Self-Destructive Behavior

Sub-Index
Psychological Effects
	Validity of Studies
	Reviews
	Risk Factors
	PTSD
	Grief and Loss
	Guilt
	Ambivalence or Inner Conflict
	Anxiety
	Intrusion / Avoidance / Nightmares
	Denial
	Dissociation
	Narcissism
	Self-Image
	Self Punishment
	Depression
	Psychiatric Treatment
	Self-Destructive Behavior
	Substance Abuse
	Long-Terms Effects of Abortion
	Replacement Pregnancies
	Sterilization
	Impact of Abortion On Others
	Violence
	Rape, Incest, Sexual Assault
	After Late Term 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 ;

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Suicide Associated with Abortion

Specific Cases of Abortion Related Suicide

See Suicide - Case Studies

Statistically Significant Studies

The association between abortion experience and postmenopausal suicidal ideation and mental health: Results from the 5th Korean National Health and Nutrition Examination Survey. Jeong HaWie, Su Kyung Nam, Hyun Sun Ko, Jong Chul Shin, In Yang Park, Young Lee. Taiwanese Journal of Obstetrics and Gynecology Volume 58, Issue 1, January 2019, Pages 153-158

Objective:The association between abortion and postmenopausal mental health has not been clearly established in Asian women. The objective of this study was to evaluate the effect of abortion experiences on suicidal ideation and mental health in Korean postmenopausal women.

Materials and methods: This study included 5133 postmenopausal women registered in the Korean National Health and Nutrition Examination Survey between 2010 and 2012. Difference in suicidal ideation according to type and number of abortions was analyzed. We used survey multiple logistic regression analysis to evaluate the effect of abortion experiences on the risk for suicidal ideation expressed as adjusted odd ratios (ORs) with 95% confidence intervals (95%CIs).

Results: The risk of suicidal ideation was significantly higher in women who experienced more than three abortions (27.9%). While the incidence of suicidal ideation was not significantly affected by the number of spontaneous abortions (p = 0.718), suicidal ideation was significantly more frequent in women who had undergone ≥ three abortions (p = 0.003). After adjusting for demographic confounding factors, women who underwent ≥ three induced abortions had higher risk for suicidal ideation (OR: 1.510; 95% CI: 1.189–1.919; p = 0.031). This risk remained elevated even after controlling for depression (OR: 1.391; 95% CI: 1.1086–1.871, p = 0.002). Moreover, the risk of experiencing a depressive mood in daily life was also increased with increasing number of induced abortions even after controlling for depression (OR: 1.657; 95% CI: 1.274–2.156, p = 0.002).

Conclusion: Undergoing three or more induced abortions during reproductive age was associated with postmenopausal suicidal ideation, stress, and depression. However, such association was not noted in those with spontaneous abortion, even in women with more miscarriages. Thus, clinicians should evaluate depression and suicidal ideation in women with multiple induced abortions.

Association between induced abortion and suicidal ideation among unmarried female migrant workers in three metropolitan cities in China: a cross-sectional study. Luo M, Jiang X, Wang Y, Wang Z, Shen Q, Li R, Cai Y. BMC Public Health. 2018 May 15;18(1):625. doi: 10.1186/s12889-018-5527-1.

BACKGROUND: Despite reports of mental health issues, suicidality has not been closely examined among the migrant population. The association between induced abortion and suicidal ideation is unknown among unmarried female migrant workers of reproductive age in China. This study aims to examine induced abortion and suicidality among the Chinese migrant population.

METHODS: We recruited 5115 unmarried female migrant workers during 2015 to 2016 from Shanghai, Beijing and Guangzhou, and collected demographic, psychosocial, reproductive and mental health information using structured questionnaires. We used logistic regression models to examine the association between lifetime induced abortion and suicidal ideation during the past year among the subjects.

RESULTS: Overall, 8.2% of the subjects had suicidal ideation during the past year, and 15.5% of the subjects experienced induced abortion. Induced abortion was associated with nearly twice the odds of having past-year suicidal ideation (Odds ratio, OR = 1.89; 95% confidence interval, CI: 1.46, 2.44) after adjusting for age, education, years in the working place, tobacco use, alcohol consumption, daily internet use, attitude towards premarital pregnancy, multiple induced abortion, self-esteem, loneliness, depression, and anxiety disorders. The association was stronger in those aged > 25 (OR = 3.37, 95% CI = 2.16, 5.28), with > 5 years of stay in the working place (OR = 2.98, 95% CI = 2.02, 4.39), the non-anxiety group (OR = 2.28, 95% CI = 1.74, 3.00), and the non-depression group (OR = 2.94, 95% CI = 2.08, 4.15).

CONCLUSIONS: Induced abortion was associated with increased odds for suicidal ideation among the unmarried female migrant workers in urban cities in China. More attention should be paid to the mental health of the population.

Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States. Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997

Objective: To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

Method: Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

Results: After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

Conclusion: Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

Note: Adjusted odds ratio for suicidal ideation was 1.69 (95% CI 1.28-2.22)

"Mandatory Waiting Periods for Abortions and Female Mental Health." J Klick. Health Matrix: Journal of Law-Medicine, Vol. 16, p. 183, 2006.

Panel data analyses suggests mandatory waiting periods prior to an abortion reduce suicide rates between 10 and 30 percent. These findings are statistically significant and appear to be robust in that the trend in findings remains the same after various attempts to control for other factors.

Decreased suicide rate after induced abortion, after the Current Care Guidelines in Finland 1987 - 2012. Gissler M, Karalis E, Ulander VM. Scand J Public Health. 2014 Nov 24. pii: 1403494814560844.

Abstract

Aim: Women with a recent induced abortion have a 3-fold risk for suicide, compared to non-pregnant women. The increased risk was recognised in unofficial guidelines (1996) and Current Care Guidelines (2001) on abortion treatment, highlighting the importance of a check-up 2 - 3 weeks after the termination, to monitor for mental health disorders. We studied the suicide trends after induced abortion in 1987 - 2012 in Finland.

Methods: We linked the Register on Induced Abortions (N = 284,751) and Cause-of-Death Register (N = 3798 suicides) to identify women who had committed suicide within 1 year after an induced abortion (N = 79). The abortion rates per 100,000 person-years were calculated for 1987 - 1996 (period with no guidelines), 1997 - 2001 (with unofficial guidelines) and 2002 - 2012 (with Current Care Guidelines).

Results: The suicide rate after induced abortion declined by 24%, from 32.4/100,000 in 1987 - 1996 to 24.3/100,000 in 1997 - 2001 and then 24.8/100,000 in 2002 - 2012. The age-adjusted suicide rate among women aged 15 - 49 decreased by 13%; from 11.4/100,000 to 10.4/100,000 and 9.9/100,000, respectively. After induced abortions, the suicide rate increased by 30% among teenagers (to 25/100,000), stagnated for women aged 20 - 24 (at 32/100,000), but decreased by 43% (to 21/100,000) for women aged 25 - 49.

Conclusions: The excess risk for suicide after induced abortion decreased, but the change was not statistically significant. Women with a recent induced abortion still have a 2-fold suicide risk. A mandatory check-up may decrease this risk. The causes for the increased suicide risk, including mental health prior to pregnancy and the social circumstances, should be investigated further.

Parental bonding and suicidality in pregnant teenagers: a population-based study in southern Brazil. Coelho FM1, Pinheiro RT, Silva RA, de Ávila Quevedo L, de Mattos Souza LD, de Matos MB, Castelli RD, Pinheiro KA. Soc Psychiatry Psychiatr Epidemiol. 2014 Feb 22. [Epub ahead of print]

A cross-sectional study of 828 pregnant teenagers revealed that prior abortion was a risk factor for a history of suicide attempts among 18 and 19 year olds, with attempted suicide rates 2.76 times higher.

Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010

Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.

Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).

Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

Abortion and mental health disorders: evidence from a 30-year longitudinal study. Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2008 Dec;193(6):444-51.

Abortion in young women and subsequent mental health. Fergusson DM, Horwood LJ, Ridder EM. Journal of Child Psychology and Psychiatry 47:1 (2006), pp 16–24

In this 25 year longitudinal study, women who had abortions had significantly higher rates of suicidal ideation than others in the cohort. 50% of those under 18 had suicidal thoughts and about one-fourth of those between the ages of 19 and 25 had suicidal thoughts.

"Deaths Associated with Pregnancy Outcome. A Record Linkage Study of Low Income Women", DC Reardon et al, Southern Medical Journal 95(8):834, August 2002

A study of 173,279 low income California women who delivered and those who aborted in 1989 were linked to death certificates over an 8 year period following the pregnancy event. Compared to women who delivered, those who had an abortion had a significantly higher age-adjusted risk of death from suicide (2.54) and an increased risk of death from all causes (1.62).

Queensland Maternal and Perinatal Quality Council Report 2013 Section 1 Maternal and perinatal mortality"

1.2.8 Suicide

"Suicide is the leading cause of death in women within 42 days after their pregnancy and between 43 days and 365 days after their pregnancy. There appears to be a significant worldwide risk of maternal suicide following termination of pregnancy and, in fact, a higher risk than that following term delivery. The potential for depression and other mental health issues at this time needs to be better

appreciated. Active follow-up of these women needs to happen. Practitioners referring women for termination of pregnancy or undertaking termination of pregnancy should ensure adequate follow up for such women, especially if the procedure is undertaken for mental health concerns."

"Suicides after pregnancy in Finland, 1987-94: register linkage study, M. Gissler et. al.. Br. Medical Journal 313: 1431. Dec 7.1996

A Finnish study of women who committed suicide in 1987-94 within one year of a pregnancy found out that the suicide incidence associated with induced abortion was 34.7 per 100,000 postabortion women compared to 13.1 per 100,000 postmiscarriage women and 5.9 per 100/000 postpartum women and a mean annual suicide rate of 11.3 per 100/000 women generally.

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

British researchers studied the frequency of admissions for attempted suicide by pregnancy event in women aged 15-49 in South Glamorgan Health Authority from 1991-1995. The overall frequency of admissions before induced abortion was 5.0 per 1000 and after induced abortion was 8.1 per 1000; The overall frequency of admissions before delivery was 2.9 per 1000 and after delivery was 1.9 per 1000. The authors concluded that, "the increased risk of suicide after an induced abortion may be a consequence of the procedure itself (and) data suggest that a deterioration in mental health may be a consequential side effect of induced abortion."

"Suicide and/or abortion. 20th Meeting of the Group for Suicide Research and Prevention: The body and suicide," J. Koperschmitt et al, Psychologie Medicale 21(4): 446, March, 1989

Abortion can have an important effect on suicidality.

The relationship between suicidal thinking and dating violence in a sample of adolescent abortion patients. Ely GE, Nugent WR, Cerel J, Vimbba M. Crisis. 2011;32(5):246-53. doi: 10.1027/0227-5910/a000082.

AIMS: This paper highlights a study where the relationship between dating violence and severity of suicidal thinking was examined in a sample of 120 young women ages 14-21 seeking to terminate an unintended pregnancy. METHODS: The Multidimensional Adolescent Assessment Scale and the Conflict in Adolescent Relationships Scale was used to gather information about psychosocial problems and dating violence so that the relationship between the two problems could be examined, while controlling for the other psychosocial problems. RESULTS: The results suggest that dating violence was related to severity of suicidal thinking, and that the magnitude of this relationship was moderated by the severity of problems with aggression. CONCLUSIONS: Specifically, as the severity of participant's general problems with aggression increased, the magnitude of the relationship between dating violence and severity of suicidal thinking increased. Limitations of the study and implications for practice are discussed. Authors recommend pre-abortion screening and assessment.

"Psychopathological effects of voluntary termination of pregnancy on the father called up for military service," DuBouis-Bonneford et al, Psychologie Medicale 14(8): 1187-1189, June 1982

Several case studies are presented of 18-22 year old males who came from disadvantaged backgrounds and were recent military recruits. All had extreme depression and/or attempted suicide brought on by the news of their wives or girlfriends having had a voluntary induced abortion. The men believed that becoming a father would make them more mature or respectable and the abortion brought on feelings of self-recrimination and self-punishment.

"Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief," E. Joanne Angelo, Linacre Quarterly 59:69-80, May 1992.

Three cases of completed suicide following abortion are presented. In one case, a 22 year old woman in the military was referred for psychiatric counseling because of an eating disorder. She had made a suicide attempt two days before her scheduled abortion, feeling unable to go through with the abortion or face the rest of her tour of duty as a single parent. Her psychiatrist had advised going through with the abortion. Following the abortion, her use of cocaine and alcohol escalated and her weight continually dropped. She felt a strong desire to be united with her baby. She made several more suicide attempts and despite continuing therapy it did happen.

In another case a 23 year old woman was referred for psychiatric counseling after a suicide attempt involving a planned drunk driving incident. She and had two abortions at ages 17 and 18 while in high school. She was the youngest child of a large family and was afraid to tell her parents for fear they would "drop dead of heart attacks." (The parents were in precarious heath.) She suffered alone with the guilt for 6 years. She had planned to tell an uncle, who was a priest, what had happened, but before she could talk with him he suddenly died of a heart attack. Mourning his death as well as her earlier loses, she had planned her own death both to end her pain and to achieve a reunion with her children and her uncle.

In a third case, an 18 year old male gas station attendant shot himself and died 3 months after his father's unexpected death. Only his closest friend knew that at the time of his suicide he was despondent over his girl friend's abortion. The child had been conceived on the day of his father's death. He had formed a mental image of the child and told his friend he planned to name his son after his father. The loss of the child and what he represented was more than he was able to bear.

"Second-Trimester Abortions in the United States," D. Grimes, Family Planning Perspectives 16(6):260, Nov/Dec 1984.

Among the 92 reported deaths of women from second-trimester legal abortion, from 1972-1981, 2 were as a result of suicide.

"Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman, Association For Interdisciplinary Research Newsletter 5(4):1-8, Sept/Oct 1993.

(In a survey of 344 post-aborted women receiving services at Akron Pregnancy Services during 1988-1993, 16% reported suicidal impulses, 7% were preoccupied with death and 7% made suicide attempts.

"Adolescent Suicide Attempts Following Elective Abortion," Carl Tischler, Pediatrics, 68(5):670 (1981).

Case studies of attempted suicide on the anniversary of what would have been the aborted baby's birth.

The Psycho-Social Aspects of stress Following Abortion, Anne C. Speckhard, (Kansas City: Sheed and Ward, 1987)

Thirty women stressed by abortion were interviewed 5-10 years since abortion; 65% had suicide ideation; 31% attempted suicide.

"Therapeutic Abortion and Psychiatric Disturbance Among Women," E.R. Greenglass, Canadian Psychiatric Association Journal 21:453-459(1976).

Of 188 women interviewed, five attempted suicide about 2.6 months after abortion; there was evidence of other traumatic difficulties in addition to abortion.

"Post-Abortive Psychoses," Myre Sim and Robert Neisser, in The Psychological Aspects of Abortion, ed. D. Mall and WF Watts, (Washington D.C.: University Publications of America, 1979).

Fifty-eight women at an Israeli Government hospital volunteered the information that abortion, induced or spontaneous, had led to their referral to the psychiatric unit; seven had made serious attempts at suicide, three others had threatened suicide.

Stress. Depression and Suicide: A Study of Adolescents in Minnesota., B Garfinkel, H. Hoberman, J. Parsons and J. Walker (Minneapolis: University of Minnesota Extension Service, 1986).

A teenage girl was about 6 times more likely to have attempted suicide if she had an abortion in the last six months compared to teenagers who had not had an abortion in that period (4% vs. 0.7%). Teenage girls attempting suicide in general were more likely to be depressed, to have recently broken up with their boyfriend, and come from chaotic homes. In an interview announcing the study results Dr. Garfinkel stated that impulsiveness, anger and anxiety are the three most important factors in teenage suicide. Too often abortion is taken as either producing an alleviation of stress or being helpful to young people. I think we need to re-examine the issues. Minnesota Daily, Oct 29,1986, p. 3/16

"Mental Disorders After Abortion," B. Jansson, Acta Psychiatrica Scandinavica41:87 (1965)

In a Swedish study of 57 women with prior psychiatric problems who subsequently had induced abortions, three committed suicide as determined by long-term follow-up studies 8-13 years after their abortion. In contrast, of 195 women with previous psychiatric problems who carried their children to term, none committed suicide.

A Detailed Survey of Post-Abortion Psychological Reactions, Reardon DC. Also reprinted in Forbidden Grief, Burke T & Reardon DC.

A survey of 260 women making contact with one of several post-abortion support groups found that 34% reported suicidal feelings after their abortions, and 28% attempted suicide, with 54% of those attempting suicide more than once.

Is voluntary abortion a seasonal disorder of mood? Cagnacci A, Volpe A. Human Reproduction 2001, 16(8):1748-52.

An analysis of yearly suicide rates and abortion rates found that the suicide rate of women in Italy peaks in June, one month after the peak in abortion rates, which is in May.

RESULTS The rate of voluntary abortions showed a seasonal rhythm with an amplitude of 6.1--6.7% and peaked in May (+/-38 days). The national frequency of female suicides, obtained from the same ISTAT database, showed a similar rhythm, with an amplitude of 11.1% and maximal rate in June (+/-37 days).

Abortion Related Suicide: Case Studies

For information regarding a well publicized case of suicide following abortion, see Emma Beck and also Suicide - Case Studies)

Other Suicide Papers of Interest

Suicidal mothers. J Inj Violence Res. 2011 Jul;3(2):90-7. doi: 10.5249/jivr.v3i2.98. Gentile S.

BACKGROUND: Epidemiological research has demonstrated that suicidal ideation is a relatively frequent complication of pregnancy in both developed and developing countries. Hence, the aims of this study are: to assess whether or not pregnancy may be considered a period highly susceptible to suicidal acts; to recognize potential contributing factors to suicidal behaviors; to describe the repercussions of suicide attempts on maternal, fetal, and neonatal outcome; to identify a typical profile of women at high risk of suicide during pregnancy.

METHODS: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, Scopus, and Google Scholar databases. Search terms were: "pregnancy", (antenatal) "depression", "suicide". Searches were last updated on 28 September 2010. Forty-six articles assessing the suicidal risk during pregnancy and obstetrical outcome of pregnancies complicated by suicide attempts were analyzed, without methodological limitations.

RESULTS: Worldwide, frequency of suicidal attempts and the rate of death by suicidal acts are low. Although this clinical event is rare, the consequences of a suicidal attempt are medically and psychologically devastating for the mother-infant pair. We also found that common behaviors exist in women at high risk for suicide during pregnancy. Review data indeed suggest that a characteristic profile can prenatally identify those at highest risk for gestational suicide attempts.

CONCLUSIONS: Social and health organizations should make all possible efforts to identify women at high suicidal risk, in order to establish specific programs to prevent this tragic event. The available data informs health policy makers with a typical profile to screen women at high risk of suicide during pregnancy. Those women who have a current or past history of psychiatric disorders, are young, unmarried, unemployed, have incurred an unplanned pregnancy (eventually terminated with an induced abortion), are addicted to illicit drugs and/or alcohol, lack effective psychosocial support, have suffered from episodes of sexual or physical violence are particularly vulnerable.

"Suicide After Ectopic Pregnancy," (letter) J. Farhi et al. New England Journal of Medicine, March 10,1994, p. 714

A study of Israeli women found that among 160 women treated for ectopic pregnancy 3.75% attempted suicide within one year thereafter and 0.625% committed suicide compared to a matched non-pregnant population rate of 0.04-0.06% and 0.002% respectively.

Absolute Risk of Suicide After First Hospital Contact in Mental Disorder. Nordentoft M, Mortensen PB; Pedersen CB. Arch Gen Psychiatry. 2011;68(10):1058-1064.

Participants A total of 176 347 persons born from January 1, 1955, through December 31, 1991, were followed up from their first contact with secondary mental health services after 15 years of age until death, emigration, disappearance, or the end of 2006. For each participant, 5 matched control individuals were included.

Main Outcome Measures Absolute risk of suicide in percentage of individuals up to 36 years after the first contact.

Results Among men, the absolute risk of suicide (95% confidence interval [CI]) was highest for bipolar disorder, (7.77%; 6.01%-10.05%), followed by unipolar affective disorder (6.67%; 5.72%-7.78%) and schizophrenia (6.55%; 5.85%-7.34%). Among women, the highest risk was found among women with schizophrenia (4.91%; 95% CI, 4.03%-5.98%), followed by bipolar disorder (4.78%; 3.48%-6.56%). In the nonpsychiatric population, the risk was 0.72% (95% CI, 0.61%-0.86%) for men and 0.26% (0.20%-0.35%) for women. Comorbid substance abuse and comorbid unipolar affective disorder significantly increased the risk. The co-occurrence of deliberate self-harm increased the risk approximately 2-fold. Men with bipolar disorder and deliberate self-harm had the highest risk (17.08%; 95% CI, 11.19%-26.07%).

Conclusions This is the first analysis of the absolute risk of suicide in a total national cohort of individuals followed up from the first psychiatric contact, and it represents, to our knowledge, the hitherto largest sample with the longest and most complete follow-up. Our estimates are lower than those most often cited, but they are still substantial and indicate the continuous need for prevention of suicide among people with mental disorders.

Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients. Suokas JT1, Suvisaari JM2, Grainger M3, Raevuori A4, Gissler M5, Haukka J6. Gen Hosp Psychiatry. 2014 Jan 13. pii: S0163-8343(14)00005-X. doi: 10.1016/j.genhosppsych.2014.01.002. [Epub ahead of print]

We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths.

Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

Accidents

"Pregnancy-associated deaths in Finland 1987-1994-definition problems and benefits of record linkage," M Gissler et al, Acta Obstet Gynecol Scand 76:651-657, 1997

A Finnish register linkage study identified all deaths that occurred up to 1 year after an ended pregnancy. The mortality rate was 27 per 100,000 births, and 101 per 100.000 abortions. Compared to women of reproductive age with no pregnancy (1.0), the risk of death from an accident following abortion was 2.08 (1.03-4.20, 95% CI) compared to 0.49 (0.18-1.33, 95% CI) for childbearing women.

"Suicide Deaths Associated with Pregnancy Outcome: A Record Linkage Study of 173,279 Low Income American Women," D Reardon et al, Clinical Medicine & Health Research clin med/2001 030003 v1 (April 25, 2001)

State funded medical insurance records identifying all paid claims for abortion or delivery in 1989 were linked to the state death certificate registry in a population of low income women in California. Compared to women who delivered (1.0), those who aborted had a significantly higher adjusted risk of dying from accidents (1.82).

"Sexual Experience and Drinking Among Women in a U.S. National Survey," A Klassen, S Wilsnack, Archives of Sexual Behavior 15(5): 363-392, 1986; "Women's Drinking and Drinking Problems: Patterns from a 1981 U.S. National Survey," R Wilsnack, S Wilsnack, A Klassen, Am J Public Health 74:1231-1238, 1984.

In a random national survey of 917 U.S. women in 1981, 4% of the abstainers and 5% of lighter drinkers reported non-spontaneous abortion compared to 13% for moderate drinkers, 13% for heavier drinkers, and 6% for women who had ever been pregnant. The same survey found that 17% of all women drinkers said they had driven vehicles while drunk or high at least once in the preceding year including 27% of moderate drinkers and 45% of heavier drinkers.

"Alcohol-Related Relative Risk of Fatal Driver Injuries in Relation to Driver Age and Sex," Paul L Zodor, J Stud Alcohol 52:302-310, 1991.

A study by the Insurance Institute for Highway Safety based on 1986-87 data found that each 0.02% increase in blood alcohol content nearly doubles the risk of being in a single vehicle fatal crash. The risk of a female 21-24 years of age at a blood alcohol level of 0.05%- 0.09% of dying in a single vehicle accident was reported to be 35 times higher compared to a blood level of 0.00%- 0.01%

"Adolescent Suicide Attempts Following Elective Abortion: A Special Case of Anniversary Reaction," CL Tishler, Pediatrics 68 (5):670-671, 1981

A 17 year old upper middle class white girl attempted to kill herself while driving under the influence of alcohol and 29 Bufferin tablets. She smashed her car into a bridge overpass repeatedly, damaging her car beyond repair. She had had an elective abortion approximately seven months prior to the suicide attempt. During the abortion process she calculated the birth date had the fetus been allowed to come to term. The date of the accident was on the perceived birth date of the child.

Repeat Abortions

"Abortion Surveillance-United States, 1997," MMWR Vol 49, No.SS-11, December 8, 2000.

The Centers for Disease Control reported that 48% of U.S. women had repeat abortions in 1997 with 28.4% reporting a second abortion, 12% reporting a third abortion, and 7.6 % reporting a fourth or more abortion.

"Abortion Surveillance-United States. 1992," L.M. Koonin et. al., MMWR 45, No. 55- 3: 1, May 3,1996

For 1992,1,359/145 legal abortions were reported to CDC, representing a 2.1% decline overall, from the number reported for 1991. 45.8% of women were repeating abortion with 26.9% reporting a second abortion, 10.8% (third), and 6.4% having 4 or more abortions. The abortion ratio was more than nine times greater for unmarried women than for married women. The abortion rate for white women was 15 per 1000 white women compared to 41 per 1000 black women and 32 per 1000 Hispanic women.

"The epidemiology of preterm birth," Judith Lumley, Bailliere's Clinical Obstetrics and Gynaecology 7(3): 477, Sept, 1993

A study of more than 300,000 first singleton births in Victoria, Australia from 1986-1990 found that 6.5 per 1000 births were 20-27 gestational weeks where the woman had one prior induced abortion compared to 10.3 per 1000 births (two prior induced abortions) and 23.1 per 1000 births (three or more prior induced abortions). The rate of preterm births at 32-36 gestational weeks was 54.1 per 1000 births where women had one prior induced abortion, 78.7 per 1000 births where women had two prior induced abortions and 120.1 per 1000 births where women had three or more prior induced abortions. For purposes of analysis women who had experienced both induced and spontaneous abortions were excluded.

"Pregnancy Decision Making as a Significant Life Event: A Commitment Approach," J. Lydon, et. al. J. Personality and Social Psychology 71(1): 141-151, 1996

Women with prior abortions were found to be more committed to a current pregnancy compared to women with no prior abortion history. Initial commitment predicted subsequent depression, guilt, and hostility among those who aborted.

"Post-Abortion Syndrome as a Variant of Post Traumatic Stress Syndrome," Robert C. Erikson, Association for Interdisciplinary Research Newsletter, 3(4) :5-8, Winter, 1991.

Repeat abortion will, to a degree, reflect a re-creation of the social, emotional and relational circumstances present before the initial abortion. Repeat abortions frequently are re-enactments of conflict between drives, and have little to do with ego functions such as learning.

===The compulsion to repeat the trauma. Re-enactment, revictimization, and masochism," PA van der Kolk, Psychiatric Clinics of North America 12(2): 389-411, June, 1989

Trauma can be repeated in behavioral, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering. Previously traumatized people tend to return to familiar patterns, even if they cause pain.

"Special Issue on Repeat Abortion,"Association for Interdisciplinary Research Newsletter 2(3): 1-8, Summer 1989.

Review of the literature on the incidence and effects of repeat abortions. It including moral and social deterioration, communication breakdown, decline in religious affiliation, emotional or psychological conflicts, replacement pregnancy, self-punishment, abortion as birth control and the evangelization of abortion.

"Repeat Abortion: Blaming the Victims," B. Howe, R. Kaplan, and C. English, American Journal Public Health, 69(12):1242-1246, December 1979,

Repeaters were found to be more sexually active than first-timers, thus increasing their risk of unwanted pregnancy even though they used contraception more than initial aborters.

"Women's Health and Abortion. I. Deterioration of Health Among Women Repeating Abortion," Association for Interdisciplinary Research Newsletter 5(1):1-8, Winter, 1993.

This article identifies 32 areas of social, medical and psychological health that deteriorate as induced abortion is repeated.

"Repeat Abortion: Is It A Problem?," C. Berger, D. Gold, D. Andres, P. Gillett and R. Kinch, Family Planning Perspectives, 16(2):70-75, March/April 1984,

Medical and counseling personnel are troubled by women who come back to their facilities for a repeat abortion. Counseling deficiencies, possible negative media coverage, unclear long-term effects on future child bearing are some of the reasons for concern. This study of Canadian women found that repeaters were more tolerant of abortion than women having a first abortion; they also had intercourse more frequently than first-time abortion patients [average 11 times per month versus 8 times per month]. Women having repeat abortions were slightly more likely to have been using contraceptives at the time they became pregnant. Repeaters described their relationships as being less satisfactory than first-time patients. More repeaters than first-time patients said they had made the decision by themselves [45 percent vs. 33 percent]. Repeaters reported fewer physical complaints but had more difficulty sleeping.

"Third Time Unlucky: A Study of Women Who Have Had Three or More Legal Abortions," Colin Brewer, Journal Biosocial Science, 9:99-105(1977).

Of 50 women having their third or subsequent legal abortion, 23 were pregnant because they claimed their contraceptive method had failed; 24 because of erratic contraceptive use; and three changed their minds after initially welcoming the pregnancy. The study concluded there was a significant relationship between erratic use and a history of consultation for psychiatric reasons, and suggested that unsettled relationships and low educational status also related to erratic use. There was no evidence that abortion was deliberately used as a method of birth control.

"Repeaters-Different or Unlucky?," C. Berger and D. Gold, et al., in P. Sechder, ed.. Abortion: Readings and Research. (Toronto: Butterworth Press, 1981).

Proceeding of the Conference on Psycho-Social Factors in Transnational Family Planning Research, W. Pasini and J. Kellerhals (Washington: American Institute for Research, 1970), 44-54.

A threefold increase in previous psychiatric consultations was found in women seeking repeat abortions compared with maternity patients.

Beyond Choice. The Abortion Story No One Is Telling, Don Baker, (Portland: Multonomah Press, 1985).

A powerful narrative true story of a woman who had three abortions. Demonstrates the moral and social deterioration in her life until she commits her life to Jesus Christ. Excerpts reprinted in the April/May 1987 issue of The Christian Reader.

"The Repeat Abortion Patient," Judith Leach, Family Planning Perspectives, 9(1):37-39, January/February 1977

Repeat abortion patients are more often dissatisfied with themselves, more often perceive themselves as victims of bad luck, and more frequently express negative feelings toward the current abortion than women who are obtaining abortions for the first time.

"Pilot Surveys of Repeated Abortion," E. Szabady and A. Klinger, International Mental Health Res. Newsletter 14:6(1972).

In a study of Hungarian women those women having a repeat abortion were less likely to be in a happy marriage and were more likely to have an abortion independently of their partner.

"Emotional Distress Patterns Among Women Having First or Repeat Abortions," Ellen Freeman, Obstetrics and Gynecology 55(5):630-636, May 1980

Repeat abortion patients showed significantly higher distress scores on interpersonal sensitivity, paranoid ideation, phobic anxiety and sleep disturbance, compared with controls. Repeaters also showed a trend in higher scores in somatization, hostility and psychoticism.

"Repeat Abortions-Why More?," Christopher Tietze, Family Planning Perspectives, 10(5):286-288, September/October 1978,

Repeaters tended to have more frequent intercourseless satisfying relationships, and more difficulty sleeping. They were less likely to live with their partners. (Women with prior abortion were almost 4 times more likely to have repeat abortion compared to women having an abortion for the first time.

"Women Who Obtain Repeat Abortion: A Study Based Upon Record Linkage," P. Steinhoff, R. Smith, J. Palmore, M. Diamond and C. Chung, Family Planning Perspectives11(1):30-38 Jan/Feb 1979.

Study noted the proportion of induced abortions that are repeat procedures increases over time. Shortcomings in making contraceptives available were cited as the reason. The women's own reporting of repeat abortions was about 20% lower than the actual number determined by record linkage.

"Abortion Recidivism - A Problem in Preventative Medicine," Joseph Rovinsky, Obstetrics and Gynecology, 39(5) :649-659, May 1972.

There was a lack of contraceptive motivation in repeaters as an etiologic basis for recurrent unwanted pregnancy; the article cites a case of 17 prior abortions.

"First and Repeat Abortions: A Study of Decision-Making and Delay," M.Bracken and S. Kasi, Journal Biosocial Science, 7:473-491 (1975).

Women having a repeat abortion took less time than those having a first abortion; women repeaters were more likely to report medical problems as a reason for contraceptive failure, compared with first-abortion women who were more likely to admit to carelessness. Women having repeat abortions were more likely to mention problems with the contraceptive, while those having first abortions were more likely to have failed to anticipate intercourse. Fewer women repeaters were pregnant by husbands, and unmarried women having repeat abortions had been in relationships of shorter duration than unmarried women having first abortions. Women having first abortions were generally more concerned with moral and ethical issues, worry over the procedure itself and the possibility of complications than were women having repeat abortions, who generally showed more desire to have children.

"Characteristics and Contraceptive of Abortion Patients," S. Henshaw, J. Silverman, Family Planning Perspectives 20(4): 158, July/August, 1988.

A national survey of 9/480 women at U.S. abortion facilities in 1987 by the Alan Guttmacher Institute found that 42.9% of those women surveyed had repeat abortions: 26.9% (second abortion); 10.7% (third abortion); 5.3% (fourth abortion or more).

"Reflections on repeated abortions: The meanings and motivations," Susan Fisher,Journal of Social Work Practice 2(2):70-87, May 1986.

The author, a social worker at a London hospital, interviewed more than 1,000 women with crisis pregnancies. Several in-depth case histories are reported. Repeaters were variously described as "chaotic, childlike" (a woman who had 15 abortions in 23 years); "doll-like" (history of numerous suicide attempts); holding "anxiety, rage and confusion" over mother's mental illness; "a delicate child-woman 16 years old with very little human warmth, depressed"; "cold and detached with little feeling"; "a suicidal woman with a history of three abortions, a first suicide attempt at age 15 and the most recent one at age 27, only six weeks ago/drug overdoses, anorexia nervosa and hospitalization for psychiatric treatment." Women had shallow relationships with putative fathers and seemed to select male partners known to be objectionable to the repeaters' parents. Unconscious conflicts and lack of nurturing in family of origin were typical. Relationships with male partners usually terminated following abortion. Repeaters were irregular in keeping appointments and in completing therapy. Some called their unborn child "monster." The author concluded that repeat abortions are both an individual and social problem with physical and emotional suffering as well as a strain on medical and counseling resources.

"A Case Study of Reproductive Experience of Women Who Have Had Three or More Induced Abortions," Elizabeth Lincoln, Ph.D. Dissertation, University of Pittsburgh (1982); Dissertation Abstracts International 44(4), October 1983, Order No. DA 8318205.

A study of eight women with three or more abortions found that women had a sex role orientation less modernistic than effective contraceptors, feared health effects, had problematic relationships with partners ,family of origin relationships were characterized by lack of affection and probable subsequent influence on adult relationships, interest in parenting and sexuality. Anger at perceived lack of male interest in contraception combined with poor communication and changing sex role expectations seemed to create conflicts increasing the likelihood of unwanted pregnancy.

"Incidence of Repeat Abortion. Second-Trimester Abortion. Contraceptive Use and Illness within a Teenage Population," Rena Bobrowsky, Ph.D. Dissertation, University of Southern California (1986); Dissertation Abstracts International 47(9), March 1987. Copies available from Micrographics Dept, Doheny Library, USC, Los Angeles, CA 90069-0182.

In a study of teenage abortion, 404 women were followed through medical records over a five-year period. Some 38% had a previous abortion and 18% had two abortions within the same year. Repeat aborters were found to have less stable relationships with their partners, more likely to show greater use of contraception post-abortion and have more medical problems that might preclude the safe use of more reliable contraceptives.

"Association of Induced Abortion with Subsequent Pregnancy Loss," A. Levin, S. Schoenbaum, R. Monson, P. Stubbelfield, K. Ryan, JAMA 243:2495(1980).

Women who had two or more induced abortions were 2.7 times more likely to have future first-trimester spontaneous abortions (miscarriage) and 3.2 times more likely to have a second-trimester incomplete abortion than were women with no history of induced abortion.

"Repeat Abortions Increased Risk of Miscarriage. Premature Births and Low Birth Weight Babies," Family Planning Perspectives, 1(1):39-40, January/February 1979.

Repeated abortion was associated with a 2- to 2.5-fold increase in the rate of low birth weight and short gestation when compared with either one abortion or one live birth.

"Ectopic Pregnancy and Prior Induced Abortion," A. Levin, S. Schoenbaum, P. Stubblefield, S. Zimicki, R. Monson and K. Ryan, American Journal of Public Health 72(3):253- 256, March 1982.

In a study at Boston Hospital for Women conducted from 1976-1978, the relative risk of ectopic pregnancy was found to be 1.6 for women with one prior abortion and reduced to 1.3 after control of confounding factors. The relative risk for two or more abortions was 4.0 for women with two or more prior induced abortions, which was reduced to 2.6 after control of confounding factors.

"Patterns of Alcohol and Cigarette Use in Pregnancy," J. Kuzma and D. Kissinger, Neurobehavorial Toxicology and Teratology 3:211-221(1981)

In a California study of more 12,000 women during 1975-1977, of those having a history of two or more abortions, virtually all (98.5%) consumed alcohol throughout the entire 9 months of a subsequent pregnancy and at higher levels, i.e., up to 3 oz. per day than any of the other categories studied.

"Low Birth Weight in Relation to Multiple Induced Abortions," M.T. Mandelson, C.B. Maden, J.R. Daling, Am.J. Public Health, 82 (3):391-394, March, 1993.

In a Washington State Study of 6541 women who delivered a child between 1984-87, 41.6% of the women smoked during this pregnancy if they had a history of 4 or more induced abortions compared with 31.0% smokers (2 prior abortions), 28.1% smokers (1 prior abortion), or 18.0% smokers (no prior abortions).

"The Concept of the Repetition Compulsion," E. Bibring, Psychoanalytic Quarterly12: 486,507 (1943).

"Perhaps the most frequent way of taking the compulsive repetition into the personality is through sexualization when the repetition compulsion becomes linked with masochistic drives."

"Repeat Abortion: Is it a Problem?," C. Berger, D. Gold, D. Andres, P. Gillett and R. Kinch, Family Planning Perspectives 16(2):70-75, March/April 1985.

Interviews with medical and counseling personnel at abortion facilities regarding women who return for repeat abortions reveal counseling deficiencies, possible negative media coverage and unclear long-term effects on childbearing as some of the reasons for concern.

"Abortion Work: A Study of the Relationship Between Private Troubles and Public," Kathleen Marie Roe, Ph.D. Dissertation, University of California, Berkeley (1985).

In a study of 90 abortion facility workers in the San Francisco area, over 95% expressed discomfort and surprise at repeaters.

"Contraception and repeat abortion," M. Shepard and M. Bracken, Journal of Biosocial Science 11:289-302 (1979).

In a study of women at Yale-New Haven Hospital during 1974-1975, women having repeat abortions were significantly more likely to be divorced than women having first abortions. Women having repeat abortions were more likely to be on public welfare than women having first abortions (38% vs. 25%).

"Dysphoric reactions in women after abortion," K. Franco, M. Tamburrino, N. Campbell, J. Pentz and S. Jurs, J. of the American Medical Women's Association 44(4): 113, July/August 1989.

Women reporting multiple abortions had more often considered suicide and scored higher on borderline personality pathology and depression. Some 40% of the 71, women studied reported anniversary reactions. None of the women aborting sought psychotherapy after the procedure.

"The First Abortion And The Last? A Study of the Personality Factors Underlying Failure of Contraception," P. Niemela, P. Lehtinen, L. Rauramo, R. Hermansson, R. Karjalienen, H. Maki and C-A Stora, International Journal of Gynaecol. Obstet. 19:93- 200(1981).

A Finnish study compared women seeking their second abortion to women who had successfully contracepted after their first abortion Repeaters rated lower in control of impulsivity, emotional balance/realism, self-esteem and stability of life as well as reflecting a lesser capacity for integrated personal relationships. Repeating women more often had a history of broken legalized or non-legalized partner relationships. Partners of repeaters took less responsibility for contraception even though the women had left them greater responsibility in this respect. Solidarity with partners was weaker in the repeaters even though the women felt greater admiration for their partners. Repeating women were less mature and more impulsive, indicating a "split" mechanism and immaturity of ego development which verged on a borderline level disturbance.

"Single and repeated elective abortions in Japan: a psychosocial study," T Kitamura et al, J Psychosom Obstet Gynecol 19:126-134, 1998.

A Japanese study found that women with two or more abortions had a longer dating period, were likely to have a non-arranged marriage, smoked more cigarettes, had an early maternal loss experience or a lower level of maternal care during childhood compared to women with women with a first abortion.

"Mourning and Guilt Among Greek Women Having Repeated Abortions," D. Naziri, A. Tzararas, Omega 26(2): 137-144,1992-93

In a clinical study of the bereavement process of Greek women following one or more induced abortions, it was concluded that strong identifications with both father and mother images were present in the women. It was concluded that abortion might be a replacement/displacement of a reparatory character in relation to the "family romance" of each woman. In several cases of repeated abortion, mourning and guilt not only refer to a murdered and lost person of the fetus, but also principally to the death and loss of an object of ambiguous desire.

"The Repeat Abortion Patient," Judith Leach, Family Planning Perspectives 9(1):37, January/February 1977.

In a study of repeat abortion patients in the Atlanta area, 21% of the repeat aborters vs. 8% of the first-time aborters reported they had no religious affiliation. The disparity was especially striking in the private clinic population, among whom eight times as many repeat abortion patients as first-time aborters said they had no religious affiliation (20% vs. 2.5%).

"Risk of Admission to Psychiatric Institutions Among Danish Women Who Experienced Induced Abortion: An Analysis Based Upon Record Linkage," Ronald Somers, Ph.D. Dissertation, University of California, Los Angeles (1979), Dissertation Abstracts International, Order No. 7926066.

A study of the Danish Central Psychiatric Register of all women who had been admitted between April 1,1973 and December 31/1975 found that psychiatric admissions increased with the self-reported number of past abortions (no abortions, 1.90%; one abortion, 3.4%; two abortions, 4.0%; three abortions, 6.0%). No increase was observed as number of live births increased; women aged 35-39 with two or more abortions had higher rates of psychiatric admission than younger women with two or more abortions.

"Increased Reporting of Menstrual Symptoms Among Women Who Used Induced Abortion," L.H. Roht, M.A. Fanner, H. Aoyama and E. Fonner, Am. Journal of Obstetrics and Gynecology 127:356-362, February 15,1977.

A study of 3,222 female residents in Southern Japan in 1971, based upon a mailed questionnaire, found that women perceived menses to occur more frequently and be of shorter duration as the number of reported prior abortions increased. "Nervousness" increased as number of prior abortions increased: 150/1,000 women (no prior abortion); 228/1,000 (one prior abortion); 256/1/000 (two or more prior abortions).

"Induced Terminations of Pregnancy: Reporting States," 1988, K. Kochanek, Monthly Vital Statistics Report 39(12): 1-32 (Suppl.), April 30,1991, Table 9, p. 20

In 1988 among the 14 reporting states, 297,251 induced abortions were performed. Some 25.5% had a second abortion, 9.0% had a third abortion and 8.7% had a fourth abortion or more. Overall, 44.1% were repeating abortion, 39.6% of white women were repeating abortion vs. 53.0% of black women.

"The Social and Economic Correlates of Pregnancy Resolution Among Adolescents in New York by Race and Ethnicity: A Multivariate Analysis," Theodore Joyce, Am. J. Public Health78(6):626-63, (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 pregnancies to term. Married adolescents were more likely to carry a pregnancy to term than unmarried adolescents.

Eating Disorders

"Self-Induced Abortion in a Bulimic Woman," C.M. Bulik et. al., Int'l J. Eating Disorders 15(3): 297-299,1994.

A case of a woman was presented who deliberately induced abortion via self-imposed starvation and vigorous exercise. She had a history of severe obsessive-compulsive and narcissistic personality disorders as well as a lifelong pattern of denial of affect and illness.

"The Impulsivist: a multi-impulsive personality disorder," J.H. Lacey et. al., Br. J. Addiction 81: 641-649,1986.

There are strong associations between eating disorders, substance abuse, impulse control, self-harm and personality disorders.

Post-Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991) 110.

In a 1990 study of 68 religiously oriented (primarily Evangelical and Lutheran) 10-15 years post-abortion, found 8.8% of the women identified themselves as having suffered from eating disorders (bulimia and anorexia). Of these women, 66.7% had increased problems with their eating disorder after their abortion. And additional 51.5% indicated they had problems with overeating and 23.5% expressed problems of under eating. Overeating behavior increased 54.3% following their abortion and under eating behavior increased 50.1% after their abortion.)

"Pregnancy : Outcome and Impact on Symptomatology in a Cohort of Eating- Disordered Women," MA Blais et al, Int J Eat Disord 27:140-149, 2000

There was an elevated incidence of eating disorders among women with therapeutic abortions which was not found among women with live births or spontaneous abortions.

"Recurrent Abortions in a Bulimic: Implications Regarding Pathogenesis," R.S. El- Mallakh, A.Tasman, Intl. J. Eating Disorders 10(2):215-219,1991.

A woman with severe bulimia used repeated pregnancies and abortions to achieve the same calming function as repeated binge eating and vomiting. It was suggested that her behavior was compatible with the view that bulimics use their own bodies as transitional objects and that the cycle of incorporation and expulsion is central to affect regulation. The woman was suicidal and preoccupied with death.

The Psycho-Social Aspects of Stress Following Abortion, Anne C. Speckhard, (Sheed and Ward: Kansas City, 1987)

In a study of 30 women who were stressed by abortion, 23 percent reported extreme weight gain, generally defined by the subjects as a 20-pound weight gain or more. Extreme weight gain was usually attributed to increased eating to calm oneself. Extreme weight loss was reported by 30 percent of the sample; 23 percent classified themselves as experiencing a period of anorexia nervosa. This was self defined, although many subjects reporting anorexia included evidence such as loss of 25 percent of body weight, cessation of menses, hospitalization and/or clinical diagnosis of anorexia nervosa.

Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 24.

In a study of 252 women who were members of Women Exploited by Abortion, two women were reported to suffer from anorexia nervosa which they attributed to their abortions. At least one woman suffered from excessive weight gain after her abortion, as she tried to bury her guilt in food.

"Ritual Mourning in Anorexia Nervosa," R.K. McAll and F.M. McAll, The Lancet,August 16,1980, p. 368.

Of 18 patients with anorexia nervosa treated in the hospital without improvement, 15 experienced total relief of symptoms following a process of ritual mourning for deceased family members who had not previously been mourned. Two patients were male. In 17 of the cases, family histories revealed a total of 25 violent deaths or deaths by suicide, five terminations of pregnancy for non-medical reasons and eight miscarriages. In one case a 17-year-old girl had anorexia nervosa since age 14 and had been hospitalized three times. At the time of referral she was unable to get out of bed. Her mother had an earlier pregnancy aborted. Without the knowledge of the patient, who was considered too ill to be involved/the parents went through a form of service in a church for the aborted child. When the patient was later told about this she admitted an awareness of the existence of her unborn "sister" but said she had not mentioned this for fear of being locked up in a mental hospital. She was immediately able to get up and in a very short time was successfully attending a college. In another case, a man of 41, had first been diagnosed as having anorexia at age 22. At the time of the examination he was not only anorectic but also severely depressed. On close questioning he admitted to having precipitated the abortion of his wife's first child. Within a week of his admission, and after following through with a process of mourning for and committal of the child, he was no longer depressed and was eating normally. The authors suggest that "hidden guilt, either in the patient or in a close member of the family, or lack of adequate recognition for a lost member of the family may be a causative factor. Providing a means of repentance, mourning for and committal of the dead can lead to dramatic relief of symptoms in the affected person, in addition to the emotional release experienced by other involved members of the family."

"Value of Family Background and Clinical Features as Predictors of Long Term Outcome in Anorexia Nervosa," H. Morgan and G.F.M. Russell, Psychological Medicine 5:355-37, (1975).

A disturbed relationship between the patient and other members of the family, and premorbid personality difficulties are predictors of unfavorable outcome.

"Diseases of the Nervous System," Asbury, McKhana, McDonald, Vol. 1(Philadelphia: WB Saunders, 1986)

Anorexia nervosa is a disorder usually affecting affluent young women 14-17 years of age but occasionally found even earlier or even up to age 40-50. The person is preoccupied with body weight, under eats even to possible starvation or self-destruction, and becomes depressed, very impatient and irritable. Anorexia nervosa is frequently associated with distressed and disturbed family relationships, suggesting a psychogenic aspect. Some have suggested that anorexia nervosa represents an aspect of affective disorder. Extreme perfectionism and self-criticism are often common traits. Mortality rates range from 4-16 percent depending on the study.

"A Study of 56 Families with Anorexia Nervosa," R.S. Kalucy, British Journal of Medical Psychology 50:381-395(1977).

A central feature was the threat to family values and stability which such events posed. Deaths and illnesses often involved waiting and then mechanisms of identification seemed important. For example/a daughter's illness was preceded by identification with the loss of another sister from leukemia; in another a father's wasting from achalasis.

"Avoidance of Anxiety and Eating Disorders," J. Keck and M. Fiebert, Psychological Reports 58: 432-434 (1986)

Female patients with eating disorders appeared to use an obsession with food and weight as a form of escape.

Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients. Suokas JT1, Suvisaari JM2, Grainger M3, Raevuori A4, Gissler M5, Haukka J6. Gen Hosp Psychiatry. 2014 Jan 13. pii: S0163-8343(14)00005-X. doi: 10.1016/j.genhosppsych.2014.01.002. [Epub ahead of print]

We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths. Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

Reproductive health outcomes in eating disorders. Linna S, Raevuori A, Haukka J, Suvisaari JM, Suokas JT, Gissler M. Int J Eat Disord. 2013 Dec;46(8):826-33. doi: 10.1002/eat.22179. Epub 2013 Sep 2.

OBJECTIVE: Eating disorders are common psychiatric disorders in women at childbearing age. Previous research suggests that eating disorders are associated with fertility problems, unplanned pregnancies, and increased risk of induced abortions and miscarriages. The purpose of this study was to assess how eating disorders are related to reproductive health outcomes in a representative patient population. METHOD: Female patients (N = 2,257) treated at the eating disorder clinic of Helsinki University Central Hospital during 1995-2010 were compared with matched controls identified from the Central Population Register (N = 9,028). Patients had been diagnosed (ICD-10) with anorexia nervosa (AN), atypical AN, bulimia nervosa (BN), atypical BN, or binge eating disorder (BED, according to DSM-IV research criteria). Register-based data on number of children, pregnancies, childbirths, induced abortions, miscarriages, and infertility treatments were used to measure reproductive health outcomes. RESULTS: Patients were more likely to be childless than controls [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.62-2.13, p < .001]. Pregnancy and childbirth rates were lower among patients than among controls. BN was associated with increased risk of induced abortion compared to controls (OR 1.85; 95% CI 1.43-2.38, p < .001), whereas BED was associated with elevated risk of miscarriage (OR 3.18; 95% CI 1.52-6.66, p = .002). DISCUSSION: Reproductive health outcomes are compromised in women with a history of eating disorders across all eating disorder types. Our findings emphasize the importance of reproductive health counseling and monitoring among women with eating disorders.

Posttraumatic Stress Disorder Symptoms and Food Addiction in Women by Timing and Type of Trauma Exposure Susan M. Mason, PhD, Alan J. Flint, DPH, MD, Andrea L. Roberts, PhD, et al. JAMA Psychiatry. Published online September 17, 2014. doi:10.1001/jamapsychiatry.2014.1208

While this study did not report on abortion, it did find that "The prevalence of food addiction increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6-7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (prevalence ratio, 2.68; 95% CI, 2.41-2.97). Symptoms of PTSD were more strongly related to food addiction when symptom onset occurred at an earlier age."

Sexual Promiscuity and Casual Sex

"Abortion and the sexual lives of men and women: Is casual sexual behavior more appealing and more common after abortion?" Coleman PK, Rue VM, Spense M, Coyle CT. Int J Clin Health Psychol, Vol. 8, Nº 1, 2008

ABSTRACT. Previous research indicates that abortion increases risk for experiencing difficulties maintaining committed relationships, sexual dysfunction, and psychological prooblems. In the present descriptive study, associations between abortion and attitudes and behaviors associated with casual sexual activity were examined after controlling for family of origin, socio-demographic, reproductive history, and sexual history variables. The National Health and Social Life Survey (NHSLS), a multistage probability sample of 3,432 men and women between the ages of 18 and 59 was the data source. Among women, abortion was associated with more positive attitudes toward sex with strangers and with being forced to have sex; whereas the male experience of a partner abortion was correlated with attitudes endorsing sex with more than one partner and with strangers. Abortion among men and women predicted disagreement relative to restricting sexual activity to love relations, more sex partners in the last year, and endorsement for having sex with an acquaintance. Male experience of a partner abortion also increased the likelihood of having sex with a friend. Finally, abortion predicted engagement in various impersonal sexual behaviors over the previous 12 months among males and females. Strengths of the study include the large nationally representative data source and employment of a variety of control variables.

National Study of Family Growth-1995, Cycle V, U.S. Department of Health and Human Services, National Center for Health Statistics, 1997

A national U.S. study of ever-pregnant women over age 35 found that women with no history of abortion had fewer sex partners before marriage (3.4 v. 9.2), and fewer lifetime sex partners (4.4 v. 12.7) compared to women with a history of abortion. Excluding women who had no sex partners before marriage, women with two or more abortions were likely to have more sex partners after marriage, (5.0), compared to women with a single abortion (2.0), or women with no history of abortion (2.0).

Forbidden Grief.The Unspoken Pain of Abortion, Theresa Burke and David Reardon, Springfield, IL:Acorn Books, 2002.

In an Elliot Institute survey of 260 women who were involved in faith-based postabortion counseling or advocacy groups, 42.7% said they became promiscuous within one month following their abortion; 51.6% said they became promiscuous within 6 months following their abortion; 46.6% said they developed an aversion to sex or became sexually unresponsive within one month, and 38.5% said they developed an aversion to sex or became sexually unresponsive within 6 months following their abortion.

Psychosocial Sequelae of Therapeutic Abortion in Young Unmarried Women, Judith Wallerstein et al, Arch Gen Psychiatry 27:828, 1972.

In-depth interviews of 22 women under 22 years of age who had an abortion At a Planned Parenthood facility in northern California in 1969-1970 at 5-7 months postabortion, 9 reported a newly begun promiscuous pattern in relationships with men following their abortion.

Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey, L Gsellman, Association for Interdisciplinary Research in Values and Social Change Newsletter 5(4) 1-8, 1993.

In a self-reported questionnaire survey of 344 postabortion women with a mean age of approximately 18 years at the time of their abortion and who were receiving general pregnancy related services (including 28% who had presented for post abortion counseling) , 9% of the women reported sexual promiscuity, 14% reported frigidity, and 23% reported a desire to get pregnant again as postabortion psychological complaints.

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

A study of 30 women who reported long term stress from abortion, 31% reported sexual promiscuity, 35% reported feelings of sexual anxiety, 35% reported a deter- ioration of their sexual relationship, and 69% reported feelings of sexual inhibition.

Health issues associated with increasing "crack" use among female sex workers, in London, H Ward et al, Sex Transm Infect 76(4):292,

Thirty-four percent of female sex workers reported using "crack" cocaine in 1995- 1996. Crack cocaine use was associated with abortion and hepatitis C infection.

What have we learned from adolescent prostitutes in the Caribbean that adult prostitutes did not tell us?, M Alegria et al, Int Conf AIDS, June, 1993; 9(1)89 (Abstract No. WS-CO8-2).

Prostitution for adolescents begins with family or academic problems leading to early sexual experience with boyfriend followed by pregnancy and abortion which leads to economic/emotional despair followed by prostitution and then drug use.

HIV risk relevant behaviors of Japanese adolescents, T Munkata and K Fujisawa, Int Conf AIDS 11(1) 385, July, 1996 (Abstract No. Tu.D.27012)

A mail survey to 10,000 Japanese adolescents age 13-24 in 1995 found that casual sex experiences were significantly influenced by self- or partners' abortion experience. Casual sex included having "first time" sex where partners were "sexually excited without love", "curiosity", "can't say No", or "nothing in particular".

Pregnancy outcome after ecstasy use; 43 cases followed by the Teratology Information Service of the National Institute for Public Health and Environment, MM van-Tonninger-van Driel et al, Ned Tijdschr Geneeskd 2;143(1): 27-31, 1999 (English Abstract).

A Dutch study of 43 women who used ecstacy during pregnancy reported that pregnancies were often unplanned and previous pregnancies had often been terminated. Besides ecstacy, mothers frequently also used other substances potentially harmful to the pregnancy and child.

Repeat Abortion: Blaming the Victims, B Howe et al, Am J Public Health 69(12):70, 1979.

Women who repeated abortion were found to be more sexually active compared to women with first abortions even though they used contraception more than women with one abortion.

Repeat Abortion: Is It a Problem?, C Berger et al, Family Planning Perspectives 16(2): 70, 1984.

A Canadian study found that women who repeated abortion had more frequent itercourse, less satisfying relations with their partner, had more difficulty sleeping, and were less likely to live with their partner compared to women with a single abortion.