Post-Abortion Syndrome (PAS)

Examination of available studies.

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Review of available studies:

Many studies have been conducted into the incidence and nature of post-abortion syndrome (PAS). Some have been "... widely cited in legislative and judicial testimony in support of the existence of adverse psychiatric sequelae of induced abortion." ₁

A study by Jocelyn T. Warren of Oregon State University _8,9 of the actual psychological risks to adolescents of terminating a pregnancy noted that purported risks have been used to justify restricting women's access to abortion. They stated:

"In the [U.S.] Supreme Court’s 2007 decision upholding the ban on so-called partial birth abortions, Justice Anthony Kennedy wrote: 'While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort. ... Severe depression and loss of esteem can follow."
"In 2010, Nebraska mandated in the Women’s Health Protection Act that [abortion] providers screen women seeking abortion for 'physical, psychological, emotional, demographic or situational' risk factors. Providers who do not comply fully with the law will be liable for damages, including 'wrongful death'."
"The risks to women’s mental health assumed by these legal decisions have been tested, with varying degrees of scientific rigor and with conflicting results. Some studies have found that women who have had an abortion have higher rates than others of some types of depression disorders, anxiety, bipolar disorder and schizophrenia, and more mental health problems overall. Other studies have found no association between abortion and adverse outcomes, including depression, anxiety and low self-esteem."
"In 2006, the American Psychological Association convened an expert panel to review empirical studies published since 1989. The panel found no credible evidence that terminating an unwanted pregnancy causes mental health problems in adult women; it also noted that some studies suffered from serious methodological flaws. ..."
"... a presumed high risk of psychological harm from abortion is one justification given for laws that mandate parental involvement in adolescents’ abortion decisions."

G.E. Robinson et al., conducted a review of 216 peer-reviewed PAS studies which had been published since 1990. Their paper appeared in the Harvard Review of Psychiatry during the fall of 2009. ₁The review found that the quality of recent studies is highly variable, with some studies being essentially useless.

An article abstract of that review states:

"Recent studies that have been used to assert a causal connection between abortion and subsequent mental disorders are marked by methodological problems that include, but not limited to: poor sample and comparison group selection; inadequate conceptualization and control of relevant variables; poor quality and lack of clinical significance of outcome measures; inappropriateness of statistical analyses; and errors of interpretation, including misattribution of causal effects. By way of contrast, we review some recent major studies that avoid these methodological errors."

"The most consistent predictor of mental disorders after abortion remains preexisting disorders, which, in turn, are strongly associated with exposure to sexual abuse and intimate violence. Educating researchers, clinicians, and policymakers how to appropriately assess the methodological quality of research about abortion outcomes is crucial. Further, methodologically sound research is needed to evaluate not only psychological outcomes of abortion, but also the [adverse] impact of existing legislation and the effects of social attitudes and behaviors on women who have abortions." ₂

"Serena," writing for Feminists For Choice, comments that the authors of this review found that:

"... most well controlled studies continue to demonstrate that there is no convincing evidence that induced abortion of an unwanted pregnancy is a per se significant risk factor for psychiatric illness." (Page 276) ₁

Robinson, et al., note that:

"... in some of the studies of abortion outcome, researchers recruited women who had already self-identified as suffering negative psychological effects from abortion, and then used the self-reports of these women as evidence for high rates of ill effects in all women who have had abortions. ..."

"The use of retrospective reports from women who had an abortion years earlier is problematic. Recall bias can affect any individual’s perspective on a historical event. Mood-related memory effects also may bias recall of both the abortion experience and the timing of previous psychiatric episodes –- especially if many years have passed. Later feelings about abortion may be influenced by subsequent reproductive experiences, failure to recall the circumstances leading to the decision to abort, current depression related to stressful life events, or the effects of public campaigns attributing psychological problems to abortion. ..."

"Some studies of abortion fail to use a comparison group, or use as a comparison group women in general or women who have never been pregnant, who have never delivered (with the wantedness of the pregnancy unspecified) but have never had an abortion, who are currently pregnant, who had a spontaneous abortion, or who have delivered following wanted pregnancies. ..."
"These circumstances ... are not comparable to those associated with a voluntary, elective abortion ..."

"At a minimum, the appropriate comparison group for assessing the relative risks of negative mental health outcomes of such abortions is women who carry unwanted pregnancies to term. An unwanted pregnancy is different from an unplanned pregnancy. Women with unwanted pregnancies are more likely to suffer from a number of co-occurring life stressors, including childhood adversity, relationship problems, exposure to violence, financial problems, and poor coping capacity, all of which contribute to emotional distress. These factors increase the risk of poor mental health, whether or not a woman has an abortion. (Page 270). ₃

Many of the studies reviewed did not define depression. Many used the respondents personal descriptions of their memories of depression rather than a clinical diagnosis of depression from a professional at the time. Most of the studies did not ask about positive outcomes -- like a feeling of relief or a satisfaction with their decision.

It is unclear whether the poor quality studies on PAS were caused by incompetence or the desire to support an ideology, or both, or neither.

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APA Study:

In the fall of 2009, the Board of Trustees of the American Psychiatric Association approved a resource document titled: "Abortion and Women's Reproductive Health Care Rights." It is largely based on the study by G.E. Robinson et al. cited above. ₁

The authors comment:

"Beyond the above basic demographic variables, it is essential to control for previous psychiatric history and pre-existing, co-occurring, and subsequent conditions. Many studies attribute postabortion mental states to the abortion itself without providing adequate control for pre-abortion mental states, despite the literature suggesting that previous psychiatric history is the most consistent predictor of post-abortion psychiatric disorder. Moreover, past psychiatric history itself may be associated with predisposition to unwanted pregnancy."

"Finally, studies that do not consider pre-existing or co-occurring stressful circumstances in women undergoing abortion might attribute emotional distress to the abortion when it is actually a product of the woman’s larger life circumstances. For instance, rape or incest might result in unwanted pregnancies. Once pregnant, others might pressure the woman to have or not have an abortion, and the woman might avoid discussing her decision with others, thereby narrowing her support network."

Some studies attempted to link abortion with a subsequent increased risk for suicide and death. Studies in Scandinavia found that suicide rates were higher among women who had had an abortion when compared with women who had given birth. However, a similar study in the U.S. showed the reverse. In 2006, Drs. Melissa A Schiff and David C. Grossman examined postpartum suicide attempts in Washington state. They found that:

"Maternal complications, including labor and delivery complications and cesarean delivery, and previous spontaneous or therapeutic abortion were not associated with postpartum suicide attempt. A fetal or an infant death was strongly associated with an attempt." ₁₀

One carefully designed longitudinal study by B. Major et al., gave:

"... standardized tests of depression, post-traumatic stress, and self esteem at one hour pre-abortion, and one hour, one month, and two years post-abortion. Two years after the abortion, 72% of women reported they were satisfied with their decision and 69% would have the abortion again if they had to make the decision over. The percent of women experiencing clinical depression within two years after the abortion equaled the rate of depression nationally among all women 15-35 years of age. Depression levels at all times were lower post-abortion than pre-abortion, while self-esteem was higher post-abortion. The most common emotion was relief. A pre-pregnancy history of depression consistently predicted poorer postpartum mental health and more negative abortion-related emotions and evaluations. ₇

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Adolescent study:

The 2009 study by G.E. Robinson et al. ₁ and the 2008/9 resource document published by the American Psychiatric Association concluded that on average, induced abortion does not cause mental health problems in women who had an abortion as an adult. However, because of lack of data, they did not draw any conclusions about women who were adolescents at the time of their abortion. Almost all studies of PAS have involved only adult women.

A 2010 study by a team led by Jocelyn T. Warren of Oregon State University was the first to examine depression and low self-esteem as potential outcomes of abortion among a nationally representative group of adolescents. The results parallel those of the ABP report mentioned above: they found no relationship, on average, between abortion and later mental health problems. They looked for negative effects one year and five years after the abortion.

They reported their findings as:

Results: Abortion was not associated with depression or low self-esteem at either time point. Socioeconomic and demographic characteristics did not substantially modify the relationships between abortion and the outcomes.
Conclusions: Adolescents who have an abortion do not appear to be at elevated risk for depression or low self-esteem in the short term or up to five years after the abortion. _8,9

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References used:

The following information sources were used to prepare and update the above essay. The hyperlinks are not necessarily still active today.

Gail. E. Robinson, et al., "Is there an 'Abortion Trauma Syndrome'? Critiquing the evidence," Harvard Review of Psychiatry, Volume 17, Issue 4, 2009-AUG, Pages 268 to 290.
An abstract of the Harvard Review of Psychiatry article is available at: http://www.informaworld.com/ and at http://www.ingentaconnect.com/
Serena, "New study debunks 'Abortion Trauma Syndrome," Feminists for choice, 2009-AUG-24, at: http://feministsforchoice.com/
Aspen Baker, comment posted on the "New study debunks 'Abortion Trauma Syndrome," article at: http://feministsforchoice.com/
Anne Speckhard and Vincent Rue, "Post-Abortion Syndrome a Growing Health Problem," Journal of Social Issues, 1992-FALL. Available at: http://www.forerunner.com/
"Abortion and Women’s Reproductive Health Care Rights," American Psychiatric Association, 2009-SEP, at: http://www.psych.org/
B. Major, et al., " Psychological responses of women after first-trimester abortion," Arch Gen Psychiat 2000; 57: Pages 777-784.
Rebecca Wind, "New study finds abortion does not cause mental health problems among adolescents,"Guttmacher Institute, 2010-SEP-24, at: http://www.guttmacher.org/
Jocelyn T. Warren, "Do Depression and Low Self-Esteem Follow Abortion Among Adolescents? Evidence from a National Study." Guttmacher Institute, at: http://www.guttmacher.org. This is a PDF file. The paper will be published in Perspectives on Sexual and Reproductive Health, Volume 42, #4, Pages 230 - 235, 2010-DEC.
Melissa A. Schiff, & David C. Grossman, "Adverse Perinatal Outcomes and Risk for Postpartum Suicide Attempt in Washington State, 1987–2001," Pediatricts, Vol. 118 No. 3, 2006-SEP, Pages e669-e675.