Although abortion is legal in Washington, Lauren B. Simonds can quickly list the ways Washingtonians — and those who come here for abortions — will be affected mentally and emotionally as abortion politics returns to the United States.
Simonds has a unique understanding of how the abortion debate intersects with mental health. She ran two clinics offering abortions, and for three years ran the abortion advocacy organization NARAL Pro-Choice Washington. For the past decade, she has served as Executive Director of the Washington Chapter of the National Alliance on Mental Illness.
“This ruling in itself is causing people anxiety,” she said of the recent Supreme Court ruling that ends the nation’s abortion rights. As abortion providers across Washington brace for an influx of patients, she added, “I can only imagine the stress and anxiety abortion providers are feeling.”
To better understand the connections between the decision to have an abortion and mental health, the Seattle Times Mental Health Project spoke with legal experts and clinicians, reviewed new abortion laws in various states, and compiled scientific studies. We found that while some things are clear – like where science stands on abortion and mental health – other issues depend on how state legislators act, how people vote, and how courts decide to apply new legal standards.
1. What does research tell us about mental health and abortion?
The most significant research on mental health and abortion comes from the landmark Turnaway Study, which spanned five years, included nearly 1,000 participants at 30 facilities and examined the consequences of refusing an abortion. The study compared people who were able to access abortion with those who were unable to because they were past the facility’s gestational age limit.
The study found that abortion was not linked to mental health issues. Several other studies, including a 2008 report from the American Psychological Association, support this finding, although there is evidence that abortion can result in a mix of emotions: some women report feeling sad, grief or loss while others report relief. The Turnaway and APA studies also suggest that a person’s history of mental health problems — not whether they had an abortion — is an indicator of their later mental well-being.
But the effects of refusing an abortion are wide-ranging: people who were refused an abortion were more likely to have serious health problems, raise their children alone without family support, and being unable to meet basic needs such as food. Regarding the mental health of the participants, those who were turned down showed more symptoms of short-term anxiety and low self-esteem. These symptoms largely resolved over time, and by the end of the study, the mental well-being of those who received and those who were denied abortions had improved.
A handful of other studies suggest that in countries where abortion is restricted, such as El Salvador, teenage pregnancy is linked to an increased risk of suicide. Studies in Bangladesh and Kenya come to similar conclusions.
2. States that prohibit abortion provide exceptions when the life of a pregnant person is at stake. Are mental health issues, such as the risk of suicide, taken into account?
The new abortion laws of most states, including those of North Dakota and Mississippi, provide general exceptions when the life of the pregnant person is threatened. But many of these laws are loosely worded and don’t specifically call out suicidality as a reasonable exception to their abortion bans.
Lawmakers in some states, including Idaho and Tennessee, appeared to have anticipated the possibility that banning abortion could cause some pregnant women to have suicidal thoughts, actions, or other serious mental health issues. Yet these states do not offer exceptions for mental illness or suicidal tendencies.
Instead, triggering laws in both states specifically state that a pregnant person’s threat to harm themselves is not an appropriate defense for an abortion provider facing criminal charges. In other words, it is illegal for a doctor to abort a patient who is threatening suicide if she cannot terminate her pregnancy.
Tennessee law also offers no exception for incest or rape. According to a large body of research, the victims of these crimes are much more likely to commit suicide.
Legal abortion advocates who follow Idaho’s ban have said a lack of protection for suicidal people contradicts the state’s stated interest in protecting fetal life.
“It does no good because it results in the death of the pregnant person and the fetus,” said Kim Clark, senior reproductive rights, health and justice attorney at Legal Voice in Seattle.
Gemma Collins, a licensed clinical social worker and psychodynamic psychotherapist in Seattle, sees merit in having an exception for mental health issues, but pointed out how it could backfire.
“If you are documented as having PTSD, anxiety, bipolar disorder, depression and if we have defined these things as dangerous to your life as a way to access abortion, then what do we do? And what impact does this have on your right to have children in the future? »
3. Will the new laws require providers to share information about patients who disclose an abortion or intend to have one?
Legal experts and associations of mental health professionals in Washington are currently examining this question. The question is particularly important since providers in Washington now have more access to out-of-state patients than ever before. Washington recently joined a multi-state pact that allows psychologists licensed here to offer telehealth appointments to patients in all other states in the pact, including several with strict abortion laws.
On Thursday, a group of psychologists nationwide affiliated with the American Psychological Association discussed how the decision could affect cross-border care. Topics included whether states would consider abortion, child abuse, which could have ripple effects for mandatory journalists like mental health professionals, said Samantha Slaughter, director of professional affairs of the Washington State Psychological Association.
In general, psychologists and other healthcare professionals are bound and protected by patient confidentiality laws. This means they must be protected from sharing clinical notes or patient records with state authorities, including those outside of Washington.
But federal law offers few protections if law enforcement gets a court order for patient records, which is why some states, like Connecticut, are passing legislation that prevents the government and healthcare providers from health to participate in out-of-state surveys.
On Thursday, Gov. Jay Inslee issued a directive that prevents the Washington State Patrol from cooperating with such investigations.
“There is nothing Washington State can do to stop a criminal or civil case in another state,” Clark of Legal Voice said. “What the state can do, and I think the governor is looking at, is to make sure that Washington, to the extent possible, is not complicit in these investigations.”
4. Are Washington mental health providers considering making any changes to the way they document or conduct therapy sessions?
Some say they are considering changes.
Lesli Desai, a licensed independent clinical social worker in Seattle who specializes in therapy for pregnant and postpartum women, spoke with other clinicians about how they will take notes in upcoming sessions.
They follow Washington’s administrative code standards, but “everyone has their own style and technique,” she said. “Some therapists are very detailed in what they document and some therapists, either by their choice or by the client’s choice, take little or no notes and documentation.”
She said some clinicians are considering launching their practice as both therapy and life coaching because there are fewer regulations for life coaches.
“Will it be safer to do life coaching rather than therapy because it’s not regulated?” she says. “How can we ethically and morally continue to serve in a way that we value and value, but also protect our licenses and protect our customers from lawsuits? »
5. What do mental health providers in Washington hear from their clients?
Alicia Ferris, a licensed mental health counselor at Olympia who specializes in reproductive health, said an individual’s mental health can be affected when personal medical decisions are subject to public debate fraught with stigma and judgment.
She also said that short-term effects may differ from long-term effects, vary from person to person, and change over time. For example, a person who had an abortion at age 16 may experience significant relief, but new emotions may surface if, at age 35, they experience infertility.
Desai said she has seen customers raise this issue before and expects it to grow.
“I think we could see an influx of customers who want to process this. It’s definitely a trigger for clients who have some form of this in their story,” Desai said.
Providers, Desai and Ferris said, must be clear about their position on abortion rights and have the proper training to help clients.
Gladys Rodriguez, a licensed associate therapist in Seattle, said in an email that she predicts anxiety and depression will increase among women.
“I expect PTSD cases to increase absolutely, whether due to unplanned pregnancy, unplanned labor and delivery, or an already existing diagnosis of PTSD,” Rodriguez said.
Slaughter noted that mental health providers also experience a range of emotions.
“Just when you thought you couldn’t take any more, there’s something else you have to deal with,” she said. “Psychologists and mental health clinicians are no different from anyone else.”