# Motivation and emotion/Book/2018/Abortion and emotion

* Multimedia presentation (3 min)

## Overview

[Provide more detail]
Focus questions:
* What is abortion?
* What is the abortion debate?
* What are the emotional effects of abortion?

## Abortion

Abortion remains a controversial topic and its availability often depends on religious, moral and political beliefs rather than medical or public health needs (ESHRE Capri Workshop Group, 2017). The below section will discuss what an abortion is; the history of abortions and traditional methods; and contemporary abortion methods. $^{(useof';'isnotcorrectlyusedhere)}$

#### What is abortion?

An Abortion is a medical process that terminates a pregnancy (American College of Midwives, 2017). It is a common procedure, and around one in four women will have an abortion at some time in their life (ESHRE Capri Workshop Group, 2017). Abortion laws are on a continuum from "highly restrictive" to "mostly legal" depending on the country and these laws can dramatically affect women's access to safe abortion practices (ESHRE Capri Workshop Group, 2017). Generally, abortions are a simple and safe procedure which offer two options (Abortion, 2017). A medication called mifepristone (the abortion pill) can be prescribed by a health care provider, or a suction, also known as a surgical abortion (most common) can be performed in an approved abortion clinic (Abortion, 2017). The practice of unsafe abortions contributes substantially to the morbidity and mortality of women around the world, from 2003 to 2009 induced abortion was estimated to be responsible to 7.9% of maternal deaths (ESHRE Capri Workshop Group, 2017). However, it is estimated that each year 100,000 women undergo an abortion and 25% of pregnancies will result in termination (Douglas & De Costa, 2015).

#### Brief history and traditional methods

In pagan antiquity, the termination of a pregnancy was a common phenomenon, as such, a newborn was not considered to be a human-being until after the rite of sublatio, in which a father, lifting the infant above his head in a temple, acknowledged the infant as a new member of his family (Solodnikov, 2011).Then the rise of Christianity came to see that abortion was equated with murder (Solodnikov, 2011). Different time periods proposed their own boundaries defining the animation of the embryo (Solodnikov, 2011). For early Christians, it was the 40th day for boys and the eightieth day for girls; this gender difference evidently served as an additional institutionalised means of selection of newborns (Solodnikov, 2011). In the middle ages, there was no longer a distinction between sexes, but the boundary was switched between the fortieth and eightieth day. This time interval is close to the current legislation concerning abortion: mostly, the law permits the termination of a pregnancy in the first trimester (up to twelve weeks) (Solodnikov, 2011).In France (1738-94), there was a noticeable tendency to reduce the level of punishment for a woman seeking an abortion, but after the French revolution, the punishment for terminating a pregnancy was reinstated (Solodnikov, 2011). In 1869 the British Parliament passed the “Act on Crimes Against the Personality”, according to which abortion was considered a heinous crime, starting from the moment of conception (Solodnikov, 2011).In the second half of the nineteenth century, a national movement to prohibit abortion began in the United States (Solodnikov, 2011) $^{(plagiarisedmaterial)}$. This was based on embryology data, where doctors argued that a fetus is a living being from the moment of conception, so for this reason, abortion was considered murder. Laws passed in 1880 where abortion was illegal in the United States except when it was necessary (to save a woman’s life), these laws remained in place until the 1960’s (Solodnikov, 2011).The death penalty was introduced in Russia in 1649 for abortions, it was repealed 100 years later to be considered murder and punishment was four to five years in prison with loss of all rights (Solodnikov, 2011).
Almost 5,000 years ago, the Chinese Emperor Shen Nung described the use of mercury for inducing abortion (Grimes et al., 2006). In more recent times, unsafe methods can be divided into several broad classes: oral and injectable medicines, vaginal preparations, intrauterine foreign bodies and trauma to the abdomen (Grimes et al., 2006). Detergents, solvents and bleach are also a method, and women in developing countries still rely on teas and concoctions made from local plant or animal products (Grimes et al., 2006). A survey done in New York City before the legislation of abortion on request, documented the techniques in common use; insertion of tubes or liquids into the uterus were one of the more successful methods (Grimes et al., 2006). Whereas coat hangers, knitting needles and slippery elm bark (bark would expand when moistened causing the cervix to open) were common methods (Grimes et al., 2006). Another widely used method was to place a flexible rubber catheter into the uterus to stimulate labour (Grimes et al., 2006). The injection of toxic solutions into the uterus with douche bags or turkey basters was common (Grimes et al., 2006). Absorption of soap solutions into the woman’s circulation could cause renal toxicity and death, potassium permanganate tablets (mild antiseptic with astringent properties used to treat weeping skin conditions), did not induce abortion but could cause severe chemical burns to the vagina, sometimes eroding through to the bowel (Grimes et al., 2006).

#### Contemporary abortion methods

There are two kinds of abortions:
Medication abortion (the abortion pill).
The medication abortion occurs in two steps. The first pill is called mifepristone, which is consumed in a health care providers office or clinic, this stops the development of the pregnancy. Between 24 to 48 hours later, a second pill called misoprostol will be consumed at home. This pill causes the uterus to cramp and pass the pregnancy tissue out of the uterus (Abortion, 2017). This procedure will require a follow-up visit 2 weeks later to ensure the individual is healthy and has passed the pregnancy tissue successfully. This procedure closely resembles having a miscarriage and is often accompanied by symptoms such as fever, back pain, nausea, vomiting, headaches, weakness, chills, and/or diarrhea for up to 24 hours after taking this medication (Abortion, 2017). Within 2 to 24 hours of taking the misoprostol strong cramps and bleeding will commence, often accompanied by blood clots. Light bleeding is expected for 1 to 2 weeks following but can last up to 6. The advantages of this method include the privacy of the procedure, as often women are in their own homes and a sense of control over the process as the pill can be taken at a time that best suits the individual. However, this method does not always result in success and works best earlier in a pregnancy (Abortion, 2017).
Suction abortion
A suction abortion is where a health care provider uses a tube with gentle suction to empty the uterus (American College of Midwives, 2017). A speculum is inserted into the vagina, just like having a Pap test. A shot of numbing medicine may be put into the cervix to create less discomfort when opening the cervix. A small tube is then put through the cervix into the uterus, the tube is connected to an electric suction pump or a manual (handheld) suction device (American College of Midwives, 2017). Gentle suction is then applied which removes any pregnancy tissue. This may cause cramping as the uterus is emptied and this process takes around ten minutes (American College of Midwives, 2017). Light bleeding may occur for 1 to 7 days and can continue to up to 6 weeks (American College of Midwives, 2017). The advantages of suction abortion is that it almost always works (more than 99% of the time) and it is a quick procedure (American College of Midwives, 2017). However, if the procedure does not work, it may have to be repeated. Other risks include infection and injury to the cervix, uterus or other organs, however, these carry a small level of risk (American College of Midwives, 2017).
* Figure 1. Disposable Speculum

## Laws on abortion

Abortion laws vary around the world but are generally much more restrictive in developing countries (ESHRE Capri Workshop Group, 2017). In Australia, there are eight different sets of abortion laws across state and territory jurisdictions, which results in great discrepancies in the legal provision of abortion services and hence women’s access to abortion (Douglas & De Costa, 2015). Abortion laws are typically described as a continuum from ‘highly restrictive’ to ‘mostly legal’ based on the combination of different indications: to save a woman’s life, preserve her physical health, preserve her mental health, for rape or incest, foetal impairment, economic or social reasons or no restrictions (ESHRE Capri Workshop Group, 2017). In 2013, 99% of women lived in countries where abortion was permitted to save their lives while less than one-third of countries (30%) allowed abortion without restriction. Under Queensland legislation, virtually unchanged since 1899, any person who carries out or assists with an abortion, may be liable to criminal prosecution, including the woman herself (Douglas & De Costa, 2015). In 1985 in R v Bayliss, Justice McGuire found that in exceptional cases’ an abortion would not be unlawful where it was carried out in good faith to avoid ‘serious danger to the mothers life or her physical/mental health (not merely the normal dangers of pregnancy and childbirth) which the continuation of the pregnancy would entail (Douglas & De Costa, 2015). This statement is a reflection of the different indicators that abortion laws are based off (to save a woman’s life). In New South Wales, abortion has been a criminal offence since Federation (Douglas & De Costa, 2015). Though, similar to Queensland, case-law has established that in certain circumstances abortion would not be unlawful (Douglas & De Costa, 2015). New South Wales does allow for broader considerations of economic and social grounds to determine whether serious danger to mental health is a risk for the woman in continuing the pregnancy (Douglas & De Costa, 2015). As these laws were formed in an era before ultrasound, foetal medicine and assisted reproductive technology were not even imagined, the law in these two states does not address issues such as gestational age, foetal health or abnormality (Douglas & De Costa, 2015). Due to this, an unclear legal position results and many doctors are reluctant to become involved in the provision of abortion (Douglas & De Costa, 2015). The lack of legal clarity may contribute to women accessing risky self-help measures, in particular the online or overseas purchase of drugs for medical termination of pregnancy (Douglas & De Costa, 2015). Abortion was decriminalised in the Australian Capital Territory in 2002, Victoria in 2008 and Tasmania in 2013 (Douglas & De Costa, 2015). Abortion in these jurisdictions are now primarily a health issue rather than a matter for criminal law and regulated in the same way as other medical procedures (Douglas & De Costa, 2015). By having restrictive laws on abortion, as it is viewed as a criminal act, it can make women very confused and unsure of their emotions towards the topic as society has told them it is wrong for centuries now.

#### Unsafe abortions

Due to the laws for abortion being very restrictive and not in favour of a woman’s free choice, unsafe abortion is a persistent yet preventable pandemic (Grimes et al., 2006). The World Health Organisation defines unsafe abortion as a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards, or both (Grimes et al., 2006). Unsafe abortion mainly endangers women in developing countries where abortion is highly restricted by law and countries where, although legally permitted, safe abortion is not easily accessible (Grimes et al., 2006). A worldwide estimate of 68 000 women die as a result of complications from unsafe induced abortions every year (Grimes et al., 2006). Morbidity (a diseased state) is a much more common consequence of unsafe abortion than mortality (death), but is determined by the same risk factors (Grimes et al., 2006). Complications include haemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus and abdominal organs (Grimes et al., 2006). There is a high proportion of women (20-50%) who have unsafe abortions and are hospitalised from the complications that arise as a result (grimes et al., 2006). Unsafe abortion and related mortality are both highest in countries with narrow grounds for legal abortion (Grimes et al., 2006). The prevalence of unsafe abortions remains the highest in the 82 countries with the most restrictive legislations, up to 23 unsafe abortions per 1000 women aged 15-49 years (Grimes et al., 2006). Legislation of abortion is a necessary but insufficient step toward eliminating unsafe abortion (Grimes et al., 2006). When abortion is made legal, safe and easily accessible, women’s health improves (Grimes et al., 2006). By contrast, women’s health deteriorates when access to safe abortion is made more difficult or illegal (Grimes et al., 2006). Though, even where legal abortion is widely available on request, misperceptions about the legality of minors having sexual intercourse delay some adolescents from seeking care (Grimes et al., 2006). In many cultures, perceptions of legality are affected by the stigma attached to premarital or extramarital sexual activity (Grimes et al., 2006). By having restrictive and illegal laws surrounding abortion, this could make women’s mental health (who have had an abortion or are thinking about getting one) worsen. This would most likely be because of all the emotions that women would be feeling pre, during and post abortion.
* “pregnancy-related deaths… are often the ultimate tragic outcome of the cumulative denial of women’s human rights. Women are not dying because of untreatable diseases.They are dying because societies have yet to make the decision that their lives are worth saving"
* — Mahmoud Fathalla

## Abortion debate

Abortion has always been an issue of controversy, debates and arguing (Mavric, 2012). It is a debate that is extremely focused on the social context rather than the women who want/need to have an abortion. Thus it is not focused on the individual herself but rather societies’ view’s on abortion and their emotion’s towards the topic.
There are two sides to the abortion debate; pro-life (against abortion) or pro-choice (for abortion). Several pro-life advocates have argued that there is a real and substantive similarity between slavery, the Holocaust and legalized abortion (Bellinger, 2017). Sociologist William Brennan, theologian James Burtchaell and physician Jack Willke are examples of this approach as they argue that slavery was based on dehumanizing blacks, the Holocaust was based on dehumanizing Jews and abortion is based on dehumanizing unborn children (Bellinger, 2017). Pro-life feminist Elizabeth Fox-Genovese wrote:
   “Among the many horrors of the Holocaust, the most dangerous lay in the attribution to one person of the power to decide whether another should live or die. The abortion culture allocates to a mother the power to decide that her own child is an object and authorises her to do away with it”
The same type of analogical argument was made by pro-choice advocates in the 1960’s and 1970’s but in the opposite direction; this sort of argument, that restrictions on abortion “enslave” women, continues to be made in the present day (Bellinger, 2017). Gloria Steinem published an essay accusing pro-life advocates of taking a stance that has parallels with Hitler’s philosophy, because both he and pro-life advocates are opposed to allowing women individual autonomy in reproduction (Bellinger, 2017).
It is interesting to note that this sort of argument, of historical analogy, is used by both sides of the abortion debate as it highlights the reality that to a great extent the abortion debate is mainly a contest over how to interpret the moral lessons that history teaches and apply them in our own age (Bellinger, 2017).
The United Kingdom and Northern Ireland continue to have more restrictive polices and the United States, one of President Trump’s first executive orders was to ban Federal money going to international groups that performed or provided information on abortion, resulting in enormous global impact for women’s lives (Bellinger, 2017). The language used in the abortion debate is strategically important as it has been shown to shape the audience response (Bellinger, 2017). Anti-abortion activists have sought to construct abortion as damaging women (Bellinger, 2017). The concept of post-abortion syndrome, modelled on the concept of Post Traumatic Stress Disorder, is strategically significant because it implies abortion results in long-term psychiatric disorder (Bellinger, 2017). Thus, abortion is seen as a medicalized (rather than overtly moral) discourse and also implies that abortion not only harms the ‘unborn child’ but the woman carrying the child as well (Bellinger, 2017). Though epidemiological research actually reveals little evidence for such a syndrome, it still continues to feature prominently in anti-abortion arguments (Bellinger, 2017). There are several reasons for this; firstly, talk of post-abortion syndrome allows activists to characterise individuals as damaged at a deep level even where there is little obvious manifestation of such damage (Bellinger, 2017). Secondly, a medicalized account of the physical and psychological costs of abortion is less obviously dependent on (more easily contested) moral precepts as the basis for opposition to abortion (Bellinger, 2017). Thirdly, it allows anti-abortion activists to represent themselves as championing women’s interests (Bellinger, 2017).
The abortion debate is highly focused on the social context and the individual beliefs that one has. Thus, emotion comes in to play when discussing this topic.

## Emotions on abortion

Every woman is a unique individual and has her own intrinsic values and sense of morality (Mavric, 2012). So the experience of abortion will be different for every woman. Though there are psycho-medical effects that may enhance negative feelings after an abortion such as; pre-existing factors in a woman’s life (emotional attachment, lack of social support, pre-existing psychiatric illness and conservative views on abortion) (Mavric, 2012). Some scientists use the term “post-abortion syndrome, as described earlier, though it is not recognised by any serious medical or psychological organisation (Mavric, 2012).
Repression is a common coping mechanism for post-aborted women, which may result in a long period of denial before a woman seeks psychiatric care (Mavric, 2012). These repressed feelings may cause psychosomatic illnesses and psychiatric or behavioural issues in other areas of her life, resulting in some counsellors reporting unacknowledged post-abortion distress being the causative factor in many of their female patients (who sought therapy for seemingly unrelated problems) (Mavric, 2012).
Women may experience abortion as a traumatic event for several reasons (Mavric, 2012).
Some may be forced into an unwanted abortion by husbands, boyfriends, parents and others may feel as if they have killed their own child (Mavric, 2012). The fear, anxiety, pain and guilt associated with the procedure are mixed (Mavric, 2012).
Post Traumatic Stress Disorder is commonly associated as the medical condition that may arise after an abortion (some clinicians refer to it as Post-Abortion Syndrome), there are three major symptoms generally classified as: hyper arousal, intrusion and constriction (Mavric, 2012).
Hyperarousal is characterised as inappropriately and chronically aroused “fight or flight” defense mechanisms (Mavric, 2012).
Intrusion is the re-experience of the traumatic event at unwanted and unexpected times. Examples of intrusion in PAS include: recurrent and intrusive thoughts about the abortion or aborted child, flashbacks in which the woman momentarily re-experiences an aspect of the abortion experience, nightmares about the abortion/child (Mavric, 2012).
Constriction is the numbing of emotional resources to avoid stimuli associated with the trauma (avoidance behaviour), this behaviour may aggravate the negative feelings associated with the trauma (Mavric, 2012).
Approximately 60% of women who experience post-abortion negative affect report suicide ideation, with 28% actually attempting suicide, of which half attempted suicide two or more times (Mavric, 2012). Suicide attempts appear to be especially prevalent among post-abortion teenagers (Mavric, 2012). Women who have one abortion, are more likely to have future abortions. This increase is due to lowered self-esteem, a conscious or unconscious desire for a replacement pregnancy and increased sexual activity post-abortion (Mavric, 2012).
In a post-abortion study, researchers found that after only 8 weeks post-abortion, patients complained of nervous disorders (44%), sleep disturbances (36%), regrets about their decision (31%) and 11% had been prescribed psychotropic medicine by their family doctor (Mavric, 2012).

#### Models that explain the role of shame and guilt in abortion

Developmental Crisis: Leon (1992) states, “as a new developmental stage, pregnancy typically precipitates a psychosocial crisis in one’s internal constellation of representations, conflicts and fantasies, which interact with cultural changes in identity that are included by becoming a parent”. Developmentally, abortion has much in common with the phenomena that Leon (1992) accepts as perinatal losses (Whitney, 2017). Until the pregnancy is terminated, this pregnancy too, constitutes a new developmental phase during which it is common for women to report an understanding of the fetus as a child and developing protective attachment to it (Whitney, 2017). Any attenuation of its impact due to the shorter duration of pregnancy is more than offset by the added potential complications of guilt associated with the active choice to abort and greater isolation because of the social invisibility of the loss (Whitney, 2017).
Stigma (Goffman, 1936): Argues that every society has stereotypical expectations of its members, for example a young woman of child-bearing age is expected to settle down into a steady relationship and in time become pregnant (Lipp, 2011). This is termed one’s ‘virtual social identity’, though Goffman (1936) argues that for some people, their ‘actual society identity’ does not match the virtual one (Lipp, 2011). For example, a young woman that has an abortion goes against society’s expectations, creating a spoiled identity and stigma, which also implies moral judgement of a shameful act (Lipp, 2011). Goffman’s (1936) theory describes stigma as an attribute or act that is deeply discrediting, though an attribute is only seen as discrediting within certain contexts and is dependent on its relationships within the context (Lipp, 2011). Women seeking or who have had abortions feel two types of discreditable stigma; firstly, self-stigma, where she internalises society’s prejudicial attitudes towards abortion and secondly, enacted stigma where behaviour by someone else focuses on the presence of stigma onto the woman (Lipp, 2011).

#### Guilt:

A pro-social emotion, that is outwardly focused and concerned with how one’s actions impact others and includes a motivation to “confess, apologise or repair” (Whitney, 2017). Guilt is associated with feelings of tension, regret and remorse (Duncan & Cacciatore, 2015). This emotion can be experienced in both public and private circumstances, as it is an individual’s interpretation of the situation that determines whether it is felt or not (Duncan & Cacciatore, 2015). In the case of guilt, one is more focused with assessing the impact of actions on others so it motivates constructive engagement in relationships (Duncan & Cacciatore, 2015). Guilt is an emotion that is evident in the majority of the post-abortion research, as women may feel the stigma associated with abortion thus creating feelings of tension, regret and remorse.
A woman may feel guilty after having an abortion as this emotion is associated with regret and remorse, and as mentioned earlier it is common for women to feel regretful after having an abortion. A woman may also feel guilty after having an abortion if the social support around her may have conservative views towards abortion, creating her to interpret the environment as judgemental and angry about her decision.

#### Shame:

A self-conscious emotion that involves self-blame (Duncan & Cacciatore, 2015). Typically associated with a sense of exposure along with a lack of trust, feelings of worthlessness, powerlessness and a desire to hide (Duncan & Cacciatore, 2015). Shame motivates avoidance or projection of anger and many researchers agree that it is a negative evaluation of the global self (Duncan & Cacciatore, 2015). Shame, but not guilt, may threaten the attachment system and general sense of belonging, and this is, perhaps, its essential source of pain (Duncan & Cacciatore, 2015). Mostly, guilt is conceptualised as adaptive and shame is maladaptive (Duncan & Cacciatore, 2015). Shame is also an emotion that is highly prevalent in post-abortion research, as suggested in the developmental crisis, a woman may feel she has not fulfilled her ‘social identity’, thus creating feelings of worthlessness and powerlessness.
A woman may feel shame after having an abortion as it involves self-blame, she may think about what she could have done differently to avoid having an abortion, thus creating a desire to hide and creating a negative evaluation of the global self.

## Take home points

[Provide more detail]
* Abortion is a controversial topic.
* There are two sides: pro-life and pro-choice.
* Laws on abortion need to be reformed.
* There is a massive stigma surrounding abortion.
* Guilt and shame are the two key emotions that are felt by women having or who have had abortions.