Men and Abortion

2

The Psychological Sequelae of Abortion

The Questions and Problems of "Psychological Sequelae"

Methodological Problems with Abortion Research

Psychological Sequelae of Abortion: Research Studies

3

Guilt, Psychopathology and Abortion

Freud's Contribution to the Study of Guilt

The Cognitive-Interpersonal Approach of Joseph Weiss, Harold Sampson & Lynn O'Connor: Work of the San Francisco Psychotherapy Research Group

4

Loss, Grief & the "Shut-Down" Male

Loss, Masculinity and Identification

Male Inexpressivity and Grieving

Oedipus Revised: New Psychodynamic-Relational Approaches to the Developmental Drama of Separation-Individuation

5

Discussion and Conclusions

Endnotes 134

References 140

Index 164

When the idea for a project that examined the psychological consequences of abortion for male partners was first suggested to otherwise sympathetic colleagues in clinical practice, the modal response was telling: "what do you mean, men and abortion?"

The response was neither one of hostility, nor polite, cursory interest, but rather a curious mixture of disbelief and genuine confusion at just how men figured into the picture of the abortion experience. And while some found the topic intriguing, they warned against pursuing it, for reasons which make all too much sense and reflect themselves in the general dearth of literature on male responses to abortion. Some made an essentially political argument that discussion of psychological sequelae of abortion in male partners drew a necessary focus away from women's responses to the experience. Behind this response was an important, quiet fear that any attention given to men around the issue would be fuel for the fires of removing the essential elements of choice and privacy in abortion, codified on January 22, 1973 with the Supreme Court's landmark decision in Roe v. Wade. As Justice Blackmun wrote in the Majority Opinion of the Court:

There is a kind of "zero-sum" thinking that warns us that an additional focus on male responses will be detrimental to women in any number of ways. For example, research on male partners that show negative psychological sequelae of abortion will be used by anti-abortion proponents to further their arguments, with all the attendant consequences of returning to a pre-1973 state of affairs; or it will be used by pro- and/or anti-abortion males to continue to wrest control over women's bodies around reproductive decisions and technology. Still others like Arthur Shostak (1996a; 1996b) argue that in a post-Roe world, the inclusion of research and family-planning perspectives that take fuller account of the male role is a win-win move with wide-ranging effects such as: sending a social message that both sex partners (whenever possible given the safety of both parties) are expected to share responsibility for the decision to terminate pregnancy; supporting spousal prenotification law while rejecting spousal consent laws which are inherently "male supremacist;" and supporting the view that abortion is fundamentally an interpersonal experience, and that questions of responsibility, intimacy, choice and healing are not the domain of one party, rooted in gender.

If research into the male response to abortion became more commonplace, no less crucial a question would arise as to just who did the research, under what socio-cultural conditions, and with what, if any, pre-figured limitations on the scope or applicability of such research. Government funding of any aspect of abortion research is often highly controversial and the subject of intense scrutiny by both pro- and anti-abortion supporters (United States Congress, 1989b). The call for a neutral or bias-free investigative position on abortion (or any subject, for that matter), while arguably fruitless, is nonetheless often used as a critical location from which to devalue the results of any study.

The highly politicized nature of the topic-which touches the deepest questions of value (e.g., Schnell, 1993). concretized in the interlocking spheres of personal and political autonomy, interpersonal relationship, parenting, sexuality, work and economics-should serve not as a warning against its exploration, but an urgent plea for it.

Shortly after Roe v. Wade was published by the Court, several researchers at the Temple University Hospital Health Sciences Center in Philadelphia produced an important edited volume entitled, The Abortion Experience: Psychological & Medical Impact (Osofsky & Osofsky, 1973). In a chapter in that volume on needed behavioral social research, Newman (1973, p. 560) was keen to point out that there were practically no studies of the "background, characteristics, psychodynamics and behavior of the male partners of females seeking and obtaining abortions" (Newman, p. 560). While he presumed that men played a significant role in concerns of sexual behavior, contraception and related matters, he noted that a consideration of men was virtually absent from the literature. This trend continued apace until Arthur Shostak and Gary McLouth's groundbreaking 1984 sociological study detailed in Men and Abortion: Lessons, Losses and Love. However, not much has been done since that work, and there are to date few theoretical or empirical researches either on the psychological sequelae of abortion or on intrapsychic dynamics of the abortion experience for male partners.

A computer search of over 3,500 documents which mentioned the terms "abortion," "psychological sequelae" and men revealed less than 100 studies, reports or theoretical pieces which dealt even marginally with the male partner's responses to abortion. Even fewer represented theoretically-based research on the psychological sequelae of abortion in men.

In the same volume with Newman's thoughtful analysis of much-needed abortion research, Osofsky, Osofsky and Rajan's (1973) meticulous review of U.S. studies on the psychological sequelae of abortion for women reported, with unsurprising cross-study consistency that, "for most women, abortion has had few, if any, psychological sequelae...[with] postabortal feelings of guilt and depression...[being] relatively uncommon" (p. 203). More recent studies which acknowledge negative psychological sequelae of abortion for women look at postabortion effects and resilience factors (Cozzarelli, Karrasch, Sumer & Major, 1994; Cozzarelli, 1993; Congleton & Calhoun, 1993; Speckhard & Rue, 1992, 1993; Major & Cozzarelli, 1992; Major, Cozzarelli, Tesa & Mueller, 1992; Wasielewski, 1992) or post-traumatic stress disorder and abortion (Bagarozzi, 1994; Clare & Tyrrell, 1994). And a relatively recent study by Posavac & Miller (1990) raised intriguing questions as to why earlier research seemed to show no significant negative psychological sequelae of abortion. While the absence of negative sequelae is part of a much larger political debate, played out within the historical context of feminism, the research results appear uniform to date. The majority of studies continue to support former US Surgeon General C. Evertt Koop's (1989) conclusion that the negative sequelae of abortion is "minuscule from a public health perspective."

Yet persistent anecdotal information-from colleagues in clinical practice doing individual, couples or family psychotherapy and from numerous friends who have experienced abortion-would suggest otherwise. The abortion experience-which 32.5 million women and over 16 million men experienced from 1973 to 1994 (The Alan Guttmacher Institute, 1995; Henshaw & Van Vort, 1994; Shostak, 1996b)-is a profound one, with long-lasting effects for many. It seems plausible that the discrepancy between research studies which report no significant negative sequelae of abortion and anecdotal reports from clinicians that the abortion experience is profound and often traumatic for the participants, can be understood from several vantage points.

The present work attempts to account for this discrepancy utilizing the insights of a relatively new cognitive-interpersonal psychodynamic theory of the mind and psychopathology called Control-Mastery theory, slowly developed over the last 30 years by Joseph Weiss, M.D., Harold Sampson, Ph.D. and more recently, Lynn O'Connor, Ph.D. of the San Francisco Psychotherapy Research Group (formerly the Mt. Zion Psychotherapy Research Group) (See Chapter 3 of the present work.)

Following Newman's (1973) call for a wide-ranging approach to the study of abortion, this project draws on multi-disciplinary resources and methods-from psychoanalytic and non-psychoanalytic theories; from attachment, developmental and evolutionary psychological perspectives and; from sociological and anthropological perspectives-to explore issues around the psychological sequelae of abortion for male partners. This exploration does not concentrate on psychological sequelae of abortion for women nor does it attempt to explain in sociological or anthropological terms the "causes" of the lack of material on the topic, although the present project refers to socio-cultural sanctions which mitigate against its exploration. Because these questions are so inexorably linked, and the social and psychological of such a piece, it is impossible to consider psychological consequences of abortion without the understanding, for example, that the sanction for the right of privacy contained in Roe v. Wade allowed women, "in the ultimate sense, the final privilege and responsibility for parenthood-a responsibility shared perforce with the medical profession" (Mudd, 1973, p. 542). The male intrapsychic response to abortion takes account of this fact, and both challenges and reinforces often intensely-held, culturally-reproduced gender roles for men (Walzer, 1994).

This last point illuminates the way to one of the central theses of this theoretical investigation and one which is contained in Martin Luther King's words which precede this volume. Namely, that if we are truly "caught in an inescapable web of mutuality," then perhaps it is with the lens of relationality that this subject must be approached.

It is one thesis of this project that there may be significant psychological sequelae of abortion for male partners (and indeed, for women), and that these effects are being missed because the theoretical underpinnings of most current researchers do not assume a relational view. This results in studies which only account for the presence of what I call "bounded effects:" effects localizable in the individual, exhibited in individual psychopathology, measurable by standard psychometric measures and relatively consistent over time. (See Chapter 2 of the present work.) However, current evolutionary psychological perspectives (Slavin & Kriegman, 1992), cognitive-interpersonal approaches which emphasize relatedness as a primary human motivation (Baumeister & Leary, 1995; Baumeister, Stillwell & Heatherton, 1994; Stolorow, Atwood & Brandchaft, 1994; Weiss, 1993; Weiss, Sampson & Members of the Mt. Zion Psychotherapy Research Group, 1986; Bowlby, 1980) or interpersonal experience as the seat of early developmental and ongoing personality structuration (Stern, 1985; Stolorow & Lachman, 1984/1985; Emde, 1988a; 1988b; 1989; Surrey, 1991) teach us that exploration of the interpersonal system is often key to understanding so-called normal as well as pathological developmental phenomena. Newman's (1973) call over 23 years ago for a broader focus in abortion studies illustrates the point when he urged researchers to look at:

While it would not be difficult to broaden the above list, the salient point remains that current discrepancies between the literature on post-abortion effects for women and anecdotal reports might be accounted for by measures and methods which do not fully appreciate the highly interpersonal nature of the psychological sequelae of abortion.

Chapter 1 introduces the reader to some of literature on female responses as well as male partner's responses to abortion, exploring abortion as a deeply interpersonal experience for the man. While close to three-quarters of a million men each year accompany their female partners to abortion clinic waiting rooms (Shostak, 1993, 1996b), the bookshelf, as Art Shostak notes, is still barren. The heuristic promise of Shostak and McLouth's Men and Abortion (1984) has yet to be realized and the primary resources on men and abortion continue to be doctoral dissertations or master's theses (Lees, 1975; Smith, 1980; Rotter, 1981; Karesky, 1986; Ortega, 1987). Articles in the psychological literature are increasing, however, and this chapter reviews recent research on psychological effects of the abortion experience on male partners.

In Chapter 2 we move more directly to the issue of report short- and long-term sequelae of abortion. Prior to Roe v. Wade, traditional psychiatric approaches tended to emphasize the abortion decision as almost tantamount to a psychopathological response (Wallerstein & Bar-Din, 1972; Cavenar, Maltbie & Sullivan, 1978). For instance, abortion could be seen as an unsuccessful attempt to resolve the Oedipus complex, "as a rejection of the feminine role, overidentification with the father, [and] a conscious or unconscious desire to take revenge on either self or another" (Illsley & Hall, 1978, p. 13). Since 1973, however, psychosocial and behavioral approaches have widened that narrow frame and abortion could be understood as a response to economic factors, avoidance of stigma, adherence to deeply-held religious convictions or "just the desire not to have a baby at that time" (ibid.).

The legalization of abortion also made possible and necessary a proliferation of studies on the sociological, legal, psychological and medical effects of abortion. Most studies show only mild and transient negative sequelae of abortion, for both men and women. For studies that show significant post-abortion effects and those that show only mild and transient negative sequelae of abortion or brief reactive symptomatology, factors such as religious affiliation, ethnicity, culture and female partner attitudes (Black, 1991) are considered to help explain how men cope with and respond to their partner's abortion, as well as how men and women make abortion choices (Wetstein, 1996). In addition, the literature reveals important predictive links between body image (Terjestam, 1989), male self-attributions and life "ownership" attitudes and abortion responses (Ross & Kaplan, 1993-94).

But of those studies which indicate negative sequelae of abortion (in women or their male partners), conscious guilt is most often reported, however mild. Of course, guilt and psychopathology are not the same. The present work argues that unconscious, irrational guilt is at the base of psychopathological reactions to trauma and that an exploration of the forms and presentation of unconscious guilt is necessary in the case of abortion.

Specifically, in Chapter 3 we look at new researches designed to more deeply explore the complexities of measuring guilt and shame-related phenomena, and make important distinctions between various subtypes of guilt. Specifically we consider those measures designed to detect more interpersonally-oriented types of unconscious guilt as opposed to those measures which seem to measure more conscious, adaptive and less interpersonally-oriented forms of guilt. Unlike Freud's early view of guilt which was based on the idea that the affect arose in response to an unconscious wish to harm others, new researches like those of June Price Tangney and her colleagues (1990; 1991; 1995; Tangney and Fischer, 1995) and O'Connor, Berry and Weiss (1996) discuss the development of guilt as an "an interpersonally driven emotion, based on the need to maintain attachment to others" (O'Connor, Berry & Weiss, p. 6).

Chapter 3 also introduces several complementary psychological views of the concepts of guilt, shame, relationality and altruism. The perspectives of evolutionary psychology (Slavin and Kreigman, 1992) and the cognitive interpersonal theory developed by Joseph Weiss and Harold Sampson (Weiss, Sampson et al., 1986; Weiss, 1993) and researched and further advanced by Lynn O'Connor and her colleagues (O'Connor, Berry, Inaba, Weiss & Morrison, 1994; O'Connor, 1995; O'Connor, Berry & Weiss, 1996; O'Connor, Berry, Weiss & Schweitzer, 1996; O'Connor, Berry ,Weiss, Bush & Sampson, 1997) are viewed as providing a fruitful framework for understanding the relational aspects of the abortion experience.

In Chapter 4, "Loss, Grief and the 'Shut-Down' Male," we investigate barriers to male participation in the abortion process-social and psychic barriers which are often mutually reinforcing. According to current statistics (Shostak, 1996b), slightly over one-half of males accompany their sexual partners to the abortion clinic. But it must be noted that "participation" in the abortion experience is not reducible to male presence at abortion clinic waiting rooms. And emotional participation with a female partner is often tied to highly segregated gender roles and other social barriers to participation, including concerns that hard-fought battles around reproductive choice may be lost in giving attention to the male experience of abortion (Rosenwasser, Wright & Barber, 1987; Roberts, 1990; Shostak, 1996b).

Informed by Bowlby's (1969; 1980; 1982) work on attachment and loss, as well as the work of the Stone Center for Developmental Services and Studies at Wellesley College, this chapter explores interlocking social and intrapsychic sanctions against male grieving as well as the effects of deferred grief. We explore how the abortion experience may influence subsequent sexual behavior and male self-attribution. We also look at how the decision to terminate pregnancy may be experienced by some men as a "denial" or "refusal" of progeny. This chapter proposes that any consideration of male response to abortion must also consider male and female responses to pregnancy in general and issues of male envy of female creativity.

The psychoanalytic literature has often linked abortion and the Oedipal complex, focusing on (unconscious) pathogenic guilt and development of depressive symptomatology as consequences of abortion in women (Deutsch, 1945; Abraham, 1969; James and Benedek, 1970; Pines, 1982, 1990; Lester & Notman, 1986). These theoretical explorations have sometimes been dismissed, since psychiatric diagnosing (based on the medical model) often avoids etiological explanations that rely too heavily on reference to repressed material or material considered too conceptually abstract (like the Oedipus complex). However, the views of Peter Blos (1985), Jessica Benjamin (1994) and Janine Chasseguet-Smirgel (1994) are considered for their more reality-based reconstructions of the Oedipal complex, which view the Oedipal drama and its consequences as offering the individual a complex network of tasks around affect attunement and separation-individuation, thus setting a stage for subsequent responses to normal developmental strain and trauma.

The brief, final chapter offers a summary and some conclusions and suggestions for future directions.

When I first began this project, I was disheartened by the lack of material on the male response to abortion. I wish to thank Arthur Shostak, Ph.D. whose thoughtful, groundbreaking work Men and Abortion finally put this difficult subject in more of a public light, and whose generosity of spirit supported the effort of this project. Early on in my researches, I came across Art Shostak's work and decided to give him a call. I had no idea that I would be met with such abundant kindness. I owe much to his over 30-year commitment to understanding the abortion experience.

As a professional colleague and tireless researcher, Lynn O'Connor, Ph.D. has been a tremendous inspiration in my thinking about men and abortion. Her thoughtful and caring comments during the course of this project were invaluable. As well, the work of Joe Weiss, M.D., Harold Sampson, Ph.D. and members of the San Francisco Psychotherapy Research Group continue to stimulate my thinking on psychotherapy and psychopathology and continue to prove that as clinicians, empirical researchers and theoreticians we don't have to choose between psychoanalytic and non-analytic approaches in thinking about object relations.

I am deeply indebted to my advisor Ruth Goldman, Ph.D. for her unwavering support and grace in ways which always went well beyond even the most generous call of duty. This project, for reasons which she understands, had to be begun over and over again. It was to her that I turned when I felt like I couldn't begin one more time, and her quiet strength offered just the bolstering I needed to approach the work.

Harvey Peskin, Ph.D., stands as a quiet presence throughout this work and the clinical sensibilities that inform the project. As a mentor and friend, his unwavering dignity and commitment to acknowledging our fundamental relatedness as human beings stands as an enlivening inspiration to whatever may be helpful in this work.

1

Introduction

While the nation's abortion rate in 1997 dropped to a twenty-year all-time low, there have still been over 32 million abortions since the Centers for Disease Control and Prevention began tracking abortions (Henshaw & Van Vort, 1994; Henshaw & Kost, 1996; "U.S. Abortion Rate," 1997). Shostak (1996b) reports that about one-half of the women obtaining abortions are accompanied by their male partners to the abortion procedure. And for the estimated 16 million males who do accompany their partner to the procedure, their experience is predominately characterized by waiting and isolation:

It's important to note that the majority of women (55 percent) obtaining abortions are under the age of 25, with 21 percent under the age of 19 (Stone & Waszak, 1992). The highest abortion rate (by age) is among single women 18-19 years of age, and thus their male partners are, for the most part, still actively dealing with issues of separation and individuation from their own families of origin. Recent studies (Stone & Waszak, 1992; Marsiglio & Sheehan, 1993) reported in Family Planning Perspectives suggest that while adolescent males on the whole support a woman's right to choose, the majority (61 percent) of adolescent males surveyed felt that it was "not appropriate for a woman to have an abortion if her male partner objected" (Marsiglio & Sheehan, p. 166). This suggests that while adolescent and young adult males usually defer to their partner's decisions concerning the abortion-even though they have no legal rights to enforce their own decision preference-they have strong feelings about the pregnancy and decision to terminate, a finding borne out by other studies (e.g., Smith & Kronauge, 1990). Interestingly, Marsiglio and Sheehan (1993) also report that for men, religious affiliation was less of a predictor of unfavorable abortion attitude than were their views about relational factors such as feelings about premarital sexual intercourse and the possible pleasure of becoming a father (p. 167). On the whole, and contrary to the estimates of both pro-choice and pro-abortion women, men are overwhelmingly in favor of a woman's right to an abortion, with abortion attitude being determined by a variety of variables including gender role experience and religious affiliation for both men and women (Fleming, 1986; Adebayo, 1988, 1990; Curtis & Standing, 1992; Brown & Shuman, 1994; Walzer, 1994).

What of those studies that specifically examine the male experience of abortion? Many of the studies to date examine the male partner's role in postabortion adjustment for the woman (Major, Cozzarelli, Tesa & Mueller, 1992; Cozzarelli, Karrasch, Sumer & Major, 1994), although a few (mostly dissertation) researches specifically raise the issue of male response to abortion and the fundamentally relational nature of the experience for men (e.g., Lees, 1975; Smith, 1980; Rotter, 1981; Ortega, 1987).

We have known for some time that the male partner plays a significant role in determining positive postabortion outcome for his partner (Rothstein, 1977; Bracken, Hachamovitch & Grossman, 1974; Zimmerman, 1981). In an early review study on abortion decisions and psychological sequelae, Bracken, Hachamovitch and Grossman (1974) made a strong case for viewing relationship factors as correlated with pre- and post- abortion adjustment. In their study of 489 women aged 14-44, they investigated the level of support from significant others for the decision to abort. They utilized measures of 9 psychological, social and intrapsychic items and found that the woman's postabortion adjustment was significantly more favorable when she perceived partner support. For younger women, their postabortion adjustment was greatest when they perceived and anticipated parental support for the abortion. It should be noted that partner accompaniment alone was not a significant variable in postabortion adjustment, in this study or subsequent ones (e.g., Cozzarelli et al., 1994). Women's distress did not decline solely as a result of accompaniment by the male partner to the abortion clinic; the women had to experience their partners as supportive in order to have a beneficial effect postabortion. Women who experienced their male partners as emotionally supportive were found to be lower in state and trait anxiety, with married women (with supportive partners) showing the lowest levels of postabortion state and trait anxiety (Kalil, Gruber, Conley & Syntniac, 1993). And women who experienced their male partners as non-supportive during the abortion experience went through more stress, which the women traced not to the abortion itself but to the interpersonal conflict with their partner (Zimmerman, 1981). In contrast to the research noted above, no studies to date have assessed the effect of partner support on male coping and postabortion adjustment, and whether maintaining support for his partner necessitates, for the traditionally socialized male, the suppression and repression of his own psychological pain.

In Rita Black's (1991) study of women who underwent abortions or had spontaneous miscarriages, the women felt that their reactions to the abortion were very similar to their male partners, and overall felt very understood and supported by them. Interestingly, however, most women noted that their responses to loss were quite different from those of their male partners, and that the male partners tended towards being "strong" or putting their own needs aside in response to the miscarriage or abortion.

And in one study of the adolescent pregnancy and psychological sequelae of male partners, it was found that men were more psychologically distressed as young adults than those who did not have a girlfriend become pregnant (Buchanan & Robbins, 1990). Young men whose girlfriend's had abortions seemed to be as distressed as those men who abrogated the parental role and those who became fathers and stayed with their partners.

Major et al. (1992) examined the impact of men's attributions for pregnancy and anticipatory feelings about the abortion. Men overwhelmingly tended to blame the unwanted pregnancy more on their own character than did their partners, perhaps indicating something about the level of omnipotent responsibility they experienced for their partners and higher levels of internal locus of control, and thus guilt for causing the abortion to occur (Ortega, 1987). When something went wrong (the unplanned pregnancy) and the result was the decision to abort, these male partners more often felt that they had not done something wrong, per se, but that they were wrong, characterologically. Surprisingly, men's attributions about the pregnancy (positive or negative) were unrelated to their partner's postabortion adjustment expect in one case, raising the question of the degree to which men's attributions about pregnancy and abortion are made conscious to their partner. When the male's coping expectancy did affect women's adjustment, it was in cases where both the woman and her partner had expectations of not coping well after the abortion. Both partners showed depressive symptomatology as measured by the Beck Depression Inventory (BDI). According to the new framework of abortion response suggested here (See Chapter 3), such a result may suggest the use of compliance in one or both partners as a means of maintaining loyalty to someone perceived as suffering and undergoing loss (Lerner & Mathews, 1967; Rawlings, 1968; Miller, 1992a; O'Connor et al., 1997).

This last hypothesis is also supported by Lees' (1975) study of relational difficulties pre- and post-abortion in which he found stress levels in male partners (as compared to other less involved people in the woman's life) significantly higher pre- and post-abortion. Of this finding, Lees wonders "whether in fact high anxiety in the males reflects a high degree of empathy and thus leads to a strengthening of the relationship" (pp. 59-60). Lees argues, in effect, that the postabortion relationship between partners constituted a new relationship, and that jointly processing guilt, regret and anger was a key to whether or not stress levels declined and the relationship (postabortion) was maintained, ended or strengthened.

But while the abortion experience may be highly interpersonal for the male, it is one primarily processed alone (Rotter, 1981; Zelles, 1984). Indeed, Zelles (1984) found that it is this very concern for the welfare of their partner-often for the purposes of keeping what they perceive as the woman's secret-that leads most men not to discuss the abortion. The pledge of secrecy is one either inferred or directly requested by the partner where the male involved was usually a non-live-in boyfriend.

Another noteworthy recent finding suggests that there are no significant differences in men's and women's abortion attitudes and their childbearing motivation (Miller, 1994). While for both men and women, acceptability of abortion increases with age, preference against childbearing for men and women appears to have a "psychological primacy," and to be set relatively early in life, "remain[ing] relatively unaffected by adult experiences" (p. 168). It makes intuitive sense and is borne out by this study that negative and ambivalent attitudes, beliefs and affects associated with childbearing (for both men and women) correlate highly with acceptance of abortion. Thus the abortion experience is one that occurs against a pre-existing background of conscious and nonconscious beliefs and affects, and is always already an interpersonal experience, since the response to abortion appears to be largely determined by earlier experience/interaction with significant others (Cozzarelli et al., 1994; Armsworth, 1991).

In a study of couple attitudes towards abortion, those couples who were higher in relationally-oriented personality traits thought to be associated with positive childbearing motivation ("nurturance" and "affiliation") were significantly more likely to hold anti-abortion attitudes than those couples who valued less relationally-oriented traits associated with negative childbearing motivation ("autonomy" and "achievement") (Miller, 1992b, p. 166).

One study that examined the effects of abortion on other than the women undergoing the procedure, showed negative sequelae among physicians, residents, students and nurses to include guilt, depression and anxiety (Kane, Feldman, Jain & Lipton, 1973). The abortion experience seems paradoxically among the most private and most public of experiences, the reach of which extends far beyond the women having the abortion.

The present study argues that male responses to abortion are determined by a complex web of factors. One important emergent factor is the degree to which the experience is perceived consciously and unconsciously as a relational experience, that is, as pertaining to one's partner, one's potential (or already existing) child(ren), one's family of origin and to the society and social values within which the abortion occurs. This should no longer surprise us since, as Winnicott (1970) observed nearly 30 years ago, the mother-infant (and today we might add, father-infant) experience is one of mutuality and it is thus through the interrelated psychic, biological and social frames of mutuality that all human development takes place (Cath, Gurwitt & Ross, 1982; Stern, 1985; Emde, 1989; Surrey, 1991).

It is the central thesis of this paper, then, that the relational, intersubjective context of abortion is the most overlooked and important factor in understanding the psychological sequelae of abortion for males.

Most men intuitively understand that their supportive presence in the abortion experience (and not just their physical presence in the waiting room) plays a significant ameliorative function, pre- and post-abortion. The conscious or unconscious decision-making process around their involvement after learning of the pregnancy is one in which the male is vulnerable to feelings of intense guilt over adequately supporting a significant other that he knows is undergoing a traumatic experience. This is not necessarily the only source of guilt, but it is an overlooked one, riding on the assumption that men, by virtue of their gender, have little capacity for empathy or other affiliative experience of pregnancy or its termination. As noted above, this is not supported by empirical research. (See for example, Chapter 4 on the work of Peter Blos and some of the new psychoanalytic thinking around pregnancy.)

As discussed in Chapter 4 of the present work, while anger is a socially sanctioned emotion in response to trauma, awareness of experiences of intense worry, concern and responsibility for the suffering of a close other are not socially supported for males, but may be a biologically-based response pattern nonetheless (Rawlings, 1968; Regan, 1971; Plutchik, 1987; Eisenberg & Strayer, 1990; Jones, Kugler & Adams, 1995). As such, the implications for the denial of such expressions ("inexpressivity") may show a positive link with pathogenesis. If the affect is experienced (see fn. 2 of the present work), there are often active pathogenic beliefs or scripts for responding in place that caution against the expression of these painful emotions, often in favor of another who is perceived as undergoing a greater suffering.

Rooted in a belief in the intersubjective context of abortion, the present study adopts a focus on abortion as traumatic largely because of the effects on engagement (both with oneself/affective world and with others, which are by no means separate processes).

In an intersubjective view of traumogenesis, painful affect becomes traumatic for a child when the requisite attuned responsiveness needed for tolerating, containing, modulating and alleviating that affect is not present (Stolorow & Atwood, 1992). Injurious childhood experiences of loss are not necessarily pathological, but in the absence of adequate attunement and responsiveness, they can become a source of traumatic states and psychopathology. The development of self-esteem and a "sense of being real" is thus dependent upon, from an intersubjective perspective, validating attunement of the caregiving environ to the child's emotional experiences. A child who is not met with an adequate response from the caregiving environ may conclude that, in fact, his own unmet needs and emotional pain are the result of self defects, and should be disavowed from conscious experience. The child can come to blame his own reactive states for the injuries that produce them and is warned off against experiencing painful affective states (for fear they will lead to similar traumas). By a similar process, the child can form organizing principles which preserve ties to the injurious caregiver (or caregiving environ) and (seemingly) protect him from further traumatization. It is important to stress the interpersonal nature of this process, because from an intersubjective psychological perspective, a person cannot autonomously regulate their own affective states; this regulation is always dependent upon another who attunes to you. Given the enormous difficult of parenting, it is not difficult to imagine the pervasiveness of organizing principles which predict malattunement.

In essence we have a descriptive process of the formation of pathogenic beliefs, as elucidated by Joseph Weiss, Harold Sampson and members of the San Francisco Psychotherapy Research Group (Weiss et al., 1986; Weiss, 1993; Sampson, 1992). A belief is termed pathogenic if it warns a person that pursuing highly adaptive and desirable goals (which are in each instance, person-specific) would be dangerous to oneself or destructive to others (Weiss, 1993, p. 3). Pathogenic beliefs are thus maladaptive, grim and fairly intransigent. We also have a closely analogous description of the formation of what Stolorow and Atwood (1992) have called "invariant organizing principles."

Once organizing principles or pathogenic beliefs are formed, they usually operate nonconsciously, although the person is usually testing these beliefs against reality and is exquisitely sensitive to the onset of experience which lends itself to being interpreted as an impending repetition of some original trauma. The efficiency and ubiquity of such a nonconscious assessment process makes intuitive sense and facilitates the mobilization of defensive activity directed against retraumatizaiton.

Retraumatization occurs, according to Stolorow and Atwood (1992) when: 1) a similar experience to an original trauma occurs or 2) when a sustaining bond is lost which had provided an alternative mode of organizing experience, and without which the old organizing principles are brought back to the fore.

In this context, abortion can be seen not as a primarily or somehow fundamentally (morally) traumatic experience but as a retraumatizing experience by virtue of the amount and intensity of earlier conflicts it can recapitulate around loss, affect attunement, threatened relational bonds (as in the resolution of the Oedipal complex), self-image, and the acceptability of complex affective states derived in relation to others. These earlier developmental challenges are once again stimulated in relation to the male partner's response to the woman, her pregnancy, the imagined loss of a child, the consideration and possible rejection of the father role, and numerous other relational dramas. The male's need to isolate his own affectivity in relation to earlier traumatic experience (see Chapter 4) while desiring connection with his partner, represents a complex network of (conscious and nonconscious) processes. It is thus difficult to pinpoint the specific impact of abortion on the male partner, in part because the effects may be subtle, may represent the stimulation of earlier pathogenic beliefs or may crystallize new ones that do not soon take shape in observable behavior post-abortion. One such result may be the stimulation of intense unconscious guilt, bolstered by earlier pathogenic beliefs, which warn the male partner against the pursuit of important normal developmental goals (Weiss, 1986). An inhibition of goals may be in relation to the female partner or any significant other (like the parents) for whom this inhibition may constitute a form of loyalty in the face of their perceived suffering. And unconscious guilt is a particularly powerful means for maintaining loyalty and attachment, and for restoring lost or threatened attachments (Weiss, 1986; Lewis, 1981; Baumeister et al., in press). For that matter, the withholding or walling off of affect can represent the resolution (albeit pathological) of a loyalty conflict between self and other. Modell, Weiss and Sampson (1983) put the point succinctly, and echo Stolorow and Atwood's (1992) emphasis on the traumatic nature of non-attunement:

In Control-Mastery theory, varieties of guilt responses, especially those derived socially/interpersonally are often the precipitate of such struggles to balance the needs and wishes of significant others and our own perceived and unperceived needs. When negative sequelae of abortion are cited for male partners, conscious guilt is most often cited. The present study will address these findings, but concentrate on the phenomenon of unconscious guilt, and its role in the creation and maintenance of pathogenic beliefs and related psychopathology (e.g., Weiss, 1986).

2

The Psychological Sequelae of Abortion

Although the OED offers no such tracing of the importation of the term into psychological literature, it is arguable picked up no doubt because of its existing usage in medical parlance and psychology's strong early link with neurobiology.

What is important for our purposes is that we come to the present understanding of psychological sequelae as, by definition, secondary to some existing state of affairs, in much the same way that Freud originally defined the sense of guilt as secondary to the formation of the super-ego and conscience.

The term "psychological sequelae" has its own socio-cultural history, one that will not be traced here. But it is crucial to note that this term, like most terminology which appears to have a kind of "natural" existence, functions differently in different domains, and at different times (Eagleton, 1984; Williams, 1976). In the ethico-legal domain, the definition of psychological sequelae has important legal implications, and is influenced by legal considerations which value empirical, observable, repeatable criteria in the construction of definition. For purposes of quantification, then, it is preferable to define "psychological sequelae" as the: a) post-event occurrence of b) a diagnosable (that is, reliable and valid) psychological disorder; c) usually presented to a treating health profession; d) within a specified period of time post-event and; e) as consistent in observable symptomatology (or as showing a consistent developmental course). While no definition is only suggested based on current standard usage, and no definition is static over time, the denotation of the term "psychological sequelae" has been relatively consistent since Freud. This has important implications for the study of the psychological sequelae of abortion. It is one of the central theses of this paper that the blindspots produced by our current understanding of "psychological sequelae" have resulted in the under- and mis-representation of the effects of abortion on both males and females.

These misunderstandings, which are beginning to be corrected by research and thinking in a wide variety of disciplines, can be understood as representing two, still dominant 19th-century views of the "self" and "emotion," namely: 1) that affect should be understood as an individual phenomenon, subjectively experienced by a "bounded self," (a non-interactive, non-intersubjective, entity localizable within the somatic boundaries of an "individual" person whose interests are inimical to society at large) (in contrast, see Jordan, 1991) and; 2) that disease is a linear process, with effect following cause.

One's view of the self ultimately determines that person's view of psychic health. Heinz Kohut's (1982, 1984) definition of psychic health was one in which the generative process was dependent upon the selfobject; he composed a structural view of the self and inscribed what could be considered a "bounded" view of self development. However, it is not necessary to understand the generative process he described in this way. When Kohut spoke of "an uninterrupted tension arc" from basic ambitions and skills, towards basic ideals, he was describing a selfobject relationship, not primarily an intersubjective one rooted in more fluid, "real experience" with others. The question of the role of object loss and generativity was thus bypassed (Modell, 1993, p.61). However, Joseph Weiss, Harold Sampson, Lynn O'Connor and their colleagues in the San Francisco Psychotherapy Research Group hold a different view of the self than that proposed by Kohut. This view shares more features with some of the social scientific views of the self proposed by George Herbert Mead (1982), Erving Goffman (1956), and Berger and Luckmann (1966). This view of the self is supported by the infant research of Daniel Stern (1985) and Robert Emde (1988a; 1988b; 1989), as well as evolutionary psychological views (Slavin & Kreigman, 1992; Buss, 1995) and contemporary views on intersubjectivity such as those proposed by Sylvan Tomkins (1962-63) and Robert Stolorow and his colleagues (Stolorow & Lachmann, 1980; Stolorow & Atwood, 1992; Atwood & Stolorow, 1993; Stolorow, Atwood & Brandchaft, 1994) and the Stone Center theorists like Judith Jordan (1991). These views eschew the structural concept of the self and posit a more descriptive, fluid and adaptable construct. The "self" of these researchers and clinicians is a progressively multi-layered, complex, constantly interactive self-in-relation in which "real experience" of social relations constructs, maintains and reconstructs other mutually-influencing selves-in-relation. These selves-in-relation are not motivated by either competing or cooperative interests, but by both, in a tapestry of "shared and divergent interests" (Slavin & Kreigman, 1992, p. 282). Slavin and Kreigman are worth quoting at length here, for their heuristic description of the relational self, oriented towards resolution of conflict inherent in a relational world:

"Self" and "individuality" are no longer co-terminous, and, as in Stern's (1985) view, the experience of the self is an experience of activity, oriented towards organization/re-organization of experience, and often subjectively experienced as mastery. One sees in Stern's concept of "representations of interactions that have been generalized" or RIGs, the way in which the self establishes, as it were, a continuity of being through action (p. 97). And this "self-seeking" behavior is supported by-in the language of computers-a kind of affective hardwiring; that is, an innate readiness to respond to internal/external affective signals.

In a related matter, since the presence of psychological sequelae generally requires a diagnosable "disease" or disorder (following the medical model of diagnosis), there is an underlying understanding of affect as cognitive or biological, not usually both. The failure to understand the inherently psychophysiological nature of affective response results in the mis- or non-diagnosis of unconscious affect and its effects. The psychophysiological effects of affect play a central role in the creation, maintenance and relief of psychopathology (Modell, 1965, 1971; Lewicki, 1986; Weiss et al., 1986; Lewicki, Hill & Czyzewska, 1992; Nathanson, 1992; O'Connor, 1995; O'Connor, Berry & Weiss, 1996).

Stern (1985) has shown us that from birth, and most probably prenatally, we are never responding solely in a reflexive manner, and that this fundamental orientation of the infant towards engagement fuels the "initiation, maintenance, termination and avoidance of social contact" not only with the mother but with all others, and is prototypical of all human relatedness.

In defining the meaning of mutuality or mutual intersubjectivity, Judith Jordan (1991) notes that most relational theories still view autonomy, separation and independence as "hallmarks of maturing...[where the] individual is separated out from context, studied as a self-contained being" (p. 81). However, in Jordan and her colleagues view-adopted from the work of Roy Schafer (1959)-mutual intersubjectivity, as a definition of the entire lifespan trajectory is characterized by:

In a view based on the above notions of mutuality, psychopathology can only be understood in intersubjective terms, as the disruption in the various capacities and effects of engagement. It is in this way that the question of the negative psychological sequelae of abortion must be approached: as disruptions of engagement.

It is in this way that the question of psychological sequelae of abortion must be approached, in terms of disruptions of engagement.

Psychological sequelae is generally understood to be a result, a secondary process. The view proposed here sees the sequelae of abortion as describing a pre-existing, potential, dynamic orientation of a self geared towards others, triggered by a secondary process, as in the case of guilt in interpersonal relationships where the guilt phenomena are understood as related to altruistic, adaptive human motivation. As noted above, standard definitions of psychological sequelae operate on a series of largely unquestioned assumptions. Definitions of psychopathology are generally based on criteria codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). Disorders are understood as the pathology of the individual, not as system-wide disruptions or disorders of an interpersonal field maintained or triggered by prior, current or anticipation of future action (Stolorow & Atwood, 1994). This makes it difficult to understand the sequelae of abortion in terms of attachment and engagement capacity in forms other than the depressive or schizoid-type disorders. However, the concept of pathogenic beliefs developed by Weiss and his colleagues (see Chapter 3) allows for the detection and understanding of pathological processes that do not take the form of diagnosable syndromes which immediately follow upon traumatic events, but that nonetheless impair a person's functioning in the world.

The current definition of psychological sequelae appears to thus have serious, inherent limitations. Just as medical illness masks and reconfigures a variety of physiological functions, psychological conditions pre- and post-trauma often mask and reconfigure types of overt behavior, affective responding, emotional cognition, and conscious and unconscious processing functions (Lewicki, 1986; Van der Kolk, 1991; Lewicki, Hill & Czyzewska, 1992, 1994; Chu, 1996). Research on the psychobiology of traumatic memory suggests that traumatic memory is different from ordinary memory, and that memory is dynamic, affected by "attention, encoding, consolidation and retrieval" (Chu, 1996).

Research in this decade has also begun to reveal complex unconscious processing functions (Kunst-Wilson & Zajonc, 1980; Lewicki, 1986; Lewicki et al., 1992, 1994) that are in fact faster and more efficient than their conscious counterparts. While the research on trauma response is growing, we do not yet fully understand the ways in which traumatic experience reconfigures memory, crystallizes new structures of belief or modifies vulnerable organizing principles-all of which may result in new scripts for interpersonal interaction (LeDoux, 1994).

According to LeDoux (1994), the brain is able to "shape itself" through the creation of new neural pathways in response to traumatic events. The creation of what LeDoux calls "emotional memory" is thus a correlate of how Weiss describes the development of pathogenic beliefs. Emotional learning and memory is thought to operate outside of conscious awareness, and can cause the individual to become depressed or anxious, as the system is reactivated. LeDoux's research indicates that both emotional and declarative memories (viz., the memory of "bare facts") are mediated by different psychophysiological systems. The declarative systems keeps a record, so to speak, of the bare content of an experience, whereas the emotional memory system stores physiologic correlates. When a memory of an earlier traumatic even is retrieved, the declarative and emotional memories are interwoven in conscious experience. This is perhaps what Nathanson (1992) means when he describes emotion as the combination of affect (the physiologic correlate) and memory (associations to previous triggering of affect). It is not that we have access to the emotional memory, in LeDoux's terminology, but that we know the consequences of that memory: we know what we are now doing and the way our bodies feel. The result of this combining of emotional and declarative memory forms a new subjective experience which in turn influences other declarative memory and cognitive processes.

LeDoux's psychophysiological theory is consonant with Weiss's (1993) explanation of the creation, maintenance and relative tenacity of unconscious pathogenic beliefs formed in childhood. It also supports Nathanson's (1992) theory on the formation of emotion and response scripts.

These new adaptations or scripts may in time prove pathological, but may also be syntonic with an individual's current environment. For example, one need only think of the ways in which an individual's over-compliant behavior inside a rigidly hierarchical, dominating family system fulfills a stabilizing function as long as that individual remains entrenched in the system that requires his compliance. When that individual's environment begins to pull for independent thought, quick decision-making, tolerance for minimal feedback and greater self-differentiation, adherence to previously scripted behaviors and beliefs can produce social mis-attunement, failure in interpersonally-oriented tasks, and attendant psychological discomfort, all of which may or may not come to the attention of a mental health professional.

The notion of psychological sequelae also contains within it the idea of a consistent presentation of effects over time, or of an identifiable (and observable) developmental course. In a Control-Mastery view of pathogenic processes, there is the notion that pathogenic beliefs are not always easily picked up by standard psychodiagnostic measures, can develop at any time as a response to trauma, can crystallize pathogenic processes rather than create them or can mesh with past and future cognitive/affect processes of understanding or meaning-making (Weiss et al., 1986; Weiss, 1993). This last point speaks to the issue of linear causality in abortion research.

The type of pathogenic process stimulated by the trauma of abortion is not the kind investigated by research. In most research, there is an attempt to show that abortion is a causal factor in the creation of depressive illness. Research then becomes a matter of isolating variables and showing significant correlation (which is still not causation). The current volume argues that abortion predisposes one to psychopathological reactions because it is a disruption of engagement (with one's partner, with one's sense of self as a self-in-relation, with the potential child, with the potential role, with one's relation to pregnancy, fatherhood, etc.), and anything that disrupts engagement triggers the system to respond. It is not that disengagement is necessarily pathological but on a continuum, and if the view of the self is one of fundamentally oriented towards engagement, then important disruptions in that function could be seen as predictive of pathological processes (e.g., Baumeister & Leary, 1995).

These authors observations, while seemingly commonplace, are nonetheless ignored in the design, research and publication of many abortion studies. It still remains all too easy to cite just those studies which support your particular position or hypothesis about abortion sequelae and many studies share important flaws in research methodology. Rogers, Stoms & Phifer's (1989) extremely thorough review of the literature on postabortion sequelae puts the point well:

Most of the studies summarized by Rogers et al. defined positive postabortion experiences as the absence of negative effects. This, of course, rules out the possibility of repressed or suppressed painful affect. However, of the studies they considered, about 32 percent showed negative postabortion outcomes, mostly depression, moderate to severe guilt and anxiety (pp. 364-367). Outcome data was sometimes spotty or missing due to attrition or unwillingness to respond; there was an attrition rate of 25 percent or higher in about 34 percent of the studies reviewed by Rogers et al. (Ibid.).

In still other studies, ideological dimensions in research design and methodology often went largely unexplored and these methodological choices influenced the validity and generalizability of results (e.g., Zimmerman, 1981).

Until very recently there have been few solid longitudinal studies on the psychological sequelae of abortion, and prospective and retrospective within-subject comparisons are lacking. Posavac & Miller (1989) bemoan the lack of meta-analysis in the published studies, also raising questions about the validity and generalizability of the reported results. And most important for our purposes, there is still almost no research attention paid to the "male partner's reactions to the abortion experience, or to the impact of the male partner's conceptualizations of this experience on women's adjustment" (Major & Cozzarelli, 1992, p. 133).

Despite calls spanning 25 years for a thorough review of methodological problems in abortion research (e.g., Newman, 1973; Posavac & Miller, 1990), few studies of the psychological sequelae of abortion rely on a theoretical framework for understanding and investigating the effects of abortion, use adequate (or any) control groups to fit the objectives of the study, or account for the validity problems of using survey interviews as the main data source in the study.

Research based on questionnaire administration raises the issue of whether the mixed reactions reportedly common among post-abortion patients can be adequately picked up using this method (Lieberman & Zimmer, 1979; Neustatter, 1986; Rogers et al., 1989). Kent, Greenwood, Nicholls & Loeken (1978) argued that women who enter psychotherapy at any time post-abortion often exhibit feelings of pain and bereavement coupled with feelings of love for the potential child. The authors reason that these feelings are often unperceived and unrecorded in post-abortion questionnaire research due to repression or "numbness" following the abortion.

When Rogers et al. Reviewed over 280 articles that dealt specifically with psychological sequelae of abortion, they excluded 204 from their review study because the article did not report original empirical data. Of the remaining 76 articles which represented empirical outcome research done between 1966 and 1988, most were studies that utilized questionnaires to determine postabortion sequelae and thus mainly relied on self-report mechanisms for determining the presence of psychopathological states or processes.

More importantly, very few studies have adequately addressed the study of the long-term sequelae of abortion. Zolese and Blacker's (1992) through review of abortion studies to date cited only two studies that contained follow-up data for more than 2 years, and only one study (Adler, David, Major, Roth, Russo & Wyatt, 1990) looked at responses 24 months after the abortion. Needless to say, none of these studies directly address the long-term sequelae of abortion for men.

Clare and Tyrrell's (1994) recent review study of the psychiatric aspects of abortion echoes the view that abortion causes at most only mild and transient negative sequelae in women. They also note the large number of studies that show that when there is a previous psychiatric history of depression, the risk of post-abortion sequelae (like depression) is significantly greater than in women who have no known psychiatric history. In one study cited by the authors, moderate to severe guilt feelings were reported in 37 percent of the women, but this dropped to 7 percent by two years. While Clare & Tyrrell's review of abortion research echoed earlier studies, it did raise some important issues in relation to the debate over abortion research methodologies.

In several studies cited by the authors, negative sequelae were determined by psychiatric hospital admissions and/or treatment with psychiatric medications (Clark & Tyrrell, pp. 93-94). In the model proposed here for considering psychological sequelae (see Chapter 3), hospital admission and/or pharmacological treatment are insufficient criteria for determining negative sequelae proposed here. And Clark and Tyrrell note that most studies they reviewed "[could] only assess the post-abortion mental states of those women prepared to comply with the demands of research. Many women, on having their termination, are lost to follow-up" (p. 93). They are also keen to point out the fact that a primary pre- and post-abortion coping mechanism for women (and arguably for men) is through a process of denial.

Zolese and Blacker (1992) rightly point out that denial "can be an adaptive as well as a maladaptive response but either way follow-up interviews can threaten the stability of this psychological adjustment and thus prove unwelcome" (p. 748). And while we do not know how many women and men seek treatment for seemingly unrelated syndromes many years after the abortion, some research has suggested that only later developmental challenges (like pregnancy) will restimulate suppressed or repressed feelings from a prior abortion (Kumar & Robson, 1984). Kumar and Robson (1984) have also detailed the increased susceptibility to psychiatric and medical illness during pregnancy, perhaps as part of the normal strains of such a developmental milestone. We should therefore bear in mind that the male response to abortion is also a response to his partner's pregnancy and attendant increased psychiatric and physical health risks (e.g., Wilmoth, de Alteriis & Bussell, 1992). This will have important implications in our discussion of male partner guilt and omnipotent responsibility. (See Chapter 3.)

Finally, Peppers (1987-88) proposes the "bonding hypothesis" in discussing reasons why abortions affect or appear to affect women but does not show up as a significant effect in the literature. He argues that early bonding and anticipatory grief can result in the absence of noted sequelae if there is a sufficiently long time period between pretest and posttest measurements. Lindemann (1979) described "anticipatory grief" as a variant on normal separation reactions, in which the person is so concerned with their adjustment after the upcoming or potential object loss (and this could refer to the imagined loss of the child, loss of the parental role, loss of relationship to the partner, etc.), that they disengage with the surround prior to the loss, warding off feelings and thoughts that might connect him to the impending loss.

Once again, in viewing psychological sequelae in purely linear terms, one is confounded by grief reactions in which there appears to be no change in the male's attitude pre- and post-abortion, but where both pre- and post-abortion attitudes and emotions may already reflect the kind of anticipatory grief reaction of which Lindemann spoke.

It is, of course, not general research practice to interview someone prior to their having taken on the criteria for inclusion in study (Zabin, Hirsch & Emerson, 1989). Studies of the psychological sequelae of abortion would not normally include interviews or assessment with a male who hadn't yet learned his partner was going to have an abortion. There is little change to determine his attitudes and feelings about the "impending event" since he can only imagine his response and abstract from that; he cannot give us his actual response to the event with his partner. As we might imagine, interviewing someone about their partner attitudes after the abortion experience has ensued (whether pre-procedure or not), may produce a different result than if that same man had been tracked and interviewed/tested: 1) prior to hearing the news of the pregnancy; 2) after hearing the news (but pre-decision for abortion); 3) after learning of the pregnancy and having made a decision, but prior to the actual procedure or; 4) during and after the procedure (including short- and long-term follow-up of not days or weeks, but months and many years postabortion).

Since the 1960s several important (national and international) review studies have investigated the impact of abortion on women (Simon & Senturia, 1966; Osofsky, Osofsky & Rajan, 1973; Shusterman, 1976; David, 1978; Kent, Greenwood, Nicholls & Loeken, 1978; Olson, 1980; Lemkau, 1988; Winter, 1988; Rogers, Stoms & Phifer, 1989; Ney & Wickett, 1989; Adler, David, Major, Roth, Russo & Wyatt, 1992; Posavac & Miller, 1990; Dagg, 1991; Wilmoth, de Alteriis & Bussell, 1992; Zolese & Blacker, 1992; Clare & Tyrrell, 1994), and these remain the most viable starting points for our purposes. However, it is important to bear in mind that the remaining sections of this work will argue that while men and women may have similar ways of responding, affectively and unconsciously to the abortion experience, they may have very different, gender-related ways of responding to their own responses. (See Chapter 4 of the present volume.)

It must be noted that the overwhelming majority of individual and review papers provide no satisfactory evidence for significant short- or long-term negative psychological sequelae of abortion in women (e.g., Ford, Castelnuovo-Tedesco & Long, 1971; David & Friedman, 1973; David, 1974; Adler, 1975; Cvejic, Lipper, Kinch & Benjamin, 1977; Illsley & Hall, 1978; David, 1978; Greenglass, 1981, Handy, 1982; Adler & Dolcini, 1986; United States Congress. 1989a; Dagg, 1991; Adler et al., 1992) and echo, to a degree, the findings of Osofsky, Osofsky & Rajan (1973) when they wrote:

This chapter does not provide an in-depth review and critique of the studies cited above, since this kind of analysis is readily available, for example, in meta-analytic studies of abortion research (e.g., Rogers et al., 1989). However, the general trend appears to be that when negative sequelae are reported for women, guilt and depression (secondary to guilt) are most often cited as consequences of abortion (e.g., Zimmerman, 1981; Ney & Wickett, 1989; Cavenar, Maltbie & Sullivan, 1978).

It must be borne in mind, however, that Rogers et al. Report most empirical researches of postabortion sequelae contain numerous methodological limitations which in turn limit the generalizability of their findings. Their important articles offers a series of cautions and suggestions for further research and readers are encouraged to consult their study.

The present work's understanding of guilt as an interpersonally-driven emotion, related to concern for others, leads to a focus on those researches which either minimize or amplify guilt responses as part of the abortion experience. The researches glossed here show (in order of predominance: 1) studies indicated no serious negative sequelae (majority); 2) studies reporting long-term sequelae, including guilt and depression (minority) and; 3) studies which argue for the serious, long-term negative sequelae of abortion, like those that posit the existence of a "postabortion syndrome" (PAS), as a sub-type of posttraumatic stress disorder (least prevalent).

Osofsky, Osofsky & Rajan (1973) were among the first to conduct large-scale studies of the psychological effects of abortion, and as noted above, represent a large proportion of studies since then which demonstrated no significant negative psychological sequelae of abortion for women. Their study combined a retrospective review of abortion research (including data from private psychiatrists and other mental health practitioners and a large study from the New York State University Hospital in Syracuse, as well as an evaluation of the author's current work at the Temple University Health Sciences Center in Philadelphia).

During the Osofsky's association with the State University Hospital in Syracuse, 742 patients seen at the Obstetrics and Gynecology clinic (for general education, contraception and/or abortion services) participated in one or more parts of their study of abortion adjustment. Of the 580 cases evaluated psychologically through the use of interviews, most (70 percent) reported feeling either moderately or very happy, experiencing "much to moderate smiling" (76 percent), feeling positive relief as regards the abortion (56 percent) and overall "feeling happy about themselves" (63 percent). Eighty-give percent of those interviewed reported feeling no guilt and 56 percent of the patients report that their abortion decision was not a difficult one (Osofsky et al., pp. 195-196). Interestingly, 44 percent reported having moderate to considerable difficulty in making a decision to obtain an abortion, with most decisions centering around issues of finances and marital status, where being married positively influenced the decision towards having an abortion). Overall, if the patient was "older, married and better educated" they experienced less emotional difficulty with the procedure.

The authors also cite Kummer's (1963) survey of 32 Los Angeles psychiatrists who overwhelmingly (75 percent) reported that in an average of 12 years of clinical practice, "they had never seen a patient with any moderate or severe psychiatric sequelae from either illegal or therapeutic abortions" (as quoted in Osofsky et al., p. 189).

Follow-up interviews in the New York State University Hospital study were conducted, when possible, at 1 and 6 months postoperatively, and of those interviewed via telephone, 78 percent told the interviewer that they had resumed their normal activity level within 2 days postabortion. However, almost 60 percent of the total sample was not interviewed after the abortion due to various forms of patient unavailability; the authors do not quantify reasons for unavailability except to say the reasons included lack of accurate telephone contact information or a desire for anonymity.

While a 60 percent drop-out rate is not uncommon in psychological studies, the larger social context of the study must be considered in assessing the generalizability of findings. It must also be noted that these studies were conducted just after the legalization of abortion in July, 1970 and the sudden sanctioning of what had been (and continued to be) a highly controversial procedure could certainly increase the likelihood that negative responses would be denied or withheld from the interviewers. (See Chapter 3 on role guilt.)

Payne, Anderson, Kravitz & Notman (1973) (in their study of methodological issues in abortion research) looked at the change in affect level in women undergoing abortion. They administered questionnaires prior to the abortion, and at 24-hours, 6 weeks and 6 months postoperatively. Of the five affects they studied (anxiety, depression, guilt, shame and anger), they found levels of anxiety, depression, guilt and anger all decreased over time; levels of shame also generally decreased postabortion, but increased among a subgroup of women who had negative relationships with their mothers. These women did not demonstrate the "sense of release from the intense emotional distress experienced in the preabortion period" but instead showed significant increases in shame. Patterns of self-blame may have been activated in these women who inferred or were explicitly made to feel shameful for their decision to have an abortion.

Greer, Lal, Lewis, Belsey & Beard (1976) tracked 360 women who underwent abortion. Using structured interviews conducted at a mean of 18 months post-abortion, they found that adverse psychiatric and social sequelae were rare, and that in those who showed psychiatric symptoms (like guilt feelings) in marital and other interpersonal relationships prior to the abortion, there had been a significant improvement upon follow-up. However, Rogers et al. (1989) cites Greer et al. as a particularly noxious study for its:

Greenglass (1977) studied women who had abortions and asked about their childbearing attitudes. Those who wanted children in the future exhibited more neurotic symptoms post-abortion than those who did not plan on having children, suggesting, as in other studies, that pathogenesis is related to a fear of or perception of harming others.

David (1978) conducted a major international research review study which emphasized the social control aspects of guilt responses in women seeking and having abortions. He examined transnational trends in abortion research and argued that guilt was utilized as an effective social control mechanism in most societies. He considered it "superfluous to ask whether patients experience guilt-it is axiomatic that they will." Thus one acts in the world and guilt is physio-psychological means by which social values are reproduced: guilt is the policing-function emotion. We are taught to feel guilty when we do something that is not socially sanctioned (by caregivers, through existing values concretized in a variety of socio-cultural forms such as codified and non-codified law, art (and all forms of popular art like film and television), literature and the like.

How have the guilt phenomena been typically understood to interact with the abortion experience?

As noted above, David (1978) seems to understand only one aspect of conscious guilt, that is, its social-control function, and appears to repeat the then-current understanding of abortion as a violation of the nature of woman as childbearer.

Included in the studies edited and compiled by David, Friedman, van der Tak & Sevilla (1978), Illsley & Hall (1978) look at selected psychosocial issues in abortion research. Their review showed guilt and depression as significant negative psychological sequelae to abortion in women if the pregnancy was ended because fetal malformation was suspected. (See also Kolker & Burke, 1993.) The authors recommend that research focus on providing more emotional support to this small minority.

Overall, they reported a discrepancy in reports of psychiatric sequelae of abortion in women citing early studies (Bolter, 1962) showing guilt feelings in each case of abortion to early 1970s studies (Osofsky et al., 1973; David & Friedman, 1973; Ewing & Rouse, 1973; Monsour & Stewart, 1973; Adler, 1975) which described "relief" as the predominant sequel to abortion. Illsley and Hall account for this discrepancy in opinions by arguing that studies like Bolter (1962) which demonstrated significant postabortion guilt feelings failed to account for: a) guilt caused by pre-abortion psychiatric functioning; b) the stigma of "illegitimate" pregnancy; c) relationship conflicts due to the abortion; d) the physical trauma of surgery; e) possible aftereffects of sterilization (sometimes combined with abortion in the 1960s and 1970s); f) conflict with hospital personnel and other ward patients relative to the abortion (see also Lasker et al., 1994); g) trauma related to the administrative difficulties of abortion and; h) ignorance about the physical sequelae of the procedure. However, Illsley and Hall's implicit suggestion that one can separate out these important relational experiences from some kind of "pure" abortion experience seems misguided. The experience of abortion, for the woman, includes all of the above elements.

Again, in the same volume (David et al., 1978)-in a study of abortion-seeking in Switzerland-Kellerhals, Pasini & Wirth (1978) found that a strong relationship existed between guilt feelings and women's perceptions of the fetus, which they categorized as showing either "fundamentalist," "relational" or "positivist." views. The fundamentalist view holds that the fetus becomes a person-to-be from conception whose life must be protected. The relational viewpoint asserts that the threshold of personhood is reached at the moment when the biological parents recognize the fetus as a human being, and give identity to the fetus as an individual human being. The positivist view states that the fetus becomes a human being based on its embryogenetic stage, for example, "at three months," or "when it has a brain." In the study, 20 percent held a fundamentalist view, 43 percent a relational view and 25 percent held a positivist view, with the remaining 12 percent as "unclassifiable."

The authors showed that 93 percent of those holding a fundamentalist outlook felt a sense of guilt about their abortion decision, which continued post-abortion, while only about 60 percent felt guilt who held the relational or positivist views. The salient factor here seems to be whether or not the fetus is determined to be an autonomous entity. The predominant viewpoint however was the relational perception of the child as determining its viability: if the fetus was seen as an identity dependent upon the mother-child relationship, it was more likely to be viewed as a person, and thus, more likely to generate a sense of guilt at decision to terminate the pregnancy.

Among single women, the study showed that the "nature of the relationship with the partner correlates with the sense of guilt towards abortion." The authors propose that this is based on the symbolic meaning of the child as a bond between them, and as the abortion decision as representing a rupture in that bond. "Negative moral judgment of abortion occurs among 81 percent of the women with steady relationships with their respective partners," but drops to 61 percent among those who became pregnant in "occasional" relationships.

If the women is married, her sense of guilt is stronger if she already has children, while only 57 percent expressed negative judgments about abortion. When the number of children in the family increases, one sees what the authors term "an unexpected result:" the more children in the family, the more guilt about the abortion. The authors conclude that "the presence of children, which does not influence the perception of the fetus, makes the women more sensitive towards the possible moral aspects of abortion."

However, it must be noted that this early study confounds "negative moral judgment of abortion" with the "sense of guilt" and does not adequately explain what is meant by either. The interviews in this study were conducted after awareness of the pregnancy and first visit to a physician, but before the visit with an advisor to discuss abortion and the authorization for abortion that was then required in Switzerland (even though abortion availability was considered very liberal there in 1970-71.

In the year following the publication of David et al.'s (1978) volume on abortion in psychosocial perspective, Liebman & Zimmer (1979) studied calls to a free, 24-hour telephone hotline for people who had problems or questions following abortion, miscarriage or adoption placement. Of the women who called about abortion-related questions or concerns, the majority were calling to express significant feelings of conscious guilt, anxiety and depression (with "guilt" being the most common emotional reaction). Interestingly enough, most of the calls came from women who had experienced an abortion over 10 months previous to the call, with several callers reporting having had an abortion up to 25 years prior.

The authors also reported receiving calls from significant others relative to the abortion. When boyfriends called, they tended to call and identify guilt feelings towards their partner for having to undergo what they perceived as the loss and trauma of abortion. As might be predicted by the theory adopted here (see Chapter 3), all callers (boyfriends, friends, parents or siblings) reported feeling excessive "concern" or guilt as the main reason for their call to the hotline, with some reporting that the abortion had stimulated feelings of guilt about other incidences involving their inability or failure to save someone or alleviate their suffering.

Abortion research continued apace into the 1980s, and studies began to grow increasingly sophisticated, focusing more on the kinds of factors outlined by Illsley & Hall (1987) as confounding the question of negative sequelae. Lemkau (1988) for example, examined pre-abortion psychiatric status, socio-cultural support around the abortion, characteristics of the medical environment and abortion procedure and postabortion events and their relation to postabortion conflict. She also began to address implications for psychotherapy for women having experienced abortion. Her literature review suggested that ambivalence is often present pre- and post-abortion (e.g., Allanson & Astbury, 1995), and that an exploration of the abortion decision and aftermath may be a crucial focus for the psychotherapy.

Zolese & Blacker's (1992) review of other abortion studies found negative sequelae (mostly depression and anxiety) on average in approximately 10 percent of the women studied. Factors determined to increase risk of negative sequelae included past psychiatric history, younger age, poor social support and belonging to sociocultural groups antagonistic to abortion.

The authors cite a study (Mueller & Major, 1989) which showed pessimistic attributional styles as casually linked to negative postabortion adjustment. Those women who engaged in higher amounts of self-blame were significantly less well adjusted shortly after the abortion. This was especially true of those whose self-blaming attributional style appeared characterological. In addition, those who were other-blaming expected their postabortion adjustment to be worse than those who blamed themselves. In that study, the authors predicted that women who received counseling designed to lessen characterological blame (or what might be seen as "self-hate guilt"; see Chapter 3) prior to the abortion showed significantly better postabortion adjustment. Since men have been shown to be higher than women in characterological self-blame as regards the pregnancy, this finding may be another important argument for the provision of counseling services to men prior to the abortion.

In a presentation to the 143rd Annual Meeting of the American Psychiatric Association, Dagg (1991) reviewed the available literature on the psychological sequelae of abortion in women and reported that of the 225 original research papers consulted, most reported that adverse sequelae in women were rare, and usually the result of the existence of pre-procedure pathology. As with many other studies, Dagg's review of the literature noted that adverse sequelae result much more frequently in the cases of denied abortion, with intrapsychic and interpersonal complications occurring in parents and children of the denied abortions.

Major and Cozzarelli's (1991) much quoted review article adopts a kind of "risk and resiliency" model for understanding adjustment to abortion and looks at psychosocial factors as predictors of abortion sequelae. Among the factors they identified as predictive of post-abortion adjustment were: 1) personal conflict; 2) attributions for the pregnancy; 3) coping expectancies and styles; 4) perceived social support, especially from the male partner; 5) social conflict; 6) pre-pregnancy psychologically functioning and; 7) post-abortion events. For purposes of the current paper, I want to focus specifically on male partner responses and self-attributions surrounding the pregnancy and its termination.

In assessing whether women's postabortion adjust was better if they were accompanied by their male partner, Major and Cozzarelli reviewed an earlier study (Major et al., 1985). They reported tracking 247 women, 34 percent of which were accompanied by their male partner. These women were significantly more depressed and showed more physical complaints than their unaccompanied counterparts. The authors attribute this surprising finding to the fact that perhaps these women were accompanied by their partners because they were showing higher pre-procedure distress levels, and thus warranted or needed accompaniment. According to Control-Mastery theory, it is more likely that these women in fact felt safer to experience depressive affect and have greater awareness of their somatic complaints and distress because of the presence of a close, supportive partner.

Weiss and Sampson's (Weiss et al., 1986; Sampson, 1989; Weiss, 1993) studies of the psychotherapeutic process indicate that patients experience painful affect and bring forth deeper material only when they (consciously or nonconsciously) judge it safe to do so. If the woman was excessively worried about her male partner's response to demonstrated distress, it is more likely that she would have masked or hidden that distress.

Evidence for this masking pattern of response was found in Major's (Major & Cozzarelli, p. 134) follow-up study when she found that depression among women was associated with low coping expectancies in their male partners. Specifically, women who expected to cope poorly after the abortion were found to be more depressed if their partner also thought they would cope poorly. When the woman expected to cope well, her partner's low coping expectation had only a minimal effect. These findings support the view in Control-Mastery theory that people who are higher in proneness towards negative self-assessment (O'Connor, 1995), tendency to make negative causal attributions about difficult life events (Menaker, 1995; O'Connor, Berry & Weiss, 1996), and submission (O'Connor et al., 1996) are also higher in survivor guilt (O'Connor, 1995) and would tend to match their responses to someone close to them that they perceive is suffering. These individuals also tend to suffer from both conscious and unconscious pathogenic beliefs-often presented in the form of negative self-attribution)-which leads to exaggerated fears of harming others (O'Connor, Berry & Weiss, 1996; O'Connor et al., 1996). This is discussed further in Chapter 3 in considering the role of survivor guilt in the maintenance of depression; it is also considered in Chapter 4 which addresses the role of altruism in empathic attunement and affective expressivity.

In a more recent review, Miller (1996) argues for the underrepresentation of concerns related to abortion for women, and asserts that women's concerns are often invisible to medical health professionals and medical research. In exploring the psychological effects of growing, limited access to abortion services within a tense political climate, as well as the introduction of RU-486, an alternative to surgical abortion, she rightly points out important links between socio-legal processes around abortion and changing women's views about the process. As noted throughout this work, men's responses to the changing socio-legal climate continue to go largely unexplored in considerations of abortion sequelae.

Finally, Butler (1996) confirms the predominant view that pregnancy termination is not usually associated with negative sequelae, but seems to echo other results which indicate that for the small groups of women who experience negative sequelae the consequences are often profound and long-lasting. These consequences include depression and guilt associated with self-destructive or self-reproachful negative attributions which the woman may or may connect to the abortion experience.

Several studies either raise the question of a distinct postabortion syndrome (Stotland, 1991; Minden & Notman, 1991), specifically argue for its existence (Ney, 1989; Speckhard & Rue, 1992, 1993; Rue, 1994; Doherty, 1995) or assume its existence and offer treatment models (Bagarozzi, 1994). Ann Speckhard and Vincent Rue are two of the most vocal proponents of significant adverse psychological sequelae of abortion, arguing for the creation of a new clinical diagnostic category called postabortion syndrome (PAS), as a specific type of posttraumatic stress disorder (PTSD). (See National Center for Post-Traumatic Stress Disorder, 1990.) They argue that male partners (as well as children, extended family members and health care providers) can and do exhibit PAS, where the trauma of abortion is repressed, patients show impacted or significantly delayed grief and complicated mourning ensues.

In related research, Ney and his colleagues (Ney, 1993; Ney & Wickett, 1989), vehement advocates for the existence of a postabortion syndrome, utilize case studies from clinical practice to outline eight types of occurrences of the syndrome, focusing on the issue of survivor guilt. They note that postabortion syndrome occurs in children and adults with accompanying sense of "existential guilt, a sense of worthlessness, and a feeling of impending disaster." Ney notes that children especially feel guilty because they are "wanted" as opposed to a potential sibling. Its interesting to note that among the eight subtypes of postabortion syndrome, Ney (unlike Speckhard and Rue) does not refer to male partners of women who undergo abortion.

Wasielewski (1992) attempts to bridge the chasm between those psychologists like Speckhard & Rue (1992) who argue for the existence of postabortion syndrome, and those whose studies (e.g., Koop, 1989) show little or no evidence to support the inclusion of PAS as a clinical diagnosis. She argues that women's experiences of abortion are primarily one of mixed emotions, and that women demonstrate those emotions deemed acceptable by close others, and the wider ideological context in which the abortion occurs. She notes that the emotional reaction to abortion is thus one already circumscribed by relational and cultural contexts, and effects both those affects which are brought to awareness (viz., experienced as emotion), and those emotions which are displayed.

Wasielewski also notes that women do not often describe negative affective experiences involving shame or guilt until they begin to talk about securing a service provider and negotiating the abortion (p. 111). Thus, Wasielewiski reminds us that responses to abortion exceed responses to the procedure: it is about both ideological and interactional level acceptance of abortion. For men, no less than for women, the abortion experience involves responses to others about how one is treated (as someone considering/having/having gone through an abortion) and how one perceives significant others and the larger community's attitudes about abortion (to what degree is the decision and experience seen as a "deviation" from social expectations?). And existing theories of the emotional sequelae of abortion, from a sociological perspective, do not adequately explain responses to abortion because they fail to account for the view that abortion engenders competing social definitions of the act of abortion and thus produce mixed emotions (e.g., Scott, 1989).

As noted above, while many studies cite relief as the primary emotional sequelae of abortion, a significant number cite the presence of mixed emotional responses, many of which are understood to resolve relatively quickly (e.g., Francke, 1978; Neustatter, 1986; Allanson & Astbury, 1995). Wasielewski posits that women do not feel either relief or guilt but relief and guilt. She goes on to consider existing theories of how mixed emotions are resolved and cites what Wiegert (1991) argues is a rare alternative: the strategy of resolving complex emotional dissonance by stoically facing ambivalence and still acting. However, Wesielewski takes issue with Wiegert to contend that this is in fact what she believes many women do, that is, overcome ambivalence by a kind of compliance through ideological acceptance. On the one hand, the woman can show the "appropriate" emotions for the social situation of abortion, but it is not clear just what is appropriate or to which social situation one is responding. Thus, she argues, women are held in "emotional limbo" by the continuing debate of issues in the public sphere. For men, the situation is much clearer because there is not the same premium placed on the display of any emotion, and stoic acceptance in the face of ambivalence (in any psychologically stressful situation) is the culturally reinforced method for the resolution of painful experience.

Indeed, Smith's (1975) study seems to support the view that for men, too, the effect of abortion is often mixed, arguing for "longitudinal studies which accurately assess the changes foreshadowed" (Smith, p. 162). But in the same study, Smith found that 66 percent of the men in his sample felt that the "abortion put no special strain on the relationship." And in Finley's (1978) study, 78 percent of those who took part in the study felt that the abortion would "either make difference in their relationship, or would bring them closer together" (Finley, p. 3). How is one to make sense of the apparent findings that men report no significant self- or relationship-effects of the abortion, yet when privately asked about behavioral changes or assessed for pre- and post-abortion anxiety levels, are found to indeed be experiencing significant effects?

Wasielewski's work forces us to consider the hypothesis that men are not held in the same emotional limbo around abortion because there are a fewer variety of processes used for emotional management available to men. If a male consciously experiences strong relief and guilt (a mixed emotional reaction) there is perhaps a greater chance, based on gender, that he will display imperturbability, rather than distress. Allanson & Astbury (1995) rightly point out that abortion studies seldom operationally define the concept of "ambivalence." Most studies use the term "conflict" rather than "ambivalence," and the authors argue that the researchers' choice of method "does not allow women to indicate both happy and unhappy, or both glad and sad about being pregnant or about the ultimate choice" (p. 124).

And we are once again challenged with the notion that by and large, men may unconsciously understand the need for certain role-based responses to abortion which include constellations of behavioral/affective response scripts around what gets felt (what emotion is acceptable to self and what gets warded off) and what of these emotions gets displayed and/or is allowed to inform behavioral expressions (what emotion is acceptable to others given relational concerns and how these can be acted upon). (See Chapter Four of the present paper.)

Because it is beyond the scope of the present work, I will not fully deal with the relationship between loss issues relating miscarriage, infertility and abortion. However, it is important to consider that there may be lessons to learn from linking a thorough review of the literature on the psychological sequelae of miscarriage and infertility, with a study of male responses to abortion. Studies detailing male partner or couple responses to miscarriage and infertility are more readily available, more often show gender-based differences in grieving (e.g., Hunfeld, Wladimiroff & Passchier, 1994; Hunfeld, Mourik, Passchier & Tibboel, 1996), and could be productively considered alongside male responses to abortion.

For example, Frost & Condon (1996) reviewed 123 articles published between 1917 and 1993 on the psychological sequelae of miscarriage. High levels of guilt were found not only in the mother but in partners, other family members and surviving children. In addition, adverse sequelae were found in a significant number including depression, anxiety and posttraumatic stress disorder (PTSD). Conway's (1995) pilot study in Australia also showed the presence of protracted bereavement processes following miscarriage and noted that adjustment post-miscarriage was related to the degree of community and health professional support received following the miscarriage. The long-term negative psychological sequelae of miscarriage were also noted in Slade (1994) and Garel, Blondel, Lelong, Bonenfant et al. (1994) who specifically focused on the increase in depressive disorders following the terminated pregnancy. These studies indicate that expression of conscious survivor guilt and presence of depressive symptomatology is more apparent in women and men who experience spontaneous abortion, where it seems psychologically safer to bring the issue of responsibility into consciousness.

Contrary to expectations, men and women experience the same levels of emotional strain around infertility, despite expectations that it is more traumatic for women. As with abortion, men and women experience infertility difficulties differently, related to sex-role identification, not gender. Masculinity is associated with decreased emotional strain and greater marital adjustment than is femininity, where femininity includes personality traits more associated with relational factors (Berg, Wilson & Weingartner, 1991).

A comparison of the literature on the sequelae of infertility, miscarriage and abortion might reveal homologously structured issues of bereavement and grief responses. It would be fruitful to compare cases where grieving is more socially sanctioned and recognized (as in the case of miscarriage and infertility) versus the case of induced abortion where there are strong social and intrapsychic barriers to grief (especially for male partners). (See Chapter 4 of the present work.)

3

Guilt, Psychopathology and Abortion