U p d a t e o n R e p ro d u c t i v e

R i g h t s an d Wo m e n ’s
Mental Health
Nada Logan Stotland, MD, MPH

KEYWORDS
 Reproductive rights  Women  Mental health  Barriers

KEY POINTS
 This article explores the origins of barriers to reproductive rights, the nature of these bar-
riers, and their impact on women’s mental health.
 Reproductive rights are essential to the recognition and treatment of women as human
beings and citizens. Barriers to reproductive rights thus pose a grave danger to women’s
overall well-being.
 The most controversial relationship is between induced abortion and women’s mental
health. There is a solid body of evidence demonstrating the absence of negative effect.
 Barriers, misinformation, and coercion affecting contraceptive, abortion, and pregnancy
care are an ongoing danger to women’s mental health and to the well-being of their families.
 Mental health professionals are obligated to know the facts, apply them, and provide ac-
curate information to protect women’s health.

INTRODUCTION

The World Health Organization declares reproductive rights to be essential human

rights and has issued many statements, manuals, and guidelines for the implementa-
tion of those rights.1–4 The American Psychiatric Association has adopted a series of

This is an update of an article that first appeared in the Psychiatric Clinics of North America,
Volume 40, Issue 2, June 2017.
Since this article was written, the New York Times, on Sunday, January 20th, 2019, published a
12-page Special Opinion Report covering the dangers to women’s fundamental rights, both
threatened and accomplished, of designating the fetus as a person. The report is titled
“A Woman’s Right;” authorship is credited to the Times’ Editorial Board.
No commercial or financial conflicts of interest.
Disclosure: Neither the author nor any member of her immediate family has any financial or
administrative interest in the topics discussed in this article. She has served on the Board of Phy-
sicians for Reproductive Choice and Health. She has testified in opposition to restrictive abor-
tion laws in the United States Congress and in several states. She accepted no remuneration for
this testimony.
Department of Psychiatry, Rush University, 5511 South Kenwood Avenue, Chicago, Illinois
60637-1713, USA
E-mail address: [email protected]

Med Clin N Am 103 (2019) 751–766

http://dx.doi.org/10.1016/j.mcna.2019.02.006 medical.theclinics.com
0025-7125/19/ª 2019 Elsevier Inc. All rights reserved.
752 Stotland

policies recognizing reproductive rights and advocating against laws and other bar-
riers to their realization.5–9
Women’s reproductive rights are not limited to access to contraception and abor-
tion. Reproductive rights compass the status of women as citizens. The many laws
and court decisions restricting contraception and abortion, and forcing interventions
on pregnant women, in the United States and elsewhere, deny women rights as do
no other health-related laws and decisions.
In the United States, no person can be legally forced to contribute 1 drop of blood,
even to save the life of a scientific genius, virtuoso musician, or world leader. Never-
theless, pregnant women may be forced to undergo surgical procedures deemed to
be necessary for the well-being of fetuses: potential persons.10 Laws limiting access
to contraception and abortion, permitting forced interventions during pregnancy, and
criminalizing personal behaviors of pregnant women are demeaning to women. They
are based on the premise that women do not understand their condition when preg-
nant, are unable to make considered decisions about their pregnancies, and that their
lives are less important than those of embryos. Laws that mandate specific proced-
ures or force physicians to provide specific misinformation to pregnant patients
contravene medical ethics, interfere with the patient–physician relationship, and
thus deprive pregnant women of their right to ethical, science-based medical care.11
This article does not use the term ‘prolife,’ coined by antiabortion groups and, unfor-
tunately, adopted almost universally in public discourse. Words are powerful.12 Of
course, life is precious. But the term ‘prolife’ limits the desired protection of ‘life’ to
the fertilized egg, embryo, and fetus. It does not compass, for example, the abolition
of the death penalty in the criminal justice system. It does not include responsibility
for a child born to an unwilling or unprepared mother, or for any human being once it
is born. It makes the pregnant woman’s life of no consequence. This article is based
on reviews of the scientific literature, and information about laws, legal cases, and other
events. Nevertheless, it must reflect the author’s deep concern about the disregard for
and hostility toward women reflected in the attacks on women’s reproductive rights.
Following are introductory examples. As this article is being written, Roman Catholic
hospitals are not permitted to perform abortions even when there is no hope of extra-
uterine life for the fetus and the pregnant woman’s life is acutely threatened by the
pregnancy.13,14 Currently, a woman is in prison for attempting suicide while pregnant.10
Michael Pence is vice president of the United States. As Governor of the State of Indi-
ana, Mr. Pence signed into law, in 2016, an act forbidding abortion for genetic defects,
making the voluntary donation of fetal tissue a felony, and requiring that all “fetal re-
mains,” regardless of their origin or stage of gestation, be buried or cremated.15
This article addresses the history of reproductive rights, the current status of repro-
ductive rights; the assumptions about and attitudes toward women reflected in those
rights, or the absence of them; the impact of rights denied versus fulfilled on women’s
mental health; and both the scientific facts and the rampant misinformation about the
impact of induced abortion on women’s mental health. The article focuses on these
issues in the United States, where they are problematic, public, and hotly contested.
Although there is some controversy over women’s right to contraceptives, the denial
of rights mostly concerns emergency contraception (eg, levonorgestrel [Plan B]) and
the rights of women during pregnancy.
In addition to the damages caused by the denial of reproductive rights to women in
general, restrictions and requirements exacerbate the negative mental health concom-
itants of poverty, domestic violence, poor education, and racial discrimination.1 The lim-
itations differentially affect women in inverse relation to their socioeconomic status; it is
poor women who are most vulnerable to unplanned and untenable pregnancies, and
 Update on Reproductive Rights and Women’s Mental Health 753

poor women who face the most barriers to ending those pregnancies.16 With regard to
abortion, there is considerable scientific evidence about its relationship to mental health.
With regard to forced bodily intrusions and differential access, we must rely on our
knowledge of the impact of injustice and abuse on mental well-being.17–21

HISTORY

The concept of reproductive rights is relatively new. Throughout history, women have
been expected to marry. Within marriage, women were bound to submit to sexual in-
tercourse and, thus, pregnancy. There were penalties for women who became preg-
nant outside of marriage.
Although effective contraception and safe abortion only became available in the
mid-twentieth century, historical and anthropological studies reveal that contracep-
tion and abortion were attempted or practiced in a wide variety of times and places.
Abortion techniques are described in Egyptian medical papyruses dating from 1700
BC. The Hippocratic Oath is often cited as evidence that abortion was forbidden in
ancient Greece. In fact, the Hippocratic Oath is evidence that abortion was practiced
in ancient Greece. Had it not been practiced, there would have been no need to
mention it. A number of ancient medical or gynecologic texts describe abortifacient
drugs, and ancient tools used for surgical abortions have been discovered.22,23
Women’s magazines in the nineteenth century carried advertisements for purported
abortifacients thinly disguised as menstrual or other remedies.24 Historical texts seem
to imply that herbal and other remedies were effective abortifacients, but no evidence
was gathered, and no such effective method is now known. As far as we know, abor-
tion was fraught with a high risk of physical pain, morbidity, and mortality until the
advent of sterile technique, anesthesia, and access to both in fairly recent decades.
The popular BBC television series Call the Midwife, set in a low-income neighbor-
hood in post World War II London, included an episode in which the impoverished,
married, mother of several children desperately sought and underwent an abortion
apparently induced by a local woman who administered some caustic substance.
The woman’s life was barely saved. Nevertheless, through her pain, the woman only
cares about one thing: “Has it [the embryo] come away?” The fact is that neither civil
laws, religious prohibitions, pain, and the very real fear of death prevent millions of
women from attempting abortions. It is estimated that 56.3 million women worldwide
per year have abortions and that well over 20,000 women per year who must resort to
illegal, unsafe abortions die from them. The fact that abortion was practiced for
millennia before it was safe, and that thousands of women worldwide die from unsafe
abortions each year, in the twenty-first century, is testimony to the intensity, the
desperation, with which women regard control of their procreative functions. Those
who prohibit or limit abortion are therefore subjecting women, and the existing chil-
dren and other dependents who need them, to mental and physical damage.

ABORTION METHODS AND SAFETY

Abortion can be accomplished medically, on an outpatient basis, using oral mifepristone

to block the progesterone essential to the maintenance of the uterine lining, followed by
misoprostol to induce contractions and empty the uterus. Years of experience with
medical abortion have led experts to lessen the recommended dose, to widen the win-
dow of effectiveness, and to relax standards for observation. The process does not
require anesthesia or the use of any medical facility. In an outpatient clinic, an early preg-
nancy can be terminated via suction or dilatation and evacuation (D and E), using local
anesthesia. The advantage, as compared with medical abortion, is that the process is
754 Stotland

complete once the patient leaves the facility. Medical abortion causes some hours of
cramping and bleeding, which are uncomfortable and inconvenient.
The data on the physical risks of abortion are clear. Abortion does not increase the
risk of breast cancer or impair future fertility. Induced abortion is among the safest in-
terventions in all of medicine. Abortion carries far less risk of physical and psycholog-
ical morbidity and mortality than childbirth—the only alternative for the pregnant
woman. Colonoscopy, a procedure strongly recommended for nearly universal appli-
cation to adults, carries a 10 times greater risk of complications than abortion.25

RELIGION, HISTORY, AND ABORTION

Many Americans may mistakenly believe that abortion is forbidden by all religions. This
is not true.26 A blanket prohibition on abortion is not part of the ancient Judeo-Christian
tradition. Traditional Judaism allowed for abortion at early stages of pregnancy, at least
under some circumstances, including danger to the mother’s health. Similar latitude ex-
ists in the Islamic tradition. The early Roman Catholic Church regarded abortion as
acceptable until the fetus was considered to have a soul, as evidenced by its move-
ments in utero as perceived by the mother: quickening. Current church doctrine,
although forbidding abortion regardless of the circumstances, states that there is
disagreement among theologians as to when the embryo becomes a person and is
thus entitled to the protections due a person. Many non-Evangelical Protestant denom-
inations, as well as non-Orthodox Jewish scholars, support latitude in abortion deci-
sions. Although traditional Taoism, Buddhism, and Hinduism explicitly forbid abortion,
abortion is widely practiced in India, China, and other countries espousing these faiths.27

ABORTION DEMOGRAPHICS

The Guttmacher Institute, New York City, gathers and makes available on its website
(www.guttmacher.org) information relevant to contraception and abortion throughout
the world. In the United States, 30% of women will have an abortion by age 45. Among
women who have abortions:
 75% are poor or have low income;
 62% profess a religious affiliation;
 59% already have a child;
 60% are in their 20s;
 12% are teens;
 4% are minors;
 39% are white;
 28% black; and
 25% Hispanic.
Women of various religions have abortions in percentages to their representation in
society as a whole; that is, women who profess religions opposed to abortion have
abortions just as often as those who do not profess such religions.28,29

BASIC REPRODUCTIVE KNOWLEDGE

The right to know is central to rights to reproductive health and health care. Many
women cannot draw a substantially accurate representation of their reproductive sys-
tems. They do not know when, during their menstrual cycles, they are most fertile.
Misinformation about conception and contraception is rife. Some adolescents believe
that douching with a carbonated beverage can prevent pregnancy, that coitus
 Update on Reproductive Rights and Women’s Mental Health 755

interruptus prevents pregnancy, and/or that pregnancy cannot result from first
intercourse.30
Unfortunately, much sex education—where there is sex education—in the United
States is predicated on the misapprehension that the provision of information about
sex encourages sexual activity. The United States government funds abstinence-
only sex education, which has proved counterproductive. To encourage abstinence,
the effectiveness of contraceptives is downplayed and the risks of contraceptives
are exaggerated. The students are given no realistic approaches to their own sexu-
ality, and those who do have intercourse are less likely to use contraception. Young
women are not given information they need about their right to make their own deci-
sions about sexual activity and assertiveness tools to enable them to effect that right.

REASONS FOR ABORTION

Women undergoing abortion report that they have chosen to terminate their pregnan-
cies because of poverty, domestic violence, lack of other social supports, youth, and
their need to complete their educations or establish their careers.31 Lay people and
professionals may assume that pregnancy would be a protection from interpersonal
violence; in fact, pregnancy does not diminish, and may even increase, the incidence
of violence against women. There are strong links between domestic violence and
abortion; abusers may coerce women into intercourse, refuse or forbid the use of
contraception, and inherently make the domestic situation dangerous for mother
and child.32–35

MENTAL HEALTH OUTCOMES OF ABORTION

Mental health risks are the cited rationale for some restrictive laws regarding abor-
tion. However, a review of the published evidence reveals several decades of consis-
tently reassuring findings, including thorough literature reviews by the American
Psychological Association and the Royal Colleges of Physicians, in contrast with a
string of methodologically unacceptable papers claiming adverse psychiatric
sequelae.36–43 Poorly done studies compare the mental well-being of women who
have abortions with that of women who go on to deliver or with the general popula-
tion of women. They fail to recognize that the circumstances of individuals undergo-
ing abortions are not comparable either with the general population or with women
who opt to continue their pregnancies. They do not provide baseline data about the
mental health of the woman before the abortion. They do not take the circumstances
that occasioned the decision for abortion into account.44,45 The reasons women
decide to abort are all mental health risk factors—poverty, lack of social supports,
domestic violence, rape, incest, heavy ongoing responsibilities, lack of educa-
tion—and preexisting mental illness. The strongest predictor of a woman’s mental
health after an abortion is her mental health before an abortion.46 Abortion may be
associated with alcohol and substance abuse, suicidality, depression, and anxiety,
but it does not cause them. Difficulty obtaining an abortion for whatever reason in-
creases a woman’s stress, as does exposure to clinic demonstrators, not to mention
criminal attacks on abortion facilities and clinic staff.47
The publication of the studies claiming to have found negative mental health effects
of abortion has led to consternation in the scientific community and the publication of
reanalyses pointing out gross methodological errors, invalidating the conclusions, and
ultimately resulting in disavowal of 1 paper by the editors of the journal that published
it.48,49 Nevertheless, misinformation and misdirection are rampant.50,51 A Google
search on abortion undertaken in June 2016 quickly led to a website called
756 Stotland

TeenBreak, which informs the hapless pregnant teen, or her adult advisers, that abor-
tion causes depression, suicidality, and other dire mental health outcomes. Many of
the resources listed at the top of such searches are actually disguised antiabortion
centers. The federal government, and some states, continue to fund so-called ‘preg-
nancy crisis centers,’ which advertise help and choice for pregnant women, but actu-
ally exist to deter women from having abortions. They provide misinformation and
antiabortion persuasion. Some offer free ultrasound imaging and deliberately delay
conveying the results to the pregnant woman so that it will be too late for her to go
to an abortion facility.
The decision to terminate a pregnancy may be easy or difficult, depending on a
woman’s circumstances and beliefs. After abortion, women experience a wide variety
of feelings: guilt, sadness, and, most prominently, relief. These feelings must not be
confused with psychiatric disorders; they evolve over time and depend on ensuing
circumstances.52

PSYCHOSOCIAL UNDERPINNINGS AND PUBLIC MANIFESTATIONS OF OPPOSITION TO

ABORTION

Strong feelings about mothers in general, and one’s own mother, are core elements of
human psychology. For a young child, its mother is the most powerful person on earth.
That power can be reassuring, but also terrifying. Anxiety about one’s own wanted-
ness may give rise to objections to abortion. Some groups representing people with
disabilities oppose abortion because they believe that aborting fetuses with genetic
or other defects is evidence that their own lives are not considered worthwhile. At
worst, abortion is felt to be the manifestation of women’s murderous wishes toward
their children. Abortion represents, for some who oppose it, the rejection of women’s
submissive and maternal role, thus threatening both the males dominant in society
and the women who feel valued only on the basis of motherhood and the fulfillment
of religious requirements that women submit to their husbands.
Unplanned pregnancy in a sexual partner can arouse a wide variety of psychological
reactions in a man. He may be proud of his virility. He may be pleased by the prospect
of having a child, and with this partner. If his partner had led him to believe that a preg-
nancy was not possible, he may feel tricked and trapped. He may feel guilty for
conceiving the pregnancy and forcing his partner either to undergo an abortion or
give birth to a baby. If the pregnancy is unwelcome to him, but his partner opts to
remain pregnant, he may feel obligated to a lifetime in the relationship and as a father.
If his partner opts to terminate the pregnancy, where that is possible, he may feel help-
less to protect, and deprived of, his potential child.
Attitudes toward women’s sexuality color beliefs and attitudes toward contracep-
tion and abortion. Although women’s ability to force men into sexual intercourse is
limited by sexual anatomy and physiology, as well as the gender differential in phys-
ical strength, women have been, and continue to be, held accountable for male sex-
ual aggression. It was Eve who ate the apple, sexually seduced Adam, and
occasioned their ouster from the Garden of Eden. Orthodox Judaism, Hinduism,
and Islam require women to cover their bodies and limit their movements and activ-
ities. The sexes are largely segregated. The lure of women’s sexuality is essentially
considered irresistible to men. Rape is blamed on lapses in women’s adherence to
social rules. Even when no such lapse is involved, in some cultures, the raped
woman may be made to marry the rapist, or to bring such dishonor to the family
that she must be killed by her own male relatives. If it is women’s irresponsible
lust that is responsible for unplanned and unwanted pregnancies, pregnancy and
 Update on Reproductive Rights and Women’s Mental Health 757

motherhood, which should be valued, become just punishments for the licentious
woman.
What about the psychology of the pregnant woman herself? Of course, women
absorb and struggle with the sexual attitudes and mores of their own cultures.53 There
is no evidence that women just want to enjoy sex without wanting or taking on the re-
sponsibilities of motherhood, that they do not desire or respect motherhood.54 In fact,
most women have abortions because they have great respect for the responsibilities
of motherhood. They feel that the decision to continue a pregnancy should take into
account the effect on their existing responsibilities, and that they should give birth
to a child only when they have maximized the resources—educational, social, finan-
cial—they can bring to its care.
Some women oppose abortion in theory but choose to terminate pregnancies they
experience as untenable under their current circumstances. At many clinics where
abortions are performed, demonstrators stand outside with signs depicting babies in
utero and dismembered fetuses, shout at incoming patients that they are going to
murder their babies, and attempt to approach and ‘counsel’ them against abortion.
Physicians who work in these clinics report that some demonstrators take them aside
and request abortions for themselves, to be performed outside regular clinic hours so
that the other demonstrators do not see them. After their abortions, they resume their
places demonstrating outside the clinic. This is not necessarily an example of hypoc-
risy, but rather of the psychoanalytic ‘vertical split’—one part of the psyche opposes
abortion on religious grounds, and feels not only justified, but compelled, to oppose
it, but another, simultaneously, concludes that a particular, personal pregnancy must
be terminated. This dual dynamic may help to explain the discordance between the fre-
quency with which women terminate abortions and the attitudes they express to friends
and family, in public, and in opinion polls.
Thus, public attitudes toward abortion, as reported in polls, are misleading.55 It is
essential to know precisely what questions were asked, in what order, and in what
context. Most polls offer stark alternatives, sometimes skewed in favor of prohibitions:
should abortion be permitted in all circumstances/at all stages of pregnancy or only un-
der conditions such as rape and incest? In fact, people’s attitudes toward abortion are
complex, nuanced, and context dependent. The same individual who endorses a more
or less severe prohibition on abortion may well, if the question is put another way, agree
that no one but the pregnant woman herself, knowing her own circumstances, can
determine whether it is a good idea for the pregnancy to continue. Opinion polls claim-
ing to demonstrate that women oppose abortion are belied by the greater than
30% incidence of abortion, and, in turn, influence women contemplating abortion; it
may be difficult to take an action that you are told that most people oppose.
Expressed attitudes also reflect a superficial resolution of unconscious contradic-
tions. More people apparently believe that an embryo or fetus is a person and that
abortion is murder than believe abortion should be illegal in cases of rape or incest.
But why should it be acceptable to destroy a fetus/person because it was conceived
via rape or incest? This logical lacuna reveals the underlying attitude that being forced
to continue a pregnancy is a punishment for a woman’s voluntary participation in sex-
ual intercourse; if the participation was not voluntary, the punishment is not necessary,
and she need not continue the pregnancy.

ABORTION AND YOUTH

Responses to overly simplistic questions do not allow for consideration of other logical
inconsistencies. For example, the reflex answer to the proposition that pregnant
758 Stotland

adolescents be required to get permission from, or to tell, their parents before being
allowed access to abortion is that adolescents are not mature enough to consider
the pros and cons of abortion and that their parents have a right, even an obligation,
to be involved in or control the decision. But consider the adolescent pregnant from
incest or rape by a family friend or relative, the adolescent in an abusive family, the
adolescent who realistically anticipates severe punishment or exclusion from the fam-
ily as a result of her pregnancy. Consider most particularly the fact that the adolescent
who is prohibited from having an abortion allegedly because of immaturity will, in a few
months, undergo labor and delivery and assume full responsibility for a newborn baby.
The scientific arguments about adolescents’ cognitive and emotional capacity to
make this decision became somewhat confused because those advocating for
parental intervention laws adduced the evidence of adolescent immaturity brought
forward by neuroscience experts urging courts and legislatures not to try and punish
adolescents for serious crimes as they do adults. Recent publications have clarified
the distinction.56 Adolescents lack adult impulse control and are therefore vulnerable
to impulsive criminal behavior. Adolescents do not lack adult capacity to consider al-
ternatives and make decisions like abortion, which cannot be carried out impulsively.
Among decisions about medical interventions, abortion is not a complex one; abor-
tion carries an extremely small risk of morbidity (physical and psychological) and mor-
tality, especially as compared with a continued pregnancy and childbirth, for an
adolescent. There is no evidence that abortion causes significant mental illness in ad-
olescents, just as it does not in adults.57 Adolescent childbirth and parenting are asso-
ciated with a variety of negative biopsychosocial consequences as compared with
abortion during adolescence.58,59

THE RIGHT NOT TO BECOME PREGNANT

The defunding of Planned Parenthood is only 1 aspect of barriers to contraception. In

the United States, 10.3 million women have had a partner who tried to make them
pregnant against their will or who refused to use a condom. More than 2 million women
have become pregnant as a result of rape by an intimate partner. Religiously affiliated
health systems and work places also have prohibitions against the provision of, or of-
fering insurance for, sterilization and contraception, leaving otherwise insured women
fearful of unwanted pregnancy and/or struggling to find the money for these services.
Movements to allow over-the-counter oral contraceptives, or allow pharmacists to
prescribe them, are a step in a positive direction.60

FETAL PERSONHOOD

Another barrier to abortion, and invitation to coercive treatment of pregnant women, is

legislation designating the fetus, embryo, or even the fertilized egg as a person, with all
the rights of a person. This of course makes abortion murder. In medical terms, preg-
nancy does not begin until a fertilized egg implants in the uterine wall. The so-called
morning after pill, which can be effective up to 72 hours after unprotected intercourse,
prevents implantation, but is considered an abortifacient by those who consider a
fertilized egg to be a human being. Some states require that a woman undergoing
an abortion after a designated gestational age undergo medically unnecessary,
possibly deleterious, general anesthesia, with the scientifically refuted rationale that
the fetus will otherwise experience physical pain.61
The starkest evidence of the denial of human rights is the treatment of pregnant
women. As a result of anti abortion activists who assert that embryos and fetuses
are persons with all the rights of persons, some women are forcibly and legally
 Update on Reproductive Rights and Women’s Mental Health 759

subjected to obstetric interventions to which they object, and others are punished for
child abuse or child murder for behaviors during pregnancy. These behaviors include
suicide attempts, the use of illegal substances, and attempts to abort with medication
obtained via the Internet. Pregnant women who are brain dead as a result of injury or
disease, who had previously expressed objections to being kept alive if they should
succumb to such a condition, and whose families want them to be allowed to die,
have been kept on artificial life support until the fetus is deemed viable and is delivered
surgically.10,62,63
Of course, it is not easy for health professionals to stand by in situations when they
believe that they could intervene to protect or save an unborn baby—but they have no
right to invade a woman’s body or limit her freedom. The American Psychiatric Asso-
ciation and the American College of Obstetricians and Gynecologists have considered
the ethics and impacts of these situations and have taken carefully reasoned official
positions opposing forced interventions and punitive approaches to pregnancy as
well as barriers to abortion and mandated physician statements and techniques.64–66
The concept of fetal personhood poses a major danger to women’s rights and
women’s health. The overwhelming majority of women who become, and decide to
remain, pregnant are highly invested in the welfare of their unborn children. Setting
up a legal conflict between woman and fetus disparages that investment and reduces
the woman with individual civil rights to an incubator for a potential person.

ANTIABORTION LEGISLATION AND THE CONSEQUENCES FOR WOMEN’S MENTAL

HEALTH

The controversy over abortion in the United States is unique in magnitude, public
attention, motivation, and outcomes. Abortion has become a political issue eclipsing
many other issues with more impact on national and global benefits and dangers.
With respect to abortion and other reproductive issues, the United States Supreme
Court has often shown itself to be out of touch with both the scientific facts and the
realities of women’s lives. The Supreme Court’s Roe v Wade decision of 1973 is
considered to be the fundamental protection for abortion rights in the United States.
The decision has some limitations. It was decided on the basis of privacy rights rather
than on reproductive rights. It ordered that states could not enact laws that imposed
“undue burdens” on access to abortion before viability. Over the ensuing years, states
passed, and the Supreme Court refused to overturn, laws that imposed serious bur-
dens: waiting periods, medically unnecessary interventions, scripted misinformation,
outdated and medically deleterious dosage regimens for abortion medications, and
rules for abortion doctors and clinics that forced many to close. More than 2500
laws restricting abortion have been introduced in state legislatures during the past
5 years. State laws criminalizing physicians who perform abortions have also been
passed.67
In the United States, federal funding of abortion services is prohibited by the Hyde
Amendment. In addition to women unable to pay for their abortions, this prohibition
affects women in the armed services, who may have access only to federally funded
care because of military assignments. The Guttmacher Institute reports that, as of
March 1, 2016, 11 states restrict coverage of abortion in private insurance plans.
Forty-five states allow individual health care providers to refuse to participate in abor-
tions, and 42 states allow health institutions to refuse. Seventeen states mandate pre-
abortion counseling including medically inaccurate statements about abortion,
namely, that it causes breast cancer or mental health disorders or that the fetus feels
pain. Twenty-eight states mandate a waiting period; one-half of these make it
760 Stotland

necessary to make 2 trips to the facility. Twenty-five states require that an adolescent
obtain parental permission to have an abortion.68,69
Both legislation and Supreme Court decisions contain language contravening the
evidence of the major medical experts and organizations in the country and mandating
unprecedented and unparalleled interference with physician’s patient care. Late-term
abortions, which are extremely rare and generally performed when the fetus has been
found to have defects incompatible with extrauterine life, are most safely performed
using the extraction technique; the fetal presenting part emerges from the birth canal
before the abortion is completed. State legislation labeled the process the horrific
‘partial-birth abortion.’ Despite the protests of the American College of Obstetricians
and Gynecologists that this procedure is safest for the mother, the Supreme Court up-
held a law forbidding it.67 Antiabortion activists have used the derogatory label for
abortions performed earlier in pregnancy as well.
In 2015, a group of antiabortion activists made surreptitious videotapes at Planned
Parenthood clinics and falsified the tapes so that they seemed to show clinic
personnel selling fetal tissue. Members of the group have been indicted criminally.
However, the notion that abortions are being performed so that clinics can profit
from the sale of fetal tissue has taken hold. A doctor has been murdered by an individ-
ual claiming his intent was to protect baby parts. A congressional committee has sub-
poenaed the records of a University of New Mexico research project involving donated
fetal tissue, demanding and planning to publish identifying information about every
person present and/or participating—despite the clear evidence that this unnecessary
information will put their lives at risk—also to protect potentially aborted fetuses. This
process is being protested as this article is being written. Similarly, the association be-
tween Planned Parenthood clinics and abortion in the public, and legislators’ minds,
has resulted in the defunding and closure of many such clinics, depriving poor women
of the contraceptive and general health care, which actually constitute the majority of
clinic services.
The US Food and Drug Administration, in 2016, after considering the evidence,
simplified the approved regimen for medical abortion.70 The governor of Arizona
signed a bill mandating the use of the previous protocol days before the new Food
and Drug Administration guidelines went into effect. This law, like many others, rein-
troduces the question of privacy into the reproductive rights debate. Monitoring re-
quirements and proscriptions requires intense, ongoing scrutiny of medical records;
a requirement for reporting is, in fact, another element of some legislation.
With regard to parental involvement in the abortion decisions of their minor children,
the Supreme Court has ruled that parental involvement can be mandated by states as
long as there is a provision for a process called a ‘judicial bypass.’ Thus, a girl who
does not wish, or is afraid, to inform her parents that she plans to terminate a preg-
nancy can go before a judge and assert both the reasons she wishes to have an abor-
tion and evidence of her decisional maturity and/or independence from her parents.
This process requires that a girl, first, knows about it, and then is able to locate the cor-
rect court and the days and hours it is in session, absent herself from her school or job
or parents’ home, and master the anxiety nearly anyone experiences in anticipation of
an appearance in court. The decisions of courts in these proceedings vary widely from
state to state.
The Supreme Court has upheld the prerogative of health systems and facilities to
refuse to provide reproductive services in the name of religious freedom.14,71–73 Reli-
gious freedom in the United States was meant to allow everyone to practice, or not to
practice, the religion of their choice. Currently, religious freedom is used to allow prac-
titioners of 1 religion to withhold services or rights with which they do not agree, from
 Update on Reproductive Rights and Women’s Mental Health 761

those of other religions. As of 2016, 1 in every 6 acute care hospital beds is in a

Catholic-controlled hospital. In 10 states, more than 30% of hospital beds are in Cath-
olic hospitals, and there are 46 such hospitals that are the sole provider of hospital
care in their geographic areas. Catholic health systems require staff to formally agree
that they will not even provide information about either contraception or abortion. This
prohibition includes mental health professionals, and conflicts with our obligation to
learn a patient’s reproductive history, intentions, and needs. Consider, for example,
the outpatient or inpatient who is pregnant as the result of hypersexual behavior while
floridly manic, the patient who becomes pregnant while on large doses of antipsy-
chotics, or the profoundly depressed patient not well enough to care for herself or a
baby.
As mentioned, a Catholic hospital will allow a woman to die rather than terminating
her pregnancy. Should a female patient in a Catholic hospital request that she undergo
sterilization after Cesarean delivery so as to avoid both future pregnancies and the
need for another surgical procedure, her request will not be granted. Thus, a woman
who has not had success with contraceptive methods must live with the fear of un-
wanted pregnancy. Catholic hospitals claiming to provide comprehensive care have
no legal obligation to inform patients or prospective patients of these restrictions.
The stigma and misinformation surrounding postcoital contraception and abortion
has caused many nonreligiously affiliated hospitals to refuse to perform abortions.
Public discovery that abortions are being performed are likely to result in demonstra-
tions and a variety of attempts to withdraw the hospital’s funding or close it entirely.
National law allows anyone in a hospital or clinic who opposes abortion to refuse to
participate in it in any way. This allowance leads to situations in which there is no anes-
thesiologist, nurse, physician, or other staff member necessary to the performance of
an abortion.
The so-called morning after pill, or Plan B, is levonorgestrel, which is simply an
increased dosage of a common oral contraceptive, effective for up to 3 days after un-
protected intercourse. This medication is now approved for over-the-counter pur-
chase—if the product is stocked at the store where the woman looks for it. In some
communities, a pharmacy or pharmacist who does offer ‘Plan B’ may be stigmatized
and intimidated. The notion that a woman, who is under time constraints because the
medication has diminishing efficacy over time, can simply find another pharmacist to
dispense the medication is unrealistic. Her request for the medication reveals her
recent sexual activity, which is now known to the pharmacist and to any other staff
or customers within hearing distance. Thus a medication that could prevent unwanted
pregnancies is not widely available. Wal-Mart, the only pharmacy in many commu-
nities, and a major national pharmaceutical source, refuses to stock this medication.
On June 27, 2016, the Supreme Court announced a major milestone in abortion law.
The court struck down the Texas law requiring physicians doing performing to have
hospital admitting privileges and abortion clinics to meet the building requirements
of surgicenters. What is particularly important is the grounds upon which the decision
was made. The court defined ‘undue burden’ for the first time as the imposition of re-
strictions on abortion that are not supported by medical or scientific evidence, replac-
ing the appellate court decision that laws may be based on “rational suspicion,” even
in the face of contrary medical evidence.

COUNTRIES OUTSIDE THE UNITED STATES

The World Health Organization proclaims access to all aspects of reproductive health
care as a basic, universal human right. Around the globe, the nations where abortions
762 Stotland

are safe, legal, and available have the lowest incidence of abortion, and unsafe abor-
tion in countries where the procedure is illegal are a, or the, major cause of maternal
mortality. Efforts to make abortion legal and available have been successful in a
growing list of countries. Before Uruguay legalized abortion, a group of medical pro-
fessionals and advocates successfully instituted a program gracefully reconciling a
nearly total legal abortion ban with the provision of information and care that saved
many lives.74 Health care professionals refrained from performing or advocating for
abortion, but informed pregnant patients about the safe use of abortifacient medica-
tion they could obtain outside the health care system, and offered safe follow-up both
to patients who abort and those who decide to remain pregnant.

SUMMARY: THE NEED FOR FURTHER RESEARCH

We have ample data about the mental health effects of abortion, both completed and
denied. There is evidence that the fear of criminal prosecution deters some pregnant
women from seeking care for substance or alcohol addiction. We do not have data
about the impact of contraception denied or unaffordable, or forced obstetric inter-
ventions, or incarceration for behaviors while pregnant. What is the impact of being
considered unable to make a decision about a pregnancy without a waiting period
or a mandated ultrasound examination? Of being given misinformation about abor-
tion? Of being subjected to surgery against one’s will? Of being forced to continue
a pregnancy that threatens one’s health? Of being forced to continue a pregnancy
that will result in the delivery of a severely handicapped infant, or one that will soon
die? Of being considered to have fewer rights as a human being than an embryo?
There are data about the mental health effects of racial discrimination; being treated
as less competent or less worthy, being denied civil rights, because of race, is highly
detrimental to mental health. So must be losing civil rights because one is or may
become pregnant.

ACTION

Given that reproductive rights are essential to women’s mental health; that nearly one-
third of women patients in the United States will have or have had an abortion in their
lifetimes; and that misinformation, including government-mandated misinformation, is
rife, with negative consequences; it is incumbent on mental health professionals to:
 Obtain full reproductive histories from our patients;
 Discuss and destigmatize contraception and abortion;
 Suggest that appropriate patients obtain emergency contraception in advance,
to have on hand;
 Inform patients, the public, and policy makers of the facts; and
 Advocate for policy and legal changes to protect women’s health.

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