Abortion is a profoundly human and complex issue. Because it is such an intensely personal experience, it carries serious and significant consequences for both the individual and society. The choice of abortion confronts moral reasoning, beliefs about human development, personal identity, family structure and functions, role conflicts in relationships and one's belief in the future. Women considering abortion and women who have had abortions commonly ask: "What kind of person am I? If others know what I am thinking of doing or have done, will they condemn me? Is this a baby? Does it have a soul? What will it feel? Was this the death of my baby, or just a bad dream, or what?"

The millions of women and men whose lives have been touched by abortion are often confronted by a lifetime of unasked, unspoken, and typically unanswered questions. Women's responses to how they feel after an abortion are time sensitive, depending upon when and how they are asked. These reactions span from feelings of relief to acts of suicide, empowerment to victimization, elation to grief. For some, it takes years to find the personal courage to acknowledge they do indeed have questions, beginning with a fundamental reexamination of the legitimacy of the decision: "Was my abortion the right thing for me to have done?"

Many stay strongly avoidant and unquestioning, fearing the power of feelings and the fear of reconsideration. For them denial, avoidance, and repression offer limited but controlling consolation. Introspection is also avoided, the price of awareness being too great a burden generally in their lives, and in particular concerning the abortion. While many have mentally altered the terrain of their memory, obliterating any recollections of the traumatic abortion death that "never happened," traces remain.

Some women project their strong negative feelings about their abortion experience toward those who oppose abortion rights. A number become abortion rights advocates or abortion counselors (though usually without professional training or credentials). This protective maneuver helps some women to keep themselves from experiencing regret or reconsideration. Information about human development or the negative consequences of abortion for some women can be too threatening. Those who supply this information must be vigorously attacked to legitimize the "choice" to abort.

But most women simply do not share their abortion-related feelings; it is too personal, too intense, and too threatening. For many of these women and men have no protection at all from their feelings or their need to review and reexamine their choice. These individuals are likely to feel overwhelmed, misinformed, angry, isolated, guilty, and filled with shame and regret. They believe their choice can neither be justified nor forgiven by themselves or others. Because they condemn themselves, they live in fear that others will condemn them, too. This fear of condemnation compels them to hide their pain. As a result, their silence can, and often does, prevent them from expressing their grief, receiving the compassion of others, or seeking out necessary counseling.

These same three reactions--denial, defensiveness, and self-condemnation--also keep society from honestly examining abortion and its impact. Those who are filled with shame or engaged in denial are not likely to talk about it. Silence is all that remains of the pregnancy. Those who might otherwise acknowledge their emotional pain following abortion are too defensive to admit their pain for fear of providing affirmation to those opposed to abortion rights. Then too, many social leaders believe we cannot give too much sympathy or compassion for those women who have exercised their legal right to abortion. If too much is made of their emotional burden, might not abortion rights be restricted out of a public health concern? These dynamics help to explain why the aftereffects of abortion are largely "invisible" in our society. These same dynamics also explain why research in the field of post-abortion reactions is so extremely difficult and hotly contested.
 

Is There Any Consensus?

Not all women who "choose" abortion have a traumatic response. Nevertheless, abortion is not always the benign psychological experience that some abortion advocates assert.

There are some 375 studies on the aftereffects of abortion. Both sides have referenced these various scientific examinations in the "abortion wars." There have even been professional journal articles devoted to assessing the quality of the scientific investigations cited by one side versus the other. Not surprisingly, the scientific studies reported by those who assert that abortion can cause serious psychological injury for some women were judged to be "less rigorous" than the studies supporting the proposition that abortion causes relief and positive outcomes. Yet even Planned Parenthood has acknowledged to some degree the need for more and better "post-abortion counseling: "Women can have a variety of emotions following an abortion (grief, depression, anger, guilt, relief, etc.) It is important to give her the opportunity to air these feelings and be reassured that her feelings are normal...."

The convergent reality is that abortion is not as psychologically safe as the public has been led to believe. Many factors have been responsible for producing changed perceptions: (1) over the past twenty-four years numerous efforts have been made to inform the mental health community about the psychological health risks of abortion; (2) repeated and persistent pressure has been placed upon the mental health community to objectively reassess and review the abortion outcome research; (3) an increased number of publications, professional presentations, individual voices, and advocacy groups have emphasized the personal tragedy and trauma that abortion can be for some individuals; (4) the U.S. Supreme Court has acknowledged in Planned Parenthood v. Casey in 1992 that women can suffer "devastating psychological consequences" from abortion if they are not fully informed beforehand and consequently there are more and more newly enacted state laws that require disclosure about the psychological effects of abortion.

The result is that today there is little controversy among researchers that some women experience serious psychological problems after abortion. The questions that remain are: which women are at greatest risk and why, which public policies might best prevent this psychological harm, and which treatment interventions might be most suitable for which women harmed by abortion.

How widespread the negative emotional effects of abortion may be however, is an even larger and more pressing question, one that remains hotly disputed. The ability to gather sufficient scientific data in order to determine how many women and men are negatively impacted by abortion is a challenging task. The widespread individual reactions previously mentioned, defensiveness, denial, and avoidance, of necessity limit the validity and reliability of data gathering. Then too, assessment of the aftereffects of abortion is often held hostage by unsympathetic administrations. Much could be accomplished if the political arena were to allocate priority, policy and funding to this public health issue. However, it has yet to occur.
 

Posttraumatic Stress Disorder - PTSD

Traumatic deaths typically tend to produce posttraumatic reactions. They overwhelm stress management capabilities and shatter a person's sense of control, safety, connection and meaning. Thanatologist Therese Rando in Treatment of Complicated Mourning reported that a person is at particularly high risk for developing posttraumatic stress if, while being involved in the same traumatic event that took the life of the loved one, the victim has feared for her own life, felt helpless and powerless, and had no forewarning (i.e., the event was shocking and unanticipated).¹

Traumatic events are extraordinary, not because they occur infrequently, but because they are emotionally overwhelming and are beyond one's capacity to adapt. The essential characteristics of a traumatic event generally include (but are not restricted to): (1) a serious threat to one's life; (2) a serious threat to one's physical integrity; (3) a serious threat or possible harm to one's children, spouse, close relative, or friends; (4) sudden destruction of one's home or community; (5) seeing another person who has been or is being seriously injured or killed; (6) physical violence; and (7) learning about a serious threat or harm to one's family or friends.²

The central aspect of PTSD is that trauma victims are attempting to deny or push away the horror of the traumatic event(s), while at the same time they are trying to master their feeling of being overwhelmed by re-experiencing their feelings. They are haunted by images that can be neither fully grasped nor fully relinquished. As a result, they may "ping pong" between (1) avoiding feelings or feeling numb and (2) feeling overwhelmed and reliving the event.

There is evidence that when the trauma is caused by human beings, as opposed to a natural disaster, the victim's reactions are more severe and longer lasting. Psychiatrist Judith Lewis Herman observed that:

When the traumatic events are of human design, those who bear witness are caught in the conflict between victim and perpetrator. It is morally impossible to remain neutral in this conflict. The bystander is forced to take sides. . . . When the victim is already devalued (a woman, a child), she may find that the most traumatic events of her life take place outside the realm of socially validated reality. Her experience becomes unspeakable. The study of psychological trauma must constantly contend with this tendency to discredit the victim or to render her invisible.³

In this respect, many women are traumatized not only by their abortion experiences but also by an unsympathetic society. These women are prevented by shame or denial from voicing their experiences. In some ways they may feel safer remaining "invisible"; in other ways, society implicitly or explicitly encourages them to remain "invisible." As an example of the latter, when a brave minority of abortion patients attempt to express their emotional pain, they frequently find themselves dismissed as "guilt trippers," "rare exceptions," or psychologically maladjusted before the abortion. In short, those women who dare to violate the social silence surrounding abortion find their experiences are denied, discredited, or simply ignored. They are in fact blamed for their post-abortion problems; they are re-victimized.
 

Post-Abortion Syndrome

Following the pattern defined for PTSD, the definition of PAS includes the following:

(1) The woman has experienced, witnessed or was confronted with an abortion event which was perceived as traumatic and involved the actual and intentional death of the unborn child. The woman's response involved fear, helplessness, or horror so as to cause significant and unwanted symptoms of reexperience, avoidance, increased arousal and grief.

(2) The woman reexperiences the abortion in one or more negative ways: through intrusive memories, flashbacks, nightmares, fetal fantasies, adverse grief reactions on the anniversary of the abortion or the baby's due date, and physiological reactivity upon being confronted with reminders of the abortion.

(3) The woman persistently attempts to avoid abortion reminders or experiences emotional numbness (not present before the abortion) as indicated by at least three of the following: avoidance of thoughts, feelings, information, activities, people, or places that arouse recollections of the abortion; inability to recall aspects of the abortion; diminished interest in activities; feeling detached from and withdrawing from others; restricted range of feelings; and/or a sense of a shortened future.

(4) The woman experiences two or more symptoms which she did not experience before her abortion: difficulty with sleep, irritability, difficulty concentrating, hypervigilance, hyperreactive, depression and/or suicidal thinking, survivor guilt, self-devaluation and/or abuse, and problems with sexuality.

The first of these symptoms, hyperarousal, refers to a disordered sense of impending danger. It is as if the human system of self-preservation goes on permanent alert, fearing that the danger may return at any moment. People experiencing hyperarousal may startle easily, react irritably to small provocations, and sleep poorly.

The second symptom, intrusion, occurs when the traumatized person experiences unexpected thoughts or memories related to the event. These thoughts and memories interrupt her daily life and prevent her from functioning normally. A woman may reexperience the abortion as if it is happening now, even years after the event took place. Thoughts of the abortion or her "missing" child may force themselves into her consciousness. These intrusive thoughts can occur as flashbacks while she is awake or as horrific nightmares while she is asleep. Events, sights, sounds or associations subconsciously connected to the abortion, or to her missing child, can "trigger" PAS symptoms at any time.

Most trauma victims dread these intrusive thoughts and feelings. Reliving the traumatic event forces them to relive all their original anger and fear. Unfortunately, efforts to avoid reliving the event only aggravate posttraumatic stress.

This avoidance behavior, or "constriction," is the third major symptom of PAS. Constriction is the narrowing of one's consciousness and a withdrawal from activities with others. Women may avoid people, events, or experiences that may trigger unpleasant feelings connected to the abortion. Constriction often involves a loss of initiative and self-direction, resulting in increased indifference, emotional detachment, and profound passivity. The price paid for this "calm" is an emotionally impoverished life.

Traumatized individuals defend themselves from emotional pain by shutting out their feelings. The result is that perceptions may be numbed or distorted in whole or in part. Memory impairment and trauma amnesia are common among these victims. When painful memories are walled off from ordinary consciousness, the woman cannot deal with and heal from her experience.

Like other trauma victims, PAS victims are caught between floods of intense, overwhelming feeling and arid states of no feeling at all. They are trapped between irritable, impulsive action and complete inhibition of action. These periodic alternations create instability in their lives that only intensify their sense of unpredictability, helplessness, and lack of control.

Traumatic events can shatter a person's core assumptions about reality. Women who suffer from post-abortion trauma may lose their basic beliefs regarding safety, trust, self worth, meaning in life, pleasure, and their relationships with others. They may feel unable to forgive themselves and feel the need to punish themselves or others for their experience. Many feel guilty about surviving their abortion and may believe that they deserve to be punished by God.

Finally, evidence suggests a woman is more likely to be traumatized if prior to the abortion she believed that abortion is psychologically safe. The false impression that abortion is "safe" may set her up for a greater shock when she finds her feelings are in greater turmoil than she expected. Events need to be given meaning before they are experienced as stressful or not.
 

Conclusion

Post-abortion research is severely handicapped by the nature of the trauma itself and the resulting patterns of silence. Over half of the women who have abortions deny any history of abortion in surveys. Of those who do admit a past abortion, many provide answers that are reflexively defensive rather than thoughtfully responsive.

For the women and men who have chosen abortion, the public controversy surrounding this event is overshadowed by the all too painful reality of their own experiences. For some the pain is minor, for others, it is overwhelming. If the abortion was perceived as traumatic, posttraumatic stress related symptoms are likely.

No matter what the public's views are on the subject, the loss of one's child is both real and devastating for the grieving parent. What is ultimately at stake for these special parents, the other victims of abortion, is their recovery and future emotional health. Those who would deny the reality of their pain are insisting that they must remain invisible for the sake of a "higher" political end. Such a price is simply too high to pay.

NOTES

1. Rando, T., Treatment of Complicated Mourning (Champaign, IL: Research Press, 1993).

2. Peterson, K., Prout, M. & Schwarz, R.,Post-Traumatic Stress Disorder: A Clinician's Guide (New York: Plenum, 1991).

3. Herman, J., Trauma & Recovery (N.Y.: Basic Books 1992).