COMMENTARY
Author’s note: Throughout this commentary, I use female pronouns and terms to designate the individuals who have abortions. I am aware that there are individuals who identify as male, transgender, or nonbinary who have abortions, but most pregnancies and abortions happen to women.
The US Supreme Court defied the court’s tradition and the expressed intentions of some of its members during their confirmation hearings by overturning the 50-year-old precedent, Roe v Wade, which had established abortion as a right. Immediately after the Dobbs v Jackson Women’s Health Organization decision was rendered on June 22, 2022, many states applied or enacted laws either severely limiting or banning abortion.1
A week after the decision, a 10-year-old girl, pregnant by rape, was taken to Indiana, having been denied an abortion in her home state of Ohio. She was at high risk, not only for exacerbations of the trauma she had already experienced but for complications of pregnancy and childbirth, not to mention those of motherhood. It is notable, and relevant, that the first responses of Mike DeWine (Ohio’s governor), The Wall Street Journal, and other media was to declare that the story was untrue or could not be confirmed.2 No apologies were offered when the rapist was arrested and confessed. Next, the physician who performed the abortion was accused of not recording the procedure as required by law. When the girl’s evidence was produced, there was no apology or retraction.3 This is the country in which we now practice not only obstetrics and gynecology but also psychiatry.3,4 This is the country where our patients live.
Across the board, pregnancy leads to more danger of morbidity and mortality than abortion. Abortion is one of the safest procedures in all of medicine. One in 4 women in the United States will have an abortion during their lifetimes. Before the Dobbs ruling, approximately 1 million abortions were performed in the United States each year.5 Clandestine, unsafe abortions deprive hundreds of thousands of children of the mothers who undergo those procedures. Abortion has been practiced throughout history and long before the advent of anesthesia and antibiotics.6 Perhaps the danger of abortion without those protections is the reason abortion is mentioned in the Hippocratic Oath. In any case, it means that abortions were happening in the fifth century BC.7
In the United States, notably, the distribution of religious affiliations among women who have abortions is the same as that of the general population.8 Every day, women who oppose abortions have abortions—and many go on actively opposing abortions.
The terms commonly used to characterize positions for and against abortion are deeply prejudicial. In my opinion, pro choice likens a decision about a pregnancy to a choice between menu options or minor purchases. A decision about a pregnancy concerns the lives of the potential mother, the potential child, and many other individuals. All the evidence indicates that women consider abortion to be a serious decision. Pro life implies that individuals who have an abortion do not care about life. It is notable that the anti-abortion movement is completely divorced from any activism to support life other than that of a conceptus. It is not linked to concerns about war or the death penalty, not to mention the lives of children born into circumstances where their mothers doubt their ability to provide for and protect them (poverty, domestic violence, immaturity, the needs of other children). The terms pro choice and pro life carry misleading and damaging meanings. One positive effect of the Dobbs decision is the emergence of the word abortion from the shadows.
Commentators decrying abortion prohibitions are especially exercised about laws that do not make exceptions for rape and incest. Stop for a minute and consider the unescapable, excruciating assumptions that underlie those exceptions. Abortion opponents proclaim themselves to be protectors of the unborn. If the embryo or fetus is a human being, why should it be deprived of life because of circumstances over which it had no control? It is because the woman pregnant by rape or incest was not responsible for the sexual act that caused the pregnancy. Exceptions for rape and incest lay bare the unspoken, unacknowledged belief that women who willingly engage in sex and become pregnant should be punished by having to stay pregnant. The punishment is usually rationalized by casting it as responsibility. It is twisted logic to consider that having a baby when one is not going to be able to care for it properly is responsible. It is twisted to make what, under good circumstances, is a blessing—a baby—into a punishment.
We are still operating under the conviction that the ills of society were caused by Eve eating the forbidden fruit in the Garden of Eden and then seducing Adam. But it does not work that way. Women with untenable pregnancies are unlikely to have conceived out of carefree unbridled lust—and what if they had?
Another unspoken assumption is that women have abortions because they do not care about children. In reality, they have abortions because they want to have wanted children—children they can provide for. In the United States, where sex education—if provided at all—may be full of misinformation, individuals sometimes become pregnant because they do not know how to avoid it.1
There are all sorts of reasons women become pregnant under circumstances adverse for motherhood. They cannot afford contraceptives. Contraceptives fail. Their partners refuse to use condoms. Their partners force them to have unprotected sex. There are many ways to force sex on someone without committing what is legally defined as rape. Some women are living in violent relationships. Most women who have abortions already have children.4 Especially in the United States, which offers minimal—if any—parental leave and subsidized child care, adding another child would deprive the existing children of essential care and protection. Some women have psychiatric and/or other medical disorders that may prevent them from providing good maternal care.
What about the hidden part of the iceberg? The Dobbs decision leaves the country in a legal and clinical quagmire. On the basis of what I consider a ragbag of dubious constitutional arguments and false statements about the psychiatric sequelae of abortion, it removes the already attenuated protections of Roe v Wade, leaving abortion’s legality to be decided by each of the 50 states. Some of the results are already apparent, and many others are expected. We have some forewarning about the implications because Catholic hospitals and inhospitable parts of the country have already significantly limited care. Catholic (and evangelical) hospitals are not required to, and do not, inform patients that medical staff are not allowed to mention contraception or abortion. This prohibition also extends to psychiatrists at the hospitals.9
In Catholic hospitals, women with incomplete spontaneous abortions, ectopic pregnancies, and fetuses with anomalies incompatible with extrauterine life are left to bleed, endure pain, and risk ectopic rupture rather than having their pregnancies terminated as medically indicated—as long as the clearly doomed fetus is considered to be alive.9 There are approximately as many spontaneous miscarriages each year as abortions. In many cases, it is impossible for a clinician to distinguish a miscarriage from an attempted abortion.10 Some of these laws will allow state officials to review medical records, question patients and doctors, and perhaps examine whatever tissue was removed in the hospital in an attempt to uncover an unlawful abortion.11
We know that physicians in some places cannot obtain misoprostol, which has been approved for the treatment of serious medical conditions, because it is also used as an abortifacient. We know that many women have been tried in court, and some incarcerated, to punish them for behaviors that legal—not medical—practitioners have deemed deleterious to the fetus, including attempted suicide.10 In an illustrative case, a woman experienced a stillbirth at home. The authorities went through her computer and found that, at some point, she had searched for information about abortion pills. There was no evidence that she had ordered, obtained, or used them. The woman had to endure 3 years of anxiety before the case was dropped. We know that, although white women and women of color are equally likely to use street drugs while pregnant, poor, minority women are more likely to face these consequences.10
As psychiatrists, we need to know the psychiatric aspects of abortion. Research clearly demonstrates that although abortion is more likely in highly stressful life situations—which may include mental illness—abortion itself does not cause psychiatric illness; the most common response is relief. Publications purporting to demonstrate psychiatric harm from abortion have been thoroughly and emphatically debunked because of unacceptable, biased, methodology.12 There is no evidence that abortion leads to later regret any more than any other life decision. There is, of course, a taboo against the expression of regret that one has had a child. Often, a woman who expresses regret about a past abortion, when asked to remember the circumstances at the time, will say that the abortion was the best option under those circumstances.
Many states have laws requiring a waiting period between the time a woman presents for abortion care and when the abortion is performed. This is a major hardship for women who have to travel to reach an abortion provider and provide coverage, if possible, for the absence from work and home. No other medical procedure, no matter how serious, requires a waiting period (except when there is a wait for available care).13 There is no evidence that abortion decisions are made on impulse. Abortion is similarly unique in being the subject of state laws mandating specific language that abortion providers must use with patients. This language generally conveys misinformation, including statements that abortion causes adverse psychiatric sequelae. Some laws require that a patient seeking abortion undergo—and view— ultrasound imaging of the embryo or fetus. Anti- abortion protesters outside abortion facilities, of course, cause distress. All these restrictions and mandates add stress to having an abortion.5,8
Many states require that the parents of an underage girl be informed about or consent to her abortion. These laws seem like common sense; youngsters need parental guidance and support. But there is no evidence that mandated parental involvement is beneficial. Abortion providers will assist those who need help approaching their parents. Some girls realistically anticipate that their parents would punish or reject them if aware of their pregnancy—and/or force them to remain pregnant. The logic of mandated parental involvement is flawed. The situation is not difficult to understand; one will have a baby or one will not. The young woman deemed too immature to make the decision to abort will otherwise, in a few months, become the mother of an infant for whom she will have legal responsibility.14
There is also the idea of fetal personhood. Many existing and pending state laws explicitly state that from the moment the sperm fertilizes the egg, that fertilized egg is entitled to all the legal rights of an individual. The conceptus, the embryo, the previable fetus can only survive inside the body of a woman. Pregnant women may be made to undergo surgery or other interventions aimed at improving the well-being of the fetus. This is a unique exception to American law, under which it is illegal to forcibly invade the body of a nonconsenting adult, even to remove 1 drop of blood that will save another person’s life. Many fertilized eggs are washed out of the body with menstrual blood, are resorbed, or otherwise disappear.15 How the states propose to protect fertilized eggs is unclear; when a law protecting them was passed in Indiana, protesting women sent used tampons to the state capitol.16
