There is no longer any dispute regarding the fact that, on average, women with a history of abortion have higher rates of mental illness compared to similar women without a history of abortion. But AMH minimalists frame this admission in the context of arguing that this is most likely due to pre-existing mental health issues.
Therefore, higher rates of mental illness following abortion are just a continuation of pre-existing mental frailty. In courtrooms, this line of arguments is known as the thin skull, or eggshell skull, defense. It asserts that a defendant should not be held accountable for injuries that would not have been suffered if the plaintiff had not been predisposed to injury due to pre-existing physical or emotional defects.
Notably, the thin skull defense has been rejected in most legal jurisdictions. In short, the argument that negative effects may be mostly due to pre-existing mental health problems simply strengthens the argument for better pre-abortion screening for this and other risk factors. While only a few studies have examined the mental health of women denied abortions, none have found any significant mental health benefits compared to other groups of women.
Still another AMH minimalist argument is that women with prior mental illness may instinctively know they are less likely to cope well with an unwanted pregnancy, so the higher rate of abortion among women with mental illness is actually a sign of these women choosing abortion wisely. It ignores the likelihood that mentally ill women, especially those with a history of being abused, may simply be more susceptible to being pressured into unwanted abortions 45 like Allie All-Risks.
Who is at risk?
Moreover, it ignores the ethical obligation of caregivers to discourage, rather than enable, patterns of behavior that may be self-destructive. Rather than just assume that mentally ill women are wisely inspired to choose abortion more often than mentally healthy women, would it not be best to screen women seeking abortions for mental illness so women can be counseled in a manner that more fully addresses their needs in the context of their mental illness?
Moreover, bearing children may actually contribute to mental health improvements through direct biological effect, , , by expanding and strengthening interpersonal relationships with the child ren and others, , , , or by behavioral adaptations that may replace risk-taking with self-improving behaviors. These benefits may also apply to bearing unplanned children. Indeed, given how common unplanned pregnancies are throughout the millennia, it could be argued that female biology has evolved mechanisms in order to adapt and adjust to unexpected pregnancies.
In short, the argument that higher rates of mental illness following abortion are simply due to mentally ill women being wise enough to choose abortion more often is simply not supported by any statistically validated research. Instead, the opposite argument, that giving birth is more likely to produce mental health benefits, is more plausible and better supported by actual data.
Closely related to the pre-existing mental illness issue is the finding that women with a history of abortion also have higher rates of abuse and violence in their lives. According to this argument, violence , or childhood adversities, not abortion, are the most likely cause of higher rates of mental illness among women with a history of abortion. This hypothesis is contradicted, however, by studies which have shown that there are higher rates of mental illness associated with abortion even after controlling for violence.
Clearly, a history of abuse contributes to a heightened risk of both pregnancy and abortion, especially abortions to satisfy the demands of others.
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At the same time, clinical experience reveals that issues related to abuse and abortion can become deeply entangled. Progress is most likely to be made when both the abuse and abortion experiences are holistically addressed. While it important to study the interactions between exposure to violence and abortion on mental health, it is also important to consider that there may be two-way interactions.
While prior abuse and mental health problems receive the most blame for why women with a history of abortion have higher rates of mental illness, a few AMH minimalists insist that the blame for mental illness following abortion can always be shifted to other risk factors. In response, AMH proponents argue that a the burden of proving safety and effectiveness is on the proponents of a medical treatment and b given the weight of the evidence, it is far more logical to accept that abortion is at least a contributing factor that may work in concert with any number of other contributing factors.
In addition, denying that abortion directly contributes to mental health problems is illogical given the fact that so many of the risk factors identified by AMH minimalists themselves see Table 1 are specifically part of the abortion experience. These include feeling pressured to abort by others; negative moral views of abortion; low expectation of coping well after an abortion; ambivalence about the abortion decision; and feelings of attachment or commitment to a pregnancy that is meaningful or wanted.
In other words, given what we know of the risk factors associated with mental illness after abortion, many of them are directly enmeshed in the abortion experience; they are not fully independent of the pregnancy and abortion experience. Therefore, even to the degree that mental illnesses can be associated with common risk factors for both unintended pregnancy and abortion, such as a history of sexual abuse, the intermeshing of elevated risk for pregnancy, abortion, and mental health issues precludes the conclusion that abortion does not contribute in any way to the observed problems.
The only support for that argument comes from ideology, not from any statistically validated studies. For example, an incest victim may be at greater risk of a high school pregnancy with the first boyfriend that she imagines will be able to free her from an abusive step-father. While it would be a mistake to blame the abortion for all of her subsequent mental health problems, even if a subsequent suicide note focuses on the abortion, it is ludicrous to assert that her abortion did not contribute to her problems.
Moreover, it is also evident that the failure of healthcare providers to identify the risk factors that made her a poor candidate for abortion missed an opportunity to assist her in using her pregnancy to break a cycle of exploitation and trauma. Finally, it should be noted that AMH minimalists frequently cite studies showing that women who deliver an unintended pregnancy have more subsequent problems than women who only have intended pregnancies. But this argument falsely presumes that abortion puts women who have unintended pregnancies back into the category of women who have never had an unintended pregnancy, and that all intended pregnancies are carried to term.
There is a third group, c women who have had abortions, who may fare worse than either of the other two groups. While AMH proponents do not dispute that on average women with unintended pregnancies may face more problems than women who have perfect reproductive lives, it appears likely that they still have fewer problems than women who abort. Indeed, as previously discussed, not a single study has found evidence that the mental health of women who deliver an unintended pregnancy is worse than that of women who have abortions.
First, it is notable that all pregnancy outcomes are associated with some PTSD risk. Both vaginal and cesarean deliveries can be experienced as traumatic with a corresponding risk of PTSD. Given the weight of the many statistically validated studies cited above, much less than the reports of clinicians and women who attribute PTSD symptoms to their abortions, it seems evident that the effort of a few AMH minimalists to categorically deny that abortion can contribute to traumatic reactions is driven by ideological considerations, not science.
That said, it should also be noted that not all women will experience abortion as traumatic.
Moreover, the susceptibility of individuals to experience PTSD symptoms can also vary based on many other pre-existing factors, including biological differences. So the risk of individual women will vary, as it does for every type of psychological reaction. The evidence is clear that some women do experience abortion as a trauma. The prevalence rates and pre-existing risk factors may continue to be disputed, but the fact that abortion contributes to PTSD symptoms in at least a small number of women is a settled issue.
Good research is essential for both healthcare providers and patients. Better information about the risks and benefits associated with abortion should contribute to better screening, better risk—benefit assessments, and better disclosures to patients, 23 that will help to shape the expectations of patients and those who advise them.
Better information will also improve the identification of at risk patients who may benefit from referrals to post-abortion counseling. As previously discussed, while the ideological divides between AMH minimalists and proponents will continue to shape how each side interprets the data, these differing viewpoints actually provide an opportunity for improving the collection of useful data, analyses of the available data, and more thorough interpretations of research findings.
Therefore, healthcare providers and patients would be better served by AMH minimalists and AMH proponents both bringing their various perspectives to bear on research efforts in a more cooperative fashion. Such cooperation would improve methodologies by better addressing the differing concerns of each perspective at the time of the study design. Collaboration in the writing of introductions and conclusions to such studies would also be improved by bringing balance to both perspectives and by reducing the tendency to overgeneralize results of specific analyses.
More specific opportunities for collaboration and better research are discussed below. A major problem with abortion research and reviews is a failure to address all of the relevant questions which need to be asked, investigated, and answered. Given the lack of any evidence for psychiatric indications for abortion, it seems likely that the NCCMH decided to ignore this question because it echoed previous allegations that UK law was not being followed in regard to limiting abortion to cases where there are therapeutic benefits.
Many additional questions were raised during the consultation process when the NCCMH team invited comments and suggestions from experts. The consultation report anticipated the many criticisms of the final report 19 , and revealed that NCCMH team was not very responsive to the issues and concerns raised during this peer review. The following is a list of some key research questions that should be addressed in future studies and reviews.
How prevalent are mental health problems in women who carry unplanned pregnancies to term compared to women who deliver wanted pregnancies, to women who have no children, and to women who have abortions? Among women who do experience negative emotional reactions not limited to mental illness which they attribute to their abortions, what reactions are reported?
The Impact of Illegal Abortion
What statistically validated indicators predict when the mental health risks of continuing a pregnancy are greater than if the pregnancies were aborted? What statistically validated risk factors predict negative outcomes following one abortion, two abortions, and three or more abortions compared to each available comparison group? What factors, if any, are associated with improved mental health following abortion compared to similar women who carry a similarly problematic pregnancy to term?
Among women with pre-existing mental health issues, what factors predict a likelihood that abortion may contribute to a reduction in mental health problems intensity, duration, and number of mental health issues , and what factors predict a likelihood that abortion may contribute to an increase in mental health problems? Among women without pre-existing mental health issues, what factors predict a likelihood that abortion may protect good mental health, and what factors predict a likelihood that abortion may contribute to subsequent mental health problems?
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Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems that can be timely addressed by appropriate offers of care? In evaluating the risk—benefits profile of a specific patient, what criteria should be met in order to reach an evidence-based conclusion that the benefits of abortion are most likely to exceed the risks? In cases of pregnancy following rape or incest, what are the short- and long-term mental health effects associated with each of the following outcomes: a abortion, b miscarriage or stillbirth, c childbirth and adoption, and d childbirth and raising the child?
While a number of analyses have been published based on longitudinal studies, none of these studies were designed to specifically investigate the intersection between AMH issues. The need for better longitudinal studies to investigate AMH has been recognized in other major reviews, 4 , 24 , yet the call for such research has not yet been heeded. We recommend that the value of such longitudinal studies would be vastly increased by expanding the goal of data collection to encompass not just mental health effects associated with abortion but also with all reproductive health issues from first menses to menopause.
This would assist in research related to infertility, miscarriage, assisted reproductive technologies, postpartum reactions, premenstrual syndrome, and more. And given the interactions with multiple pregnancy outcomes already seen in AMH research, 88 , 94 , , comprehensive reproductive health histories are needed in any case. An explicit objective should be ensuring that every line of questioning either side considers important is included. When both sides contribute to the design of such studies and have equal access to the same data, concerns about suppressed findings or incomplete analyses will be dramatically reduced … at least after re-analyses.
When both sides have equal access to better data, it is more likely that the areas of consensus will increase. The value of longitudinal studies would also be enhanced by seeking the consent of participants to link their medical records to their questionnaires. This would be most helpful given the fact that many women are reluctant to reveal abortion information even in responding to a confidential questionnaire. While many will likely refuse this option, the refusal to permit record linkage is itself a data point for analyzing patterns associated with concealment and dropout.
Along the same lines, at each wave there should be included a query regarding the level of stress associated with completing the questionnaire. It is precisely because data can be selectively analyzed and interpreted to produce slanted results, — that data should be made available for re-analyses by third parties.
Most importantly, data sharing enhances confidence in the reliability of research findings, especially when related to controversial issues. Unfortunately, though many publications and professional organizations encourage or require post-publication sharing of data, in practice many researchers across many disciplines evade data sharing.
Cause and Effect Essay - Emergency Contraception Causes Abortion
She even refused to comply with a request for the data from the US Department of Health and Human Services, even though the study was funded by that agency. Such data hoarding undermines confidence not only in the published findings of a specific study but also diminishes the value of syntheses or reviews relying on those unverified findings.
Data sharing is especially important when the process of collecting data may be blocked by ideological litmus tests. For example, abortion providers are naturally unlikely to cooperate with studies initiated by AMH proponents who they perceive as opponents of their work. On the contrary, they have frequently cooperated with AMH minimalists—precisely because of their shared ideology.
Implicit in granting that cooperation may be the expectation that pro-choice researchers will not report any findings that may contribute to anti-abortion rhetoric. Conversely, many post-abortion counseling programs may also limit their cooperation to AMH proponents whom they perceive as most accepting and supportive of the issues raised by their clientele. In both cases, the ideological alignments required to collect data may create biases in the design, analysis, and reporting of results.
This does not mean that meaningful results cannot be obtained. But it does mean that such results should always be presumed to reflect sample and investigator biases until the findings have been confirmed in reanalyses conducted by investigators of all perspectives. It is only through equal access to the data that consensus will grow around results which survive reanalyses. It is also through this process that new research objectives will be better identified in response to these reanalyses. In many cases, legal restrictions government or contractual may bar the sharing of underlying data.
In such cases, reasonable requests for additional information, tables, and reanalyses should be honored through personal communication, publication of a response, or, if a major reanalysis is required, in publication of a subsequent paper. Such cooperation is especially important in regard to data sets that have access restrictions, such as those collected by government agencies.