Speaking of Psychology - Abortion and mental health, with Antonia Biggs, PhD

Episode Date: June 15, 2022

Dozens of states are poised to outlaw or dramatically restrict abortion if the Supreme Court overturns its 1973 Roe v. Wade decision. Antonia Biggs, PhD, a social psychologist at the University of California San Francisco, talks about the results of the Turnaway Study, which examined how receiving an abortion – or being denied one – affects mental health and well-being, the effects of laws that limit access to abortion, and what a post-Roe future might look like. Links Antonia Biggs, PhD The Turnaway Study Speaking of Psychology Home Page Learn more about your ad choices. Visit megaphone.fm/adchoices

In May, a leaked draft of a Supreme Court decision indicated that the court might soon overturn 50 years of legal precedent and strike down Roe v. Wade, the 1973 ruling that found there is a constitutional right to abortion. Dozens of states are poised to outlaw or dramatically restrict abortion if Roe is overturned. While the court has yet to issue a final ruling, we're going to talk today about one aspect of what a post-row future would look like. What could happen to the mental health and well-being of people who are no longer able to access abortion? Abortion opponents have long argued that the procedure harms women's mental health and that it leads to depression, anxiety, regret, and even post-traumatic stress disorder.

But years of research have failed to find that abortion itself causes these outcomes. So how does obtaining an abortion or being denied one affect mental health and well-being? What are the effects of laws that limit access to abortion, such as those that mandate waiting periods or pre-abortion counseling? And how might new laws that outlaw abortion affect people, even in parts of the country, where abortion remains legal? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. Our guest today is Dr. Antonia Biggs, a social psychologist and associate professor at the advancing new standards in reproductive health program at the University of California, San Francisco.

Dr. Biggs studies the mental health effects of abortion. She led the mental health analysis for the Turnaway study, a nationwide examination of the health and well-being of women who seek abortions. She also researches the challenges people face when accessing sexual and reproductive health services, as well as public attitudes toward abortion, particularly medication-induced abortion. Thank you for joining me, Dr. Biggs. Hi, thank you so much for having me. So excited to be here. As I mentioned a moment ago, abortion opponents often argue that abortion is in itself bad for people's mental health and can lead to many negative mental health outcomes. The turnaway study on which

you worked, address this question directly. Would you start by telling us about that study how it was conducted and what it found? Sure. So the turnaway study is a national study that was led by my colleague, Dr. Diana Green Foster at ECSF. And in this study, the impetus behind this study really came from this idea that abortion harms women's mental health. This is something that Justice Kennedy had stated in the Gonzalez v. Carhart case where he literally said that we don't have reliable data to measure the phenomenon, but that it seems unexceptional to conclude that some women come to regret their abortion and that severe depression and low self-esteem is going to follow. So this is an assumption that has been integrated in a lot of the state. level restrictions on abortion, yet he clearly states that we don't have reliable data. So the turnaway study really aimed to provide that reliable data. So it's one of the most rigorous

studies that we have studying that question. So we recruited nearly a thousand women and followed them for five years. And we compared people who had an abortion to people who were denied an abortion because they were just above a facility facility's gestational age limit. And we recruited people across the U.S., and we were really able to assess whether the people who had an abortion were at increased risk of having negative mental health outcomes when compared to the people who were denying an abortion. And what we found is that this assumption is wrong. that we found that people who had an abortion were at no, they were not at an increased risk of experiencing depression, anxiety, suicidal ideation, post-traumatic stress disorder.

So we looked at all of those outcomes and we did not find an increased risk among the women who had abortion. But what we did find is that the women who were denying an abortion did have short-term elevated levels of stress, anxiety, low life-satisfaction. and low self-esteem when compared to the women who were able to get their wanted abortion. So, in fact, we found the opposite of what people were assuming. And then the other thing we found is that women, most women do not regret their abortion. Actually, we found that nearly 99% of women, when we follow them for over five years, say that the abortion was the right position for them. Okay, so you're a psychologist and you focused on the men,

health outcomes in the analyses of the turnaway data. But the study also looked at other outcomes like physical health and the economic effects of getting or being denied an abortion. What were some of the highlights of those findings? Yeah. So what we found, when we look at all the other outcomes that we looked at, we found that the people who were denying abortion were much more likely to experience economic hardship and economic insecurity that lasted for years. This impacted the financial well-being of the people who were denying abortion as well as their children and families, so they were much more likely to live in poverty. We also found that people who were experiencing intimate partner violence were significantly more likely to be tethered to those

partners over years, the people who were denying an abortion were more likely to stay in contact with those violent partners than the people who were able to get their abortions. And then from a physical health perspective, we also, we know that abortion is much safer than childbirth. And in the turnaway study, we found that people who were denied an abortion and carried those pregnancies to term, were much more likely to experience hypertension, chronic pain. They had a greater likelihood of poor health compared to those who have received an abortion. And then most tragically, we actually had two people who died in childbirth of the women who were denying abortion. And that's really an astronomical number when you think of the number

of people that we included in this study. And nobody who had an abortion. died. So we found, you know, very severe consequences to their physical health. What are the biggest challenges of doing this type of research? Was it hard to collect the sample? Was it difficult to structure the questions in a way that would get you what you needed? Tell us about that. Well, I think that one of the reasons why we haven't had good data up until the turnaway study is because of the challenges conducting this kind of research. So you can't randomize people to an abortion group or not abortion group ethically for obvious reasons. And so that has led to a lot of correlational studies that don't take into account some of, some important factors that could predispose people to negative mental health outcomes.

So what was unique about this study is that my colleague, Dr. Diana Green Foster, was brave enough to do the study that nobody thought she could do, which is to interview people who are denied an abortion at the time of being denied an abortion. So, you know, people didn't think that she could do it, but she did with the help of amazing clinics who helped with the recruitment. It was that the idea was spawned by a colleague of mine who's a clinician, Dr. Eleanor Dre, who knew that women were being turned away and was wanting to know what happens to those people. So that prompted the study design and it was a tremendous amount of work involved all the clinics who helped to recruit. And then we followed people for five years interviewing them every six months, so 11 waves of interviews.

So it was a huge, tremendous amount of work and involved a multidisciplinary team of everything. experts, clinicians, stemographers, epidemiologists, which is one of the strengths of the study, but also a challenging study to conduct. What were the limitations? I mean, if you could have done an ideal study with no limitations,

what would it have looked like compared to what you had to do? So every study has its limitations. I think in terms of this particular study design, I think it's one of the best. It sort of takes advantage of a quasi-experimental design. One of the limitations is that more people did participate. So our participation, you know, ideally you want everyone to participate, but of course that's never going to be possible. So I'm not sure what we would have done differently other than in terms of getting more people to participate.

I think in retrospect, there's probably like tweaks that we would have done to our survey instrument. But overall, I think it's a study that we're all very proud of. There's another idea that's often cited by abortion opponents that many women come to. regret having had an abortion. What does the research say about abortion and regret? So the research says that, well, the turnaway study research says that most people do not regret their abortions. Ninety-nine percent of women say that the abortion was the right decision for them, and this continues over five years. We also have a lot of, research from other studies that have looked at women. So my colleague, Dr. Katrina Kemport,

has done interviews with people who said that they had emotional, really specifically trying to find people who may have regretted their abortions. And it was very hard to find those people. But when she did, she conducted, I think, 17 interviews. And what she found, was that it wasn't that people were regretting the abortion itself. It was that people were regretting the circumstances around the abortion. So there's something that we call decisional regret versus situational regret, which is a term that a colleague of mine, Katie Watson, wrote a paper about. And the idea is, in the case of abortion, is that you wish you were in that circumstance that led you to need an abortion.

You wish that maybe your partner reacted differently and was more supportive, or you wish that you had better financial circumstances, or you were more stable housing. There are situations in your life that you wish were different so that you could have that and carry that pregnancy to term. And so there's regret about that. And really, it's very rare that people are regretting that they actually had the abortion once they had no other option. Now, you've also done research into the reasons why women seek abortions. What are some of the most common reasons?

And do they differ from what most people think? Well, women have abortions for many reasons. Often there's more than one reason for them choosing to have an abortion. But I don't know that they differ from why people think. The most common reason is financial reasons, economic reasons, not being having the right financial circumstances to raise a child. Many women are concerned about their existing children and want to, you know, they want to provide a better life than they think they can provide for that child at the time.

some choose to have an abortion due to partner-related reasons they're not with the right partner and yeah lots of different reasons have those reasons changed over time they tend to be the same reasons that people people um any reason why it might not be a good time to have carry a pregnancy to term tends to be the reason why people have an abortion, and that hasn't really changed over time.

What has the availability of medication-induced abortion done to change the landscape out there? Are we seeing more women accessing that type of treatment as opposed to surgical abortion? Yeah, we've seen tremendous growth in the provision of medication abortion. now it's over half of people, of half of abortions are medication abortions, and it needs to be much lower. I think that in part that has to do with now we have telemedicine provision of medication abortions. So particularly during the pandemic, telemedicine became available in the case of medication abortion, so more people are able to access it. People prefer, in some cases, people prefer medication abortion because it feels more natural or more private.

They would prefer to carry, you know, to pass a pregnancy, be at home at the time. So, but then there's, of course, people who prefer in in-clinic procedure as well. How much do we know about the children who were born to women who had wanted to have an abortion but were unable to obtain one? What happens to them? And are most of them adopted? Do mothers tend to keep them? Or is this just an area that needs more study? Well, in the turnaway study, we looked at the people who were denied an abortion and carried those pregnancies to term.

And we looked at the outcomes of those children. So they were significantly more likely to live in poverty, as I had mentioned before. Very few place those children up for adoption. that was a very uncommon scenario. So this idea that has been purported that adoption is going to take the place of access to abortion is not evidence-based. We know that that is very unlikely to happen. We also saw very sadly and tragically that the people who were denying an abortion carried those pregnancy to term were less likely to bond with that child.

So we looked at indicators of maternal bonding, and that was lower. And we also saw that the existing children were less likely to reach those classic developmental milestones that are measured, and they weren't quite reaching the same milestones. So the impacts for the children are very real. She talked about existing children, meaning that a lot of these women already had children and the children that they had were also affected by the outcome, the fact that the woman couldn't get an abortion. That's right. Yeah. So the entire families are affected, including the ones who were already in the household. And that is one of the important reasons why people want an abortion, too, is that they're thinking about their other children and families.

Many states already have laws mandating that people undergo a waiting period or counseling before they can have an abortion. How do those kinds of requirements affect women's access to abortion? And then how do they affect the women's mental health afterward? Yeah, well, it's really interesting that these mandated waiting period and mandated counseling laws are passed with this idea that they're going to protect women from harm, protect them from physical harm and mental health harm in Texas. One of the women are required to receive this a booklet that warrants them of an increased risk of becoming suicidal.

And these, the idea that they're going to protect people's mental health is definitely not based in evidence. And we see that, as I just shared, it's very much quite the opposite. But what's really, really hard to stomach with these laws is that they're not thinking about what kind of mental health risks are they. So they're saying they're protecting people from mental health harm, but they may also be increasing mental health harm. And we did some work where we looked at the people who had to overcome burdens accessing care and what those associations were with mental health symptoms. And we found that people who had to overcome barriers accessing care, so traveling far, who had trouble finding a clinic and other obstacles, they were more likely to experience

symptoms of stress, anxiety, and depression, than people who didn't have to overcome those obstacles. And the other thing that we found is that lack of autonomy, so being forced to wait, which is what is required in a mandated waiting period law, being forced to wait after you've made a decision is also associated with more stress, anxiety, and depression. So these laws are harmful to people's mental health and do the opposite of what they claim to do. You've studied the role that stigma plays in how women experience abortion and how they feel about it afterward. Can you talk about that? Yeah.

So we, in the Tunaway City, we looked at people, we asked people whether they felt that their community or people close to them would look down on them if they knew they had an abortion and the vast majority said that they did. So perceived abortion stigma was pervasive. And then when we looked to see those who experienced perceived abortion stigma and their mental health outcomes years later, we found that those who perceived more stigma were significantly more likely to experience psychological distress in the five years after having sought or been denied an abortion. And I would think that that would be part of the reason that it's so hard to get the sample, right? I mean, just the stigma associated with getting the abortion is, it was hard enough going to get the abortion, right? And now a researcher

wants to talk to you about how you feel. That's got to be tough. Yeah, I think that, I mean, we found that many people actually enjoyed sharing their stories because this might be the, that the interviewer may be the only person that they could share their stories with due to stigma. So, for some people, I think that it was a good reprieve to be able to be with people who aren't going to judge you about your abortion and actually be interested in your experience. And then in other cases, we would ask them so many questions about the abortion. And we heard from the interviewers that they said they never thought about their abortion until we picked up the phone and called them because it's something that they sort of had moved on and weren't really thinking about it. If Roe is overturned, what kinds of effects do you anticipate we're going to see on women who live in parts of the country where abortion remains legal? And what about where it's illegal? I mean, you know, we've already got a mental health crisis in this country. What do you believe? And maybe this is unfair because you haven't done the research yet. But I mean, what would you anticipate as a researcher would be the outcome? Well, we expect, if we're always overturned, we expect that half the country is going to lose access to abortion, which is, which means that more women are going to need to travel out of state to get an abortion, or that more women are going to choose to self-manage their abortion, so have an abortion on their own without.

out clinical assistance. This may be something that is likely to be much safer than in pre-row years in that people, many people will have access to medication abortion, but some may not. I mean, some may choose to use physical methods. And then the other outcome is that more people are going to carry to term, which we already know is riskier physically and can lead to a host of negative outcomes. as we found in the turnaway study. I worry about the lack of bodily autonomy that this decision means for people.

It means that they are being denied a right to exercise their own bodily autonomy and being forced to travel or forced to carry to term or forced to end the pregnancy on their own. When they may prefer to have clinical assistance. So I think this is going to push people later in pregnancy. It's going to force more travel and it's going to negatively impact in particular people who have fewer resources, whether that's financial resources or emotional resources. And I also worry about people being criminalized. people who self-manage their abortions are at risk of being criminalized. And then we know that certain groups of people are more likely to be targeted by the criminal

justice system. And so there are a lot of things that I worry. But I also think that maybe this is going to have an increase abortion stigma. So I think if abortion is illegal, does that mean that more people are going to think that being against abortion is, I don't know, are people, our attitudes about abortion? Or could those change and will people be judged more for seeking abortion? I don't know. Those are things I don't know. So what are the biggest questions you think researchers still need to answer about abortion and mental health?

So we know that for most people, the population level, abortion, it doesn't increase people's risk for mental health harm. But there's some people who may need support. but what we know very little about is what is the impact of all of these the structural stigma and these laws and these increased barriers and all the obstacles that people need to overcome. I feel like we need more work to understand how that might negatively impact people. There's some qualitative work that shows that overcoming these barriers can be very traumatic. and I think that's something that I would want to understand

who is more effective from a mental health perspective. Well, Dr. Biggs, I want to thank you so much for joining me today. This has been very interesting. Thank you. Thank you for having me. You can find previous episodes of Speaking of Psychology on our website at www.spokenof psychology.org. We're on Apple, Stitcher, or wherever you get your podcasts.

If you have comments or ideas for future podcasts, you can email us at speaking of psychology at APA.org. Speaking of Psychology is produced by Lee Wynerman. Our sound editor is Chris Condihan. Thank you for listening. For the American Psychological Association, I'm Kim Mills.