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Newsgroups: talk.abortion Path: sparky!uunet!elroy.jpl.nasa.gov!ncar!neit.cgd.ucar.edu!kauff From: kauff@neit.cgd.ucar.edu (Brian Kauffman) Subject: regrets: abortion completed/denied (long) Message-ID: <1992Sep14.171321.21119@ncar.ucar.edu> Sender: news@ncar.ucar.edu (USENET Maintenance) Organization: NCAR, Boulder CO References: <1992Sep14.155728.28045@watson.ibm.com> Date: Mon, 14 Sep 1992 17:13:21 GMT Lines: 908 ======================================================================== From: psb@eesun1.eece.ksu.edu (Phil Buckland) SOURCE: the American Journal of Psychiatry, Volume 148, Issue 5, May 1991. copyright by the American Psychiatric Association ((C) 1991) copied without permission. The Psychological Sequelae of Theraputic Abortion - Denied and Completed by Paul K.B. Dagg, M.D., Department of Psychiatry, Mount Sinai Hospital. _________________________________________________________________ OBJECTIVE: The purpose of this article is to review the available literature on the psychological sequelae of theraputic abortion, addressing both the issue of the effects of the abortion on the woman involved and the effects on the women and on the child born when abortion is denied. METHOD: Papers reviewed were initially selected by using a Medline search. This procedure resulted in 225 papers being reviewed, which were further selected by limiting the papers to those reporting original research. Finally, studies were assessed as to whether or not they used control groups or objective, validated symptom measures. RESULTS: Adverse sequelae occur in a minority of women, and when such symptoms occur, they usually seem to be the continuation of symptoms that appeared before the abortion and are on the wane immediately after the abortion. Many women denied abortion show ongoing resentment that may last for years, while children born when the abortion is denied have numerous, broadly based difficulties in social, inter- personal, and occupational functions that last at least into early adulthood. CONCLUSIONS: With increasing pressure on access to abortion services in North America, nonpsychiatrist physicians and mental health professionals need to keep in mind the effects of both performing and denying theraputic abortion. Increased research into these areas, focusing in particular on why some women are adversely affected by the procedure and clarifying the relationship issues involved, continues to be important. (Am J Psychiatry 1991; 148:578-585) _________________________________________________________________ After a period of relative quiescence, theraputic abortion services are once again attracting significant political and public attention in North America and elsewhere. Systematic evaluation of any medical procedure usually requires examination of both the effects of perform- ing that procedure and the effects on that patient when nothing is done. Despite a great deal of concern about the psychological effects of theraputic abortions in both the lay and scientific press, the research examining either side of this issue, particularly that looking at the effects of denying abortion on the parent and child, is sparse. The last half century has seen a trend toward progressively more liberal laws with respect to access to abortion, particularly in developed nations. Currently in the Unites States approximately 1.5 million theraputic abortions are performed annually, involving 27.4 of every 1,000 women between the ages of 15 and 44. Worldwide, an estimated 30-40 million legal abortions are performed annually, with perhaps another 20 million illegal abortions (1). Recently, in North America, as well as in some European Countries, we have seen a trend toward reexamination of this liberalization and reinsti- tution of more restrictive laws. Moreover, in the developing countries highly restrictive laws often persist, a situation complicated by "right-to-life" groups in Western nations that ally themselves with conservative forces in some developing nations to try to strengthen restrictive abortion laws there (2). This paper has broken down the existing literature in order to address the following essential questions. The first is the simplest to address, and hence the one that has generated the most research interest. What are the psychological sequelae of theraputic abortion, both the immediate effects and the more subtle, long-lasting effects? When abortion is denied, the issues are more varied. What proportion of women go on to find abortion elsewhere? If the fetus is not aborted, how many of the infants are actually adopted away, the alternative most often offered? Most importantly, what are the effects on the mother and the child when the abortion is denied? Obviously, these are questions not easily addressed scientifically. There can be no random assignment of pregnant women to a group granted abortion and to one denied abortion. Follow-up, particularly for women denied abortion services, is understandably difficult. Cultural, social, and legal variations from place to place make comparability of studies difficult. PSYCHOLOGICAL SEQUELAE OF COMPLETED ABORTION The first group to review systematically this particular side of the abortion issue was Simon and Senturia (3) in 1966; they commented on the wide range of results quoted by various studies, most of whose methodology they severely criticized. In 1981, Doane and Quigley (4) published an even more exhaustive review of the literature, also commenting on the large proportion of studies that were severely hampered by major methodologic flaws. They criticized in particular the lack of any control group and the fact that the majority of studies were impressionistic reports of a handful of cases. Other problems included short periods of follow-up, vague and poorly defined symptoms without objective measurement, low response rates, and unspecified indications for abortion. The last problem is particularly significant in that it has been clearly demonstrated that medical or genetic indications for abortion increase the risk of adverse psychological sequelae in the mothers (5,6). Since those two reviews, research has continued in this area. The ongoing trend to liberalize abortion access laws toward the principle of abortion on demand has had an impact on research in this field. Early research tended to concentrate on psychiatric or medical complications of abortion, emphasizing a disease model, as some conception of disease was often required for abortion to be performed legally. The emphasis has now shifted toward a model in which research examines the psychological sequelae and antecedents that affect a woman who seeks an abortion. In examining past research that covers a variety of legal climates, one must differentiate between research on "theraputic" abortion, which requires medical or psychiatric consultation in the decision-making process, and research on open abortion, in which the woman involved is the sole decision maker. A recent review by Adler et al. (7), which limited itself to U.S. studies in order to reduce the confounding variables of social, cultural, and legal differences, found that "legal abor- tion of an unwanted pregnancy in the first trimester does not pose a psychological hazard for women" in the legal context of open abortion. None of the reviews mentioned there, however, address the issue of denied abortion. Although many studies have examined the short-term consequences of theraputic abortions, few have used a comparison group or objective measure of symptoms. A few studies of abortion do meet these criteria. Freeman et al. (8), in one of the more objective studies involving over 400 women, found that SCL-90 scores were elevated on several subscales in women before the procedure but decreased significantly toward normal quite rapidly after the abortion. Those scales on which the preabortion scores were highest, indicating the highest level of disstress, had the greatest decrease after the abortion. In 1985 Major et al. (9) surveyed over 200 women before their abortion, 30 minutes afterward, and at the end of 3 weeks, using the Beck Depression Inventory and clinical interviews. They found the average score to be in the nondepressed range immediately after the abortion; 3 weeks after the abortion the women's mood had continued to improve, and there was less depression and less anticipation of negative consequences. Using the SCL-90 before and immediately after the procedure, Cohen and Roth (10) demonstrated a dignificant drop after the abortion in scores on the depression subscale of the SCL-90 and the Impact of Events Scale. Prospectively following hospital admis- sions in a study of theraputic abortion in the United Kingdom, Brewer (11) found an admission rate of 0.3/1,000 for postabortion psychosis compared to a rate of 1.7/1,000 for postpartum psychosis in normal-term deliveries. Other studies, using less objective measures and examining theraputic abortions that required psychiatric or other medical consultation, still seem to point in the same direction when comparison groups are available. Ewing and Rouse (12) found depressive symptoms in 3% of women granted abortions for psychological indications and in 12% of those women with previous psychiatric contact. Mackenzie (13) comment- ed that women were more likely to be depressed before the abortion than after and that 78% expressed predominant feelings of relief, while 33% reported some feelings of guilt, with 80% of the guilt rated as mild. Niswander and Patterson (14) found that most women report an improve- ment in emotional health. In their study, women who had abortions for medical reasons reported more "unfovourable reactions" than those who had abortions for psychogenic indications. In 1965 Jansson (15) reported the following rates of admission to psychiatric hospitals immediately after abortion or delivery: 0.70% after term delivery, 1.92% after legal abortion, and 0.27% after illegal abortion and spontaneous abortion. It was felt that the apparent difference in reaction to legal and illegal abortion was due to the much higher pro- portion of women in the legal abortion group (over 50%) with a previous psychiatric history. Unmarried women were also more likely to be hospitalized. Other short-term studies that lack such comparison groups are summarized in table 1 (3, 16-27). TABLE 1. Studies of the Immediate Psychological Sequelae of Abortion ___________________________________________________________________________ Number of Results Study and Year Subjects Positive Negative ___________________________________________________________________________ Ekblad, 1955 (16) 479 ___ 2% had severe self- reproach Simon and ___*a ___ 0%-41% felt guilty Senturia, 1966 (3) Patt et al., 1969 (17) 35 ___ 40% had symptoms, all mild; in one- half, symptoms were present before abortion Bacon, 1969 (18) 9 55% felt consid- 33% felt mild guilt erable relief lasting a few days Walter, 1970 (19) ___*a ___ 0%-30% felt mild guilt Osofsky and Osofsky, 250 65% were happy 14% were sad, 24% 1972 (20) *b felt guilty Lazarus, 1985 (21) *b 292 76% felt relief 15% felt guilty and were depressed; 10% had overall nega- tive symptoms Pare and Raven, 128 Most experienced A few felt mild 1970 (22) marked relief and guilt for 1-2 improved relation- weeks ships Marder, 1970 (23) 147 Most experienced ___ marked relief of symptoms and im- proved relation- ships Bracken et al., 489 Positive reactions ___ 1974 (24) increased with more support Adler, 1975 (25) *b 95 Most had positive A few felt guilt feelings and doubt Spaulding and Cavenor, 2*c ___ Two subjects devel- 1978 (26) *b oped psychosis, one organic McAll and Wilson, 6*c ___ Six subjects devel- 1987 (27) *b oped psychiatric symptoms ___________________________________________________________________________ *a Review study. *b Studies examined abortion on request. All other studies involved theraputic abortion requiring some degree of psychiatric or other medical consultation. *c Case reports. When studies have examined the effects of abortion months or years after the procedure, similar trends continue. Brody et al. (28) and Niswander et al. (29), who used pregnant women with normal deliveries for control subjects in examining theraputic abortion, showed that MMPI scored, which may be abnormal before the abortion, normalize within 6 months to a year after abortion. The control subjects, who had less abnormal scores before delivery, showed no change in their scores after delivery. In the study by Brody et al., a group of women who were denied abortion continued to have quite abnormal scores after the delivery of the infant. Studies of open abortion show similar results. Athanasiou et al. (30), who also used pregnant women with normal deliveries as control subjects and matched for socioeconomic status, found no difference in MMPI and SCL-90 scores between the two groups after delivery or abortion. A study by Jacobs et al. (31), who used women undergoing minor gyneco- logical surgery as control subjects, showed higher preabortion scores for the pregnant women on the Psychopathic Deviate, Schizophrenia, Hysteria, and Depression scales of the MMPI; these differences disappeared after the abortion. Using a different control group, Zabin et al. (32) examined a group of adolescents who presented initially for pregnancy testing and subsequently studied three groups - those who were pregnant and chose to abort the fetus, those who were pregnant and chose to complete the pregnancy, and those whose test results were negative. One and 2 years later they found that the abortion group showed no evidence of psychological distress compared to either control group and that, indeed, there was a non- significant trend toward better psychological health with less anxiety on the State-Trait Anxiety Inventory and more internal locus of control. In addition, the women who completed their pregnancy showed a significant economic deterioration afterward and were significantly more likely to discontinue school than the abortion group; this difference actually increased between the first and second years after delivery or abortion. In a study in Denmark (33) that tracked psychiatric hospitilization rates for 3 months after abortion or delivery, there was no difference between postpartum and postabortion rates in married and never married women. Higher postabortion rates of admission were found in seperated, divorced, and widowed women, women who were more likely to be isolated and alone. Among the older studies of theraputic abortions with less rigorous methodology, Peck and Marcus (34) and Smith (35) found more symptoms of depression and negative feelings, up to 2 years afterward, in women for whom the abortion was performed for medical/genetic indications. Significant distress occurred in less than 10% of women who had abortion for psychosocial indications. Ewing and Rouse (12) found that approximately 95% of their study subjects reported improved emotional health as a result of the abortion at 2-year follow-up. Table 2 presents data on other long-term studies (16, 17, 22, 36-47) that lacked comparison or control groups (thereby making interpretation difficult). All studies in this group involved theraputic abortion in which psychiatric or other medical consultation was required before the abortion. Noteworthy, again, is the relative lack of significant negative responses in the women. The two studies that found relatively higher rates of negative responses are those of Wallerstein et al. (42) and Ashton (46). The low response rate (less than 20%) to a mailed questionaire in the first study and the minor nature of symptoms measured in the second may account for the difference. Table 3 presents data on studies (12, 14, 17, 22, 36, 37, 39, 44, 45, 48) that queried subjects concerning the presence of regrets after the procedure (a measure of ambivalence about the abortion decision). This question is frequently posed, and yet despite the subjective nature of the question, the results are surprisingly uniform. They reveal that for the large majority of women, the decision about abortion, although undoubtedly difficult, is not one for which a great deal of conscious ambivalence exists. TABLE 2. Studies of the Long-Term Psychological Effects of Abortion *a ____________________________________________________________________________ Length of Number of Results Study and Year Follow-up Subjects Positive Negative ____________________________________________________________________________ Ekblad, 1955 (16) 2 years 479 ___ 11% had self- reproach Kretzchmar and Norris, 1-5 years 24 ___ ___ 1967 (36) Patt et al., 1969 (17) 2-6 months 35 74% 14% Pare and Raven, 3 months 321 ___ 13% felt guilty 1970 (22) Whittington, 1970 (37) 2-12 months 31 87% 6% Ford et al., 1971 (38) 6 months 22 ___ 14% *b Margolis et al., 1971 3-6 months 43 67% 9% (39) Meyerowitz et al., 1-84 months 114 78% 9% 1971 (40) Todd, 1972 (41) 1-3 years 83 91% had no ad- ___ verse symptoms Wallerstein et al., 5-7 months 22 ___ 32% 1972 (42) Perez-Reyes and Falk, 3 months 41 75%-90% ___ 1973 (43) Lask, 1975 (44) 3 months 50 68%-89% 8% Greer et al., 1976 (45) 18 months 217 ___ 7% felt guilty, 19% had other symptoms Ashton, 1980 (46) 6 weeks 64 ___ 24% felt guilty, 31% felt worried Schmidt, 1981 (47) 3-6 years 10 Normalization ___ of scale scores *c ____________________________________________________________________________ *a All studies involved theraputic abortion requiring some degree of psychiatric or other medical consultation. *b According to the MMPI. *c On the Hostility and Direction of Hostility Questionnaire and the Symptom-Sign Inventory Table 3. Studies of the Prevalence of Regrets After Abortion *a _______________________________________________________________ Total Study and Year Subjects Subjects With Regrets _______________________________________________________________ Greer et al., 1976 (45) 217 3% at 3 months, 3.7% at 18 months Niswander and 116 3% Patterson, 1967 (14) McCoy, 1968 (48) 62 32% had regrets of some degree at some time Ewing and Rouse, 126 3% 1973 (12) Margolis et al., 43 4.4% 1971 (39) Patt et al., 1969 (17) 35 5.7% Whittington, 1970 (37) 31 6.5% Kretschmar and Norris, 24 12.5% had occasional 1967 (36) regrets Lask, 1975 (44) 50 16% had some regrets Pare and Raven, 321 1.6% 1970 (22) _______________________________________________________________ *a All studies involved theraputic abortion requiring some degree of psychiatric or medical consultation. In women undergoing induced abortion, several factors have been identified that correlate with higher rates of psychological distress after abortion. As previously mentioned, it has been clearly demon- strated that a medical or genetic indication for abortion increases the risk of a negative reaction (5, 6, 34, 35). Previous psychiatric contact has also been clearly shown to increase the likelihood of the woman having a negative emotional response to the abortion (12, 34, 38). The presence of support seems to be a more complex issue, with possibly contradictory results. Several studies have shown that a woman's perceived degree of support at the time of the abortion was positively correlated with a good psychological response afterward (20, 24, 33, 49, 50), but Major et al. (9) found that women whose partners accompanied them to the clinic for the procedure were more likely to feel depressed afterward and experienced more physical complaints. Similaryl, Robbins (51) found that single women who maintained a strong relationship with their partners after the abortion were more likely to experience regrets at 1 year and had more negative scores on the MMPI at 6 months. The decision on whether to abort the fetus or to carry it to term is a complex one that has several effects on the psychological state of the woman. Not surprisingly, women undergoing mid-trimester abortions experienced more difficulty with the decision than those having first- trimester abortions (25), and they experienced greater ambivalence about the pregnancy (52). They also appearedmore likely to experience negative reactions after the abortion (25, 30, 53), particularly if the late abortion required induction of labor and delivery (54). Adolescents who felt that they themselves made the decision to abort, regardless of the length of the pregnancy, without pressure from parents or others, were less likely to experience negative emotions after the abortion (24, 43). Several studies have examined the effect of the woman's preabortion psychological status on her postabortion course. Spreckhard (55), inlooking at women who reported significant postabortion distress, found that they used a great deal of denial and repression, as well as projectino on their partner or the medical staff, in dealing with the stress of their pregnancy and subsequent abortion. These women also described high degrees of boundary ambiguity with respect to the aborted fetus and maintained an ongoing, high level of attachment to the fetus, despite its loss. Athanasiou et al. (30) found that women who experienced the most distress after an abortion were more likely to have lower self-esteem, a higher sense of alienation, and less knowledge of contraceptives before the abortion. Bracken et al. (56) found that women with a relatively internal locus of control and high level of ego resiliency responded most favorably to the abortion. PSYCHOLOGICAL SEQUELAE OF DENIED ABORTION Even more difficult to determine, and hence even less often examined, is the issue of the effects of denying abortion on the mother and child. The studies that have been done are often older, since the access to abortion has improved in many countries. Before an examination of the direct effects of the denied abortion, two issues need to be clarified. How many pregnancies will go on to completion if abortion is not performed as requested, and of those, how many women will eventually put their infants up for adoption? Table 4 presents data on studies (22, 34, 40, 57-67) that addressed the first question. Particularly in the more recent studies, a large proportion of women (over 40% in one large study [64]) will continue to seek abortion elsewhere and will succeed. Particularly alarming are the reported rates of "spontaneous" abortion in this population. Because women who request abortion are often past the first trimester (the stage at high risk for spontaneous abortion), truly spontaneous miscarriage should be rare. However, when these pregnancies are carried to term, studies (22, 60, 61, 65, 66, 68, 69) show that the proportion of children put up for adoption is quite small, ranging from 6.7% to 19.0% (table 5). From these studies it would seem that when an abortion request is denied, the result is often either an abortion obtained elsewhere or a mother raising an infant from an unwanted pregnancy in the situation that led her to request the abortion in the first place. TABLE 4. Studies of the Outcome of Pregnancy After Abortion Was Denied ______________________________________________________________________________ Number Full-Term Abortion (%) Study and Year of Subjects Pregnancy (%) Induced Spontaneous ______________________________________________________________________________ Lindberg, 1948 (57) 344 ___ 14.5 ___ Delcomyn, 1952 (58) 136 ___ 39 ___ Hultgren, 1959 (59) 4,214 85.6 10 4.4 Hook, 1963 (60) 249 69 ___ ___ Peck and Marcus, 9 ___ 56 ___ 1966 (34) Forssman and Thuwe, 196 65.3 34.7 ___ 1966 (61) Pare and Raven, 120 ___ 36 ___ 1970 (22) Meyerowitz et al., 4 ___ 75 ___ 1971 (40) Hultin and Ottosson, 1,008 81.2 ___ ___ 1971 (62) Dytrych et al., 439 72 10 18 1975 (63)b Hunton, 1977 (64) 253 34.5 46.6 5 Drower and Nash, 69 55 ___ ___ 1978 (65, 66) Binkin et al., 258 72 20 ___ 1983 (67) ______________________________________________________________________________ TABLE 5. Studies of the Adoption of Children Born After Abortion Was Denied ____________________________________________________________ Number of Children Adopted Study and Year Children Born Away (%) ____________________________________________________________ Malmfors, 1951 (68) 85 8 Aren and Amark, 162 7.4 1957 (69) Forssman and Thuwe, 120 6.7 1966 (61) Hook, 1963 (60) 204 7.4 Pare and Raven, 73 19 1970 (22) Drower and Nash, 38 16 1978 (65, 66) ____________________________________________________________ The few studies that have examined the effect of the denied abortion on the parents have focused on the effects on the mother. While the effects on the father have been reported occasionally in an anecdotal fashion, systematic studies are lacking. The earliest study (60) evaluated 249 women 7 years after the denied abortion. It found that 27% of the women had been able to cope fully with the pregnancy and the child, 22% still showed signs of mental illness and poor adjust- ment, and 51% had shown symptoms of mental disturbance and great emotional strain for a period of considerable length since the birth but seemed to have overcome these problems. Unfortunately, the study did not distinguish between women who aborted the fetus elsewhere, gave the child up for adoption, or raised the child themselves. Drower and Nash (65, 66) reported that those women denied abortion expressed greater guilt and anxiety than for women for whom an abortion had been performed. In the most compelling of these studies, Pare and Raven (22) looked at 73 women 1-3 years after their request for abortion was denied and found that 59% reported that they accepted the child and were glad that they had not aborted the fetus, while 34% reported that the child was a burden that they frequently resented. Addmittedly quite subjective, these studies nonetheless show that although an unwanted pregnancy does not always result in an unwanted child, there is reason to be concerned that significant numbers of these women will continue to harbor quite negative feelings toward their children, feelings that are easily elicited by interviewers. The final and most difficult question concerns the effects on the children themselves of being born after an abortion request is denied. In a study of the world literature on infanticide, Resnick (70) found that 83% of the newborns killed and 11% of the children killed by their mothers had been born of unwanted pregnancies. Studies by Blomberg (71) and Hultin and Ottosson (62) found no difference in the rate of pregnancy-related or perinatal complications in children born of unplanned pregnancies, while Nielsen (72) found a slightly above normal rate of physical abnormalities in newborns born in this situation. In a classic study that continues to have relevanve today, Forssman and Thuwe (61) compared, up to age 21 years, 120 children born of unwanted pregnancies with control subjects matched by date of birth. They found that the study group had a more insecure childhood, more psychiatric care, more childhood delinquency, and more early marriages and were more often young mothers; all these findings were statistic- ally significant. Even after socioeconomic class was controlled, fewer of the study subjects had more than secondary education and fewer were without defects of any kind, when all these problems were grouped together. A recent update (73) on the study group, then 35 years old, found that the differences were diminishing; however, the study subject were still significantly more likely to appear on some kind of registry, indicating contact for psychiatric care, because of crime or delinquency, or for public assistance. Hook (cited in reference 74) studied 88 children born after abortion was denied, comparing them with a control group made up of the same-sex class- mate of nearest age to each study individual. At age 18, the boys in the study group had a higher rate of conduct disorder, criminality, and unstable homes, with lower emotional maturity. At 23, more of the men in the study group were likely to require economic assistance, and the women in the study group began to show evidence of lower self-esteem and more depression. A study (75) with a more rigorous control group, which was matched for age, sex, number of siblings, and socioeconomic class at the time of the child's birth, evaluated the children until their 15th birthday. The study group had poorer school performance throughout this time, as well as more neurotic and psychocomatic symptoms recorded in the school health registry, and more likelihood of being registered with social welfare authori- ties. Perhaps the most ambitious study to date is that of Matejcek et al. (63, 76-80), who compared a control group of 220 children born in Prague in 1961-1963, after abortion was denied. The two groups were matched for socioeconomic class, sex, age, birth order, number of siblings, and parental marital status. Early findings in 1970 found that the study subjects were less likely to be breast fed, had more acute medical illness, were more likely to be reported as difficult when they were preschoolers, were more likely to be rejected by friends and teachers, and were less adaptive to frustra- tion; boys were more likely to be affected. At ages 14-16 (79), 216 of the original 220 were still being studied. School performance in this group continued to deteriorate, and various indicator scales showed that this group had more negative relationaships with their mothers. Current studies (80) of the children in their early 20s show an ongoing propensity for social problems that remains markedly prevalent in this group. The study subjects had more job dissatis- faction and fewer friends and reported dissatisfaction with life (all significant findings) and less education, more criminality, and more registration by the authorities for drug and alcohol problems (trends). DISCUSSION In spite of numerous difficulties facing researchers who attempt to address the issue of theraputic abortion, the findings do appear to be remarkably uniform. Precise answers, unaffected by bias, are probably not possible, but the research examined here does highlight several things. Immediately after abortion, symptoms of distress and dysphoria do occur in many women. However, these symptoms seem to be continuations of symptoms present before the abortion and more a result of the circumstances leading to the abortion than a result of the procedure itself. Indeed, many studies report significant positive feelings after the abortion. When the women are studied over the course of the episode, the dysphoria is found to wane after the abortion. Longer-term studies, over months and years, show similar trends; the majority of women express positive reactions to the abortion, and only a small minority express any degree of regrets. Similarly, negative feelings present before abortion disappear, with normalization of various scores. Although it is difficult to generalize about factors that are more likely to be involved in women who experience a negative psychological response to abortion, and potentially misleading when dealing with an individual, several trends are evident. Abortion for medical or genetic indications, a history of psychiatric contact before the abortion, and mid-trimester abortions often result in more stress afterward. When women experience significant ambivalence about the decision or when the decision is not freely made, the results are also more likely to be negative. The issue of support is a more complex one and is not easily measured; many studies indicate that support by the parent or partner can be positive, although apparently contradictory studies exist. Prior psychological coping styles and resiliency also appear to play an important role in the psychological sequalea of an abortion, in that certain defensive styles such as projection, repression, and denial may hinder a woman's working through and resolving the loss of a fetus, particularly when it is one that is ambivalently regarded. When abortion is denied, a different picture seems to arise. Many women, up to 40% in some studies, have the abortions elsewhere, depending on availability. Relatively few of the children are put up for adoption, and the majority born of unwanted pregnancies are raised by their biological mother. A significant minority - about 30% - of the women examined in the few long-term studies continue to report negative feelings toward their child and difficulty in adjusting. Finally, the most disturbing part of the whole issue is the evidence of significant negative effect on the child. With the caveat that the unwanted pregnancy does not necessarily result in an unwanted child, the carefully designed and executed prospective studies of Matejcek et al., Hook, Blomberg, and Forssman and Thuwe reveal long- lasting, broadly based, negative effects of the denial of abortion on the children subsequently raised in the situation that the parents had tried so desperately to avoid. While this paper has not addressed any of the ethical issues raised by theraputic abortion, it has attempted to give a psychiatric perspective that has hitherto been unavailable in this debate. Further research on some of the questions examined is important, particularly if society moves toward more restrictive legislation on the issue, since the question of the effects on the mother and child in particular has only begun to be explored. REFERENCES 1. Tietze C, Henshaw SK: Induced Abortion: A World Review, 6th ed. New York, Alan Guttmacher Institute, 1986 2. Dixon-Mueller R: Abortion policy and women's health in de- veloping countries. Int J Health Serv 1990; 20:297-314 3. Simon NM, Senturia AG: Psychiatric sequelae of abortion, re- view of the literature 1935-64. Arch Gen Psychiatry 1966; 15: 378-389 4. Doane BK, Quigley BG: Psychiatric aspects of theraputic abor- tion. Can Med Assoc J 1981; 125:427-432 5. Blumberg BD, Golbus MS, Hanson HK: The psychological sequelae of abortion performed for a genetic indication. Am J Obstet Gynecol 1975; 122:799-808 6. 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