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Stotland, N.S., Robinson, G. E., Russo, N. F., Lang, J. A., Occhiogrosso, M., . Is there an "Abortion Trauma Syndrome"?: A critical review. Harvard Review of Psychiatry (2009).



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

Critiquing the “Critique”: Efforts to Distort the Post-Abortion Mental Health Literature Become More Obvious with each Successive Attempt


Robinson, Stotland, Russo, Lang, and Occhiogrosso recently published a paper in the Harvard Review of Psychiatry entitled “Is there an “Abortion Trauma Syndrome”? Critiquing the Evidence” This is the latest in a series of attempts to review the world literature on abortion and mental health in an effort to “substantiate” the claim that abortion does not carry risks for psychological harm. Prior efforts included the American Psychological Association’s Task Force Report and a review piece published by Johns Hopkins University researchers in the journal Contraception. In the most recent review, the authors’ primary conclusions that “the most well-controlled studies continue to demonstrate that there is no convincing evidence that induced abortion of an unwanted pregnancy is per se a significant risk factor for psychiatric illness” is entirely unfounded for serious scientifically-based reasons. A few of the problems are highlighted below.


1) The most glaring problem with the article is the arbitrary number of papers selected to review and the manner in which the authors chose particular published reports to analyze. The authors mention having identified 216 peer-reviewed papers on the topic of abortion and mental health and then note selection of a sample of studies that “exemplify common errors in research methodology” as well as “major articles that attempt to correct the flaws.” Their choice of studies in each category was based on the conclusion derived as opposed to the integrity of the design. Numerous methodologically sound studies that have yielded results counter to the authors’ politically driven conclusion are entirely ignored with no rationale offered. In a valid scientific review, criteria for selection (e.g., sample size, representativeness, type of comparison group, how well controlled it is, etc.) are specified at the outset and then the results of each study meeting the criteria are examined to identify general trends. This review lacks a systematic methodology for selection of studies to evaluate rendering the conclusions entirely invalid.

A sampling of important studies with good methodology which were omitted from the review are detailed below. Readers are encourage to visit the Alliance for Post-Abortion Research and Training's website, www.standapart.org, for straightforward, systematic, unbiased synopses of the literature including details pertaining to the studies listed below.

  1. Coleman, P. K. (2006). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. The Journal of Youth and Adolescence, 35, 903-911.
  2. Coleman, P. K. et al. (2009), Induced Abortion and Anxiety, Mood, and Substance Abuse Disorders: Isolating the Effects of Abortion in the National Comorbidity Survey. Journal of Psychiatric Research, 43, 770-776.
  3. Coleman, P.K., & Nelson, E.S. (1998). The quality of abortion decisions and college students' reports of post-abortion emotional sequelae and abortion attitudes. Journal of Social and Clinical Psychology, 17, 425-442.
  4. Coleman, P. K., Reardon, D. C., & Cougle, J. (2005). Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. British Journal of Health Psychology, 10, 255-268.
  5. Dingle, K., et al. (2008). Pregnancy loss and psychiatric disorders in young women: An Australian birth cohort study. The British Journal of Psychiatry, 193, 455-460.
  6. Fayote, F.O., Adeyemi, A.B., Oladimeji, B.Y. (2004). Emotional distress and its correlates. Journal of Obstetrics and Gynecology, 5, 504-509.
  7. Fergusson, D.M. et al. (2008). Abortion and mental health disorders: Evidence from a 30-year longitudinal study, The British Journal of Psychiatry, 193, 444-451.
  8. Hope, T. L., Wilder, E. I., & Watt, T. T. (2003). The relationships among adolescent pregnancy, pregnancy resolution, and juvenile delinquency, The Sociological Quarterly, 44, 555-576.
  9. Miller, W. B., Pasta, D. J., & Dean, C. L. (1998). Testing a model of the psychological consequences of abortion. In L. J. Beckman and S. M. Harvey (eds). The new civil war: The psychology, culture, and politics of abortion. Washington, DC: American Psychological Association.
  10. Pedersen W. (2008). Abortion and depression: A population-based longitudinal study of young women. Scandinavian Journal of Public Health, 36 (4):424-8.
  11. Pedersen, W. (2007). Addiction. Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study, 102 (12), 1971-78.
  12. Pope, L. M. et al. (2001). Post-abortion psychological adjustment: Are minors at increased risk? Journal of Adolescent Health, 29, 2-11.
  13. Reardon, D. C., Coleman, P. K., & Cougle, J. (2004) Substance use associated with prior history of abortion and unintended birth: A national cross sectional cohort study. Am. Journal of Drug and Alcohol Abuse, 26, 369-383.
  14. Reardon D.C., Ney, P.G. (2002) Abortion and subsequent substance abuse. American Journal of Drug and Alcohol Abuse, 26, 61-75.
  15. Rees, D. I. & Sabia, J. J. (2007) The relationship between abortion and depression: New evidence from the Fragile Families and Child Wellbeing Study. Medical Science Monitor, 13(10), 430-36.
  16. Sivuha, S. Predictors of Posttraumatic Stress Disorder Following Abortion in a Former Soviet Union Country. Journal of Prenatal & Perinatal Psych & Health,17, 41-61 (2002).
  17. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. British Journal of Obstetrics and Gynecology,105,1288-95.
  18. Söderberg et al. (1998). Emotional distress following induced abortion. A study of its incidence and determinants among abortees in Malmö, Sweden. European Journal of Obstetrics and Gynecology and Reproductive Biology 79, 173-8.
  19. Suliman et al. (2007) Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia vs. intravenous sedation. BMC Psychiatry, 7 (24), p.1-9.
  20. Suri, R, Altshuler, L., Hendrick, V. et al. (2004). The impact of depression and fluoxetine treatment on obstetrical outcome. Archives of Women’s Mental Health, 7, 193-200.


2) Another major problem with the review is the use of very dated sources to make sweeping claims. For example, on the first page, the risk of death from abortion in the U.S. is reported as 1:160,000 with reference to a single 1992 citation. A brief sampling of problems with this statistic is offered below.

a. The International Classification of Diseases (ICD-9) defines maternal death as one that occurs during pregnancy or within 42 days of the termination of pregnancy. Pregnancy-associated deaths occurring outside this window are not captured in the data.
b. Coding rule 12 of the ICD-9 requires deaths due to medical and surgical treatments to be reported under the complication of the procedure (e.g., infection) rather than the treatment (e.g., elective abortion).
c. Most women leave abortion clinics within hours of the procedure and go to hospital emergency rooms if there are complications. The data reported by abortion clinics to state health departments and ultimately to the CDC therefore under-represents abortion morbidity and mortality.
d. Abortion reporting is not required by federal law and only 27 states report abortion complications.
e. The abortion-related mortality rates typically fail to factor in abortions beyond the first trimester, which constitute 12-13% of al abortions [1-2]. Using national U.S. data spanning the years from 1988 to 1997, Bartlett and colleagues reported the relative risk of mortality was 14.7 per 100,000 at 13–15 weeks of gestation, 29.5 at 16-20 weeks, and 76.6 at or after 21 weeks [3].
  1. Jones, R.K., Zolna, M.R., Henshaw, S. K. & Finer L.B. (2008). Abortion in the United States: Incidence and Access to Services, 2005. Perspectives on Sexual and Reproductive Health 40, 6-16.
  2. Gamble, S.B., Strauss, L.T. Parker, W. Y., Cook, D. A. Zane, S. B., & Hamdan, S. (2008). Abortion Surveillance – United States, 2005. MMWR Surveillance Summaries 57 (SS-13). Atlanta, Ga: Centers for Disease Control and Prevention, Department of Health and Human Services.
  3. Bartlett, L. A. et al. (2004). Risk Factors for Legal Induced Abortion-Related Mortality in the United States. Obstetrics & Gynecology, 103 (4), 729–37.
f. At least 50% of women who have aborted deny the experience and therefore the medical records of many women who have aborted are not likely to contain an accurate history.
g. Suicide deaths are rarely, if ever, linked back to abortion in state reporting of death rates. Further, suicides are often not recorded on death certificates.


3) Studies pertaining to increased risk for substance abuse are omitted just as they were in the Contraception report. Substance abuse disorders are widely accepted mental health problems and they have been implicated in anxiety and mood disorders.


4) The review seems to have been put together rather hastily as two of the studies, #23 which is Fergusson and colleagues’ 2006 paper and #39 which is one published in the Canadian Medical Association Journal by Reardon et al. in 2003, had conclusions contradicting their conclusion yet these studies are cited among others as supporting their claim.


5) A final point to consider, the Impact Factor (IF) for the journal that published this review is considerably lower than that of most of the journals where the omitted studies were published. The IF indicates the number of citations to articles published in science and social science journals and it is a widely accepted indicator of the relative importance of a journal to the developing knowledge of a field. If this review truly had merit, surely it would have been submitted to one of the leading journals.


More Comments By Others

  1. Abortion is at least a marker for higher risk of mental health problems, and therefore it is a useful marker for screening mental health patients. What is at dispute is only whether abortion itself is the cause of mental health problems or whether it is merely something that women at risk of mental health problems for other reasons are more likely to experience. In their haste to dismiss abortion as a mental health risk, the authors fail to underscore that it is a marker which should be utilized in screening new patients.
This omission is curious since Stotland has recently suggested that psychiatrists should take a sexual history and include questions about previous abortions.
"If a woman has had an abortion, ask about the circumstances surrounding her decision-whether she thought it through beforehand and talked about her experience with friends and/or relatives," Stotland advised.
The patient should also be asked whether she is comfortable with her decision and experience. "If not, ask whether she wants to work on unresolved issues. This can be accomplished by various means including a religious consultation and psychotherapy," she advised.[1]
  1. All studies have methodological flaws.
  2. Different studies have different flaws. When examined as a group, the strengths of one study may fill in for the flaws of another.
  3. All agree, and Surgeon General Koop recommended, that the best way to study the mental health effects is by means of a longitudinal cohort study. Perhaps the most methodologically sound longitudinal cohort study has been done by Fergusson. Robinson et al, however, only discuss Fergusson's 2006 study. They appear to do so because that 2006 study can be criticized for lacking a control variable regarding wantedness of the pregnancies. That weakness was corrected in the 2008 study, which showed that abortion was associated with elevated mental health problems after controlling for prior mental health and wantedness. That the 2008 study was omitted from the review can only be explained by the fact that it is clearly the best study done to date and does not have the flaws the authors wanted to criticize.
  4. The authors give great praise to the Gilchrist study but they fail to note any of it's major flaws. See Here Curiously, one of the points the criticize about the Fergusson study is that in New Zealand two doctors have to agree that the abortion is necessary. But the exact same condition applies to Great Britain, where Gilchrist's study was conducted. If Fergusson's study is not generalizable for this reason, why would Gilchrist's be? Moreover, they suggest that physician screening may create "an inclusion bias toward vulnerable, high-risk women in the abortion group." But if physicians are in fact doing their job and screening out abortion candidates for whom abortion is more likely to cause harm than good, the "bias" should be exactly in the opposite direction, in other words physician screening should lead to a bias toward providing abortion for those women who are most likely to benefit from it and who are least likely to experience negative reactions.
  5. The authors ignore a whole host of strong studies showing a consistent association between abortion and substance use.
  6. They assert there is “there is no convincing evidence that induced abortion of an unwanted pregnancy is per se a significant risk factor for psychiatric illness." In other words, after deliberately excluding the problem of women who abort 'wanted pregnancies' due to coercion (an area where even they cannot deny subsequent psychological injury), they effectively dismiss the objective standard of judging evidence based on statistical tests of significance and simply assert that statistically significant findings can be dismissed if it is no “convincing” enough for them.
  7. The authors ignore the fact that there are no studies showing statistically validated mental health benefits associated with abortion. At best they can point to a number of studies indicating that abortion is "benign" for the majority of women studied. Even if they could bring forth such studies, if the same standards for proving causality were to apply, it is unlikely that they could ever provide enough proof of benefits that abortion, if it were a drug, could be approved by the FDA using the same standards for proving benefits which apply to drugs.
  8. Reports of "relief" are inconsistent and vague as relief can mean anything. Relief to have survived. Relief that one's boyfriend is no longer badgering her to have an abortion. Relief that it is simply over.
  9. Their argument regarding causality is severely flawed for the following reasons:
  1. Causality is nearly impossible to prove. In many, perhaps most cases, abortion will be a contributing cause to mental health issues. It will be a stressor that will trigger or aggravate problems in a direction for which the individual is most prone to have problems. Their is no obligation on the part of aboriton critics to prove that the abortion procedure itself--totally exclusive other factors going into the abortion experience such as pressure to abort, pre-existing problems, lack of adequate followup--is the sole cause of negative mental health effects. Such an argument reveals the great weakness in their position because literally all of their own studies consistently show at least small subgroups of women who are at elevated risk for having negative reactions to abortion. Traditionally, they have dismissed these subsets of women with "blame the victims" type comments such as "they would likely have fared worse if they had carried to term." In fact, they have yet to provide any evidence in a well designed study that women with risk factors for negative reactions to abortion fair better after an abortion than do similar women who carry to term.
  2. Regarding causality, they ignore that women self-attribute their symptoms to abortion. They fail to mention suicide notes by women attributing their suicides to grief over their abortions. This dismissal of literally thousands of women's testimonies is an insult to the witness of women themselves.
  3. They ignore that trained therapists have affirmed the association between abortion and subsequent problems and their reports that treating unresolved abortion issues alleviates the associated mental illnesses. Stotland herself previously wrote about her surprise when treating a woman whose past abortion emerged as a major psychological issue years later when she experienced a subsequent miscarriage. She states that "the loss of a potential life" caused by abortion "leaves the person vulnerable to reminders and reenactments, to difficulties that may surface in life and in subsequent psychotherapy." (In 'Abortion: Social Context, Psychodynamic Implications" Am J Psychiatry, 155(7):964-967, 1998')
  4. Critics of abortion do not claim that large scale studies have, by themselves, "proven" a causal connection between abortion and mental health problems. Instead, critics argue that at least in isolated cases a causal connection has been clearly proven through individual self-attribution and confirmed by treating therapists. The question raised by these isolated cases, however, is if these kinds of reactions are occurring often enough to show up in large scale studies. Studies designed to examine this question indicate that yes, negative reactions reported by women to their therapists are associated with abortion at statistically significant rates in the general population.
  5. They presume that it is the obligation of abortion critics to prove a causal connection between abortion and subsequent mental health problems but ignore that an equal burden is on them to prove a casual connection between abortion and positive outcomes.

On Causality

Regarding factors relevant to evaluation of causality, see

Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965;58:295–300.

and Ward AC. The role of causal criteria in causal inferences: Bradford Hill's "aspects of association". Epidemiol Perspect Innov. 2009 Jun 17;6:2.

  • temporal relationship,
  • biological plausibility,
  • strength of association,
  • dose–response effect (increased risk with increasing number of abortions),
  • consistency (reported by several studies)
  • coherence (matching with current theory of knowledge).
  • alternate explanations (are alternate reasons for the outcome addressed?)
  • specificity (is abortion the only cause for an associated outcome)
  • alteration of outcome (can an opposite experiment demonstrate an opposite outcome)


EXAMPLE of applying these criteria Shah and Zao. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses

A step further, we would like to mention that this strong association meets several of the criteria suggested by Professor Hill78 regarding causation such as temporal relationship, biological plausibility, strength of association, dose–response effect (increased risk with increasing number of abortion), consistency (reported by several studies) and coherence (matching with current theory of knowledge). The criteria of an alternate explanation (accounting for other confounders/reasons for the outcome) could be considered satisfied. Two criteria for causation are not satisfied: Specificity (I-TOP is the only cause of LBW/PT births) and alteration of outcome with an opposite experiment are not satisfied. We must caution readers that we have restricted ourselves to explore the association of I-TOP and pregnancy outcomes. Several biomedical, social, environmental, lifestyle-related, genetic and other factors contribute to a preterm and/or LBW births and this needs to be kept in mind in interpreting our results. We caution interpretation being causal as confounding effects of socio-economic factors, which are important, were considered in very few studies only. Discussion regarding downsides of I-TOP are incomplete without discussing downside of unwanted pregnancies as they are also at risk of adverse outcomes. From pragmatic viewpoint, future studies should assess benefits and risks in both situations.
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