APA Abortion Report

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

The 2008 pro-abortion APA Task Force report was prepared by Brenda Major, Nancy Russo and others. The report is properly described as the pro-abortion APA task force report because the task force was carefully selected to include only abortion proponents and to exclude any experts who did not support the pro-choice position on this issue. The correct citation to it is

APA Task Force on Mental Health and Abortion. (2008). Report of the APA Task Force on Mental Health and Abortion. Washington , DC : Author.

From Executive Summary:

"None of the literature reviewed adequately addressed the prevalence of mental health problems among women in the United States who have had an abortion. In general, however, the prevalence of mental health problems observed among women in the United States who had a single, legal, first-trimester abortion for nontherapeutic reasons was consistent with normative rates of comparable mental health problems in the general population of women in the United States."

"Nonetheless, it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety. However, the TFMHA reviewed no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors."

Official APA Press Release APA Task Force Finds Single Abortion Not a Threat to Women's Mental Health

"There is no credible evidence that a single elective abortion of an unwanted pregnancy in and of itself causes mental health problems for adult women..."

This carefully worded spin on the report is actually an admission that there is credible evidence that abortion contributes to mental health problems when (a) there is more than one abortion, (b) the abortion is for non-elective, therapeutic reasons, (c) the pregnancy is wanted or (d) the woman is not an adult. The full report actually identified many other risk factors.

Risk Factors For Negative Mental Health Effect Identified By Task Force

Link to the official APA task force report.

Risk Factors identified:

• This review identified several factors that are predictive of more negative psychological responses followingfirst-trimester abortion among women in the United States. Those factors included perceptions of stigma, need for secrecy, and low or anticipated social support for the abortion decision; a prior history of mental health problems; personality factors such as low self-esteem and use of avoidance and denial coping strategies; and characteristics of the particular pregnancy, including the extent to which the woman wanted and felt committed to it. Across studies, prior mental health emerged as the strongest predictor of postabortion mental health. (p4.)

• Research derived from a stress-and-coping perspective has identified several factors that are associated with more negative psychological reactions among women who have had an abortion. These include terminating a pregnancy that is wanted or meaningful; perceived pressure from others to terminate a pregnancy; perceived opposition to the abortion from partners, family, and/or friends; and a lack of perceived social support from others. Other factors found to be associated with more negative postabortion experiences include personality traits (e.g., low self-esteem, a pessimistic outlook, low- perceived control) and a history of mental health problems prior to the pregnancy. (p11)

• The most methodologically strong studies in this group showed that interpersonal concerns, including feelings of stigma, perceived need for secrecy, exposure to antiabortion picketing, and low perceived or anticipated social support for the abortion decision, negatively affected women’s postabortion psychological experiences. Characteristics of the woman also predicted more negative psychological experiences after first-trimester abortion, including a prior history of mental health problems, personality factors such as low self-esteem and low perceived control over her life, and use of avoidance and denial coping strategies. Feelings of commitment to the pregnancy, ambivalence about the abortion decision, and low perceived ability to cope with the abortion prior to its occurrence also predicted more negative postabortion responses. (p 92)

• They also report a positive association between more mental illness and multiple abortions (dose effect) and limit their conclusion that abortion has no higher risk to women who have an "adult women who have an 'unwanted pregnancy'" (p4)

• "[I]t is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety." (p4)

COMPLETE APA LIST OF RISK FACTORS

1. terminating a pregnancy that is wanted or meaningful
2. perceived pressure from others to terminate a pregnancy
3. perceived opposition to the abortion from partners, family, and/or friends
4. lack of perceived social support from others
5. various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)
6. a history of mental health problems prior to the pregnancy
7. feelings of stigma
8. perceived need for secrecy
9. exposure to antiabortion picketing
10. use of avoidance and denial coping strategies
11. Feelings of commitment to the pregnancy
12. ambivalence about the abortion decision
13. low perceived ability to cope with the abortion
14. history of prior abortion
15. late term abortion
16. By parsing of the APA summary conclusion that "adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy," it also appears that the APA is identifying the following as risk factors

• being an adolescent (not an adult)
• having a non-elective (therapeutic or coerced) abortion
• prior history of abortion (having a second or third abortion, or more)

Others Recommending Screening and Doctor's Obligation

When is a physician legally or ethically obligated to refuse a contraindicated abortion? Sylvia Stengle, executive director of the National Abortion Federation, which represents abortion clinics, admitted in a Wall Street Journal interview (October 28, 1994) that at least one in five patients (probably a low estimate) are at psychological risk from abortion due to prior philosophical and moral beliefs contrary to abortion. In short, because of external pressures, they are aborting in violation of their consciences. Stengle admits that "It's a very worrisome subset of our patients. Sometimes, ethically, a provider has to say, 'If you think you are doing something wrong, I don't want to help you do that.'"

On March 14, 2008, the British Royal Academy of Psychiatrists issued an official statement endorsing the importance of pre-abortion screening for risk factors:

Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.

A highly relevant article regarding abortion risks is Limitations on Post-Abortion Research: Why We Know So Little by David C. Reardon

Selective Use of Foreign Studies

APA report embraces a single foreign study by [Gilchrist]] as the only reliable study on abortion and mental health. Therefore, one should carefully review this posting regarding the Gilchrist study to understand that it too has flaws.

What is most curious, however, is that the APA also deliberately chose to ignore a number of important foreign studies, precisely because they did not support their agenda.

This included ignoring the latest New Zealand studies by Fergusson, even though they were provided advanced copies, and also the Suliman 2007 which disclosed about 18% of women had PTSD after an abortion. What is striking about the Suliman study is that it was prompted by abortion doctors at a Marie Stopes clinic noticing a "high" rate of PTSD in their clients which prompted the docs to undertake a study to see if one type or anesthesia or another would make any difference. It didn't. Three months out, 18% of the post-abortive women had PTSD. The authors, apparently pro-abortion, pointed that this was almost one in five, and pointed out that they considered this a "high" rate of PTSD. So, how can the APA be so certain that nobody but nobody ever gets PTSD after abortion which is how they want to spin this.

Also ignored were the very excellent studies by Soderberg Using extensive interviews, Soderberg found that at a 12 month follow-up, 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases.

Bias of the APA

1. The APA has adopted a political, not a scientific, position on abortion. This was officially done in 1967 by a vote to treat abortion as a "civil right."

2. The bias of the APA to promote an "ultra-liberal agenda" has been documented in the 2005 book 'Destructive Trends in Mental Health: The Well Intentiond Path to Harm', by Rogers H. Wright, Nicholas A. Cummings. See a review here

3. The APA Task Force report was prepared by Brenda Major, Nancy Russo and others. The task force was selected to include only abortion proponents.

4. See this interesting article on "tribal" bias in the social sciences from the New York Time: Social Scientist Sees Bias Within By JOHN TIERNEY Published: February 7, 2011.

“If a group circles around sacred values, they will evolve into a tribal-moral community,” says Jonathan Haidt, a social psychologist at the University of Virginia. “They’ll embrace science whenever it supports their sacred values, but they’ll ditch it or distort it as soon as it threatens a sacred value.”

More Examples of Political Bias in "Official Scientific Consensus"

ACOG's "official" report on partial birth abortions was edited by White House staffer, Elena Kegan to insert language that would be cited by the courts. According to Slate columnist William Saletan,

With this clever phrasing, she obscured the truth: By reframing ACOG's judgments, she altered their political effect as surely as if she had changed them.

She also altered their legal effect. And this is the scandal's real lesson: Judges should stop treating the statements of scientific organizations as apolitical. Such statements, like the statements of any other group, can be loaded with spin. This one is a telling example....

[The courts], like the rest of us, was apparently unaware that after the ACOG task force formulated its proposed statement, the statement was politically vetted and edited. Kagan's memos and testimony confirm that ACOG consulted the White House and altered its statement accordingly. As a result, the statement reframed ACOG's professional findings to support the policy views it shared with the White House.

Tribal Mentality

See this interesting article on "tribal" bias in the social sciences from the New York Time: Social Scientist Sees Bias Within By JOHN TIERNEY Published: February 7, 2011.

“If a group circles around sacred values, they will evolve into a tribal-moral community,” says Jonathan Haidt, a social psychologist at the University of Virginia. “They’ll embrace science whenever it supports their sacred values, but they’ll ditch it or distort it as soon as it threatens a sacred value.”

Fudging by Scientists is Common

A study in Nature found that "One-third of scientists surveyed said that within the previous three years, they’d engaged in at least one practice that would probably get them into trouble, the report said. Examples included circumventing minor aspects of rules for doing research on people and overlooking a colleague’s use of flawed data or questionable interpretation of data," and "nearly 16 percent said they had changed the design, methods or results of a study “in response to pressure from a funding source.” [1]

Articles Related to APA Task Force

• Tales From an Insider: How The APA Denied Abortion's Mental Health Risks by Rachel McNair, Ph.D.

• The APA Task Force Report dismisses a large body of evidence demonstrating a link between abortion and mental health problems. And in the end it is left with only one study which it deems to be definitive in demonstrating no higher mental health risks associated with abortion. That study Gilchrist has a number of flaws described here which demonstrate that the findings should not be treated with any greater preference than the other studies reviewed.

• Researcher: APA Chair Withholding Info on Abortion's Mental Health Risks by Steven Ertelt

• Brenda Major, Chair of APA Abortion Task Force - Biography and biases

• Letters to APA Regarding Task Force on Abortion

• David Fergusson reacts to the APA Mental Health and Abortion task force report

• Psychiatric Bulletin publishes David Fergusson editorial on mental health and abortion

• Allegations cloud APA Mental Health and Abortion report

• APA denials of abortion mental health risk contradicted by other studies Good overview article from Catholic News Service.

• APA abortion and mental health report: Single abortion not a threat to women’s mental health

• What the headline's avoid saying, "APA finds more than one abortion is threat to women's mental health"

• APA Report Unconvincing. 100 Scientists Report Abortion Does Cause Mental Health Problems

• On March 14, 2008, the British Royal Academy of Psychiatrists recognized the need to screen for risk factors associated with mental health problems associated with abortion, stating:

“Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met."

“The Royal College of Psychiatrists recognizes that good practice in relation to abortion will include informed consent. Consent cannot be informed without the provision of adequate and appropriate information regarding the possible risks and benefits to physical and mental health."

Here is the full text of the Royal College of Psychiatrists statement

• Women Hurting From Abortions Say APA Report Discounts Their Experiences

• Researcher on Abortion-Depression Link Says APA Report Ignores Best Studies

• APA Report on Abortion-Mental Health Problem Link Politically Biased

Media Reports

• Medpage Today

Excerpts:

The review identified several factors predictive of more negative psychological responses following first-trimester abortion:

• Included perceptions of stigma
• Need for secrecy
• Low or anticipated social support for the abortion decision
• Prior history of mental health problems
• Personality factors such as low self-esteem and use of avoidance and denial coping strategies
• Characteristics of the particular pregnancy, including the extent to which the woman wanted and felt committed to it
• Prior mental health which was the strongest predictor of postabortion mental health

The report noted that many of these same factors also predict negative psychological reactions to other types of stressful life events, including childbirth.

National Health Services

Daily Herald

Abortion has risks, whatever the research says The Times August 19, 2008

Med India

"Certain factors were found to increase the risk of lingering mental health effects ranging from higher stress levels to anxious feelings to full-blown depression:

• Being pressured into having an abortion when the pregnancy was wanted

• Not having adequate emotional support after the abortion

• Feeling the need to keep the abortion a secret from loved ones because of the stigma associated with it

Analysis by Priscilla Coleman

APA Task Force Report on Abortion and Mental Health:

Violation of the Methods of Science and a Breech of Public Responsibility

Priscilla K. Coleman, Ph.D. Bowling Green State University

There is sufficient data in the scientific literature to conclude that induced abortion substantially increases risk of anxiety, depression, substance use, suicide ideation, and suicide. Over the last two decades hundreds of studies documenting abortion as a significant risk factor for mental health problems have been published in premier psychology and medical peer-reviewed journals. The research has been conducted by investigators with diverse disciplinary affiliations residing in nations across the globe (United States, Canada, Japan, Australia, New Zealand, Norway, Canada, and South Africa among others).

Unfortunately the rapidly accumulating evidence was largely discounted in a report released by the American Psychological Association (APA) in 2008. The organization convened a Task Force of researchers holding strong pro-choice views to provide an analysis of the scientific evidence pertaining to abortion and mental health. Tragically for the millions of individual women and professionals who trust the APA to provide valid assessments of scientific information, the work was clearly politically driven and the report produced seriously distorted the literature.

To arrive at their conclusion indicating the relative risk of mental health problems is no greater for a first-trimester abortion than it is for an unplanned pregnancy carried to term, the organization critically departed from accepted scientific protocol. Problems plaguing the report included the following:

1) selective reporting of previously published reviews of the literature;

2) avoidance of methodologically based criteria to select studies to review;

3) a deceptive strategy to justify ignoring large groups of studies indicating negative effects;

4) shifting standards of evaluation of individual studies based on the results being congruent with a pro-choice agenda; and

5) avoidance of quantification of effects which offers the most objective means of pooling results across several studies.

Perhaps most egregious was the fact that the Task Force relied on one study from England published in 1995 to draw their definitive conclusion.

One brief example of the many false statements from the APA Task Force report is where they claim “Rarely did research designs include a comparison group that was otherwise equivalent to women who had an elective abortion.” I have personally authored or co-authored three studies with unintended pregnancy delivered as a comparison group. (Coleman, 2006; Cougle, Reardon, Coleman, & Rue, 2005; Reardon, Coleman, & Cougle, 2004). All three studies indicated abortion was associated with more mental health problems than unintended pregnancy delivered.

Within weeks of the release of the APA Task Force Report, seven researchers who together authored nearly 50 peer-reviewed article demonstrating negative effects of abortion wrote a petition letter to Dr. Alan Kazdin, President of the APA. Key points raised included the following:

1) the wholesale dismissal of most of the evidence in the field;

2) the fact that in no other area of public health research has a highly contested issue been resolved on the basis of a single out of date research study as was done in the APA report; and

3) the APA report was not an impartial assessment of the mental health risks of abortion and its conclusions were unduly colored by the views of its authors.

In closing, we requested a retraction or revision indicating that the weight of the evidence in this area is not consistent with the conclusions drawn by the Task Force. The APA did not take any public action on our letter.

When considering the many deviations from accepted values and methods of science characterizing the process and conclusion of the APA Task Force along with the results of sophisticated, large scale studies conducted by independent research groups in recent years, it becomes clear that the conclusions of the APA Task Force are grossly inaccurate. The findings should therefore not be accepted at face value by the public, health care professionals, or legislative bodies.

Additional Criticisms

The APA report, and in the members' individual papers, acknowledges that feelings of sadness, guilt and grief are common after an abortion but insists that these are just feelings, not clinically significant mental illness.

But there is substantial evidence that such feelings are markers for mental illness:

Emotions and the emotional disorders: A quantitative hierarchical perspective

David Watson1, Lee Anna Clark, and Sara M. Stasik

International Journal of Clinical and Health Psychology. 2011, Vol. 11, Nº 3, pp. 429-442

ABSTRACT. Previous evidence has established that general negative affect represents a non-specific factor common to both anxiety and depression, whereas low positive affect is more specifically related to the latter. Little is known, however, about how specific, lower order affects relate to these constructs. We investigated how six emotional disorders—major depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), panic disorder, social phobia, and obsessive compulsive disorder — are linked to both general and specific types of affect in two samples (Ns = 331 and 253), using the Expanded Form of the Positive and Negative Affect Schedule (PANASX). Replicating previous results, the General Negative Affect scale was nonspecifically related to the emotional disorders, whereas General Positive Affect had a specific (inverse) association with major depression. Fear emerged as the broadest predictor at the lower order level, showing strong and consistent associations with major depression, GAD, PTSD, and panic disorder. In contrast, three lower order scales —Sadness, Guilt, and Joviality— displayed clear specificity and were significant predictors of major depression. These results demonstrate the usefulness of examining affect-psychopathology relations at the specific, lower order level.

Standard for Medical Recommendations

Notably, the APA Task Force ignored all standards used for judging the quality of evidence and the effectiveness of medical treatments. The definition of such standards is a field called evidence based medicine.

Below are the standards that should apply to an evaluation of abortion and abortion related risks and benefits (if any).

Ranking Quality of Evidence

The U.S. Preventive Services Task Force (USPSTF) within the Agency for Healthcare Research and Quality, which is a division of the U.S. Department of Health and Human Services (http://www.ahrq.gov/clinic/3rduspstf/ratings.htm), has identified basic guidelines for how scientific evidence should be used to inform practice. These are summarized below and are based on an analysis of risks and benefits as established in the scientific literature.

• Level A: Good scientific evidence indicates the benefits of the service substantially outweigh the risks with clinicians advised to discuss the service with eligible patients.

• Level B: Fair scientific evidence indicates the benefits of the service outweigh the risks with clinicians encouraged to discuss the service with eligible patients.

• Level C: At least fair scientific evidence indicating benefits are provided by the service, but the balance between benefits and risks precludes general recommendations. Clinicians are advised to only offer the service if there are special considerations.

• Level D: At least fair scientific evidence indicates the risks of the service outweigh benefits with clinicians advised not to routinely offer the service.

• Level I: Scientific evidence is deficient, poorly done, or conflicting precluding assessment of the risk benefit ratio. Clinicians are advised to convey the uncertainty of evidence surrounding the service to patients.

Given these guidelines, it is clear that responsible physicians should not be routinely offering abortion. The best published evidence shows clear risks associated with abortion but no clear benefits, meaning that Level's D and I are most applicable. According to the APA Task Force Report, level I would apply.

US Preventive Services Task Force Ranking of Evidence Quality

Systems to stratify evidence by quality have been developed, such as this one by the US Preventive Services Task Force|U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments or screening:

• Level I: Evidence obtained from at least one properly designed randomized controlled trial.
• Level II-1: Evidence obtained from well-designed controlled trials without randomization.
• Level II-2: Evidence obtained from well-designed cohort study or case-control analytic studies, preferably from more than one center or research group.
• Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
• Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Grading Treatment Efficacy and Safety

Medical treatments can be classified by the balance of risk versus benefit of the treatement and the quality of evidence on which this information is based. The U.S. Preventive Services Task Force uses the following criteria for grading treatments:

Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients.

Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.

Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.

Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.

Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

Comparative Effectiveness Research

From the Agency for Healthcare Research and Quality:

What Is Comparative Effectiveness Research?

Comparative effectiveness research is designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.

There are two ways that this evidence is found:

• Researchers look at all of the available evidence about the benefits and harms of each choice for different groups of people from existing clinical trials, clinical studies, and other research. These are called research reviews, because they are systematic reviews of existing evidence.
• Researchers conduct studies that generate new evidence of effectiveness or comparative effectiveness of a test, treatment, procedure, or health-care service.

...It’s true that some treatments may not work for everyone, and that some treatments may work better for some people than others. This research can help identify the treatments that may work best for you. ... Every patient is different — different circumstances, different medical history, different values. These reports don’t tell you and your doctor which treatment to choose. Instead, they offer an important tool to help you and your doctor understand the facts about different treatments.

Recommendations for Improving Observational Studies - STROBE

(Abstract) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies

ABSTRACT: Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the Web sites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.

A number of strategies for accessing the quality of observational studies have been proposed and tested.

Regarding the Bogus Causality Argument

See this discussion of the causality argument -- namely, the claim that there is no evidence that abortion "in and of itself" is the cause of mental health problems.

REFERENCES