit suicide afterwards because of the abortion per se. Researchers in this area should be alerted to the possibility that traumatic events occurring near the time of the abortion, such as a break or difficulties with the man involved, extreme financial problems, and so on, and not the abortion, may well be the reasons for a woman attempting suicide after an abortion. One factor that appeared to be related to the appearance of psychiatric symptoms
after abortion was the woman's psychiatric history. When this factor was considered it was found that women with a history of any psychiatric disturbance were three times as likely to have some psychiatric disturbance afterwards as those who did not report psychiatric disturbance in the past. These results are similar to previous ones reported in countries other than Canada (4, 8, 17). Conceivably, coping in general and with abortion in particular, for the woman who has experienced some psychiatric distur-
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CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
bance in the past may be more difficult than for the woman with no history of psychiatric disturbance. Since norms and attitudes relating to having an abortion for Canadian women may be conflicting and at times ambivalent, the abortion event may be particularly uncertain and anxietyprovoking for one who has had difficulty coping. Or, it may be that psychiatric disturbance after abortion may simply be a continuation of the disturbance that was present in the woman before the abortion. In this study, when a woman had psychiatric illness prior to abortion, this did not mean that she had difficulties afterwards since the majority of those with disturbance before abortion did not report subsequent psychiatric difficulties. In another study, having an abortion was shown to result in a greater lifting of depression and lessening of hostility than was carrying an unwanted pregnancy to term (13). Clearly then, the mental health of a woman faced with an unwanted pregnancy stands a greater chance of improving when the woman chooses to have an abortion than when she is forced, against her will, to deliver a child. Most of the women who had psychiatric difficulties after abortion said that they had only sought psychiatric help as outpatients. Additional data from the same study showed that women who obtained abortions had more feelings of rebelliousness than those who did not have abortions (6). Feelings of being different, having done something deserving of punishment, and feeling stigmatized as a result of having had an abortion have been observed in the past (2,3). Moreover, these are the feelings that may motivate a person to seek psychiatric help. Thus, it may be that major factors in help-seeking behaviour on the part of women having abortions are uncomfortable feelings of being stigmatized as a result of having an abortion in a society which is somewhat ambivalent about this issue. A relatively high proportion of women (11 percent) had attempted to commit suicide before their abortions. The grounds for legal abortion in Canada are that the pregnancy is judged to endanger the life or
Vol. 21, No.7
health of the woman. It is suggested that hospital therapeutic abortion committees are sensitive to the threat of suicide on the part of a woman who applies for abortion. Moreover, they may be more responsive to women whom they consider serious suicidal threats (because of their previous history) and therefore grant more of them permission to have legal abortions. A similar suggestion has been made by an investigator in Sweden where the grounds for legal abortion are similar to those in Canada (7). The finding in the present study that approximately 30 percent of the women had. experienced some form of psychiatric disturbance prior to abortion suggests that legal abortion in Canada is either not sought or granted to women in general. It may be that women applying for legal abortion in Canada may be culled by therapeutic abortion committees for those who appear to be the most troubled. The implications are that legal abortion is probably being granted relatively strictly in accordance with the present law, and also that, frequently, applications of women judged not to be 'sick enough' to be granted abortions may be rejected. But does this mean that these women are in any less need of a therapeutic abortion? A woman with no psychiatric history may apply for a therapeutic abortion because of an intolerable social situation. To a large extent her psychological state (which may not be labeled as psychiatric as yet) is dependent on her social situation which might eventually precipitate a psychiatric state should she bear an unwanted child. If this woman requests an abortion, are her reasons social, or psychiatric, or potentially psychiatric? Where does one draw the line? Such considerations should lead us to question the Canadian abortion law which appears to be more concerned with compartmentalizing reasons for abortion than with human and social needs.
Summary The majority of one hundred and eightyeight women interviewed after having legal, therapeutic abortions did not experience psychiatric disturbance. While women with
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459
THERAPEUTIC ABORTION
a psychiatric history were more likely than 8. Jansson, B.: Mental disorders after abortion, Acta. Psychiatr. Scand., 41, 87-110, their more mentally healthy counterparts to 1965. experience some psychiatric disturbance 9. Kretzschmar, R.M., Norris, A.S.: Psychiatafterwards, the majority of those with ric implications of therapeutic abortion, psychiatric problems in the past appeared to Am. J. Obstet. Gynecol., 98, 368-373, be coping reasonably well afterwards. 1967. It was pointed out that factors and 10. Kummer, J.M.: Post-abortion psychiatric circumstances other than the abortion itself, illness - A myth? Am. J. Psychiatry, 119, but occurring around the same time, may 10,980-983,1963. constitute reasons for the subsequent ap- II. Levene, H.I., Rigney, F.: Law, preventive psychiatry and therapeutic abortion, J. pearance of psychiatric disturbance, such as Nerv. Ment. Dis., 151,51-59,1970. suicide attempts. Finally, the grounds for legal abortion in 12. Malmfors, K.: The problem of women seeking abortion. In, M.S. Calderone (Ed.,) Canada were questioned - particularly the Abortion in the United States, New York, artificial practice of compartmentalizing Harper and Row, 1958. and labeling reasons for abortion as 13. McCance, c., Olley, P.C., Edward, V.: psychiatric and non-psychiatric. While such Long term psychiatric follow-up In, G. practices may facilitate the decision-making Horobin (Ed.), Experience with Abortion, processes involved in reviewing applicaLondon, Cambridge, Univ. Press, 1973. tions for abortion, they do not take account 14. Meyerowitz, S., Sadoff, A., Romano, 1.: Induced abortion for psychiatric indication, of the full range of human and social need. Acknowledgements Many thanks are due to Jo-Anne SkinnerGardner whose hard work and dedication contributed greatly to this research. The author wishes to thank Janet Patterson for her continuing loyalty and conscientious assistance.
References
Am. J. Psychiatry, 127, 1153-1160, 1971. 15. Pare, C.M., Raven, H.: Follow-up of patients referred for termination of pregnancy, The Lancet, 1, 635-638, 1970. 16. Peck, A., Marcus, H.: Psychiatric sequelae of therapeutic interruption of pregnancy, J. Nerv. Ment. Dis., 143, 417-425, 1966. 17. Simon, N., Senturia, A., Rothman, D.: Psychiatric illness following therapeutic abortion, Am. J. Psychiatry, 124, 97-103. 18. Smith, E.M.: Counseling for women who seek abortion, Social Work, 17, 62-68, 1972. 19. Todd, N.A.: Follow-up of patients recommended for therapeutic abortion, Br. J. Psychiatry, 120,645-646,1972.
1. Bacon, H.M.: Psychiatric aspects of therapeutic abortion, Canada's Mental Health, 17, 18-21, 1969. 2. Bernstein, N.R., Tinkham, C.B.: Group therapy following abortion, J. Nerv. Ment, Dis., 152, 303-314,1971. 3. Burnell, G.M., Dworsky, W.A., Harrington, R.L.: Post-abortion group therapy, Am. J. Psychiatry, 129, 220-223, 1972. Resume 4. Ekblad, M.: Induced abortions on psychiatLa majorite des cent-quatre-vingt-huit ric grounds: A follow-up study of 479 la suite d'un avwomen, Acta. Psychiatr. Neurol. Scand. femmes interviewees ortement legal et therapeutique n' ont pas Supp.199, 1-238,1955. 5. Ford, C.V., Castelnuovo-Tedesco, P., ressenti des troubles psychiatriques. Alors Long, K.D.: Abortion: Is it a therapeutic que les femmes ayant un passe psychiatprocedure in psychiatry? J.A.M.A., 218, 8, rique etaient plus sujettes que leurs 1173-1178,1971. analogues plus saines mentalement a 6. Greenglass, E.: Therapeutic abortion and its traverser des experiences de troubles psychological implications, Can. Med. As- psychiatriques, la suite d'une telle intersoc.J., 754-757, Oct. 1975. vention; la majorite de celles qui avaient eu 7. Hook, K.: Refused abortion: A follow-up dans Ie passe des problemes psychiatriques study of 249 women whose applications semblaient mieux armees pour y faire face were refused by the National Board of Health in Sweden. Acta. Psychiatr. Scand. la suite d'un avortement. On a souligne que les facteurs et les Supp.168, 1-156,1963.
a
a
a
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CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
circonstances autres que l'avortement luimeme, mais se produisant presqu' au meme moment que l' avortement, peuvent constituer des raisons qui produisent des apparences subsequentes comme des tentatives de suicide. Finallement, les raisons pour l'avortement legal au Canada furent serieusement remises en question, en particulier les
Vol. 21, No.7
pratiques artificielles de compartementaliser et d'etiquetter les raisons pour un avortement psychiatrique ou non psychiatrique. Alors que de telles pratiques peuvent faciliter Ie processus de decision engage dans la revision des demandes pour un avortement; elles ne prennent pas en consideration la veritable portee humaine et sociale.
Modem invention has banished the spinning wheel, and the same law ofprogress makes the woman oftoday a different woman from her grandmother. Susan B. Anthony 1820-1906
No.7
Ottawa, Canada, November 1976
THERAPEUTIC ABORTION AND PSYCHIATRIC DISTURBANCE IN CANADIAN WOMEN*
ESTHER
Introduction While controversy appears to be the order of the day in most discussions on abortion, the question of whether there are psychiatric consequences remains one of the most controversial. Moreover, an examination of research in this area suggests that the relationship between therapeutic abortion and psychiatric disturbance is far from simple. However, the data do not support the conclusion that therapeutic abortion is an emotional trauma for most women. For example, Ekblad (4) found that only I percent of the 479 Swedish women interviewed after legal abortion were disturbed to the point where their work capacity was impaired, but these women had long histories of neurotic illness. In four of these cases it was the break with their male partner that was related to the decompensation and not the abortion. In the fifth case, Ekblad suggested that it was 'Associate Professor, Department of Psychology, York University. Downsview, Ontario. "This study is part of a larger project sponsored by Canada Council Grants S71-0471, S73-0846 and S74-1322. Manuscript received November 1975. Revised June 1976.
Can. Psychiatr. Assoc. J. Vol. 21 (1976)
R.
GREENGLASS, Ph.D.l
difficulties with an alcoholic husband rather than the abortion which probably contributed to the psychiatric difficulties. In another Swedish study, about 12 percent of the women interviewed after abortion suffered mental health impairment (12), but all of them had various neurotic complaints before the abortion. Because of lack of clarity in diagnostic terms used in previous research it might be useful to examine the incidence of psychiatric disturbance after abortion in studies where relatively objective criteria have been employed. One way of objectively assessing psychiatric disturbance is to record the incidence of women seeking psychiatric help on an outpatient basis, being hospitalized for emotional or nervous disturbance, or attempting suicide after abortion. Research indicates that the percentage of women seeking psychiatric help after abortion ranges from zero to about fourteen (5, 9, II, 14, 18). Other findings suggest that hospitalization for emotional disturbance after abortion is considerably less frequent than the seeking of help on an outpatient basis. In four studies, none of the women were reported to have been hospitalized after abortion (I, 11, 16, 18). Moreover,
453
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when hospitalization has occurred, the doing research with Canadian women who percentage involved has tended to be less live in Canada when aborted. than 10 percent (5, 14, 17). Because of insufficient information on their pre- Method abortion psychiatric state, and the tendency Subjects for investigators not to say how many One hundred and eighty-eight women women had been hospitalized for the first who had legal abortions were individually time, the conclusions to be drawn are interviewed'] for this study in 1972-73, an limited. average of 36.55 weeks after abortion In other studies, 1 to 2 percent of the (range: 17.00-68.00). While most of the women interviewed were reported to have women had obtained their abortions in attempted suicide after abortion - both Canada, 31 reported going to the United legal and illegal (14,15,19). But, psychiat- States for a legal abortion and three had ric sequelae of legal abortions performed in obtained them elsewhere. Table I presents a proper medical setting should be very the demographic characteristics of the different from those associated with illegal women in the study. abortions usually done under medically and emotionally inadequate circumstances. The Interview Therefore, it is necessary to assess these Each woman was asked to provide separately. Moreover, studies reporting the information on three basic measures of incidence of suicide attempts after abortion psychiatric disturbance: whether or not she do not generally include data on pre- had ever sought psychiatric help as an abortion psychiatric health. Without these outpatient; had ever been hospitalized for data, it is difficult to ascertain to what emotional or mental disturbance; or had extent the suicide attempt represented an ever attempted suicide. Any reported disinability to cope among women who might turbance was categorized according to have been emotionally disturbed before the whether it occurred before or after abortion. abortion. Further, there has been little The time of disturbance in relation to' the attention paid to the examination of cir- abortion was also recorded as well as the cumstances other than the abortion which length of any psychiatric treatment. might have been responsible for the recorded suicide attempts. Results Since many studies in this area have been Most of the women, 166 (88.3 percent) done in different countries, where grounds reported having had no psychiatric disturfor legal abortion may differ, it is difficult bance after abortion. In all, 22 (11.7 to compare research results. Thus, ques- percent) reported having had psychiatric tions about the relationship of psychiatric disturbance after abortion on one or more of disturbance in Canadian women and the measures employed here. Most of these therapeutic abortion should be explored by had only sought psychiatric help as outpatWomen who had legal therapeutic abortions were reached in tients on an average of 3.19 months after abortion (N=16, S.D.=3.64, Range: two ways: some contacted the interviewer (there were five interviewers in all, none of whom was the author) and 1.00-12.00). Length of treatment was an requested to participate after seeing an advertisement or flyer average of 17.63 weeks (N=16, describing the study; other women were contacted by an interviewer and asked to participate in the study. Initial S.D.=18.34, Range: 1.00-52.00). An addicontact was made primarily in abortion clinics of a hospital tional two women reported having been where women came for an examination to confirm their hospitalized for emotional disturbance, an pregnancy. The doctor in charge told them about this study and asked them if they were interested in hearing more about it average of 3.25 months after abortion from the interviewer in the 'next room. It was only after the (N=4, S.D.=2.63, Range: 1.00-6.00). woman herself agreed.to see us that she was approached by the interviewer and asked to participate in the study. Thus this Length of treatment lasted an average of study overcame the bias frequently present in many studies of 2.50 weeks (N=4, S.D. =.58, Range: this kind which include only women who take the initiative 2.00-3.00). (One of these women had also and request to participate in a study. Interviews were conducted either in the woman's home or in an office. received psychiatric help). A total of five
November, 1976
455
THERAPEUTIC ABORTION TABLE I Demographic Variables of Women Who Had Abortions
Variable
Categories
Marital Status
Single Married Divored or Separated
Age
24 years old or less 25 years old or more
Education
Non-university University
Religion
Protestant Catholic Jewish Agnostic and Atheist Other*
Woman's full-time occupational status***
High Low
Husband's full-time occupational status
High Low
Frequency
Percent
100 63 25
53.2 33.5 13.3
188
100.00
91 97
48.4 51.6
188
100.00
130 58
69.1 30.9
188
100.0
82 34 13 49 10
43.6 18.1 6.9 26.0 5.3
188
99.9**
27 69
28.1 71.9
96
100.0
28 29
49.1 50.9
57****
100.0
*Includes Buddhist, Humanist, Hindu, Christian, Spiritualist, Greek Orthodox, Unitarian, Pantheist, etc. **Does not add up to 100% due to rounding _ ***High status occupations include those labeled as professional, proprietaI, managerial, financial, semi-professional and technical. Low status occupations include those labeled clerical, sales, artisan, foreman, skilled factory, repair and service. ****57 of 63 married women reported their husbands working full-time.
women had attempted suicide an average of S.D.=41.87, Range: 1.00-216.00). Treat2.60 months after abortion (N=5, ment lasted an average of 66.26 weeks S.D. =2.30, Range: 1.00-6.00). (Two of (N=39tt S.D.=107.77, Range: 1.00these had also been hospitalized for emo- 468.00). Eight women had been hostional disturbance). pitalized for emotional disturbance an Psychiatric disturbance before abortion average of 49.88 months before abortion was reported by 56 (29.8 percent) of the (N=16, S.D.=43.97, Range: 3.00-142.00) women. Twenty-seven women said that and their stay in hospital lasted an average they had only received psychiatric help on of 5.19 weeks (N=16, S.D.=5.68, Range: an outpatient basis, an average of 39.73 1.00-20.00). (Some of these women had months prior to abortion (N =40, also received psychiatric help). Twenty-onewomen had attempted suicide an average of ttone woman did not give information on the length of her psychiatric treatment. 66. 10 months before the abortion (N = 21 ,
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S.D.=55.04, Range: 5.00-188.00). (Eight problems afterwards requiring psychiatric of these women had also been hospitalized intervention. Similar findings have been and some had also received psychiatric reported elsewhere (4, 10, 12). In this present study, of those who did have help.) To what extent did women with distur- psychiatric difficulties afterwards, most of bance prior to abortion also have psychiatric them reported only having sought psychiatdisturbance afterwards? Of the 56 women ric help as outpatients. who reported disturbance before abortion, While it might be tempting to draw a 12 (21.4 percent) showed some signs of causal relationship between abortion and disturbance afterwards (see Table 11). Of the subsequent appearance of some form of the 132 women who had no disturbance mental disturbance, it is noteworthy that for before abortion 10 (7.6 percent) reported four out of the five women who had some disturbance afterwards. attempted suicide, circumstances other than Table 1Il shows the nature of disturbance the abortion may have been the precipitatbefore abortion for women who had distur- ing factor. For example, three ofthe women bance after the abortion and for those who said that they had attempted suicide because had no disturbance. Fifty-three percent who of difficulties with the man involved, or sought help after abortion had some because of 'family circumstances'. In the psychiatric difficulties before. Both of the fourth case, the woman had attempted women who were hospitalized after abor- suicide before the abortion and the pretion had either received help before or had gnancy (suggesting that she may have been been hospitalized and, two of the five somewhat unstable before the abortion) and women who attempted suicide after abor- she also believed that her mother had tion had some disturbance before. Of those pushed her into having the abortion against who showed no disturbance afterwards, her will. Other data suggest that being 26.5 percent had some disturbance before. forced into having an abortion against one's will can lead to neurotic dispositions Discussion afterwards (6). Nevertheless, it would The majority of women who had abor- appear that when a woman chooses to have tions said that they did not have emotional an abortion, it is highly unlikely that she TABLE 11 Women with (no) pre-abortion psychiatric disturbance who reported (no) post-abortionpsychiatric disturbance
Pre-abortion psychiatric disturbance
Post-abortion Psychiatric Disturbance Absent N=166 Present N=22
Total 188 *Row percentage **Column percentage
Absent N=132
Present N=56
Total N=188
122 *73.5% **92.4%
44 26.5% 78.6%
166
45.5% 7.6%
12 54.5% 21.4%
22
132
56
10
188
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457
TABLE III Women with post-abortion psychiatric disturbance who had previously shown pre-abortion psychiatric disturbance
Psych. dist. after Psych. help only
Frequency of women
Percent of total women
15
8.0
Psych. dist before
Frequency of women
Psych. help only Hospitalization Suicide attempt No psych. dist.
6 I I
Total Hospitalization*
2
1.1
Psych. help only Hospitalization Total
Suicide attemprw
5
2.7
Psych. help only Suicide attempt No psych. dist.
Total
166 188
88.3 100.1***
46.7
15
100.0
I I
100.0 6
2
100.0
3
Psych. help only Hospitalization Suicide attempt No psych. dist. Total
53.3 5
7
I I
Total No psych. dist.
Percent of women with (no) psych. dist. before
5
40.0 7 60.0 100.0
19 6 19 122
73.5
166
100.0
26.5 8
*Includes women who have been hospitalized only, as well as those who have received psychological help as well as having been hospitalized **Includes women who have attempted suicide only; attempted suicide and received help; were hospitalized and attempted suicide; and those who attempted suicide, received help and were hospitalized as well ***Does not add up to 100% due to rounding 5Percent of all women who received psychological help only after the abortion 6}>ercent of all women who were hospitalized after the abortion (and who might have received psych. help as well) 7percent of all women who attempted suicide after the abortion (and who might have received psych. help and hospitalization as well) Bpercentof all women with no psychiatric disturbance after the abortion,
will attempt to commit suicide afterwards because of the abortion per se. Researchers in this area should be alerted to the possibility that traumatic events occurring near the time of the abortion, such as a break or difficulties with the man involved, extreme financial problems, and so on, and not the abortion, may well be the reasons for a woman attempting suicide after an abortion. One factor that appeared to be related to the appearance of psychiatric symptoms
after abortion was the woman's psychiatric history. When this factor was considered it was found that women with a history of any psychiatric disturbance were three times as likely to have some psychiatric disturbance afterwards as those who did not report psychiatric disturbance in the past. These results are similar to previous ones reported in countries other than Canada (4, 8, 17). Conceivably, coping in general and with abortion in particular, for the woman who has experienced some psychiatric distur-
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bance in the past may be more difficult than for the woman with no history of psychiatric disturbance. Since norms and attitudes relating to having an abortion for Canadian women may be conflicting and at times ambivalent, the abortion event may be particularly uncertain and anxietyprovoking for one who has had difficulty coping. Or, it may be that psychiatric disturbance after abortion may simply be a continuation of the disturbance that was present in the woman before the abortion. In this study, when a woman had psychiatric illness prior to abortion, this did not mean that she had difficulties afterwards since the majority of those with disturbance before abortion did not report subsequent psychiatric difficulties. In another study, having an abortion was shown to result in a greater lifting of depression and lessening of hostility than was carrying an unwanted pregnancy to term (13). Clearly then, the mental health of a woman faced with an unwanted pregnancy stands a greater chance of improving when the woman chooses to have an abortion than when she is forced, against her will, to deliver a child. Most of the women who had psychiatric difficulties after abortion said that they had only sought psychiatric help as outpatients. Additional data from the same study showed that women who obtained abortions had more feelings of rebelliousness than those who did not have abortions (6). Feelings of being different, having done something deserving of punishment, and feeling stigmatized as a result of having had an abortion have been observed in the past (2,3). Moreover, these are the feelings that may motivate a person to seek psychiatric help. Thus, it may be that major factors in help-seeking behaviour on the part of women having abortions are uncomfortable feelings of being stigmatized as a result of having an abortion in a society which is somewhat ambivalent about this issue. A relatively high proportion of women (11 percent) had attempted to commit suicide before their abortions. The grounds for legal abortion in Canada are that the pregnancy is judged to endanger the life or
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health of the woman. It is suggested that hospital therapeutic abortion committees are sensitive to the threat of suicide on the part of a woman who applies for abortion. Moreover, they may be more responsive to women whom they consider serious suicidal threats (because of their previous history) and therefore grant more of them permission to have legal abortions. A similar suggestion has been made by an investigator in Sweden where the grounds for legal abortion are similar to those in Canada (7). The finding in the present study that approximately 30 percent of the women had. experienced some form of psychiatric disturbance prior to abortion suggests that legal abortion in Canada is either not sought or granted to women in general. It may be that women applying for legal abortion in Canada may be culled by therapeutic abortion committees for those who appear to be the most troubled. The implications are that legal abortion is probably being granted relatively strictly in accordance with the present law, and also that, frequently, applications of women judged not to be 'sick enough' to be granted abortions may be rejected. But does this mean that these women are in any less need of a therapeutic abortion? A woman with no psychiatric history may apply for a therapeutic abortion because of an intolerable social situation. To a large extent her psychological state (which may not be labeled as psychiatric as yet) is dependent on her social situation which might eventually precipitate a psychiatric state should she bear an unwanted child. If this woman requests an abortion, are her reasons social, or psychiatric, or potentially psychiatric? Where does one draw the line? Such considerations should lead us to question the Canadian abortion law which appears to be more concerned with compartmentalizing reasons for abortion than with human and social needs.
Summary The majority of one hundred and eightyeight women interviewed after having legal, therapeutic abortions did not experience psychiatric disturbance. While women with
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THERAPEUTIC ABORTION
a psychiatric history were more likely than 8. Jansson, B.: Mental disorders after abortion, Acta. Psychiatr. Scand., 41, 87-110, their more mentally healthy counterparts to 1965. experience some psychiatric disturbance 9. Kretzschmar, R.M., Norris, A.S.: Psychiatafterwards, the majority of those with ric implications of therapeutic abortion, psychiatric problems in the past appeared to Am. J. Obstet. Gynecol., 98, 368-373, be coping reasonably well afterwards. 1967. It was pointed out that factors and 10. Kummer, J.M.: Post-abortion psychiatric circumstances other than the abortion itself, illness - A myth? Am. J. Psychiatry, 119, but occurring around the same time, may 10,980-983,1963. constitute reasons for the subsequent ap- II. Levene, H.I., Rigney, F.: Law, preventive psychiatry and therapeutic abortion, J. pearance of psychiatric disturbance, such as Nerv. Ment. Dis., 151,51-59,1970. suicide attempts. Finally, the grounds for legal abortion in 12. Malmfors, K.: The problem of women seeking abortion. In, M.S. Calderone (Ed.,) Canada were questioned - particularly the Abortion in the United States, New York, artificial practice of compartmentalizing Harper and Row, 1958. and labeling reasons for abortion as 13. McCance, c., Olley, P.C., Edward, V.: psychiatric and non-psychiatric. While such Long term psychiatric follow-up In, G. practices may facilitate the decision-making Horobin (Ed.), Experience with Abortion, processes involved in reviewing applicaLondon, Cambridge, Univ. Press, 1973. tions for abortion, they do not take account 14. Meyerowitz, S., Sadoff, A., Romano, 1.: Induced abortion for psychiatric indication, of the full range of human and social need. Acknowledgements Many thanks are due to Jo-Anne SkinnerGardner whose hard work and dedication contributed greatly to this research. The author wishes to thank Janet Patterson for her continuing loyalty and conscientious assistance.
References
Am. J. Psychiatry, 127, 1153-1160, 1971. 15. Pare, C.M., Raven, H.: Follow-up of patients referred for termination of pregnancy, The Lancet, 1, 635-638, 1970. 16. Peck, A., Marcus, H.: Psychiatric sequelae of therapeutic interruption of pregnancy, J. Nerv. Ment. Dis., 143, 417-425, 1966. 17. Simon, N., Senturia, A., Rothman, D.: Psychiatric illness following therapeutic abortion, Am. J. Psychiatry, 124, 97-103. 18. Smith, E.M.: Counseling for women who seek abortion, Social Work, 17, 62-68, 1972. 19. Todd, N.A.: Follow-up of patients recommended for therapeutic abortion, Br. J. Psychiatry, 120,645-646,1972.
1. Bacon, H.M.: Psychiatric aspects of therapeutic abortion, Canada's Mental Health, 17, 18-21, 1969. 2. Bernstein, N.R., Tinkham, C.B.: Group therapy following abortion, J. Nerv. Ment, Dis., 152, 303-314,1971. 3. Burnell, G.M., Dworsky, W.A., Harrington, R.L.: Post-abortion group therapy, Am. J. Psychiatry, 129, 220-223, 1972. Resume 4. Ekblad, M.: Induced abortions on psychiatLa majorite des cent-quatre-vingt-huit ric grounds: A follow-up study of 479 la suite d'un avwomen, Acta. Psychiatr. Neurol. Scand. femmes interviewees ortement legal et therapeutique n' ont pas Supp.199, 1-238,1955. 5. Ford, C.V., Castelnuovo-Tedesco, P., ressenti des troubles psychiatriques. Alors Long, K.D.: Abortion: Is it a therapeutic que les femmes ayant un passe psychiatprocedure in psychiatry? J.A.M.A., 218, 8, rique etaient plus sujettes que leurs 1173-1178,1971. analogues plus saines mentalement a 6. Greenglass, E.: Therapeutic abortion and its traverser des experiences de troubles psychological implications, Can. Med. As- psychiatriques, la suite d'une telle intersoc.J., 754-757, Oct. 1975. vention; la majorite de celles qui avaient eu 7. Hook, K.: Refused abortion: A follow-up dans Ie passe des problemes psychiatriques study of 249 women whose applications semblaient mieux armees pour y faire face were refused by the National Board of Health in Sweden. Acta. Psychiatr. Scand. la suite d'un avortement. On a souligne que les facteurs et les Supp.168, 1-156,1963.
a
a
a
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circonstances autres que l'avortement luimeme, mais se produisant presqu' au meme moment que l' avortement, peuvent constituer des raisons qui produisent des apparences subsequentes comme des tentatives de suicide. Finallement, les raisons pour l'avortement legal au Canada furent serieusement remises en question, en particulier les
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pratiques artificielles de compartementaliser et d'etiquetter les raisons pour un avortement psychiatrique ou non psychiatrique. Alors que de telles pratiques peuvent faciliter Ie processus de decision engage dans la revision des demandes pour un avortement; elles ne prennent pas en consideration la veritable portee humaine et sociale.
Modem invention has banished the spinning wheel, and the same law ofprogress makes the woman oftoday a different woman from her grandmother. Susan B. Anthony 1820-1906
