Hours after the Supreme Court’s Dobbs decision overruled women’s civil rights to abortion, Planned Parenthood clinics in Ohio began turning away patients who were seeking or had already scheduled abortions. Sharon Liner, medical director for Planned Parenthood’s southwest Ohio region, is worried about the mental health – and the safety – of the women her clinics are no longer allowed to serve. Ohio is one of many states with so-called “trigger laws” on the books to ban or severely limit abortion – in this case, just six weeks after pregnancy.
“We know that domestic violence and abuse can escalate during pregnancy,” she told MindSite News. One in five adult women and about a third of adolescent girls experience domestic violence during pregnancy. And recently, she said, two patients with pre-existing mental health issues experienced a worsening of those conditions as a result of an unwanted pregnancy. “Both described feeling better when they knew they could obtain an abortion,” Liner said.
But now women in these situations may be unable to get abortions – and many will face serious psychological consequences, she said. Even rape victims are at risk: Ohio just denied an abortion for a 10-year-old girl who found herself pregnant after being raped – a decision that forced her to cross state lines to Indiana for the procedure
The overall effect of the ban on her clients is fear, according to Rebecca Jones, a licensed professional counselor with a private practice in San Antonio County, Texas. “It’s terror they might get pregnant, even those who are not sexually active or asexual. It’s terror of being oppressed and marginalized. It’s hopelessness, helplessness, and despair.”
Such overwhelming stress and anxiety “will only increase as access becomes more challenging, especially for our patients with the least resources,” says Liner.
Many of those patients will be unable to travel – given the costs, risks of losing a job, or their domestic situation – and will be forced to give birth to unwanted children, she said.
Nada Stotland, a psychiatrist and past president of the American Psychiatric Association, has written extensively about the mental health effects of abortion denial. “The reasons women decide to abort are all mental health factors,” she wrote in a journal article. “These include poverty, lack of social supports, domestic violence, rape, incest, heavy ongoing responsibilities, lack of education, and preexisting mental illness.
Some 60% of women who have abortions already have children, Stotland said in an interview. “They’re thinking about protecting those children and having an abortion because they can’t afford another child. They’re having abortions not because they don’t care about babies, but because they care about the children they already have.”
Women’s financial situation is also a factor in their decision. Three-quarters of women who have abortions are at or below the poverty line, Stotland said, and they don’t have the time, money, or energy to take care of the children they already have. “This is a treatment that women have always felt desperate about, and not taken lightly,” she said. “Being denied abortion opens the door to a general feeling of helplessness and terror.”
And for women forced to give birth to a baby that was conceived by rape or incest, the impact is intense and never-ending – “unthinkable,” Stotland said. “If the mother is forced to keep that child, every time she looks at it, she sees the rapist, or her horrible father or brother. That’s what she walks around with for the rest of her life – and tries to love this child who’s a reminder of a horrible crime.”
The mental health effects of being denied an abortion are not just anecdotal. They’ve been documented in a prospective, longitudinal study conducted by ANSIRH, a research unit of the University of California, San Francisco, focused on reproductive issues. For the research, published in JAMA Psychiatry in 2017, team members surveyed 1,132 women who sought abortions at 30 clinics in 21 states. Some of them would go on to have abortions, but others were turned away because they’d missed the fetal gestational limit set by the clinics, which varied among the sites and states between 10 weeks and the second trimester.
Over a five-year period, researchers leading the so-called Turnaway Study used a battery of psychological measures and interviews to compare the women who received abortions with those forced to carry their pregnancy to term (or who received late abortions elsewhere). A number of states had passed wait-and-see laws that required women to undergo counseling before getting an abortion, and the study was undertaken to assess the assumption that people who have abortions are worse off from a mental health perspective.
“We found the opposite,” said Antonia Biggs, PhD, a psychologist at UCSF’s Bixby Center for Global Reproductive Health, one of the researchers involved in the Turnaway Study. “Having an abortion was not associated with adverse mental health outcomes. It was being denied an abortion that was associated with more symptoms of stress, anxiety, lower self-esteem and lower life satisfaction.” These mental health symptoms persisted for five years, and then declined.
The difficulties women experienced accessing abortion care were especially stressful, Biggs said. “Having to go through all the logistical barriers it can take to access abortion care – travel, time-sensitive care – was associated with more stress, anxiety and sense of depression.”
Women who had less autonomous decision-making and who were forced to disclose their pregnancy decision also reported negative mental health symptoms, she said.
The researchers also looked at the effect of abortion stigma on mental health outcomes – both the feeling many women have that others will look down on them if they’ve had an abortion and the structural stigma that comes from restrictive abortion laws. “Both can be internalized as stigma and can impact your mental health,” Biggs said. “People who experience abortion stigma are significantly more likely to experience adverse mental health outcomes.”
The economic consequences that come from having an unwanted pregnancy also added to the stress experienced by women turned away from abortions. “Denying someone an abortion had huge results in economic hardship and economic insecurity,” Biggs said. “People were less likely to have enough money to cover basic living expenses. We also saw a big impact on people’s credit scores and debt as well as evictions and bankruptcies.”
These consequences affected not only the women denied abortion but their families, including the existing children and the new baby. The researchers also found that women who were turned away were more likely to stay in contact with a violent partner, whereas physical violence decreased for women who were able to get abortions.
Being denied an abortion also affected the developmental milestones of a woman’s existing children. They used an instrument of developmental status to assess the children for expressive language, fine and gross motor skills, receptive language, social-emotional and self-help skills, and found that the mean score from six months to five years among children in the Turnaway group was 4 percentage points lower than that of the existing children of women in the Abortion group.
The new babies, too, suffered negative impacts. The study used a Postpartum Bonding Questionnaire for children under 18 months, and found the Turnaway mothers were five times more likely to have a high score, indicating difficulties bonding. “We found carrying unwanted pregnancies to term resulted in poorer maternal bonding, feeling trapped with a baby.”
Finally, giving birth is associated with more serious health problems than having an abortion. “Two women in the study who gave birth who were denied an abortion died during delivery,” Biggs said. “We had no women who died during abortion.”
For her part, former APA president Stotland believes that adoption as a “solution” to an unwanted pregnancy also carries psychological consequences, but said it’s impossible – and, she believes, unethical – to conduct a study of women who gave up babies for adoption.
“We know anecdotally that it never goes away, they never forget, they wonder, they know the child is wondering, ‘Why did you give me away, didn’t you love me?’” Stotland said. “You’ll be the woman who gave away her baby for the rest of your life. If that doesn’t have horrendous psychological effects, I don’t know what does. It’s a burden they both carry forever.”
The Turnaway Study showed that after five years, the psychological wellbeing of women who were denied abortions improved, converging with the mental health of those who were able to have abortions. Stotland credits the improvement to resilience. “Women are going to pull it together one way or another and survive as they have through the centuries,” she says. “But they’ll still be disadvantaged, and many still won’t have an education.”
Jones, the professional counselor in San Antonio County, said many clients came to her for help and advice when they found out they were pregnant. “Their initial mindset was panic, fear, depression, and feeling like their life is pretty much over if they don’t get an abortion,” she said. “When they come to the decision to travel, they feel instantly better.”
When the Supreme Court decision came down, two of her clients were already traveling to other states to get abortions because they exceeded Texas’ ban on abortions after six weeks of pregnancy. But not all women – and not all of Jones’ clients – can afford to take time off work or drive to seek abortion care
“My clients who can’t afford to travel are hoping and praying and crossing their fingers that they have a miscarriage,” she said. “Pregnancy would derail their lives in terms of what they had in mind for their career, education, and relationships. Now abortion has become about privilege. Can you travel? Can you take time off your job?”
A lot of the people Jones works with have long histories of depression and anxiety. “They’re struggling to take care of themselves and don’t feel they’d be the best parent or emotionally available because they’ve been traumatized throughout their entire lives in various ways,” she said. “They don’t feel that’s fair to the kid.”
Children born to women who haven’t planned for them and are prevented from having an abortion may also face lives of poverty, poor care and serious emotional issues, Jones said.
“Texas child protective services are overrun, they can’t take care of people, they’re overworked, and the abortion ban is just going to strain our system more in so many ways,” she said. Texas is consistently ranked at the bottom of states for mental health services, she noted. “There’s definitely not enough support and therapists for children and teens.”
Jones is battling with stress and burnout herself. “Like other therapists, I’m trying to not feel hopeless, to keep carrying the torch and keep leading the way, helping people, doing what we do best, which is support our clients no matter what decision they make.”
But she also knows that if she refers a client for an abortion, she could be in trouble. “There is a bounty, so someone could report the client and me and I would be in a precarious situation,” she says. “It messes with their lives and with the care I provide.”
Such policies place counselors “in an unethical position,” the American Counseling Association said in a statement after the Supreme Court decision was released. “In counseling, clients are entitled to self-determination and to make decisions in the best interest of their health and well-being. Clients should have access to high-quality professional counseling without the fear of having their confidentiality unjustly waived.”
Planned Parenthood’s Liner adds that women struggling with mental health or substance abuse are at particular risk. “We see patients who have struggled with alcohol and drug abuse who would potentially lose their children or lose ground in their recovery if they were forced to remain pregnant when they did not want to be.”
It boils down to this, she says: “Each patient we see has spent time determining what is best for their individual situation. We should trust them and be able to offer them the care they need, including abortion.”