309.89 Post-traumatic Stress Disorder

The stressor producing this syndrome would be markedly stressing to almost anyone, and is usually experienced with intense fear, terror and helplessness. The characteristic symptoms involve reexperiencing the traumatic event, avoidance of stimuli associated with the event or numbing of general responsiveness, and increased arousal. (APA, Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, 1987)¹

Post-Abortion Syndrome (PAS), by definition then, is a type of Post-Traumatic Stress Disorder that is characterized by the chronic or delayed symptoms resulting from impacted emotional reaction to the perceived physical and emotional trauma of abortion. (RUE, 1994)²

[Moral Injury] is the deleterious psychological and spiritual outcomes that occur after engaging in an action that goes against, or transgresses, moral beliefs and values. (Carleton and Snodgrass, 2022)³

Halfway through his second term in office, President Ronald Reagan set out a plan to help protect the unborn at a White House Briefing for Right to Life Activists. “Growing numbers of women who’ve had abortions now say that they have been misled by inaccurate information,” he said before instructing the Surgeon General to issue a report on the emotional and physical health effects of abortion.⁴ Of course, such a report would enhance a woman’s right to choose by ensuring her consent was truly informed. Yet those on all sides of the abortion issue suspected that a report of negative health effects would erode the standing of Roe v. Wade. Reagan’s explicit mention of the “emotional” effects of abortion meant that the report could also settle the decades-long dispute in psychiatric circles over whether a “Post Abortion Syndrome” (PAS) similar to Post Traumatic Stress Disorder was in fact a diagnosable psychiatric condition. A formal diagnosis would offer scientific validity for the suffering of women who experienced depression, grief, guilt, and repressed emotions after choosing to abort.

Days before President Reagan left office, Surgeon General C. Everett Koop delivered a letter summarizing his findings. After a multi-agency assessment of the scientific literature and consultations with 27 professional, political, and patient advocacy groups, the openly anti-abortion Koop offered the nation a virtual shoulder shrug: “[T]he data do not support the premise that abortion does or does not cause or contribute to psychological problems.”⁵ A more definitive answer, he averred, would require a five-year study costing up to $100 million. Fewer than five months into President George H. W. Bush’s first term, Koop resigned as surgeon general, taking with him all hopes of the White House conducting a more decisive study.

Abortion advocates in the American Psychiatric Association (APA) took advantage of Koop’s uncertainty to assert that PAS was a “myth.” Nada L. Stotland, a psychiatrist who would go on to become president of the APA, attempted to have the final word on the subject in a commentary published in the Journal of the American Medical Association in 1992. She intoned, “There is no evidence of an abortion trauma syndrome.”⁶ Her claim was backed by an “extensive search” of “the psychiatric and psychological literature.” However, she dismissed research “published under religious auspices and in the nonspecialty literature” that demonstrated negative postabortion effects. The studies Stotland deemed unacceptable lacked scientific credibility because they privileged the voices of suffering women and the observations of the professionals who helped them. She reduced patient reports of post-abortion adversity and clinical case reports to “anecdotal evidence.” But Stotland’s review of the scientific literature undermined her hardline position against abortion-related negative mental health effects. She acknowledged, “Significant psychiatric sequelae after abortion are rare, as documented in numerous methodologically sound prospective studies in the United States and in European countries.” In fact, those contrary studies found that abortion can cause adverse psychological reactions when women have pre-existing mental health problems, are coerced into abortion, and undergo abortion in “adversive circumstances.” All told, Stotland’s denial of post-abortion mental health problems amounts to blaming women who did not have perfect lives and the fairy-tale abortion experience promoted by pro-choice activists.

Disregard from the psychiatric establishment did little to dissuade pro-life researchers from seeking to fill gaps in the scientific literature on abortion and mental health. Surgeon General Koop had commented in his 1989 letter to President Reagan that all of the nearly 250 studies reviewed in his inquiry “were found to be flawed methodologically.”⁷ By 1994, Vincent M. Rue and other pro-life researchers had systematically articulated a symptomatology of PAS that demonstrated it met the criteria to be considered a subtype of PTSD.⁸ Despite tomes of new research on abortion’s negative mental health consequences being published annually by organizations like Elliot Institute, Charlotte Lozier Institute, and others, pro-abortion researchers continued to dismiss their findings on ostensibly arbitrary scientific grounds—so much so that “flawed methodology” has become a koan recited in social science research on abortion and mental health over the last two decades.

Sadly, a woman seeking information about the side effects of abortion today faces the same problems of misinformation President Reagan sought to ameliorate four decades ago. A visit to The American College of Obstetricians and Gynecologists’ oxymoronically titled “Abortion Care” webpage answers the question “Does having an abortion affect your future health?” with the terse and myopic statement: “Abortion does not increase the risk of breast cancer, depression, or infertility.”⁹ Planned Parenthood also minimizes the psychological impacts of abortion on its “What Facts about Abortion Do I Need to Know?” webpage. They obfuscate potential harms by referring rather casually to them as “emotions”: “It’s totally normal to have a lot of different emotions after your abortion. Everyone’s experience is different, and there’s no ‘right’ or ‘wrong’ way to feel. Most people are relieved and don’t regret their decision. Others may feel sadness, guilt, or regret after an abortion. Lots of people have all these feelings at different times. These feelings aren’t unique to having an abortion.”¹⁰ Rather than receiving reliable information, visitors to these websites and their innumerable imitators are condescended to with language games.

What seems to have been lost from view on both sides of the abortion and mental health debate is that abortion is first a moral issue. When we talk about abortion in terms of science—whether or not a woman develops a mental pathology in the aftermath of her abortion—we reduce her, her lost child, and the circumstances of the abortion to statistics. By acknowledging the moral dimension of her decision, we acknowledge that she made her decision within a variety of contexts. Sometimes in these complex moral universes, women make choices that transgress their own deeply held moral beliefs. For example, a woman with type-2 diabetes may be told by her physician that her unplanned pregnancy poses a significant threat to her own health, prompting her to consider abortion. Other times, a woman who was satisfied with her decision to abort becomes remorseful years later. As painful as these situations may be, neither category meets the APA’s criteria for being a traumatic stressor that could pathologize into PTSD. However, the moral stress women experience hours or years after abortion is the foundation for a different type of emotional and spiritual wound called moral injury.

What Is Moral Injury?

Psychiatrist Jonathan Shay is credited with being the first to articulate a definition of moral injury.¹¹ In his 1994 book Achilles in Vietnam: Combat Trauma and the Undoing of Character, Shay described how many of the Vietnam veterans he counseled in the Boston, MA, Veterans Affairs clinic suffered from a condition that seemed like PTSD but had a cause that was not recognized in the APA’s definition of a traumatic event. Indeed, military combat is rife with traumas that could lead to PTSD. However, the particular sufferings that Shay was attempting to define, he argued, were the consequences of veterans violating conscience, or their sense of “what’s right,” in the course of carrying out their duties. Through interactions with thousands of veterans, Shay codified a syndrome caused by transgressions of conscience: “Moral Injury is the sum total of the psychological, social, and physiological consequences that a person undergoes, when all three of the following are present:

1. Betrayal of what’s right (the code of what is praiseworthy and blameworthy, part of culture)

2. By someone who holds legitimate authority (legitimacy and authority are phenomena of the social system)

3. In a high-stakes situation (what is at stake clearly has links to the culture and social system, but must be present in the mind of the person suffering the injury).”¹²

These violations are more than emotional disturbances. Shay holds that “the body codes Moral Injury as a physical attack.” Moral injury, therefore, is a comprehensive wound that begins in the culture outside the body, makes its way into the victim through his or her social system, and finally lodges in the mind and body.

This early codification of moral injury emphasizes exterior causes. Preventing moral injury begins with leaders of cultural institutions like the military taking responsibility for the potential consequences of their orders before they give them. Equal parts social critique and explanation of the interplay among the psyche and society, Shay’s notion of moral injury gained purchase with psychotherapists like Ed Tick, who distilled the condition down to its essence: “soul wound.”¹³

While working with veterans of the Global War on Terror, Brett T. Litz and fellow clinicians from the VA developed a more robust model of moral injury. In particular, their definition broadens the spectrum of who can be morally injured and what actions can wound. Their definition of moral injury is Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code.¹⁴

Although Litz and colleagues’ definition is widely referenced in studies of moral injury, there is no consensus definition of moral injury at this time, according to the Department of Veteran Affairs Moral Injury website.¹⁵

The first step toward a universally accepted definition is to clarify the language used to distinguish potentially morally injurious events (PMIEs) from the condition of being morally injured. Like PTSD, which requires that a person be exposed to a traumatic stressor, moral injury cannot be diagnosed unless a person is exposed to a PMIE. Mercifully, not everyone who faces a painful betrayal or ethically confusing experience will develop the symptoms of moral injury. In the case of PTSD, George Bonanno, the leading researcher on resilience following traumatic exposure, holds that two-thirds of people exposed to an adverse event either will not be affected or will recover completely in weeks or months.¹⁶ It’s the final third who suffer long-term and require significant interventions to heal. Whether the clinical insights and studies gathered over the past fifty years on PTSD can be readily applied to moral injury remains an open question. Distinctions are important. As the VA states, we now can distinguish moral injury “from moral frustration, which is a more transitory reaction to a moral challenge, or moral stress, which is an acute reaction to a moral stressor.”¹⁷ More importantly, we know that moral injury can occur alongside PTSD,¹⁸ and, in some cases, make the symptoms of PTSD worse.

In the context of abortion, we can readily draw a parallel with a physician recommending that a woman terminate her pregnancy. The physician’s order may accord with local laws and his professional organization’s guidelines for best practice. Yet, the woman’s moral universe complicates matters. She knows “what’s right” and must weigh it against the recommendations of an authority figure. As the soldier relies on the military organization for his or her survival, so too does the woman who consults her physician about her unintended pregnancy rely on the morality of the medical organization. By shifting from a trauma framework to a moral injury framework to understand this situation, we accelerate far beyond clinical studies of whether the abortion procedure itself causes psychopathology into the realm of whether abortion will wound the woman’s soul.

Abortion and Moral Injury

The potential moral hazards faced by women who undergo induced abortions, either electively or under coercion, have been acknowledged,¹⁹ but not until recently have researchers investigated the psychological implications those decisions may have for women. Tara C. Carleton and Jill L. Snodgrass offer the first systematic exploration of abortion and moral injury in Moral Injury after Abortion: Exploring the Psychospiritual Impact on Catholic Women. Despite the book’s title, the authors did not set out to conduct an examination of Catholic motherhood lost. Thirty women participated in their qualitative (interview-based) study. All experienced their decisions to abort as moral stressors. Yet the only participants who suffered profoundly from the emotions associated with guilt, shame, betrayal, and culpability of moral injury were Catholic.

As researchers, Carleton and Snodgrass set out a framework for understanding moral injury and abortion that borrows generously from researchers like Shay and Litz, among others. Unlike their predecessors, they are theologians first and approach their subject from a religious lens of healing instead of a psychiatric lens of pathologizing moral injury into a diagnosable mental illness, like PTSD. They write, “it is important to consider the connection between moral injury and PTSD and why, from our perspective, moral injury as experienced by women post-abortion, and so many others, does not belong in the Diagnostic and Statistical Manual.”²⁰ In short, moral processes are not mental illnesses, regardless of how troubling and painful they may be.

Their approach is even-handed and dodges the political landmines that riddle the discursive battlefield of abortion and mental health. Undoubtedly, interlocutors entrenched on either side will wish for more vim in the authors’ assessment of abortion as a medico-legal phenomenon. Any designs on settling that subject are absent from their text, though. The authors occupy polar positions on the spectra of Christianity and the abortion issue itself. Carleton, who holds a doctorate in Counselor Education and Supervision, is a pro-life Catholic. Snodgrass, a PhD in theology, is an ordained minister in the United Church of Christ and “politically pro-choice.” The resulting book serves as an answer to longstanding calls from researchers of abortion and mental health to cooperate in exploring the psychological aftermath of abortion. The authors’ ultimate concern is helping the marginalized minority of women who suffer spiritually post-abortion to find healing by equipping religious and secular professionals to walk with women through the haunting consequences of their abortions. By declaring their individual standpoints on the subject, the authors both lend credibility to their findings and instill an ethos of care into the recommendations for helping women through their post-abortion struggles, which they present in the book’s final chapter.

Moral Injury after Abortion offers an illuminating framework for post-abortion turmoil that focuses on moral processes. Carleton and Snodgrass introduce unplanned pregnancy as a moral challenge that may either cause negative emotional experiences like stress and suffering or positive experiences, like personal growth. Those women who choose abortion may transgress their deeply held beliefs and values, and, at some point post-abortion, experience the guilt and shame of moral stress. Women who successfully manage and cope with their moral stress go on to a state of moral repair, in which they integrate their decision and actions into their conception of self. Those women who do not or cannot manage or cope with their moral stress experience brief, long-term, or chronic moral injury. There is room in this heuristic for women to move along a continuum from challenge to injury to repair. As with Bonanno’s rule of thirds, a woman facing the moral challenge of unplanned pregnancy is not guaranteed to develop moral injury. Furthermore, Carleton and Snodgrass portray moral injury as a problem of an individual’s coping with lived experience and circumstances. Moral injury is never a foregone conclusion, but it looms on the horizon for those who do not have the spiritual and social resources to come to terms with their transgressions of conscience.

To illustrate the profound impact of moral injury, the authors present ten Catholic women’s stories with compassion and accuracy, drawing attention to the circumstances that resulted in their decisions to choose abortion. Like the Vietnam veterans Shay describes who were betrayed by people in power during high-stakes situations, seven of the participants were coerced into aborting their babies by family members or romantic partners. One participant, now in her 30s, recounted her moral stress as a sixteen-year-old telling her mother that she had engaged in sex before marriage and was pregnant. The teenager had transgressed a family value, and to avoid shaming the family, her mother and boyfriend took her to the abortion clinic before others could learn the news. Her Catholic mother’s complicity in the abortion profoundly confused her: “Why didn’t she stop it? Why didn’t she advise me? Why didn’t she tell somebody? Had we told one more person out of this little circle, somebody would have stopped that, and I would not have regretted having a baby at that age.”²¹ The wound from her mother was complicated by her own regrets of not telling her father, whom she believed would have stopped the abortion: “I don’t know what he would have said or done, but I know it wasn’t that [abortion].” She continued, acknowledging her abandonment of her Catholic mores: “We didn’t have the chance to think religiously or faith-wise like ‘Is this a sin […] what are my morals?’”²²

Another woman in her mid-twenties was convinced by her friends to have an abortion because of her financial problems. Beyond their selfish counseling, she testified about the betrayal she felt at the hands of the medical professionals who conducted the procedure. She remembered feeling a coldness when the doctor entered the surgery room and went straight to his task without introducing himself. The feeling compelled her to ask that the procedure be stopped, but a nurse told her it was too late. Summarizing the indignity of the episode, she stated, “You’re treated more as a person when you have a tooth pulled than you are when you have an abortion.”²³

In the authors’ final analysis, they conclude that the women’s moral injury was caused by their “struggle to cope with the moral stress they experienced from engaging in what they considered to be the morally transgressive act of abortion.”²⁴ These struggles included “negative emotion-focused coping, namely avoidance, and negative religious coping, specifically struggles with the church, God, and self.” Participants recall turning to substance abuse, social isolation, and depressive behaviors to deal with the pain of their decisions. One participant who sought psychological therapy was “mocked by the psychiatrist, who called her ‘crazy’” and refused to “validate her moral suffering and moral injury,” further exacerbating her negative emotions.²⁵ Certainly Carleton and Snodgrass’s analysis will be construed by some as a blanket condemnation of a hypocritical Catholic Church that does not go in search of its lost sheep. As one woman described her damaged relationship with the divine, “I was convinced [after the abortion] that God had to really hate me now. Any chance there had ever been of God wanting me around was gone.”²⁶ The authors, however, argue it is through religion that their participants and other women who are morally injured by abortion will find moral repair.

The final chapter of Moral Injury after Abortion is dedicated to guiding helping professionals, like therapists, to counsel women through moral injury to a place of moral repair. They write, “Moral repair can be enhanced when women are able to share about their abortion experience with trusted others, embrace a sense of spiritual connectedness with other women post-abortion, and feel the support of a broader, compassionate community.”²⁷ As moral injury begins with a moral challenge, moral repair begins when women find a moral resource in a friend, family member, therapist, or clergy member. With this resource, they then can seek a relationship with God, ask for His forgiveness, make amends, and begin the process of forgiving themselves. Since transgressing their deeply held beliefs was where their moral injuries began, growing in their faith through religious practices and rituals is where healing awaits.

Finding the Right Words

Moral injury represents a promising shift in the discourse of post-abortion suffering. Decades of debate over the scientific veracity of post-abortion syndrome and abortion as a traumatic stressor has ossified shut the supposedly open and objective minds of researchers. Moral injury introduces a new terminology, reanimating old debates, but in an altogether different way. Proabortion organizations have already acknowledged the moral dimensions of post-abortion life for women.

Take, for example, the APA Task Force on Mental Health and Abortion’s (TFMHA) 2008 Report.²⁸ Like Surgeon General Koop’s report in 1989, the task force members surveyed the scientific literature and professed that there was “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”²⁹ But they attest that the same studies show “it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety.” Such an admonition already debunks claims from decades prior that the connection between abortion and negative mental effects is a myth.

Carleton and Snodgrass’s study presents readers with actual moral suffering and moral injury. Indeed, only a third of their small sample experienced moral injury. The TFMHA recognized in its report that “Women’s experience of abortion may also vary as a function of their religious, spiritual, and moral beliefs and those of others in their immediate social context.”³⁰ They draw special attention to moral challenges in marginalized groups, too: “[I]t appears that for women of color, moral and religious values intersect with identities conferred by race, class, or ethnicity to influence women’s likelihood of obtaining an abortion and, potentially, their psychological experiences following it.”³¹ Even Planned Parenthood cannot deny the psychospiritual challenges of abortion and the moral dilemmas it poses to vulnerable women before, during, and after their decisions are made. Its website directs women to another website that provides spiritual counseling, albeit of the anti-life kind.^32, 33 We can only hope that the lens of moral injury offered in Moral Injury after Abortion will inspire new research that reappraises old psychological facts and takes seriously the potentially chronic suffering abortion causes women who transgress their consciences.

Moral injury may be exactly the term needed for people across the ideological divide to come together in support of the women who need moral repair after abortion. We can only guess what Surgeon General Koop’s report to President Reagan on the emotional and psychological effects of abortion would have said had moral injury research been available in the 1980s. Though Koop’s January 9, 1989, report does reference the betrayals of “what’s right” by institutions in power during high-stakes situations, “Even among groups committed to confirming a woman’s right to legal abortion there was consensus that any abortion represented a failure in some part of society’s support system,—individual, family, church, public health, economic, or social.”³⁴

 

NOTES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (3rd. Ed. Revised). Washington, DC: 1987.

2. Vincent M. Rue. “The Psychological Realities of Induced Abortion.” In Post-Abortion Aftermath, edited by Michael T. Mannion (Kansas City, MO: Sheed & Ward, 1994), 30.

3. Tara C. Carleton and Jill L. Snodgrass. Moral Injury after Abortion: Exploring the Psychospiritual Impact on Catholic Women. (New York, Routledge, 2022), 2.

4. Ronald Reagan. “Remarks at a White House Briefing for Right to Life Activists.” July 30, 1987. https://www.reaganlibrary.gov/archives/speech/remarks-white-house-briefing-right-life-activists

5. CE Koop. Letter to President Reagan. Medical and psychological impact of abortion. Washington, DC: Government Printing Office, 1989.

6. Nada L. Stotland. “The Myth of the Abortion Trauma Syndrome,” JAMA, 268 no. 15 (1992): 2078-9.

7. Koop, np.

8. Vincent M. Rue. “The Psychological Realities of Induced Abortion.”

9. https://www.acog.org/womens-health/faqs/induced-abortion

10. https://www.plannedparenthood.org/learn/abortion/considering-abortion/what-facts-about-abortion-do-i-need-know

11. Jonathan Shay. Achilles in Vietnam: Combat Trauma and the Undoing of Character. (New York: Atheneum, 1994).

12. Jonathan Shay. “Moral Leadership Prevents Moral Injury.” in War and Moral Injury: A Reader, ed. Robert Emmet Meagher and Douglas A Pryer (Eugene, OR: Cascade Books, 2018), 301-306.

13. Edward Tick. War and the Soul: Healing Our Nation’s Heroes from Post-traumatic Stress Disorder. (Wheaton, IL: Quest Books, 2005).

14. Brett T. Litz, et al., “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy.” Clinical Psychology Review 29, no 8 (2009) 695-706. http://doi.org/10.1016/j.cpr.2009.07.003

15. https://www.mirecc.va.gov/visn17/moralinjury/research.asp

16. George Bonanno. The End of Trauma: How the New Science of Resilience is Changing How We Think about PTSD. (New York: Basic Books, 2021).

17. https://www.mirecc.va.gov/visn17/moralinjury/research.asp

18. https://neuro.psychiatryonline.org/doi/10.1176/appi.neuropsych.19020036

19. The following resources acknowledge that abortion could potentially cause moral injury:

The Shay Moral Injury Research Center, Frequently Asked Questions about Moral Injury (Alexandria: Volunteers of America, n.d.), www.voa.org/moralinjury-faq.;

Support After Abortion, “Moral Injury: A New Concept for Looking at Abortion Healing,” https://supportafterabortion.com/blog/moral-injury-a-new-concept-for-looking-at-abortion-healing/

Brandon J. Griffin, Natalie Purcell, Kristine Burkman, Brett T. Litz, Craig J. Bryan, Martha Schmitz, Claudia Villierme, Jessica Walsh, and Shira Maguen, “Moral Injury: An Integrative Review,” Journal of Traumatic Stress 32, no. 3 (2019): 357.

20. Tara C. Carleton and Jill L. Snodgrass. Moral Injury after Abortion: Exploring the Psychospiritual Impact on Catholic Women. (New York, Routledge, 2022), 51.

21. Ibid., 71.

22. Ibid., 71.

23. Ibid., 81.

24. Ibid., 95.

25. Ibid., 75.

26. Ibid., 81.

27. Ibid., 122.

28. American Psychological Association, Task Force on Mental Health and Abortion. (2008). Report of the Task Force on Mental Health and Abortion. Washington, DC: Author. Retrieved from https://www.apa.org/pi/wpo/mental-health-abortion-report.pdf

29. Ibid., 4.

30. American Psychological Association, Task Force on Mental Health and Abortion, 10.

31. Ibid., 10.

32. https://www.plannedparenthood.org/learn/abortion/considering-abortion/what-facts-aboutabortion-do-i-need-know

33. https://abortionswelcome.org/

34. Koop, np.

 

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Original Bio:

Leonard F. Grant III, PhD, is Assistant Professor of Writing and Rhetoric at Syracuse University.