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The psychological sequelae of abortion performed for a genetic indication
American Journalof Obst&rics and Gynecology volume
122
number
7
AUG~JST 1, 1975
OBSTETRICS
The psychological sequelae of abortion performed for a genetic indication BRUCE
D.
BLUMBERG,
MITCHELL KARL
S. H.
M.D.
GOLBUS,
HANSON,
San Francisco,
M.D. M.D.
California
Psychometric testing and psychiatric interviews mere conducted on 13 families in which the women had undergone amniocentesis for the prenatal detection of a genetic defect in the fetus and, upon receiving positive results, elected to have a therapeutic abortion. The indication for amniocentesis was maternal age in two families, a previous child with Down’s syndrome in one family, a previous child with a recessively inherited inborn error of metabolism in four families, and the mother being a carrier for an X-linked disease in six families. The incidence of depression following selective abortion may be as high as 92 per cent among the women and as high as 82 per cent among the men studied, and was greater than that usually associated with elective abortion for psychosocial indications or with delivery of a stillborn, Four families e.xperienced separations during the pregnancy-abortion period. Despite the emotional trauma of the procedure, most of the families studied would repeat their course of action and consider selective abortion preferable to the alternative birth of a defective child. Several modifications in the amniocentesis and selective abortion procedure which might diminish the concomitant emotional trauma are suggested.
T H E P R E N A T A L detection of many genetic defects is now available and has begun to influence the way parents make decisions about childbearing. There may, however, be a psychiatric price that the family pays for this newly available knowledge. In follow-up studies of women who had experienced amniocentesis specifically for the prenatal detection of a genetic defect in the fetus, feelings of guilt, doubt, and ambivalence were common.‘. 2 Of greater significance is the risk of psychological trauma to the family which elects therapeutic abortion upon being told the fetus is “genetically defective.”
From the Departments of Obstetrics and Gynecology, of Pediatrics, and of Psychiatry, University of California School of Medicine. Supported
in part
by grants
from
Company, The National Institutes (GM-19527), Education, Received Revised Accepted
and
and the Department Welfare (Project
for publication October October
September
The Upjohn of Health of Health, 445). 16, 1974.
21, 1974. 23, 1974.
Reprint requests: Dr. Mitchell S. Golbus, Department of Obstetrics and Gynecology, University of California Medical Center, Francisco, California 94143.
San
799
IIoT.nTC 7
Fig. 1. Minnesota men who completed per cent confidence
reacted
to
this
F
x Hs*SI D H” w+.a L*I4sI1*Po
Multiphasic Personality Inventory mean profiles of the MMPI forms are given. The three dark lines represent level scores for the normal population.
During the 1960’s, women who had abortions cause of rubella exposure and the risk of fetal formity
L
procedure
with
bede-
depression,
guilt, and self-reproach”-’ and exhibited a higher incidence of emotional side-effects following the procedure that women who had abortions for psychosocial indications. This typical response occurred in approximately 50 per cent of the patients. It might be anticipated, then, that termination of a pregnancy w-hich has been demonstrated by amniocentesis to be at a high risk of producing a genetically defective child would bear emotional consequences similar to those observed for the rubella abortions. Since amniocentesis for the prenatal detection of genetic defects has been practiced at a number of genetic centers during the past five years, and since this practice is becoming more widespread, it is pertinent to study the psychological sequelae of selective abortion. We are presenting data derived from follow-up interviews and psychometric testing of 13 families in which the women have undergone amniocentesis and selective abortion. We hope that our findings will suggest refinements in the amniocentesis-abortion procedure and/or in the concomi-
tant counseling and mize the emotional experience. Material
and
~i-~
y
Fa Rill: sr*IKM.z+x
-0 SI TorTE
&
m-
20
hu
1 I women the mean
and and
10 95
that they may serve to minitrauma associated with the
methods
The families for this study were from the first 200 studied in the prenatal detection program in the University
of
California
at San
gram has been described amniocenteses affected
yielded fetus
a potentially results were center rent
for study.
or>
in
21 the
Francisco.
previously.‘. results case
of
The
pro-
Ii The first 200 positive
X-linked
for
an
diseases,
affected fetus. Two of the 21 positive derived from specimens niailed to our analysis
and
One
positive
are
excluded result
from represents
the
cur-
a male
fetus in a family with a history of hemophilia R (PTC deficiency) whose parents elected to accept the 50 per cent risk that he might be affected. One other family \vas excluded because they spoke no English. The 15 families who represent the remaining 17 positive results \vere contacted. All 15 families agreed to participate in the study and were mailed packets including a letter explaining the study and instructions for completing the test material. This included duplicate copies of the
Volumr iSumber
122 7
Psychological
FAMILY
Fig.
2. The
family
pedigrees
of the
13 families
Minnesota Multiphasic Personality Inventory (MMPI) and a questionnaire. The MMPI is a well-standardized test designed to elicit a wide range of self-descriptions from each test subject and to provide, in quantitative form, a set of evaluations of individual personality status and emotional adjustment.7 Its scoring generates a test profile, or psychogram, composed of four validity indicators and 10 clinical or personality scales. The validity scales are intended to reflect test-taking attitudes, deliberate lying, random responses, or attempts to present an exaggerated (either “good” or “bad”) image of oneself, The 10 basic clinical scales measure tendencies toward hypochondriasis (Hs) , depression (D), hysteria (Hy), sociopathy (Pd) , masculinity/femininity (Mf), paranoia ( Pa), psyrhasthenia ( Pt) (obsessive-compulsive), schizophrenia (SC), hypomania (Ma), and social introversion (Si) . Ry plotting the values of individual
having
9
sequelae
FAMILY
of abortion
10
0
MALE
@
AFFECTED
0
FEMALE
q
HETEROZYGOTE ICARRIER)
0
SEX UNKNOWN
0
Ef
DECEASED
selective
abortion
801
CARRIER OF X-LINKED DISEASE
,
AMNIOCENTESIS PERFORMED
.
ABORTION
are given.
scales against male or female norms it is possible to detect any deviations from a “baseline personality.” Combination of elevations or depressions on various scales may be interpreted by reference to sources which have analyzed individuals exhibiting similar profiles.“. !’ The questionnaire attempted to assess attitudes toward amniocentesis and had been administered previously to families whose negative amniocentesis results had allowed completion of their pregnancies. The MMPI was to be completed by the husband and wife individually and the questionnaire was to be completed jointly. An interview was then successfully arranged for I3 of the 15 families: in the remaining two, scheduling conflicts prevented such a meeting. Exclusion of these two families was random, since both families agreed to the interview, so that their elimination should not bias the over-all results of the investiga-
802
Blumberg,
Table
Golbus,
and
I. Demographic
Hanson
statistics
on families
electing -
selective
Time of
indication
for
amniocentesis
No.
OCCUAge
pation
Time from therapeutic abortion to interview
Would have another amniocentesis if pegnant
therapeutic abortion relative to quickening
Married 15 yr.
37 mo.
Yes
4 wk. after
Married 5 yr.
37 mo.
Yes
Before
34 mo.
No
2 days after
32 mo.
NO
Before
Paternal
Maternal
Famity
abortion
Education
Age
i
Occupation
Education
3 yr. graduate school College degree
Marital status
1. The
L.‘s
Previous child with NiemannPick’s disease
35
Housewife
2 yr. college
36
Teacher
2. The
B’s,
Mrs. B. carrier for hemophilia B
26
Housewife
27
Police officer
3. The
M.‘s
Mrs. M. carrier for Duchenne’s muscular dystrophy
29
Salesaudit clerk
Highschool diploma 2 yr. secretarial school
4. The
C.‘s
Mrs. C. possible (50% ) carrier for Renpenning’s syndrome Previous child with Gaucher’s disease
29
Housewife
College
31
Physician
Medical school
Divorced between conception and amnio Married 9 yr.
26
Housewife
36
Bookkeeper
Business college
Married 5 yr.
32 mo.
Yes
2 wk. after
Maternal
46
Business manager
Highschool diploma 1% yr. graduate school College degree
50
Writer
6 yr. graduate school Master’s degree
Married
26 mo.
Yes
Before
Married 5 yr.
L’5 and 20 mo.
Yes
5. The
E.‘s
6. The
D.‘s
age
7. The
F.‘s
Mrs. F. probable carrier for Duchenne’s muscular dystrophy
27
Teacher
8. The
H.‘s
Previous with 21
35
Housewife
9. The
G.‘s
29
Housewife
10. The
P.‘s
36
Housewife
11. The
A.‘s
Mrs. G. carrier for Duchenne’s muscular dystrophy Previous children with NiemannPick’s disease Maternal age
39
11. The
S.‘s
child trisomy
Mrs. S. carrier for Duchenne’s muscular dystrophy
30
Unavailable
degree
a yr.
27
Mental health counselor
1 yr. graduate school Highschool diploma Tenth grade
35
Physicist
Ph.D.
Married 11 yr.
18 mo.
Yes
2 wk. after (first) and before (second) Before
34
Jeweler
2 yr. college
Married 9 yr.
18 mo.
Yes
1%
36
1% yr. college
Married 17 yr.
10 mo.
Yes
6 wk. after
Housewife
College
42
Career Air Force Pharmacist
Married 17 yr.
3 mo.
Yes
1 wk. after
Machine operator
3 yr. college
Pharmacy school Highschool diploma
Married since the abortion
2% mo.
NCJ
Before
degree 34
Deputy sheriff
wk. after
VchnP Number
122 7
Table
Psychological
sequelae
of
abortion
803
I--Cont’d
-
Time from
Maternal Family NO. 13. The
Indication for amniocentesis K.‘s
Prevous with emia
child galactos-
I
Paternal Marital status
Age 22
Housewife
24 Laborer
?
?
Separated
therapeutic abortion to interview 2 days
Would have another amniocentesis if pregnant Yes
Time of therapeutic abortion relatiue to quickening 4 wk.
after
after 6 yr. common-
law marriage
tion. The interviews were conducted at the patients’ homes and attempted to elicit an open-ended account of their emotional response to the amniocentesis-abortion experience. All interviews were conducted by one of the authors (B. D. B.) in an attempt to maintain interpretive consistency, required from 1 to 2vz hours for each family, and occurred from 2 days to 37 months following the abortion (mean interval, 2 1 months). Results
Psychometric testing. Mean results for the 11 women and 10 men who completed MMPI forms can be seen in Fig. 1. The results for the women were very close to the population mean profile, whereas the group profile exhibited by the men shows some elevation in the scales of depression, hysteria, sociopathy, femininity, and hypomania. Femininity elevation is positively correlated with intelligence’ and the men studied represent a very intelligent group, possessing a mean of 5vz years of education beyond high-school graduation; it is quite likely that the observed femininity elevation reflects exceptional intelligence. The elevation of the hysteria and depression scales is commonly seen in individuals esperiencing somatic symptoms as an expression of underlying tension, anxiety, and worry.” Illustrative case histories. Fig. 2 shows the family pedigrees for the 13 families involved and Table I is a summary of
the
and
of
families.
recorded
demographic All
prior
information
interview
data
to MMPI
scoring
for
were
each
analyzed
or interpreta-
tion. In
Family
I, referred
because
of a prior
child
with
Niemann-Pick’s disease, Mrs. L. commented, “If it just depended on me, I wouldn’t have had the abortion, but I had to think of our daughter who has already lived through our first child’s illness.” She reacted to the news
that the fetus was affected by “crying
for a while
and
keeping really busy during this very difficult week.” Following the abortion, serious marital difficulties ensued, and Mr. L. left home for a week in order to be by himself. Mrs. L. reported she “didn’t understand why my husband couldn’t support me.” Even after Mr. L.‘s return home, they continued to deal with the postabortion experience separately, and Mrs. L. developed the opinion that her husband was “being selfish” in his method of dealing with the problem. She continued to experience sleep loss, nervousness, and tension, and finally contacted a psychiatric social worker who helped her work through her feelings during a month of counseling sessions. Mr. L.‘s response to the abortion experience was one of “bitterness and feeling that the basic strivings of life (i.e., raising a healthy family) were unattainable.” He “wanted to fight someone or something” and felt that “a lot of things in the world are unjust.” He has sublimated these feelings by becoming involved in various movements for social change during recent years. Mr. L. said their marriage was “rocky” for approximately 8 months and that the marital situation required ‘2 years, until the birth of a normal son, to completely restabilize. The birth of the normal son was preceded by an amniocentesis, the results of which indicated that the child would not be affected. Both of the L.‘s denied any guilt in the knowledge that they are carriers of a lethal recessive gene and view the situation as being “bad luck” and “not through anyone’s fault.”
The
MMPI
indicated
that both the L.‘s exhibit
a
strong tendency to deny emotional problems. Mrs. L.‘s profile indicated possible chronic mild hostility and aggressive feelings. Mr. L.‘s profile suggested a poor family adjustment, especially in the sexual realm, and possible
804
Blumberg,
exaggerated
Golbus,
masculinity.
and
His
August 1, 1975 Am. J. Ohstrt. Gynecol.
Hanson
profile
also reflected
periods
of frank hypomania. Family 2 was referred because Mrs. B. is a known carrier for PTC deficiency (hemophilia B) so that a male fetus would have a 50 per cent chance of having hemophilia B. Mrs. B. described her reaction to receiving the results of the amniocentesis as being “very depressed and by “crying for a while.” After upset, ” and she responded the abortion, she was very depressed and “broke down” when a nurse commented, “you would have had a beauto which Mrs. B. responded with “anger and tiful boy,” bitterness.” Following the abortion, Mrs. B. said her feelings of guilt were increased with the knowledge that her family did not believe in this procedure, IJUt she was the right thing.” She relieved and felt, “I had done “seeing our first child suffer with hemoasserted that philia helped us to go through with this.” Mr. B. was especially concerned about his wife’s frame of mind and was “depressed, but I had to bring her out of the dumps. That was more important. What upset me was that she was upset. If she had been really depressed, I would have felt even worse, since I had an equal part in the decision (to abort) every now and then we think about it and wonder if the fetus was affected. We just put it in our minds that he was a bleeder. You can never really understand something like this unless you’ve been through it.” The following year, Mrs. B. became pregnant again and had another amniocentesis which indicated that the fetus was male. However, “the negative experience of the first abortion and the excuse of our doctor being on vacation” combined to dissuade them from proceeding with the abortion, although they “probably would have done it if our doctor had been there.” This child is not afllicted with hemophilia B and “his being normal helps us to believe that the aborted fetus was a bleeder.” Both of the B.‘s acknowledge that Mrs. B. feels guilty that she is a carrier of a detrimental gene but express no regrets for their course of action. The MMPI indicated that Mrs. B. has a tendency to deny emotional problems and has a rather conventional and rigid personality. Mr. B. appeared to be somewhat dependent and passively handles anxiety and conflict. Family 7 was referred to the prenatal detection clinic from the genetics clinic of another university hospital because Mrs. F. was a probable carrier for Duchenne’s muscular dystrophy. They felt that they were “prepared as best as could be for the possible critical decision. of whether to abort a male fetus” and, when informed that the fetus was a male, Mrs. F. insisted upon an abortion, although Mr. F. felt “this decision came from thin air.” Mrs. F. reacted to the news with “crying and a feeling of disbelief that the whole thing was happening.” Following the abortion, Mrs. F. felt “physically and emotionally empty” and was “really sad” for approximately one month. Shr commented that “both of us had a lot of faith, hope, and ideals. There was so much unhap-
piness and let-down. There is no substitute for a family, and we had pictured ourselves as a family.” She suffered from weight loss and decreased concentration after the not pay attention and could not abortion and “could handle being by myself or alone” for 3 weeks after the procedure. Mr. F. felt that when he was given the result of the amniocentesis he was “torn up inside” and “I hated myself for having to make the decision.” He observed “we both went through a mourning process folI still feel a lot of resentment lowing the abortion . and anger, but mostly sadness.” After the abortion, Mrs. F. was instructed to wait one month before restarting birth control pills and, unfortunately, another method of contraception was not suggested. She again became pregnant and, although her husband desired an immediate abortion without benefit of amniocentesis, she insisted upon waiting and having an amniocentesis at the appropriate time. When the fetus was identified as male in the second instance, abortion was performed at 5 months, prior to quickening. Following this second abortion, Mrs. F. stated she was “on the brink of being hysterical and was really sad for almost a year.” She related this to the experience of the death of something that was very close to her. Although she had been a teacher for 4 years prior to her ill-fated pregnancies she now took a job as a secretary because she “didn’t want to teach any more.” She stated she was very reluctant to deal with children. After the second abortion, Mr. F. experienced bloody diarrhea and a “tight stomach” and was under the impression that he was sufcring from colitis. He described his feelings at this time as those of “having insurmountable problems and being worthless, and had fears of impotence, both physically and as a human being.” He left his job as a youth guidance counselor because he “didn’t want to work with kids any more” and dropped out of his Master’s program. FIe withdrew and spent less time with his friends because “isolation prevents hurt.” In the wake of these feelings, Mr. F. left his wife 3 months after the second ahortion because he “felt threatened and wanted to re-establish my identity.” After 6 weeks of separation, Mr. F. realized that he teas more depressed than previously, and returned to his wife. He has had a change of philosophy and “I now see life as a struggle instead of minor ups and downs. I now accept obstacles rather than denying them.” Despite the magnitude of the trauma which the F.‘s described, they expressed no regrets for their coursr of action; in fact, Mr. F. claimed “we’ll he more prepared now, v,,hen we do have a child.” Mrs. F.‘s MMPI scores indicated that she is an mterprising, idealistic, energetic, and persevering person. Mr. F.‘s scores suggested that he is thoughtful, idealistic, and persevering. He also exhibited strong hypomanic tendencies and may be somewhat self-centered and selfdissatisfied. Family
8 was
referred
to the
program
because
their
Psychological
first child had trisomy 2 1 (Down’s syndrome) and they were concerned about a recurrence. During the 3 to 4 tvrck period while waiting for the results of the amniocentesis, the uterine size did not seem to increase as rapidly as cspected. Therefore, there was some question of fetal drath by the tilne the H.‘s were notified the fetus had Turner’s syndrome. They felt that after the experil’nce with their first child they did not want an abnormal child, rven with the more minor problems of Turner’s syndrome. When informed of the result, Mrs. H. angrily :tcked herself, “Why did it happen again? Is there something cvrong with us?” She also expressed the feeling that ahe “lvantrd the pregnancy and the abortion to be over as soon as is possible” and her immediate reaction to the abortion \\a~ one of “relief of the discomfort of pregnancy.” She felt “ashamed to tell anyone that the child had ‘l‘urnt>r’s syndrome” because she felt they might not cmdcrstand the sporadic nature of its incidence and
concltldp that there was something wrong with her. She I>ecame involved in community volunteer work and kept very busy immediately after the abortion, but her negative feelings did not fade for 4 months, until the H.‘s adopted a normal bahy girl. Mr. H. was reticent to discuss his fceiings but offers some insight with his statement. “in a way you never recover, but you do cope.” Concerning future reproduction, Mrs. H. both desires and fears a new pregnancy, and this conflict has led to
a significant deterioration of their sexual relationship. Mr. H. is considering vasectomy but his wife prohibits this until she is able to resolve her ambivalence about desiring
another
child.
Her
disappointment
that
she has
produced a child “to be proud of” is intensified by her “lack of personal success in a career” or any other not
endeavor. She exprehsed resentment that her childbearing was delayed by the precedence of her husband’s career
and felt this delay may be implicated in causing the fetal defects. Mr. H. admitted that these concepts arouse significant guilt in him, and he has warned his wife that any further intensification of these feelings would neccsvitate divorce. The MMPI results on Mrs. H. demonstrated severe depression, social insecurity, and a lack of self-confidence. She is socially withdrawn, unhappy, tense, and worried. This corrrlates well lvith her prior history of psychiatric depression. Mr. H. exhihits marked hypomanic tendencies lvhich serve as his mechanism for preventing environmenral pressure from overwhelming him. Comment
The most obvious conclusion from the data presented is the frequent appearance of depression as an immediate response to selective abortion. Only t\co of the 13 women and four of the 11 men in the present study failed to mention depression in describing their emotional reaction to abortion. Of these six nondepressed individuals, one woman and
sequelae
of
abortion
805
two men exhibited MMPI profiles which reflect a tendency to deny emotional problems ; therefore, the actual incidence of depression following selective abortion may be as high as 12 of I3 (92 per cent) among the women and as high as nine of 11 (8’2 per cent) among the men studied. The intensity and duration of depression experienced showed wide variability and reflect both individual personality differences and varying exogenous factors. Certainly these patients exhibited more depression than that described in the literature for women undergoing abortion on psychosocial grounds. Mrs. A. (Family 11) provides an internal control for the present study. She previously experienced an “abortion of convenience,” and the depression which ensued lasted less than one week. She stated that she never had any regrets about this elective abortion until she was unsuccessful in producing a healthy fourth child, as desired, during the most recent pregnancy. In contrast, she described selective abortion as “the worst thing that ever happened to me” and is uncomfortable about the procedure even 3 months later. This contrast between reactions is probably due to the selective abortion representing rhe termination of a desired pregnancy and precluding the birth of a wanted child, while a psychosocially indicated abortion is usually utilized as a solution to an undesired pregnancy with prevention of the birth of an unwanted child. Selective abortion, however, is more than just the loss of a wanted pregnancy, as illustrated by Mrs. G. (Family 9), who maintained that selective abortion produced much more depression than a previous stillborn. Certainly, the stillbirth of a wanted child is associated with the disappointment. regret, and sense of loss which are also experienced after selective abortion. Perhaps the role of decision making and the responsibility associated with selective abortion explains the more serious depression following the latter. A stillbirth is usually regarded as an unfortunate accident, while the etiology of fetal loss in selective abortion is much more clearly comprehended. Even when selective abortion is accepted as the only alternative, and preferable to the birth of a defective child, the responsibility of making the decision to abort may prove to be an uncomfortable burden for the parents. This burden was significant enough for Mrs. G. to insist on a postabortal tubal ligation. There may be a relationship between this perception of responsibility and the sense of guilt sometimes associated with abortion. This guilt has gen-
806
Blumberg,
Golbus,
and Hanson
erally been attributed to the self-chastisement arising from the transgression of societal or deep personal values. Even more important is the woman’s realization that she is responsible for a decision which must sacrifice some important goals and values (motherhood and the value of life) in order to sustain or attain other beliefs or achievements independence). Thus, ( career, self-determination, as society has increasingly accepted abortion as permissible, the extrinsic guilt formerly associated with the procedure has been at least partially rrplaced by an intrinsic awareness of responsibility. In selective abortion there is the additional problem of the sense of guilt and shame associated with ger?etic disease. Fletchcrl noted that “added to the guilt associated with being a carrier of genetic disease was the realization that their esperiment to get a healthy child had failed.” The implications of selective abortion may extend beyond the termination of that pregnancy. A positive amniocentesis may reignite the depression, guilt, and/or frustration associated \vith the birth of a previously aff‘erted child or close relative. There is also a threat to self-esteem, as evidenced by Mrs. H. (Family 8), xvho admitted that she was disappointed that she “has not produced a child to be proud of.” It appears that selective abortion shakes the foundations of self-worth, especially to the extent that selfesteenl is predicated by societal and personal values upon the ability to create a normal, healthy famil~~. Memories of previous misfortunes, realizations of present failures, and anticipation of future difficulties combine to produce the significant emotional impact of selective abortion. The choice is not eas) since the production of a defective child is more than a physical and financial burden. The parents of such children often experience chronic sorro\v. anger, and resentment and exhibit the same guilt and shame generated by their sense of being “genetically inferior.““‘. ‘I Tllis “genetic guilt” is probably more acute after the birth of a defective child than follolving the abortion of ;I defectivf fetus. Thus, most families elect selective abortion and its concolllitant emotional trauma as an alternative to the e\‘en more burdensome birth of an ill or handicapped child. Despite the operation of various normal psychiatric defense mechanisms, the stresses attendant to selective abortion also produce undesirable marital consequences. Two families (Nos. 3 and 13) experienced separation during the pregnancy in question, even prior to the performance of amniocentesis: in
each case, related to the problems engendered by their genetic circumstances. In addition, separation occurred in two families (Nos. 1 and 7 ) after the abortion; although these separations were for less than 6 weeks, they produced repercussions \~+ich threatened marital stability for many months or even years afterward. Significantly, both these husbands exhibited marked elevation on the hypomania scale of the MMPI. The separation in these two families, instigated by the husband in each case, ma); be viewed as an ;acting out of the anger, depression, and guilt verbalized by these individuals. Another frequently observed phenomenon following selective abortion may be described as a “flasheffect, which may persist for many months hark“ or even years after the procedure. Many women in the present study reported discomfort when renlinded of their abortion. Such recollections could be triggered by objects or events related to childbearing or babies. A flash-back efiect is by no nleans unique to selective abortions; an analogous process has been observed in psychosocially indicated therapeutic abortions.“, “’ This revi\,al of previous emotions represents an incomplete resolution or repression of the negative feelings engendered by the aborrion experience. Selective abortion is a second-trimester procedurr. ‘I’he resort to late abortion is necessitated by the requirenients of a I3 ireek gestational size ilterus for ;I sue-ccssful amniocentesis and by the .l. weeks nerded for cell culture and analysis. It has lon,~ been postulated that latch abortion conveys an emotional impact of greater extent than earlier abortion. Ribring and associates ” focused upon quicken~rlg as the physiologic e\.ent which signals maturation, from the narrissism and self-rathesis of early pregnancy to 3 vie\\ of the fetus as 371 ohjcrt 01 inrreasin,gly independent existence. ‘I’lic~orc~tirally, early abortion is arrolrll)anied b\ ;III inhibition of the normal fantasies about thr fr:us.’ ’ Presumably., surh inhibition is threatened b) the onset of quickening. after which the fetus comes to be considered as a potential “future child,” with a proliferation of fantasies concerning the child’s
Volumr Number
122 7
found long, continued preoccupation with the abortion. Intense and vivid fantasies persisted without much fading 12 to 14 months afterward. Fantasies whicll tyere mild and infrequent at the time of the pregnancy and abortion tended to disappear soon after.” Despite the emotional trauma of the procedure, 77 per cent of the families in our study reported that they would again opt for amniocentesis and, if indicated, selective abortion in any future pregnancy. These families have accepted selective abortion and its attendant problems as preferable to the alternative birth of a defective child. Of the families in our program who had a favorable result to their amniocentesis, 96 per cent had indicated they would have the procedure again in a future pregnancy.’ Probably the most important factor influencing a family’s ability to accept amniocentesis and selective abortion without self-reproach is their previous experience \vith the disease for which they are at risk. This is well demonstrated by Mr. E. (Family 5), who remarked, “After seeing what the first baby went through, there bvas nothing to think about in deciding to abort. It is hard to feel guilt after seeing that baby suffer.” Mrs. F. (Family 7) felt that living with an affected brother made it easier for her to say that she did not want a male child. She speculated that her husband’s lack of a similar experience with muscular dystrophy accounted for the “harder time he had dealing bvith the abortion.” These families have known the depression that selective abortion can produce, but they have also observed the tragedy of genetic illness at first hand. While this latter experience may not always reduce the sense of loss associated \vith selective abortion, it allows the family to feel less guilt about their decision. A family’s experiences subsequent to selective abortion are also important in shaping or modifying the emotional aftermath of the procedure. Many espressed the belief that the subsequent birth of a normal child aided the resolution of lingering postabortion emotional difficulties. Such a birth may assuage any residual feelings of regret or selfreproach associated with the earlier abortion. The new child may serve as a replacement for the and ameliorate the depression aborted “child” caused by the earlier loss of this fantasized baby. The birth of a healthy child also provides a source of self-esteem and helps alleviate much of the guilt engendered by the previous confrontation with genetic disease. The creation of a normal child ma)
Psychological
sequelae
of abortion
807
reaffirm the personal sense of worth of the parents. We have, thus far, considered selective abortion patients as comprising a homogeneous group. From a genetic perspective, however, there are three subgroups representing various modes of inheritance: recessive, X-linked, and sporadic. The mode of inheritance appears to have little influence upon a family’s depression following selective abortion. In contrast, the occurrence of guilt feelings induced by the genetic situation appeared to be somewhat specific to the women known to be carriers of an X-linked disease. All other families professed a sense of misfortune rather than feelings of guilt with regard to their role in the transmission of a genetic disease. It is also noteworthy that for sporadic or recessive disorders, selective abortion was performed because the fetus was definitely defective, whereas for the X-linked diseases the pregnancy was terminated with a 50 per cent risk of producing a defective child. Most families coped with this ambiguity by convincing themselves retrospectively that the aborted fetus was definitely affected, thus rationalizing doubts which might otherwise linger. This study suggests several modifications in the amniocentesis and selective abortion procedures which might diminish the concomitant emotional trauma. By performing earlier abortions one might avoid the cathexis and personification of the fetus Lvhirh have been noted. Advancement of the aluniocentesis by 1 or 2 weeks or the ability to shorten the 4 week culturing period required for sample analysis could be significant, particularly if termination could occur prior to the inception of quickening. The development of an alternative to the invasive techniques of selective abortion (amnioinfusion or !lysterotomy) would be viewed as an improvement by all patients. It has been noted that the methods employed in late abortions are contributory to the psychological trauma of the experience of terminations. For instance, if the intramuscular administrations of prostaglandins should prove to be an effective second-trimester abortifacient, it might well be a psychiatrically less traumatic method of terminating the pregnancy. Improved preamniocentesis counseling might also diminish the observed trauma of the amniocentesisabortion experience. The families in our study all received excellent counseling regarding the genetic and technical facets of amniocentesis, but without discussion of the psychological aspects of the pro-
808
Blumberg,
Golbus,
and
Hanson
cedure. An intelligent decision requires the input of all available data, and ignorance of the psychological aspects of selective abortion precludes a fully informed decision. Families should be made fully aware of the strains and anxieties that may be expected during the 4 week waiting period, and supportive counseling should be made available during this period. They must be made cognizant of the fact that one of the risks of amniocentesis is the potential for a positive diagnostic result, even though intellectual awareness of this possibility is not always equivalent to emotional acceptance. Complete foreknowledge may not lessen the blow of a positive result but, hopefully, it will provide time for careful consideration of alternatives in preparation for the quick decision which may become necessary in the face of a positive test result. Many families, once having experienced the emotional consequences of selective abortion, may decide that this is an experience that should not be repeated. It must be the responsibility of the counselor to convey the experiences of others to the patient in order to promote a well-considered decision and to allow preparation for the consequences of that decision. Further, the method of abortion to be utilized is another issue which must be broached by the counselor.
REFERENCES
1. Fletcher, J.: Theolog. Stud. 33: 457, 1972. 2. Golbus, M. S., Conte, F. A., Schneider, E. L., and Epstein, C. J.: AM. J. OBSTET. GYNECOL. 118: 897, 1974. 3. Peck, A., and Marcus, H.: J. Nerv. Ment. Dis. 143: 420, 1966. 4. Niswander, K., and Patterson, R.: Obstet. Gynecol. 29: 703, 1967. 5. Simon, N., Senturia, A., and Rothman, D.: Am. J. Psychiatry 124: 60, 1967. 6. Epstein, C. J., Schneider, E. L., Conte, F. A., and Friedman, S.: Am. J. Hum. Genet. 24: 214, 1972. 7. Hathaway, S., and McKinley, J.: Minnesota MultiPhasic Personality Inventory, New York, 1970, The Psychological Corporation.
The importance of postabortion follovv-up and counseling is also suggested by our findings. Several individuals sought help on their own initiative following abortion, and the frequently prolonged emotional difficulties described by others also indicate the need for supportive counseling after selective abortion. Mental health personnel should be available for supportive counseling in clarifying decision-making processes and the consequences of such decisions. Emotionally oriented preamniocentesis and postabortion counseling would also help to alleviate the sense of isolation expressed by many patients. The experience also could be improved by training ward personnel to understand what the family is going through and to be supportive during this difficult period. Positive entotional support from the physician, other medical personnel, family, and any friends informed of the situation can be a significant sustaining factor for the family undergoing amniocentesis and/or selective abortion. Only when experience allows an examination of the efficacy of various counseling schedules and methods will an optimal counseling approach be achieved. We are in the process of making such an addition to our program and suggest that other genetic centers consider doing likewise.
8. 9.
10. 11. 12. 13. 14. 15. 16.
Butcher, J.: MMPI: Research Developments and Clinical Applications, New York, 1969, McGraw-Hill Book Company, Inc. Dahlstrom, W., Welsh, G., and Dahlstrom, L.: An MMPI Handbook. Vol. I: Clinical Interpretation, Minneapolis, 1972, University of Minnesota Press. Cohen, P.: Social Casework 43: 137, 1962. Olshansky, S.: Social Casework 43: 190, 1962. Hamilton, Y.: AM. J. OBSTET. GYNECOI.. 43: 285, 1941. Senay, E.: Arch. Gen. Psychiatry 23: 408, 1970. Bibring, G.: Dwyer, T., Huntington, D., and Valenstein, A.: Psychoanal. Stud. Child. 16: 9, 1961. Raphael, B.: Med. J. Aust. 2: 100, 1972. Wallerstein, J., Kurtz, P., and Bar-Din, M.: Arch. Gen. Psychiatry 27: 831, 1972.
122
number
7
AUG~JST 1, 1975
OBSTETRICS
The psychological sequelae of abortion performed for a genetic indication BRUCE
D.
BLUMBERG,
MITCHELL KARL
S. H.
M.D.
GOLBUS,
HANSON,
San Francisco,
M.D. M.D.
California
Psychometric testing and psychiatric interviews mere conducted on 13 families in which the women had undergone amniocentesis for the prenatal detection of a genetic defect in the fetus and, upon receiving positive results, elected to have a therapeutic abortion. The indication for amniocentesis was maternal age in two families, a previous child with Down’s syndrome in one family, a previous child with a recessively inherited inborn error of metabolism in four families, and the mother being a carrier for an X-linked disease in six families. The incidence of depression following selective abortion may be as high as 92 per cent among the women and as high as 82 per cent among the men studied, and was greater than that usually associated with elective abortion for psychosocial indications or with delivery of a stillborn, Four families e.xperienced separations during the pregnancy-abortion period. Despite the emotional trauma of the procedure, most of the families studied would repeat their course of action and consider selective abortion preferable to the alternative birth of a defective child. Several modifications in the amniocentesis and selective abortion procedure which might diminish the concomitant emotional trauma are suggested.
T H E P R E N A T A L detection of many genetic defects is now available and has begun to influence the way parents make decisions about childbearing. There may, however, be a psychiatric price that the family pays for this newly available knowledge. In follow-up studies of women who had experienced amniocentesis specifically for the prenatal detection of a genetic defect in the fetus, feelings of guilt, doubt, and ambivalence were common.‘. 2 Of greater significance is the risk of psychological trauma to the family which elects therapeutic abortion upon being told the fetus is “genetically defective.”
From the Departments of Obstetrics and Gynecology, of Pediatrics, and of Psychiatry, University of California School of Medicine. Supported
in part
by grants
from
Company, The National Institutes (GM-19527), Education, Received Revised Accepted
and
and the Department Welfare (Project
for publication October October
September
The Upjohn of Health of Health, 445). 16, 1974.
21, 1974. 23, 1974.
Reprint requests: Dr. Mitchell S. Golbus, Department of Obstetrics and Gynecology, University of California Medical Center, Francisco, California 94143.
San
799
IIoT.nTC 7
Fig. 1. Minnesota men who completed per cent confidence
reacted
to
this
F
x Hs*SI D H” w+.a L*I4sI1*Po
Multiphasic Personality Inventory mean profiles of the MMPI forms are given. The three dark lines represent level scores for the normal population.
During the 1960’s, women who had abortions cause of rubella exposure and the risk of fetal formity
L
procedure
with
bede-
depression,
guilt, and self-reproach”-’ and exhibited a higher incidence of emotional side-effects following the procedure that women who had abortions for psychosocial indications. This typical response occurred in approximately 50 per cent of the patients. It might be anticipated, then, that termination of a pregnancy w-hich has been demonstrated by amniocentesis to be at a high risk of producing a genetically defective child would bear emotional consequences similar to those observed for the rubella abortions. Since amniocentesis for the prenatal detection of genetic defects has been practiced at a number of genetic centers during the past five years, and since this practice is becoming more widespread, it is pertinent to study the psychological sequelae of selective abortion. We are presenting data derived from follow-up interviews and psychometric testing of 13 families in which the women have undergone amniocentesis and selective abortion. We hope that our findings will suggest refinements in the amniocentesis-abortion procedure and/or in the concomi-
tant counseling and mize the emotional experience. Material
and
~i-~
y
Fa Rill: sr*IKM.z+x
-0 SI TorTE
&
m-
20
hu
1 I women the mean
and and
10 95
that they may serve to minitrauma associated with the
methods
The families for this study were from the first 200 studied in the prenatal detection program in the University
of
California
at San
gram has been described amniocenteses affected
yielded fetus
a potentially results were center rent
for study.
or>
in
21 the
Francisco.
previously.‘. results case
of
The
pro-
Ii The first 200 positive
X-linked
for
an
diseases,
affected fetus. Two of the 21 positive derived from specimens niailed to our analysis
and
One
positive
are
excluded result
from represents
the
cur-
a male
fetus in a family with a history of hemophilia R (PTC deficiency) whose parents elected to accept the 50 per cent risk that he might be affected. One other family \vas excluded because they spoke no English. The 15 families who represent the remaining 17 positive results \vere contacted. All 15 families agreed to participate in the study and were mailed packets including a letter explaining the study and instructions for completing the test material. This included duplicate copies of the
Volumr iSumber
122 7
Psychological
FAMILY
Fig.
2. The
family
pedigrees
of the
13 families
Minnesota Multiphasic Personality Inventory (MMPI) and a questionnaire. The MMPI is a well-standardized test designed to elicit a wide range of self-descriptions from each test subject and to provide, in quantitative form, a set of evaluations of individual personality status and emotional adjustment.7 Its scoring generates a test profile, or psychogram, composed of four validity indicators and 10 clinical or personality scales. The validity scales are intended to reflect test-taking attitudes, deliberate lying, random responses, or attempts to present an exaggerated (either “good” or “bad”) image of oneself, The 10 basic clinical scales measure tendencies toward hypochondriasis (Hs) , depression (D), hysteria (Hy), sociopathy (Pd) , masculinity/femininity (Mf), paranoia ( Pa), psyrhasthenia ( Pt) (obsessive-compulsive), schizophrenia (SC), hypomania (Ma), and social introversion (Si) . Ry plotting the values of individual
having
9
sequelae
FAMILY
of abortion
10
0
MALE
@
AFFECTED
0
FEMALE
q
HETEROZYGOTE ICARRIER)
0
SEX UNKNOWN
0
Ef
DECEASED
selective
abortion
801
CARRIER OF X-LINKED DISEASE
,
AMNIOCENTESIS PERFORMED
.
ABORTION
are given.
scales against male or female norms it is possible to detect any deviations from a “baseline personality.” Combination of elevations or depressions on various scales may be interpreted by reference to sources which have analyzed individuals exhibiting similar profiles.“. !’ The questionnaire attempted to assess attitudes toward amniocentesis and had been administered previously to families whose negative amniocentesis results had allowed completion of their pregnancies. The MMPI was to be completed by the husband and wife individually and the questionnaire was to be completed jointly. An interview was then successfully arranged for I3 of the 15 families: in the remaining two, scheduling conflicts prevented such a meeting. Exclusion of these two families was random, since both families agreed to the interview, so that their elimination should not bias the over-all results of the investiga-
802
Blumberg,
Table
Golbus,
and
I. Demographic
Hanson
statistics
on families
electing -
selective
Time of
indication
for
amniocentesis
No.
OCCUAge
pation
Time from therapeutic abortion to interview
Would have another amniocentesis if pegnant
therapeutic abortion relative to quickening
Married 15 yr.
37 mo.
Yes
4 wk. after
Married 5 yr.
37 mo.
Yes
Before
34 mo.
No
2 days after
32 mo.
NO
Before
Paternal
Maternal
Famity
abortion
Education
Age
i
Occupation
Education
3 yr. graduate school College degree
Marital status
1. The
L.‘s
Previous child with NiemannPick’s disease
35
Housewife
2 yr. college
36
Teacher
2. The
B’s,
Mrs. B. carrier for hemophilia B
26
Housewife
27
Police officer
3. The
M.‘s
Mrs. M. carrier for Duchenne’s muscular dystrophy
29
Salesaudit clerk
Highschool diploma 2 yr. secretarial school
4. The
C.‘s
Mrs. C. possible (50% ) carrier for Renpenning’s syndrome Previous child with Gaucher’s disease
29
Housewife
College
31
Physician
Medical school
Divorced between conception and amnio Married 9 yr.
26
Housewife
36
Bookkeeper
Business college
Married 5 yr.
32 mo.
Yes
2 wk. after
Maternal
46
Business manager
Highschool diploma 1% yr. graduate school College degree
50
Writer
6 yr. graduate school Master’s degree
Married
26 mo.
Yes
Before
Married 5 yr.
L’5 and 20 mo.
Yes
5. The
E.‘s
6. The
D.‘s
age
7. The
F.‘s
Mrs. F. probable carrier for Duchenne’s muscular dystrophy
27
Teacher
8. The
H.‘s
Previous with 21
35
Housewife
9. The
G.‘s
29
Housewife
10. The
P.‘s
36
Housewife
11. The
A.‘s
Mrs. G. carrier for Duchenne’s muscular dystrophy Previous children with NiemannPick’s disease Maternal age
39
11. The
S.‘s
child trisomy
Mrs. S. carrier for Duchenne’s muscular dystrophy
30
Unavailable
degree
a yr.
27
Mental health counselor
1 yr. graduate school Highschool diploma Tenth grade
35
Physicist
Ph.D.
Married 11 yr.
18 mo.
Yes
2 wk. after (first) and before (second) Before
34
Jeweler
2 yr. college
Married 9 yr.
18 mo.
Yes
1%
36
1% yr. college
Married 17 yr.
10 mo.
Yes
6 wk. after
Housewife
College
42
Career Air Force Pharmacist
Married 17 yr.
3 mo.
Yes
1 wk. after
Machine operator
3 yr. college
Pharmacy school Highschool diploma
Married since the abortion
2% mo.
NCJ
Before
degree 34
Deputy sheriff
wk. after
VchnP Number
122 7
Table
Psychological
sequelae
of
abortion
803
I--Cont’d
-
Time from
Maternal Family NO. 13. The
Indication for amniocentesis K.‘s
Prevous with emia
child galactos-
I
Paternal Marital status
Age 22
Housewife
24 Laborer
?
?
Separated
therapeutic abortion to interview 2 days
Would have another amniocentesis if pregnant Yes
Time of therapeutic abortion relatiue to quickening 4 wk.
after
after 6 yr. common-
law marriage
tion. The interviews were conducted at the patients’ homes and attempted to elicit an open-ended account of their emotional response to the amniocentesis-abortion experience. All interviews were conducted by one of the authors (B. D. B.) in an attempt to maintain interpretive consistency, required from 1 to 2vz hours for each family, and occurred from 2 days to 37 months following the abortion (mean interval, 2 1 months). Results
Psychometric testing. Mean results for the 11 women and 10 men who completed MMPI forms can be seen in Fig. 1. The results for the women were very close to the population mean profile, whereas the group profile exhibited by the men shows some elevation in the scales of depression, hysteria, sociopathy, femininity, and hypomania. Femininity elevation is positively correlated with intelligence’ and the men studied represent a very intelligent group, possessing a mean of 5vz years of education beyond high-school graduation; it is quite likely that the observed femininity elevation reflects exceptional intelligence. The elevation of the hysteria and depression scales is commonly seen in individuals esperiencing somatic symptoms as an expression of underlying tension, anxiety, and worry.” Illustrative case histories. Fig. 2 shows the family pedigrees for the 13 families involved and Table I is a summary of
the
and
of
families.
recorded
demographic All
prior
information
interview
data
to MMPI
scoring
for
were
each
analyzed
or interpreta-
tion. In
Family
I, referred
because
of a prior
child
with
Niemann-Pick’s disease, Mrs. L. commented, “If it just depended on me, I wouldn’t have had the abortion, but I had to think of our daughter who has already lived through our first child’s illness.” She reacted to the news
that the fetus was affected by “crying
for a while
and
keeping really busy during this very difficult week.” Following the abortion, serious marital difficulties ensued, and Mr. L. left home for a week in order to be by himself. Mrs. L. reported she “didn’t understand why my husband couldn’t support me.” Even after Mr. L.‘s return home, they continued to deal with the postabortion experience separately, and Mrs. L. developed the opinion that her husband was “being selfish” in his method of dealing with the problem. She continued to experience sleep loss, nervousness, and tension, and finally contacted a psychiatric social worker who helped her work through her feelings during a month of counseling sessions. Mr. L.‘s response to the abortion experience was one of “bitterness and feeling that the basic strivings of life (i.e., raising a healthy family) were unattainable.” He “wanted to fight someone or something” and felt that “a lot of things in the world are unjust.” He has sublimated these feelings by becoming involved in various movements for social change during recent years. Mr. L. said their marriage was “rocky” for approximately 8 months and that the marital situation required ‘2 years, until the birth of a normal son, to completely restabilize. The birth of the normal son was preceded by an amniocentesis, the results of which indicated that the child would not be affected. Both of the L.‘s denied any guilt in the knowledge that they are carriers of a lethal recessive gene and view the situation as being “bad luck” and “not through anyone’s fault.”
The
MMPI
indicated
that both the L.‘s exhibit
a
strong tendency to deny emotional problems. Mrs. L.‘s profile indicated possible chronic mild hostility and aggressive feelings. Mr. L.‘s profile suggested a poor family adjustment, especially in the sexual realm, and possible
804
Blumberg,
exaggerated
Golbus,
masculinity.
and
His
August 1, 1975 Am. J. Ohstrt. Gynecol.
Hanson
profile
also reflected
periods
of frank hypomania. Family 2 was referred because Mrs. B. is a known carrier for PTC deficiency (hemophilia B) so that a male fetus would have a 50 per cent chance of having hemophilia B. Mrs. B. described her reaction to receiving the results of the amniocentesis as being “very depressed and by “crying for a while.” After upset, ” and she responded the abortion, she was very depressed and “broke down” when a nurse commented, “you would have had a beauto which Mrs. B. responded with “anger and tiful boy,” bitterness.” Following the abortion, Mrs. B. said her feelings of guilt were increased with the knowledge that her family did not believe in this procedure, IJUt she was the right thing.” She relieved and felt, “I had done “seeing our first child suffer with hemoasserted that philia helped us to go through with this.” Mr. B. was especially concerned about his wife’s frame of mind and was “depressed, but I had to bring her out of the dumps. That was more important. What upset me was that she was upset. If she had been really depressed, I would have felt even worse, since I had an equal part in the decision (to abort) every now and then we think about it and wonder if the fetus was affected. We just put it in our minds that he was a bleeder. You can never really understand something like this unless you’ve been through it.” The following year, Mrs. B. became pregnant again and had another amniocentesis which indicated that the fetus was male. However, “the negative experience of the first abortion and the excuse of our doctor being on vacation” combined to dissuade them from proceeding with the abortion, although they “probably would have done it if our doctor had been there.” This child is not afllicted with hemophilia B and “his being normal helps us to believe that the aborted fetus was a bleeder.” Both of the B.‘s acknowledge that Mrs. B. feels guilty that she is a carrier of a detrimental gene but express no regrets for their course of action. The MMPI indicated that Mrs. B. has a tendency to deny emotional problems and has a rather conventional and rigid personality. Mr. B. appeared to be somewhat dependent and passively handles anxiety and conflict. Family 7 was referred to the prenatal detection clinic from the genetics clinic of another university hospital because Mrs. F. was a probable carrier for Duchenne’s muscular dystrophy. They felt that they were “prepared as best as could be for the possible critical decision. of whether to abort a male fetus” and, when informed that the fetus was a male, Mrs. F. insisted upon an abortion, although Mr. F. felt “this decision came from thin air.” Mrs. F. reacted to the news with “crying and a feeling of disbelief that the whole thing was happening.” Following the abortion, Mrs. F. felt “physically and emotionally empty” and was “really sad” for approximately one month. Shr commented that “both of us had a lot of faith, hope, and ideals. There was so much unhap-
piness and let-down. There is no substitute for a family, and we had pictured ourselves as a family.” She suffered from weight loss and decreased concentration after the not pay attention and could not abortion and “could handle being by myself or alone” for 3 weeks after the procedure. Mr. F. felt that when he was given the result of the amniocentesis he was “torn up inside” and “I hated myself for having to make the decision.” He observed “we both went through a mourning process folI still feel a lot of resentment lowing the abortion . and anger, but mostly sadness.” After the abortion, Mrs. F. was instructed to wait one month before restarting birth control pills and, unfortunately, another method of contraception was not suggested. She again became pregnant and, although her husband desired an immediate abortion without benefit of amniocentesis, she insisted upon waiting and having an amniocentesis at the appropriate time. When the fetus was identified as male in the second instance, abortion was performed at 5 months, prior to quickening. Following this second abortion, Mrs. F. stated she was “on the brink of being hysterical and was really sad for almost a year.” She related this to the experience of the death of something that was very close to her. Although she had been a teacher for 4 years prior to her ill-fated pregnancies she now took a job as a secretary because she “didn’t want to teach any more.” She stated she was very reluctant to deal with children. After the second abortion, Mr. F. experienced bloody diarrhea and a “tight stomach” and was under the impression that he was sufcring from colitis. He described his feelings at this time as those of “having insurmountable problems and being worthless, and had fears of impotence, both physically and as a human being.” He left his job as a youth guidance counselor because he “didn’t want to work with kids any more” and dropped out of his Master’s program. FIe withdrew and spent less time with his friends because “isolation prevents hurt.” In the wake of these feelings, Mr. F. left his wife 3 months after the second ahortion because he “felt threatened and wanted to re-establish my identity.” After 6 weeks of separation, Mr. F. realized that he teas more depressed than previously, and returned to his wife. He has had a change of philosophy and “I now see life as a struggle instead of minor ups and downs. I now accept obstacles rather than denying them.” Despite the magnitude of the trauma which the F.‘s described, they expressed no regrets for their coursr of action; in fact, Mr. F. claimed “we’ll he more prepared now, v,,hen we do have a child.” Mrs. F.‘s MMPI scores indicated that she is an mterprising, idealistic, energetic, and persevering person. Mr. F.‘s scores suggested that he is thoughtful, idealistic, and persevering. He also exhibited strong hypomanic tendencies and may be somewhat self-centered and selfdissatisfied. Family
8 was
referred
to the
program
because
their
Psychological
first child had trisomy 2 1 (Down’s syndrome) and they were concerned about a recurrence. During the 3 to 4 tvrck period while waiting for the results of the amniocentesis, the uterine size did not seem to increase as rapidly as cspected. Therefore, there was some question of fetal drath by the tilne the H.‘s were notified the fetus had Turner’s syndrome. They felt that after the experil’nce with their first child they did not want an abnormal child, rven with the more minor problems of Turner’s syndrome. When informed of the result, Mrs. H. angrily :tcked herself, “Why did it happen again? Is there something cvrong with us?” She also expressed the feeling that ahe “lvantrd the pregnancy and the abortion to be over as soon as is possible” and her immediate reaction to the abortion \\a~ one of “relief of the discomfort of pregnancy.” She felt “ashamed to tell anyone that the child had ‘l‘urnt>r’s syndrome” because she felt they might not cmdcrstand the sporadic nature of its incidence and
concltldp that there was something wrong with her. She I>ecame involved in community volunteer work and kept very busy immediately after the abortion, but her negative feelings did not fade for 4 months, until the H.‘s adopted a normal bahy girl. Mr. H. was reticent to discuss his fceiings but offers some insight with his statement. “in a way you never recover, but you do cope.” Concerning future reproduction, Mrs. H. both desires and fears a new pregnancy, and this conflict has led to
a significant deterioration of their sexual relationship. Mr. H. is considering vasectomy but his wife prohibits this until she is able to resolve her ambivalence about desiring
another
child.
Her
disappointment
that
she has
produced a child “to be proud of” is intensified by her “lack of personal success in a career” or any other not
endeavor. She exprehsed resentment that her childbearing was delayed by the precedence of her husband’s career
and felt this delay may be implicated in causing the fetal defects. Mr. H. admitted that these concepts arouse significant guilt in him, and he has warned his wife that any further intensification of these feelings would neccsvitate divorce. The MMPI results on Mrs. H. demonstrated severe depression, social insecurity, and a lack of self-confidence. She is socially withdrawn, unhappy, tense, and worried. This corrrlates well lvith her prior history of psychiatric depression. Mr. H. exhihits marked hypomanic tendencies lvhich serve as his mechanism for preventing environmenral pressure from overwhelming him. Comment
The most obvious conclusion from the data presented is the frequent appearance of depression as an immediate response to selective abortion. Only t\co of the 13 women and four of the 11 men in the present study failed to mention depression in describing their emotional reaction to abortion. Of these six nondepressed individuals, one woman and
sequelae
of
abortion
805
two men exhibited MMPI profiles which reflect a tendency to deny emotional problems ; therefore, the actual incidence of depression following selective abortion may be as high as 12 of I3 (92 per cent) among the women and as high as nine of 11 (8’2 per cent) among the men studied. The intensity and duration of depression experienced showed wide variability and reflect both individual personality differences and varying exogenous factors. Certainly these patients exhibited more depression than that described in the literature for women undergoing abortion on psychosocial grounds. Mrs. A. (Family 11) provides an internal control for the present study. She previously experienced an “abortion of convenience,” and the depression which ensued lasted less than one week. She stated that she never had any regrets about this elective abortion until she was unsuccessful in producing a healthy fourth child, as desired, during the most recent pregnancy. In contrast, she described selective abortion as “the worst thing that ever happened to me” and is uncomfortable about the procedure even 3 months later. This contrast between reactions is probably due to the selective abortion representing rhe termination of a desired pregnancy and precluding the birth of a wanted child, while a psychosocially indicated abortion is usually utilized as a solution to an undesired pregnancy with prevention of the birth of an unwanted child. Selective abortion, however, is more than just the loss of a wanted pregnancy, as illustrated by Mrs. G. (Family 9), who maintained that selective abortion produced much more depression than a previous stillborn. Certainly, the stillbirth of a wanted child is associated with the disappointment. regret, and sense of loss which are also experienced after selective abortion. Perhaps the role of decision making and the responsibility associated with selective abortion explains the more serious depression following the latter. A stillbirth is usually regarded as an unfortunate accident, while the etiology of fetal loss in selective abortion is much more clearly comprehended. Even when selective abortion is accepted as the only alternative, and preferable to the birth of a defective child, the responsibility of making the decision to abort may prove to be an uncomfortable burden for the parents. This burden was significant enough for Mrs. G. to insist on a postabortal tubal ligation. There may be a relationship between this perception of responsibility and the sense of guilt sometimes associated with abortion. This guilt has gen-
806
Blumberg,
Golbus,
and Hanson
erally been attributed to the self-chastisement arising from the transgression of societal or deep personal values. Even more important is the woman’s realization that she is responsible for a decision which must sacrifice some important goals and values (motherhood and the value of life) in order to sustain or attain other beliefs or achievements independence). Thus, ( career, self-determination, as society has increasingly accepted abortion as permissible, the extrinsic guilt formerly associated with the procedure has been at least partially rrplaced by an intrinsic awareness of responsibility. In selective abortion there is the additional problem of the sense of guilt and shame associated with ger?etic disease. Fletchcrl noted that “added to the guilt associated with being a carrier of genetic disease was the realization that their esperiment to get a healthy child had failed.” The implications of selective abortion may extend beyond the termination of that pregnancy. A positive amniocentesis may reignite the depression, guilt, and/or frustration associated \vith the birth of a previously aff‘erted child or close relative. There is also a threat to self-esteem, as evidenced by Mrs. H. (Family 8), xvho admitted that she was disappointed that she “has not produced a child to be proud of.” It appears that selective abortion shakes the foundations of self-worth, especially to the extent that selfesteenl is predicated by societal and personal values upon the ability to create a normal, healthy famil~~. Memories of previous misfortunes, realizations of present failures, and anticipation of future difficulties combine to produce the significant emotional impact of selective abortion. The choice is not eas) since the production of a defective child is more than a physical and financial burden. The parents of such children often experience chronic sorro\v. anger, and resentment and exhibit the same guilt and shame generated by their sense of being “genetically inferior.““‘. ‘I Tllis “genetic guilt” is probably more acute after the birth of a defective child than follolving the abortion of ;I defectivf fetus. Thus, most families elect selective abortion and its concolllitant emotional trauma as an alternative to the e\‘en more burdensome birth of an ill or handicapped child. Despite the operation of various normal psychiatric defense mechanisms, the stresses attendant to selective abortion also produce undesirable marital consequences. Two families (Nos. 3 and 13) experienced separation during the pregnancy in question, even prior to the performance of amniocentesis: in
each case, related to the problems engendered by their genetic circumstances. In addition, separation occurred in two families (Nos. 1 and 7 ) after the abortion; although these separations were for less than 6 weeks, they produced repercussions \~+ich threatened marital stability for many months or even years afterward. Significantly, both these husbands exhibited marked elevation on the hypomania scale of the MMPI. The separation in these two families, instigated by the husband in each case, ma); be viewed as an ;acting out of the anger, depression, and guilt verbalized by these individuals. Another frequently observed phenomenon following selective abortion may be described as a “flasheffect, which may persist for many months hark“ or even years after the procedure. Many women in the present study reported discomfort when renlinded of their abortion. Such recollections could be triggered by objects or events related to childbearing or babies. A flash-back efiect is by no nleans unique to selective abortions; an analogous process has been observed in psychosocially indicated therapeutic abortions.“, “’ This revi\,al of previous emotions represents an incomplete resolution or repression of the negative feelings engendered by the aborrion experience. Selective abortion is a second-trimester procedurr. ‘I’he resort to late abortion is necessitated by the requirenients of a I3 ireek gestational size ilterus for ;I sue-ccssful amniocentesis and by the .l. weeks nerded for cell culture and analysis. It has lon,~ been postulated that latch abortion conveys an emotional impact of greater extent than earlier abortion. Ribring and associates ” focused upon quicken~rlg as the physiologic e\.ent which signals maturation, from the narrissism and self-rathesis of early pregnancy to 3 vie\\ of the fetus as 371 ohjcrt 01 inrreasin,gly independent existence. ‘I’lic~orc~tirally, early abortion is arrolrll)anied b\ ;III inhibition of the normal fantasies about thr fr:us.’ ’ Presumably., surh inhibition is threatened b) the onset of quickening. after which the fetus comes to be considered as a potential “future child,” with a proliferation of fantasies concerning the child’s
Volumr Number
122 7
found long, continued preoccupation with the abortion. Intense and vivid fantasies persisted without much fading 12 to 14 months afterward. Fantasies whicll tyere mild and infrequent at the time of the pregnancy and abortion tended to disappear soon after.” Despite the emotional trauma of the procedure, 77 per cent of the families in our study reported that they would again opt for amniocentesis and, if indicated, selective abortion in any future pregnancy. These families have accepted selective abortion and its attendant problems as preferable to the alternative birth of a defective child. Of the families in our program who had a favorable result to their amniocentesis, 96 per cent had indicated they would have the procedure again in a future pregnancy.’ Probably the most important factor influencing a family’s ability to accept amniocentesis and selective abortion without self-reproach is their previous experience \vith the disease for which they are at risk. This is well demonstrated by Mr. E. (Family 5), who remarked, “After seeing what the first baby went through, there bvas nothing to think about in deciding to abort. It is hard to feel guilt after seeing that baby suffer.” Mrs. F. (Family 7) felt that living with an affected brother made it easier for her to say that she did not want a male child. She speculated that her husband’s lack of a similar experience with muscular dystrophy accounted for the “harder time he had dealing bvith the abortion.” These families have known the depression that selective abortion can produce, but they have also observed the tragedy of genetic illness at first hand. While this latter experience may not always reduce the sense of loss associated \vith selective abortion, it allows the family to feel less guilt about their decision. A family’s experiences subsequent to selective abortion are also important in shaping or modifying the emotional aftermath of the procedure. Many espressed the belief that the subsequent birth of a normal child aided the resolution of lingering postabortion emotional difficulties. Such a birth may assuage any residual feelings of regret or selfreproach associated with the earlier abortion. The new child may serve as a replacement for the and ameliorate the depression aborted “child” caused by the earlier loss of this fantasized baby. The birth of a healthy child also provides a source of self-esteem and helps alleviate much of the guilt engendered by the previous confrontation with genetic disease. The creation of a normal child ma)
Psychological
sequelae
of abortion
807
reaffirm the personal sense of worth of the parents. We have, thus far, considered selective abortion patients as comprising a homogeneous group. From a genetic perspective, however, there are three subgroups representing various modes of inheritance: recessive, X-linked, and sporadic. The mode of inheritance appears to have little influence upon a family’s depression following selective abortion. In contrast, the occurrence of guilt feelings induced by the genetic situation appeared to be somewhat specific to the women known to be carriers of an X-linked disease. All other families professed a sense of misfortune rather than feelings of guilt with regard to their role in the transmission of a genetic disease. It is also noteworthy that for sporadic or recessive disorders, selective abortion was performed because the fetus was definitely defective, whereas for the X-linked diseases the pregnancy was terminated with a 50 per cent risk of producing a defective child. Most families coped with this ambiguity by convincing themselves retrospectively that the aborted fetus was definitely affected, thus rationalizing doubts which might otherwise linger. This study suggests several modifications in the amniocentesis and selective abortion procedures which might diminish the concomitant emotional trauma. By performing earlier abortions one might avoid the cathexis and personification of the fetus Lvhirh have been noted. Advancement of the aluniocentesis by 1 or 2 weeks or the ability to shorten the 4 week culturing period required for sample analysis could be significant, particularly if termination could occur prior to the inception of quickening. The development of an alternative to the invasive techniques of selective abortion (amnioinfusion or !lysterotomy) would be viewed as an improvement by all patients. It has been noted that the methods employed in late abortions are contributory to the psychological trauma of the experience of terminations. For instance, if the intramuscular administrations of prostaglandins should prove to be an effective second-trimester abortifacient, it might well be a psychiatrically less traumatic method of terminating the pregnancy. Improved preamniocentesis counseling might also diminish the observed trauma of the amniocentesisabortion experience. The families in our study all received excellent counseling regarding the genetic and technical facets of amniocentesis, but without discussion of the psychological aspects of the pro-
808
Blumberg,
Golbus,
and
Hanson
cedure. An intelligent decision requires the input of all available data, and ignorance of the psychological aspects of selective abortion precludes a fully informed decision. Families should be made fully aware of the strains and anxieties that may be expected during the 4 week waiting period, and supportive counseling should be made available during this period. They must be made cognizant of the fact that one of the risks of amniocentesis is the potential for a positive diagnostic result, even though intellectual awareness of this possibility is not always equivalent to emotional acceptance. Complete foreknowledge may not lessen the blow of a positive result but, hopefully, it will provide time for careful consideration of alternatives in preparation for the quick decision which may become necessary in the face of a positive test result. Many families, once having experienced the emotional consequences of selective abortion, may decide that this is an experience that should not be repeated. It must be the responsibility of the counselor to convey the experiences of others to the patient in order to promote a well-considered decision and to allow preparation for the consequences of that decision. Further, the method of abortion to be utilized is another issue which must be broached by the counselor.
REFERENCES
1. Fletcher, J.: Theolog. Stud. 33: 457, 1972. 2. Golbus, M. S., Conte, F. A., Schneider, E. L., and Epstein, C. J.: AM. J. OBSTET. GYNECOL. 118: 897, 1974. 3. Peck, A., and Marcus, H.: J. Nerv. Ment. Dis. 143: 420, 1966. 4. Niswander, K., and Patterson, R.: Obstet. Gynecol. 29: 703, 1967. 5. Simon, N., Senturia, A., and Rothman, D.: Am. J. Psychiatry 124: 60, 1967. 6. Epstein, C. J., Schneider, E. L., Conte, F. A., and Friedman, S.: Am. J. Hum. Genet. 24: 214, 1972. 7. Hathaway, S., and McKinley, J.: Minnesota MultiPhasic Personality Inventory, New York, 1970, The Psychological Corporation.
The importance of postabortion follovv-up and counseling is also suggested by our findings. Several individuals sought help on their own initiative following abortion, and the frequently prolonged emotional difficulties described by others also indicate the need for supportive counseling after selective abortion. Mental health personnel should be available for supportive counseling in clarifying decision-making processes and the consequences of such decisions. Emotionally oriented preamniocentesis and postabortion counseling would also help to alleviate the sense of isolation expressed by many patients. The experience also could be improved by training ward personnel to understand what the family is going through and to be supportive during this difficult period. Positive entotional support from the physician, other medical personnel, family, and any friends informed of the situation can be a significant sustaining factor for the family undergoing amniocentesis and/or selective abortion. Only when experience allows an examination of the efficacy of various counseling schedules and methods will an optimal counseling approach be achieved. We are in the process of making such an addition to our program and suggest that other genetic centers consider doing likewise.
8. 9.
10. 11. 12. 13. 14. 15. 16.
Butcher, J.: MMPI: Research Developments and Clinical Applications, New York, 1969, McGraw-Hill Book Company, Inc. Dahlstrom, W., Welsh, G., and Dahlstrom, L.: An MMPI Handbook. Vol. I: Clinical Interpretation, Minneapolis, 1972, University of Minnesota Press. Cohen, P.: Social Casework 43: 137, 1962. Olshansky, S.: Social Casework 43: 190, 1962. Hamilton, Y.: AM. J. OBSTET. GYNECOI.. 43: 285, 1941. Senay, E.: Arch. Gen. Psychiatry 23: 408, 1970. Bibring, G.: Dwyer, T., Huntington, D., and Valenstein, A.: Psychoanal. Stud. Child. 16: 9, 1961. Raphael, B.: Med. J. Aust. 2: 100, 1972. Wallerstein, J., Kurtz, P., and Bar-Din, M.: Arch. Gen. Psychiatry 27: 831, 1972.