Now, what is going to happen to the women that were having the illegal abortions before the Supreme Court ruling?

Do you feel that what we do or do not do is going to have an impact on the desire of a woman who wants to have an abortion? Dr. BERNSTEIN. I would think, Senator, that if somebody wants an abortion they are going to get it unless they get some kind of psychiatric kind of care or good counseling. I think we could carry them through. But if somebody really wants it, they are going to get it.

Now, as you well know, we did not have a lot of deaths in Minnesota from the illegal abortions. There is no question of that. And one of the funny stories was, with all the exaggerated figures coming from other States, was send them to Minnesota for illegal abortions and everything will be all right. We did not have many deaths. They did them well. I do not know why. I cannot explain that. But there were not very many.

But I do not believe in the illegal abortions. I think if we have to have abortions for medical reasons-and I think there are some— I think they should be done in hospitals by competent people.

Senator BAYH. Let me ask you one more question. To define once again the parameters you would place on abortions, you said you felt there should be some legal abortions?

Dr. BERNSTEIN. Yes. I have been on abortion committees. If somebody had a malignant hypertension and was going to die, I think it would be passed to have the life of the mother. There are certain things that you have to do to save the life of the mother.

Senator BAYH. One of the witnesses we had last time had given birth to and subsequently lost a Tay-Sachs child.

Would there be grounds for abortion, if a thorough examination had disclosed with certainty that the Tay-Sachs trait was present in the embryo?

Dr. BERNSTEIN. I suppose I would have to beg the question, because I do not think this is something I know a great deal about, for one thing. I do not think I could tell you that.

Senator BAYH. Maybe you are safe not to answer it, then, because that is a tough one.

Thank you very much, Doctor. I appreciate your contribution.

Our next witness, Dr. Zigmond M. Lebensohn, chief, Department of Psychiatry, the Sibley Memorial Hospital and clinical professor of psychiatry at Georgetown University Medical School.

Doctor, we appreciate your taking the time to be with us.

STATEMENT OF ZIGMOND M. LEBENSOHN, M.D., CHIEF, DEPARTMENT OF PSYCHIATRY, SIBLEY MEMORIAL HOSPITAL. AND CLINICAL PROFESSOR OF PSYCHIATRY, GEORGETOWN UNIVERSITY MEDICAL SCHOOL

Dr. LEBENSOHN. Mr. Chairman, and members of the subcommittee, I should first like to thank the members of the subcommittee for this opportunity to testify today in opposition to the proposed amendments to the Constitution which would prohibit abortion.

Throughout my professional career, I have been acutely aware of the destructive nature and impact of restrictive abortion laws. I

became most intensely involved in the abortion issue through joint discussions with my colleagues when serving as chairman of the committee on psychiatry and law of the group for the advancement of psychiatry.

In 1969 the committee issued the report, The Right to Abortion: a Psychiatric View. This report was issued following a two-decade period when there was an increasing tendency to invoke the psychiatrist as the arbiter in the issue of abortion and the psychiatric profession began to examine or reexamine its responsibilities in this regard.

I would like to begin by discussing some of the basic concerns raised in that report.

First and foremost, the committee felt that the regulation of access to abortion should be the product of religious, moral, ethical, socioeconomic, political, and legal considerations. Psychiatric factors, if they existed, must be examined in relation to these broader perspectives.

Before the Supreme Court decisions of January 22, 1973, the majority of State abortion laws required virtually all women, married or single, old or young, to carry the fetus to term, regardless of their emotional, environmental, or economic situations. This pregnancy, whether voluntary or compulsory, would then have lifetime consequences for the woman and the child. The woman who became pregnant out of ignorance or inability to utilize effective contraception lost permanently the right to control her own fate unless she could prove to doctors that her mental or physical health were in danger.

In the years preceding the Supreme Court decisions, several States legalized abortion or greatly liberalized the conditions under which it could be obtained legally. It is ironic that now, close to 18 months after the Supreme Court has spoken on the subject, this country is considering proposals which are even more restrictive than those imposed in the past, and which would totally disregard the mental or physical health, and in one instance even the life, of the mother. The first step toward liberalization of abortion laws followed the proposals outlined by the American Law Institute-ALI-which stated in part that:

A licensed physician is justified in terminating a pregnancy if: (a) he believes there is substantial risk that continuance of the pregnancy would gravely impair the physical or mental health of the mother. For a number of reasons, the ALI proposal was unsatisfactory.

First: The ALI proposal was of no help in providing a social resolution of the moral issues involved. Second: The extent of the role assigned to psychiatrists was unacceptable because the language used defied objective or consistent interpretation. The crucial question which remained unanswered was: Are there psychiatric criteria. that can be consistently and validly applied in the face of an ambiguous medico-legal standard?

The issue of whether or not there are psychiatric indications for abortion engendered debate in the psychiatric community which still continues today, and Dr. Bernstein in his testimony alluded to

this. The debate reflects the different concepts of what is mental health and what constitutes a threat to mental health.

Some would have us believe that unless an unwanted pregnancy were to bring about suicide or total breakdown, abortion could not be justified on psychiatric grounds. All of us know that such cases are extremely rare, although women have been known to take extraordinarily dangerous and damaging measures to terminate an unwanted pregnancy.

The major, and real, question is: When should abortion be recommended on psychiatric grounds? The Group for the Advancement of Psychiatry defined those criteria as follows; on the basis of the answer to this question: Will the abortion and its effect be more traumatic than pregnancy, childbirth, and forced motherhood? Senator BAYH. Doctor, may I just interject here a poor layman's observation?

Dr. LEBENSOHN. Please.

Senator BAHY. As a lawyer, I find it difficult to nail down the criteria definition given by the American Law Institute. Could you tell me, how you as a doctor, nail down the definition you just read? Is there a way that you can weigh that on the scales?

Dr. LEBENSOHN. Toward the end of my testimony, Mr. Chairman, I will try to point out that I am in favor of psychiatry getting out of the abortion business entirely, with very rare exceptions.

Senator BAYH. Then just go ahead with your statement.

Dr. LEBENSOHN. The question which puzzled you as a lawyer puzzled us also as psychiatrists. Therefore, we felt that abortion should be, a matter between the woman and her physician, and that psychiatrists ought to stay out of the situation except for research, conducting studies on the psychiatric sequelae of abortion or pregnancy, and treating those clear-cut cases where there is psychiatric illness. Other than that, I do not feel that the average woman, faced with an unwanted, unplanned pregnancy desiring an abortion, needs a psychiatrist. So in a sense we felt that was a decision that psychiatrists should not make.

Senator BAYH. I just did not want to forget that one.

Dr. LEBENSOHN. I completely agree. This issue puzzled our committee so much, that we concluded this should be the decision of the woman in consultation with her doctor.

Until fairly recently, we thought women often experienced severe mental and physical trauma as a result of abortion. It was not clear to us whether these apparently negative reactions were due to the fact that the operations for the most part were conducted illegally, under clandestine and demeaning conditions, or whether they were a more direct effect of the procedure itself.

We have found, however, that the older literature is full of alarming reports suggesting that women who had experienced abortions suffered deep psychic trauma and profound guilt which would haunt them to the end of their days and which would eventually form the basis for future depressive or psychotic episodes. Most of these studies simply do not stand up to serious critical review. Simon and Senturia in one of the best papers on the subject reviewed 28 publications which included the major studies conducted between 1935

and 1964 and found the conclusions widely divergent and their methodology often insufficient. I would like to have this report made a part of the record.

Senator BAYH. We would be glad to have it.

[The information referred to follows:]

PSYCHIATRIC SEQUELAE OF ABORTION-REVIEW OF THE LITERATURE, 1935–1964

(By Nathan M. Simon, MD, and Audrey G. Senturia, BA, St. Louis) Therapeutic abortion has become a subject of increasing concern for the psychiatrist in the United States. While the rate of therapeutic abortion has decreased over the last 30 years, there has been a marked increase in the relative proportion of psychiatric indications for therapeutic abortion (1)

Since therapeutic abortion raises problems that directly involve religious, political, social, and philosophical values, it is not surprising that the literature takes on the quality of a debate. The purpose of this paper is to examine: (1) the research design, if any, of the reports: (2) the results; and (3) the conclusions drawn from the results. It is our belief that such an appraisal can be useful in planning future studies that will avoid the repetition of errors and direct efforts more fruitfully to elucidating unsolved problems. The primary interest of this review is therapeutic abortion but some references, of necessity, will be made to sponstaneous and criminal abortion.

Taussig (1936) (2), in his well-known monograph on abortion, cites a few case histories of psychosis following induced abortion. He makes no estimate as to the general incidence of such consequences. In his survey of the Russian experience in the 1920's and early 1930's when abortions were carried out in large numbers, he quotes Russian physicians as saying that tiredness, nervousness, backache, and neurasthenia were common sequelae of abortion.

COMMENT

Of the three cases of psychosis following abortion cited by Taussig, only one case was from his own practice and in that instance the woman had severe psychiatric illness prior to the abortion. The other two cases were from the European literature and are reported in a sketchy fashion. The Russian experience is reported anecdotally and must be interpreted in the light of a high incidence of organic complications. Although Taussig makes only the most cursory references to psychiatric sequelae of therapeutic abortion, he is quoted by nearly every author since 1936 as warning against serious psychiatric sequelae to abortion. Hamilton (1940) (3) interviewed 537 women at the Bellevue Hospital whose pregnancies were terminated before the 28th week. The women were interviewed initially within 24 hours of admission for one half to one hour. Some were seen for more than one interview. Thirty women had therapeutic abortions and 507 had either criminal or spontaneous abortions. Information about religion, age, income, coitus, and children was routinely elicited. There were no significant sociological differences between groups which denied or admitted interference. Forty-six percent felt regret about the abortion, 39% relief, and 15% were indifferent. Twenty-three percent of the induced (therapeutic and criminal) abortion group felt regret. Sixty-one percent of the spontaneous group felt regret. Eleven women with induced abortions and three with spontaneous abortions felt remorse.

Hamilton (1941) (4) reinterviewed 100 women from her first study who were the only ones to return as requested for a four-week checkup. Eight of this group had therapeutic abortions. Symptoms such as weakness, tiredness, abdominal pain, backache, depression, and constipation, which were denied prior to the abortion, were reported by a large number of the women. Fifteen of the 70 women who had initially said they loved and respected their male partners now reported mixed emotions or dislike. In 13 cases the sexual relationship responsible for the pregnancy was terminated and feelings of dislike and repugnance existed. Attitudes toward coitus changed in 32 of the 68 women who were initially positive, ten disliked it, and 22 were indifferent. One third of the women who expressed relief. satisfaction, or indifference complained of depression. Fifty-four of these 100 women expressed regret at the

initial interview, while 46 expressed regret at the follow-up. The author believes there is a trend, with time, to find relief and satisfaction in abortion.

COMMENT

In these studies there was systematic data gathering, at least for sociologic variables. The initial and follow-up interviews were done by the same observer. The data indicate a marked difference in response of women who had been active in inducing abortions from those with spontaneous abortions. The former group had unwanted pregnancies and in the latter group most of the pregnancies were desired. The studies do not differentiate the therapeutic abortions in the group from other induced abortions.

In both studies the samples are biased. In the first study only women with complications of illegal abortions are included. In the follow-up study there was a large element of self-selection in the sample. No attempt was made to follow those women who did not return voluntarily. One would suspect that women with complaints would be more likely to return. While the sample contained groups of women with different types of abortions and provided an opportunity to compare groups whose abortions came about in different ways, this was not done. No criteria was presented about preabortion psychological condition. The follow-up was done soon after abortion, so only immediate effects were measured. Mild depressions seem to be the rule. No other specific psychiatric disorder is mentioned.

Hesseltine et al (1940) (5) reported on 82 out of a group of 134 women who had therapeutic abortions for a wide variety of indications. The patients in the series were urged to return to the hospital to be followed for the condition for which the abortion was indicated. Fifty-one were followed for a period longer than one year, 21 for three years, and ten for five to eight years. The authors state that the patients were followed by "“various clinics and specialists." "Outcome" following abortion was designated as "satisfactory," i.e., improvement in the patients health attributable to the abortion; "unchanged," "unsatisfactory" and "undetermined." Outcome in 21 cases was designated as satisfactory, unchanged in 22, unsatisfactory in three and undetermined in 36. There were ten cases in the series terminated for psychosis and psychoneurosis. Of these ten, six fell in the "undetermined" group, three were "satisfactory," and one “unchanged.” The authors conclude that therapeutic abortion is necessary, but only infrequently.

COMMENT

In this study the patients were followed for periods up to eight years. There was 61% follow-up. Self-selection was an important factor in the sample composition. What actually comprised the follow-up was not stated. The patients were followed by "various clinics and specialists" and it is not clear how the findings of the various observers were correlated and what kind of data was collected. The large number of "undetermined" outcomes (44%) leaves an element of uncertainty about the results. Why so many cases fell into this category is not explained. There is no correlation of outcome and indication. It is not clear if there was any psychiatric illness among the "unsatisfactory" outcome group.

Deutsch (1945) (6) believes that abortions are handled differently by different women. Women with compulsive need to conceive react to abortion either with severe neuroticism or a new pregnancy. Women with excessive guilt reactions use the abortion for severe self-accusations. In depression of the climacterium, the self-acusation of a long forgotten abortion may be an important factor. Since pregnancies fill old wishes, interruption constitutes a trauma regardless of reality. Relations to men and sex are changed. However, the trauma is not irremedial unless it caused an organic injury. Even as the "best" solution, it is not always successful because "adjustment to reality sometimes involves severe emotional disturbance."

COMMENT

Deutsch, a psychoanalyst, derived her data from a "large number' of cases. The exact number is not specified. The circumstances under which they were seen, i.e., analysis, psychotherapy, evaluations, etc. is not stated. There is an

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