Copyright 1996 David C. Reardon. Excerpted with permission for from Making Abortion Rare, published by Acorn Books, PO Box 7348, Springfield, IL 62791-7348 for internet posting exclusively at www.afterabortion.org. All Rights Reserved.

The demand for adequate screening of abortion patients is one of the most important keys to our pro-woman/pro-life strategy. Proper screening is especially important to women because the vast majority of women fall into one or more high risk categories. 

The duty to properly screen patients prior to abortion is derived both from the physician's obligation to form a treatment plan which safeguards his patient's health, and also from the woman's right to be given of all the information relevant to her decision to accept or reject his recommendation. 

The failure to adequately screen patients for pre-identifying factors is negligence. Additional negligence occurs if a risk factor is identified and not mitigated by proper treatment, referral, or additional counseling. In addition, the failure to tell a woman, or in the case of a minor, the minor's parents, of identifiable risk factors is concealment of relevant information and a violation of the patient's right to full disclosure. Thus, the need to hold the abortion industry accountable for proper pre-abortion screening is undisputable. 

Identifying High Risk Abortion Patients

In determining the risks and benefits of management options for a crisis pregnancy, a physician is clearly obligated to make an assessment of risk factors associated with specific physical and psychological adverse reactions.⁽¹⁾ Risk factors for physical complications include uterine abnormalities, multiple gestation, cardiovascular disease, renal disease, asthma, epilepsy, diabetes, venereal infection, intoxication or being in a drugged state, obesity, and other pre-existing conditions.⁽²⁾

While the physical risks of abortion are significant, the published literature demonstrates that emotional and psychological complications following an abortion are far more common. While there is wide variation among what researchers define to be "significant" emotional complications, all studies show that at least some women are negatively affected by abortion. Even the most dedicated of pro-choice researchers generally admit that "There is now virtually no disagreement among researchers that some women experience negative psychological reactions postabortion."⁽³⁾ The lowest estimate for adverse outcomes is 6 percent, with typical reports ranging from 12 to 25 percent, and the highest estimates ranging up to 80 percent.⁽⁴⁾

While there is intense controversy among researchers regarding how frequently women experience post-abortion psychological sequelae, there is general agreement concerning the pre-identifying factors which can be used to predict an increased risk of significant post-abortion psychological distress. Indeed, most of the research on pre-identifying risk factors has been published by abortion proponents and so these findings are immune from the charge of bias. 

The risk factors for post-abortion psychological maladjustments can be divided into two general categories. The first category includes women for whom there exists significant emotional, social, or moral conflicts regarding the contemplated abortion. The second category includes women for whom there are developmental problems, including immaturity, or pre-existing and unresolved psychological problems. A summary list of established risk factors includes: conflicting maternal desires; moral ambivalence; feeling pressured to abort by others; feeling the decision is not her own, or is her "only choice;" feeling rushed to make a decision; immaturity or adolescence; prior emotional or psychological problems including poor development of coping skills or prior low self image; a prior history of abuse or unresolved trauma; a history of social isolation as indicated by having few friends or lack of support from one's partner or family; a history of prior abortions; or a history of religious or conservative values which attach feelings of shame or social stigma to abortion. Readers may refer to Appendix A for a more complete list of these pre-identifying risk factors. 

These risk factors clearly suggests that a substantial number of women - most probably the majority - are predictably at risk of a experiencing adverse psychological reactions.⁽⁵⁾

The conscientious physician would be legally and ethically bound to consider these risk factors in forming a recommendation, to advise the woman of the existence of these risk factors, and, in at least some cases, to refuse to perform an abortion until these risk factors had been alleviated through appropriate counseling.⁽⁶⁾

Proper pre-abortion counseling should include screening for all of the high risk factors listed above, notification of the patient of any existing risk factors, and appropriate counseling or referral to care and counseling resources outside the clinic where these risk factors can be addressed or treated.⁽⁷⁾ Furthermore, after the intake screening, patients should routinely instructed about all pre-existing risk factors, even those which the patient does not report, because it is well known that abortion patients may conceal a history of prior abortions, coercion, or other relevent information. In anticipation of such concealment, routine disclosure of all risk factors is necessary for the purpose of ensuring that the patient at least has the opportunity to make an informed self-evaluation of her risk profile. Inadequate psycho-social screening endangers patients' health and should be considered sufficient to establish negligence. 

A Look At Motivations Behind This Research

This issue of inadequate pre-abortion screening is one which pro-abortion researchers have virtually handed to us on a silver platter. This was not their intent, of course. 

Instead, the real reason pro-abortion researchers have published so much on risk factors is that they have been seeking a way to dismiss the complaints of the troublesome "minority" of women who clearly have post-abortion maladjustments within even a few weeks after the abortion. In order to dismiss these patients, pro-abortion researchers have tried to identify how these women are different from those who appear to be "unaffected" by abortion. Having identified these pre-existing factors, they then argue that it is not abortion which causes these women to have problems; their distress is instead the result of some other pre-existing problem. This "politically correct" view of post-abortion trauma includes a kernel of truth, but it is mostly coated with a lot of "blaming the victim." 

It is certainly true that women who are suffering from mental disorders or have previously suffered psychological trauma are more likely to subsequently report more severe negative post-abortion reactions. Indeed, if one thing is clear from post-abortion research over the last forty years, it is that abortion is contraindicated when a woman already has mental health problems. This is true because abortion is always stressful. How well a person copes with this stress depends on the individual's resiliency and the conditions under which the stress occurs. When a woman's psychological state is already fragile, the stress of an abortion can more easily overwhelm her. But the fact that she was more vulnerable to stress than others does not mean that the abortion is not the cause of her psychological injuries. 

If a glass plate and a plastic plate are both dropped, the glass plate is likely to shatter, while the same stress may cause the plastic plate to only crack or chip. In either case, the damage cannot be blamed on the material; it must be blamed on the fall. While the extent of the damage is related to the nature of the material, the fall itself is the direct cause of the damage. In the same way, while the nature of an individual psyche determines the extent of post-abortion injuries, it is the abortion itself which is the direct cause of these injuries. 

Pro-abortion researchers, on the other hand, insist that post-abortion maladjustments must be blamed on the character flaws of the individual. This "blame the victim" strategy is not new. It is identical to the type of reasoning used during World War I when veterans suffering from "shell shock" were diagnosed by military psychiatrists as "malingerers" or even cowards. In an age when fighting for one's country was romantically idealized as adventurous passage into manhood, this "politically correct" diagnosis was necessary to deflect attention away from the fact that modern warfare was often more traumatic than ennobling. Military officials therefore attempted to suppress reports of psychiatric casualties because accurate reports would have had a demoralizing effect on the public.⁽⁸⁾

In the same way, when pro-abortion researchers are confronted with women who suffer from post-abortion trauma, there is a tendency to blame the women for being "whiners" or "dysfunctional." This judgment is a result of their a priori belief that abortion "empowers" women. This bias is so strong that some pro-abortion researchers even argue that women should not be told of any psychological risks associated with abortion because such "demoralizing" information may make them even more prone to an adverse outcome. It is better, they would claim, to be ignorantly optimistic about the future than informed and worried. Essentially, these pro-abortion researchers are arguing that the suffering of a "few" misfits should not be used to raise doubts among the many. 

The Strategic Importance of Screening Requirements

The biases of pro-abortion researchers, however, are not nearly as important as their findings. When examined as a body of literature, the information they have handed us actually demonstrates that the vast majority of women fall into one or more statistically significant high risk categories. They, themselves, have clearly established the importance of adequate screening. 

These findings have inadvertently placed the abortion industry in a Catch-22. Failure to screen makes them liable for negligence. Adequate screening, on the other hand, will demand from them far greater attention to evaluation of each case and a much higher standard of counseling to alleviate the risk factors which are identified. In addition, it must be remembered that the physician has a right and duty to refuse to do a contraindicated abortion. If he performs an abortion despite the presence of known risk factors, and the woman subsequently experiences negative emotional consequences, his recommendation to perform an abortion which was contraindicated would itself be evidence of either incompetence or negligence. 

In short, proof that high risk factors were present at the time of the abortion, whether identified or not, increases the liability of the abortionist. If left unidentified, he is guilty of negligence. If they were identified, and the abortionist persisted in recommending abortion, there was negligence. Whether the abortion caused the subsequent emotional problems, or whether it simply triggered the worsening of previously existing emotional problems is mostly a philosophical issue. The relevant fact is that the abortionist knew, or should have known, that the woman's psychological health was at risk. 

Another way of looking at the issue of pre-identifying risk factors is to examine how this knowledge should affect the standard of care for abortion. A competent physician would properly be expected to: 1) provide pre-consent information about the types of psychological reactions which have been linked to a negative abortion experience and the risk factors associated with these adverse reactions; 2) provide adequate pre-abortion screening using the criteria outlined above to identify women who are at risk of negative post-abortion reactions; 3) provide individualized counseling to high risk patients which would more fully explain why the patient is at risk along with more detailed information concerning possible post-abortion reactions; and 4) assist women who have pre-identifying high risk factors in evaluating and choosing lower risk solutions to their social, economic, and health needs. 

The Duty to Look Deeper 

In evaluating a patient's psychological risks, the idealized standard of care established by the medical community does not allow abortion counselors to rely simply on what ever the patient volunteers. Instead counselors should actively look for "red flags" which would indicate the presence of risk factors. Uta Landy a former executive director of the National Abortion Federation, encourages counselors to be aware of the fact that: 

Some women's feelings about their pregnancy are not simply ambivalent but deeply confused. This confusion is not necessarily expressed in a straightforward manner, but can hide behind such outward behavior as: 1) being uncommunicative, 2) being extremely self assured, 3) being impatient (how long is this going to take, I have other important things to do), or 4) being hostile (this is an awful place; you are an awful doctor, counselor, nurse; I hate being here).⁽⁹⁾ 

Landy also admits that because women seeking abortion are experiencing a time of personal crisis their decision making processes can be temporarily impaired. This crisis-related disability may lead them to make a poor decision which will subsequently result in serious feelings of regret. Landy defines four types of defective decision making observed in abortion clinics. She calls the first defective process the "spontaneous approach" wherein the decision is made too quickly without taking sufficient time to resolve internal conflicts or explore options. A second defective decision making process is the "rational-analytical approach" which focuses on the practical reasons to terminate the pregnancy (financial problems, single parenthood, etc.) without consideration of emotional needs (attachment to the pregnancy, maternal desires, etc.). A third defective process is the "denying-procrastinating" approach which is typical of women who have delayed in making a decision precisely because of the many conflicting feelings she has about keeping the baby. When such a "denying-procrastinator" finally agrees to an abortion it is likely that she has still not resolved her internal conflicts, but is submitting to the abortion only because she has "run out of time." Fourth, there is the "no-decision making approach" wherein a woman refuses to make her own decision but allows others, such as her male partner, parents, counselors, or physician to make the decision for her.⁽¹⁰⁾ 

The standard of care for pre-abortion screening is further described in Obstetrical Decision Making. In the section regarding induced abortion it is clearly stated: 

"It is essential for the gravida [pregnant woman] to be fully informed about alternative resources and options and about the safety and risks of the procedure. Psychosocial assessment and counseling are done at the very first visit [see section on psychosocial assessment]. In addition to the medical history, an in-depth social history including relationships with others, attitudes about abortion, and support systems must be obtained at this time...No decision should be made by the gravida in haste, under duress, or without adequate time and information. Special attention should be given to feelings of ambivalence, guilt, anger, shame, sadness, and sense of loss.... Patients requesting abortion must also be screened to uncover any serious medical or psychiatric conditions."⁽¹¹⁾  [Italics added] 

Under the section on psychosocial assessment, the obstetrician is also told that "he or she needs to be alert to gravid women who are at greatest risk, such as those who were victims of child abuse or neglect themselves and those with a history of psychologic impairment, drug dependency, or behavioral problems." [Italics added] 

At least one pro-choice researcher, suggests that pre-abortion screening should be used to determine which patients need in depth counseling from those who need only supportive counseling. Using just five screening criteria: 1) a history of psychosocial instability, 2) a poor or unstable relationship with her partner, 3) few friends, 4) a poor work pattern, and 5) failure to take contraceptive precautions, Belsey determined that 64 percent of the 350 abortion patients she studied should have been referred for more extensive counseling using these criteria. Of this high risk group, 72 percent actually did develop negative post-abortion reactions within the time frame of the study's followup. "From a clinician's point of view," she writes, "this result can be viewed as erring on the right side, for a [pre-abortion screening] system that tends to select more women for counseling than is actually necessary is preferable to the reverse."⁽¹²⁾ 

Of special concern are cases when a woman desires to have her child but is submitting to the abortion to satisfy the demands of others.⁽¹³⁾ Patients should be carefully questioned, in private, to determine if this risk factor is present since the abused or coerced patient may attempt to conceal the abuse out of fear. This abuse or coercion can be subtle or overt, such as threatening to withhold love or approval unless she "does the best thing." Even lack of emotional support to keep a pregnancy may be experienced as a pressure "forcing" a woman to choose abortion.⁽¹⁴⁾ 

In addition, pressure from adverse circumstances, such as financial problems, being unmarried, social problems, or health problems may also make a woman feel she is being "forced" to accept abortion as her "only choice." If her "only choice" is contrary to her maternal desires, she should be assisted in finding resources and alternatives which may provide her with an option which does not violate her emotional, maternal, and moral needs. 

Insights from Pre-identifying Risk Factors 

If I may be allowed a brief detour, I would like readers to take a closer look at the list of pre-identifying risk factors. These risk factors are very instructive for helping to understand exactly why abortion patients suffer psychological sequelae. 

In the majority of cases, women seeking abortion feel under some external pressure to do so. Yet at the same time, 60 to 70 percent of women seeking abortions have moral qualms about abortion itself, and over 60 percent are struggling with a maternal desire to protect their pregnancies. 

For these women, abortion is not a glorious right by which they are able to reclaim control of their lives; instead it is an "evil necessity" which they submit to because they "have no choice." Rather than affirming their own values, these women feel forced to compromise their values. Rather than feeling proud of themselves for standing up for what they believe in difficult circumstances, they feel ashamed of themselves for being "spineless cowards." 

This feeling of self-betrayal is a devastating blow to the woman's self-image and her feelings of self-worth.
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1. "An adequate medical and psychological case history is important to the physician." H.L. v. Matheson, 411. 

2. Hern, Abortion Practice, 67-74, 166. 

3. Wilmoth, "Abortion, Public Health Policy, and Informed Consent Legislation," Journal of Social Issues 48(3):1-17. See also, Anne Baker, "Counselor's Corner" Hope News (Granite City, IL: The Hope Clinic for Women, Ltd., December 1994) 2-4. 

4. In 11 studies reviewed by Dagg searching for various long term negative psychological effects of abortion, the lowest incidence rate reported was 6 percent and the highest was 32 percent, the average reported rate being 15 percent. Dagg, "The Psychological Sequelae of Therapeutic Abortion - Denied and Completed," Am. J. Psychiatry, 148:5, May 1991, 578-585 (Table 2). Another major study found that 49% of 360 women experienced psychological maladjustments post-abortion. Belsey, et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV," Soc. Sci. & Med., 1977, Vol 11, pp 71-82. Still other researchers have reported even higher rates by accounting for women who refuse to participate in followup programs precisely because they have had, or continue to experience, psychological stress related to the abortion and do not wish to aggravate this stress by participation in the study. 

5. Over 70% of women having abortions are doing so against their conscience, with 74% agreeing with the statement: "I personally feel that abortion is morally wrong, but I also feel that whether or not to have an abortion is a decision that has to be made by every woman for herself." (Los Angeles Times Poll, March 19, 1989. See also Zimmerman, Passages Through Abortion and Reardon, Aborted Women). Thirty to 55% report feeling pressured to abort by others, and a similar percentage express some desire to keep the child (Zimmerman, Reardon). Approximately 45% of abortions are for women with a prior history of abortion, and over one-fourth are for teenagers. In addition, some truama experts estimate that as many as one in three women have been sexually abused in childhood. (Herman, Trauma and Recovery, New York: Basic Books, 1992, p.30) It is likely that the percentage of women having abortions who have a prior history of abuse, trauma, or other psychological problems is as high, or higher, than that for the general population. 

6. Sylvia Stengle, executive director of the National Abortion Federation, has affirmed in interviews that there are conditions in which an abortionist would be "ethically bound" to refuse a contraindicated abortion. Junda Woo, "Abortion Doctor's Patients Broaden Suits," Wall Stree Journal Oct. 28, 1994, B12:1. 

7. Hern, Abortion Practice, 84, 86-87. 

8. Judith Lewis Herman, M.D., Trauma and Recovery (New York: Basic Books, 1992) 20-28. 

9. Landy, "Abortion Counseling - A New Component of Medical Care," Clinics in Obs/Gyn, 13(1):33-41 (1986). 

10. Ibid. 

11. Friedman, E., ed., Obstetrical Decision Making (Second Edition (1987), especially Borton, "Induced Abortion" p. 44 and Stewart, "Psychosocial Assessment" p. 30. 

12. Belsey, et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV," Soc. Sci. & Med., 11:71-82 (1977). See also, Miller, "An Empirical Study of the Psychological Antecedents and Consequences of Induced Abortion," Journal of Social Issues, 48(3):67-93 (1992). 

13. "It is common to find that a woman has presented herself for an abortion even though she does not really want one; her partner or her parents want her to have one. In this instance, it is extremely important for the counselor to make it clear to the patient that the decision is hers and that no one can force her to have an abortion." Hern, Abortion Practice, 81. 

14. "It is difficult at times to determine whether subtle coercion is occurring or whether the patient is truly making the decision herself. Under these circumstances, it is especially important that the counselor determine the patients true attitude and decision as distinguished from how she may feel about the decision." Hern, Abortion Practice, 80. 
 

Copyright 1996 David C. Reardon. Excerpted with permission for from Making Abortion Rare: A Healing Strategy for a Divided Nation, published by Acorn Books, PO Box 7348, Springfield, IL 62791-7348 for internet posting exclusively at www.afterabortion.org. All Rights Reserved.