Adolescents and Abortion

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

Sub-Index
Physical Effects
Abortion Technique Risks
Short Term Complications
Immediate Complications
Pain in Women
Organ or System Failure
Infections Related Complications
Impact on Later Pregnancies
Cancer Risks

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Adolescents face many of the same issues and risks as older women, of course. But because of the special legal issues associated with adolescents, the literature related specifically to adolescents is segregated here. Readers are advised to also examine similar headings in the sections above for related information.

Adolescent Developmental Issues

"Mourning in Adolescence: Normal and Pathological," Benjamin Garber, Adolescent Psychiatry 12:371-387(1985).

Adolescents consider it crucial to be part of a group and equally important to conform to the group. They are very conscious of anything that may set them apart from others. Whatever factors set them apart-physical, social or emotional-typically adolescents will try to diminish them.

"Depression in an Adolescent Delinquent Population," J.A. Chiles, M. Millert and G. Cox Archives of General Psychiatry, 37: 1179-1184, October 1980,

Depressed adolescents are more likely to be girls; depressive symptoms include cognitive changes. Difficulty concentrating and indecision were significantly elevated in depressed adolescents, as compared with nondepressed adolescents.

"Abortion Counseling: Focus on Adolescent Pregnancy," Carol Nadelson, Pediatrics 54(6): 765-769, December 1974,

The adolescent who is making a decision about an abortion, having an abortion, or is in the post-abortion period needs a trusted ally who can help her understand her motivation for pregnancy and abortion, explore her ambivalence and consider alternative solutions. Ambivalence is universal. It is related to the conflict between the positive aspects of conception and pregnancy, and the frustration and sadness over choosing to terminate a pregnancy. Since ambivalence occurs as part of the developmental process of adolescence, it is especially prominent in this age group, and it is more difficult to assess its particular significance. The adolescent who is involved in other critical developmental issues may be desirous of an abortion because her family wants the opposite, or vice versa. These issues must be clarified. In addition, the counselor must remember that the adolescent will continue to live with her family, so that helping her with her own decision is not enough. Work with the family is important in order [1] to avoid repetition of the unwanted pregnancy, which is most frequently a distress signal for the adolescent, and [2] to work out problems reflected by the mutual acknowledgment of the adolescent's sexuality.

"Physician Assessed Competitiveness in Adolescent Health Care," R. Blum, Journal Medical Education 62:401-407, (1987),

Health care providers described themselves as poorly trained and insufficiently skilled in managing adolescent concerns of social and psychological origins.

"The Contemporary Adolescent Girl," Helene Deutsch, Seminars in Psychiatry, 1(1): 99- 112, February 1969.

Illegitimate motherhood occurs not because of a lack of sexual information but because such pregnancies are compulsive. Too early involvement in sexual gratification interferes with the development of real tender feelings of love and enchantment. The lack of deeper emotional participation-of longing and wishing, of pain and joy, of hope and despair- constitutes a psychological disaster. The ego ideal of the girl is built, to a large extent, upon the mother-the ideal mother, not the sexually devalued one.

"How Adolescents Approach Decisions: Chances Over Grades Seven to Twelve, and Policy Implications." Catherine Lewis, Child Development 52:538-544(1981).

Even when the point of comparison is twelfth graders, rather than adults, seventh, eighth and tenth graders show relative deficiencies in certain aspects of approaching decisions, including imagining risks and future consequences, recognizing the need for independent professional opinions in certain situations, and recognizing the potential vested interests of professionals in providing certain information.

"The Competency of Children and Adolescents to Make Informed Treatment Decisions," L. Weithom and S. Campbell, Child Development, 53:1589-1598(1982).

In general, 14- year-old minors were able to demonstrate a level of competency equivalent to that of adults, according to four standards of competency-evidence of choice, reasonable outcome, rational reasons and understanding-and for four hypothetical dilemmas- diabetes, epilepsy, depression and enuresis.

"Understanding Adolescent Pregnancy and Abortion," Sherry Hatcher, Health Care for Women: 1. Current Social and Behavioral Issues, Primary Care 3(3): 407A24, September 1976.

Studies conclude that much of the relevant medical and behavioral research fails to distinguish between the tomboyish early adolescent girl, the oedipally activated and rebellious middle adolescent girl, and the "almost adult" late adolescent. Psychological development models must be based upon individual psychic-social maturity rather than chronological age. Early adolescents tend to deny any responsibility for the pregnancy. A girl's motivation may be to become closer to her mother by becoming a mother herself, or to see if her body really "works." When she admits to herself that she is pregnant she moves to obliterate the pregnancy and seeks abortion as the only way out. The middle adolescent tends to make the male father figure responsible for her situation. The underlying fantasy is one of competition with mother for father; there is a growing desire for autonomy. Ambivalence between moralistic judgment and hedonistic retreat is typical. The man who impregnated her is a means to an end-autonomy and independence from her family. She feels disappointed when her pregnancy does not alter the state of her unresolved dependency needs. The late adolescent is more in touch with her feelings and has the most difficulty deciding to terminate her pregnancy. She is probably the only one of the three groups who will wish to continue her relationship with the responsible boyfriend following her abortion. Following abortion, each group had developmental conflicts at the same stage of psychological maturation.

"Selected Problems of Adolescence," H. Deutsch, Psychoanalytic Study of the Child, Monograph No. 3(1967)

Early adolescents try out relationships by play acting them- without the benefit of a solid ego or sense of self. Middle adolescence represents the most egocentric stage. Late adolescents are closest to developing a "motherly ego." See also The Psychology of Women, Helene Deutsch, Vols.I and II (1944) (1945).

"Problem Pregnancy and Abortion Counseling with Teenagers. T," Chesler and S. Davis, Social Casework, The Journal of Contemporary Social Work, March, 1980 pp. 173-179

Discusses practical approaches to counseling as problem solving using crisis counseling strategies that emphasize both client and paternal assertiveness and the importance of compromise. Demonstrates that relationships and attitudes of adolescents and parents are not fixed but can change over time.

"A Theoretical Framework for Studying Factors that Impact on the Maternal Role," Ramona T. Mercer, Nursing Research, 30(2): 73-77, March-April 1981.

A summary of numerous studies on the subject. The maternal role, far from being an intuitive feminine function, is a complex social and integrative process that is learned. Maternal role attainment has been described as occurring in progressive stages through the operations of mimicry, role play, fantasy, introjection-projection-rejection, and grief work over a 12-15 month period including pregnancy and six months afterward. See Reva Rubin, "Attainment of the Maternal Role: Part 1. Processes: Part II, Models and Referents," Nursing Research 16:237-245, 342-346, Summer/ Fall 1967; Rubin, "Binding- In in the Post Partum Period" , Matern. Child Nurs. 6:67-75, Summer, 1977.

The foundation for the anticipatory stage may be laid as a child observes mothering behaviors in the family context. The formal stage begins with the birth of the infant, as the mother begins identifying her role partner and assumes care-taking tasks. Teenage mothers required from six to ten months postpartum to move to the formal stage. Current research supports that the infant's ability to see, hear and track the human face depict socialization capabilities present at birth. The infant is considered an active partner in the maternal role-making process. The infant initiates approximately 50 percent of the parent- infant interactions. Adaptive maternal behavior is influenced favorably by the mother's perceptions of the amount of positive support she received.

"Early Adolescence. A Time of Transition and Stress," B. Hamburg, Post Graduate Medicine 78(1): 158-167, July 1985,

Coming of age in modern America has become increasingly complex, lengthy and, according to many indicators, much more stressful. Early adolescence is probably the most stressful of all developmental transitions. Autonomy in adolescence should not be regarded as requiring rebellion and alienation from parents, but as achieving mature, interdependent relationships. Many early adolescents who engage in sexual relations are actually seeking friendship and approval; sexual activity is not a good way for them to become acquainted.

"Behavioral Considerations in the Health Care of Adolescents," M.E. Felice, Pediatric Clinics of North America 29(2): 399-412, April 1982,

The psychological tasks of growth have been described from various perspectives as follows: to establish independence; to become comfortable with one's body; to build new and meaningful relationships; to seek economic and social stability; to develop a workable value system; to verbalize conceptually. See Adams, "The Pregnant Adolescent -A Group Approach," Adolescence 11:467-485(1976).

"Pregnancy, Abortion and the Developmental Tasks of Adolescence," C. Schaffer and F. Pine, Journal of the American Academy of Child Psychiatry ll(3):511-536 (1972).

Pregnancy followed by therapeutic abortion in adolescent girls heightens, and is experienced in terms of conflicts already present during that developmental period. The conflict most generally aroused was between passive longings for one's own mother and an urge toward active mothering of self, infant and others. There were wide differences in the way the girls handled their abortions. Resolutions included regressive reattachment to their mother; progressive steps toward self-care, in which the abortion serves as an organizing experience; a middle ground where resolutions seem to be highly influenced by external events. Girls who make the more regressive solution are unlikely to use birth control; self-caring will use birth control.

"Adolescent girls and their mothers: Realigning the relationship," Paul Trad, Am J Family Therapy 23(1): 11-24, Spring, 1995

A case is presented involving a 14-year old girl who became pregnant impulsively and after having had an abortion, harbored a wish to become pregnant again. The interactional patterns suggested that the mother and daughter were involved in a complex negotiation between developmental progression and regression.

"Normal Adolescent Development," R.E. Kreipe, New York State Journal of Medicine 85(5): 214-217, May 1985,

The establishment of an identity is an essential task of adolescence. In the process, there is a consolidation of one's ego, one's self-concept, and one's role in life. According to Erikson's theory of development, if an adolescent fails to attain a stable role or identity, role confusion follows. See Erikson, E. H., Identity: Youth and Crisis, (New York:W.W. Norton, 1968). Adolescents who have difficulty establishing an identity do not know who they are, do not know where they are going in life and have trouble establishing long- lasting relationships. Children normally enter adolescence with an unformed sense of identity, but if they enter adulthood without this sense, their further development is impeded. Adolescent mothers often see themselves in shallow terms, in which education, marriage or a career have no relevance. Although intellect does not change dramatically during adolescence, the mode of thinking does change. Inhelder and Piaget proposed the terms "concrete operational thinking" to describe the way adults think. Concrete operations limit one's thinking to literal, here-and-now interpretations of questions. Formal operational thinking, on the other hand, enables one to understand figurative speech. It enables one to think about abstractions, such as future options, or to ask "what if" questions. The transition from one cognitive style to the other occurs during adolescence. Normal adolescents are egocentric; they think about themselves a great deal. Egocentrism is the normal self-centered focus of the adolescent's attention. Often viewed by parents as selfishness or narcissism, egocentrism is a reflection of the adolescent who is appropriately engaged in self-study, self-exploration, and self-determination. See The Growth of Logical Thinking from Childhood to Adolescence. B. Inhelder, J. Piaget, (New York: Basic Books, 1958).

"Family Correlates of Female Adolescent's Ego-Identity Development, G," Adams, Journal of Adolescence 8:69-82(1985).

Parent-child relations were assessed from both the adolescents, and the parents' perspectives. The findings indicated that parental identity status formation may have an effect on the adolescents' identity formation and that parent-child relations differentiate between less and more mature female adolescent identities. In general, the daughter's perception of her father's and mother's behavior held a very modest association with how the parents viewed their own conduct.

"Coping in Adolescence," J. Shen, Postgraduate Medicine 78(1): 153-157, July 1985,

Understanding the "good" foundation stones in personality development is important. Erikson described these as crucial developmental tasks: trust in early infancy, autonomy in late infancy, initiative in early childhood, industry in late childhood, identity in adolescence, intimacy in young adulthood, generativity in adulthood, and integrity in maturity. The "bad" foundation stones are mistrust, shame and doubt in infancy; inferiority and guilt in childhood; and role diffusion in adolescence. The cumulative effect of such desirable or detrimental processes is either growth and development or breakdown. See E. H. Erikson, Childhood and Society. New York:W.W. Norton (1950); E. H. Erikson, Identity: Youth and Crisis, New York:W.W. Norton (1968).

The Adolescent and Pregnancy, Margaret-Ann Corbett and Jerrilyn H. Meyer, (Boston: Blackwell Scientific Publications, 1987), pp. 267-269.

Pregnant adolescents in the Young Mothers Program [YMP] at Yale-New Haven Hospital consented to discuss their feelings about pregnancy and related matters if they could do so anonymously. The staff designed questions to which the adolescents responded. Contraception was viewed with ambivalence and a fluctuating commitment to its use. About a third of the group acknowledged they had considered an abortion because of fears about [1] their capabilities to raise a child by themselves, [2] their being "too young to have a child, " or [3] their capabilities to cope with family/peer reaction to their pregnancy ("I was so frightened I didn't know what to do.") The rest of the group voiced opposition to abortion. While most said they did not believe in abortion, much of their discussion reflected their mothers, opinion on the subject. ("My mother doesn't believe in it and neither do 1.") When asked who helped most during the pregnancy, the girls overwhelmingly indicated mothers or a mother figure such as an aunt. When adolescents were asked what helped most upon learning they were pregnant, they identified love and acceptance. By far the most important source of love was their mothers. Boyfriends were the second most significant group. About 80 percent of the group did not properly predict their mother's reaction. For that group, the negative response they anticipated occurred but later resolved itself in acceptance.

"Self-Destructive Behavior in Children and Adolescents," ed. C. F. Wells and 1. Stuart, Pregnancies and Abortions, Lucie Rudd, (New York: Van Nostrand Reinhold, 1981), pp. 208-223.

In our present day mores, many parents do not recognize the great need among children and adolescents for cuddling, physical touching, verbal and physical expressions of parental love. The composite of self, influenced by many inputs, is often one of inadequacy, guilt, self-belittling, and acceptance of the mother's unflattering judgment.

Most of the adolescents who later get into trouble have poor self-images and very often no nurturing to help them change. The need to be petted and admired in a society of peers who are vying with each other to attract and retain the available males will push some adolescents into early sexual activity. When sexual activity satisfies the need for acceptance, and the longing for intimacy, as well as the adolescent need for experimentation, it is very attractive. Pressure occurs not only from the peer group, but also from the mass media. Sex is used to sell everything from toothpaste to cars. The family of the girl plays an essential role. Chaotic families in which the only way to get attention is to act in a negative fashion quite often produce boys who engage in drug abuse and antisocial activities, and girls who experiment in very early sexual activity. HEW deemed in 1975 that adolescent pregnancies were all due to "acting out" a professional term for deviant if not pathological behavior. Some teens become pregnant to improve status, others to defy their families. Some are victims of sex abuse who become pregnant. Even though these pregnancies are not always planned, some of them seem to be linked to deep unconscious needs. It appears almost impossible to prevent them.

"Identification of Women at Risk for Unwanted Pregnancy," V. Abernethy, D. Robbins, G. Abernethy, H. Grunebaum and J. Weiss, American Journal of Psychiatry 132 (10): 1027- 1031, October 1975.

There is growing evidence in the psychological and demographic literature that knowledge and availability of modern contraceptive methods is not a sufficient condition for effective birth control. Family life experiences in adolescence appear to be critical in the development of relatively stable attitudes and personality traits that can be implicated in women's predisposition to risk unwanted pregnancy. Both promiscuity and irresponsible use of contraception seem to be common outcomes if [1] the parents' marriage was characterized by distance and hostility; [2] a woman felt alienated from her mother as a young teenager, and [3] the relationship with the father was excessively intimate and excluded the mother. In these situations, there is a redefinition of roles, with the daughter assuming some of the mother's functions as a companion to the husband/father. Low self-esteem in teenage girls motivates a young woman to measure herself primarily on the standard of male approval and attention, which she attempts to win by stereotypic feminine behavior. Unresolved dependency needs and low self-esteem militate against contraceptive behavior.

The Adolescent and Pregnancy, Margaret Ann Corbett and Jerrilyn H. Meyer, (Boston: Blackwell Scientific Publications, 1987).

When a pregnancy occurs because of a contraceptive failure or a failure to use contraceptives, the adolescent is often in a predicament. Consequently, she may deny the pregnancy and delay finding professional help. Adolescents frequently fear parental reaction to their pregnancies, let alone a request for an abortion. This is natural and, in cases of parental child abuse, appallingly real. An adolescent who becomes pregnant to escape abuse herself will often, as an adolescent mother, expect unrealistic obedience and what she believes to be correct responses from her child. If her infant fails to meet her expectations, child abuse may result. Therefore, while we promote the quality of care of both the baby and mother in pregnancy, we must do likewise after birth. The clinician who is aware of an abused child's characteristics can identify their presence in pregnancy. If counseling is immediately begun, future child abuse may be successfully averted.

"Emotional Crises of School A- Girls During Pregnancy and Early Motherhood," H. LaBarre, Journal of the American Academy of Child Psychiatry 11(3): 537-557(1972).

Describes in detail a separate junior-senior high school for pregnant girls while they carry their babies to term. The sudden loss of the major role and occupation of adolescents, that of student, constitutes a real rejection and punishment of the pregnant girl. To some students, withdrawal from school seemed an overwhelming frustration of hopes and plans and loss of their self-esteem. Pregnancy provides the most profound sisterhood of mutual feelings and experience. The emotional import of belonging to a group of peers, all of whom are involved in the same basic life experience and with whom they can identify, share, learn from and give to, is very significant for pregnant girls.

"Adolescent Morality-A Theologian's Viewpoint," Paul Ramsey, Post-Graduate Medicine 72(1): 233-236, July 1982,

Teenage attitudes toward sex are simply a response to the pressures of today's society, a society that almost insists that its young members become sexually active. Loss of virginity and pregnancy are puberty rites devised by our youngsters to fill the void created by a liberalism that hesitates even to pass on its cultural heritage for fear of imposing on individual freedoms. Increasing the number of sex education programs and the availability of contraceptives are not the answer to the current epidemic of teenage pregnancy.

"Current Contradictions in Adolescent Theory," J.C. Coleman, Journal of Youth and Adolescence 7(1): 1-11, 1978,

The article points out two contradictions in adolescent theory, i.e., the "classical" point of view and the "empirical', view. One espouses the notion of "storm and stress, " while the other supports a concept of relative calm. One reason for divergence of view is that psychologists responsible for large-scale surveys have tended to overestimate the individual adolescent's ability or willingness to talk about his innermost feelings. Much depends upon the way the study is carried out, but it is important to note how very difficult it often is for anyone-let alone an anxious or resentful teenager-to share fears, worries, or conflicts with a strange interviewer. Those responsible for the empirical view may have underestimated the amount of inner stress experienced by young people.

"Motivational Factors in Abortion Patients," F. Kane, M. Lachenbruch, M. Lipton and D. Baram, American Journal of Psychiatry 130(3): 290-293, March 1973,

Forty percent were found to have motivational factors that may have influenced the outcome of the pregnancy, such as guilt over the use of contraception, a severe acting out character disorder or reaction to loss.

"Motivation Factors in Pregnant Adolescents," F. Kane, C. Moan and B. Bolling, Diseases of the Nervous System 35:131-134(1974).

Factors such as guilt about the use of contraception, loss of love objects via death of father or mother, and overt wishes for pregnancy by the female or her partner were observed.

"A Comparison of Minor's and Adult's Pregnancy Decisions," Catherine Lewis, American Journal Orthopsychiatry 50(3): 446-453, July 1980.

Concludes that minor's decisions were more "externally" based, i.e., what parents thought. Minors more often considered possible deformity of the child.

"Social and Psychological Correlates of Pregnancy Decisions Among Adolescent Women," Lucy Olsen, American Journal Orthopsychiatry 50(3), 432-445, July 1980.

Concludes that those who seek and go through an abortion are not a "special" population of unmarried adolescents but are similar to those of the same age in many of their social and psychological characteristics. Pregnancy resolution is a process of "enormous complexity."

"Pregnancy in the Single Adolescent Girl: The Role of Cognitive Functions," W. Godfrey Cobliner, Journal of Youth and Adolescence, 3(1): 17-29, (1974),

Three psychological mechanisms were uncovered which virtually block the conversion of birth control knowledge into successful practice. Somatic Area: Only about one fourth of the pregnancies were intended. Sex is mechanistic; a premium is placed on performance to create a desire for repetition. There is a lack of curiosity about one's own body.

"Reasoning in the Personal and Moral Domains: Adolescent and Young Adult Women's Decision-Making Regarding Abortion," Judith G. Smetana, Journal of Applied Developmental Psychology 2:211-226(1981).

Subjects treating abortion as a moral issue were more likely to continue their pregnancies, while subjects treating abortion as a personal issue were more likely to obtain an abortion. avoidance and reduced abortion rates in 15- to 17-year olds.

"Impact of the Minnesota Parental Notification Law on Abortion and Birth," J.L. Rogers, R. Boruch, G. Stomsard, D. DeMoya, American Journal of Public Health 81 (3):294-298, March 1991.

The impact of the Minnesota Parental Notification Law enacted in 1981 and enjoined in 1986 was examined using linear models and outcome parameters before and after enactment. Data suggested that parental notification facilitated pregnancy old Minnesota women.)

"Pregnancy and Abortion Counseling," American Academy of Pediatrics Committee on Adolescence, Pediatrics 63(6)  :920-92 I, June 1979.

All options should be explored, including [1] Keeping the pregnancy, marrying the father and raising the child at home. [2] Keeping the pregnancy and relinquishing the infant for adoption. [3] Keeping the pregnancy and raising the child with the help of other family members. [4] Keeping the pregnancy and raising the infant, remaining single. [5] Having an abortion.

Abortion Decision-Making Among Adolescents

"Developmental Profiles of Adolescents and Young Adults Choosing Abortion: State Sequence, Decalage, and Implications for Policy," V Foster and NA Sprinthall, Adolescence 27, No. 107:655, Fall, 1992

The level of reasoning among adolescents and young adults related to abortion was lower than their cognitive reasoning generally. Kohlberg's moral maturity scores on the standard dilemmas for 16-18 year olds was one full stage higher than the abortion scores of the young females in the study. See also "Follow-up After Abortion in Early Adolescence," M Perez-Reyes and R Kalk, Arch Gen Psychiatry 28:120, 1973. Many adolescents believed that abortion was not justified but they had rationalized their guilt by considering themselves "exceptions to the rule."

"Psychological Problems of Abortion for the Unwed Teenage Girl," CD Martin, Genetic Psychology Monographs 88:23-110, 1973

In-depth interviews found that 60% of girls had strong post-abortion guilt.

"Reasoning in the Personal and Moral Domains: Adolescent and Young Adult Women's Decision-Making Regarding Abortion," Judith G Smetana, Journal of Applied Developmental Psychology 2:211-226, 1981

Subjects treating abortion as a moral issue were more likely to continue their pregnancies, while subjects treating abortion as a personal issue were more likely to obtain an abortion.

"Factors in Pregnancy Decision Making by Teenagers," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 7(4): 1-8, Jan/Feb, 1995

Major factors in pregnancy decision-making by teenagers include (1) the personality of the teenager; (2) her attitude toward the current pregnancy; (3) previous reproductive history; (4) the attitude and degree of involvement of parents and other family members, the prospective father and peers and (5) the cultural and public policy aspects which may favor or disfavor childbirth.

"Teen Pregnancy in New Orleans: Factors that Differentiate Teens Who Deliver, Abort, and Successfully Contracept," E Landry et al, Journal of Youth and Adolescence 15(3): 259, 1986

Among black, never married teenagers age 12-18 who became pregnant, childbearers were more likely to be happy or proud themselves or have parents and boyfriends who were happy and proud of the pregnancy compared to teenagers who had abortions. Teenagers who became pregnant and had abortions were more likely to be angry at the pregnancy or have boyfriends who were angry compared to childbearers. The vast majority knew about birth control and where to get it, but few were using birth control when they became pregnant. Those who had abortions were more likely to try to deny the pregnancy (28.3%) compared to childbearers (18.4%). Those who had abortions were somewhat less likely to tell their parents about the pregnancy than childbearers (83.7% vs. 99.3%).

"Delivery or Abortion in Inner-City Adolescents," Susan H Fischman, American Journal Orthopsychiatry 47(1):127, 1977.

A study of unwed black adolescents in Baltimore found that those who delivered were characterized by parents and boyfriends who provided greater support for their decision compared to those who had abortions. The adolescent's relationship with her boyfriend was an important factor. In general, the longer the duration of the relationship, the lower the incidence of abortion. The deliverer's boyfriend was more likely to be working full-time, compared to the aborters' boyfriend who was apt to be attending school full-time or part- time. Deliverers attached greater importance to religion. Those having abortions were more likely to be attending school and at the appropriate grade level compared to deliverers who had a higher probability of having discontinued school. The pregnancy per se was not the primary reason for discontinuance. Pregnancy frequently occurred after the adolescent had left school. Those having abortions came from families with higher socioeconomic status and were less likely to be receiving welfare support (28%) compared to deliverers' families (44%).

"Why Do Women Have Abortions," ? , A Torres and JD Forrest. Family Planning Perspectives 20(4):169, 1988.

A 1987 Alan Guttmacher survey of U.S. abortion facilities found that almost two thirds (63%) of teenagers who had abortions at 16 gestational weeks or more attributed the delay to being afraid to tell their partner or parent that they were pregnant.

Psycho-Social Stress Following Abortion, Anne Speckhard (Kansas City, MO: Sheed&Ward, 1987).

A study of postabortion women where women frequently had second trimester abortions at a young age reported that abortion was used as a strategy for coping with the pregnancy without ever fully admitting that the pregnancy existed. For possible consequences of denial, see Integration of Teen Pregnancy and Child Abuse Research: Identifying Mediator Variables for Pregnancy Outcome, E. Becker-Lausen, A.U. Rickel, J. of Primary Prevention 16(1): 39, 1995 (Dissociation among adolescents was found to be associated with reports of becoming pregnant or of having an abortion in high school. Individuals who detach from reality by dissociation may disregard clues that may otherwise warn them of danger and they become " sitting ducks" for later abuse.

"Factors Discriminating Pregnancy Resolution Decisions: Issues of Unmarried Adolescents," Marvin Eisen, G. Zeilman, A. Leibowitz, W. Chow and J. Davis, Genetic Psychology Monographs 108:69(1983).

In a study of 368 white and Mexican-American adolescents from 13-19 years of age, a teenager whose boyfriend, best girlfriend and mother thought she should have an abortion was more likely to abort; when other factors were controlled, her own father's opinion of abortion was not a factor in the adolescent's decision. The most powerful predictor of the teenager's attitude toward abortion for others was her girlfriend's opinion.

"Adolescent Pregnancy: Effects of Family Support, Education, and Religion on the Decision to Carry or Terminate Among Puerto Rican Teenagers," CG Ortiz and EV Nuttall, Adolescence Vol XXII. No.88: 897- 917, 1987

Interviews with Puerto Rican teenagers found that those who carried to term were more significantly influenced and supported by family and friends compared to those who had abortions. Fathers were the least influential in both groups, while mothers were the most influential among those to carried to term, and sisters were the most influential among those who had abortions. Contrary to expectations, teenagers in the abortion group had a greater degree of religiosity than those who carried to term. Teenagers who had abortions were more likely to continue their education than those who carried to term.

"Influence of Maternal Attitudes on Urban Black Teens' Decisions About Abortion v. Delivery," E Freeman et al, The Journal of Reproductive Medicine 30(10): 731, 1985

A study of black urban, teenagers age 14-17 found that 81% chose the pregnancy outcome that their mothers supported.

"The Significance of Pregnancy Among Adolescents Choosing Abortion as Compared to Those Continuing Pregnancy," M Morin-Gonthier and G Lortie, The Journal of Reproductive Medicine 2(4): 255-259, 1984

A French-Canadian study found that family members, girl friends and others were more likely to know about a term pregnancy as compared to abortion. The adolescents wish to be pregnant, wanting someone to love who would love her in return , and opposition to abortion by family, partner and the adolescent was significantly more likely to result in childbirth; If the adolescent believed that she was too young to have a child, or unable to provide for and bring up a child with no one to help her, or if she did not want to prejudice her future was significantly more likely to result in abortion. (Ed Note: The adolescents' perception of her support system appeared to be an important factor.

Pregnant Teenagers' Reliance on Others to Make Pregnancy Resolution Decisions

"Factors Discriminating Pregnancy Resolution Decisions of Unmarried Adolescents," M Eisen, et al, Genetic Psychology Monographs 108:69 (1983)

Peer influence was an important factor among pregnant Mexican-American teenagers. Also, if the teenagers mother or the prospective father favored abortion, one-third of the teenagers who initially favored childbirth had an abortion.

"Adolescent Pregnancy-Decision Making: Are Parents Important?" RH Rosen, Adolescence, 15(57):44 (1980)

A Michigan study found that more than half of the adolescents involved their mothers in pregnancy decision making. Male partners also had a major influence, and to a lesser extent, fathers and girlfriends of the adolescent.

"Influence of Maternal Attitudes on Urban, Black Teens Decisions About Abortion v. Delivering," E Freeman, et al The Journal of Reproductive Medicine 30(10): 731 (1985)

Among black inner city teenagers, 81% chose the pregnancy outcome that their mothers supported.

"The Significance of Pregnancy among Adolescents Choosing Abortion Compared to Those Continuing Pregnancy," M Morin-Gonthier, and G Lortie, The Journal of Reproductive Medicine 29(4):255 (1984)

In a French-Canadian study the attitude of the male partner as well as that of family and friends was important to the outcome.

"To Whom Do Inner-City Minors Talk About their Pregnancies? Adolescents' Communication With Parents and Surrogate Parents," LS Zabin, et al Family Planning Perspectives 24(4):148 (1992)

In a study of black, urban teenagers in Baltimore, the probability that an adolescent would consult a parent before deciding what to do about her pregnancy was higher if she was younger, if she lived with the parent, and if she found the parent easy to talk to. Disatisfaction with the pregnancy decision one year after the pregnancy test was most likely if the parent did not support the final outcome, if someone other than the teenager had made the decision, or if the outcome was different from the teenagers preference at the time of the pregnancy test.

Adolescent Abortion and Parental Involvement

Parental Notice or Consent

"Mandatory Parental Consent to Abortion" Council on Ethical and Judicial Affairs, American Medical Association, JAMA 269(1):82 (1993) ==

Minors may not make considered choices about abortion because of immaturity, inexperience, or poor judgment. Parents are generally in the best position to counsel minors about their reproductive options, and they usually have a deep and respected interest in any significant matter involving their children. However, some minors may, in fact, be physically or emotionally harmed if they were required to involve their parents in the decision to have an abortion. In addition... parental involvement could interfere with the minors need for privacy on matters of sexual intimacy.

"Protecting Adolescents From Harm. Findings From the National Longitudinal Study on Adolescent Health," MD Resnick, et al JAMA 278(10):823 (1997) ==

Parent-family connectedness and school perceived connectedness was protective against every health risk of adolescents except history of pregnancy. Protective effects included less likelihood of emotional distress, suicidality, violence, substance use and cigarette use, alcohol use, marijuana use, and early age at first intercourse.

The Benefits of Legislation Requiring Parental Involvement Prior to Adolescent Abortion, Values and Public Policy, EL Worthington, et al (Family Research Council: Washington DC, 1988) 221-243 see also "The Benefits of Legislation Requiring Parental Involvement Prior to Adolescent Abortion," E Worthington, et al (Comment) American Psychologist, December, 1989, p. 1542-1545 ==

Parents have a social responsibility and thus a right to be involved in decisions about an adolescent's pregnancy. Adolescent pregnancy should be considered in a social and familial context. (Many teens fear telling their parents about their pregnancy, overestimating the effect of their parents' anger and underestimating the parents' supportiveness.) An adolescent who is afraid to consult her parents prior to an abortion and who is supported by legislation to the extent that she need not consult them probably will not consult them and compounds her dearth of social support.

"Abortion Counseling: Focus on Adolescent Pregnancy," C Nadelson, Pediatrics 54(6):765 (1974) ==

The adolescent who is making a decision about abortion, having an abortion, or is in the post-abortion period needs a trusted ally who can help her understand her motivation for pregnancy and abortion. Ambivalence is especially prominent in this group. The counselor must remember that helping her with her own decision is not enough. Work with the family is important in order to (1) avoid repetition of the unwanted pregnancy, which is most frequently a distress signal for the adolescent, and (2) to work out problems reflected by the mutual acknowledgement of the adolescent's sexuality.

"Predictors of Repeat Pregnancies Among Low-Income Adolescents," M Gispert, et al. Hospital and Community Psychiatry 35(7): 719 (1984) ==

Regular use of contraception following childbirth or induced abortion was associated with a positive relationship between the girls and their mothers and with the presence of the father in the home. The authors concluded that interventions with sexually active adolescents will have little effect if they only focus on changing the adolescents' attitiudes toward contraception. Findings suggest that the mother has an important role and interventions aimed solely at sexually active adolescents that do not include their parents will miss an important part of the picture.

"Teen Pregnancy n New Orleans: Factors that Differentiate Teens Who Deliver, Abort, and Successfully Contracept," E Landry, et al. Journal of Youth and Adolescence 15(3): 259 (1986)==

Among black, never married teenagers age 12-18 who had abortions, 28.3% tried to deny pregnancy, 88% knew about birth control, 77% knew where to get birth control, but only 22.8% were using a birth control method at the time they became pregnant.

Effect of Parental Involvement Laws

"The Economic Impact of State Restrictions on Abortion: Parental Consent and Notification Laws and Medicaid Funding Reastrictions," D Haas-Wilson, Journal of Policy Analysis and Management 12(3):489-511, 1993

In an analysis of 11 states with parental notification states compared to 40 states without such laws, Minors abortions per 1000 teenage pregnancies in 1985 were 320.8 vs. 382.6; Minors abortions per 1000 women aged 15-19 in 1988 were 9.87 vs. 13.22; Percentage of abortions obtained by minors, 1988 were 9.0% vs. 12.0%)

"Impact of the Minnesota Parental Notification Law on Abortion and Birth," JL Rogers, et al Am J Public Health 81(3): 294 (1991)

A decline in abortion rates was observed when the Minnesota parental notification law went into effect while birth rates continued to decline which suggested that the parental notification law facilitated pregnancy avoidance.

"Judging Teenagers: How Minors Fare When They Seek Court-Authorized Abortions," P Donovan, Family Planning Perspectives 15(6): 259, Nov/Dec, 1983

In Minnesota between 1980, the last full year without the notification law, and 1982, the first full year during which the law was in effect, the number of abortions obtained by minors decreased by 33 percent, from 2327 to 1565.

"Mandatory Parental Involvement in Minors' Abortions: Effects of the Laws in Minnesota, Missouri, and Indiana," C Ellertson, Am J Public Health 87(8): 1367 (1997)

In each state, the in-state abortion rate for minors fell relative to the rate for older women when parental involvement laws went into effect. The laws did not increase the birthrate for minors. The laws appeared to delay minors' abortions past the eighth week but probably not into the second trimester. The impact of out of state abortions was not clear from the data.

"Missouri's Parental Consent Law and Teen Pregnancy Outcomes," VH Pierson, Women & Health 22(3): 47 (1995)

Data suggest that since enforcement of the parental consent in 1985, there has been a decrease in selection of abortion as a pregnancy outcome, particularly among white teens. There has been an increase in the percentage of abortions among teens taking place in other states. There has been an increase of births to teenage mothers in the last decade.

"Parental Consent for Abortion: Impact of the Massachusetts Law," VG Cartoff, and LV Klerman, Am J Public Health 76(4): 397 (1986)

In the first 20 months after implementation of a parental consent law, only half as many adolescents obtained in-state abortions as had previously done so. More than 1800 minors went to five surrounding states to obtain abortions which accounted for the reduction in in-state abortions. In 1982, an estimated 50-100 minors bore children rather than having abortions , possibly because of the law.

Necessity of Parental Involvement

Family Estrangement

"Counseling the pregnant adolescent within a family context: Therapeutic Issues and Strategies," D Bapiste, Family Therapy 13:163 (1986)

Family needs to deal with its pervasive sense of failure precipitated by the pregnancy; family members need to clarify their different views about the pregnancy and unborn baby ; parents and adolescent need to resolve any pre- existing conflict ; it is important to communicate in a crisis situation; parents need to maintain their relationship while they "parent" their daughter through the crisis; parents and adolescents need to resolve developmental independency-dependency issues

"Abortion in teenagers," M Hanson, Clinical Obstetrics and Gynecology 21:1175 (1978)

Teenager should enlist the support of a parent or older sibling rather than "go it alone." Parents can help pay for the abortion.

"The genetics of antisocial acting out in children and adults," AM Johnson and SA Szurek, Psychoanalytic Quarterly 21:323 (1952)

Unwitting sexual permissiveness by the parent may encourage sexual acting out by the child. Both the parent and the child may need therapy.

"The Impact of a Parental Notification Law on Adolescent Abortion-Decision Making," R Blum et al, American Journal Public Health 77(5): 619, May, 1987

In a study of Minnesota teenagers seeking abortion, 70% of those who reported never attending religious services notified at least one parent prior to the abortion vs. 49% of those teenagers who reported attending religious services 10 or more times. (Ed Note: It appears that those parents who may be more likely to object to abortion were less likely to be notified by the teenager.)

"Abortion in Relationship Context," VM Rue, Int'l Review of Natural Family Planning 9:95 (1985)

A secret abortion , without disclosure or discussion, creates a psychological burden for the pregnant woman and a barrier to her future relationships with those most significant to her. e.g. Psychosocial Sequelae of Therapeutic Abortion in Young Unmarried Women, JS Wallerstein, et al Arch Gen Psychiatry 27:828 (1972)( Keeping the adolescent pregnancy and abortion secret from family caused a burden of guilt which was a continuing source of difficulty.; Psycho-Social Stress Following Abortion, A Speckhard, (Sheed & Ward: Kansas City, 1987) 81-82 (Young women from families which were opposed to out of wedlock sex often made the decision to keep the pregnancy and abortion secret to protect the family from stress and to protect their membership in their family of origin. This was often at the cost of increased personal stress and alienation, as well as imitating coping mechanisms both within and outside the family system.

"Parental Influence on the Pregnant Adolescent," A Young, et al, Social Work 2:387(1975)

Four-fifths of pregnant adolescents stated that their mother was the most significant person in their lives and social work counseling should include these mothers as well.

Parental Reaction to Pregnancy Less Negative than Anticipated by Adolescent

"Minor women obtaining abortions: A Study of Parental Notification in a metropolitan area," F Clary, Am J Public Health 72:283 (1982)

A Minnesota study found that , among the 37% of mothers notified of adolescent plans for abortion, 67%had a positive reaction, while 13% were neutral and 13% had a negative reaction.

"Adolescent Abortion and Parental Notification: Evidence for the Importance of Family Functioning on the Perceived Quality of Parental Involvement in U.S. Families," MS Griffin- Carlson, and PJ Schwanenflugel, J Child Psychol Psychiat 39 (4): 543 (1998)

In a study of 159 adolescents and their parents who accompanied their daughter to seven private abortion facilities in three states, 89.1% of the adolescents said they were glad they told their parents. Negative experiences were reported by 40.9% of the adolescents when they confided in their parents but there were no reports of physical violence. (Most of the adolescents described their parents as permissive.

"Teen Pregnancy in New Orleans: Factors that Differentiate Teens Who Deliver, Abort, and Successfully Contracept," E Landry, et al Journal of Youth and Adolescence 15 (3): 259 (1986)

Among black, never married teenagers aged 12-18 who had abortions, 28.3% tried to deny pregnancy, 76% were afraid of their parents reaction and 84% told their parents about the pregnancy. Of the parents who were told about the pregnancy, 6.5% were happy, 80% were surprised, 40.3% were angry, and 2.6% were proud.

Unplanned parenthood: The social consequences of teenage childbearing, FF Furstenberg (New York: The Free Press, 1976) 54

Pregnant adolescents often delayed telling their parents and frequently adolescents did not tell their parents at all. Two-thirds of parents stated they were angry when they heard of their daughters pregnancy. The response to the pregnancy was subject to considerable revision by both adolescents and their families during the course of gestation. Both parents and adolescents continually reevaluated their situation as the pregnancy proceeded and, in nearly every instance, their responses became more positive as the pregnancy proceeded.

"Counseling adolescents with problem pregnancies." J Maracek, American Psychologist 42:89 (1987)

Parental reactions are often less negative than anticipated, but the anticipation itself is a major source of anxiety.

The Adolescent and Pregnancy, M-A Corbett and JH Meyer, (Boston: Blackwell Scientific Publications, 1987) 267-269

About 80% of pregnant adolescents in a young mothers program did not properly predict their mother's reaction to her pregnancy.The negative response they anticipated occurred but later resolved itself in acceptance.

Profile of Adolescents Not Disclosing Pregnancy or Abortion to Parents

"Parental Consent: Factors Influencing Adolescent Disclosure Regarding Abortion," MS Griffin-Carlson and KJ Macklin, Adolescence 28 (109):1,1993 (1993)

Among women age 12-21 from 5 Atlanta area abortion facilities, 51% confided in their parents, The degree of financial and emotional dependence and the quality and nature of family communication were closely related to the teenagers decision to confide in her parents about the decision to seek an abortion.

"Factors Associated with the Use of Court Bypass by Minors to Obtain Abortions," RW Blum et al Family Planning Perspectives 22(4):158 (1990)

A study of minors interviewed at 4 Minnesota abortion facilities found that 43% used the court by-pass option which was part of the state parental notification statute.Minors from the two lowest socioeconomic strata were significantly less likely than wealthier peers to use the court bypass.Minors who reported the most frequent attendance at religious services were significantly less likely than those whose attendance was less frequent to tell both parents of their abortion plans.Perceived maternal supportiveness was the key discriminating factor between those who notified parents and those who went to court. Avoidance of parental notification was only partly due to perceived parental disagreement with the decision. Minors who told neither parent were more likely to live with both parents and to see communication with their mother as less open. Fathers, had the opposite effect; when communication was good and they had been open about sexual matters, their daughters were less likely to discuss the abortion decision with them out of fear that he would be disappointed and hurt.

Availability of Financial Resources as a Factor

"Why Do Women Have Abortions?" A Torres and JD Forrest, Family Planning Perspectives 20(4):169 (1988)

A 1987 Alan Guttmacher study found that 73% of teenage women stated as a contributing reason for having an abortion was that she cannot afford a baby now.

"The Social and Economic Correlates of Pregnancy Resolution among Adolescents in New York City by Race and Ethnicity: A Miltivariate Analysis" T Joyce, Am J Public Health78(6):626 (1988).

The receipt of Medicaid benefits strongly correlated with decisions for childbirth among unmarried teenagers in New York City in 1984. The likelihood of abortion was only one- half among Puerto Rican teenagers, one-third among Latinos who were non-Puerto Rican, one-sixth for white teenagers, and one-third among black teenagers if they received Medicaid benefits.

"Adolescent Pregnancy in the United States: An Interstate Analysis," S Singh, Family Planning Perspectives 18(5):210 (1986)

An Alan Guttmacher study found that the availability of Medicaid funds to pay for abortions was associated with higher abortion rates for pregnant teenagers.

Differential Psychosocial Impact on Adolescents

Mental health may deteriorate as a direct effect of induced abortion, C Morgan et al, British Medical Journal 314:902, 1997.

The frequency of admission per 1000 population for attempted suicide by pregnancy event in women aged 15-19 in South Glamorgan Health Authority from 1991-1995 was 3.6 per 1000 before induced abortion and 10.8 per 1000 after induced abortion compared to 14.0 per 1000 before delivery and 2.6 per 1000 after delivery.

Psychiatric admissions of low income women following abortion and child- birth, DC Reardon et al, Canadian Medical Association Journal 168(10); 1253 2003.

The frequency of psychiatric admission rates for women age 13-19 for a 4 year period following their pregnancy outcome was 915.4 per 100,000 following abortion compared to 517 per 100,000 following delivery (OR 1.8, 95%CI, 1.1-2.9).

"Differential Impact of Abortion on Adolescents and Adults," W Franz and D Reardon, Adolescence 105:162 (1992).

Women members of Women Exploited by Abortion who aborted as teenagers compared to women who aborted at 20 years or older were less satisfied with services at the time of the abortion, were more likely to feel forced by circumstances to have the abortion, were more likely to report being misinformed, more often reported severe psychological distress, and more often wanted to give birth and keep the baby.

Data from 252 members of support groups of Women Exploited by Abortion from 42 states in the US were analyzed to determine factors that characterize this distressed group and compare adolescent and adult reactions to abortion. Most were young and unmarried at the time of the abortion. Women whose self-image suffered after the abortion were much more likely to have reported being dissatisfied with the abortion experience, feeling pressured to have the abortion, and feeling misinformed. Women who felt rushed to decide to have an abortion had at the most 1 week to make the decision and had the greatest severity of psychological problems (p.003). Women who were adolescents at the time of abortion were more likely to have had the abortion a longer time ago than those who were adults at the time of the abortion (p.03). They also tended to have the abortion at a greater gestational age (p.04) and were more unsatisfied with the abortion services at the time of the abortion (p.01) than adults. Adolescents were much more likely to feel that circumstances coerced them to have an abortion (p.0008), they tended to believe that they were misinformed at the time of the abortion (p.04), and they claimed to have suffered much more psychological stress than adults (p.006). In addition, prior to their own abortion, they tended to view abortion negatively (p.057). Adolescents stated that they had wanted to complete the pregnancy (p.003) and keep the infant (p.056). It is concluded that adolescents may be developmentally limited by immature decision making abilities, idealism, egocentricism, and belief in a personal fable which places them at greater risk for postabortion stress. Inadequate counseling appears to also contribute to this stress. Therefore, counselors need to realign their counseling skills to take into account these results.

"Abortion in Adolescence," N Campbell, et al., Adolescence 23(92):813 (1988).

Women in a patient led postabortion support group who had poorly assimilated their abortion and who had abortions as adolescents were more likely to report parental marital difficulties, attempt suicide, have severe nightmares, and exhibit immature coping defenses such as retreating into sexual activity or drug and alcohol abuse compared to women who had abortions after the age of 20.

"Family Relationships and Depressive Symptoms Preceding Induced Abortion," D Bluestein and CM Rutledge, Family Practice Research Journal 13(2):149-156, 1993.

In a study of pre-abortion depression in a sample of women age 14-43 years, depressive symptoms preceding abortion were moderate to severe in intensity and were more likely to increase as age decreased.

"Pregnancy in the Adolescent Patient," M Polanecyk and K O'Connor, Pediatric Clinics of North America 46(4):649 (1999).

Adolescents in general are known to comply with medical regimens more poorly than adults) see "Postabortion Medical Care: Management of Delayed Complications," KA Nichols and SJ Rasmussen, Journal of the American Medical Women's Association 49(5): 165, 1994 Adolescent who had not told her mother prior to abortion, failed to comply with antibiotic regiment and developed a potentially serious postabortion infection.

"Therapeutic Abortion During Adolescence: Psychiatric Observations," P Barglow and S Weinstein, Journal of Youth and Adolescence 2(4): 33 (1973)

Two major factors distinguish adolescent emotional response to abortion from those of adult patients: (1) the adolescent decision is more "outer-other"-directed by parents, peer group, or sexual partner and is therefore more difficult and hazardous; (2) developmental immaturity contributes to ambivalence about the decision, to a distorted perception of the procedure, and to a variety of pathological reactions.

"A Comparison of Minors and Adult's Pregnancy Decisions," Catherine Lewis. American Journal of Orthopsychiatry 50(3):446-453, July, 1980

This article concludes that minor's decisions were more externally-based compared to adults i.e. what parents thought. Minors more often considered possible deformity of the child.

"Abortion Surveillance-United States, 1996." LM Koonin, et al Centers for Disease Control MMWR 48"No.SS4: 1, July 30, 1999

Adolescents are more likely to have a late term abortion i.e. 13 gestational weeks or later compared to older women); Adler, N et al (1990) Psychological responses after abortion, Science 248:41 (A late term abortion is generally acknowledged to be a risk factor for adverse psychological sequelae compared to a first trimester abortion.

"Adolescent Mourning Reactions to Infant and Fetal Loss," NH Horowitz, Social Casework 59:551 (1978)

Replacement pregnancies may follow adolescent abortion.

"Adolescent Suicide Attempts Following Elective Abortion: A Special Case of Anniversary Reactions," CL Tishler, Pediatrics 68:670 (1981)

Adolescents attempted suicide on the perceived due date of their aborted child.

"Suicides after Pregnancy in Finland: register linkage study,"M Gissler, et al. British Medical Journal 313:1431 (1996)

Adolescent suicide during one year following induced abortion was significantly higher than adolescent suicide following childbirth.

"Mediation of Abusive Childhood Experiences: Dissociation and Negative Life Outcomes," E Becker-Lausen, Am J Orthopsychiatry 65(4):560 (1995)

Dissociation was significantly related to reports by females of previously becoming pregnant and having an abortion in high school. Individuals who detach from reality by dissociation may disregard clues that may otherwise warn them of danger and become "sitting ducks" for later abuse.

"HIV/AIDS Prevention and Multiple Risk Behaviors of Gay Male and Runaway Adolescents," C Haignere, et al Int Conf AIDS 6(3):234. abstract no. S.C. 581, June 20-23, 1990

A study of 75 female runaway adolescents in New York City found that suicide attempts and suicide ideation were found to be significantly related to having had an abortion.

"HIV+ adolescents: factors linked to transmission and prevention," D Futterman et al, Int Conf AIDS 9(2):725, abstract no. PO-C19-3049, June 6-11, 1993

Among inner-city adolescents, HIV+ youths were more likely to have STD's and abortion.

"Drug Use Among Adolescent Mothers: Profile of Risk," H Amaro, et al, Pediatrics, 84(1):144 (1989)

Drug users among inner city teenage women were significantly more likely to have a prior elective abortion compared to drug non-users. Teenage women with two or more live born children had a much lower incidence of drug use compared to women with a history of elective abortion.

"Drug Use as a Risk Factor for Premartal Teen Pregnancy and Abortion in a National Sample of Young White Women," B Mensch, and DB Kandel, Demography 29(3):409 (1992)

Illicit drug use has the strongest effect of any predictor on experiencing an abortion: the odds of an abortion are nearly five times as large for premaritally pregnant white teens who used other illicit drugs compared to those who did not use these drugs.

Adolescent Violation of Conscience or Belief

"Psychological Problems of Abortion for the Unwed Teenage Girl," CD Martin, Genetic Psychology Monographs 88:23 (1973)

Among San Diego teenagers undergoing abortion for mental health reasons, 60% had strong post-abortion guilt. A substantial number changed their moral and religious convictions following pregnancy and abortion including feeling differently about sex, abortions, or killing, changes in formal religious faiths, and changed feelings about their view of God and what was sinful.

"Follow-up After Abortion in Early Adolescence," M Perez-Reyes, and R Falk, Archives Gen Psychiatry 28:120 (1973)

In a North Carolina study of adolescents who had abortions, 34% opposed abortion on request, 20% thought abortion was justified only to save the life of the mother, and 29% thought it was permitted only on medical recommendation, yet none of those aborting gave those reasons for doing so. It was concluded that many had rationalized their guilt by considering themselves "exceptions to the rule."

"Developmental Profiles of Adolescents and Young Adults Choosing Abortion: Stage Sequence, Decalage, and Implications for Policy," V Foster and NA Sprinthall, Adolescence 27(107): 655 (1992).

Principled moral reasoning was infrequently used as a basis for decision-making among adolescents and young adults.

Adolescent Long Term Psychological Sequelae

"A disproportionately high percentage of women who had abortions as adolescents have been found in postabortion support or recovery groups." J Vought, Post-Abortion Trauma (1991) (39% were teenagers at time of abortion); "Abortion in Adolescence," NB Campbell, et al, Adolescence Vol XXIII, No.92, Winter, 1988

49% were between 15-20 at the time of their abortion. Women who had an abortion as adolescents are also more likely to join Women Exploited by Abortion. In a study of 252 WEBA members, 45% reported having had abortions as teenagers, Aborted Women: Silent No More, D Reardon, (1987). Women who had abortions as adolescents have been found to be more likely to report chronic long term stress reactions. The Psycho- Social Aspects of Stress Following Abortion, AC Speckhard,(1987) 31% of women with long term stress were 14-18 years of age at the time of their abortion.

Adolescent Demographic Data

"The Social and Economic Correlates of Pregnancy Resolution Among Adolescents in New York City by Race and Ethnicity: A Multivariate Analysis," T Joyce, Am J Public Health 78(6):626 (1988)

Teenagers who experienced one prior abortion were approximately four times more likely to terminate a current pregnancy by abortion compared to teenagers with no prior abortion history. Medicaid tended to increase the likelihood of carrying to term. Married adolescents were more likely than unmarried adolescents to carry a pregnancy to term.

"Induced Terminations of Pregnancy: Reporting States, 1988," KD Kochanek, Monthly Vital Statistics Report 39(12) Supplement 1-32, April 30, 1991

The National Center for Health Statistics reported that among white teenagers age 18-19 with induced abortions, 22.5% were having their second abortion or more. Among black teenagers age 18-19 with induced abortions, 35.5% were having their second abortion or more.

"Induced Terminations of Pregnancy: Reporting States, 1988," KD Kochenek, Monthly Vital Statistics Report 39 (12), Supplement, April 30, 1991, Table 2, Table 11

The National Center for Health Statistics reported detailed abortion statistics for a 14 state area in 1988. Among women under 14 years of age, 28.3% had abortions at 13 gestational weeks or more compared to 24.6% of women age 14, 20.3% of women age 1, 19.0% of women age 16, 16.6% of women age 17, 13.8% of women age 18, 12.2% of women age 19, 11.2% of women age 20-24, 9.1% of women age 25-29, and 7.4% of women age 30-34 years.

"Why Do Women Have Abortions?" A Torres, and JD Forrest, Family Planning Perspectives 20:169 (1988)

According to a 1987 Alan Guttmacher survey ,63% of U.S. women who had abortions as teenagers at 16 weeks gestation or more attributed the delay to being afraid to tell their partner or parent that they were pregnant compared to one-third of the women in the overall sample.

Differential Physical Complications of Adolescent Abortion

"Morbidity Risk Among Young Adolescents Undergoing Elective Abortion," R Burkman et al Contraception 30:99 (1984)

Teenagers 17 years old or less were significantly more likely to have postabortion endometritis, cervical lacerations , or hemorrhage greater than 500 ml. following abortion compared to women age 20-29.

"Postabortal pelvic infection associated with chlamydia trachomatis infection and the influence of humoral immunity," S Osser, and K Perrson, Am J Obstet Gynecol 150:699 (1984)

Chlamydia positive women age 13-19 were more likely to develop postabortion endometritis (28%) compared to women aged 20-24 (22.7%) or women aged 25-29 (20%). Chlamydia positive women aged 13-19 were more likely to develop postabortion salpingitis (21.9%) compared to women aged 20-24 (13.6%). see Nederlof, KP et al (1990) Ectopic Pregnancy Surveillance United States, 1970-1987, MMWR 39, No. SS-4:9 ( Ectopic pregnancy is estimated to occur 5-10 times more frequently among women with a prior history of salpingitis. Ectopic pregnancy case-fatility rates are higher in women age 15-19 compared to older women.

"Postabortion Medical Care: Management of Delayed Complications," KA Nichols and SJ Rasmussen, Journal of the American Medical Women's Assn 49(8):165 (1994)

A teenager underwent an abortion but did not take her antibiotics as prescribed and developed a low grade fever. She went to an emergency room of a hospital four days after the abortion where she saw a doctor who refused to treat her. Instead, the doctor called the abortion facility and the teenager's mother, who, for personal reasons, the teenager had not told about her pregnancy and abortion. The teenager and her mother then came to the abortion facility where it was determined that the teenager had endometritis. Antibiotics were administered and the infection was cleared up. The article stated that had the teenager not received the appropriate medication, her endometritis could have been quite severe and required hospitalization and intravenous antibiotics and could have resulted in infertility. The state where the abortion occurred did not have any parental notice or consent law. see also Polaneczky, M and O'Connor, K (1999) Pregnancy in the Adolescent Patient, Pediatric Clinics of North America 46(4): 649 Adolescents in general are known to comply with medical regimens more poorly than adults.

"Pain of First Trimester Abortion: A Study of Psychosocial and Medical Predictors," E Belanger, et al. Pain 36:339 (1989)

In a Canadian study, pain was more severe in adolescents who underwent first trimester suction abortion under local anesthesia compared with older women. Pre-abortion depression was the principal predictor of pain.

Pelvic inflammatory disease in adolescents, V Igra, AIDS Patient Care STDS 12(2): 109-124, 1998

One in five cases of pelvic inflammatory disease (PID) occurs among younger women less than 19 years of age. The risk of developing PID for a 15 year old sexually active girl is estimated to be 10 times that of a 24 year old woman. The higher risk of PID for younger women has been attributed to their greater biologic vulnerability and their behavioral and cognitive risk factors.

Adolescent Risk of Breast Cancer

Adolescent Reproductive Events and Subsequent Breast Cancer Risk, PM Marcus et al, American Journal Public Health 89(8):1244, 1999.

Among parous premenopausal women who were breast-feeding before 20 years of age compared to no history of breast-feeding , there was a substantial risk reduction for breast cancer (OR 0.2, 95%CI, 0.1-0.6).

"Age at First Birth and Breast Cancer Risk," B MacMahon, et al, Bulletin of the World Health Organization 43:209 (1970)

In a large international study it was found that women having their first birth under age 18 had only about one-third the risk of breast cancer compared to those whose first birth is delayed until age 35 or more. The study also stated that " data suggested an increased risk associated with abortion contrary to the reduction in risk associated with full-term births."

"The Independent Assocations of Parity, Age at First Full Term Pregnancy, and Duration of Breastfeeding with the Risk of Breast Cancer," PM Layde, et al, J Clin Epidemiol 42(10):963 (1989)

A Centers for Disease Control study found that increasing number of live born children and duration of breast feeding had a strong protective effect on the risk of breast cancer.

"Effect of Family History, Body-Fat Distribution, and Reproductive Factors on the Risk of Postmenopausal Breast Cancer," TA Sellers, et al, New England Journal of Medicine 326:1323 (1992)

The increase in risk of breast cancer associated with low parity or greater age at first pregnancy is more pronounced among women with a family history of breast cancer.

"Familial risk, abortion and their interactive effect on the risk of breast cancer- a combined analysis of six case-control studies," N Andrieu, et al, Br J Cancer 72:744 (1995)

The relative risk of breast cancer conferred by a family history of breast cancer increased with the number of abortions.

"Risk of Breast Cancer Among Young Women: Relationship to Induced Abortion," JR Daling et al, Journal of the National Cancer Institute 86(21):1584-1592, 1994

Higher risks for breast cancer following induced abortion when the abortion was done at age 18 or younger and particularly if it took place after 8 weeks gestation. see also "Induced Abortion and the Risk of Breast Cancer, M Melbye" et al, New England Journal of Medicine 336(2): 81-85, 1997 The relative risk of breast cancer increased with the increasing gestational age of the fetus at the time of the most recent abortion. (Ed Note: Adolescents are more likely to have an abortion at a later gestational age compared to older women.)

"Induced abortion as an independent risk factor for breast cancer: a comprehasive review and analysis," J Brind, et al Journal of Epidemiology and Community Health 50:481 (1996).

A meta-analysis of 28 published reports concluded there was an independent increased risk of 30-50% for breast cancer as a result of induced abortion. Higher risks for breast cancer occurred among women with two or more induced abortions compared to women with one induced abortion in seven of ten studies. see also www.abortion cancer.com website for further updates on breast cancer and abortion.