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Traumatology
XX(X) 1–15
© The Author(s) 2010
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DOI: 10.1177/1534765609347550
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Inadequate Preabortion Counseling
and Decision Conflict as Predictors of
Subsequent Relationship Difficulties and
Psychological Stress in Men and Women
Catherine T. Coyle, RN, PhD, Priscilla K. Coleman, PhD, Vincent M.
Rue, PhD
Abstract
The purpose of this study was to examine associations between perceptions of preabortion counseling adequacy and
partner congruence in abortion decisions and two sets of outcome variables involving relationship problems and individual
psychological stress. Data were collected through online surveys from 374 women who had a prior abortion and 198
men whose partners had experienced elective abortion. For women, perceptions of preabortion counseling inadequacy
predicted relationship problems, symptoms of intrusion, avoidance, and hyperarousal, and meeting full diagnostic criteria
for posttraumatic stress disorder (PTSD) with controls for demographic and personal/situational variables used. For men,
perceptions of inadequate counseling predicted relationship problems and symptoms of intrusion and avoidance with the
same controls used. Incongruence in the decision to abort predicted intrusion and meeting diagnostic criteria for PTSD among
women with controls used, whereas for men, decision incongruence predicted intrusion, hyperarousal, meeting diagnostic
criteria for PTSD, and relationship problems. Findings suggest that both perceptions of inadequate preabortion counseling
and incongruence in the abortion decision with one’s partner are related to adverse personal and interpersonal outcomes.
Keywords
elective abortion, abortion counseling, abortion decision, relationship problems, psychological stress, PTSD
Introduction
Few contemporary social issues have evoked more contro-
versy than elective abortion. The continuing debate over
abortion and mental health has focused on the nature and
frequency of adverse postabortion psychological sequelae.
There is now consensus, however, that a significant percent-
age of women experience negative psychological reactions
following abortion (Bradshaw & Slade, 2003; Coleman,
Reardon, Strahan, & Cougle, 2005; Wilmoth, deAlteriis, &
Bussell, 1992). This study was designed to identify poten-
tially key factors predictive of postabortion relationship
problems and psychological stress in both women and men.
Women and Abortion
Recent studies have corrected methodological weaknesses of
earlier studies and have revealed increased mental health
risks associated with the experience of abortion. The most
thoroughly researched adverse consequences include anxiety,
depression, substance abuse, suicidal ideation, and suicide
(Broen, Moum, Bodtker, & Ekeberg, 2004; Coleman et al.,
2005; Cougle, Reardon, & Coleman, 2003; Cougle, Reardon,
Coleman, & Rue, 2005; Coleman, Reardon, Rue, & Cougle,
2002; Fergusson, Horwood, & Ridder, 2006; Gissler, Berg,
Bouvier-Colle, & Buekens, 2005; Gissler, Hemminki, &
Lonnqvist, 1996; Pedersen, 2007, 2008; Reardon & Cougle,
2002; Reardon, Coleman, & Cougle, 2004; Reardon et al.,
2003; Rees & Sabia, 2007; Soderberg, Janzon, & Sojberg,
1998; Thorp, Hartman, & Shadigan, 2003).
An estimated 43% of U.S. women will experience at least
one anxiety disorder in their lifetime (Breslau, Schultz, &
Peterson, 1995). Posttraumatic stress disorder (PTSD) is a rela-
tively common and particularly disabling anxiety disorder
that may be caused by one or more profound stressors. Exten-
sive research has documented how traumatic stress can signi-
ficantly alter the quality of individuals’ lives (Kapfhammer,
Rothenhausler, Krauseneck, Stoll, & Schelling, 2004; Marshall
1APART Inc., Madison, WI, USA
2Bowling Green State University, Bowling Green, OH, USA
3Institute for Pregnancy Jacksonville, FL, USA
Corresponding Author:
Catherine T. Coyle, APART, Inc., Madison, WI 53711, USA Email: ctcoyle
@charter.net
2 Traumatology XX(X)
et al., 2001; Schnurr, Hayes, Lunney, McFall, & Uddo, 2006;
Warshaw et al., 1993). In the United States, an estimated
13% of women develop PTSD in their lifetime (Butterfield,
Becker, & Marx, 2002). Systematic exploration of the role of
elective abortion as a traumatic stressor associated with
symptoms of PTSD has grown substantially in recent years
(American Psychological Association, 2008; Bradshaw &
Slade, 2003). Various clinicians have identified abortion as
potentially traumagenic (Bagarozzi, 1993, 1994; Burke &
Reardon, 2002; De Puy & Dovitch, 1997; Speckhard, 1987;
Speckhard & Rue, 1993; Torre-Bueno, 1996). Moreover,
recent research has provided empirical evidence of this link
between abortion and PTSD symptomatology (Kubany, Hill,
& Owens, 2003; Mufel, Speckhard, & Sivuha, 2002; Rue,
Coleman, Rue, & Reardon, 2004; Steinberg & Russo, 2008;
Suliman et al., 2007). Rue et al. (2004) and Suliman et al.
(2007) reported that 12% to 18% of women met the full diag-
nostic criteria for PTSD after an abortion. An even greater
number of women in these studies experienced subthreshold
or partial PTSD symptoms following abortion (Barnard, 1990;
Rue et al., 2004). The higher the number of these subthreshold
symptoms present, the greater the risk of impairment, comor-
bidity, and suicidal ideation (Marshall et al., 2001).
Informed consent and preprocedure counseling can bene-
fit the patient’s decision making and postprocedure emotional
and physical adjustment (Baker, Beresford, Halvorson-Boyd,
& Garrity, 1999). The perceived adequacy of preabortion
counseling may also play an important role in mitigating or
increasing the amount of stress women feel following abor-
tion. Preabortion counseling has been criticized as being too
time limited, inadequate to address the ambivalence and the
complexity inherent in the abortion decision, lacking in discus-
sion of alternatives to abortion, deficient in assessing coercion
or pressure to abort, provided by nonprofessionals who are
biased, and not tailored to the needs of the individual patient
(Singer, 2004; Steinberg, 1989; Stites, 1982). The National
Abortion Federation (2007) advises that “there should be an
opportunity for discussion of the patient’s feelings about the
abortion decision” (p. 3). However, there is no current stan-
dard of care in abortion clinics requiring individualized
and thorough counseling regarding the patient’s feelings
and decision making. In a cross-cultural study, Rue et al.
(2004) reported that only 29% of women in the U.S. sample
received preabortion counseling, and 84% stated that it was
inadequate.
Individual psychological responses to abortion have also
been found to be related to the quality of preabortion deci-
sion making and, particularly, lack of partner support for the
decision (Bradshaw & Slade, 2003; Coleman et al., 2005).
Research has consistently identified ambivalence and absence
of partner support as predictive of negative abortion out-
comes (Bracken, 1978; Coleman et al., 2005; Major &
Cozzarelli, 1992; Major et al., 1990; Osofsky & Osofsky,
1972). Payne, Kravitz, Notman, and Anderson (1976) found
that women electing abortion were significantly more angry
and depressed afterward, if they were in conflict with their
husband or lover over the abortion. Rue et al. (2004)
reported that most women were unsure about their decision
at the time of the abortion, and only 24% perceived their
partners as supportive. Thus, the degree of perceived partner
support and perceived quality of preabortion counseling
are seemingly central factors in possible adverse psycho-
logical outcomes following elective abortion and they are
addressed in this investigation.
Men and Abortion
Although few studies have addressed men’s psychological
responses to elective abortion (Coyle, 2007), there are iden-
tifiable, recurring themes within the scientific literature. A
number of reports have noted men’s need and/or desire for
counseling (Gordon, 1978; Lauzon, Roger-Achim, Achim,
& Boyer, 2000; Myburgh, Gmeiner, & van Wyk, 2001a;
Rothstein, 1977a; Shostak & McLouth, 1984). Most men
who experience a partner’s abortion do not perceive it to be
a benign experience (Blumberg, Golbus, & Hanson, 1975;
Gordon & Kilpatrick, 1977; Poggenpoel & Myburgh, 2002;
Shostak, 1979, 1983; White van-Mourik, Connor, &
Ferguson-Smith, 1992) and specific emotions identified
among men include anger, anxiety, guilt, grief, and powerless-
ness (Gordon & Kilpatrick, 1977; Holmes, 2004; Mattinson,
1985; Speckhard & Rue, 1993). In studies of men dealing
with therapeutic abortion following amniocentesis, 82%
(Blumberg et al., 1975), 50% (Jones et al. 1984) and 47%
(White van-Mourik et al. 1992) of men have reported depres-
sion. Furthermore, clinicians have observed symptoms among
postabortion men that are consistent with delayed or compli-
cated grief reactions and PTSD (Mattinson, 1985; Robson,
2002; Speckhard & Rue, 1993). These clinical reports
involved small numbers of men and, to date, no quantitative
studies have looked at the potential for PTSD among men
following a partner’s abortion. In light of established comor-
bidity of PTSD with depression and other forms of anxiety
(Shalev, 2001), further investigation is warranted to deter-
mine the extent of risk of psychological trauma among men
whose partners undergo elective abortion.
Men tend to defer the abortion decision to their partners
and suppress their own emotions and desires as they attempt
to support their partners (Gordon & Kilpatrick, 1977;
Robson, 2002; Shostak & McLouth, 1984), and men who
disagree with their partners’ abortion decisions may be more
susceptible to intense anger (Naziri, 2007; Reich & Brindis,
2006). Even men who agree with the abortion decision may
suffer from ambivalence (Kero & Lalos, 2000, 2004; Kero,
Lalos, Hogberg, & Jacobsson, 1999) and their relationships,
both social and sexual, with their partners may be strained
or come to an end (Berger, 1994; Coleman, Rue, Spence &
Coyle, 2008; Myburgh, Gmeiner, & van Wyk, 2001b;
Naziri, 2007; Rothstein, 1977b; White van-Mourik et al.,
1992).
Coyle et al. 3
Although little is known about the long-term effects on
men, M. Buchanan and Robbins (1990) provided evidence
that adolescent pregnancy resolution may have effects that
last into adulthood. These authors found that adult men who
experienced abortion during adolescence were more psycho-
logically distressed than adult men who became fathers
during adolescence.
Although men are involved with conception and abortion,
they are not routinely offered abortion counseling. Despite
the call for greater inclusion of and attention to males in
abortion clinics (Shostak, 2007), little has changed. Most
men who accompany women for abortion do not receive
counseling and are left alone to wait.
Given that abortion is a highly personal and sensitive
issue, an online investigation seems ideally suited to this
topic. Participants may remain anonymous thereby increas-
ing their comfort with self-disclosure. The very existence of
an online survey concerning the emotional and relational
aspects of abortion may serve to normalize respondents’
experiences and encourage them to seek help if needed.
Web-Based Research
This investigation represents one of the first online studies
pertaining to the topic of abortion and, in this section, estab-
lished advantages and disadvantages of this contemporary
data collection mode are examined. Use of the Internet to
engage in data collection is time- and cost-efficient (Duffy,
2000; Wilson, 2003), effective in accessing difficult-to-reach
populations (Mangan & Reips, 2007; Yeaworth, 2001), and
enhances respondents’ comfort with the process and motiva-
tion to participate (Adler & Zarchin, 2002; Gosling, Vazire,
Srivastava, & John, 2004). A review of Web-based studies
published in the American Psychological Association journals
between 2003 and 2004 (Skitka & Sargis, 2006) revealed that
21% of those journals had published at least one such study.
Gosling et al. (2004) compared a large Internet sample with
510 traditional samples and found that Internet samples “are
generally more diverse than samples published in a highly
selective psychology journal” (p. 99). Similarly, Mathy,
Schillace, Coleman, and Berquist (2002) reported their Inter-
net sample as being more representative in terms of
education, income, and ethnic diversity than that of a large
sample obtained through random digit dialing. Still others
have argued that Internet samples are at least as representa-
tive as the ubiquitous college-student samples (Gosling
et al., 2004; Smith & Leigh, 1997).
Because data collected through Web-based surveys are
often obtained from self-selected, convenience samples,
generalization must be approached with caution. However,
the voluntary nature of such samples offers considerable
benefits (Buchanan & Smith, 1999; Reips, 2000) such as
superior responses in terms of clarity and completeness
(Petit, 2002; Walsh, Kiesler, Sproull, & Hesse, 1992), and
responses that are less likely to be contaminated by social
desirability (Richman, Kiesler, Weisb, & Drasgow, 1999).
Furthermore, research indicates that data collected online
appears to be equivalent to that collected via more traditional
methods (Ballard & Prine, 2002; Hewson & Charlton, 2005;
Knapp & Kirk, 2003; Robie & Brown, 2006) and Meyerson
and Tryon (2003) concluded that “data collection on the
Web is (1) reliable, (2) valid, (3) reasonably representative,
(4) cost effective, and (5) efficient” (p. 614).
Potential risks of online survey administration such as
inaccurate responses, failure to respond, and the influence of
phrasing and ordering of questions are applicable to tradi-
tional survey administration methods as well. The risks of
multiple survey submissions and nonserious responses
(Buchanan & Smith, 1999; Schmidt 1997) may be avoided by
using Internet protocol numbers to identify surveys coming
from the same respondent (Birnbaum, 2004; Gosling et al.,
2004). Furthermore, the anonymity afforded by the Internet
facilitates honest disclosure (Levine, Ancill, & Roberts, 1989;
Locke & Gilbert, 1995; Mangan & Reips, 2007).
Ethical considerations in Web-based research are the same
as those for other research forms. Consent to participate may
be defined as and verified by submission of an online survey.
The risk of psychological harm in online surveys has been
deemed to be no greater than that of offline surveys (Kraut
et al., 2004) if initial instructions include a clear statement
respecting the participant’s freedom to withdraw from the
study at any time. For studies involving sensitive subjects,
information concerning referrals for counseling or support
may be provided.
Objectives and Hypotheses
Based on the literature reviewed here, it appears that pre-
abortion counseling for women may be limited, whereas for
men, it is nonexistent. In addition, men and women may be
arriving at abortion decisions that are made without adequate
communication and candor between them thus resulting in
decisions that are less than satisfactory to one or both parties.
Consequent to both the crisis of pregnancy resolution and
insufficient communication, relationships may be strained
(Rue et al., 2004; Speckhard & Rue, 1993) and psychologi-
cal stress increased (Bagarozzi, 1994; Coleman & Nelson,
1998; Fergusson et al., 2006).
Both inadequate preabortion counseling and the incon-
gruence of partner abortion decision making may therefore
predict postabortion relationship difficulties and/or psycho-
logical trauma. Given that some studies on women have
found factors such as prior mental health (Major et al., 2000),
religious beliefs (Adler et al., 1990; Major, Richards, Cooper,
Cozzarelli, & Zubek, 1998), opinions or attitudes about
abortion (Soderberg et al., 1998; Zolese & Blacker, 1992),
number of abortions (Rue et al., 2004), and various sociode-
mographic characteristics (Zavodny, 2001) are likely to
influence the decision to abort and/or postabortion adjust-
ment, these factors were used as control variables in this
4 Traumatology XX(X)
study. In addition, history of physical or sexual abuse during
childhood or adulthood may be a confounding variable in
terms of postabortion mental health given the evidence
that such abuse may contribute to emotional problems
(Fergusson, Horwood, & Lynskey, 1996; Schilling, Aseltine,
& Gore, 2007). Therefore, controls were also implemented
for various forms of childhood and adulthood victimization.
The primary objective of this study was to investigate the
extent to which perceived inadequacy of preabortion coun-
seling and partner incongruence in abortion decision making
predicted postabortion relationship problems and psycho-
logical stress. The following hypotheses were tested:
Hypothesis 1: Men and women who do not perceive
preabortion counseling as having been adequate
will be at significantly greater risk for abortion-
related anger, relationship problems, and sexual
problems after controlling for sociodemographic
and personal history variables.
Hypothesis 2: Men and women who do not perceive
preabortion counseling as adequate will report
significantly higher abortion-related stress as evi-
denced by symptoms of intrusion, avoidance, and
hyperarousal, and they will be at significantly
greater risk of meeting the Diagnostic and Statis-
tical Manual of Mental Disorders, fourth edition
(DSM-IV) diagnostic criteria for PTSD after con-
trolling for sociodemographic and personal history
variables.
Hypothesis 3: Men and women who were not in agree-
ment with their partners regarding the decision to
abort will be at significantly greater risk for abor-
tion-related anger, relationship problems, and sexu-
al problems after controlling for sociodemographic
and personal history variables.
Hypothesis 4: Men and women who were not in
agreement with their partners regarding the deci-
sion to abort will report significantly higher abor-
tion-related stress as evidenced by symptoms of
intrusion, avoidance, and hyperarousal, and they
will be at significantly greater risk of meeting the
DSM-IV diagnostic criteria for PTSD after con-
trolling for sociodemographic and personal his-
tory variables.
Method
Procedure
Surveys were posted at www.abortionresearch.net from
April, 2005 through August, 2008. The surveys consisted of
questions concerning sociodemographics, meaningfulness
of religious affiliation, abortion history, reasons for abortion,
perceived adequacy of preabortion counseling, agreement in
abortion decision making, opinion regarding abortion at time
of procedure, relationship status with partner postabortion,
mental health history, abuse history, trauma symptoms related
to abortion, abortion-related anger, relationship problems,
sexual problems, and general stress attributed to abortion.
The introduction to the survey clarified that submission of
the survey would qualify as consent to participate and that
respondents could withdraw from participation at any time.
Links were provided for those respondents who desired sup-
port or counseling. Participants were recruited through
e-mail requests to crisis pregnancy centers across the United
States and to a few other organizations that offer postabor-
tion counseling. Potential participants could also find the
survey via search engines using phrases such as “men and
abortion,” “women and abortion,” or “abortion research.”
Sample
Surveys were completed by 374 women and 198 men. U.S.
citizens comprised 81% of the female sample and 78% of the
male sample. Citizens from England (6.5% male and 4%
female surveys), Canada (4.5% male and 6.4% female
surveys), and Australia (2.5% male and 2.7% female sur-
veys) contributed the next largest number of surveys.
Respondents also identified the following as country of citi-
zenship: France, Ireland, Norway, Romania, Czechoslovakia,
Germany, Sweden, New Zealand, South Africa, Kenya,
Mexico, Nicaragua, Brazil, Nepal, and South Korea. The
average age of both male and female respondents was 38
years (SD = 12.8 for males and 11.1 for females). Religious
affiliation of women was as follows: 81.6% Christian, 0.3%
Jewish, 9.5% Other, and 8.6% None. Religious affiliation of
males was 82% Christian, 0.5% Jewish, 0.5% Islam, 7.2%
Other, and 9.8% None. Females reported an average of 15
years (SD = 11.8) had elapsed since abortion and males
reported a mean of 14.7 years (SD = 12) had passed since
abortion occurred. Approximately half of the respondents
endorsed liberal views prior to abortion with 21% of males
and 24% of females agreeing that abortion “should be legal
for any reason at any time during pregnancy” and 27% of
males and 36% of females agreeing that abortion “should be
legal for any reason during the first trimester of pregnancy.”
Additional demographic information can be found in Table 1.
Measures
Perceived adequacy of preabortion counseling was assessed
via a single item question, “Do you think the counseling you
received at the abortion clinic was adequate?” to which
respondents indicated “yes” or “no.” Agreement regarding
abortion decision making was determined by respondents’
endorsement of agreement or disagreement with their part-
ners about the decision to abort.
Relationship quality was assessed with single item
variables indicating the presence or absence of abortion-
related relationship problems, abortion-related anger, and
Coyle et al. 5
Table 1. Descriptive Statistics for Primary Study Variables and
Control Variables
Percentage
Variables Women Men
Independent variables
Inadequate preabortion counseling
Endorsed 85.8 86.6
Not endorsed 14.2 13.4
Respondent and partner did not agree
on abortion decision
Endorsed 50.7 52.9
Not endorsed 49.3 47.1
Control variables
Race
White 85.4 85.2
Black 3.0 7.7
Hispanic 5.7 2.0
Asian 0.5 1.0
Other 5.4 4.1
Education
Less than 12 years 2.7 4.1
High school diploma 21.4 19.4
Technical/associates degree 29.2 26.5
Bachelor degree 28.7 29.6
Graduate degree 18.0 20.4
Employment
Full-time 49.0 74.5
Part-time 24.3 10.7
Unemployed 26.7 14.8
Marital status
Married 48.0 37.8
Remarried 10.5 6.1
Single (never married) 26.4 39.3
Single (divorced) 12.1 14.8
Separated 2.2 2.0
Number of children
None 42.0 55.1
One 12.8 11.1
Two 23.0 17.7
Three 13.9 9.6
Four or more 8.2 6.5
Number of abortions
One 73.4 81.8
Two or more 26.6 18.2
Meaningfulness of respondent’s religion
Not at all 8.2 10.3
Not very 4.4 8.8
Somewhat 10.7 17.5
Important 12.1 14.4
Very important 64.6 49.0
Abortion position at time of procedure
Legal for any reason at anytime 24.2 20.9
in pregnancy
Legal for any reason in first trimester 36.3 27.0
Legal only in rape, incest, 9.2 11.7
genetic disorders, and to
preserve health of mothers
Legal only in rape, incest, and to 6.7 16.6
preserve mother’s health
(continued)
Table 1. (continued)
Percentage
Variables Women Men
Legal only if mother’s 7.6 8.6
health is threatened
Never legal 15.9 15.3
Mental health counseling
prior to abortion
Yes 27.5 13.5
No 72.5 86.5
Hospitalized for emotional
reasons prior to abortion
Yes 3.8 4.2
No 96.2 95.8
Told needed counseling
before abortion but did not go
Yes 22.7 20.2
No 77.3 79.8
Felt needed counseling before
abortion but did not go
Yes 23.6 17.2
No 76.4 82.8
Victim of child abuse
Yes 24.1 15.6
No 75.9 84.4
Victim of child neglect
Yes 18.9 17.8
No 81.1 82.2
Victim of sexual abuse in
childhood or adolescence
Yes 36.7 19.4
No 63.3 80.6
Victim of physical abuse
during adulthood
Yes 26.3 6.5
No 73.7 93.5
Victim of sexual abuse
during adulthood
Yes 32.5 5.5
No 67.5 94.5
Dependent variables
Abortion-related anger
Yes 86.6 79.8
No 13.4 30.2
Abortion-related relationship problems
Yes 82.6 81.8
No 17.4 18.2
Abortion-related sexual problems
Yes 69.5 55.6
No 30.5 44.4
Met DSM-IV criteria for intrusion
Yes 83.5 77.6
No 16.5 22.4
Met DSM-IV criteria for avoidance
Yes 74.1 59.4
No 25.9 40.6
Met DSM-IV criteria for hyperarousal
Yes 61.6 54.2
No 38.4 45.8
(continued)
6 Traumatology XX(X)
abortion-related sexual problems. These items had dichoto-
mous (yes/no) responses.
Psychological stress was assessed using the PTSD
Checklist–Civilian Version (PCL-C). The entire PCL-C was
contained within the online survey. The PCL is composed of
17 items that measure the severity of PTSD symptoms. The
PCL yields a total score of 17 to 85 and assesses three symp-
tom clusters: arousal, avoidance of, and re-experiencing of the
traumatic event. The response format of the PCL is a 5-point
Likert-type scale with higher scores indicative of greater trau-
matic stress. The diagnosis of PTSD was determined using
DSM-IV criteria: (a) one or more endorsements of
re-experience symptoms; (b) three or more endorsements of
avoidance symptoms; and (c) two or more endorsements
of hyperarousal symptoms not present prior to the abortion.
Reliability and validity of the PCL have been established
(Weathers, Litz, Herman, Huska, & Keane, 1993). With the
current sample, internal consistency reliability estimates for the
full scale and for the arousal, avoidance, and re-experiencing
subscales were equal to .89, .77, .78, .80, and .92, .82, .80, .82
using the women’s and men’s data, respectively.
Results
Table 1 provides frequency data for the independent variables,
sociodemographic and personal history control variables, and
dependent variables separately for men and women. To test
the first and third hypotheses, which predicted that percep-
tions of inadequate preabortion counseling and disagreement
with one’s partner regarding the decision to abort would be
associated with increased risk for abortion-related anger,
relationship, and sexual problems after employing various
controls, three sets of logistic regression analyses were con-
ducted separately for males and females in the sample. In the
first set, perceptions of counseling inadequacy and partner
disagreement operated as the independent variables with
abortion-related anger problems functioning as the depen-
dent variable. A similar logistic regression analysis was then
conducted incorporating the control variables listed in Table 1.
In the second set of two logistic regression analyses, the
analyses were structured similarly to the first set except rela-
tionship problems functioned as the dependent variable.
Finally, in the third set of logistic regressions employing a
similar structure to the preceding analyses, sexual problems
operated as the dependent variable.
The results of these tests are provided in Table 2 for the
female respondents and in Table 3 for the male respondents.
As indicated by the data presented in Table 2, prior to inclusion
of the control variables, both independent variables (disagree-
ment regarding the abortion decision and perceptions of
preabortion counseling as inadequate) were significant predic-
tors of abortion-related anger, relationship, and sexual problems.
However, once the controls were entered into the analyses,
only the inadequate preabortion counseling variable signifi-
cantly predicted postabortion-related anger, relationship, and
sexual problems in the women sampled. More specifically, the
inadequate counseling variable was associated with a 592%,
831%, and 340% increased risk for anger, relationship, and
sexual problems, respectively, among the females.
A different pattern of results emerged with the male data.
As indicated in Table 3, both independent variables were sig-
nificant predictors of postabortion-related anger, relationship,
and sexual problems after statistically controlling for the
wide range of sociodemographic and personal situational
variables. Inadequate counseling was specifically associated
with a 1,797% increased risk of postabortion anger, a 1,421%
increased risk of postabortion relationship problems, and a
407% increased risk of postabortion-related sexual prob-
lems. In addition, disagreement with one’s partner regarding
the abortion decision was associated with a 4,248%, 469%,
and a 331% increased risk of postabortion-related anger,
relationship problems, and sexual problems, respectively.
To test the first part of the second and fourth hypotheses,
two sets (one for males and one for females) of analyses of
variance were conducted. In each test, the independent vari-
ables of partner disagreement on the decision and preabortion
counseling inadequacy served as the independent variables
with scores on the single item measure of abortion-related
stress serving as the dependent variable. Higher scores on the
stress measure are indicative of greater stress. One analysis
in each set incorporated controls and one did not. Using the
female data, without controls employed, the main effect for
counseling inadequacy was significant, F(1, 334) = 71.92,
p < .0001, as was the main effect for partner disagreement,
F(1, 334) = 71.92, p < .0001, and the interaction was signifi-
cant as well, F(1, 334) = 20.58, p < .0001. Then, with the
controls instituted, the results were similar—counseling
inadequacy: F(1, 218) = 36.31, p < .0001; partner disagree-
ment: F(1, 218) = 12.23, p < .0001; interaction: F(1, 334) =
5.45, p < .0001. Means were as follows—no agreement,
counseling inadequate: 8.80 (SE = .21); no agreement,
Table 1. (continued)
Percentage
Variables Women Men
Met DSM-IV diagnostic
criteria for PTSD
Yes 54.9 43.4
No 45.1 56.6
Stress associated with the abortion
(0 = no stress; 4 = moderate stress; 7
= high stress; 10 = overwhelming stress)
0-2 5.7 6.2
3-4 7.9 14.4
5-6 8.2 8.3
7-8 22.1 29.9
9-10 56.3 41.2
Note: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, fourth
edition; PTSD = posttraumatic stress disorder.
Coyle et al. 7
counseling adequate: 8.26 (SE = .23); agreement, counseling
inadequate: 6.78 (SE = .77); agreement, counseling adequate:
3.96 (SE = .56).
Using the male data, without controls employed, only the
main effect for partner disagreement was significant, F(1,
152) = 10.99, p < .001. Then, with the controls instituted,
partner disagreement remained significant, F(1, 95) = 8.24,
p = .005, and the interaction effect was likewise significant,
F(1, 95) = 4.00, p = .048. Adjusted means were as follows—
no agreement, counseling inadequate: 7.81 (SE = .36); no
Table 2. Results of Logistic Regression Analyses With Relationship-Based Dependent Variables for Females
Dependent Variable Independent Variable B SE Exp(B) 95% CI for Exp(B) Significance
Abortion- Respondent and partner not in 1.45 0.42 4.25 1.85-9.74 .001
related anger agreement on abortion
Inadequate preabortion counseling 2.69 0.38 14.68 6.95-30.98 .0001
Abortion-related angera Respondent and partner 0.56 0.55 1.75 0.60-5.13 .309
not in agreement on abortion
Inadequate preabortion counseling 1.93 0.64 6.92 1.97-24.34 .003
Abortion-related Respondent and partner not 1.08 0.35 2.94 1.474-5.89 .002
relationship problems in agreement on abortion
Inadequate preabortion counseling 2.54 0.36 12.69 6.26-25.66 .0001
Abortion-related Respondent and partner 0.73 0.48 2.08 0.813-5.33 .126
relationship problemsa not in agreement on abortion
Inadequate preabortion counseling 2.23 0.61 9.31 2.805-30.91 .0001
Abortion-related Respondent and partner 0.52 0.25 1.68 1.03-2.76 .039
sexual problems not in agreement on abortion
Inadequate preabortion counseling 1.66 0.33 5.26 2.74-10.10 .0001
Abortion-related Respondent and partner not 0.44 0.34 1.55 0.80-3.03 .196
sexual problemsa in agreement on abortion
Inadequate preabortion counseling 1.48 0.53 4.40 1.56-12.38 .005
a. Controlled for race, education, marital status, employment, number of children, number of abortions, the meaningfulness of the respondent’s religion,
the respondent’s view on the legality of abortion prior to the abortion, mental health counseling before the abortion, hospitalized for emotional reasons
before the abortion, told he or she needed counseling before the abortion, respondent felt he or she needed counseling before the abortion, victim of
child abuse, child neglect, sexual abuse in childhood or adolescence, physical abuse in adulthood, or sexual abuse in adulthood.
Table 3. Results of Logistic Regression Analyses With Relationship-Based Dependent Variables for Males
Dependent Variable Independent Variable B SE Exp(B) 95% CI for Exp(B) Significance
Abortion-related anger Respondent and partner 2.78 0.64 16.10 4.58-56.62 .0001
not in agreement on abortion
Inadequate preabortion counseling 1.46 0.56 4.30 1.42-13.01 .010
Abortion-related angera Respondent and partner not 3.77 1.08 43.48 5.24-360.43 .0001
in agreement on abortion
Inadequate preabortion counseling 2.94 1.01 18.97 2.63-136.69 .003
Abortion-related Respondent and partner 1.55 0.56 4.70 1.57-14.05 .006
relationship problems not in agreement on abortion
Inadequate preabortion counseling 2.67 0.60 14.47 4.43-47.29 .0001
Abortion-related Respondent and partner 1.74 0.81 5.69 1.15-28.02 .033
relationship problemsa not in agreement on abortion
Inadequate preabortion counseling 2.72 0.91 15.21 2.57-89.95 .003
Abortion-related Respondent and partner 0.89 0.34 2.43 1.23-4.78 .010
sexual problems not in agreement on abortion
Inadequate preabortion counseling 1.37 0.61 3.95 1.20-12.97 .023
Abortion-related Respondent and partner not 1.46 0.51 4.31 1.58-11.74 .004
sexual problemsa in agreement on abortion
Inadequate preabortion counseling 1.62 0.83 5.07 1.00-25.77 .050
a. Controlled for race, education, marital status, employment, number of children, number of abortions, the meaningfulness of the respondent’s religion,
the respondent’s view on the legality of abortion prior to the abortion, mental health counseling before the abortion, hospitalized for emotional reasons
before the abortion, told he or she needed counseling before the abortion, respondent felt he or she needed counseling before the abortion, victim of
child abuse, child neglect, sexual abuse in childhood or adolescence, physical abuse in adulthood, or sexual abuse in adulthood.
8 Traumatology XX(X)
agreement, counseling adequate: 8.28 (SE = 1.77); agreement,
counseling inadequate: 6.94 (SE = .38); agreement, counsel-
ing adequate: 3.49 (SE = .73).
To test the second part of the second and fourth hypotheses,
which predicted that inadequate preabortion counseling and
partner disagreement on the abortion decision would be asso-
ciated with higher risk for experiencing intrusion, avoidance,
hyperarousal, and with meeting diagnostic criteria for PTSD
after employing controls, four sets of logistic regression
analyses were conducted separately for males and females in
the sample. The dependent variable in each of the four sets
of two analyses was different (intrusion criteria, avoidance
criteria, hyperarousal criteria, and general PTSD criteria
met) and as in the previous set of logistic regressions per-
formed to test the first and third hypotheses, there were
separate tests conducted with and without the controls.
Table 4 provides these results for women, and Table 5 pro-
vides these results for men.
With the female data, both independent variables were
associated with increased risk for meeting the DSM-IV crite-
ria for intrusion (202% and 2,383% for the partner
disagreement and inadequate counseling variables, respec-
tively) and full PTSD diagnostic criteria after the controls
were applied (89% and 283% for the partner disagreement
and inadequate counseling variables, respectively.) How-
ever, only the inadequate counseling variable was a
significant predictor after the controls were included on the
avoidance subscale (559% increased risk) and on the hyper-
arousal subscale (425% increased risk). Using the male data,
both independent variables were associated with increased
risk of meeting the DSM-IV criteria on the intrusion subscale
(925% and 1,737% for the partner disagreement and inade-
quate counseling variables, respectively). However, only the
inadequate counseling variable was associated with increased
risk for meeting the DSM-IV criteria for the avoidance sub-
scale (1,005%) after controls were applied. Only partner
disagreement over the abortion decision increased risk for
experiencing hyperarousal symptoms (384%) and for meet-
ing the full diagnostic criteria for PTSD (210%).
Discussion
The purpose of this study was to explore associations bet-
ween two independent variables (perceptions of preabortion
counseling adequacy and partner abortion decision congru-
ence) and two sets of dependent variables (postabortion
relationship problems and psychological stress). Perceptions of
inadequate preabortion counseling significantly predicted
all the dependent relationship variables for both men and
women with utilization of control variables. Although other
research has found abortion in itself to be associated with
abortion-related anger (Kero, Hogberg, & Lalos, 2004; Naziri,
2007), relationship difficulties (Barnett, Freudenberg, &
Wille, 1992; Lauzon et al., 2000; Rue et al., 2004), and
sexual dysfunction (Bradshaw & Slade, 2003; Rue et al.,
2004), no studies had previously investigated the association
between preabortion counseling and postabortion relation-
ship challenges. The inclusion of participants’ perceptions of
counseling adequacy is therefore an important contribution
of the current study.
For women, perceived inadequate counseling also pre-
dicted all trauma subscale scores (i.e., intrusion, avoidance,
hyperarousal) and predicted meeting diagnostic criteria for
PTSD. For men, only intrusion and avoidance scores were
predicted by perceptions of inadequate counseling. Simi-
larly, Peters, Issakidis, Slade, and Andrews (2006) observed
that whereas women were significantly more likely to report
arousal symptoms, men were significantly more likely to
report avoidance symptoms particularly the symptom of
detachment. Both biological (Bryant & Harvey, 2003) and
sociocultural (Gavranidou & Rosner, 2003) explanations
have been proposed to explain these observed differences
between men’s and women’s endorsement of specific PTSD
symptoms. From a biological perspective, males and females
may have innate predispositions that differentiate their res-
ponses to trauma. Alternatively, culturally prescribed gender
roles may influence which trauma symptoms men and women
are likely to endorse depending on whether symptoms are per-
ceived as being gender appropriate.
Sex differences in the association between perceived cou-
nseling inadequacy and meeting full diagnostic criteria for
PTSD may be related to women’s direct participation in the
abortion procedure, which could predispose them to greater
trauma and an increased likelihood of developing PTSD
regardless of the quality of counseling. Nonetheless, a large
majority of both women and men (85.8% and 86.6%, respec-
tively) in this study indicated that they did not perceive
preabortion counseling to be adequate. Because abortion is
the legal right of females in the United States and continues
to be viewed as an exclusively women’s issue, there are no
requirements or incentives to offer counseling to male part-
ners. If men receive any counseling at all, it is likely to occur
informally if and when they accompany their partners for
preabortion clinic visits.
When unplanned pregnancy is experienced as a crisis situ-
ation for one or both partners, the individuals tend to use more
primitive coping skills and to be psychologically vulnerable as
they struggle to solve the problem and regain equilibrium
(Caplan, 1961). The emotional strain of the crisis and the lack
of effectiveness of one’s usual coping mechanisms may result
in anxiety and an inability to function (Caplan, 1961). Thus,
men and women facing a crisis pregnancy may need consider-
ably more counseling than is currently being offered.
With control variables applied, incongruence of abortion
decision significantly predicted trauma symptoms of intru-
sion and meeting diagnostic criteria for PTSD for both men
and women. Contrary to the findings concerning counseling
adequacy, disagreement about the abortion decision predicted
Coyle et al. 9
Table 4. Results of Logistic Regression Analyses With Posttraumatic Stress Disorder (PTSD) Subscales and Total Scale Criteria Met for
Females
Dependent Variable Independent Variable B SE Exp(B) 95% CI for Exp(B) Significance
Intrusion subscale Respondent and partner 1.00 0.37 2.73 1.33-5.59 .006
not in agreement on abortion
Inadequate preabortion counseling 2.88 0.38 17.74 8.51-37.00 .0001
Intrusion subscalea Respondent and partner 1.11 0.51 3.02 1.11-8.21 .030
not in agreement on abortion
Inadequate preabortion counseling 3.21 0.74 24.83 5.80-106.37 .0001
Avoidance subscale Respondent and partner 0.86 0.29 2.35 1.33-4.17 .003
not in agreement on abortion
Inadequate preabortion counseling 2.54 0.39 12.72 5.98-27.04 .0001
Avoidance subscalea Respondent and partner 0.67 0.39 1.95 0.92-4.15 .083
not in agreement on abortion
Inadequate preabortion counseling 1.89 0.57 6.59 2.16-20.11 .001
Hyperarousal subscale Respondent and partner 0.38 0.24 1.47 0.91-2.35 .114
not in agreement on abortion
Inadequate preabortion counseling 1.66 0.35 5.25 2.63-10.47 .0001
Hyperarousal subscalea Respondent and partner 0.31 0.31 1.36 0.74-2.52 .325
not in agreement on abortion
Inadequate preabortion counseling 1.48 0.54 4.39 1.53-12.61 .006
PTSD total scale Respondent and partner 0.64 0.24 1.89 1.17-3.05 .009
not in agreement on abortion
Inadequate preabortion counseling 1.80 0.41 6.06 2.69-13.66 .0001
PTSD total scalea Respondent and partner 0.64 0.32 1.89 1.01-3.55 .046
not in agreement on abortion
Inadequate pre-abortion counseling 1.34 0.57 3.83 1.25-11.74 .019
a. Controlled for race, education, marital status, employment, number of children, number of abortions, the meaningfulness of the respondent’s religion,
the respondent’s view on the legality of abortion prior to the abortion, mental health counseling before the abortion, hospitalized for emotional reasons
before the abortion, told he or she needed counseling before the abortion, respondent felt he or she needed counseling before the abortion, victim of
child abuse, child neglect, sexual abuse in childhood or adolescence, physical abuse in adulthood, or sexual abuse in adulthood.
hyperarousal in men but not in women. Furthermore, decision
incongruence predicted abortion-related anger, relationship
problems, and sexual difficulties for men only. The inherent
inequality of abortion decisions may explain these differen-
tial associations.
Numerous studies (Bracken, Hachamovitch, & Grossman,
1974; Major, Zubek, Cooper, Cozzarelli, & Richards, 1997;
Moseley, Follingstad, Harley, & Heckel, 1981; Payne et al.,
1976) have identified conflict with one’s partner and lack of
partner support for abortion as predictors of women’s posta-
bortion distress. In contrast, very few studies, with the
exception of work by Shostak and McLouth (1984) and Naziri
(2007), have examined the male’s reaction to an abortion that
occurs against his wishes. Our findings suggest that disagree-
ment about abortion decisions may be a more robust predictor
of traumatic stress among men compared with women.
A notable feature of this study is that it is the first to
explore the association between preabortion counseling and
postabortion relationship problems and postabortion psycho-
logical stress. Employment of numerous control variables,
including prior mental health, which has been found to be a
determinant of both postabortion adjustment (Major et al.,
2000) and PTSD (Brewin, Andrews, & Valentine, 2000), is a
major strength of this investigation. Also included as control
variables were other known risk factors for the development
of PTSD, including history of childhood sexual abuse (Astin,
Lawrence, & Foy, 1993), childhood physical abuse (Bremner,
Southwick, Johnson, Yehuda, & Charney, 1993; O’Keefe,
1998), physical abuse during adulthood (Breslau, Davis,
Andreski, & Peterson, 1991), and sexual abuse during adult-
hood (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).
The use of the Internet is another asset of this study as it
enabled acquisition of an international sample and offered ano-
nymity for those who may have been hesitant to participate in
research concerning such a sensitive topic. The anonymity
afforded by an online survey may augment respondents’ per-
ceptions of safety and enhance honest disclosure. Finally, the
inclusion of men as well as women is an essential strength of
this investigation as the research pertaining to men’s responses
to abortion is severely inadequate.
A limitation of this study is the fact that the sample was
self-selected. Although self-selection may bring some bene-
fits such as a high level of motivation and a genuine desire to
contribute to science, self-selected samples limit generaliz-
ability of findings. Moreover, the high rate of PTSD among
respondents (54.9% of women, 43.4% of men) is indicative
of a traumatized sample. By comparison, prevalence of
PTSD among women with a history of assault has been
10 Traumatology XX(X)
reported as 21% (Breslau et al., 1991), among rape survi-
vors, 50% (Foa, 1997), and among Vietnam veterans with
high combat exposure, 31% (Kulka et al., 1988).
On the other hand, this highly traumatized sample may
represent those who drop out of other studies concerning
abortion. In a review of 17 such studies (Adler, 1976), the
attrition rate was found to be from 13% to 86% leading to the
conclusion that those women who do not participate in
follow-up assessments tend to be the most stressed by abor-
tion. As a result, follow-up studies may underestimate
negative responses to abortion. Conceivably, anonymous
surveys conducted online may be an effective means to reach
these traumatized individuals and to gather information from
them concerning their abortion experience.
Abortion is one of the most common surgical procedures
among women aged 15 to 44 years (Owings & Kozak, 1996)
and from 1973 through 2005, more than 45 million elective
abortions were performed in the United States (Guttmacher
Institute, 2008). If even a small percentage of the men and
women involved in abortion are severely traumatized, this
may represent a large absolute number of individuals who
need psychological support. In addition, the increase in sui-
cidal ideation among those with PTSD (Sareen, Houlahan,
Cox, & Asmundson, 2005) and with subthreshold PTSD
symptoms (Marshall et al., 2001) raises serious public
health concerns if these individuals are not identified and
offered help.
In this study, perceptions of preabortion counseling inade-
quacy were associated with more negative postabortion
outcomes in both women and men. Future research should
seek to identify the specific elements of counseling that need
to be changed or added to achieve better satisfaction with the
content and process. Aspects of preabortion counseling to
explore further might include the following: (a) the sufficiency
of time allotted for counseling, (b) the nature and quality of
training of counselors, (c) the inclusion of men in the preabor-
tion counseling process, (d) whether it is better for men and
women to be counseled separately or together, and (e) the
comprehensiveness and accuracy of information provided.
Findings reported herein provide preliminary evidence
that perceptions of inadequate preabortion counseling
and abortion decision incongruence may contribute to rela-
tionship challenges between partners and to individual
psychological stress. Future research to investigate factors
that improve the quality and comprehensiveness of preabor-
tion counseling as well as factors that contribute to decision
Table 5. Results of Logistic Regression Analyses With Posttraumatic Stress Disorder (PTSD) Subscales and Total Scale Criteria Met for
Males
Dependent Variable Independent Variable B SE Exp(B) 95% CI for Exp(B) Significance
Intrusion subscale Respondent and partner 2.19 0.53 8.94 3.16-25.29 .0001
not in agreement on abortion
Inadequate preabortion counseling 1.70 0.57 5.48 1.78-16.89 .003
Intrusion subscalea Respondent and partner 2.33 0.73 10.25 2.47-42.49 .001
not in agreement on abortion
Inadequate preabortion counseling 2.91 0.97 18.37 2.77-121.83 .003
Avoidance subscale Respondent and partner 1.02 0.36 2.76 1.36-5.62 .005
not in agreement on abortion
Inadequate preabortion counseling 1.91 0.67 6.76 1.82-25.15 .004
Avoidance subscalea Respondent and partner 1.01 0.52 2.75 0.99-7.64 .052
not in agreement on abortion
Inadequate preabortion counseling 2.40 0.92 11.05 1.82-67.18 .009
Hyperarousal subscale Respondent and partner 1.27 0.35 3.57 1.78-7.14 .0001
not in agreement on abortion
Inadequate preabortion counseling 0.63 0.58 1.87 0.60-5.86 .279
Hyperarousal subscalea Respondent and partner 1.50 0.55 4.84 1.53-13.13 .006
not in agreement on abortion
Inadequate preabortion counseling 1.28 0.89 3.60 0.64-20.24 .148
PTSD total scale Respondent and partner 1.28 0.37 3.61 1.75-7.45 .001
not in agreement on abortion
Inadequate preabortion counseling 0.92 0.69 2.52 0.66-9.64 .178
PTSD total scalea Respondent and partner 1.13 0.53 3.10 1.09-8.85 .034
not in agreement on abortion
Inadequate preabortion counseling 0.89 0.91 2.44 0.41-14.57 .326
a. Controlled for race, education, marital status, employment, number of children, number of abortions, the meaningfulness of the respondent’s religion,
the respondent’s view on the legality of abortion prior to the abortion, mental health counseling before the abortion, hospitalized for emotional reasons
before the abortion, told he or she needed counseling before the abortion, respondent felt he or she needed counseling before the abortion, victim of
child abuse, child neglect, sexual abuse in childhood or adolescence, physical abuse in adulthood, or sexual abuse in adulthood.
Coyle et al. 11
congruence could do much to improve men’s and women’s
postabortion adjustment. In-depth interviews with men and
women prior to and after abortion might reveal specific
counseling needs that could be incorporated into preabortion
counseling protocols. Qualitative studies are needed to delve
more deeply into the processes of decision making between
women and men facing crisis pregnancies to further our
understanding of both intraindividual factors and interper-
sonal dynamics that may affect the quality and congruence
of abortion decisions.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research and/or
authorship of this article.
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Bios
Dr. Coyle is a co-director of the Alliance for Post-Abortion Research
& Training, Inc. Her research interests include the psychological
effects of abortion on men and the psychology of forgiveness.
Dr. Coleman is an Associate Professor of Human Development
and Family Studies at Bowling Green State University. Her
current research focuses on women’s responses to induced abor-
tion including mental health (anxiety, depression, suicide
ideation), substance abuse, intimate partner relationship issues,
and parenting.
Dr. Rue is the director of the Institute for Pregnancy Loss in
Jacksonville, FL. For 35 years he has treated women and men who
have experienced abortion as traumagenic and is an active litigation
consultant.
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