(Paper presented at the conference on family politics in the Swedish parlament, March 29, 2006). Copyrigth: The Doha International Institute for Family Studies and Development

Abstract in swedish:

Bakgrundsmaterial till seminar i Riksdagen, onsdagen 29 mars 2006 om "Nordisk forskning om familj och familjepolitik", arrangerad av riksdagsföreningen Forum för familj och människovärde i samverkan med The Doha International Research Institute for Family Studies and Development samt Föreningen Internationella Familjedagen.

Skam, svek och hemligheter - om låsta familjerelationer / komplicerad förlustupplevelse efter abort

Syftet med detta material är att presentera kliniska observationer och forskningsresultat som indikerar hur kvinnor och deras närmaste kan lida psykiskt efter abort.

Min egen erfarenhet visar hur illa förberedd man som psykologutbildad är på att möta de starka emotionella svårigheter som ofta hänger ihop med en abortupplevelse. Även läkare och familjemedlemmar verkar bortförklara ångest och komplicerad sorg efter abort som uttryck för kvinnans svaga psyke och kan därmed riskera att bidra till hennes isolering och desperationskänslor. Det verkar socialt oacceptabelt att sörja ett aborterat barn eftersom "du valde det ju själv".

Hemlighållande och skam kring aborterna bidrar till isolering och kan skada den egna förmågan till att vara öppen och spontan och därmed också skada de närmaste relationerna.

Två fallbeskrivningar presenteras grundligt. Båda visar - på var sitt sätt - hur beslutet att avsluta en graviditet får en hämmande inverkan på ett pars känsloliv. Insikten - medgivandet - av det egna misstaget skapar lättnad och möjliggör ny livsorientering.

Sedan presenteras utvald forskning (delvis rör det sig om sammanställningar av ett stort antal forskningsrapporter från jämförbara länder). Dessa pekar på ökade siffror för bl.a. ångest, depression, suicidalt beteende och sexuella svårigheter efter abort - dock inte alla: En del studier visar visserligen spår av detta, men drar konklusionen att det inte är så allvarligt.

En helt ny norsk forskningsrapport med hög grad av metodmässig reliabilitet presenteras som visar att kvinnor kort efter en abort genomsnittligt reagerar med mindre stark ångest och depression än jämförbara kvinnor gör kort efter ett missfall, men däremot med tydligt starkare ångest och depression några månader efter (speciellt i fråga om ångest och beteende som normalt ses vid post-traumatisk stress). Detta trots en hög grad av upplevd "lättnad" hos dessa kvinnor vilket kan tyda på obearbetade konflikter.

En omfattande studie från Malmö presenteras, som bl.a. drar slutsatsen att över hälften av alla kvinnor lider av emotionella svårigheter från abortsituationen ett år efter ingreppet, varav ca. 16 % bedöms som allvarliga, kliniska fall. Därtill ska lägga 33 % som inte orkade besvara frågor om detta och som statistiskt kan urskiljas som en typiskt belastad grupp där starka efterverkningar kan förmodas.

En forskningsöversikt presenteras som bl.a. konkluderar att aborterna tvärt emot vanliga uppfattningar oftast medför färre psykologiska problem i efterhand jämfört med innan aborten. Förslag till tolkning av dessa resultat föreslås.

Undersökningar - det finns inte många - som handlar om aborternas inverkan på parrelationer och kvinnornas manliga partners omtalas.
En diskussion om vad vetskapen om abort i familjen kan betyda för barn förs utifrån hur kliniska observationer och allmän barnpsykologi beskriver effekter av andra plågsamma familjehemligheter och komplicerade förlustupplevelser.

Både forskningen och enskilda behandlare verkar ibland betrakta alla former av skam som samma sak. Då skiljer man inte mellan vad man skulle kunna kalla för moralisk skam (som har att göra med misslyckande att leva upp till egna standarder och värderingar) och psykologisk skam, (ett destruktivt och förlamande tillstånd med känslor av värdelöshet). Då blockeras de positiva möjligheter som kan finnas i att inse och ångra misstag och återfinna harmonin med det egna samvetet.

Kunskapen om fostrets värld ökar. Ju mer vi vet och genom modern teknik kan se och identifiera oss med fostret, desto större upplevelse av fostret som en människa kommer vi att ha. Eftersom denna utveckling inte kan vändas betyder detta att det kan bli allt mer plågsamt att välja abort.
Därför kan de moraliska frågor som många kämpar med inte uteslutas från abortrådgivning, där samtalen tyvärr ofta verkar begränsas till att handla om abort såsom nödvändig följd av "misslyckad användning av preventivmedel".

Presentationen slutar med en uppmaning till en ökad medvetenhet bland professionella rådgivare om de psykiska skador som abort kan medföra samt en öppen offentlig debatt, där människor vågar träda fram som har skadats av abort. Det föreslås stöd till alternativa krismottagningar utanför det vanliga behandlingssystemet såsom redan är fallet i Norge och Danmark och det uppmanas till att analysera den tyska lagen om abort, där ett besök hos en familjerådgivning måste ske innan abort kan tillåtas.

Björn Håkonsson

 

Secrecy and shame

- about the impact of emotional distress following induced abortion, on individuals and their relatives

Families are often vulnerable to reactions after traumatic life events, especially when these include losses combined with ambivalence, anxiety, feelings of guilt and shame. Some clinical experience and scientific research indicate that individuals and relationships are traumatized in this way in many cases of induced abortion aftermaths. The aim of this presentation is to demonstrate this and so provide critical viewpoints for a new, more open-minded and realistic discussion of how to prevent families, couples and individuals from getting hurt by abortion.

Is abortion psychologically harmful? Is there a "post-abortion-syndrome" and does it harm family relations and family members? How doctors and psychologists answer this determines to a serious degree how patients are treated under such circumstances.

Some personal remarks and observations

Finishing my five-and-a-half years of studies in (clinically oriented) psychology at the University af Copenhagen in 1993, I had never learned that abortions was something to really worry about. Encountering the importance of abortion decisions in the life of women (and men) made me search for studies that could explain why this important life event - one of the most common surgery operations in our hospitals - does bring about such strong emotional difficulties, often surprising both the victims and their relatives, since they were not prepared for this in advance. I also became curious because patients complained to me about the way they were treated by medical staff when they reported unexpected pregnancies. So I looked into normal procedures and information materials and found that they almost entirely used to think of the situation as a "failure in the use of contraceptives" not taking seriously the emotional (and moral) dilemmas of patients, thereby - and sometimes under time pressure - bringing them into a procedure, they perhaps never really wanted. As some patients have not always really sorted out in advance for themselves what to do, this can easily led to despair, anger and helplessness afterwards. As many therapists know, such reactions after abortions are not always socially accepted, and the woman can become isolated and even blamed for what she now feels ("you shouldn´t complain, after all you chose it yourself and you said you felt relief afterwards", "abortion is a safe procedure, if you feel like this, something must have been wrong with you before the abortion") and so a mourning process can be blocked and lead to depression.

Doctors, referring to rules saying that is it "forbidden to question a woman's decision by asking for motives", obviously fail to regognize the need for at least some pregnant women to find a patient listener who supports her in seeing the positive sides of pregnancy and childbirth. Cases where a pregnant woman is left alone by relatives - out of a sort of "respect for her own choice" - can easily result in an increased anxiety and feeling of isolation, where a decision to abort is made in spite of the womans own will to have the child.

Example 1: One woman told me that on her way to the abortion clinic by accident she met an old friend who saw on her face that "something was wrong" and asked in a caring way how she was doing. This little kindness was enough to let "the mask" fall - as she said; she suddenly became aware of her own feelings and began to cry. She immediately knew that she wanted the baby and went home, which she never regretted. (In fact, women not showing up at abortion appointments is a very common phenomenon that abortion staff can confirm, indicating that this woman´s experience is not uncommon).

Among my clients - and other counselor´s clients I know about - there have been persons, trying hard to get rid of memories and feelings connected with their abortion experience. They might carry (socially unaccepted) feelings of disappointment and anger towards their closest relatives (boyfriend, mother) or towards medical and psychotherapeutical staff, unplesant to listen to. Some women reject the abortion clinic´s normal offer of psychological support - probably because that place is so connected with the experience of not being understood.

Abortion on demand was not introduced into our culture without hard struggles between different ideologies and value-systems, not too long ago. This could explain some difficulties in accepting how abortions hurt.

Shame, secrets and emotional inhibition in the abortion aftermath

The following description by Rue [1] corresponds well with my own observations:

"The personal context of an unwanted pregnancy is typically one of surprise and failure, surrounded by secrecy and shame. Because of this, denial of ones abortion experience and self-deception regarding post-abortion feelings are common ..." (p.7)

" .... individuals experiencing this procedure may commonly condemn themselves to a life of silence and antonement or denial and fear. Unacknowledged grief and guilt, anticipated condemnation by others, as well as the terror of reexperiencing the trauma all enable and maintain the parameters of secrecy and isolation...
By not acknowledging an abortion experience to one´s self and/or to one´s significant others, a psychological barrier is erected and a emotional toxicity is perpetuated. Coupled with denial, avoidance of abortion-related traumata can occur on a number of levels: (1) avoidance of affect/ feelings (numbing); (2) avoidance of the knowledge of the event (amnesia); (3) behavioral avoidance (phobic responses); and (4) avoidance of communication about the event (interpersonal distancing)". (p. 9)

The following two cases from my own practice show in different ways how a decision to terminate a pregnancy inhibited normal emotional communication in marital relations [2].

A. A qualitative perspective - abortion and emotional inhibition:

1. The child long wished for - Karen and Ron

Karen and Ron - aged 24 and 28, both university students, she a practising catholic, he an atheist - have been married for four years. They have tried hard to become parents, but until now have not succeeded. For some time they have both experienced a feeling of "emptiness in life". Sometimes they do not know "what use they are to each other" (Rons words). Arguments and disagreements arise almost "out of nothing", something Karen talks about with her student friends. Suddently during this period Karen gets pregnant. Karen and Ron are surprised and happy about this but still argue a great deal. Karen´s friends tell her that since she is having trouble with her husband she should have an abortion, since "everybody knows that a child cannot save a marriage". Karen begins to have doubts, which Ron takes as a evidence that she does not love him any more. Karen makes an appointment for an abortion. Then Ron accepts the situation, turns silent and gets depressed. They both feel trapped and unhappy with each other. At this point they turn to professional help and contact me.

Taking place in my room Karen and Ron put their chairs at some distance, Karen even leaning away from Ron and looking out of the window, Ron is silent, looking down, biting his nails. After describing their situation - in remarkable aggreement - I begin to wonder how they can unite the contradicting attitudes they both carry towards this pregnancy: their yearlong dream about becoming parents and now their identical, almost mechanical statement, that "we shouldn´t have a child since a child cannot save a marriage."

Up till now there has been a remarkable absence of strong feelings in the atmosphere of our talk. Questions and answers have followed automatically and the emotional distance is obvious in spite of the clear agreement of the two on a cognitive level. Karen is sitting in an upright, stiff sort of position, which many therapists would describe as a kind of "being in her head, out of touch with her body".

I ask Karen how she feels towards "this" that she carries inside of her (I usually never speak of "child" og "fetus" in order to enable the parents to first define the situation by themselves). Now she initially becomes silent, somewhat confused. Then - for the first time during this meeting - she becomes visibly moved by emotions, fighting to find words as she begins to express how this child was indeed longed for. From now on the two begin to look at each other, just as if a new way of seeing things begins to become allowed.

Already before they come home they decide together that they just can´t choose to have an abortion. Karen simply stays away from her appointment at the clinic. She delivers her child - a boy - and the marital relationship improves. Years later, Karen is grateful for this conversation. Karen only needed a small question inviting her to explore the positive side of this pregnancy to overcome the influence of her surroundings, including her doctor, who neither understood nor cared for her real desire in a period where she and her husband were vulnerable and needed positive encouragement. Today she is worried by the fact that she at a point hade felt "strangely sure" about having the abortion, contradicting her own inner feelings and religious beliefs, and that nobody she knew had the courage to see that.

2. Abortion as the end of emotional trust - Rosa and John

Rosa and John - she aged 40, he 32 - met some years ago at a conference in Germany, he coming from Sweden and she from a southern european country. John immediatly fell in love with this woman, eigth years older than himself. He admired her a lot - as he said - for her strong self esteem, and even she fell in love with him. Shortly after they married and had a son. She worked part-time (after having the child) as a medical secretary, he as medical salesman man with a lot of traveling in his work. Rosa became the one who mostly took care of housework, John began to work a lot more and was so earning the main part of the family´s income. He felt proud of his position as the one who took care of finances, whereas Rosa was increasingly criticising his absence from the family as she felt let down and abandoned. John felt hurt and blamed his wife for not being grateful for all that he was doing for the family. A period of more extended business travelling follows. Rosa gets a new job, where she earns a lot more, and slowly decides to seperate, and possibly divorce. Communications between the two gradually worsen. John simply does not understand Rosa and finally they talk as little as possible with each other. At this point John looks for professional help and comes to me, telling me the story as it is described above.

After some days I meet them together. Rosa shows up as a very calm and kind person, firmly determined to get a divorce but at the same time open and ready to co-operate with John and me in this counseling situation, mostly - as she says - because she sees that he is suffering a lot and she wants to help him "to mature and develop his personality" like she herself had done earlier in life, before she met him and gave up her home country and career.
Rosa`s apperance in the next conversations stays relaxed but in a controlled way. The communication is improving as we solve misunderstandings, without accusations or strong emotional signs, except for some silent tears on Johns face. After some meetings we enter a phase of increasingly superficial talks, where I begin to wonder if we have a kind of "missing link" in our story - some obstacle yet not revealed.

This is when John changes facial expression in an new way. Looking tired he turns to Rosa saying: "Should we tell Björn about ....?" She, immediately getting uncomfortable in her chair, nods her head, and now I hear a story, untill now unknown to me, about a very serious conflict they had when she went through an abortion one year before. Rosa´s appearance changes, showing another and much more sad side, revealing feelings of deep disappointment, helplessness, anger, almost hate against John, who is silently listening, his head bowed down. I hear about a situation where John was coming home, Rosa is telling him that she is pregnant with their second child, John speechless, turns around on the spot, drives away in his car and thereafter hiding from her for a week in his mother´s house, only leaving messages on her phone answering machine saying that he did not want any more children with her. Rosa felt "as if going insane", called for a neighbour to take care of her son and went ito hospital for psychiatric care. There she decided to "abort the baby", which no-one in the professional staff ever questioned, something that confounded her. After the abortion she found herself screaming and crying desperately and was treated with hard drugs. This brought her "down to earth" (Johns words) and after a while they actually lived together again, since that day however without any sexual contact, he working more ("I just needed that") and she back again in their little apartment.

After this conversation it was clear that this experience had for both of them been an ultimate proof of not being loved by the other. John had demanded the abortion as a desperate way of expressing his frustration over her criticism, and she - reacting similarly - wanted to get rid of her disappointment with the way he was treatening and abandoning her and did this by getting rid of the pregnancy itself, not really acting out of her own inner will. Both felt they had done a terribly wrong and a despair because this could not be undone. Paradoxically as it seems, both also felt relief after the painful talk about the abortion. Afterwards John gave up his wish of getting her back, since he realized the impact of Rosa´s abortion: The death of their second child had killed emotional trust between them, as he saw it. They decided together that they were "mature for divorce" (in Rosa´s words) and did not want any further help. There was no hope left.
Rosa and John should have got competent assistance at an earlier state. As their counselor I feel sure that things could have been sorted out better, if they themselves or somebody around them had understood that they were in dire need for help from outside. Maybe they had been looking for this without finding it.

B. Quantitative perspective - The search for the prevalence of harmful effects of abortions on individuals and relations

As in many cases where difficult personal conflicts are involved, academic opinions differ considerably in the discussions of the extent to which abortion has mentally harmful consequences. There are many studies of womens mental health after abortion (of different quality) but studies that focus on abortions and subsequent family problems in particular are rare which is surprising, since it is evident that abortion never occurs in a relational vacuum, and since common clinical experience confirms that secrecy and shame, anxiety, feelings of guilt and depression - common symptoms in many womens reactions after abortions - are often connected with all kinds of family problems. This is why some qualified assumptions can be made about family relations, even where specific empirical material is poor.

Recently Fergusson, Horwood and Ridder [3] published the results of an unusually long-term study (25 years) of a birth cohort of children in New Zealand. The aim of the study was to examine the links between having an abortion and mental health outcomes over the interval from age 15 -25 years. Fergusson and his team looked at the histories of pregnancies and abortions for female participants over the interval from 15-25 years in relation to psychodiagnostic measures (following the DMS-IV system). The study shows that young women choosing abortions had clearly elevated rates of mental health problems when compared with those carrying their pregnancy to term and with those who did not become pregnant, and this is especially clear for the youngest group (15 - 18 years: prevalence of major depression 78,6 %, anxiety disorder 64,3 %, suicidal ideation 50 %). The study has several advantages compared to a many others on this field. Firstly, it contains a control for a range of confounding factors (such as family problems, family background and childhood problems) and shows that the associations still persisted after adjusting to these factors, suggesting a possible causal link between exposure to abortion and mental health problems. Secondly, the long-term design of the study and the use of standardised psychodiagnostic criterias made it possible to detect symptoms which shorter studies using non-standardized score systems easily would overlook.

Some years ago Rue [4] reviewed 375 studies on the psychological after-effects of induced abortion. However different in numbers and design, some of these studies confirm a very high percentage (up to more than 50 % found) of participants reporting lower self-esteem, guilt, regret and remorse, anniversary reactions, flash-backs (sudden, compulsive memories about the abortion event) and sexual dysfunction. Other strongly represented (less than but close to 50 % of participants) symptoms were: nightmares, suicidal ideation, suicidal impulses or attempts, inability to forgive oneself, use of drugs and finally admissions to psychiatric hospital.

Rogers [5] analysed 239 articles according to the research design of the studies described and made the interesting finding that uncontrolled studies with the weakest methodological design were more likely to report higher rates of positive experience after abortion. The tendency not to expect abortion to be very harmful seems to be supported by many psychologists and psychiatrists - in spite of studies demonstrating the opposite and in spite of a common scientific aggreement, that women who suffer from abortion experience may be under-represented in volunteer samples (this is documented f.i. in the two nordic studies mentioned below) and therefore in reality may be many more than is shown in quantitative studies.

Fergusson et. al. - concluding the above mentioned report [6] - state:

"... the present research raises the possibility that for some young women, exposure to abortion is a traumatic life event which increases longer-term susceptibility to common mental disorders. These findings are inconsistent with the current consensus on the psychological effects of abortion. In particular, in it´s 2005 statement on abortion, the American Psychological Association concluded that "well-designed studies of psychological responses following abortion have consistently shown that risk of psychological harm is low ... the percentage of women who experience clinical relevant distress is small and appears to be no greater than in general samples of women of reproductive age" (American Psychological Assosciation, 2005). This relatively strong conclusion about the absence of harm from abortion was based on a relatively small number of studies which had one or more of the following limitations: a) absence of comprehensive assessment of mental disorders; b) lack of comparison groups; and c) limited statistical controls. Furthermore, the statement appears to disregard the findings of a number of studies that had claimed to show negative effects for abortion (Cougle et al., 2003; Gissler et al., 1996; Reardon & Cougle, 2002)".

Anne Nordal Broen´s study in Norway (2006)

Very recently, a longitudinal, five-year follow-up study was published [7], comparing women´s emotional life after miscarriage and induced abortion, thus allowing to find out if some specific reactions could be adressed specifically to induced abortions as opposed to miscarriages. 40 women who had miscarried and 80 women who had had an induced abortion filled in questionnaires about their feelings related to the pregnancy termination and about their quality of life, including a psychological trauma-test, at four times (ten days, six months, two years and five years after the experience). Among other findings, Nordal Broen found that 25 % of the women had experienced pressure from her male partner to have the abortion and this showed up statistically to be the most important factor predicting later, long term traumatic suffering (f.i. tendencies to avoid thoughts and feelings related to the event, or having sudden flash-backs or feelings of anxiety about the event). This shows clearly that the stress around the abortion decision process had turned out to have long-term harmful effects for some of the participants in that study.

This raises again the difficult question often too quickly discussed in the literature of this subject, namely if the post-abortion reactions should be adressed more to the procedure itself or more to the stress that the unexpected pregnancy lays on the woman and the couple. Some studies - like some reviewed by Bradshaw and Slade [8] - seems to stress the second factor, supporting this view by showing that the stress reported before the procedure is often stronger than the stress experienced afterwards. In addition, some studies mentioned in their review, show that the levels of reported sequelae afterwards is "similar" between women who deliver and women who choose abortion.
But if emotional problems are mainly due to the stress that a unwanted pregnancy creates, then symptoms surely should be expected to disappear afterwards, just like stress in connection with toothache would be expected to disappear after the reason for the pain is eliminated. Obviously, this does not happen in many cases following abortion, indicating that the procedure itself may contribute to a trauma. The similar levels of distress in women who have delivered and women who chose to abort does not either speak in favor of abortions if abortion is seen as ending a stressing situation, since gaining a new family member normally is a life event with a very high degree of psychophysiological stress, where problems should arise (see for instance the well-known Holmes-Rahe social readjustment rating scale).

At all four points during the five years, women in the induced abortion group showed significantly higher mean scores in question of avoidance problems, thus indicating traumatization (and also when compared to women of the same age in the general population). This was also mostly the case in question of anxiety. Women who had had a miscarriage responded emotionally stronger than the induced abortion group shortly after pregnancy termination (feelings of grief and loss), however, about six months after the event, the mental health scores in this group were normalized, whereas at this point the women in the induced abortion group were struggling with more anxiety, elevated avoidance behavior and some guilt and shame.
Why this difference? Perhaps because miscarriage is commonly accepted as a traumatic event and grief reactions are normally met with caring support and understanding. More persons are hurt and involved in the grief following the loss (male partner and whole family) and can support each other. Taken together with the suddenness and unpreparedness of this tragedy, the cultural and social acceptance of the pains following miscarriage may explain why those women are able to react openly and strongly and then sooner recover than the women with voluntary abortions .
The worse long-term outcome for the induced abortion group (especially after six months) is somehow contradicted by the fact that those women at all points had very high scores on feeling "relief" and of "having done the right thing" and needs consideration.

Example 2: A client of mine - a teacher with a clear ethical conviction supporting the legal rigths to abortion - contacted me for "sorting out problems concerning me and my boyfriend". During many of our meetings she could talk about her three abortions in a calm and self-assured way as "having done the rigth thing". At some meetings, however, she would reveal other feelings, a terrible emptiness, like wearing a "monster-like" hole in her stomach, destroying her from inside, and of confusion and distress. This example shows the difficulties when making questionaires, where a feeling of the moment may be recorded and seen as representing all of a woman's experience. Therefore, the reliability of quantitative studies in general, where this is done with a sample of many women, will allways be problematic, when not supplied with individual, in-depth interviews. But even when those exist - as my example shows - negative feelings may be avoided for long, since they are not present or conscious for the moment. Clinical evidence shows that the roots of many traumas will not be revealed to a patient unless a safe and stable therapeutic relationships is established. The clear prevalence of avoidance problems in the patients described by Nordal Broen indicates the presence of a lot of unresolved ambivalence, which would problably need psychotherapy to become conscious.
Another important thing is that the meaning of an abortion to a woman can change. Life changes many things, and what we feel in young years can change dramatically, and so old decisions, that can never be undone, may cause new pain. This can be the case when a woman has had abortions in her young years and then, when she wants to become a mother, is unable to get pregnant. Another example is the feelings of guilt that can arise, when a person has a religious conversion, and sees her former life in a new way. This means that the "relief" or even "satisfaction" that a woman can experience in the years after an abortion is no guarantee for a life time "freedom of symptoms".

An interesting observation in this study was the fact that the project met some lack of cooperation from parts of the medical staff, which had to be confronted by the researcher. It was also observed that the will to cooperate in the patients was much higher when a staff member had a positive attitude to the project. Such human factors are clearly very influential but may be rarely considered in studies. This weakens somehow the reliability of all quantitative research on a delicate matters like this.

Hanna Söderberg´s study in Malmö (1998)

A comprehensive study of socio-demographic factors and psychological problems after abortions was presented by Hanna Söderberg [9] in Malmö some years ago. The study included a whole annual sample, i.e. all women applying for abortion 1989 in Malmö, Sweden, and contains interesting findings showing the severity of mental pain following abortion.

First of all it affirms a phenomenon decribed by several other researchers: Many women do not want to answer questionaires about how they feel post-abortion. Söderberg, an abortion doctor herself with decades of experience and so an excellent first-hand witness to emotional reactions, was surprised to see that one-third of the whole sample (who all in advance had accepted preliminarly to be interviewed one year after the event) denied to answer such questions. A typical answer was: "I do not want to talk about it. I just want to forget".

Söderberg is the only researcer known to me who has tried to analyze this one-third group of non-responding women, also reported in other studies. She found that, statistically, they tended to belong to the kind of patients who are typically known to be vulneable in other ways (young, living alone, poorly educated, often unimployed or students). This means that we should expect a considerable amount of psychological pain not covered or counted into ordinary research.

From the patients willing to answer questions on emotions, Söderberg defined those who showed "slight emotional distress." That means (to her) persons who reported "remorse, guilt feelings, a tendency to cry without cause, discomfort upon meeting children, or recurrent fantasizing about the child that might have been (its gender, looks, etc.)" Then she continues: "Women who had needed help from a psychiatrist or a psychologist or who could not work because of depression, were considered to have serious emotional problems" (9, p. 15). Söderberg found 50-60 % of her sample having emotional problems like this which she would classify as severe in 16 % of cases (in cases of so called "late abortions" - second trimester abortions - 9 women out of 24, that means 37,5 % belonged to the group with "severe emotional problems").

The risk factors that could be identified were similar to what other studies have confirmed, namely:

• poor quality of partner relationship
• ambivalence in the decision proces
• engagement in religious activities
• having a negative attitude towards induced abortion

Söderberg judged that out of 854 women who fullfilled the interviews one year after abortion

• 500 affirmed having experienced "emotional distress" related to the abortion
• 169 affirmed having had "doubt about their abortion decision"
• 650 affirmed that they would "not consider abortion again".

A strength in Söderberg´s study surely is the big number of participants; an important weakness could perhaps be seen in the evaluation process, where no standardized trauma test (as in Nordal Broens study above) sems to be used, thereby leaving the interpretations to the personal judgement of the doctor involved. Söderbergs study suggests that at least - and probably a lot more than - 100 women each year may be seriously traumatized in connection with induced abortion each year in the city of Malmö. One have good reason to ask: What would happen if any other medical treatment showed up with such numbers?

Problems in relations - problems in male partners / other family members

Bradshaw and Slade [8b] from the UK had tried to evaluate post-1990 literature from different western world countries on psychological experiences and sexual relationships prior to and following induced abortion. They found negative effects on sexual relationships in the first months following abortion for about 10-20 % of women and on couples relationships, prior to and following abortion, with about the same percentage.

But comparing measured levels of anxiety and depression before and after abortion they concluded, that "distress reduces following abortion" (8, p. 929).

The question such a postulate raises is: "What can meaningfully be inferred from that?". Bradshaw and Slade seems to focus in their search for material on pre-abortion distress without taking notice of the totally difference between the situation before and after abortion. But they do admit - concluding from their material - that "up to 30 % of women are still experiencing emotional problems after a month" (8, p. 929).

Bradshaw and Slade´s review contains interesting studies on the quality of relationships and sexual functioning. However, we meet results hard to interpret since many factors remain unclear. Degrees of experienced negative impact of the abortion on the woman´s relationship with her partner differ considerably between the studies, but still indicate that perhaps up to 20 % of women would feel this.

As a contrast to the group of studies reported by Bradshaw and Slade, a study from 1991 [10] can be mentioned, with a sample of 232 women from 39 US-states with a mean time post-abortion of 11 years. Vaughan found that only 5,9 % of those not married but in a relationship as the abortion occured continued their relationship. She was even able to show that worsened relationships correlated with higher levels of anger and guilt after abortion, something perhaps not looked for in the studies presented by Bradshaw and Slade.

Performing a study involving 1.000 men who escorted their girlfriends to abortion in 18 US-states in 1984, Shostak [11] concluded that abortion is an unrecognized trauma for men, who mostly go through this without help, hiding their feelings to protect their partners, feeling isolated, helpless, angry with themselves and with their partner.

Example 3: Some years ago a social worker from a public youth clinic in Denmark who had tried to collect diaries from men talking about their experience of their partners abortion (which they had not supported), contacted me. He gave up his research partly as it seemed because he was afraid of being seen in his job as "against abortions" (which he was not in any way). Thus he became a victim of a special group pressure reported by other individuals working in nordic countries health systems. He gave me his material, which I have until now not published. In these reports you find feelings of being left out, being powerless and personally rejected in the child that is rejected by the partner.

Example 4: Medical staff sometimes suffer from what they have to do in hospitals performing abortions. "What´s on your schedule next week?" a nurse known to me asked a male collegue. "I am going to kill little babies" the collegue answered, with a bitter voice full of disillusion. In fact, abortion activities are not popular among staff and it can be hard to find persons who want to work with this. I have heard both male and female staff complaining about the emotional impact of this work and the lack of counseling support for themselves.

Example 5: In regard to the mental stress of medical staff, I would like to mention a man who worked with abortions and who had a terrible time after his girlfriend´s abortion. After many counseling talks with me he was able to return to work without too much emotional distress. He shifted to the birth department and so did not have to work with abortions any more. But there he sometimes felt overwhelmed by guilt feelings when he encountered couples, who had their babies, younger and under worse social conditions than he and his girlfriend had ever been in. This man - and his partner - had consciously no ethical problems with abortions. In spite of that he could not get rid of upcoming feelings of guilt and bad conscience for a long time afterwards, and this may be so for him still.

According to Rue´s (4, p. 25) review of studies on post-abortions aftermaths, "Most unmarried relationships evidence increasing conflict and decline post-abortion. The following disruptions in both unmarried and married relationships are all too common post-abortion: (1) a reduction in the amount and quality of self-disclosing statements; (2) an increase in the use of defensive communicational strategies, e.g. hostility, avoidance; (3) increased partner communication apprehensiveness resulting in a loss of trust and evolving into a closed versus open system; and (4) a loss of psychospiritual connectedness between the couple, with shame and guilt predominant." The first three conditions are clearly present in the two qualitative studies above (the fourth is relevant in couples, where both partners share(d) a religious life, and is also confirmed by my own observations).

Example 6: About losing the curative means of religious practice: A young catholic woman - known to me, but no client - had ceased to practise the sacrament of reconciliation (confession of sins to the priest) after having an abortion. This seemed somehow strange to me since she said that she longed for this and needed this sacrament, and she "knew that it would help" her. Then, in a moment of special confidence, she revealed to me that she didn´t go to a priest because she thought that she did not deserve any forgiveness. This might demonstrate how religious observance, even when missed and once highly appreciated, can be lost and of no use, when a depressive or self-destructive attitude that blocks a person from serving her own needs is not being confronted therapeutically.

Regarding families Rue concludes (4, p. 26): "If the abortion is a family secret, the woman often feels like her relationships with her family members are altered. She may feel depressed, guilty and shame-filled and be less disclosing, or she may attempt to overcompensate and deny any sense of loss by compulsively pretending. She may also avoid extended family gatherings at which pregnant siblings or young nieces or nephews are present. For some, the abortion secret is compelling evidence of their personal unworthiness and inability to ever be loved and accepted for who they are, both within the family and with friends. Biological grandparents can bear a double burden of loss if their daughter elects an abortion. They not only experience the loss of their grandchild and all the attendant possibilities for love and affection in their life, but they also feel the loss of their daugther or an altered relationship with her because of her distancing after the abortion. If parents were involved in promoting the abortion decision, afterwards the daughter may feel punitive toward them."

Concerning the very most vulnerable group in families, the children, I have until now found almost no documentation of how they react psychologically upon learning about a mother´s abortion. This reveals a very serious lack of research, since it is commonly known that painful family secrets can heavily harm the self-image of children. Even in families where the parents try to hide what has happened, children worry about their mother´s crisis reactions and sooner or later, more or less conciously, they are probably able to understand that something terrible has happened, something the parents are not proud of, something that is better not talked about, that should be forgotten or even denied.

Example 7: In a family with four or five children down to the age of 4 - known to me but not clients of mine - the mother chose to apply for - and was permitted - an abortion in the late part of her second trimester (when her pregnancy was quite visible). This means that the whole family knew what happened. Shortly after the abortion they moved to another place and I was not able to follow them. One can only speculate about the silent horror that the living children must have felt, fantasizing about what mother had done - especially in the inner world of the youngest, the four year old boy: "Can mummy do the same to me?" As Weiner and Weiner [12] puts it: "An abortion can be, for the preschooler, a proof of the parent´s capacity to be dangerous" - something producing unbearable confusion and anxiety, that inevitably must be denied in order to keep alive basic trust, crucially needed by all children.
In families who want to prevent children from becoming afraid by talking "in a relaxed way" about the abortion as "something natural," children might try to live up to their parents standards by denying the fear the abortions raises in them. Other children who hear about the abortion but do not understand that there was a fetus who was actually a sibling-to-be, might feel terryfied later on in childhood when they understand what a fetus is, and that they themselves once had been in the same position and theoretically could have been aborted. According to Ney [13] especially children with developmental defects often wonder whether their parents would have aborted them if they had known about their defects.

Knowing this, a secondary traumatization of children must be an almost certain phenomenon but also something very difficult to trace since children always accomodate themselves to their family situation and try to avoid everything that could make their parents feel unhappy. But in some cases the trauma may be visible: Children who show an intense overinvolvement in the emotional life of the mother, children who have painful fantasies about abortions or show denial, anxiety and emotional numbing could very well be such secondary victims of an abortion. Ney has desbribed a typology of children who he sees as living as a kind of hostages to an aborted sibling, as "the haunted child, the bound child, and the substitute child" [14].
These children may incorporate what Rue calls a "survivor guilt" (4, p. 28), like what children with other dead siblings commonly suffer from.

Regarding elder children in a family, Rue writes (same page):

"At such a time of particular developmental vulnerability, the abortion decision sends a highly contradictory message to the adolescent regarding the control of aggressive impulses, support and nurturance for the weak, and the value of human life. This in turn can escalate the generation gap by increasing disillusionment and the erosion of parental respect."

Surely, to a culture that tries strongly to defend a woman´s legal rigth to abortion and at the same time focuses equally strongly on welfare for children, this perspective presents a serious challenge. That might explain why research is not performed about the effects of abortions on a family´s children. However, facts from child psychology suggests that this must be a considerable, though well-hidden problem, that should be adressed no matter how unpleasant the result will be. But it is thinkable that society might prefer not to know, and so try to avoid a contradiction that could be felt as a threat to central aspects of our modern life style.

Perhaps the wise words of C.G. Jung are tragically relevant here:

"A lie makes no sense unless the truth is felt to be dangerous."

Some special remarks on moral shame and shame as an emotional inhibition

When talking about "shame" it could be useful - though this often seems to be neglected - to distinguish between what could be called "moral shame" and "psychological shame" . In our common language the word "shame" is obviously sometimes used as a positive word, especially in cases when moral appeals are made, urging people to become active and change things and so not meant to inhibit people. For instance a preacher would criticize a whole society for ignoring the needs of poor countries, the environment, cruel treatment of animals and so on. This "life-affirming" appeal for moral shame which serves the purpose of mobilizing people to openly debate and actively improve social conditions could also point to questions as diverse as society´s denial of violence against women, the lack of legal protection of unborn children or the unwillingness to remember the horrors of the holocaust. But this use of the word "shame" must clearly be distinguished from what is meant when shame as a psychological or mental inhibition is discussed, like in this paper. "Shame" is then mostly meant as a destructive condition, distorting a person´s ability to maintain a positive self-image, usually caused by emotional events in one´s personal life, involving anxiety and isolation, and sometimes guilt. The role of this kind of shame in relationships is shown in for instance lack of spontaneity and open self-disclosure or in rigid communication patterns, as demonstrated above.

Morality and emotions are often intertwined. I find it helpful to consider the following four cases, which can be inferred from the distinction above, and which all need to be met with by a counselor in different ways:

1. A person is living in a condition of moral shame, but without having detectable symptoms of psychological distress. Here the main question will be, how this person can find ways of getting back to living in harmony with his or her own moral/ethic standards, using the tools that culture - f.i. the persons religion - provides for such cases.
2. A person suffers psychologically, while also living in awareness of moral shame. The person will primarily need appropiate therapeutic support and then the presence of a supportive listener helping her/ him with the above mentioned reconciliation with his or her norms and ethics.
3. A person suffers psychologically, without seeing one self as living in moral shame. A therapeutic approach according to the symptoms and the person´s background is necessary. If this does not help, the counselor should consider if a moral conflict which has not been not acknowledged, could be involved.
4. A person reports no psychological suffering and no moral shame. Obviously, no special support is needed (at least not yet, since - as shown above - some troubles can occur later in life, when youth decisions can get a new meaning).

We probably meet all these variations (and more) in the aftermaths of an abortion. The examples 4, 5, 6 and 8 above vividly illustrate such variations. I think that difficulties arise, when researchers or individual treaters are unaware of such distinctions and so see all kind of shame - the ones motivated by personal conscience and the ones motivated by isolation and despair - in a unilateral way. This might be a common mistake, easy to make because of the unease we may feel, meeting such stories, or because of ideological factors, or our lack of knowledge about post-abortion aftermaths.

The ever-present problem of moral conflicts

Among the factors predicting a "good" emotional outcome in the time following abortion, which many studies constantly agree on are: a) a positive attitude to abortion, and b) absence of strong religious beliefs and engagements. This could support the idea that changing the women´s attitudes on these two factors could improve the way they would feel post-abortion.

This is perhaps why children and adolescents often are provided with information that mainly stresses abortions as a problem about failed pregnancy prevention, as a "solution" to the "disaster of an unwanted pregnancy" and as a realisazion of values like "womens free choice" thereby not informing about what the religions, to which the young people belong, say and why they say it; or discussing ethical questions, like the question of the interests of the real existing other human individual in the womb that is about to enter life and is living in a position where we ourselves have all been. To my experience, however, those can be very important questions that worry women, independent of beliefs.

If this last aspect - the interests of the fetus - could be totally ruled out in the consciousness of women and men, it would surely be much easier to recover mentally after abortion. However, it seems as if this kind of denial is becoming increasingly difficult as more and more scientific discoveries, photographic techniques and knowledge about pregnancies bring us closer to the world of the unborn child and so enhances our natural tendency to identify with and to protect and care for the yet not born.

Choosing abortion today probably more than ever includes some kind of conciousness about having "denied a baby its right to life", a terribly painful step to take since it demands of a woman (often in crisis) to deny and overcome a natural tendency (and moral duty) to care for her offspring. Abortion often means having made such an attack on one´s own instincts, having done away with something which is somehow also naturally longed for, and finding oneself left with a loss, where nothing can be undone. This explains, as I see it, why the grief reaction can become so complicated; it is all too automatically intoxicated by self-blame and self-hatred that is resistant to consolement and well-intended arguments, since on some level the person knows that she did the - morally - wrong thing (even when she at some other level can report a cognitive conviction of the opposite).

Example 8: The importance of not trying to influence a person "to accept herself" too quickly in such a situation - as I think is often done with the best of intentions - can be stressed by the following example: A woman feeling terribly depressed after her abortion, looked for help from different therapists but gradually got worse in spite of every encouragement she recieved. At some point then she took part in a session based on a "drama therapy" (a holistic group therapy where the participants are encouraged to engage in unusual feelings and roles in order to develop personality). There she met at therapist who had the courage - as she says - to say the unbearable truth: "You feel that you murdered your child. Why don´t you accept this is your real own view of what happened?" This - she says - felt like a real emotional liberation, since it enabled her to be more honest to herself and to live on, taking responsability and going through a healing remorse process. Hearing her telling this story made me review some of my own fundamentals beliefs of what psychoterapy should be. Surely, this kind of therapeutic intervention can not be done anytime and in any case. It shows however, that taking moral guilt seriously can be a turning point for a woman post-abortion and so serve an important therapeutic purpose.

The unresolved grief reaction may also explain why many of those women become pregnant again within 12 months after the abortion (and fullfill pregnancy), which is so shortly that it seems improbable that the life conditions, which were the reasons for the abortion, could have changed very much (according to Söderberg, (9, p. 24), some 10 % of the women who had an abortion do this - something also confirmed by other studies). In many cases these women may deliver what psychologically could be called a "substitute" child.

I can imagine that many people, even professionals, would like stories, memories and observations like the ones mentioned in this paper to be put away. They seem to have the opinion that wounds occuring from abortions can only heal in silence. But this is simply not the way that people, traumas and healing function. That is why an atmosphere needs to be created, where such experiences can become allowed to be heard and respected in order to help women and men to get rid of the effects of shame and destructive secrecy following this important event of life. No lost unborn lives can be saved, but their parents can be rescued from a reduced life quality. My hope is that this paper, talking openly about all too shameful secrets, will contribute to that.

Proposals for a better counseling system for women with unplanned pregnancies:

Knowledge about when and why negative emotional effects of abortion can be expected should generally be spread among professional staff. Efforts should be made to welcome a more open public debate on the sequelaes of abortion, where critical viewpoints and ideas are invited and heard (even when this at first might become overwhelming, a "Pandora´s box," just like revelations of sexual abuse of minors in our society during the last two decades have been, or like the glasnost process in the former Soviet Union).

Given the current public situation of Sweden, I propose the following:

1. The first step to a reduced number of abortions should be to care more for couples and lone pregnant women in crisis. This could also be done partly by private initiatives such as the "minna" organization in Sweden that should gain financial support from the state, as do the private "Amathea"-organisazion in Norway, and as the "Tilflugten" in Copenhagen, Denmark have done. Women who would like to have professional help to find alternatives to abortion or who need emotional support under unwanted pregnancy circumstances, or who are in post-abortion crisis, could surely gain a great deal if such instances outside of the public health system was promoted also in Sweden.

2. Legislators in Sweden should analyze the modell used in Germany in recent years. In Germany abortions are only allowed after a visit to a family counseling, where also alternatives that could save the life on the unborn are discussed. The ethical questions need to be adressed in a pre-abortion situation since research and clinical experience seem to point at the harmful effects of going through an abortion quickly without considering personal life questions. Surely this must be done in an non-directing atmosphere of listening, respect and trust.

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Reference List:

[1] Vincent M. Rue, Ph.D.: The psychological Realities of Induced Abortion, published in [[15n]], quotations here are from p. 9 and p. 7.

[2] To make sure that any identification is impossible, circumstances and names are altered, the two stories and some of the other examples mentioned in this paper are partly mixed up from different cases of my own and of other cases, well known to me.

[3] David M. Fergusson, L. John Horwood, and Elizabeth M. Ridder: Abortion in young women and subsequent mental health, in: Journal of Child Psychology and Psychiatry 47:1 (2006), pp. 16 - 24

[4] see (1, p. 25). The whole survey of studies in pp. 11-23 is outstanding, as I see it, especially the tables pp. 15-17 with an excellent graphical overview of the results from 22 studies performed in the years 1980 - 1993. I find the whole article very useful, because it combines a comprehensive statistical material with solid clinical evidence. Rue´s analyses - although brief - have been an eye-opener to my own understanding of symptoms, which my clients showed. That is the reason why several quotations from his article are made in this paper at various points (and some studies he summarizes there).

[5] Rogers´ contribution is found in: Rue, V., A. Speckhard, J. Rogers, & W. Franz, (1987): The Psychological Aftermath of Abortion: A White Paper. Presented to the Office of the Surgeon General, Department of Health & Human Services, Washington D.C. The results are shortly presented in (1, p. 13)

[6] See (3, p. 22-23)

[7] Anne Nordal Broen: Women´s emotional life after miscarriage and induced abortion - a longitudinal, five-year follow-up study in Norway, Faculty of Medicin, University, 2006

[8][8b] Zoë Bradshaw and Pauline Slade: The effects of induced abortion on emotional experiences and relationships: A critical review of the literature, in: Clinical Psychology Review 23 (2003) 929 - 958

[9] Hanna Söderberg: Urban women applying for induced abortions - Studies of epidemiology, attitudes and emotional reactions, Departments of Obstetrics and Gynecology and Community Medicine, Lund University, University Hospital, Malmö, Sweden, 1998

[10] Vaughan, H.: Canonical Variates of Post Abortion Syndrome, Portsmouth, NH: Institute for Abortion Recovery and Research, 1991 - Vaughans results are shortly mentioned in (1, p. 21)

(11) Shostak, A. et al.: Men and Abortion: Lessons. Losses & Love, New York: Praeger, 1984, this study is described in (1, p. 24 - 25)

[12] Weiner & Weiner: The Aborted Sibling Factor, in: Clinical Social Work Journal, 34: 209 - 215, 1984, also summarized in (1, p. 27)

[13] Philip G. Ney: Emotional and Physical Effects of Pregnacy Loss on the Woman and Her Family: A Multi-centered Study of Post-Abortion Syndrome and Post-Abortion Survivor Syndrome, in (15, p. 69 - 88, the information here mentioned is on p. 74)

[14] Philip G. Ney: A Consideration of Abortion Survivors, Child Psychiatry in Human Development, 13: 168-179 - quotation here from (1, p. 27)

[15][15n] Michael T. Mannion (ed.): Post-Abortion Aftermath: A Comprehensive Consideration, Writings generated by various experts at a "Post-Abortion Summit Conference, Sheed & Ward, 1994

 

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