Abortion: What's Happening and Why It Matters to Women, Psychiatry, and Society

By Nada Logan Stotland MD MPH       

Delivered on May 15, 2016 at the 2016 AASP Humanitarian Award Forum, Atlanta, Georgia

Nada L. Stotland, MD. MPH.JPG

First of all, I would like to thank the AASP for this extraordinary award.  It seems to me that a humanitarian award should be a reward for acts that are difficult.  So I’ve decided to talk about abortion, because my involvement with abortion has been difficult.  I’ll offer a little history about my involvement, information about psychiatric aspects of abortion, and a look at the laws and practices in the United States, with some perspectives from around the world.

Then I want to consider, with you, why we are where we are with reference to abortion in the United States, why it matters, and what we can do about it---because something needs to be done.

Roe v. Wade was decided, in 1973; in the preceding years, abortion was illegal and illicit in my state and my world.  Except in cases of incest and rape---exceptions still for most people today--it conjured promiscuity and irresponsibility.  Everybody knew that pregnancy was the result of sexual intercourse and could be prevented by abstinence or by contraception; there were condoms, diaphragms, and even ‘the pill.’  What kind of person would get pregnant ‘accidentally’?  Children should be wanted and planned, and only when their parents had the resources to care for them. 

I had seen the hospital wards full of septic, bleeding women who claimed to have had miscarriages but were understood to have undergone illegal, unsafe abortions.  It was a dirty business, and handled like one.  Only later did I come to realize the assumptions and motivations underlying laws criminalizing abortion, the realities underlying the occurrence of unintentional and undesired pregnancies, and the full impact of those laws on society. 

When I was a resident, in 1970 (pre Roe v. Wade), abortions could be performed legally in Illinois only if a physician certified that continuing a pregnancy posed a danger to a woman’s life.  One day, my assigned diagnostic outpatient was a woman desperate for a psychiatrist’s indication for an abortion.  She told me that she would commit suicide if her pregnancy were not terminated.  I think that was the first time I was confronted with a real woman pregnant in an untenable situation, and the first time I had the power to change that situation.  Somehow I knew that the decision had to be hers.  I didn’t do the suicide evaluation I had been trained to do.  I chose to take her at her word.  I wanted to grant her request, but not to lie.  I wrote a report stating that the patient threatened she would commit suicide unless her pregnancy was terminated—without questioning or endorsing it-- signed my name, and she had a safe, legal abortion. 

Here was the reality; with money, sophistication, and/or power, any woman in the United States could have had a safe abortion, and, as we learned later, when they came forward, many did.  Nearly fifty years later, with abortion clinics being forced to close by hypocritical, cruel laws in state after state, rich or well-connected women can still end their pregnancies if they wish—and they do.  Women whose lives are already constrained by poverty, inescapable responsibilities, lack of information, lack of access to contraceptives, victimization—cannot.  The belief that these women are sexually irresponsible, careless, heedless, selfish still and powerfully underlies the anti-abortion legislation rampant in the United States.  So does a culture of blaming the woman that goes back to Adam and Eve.  So does people’s ambivalence about their own mothers and their own wantedness.  So does the terror, felt not only by men, but also by women, of changing roles, responsibilities, and power, in society.  And so does the cynical political manipulation of politicians, funded by those aiming to protect their funds, causing those social conservatives to vote against their economic self-interest.

Campaigns for abortion access have focused on a woman’s ‘right to choose’---but, in fact, the consequences of limitations fall not only on them, but on their children, families, and all of us.   

How did I get interested in abortion?  When my babies were born, childbirth care was not kind to women, either.  Women in labor were isolated from their loved ones, kept immobile and supine, forbidden food and beverages, sedated, strapped down, and delivered, in university hospitals, via episiotomies and prophylactic forceps.  (I later learned that there was no empirical evidence for these interventions, and developed a healthy skepticism about medical orthodoxy.)  I studied prepared childbirth techniques, which worked, and eventually became an officer in the Lamaze prepared childbirth organization.  I elected to spend my fourth residency year, and the first part of my career as an attending psychiatrist, as a psychiatric liaison/consultant to academic and clinical departments of obstetrics and gynecology.  My first academic presentations were about childbirth.

My interests in ob/gyn and in women’s issues led me to found a Committee on Women in my state psychiatric society.  When Carol Nadelson became the first woman president of the APA, she appointed me to the national committee.  I happened to be the chair of that committee when President Ronald Reagan appointed Dr. C. Everett Koop Surgeon General of the United States, largely on the basis of Dr. Koop’s opposition to abortion, and ordered him to prepare a report on the impact of abortion on women in America.  Dr. Koop set about gathering evidence.  He summoned experts from the relevant academic and professional associations to present the data.  One of those organizations was the American Psychiatric Association, which had had an official position in favor of reproductive choice antedating Roe v. Wade.  The APA President then assigned this task to me, as the chair of the Committee on Women.  I didn’t want to get involved with abortion; my expertise and interest were perinatal.  But he insisted; this testimony would be my job. 

Dr. Koop was a forbidding figure.  I lay on my training analyst’s couch bemoaning my anxiety about appearing before him.  Suddenly my analyst broke the analytic silence to declare “It’s going to be all right.”  I was so startled that I sat up on the couch and turned around to face him.  He went on “I went to college with Everett Koop.  He is an honest man.”  So, with the help of APA staff, I reviewed the literature, learned, and reported to the Surgeon General, that, according to the published data, abortion did not cause psychiatric problems, and that access to abortion was necessary for women’s mental well-being.  My analyst was right.  Dr. Koop refused to write the report for President Reagan.  He sent a letter to Congress stating that the impact of abortion on women in America was “miniscule from a public health perspective.”  As I stand here today, the public health problem has become the overwhelming political attack on abortion, taking with it, in state after state, not only abortion clinics, but also the Planned Parenthood clinics, access to general and reproductive health care for tens of thousands of women.  State legislatures have passed over 250 anti-abortion laws within the past 5 years. 

The anti-abortion movement has also diminished access to abortion services by spreading misinformation to the public, to medical students, and to legislators and judges, and by intimidating hospitals and physicians.  Few hospitals permit the performance of abortions for fear of picketers and loss of state and federal funding.  Just recently, we learned of a physician ordered, under threat of dismissal, by her hospital administration, for publicly advocating for access to abortion.  Few residencies in family medicine and ob/gyn train residents to perform abortions.  In academic departments of ob/gyn, performing abortions diminishes academic stature.  So abortion is largely relegated to Planned Parenthood, which spends most of its resources on other services, and abortion clinics.  Thanks to the anti-abortion movement, women seeking abortion services have to traverse a gauntlet of picketers carrying gory posters and begging them not to murder their babies.  Thanks to the anti-abortion movement, clinics are bombed and doctors are murdered.

Reading about abortion in a classic reference, I learned that there was evidence of attempts to terminate pregnancy in every society that had been studied and at every point in recorded history.  If the Hippocratic Oath forbids abortions, that has to mean that abortions were being sought and performed in ancient Greece.  Presumably the outcomes tended to be complicated; perhaps that was the reason for the prohibition.  Today abortion is perhaps the safest medical procedure performed.  The fact that women have sought and undergone it for millennia is testimony to the desperation women feel when they are pregnant without the psychosocial resources to become a good parent---and/or to continue to fulfill their other ongoing responsibilities.

Carol Nadelson, who had now become the Editor of the American Psychiatric Press, convinced me to put my literature review to good use by editing a book on abortion.  Now informed on the subject, I also wrote an abortion book for the public.  I discovered that the situation in psychiatry was much like that in ob/gyn; most psychiatrists and gynecologists supported abortion access, but few were acquainted with the psychiatric data or wanted to do anything with it or talk about it.  I began to give grand rounds and talks at scientific meetings.

Thus I unwillingly became, and remain, the psychiatric expert on abortion.  Abortion is a procedure undergone by thirty percent of the women in the United States, and presumably at least as high a proportion of our female psychiatric patients.  Psychiatrists knowledgeable about it, and prepared to offer that knowledge in public settings, are vanishingly rare.  It so happens that I had undergone APA media training.  I am pretty good at doing interviews.  Testifying against legislation limiting abortion is my humanitarian contribution.  (I won’t count speaking out against Scientology; that has been somewhat scary, but kind of fun.)   I’ve given testimony and consultation against laws limiting abortion in courts and legislative bodies:  the states of California, Alaska, Wisconsin, South Dakota, Texas, Louisiana, and committees in both the U.S. Senate and House of Representatives.  Testimony in Montana is on the calendar.  As far as I know, I am still the only psychiatrist doing so.  Giving this testimony, an ordeal I face as I speak today, is one of the most miserable experiences I have ever undergone.  It is loathsome to answer specious questions from attorneys general and legislators, and to listen to testimony from the small band of anti-abortion activists masquerading as sources of empirical data.  Reporting the scientific facts is not enough.

Here are some of my humanitarian efforts:  at a hearing in the U.S. Congress, I listened to a gynecologist on the faculty of the University of Michigan testify that abortion increases the risk of breast cancer.  When I countered that a large international expert panel had concluded the opposite, she coyly said “Dr. Stotland is right.  It’s a shame that there wasn’t a minority report---you know, like in the Supreme Court.”  When Senator, now Governor, Brownback asked me whether I was concerned that women would regret having abortions, I replied that half the marriages in our country end in divorce, that it was reasonable to suppose that a number of the individuals involved regretted having married the persons they were divorcing, but that the Senate had not considered placing obstacles in the way of marriage. 

I listened in Congress to two married, comfortably-off mothers—stay-at-home parents who frequently left home to participate in anti-abortion activities-- testify that they had had abortions while in their teens and had suffered a laundry list of psychological symptoms as a result.  (The symptoms did not add up to any recognized psychiatric disorder.)  They testified that when their children learned of the past abortions (why?), they asked ‘why did you kill my baby brother or sister?  I did not have the opportunity to say that if their mothers had not been able to have abortions in their teens, when they had neither the financial, social, nor psychological resources to care for themselves or babies, it’s unlikely that their mothers would later have been able to have the children now asking the questions, and raise them in the comfortable circumstances they now enjoyed.

When I testified in the Alaska Supreme Court in a challenge to a parental consent law, the Attorney General of Alaska posited that a girl in the average nice, normal family should have no problem involving her parents in an abortion decision.  I answered that parents could be loving parents and still announce regularly and vehemently at the dinner table that ‘if any daughter of ours got pregnant out of wedlock, we would throw her out in the street.’ 

Anti-abortion legislation is generally couched in terms of women’s welfare. When anti-abortion groups invented an ‘abortion trauma syndrome,’ I wrote a paper:  ‘The Myth of the Abortion Trauma Syndrome.’  After an exhaustively thorough editing process, the paper was published in JAMA.  Because abortion is a mental, as well, as physical, health issue, the APA continues to have an official pro-choice position-- but rarely participates in public discussion and judicial and legislative advocacy of its own position.   I would still prefer to be a childbirth expert.  But I made myself include abortion in my APA Presidential Address.  One of my daughters said that moved her to tears; that’s testimony to the ongoing taboo on the subject, and perhaps my most treasured memory of this ongoing struggle—until today. 

The discussion of abortion reveals psychiatrically significant fault lines in personal and social mental functioning.  In psychoanalytic terms, abortion is a perfect example of a ‘vertical split’.  Women will support anti-abortion activities and policies but have abortions when they find pregnancies personally unsupportable.  Abortion providers report anecdotally that some women who picket their clinics come to them requesting abortions after hours or on weekends, when their colleagues won’t see them, and then reappear on the picket lines.  Women who profess membership in anti-abortion religions have abortion in proportion to their representation in the general population.  It is a brave act when celebrities come forward to reveal that they have had abortions.  Most women are reluctant to talk about it, adding isolation and confabulation about a significant event to the stresses in their lives.

Our national discomfort with abortion, and with women’s rights in general, have allowed anti-abortion activists to co-opt the language and the arguments.  Why and how is denial of access to abortion ‘pro-life’?  Whose life?  How did we allow this misuse of language?  Policies play on the fault lines and fly in the face of science and logic.  Childbirth is associated with many orders of magnitude larger obstetrical and psychiatric risks than abortion, but, except in the gynecological and so-called pro-choice literature, abortion is always discussed without the comparison.  Have we forgotten that only pregnant women have abortions, and that therefore they will either miscarry or deliver if they don’t have abortions?  If abortion murders babies in the womb, why should rape and incest be exceptions to abortion prohibitions?  It’s not the unborn baby’s fault that its mother was the victim of rape or incest.  If abortion kills a full-fledged human being, why isn’t it murder?  We are still operating under the unacknowledged, misogynistic premise that pregnancy is the result of women’s voluntary, knowing, lustful, indulgence in sexual intercourse.  Pregnancy and motherhood, rather than desired and joyous events, are just punishments for these women.  The anti-abortion message is that women have abortions because they don’t value motherhood.  The reality is that responsible women have abortions because they recognize the realities of parenthood and want to have babies when they can care for them, and for the children and other responsibilities they already have. 

Anti-abortion activists, however, have carefully couched their arguments in platitudes about women’s well-being.  They do not want women who have abortions to be prosecuted for murder because that would be a political, judicial, and logistical nightmare---so they say that these women are, like the unborn children they were carrying, victims.  This is another powerful, atavistic, misogynistic, but unacknowledged premise for anti-abortion laws.  Women are vulnerable, impressionable, fragile humans, preyed upon, not by the male sexual partners who are equal partners in the pregnancy---whose punishment is never proposed—but by health care professionals performing abortions for profit. Abortion clinics need to meet medically unnecessary physical standards.   Women need to wait forty-eight hours to make sure they want abortions.  Women are unaware of the (nonexistent) social supports for themselves and their children-to-be—supports that these legislators actually oppose.  Women need to be shown graphics of fetal development and ultrasound images to understand that there are embryos or fetuses inside them. 

The other side of the Madonna-prostitute coin, the psychoanalytic duality, is the mother as a child murderer.  Pregnant women are treated as potential murderers.  There are, at this moment, women incarcerated for ordering abortifacient medication over the internet; for using illegal substances while pregnant; for attempting suicide while pregnant.  The pregnant woman is an incubator of a state property and therefore a state property herself.  Her actual well-being, her actual self, doesn’t matter.  Anti-abortion images never depict a woman with a fetus in her uterus.  The image is of a baby floating angelically in amniotic fluid---or aborted and dismembered. 

Parental notification and permission laws are premised on the argument that teenagers—and girls who become pregnant before their teens—do not have the cognitive and emotional capacity to make decisions about their own pregnancies.  The reports of the opposing experts in the current Montana challenge go into considerable detail about brain development.  They cite the arguments used by those, including some of our child and adolescent psychiatry colleagues, who are humanistically attempting to protect minors who commit murder and other crimes from the death penalty and life imprisonment without parole imposed on adult perpetrators. 

These anti-abortion arguments have several fatal flaws.  The criminal protections derive from the adolescent vulnerability to impulsive behavior.  Abortion cannot be performed impulsively.  It requires appointments, interviews, the procurement of abortion medication.  The capacity of the average adult human to make informed decisions about medical care and medical research is, according to the literature as well as my clinical experience, highly variable and, in the end, questionable.  The decision to have an abortion is as medically straightforward as such a decision can be.  The procedures are clear.  They are among the safest in all of medicine and carry a small fraction of the risk associated with the only alternative-- childbirth—especially for an adolescent.   And the adolescent deemed by these laws to be too immature to decide to terminate a pregnancy will, in a few months, if the pregnancy is not terminated, undergo childbirth and assume the total legal, social, psychological, and physical responsibility for a helpless infant.  Of course an adolescent is not the ideal human being to make a decision about her pregnancy----but there is no one else more able or more morally entitled to do it.

In the United States, in every other respect, bodily sanctity is protected.  Should the life of a scientific or artistic genius require one drop of someone else’s blood, the state may not force that person to provide that drop of blood.  How is it that the state can require a woman to provide her whole body for the potential life of an embryo?

Because misinformation and inaccurate assumptions about abortion are rampant, let me offer a little barrage of facts from the Guttmacher Institute, a source for data about abortion and other reproductive not only in the United States, but worldwide.  In this talk, I’m going to focus on abortion in the United States.  This is the only country where the issue dominates political discourse.  (It remains to be seen what effect the horrendous teratogenic effects of the Zika virus is going to have on contraception and abortion, as the virus is so far clustered in countries where abortion is illegal.  As I wrote this address, they were advocating abstinence.)

According to the Guttmacher Institute:

  • Half of American women will have an unintended pregnancy [and nearly 3 in 10 will have an abortion] by age 45
  • Between 1994 and 2008, unintended pregnancy increased 55% among poor women, while decreasing 24% among higher-income women [1, 6]
  • Abortion increased 18% among poor women, while decreasing 28% among higher-income women [3]
  • Some 1.06 million abortions were performed in 2011, down from 1.21 million abortions in 2008, a decline of 13% [4]
  • Eighty-nine percent of all U.S. counties lacked an abortion clinic in 2011; 38% of women live in those counties [4]
  • Nine in 10 abortions occur in the first 12 weeks of pregnancy.  Delays beyond the first trimester are often related to lack of access
  • A broad cross section of U.S. women have abortions:
    • 61% have one or more children
    • 69% are economically disadvantaged; and
    • 73% report a religious affiliation

You can access information about your particular state and other reproductive issues on the Guttmacher Institute website.  The World Health Organization has data from other countries, and the Reproductive Law Center at the University of Toronto has up-to-the-minute information about associated legal issues from all over the world.  You can subscribe electronically.

The laws and inquiries in the United States are on a crescendo of irrationality, intrusiveness, and destructiveness.  The United States House of Representatives recently created a new “House Select Investigative Panel on Infant Lives.”  The Chairwoman of that Panel, Representative Marsha Blackburn, Republican of Tennessee, over the objection of some panel members, unilaterally issued subpoenas to the University of New Mexico, which conducts research using donated fetal tissue, and an abortion clinic in Albuquerque.  The subpoenas demand that the organizations identify all personnel, including medical students, who were in proximity to abortions.  The organizations must name these names or risk contempt of Congress—a criminal charge.  Representative Blackburn seeks this information to “get the facts about the business practices of the procurement organizations who sell baby body parts.”  There are no such organizations; the individuals who doctored recordings from Planned Parenthood claiming to show the sale of fetal body parts have since been charged with crimes.  Repeated fatal attacks on the staffs of abortion clinics leave no doubt that the publication of the names she seeks places those individuals under the threat of death.  Despite the fact that the vast majority of services provided by Planned Parenthood clinics have nothing to do with abortion, Congress and individual states, including Governor Kasich’s Ohio, have shut down what is for thousands of indigent women their only source of contraceptive and other health care.   

The current Supreme Court position on abortion is that abortion laws should place “no undue burden” on women seeking the procedure.  The majority of Supreme Court justices do not recognize that leaving home and job, finding child care, risking losing the job, getting a ride or paying for a bus ticket, often without being able to tell an employer or care provider or school the reason for your absence, or for an adolescent to convince a judge that involving her parents risks her health and safety, to travel to a clinic hours away – is an undue burden—and that every obstacle increases the stage of gestation at which the procedure must be performed. 

Currently, in the United States:

  • 11 states restrict coverage in private insurance plans unless life threatening; most allow additional coverage at additional cost
  • 45 states allow individual health care providers to refuse to participate; 42 allow institutions to refuse to perform, of which 16 limit refusal to private or religious institutions
  • 17 states mandate counseling including breast cancer 5; fetal pain 12; long term mental health consequences 7
  • 38 states mandate parental involvement; 25 consent, 13 notification
  • 28 mandate waiting periods; 14 effectively require 2 trips

Indiana law, as of April 2016, outlaws abortions performed because of fetal genetic defects; requires abortion providers to bury or cremate aborted or miscarried fetal remains; and makes donation of fetal tissue a felony.

Arizona has passed a law requiring general anesthesia for any abortion at or after twenty weeks’ gestation---to protect the fetus, not the mother, from pain, and without regard for the wishes of the woman or the medical judgment of the doctor—despite a Supreme Court case and ample testimony disputing the assertion that a twenty-week fetus feels pain as we understand it. 

Mifepristol, the abortion medication, has been under attack in this country since it was developed.  Recently the Food and Drug Administration, on the basis of many years of evidence, substantially simplified and cut back the recommended dosage by 2/3.  It has been prescribed that way ‘off-label’, on the recommendation of major medical organizations, for some years.  Nevertheless, the governor of Arizona managed to sign a law mandating the old label usage one day before the new FDA labeling came into effect.  In Texas, facilities providing only medication abortions are required to meet the same structural standards as facilities where traditional abortions are performed.  Those facilities, in turn, are required to meet the standards of outpatient surgi-centers—despite briefs submitted by the AMA and ACOG stating that those standards are medically unnecessary.  Abortion is one of the safest procedures in all of medicine.  Childbirth, for which there are no such restrictions, has ten times the fatality rate of abortion---and colonoscopy thirty times.  Many clinics have had to close. 

Abortion has occasioned unprecedented intrusions into the doctor-patient relationship and into medical practice itself.  Laws require physicians-us-to lie to our patients.  There are laws requiring physicians to do medically unnecessary ultrasounds—and show them to patients---and provide misinformation about sequelae:  that abortion increases the risk of breast cancer, substance abuse, and suicide, for example. 

Mostly under the radar is the fact that all Catholic and many evangelical health systems----which constitute a large proportion of health care facilities, and are the only facilities available in many geographic areas, forbid not only abortion, but the mention of abortion---and, in Catholic hospitals, contraception—including patients whose health or life is significantly threatened by pregnancy, and patients pregnant with fetuses with anomalies incompatible with extrauterine existence.  Those very rare late-term abortions, for anencephalic fetuses, have been dubbed ‘partial-birth’ abortions and been forbidden.  Recently, a woman was sent home by a Catholic hospital while in labor at twenty weeks’ gestation---with the birth of a non-viable fetus inevitable—because the hospital refused to terminate the pregnancy.  These health care systems require all their physicians to sign agreements that they will abide by their policies.  Good psychiatric care requires us to discuss with our patients, for most of whom we prescribe psychotropic medications, about their reproductive status and plans.

The scientific facts are these.  Abortion may be associated with psychiatric disorders.  That’s because partner abuse can cause both psychiatric symptoms and pregnancies.  Mania can lead to unprotected and promiscuous sexual activity.  Psychosis makes it difficult to access contraception and to protect oneself from unwanted sexual activity.  Depression is associated with helplessness, hopelessness, poor self-esteem—making it difficult to access contraception and refuse unprotected sexual intercourse.  Alcohol and substance use are associated with poor judgment and the exchange of sex for the abused substance.  Women who become pregnant while taking large doses of psychotropic medication may be unwilling to either risk psychiatric relapse or exposure of the fetus to the medication.  But there is no credible evidence that abortion causes psychiatric disorders—in adult women or minors.  The best predictor of a woman’s mental state after an abortion is her mental state before the abortion.  Anxiety and mood symptoms decrease after the problem pregnancy has been terminated.  Clinic picketers and misinformation about abortion sequelae demonstrably increase psychological distress.  Required ultrasounds, waiting periods, parental notification, anesthesia, etc., must do so as well.

In the absence of accurate scientific information, not only the general public, but also medical students, residents, and graduate physicians fall prey to widely distributed misinformation.  Abortion, an experience of one-third of our female fellow citizens,  is only visible, tangible, in our society is as a political football, a way to get people to vote for candidates they would not select on the basis of their other political beliefs, values, and their own self-interest.  Abortion is hardly an issue in Canada, England, France, Scandinavia. 

I don’t like abortion; it’s sad.  I like planned, joyous pregnancies.  Children need sex education, not the mandated abstinence propaganda shown to be ineffective.  There is a little good news about contraception.  Several states are covering or providing the long-acting methods that are more effective than the pill and barrier methods.  The FDA has endorsed the provision of oral contraceptives, without medical prescriptions, by pharmacists, and the AMA and ACOG are encouraging that they be made even more accessible than that.  But abortion is an irrepressible reality that should be accepted and provided by an enlightened society. 

 I have no problem, as a humanitarian, with opposition to abortion on genuinely moral or religious grounds, but I have a very great problem with specious grounds, with assaults on science, medical practice, and women’s competence and integrity.  I have a very great problem with a country that forces women to have babies they can’t support, supposedly in order to protect women and ‘life,’ and fails to provide the most minimal support for the lives of those babies, their mothers, and their families.

What is to be done, specifically, by psychiatrists?  I don’t know whether you are aware that the American Psychiatric Association adopted an official position in favor of reproductive rights before the Roe v Wade decision.   But the APA’s position, and expertise, are never mentioned in our news releases or in news reports.  During the (W) Bush administration, struggling with the APA Government Relations staff to play our rightful role in abortion law debates, I was told that they had been told that any advocacy for reproductive care laws would destroy any hopes for laws that would improve access to mental health care.  Thousands fewer psychiatric beds, health insurance hurdles, and underfunded mental health clinics later, muting our advocacy for women’s rights and women’s health has gotten us nothing.  It is our obligation to know our association’s well-founded position and to encourage our association to provide our expertise to legislators and judges, up to and including the Supreme Court, whose ‘no undue burden’ standard tramples on the realities of women’s lives.  That’s one thing we can do.  We can take past and current reproductive histories from our patients, thus not only obtaining important medical and psychosocial information relevant to their treatment but also de-stigmatizing the topic of abortion.  We can learn whether our own academic departments, hospitals, and health care organizations stifle or forbid discussion of abortion with our patients, and struggle with them and our own consciences when they do.  We can support and honor those moral medical colleagues who brave danger to provide women with this essential intervention.

I am tired of and discouraged by my unofficial position as the psychiatric advocate, not for abortion, but for access to abortion.  But our politicians continue to savage women’s well-being under the guise of promoting it, and I am supposed to be a humanitarian, and the state of Montana has passed two laws limiting adolescents’ access to abortion, and I am again the psychiatric expert in the challenge to those laws.  There will be another loathsome deposition, and maybe court testimony.  If anyone is obligated to know the facts about abortion, to teach the public and our colleagues and trainees about them, to testify about them, and to utilize them in the care of psychologically vulnerable women, it is we psychiatrists. 

The anti-abortion movement is insatiable.  The same groups, the same legislators, who are trying to eliminate abortion, demand that health insurance not cover contraceptives.  In that debate, legislators have felt free to call women who need contraception ugly names.  The anti-abortion movement forces families to watch their dying, or essentially dead, pregnant daughters maintained on machines until their fetuses come to term, or have surgical deliveries that hasten their deaths.  It calls the morning-after pill an abortifacient and works tirelessly to prevent women from obtaining it.  The very same legislators work to diminish or eliminate, or never establish, supports such as welfare for indigent mothers and their children; child care; and maternity leave.  They incarcerate pregnant women who seek care for their substance abuse, try to take their lives in desperation, or self-abort.  Rather than taking a morally justifiable anti-abortion stance, they cloak themselves in women’s welfare.  Ignoring ‘life’ once it is born; demanding senseless sacrifices of maternal well-being; it is a hypocritical movement. It is an immoral movement, willing to lie, cheat, intimidate, and kill. 

I have never articulated my advocacy so brutally, but today I must; I speak as a humanitarian. 

---Nada Logan Stotland, MD, MPH