Gebhard, Pomeroy, Martin, and Christenson reported on a study of 442 American women who had induced abortions, most of which had been performed illegally, and these women demonstrated only rare emotional sequelae. The careful studies of Simon et al., and Peck and Marcus suggest that psychiatrically normal women may, indeed, show a mild and self-limited depression but without significant psychiatric sequelae. More important, however is their finding that for those women who are emotionally disturbed, the abortion is truly therapeutic. This conforms to my own experience with psychiatric consultations on over 350 women in the District of Columbia, during the years when such psychiatric consultations were mandatory. Fortunately, they are no longer required. For women who are emotionally disturbed, suffering from the anxiety, depression and despair caused by an unwanted, unplanned pregnancy, the abortion is truly therapeutic, truly the treatment of choice. For the most part the patients stabilize or even improve following the abortion. In their excellent report, Simon et al. concluded:

Our study did not produce support for the frequently expressed belief that therapeutic abortion results in involuntary infertility, difficulty in sexual relations or is a precipitant in involutional depression.

The Osofskys, in the conclusions of their study of abortions performed in New York City in 1970 following liberalization of the New York abortion law observe:

Wherever objective studies have been performed, there has been a low incidence of psychological sequelae. Incidences have varied with sample studied, existence of prior difficulties, relative ease of abortion attainment, and attitudes of the professional staff. However, in no case has the incidence of problems been high-and in most cases, it is questionable as to whether the abortion, or preexisting difficulties provoked the sequelae. The predominant reaction has appeared to be relief.

Beginning in July 1971, the Osofskys, along with Dr. Renga Rajan, studied the psychological effects of abortion at Temple University Hospital in Philadelphia. Since abortion in that State, at that time, could be performed only for strictly therapeutic reasons. all patients were required to obtain medical or psychiatric consultation and be cleared through a departmental committee. Intensive interviews were initiated shortly before and after the abortion procedures. This study undertook a comparison of patient characteristics and emotional reactions related to the first and midtrimester abortions. That is to say, abortions done in the first 3 months or the second 3 months of the pregnancy. Preliminary findings indi. cated statistically significant differences between the first and second trimester patients. Although postabortal feelings of guilt and depression were uncommon among all patients, differences were noted between the two groups. Only 2 percent of first and 10 percent of second trimester patients noted some degree of guilt following the procedure, and 2 percent of first and 12 percent of second trimester individuals reported having some feelings of depression; only 4 percent of individuals in either group had any uncertainty concerning the appropriateness of their decision. It is important therefore that data from all studies on the psychiatric sequelae of abortion be scrutinized to ascertain whether the data refers to first or second trimester abortions, rather than citing indiscriminantly the negative

impact of abortion. In those countries where medical systems cause delay in obtaining abortions, as in Sweden and Great Britain, we would naturally expect to see results which showed greater levels of anxiety. In that connection it is worthwhile noting that here in the District of Columbia where it is a relatively easy matter to obtain an abortion without a psychiatric consultation at one of the freestanding clinics such as Preterm or others, the tendency is to perform the abortion within the first 9 to 12 weeks. In these early abortions the amount of trauma, both psychological and physical, is so slight that there are few or no sequelae of any kind in the physical or mental spheres.

The most recent study of the psychiatric sequelae of abortion was conducted at Johns Hopkins University. This study compared three groups of women in an effort to determine whether women who seek abortions are likely to differ psychologically from those who choose to carry pregnancies to term. The three groups included women who obtained an abortion by suction curettage, induced abortion by saline injection, which is a second trimester procedure, and full-term delivery. Tests were administered to identify patients who were at risk of psychological disturbance resulting from or triggered by abortion, and to find out if carrying a pregnancy to term tended to increase one's self-esteem or if having an abortion decreased it, or vice versa. Psychological tests were also administered to determine whether or not term patients-that is, those who carried the pregnancy to term-differed from abortion patients in psychopathology and in psychosomatic complaints after their preg nancy was past. The results of the study showed that the suction curettage group had fewer complaints after the abortion than either the saline or term patients.

"The term birth patients and abortion patients, matched for age, color, parity" that means the number of children they have had in the past"marital and socioeconomic status, were startlingly similar." They also found that "there were striking improvements among all three groups of patients with regard to contraceptive use."

The team of Osofsky, Osofsky and Rajan has also compiled the most complete and current survey of literature in the field. After reviewing almost 30 pieces of research they state: "In conclusion, it should be emphasized in this time of increasing availability of services, that for most women, abortion appears to be accompanied by few, if any, negative psychological sequelae. More often, abortion appears to lead to individual growth and resolution of problems." Rather than take the time to review this article in detail, with the chairman's permission, I would like to have it made a part of the record.

Senator BAYH. Without objection.

[The information referred to follows:]

[From "The Abortion Experience" Harper & Row, 1973]

PSYCHOLOGICAL EFFECTS OF ABORTION: WITH EMPHASIS UPON IMMEDIATE REACTIONS AND FOLLOWUP

(By Joy D. Osofsky, Ph. D., Howard J. Osofsky, M.D., and Renga Rajan, M.D.) As a result of the legislative changes and judicial rulings of the past several years, legal abortion has become an option for large numbers of women

in the United States. Undoubtedly the recent Supreme Court ruling will lead to still further increases in the availability of the procedure. Because of the importance of the legalization of abortion, and because of the impact that has already resulted, some of the existent data from the United States concerning patients' psychological reactions to abortion will be presented in this chapter. (David, in Chapter 15, will review comparable information from other countries.) We then will share the results of our studies, first during the implementation of an abortion program in New York State, and then with a program in Pennsylvania.

Nationally available data concerning both therapeutic abortion, requiring a diagnosis of illness substantiated by consultation with several doctors, and illegal abortion, performed under stigmatized and furtive conditions, might be expected to result in different psychological responses and sequelae than would legal abortion. (Similarly, procedures performed in other countries, with cultural traditions and patterns, might be anticipated to have a somewhat different outcome than would those performed in this country.) However, the studies in these areas provide considerable general, and in some cases specific, relevant information and therefore will be included in this chapter. For the sake of pertinence and brevity, an exhaustive review will not be attempted; the interested reader is referred to several good compilations that have appeared in recent years (10, 11, 12, 16, 22, 30, 32, 34, 36, 37). In the presentation of data from our experience, emphasis will be placed upon the patients' psychological reactions to the procedure, and parameters that are related to the reactions.

PSYCHOLOGICAL EFFECTS OF ABORTION-DATA PRIOR TO LEGALIZATION

In reviewing the interpretive findings and conclusions of studies performed prior to legalization, one finds a variety of opinions ranging from frequent to severe sequelae (1, 8, 40), to occasional direct or indirect problems (29, 30), to no noticeable difficulty (10, 12, 15). However, almost regardless of the source, the objective data reveal low incidences of psychological complications. Undoubtedly related to the condiitons of illegality, little data are available concerning the psychological effects of illegal abortion. Whittemore, as part of a study related to illegal abortion practices in an American city with a population of between 100,000 and 300,000, interviewed "over 30" women who had undergone such procedures (38). Criteria for patient selection were not given; the majority of patients had their abortions within the 6 months prior to interview; however, some had the procedures as long as 7 years earlier. Although 10% had experienced postoperative infection, none of the women regretted their decision. It is some interest that two of the patients had previously given birth to a child out of wedlock; both regretted that decision. Gebhard et al., in a better controlled investigation, studied 442 American women who had induced abortions; most of the procedures were performed illegally (9). Their results demonstrated only rare significant emotional sequelae. The Whittemore and Gebhard reports are perhaps of special note because of the commonly held assumptions concerning the psychological dangers of criminal abortions.

Kummer surveyed the experience of 32 psychiatrists in Los Angeles (15). He found that, during an average of 12 years' experience in practice, 75% of the doctors had never seen a patient with any moderate or severe psychiatric sequelae from either illegal or therapeutic abortions. The other 25% had encountered significant sequelae only rarely.

Peck and Marcus studied 50 women who had therapeutic abortions prior to legalization in New York; one-half of these were done for psychiatric indications (28). Patients were interviewed prior to the surgical procedure and 3 to 6 months following the abortion. There was one case of acute negative reaction to the procedure, which was quickly relieved. Mild guilt occurred in 20% of cases, but was short lived and disappeared by the time of followup; 98% of the subjects stated that, if they were to make the decision again, they would still prefer the abortion to continuation of the pregnancy.

Kretzschmar and Norris reported on the psychiatric sequelae of 32 therapeutic abortions carried out over a 6-year period in Iowa (14). In a 1- to 5year followup study of 24 patients, they found no negative psychological effects or problems.

Patt, Rappaport, and Barglow attempted to follow up 48 patients who had therapeutic abortions, with strict psychiatric indications, at Michael Reese Hospital in Chicago (27). Twelve patients had been lost to followup, and one refused to participate in the study. Among the remaining 35, who were evaluated through direct interview or physician report, the results indicated that, with rare exceptions, abortion could be considered genuinely therapeutic, primarily having a positive effect on the patients' psychological status.

Simon, Senturia, and Rothman similarly attempted to gain information concerning all individuals who received therapeutic abortions at the Jewish Hospital of St. Louis between 1955 and 1964. (33) The investigators were able to contact 46 of the original 65 women; they administered interviews, psychological tests, and questionnaires. Of the 46 patients, 35% were aborted for psychiatric reasons, 39% for rubella, and 26% for medical reasons. The investigators found that the emotionally healthier women responded to the abortion more easily than did those with severe psychiatric disorders. However, among all patients there was little new psychiatric illness following the therapeutic abortion that could be related to the procedure.

Meyerowitz, Satloff, and Romano evaluated the outcome of 114 therapeutic abortions performed under extremely strict indications at the University of Rochester Medical Center between 1963 and 1969 (21). The strictness of their indications is emphasized by the fact that nine of 26 patients, who were sufficiently ill as to require psychiatric hospitalization during pregnancy, were refused permission for abortion. In spite of the severity of their emotional illnesses, most patients did well psychiatrically following abortion; 64% of the individuals had an immediate manifest response of relief. Approximately 10% had initial significant psychiatric difficulties; most of these appeared related to the underlying emotional illness. At long range followup, most patients were either unchanged or better in overall psychological competence. The two final studies to be cited in this section were carried out by Niswander and coworkers prior to the liberalization of the New York law. Both were carried out in one of the affiliated hospitals of the State University of New York at Buffalo. Although the abortions were performed under a strict law, the law had been interpreted liberally with nonstringent psychiatric indications. The indications for and the milieu surrounding the procedures were similar to those which went into effect subsequently, when the liberalized law was passed.

In the first study, Niswander and Patterson followed 116 patients who underwent therapeutic abortion during the years 1963 to 1965 (23). They found few women who regretted having the procedure. Further, among the small number of individuals who had regrets, the regrets usually were noted shortly after the abortion and tended to disappear by the time of an 8-month followup.

In the second study, Niswander et al. administered the Minnesota Multiphasic Personality Inventory test preoperatively and then again 6 months postoperatively to 65 patients (24). The results were compared to those available for a smaller group of individuals undergoing a normal pregnancy experience. Preoperatively, the abortion patients appeared considerably more abnormal in their psychological assessments than did the maternity patients. Both groups appeared somewhat improved at the followup evaluation; the abortion patients improved to a far greater extent than did the maternity patients. Especially striking findings were noted in the measures for overall adjustment and depression.

It is of some interest to compare the findings of this study with the work done by Brody et al. in Canada (2). The latter investigators administered the MMPI test to 117 individuals who applied for therapeutic abortion. Of the 177, 94 were granted abortions. Those who received abortions were followed 6 weeks postoperatively; those who were denied abortions were followed 6 weeks postpartum. Both groups demonstrated considerable psychopathology, on the basis of the MMFI test, at the time of the initial interview. The individuals who received therapeutic abortion scored considerably better at the time of followup examination; no such changes were noted following delivery in the supposedly more healthy group who were denied abortion. These MMPI findings are consistent with Hook's interviews and evaluations in a followup study of 294 women whose applications for abortion were refused, because of in sufficient indications, by the National Board of Health in Sweden

in 1948 (13). In the original sample 45 women were excluded from followup; 24 of these were excluded because their subsequent symptoms allowed them to gain a therapeutic abortion. Of the 249 individuals who were followed, 23% accepted the pregnancy after the refusal and were able to handle the situation satisfactorily; 53% finally adjusted themselves after having had a variety of insufficiency reactions during an 18-month observation period; the remaining 24% found the situation of refusal so unfavorable that the symptoms of insufficiency, which had arisen within 18 months of the application, were still present at the time of followup, 71⁄2 years later. A higher percentage of subsequent incapacitating emotional insufficiency was noted among the apparently healthy women who could not qualify for abortion than among the emotionally and physically disturbed individuals who did qualify.

PSYCHOLOGICAL IMPACT OF LEGALIZED ABORTION

Because of the relative recency of legislation legalizing abortion in some areas of the United States, and because of the extreme recency of the Supreme Court decision, few studies are available concerning the effect of abortions performed under such circumstances. Elsewhere in the volume, authors will report on various aspects of the psychological experience from material which they have gathered personally. Their work represents some of the most informative and best controlled national data, but, for obvious reasons, will not be included in the review in the present chapter.

Much of the available data has accumulated from California because of the comparative length of existence of its liberalized legislation. Marder summarized early results under the 1967 California Therapeutic Abortion Act (19). As has been mentioned elsewhere, this modification of existent legislation represented a liberalization, but not a total legalization. As of September 1969, approximately 600 applications had been received, and 550 had been approved. Few serious emotional problems of guilt or remorse were noted in the patients.

Levene and Rigney sent followup questionnaires to 70 consecutive women granted therapeutic abortion for psychiatric indications in San Francisco under the liberalized California law (17). No serious psychiatric sequelae were found. Guilt feelings, when present at all, were short lived. Any depressive phenomena decreased significantly between 2 weeks and 3 to 4 months postoperatively.

Margolis et al., in San Francisco, followed 43 patients for 4 to 6 months after their abortions. (20) Although indications for abortion were liberal, five other patients were refused abortion, and only six individuals in the sample had no obvious psychiatric problems. Postoperatively, 29 of the 43 patients experienced positive psychological or growth experience or both; ten indicated no change in attitude; four had some type of negative reaction, such as guilt or fear of men. Patients' MMPI scores prior to the abortion showed abnormal elevations; at the time of followup, testing revealed essentially normal findings. Ford et al. assessed approximately 500 clinic patients and a limited number of private patients in Los Angeles between 1968 and 1970 (5). Their report did not include data presentation or analysis. However, they concluded that, although transient mild depression was common, most individuals had a benign course after abortion. Again, without corroborative numerical data, the authors classified patients into categories in an attempt to define which patients might benefit from psychiatric evaluation.

Ford et al. attempted a more extensive evaluation and followup of 40 clinic patients who applied for abortion during the same year (6). Of the group, 30 were approved for the procedure with psychiatric indications; 47% of this group had a history of psychiatric consultation or hospitalization in the past. Five were felt to be psychotic at the initial interview. The authors were able to follow up 22 of the 30, 6 months postoperatively. In most of the patients, psychiatric symptoms were considerably reduced. Only three women were more disturbed, and the disturbance appeared related to the initial severe psychopathology. Similarly to the previously cited studies by Niswander et al. (24), Brody et al. (2), and Margolis et al. (20), patients' MMPI scores, which demonstrated considerable deviance prior to the abortion, were much improved at the followup evaluation.

Burnell et al. reported data from 924 women receiving therapeutic abortions at the Kaiser Permanente Medical Center in Santa Clara, California (3).